Volume 179 Issue 6

The new guidelines should be useful to all medical practitioners and fair to patients Driving a motor vehicle is a complex task involving perception, good judgement, adequate response time and reasonable physical capability. A range of medical conditions, as well as certain treatments, can impair any of these factors. Such impairment may adversely affect driving ability, possibly resulting in a crash causing injury or death (Box). Case report An eight-year-old girl was walking with her family on a footpath. A car driven by a driver who had poorly controlled diabetes and was suffering a hypoglycaemic episode mounted the kerb, killed the girl, and injured members of her family. The coroner was critical of the driver who failed to take responsibility for his condition, failed to attend medical appointments and education as requested, ignored the obvious risk of his continuing to drive, and deliberately sought to retain his driver licence by “doctor shopping”. The various doctors involved in the driver’s treatment were also criticised for the lack of clarity and consistency of information given to the driver regarding driving restrictions and the lack of action in response to “red flags”. They were also criticised for not notifying the driver licensing authority of concerns about the person’s continued driving.1 Although South Australia differs from most states and territories in explicitly requiring a medical practitioner to notify the authorities of patients who have conditions likely to impair driving, the issue has ethical resonances for the profession nationwide: doctors have significant medicolegal responsibilities regarding their patients and safe driving, and should act accordingly; although doctors must respect patient confidentiality, nearly all states and territories provide indemnity for a doctor to notify the driver licensing authority if an unsafe patient cannot be persuaded to self-notify and continues to drive; and conditional licences may be recommended for patients if certain treatment, compliance, response and review criteria are met. This helps ensure the quality of life for the patient. Doctors should be aware of these options. The newly published Assessing fitness to drive 20032 gives guidance to healthcare practitioners faced with various clinical situations. It also provides specific guidance on conducting medical examinations required by the licensing authorities. The overall intent of these national guidelines is to help clinicians: identify and manage patients who may not be capable of adequately controlling a vehicle (and who are thus a risk to public safety); counsel patients regarding the impact of their condition on their driving ability; inform patients of their legal obligations to report long-term or permanent illnesses or injuries likely to affect their driving to the driver licensing authority; and if needed, because of inaction by the driver and immediate concerns about public safety, advise the driver licensing authority regarding the patient’s fitness to drive. The new publication replaces the existing booklets Medical examinations for commercial vehicle drivers (1997)3 and Assessing fitness to drive (2001) for private vehicle drivers,4 and combines both these booklets into one reference for ease of use. The medical criteria for commercial drivers are more stringent than those for private vehicle drivers, reflecting their extensive time on the roads and the likelihood of more serious consequences of loss of control of, say, a petrol tanker or bus compared with a domestic car. These different criteria are set out in colour-coded format throughout the new book. In addition to combining the standards for commercial and private vehicle drivers, the content has been extensively revised to reflect advances in diagnosis, treatment, and prognosis of various conditions affecting driving ability. For example, increasing recognition of the importance of fatigue and sleep disorders in accidents5 has led to inclusion of the Epworth Sleepiness Scale as a screening tool in the health questionnaire,6 and the more accurate and cross-culturally validated AUDIT questionnaire has replaced the CAGE questionnaire for alcohol dependency screening.7 Similarly, advances in treatment of diabetes, epilepsy, and psychiatric disorders have been incorporated. Much attention has been given to “conditional licences”, whereby a person who does not meet the medical criteria may be supported in retaining a driving licence that is conditional on supplementary criteria relating to compliance and response to treatment, possible driving restrictions, and a detailed plan for monitoring the patient’s condition. This should help in rehabilitation of patients with various conditions, and address concerns about disability discrimination and equal employment opportunity issues. Several legal and ethical issues are also identified in the guidelines. The book emphasises the legal responsibility of drivers to notify the driver licensing authority if they have any permanent or long-term condition likely to affect their driving ability. The relevant state legislation in this regard is included as an appendix. The legislation relating to reporting by healthcare practitioners is also summarised in the book. Most states (with the exception of South Australia and the Northern Territory, where legislation is under review) do not require mandatory reporting by healthcare professionals. However, there remains a duty of care in cases where the healthcare practitioner is aware of the patient’s continuing driving and there is a definite risk to public safety.8 Practitioners who are unsure about confidentiality and notification should consult their medical defence organisation or state driver licensing authority regarding their legal position. The introduction of privacy legislation in most states has also been a consideration, and has led to clarification of the information to be recorded and kept by the practitioner (and to be readily available to the patient/driver), as distinct from the medical information to be provided on a “need to know” basis to the licensing authority. The exception is information required to be provided to the authority under law. This has led to new forms and procedures to guide practitioners. Although overall there is a move to uniformity of licensing procedures in the different states and territories, there are still some important differences. Tables set out these differences for easy reference. In summary, Assessing fitness to drive 2003: outlines clear medical criteria for driver capability, based on available evidence and expert medical opinion; clearly differentiates national minimum standards for licensing drivers of commercial and private vehicles; outlines the legal obligations for medical practitioners and drivers; provides medical examination proformas to help guide the assessment process; provides a reporting template to guide reporting to the licensing authority if required; and provides links to supporting and substantiating information. The new guidelines have been developed through extensive consultation with the medical profession, the licensing authorities, the trucking industry and unions, and lay groups. The development of the book is one of a series of initiatives by the National Road Transport Commission to create uniformly efficient and safe transportation in Australia.9 In recognition of its importance, the book has been signed into force by the ministers of transport of all states and territories. The book has been assessed by general practitioners and found to offer clear clinical and procedural advice for various situations. It is intended the new guidelines will be useful to all practitioners, be fair to patients, and contribute to road safety. Copies of the new guidelines are being distributed to all GPs, and may also be obtained free of charge from state driver licensing authorities. The guidelines are also accessible online from the Austroads website (www.austroads.com.au), and an online tutorial package is being developed to support implementation.

Bruce Hocking FAFOM, FAFPHM, FRACGP · Fiona Landgren B Pharm, Grad Dip Hosp Pharm

The recording process needs to become more efficient, more useful to clinicians and multipurpose Medical records serve a variety of purposes: they reflect the care process, provide a line of communication between clinicians and health services, and constitute legal evidence of referral, presentation, assessment and care given. If it is not in the medical record, it did not happen! They are also used for quality assurance, casemix funding, deriving statistics on diseases and procedures, and research. However, many clinicians seem to regard record-keeping as a chore. Why is it important and how can it be made more efficient and exciting? In this issue of the Journal, the report by Lee and colleagues (page 289) demonstrates an important use of medical records.1 Their study of survival of patients after stroke in Western Australia was made possible by linking morbidity data derived from hospital medical records with death reports using unique patient identifiers. This data linkage project and associated efforts to improve the quality of hospital data are well known in Australia and internationally for their contributions to understanding outcomes of care. Moves to introduce data linking over time and place using probabilistic matching or unique patient identifiers are gathering momentum throughout Australia.2-4 Studies such as that of Lee and colleagues depend on accurate, consistent coding of information on diseases and procedures from patient medical records. The coding process is multifaceted, involving: abstracting from the patient record the diagnoses and procedures to be coded; choosing codes for each diagnosis and procedure; and “sequencing” (ranking) of codes to identify the principal diagnosis, which determines the diagnosis-related group5 for that episode of care. In Australia, considerable effort has gone into developing standards for the coding process. The National Centre for Classification in Health (NCCH), with input from clinicians and clinical coders in all states and territories, has developed an Australian modification of the World Health Organization’s classification of diseases, The international statistical classification of diseases and related health problems, and an accompanying Australian classification of procedures, originally based on the items in the Medicare Benefits Schedule — together making up the ICD-10-AM.6 This publication also includes the Australian coding standards, the “rules” for applying and interpreting the ICD codes. The NCCH maintains these systems, updating not only the categories within the ICD-10-AM, but also colloquial clinical terms, so that coders can match the language in patient records with that in the classification. The NCCH also produces the ICD-10-AM chronicle,7 which maps categories and terms from one ICD-10-AM edition to another, so that coded data can be used for longitudinal studies. Use of the morbidity coding process as the foundation for casemix grouping, and in turn casemix funding or contracting, has turned the spotlight on the accuracy of the coding process. While the emphasis has been on obtaining the “correct” diagnosis-related group, this is possible only if the coding is a true reflection of patient characteristics and care. However, coders can only work with what they are given. To produce quality data, they require accurate, comprehensive medical records that are clearly and concisely expressed and in predictable format. Yet, the quality of many medical records leaves much to be desired, with little change in format or content in the past 40 years. In 1995, the Quality in Australian Health Care study found that over half the medical records reviewed were missing one or more key elements, such as assessment, progress notes, discharge summary, or diagnostic and therapeutic procedures, and that adverse events are less likely to be detected if documentation is missing.8 All this points to the need for revolution rather than evolution. There have been many attempts to improve the quality of medical records, such as the development of problem-oriented medical records9 and, more recently, the move towards electronic medical records. The Clinical Casemix Committee of Australia recently commissioned the NCCH to produce the Good clinical documentation guide10 to help clinicians understand the process of coding and to enhance the quality of coded data. This guide reflects the change in focus from coding for casemix to reinforcing the conjunction between good clinical care, good recording and good morbidity data. To promote a uniform approach to information and communication technologies in the health sector, the federal government has initiated Health Online, a national strategic plan for health information management.11 One Health Online project, HealthConnect, proposes a national approach to electronic health records, with patient “event summaries” collected in standard electronic format at the point of care (eg, hospital or general practice) for retrieval and exchange with other healthcare providers.12 Although this project holds out hope, so far health information has not seen the technological advances that have occurred in other information intensive industries. Much clinical time is devoted to recording the care provided to patients. It is our challenge to make that recording as efficient as possible, to free as much time as possible for clinical rather than administrative functions, and to make the data work for clinical care and for research. Clinicians need to feel that the recording process is useful to them, tied to decision support and the literature, including information about drug interactions and evidence of treatment outcomes. Data extraction should not be an after-the-event exercise but a continuous, real-time process and an intrinsic part of care, occurring at the bedside and integrated with ordering of investigations and prescribing. While electronic health records will impose more discipline on how information is recorded, they will not be a panacea for poor recording practices. We must get our collective act together to promote the goal of recording information once at the point of care for the many subsequent uses, with research a by-product of clinical care. While techniques of data linkage, such as those used in Western Australia, already make a major contribution to this, there is still a long way to go in rationalising record-keeping by clinical staff within and between health services.

