Volume 181 Issue 1

On July 4, exactly 90 years ago, The Medical Journal of Australia began its life “as the official organ of the British Medical Association in Australia”. Its purpose was clear — “to record the progress of scientific medicine, and to assist in rendering the practice of medicine in all its branches of the greatest benefit to the people of Australia”.1 In that first issue, the president of the Victorian branch of the British Medical Association warmly welcomed the Journal, noting that it symbolised “the intimate union of all the branches of the British Medical Association in Australia”, and that it would “continue every week to indicate and advocate the common aims, interests, and ideals of the profession”. He closed by wishing that the Journal prospere, procede et regna2 — “proceed prosperously and reign”! This bridging between the readers and the profession is the stuff of the Journal. The following 90 years have seen the formation of the Australian Medical Association in 1962,3 and, with the advent of the AMA Gazette in 1968, the disappearance of Federal and Branch news in the Journal. In the late 1980s, after nearly 60 years of living the Australian dream of being an owner/occupier, the Journal’s publisher — the Australasian Medical Publishing Company (AMPCo) — sold its Sydney premises to finance the AMA’s move to Canberra. This was the culmination of the Journal’s Sturm und Drang decade, with the destabilising turnover of editors — six in all — and tensions caused by AMPCo’s financial difficulties. However, after 90 years, the Journal’s purpose remains clear — to “be the recognised forum for information and commentary on all aspects of health care in Australia” through “original peer-reviewed clinical research of the highest standard”, “high level continuing medical education”, and “commentary and informed debate on standards of clinical practice, ethics, social, legal and other issues related to health care in Australia”.4 In this 90th anniversary issue, Gregory (page 9) surveys the “clinical research of the highest standard” published by the Journal during this time.5 Its ongoing commitment to “commentary and informed debate on standards of clinical practice” is exemplified by the Quality in Australian Health Care Study6 and the study of adverse events in Australian general practice,7 both of which played a part in the lead-up to establishing the Australian Council for Safety and Quality in Health Care. The Journal’s role as a forum for “ethics, social, legal and other issues” is reflected in our reports on end-of-life decisions,8,9 the health of asylum seekers in detention,10,11 and in our commitment to Indigenous health.12 Finally, pragmatic links to the world of medical research and to specialist and general practice were pursued through networking and the Journal’s Content Review Committee. A cursory review of the Journal’s progress over the past 90 years will readily identify broad changes which have come to pass. There has been a noticeable decline in the number of clinical studies, case reports and the more leisurely reviews, with a concomitant increase in studies of healthcare interventions and health system performance, as well as those on adverse lifestyles, substance misuse, mental illness and, more recently, consumer concerns. With the rise of evidence-based medicine came a barrage of evidence-based guidelines and further delineation of levels of evidence. The design and reporting of research itself adopted more rigorous formats, such as controlled trials, systematic reviews and structured abstracts. Significantly, the number of authors per article continues to multiply,13 and the international trend now is for authorship to involve a team of doctors, other healthcare professionals and scientists. Correspondingly, the number of Journal editors has also increased as the number of submissions continues to rise.13 In 2003 we received a record 917 submissions, compared with 856 in 2001 and 741 in 1999. On the downside, the blurring of the boundaries between commerce and research has spawned a culture of suspicion, particularly for research supported by pharmaceutical companies.14 It is interesting to note that all Journal articles are now accompanied by an item noticeably absent a decade ago — the competing interests statement. The Journal’s policy of safeguarding the integrity of research by exploring potential conflicts of interest of contributors and reviewers is detailed by Chew.15 What does the future hold? Just as Gutenberg’s printing press saw the demise of the monastic monopoly of manuscript production, electronic technology has changed both the essence of publishing itself, and ease of access to the latest research. The Medical Journal of Australia, like most other medical journals, simultaneously releases the electronic (eMJA) with the print Journal, and uses rapid online publication for selected articles. Future electronic developments are also anticipated. There are those who promote the notion that peer review and editing are things of the past.16 They believe science should simply be posted on the Internet, thus letting the world judge its quality. However, an editor’s first responsibility is to the readers, and they have signalled that they are too busy to separate the wheat from the chaff.17 They prefer that to be the function of quality filters — the editors, peer reviewers and editorial staff who ensure the clarity, brevity and non-exclusive language of the final product. This bridging between the readers and the profession is the stuff of the Journal. Despite enthusiastic predictions of its demise,18 the printed Journal will live on for some time. There is something reassuring about knowing where a journal’s contents will be revealed, its portability from bed to breakfast table, and the feel of something physical, that binds readers to the paper Journal.19 In any event, whatever changes the future may bring, as long as the Journal continues to add value to its core content of original articles, editorials, reviews and informed debate on contemporaneous healthcare issues in Australia, The Medical Journal of Australia will most certainly prospere, procede et regna.

Martin B Van Der Weyden MD, FRACP, FRCPA

“If in doubt, disclose” — Committee on Publication Ethics1 Under full glare of the media spotlight in February this year, the editor of The Lancet, Richard Horton, partially retracted an article published 6 years before.2,3 This act was triggered by allegations of research misconduct in the study, taken to The Lancet by a Sunday Times journalist.4 The Lancet’s investigations5 and the events that ensued involved the article’s authors (doctors at London’s Royal Free and University College Medical School), the institution’s ethics committee, the General Medical Council, the British Parliament, and even the Prime Minister, Tony Blair. Why the fuss? In 1998, this research report implied a link between autism, bowel disease and the combined measles– mumps–rubella (MMR) vaccine.3 A storm of controversy erupted, and MMR vaccination rates in England fell from 92% of children reaching the age of two in 1996/97 to 82% in 2002/03.6 Confirmed cases of measles rose from 112 in 1996 to 442 in 2003. When the allegations of misconduct were probed this year, it was found that, at the time the article was submitted and published, its lead author and senior investigator, Dr Andrew Wakefield, had not disclosed that he had been commissioned by the Legal Aid Board (for the sum of £55,000) to determine if there was evidence to support legal action by parents of children allegedly harmed by the MMR vaccine. Some of these children were also in Wakefield’s Lancet study. This led to a partial retraction of the article by 10 of its original 13 authors, but not by Wakefield.7 Richard Horton remarked, “If we had known the conflict of interest Dr Wakefield had in this work I think that would have strongly affected the peer reviewers about [its] credibility . . . in my judgement, it would have been rejected”.2 The Medical Journal of Australia has not had such sensational experiences (yet!). Conflict of interest in publication was first raised in a position statement by the International Committee of Medical Journal Editors, published in 1993.8 Our first conflict of interest statement appeared in the late 1990s, but declaring conflict of interest was deemed by many then to be optional — an exercise in political correctness. So, except in extreme situations, does conflict of interest really matter? Unfortunately it does. It is a principle long enshrined in the conduct of scientific research.9 Moreover, we can no longer ignore the growing body of evidence that conflict of interest can bias research outcomes. Systematic reviews have shown that results of sponsored studies are more likely to favour the sponsor when it is a pharmaceutical company,10 and industry-sponsored studies are not only associated with pro-industry conclusions, but with restrictions on publication and data sharing.11 As more research is funded by non-academic sources, we cannot ignore the potential for bias to affect its outcomes.12 Neither can we ignore an increasingly educated, involved 21st-century Western society that is calling for greater accountability in health research. What conflict of interest is notConflict of interest is not always present, and may be potential rather than actual. Such dual interests are better termed “competing” rather than “conflicting” interests (eg, commitment to a patient’s welfare and to a research project). Having a conflict of interest is, in itself, not wrong, and may be unavoidable. Disclosing competing interests should not be seen as an admission of wrongdoing, but as promoting transparency in the public record. What conflict of interest is“Financial or personal relationships that inappropriately influence (bias) . . . actions [of an author (or the author’s institution), reviewer, or editor] . . . The potential for conflict of interest can exist whether or not an individual believes that the relationship affects his or her scientific judgment”.13 Anything, be it personal, financial, academic, religious, or political, “which, when revealed later, would make a reasonable reader feel misled or deceived”.1 Current MJA policyAuthorsAll authors are required to provide a disclosure statement (Box). Funding sources are to be acknowledged, together with any role they played in study design, data collection, data analysis, interpretation of the data, their reporting and publication. A study may not be published if its sponsor asserts the right to control publication.13 We publish competing interests statements for all research, viewpoint and review articles, and, where such interests are declared to exist, for editorials and letters to the Editor. ReviewersPeer review is a useful but imperfect tool that we can refine by seeking to clarify potential biases: We do not ask those from the same institution(s) as the author(s) to review an article. We now ask all reviewers to provide a disclosure statement similar to the one authors provide (Box). Reviewers who disclose competing interests are not necessarily disqualified. Their reviews will be carefully considered by the editors, bearing their potential biases in mind, and in conjunction with comments from other reviewers. EditorsEditors commission articles, assess submitted articles, and ultimately decide their fate. Thus, MJA editors with competing interests relating to an article will exclude themselves from taking primary responsibility for it. ConclusionOur aim is not to exclude anyone with a potential conflict of interest from publishing or reviewing — to do so would disqualify virtually everyone (including editors). Conflicts of interest may occasionally be too extreme to allow publication of the article or involvement of someone in the decision-making process. However, our ultimate goal in advocating disclosure is to promote transparency, reduce bias, and maintain public trust in what we publish. Let the reader to be the judge! MJA disclosure statement for authors and reviewers (A) Authors are asked to indicate Yes or No to questions about affiliations with manufacturers of products mentioned in the article or of competing products: Ownership of stock or stock options or other financial instruments of companies whose products are mentioned in the article or who manufacture competing products (does not include mutual fund ownership) Ongoing paid consultancy with company or a competitor (actual or within the last 2 years) Employment with company or competitor (actual or within the last 2 years) Honorarium or other compensation for writing the article or for participating in the development of the article Honorarium or other compensation for conducting research related to material contained in the article Speaker fees and/or educational grants Travel assistance to attend meetings. (B) Authors are asked to provide details where the answer to any of the above questions is “yes”. (C) Authors are asked to declare any other (non-financial) competing interests.

Mabel Chew MB BS(Hons), FRACGP, FAChPM

1914 2004 1956 1978 1982 1989 1993 For more covers, see the pdf version of this article. As the eyes are said to be the window to a person’s soul, so is a journal’s cover a window into the ethos of its editors and readers. Over the past 90 years, the cover of The Medical Journal of Australia has changed many times, reflecting the national and international events of the times, the perceived desires of its readers and, occasionally, the whims of its editors. The Journal’s first issue was published on 4 July 1914. The MJA arose from the amalgamation of the Australasian Medical Gazette (published by the NSW Branch of the British Medical Association since 1881) and the Australian Medical Journal (published by the Victorian Branch of the BMA since 1856). This union was not without some opposition, but there was a clear need for a national journal that would unite the six Australian branches of the BMA and reach the whole medical profession in Australia. The cover changed little in the first 40 or so years, featuring only the title, issue details and a large monochrome advertisement. This was a time of war (World War I, with Britain declaring war against Germany exactly a month after the first issue of the fledgling journal appeared), financial difficulties as the cost of paper and printing suddenly rose, the Great Depression, another war (World War II, when many of the Journal’s contributors were in the armed forces), and editors in for the long haul (Henry William Armit [featured on this issue’s cover] served 16 years [1914–1930], Mervyn Archdall served 27 years [1930–1957], and Ron Winton, whose obituary is published on page 26 of this issue, served 20 years [1957–1977]). In the post-war years, medicine experienced a technological explosion and the Journal took on a more modern layout with a bright blue cover, better-quality paper and some colour printing. The MJA’s content adopted a more global perspective, reflecting Editor Ron Winton’s Chairmanship of the Council of the World Medical Association for many years. The MJA also officially became the journal of the Australian Medical Association when the shackles of the BMA were cast off in 1962 and the Association became fully independent. At this time, the number of specialist journals increased greatly, with some fragmentation of the readership of the MJA. Winton countered this with an editorial policy of a mix in each issue to appeal to both generalists and specialists, a policy which continues today in recognition that our readership is almost equally divided between specialists and general practitioners. After Ron Winton, the Journal went through a turbulent time, with six editors in 10 years. These were also lean years, when the Journal changed from a weekly to a fortnightly publication (1978), and The Printing House in Glebe, Sydney, closed (after publishing and printing the Journal completely “in-house” for more than 60 years). During the late ’70s and early ’80s, the covers changed almost as often as the editors. Of particular note were Alan Blum (1982–1983), who came to the Journal from the United States and was responsible for some of its most controversial covers on topics such as smoking, nuclear war and AIDS, and Alistair Brass (1983–1985), described as a liberal thinker and an outspoken critic, who put Australian artworks on the cover. The Journal subsequently returned to its more conservative roots in the late ’80s under Kathleen King with, for the first time, the full contents displayed on a bright green cover. This was initially a space-saving device, but it proved popular with readers. In the early ’90s, joint editors Laurel Thomas and Jill Forrest continued to appease the scientific purists with the full contents on the cover, but softened it with a picture and a less stark grey–blue background. Martin Van Der Weyden took the helm in 1995 and the cover slowly evolved, with only minor changes in colour and typeface. With this issue, however, we present a major overhaul. We’ve aimed for cleaner lines, a less cluttered look and a Journal that’s generally easier on the eye. Our ideas are perhaps most succinctly stated by Joseph Pulitzer: “Put it before them briefly so they will read it, clearly so they will appreciate it, picturesquely so they will remember it and, above all, accurately so they will be guided by its light.” We hope you approve.

Bronwyn Gaut

According to data from the Institute for Scientific Information (ISI), the most-cited MJA article is Cade’s ground-breaking report on the effect of lithium in mania (1949; 888 citations), followed by Marshall et al’s reports on the role of Helicobacter pylori in gastroduodenal disease (1985; 766 and 523 citations, respectively). Others in the “top 10” span decades and disciplines; all have a common grounding in Australian data of global relevance. For the year 1995, shortly after the 80th anniversary of The Medical Journal of Australia (MJA), researchers from the Australian National University used citation analysis to determine Australia’s contribution to new knowledge in medical and health sciences. They found that Australians contributed 2.5% of all publications in the Science Citation Index — 18 390 publications, which had been cited over 88 000 times.1,2 In 2003, the MJA used citation data provided by Thomson ISI (www.isinet.com) to identify the “top 10” articles published in the MJA — that is, the articles which had been cited most often. Data comprised citations within journal articles covered by the database of the Institute for Scientific Information (ISI) for the years 1945–2002; thus, articles published before 1945 could be cited. The MJA top 10 articles span more than 60 years (Box 1). They have in common a grounding in Australian data, but a global relevance. In addition, all provide evidence of the importance of basic as well as clinical research, and of that endangered species the physician–scientist. 1 The MJA’s top 10 articles, by citation analysis Number 1 (888 citations) Cade JFJ. Lithium salts in the treatment of psychotic excitement. Med J Aust 1949; 2: 349-352. Number 2 (766 citations) Marshall BJ, Armstrong JA, McGechie DB, Glancy RJ. Attempt to fulfil Koch’s postulates for pyloric campylobacter. Med J Aust 1985; 142: 436-439. Number 3 (523 citations) Marshall BJ, McGechie DB, Rogers PA, Glancy RJ. Pyloric campylobacter infection and gastroduodenal disease. Med J Aust 1985; 142: 439-444. Number 4 (299 citations) Derrick EH. “Q” fever, a new fever entity: clinical features, diagnosis and laboratory investigation. Med J Aust 1937; 2: 281-299. Number 5 (267 citations) Swan C, Tostevin AL, Moore B, Mayo H, Barham Black GH. Congenital defects in infants following infectious diseases during pregnancy. Med J Aust 1943; 2: 201-210. Number 6 (203 citations) George LL, Borody TJ, Andrews P, Devine M, Moore-Jones D, Walton M, Brandl S. Cure of duodenal ulcer after eradication of Helicobacter pylori. Med J Aust 1990; 153: 145-149. Number 7 (170 citations) Trautner EM, Morris R, Noack CH, Gershon S. The excretion and retention of ingested lithium and its effect on the ionic balance of man. Med J Aust 1955; 2: 280-291. Number 8 (169 citations) Bower C, Stanley FJ. Dietary folate as a risk factor for neural-tube defects: evidence from a case–control study in Western Australia. Med J Aust 1989; 150: 613-619. Number 9 (167 citations) Wilson RMcL, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The Quality in Australian Health Care Study. Med J Aust 1995; 163: 458-471. Number 10 (166 citations) Borody TJ, Cole P, Noonan S, Morgan A, Lenne J, Hyland L, Brandl S, Borody EG, George LL. Recurrence of duodenal ulcer and Campylobacter pylori infection after eradication. Med J Aust 1989; 151: 431-435. Simple cation holds promise as psychotropic agentJohn Cade (1912–1980), the author of our most-cited article, once described himself self-deprecatingly as “an unknown psychiatrist, working alone in a small chronic [sic] hospital with no research training, primitive techniques and negligible equipment”.3 Born in Murtoa, a small country town in Victoria, Cade seemed destined to enter psychiatry. His father was a psychiatrist, and as a child Cade lived in the grounds of various “lunatic asylums”. He entered psychiatry in 1936, shortly after graduating in medicine (with honours in all subjects), but spent much of the Second World War as a prisoner of war in Changi, Singapore, returning to Australia as a 40 kg “walking skeleton”.4,5 Cade’s interests included all the sciences, and his “enquiring mind” stayed with him throughout life. The coauthor of his first article (published in 1940), detailing the serological response to influenza virus infection, was none other than Frank Macfarlane Burnet.6 While Cade was investigating potential anticonvulsant agents in guinea-pigs, he came to suspect that the cation lithium had a sedative effect which might be useful in treating mania. He demonstrated this sedative effect in guinea-pigs, and then took lithium himself, before extending his study to patients.3 In his MJA article, Cade reported the Results of a study of the effect of lithium salts in 10 patients with mania (as well as six with schizophrenia and three with “melancholia”). Lithium had a clear effect in mania. He published no further research on lithium, but did search for other cations with psychotropic activity.3 In commenting on his research career, he said: “My own research efforts have been sporadic over many years. Most have ended in blind alleys. Some have been successful. All have been fun. In the process I have learned a greater deal . . . , and en passant something of the causes and effective treatment of manic–depressive illness.”7 Cade’s findings were not immediately accepted in the rest of the world (and not until the 1970s in the United States), so it is not surprising that further notable research on lithium was also conducted in Australia. Ranked seventh in the MJA top 10, The excretion and retention of ingested lithium and its effect on the ionic balance of man was published in 1955. The authors included Trautner, a physiologist at the University of Melbourne, and Noack, a psychiatrist at Melbourne’s Mont Park Hospital. Their research, conducted on themselves and on patients with mania, showed that lithium is retained during the acute phase of mania, necessitating higher doses. These can be reduced as the mania resolves. They also showed that intercurrent illness increases the risk of lithium toxicity. Spiral bacterium linked with gastritis and peptic ulcerToday, we know that Helicobacter pylori colonises the stomach and infects about half the world’s population.8 Further, it has infected people since the dawn of human history, and its geographic variation is being used to map the earliest human migrations, including the arrival of Europe’s first neolithic farmers.9 However, as recently as two decades ago, notwithstanding reports suggesting otherwise (“dispersed over 100 years, in journals of different languages and subspecialities”10), the prevailing dogma was that the human stomach was sterile, and that bacteria could not survive in gastric acid.10 Gastroenterologist Barry Marshall and pathologist Robin Warren first described the association of a campylobacter-like organism with gastritis in two letters to the editor of The Lancet.11,12 Marshall and colleagues later published two articles — in the 15 April 1985 issue of the MJA — providing evidence of a causal relationship. These articles rank second and third in the MJA top 10. 2 Illustrations from Marshall et al’s two “top 10” MJA articles A. Numerous Helicobacter pylori organisms in a gastric biopsy specimen from Barry Marshall, taken 10 days after he ingested a pure culture of the organism (Warthin–Starry silver stain; original magnification x 900). B. Heavy growth of H. pylori from an antral biopsy specimen from a patient with duodenal ulcer. (Larger white colonies are commensal flora of the mouth.) In the first MJA article, the researchers successfully fulfilled Koch’s third postulate by demonstrating that H. pylori (then known as pyloric campylobacter) could colonise histologically normal mucosa. After trying to infect animal models without success, Marshall used himself as a “guinea-pig”. About 5 days after drinking a pure culture of H. pylori (109 organisms), he became ill, with early-morning nausea, vomiting of acid-free gastric juice, and “putrid” breath. Although the illness resolved spontaneously after 14 days, culture and histological examination on the 10th day showed severe acute gastritis with many H. pylori organisms (Box 2A). The experiment allowed Marshall and colleagues to link H. pylori to epidemic gastritis with hypochlorhydria. In the second MJA article, Marshall and colleagues proposed that pyloric campylobacter infection was responsible for damage to the duodenal epithelium, as well as the gastric antral mucosa, based on gastroduodenal biopsy and culture findings from over 100 patients referred to their dyspepsia research clinic (Box 2B). Looking back on these discoveries, Marshall later wrote that early reports of an association between peptic ulcer and H. pylori were met with extreme scepticism by many doctors, who were convinced that psychic stress, cigarette smoking and hyperacidity were the causes of peptic ulcer. Reports of the first therapy ever shown to heal gastritis received “a cool reception at gastroenterological meetings”.10 Compared with Cade’s era, communication among the world’s scientific community had accelerated greatly, and, in 1991, the first convincing study of cure of duodenal ulcer through eradication of H. pylori was published in the United States. However, this was preceded by another pair of notable articles on the same topic in the MJA, from the Centre for Digestive Diseases in Sydney. In 1989, the study by Borody and colleagues, which ranks tenth in the MJA top 10, showed that “triple chemotherapy” with bismuth, tetracyline and metronidazole could lead to long-term eradication of H. pylori in most patients with duodenal ulcer or non-ulcer dyspepsia. Further, they suggested that this eradication could reduce recurrence of, or even cure, duodenal ulcer. The group subsequently reported such cure in their 1990 MJA article, which ranks sixth in the top 10. H. pylori infection is now recognised as the major cause of peptic ulcer disease and an important risk factor for gastric malignancy. For discovering its role in peptic ulcer disease, Marshall was awarded the 1995 Albert Lasker Clinical Research Award.13 Mystery abattoir fever confirmed as new disease 3 Edward Derrick, who first described Q fever In 1961, Derrick became director of the Queensland Institute of Medical Research. (Illustration courtesy of the Brisbane Courier-Mail.) In 1935, unexplained fevers in abattoir workers in Queensland were referred for investigation to Edward Holbrook Derrick, newly appointed director of the state’s Laboratory of Microbiology and Pathology14 (Box 3). He was unable to identify a cause but found that “abattoir’s fever” had a distinctive natural history. The clinical resemblance to murine typhus led him to inoculate patients’ blood into guinea-pigs, which became febrile. The agent could be transmitted serially from one to another, and, after recovery, the guinea-pigs remained resistant to infection. These findings were reported in the MJA in 1937, in an article that ranks fourth in the top 10. Thirty years later, Macfarlane Burnet wrote that “these findings provided a rather cumbersome, but perfectly adequate means of establishing that abbatoir’s fever was a specific entity definable immunologically, and also of allowing laboratory diagnosis in a doubtful clinical case”.15 Although Derrick described the disease and named it “Q” fever, it was Macfarlane Burnet who showed it was caused by a rickettsial agent, as described in his article, coauthored with Mavis Freeman, which followed Derrick’s in the same issue of the MJA.16 The causative organism is now known as Coxiella burnetii. Derrick (1898–1976) received international recognition for discovering not only Q fever, but also the form of leptospirosis caused by Leptospira pomona.17 When Derrick was made a Fellow of the Australian Postgraduate Federation, Macfarlane Burnet stated that “to have defined and elucidated the aetiology of two worldwide infectious diseases is something no other living scientist can claim.”17 German measles in pregnancy may damage the fetusIn 1941, the teratogenic effects of rubella (German measles) were uncovered by the Australian ophthalmologist Norman Gregg.18 At that time, it was generally believed that birth defects were inherited, and that the placenta was an absolute barrier to infectious diseases. Gregg’s suggestion that maternal rubella played a causal role in congenital cataract was considered revolutionary, and several years passed before overseas medical journals commented on the idea.19 However, in Australia only a year later, Charles Spencer Swan was appointed by the National Health and Medical Research Council to investigate the possible relationship.19 On 7 October 1942, a circular sent to all South Australian general practitioners informed them of Gregg’s findings and asked them to complete a form for all children born to women who had an acute exanthem during pregnancy. From these data, covering the years 1939–1943, Swan and colleagues identified 49 infants whose mothers had been exposed to rubella during pregnancy; 31 had congenital malformations, including cataract, deaf-mutism, heart disease, microcephaly and mental retardation. In all but two of the 31 cases, rubella had been contracted in the first 3 months of pregnancy. Further, Swan and colleagues suggested that the type of congenital malformation depends on the stage of pregnancy at which the mother acquired rubella. Their MJA report ranks fifth in the top 10. The rubella virus itself was not identified for about another 20 years. Although Gregg’s landmark article on congenital cataract and maternal rubella was formally published in the Transactions of the Ophthalmological Society of Australia,18 he had presented his observations at the annual meeting of the society in October 1941. A description of the proceedings was published with permission in the MJA in December 1941,20 before the formal article appeared. In defence of the rapid publication, the MJA stated: “The series [of cases] is so striking and the sight of the children is so seriously affected that the facts must be made known without undue delay to the general body of the medical profession.”20 Folic acid in pregnancy can prevent spina bifidaFiona Stanley graduated in medicine from the University of Western Australia and trained in epidemiology at the London School of Hygiene and Tropical Medicine and the National Institutes of Health in the United States. In 1977, she returned to Perth for family reasons and, although a researcher at heart, became Senior Medical Officer in Child Health.21 Yet, this chance worked in both her and our favour, as it allowed her to establish, with colleagues, the Western Australian Congenital Malformations Registry. The registry provided the data for her landmark MJA article, coauthored with Carol Bower, which showed that dietary intake of folate in early pregnancy protects against the occurrence of isolated neural-tube defects in infants. It ranks eighth in the MJA top 10. 4 Fiona Stanley Since her discovery of the role of folate in preventing neural-tube defects, Stanley continues to investigate the epidemiology of childhood and maternal illness. In 1990, a year after her top 10 MJA article was published, Stanley became founding director of the Telethon Institute for Child Health Research in Perth. She continues to explore the promise of epidemiology and other scientific disciplines in tracking trends and preventing major childhood and maternal illnesses.22 Stanley (Box 4) was Australian of the Year in 2003. Healthcare can harm patientsThe Quality in Australian Health Care Study (QAHCS) arose from the Tito Review of Professional Indemnity Arrangements for Health Care Professionals, established by the Australian government in 1991. The review was to examine the adequacy of compensation and funding arrangements for healthcare misadventures in Australia, but lacked the data to answer the fundamental questions: How many adverse patient outcomes arise from healthcare services? How severe are they? What impact do they have on those services? A consortium of the University of Newcastle, the University of Adelaide and Sydney’s Royal North Shore Hospital was awarded the contract to provide these data, led by intensive care physician Ross Wilson. The QAHCS, based on the Harvard Medical Practice Study, was set up to measure preventability rather than negligence. Nevertheless, it provided a national measurement of the safety of healthcare, a measurement many other countries still lack. The most-cited report from the QAHCS was published in the MJA in 1995 and ranks ninth in the top 10. It found that 16.6% of hospital admissions in Australia in 1992 were associated with an “adverse event” to patients, that those events meant patients were injured by their healthcare, and that the injury had caused them some disability. About half the adverse events were considered preventable. In 1999, also in the MJA, the consortium reported further on the preventability of these events.23 “The spirit of the researcher”The MJA’s 10 most-cited articles are testimony to the power of clinical research to revise our understanding of disease and treatment methods, and to enhance prevention of disease and adverse events. Despite the refinements in clinical research methods over the decades, which will continue to evolve, these top 10 articles and the pioneering spirit of their authors should inspire new generations of doctors to make the most of any opportunities or insights that come their way. Derrick, in his address to the inaugural meeting of the Queensland Branch of the Australian Society for Medical Research in 1969, quoted the American physiologist Walter Cannon: Phenomena, no matter how mysterious they may appear to be, have a natural explanation and will yield their secrets to the persistent, ingenious, and cautious efforts of the investigator.24 Cade, in his presidential address to the Seventh Annual Congress of the Australian and New Zealand College of Psychiatrists in 1970, said: Almost everyone can and should do research, both because almost everyone has a unique observational opportunity at some time . . . and also because the intellectual discipline and technical training that it imposes is an essential prerequisite to expertise in a professional field.7 Derrick was said to have had a feeling for the historical context in which his research was done, an awareness of the stepwise progress of knowledge to which all, “however ill-equipped”, might hope to add. He was said to be fond of quoting the wisdom of Descartes: The last should commence where the preceding had left off, and thus by joining together the lives and labours of many, we should collectively proceed much further than anyone in particular would succeed in doing.17