Rosemary F Roberts MPH, MBA · Ralph M Hanson FACEM. MPH. MRACPA, FRACP

If we address the obstacles, high quality CAM research is possible About half the general population in developed countries uses complementary and alternative medicine (CAM).1 Yet many conventional healthcare professionals refuse to take CAM seriously — one often-voiced argument is “there is no research in CAM”.2 Certainly, for some modalities there is no compelling evidence base,3 and some of the research into CAM has methodological flaws and biases.4,5 On the other hand, many doctors and medical educators are uninformed about the quality evidence that does exist.6 In this article, I discuss some of the obstacles to developing an evidence base for CAM. Financial obstaclesIn most countries, CAM research funding is on a very small scale. For instance, only 0.08% of the British National Health Service research budget goes towards CAM research.7 Even though recent initiatives in the United Kingdom, United States and Australia have specifically freed up funds for CAM research, these amounts are minute compared with funding in other areas of medicine. It is likely that lack of plausibility of many CAM therapies deters scientific review committees from defining CAM as a priority. A vicious circle may ensue: little plausibility means no funds, therefore no preliminary research, therefore little plausibility. Clinical trials of CAM can be even more expensive than those of conventional medicine. CAM treatments are often therapist-led, effect sizes are often small (requiring large sample sizes), and therapeutic effects may appear only after long treatment periods, all of which mean greater expense. For most CAM modalities, intellectual property cannot be protected; thus commercial investments are rarely forthcoming. This shortage of CAM research funds has three important consequences: it prevents relevant projects from happening; it hinders the development of a research infrastructure similar to that of conventional medicine; and it keeps well-trained career scientists from entering into the field. Methodological obstaclesMany CAM therapies (eg, massage therapy) are physical by nature, which creates methodological challenges. What, for instance, is an acceptable “placebo” control for a trial of massage treatments? Like several other areas of conventional medicine (eg, physiotherapy, surgery, psychotherapy), blinding patients in clinical trials can be difficult or even impossible. Thus the highest level of scientific rigour can be barred to trials of CAM. Many CAM researchers also believe that their holistic approach can not be readily put into the “straitjacket” of a randomised controlled trial (RCT).8 This argument is demonstrably wrong, and its persistence in CAM circles continues to impede efficacy research. One can, of course, conduct an RCT comparing a complex, individualised, “holistic” treatment package to the standard care for that condition. This may require some innovative adaptations to the standard design, but, in principle, RCTs are usually feasible.9 For many people, CAM is an emotive subject. As a result, patients may not want to take a chance with randomisation, and many CAM practitioners may oppose scientific evaluation of their treatments, further hindering clinical trials. There is more to most CAM interventions than meets the eye. For instance, some are based on theories that fly in the face of science. Researchers might conduct a clinical trial of traditional acupuncture, spiritual healing or homoeopathy and see this as a relatively straightforward exercise. Proponents of these therapies may, however, view it as a test of some ancient theories of life forces, spiritual energies or ultramolecular phenomena. Such discrepancies can (and usually do) create unforeseeable methodological problems, as well as obstacles for research and interpretation of results. Ethical obstaclesIt is an important ethical requirement for randomised clinical trials that the investigators be in the state of equipoise (ie, they must believe that the test intervention is at least as good as the control intervention or placebo). If this is not the case (as for many CAM researchers), it is, strictly speaking, unethical for investigators to conduct the study. “Randomisation is only ethical if there is substantial uncertainty about the best treatment for that patient”.10 A further important ethical requirement for clinical research is informed consent from patients or healthy volunteers.11 As mentioned above, this may be difficult or impossible to obtain in an environment where patients’ enthusiasm often is strongly in favour of CAM and against receiving a control (placebo or non-CAM) treatment. Such problems constitute further impediments to good CAM research. ConclusionAlthough high quality CAM research does exist,3 many projects have, in the past, been less rigorous than they could have been. Before we condemn CAM for this situation, we should ask what the obstacles to CAM research are. Removing these obstacles will require dedicating adequate funds to CAM research, attracting career scientists into the field, adequately addressing the complexity of CAM and minimising bias with carefully designed studies.

Edzard Ernst MD, PhD, FRCP

All is not well with Australia’s health system Internationally, Australia’s health system is held in high regard. Our citizens enjoy life spans second only to those in Japan.1 The World Health Organization measures a nation’s health attainment as a composite of the average level of population health and the general distribution of population health or health equality, the level and extent of the health system responsiveness, and the fairness of contributions to health financing by households. According to the WHO’s benchmark — the overall health system attainment index — in 1997, we ranked 12th among 191 nations.1 But all is not well with Australia’s health system. Its edifice is cracking under the strains of a growing mismatch between its capacity to deliver quality healthcare and the changing demands of our communities. Symptoms of the system’s stresses include: the free fall in the number of general practitioners who bulk bill,2 and the consequent threat to Medicare’s principles of universality and equity of access; the short supply of health professionals, particularly nurses3 and general practitioners;4 the increasing occurrence of hospital access block and hospital ambulance bypass,5 and the growing elective surgery queues; the problem of hospital exit block, reflecting the short supply of community-care services, particularly for older people,6 and the breakdown in social networks; the inherent inability of a system organised for acute, episodic care to efficiently provide continuous long-term care;7 and finally the conflict between society’s increasing demand for health services, the high cost of technology-driven medicine and new pharmaceuticals, and the political and fiscal imperatives of the guardians of the public purse. Critical to the viability of our health system are the Australian Health Care Agreements (AHCAs). These 5-yearly political pacts define the joint funding responsibilities of federal and state or territory governments in providing free public hospital services.8 One of the drawbacks of the AHCAs is their impotence in promoting reform. And our health system is sorely in need of reform! This imperative was recognised by Australian ministers of health in April 2002, when they collectively adopted a reform commitment, underpinned by the principles that the federal and state or territory relationship in health funding should ensure that: the provision of optimal care and health outcomes be independent of jurisdictional boundaries; the respective jurisdictions work cooperatively to improve the health and wellbeing of the community; and the next round of AHCAs (2003–2008) be outcome-oriented.8 Suddenly, the winds of change were stirring in Australian healthcare and fanning expectation of reform. The ministers promptly established nine reference groups to address and advise on issues affecting current healthcare. These briefs included the continuum across preventive, primary, chronic and acute care; improving the interface between aged care and acute care; cross jurisdictional cooperation on workforce training and education; the interaction between hospital funding and private insurance; improving Indigenous health, mental health and rural health; quality and safety; and, concluding this impressive and inclusive list, was information technology and research.8 The nine expert groups met, deliberated, and, in record time, in September 2002, presented to Australia’s health ministers a comprehensive agenda for reform.9 The ministers considered the road maps for reforms, and highways were identified for their implementation, but, to date, the reform vehicles have remained locked up in bureaucratic and ministerial garages. In the meantime, the ministers have resumed their adversarial political rhetoric, punctuated as always by fiscal bickering and buck-passing. This return to tiresome political form has undoubtedly fuelled widespread mistrust and cynicism among health professionals and consumers. One outcome of this despair and discontent has been the Australian Health Care Summit held in Canberra on August 17–19, 2003. The Summit was attended by more than 250 delegates, drawn from across the healthcare spectrum. They included academics; administrators; allied health and other professionals; clinicians; consumers, economists; experts in health policy, mental and public health; politicians; and people and health professionals from Indigenous, rural and remote communities. Despite the Summit’s claim to be an independent, bipartisan gathering, the absence of the Federal Minister for Health and Ageing, Senator Kay Patterson, and the minimal representation of the Australian Department of Health and Ageing, were duly noted. Furthermore, the Summit’s claim of independence did not deter lightning forays by the Premier of New South Wales, Bob Carr, and the Leader of the Federal Opposition, Simon Crean. Despite the politics, what did the Summit achieve? It reaffirmed the egalitarian and socially cohesive principles underpinning Australia’s healthcare (Box). It identified inhibitors of and promoters for health reform, which are detailed in the Summit Communiqué.10 The Summit’s sixteen workshops spawned detailed suggestions for reform. Finally, there was a recommendation for an independent national body to drive health reform.10 However, the real message emanating from the Summit was the depth of desire for healthcare reform among consumers and professionals, and the wealth of innovative ideas and solutions that the healthcare community has to offer when committed to the cause. If only one message comes from the Summit it is that Australian healthcare reform is in dire need of political champions and cooperative federalism to harness the people and professional power so evident at the Summit. Without the spirit of cooperation, future health ministers may well look back to 2003 and say “we did nothing”. And that would be a shame. Australian Health Care Summit Statement of principles We believe the following principles must underpin our Australian health system: Universal access – in a timely fashion, to an appropriate service, available because of health needs, not one’s ability to pay; Equity of health outcomes – irrespective of socioeconomic status, race, cultural background, disability, mental illness, age, gender or location; Health care services must be focused on the needs of patients and their carers and the needs of Australians wishing to avoid illness; Health promotion – preventing disease and maintaining health must be appropriately emphasised and balanced with our duty of care to those already unwell; Personal and corporate tax contributions should fund our health care. This is the way we wish to provide health insurance to each other; A fair balance of public and private resources and investment is needed [to] ensure equitable health outcomes for all Australians; The health outcomes of Aboriginal and Torres Strait Islander Australians must be improved so that they match those of other Australians; Health services must be appropriate, safe and of high quality; The community – especially consumers and carers, must play an integral part in the development, planning and implementation of our health services; The health workforce must be valued and appropriately supported.