Ann T Gregory MB BS, GradDipPopHealth

Even for nonagenarians, anniversaries are an opportunity for looking forward as well as looking back. Wondering what sort of articles the MJA might be publishing in the near future, and what might be the areas of focus and challenge for the medical profession, we asked over 40 of Australian medicine’s current opinion leaders: “. . . what area in your discipline is not currently researched or not resourced [by conventional conservative funding bodies], but ought to be developed as it will yield dividends.” In true editorial spirit, each contributor was asked to answer the question in less than 100 words, and to “think outside the square”. The replies came in thick and fast and we can’t publish them in full in print. However, a number of themes emerged, within which we have grouped excerpts from contributors’ responses. (The full text from the contributors is available here) Promising technologiesFor complex reasons, medicine lags behind the rest of the world in its use of information technology, but several contributors say it’s time we caught up! Information technology allows the “bedside" to be anywhere a mobile phone data signal can be received (photo courtesy m. Net Corporation). Cameron (emergency medicine) believes that patient-held electronic health records would save lives. An unconscious patient is brought “lights and sirens” to the emergency department. “The ED team work feverishly to save the person’s life, knowing nothing of the past medical history, medications, allergies or advance directives”. Why aren’t we already using these “health cards”? “The technology exists but the political will and the resources do not.” Discussing anaesthetics, Kerridge was on the same wavelength. The current speed and complexity of inpatient care have increased the need for “rapid access to comprehensive patient and other information, and decision making in the face of uncertainty”. To ensure that care remains “safe and high-quality”, we need to develop both clinical information and decision-support systems. Roberton (paediatrics) would like to see information technology used for research and policy development to ensure the wellbeing of children. The “singularly important need”, he believes, is “development and linkage of databases relevant to child health”. Databases to be linked might include those relating to perinatal statistics, mortality/morbidity data, immunisation records, health service utilisation and prescribing data, cancer databases, educational outcome assessments, and Australian Bureau of Statistics and Social Health Atlas information. While Roberton referred to his proposal as a “policy and funding challenge”, Scott, Braund and Ng (internal medicine) were bolder, entitling their contribution, “Stop funding laboratory benches. Start funding decision support and communication!”. As patients present with more and more comorbidities, we need mobile computers to provide real-world decision support at the bedside. Research findings should appear as “critically appraised evidence summaries and guidelines, accessible via desktop icons”. The justification for shifting our efforts to decision support? — “remembering to apply what’s known saves more lives than new knowledge”. Computer-assisted knee-joint replacement surgery. A camera detects markers on the patient and the instruments, and transmits information to a computer monitor. Size, position and alignment can be computer modelled before surgical bone cuts, or selection of a definitive implant (photo courtesy Professor Peter Choong). Contributors saw the computer age as a boon for the surgical specialties. According to Choong (orthopaedics), “the power of the computer will revolutionise, innovate, and enhance our understanding of what we do as surgeons”. Computer-assisted surgery in orthopaedics can improve surgical precision and accuracy. “While prosthetic implantation is a major beneficiary of computer-assisted surgery, so too is minimally invasive surgery, which will change not only how surgery is performed, but also the type of surgery possible, implant design, and patient outcomes.” O’Leary (ear, nose and throat surgery) finds the idea of virtual-reality surgical training exciting. “Immersed in a 3-D environment . . . trainee surgeons may one day be able to ‘see’ and ‘feel’ their virtual patient as they acquire skills in ear and nose surgery.” Improvements in safety, standardisation, access and quality control are reasons to develop this technology “now”. Some contributors whose specialties use evolving technologies nominated areas of promise in their disciplines. Peters (radiation oncology) believes more research is needed on a new technique which uses “the single greatest attribute of radiation as a therapeutic tool — the accuracy and certainty with which a specified dose can be delivered to any site in the body.” The technique involves using targeted beams of radiation to activate toxic pro-drugs within tumour-bearing tissues. Meanwhile, Rowe (nuclear medicine) predicts an expanding role for positron emission tomography. “Over the next decade, PET will become routine, not only for cancer staging, but also for tailoring treatment. It will be used to assess early response, plan radiotherapy and, through the use of more specific tracers, will permit better treatment selection.” Virtual ear surgery trainer developed by the University of Melbourne and the CSIRO (photo courtesy Associate Professor Stephen O'Leary, University of Melbourne, and CSIRO). Two contributors commented on the way we use existing technology. Cicuttini (rheumatology) believes an area that has received little attention is the most cost-effective way to investigate common painful conditions. “As in many other areas of medicine, there has been a history of adding new investigations to the old ones, rather than substituting new for old.” She suggests the need for research on the rational use of investigations. For instance, does a patient with back pain still need a plain radiograph of the spine? Also ripe for research, says Cordner (forensic pathology), is the use of new imaging techniques at autopsy. He believes that this will lead to “improved characterisation of pathology, and, in some cases, improved decision making about the value of autopsy”. Bringing into focusA group of contributors suggested a new angle or a new focus for research in their specialties. In the first two of these, the results of the research may also benefit other disciplines. Those dealing with inflammatory or immunological disease processes may well be interested in Marks’ (dermatology) suggestion that, instead of continuing to investigate what turns on the inflammatory/immunological response in atopic disease, we should be focusing on what turns off the response. O’Hehir (allergy and immunology), surprised by the escalating use of alternative therapies, wants not only clinical and laboratory research on alternative therapies, but also “well-conducted qualitative studies to determine motivations for their uptake”. These data might be useful in other disciplines. Baby with atopic eczema. What turns off the inflammatory response? (photo courtesy Professor Robin Marks). Chronic venous disease is the forgotten child of vascular surgery, says Myers, and the costs of treating varicose veins and their complications are enormous. We must understand the pathogenesis. “Do abnormal haemodynamics distend normal veins or do normal pressures distend abnormal veins? Intensive biochemical and cellular research is needed to devise biological mechanisms to retard varicose disease.” In gastroenterology, there is a new subspecialty — neurogastroenterology. The gut is unique for the complexity of its intrinsic nervous system, says Hebbard. In 30%–50% of patients with disordered gastrointestinal function, no organic causes can be found. Research in neurogastroenterology is classifying the disorders; subclassifying patients by epidemiological, psychological and symptom analysis; measuring function by motor and sensory testing; and expanding understanding of the neurophysiology of the enteric system. The deplorable state of the health of Aboriginal and Torres Strait Islander peoples troubled several contributors. After decades of research in the epidemiology of Indigenous health, says Anderson (Aboriginal health), the “research agenda needs to be refocused on the development and evaluation of interventions in clinical care and population health, and an investigation of systemic barriers to providing accessible and effective healthcare”. Marks (respiratory medicine) hypothesises that suppurative airway disease in Indigenous Australian children and adults, and obstructive lung disease in Indigenous adults, may have a common pathological pathway. He calls for research focusing on “understanding the respective roles of a pathogenic environment and compromised airway and mucosal defences”. There may be ancillary benefits for control of respiratory infectious diseases in the wider community. House dust mite – a common cause of asthma and hayfever. What motivates people to seek out alternative remedies? In renal medicine, research efforts and resources have concentrated on end-stage kidney disease, but Walker (renal medicine) says the focus has shifted to earlier kidney disease (proteinuria and/or impaired glomerular filtration rate), “which has assumed epidemic proportions, is a major cause of morbidity and mortality, and an independent and highly significant risk factor for a dramatically increased, all-causes cardiovascular disease mortality.” Funding is required for large-scale, intervention randomised-controlled trials. Out of the vacuumMany contributors expressed a desire to reconnect medicine with the person; a replacement of the reductionist approach by a more holistic view. Kerridge (anaesthesia) called for a shift from “small studies using surrogate endpoints, such as physiological or biochemical changes”, to “large, multicentre trials which examine common ‘simple’ interventions in ‘normal’ patient care”, measuring “ ‘real’ outcomes such as mortality, morbidity, or length of stay.” Cameron (rehabilitation medicine) was similarly minded, citing a need for research to “. . . understand better what will improve life for people with disability in the long term through careful epidemiological studies and clinical trials, looking particularly at appropriate environmental and personal factors”. At the same time he saw a need to reorient healthcare services to provide “rehabilitation with a community focus”. Mendelson (radiology) says imaging specialists have been slow to take up the challenge of measuring the effects of their craft on patient outcomes and quality of life. For instance, “Does the detection of ‘incidentalomas’ benefit the patient or just cause anxiety, expense and morbidity? Does recurrent imaging of patients receiving palliative therapy for malignancy confer any benefit?” These are questions which need to be considered in this era of expensive and limited technology. Connecting with the communitySeveral contributors saw the need to begin taking patient and community preferences into account. Scott, Braund and Ng (internal medicine) applied this to research: “Meta-analyses of effectiveness address the physician’s perspective. Patients need meta-analyses of the downside (risk) as well.” Others, such as Maddern (surgery), see it as imperative that we live up to community expectations to be “competent, up-to-date and able to achieve world-class results”. In doing this, he says, surgical research will need to be able to demonstrate not only that procedures are effective in the short term, but to show “long-term results in terms of cure or function within communities”. The establishment of optimal training environments (so surgeons and their teams can master the necessary skills before treating patients), ongoing national audit of surgeons, hospitals and operative approaches, and corrective systems are important if we are to achieve these results. Then there is a need for greater understanding of community values and societal pressures. Harris (general practice) points out that, while GPs can offer patients more options than ever before, “our patients are increasingly sceptical and misinformed (especially by the media and Internet)”. He believes we need more research on “how much Australian GPs and their patients agree on management or what factors or supports can make agreement easier or harder to achieve”. Wodak sees community values as creating tension in the area of drugs and alcohol as “the irresistible obstacle of community abhorrence of illicit drugs opposes the irresistible force of demand for these drugs”. The future should see us looking for compromises. Similar to the current acceptability of methadone, he suggests we need to develop “some form of regulated supply of orally well-absorbed, dilute and mild opiates, stimulants and hallucinogens” which are “reasonably acceptable to both the drug-abhorring majority and the drug-seeking minority”. Compassion and a need to research and resource ways to improve quality of life were also emphasised by some. Cordner (forensic medicine) sees a need to provide resources to “consult families about autopsy (eg, tissue retention for transplantation, research or diagnosis) and provide them with its results”. Meanwhile, in developing countries, the lack of appropriate expertise in detecting human rights abuses has led to “community mistrust of the criminal justice system, and therefore continuing instability and poverty”. These countries require aid to train forensic physicians and pathologists. In palliative care, Currow believes we should provide care for the caregivers through “. . . information, emotional support and respite that is responsive and funded”. Furthermore, palliative-care services should be judged on the carers’ outcomes, including “the ability to have health, create a life without the person for whom they have cared, and achieve a level of function with which they are satisfied”. Even our opinion leader in the world of health informatics regarded the human and systemic factors as being as important as the IT infrastructure. Coiera describes the computer as “the sacred ground in health informatics research”. This includes multiple information systems, such as the electronic health record, the Internet and mobile computing. However, he adds that “the profane ground, largely ignored, is the broader human system that is needed to make anything actually work. Technological systems repeatedly fail for cultural and organisational reasons”. The focus now needs to be on fusing the human and technical elements into effective systems. The da Vinci robot for radical prostatectomy. Brilliant advance or expensive toy? (© 2004 Intuitive Surgical, Inc). Hirst (urology) takes a broader cultural and societal view, saying that “the last 30 years has seen a significant shift in medicine from a moral economy to an increasingly market-based economy”. Several forces, such as pharmaceutical, instrument and device manufacturers and competitive behaviour within the profession, contribute to this. The shift has had most impact on procedural specialties like urology, and we need to take steps to ensure that its impact on quality, cost and training is positive. Age shall not weary usNot surprisingly, several contributions acknowledged the implications for future clinical practice of the “greying” of the Australian population. Flicker (geriatric medicine) is concerned about the dire lack of evidence to guide the management of people in advanced old age, and wants to see “evaluation of multicomponent interventions for the many coexisting diseases in old people with reduced physiological reserves”. Dobb (intensive care) was similarly concerned: as the cohort of elderly people is growing, so is our ability to ensure survival after severe illness. “We need to target intensive care to the patients who will truly benefit”, which requires understanding more about “the effects of age, comorbidities and functional status on recovery from severe illness”. Women ageing well (photo courtesy Dr Kay Cox). The dilemma of the upper-age entry limit (70 years) for clinical trials in cancer therapy — and that half the patients with cancer are now aged over 70 at diagnosis — was raised by Fox (medical oncology). “There is insufficient evidence-based data to guide management of ageing patients. We need to recognise that cancer will be predominantly a disease of the aged, and investigate it and manage it as such.” Constable (ophthalmology) reminds us about the epidemic of age-related macular degeneration. While Australian research has contributed to the epidemiology of macular degeneration, we know little about genetic predisposition and biological determinants. “Cellular biology, genetic manipulation, transplantation and induction of animal models will accelerate our understanding, create intellectual property and result in an early interventional approach.” Tonkin (cardiology) takes the bull by the horns and suggests “a public-interest trial: aspirin for primary cardiovascular prevention in the elderly.” The rationale? Previous trials mostly involved middle-aged males, and the risk of bleeding increases with age. At present, only a third of Australians 70 years and over, including those with overt disease, take aspirin routinely. “Aspirin is cheap and equitable; it may be extraordinarily cost-effective; and it may also prevent cognitive decline, depression and cancer.” There is a drawback — “with few gains for industry, this trial appears unfundable — 20 500 subjects, 5 years’ follow-up, $35 million!” How about it, Bill and Melinda? A panacea for the elderly? A bottle of aspirin powder, first marketed in 1899. Finally, Flicker points out that we still need to establish “which mix of lifestyle, health and social activities would maximise our chances of ageing well, an outcome which is not simply the absence of disease”. Connections between silosOne of the biggest changes in medicine since the MJA was born 90 years ago is ever-increasing subspecialisation. Some contributors saw a need to broaden the knowledge base of their disciplines. Sawyer, Sanci and Patton (adolescent health) say young people’s health problems are complex, but that the responses to problems such as depression, chronic physical illness, eating disorders and obesity often draw on “too narrow a skill-set from single-discipline practitioners who claim clinical expertise and responsibility”. More effective clinical, research and training responses will require “broader engagement of the health system and other sectors”. Wesselingh also sees a need for “adequately resourced, multidisciplinary responses” in the field of infectious diseases. Despite the extraordinary success and high profile of Australian infectious diseases research, he identifies three significant failures that warrant a multidisciplinary approach. “Firstly, our Aboriginal communities still suffer from excessive infection-related morbidity; secondly, our hospitals remain environments with a significant risk of acquiring infection with a multiresistant organism; and, thirdly, the Asia-Pacific region is following Africa towards an HIV/AIDS- and TB-led catastrophe.” In considering burns care, Wood (plastic surgery) believes we need a multidisciplinary scientific approach “to ensure the quality of the scar is worth the pain of survival”. This approach has potential for dealing with the three management steps: assessment (using multimodality imaging, including confocal microscopy and synchrotron technology); debridement (combining autolytic and image-guided physical debridement techniques); and reconstruction (using nanotechnology to provide the framework for appropriate tissue regeneration). The new geneticsAs genetics is a newer “basic science” discipline, contributors called for more integration with clinical research and practice. Waring (molecular genetics) notes that the availability of genetic tests for many diseases, such as inherited neurological and cardiovascular conditions and cancer, has created strong clinical demand. There is now “an urgent need to build integrated clinical and laboratory genetic infrastructure and to train scientists, pathologists and clinicians in molecular genetics”. Also required are a national strategy and a funding model for molecular genetics. Understanding how the brain works. MRI, showing brain fibre tracks in an infant with brain injury (photo courtesy Professor Terrie Inder). Williamson (genetics) says that “the Human Genome Project has given lots of data on genes of known function, and we know about single-gene diseases caused by their mutations. However, two-thirds of our genes are still a mystery”. Where are these genes? Mostly in the brain, he says, where genetic and environmental factors interact to produce “brain function, intelligence, consciousness, values and culture”. Williamson’s wish is for a project which integrates the Human Genome Project, neurogenetics, psychology, MRI fetal imaging and artificial intelligence “so we can really understand how the brain works”. Wiley (haematology) believes we now have “a major opportunity to explore genetic risk factors for pathogens which, in some people, survive and flourish in our intracellular environment”. Pathogens such as mycobacteria, chlamydia, toxoplasma and leishmania are killed by macrophages of the innate immune system, following similar pathways, but we are not sure which genetic factors in the host predispose to these diseases. “Studies which bridge haematology, immunology and infectious diseases are much needed to define genetic defects in innate immunity.” Just do it!A sense of urgency pervaded several of the contributions. “The world desperately needs an HIV vaccine”, says Kent (HIV medicine). “How can this slippery virus be checkmated? Where is its Achilles heel? What cells can be manipulated to exploit any weaknesses? What is the innate immune system doing? Can we generate an immune barrier to resistant strains? History will judge our dedication to this task.” Driscoll (occupational health) sees an urgent imperative for research into “establishing links between occupational exposure and disease, preferably at a stage early enough to modify the disease process”. We also need “better understanding of health risks (and benefits) associated with the large-scale transfer of jobs from heavy industry to information and service industries”. Mindel (sexual health) says there is an urgent need to control the commonest bacterial sexually transmitted infection in Australia. “Chlamydia is a leading cause of infertility and a significant drain on the public purse.” A national strategy is needed to encourage yearly screening of sexually active adults under 25 years (with a suitable urine chlamydia test), with treatment of those infected and their contacts, supplemented by promotion of consistent condom use, and testing and treatment for other STIs. For Mitchell (psychiatry) it is time to “grasp the nettle”. We now have new investigatory tools (genetic markers, structural and functional brain imaging), and have “rediscovered” gene–environment interactions (gene variants that increase the risk of mental illness, but only in conjunction with environmental factors). Thus, “the time is ripe for funding of large-scale, longitudinal studies to examine the roles and contributions of these factors combined (and in isolation) in determining the development and timing of onset of the major mental illnesses — schizophrenia, bipolar disorder and depression. Potential benefits in understanding aetiology, and thereby designing ‘tailored’ therapies, are enormous.” Leeder (public health) also takes a “just do it” attitude. He quotes Jeffrey Sachs, Director of the Earth Institute at Columbia University (New York), who says public health is “whatever it takes to improve the public’s health”. And what are the imperatives in public health? “Developing a robust ethic for public health; inviting private enterprise, unions, insurers and the public to the public health table; and learning the skills to speak eloquently with these people. Whatever it takes!” A doubling in prevalence of type 2 diabetes in Australia since 1980 means we simply can’t wait 10–15 years to do conventional research studies, says Chisholm (endocrinology). Intensive interventions (modified diet plus physical activity) can dramatically reduce diabetes incidence in predisposed people, but are prohibitively costly for whole communities. “To combat diabetes, obesity and cardiovascular disease, Australia should immediately implement ‘best-guess’ measures with progressive research analysis and modification (as was done to reduce cigarette smoking).” In short, let’s just do it! The future belongs to those who dare! Contributors: A/Prof Ian P Anderson, Dr Wilton Braund, Prof Ian D Cameron, Prof Peter A Cameron, Prof Donald J Chisholm, Prof Peter F M Choong, A/Prof Flavia M Cicuttini, Prof Enrico W Coiera, Prof Ian J Constable, Prof Stephen M Cordner, Prof David C Currow, Dr Geoffrey J Dobb, Dr Tim Driscoll, Prof Leon A Flicker, Prof Richard M Fox, Prof Mark F Harris, Dr Geoffrey S Hebbard, Dr Geoffrey H L Hirst, A/Prof Stephen J Kent, Dr Ross K Kerridge, Prof Stephen R Leeder, Prof Guy J Maddern, Dr Guy B Marks, Prof Robin Marks, A/Prof Richard M Mendelson, Prof Adrian Mindel, Prof Philip B Mitchell, Prof Kenneth A Myers, Dr Kenneth Ng, Prof Robyn E O’Hehir, A/Prof Stephen J O'Leary, Prof George Patton, Prof Lester J Peters, Prof Donal M Roberton, Dr Christopher C Rowe, Dr Lena A Sanci, Prof Susan Sawyer, A/Prof Ian A Scott, Prof Andrew M Tonkin, A/Prof Rowan G Walker, A/Prof Peter Waring, Prof Steve L Wesselingh, Prof James S Wiley, Prof Robert Williamson, Dr Alex D Wodak, Prof Fiona M Wood.