Martin B Van Der Weyden MD, FRACP, FRCPA

Objective: To determine the effect on cardiac arrests and overall hospital mortality of an intensive care-based medical emergency team.Design and setting: Prospective before-and-after trial in a tertiary referral hospital.Patients: Consecutive patients admitted to hospital during a 4-month “before” period (May–August 1999) (n = 21 090) and a 4-month intervention period (November 2000 –February 2001) (n = 20 921).Main outcome measures: Number of cardiac arrests, number of patients dying after cardiac arrest, number of postcardiac-arrest bed-days and overall number of in-hospital deaths.Results: There were 63 cardiac arrests in the “before” period and 22 in the intervention period (relative risk reduction, RRR: 65%; P < 0.001). Thirty-seven deaths were attributed to cardiac arrests in the “before” period and 16 in the intervention period (RRR: 56%; P = 0.005). Survivors of cardiac arrest in the “before” period required 163 ICU bed-days versus 33 in the intervention period (RRR: 80%; P < 0.001), and 1353 hospital bed-days versus 159 in the intervention period (RRR: 88%; P < 0.001). There were 302 deaths in the “before” period and 222 in the intervention period (RRR: 26%; P = 0.004).Conclusions: The incidence of in-hospital cardiac arrest and death following cardiac arrest, bed occupancy related to cardiac arrest, and overall in-hospital mortality decreased after introducing an intensive care-based medical emergency team.

Rinaldo Bellomo MD, FJFICM · Donna Goldsmith RN · Shigehiko Uchino MBBS · Jonathan Buckmaster FJFICM, FANZCA · Graeme K Hart FJFICM, FANZCA · Helen Opdam FJFICM, FRACP · William Silvester FJFICM, FRACP · Laurie Doolan FANZCA · Geoffrey Gutteridge FJFICM, FANZCA

Objective: To determine the factors influencing survival among patients admitted to Western Australian hospitals for the first time with stroke or transient ischaemic attack (TIA).Design, setting and patients: Linked hospitalisation and death records of 7784 patients admitted to hospital for first-ever stroke or TIA between July 1995 and December 1998 were retrieved retrospectively to determine survival; effects of risk factors on death due to stroke were assessed using the Cox proportional hazards regression model.Main outcome measures: All-cause stroke survival; short- and long-term stroke survival probabilities.Results: Survival at 28 days was lowest for haemorrhagic stroke. However, following the first month after admission survival after haemorrhagic stroke was similar to, if not higher than, after ischaemic stroke. Among all patients, significant predictors of death were age (all subtypes of stroke), atrial fibrillation (intracerebral haemorrhage and ischaemic stroke), other cardiac conditions (ischaemic stroke and TIA), and sex and diabetes (TIA). Further predictors of death were residence in rural or remote areas (ischaemic stroke), and Aboriginality (TIA). Among 28-day survivors of ischaemic stroke, additional predictors of death were sex, diabetes and urinary incontinence still present 7 days after admission.Conclusion: Use of linked hospitalisation and death data allowed us to increase the scope and size of our study compared with previous studies of survival after stroke and TIA in WA. We confirmed the importance of type of stroke, age and comorbidities to this survival, and found that Aboriginality and place of residence are also important.

Andy H Lee PhD · Peter J Somerford BSc · Kelvin K W Yau PhD, AStat

Objective: To determine whether high maternal parity has any effect on pregnancy outcome independent of other maternal characteristics.Design and setting: Retrospective observational study using the database of a referral obstetric unit in a 280-bed regional hospital in far north Queensland.Participants: All 15 908 women who had singleton births between 1992 and 2001, comprising 653 women with grand multiparity (≥ 5 previous births at gestation ≥ 20 weeks) and 15 255 women with lower parity.Main outcome measures: Spontaneous vaginal birth, postpartum haemorrhage (estimated blood loss > 500 mL), placental retention requiring manual removal, blood transfusion associated with the birth, and perinatal death.Results: Women with grand multiparity were significantly older than those with lower parity, more likely to be Indigenous, not to have had antenatal care, to have smoked during pregnancy and to have had one or more previous caesarean sections. On univariate analysis, women with grand multiparity were more likely to have a postpartum haemorrhage (9.2% v 5.3%) and blood transfusion (2.8% v 1.5%). However, multivariate logistic regression analysis of women who began labour (ie, did not have an elective caesarean section) showed that grand multiparity was not significantly associated with postpartum haemorrhage or blood transfusion when other maternal characteristics were included in the model (regression coefficients [95% CI], 1.36 [0.99–1.87] and 1.09 [0.59–2.02], respectively). However, they remained more likely to have a spontaneous vaginal birth (regression coefficient [95% CI], 2.10 [1.56–2.74]).Conclusions: Women with grand multiparity do not have an increased likelihood of poor pregnancy outcomes. Birth-suite protocols which dictate extra interventions as routine during labour in these women should be revised.

Michael D Humphrey PhD, FRANZCOG, FRCOG

Objectives: To compare the characteristics of complementary and alternative medicine (CAM) users and non-users among Australian women.Design: Cross-sectional postal questionnaire conducted during 1996, forming the baseline survey of the Australian Longitudinal Study on Women’s Health.Participants: Women aged 18–23 years (n = 14 779), 45–50 years (n = 14 099) and 70–75 years (n = 12 939), randomly selected from the Health Insurance Commission database, with over-sampling of women from rural and remote areas of Australia.Main outcome measures: Consultation with an alternative health practitioner in the 12 months before the survey.Results: Women in the mid-age cohort were more likely to have consulted an alternative health practitioner in the previous year (28%) than women in the younger cohort (19%) or older cohort (15%). In all age groups, CAM users were more likely than CAM non-users to reside in non-urban areas, to report poorer health, have more symptoms and illness, and be higher users of conventional health services.Conclusions: Women in non-urban Australia are more likely to use CAM but do so in in parallel with conventional health services.

Jon Adams PhD · David W Sibbritt PhD · Gary Easthope PhD · Anne F Young PhD

Objectives: To explore doctors’ perceptions of the acceptable limits to self-treatment and to identify barriers to doctors seeking appropriate healthcare.Design: Self-completion, postal survey using three hypothetical case vignettes.Setting and participants: 896 Australian doctors randomly selected from the Health Insurance Commission database and stratified by sex, discipline (general practitioner or specialist) and location (urban or rural). Data were collected between May and July 2001.Main outcome measures: Doctors’ self-reported attitudes on illness behaviour and choice of medical care in response to case vignettes.Results: 358 (40%) doctors returned questionnaires. More participants believed it was acceptable to self-treat acute conditions (315/351; 90%) than to self-treat chronic conditions (88/350; 25%). Nine per cent (30/351) of participants believed it was acceptable to self-prescribe psychotropic medication. A greater proportion of GPs (206/230; 90%) than specialists (101/121; 83%) believed doctors are reluctant to attend another doctor, especially if the problem is psychological. Women and GPs were significantly less likely to report that it was easy to find a satisfactory treating doctor (women, 58/140 [41%]; men, 128/211 [61%]; GPs, 106/231 [46%]; specialists, 80/120 [67%]). Being a specialist was predictive of seeking appropriate healthcare for all three vignettes.Conclusion: Doctors have varying opinions regarding the acceptability of self-treating chronic conditions, and perceive considerable barriers to seeking appropriate medical care. Strategies are needed to challenge the culture of self-reliance.

Sandra K Davidson BA, GradDipBehlStudiesHlthCare · Peter L Schattner MD, MMed, FRACGP

A 79-year-old man presented with diarrhoea and vomiting but with no abdominal peritoneal signs. He had a raised C-reactive protein level, but other blood test results (including amylase and liver function) and an abdominal radiograph were within normal limits. After conservative treatment failed, the patient underwent colonoscopy, which revealed cobblestone nodularity with ulceration in the terminal ileum, consistent with Crohn’s disease. There was no evidence of large bowel obstruction. A subsequent computed tomography scan revealed concentric circles in the terminal ileum consistent with a gallstone (Box). A diagnosis of gallstone ileus was made and the gallstone was removed with laparoscopic assistance. A fistula between the gallbladder and the duodenum, observed at operation, was left alone. The patient made an uneventful recovery.

Hashim Hashim MB BS, MRCS Surgical · Alec Engledow MB BS, FRCS · Steve Warren MS, FRCSE (Gen Surg) Consultant

The foundation of treatment for patients with hypertension is ongoing use of lifestyle measures such as physical exercise, weight reduction, and salt restriction. There should be emphasis on reduction of total cardiovascular risk, including smoking cessation and achievement of goal blood pressures. There are now five classes of first-line blood-pressure-lowering drugs — diuretics, β-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and calcium antagonists. In most patients, the choice of drug will be guided by the clinical situation in the individual patient, including the presence of target organ damage, diabetes, established vascular or kidney disease, or other comorbidities. In the absence of such clinical indications, start drug therapy with a low-dose diuretic. Combination therapy will be needed in around two-thirds of patients, and a diuretic will normally form one element of most combinations, with the second or third drug coming from among the remaining four. Consider the use of fixed-dose combinations to improve adherence to therapy. Use long-acting, once-daily preparations.