Ruth M Armstrong BMed · Helen M Randall BSc, DipOT · Martin B Van Der Weyden MD, FRACP, FRCPA

Barber-surgeons at work! This caricature from the 16th century shows barber-surgeons combining haircuts with various surgical tasks (from Hæger K. The illustrated history of surgery. London: Harold Starke, 1998). The tradition of addressing surgeons as “Mister” or “Miss” rather than “Doctor” is firmly entrenched in English surgical practice. This tradition is generally thought to have had its origins in the days of the “barber-surgeons”, after the Company of Barbers united with the various guilds of surgeons in 1540.1 The blade-wielding skills of barbers had given them opportunities for surgical practice, and “surgeons” at that time seldom had formal qualifications. Whether the two professions united for financial reasons or to bolster their numbers after the Black Plague of the 14th century is unclear.2 By the beginning of the 18th century, physicians and a few surgeon members of the Great Company of Barbers and Surgeons had gained university qualifications.3 All other surgeons were, quite naturally, addressed as “Mister”. With the separation of the surgeons from the Great Company of Barbers and Surgeons1 in 1745 and the establishment of the Royal College of Surgeons of London, the title “Mr” was retained and began to be seen as a label of status, as it marked the completion of formal examinations. The strong influence of the Royal College of Surgeons of England in the formative years of the Royal Australasian College of Surgeons (RACS) led to the persistence of the term in Australia. Anecdotally, the use of the term “Mr” appears to be losing favour, at least in New South Wales, and we sought to determine the prevalence of “Mr’s” among urologists in New South Wales and Victoria. MethodsPractising urologists with workplace addresses listed as NSW or Victoria were identified from the List of Members 2003 booklet of the Urological Society of Australasia.3 Data were collected from the letterheads (or signatures on letters) of practising urologists and, if letters were not available, by contacting urologists’ secretaries by telephone. The level of membership and year of attainment were recorded from the booklet. ResultsOf a total of 134 urologists, data about preferred title were collected from 69 with practice addresses in NSW and 56 with practices in Victoria (response rate, 93%). Year of commencing Society membership ranged from 1963 to 2002. The preferred title across NSW was “Dr”, whereas “Mr” predominated in Victoria (Box). Five Victorian urologists preferred the title “Dr” included among these were all the female urologists contacted who were practising in Victoria. DiscussionThe use of the title “Mr” among NSW urologists appears to have become obsolete. As NSW is the state with the most urologists, the umbrella title of “Mr”, as dictated by English tradition, can no longer be used for male urologists. The first female urologist in Australia completed her training in 1993, and currently about 10 women are practising as urologists in Australia. Greater numbers of women are entering urological surgery training, and, at the time of writing, there are 10 female trainees in advanced urological training posts across Australia. The use of the salutation “Dr” among female urologists, in states where “Mr” is used for male urologists, potentially may cause some confusion — patients may be uncertain of their surgeon’s qualifications. Female surgeons in the United Kingdom are traditionally addressed as “Miss”, regardless of marital status, but convention has expanded to include more recently “Ms” and “Mrs”.4,5 The attitudes and practices of surgeons across Australia, as well as the shift to more women in the profession, should be reflected in surgeons’ titles, and consideration given to phasing out the archaic title of “Mr”. Title preferred by urologists in New South Wales and Victoria Title NSW VIC Doctor 63 (91.3%) 5 (8.9%) Mister 0 48 (85.7%) None 5 (7.2%) 1 (1.8%) Professor 1 (1.4%) 2 (3.6%) Total 69 (100.0%) 56 (100.0%)

Clair Whelan MB BS · Henry H Woo MB BS, FRACS(Urol)

It was towards the end of 1963 — my final year of medical school at the University of Melbourne — when I read about the new contraceptive method in the Medical Journal of Australia. On our last day, after the Professor of Obstetrics and Gynaecology bade us farewell, I ran after him and asked: “Professor Townsend, what do you think about the Pill?” “It’s good stuff,’’ he replied, with a smile and a wink. And so I began my career just as the sexual revolution was poised to change society forever. One of my first patients was a migrant from Eastern Europe, who was raising two children as a single mother in the days before the safety net of generous social security benefits. She performed her own abortion with a knitting needle when I could not find a doctor to do it for her. But, as the years went by, struggling women and blushing teenagers came to me instead for “Anovlar”. Gradually, the unwanted pregnancy became less common, and so, thankfully, did the do-it-yourself abortion. In 1963 there were few female GPs. Indeed, some patients never came into contact with a female doctor. Once a 3-year-old child of one of my patients, staring with a puzzled look as I examined his mother, asked in Hungarian: “Mummy, is this lady a gentleman?”. Our family practice was situated in Elwood, a suburb that was then a bit “rough around the edges”. The practice started in a flat, with the living room serving as the waiting area. This arrangement did not worry our fellow compatriots and the other colourful immigrants of various religious and ethnic backgrounds who streamed through the doors. And Australian women came from all over Melbourne to see a female doctor for their “women’s problems”. Gifts of paintings, flowers, handcrafts, boxes of chocolates, and silver plates engraved with messages of gratitude all adorned our home. Every year I still receive a Christmas present from an Italian family I stopped treating long ago. We worked 6 days a week and attended emergency calls each night. There was no time to stop and smell the roses; I noted the changing seasons by the reappearance of patients with chronic peptic ulcers in the spring and autumn. What a difference the first histamine H2-receptor antagonist made! Not to mention proton-pump inhibitors. I often think about the patients who suffered penetrated, perforated or bleeding ulcers before the advent of these drugs. I can recall more recent cases too, but most of these were iatrogenic, as a result of taking non-steroidal anti-inflammatory drugs (NSAIDs). When I started practice, phenylbutazone was the only anti-inflammatory drug available, and I’ll never forget the life-threatening Stevens–Johnson syndrome that it caused in one of my patients. It was a relief when indomethacin and the other NSAIDs, and later still the COX-2 inhibitors, came along as alternatives. The way we viewed and treated cardiovascular disease changed over the years. In the early days our waiting room was awash with ashtrays. We doctors sometimes even smoked with our patients! We also knew all about the links between cholesterol and heart disease, but didn’t take it too seriously, as there were no effective cholesterol-lowering drugs. I remember attending patients with suspected acute coronary occlusions in the surgery, in their homes, on the street, and on garage floors. They were common occurrences, and neither ambulances nor hospitals had coronary care facilities or units. Still, I clearly remember saving the lives of two patients by rushing them to hospital and arriving just minutes before they had a cardiac arrest. The treatment for hypertension was straightforward and simple compared with the choices we have now. We used mainly Aldomet and chlorothiazide; our aim was a blood pressure of 140/90 mmHg, although 150–170/90–95 mmHg didn’t alarm us. In the elderly, high systolic pressure was generally not treated if the diastolic pressure was normal. In those days, near enough was good enough. The new and effective cardiovascular drugs came slowly, and a few decades later we began to notice that our patients were living longer and not succumbing to early heart attacks and strokes. I often think with great sadness of the friends and patients who died at that time, but might have been saved with better medications or bypass surgery. I still remember the suffering of patients with severe chronic asthma that I couldn’t adequately treat. All we had was ephedrine and phenobarbitone, combined with aminophylline or theophylline. We used adrenaline in emergencies, and also had prednisolone, but did not know how to use it safely. No wonder we embraced the first salbutamol and steroid inhalation devices, and later the individual asthma management plans, so enthusiastically! In the late 1960s, I saw a one-year-old baby with a minor complaint. To my horror, the next patient was an 8-year-old with a high temperature, cough and Koplik spots. I feared for the baby, who would surely catch measles from the 8-year-old. I knew the incubation period for measles was 2 weeks, but remembered reading about a new vaccine that gave protection within a week. I urged my pharmacist to try to obtain the vaccine for me, as it was not yet readily available. Luckily, it arrived and was given to the baby the same night. He never developed measles! I probably overprescribed antibiotics for many years, especially penicillin, but I am proud that no child in my practice ended up with damaged eardrums, rheumatic fever, nephritis or chronic chest infection, and I can’t remember many tonsillectomies either. On the other hand, a lot of patients developed thrush. I remember using antiviral drugs for the first time — to treat herpes zoster and a severe case of genital herpes — and dreading the side effects that, in fact, never came. We used barbiturates freely for anxiety, nervousness and sleeplessness. The 30 mg amylobarbitone (Amytal) was even more popular than Valium is today. The 200 mg dose Sodium Amytal was a good hypnotic — and a common cause of successful suicide! One of my patients took all 25 capsules, never to wake again. By contrast, not so long ago, one of my young patients reported downing 25 Mogadon tablets at once. “What happened?” I asked. “I woke up 2 days later,” she replied. “How did you feel?” “Very hungry!” No wonder, given their obvious safety (although, of course, it’s no excuse), we overprescribed the benzodiazepines. It is still an ongoing problem. The introduction of ultrasound, computed tomography scanning and endoscopy, and the new, less invasive surgical procedures, had a revolutionary effect. I remember the first of my patients who braved a laparoscopic cholecystectomy when it was still a very new procedure. Both of us were pleased with the outcome. Substance misuse, especially drug addiction, was always a problem in the Elwood area, and sadly remains so. The relationship between user and doctor was mutually unsatisfactory. The addict failed me by lying, cheating and stealing. They came not for help, but for drugs. I, in turn, failed them, because I refused to supply the drugs they craved. Even little things like disposable syringes, office pregnancy tests and one-drop blood sugar testers represented a great leap forward. Later still came the mobile phone and the computer, and no more arriving home only to be immediately called out again, and no more misplaced reports. Medicare deserves a whole chapter. For my practice, it meant I could order pathology or radiology services for pensioners, who previously had to attend public hospitals for these services. Sometimes, very poor patients were given free treatment, and this dilemma was also solved by bulk-billing. As the years flew by we had to learn about new diseases and their social impact, such as chronic fatigue syndrome, and new infectious diseases — AIDS, hepatitis B and C and, most recently, SARS. And diseases that were once less prevalent, such as type 2 diabetes mellitus and breast and prostate cancers, now became more common. As people ate more and exercised less, obesity reached epidemic proportions. Sleeping with multiple partners increased the prevalence of genital herpes. When I first started, choosing specialists was easy. Today, it is a matter of matching the right specialist to the right condition, as specialists themselves are now increasingly specialised. You have to know which orthopaedic surgeon is experienced at hip replacements, and which gynaecologist treats stress incontinence. But along with the new advances came the demise of the “old-style” doctor, devoted to treating several generations of the same family — the doctor who does home calls and has patients whom he or she has seen for 40 years or more. Now, fewer and fewer doctors are willing to do house calls, while the public expects service from early morning to late at night and during weekends, something no single doctor can provide. Doctors, whose only duty was to look after their patients, now spend a lot of time and money protecting themselves from potential litigation. With these pressures, I too eventually joined a mega-clinic with efficient, up-to-date, accredited services. The patient care is excellent, but also less personal. And while we look to evidence-based medicine, the public spends more and more money on poorly regulated and sometimes harmful “natural” therapies. So, how would a wish-list of a doctor nearing the end of her working life read? What do I want that we still haven’t got? Try this: a simple, non-invasive test for detecting colon carcinoma; clearer guidelines about when and how to investigate patients with high erythrocyte sedimentation rates and high C-reactive protein levels; still safer NSAIDs; guidance on when to stop postponing death and begin palliative care; a clever device for testing blood sugar that would administer insulin automatically; more places for taking long walks safely in our suburbs and towns; a society in which families take more responsibility for their elderly relatives; baby-friendly workplaces; and less violence in films, videos, computer games and, of course, in life itself. Yes, general practice has “all changed, changed utterly”*. *Easter 1916 — William Butler Yeats