John P Chalmers MD, FRACP · Leonard F Arnolda PhD, FRACP

The medical emergency team (MET), which may be summoned by anyone in a hospital to treat a patient who appears acutely unwell, has been generally accepted as scientifically rational, with no adverse clinical outcomes and only modest resource requirements. Despite this, many centres appear to be awaiting “gold standard” evidence of its effectiveness. We suggest that the quest for evidence is providing scientific justification for institutional inertia, and that further delay in implementing this system may even be unethical. We propose that decisions about changes in healthcare should consider scientific rationality, clinical reasonableness and resource implications, as well as evidence and ethical implications. A medical emergency team (MET)1 can be simply described as a cardiac arrest team with changed calling criteria. Anyone in a hospital may summon the team to a patient who appears acutely unwell, even if the patient has not actually had a cardiac arrest. The introduction of a MET may be accompanied by education on better recognition of acute illness, and an ongoing audit and education process. There is an implied and unquantified increase in the workload of the intensive care unit (ICU) staff, and a need for them to shift the focus of their work (at least temporarily) outside ICU. The in-hospital response to acute illness has been shown to be suboptimal.2 As a remedy, the MET system appeals to many, but has been the subject of ongoing debate. There have been no suggestions that there may be adverse clinical outcomes from a MET; rather, the concept has been challenged on the basis of the quality of the evidence.3 In this age of evidence-based medicine (EBM), such a challenge is justification for a pre-emptive halt to change, while evidence is accumulated. Possible resource implications have also been a point of discussion.4 Perhaps the most important (though unstated) factor preventing implementation of the MET system is that it represents a change to established hospital systems, hierarchies, and departmental responsibilities. In this regard, we feel that the quest for evidence has provided scientific justification for institutional inertia. New evidence for the MET systemThose who have been following the debate about the possible benefits of the MET in hospitals will welcome the study by Bellomo and colleagues5 in this issue of the Journal. In a major teaching hospital, introducing a MET was associated with a 65% reduction in cardiac arrests. Perhaps more surprisingly, there was a 26% reduction in the overall hospital death rate, equivalent to three lives per 1000 admissions. The authors did not limit their study to patient outcomes, but also considered some resource implications of the MET system and characterised the interventions by the MET. The increased workload does not appear to be excessive. Interestingly, most interventions appeared relatively “simple”, a finding somewhat reminiscent of that in a study of interventions by a hospital trauma team.6 Are patients dying while we wait for evidence? The results of Bellomo et al support the findings of others,7 and appear to strongly support the MET system. However, those who enjoy academic disputation should not lose heart — there are plenty of opportunities to dispute some aspects of the study, and the MET system generally. This ongoing controversy may also teach us much about the possible ethical implications of misuse of the concepts of EBM, and the dangers of attempting to base decisions about the delivery of medical care solely on “evidence”. The limits of evidence-based medicineEBM may be misused in scientific debate. Desire for scientific certainty and enthusiasm for scientific rigour may lead to inappropriate discounting of anything less than Level 1 evidence. The more rigorously EBM is applied, the less the evidence that the intervention being studied is effective — the “stainless steel” law of evaluation.8 This can lead to an apparent inability to prove anything, so that EBM produces a lot of “negative” outcomes. These limitations have been well recognised by Sackett et al9 and others.10 Despite this, there remains a widespread perception that EBM requires high-level evidence, such as randomised controlled trials. It is easy to misconstrue the resulting absence of evidence of benefit as being evidence of absence of benefit. The conclusions drawn from examining the evidence can be determined by the framing of the question and the standard of proof required — both of which can be controlled by those with established power or authority. The EBM website, Bandolier, comments: “The trouble is that people use phrases like ‘evidence-based medicine’, or ‘meta-analysis’ or ‘systematic review’ as some form of talisman. Attach one of these phrases to a point of view and an argument is won!”.11 Armed with the talisman of EBM, opponents of change can point to lack of evidence, or, if evidence is abundant and homogeneous, to weaknesses in study design. With apparent impartiality, other, less convincing reasons for conservatism may be concealed. Earlier in the ongoing MET debate, Buist et al reported on the introduction of a MET,7 with similar results to the study by Bellomo and colleagues. The extensive correspondence that the article by Buist et al generated drew attention to confounding factors, lack of applicability in other settings, failure to describe a mechanism of benefit, the use of historical controls, the possibility of a Hawthorne effect, and even accused the British Medical Journal of using an inaccurate and sensational cover title and a fake photo.12 Many of these criticisms are justifiable in (inappropriately rigorous) EBM terms, but we may be seeing the “stainless steel” law of evaluation at work — the more rigorously the criteria for EBM are applied, the less the evidence that the intervention is effective. Ellis (and Sackett) et al recognised the limitations of EBM in regard to life-saving treatment in emergency settings.13 In 1995 they acknowledged that certain interventions were “self-evident”, defined as interventions that, if omitted, would do more harm than good. “Face validity” may be accepted on the basis of “convincing non-experimental evidence”. This must be possible if innovation in acute, life-saving medicine is to continue. Ethical aspects of EBM misappliedThere have been a number of recent critiques of EBM and ethics, including some by Australian authors.14-16 Many of the issues raised, including funding and service decisions, and impact on research activity, are of some relevance to the MET controversy. Enthusiasm for EBM has grown at a time of increasingly overt economic constraint in healthcare. In this setting, EBM has been used as a justification for rationing decisions. At a national level, politicians have proposed that health funding should follow evidence (as defined by EBM).17 At a hospital level, “lack of evidence” may provide a useful justification to avoid shifting funds to facilitate system change, particularly for changes (such as a MET) that may result in “turf wars”. Regardless of funding, “lack of evidence” may provide service managers or clinician leaders with a justification to avoid involvement in service activity they would prefer to avoid for reasons unrelated to patient welfare. Uncritical application of EBM may also change the “respectability” of research or other activity that is not organised in the EBM paradigm. This may divert scarce resources (dollars, intellectual energy and enthusiasm) into research involving large randomised controlled trials. In many areas of healthcare, greater improvement in patient outcomes could be achieved by locally focused effort, based on quality improvement or process redesign methodology. It is interesting to speculate on what else could have been achieved with the funds, energy and intellect that have been and are being expended on research to produce evidence about the MET system. Implications for MET implementationMost of the foregoing discussion may seem to be of interest to philosophers, but only a diversion to clinicians. But consider the implications of the “quest for evidence” with regard to the MET. The MET concept was established at Liverpool Hospital, Sydney, in February 1990. Reports of the initial results, and experience with the MET, were presented at various conferences after 1991, and formal publications in peer-reviewed journals were produced after 1995. The concept was generally accepted as a scientifically rational and clinically reasonable response to the challenge of acute in-hospital illness. No adverse clinical outcomes have been suggested, and the resource requirements for the MET system are modest. Many would suggest that in a “reasonable” health system the MET system would have been introduced generally by (say) 1997, with appropriate audit of the effects of implementation. In fact, despite attracting international interest in the concept, introduction of the MET system in Australia has been patchy (about 25% of hospitals with ICUs). Many centres appear to be awaiting evidence — in particular, the multicentre trial of the concept sponsored by the Australian and New Zealand Intensive Care Society (the MERIT study) currently being conducted. But if the results of the study by Bellomo et al are extrapolated across Australia, introducing the MET system nationwide would prevent some 5000 hospital deaths annually. Could it be that thousands of Australians have died waiting for evidence to be collected to justify an intervention that is scientifically rational and clinically reasonable, with modest resource implications? Appropriate evidence-based decision-makingAll changes in healthcare have some risk of adverse outcomes, cost implications, and, once implemented, may be difficult to reverse. Clearly, decision-making must be based on something other than intuition or whim. It is appropriate to require some level of evidence for any decision (whether to change or to not change). But in some areas of medicine, it is unrealistic to ever expect evidence approaching the “gold standard”. In these areas, asking for “gold standard” evidence may be mischievous. We propose that decisions about changes in healthcare should consider three Rs and two Es. Is the proposal scientifically rational? Is it clinically reasonable? What are the resource implications? Is there evidence to guide our decision? What are the ethical implications? The three Rs should allow the proposal to be broadly categorised on the basis of risk (including cost) and benefit. The requirement for evidence should be proportional to the apparent risk and benefit. For interventions with a high risk (cost) and marginal benefit, particular rigour may be worthwhile in assessing the evidence. Recent examples of such interventions include activated protein C18-20 and cyclooxygenase-2 (COX-2) selective inhibitors,21,22 in which evidence was produced to support the intervention, but the cost of the evidence-based decision was high for a marginal benefit. If the evidence was even slightly flawed, the conclusion could have been very different. Conversely, in the case of interventions with high apparent benefit and low risk (including cost), it may be more illuminating to rigorously examine the motivation for opposition to the change, rather than accept as justified the demand for better or more evidence. We would suggest that the MET system fits the latter category. ConclusionThere is no doubt that the “best available evidence” is an important component of medical decision-making. EBM should be seen as a powerful method to identify the best available evidence to assist decision-making. However, EBM is not an impartial or value-neutral force in modern medicine, and has as much capacity for abuse as any other double-edged sword forged by science. EBM should not be enlisted as a tool to prevent healthcare changes that may benefit patients but are uncomfortable or challenging to the established order. In many areas of medicine, when considering possible interventions that are rational, reasonable, and with modest resource implications, it is appropriate to implement change without “absolute” evidence. It may even be unethical to delay change while inappropriately demanding more evidence. How many people should be allowed to suffer or die in the absence of “Level 1 evidence”, when reason suggests change, and our duty of care demands it?

Ross K Kerridge MB BS, FRCA, FANZCA · W Peter Saul MRCP, FRCA, FFICANZCA

In response to the increasing use of complementary and alternative medicine (CAM), governments are exploring ways to ensure patients’ safety and respond to complaints. One solution is to establish registration boards and procedures based on the model of existing health practitioner Acts. Registration will require defined minimum standards for competence, which will have to be based on scientific evidence. As scientific evidence accumulates, these modalities are likely to lose their identities as “alternative” and become assimilated into Western medicine.

Malcolm H Parker MB BS, MLitt

A 6-year-old child, held in detention with his parents pending the outcome of their application for refugee status, manifested psychological distress by repeated episodes of refusing to eat or drink. This case presented clinical and ethical dilemmas for health professionals who were constrained from acting in the child’s best interests by government policy of mandatory detention. It is Australian government policy to detain asylum seekers who do not have a valid entry visa in one of six privately operated immigration detention centres while their refugee status is determined (Box 1). The detention environment has been implicated as a direct contributor to psychological distress, either de novo or as a “retraumatising influence”.1 This is reflected in the suicide rate in detention centres, which is conservatively estimated at 3–17 times that in the Australian community.2 Justice P N Bhagwati, Regional Advisor, United Nations High Commission for Human Rights, identified key human rights issues pertaining to immigration detention in Australia.3 These included the lack of independent monitoring mechanisms, restricted access by healthcare workers and lawyers, lack of protection of the family unit (exemplified in the Woomera Housing Project, whereby women and children were allowed to live in the community while their husbands remained in detention), the policy of detaining unaccompanied minors, and the prison-like conditions, which are not conducive to healthy childhood growth and development. In August 2001, Australasian paediatricians and psychiatrists issued a joint position statement calling for children and their families to be released from Australian detention centres, and highlighting concern for children’s “subsequent emotional development and for the effects of detention on the functioning of their families”. In June 2003, there were 315 children held in detention in Australia and Australia’s “excised offshore places” (such as Ashmore and Christmas islands),4 as well as on Manus Island (Papua New Guinea) and Nauru.5 The clinical and ethical dilemmas that arise when government policy restricts clinicians’ decision-making are illustrated by the clinical record of a 6-year-old boy in detention with his family, who had repeated episodes of refusal to eat or drink (Box 2). This case highlights issues applicable to many children in detention in Australia. DiscussionThis boy was in a state of distress, and preoccupied by imprisonment and the violence he had witnessed, as depicted in his drawings (Box 4). The form of his response may have been influenced by the behaviour of distressed adults (as role models) in Woomera and Villawood detention centres who staged hunger strikes. His improvement when away from the detention centre, and rapid deterioration on returning, communicated the impact of an aversive environment. Several authors have described high levels of depression, anxiety and post-traumatic stress disorder (PTSD) in adult asylum seekers detained in Australia. They have also observed that detention may profoundly undermine the parental role, leaving children with little protection or comfort.1,7,8 Considerable evidence exists that refugee children themselves are at significant risk of developing psychological disturbance (PTSD, depression, anxiety and sleep disorders),9 but they frequently present with mixed symptoms, not necessarily fulfilling a single diagnostic category.10 The likelihood of psychological disturbance increases with the synergistic impact of multiple risk factors, including observing parental helplessness, separation from parents, witnessing or experiencing traumatic events, and the time taken for immigration status to be determined.11 Psychological distress in the early years may have implications for long-term functioning12,13 and competence in adult life.14,15 Protective factors for children exposed to trauma include being with their parents,16 having a safe and predictable environment,17 and achieving a sense of mastery over the environment by becoming part of a school community.18,19 In May 2001, when this child first presented, public and professional criticism of the conditions in detention centres was beginning to be voiced. The treating team studiously avoided media attention, on the assumption that maintaining confidentiality and advocacy at the individual level was likely to produce the most favourable mental health outcome. The team was challenged by differing views on the extent to which healthcare workers should confront the systems issues contributing to this child’s distress. This child’s presentation highlighted both a hiatus in the evidence base for effective treatment options for such children, and the frustrations of health professionals at being unable to provide best-practice care. Although we offered play and art therapy, family and individual sessions, “therapy” made little sense, given the boy’s awareness of the constant threat of discharge back to the “camp” and the uncertain outcome of the family’s refugee claim. Clinical recommendations, such as maintaining family integrity or school attendance, could not be accommodated by the Department of Immigration and Multicultural and Indigenous Affairs (DIMIA) and the agency managing the detention centre (Australasian Correctional Management). Child protection, legal and ethical issues were extensively discussed in managing this case. The overarching constraint was the clash between the principle of acting in the child’s best interests and government policy on mandatory detention — often prolonged mandatory detention. t Under the Children and Young Persons (Care and Protection) Act 1998 (NSW), healthcare workers in New South Wales are mandated to report children at risk of harm to the NSW Department of Community Services, so that appropriate protective measures can be instituted.20 This child fulfilled the criteria for reporting, and various attempts to report him were made. Child protection is governed by state legislation and could not be activated, as detention centres are a federal responsibility. Furthermore, the Minister for Immigration has certain guardianship rights with respect to asylum-seeker children, creating difficulties for state welfare authorities. The ethical dilemma of returning a child to an aversive environment is not unusual for health professionals. When the environment is known to be abusive, healthcare workers can call on nominated child-centred agencies to assist in maintaining children’s wellbeing. However, this was not possible in this case, as detainee children are not subject to Australian child protection legislation, and their welfare is not systematically monitored. In 1990, Australia signed the United Nations Convention on the Rights of the Child. This convention embodies the principles of provision (of education, health and other services), protection (from torture, abuse and arbitrary detention) and participation by children in decisions affecting their lives. Article 22 proposes that refugee children should have the same rights as citizen children.21 In May 2002, an alliance of health professionals launched a submission to the Human Rights and Equal Opportunity Commission (HREOC) Inquiry into Children in Immigration Detention, and recommended that children should not be held in anything other than minimal detention for processing purposes only, and that all children and their parents should be released immediately.22 The child presented in this article was the subject of a complaint to the HREOC, which “recommended” that the Australian government pay $70 000 compensation to the child for harm suffered. The government rejected the Commission’s findings and recommendations.23 Under present government policy, children seeking protection in Australia are unlikely to receive services that fulfil their complex needs, and we remain concerned that their prolonged detention will impair their psychological well-being and their capacity to become integrated members of the community.1 1: Schematic representation of the process for asylum seekers without a valid entry visa for obtaining a Temporary Protection Visa* * Information from Department of Immigration and Multicultural and Indigenous Affairs (DIMIA) website (www.immi.gov.au/facts/index.htm). †A Temporary Protection Visa entitles the holder to: temporary residence for 3 years; limited Welfare and resettlement assistance; access to Medicare benefits; no access to government English lessons; no family reunion; cannot leave and re-enter Australia (www.immi.gov.au/facts/64protection.htm). 2: Clinical record — a 6-year-old boy with recurrent refusal to eat or drink A 6-year-old boy presented to the Emergency Department of the Children’s Hospital at Westmead in May 2001. He was accompanied by his mother, infant sister and a uniformed officer from the Villawood Detention Centre. His mother reported, via an interpreter, that he had refused to talk or eat for the last 4 days, but that she had managed to coerce him to take small amounts of liquid. This episode began after the boy observed a man cutting his wrists (in the boy’s words “killing himself”) at the detention centre. The family was of Middle Eastern origin and belonged to a small religious group regarded as heretics in their country of origin. They had arrived in Australia by boat in March 2000, and then spent 11 months at Woomera Detention Centre and almost 3 months at Villawood Detention Centre. The younger child was born in detention. The family had been refused refugee status at all the initial stages of processing (Box 1), and were making a final-resort appeal to the Minister for Immigration and Multicultural and Indigenous Affairs for humanitarian consideration, a process seldom successful. The chronology of events is shown in Box 3. For 6 months before presentation, the boy had withdrawn from play with other children, and had been drawing similar repetitive images (Box 4). He became startled when he heard two-way radios used by detention centre officers. His mother described a chronic history of bedwetting and nightmares, which began after he witnessed riots and people setting themselves alight at the Woomera Detention Centre. Before this, he had been healthy, with normal development, although he had refused to eat and talk for half a day after one incident at Woomera. On examination, the boy was pale, listless and had clinical signs of mild dehydration. His height and weight were on the 75th and 50th percentiles, respectively. He was admitted to hospital for 6 days during which he gradually resumed talking and eating, although his bedwetting and nightmares persisted. Mental-state examination revealed a dull affect with slow, quiet speech and an anxious penetrating stare. He was unable to verbalise any wishes for the future, and said there was no point in making friends, because they all left while he remained in the “camp”. He described bad dreams about officers taking his father to gaol, and people cutting children with glass. The only drawing he produced in which the figures were not covered with bars was one of “the man who cut himself” (Box 5). He displayed extreme separation anxiety when his father departed after visits. He was assessed by the child psychiatry team as having acute on chronic post-traumatic stress disorder, fulfilling the Diagnostic and statistical manual of mental disorders (DSM-IV) criteria6 in that: (i) he was exposed to traumatic events; (ii) his response involved intense fear and helplessness; (iii) he had persistent re-experiencing of his trauma (through nightmares and with various triggers); (iv) he had a numbing of general responsiveness (with social withdrawal and refusal to speak or eat); and (v) he had symptoms of increased arousal (resulting in disturbed sleep). The differential diagnosis included depression, but this was considered less likely when many of his symptoms resolved within his short admission. He was discharged back to the detention centre after 6 days in hospital, with follow-up arranged with the centre psychologist and hospital team. The discharge summary, copied to the Centre Manager of Villawood Detention Centre, stated that he was at high risk of recurrence unless a more normal environment could be provided, that he should remain together with his family, and that access to a school with stable peer relationships would be important. In addition, it was asserted that the uncertainty about his family’s future was likely to be perpetuating his symptoms. Six days later, the boy re-presented to the hospital with refusal to eat or drink and mild dehydration. His readmission necessitated a series of complex interagency negotiations in an attempt to provide a reasonable standard of care. The negotiations involved Australasian Correctional Management (the agency managing the detention centres), Villawood Detention Centre management and health services teams, and various case managers assigned by the Department of Immigration and Multicultural and Indigenous Affairs (DIMIA), and covered coordinating parental visits and family counselling sessions, interpreters, visitors, culturally appropriate food, and possible discharge arrangements. Other difficulties included the lack of a structured daily program (as an asylum seeker, he was not eligible to attend the hospital [Department of Education] school), the social alienation of the child and family within the ward, the emotional distress experienced by the interpreters encountering the family situation, and dealing with the dilemma of whether the hospital should be acting as a place of safety for the child. Since protection from trauma was the most important part of treatment, discharge to the detention centre was likely to re-traumatise him. During the 8-week hospital stay, the boy became increasingly frustrated and difficult to contain because of his limited access to recreational, educational and other stimulating activities. He resented that detention centre officers were in close proximity at all times. His separation anxiety was fuelled by unpredictable parental visits, and the alternating arrangement of one parent staying with him. Multiple case planning meetings involving Villawood and DIMIA representatives failed to produce a resolution to the dilemma of a discharge placement for the child. The municipal office of the Department of Community Services was unable to intervene. There was no alternative except to discharge him back to the detention centre. The child now entered a phase of repeated presentations to the emergency department every few days over a period of 4 weeks, with a pattern of food refusal and dehydration. On each occasion, he required nasogastric rehydration and stayed for 1–2 days. His mother described how he would become pale, quiet and sweaty when he saw the fences that featured in his drawings. After six such presentations, he was readmitted for nutritional review as he had lost 3 kg. Two weeks later, his parents agreed to DIMIA’s offer of discharge to foster carers, and DIMIA arranged Department of Community Services approval of the nominated carer. DIMIA declared the boy’s new home and school a “place of detention”, and engaged a private psychotherapist. He was reported to have frequent emotional outbursts, disrupted sleep and difficulty coping with separations from his family after weekend access. The foster carers were ill-prepared for dealing with his distress, and the placement was continuously under threat. With no placement alternative, DIMIA granted permission for the boy to live with his mother and sister in the community. Seven months later, his father joined them when the Federal Court allowed re-application to the Refugee Review Tribunal and Temporary Protection Visas were granted. Of interest is that no new evidence was presented, compared with the family’s original application. These visas are valid for 3 years, and the future thereafter is uncertain for the family. Although an eager learner at school, the boy currently has regular nightmares and is fearful that his family may be returned to the “camp”. At the time of publication, the family are being seen by therapists at a state-funded trauma counselling service. 3: Chronology of events related to the child March 2000 Arrived in Australia (age 5 years) March 2000 – February 2001 Woomera Detention Centre. Infant sister born March – May 2001 Villawood Detention Centre May 2001 Initial hospital presentation and admission (age 6 years) May 2001 Re-presented 6 days after discharge May 2001 First letter and fax to the Minister for Immigration from treating team at Children’s Hospital at Westmead May – July 2001 8-week hospital admission June 2001 Subsequent letter to the Minister for Immigration from treating team at Children’s Hospital at Westmead July – August 2001 Six emergency department presentations August 2001 Received reply from the Minister for Immigration September 2001 2-week hospital admission September 2001 Granted Bridging Visa.* Discharged into foster care January 2002 Mother and sister granted Bridging Visas, and child returned to mother’s care in the community (aged 7 years) August 2002 Family granted Temporary Protection Visas, allowing family to live together in the community *Used to allow an applicant for a substantive visa to remain in the country out of detention while their visa application is being processed. 4: The child’s drawings were dominated by the fence “They’re crying. They’re all scared. Scared of officers — all of them” (the child’s description of the people in the foreground). “It’s a stick. They bash up children with that wood” (the child’s description of the person in the background). 5: The child’s drawing after seeing a detainee cut his wrists “The man who cut himself”