Eva Szego MB BS

Objective: To assess changes in people’s knowledge and beliefs about cancer between 1964 and 2001.Design: Questions in a 1964 survey of beliefs about cancer (randomly selected households) were replicated in a 2001 telephone survey (random-digit dialling).Setting: Perth, Western Australia.Participants: 984 and 491 participants aged 20 years or older in the 1964 and 2001 surveys, respectively (response rates, 86.8% and 47.0%).Main outcome measures: Changes in knowledge and beliefs about cancer.Results: Between 1964 and 2001, there were major improvements in knowledge about the causes of cancer, with several myths dispelled. In 1964, the proportion of Perth residents surveyed who believed that cancer is contagious was 20% (95% CI, 18%–22%), compared with 3% (95% CI, 2%–4%) in 2001. Similarly, the proportion who believed cancer is caused by “a knock” was 25% (95% CI, 22%–28%) in 1964, compared with 1% (95% CI, 0–2%) in 2001. Cancer screening participation rates also greatly improved, from 18% (95% CI, 16%–20%) in 1964 to 77% (95% CI, 73%–81%) in 2001. Changes in participants’ sources of knowledge about cancer were also evident, with family members and television increasing markedly as sources of information.Conclusions: Improved education of the public in health matters over the past four decades appears to have had a major and positive impact on knowledge about cancer.

Robert J Donovan BPsych(Hons), PhD · Owen B J Carter BPsych, DPsych · Geoffrey Jalleh BComm, MPH · Sandra C Jones BA, MPH, PhD

Ronald Winton was Editor of The Medical Journal of Australia from 1957 to 1977. He would be the first to agree that his life had been a good one. Departing it, on 13 February 2004, at the age of 90, he would have thanked God for its variety, its achievements, and the love he received from his family, friends, colleagues and staff, as well as the many students for whom he became a surrogate father. Ron was born in 1913 in Campbelltown, New South Wales. His medical career began at Brisbane Hospital in 1935 and continued during Army service. He described his war as “quiet”, but managed to have some adventures in Palestine and New Guinea, retiring with the rank of Lieutenant-Colonel. Ron came to the Journal in 1947 as assistant to Mervyn Archdall, succeeding him as Editor in 1957. In those days, the Journal was wholly produced within The Printing House, at Glebe, from subedited manuscript through typesetting in hot metal to printing and binding. Ron’s term saw many changes — in medicine itself, in publishing procedures, in practice management and in medical insurance. He also saw the transition from the branches of the British Medical Association in Australia to the independent national and state bodies of the Australian Medical Association (AMA), and the controversial negotiations with government during the early days of Medibank. His editorials on medicopolitical topics were always insightful and balanced. Ron left his stamp on medical journalism in Australia in many ways. He edited the Australasian Annals of Medicine for some years and helped to formulate the Code of Conduct for pharmaceutical advertising for the National Medical Media Council. Through all the changes he steered the MJA, the “flagship” of the AMA, enabling it to keep honourable company with the great journals of the world. On his retirement he was awarded the Gold Medal of the AMA. Outside work, his passions included music, literature, theology and history (he lectured in the history of medicine at the University of Sydney). These topics often flavoured staff morning teas, to everyone’s great delight. On the world scene, Ron was a member of the World Medical Association, chairing its Committee on Medical Ethics, as well as the International Congress of Christian Physicians. His love affair with books led him to write several of his own.1-12 The great guiding force in his life was his deep Christian faith, exemplified in all his activities, especially his 20 years as Honorary Warden of “Wingham”, an Anglican hostel for country and overseas students. The Journal had been fortunate in its editors. Henry William Armit established its tradition of scrupulous accuracy, Mervyn Archdall brought wit and flair, and Ron Winton injected his own brand of wisdom and grace. As an editor, he was a hard act to follow. As a man, he inspired loyalty and love.

Laurel Thomas

Reducing error is an ongoing process, always in need of fine-tuning A crucial challenge in efforts to prevent or reduce the occurrence of medical error is obtaining information about the diverse types of medical mishaps. “Mishap” is a useful term — it is neutral and broad enough to encompass the wide range of things that can go wrong in clinical practice. The types of medical mishaps include the “near-miss”, the “incorrect procedure or treatment which does not harm the patient”, the “adverse event” (either anticipated or unanticipated), and, finally, the “sentinel event” (a blatant error, such as a blood transfusion error). All these forms of mishap have the potential to provide important information to help minimise or prevent patient harm and enhance standards of medical practice. The need for a flow of information far outweighs fingerpointing There are arguments about the definitions of medical error, and my assertion — that lessons can be learned from all forms of medical mishap — deliberately cuts a broad swath. Close examination of each of these types of mishap provides different learning opportunities. Near-misses, or errors that cause no harm, can trigger a re-evaluation of correct procedures to prevent these events; Adverse events, both “anticipated” and “unanticipated”, can help clinicians develop more rigorous thinking about evidence and standards; and Sentinel events can show how the protective systems put in place can be breached. Collecting extensive information in all these mishap categories not only leads to interventions to minimise and prevent harm, but also allows detection of patterns of error. For example, if an inordinate number of errors occur during night shifts, or when the change of shift occurs, organisational changes may be required. Information about mishaps also provides material for teaching medical students, residents and community practitioners, with the aim of preventing future errors. If the information prevents errors then there will be impressive cost savings for hospitals and healthcare systems, as well as for patients and their families.1 Finally, information about errors and patterns of errors forearms clinicians to avoid patient injury, thus reducing the stress involved in suspecting or knowing their actions may have caused harm. But there remains an ongoing impediment: can healthcare data systems provide timely information for risk management and reducing medical mishaps? In the book Medical mishaps. Pieces of the puzzle contributors from several countries identified “multiple overlapping and faulty mechanisms for the revelation, investigation and mitigation of errors”. There was “clearly considerable scope for greater collaboration, integration and coordination”.2 And the situation in Australia appears to be no exception. One of the key priorities of the Australian Council for Safety and Quality in Health Care (ACSQHC) is enhancing processes for measuring local quality improvement and aggregate-level reporting of performance and outcomes.3 A report in this issue of the Journal by Kingston and colleagues (page 36)4 explores the attitudes of the two main health-professional protagonists involved in reporting medical error. It analyses the differential use of incident reporting by doctors and nurses, and attributes this to the different cultures of the two professions. This finding has been well substantiated. Nurses work in a culture that responds to directives, including the directive to report incidents; doctors work in a culture that values intragroup action and professional–cultural definitions of error or mistake.5 Other, systems factors also influence the decision to report incidents: time constraints, dissatisfaction with the process, inadequate feedback, and failure to value the process.5 In addition, there may be confusion about what should be reported, feelings of fear of retribution and doubts about the possibility of remediation. Finally, what are the views of healthcare consumers? In a study published in the 7 June issue of the Journal,6 a random sample of Australians supported vigorous reporting of errors, and 68% of those surveyed also wanted disclosure of the identity of the healthcare worker involved. While this is understandable, it shows the need to educate the public about the importance of a “no-blame” culture to ensure that reports will be made in the first place. The need for a flow of information far outweighs fingerpointing. Clinicians want error reduction, and favour anonymity. Patients and the public want error reduction and are likely to accept anonymity in the name of this goal. The ACSQHC supports the principle of “no blame”, and has recently published a document Open disclosure standard: a national standard for open communication in public and private hospitals, following an adverse event in health care. This provides clear guidelines for patients, healthcare professionals and organisations confronting and dealing with medical error, and the legal issues attending such events. Its major message is an open, blame-free culture.7 Despite the human and systems factors impeding reporting of medical error, many of these can be overcome by adequate incident-reporting systems. These have the following characteristics:8 they are anonymous and easy to use (computerised); they acknowledge receipt of a report and confirm that it is being investigated; they report back the results of the investigation in a timely manner; they use the information for programs of reduction; they provide feedback about successful reduction efforts; and they receive continual public support from key physicians in leadership positions. The process of error reduction involves long-term effort. There needs to be consistent and persistent emphasis on a cycle of attention to information, patterns revealed by information, error-reduction efforts, evaluation, more information and more reduction efforts. These efforts now also include producing informed patients, who are coached to ask the questions that might avoid errors. We should think about this cyclic process to reduce error as an ongoing one, always in need of fine-tuning. Its effectiveness depends on clinical leadership providing a continuing example in error reporting.