Karen J Zwi FRACP · Brenda Herzberg FRANZCP · David Dossetor FRCPsych · Jyotsna Field MPsych

Donna B Mak,* Alastair MacKendrick,† Max K Bulsara,‡ Sharon Weeks,§ Lewis Leidwinger,¶ Harvey Coates,** Francis J Lannigan,** Deborah Lehmann†† * Public Health Physician, ¶ Audiologist, Kimberley Public Health Unit, Derby, WA; † Ear, Nose and Throat Surgeon, Southern Corridor ENT Services, South Fremantle, WA; ‡ Biostatistician, Biostatistical Consulting Service, School of Population Health, University of Western Australia, Crawley, WA; § Audiologist, Disability Services Commission, West Perth, WA; ** Ear, Nose and Throat Surgeon, Department of Otorhinolaryngology – Head and Neck Surgery, Princess Margaret Hospital for Children, Subiaco, WA; †† Senior Research Fellow, Centre for Child Health Research, University of Western Australia, Telethon Institute for Child Health Research, Subiaco, WA. Correspondence: Dr Donna B Mak, 189 Royal Street, East Perth, WA 6000. makhoATbigpond.com To the Editor: Chronic suppurative otitis media is very common among Australian Aboriginal children, resulting in hearing loss and educational and social disadvantage.1 Reconstructive middle-ear surgery has been part of the accepted treatment for decades. However, there are no publications about long-term outcomes in Aboriginal populations.2 We report here the results of a study of long-term postoperative outcomes in Aboriginal children following reconstructive middle-ear surgery. We studied all Aboriginal children aged ≤ 15 years who underwent middle-ear surgery for a tympanic membrane perforation (excluding cholesteatoma) in the Kimberley region of Western Australia between 1 October 1986 and 31 December 1995. Data had been collected prospectively during a previous study, and long-term follow-up was undertaken as part of a recent study of middle-ear surgery outcomes.2,3 Ethical approval was obtained from the WA Aboriginal Health Information and Ethics Committee. The study population consisted of 93 children (57 girls, 36 boys), aged 5–15 years (mean, 10 years; median, 10 years) at the time of operation. Preoperative air–bone gap (ABG) measurements ranged from 8.75 to 58.75 dB (mean, 36.7 dB; median, 36.25 dB). The operations were performed by nine surgeons at three hospitals and included tympanoplasty using temporalis fascia (73%), dura (13%), and other graft materials (8%), and mastoidectomy (6%). Sixty-four children (69%) underwent early postoperative review (median follow-up interval, 11 months) and 73 children (78%) underwent late postoperative review (median follow-up interval, 103 months). More of the patients had a late review because, at the time, additional resources were available to actively locate the patients for follow-up. At late postoperative review, 56/93 (60%) patients had a successful outcome (intact tympanic membrane and normal hearing) and 17/93 (18%) did not (20/93 [22%] did not undergo late postoperative review). Of the 32 patients who had a successful outcome at the early postoperative review (median follow-up interval, 5 months), 26 (81%) underwent late postoperative review; 24/26 (92%) still had an intact tympanic membrane and ABG ≤ 25 dB at late postoperative review (median follow-up interval, 109 months) (Box). These findings indicate that successful tympanic membrane closure with hearing improvement after middle-ear surgery in Aboriginal children is probably longlasting. The major limitation of our study is the absence of clinical information in the time period (mean, 8 years) between the early and late postoperative reviews. An unknown (but likely to be small) number of patients may have had further operations and/or conservative management, which may have influenced their ear health status at late postoperative review. Collection of these data would have been extremely difficult given the nomadic lifestyle of many patients and the logistical realities of remote-area healthcare. Our findings support the current recommendation of the Office of Aboriginal and Torres Strait Islander Health that Aboriginal children should be offered tympanoplasty if conservative management of chronic suppurative otitis media is unsuccessful.4 Postoperative review status of 93 Aboriginal children who underwent middle-ear surgery for a tympanic membrane (TM) perforation* in the Kimberley region of Western Australia between 1 October 1986 and 31 December 1995† * Excluding cholesteatoma. † If a patient had more than one operation, the first ear operated on during this time period was included in the analysis. If a patient had operations on both ears on the same date, the ear with the largest preoperative hearing loss was included. If hearing loss was the same on both sides, the right ear was chosen.

Donna B Mak · Alastair MacKendrick · Max K Bulsara · Sharon Weeks · Lewis Leidwinger · Harvey Coates · Francis J Lannigan · Deborah Lehmann

Rosie G Scott,* John T Edwards,† Richard M Mendelson,‡ Geoffrey M Forbes§ * Research Fellow, ‡ Radiologist, Department of Diagnostic and Interventional Radiology; † Gastroenterologist, § Gastroenterologist (corresponding author), Department of Gastroenterology and Hepatology; Royal Perth Hospital, PO Box X2213 GPO, Perth, WA 6000 geoff.forbesAThealth.wa.gov.au To the Editor: The burden of colorectal cancer can be minimised, firstly, by early and appropriate investigation of symptoms; secondly, by screening those at higher-than-average risk without symptoms; and thirdly, by community-based screening of asymptomatic people aged over 50 years who are at average risk. Major screening programs using faecal-occult-blood testing (FOBT)1-3 or flexible sigmoidoscopy4 have not necessarily made this differentiation. These tests lack the sensitivity of colonoscopy, which is generally indicated for those with symptoms or a strong family history of colorectal cancer. In our recent community-based screening program in which we used virtual colonoscopy, we excluded those at higher than average risk for colon cancer (that is, they were symptomatic or had at least one first-degree relative with colon cancer), as our standard of care for these patients is colonoscopy. They were given verbal and written advice to see their general practitioner, with the expectation that most should have colonoscopy. They were followed up an average of 12 months (range, 6–15 months) later, by letter and telephone, to determine the outcome of this advice. Of 2000 participants aged 50–69 years who were offered screening, 90 (4.5%) described having symptoms or a first-degree relative with bowel cancer, but had not undergone investigation. Follow-up information obtained from 71 of these people indicated that 21 had a relevant family history and 50 described recent bowel symptoms. Only 35 (49%) had discussed further investigations with their GPs — 19 (27%) had undergone colonoscopy, and five of these (26%) had advanced colorectal neoplasia (CRN). One had tubular adenoma (> 1 cm), one showed villous architecture, one had intramucosal carcinoma, and two had cancer. Four other participants had had negative results on other investigations. These were FOBT alone in three (two symptomatic, one with family history) and barium enema in one who had bleeding. Common reasons for not consulting their GPs were because of good health (15 participants), resolution of symptoms (12), and perceived lack of need for tests (10). These data have important implications for CRN screening programs, including recently commenced Australian pilot programs (www.cancerscreening.gov.au). Firstly, there is likely to be an improved yield of advanced CRN when a previously uninvestigated high-risk group is identified within a screening program. Secondly, people identified as having higher-than-average risk for CRN need special attention to ensure there is adherence to advice on appropriate follow-up. Thirdly, procedures are required to ensure colonoscopy is appropriately undertaken when participants do consult their GPs. Accordingly, rather than adopting an exclusion policy within a screening program based on FOBT or flexible sigmoidoscopy, we believe it is appropriate that people at greater risk for CRN are identified and offered colonoscopy within that program.