Marilynn M Rosenthal PhD

The health service reforms fuelled by whistleblowing continue In 1995, the tragedy in paediatric cardiac surgery at the Bristol Royal Infirmary, exposed by a whistleblower, ended the laissez-faire approach to patient safety, management of clinical quality and professional self-regulation in the National Health Service (NHS). Indeed, the impending impact of the Bristol case was poignantly captured by an editorial in the British Medical Journal, entitled “All changed, changed utterly”.1 Britain may not be alone in whistleblowing. In this issue of the Journal, Faunce and Bolsin report on three such recent events in Australia2 (page 44). These show an uncanny commonality with the Bristol case. What has happened in the NHS since 1995? In the immediate aftermath of Bristol, the then Health Secretary, Frank Dobson, took urgent action to place a duty of quality of care on chief executives of NHS Trusts, effectively ending any doubt about where responsibility would lie. In 1998, the new Labour government introduced two white papers, The new NHS: modern, dependable3 and A first class service: quality in the NHS.4 Although these described the regulatory framework for a quality-oriented healthcare service in England, the principles were to apply across the UK. Subsequent policy papers have added many refinements — including some 42 quasi-autonomous regulatory bodies in healthcare. These have just been pruned after criticisms of overly oppressive regulation. The following are key elements of change in England: The National Institute for Clinical Excellence (NICE) is tasked to develop evidence-based clinical guidelines and to assess and evaluate new technologies and pharmaceuticals for the NHS. Complementing the clinical guidelines, National Service Frameworks were created to map out the essential ingredients of good clinical service provision. Originally, there were three — for coronary heart disease, cancer and mental health. Paediatric care was added after the report of the Bristol Inquiry.5 However, the focal process for the delivery of clinical care is clinical governance, which is defined as “a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding standardised care by creating an environment in which excellence in clinical care can flourish”.3 To monitor compliance, the government established the Commission for Health Improvement, which was superseded this year by the independent Commission for Health Audit and Inspection, to regulate institutional quality in both the public and private healthcare sectors. Adding to all this bureaucracy and control are bodies with more specific functions. For example, the National Patient Safety Agency manages the reporting and analysis of “near misses”. The National Clinical Assessment Authority advises NHS Trusts and complements the work of the General Medical Council (GMC) in assessing and retraining poorly performing doctors. In addition, there is a new, overarching body for coordinating the regulators of the individual health professions — the Council for the Regulation of Health Professionals. For the citizens, the Commission for Patient and Public Involvement in Health, together with local Patients’ Forums, is to champion and promote public participation in the direction of local health services. This is a breathtaking array that even the distant observer in Australia might find daunting. For doctors, the regulatory landscape has also changed dramatically. The recent consultant and general practitioner NHS contracts increase employers’ control over the organisation of medical work, incorporate performance incentives and strengthen accountability. But it is the GMC’s proposals for doctors’ registration, training and discipline that are potentially most far reaching. The GMC changes began in 1992 with a new approach to basic medical training — Tomorrow’s doctors.6 Even more radical was the publication, in 1995, of a patient-centred code of practice, Good medical practice.7 If embedded successfully in the medical culture, the code will lead to positive changes in attitude on matters such as communication with patients and colleagues, teamwork, risk management, transparency, and whistleblowing. To strengthen compliance, the GMC tied the code directly to registration in 1998. The full effect will begin to be felt in 2005, when all UK doctors in active practice will have to have a licence to practise that must be revalidated every 5 years. Revalidation will require doctors to submit evidence of their continuing competence and performance (assessed against the template of Good Medical Practice) regularly for review. So where do things stand now? Two recent reviews of the NHS show a picture of patchy performance through clinical governance, particularly in the workplace.8,9 Data quality and some other systems issues are still a serious problem. But the central questions are about the medical and healthcare culture, and therefore medical leadership. Have the GMC and the Royal Colleges the will to see revalidation — and with it clinical governance — implemented as rigorously as required to give patients the assurances of the quality and consistency of medical care they are entitled to expect? Such questions are likely to be aired publicly again later this autumn when the Shipman Inquiry reports. All these changes raise the question: will the need for whistleblowing ever pass away? I believe this will only happen if the medical profession is prepared to put the task of embedding, demonstrating and communicating patient-centred professionalism at the heart of its vision for the future.10 This task has to become central to our professional practice, our teaching and our research. It is the object on which our mutual leadership should be focused. The public expect no less.

Donald Irvine CBE, MD, FRCGP

Objective: To describe complaints by patients and compare rates of complaint in demographic subgroups of patients and hospital departments.Design and setting: Retrospective analysis of complaints made by patients attending 67 hospitals (metropolitan, 25; rural, 42) in Victoria, and lodged with the Victorian Health Complaint Information Program (January 1997 – December 2001).Main outcome measures: Demographic characteristics of patients lodging complaints and the hospital department involved; nature and outcome of complaints.Results: From a total of over 13 million patients presenting to hospital during the study period, 19 156 patients or their representatives (mostly their parents, children or spouses) lodged 26 785 “issues” of complaint (overall complaint rate, 1.42 complaints/1000 patients). Significantly more complaints (P < 0.001) were lodged by (or on behalf of) female patients (complaint rate ratio, 1.3; 95% CI, 1.2–1.3), public patients (rate ratio, 2.1; 95% CI, 2.0–2.2) and Australian-born patients (rate ratio, 8.9; 95% CI, 8.3–9.6). The complaint rate for general wards was 6.2/1000 patients (95% CI, 6.1–6.3). Intensive care units had a similar rate of 5.9/1000 (95% CI, 5.4–6.5), but aged-care departments had a significantly higher rate of 45.2/1000 (95% CI, 39.5–51.7), while emergency departments (1.9/1000; 95% CI, 1.8–2.0), operating theatres (1.0/1000; 95% CI, 1.0–1.1), day-procedure units (0.5/1000; 95% CI, 0.5–0.6) and outpatient departments (0.4/1000; 95% CI, 0.4–0.4) had significantly lower rates. Complaints relating to communication (poor attention, discourtesy, rudeness), access to healthcare (no/inadequate service, treatment delays) and treatment (inadequate treatment and nursing care) accounted for 29.2%, 28.5% and 22.5% of complaints, respectively. Most (84.5%) complaints were resolved. Apologies or explanations resolved 27.8% and 27.5% of complaints, respectively.Conclusion: Interventions to decrease the number of complaints in the areas of communication and access to healthcare need to be implemented. The active use of complaint data for quality-improvement activities is recommended.

David McD Taylor MD, MPH, FACEM · Rory S Wolfe BSc, PhD · Peter A Cameron MD, FACEM

Objectives: (i) To examine attitudes of medical and nursing staff towards reporting incidents (adverse events and near-misses), and (ii) to identify measures to facilitate incident reporting.Design: Qualitative study. In March 2002, semistructured questions were administered to five focus groups — one each for consultants, registrars, resident medical officers, senior nurses, and junior nurses.Participants and setting: 14 medical and 19 nursing staff recruited using purposive sampling from three metropolitan public hospitals in Adelaide, South Australia.Main outcome measures: Attitudes and barriers to incident reporting; differences in reporting behaviour between disciplines; how to facilitate incident reporting.Results: Cultural differences between doctors and nurses, identified using Triandis’ theory of social behaviour, were found to underpin attitudes to incident reporting. Nurses reported more habitually than doctors due to a culture which provided directives, protocols and the notion of security, whereas the medical culture was less transparent, favoured dealing with incidents “in-house” and was less reliant on directives. Common barriers to reporting incidents included time constraints, unsatisfactory processes, deficiencies in knowledge, cultural norms, inadequate feedback, beliefs about risk, and a perceived lack of value in the process.Conclusions: Strategies to improve incident reporting must address cultural issues.

Marilyn J Kingston RN, RM, BAPsych(Hons) · Sue M Evans BN, GradDipClinEpi · Brian J Smith MB BS, GradDipClinEpi, PhD · Jesia G Berry BHSc(Hons), GDPH