Rosie G Scott · John T Edwards · Richard M Mendelson · Geoffrey M Forbes

Gavin Turrell,* Brian F Oldenburg,† Elizabeth Harris,‡ Damien J Jolley,§ Merel L Kimman¶ * Senior Research Fellow, † Head of School, ¶ Student, School of Public Health, Queensland University of Technology, Victoria Park Road, Kelvin Grove, QLD 4059; ‡ Director, South West Sydney Area Health Service, Centre for Health Equity Research, Training and Evaluation, Liverpool, NSW; § Director, School of Health Sciences, Biostatistics and Epidemiology Unit, Deakin University, Burwood, VIC. g.turrellATqut.edu.au To the Editor: Studies investigating the relationship between socioeconomic status (SES) and use of healthcare services suggest that, in metropolitan regions, low-SES groups consult general practitioners more frequently than high-SES groups.1 The primary reason is their poorer health and hence greater medical need (however, distributional, operational and financial factors associated with the provision of general practice services are also important). Is a similar relationship found between SES and GP use in non-metropolitan areas? We investigated this issue using data from the Social health atlas of Australia project.2 We defined “GP use” as unreferred services3 provided by general and vocationally registered practitioners (not specialist medical practitioners), delivered at a surgery or clinic, a patient’s home, or an institution such as a hostel or nursing home. Specifically, 952 statistical local areas (SLAs), comprising 98.6% of all SLAs for the six Australian states, were classified into four geographic remoteness categories (see Box) using the Accessibility/Remoteness Index of Australia (ARIA).4 Within each ARIA category, we grouped SLAs into tertiles of socioeconomic disadvantage based on their Australian Bureau of Statistics’ Socio-Economic Indexes for Areas (SEIFA) score. We then compared the average rates of GP use between tertiles for the 2-year period 1996–1997. Our analysis included a measure of the number of full-time equivalent (FTE) GPs per 10 000 population in each SLA as a test of equity: similar or higher rates of GP use in disadvantaged SLAs independent of GP availability suggest equity of access. In areas classified as “highly accessible”, rates of GP use were significantly (10%) higher in disadvantaged SLAs after adjusting for GP availability (Box). The reverse was found in “remote/very remote” areas, where rates of GP use were about 36% lower in disadvantaged SLAs. Also, the strength of the relationship between GP availability and GP use differed across the ARIA categories. In “highly accessible” areas, a unit increase in the number of FTE GPs per 10 000 population was associated with a 1% increase in GP use, whereas in “remote/very remote” areas it was associated with a 15% increase (data not shown). This suggests that disadvantaged groups in rural and remote areas experience disproportionate difficulty accessing GP services. These areas are underserved by GPs, who charge more for their services and are less likely to bulk-bill.5 It seems that in metropolitan regions the Medicare principle of equity of access to GP services is being realised (ie, people with higher levels of morbidity are making greater use of GP services), whereas in remote and very remote areas this is not the case. The findings might also reflect the fact that disadvantaged groups (especially in rural and remote areas) make greater use of emergency departments of local hospitals or other community-based or primary care outreach services — these services are not covered by Medicare and, therefore, are not taken into account in the rates of GP use presented here. Association between socioeconomic disadvantage and use of general practitioners within ARIA* categories† * ARIA (Accessibility/Remoteness Index of Australia) categories:4 Highly accessible: areas with relatively unrestricted access to a wide range of goods and services and opportunities for social interaction. Accessible: areas with some restrictions to accessibility of some goods, services and opportunities for social interaction. Moderately accessible: areas with significantly restricted accessibility of goods, services and opportunities for social interaction. Remote/very remote: areas with very restricted or very little accessibility of goods, services and opportunities for social interaction. † Relationship between area disadvantage and GP use is adjusted for number of full-time equivalent GPs per 10 000 population. ‡ Each tertile comprises approximately a third of the statistical local areas (SLAs) in the six Australian states. The high and low tertiles comprise the 33% least and most socioeconomically disadvantaged SLAs, respectively.

Gavin Turrell · Brian F Oldenburg · Elizabeth Harris · Damien J Jolley · Merel L Kimman

Lynne Hillier,* Richard De Visser,† Anne M Kavanagh,‡ Ruth P McNair§ *,† Research Fellows, ‡ Senior Research Fellow, Australian Research Centre in Sex Health and Society, La Trobe University, Level 1, 215 Franklin Street, Melbourne, VIC 3000; § Senior Lecturer, Department of General Practice, Melbourne University, Carlton, VIC. l.hillierATlatrobe.edu.au To the Editor: Studies of non-representative population samples show that recreational drug use is more prevalent among non-heterosexual women than heterosexual women.1 The Australian Longitudinal Study of Women’s Health2 allowed an examination of the links between sexuality and recreational drug use in a representative sample of 9260 women aged 22–27 years in 2000. Respondents reported their history of tobacco, alcohol and illicit drug use. Reported frequency and volume of alcohol consumption were recorded according to National Health and Medical Research Council guidelines.3 Use of illicit drugs in the last year was dichotomised between marijuana and other illicit drugs (see Box). Respondents also indicated whether they had ever injected illicit drugs. Analyses compared exclusively heterosexual women with all other women. Data were weighted to correct for over-sampling in non-metropolitan areas. Odds ratios were adjusted for age, region of residence, and father’s occupation (as a measure of social class). Younger women were significantly more likely to report risky drinking and illicit drug use. Women from urban areas were significantly more likely to be non-heterosexual and to use illicit drugs, but less likely to report risky levels of alcohol consumption. Women whose fathers were professionals or managers were significantly more likely to be non-heterosexual and more likely to use illicit drugs, but less likely to smoke or report risky drinking. Details are available from the authors. Non-heterosexual women were significantly more likely than heterosexual women to have ever smoked, to be current smokers, to report risky levels of alcohol consumption, to have used marijuana and other illicit drugs in the last year, and to have ever injected drugs (Box). Although these relative differences are important, so too are the absolute values — 45.6% of non-heterosexual women were smokers, and 45.6% reported alcohol consumption of concern. In the last year, 58.2% used marijuana and 40.7% used other illicit drugs. One in 10 had ever injected illicit drugs. Although women are generally less likely than men to use drugs, and may not be a high-priority target for drug education, non-heterosexual young women’s rates of illicit drug use are at least as high as those of young men.4 Higher levels of drug use among young non-heterosexual women may be the result of individual experiences of homophobic discrimination, where drugs are used as an — albeit, short lived — panacea.1 Greater drug use may also be the result of normalisation of recreational drug use within lesbian communities.5 There is a need for specific interventions in young non-heterosexual women, and for further research to determine the reasons for their high levels of recreational drug use. Frequencies and adjusted odds ratios for drug use among 9260 heterosexual and non-heterosexual Australian women aged 22–27 years, 2000 Drug use Exclusively heterosexual Bisexual and lesbian Adjusted odds ratio* (95% CI) Smoking status (n = 8284) (n = 755) Never smoked 60.8% 37.0% 1.00 Former smoker 14.2% 17.4% 2.15 (1.65–2.79) Current smoker 25.0% 45.6% 3.18 (2.61–3.89) Alcohol consumption† (n = 8419) (n = 796) No risk 36.7% 23.9% 1.00 Low risk (no bingeing) 31.5% 30.6% 1.33 (1.05–1.69) Low risk (with bingeing) 27.9% 38.6% 2.01 (1.60–2.52) Risky 3.9% 7.0% 2.50 (1.68–3.72) Illicit drugs (n = 8409) (n = 797) Marijuana (in the last year) 21.5% 58.2% 4.68 (3.91–5.61) Other illicit drugs‡ (in the last year) 10.2% 40.7% 5.50 (4.51–6.71) Injected drugs (ever) 1.2% 10.8% 12.26 (8.53–17.63) * Adjusted for age, region of residence, and father’s occupation. † According to National Health and Medical Research Council guidelines.3 ‡ Amphetamines, LSD (d-lysergic acid diethylamide), ecstasy/designer drugs, tranquillisers, natural hallucinogens, cocaine, inhalants, heroin, barbiturates.

Lynne Hillier · Richard De Visser · Anne M Kavanagh · Ruth P McNair

Andrew B Black,* Sam F Berkovic† * Neurologist, The Queen Elizabeth Hospital, Woodville, SA; and Chair, Driving Committee, Epilepsy Society of Australia. † Neurologist, Austin and Repatriation Medical Centre, West Heidelberg, VIC; and President, Epilepsy Society of Australia. Correspondence: Dr A B Black, Ashford Specialist Centre, 57–59 Anzac Highway, Ashford, SA 5035. abblackATchariot.net.au To the Editor: Seizure disorders are often the most scrutinised medical conditions in relation to road accidents.1 Epileptologists internationally have reached some consensus on the role best played by treating doctors: ensuring patients receive proper medical care; advising on assessed risk and its minimisation; and reporting (if necessary, without patient consent) when a patient becomes a risk yet continues to drive.2 In a recent editorial on sleep disorders and driving,3 McEvoy also emphasises the essential role of first establishing the therapeutic relationship, and refers to the impending release by the National Road Transport Commission of new medical standards for all vehicle types.4 Australian neurologists and the Epilepsy Society of Australia find that the new guidelines are imprecise in defining the role played by doctors and Driver Licensing Authorities (DLAs), and are excessively detailed with cumbersome processes that are open to confusion. The instructions for using four separate forms (3.3) are complex and imprecise, giving no indication about discretion in their use or non-use. Moreover, it is not the role of doctors to define specific restrictions for holders of conditional licences (3.3.1), but that of the DLA. Demands on doctors for surveillance and enforcement are excessive, and by interfering with the maintenance of proper rapport may prove counter-productive. The roles for consultants are not clearly defined. A more desirable model is one in which the DLA takes responsibility for all legally enforceable decisions and does not expect treating doctors to decide on fitness-to-drive. A treating doctor may provide factual information, but is not expected to give an opinion on licensing questions. This model, used in the United Kingdom,5 is simple, well understood and respected. The DLA there obtains independent medical advice in deciding borderline cases, an optional mechanism given little attention in the Australian review. Doctors in the UK are well aware of their common law duty to report patients if their actions are endangering. We are drifting away from this simpler and ethically and medicolegally more satisfactory model at our peril. We should re-engage our DLA colleagues to establish a more effective relationship, in which they ensure their licence holders are well informed of their obligations, while we provide the expert care and management of our patients which will best encourage a safer driving environment.

Andrew B Black · Sam F Berkovic

Keith V Woollard Cardiologist, 34 Murdoch Drive, Murdoch, WA 6015. KeithWoollardATwacardiology.com.au To the Editor: The recent review of digoxin by Campbell and MacDonald1 pointed out that a serum digoxin level of over 1.0 ng/mL is associated with excess mortality. Indeed, higher blood levels (≥ 1.2 ng/mL) are associated with higher crude rates for all-cause hospitalisation, and for increased hospitalisation for worsening heart failure or suspected digoxin toxicity.2 The post hoc analysis of the DIG trial2 suggests that the optimal range is 0.5–0.8 ng/mL. I recently surveyed 31 private pathology laboratories across Australia to determine their recommendations about the therapeutic range of serum levels of digoxin. In summary, their recommendations ranged from a lower limit between 0.5 ng/mL and 1.0 ng/mL, and an upper limit between 1.6 ng/mL and 2.1 ng/mL. Twenty-six of the 31 suggested that values below 0.8 ng/mL were subtherapeutic. It is likely that many doctors will heed such advice and inappropriately increase the dose of digoxin in patients being treated for heart failure. It is possible that adverse effects will flow from current laboratory industry recommendations, and these should be revised.

Keith V Woollard

Francis Gerald Tighe, a dedicated suburban family physician, died suddenly from a coronary occlusion on 5 December 2002. He was a wonderful human being and had a profound influence on all who had the privilege to know him. Frank was born in Oakleigh, Victoria, on 18 April 1936, and was educated at local Catholic schools. He had already completed a degree in Agricultural Science at the University of Melbourne, and was well into research for his Masters degree, when he was accepted into the medical faculty in 1960. His Masters thesis on myxomatosis was never finished as he became immersed in the intricacies of human diseases, general practice and then family life. Frank won the Ryan Prize for surgery in his final year as a medical student. He did his residency at St Vincent’s Hospital, Melbourne, in 1965 and served with the Royal Australian Air Force from 1966 to 1970. After a flirtation with ophthalmology at the Royal Victorian Eye and Ear Hospital, Frank decided to make a career of general practice and joined the Valewood Clinic in Mulgrave, Victoria. He obtained a Diploma in Obstetrics from the Royal College of Obstetricians and Gynaecologists (1971) and a Fellowship of the Royal Australian College of General Practitioners (1975). Frank remained in the same practice until his death. He had always been a compassionate and caring person, and the overflowing church at his funeral was testimony to the high regard in which he was held by all. Frank retained his interest in agriculture and owned a succession of small properties, but never got around to buying the trotter that had been his ambition in student days. He loved gardening and, at the time of his death, was preparing to retire to his holiday cottage at McCray. The qualities that made Frank so special were his confidence and maturity, his compassion and strong sense of justice, and his outstanding abilities as a teacher, communicator and leader. He had a remarkable talent for being able to break down complex topics into fundamentals that could be easily understood by others. His warmth, friendliness and air of gentle authority earned him tremendous popularity and respect from both colleagues and patients. He is survived by his wife Daphne and children Francine and Lucas.

Richard C Shiell

Virtue ethics and professional roles. Justin Oakley, Dean Cocking. Melbourne: Cambridge University Press, 2002 (xii + 188 pp). ISBN 0 521 79305 X. Authors Oakley and Cocking have spent the past ten years reflecting on which moral theory enables professionals to pursue their work ethically. In this book they offer an incisive argument for selecting virtue ethics over two commonly applied rivals — utilitarianism and Kantianism. The authors believe that this virtue-based model has the advantage of being both theoretical and practical. The novice moral philosopher is given a brief guide to the origins and variants of virtue ethics. We are introduced to the Aristotelian view that a specific set of character traits is needed in order to live a "flourishing life". We are also told that to live the good life we need to acquire phronesis — practical wisdom. The authors then add their own concept of the "regulative ideal" to the Aristotelian argument. People are guided by a "regulative ideal" when they have "internalised a certain conception of correctness or excellence in such a way that they are able to adjust their motivation and conduct so that it conforms — or at least does not conflict — with that standard". The idea is aligned to Aristotle's practical wisdom in that it encompasses an appreciation of what constitutes the general good. The book describes how virtue ethics and the "regulative ideal" apply to medical practice and links the concept of a "flourishing life" to the goals of the medical profession. Consideration is given to what constitutes desirable virtues in a doctor and what character traits enable them to achieve the goal of enhancing health and corresponding human "flourishing". The authors settle on a familiar catalogue of virtues: a deep capacity for compassion, truthfulness, trustworthiness, courage, humility and a consistent inclination to act justly. Does the book convince the reader of the benefits of virtue ethics for the professions? Many would support the view that inculcating and promoting certain character traits in doctors would enable them to make a more positive contribution to their patients and patients’ families — but is this a sufficient basis for good practice? Does virtue ethics provide the means to disentangle the myriad moral dilemmas that doctors encounter in their day-to-day practice? Does virtue-based ethics sort out complex issues like euthanasia, abortion, gene therapy, involuntary hospitalisation, respecting confidences, allocating resources, and many other quandaries? All theories have their limitations. Ultimately, we may find common ground between various theories and achieve an integrative view where their advantages are harnessed. Sidney BlochProfessor of Psychiatry University of Melbourne, VIC

Sidney Bloch

Work and mental health: an employer’s guide. Doreen M Miller, Maurice Lipsedge, Paul Litchfield (editors). London: Royal College of Psychiatrists, 2002 (176 pp). ISBN 1 901242 85 4. This useful book is a joint effort by the Royal College of Psychiatrists and the Faculty of Occupational Medicine, Royal College of Physicians to give practical advice on mental illness in the workplace. Contrary to the subtitle, however, it will be of more use to doctors than employers because of its clinical focus. Most chapters are written jointly by a psychiatrist and an occupational physician, which helps to maximise relevance to the workplace. There are a few chapters written by others such as a human resource manager and an organisational psychologist. The book falls roughly into two sections; one dealing with specific psychiatric conditions and the other with workplace stress. The former begins with a superb chapter “Assessing mental health problems in the workplace”. There are also chapters on anxiety, depression, substance abuse, critical incidents, chronic fatigue syndrome, schizophrenia and organic states. These combine a good resume of salient clinical points with a discussion of the issues in managing the employability of the patient. The high quality information on these difficult topics will be appreciated by many clinicians. On the other hand, the chapters dealing with workplace stress are disappointing and emphasise how little progress has been made in this area over many decades. Several case studies of stress programs in various organisations are presented, including pharmaceutical, electricity and telecommunications companies. Each is claimed to have been beneficial. However, there is a distinct lack of candour in the presentations, which lessens their credibility. It is highly unlikely that so many programs were successful without some setbacks, but none are reported. Also, there is no substantial statistical data presented to support the claims of benefit even though it is stated that surveys of “staff opinion” (or similar stress indices) were done periodically. The main advance appears to arise from major legal decisions under disability discrimination law which require employers to make reasonable adjustment for the employment of those affected by work stress or other mental illness. The book is a timely summary of mental illness in the workplace, showing both the strengths and weaknesses of current practice. It will be of much interest to those who provide medical care to workers and workplaces. Bruce HockingOccupational Physician Camberwell, VIC

Bruce Hocking

At risk of miscarriage Taking NSAIDS, including aspirin, may increase the risk of miscarriage, according to a prospective cohort study conducted in California. Over 1000 women in early pregnancy were interviewed about their use of NSAIDs, aspirin and paracetamol; later on, their pregnancy outcome at 20 weeks' gestation was sought. The use of NSAIDs during pregnancy was found to increase the risk of miscarriage, especially in two circumstances. One: if taken around conception, consistent with a hypothesis that prostaglandin inhibition by NSAIDs interferes with implantation. Two: if used for longer than one week, which indicated a dose-response relationship. Taking paracetamol was not found to increase the risk of miscarriage. BMJ 2003; 327: 368-371 Pools as a health tool Australian researchers have reported that swimming pools in remote communities can have health as well as social benefits. Government-funded salt-water pools in two outback communities in Western Australia have led to at least a short-term drop in the prevalence of both pyoderma (known locally as "skin sores") and tympanic membrane perforations. School attendance also improved in one of the communities — thought to be a result of a "no school, no pool" policy. Fingers crossed, these gains will persist past the pools' early years. BMJ 2003; 327: 415-419 Surgical mules Body packing — the practice by which international drug smugglers use human beings to hide cargo in their bodies — is no longer confined to adults alone. Two cases of paediatric body packing occurring in boys, aged 12 and 16 years old, have been reported in the USA. One of the boys was found unresponsive on a city street a day after arriving from Europe; the other presented to hospital with rectal bleeding. Both recovered after medical management and passing over 50 packets of heroin each. Arch Pediatr Adolesc Med 2003; 157: 174-177 Virus via venison Hepatitis virus E (HEV) is a zoonotic infection, directly transmitted from animals to humans, according to a Lancet research letter. Japanese authors reported a case series of four people from two families who became infected with HEV by eating the raw meat — prepared sushi style — of a wild-caught Japanese deer (Sika deer). These patients' serum samples were positive for HEV RNA and for IgM and IgG antibodies to HEV. The HEV RNA nucleotide sequence in the meat of the infected deer was identical to that found in most of the patients' serum samples. Direct HEV transmission from animals to humans had been previously suspected but not proven, especially in non-endemic areas. Lancet 2003; 362: 371-373 Flight class-conscious? Although now a part of popular mythology, there is no evidence that the economy class syndrome exists, say BEST study researchers. Their prospective study — the Business class versus Economy class Syndrome as a cause of Thrombosis study — was designed to compare the incidence of venous thromboembolism in first and business class passengers with that in economy class passengers. They recruited 899 passengers, at low or intermediate risk of developing a deep vein thrombosis (DVT), who were boarding long haul flights from London to Johannesburg — study subjects were awarded 5 000 frequent flyer points for their participation. Over 8% of the passengers had elevated D-dimer levels on arrival but this did not lead to DVT and was unrelated to flight class. None of the 434 study subjects who agreed to go on to venous duplex scanning of the lower limbs had ultrasonic evidence of a DVT. The researchers said that raised D-dimer levels may have been the result of immobility rather than a cramped body position in-flight, as only 6% of passengers reported exercising during the flight. S Afr Med J 2003; 93: 522-528 Marketing mayhem Researchers from The Johns Hopkins University School of Medicine, Baltimore, USA, have called for substantial reform in the regulation of Internet advertising for the dietary supplement ephedra. They reviewed 32 web sites that marketed weight-loss supplements containing ephedra, and systematically identified deviance from truth-in-advertising standards. Many of the sites failed to disclose potential adverse effects or contraindications; about a third of the sites also contained incorrect or misleading statements, some of which could lead to serious harm to consumers. Mayo Clin Proc 2003; 78: 944-946 — Dr Ann Gregory, MJA

Med J Aust 2003; 179 (6 Suppl).