On 18 January 2003, Canberra experienced major bushfires. Over 6 hours, The Canberra Hospital Emergency Department treated 139 patients, 105 with fire-related problems (mostly ophthalmological and respiratory), representing an additional workload of one patient every 4 minutes above average. Only 15% required hospital admission. We believe this is the largest single emergency department response to a disaster since Cyclone Tracy devastated Darwin in 1974, although the total severity of injury was relatively low. Major issues were communication difficulties and transport, with most patients (including the two most critically ill) arriving by private vehicle. Overall, medical outcomes were excellent, and the hospital system coped well. On Saturday, 18 January 2003, bushfires hit Canberra, the national capital of Australia. Driven by hot westerly winds, wildfire swept through most of the urban bushland in the southern suburbs, crossed the bush–urban interface, and penetrated deeply into the westernmost urban area, destroying 501 homes and causing four deaths (Box 1). We describe the response at The Canberra Hospital, which is the regional major trauma service and the community hospital for the southern suburbs of the city. 1 Canberra, 18 January 2003 View south-west from Red Hill, showing fires burning on Mount Taylor, within the southern suburbs of Canberra. Woden Town Centre is in the centre of the skyline, with The Canberra Hospital on the left. (Photo courtesy of Brian Gunning, published at http://canberrafires.xsnet.org.) Canberra, in the Australian Capital Territory, is a planned city with a population of about 300 000. It is roughly divided into northern and southern sections by Lake Burley Griffin and features large tracts of bushland within urban areas. The Canberra Hospital is one of two public hospitals in the city. It is a modern, tertiary hospital of 483 beds, of which 362 were nominally available, and an Emergency Department (ED) which treats 52 000 adult and paediatric patients annually. The hospital has a regularly reviewed external disaster plan, which had been tested in a tabletop exercise 2 months before the bushfires. That exercise concerned a bombing causing multiple burns, but, like previous exercises, involved multiple casualties from one site rather than the effects of a geographically extensive disaster. The fires caused more property damage than any single recorded Australian fire except that at Mount Macedon in Victoria on “Ash Wednesday” (16 February 1983), when 628 homes and seven lives were lost.1 However, there were multiple fires at multiple sites on Ash Wednesday, as well as in Tasmania on 7 February 1967, which caused much more damage overall than the Canberra fires. ACT police took an aggressive approach to evacuation, which contributed to an extremely low ratio of deaths to property damage (Box 2). The Canberra Hospital response On the basis of available information, the ED staff specialist activated the “Standby Code Brown” (external disaster) procedure at 14:30 on 18 January. The Chief Minister of the ACT declared a state of emergency at 14:45.2 The first patient with a major fire-related presentation (exacerbation of chronic lung disease) arrived at 15:35, and the first patient with burns at 16:30. At 17:00, “Code Brown” was activated in response to three events in rapid succession: unexpected radio communication from a helicopter about to land with three injured fire fighters, loss of all computing facilities due to network outage, and loss of the power supply to the medical imaging department. Disaster mode was maintained until 09:00 the next morning. PatientsThe patients treated at The Canberra Hospital represented all the cases of serious injury and most cases of significant injury from the fires. Minor injuries were treated by general practitioners in private surgeries and evacuation centres, and almost no fire-related cases were seen at Calvary Hospital, the public hospital on the north side of Canberra, during the first day. Our description of patients is based on data from the Emergency Department Information System (EDIS), medical records, and the debriefing process. As part of the response, clerical staff identified disaster-related cases on arrival; these were later audited by the authors and other ED staff. Usually, the relationship to the fires was obvious, but, in doubtful cases, the definition was a clinical decision that the patient would not have presented had the fires not occurred. Over the 6 hours from 16:00 to 22:00, the ED treated 139 patients, 105 of whom had fire-related problems (Box 3). This represents 90 more patients than average, or one additional patient every 4 minutes. As in similar Australian fires, respiratory and ophthalmological problems were more prevalent than burns3,4 (Box 4). Only two patients required transport to interstate burns centres, and there were no deaths in hospital. Unlike many disasters, a significant feature was the continuation of “background” ED workload (Box 5). Even during the critical 6 hours, there were 34 non-fire-related presentations, and the expected fall in other workload did not occur until the following day. There was little opportunity to divert patients elsewhere, as The Canberra Hospital is the major tertiary hospital in the region and offers the only paediatric, acute orthopaedic, neurosurgical and major trauma services. Twenty-one people presented requesting supplies of their usual medications, as their homes had been destroyed or were inaccessible. These requests were concentrated in the first 16 hours. Medications commonly required were insulin, antipsychotics, antihypertensives and home oxygen. This was also reported as a major problem by a general practitioner (GP) working in one of the evacuation centres. The hospital’s GP liaison was contacted about this problem on the morning after the fires, after which GPs visited the evacuation centres and provided prescription and other services. StaffingThe fires occurred during school holidays and the hospital’s medical changeover period, when junior staff move to new positions, often interstate. Many regular staff were out of the city, and many of the previous year’s staff had already left. During the disaster, the ED medical workforce was boosted by staff working overtime and by 14 staff not rostered to the ED that day, including four from outside the hospital. Some of the staff contacted were unable to attend because of fire in or near their homes, and some responded without returning home, working while unsure whether their properties had survived. A major contribution was also made by a small number of relevant hospital specialists (plastic surgery, general surgery, respiratory medicine) and outsiders, including an emergency physician who travelled from Sydney. Issues and lessonsThe major issues that became apparent from the disaster were transport and communication difficulties, both of which are well recognised. Use of private transport: Sixty percent of disaster patients and 30% of those who required hospital admission arrived by private vehicle (including the two most critically ill). Although this made little difference to the hospital response on this occasion, it might be a major problem when multiple hospitals are involved, and pre-hospital personnel have the task of balancing workload between institutions. The experience was similar in the Granville rail disaster (1977)5 and Cyclone Tracy,6 and had been specifically predicted as a problem in the most recent Canberra Hospital disaster exercise. The high use of private transport during this disaster is an important lesson for the national capital, where exposure to chemical, biological or radiological weapons is considered a real threat. As there appears to be no realistic prospect of containing an exposed population, services must plan around patients presenting by private transport and requiring decontamination at hospitals.7 Communication difficulties: Communication was hampered by disruption of the mobile phone network, and also by the lack of a television, radio or adequate mobile phone coverage in the disaster control room, which was therefore moved to a more appropriate location. It should perhaps be noted that mobile phones were not a significant means of communication when the disaster plan was last activated (the landslide at the Thredbo ski resort, 19978). Communication lines with the ACT Emergency Control Centre remained open, but little or no information relevant to the hospital response was available, as the Emergency Services Bureau experienced significant command and control problems.2 In addition, it was found that the key hospital staff were unfamiliar with the two-way radios provided as part of the disaster plan, and that there was no STD telephone in the room designated for relatives, both of which increased the load on the hospital switchboard. Electricity supply: Fluctuations in the electricity supply caused by the fires led to frequent power outages. In retrospect, the hospital should have continued to use its emergency generators until the disaster was over. Operating theatre standby for “major cases”: All non-urgent surgery was cancelled, and operating theatres set up to receive “major cases”. This proved unnecessary, as no such cases presented, and also significantly delayed surgery, particularly acute orthopaedic surgery, increasing hospital bed use. Emergency department triage officer: Within the ED, it was found that experienced triage nurses provided a more appropriate triage service than the ED registrars designated in the disaster plan. While senior medical input may be required (for example, when a decision is needed about withholding care because of “expectant death”), triage and other tasks should generally be allocated to the most experienced staff. External liaison: A need for prescription and other GP services at evacuation centres became apparent. GP after-hours services should be opened early, and GPs should be asked to attend evacuation centres early in the course of a disaster. Photographic documentation: A less important failure was the lack of any photographic documentation of the disaster response for historical and teaching purposes. Although volunteers, such as medical students, were available, none were allocated to “camera duty”. Hospital evacuation: Fire came to within 2 km of the hospital campus (Box 1), but little thought was given to the possibility that it might reach the hospital. Although unlikely, this is a potentially catastrophic event which should be included in future planning. In light of The Canberra Hospital experience, detailed plans were drawn up for the evacuation of Calvary Hospital when fire threatened the northern suburbs of Canberra a few days later. ConclusionsBy definition, a disaster is an event that overwhelms available resources. Many internal and external hospital disasters have been described, with different workloads falling on a range of hospital services. In this case, the major burden clearly fell on the ED. The overall ED workload on 18 January was 252 presentations, almost 7 standard deviations above the daily mean of 137 for the period 1998–2002. However, the number of admissions (52) was less than 3 standard deviations above the mean for this period (34), and, measured by admissions, this was only the 14th-busiest day in the past 5 years. To our knowledge, this is the highest number of patient presentations from a single event treated in one ED since Cyclone Tracy devastated Darwin in 1974.3,5,6,9 It represents one of the largest responses to a disaster ever by a single Australian hospital, although injuries were less severe overall than in many other disasters. Overall, The Canberra Hospital coped well, despite significant disruption of staffing and infrastructure. Disaster conditions exposed some weaknesses in previous planning, particularly patient transport and the possibility of hospital evacuation, but the medical outcomes of the response were excellent. Most of the problems which occurred involved interdepartmental or interagency issues. 2 Significant single urban or rural fires in Australia in the past 40 years1 Date Location Deaths Homes lost Ratio 16 Feb 1983 Mt Osmond, SA 9 100 1:11 16 Feb 1983 Beaconsfield, VIC 21 238 1:11 7 Feb 1967 Hobart, TAS 20 310 1:16 14 Jan 1964 Dandenong, VIC 8 454 1:57 16 Feb 1983 Mt Macedon, VIC 7 628 1:90 8 Jan 1994 Como, NSW 1 101 1:101 18 Jan 2003 Canberra, ACT 4 501 1:133 3 Hourly workload during the disaster * Average weekend workload during the fourth quarter of 2002. 4 Major fire-related presentations at The Canberra Hospital, 18–19 January 2003 Condition Presentations Admissions Breathing problems/smoke inhalation 65 10 Eye problems (irritation, ulcer, foreign body) 43 0 Trauma (falls and motor vehicle) 45 6 Burns 24 10 Medication issues* 21 0 Accommodation and chronic disease† 5 5 Other 30 5 Total 233 36 *Supply of usual medications required by people unable to return home. † Person with chronic disease requiring emergency accommodation. 5 Daily workload for the fortnight in January 2003 that included the bushfires

Drew B Richardson FACEM · Sashi Kumar FACEM

The protracted and costly investigations into Camden and Campbelltown hospitals (New South Wales), The Canberra Hospital (Australian Capital Territory), and King Edward Memorial Hospital (Western Australia) recently uncovered significant problems with quality and safety at these institutions. Each investigation arose after whistleblowers alerted politicians directly, having failed to resolve the problems using existing intra-institutional structures. None of the substantiated problems had been uncovered or previously resolved by extensive accreditation or national safety and quality processes; in each instance, the problems were exacerbated by a poor institutional culture of self-regulation, error reporting or investigation. Even after substantiation of their allegations, the whistleblowers, who included staff specialists, administrators and nurses, received little respect and support from their institutions or professions. Increasing legislative protections indicate the role of whistleblowers must now be formally acknowledged and incorporated as a “last resort” component in clinical-governance structures. Portable digital technology, if adequately funded and institutionally supported, may help to transform the conscience-based activity of whistleblowing into a culture of self-reporting, linked to personal and professional development.

Thomas A Faunce BA LLB(Hons), BMed, PhD · Stephen N C Bolsin MHCA, FRCA, FANZCA, MRACMA

There was an increase in the frequency of rugby union spinal injuries worldwide during the 1970s and early 1980s. The United Kingdom and Australia have since had some success in reducing this increase in spinal injuries. These changes were the result of actions by rugby union authorities in response to recommendations by medical advisors; legal action by injured players has also played a part. The frequency of spinal injuries has not decreased in New Zealand (up to 2000) and South Africa (up to 1997). Rugby union authorities’ responsibilities should include establishing and maintaining national and international spinal injury registers to forge closer working relationships with medical researchers. Such registers would provide up-to-date information for enhancing and developing preventive measures. There has been no specific publicly available record of the incidence of rugby union spinal injuries in Australia since 1996, so it is uncertain whether the safety measures introduced so far have had a lasting impact.

Paul T Haylen BECivil(Hons), MBA

In November 1999, in the United Kingdom, a woman was convicted of the murder of her two infant sons. An appeal against the conviction was dismissed in October 2000, but the conviction was quashed by a second court of appeal in January 2003. Review of the autopsy findings showed that standard procedures had not always been followed, thus limiting verification of the alleged findings. Some potentially important diagnoses and conclusions were also altered over time. This case and its sequelae demonstrate the difficulties that may arise if cases are not fully investigated by pathologists with specific training or experience in paediatric forensic pathology, with all of the results being clearly summarised and discussed in autopsy reports. Trying to clarify findings, diagnoses and circumstances of death at a later stage may simply not be feasible, owing to a wide variety of possibilities other than inflicted injury. This type of case has unfortunately led to mistrust of the medical and legal systems and has made the investigation of such emotive and tragic cases all the harder.

Roger W Byard MD, FRCPath

Susan D Huckson Project Manager, National Institute of Clinical Studies, 499 St Kilda Rd, Melbourne, VIC 3004. shucksonATnicsl.com.au To the Editor: Stacey, in his recent editorial on preventing pressure ulcers, stated that it is a major challenge to successfully implement guidelines in clinical practice and that a combination of strategies is required.1 In this context, your readers may be interested in the new pressure ulcer resource guide, developed by the National Institute of Clinical Studies (NICS).2 The resource guide provides health professionals and consumers with easy access to: the latest guidelines; literature reviews; health professional and consumer information resources; current Australian research activities, journal articles and papers; and links to a range of groups undertaking significant work in this area. The guide was developed in consultation with leading experts and professional groups with a strong interest in the management of pressure ulcers in Australia. This guide is an example of the efforts of NICS to help healthcare organisations and practitioners improve patient care by providing them with access to the best available evidence, proven strategies, tools and resources. The guide can be freely accessed from the NICS website www.nicsl.com.au (under “Quick Links”).

Susan D Huckson

Adrian B Wenban Associate Governor, Australian Spinal Research Foundation, PO Box 1047, Springwood, QLD 4127. adrianwenbanATwanadoo.es To the Editor: Bogduk, in his recent clinical update on management of chronic low back pain, stated that “zygapophysial joint pain can be relieved by radiofrequency neurotomy (E2, E3), and techniques are emerging for treating sacroiliac joint pain and internal disc disruption (E2, E3, E4)”.1 (E2, E3 and E4 refer to the levels of evidence: E2 evidence is obtained from at least one properly designed randomised controlled trial; E3 from pseudorandomised controlled trials or comparative studies; and E4 from case series, either post-test or pre-test and post-test.) I have two concerns about this statement. Both involve the fact that at least three systematic reviews (E1 level of evidence) have now been published on treatment of lumbar zygapophysial joint-mediated low back pain with radiofrequency procedures.2-4 Together, these three reviews cast considerable doubt on Bogduk’s claim about the role of radiofrequency neurotomy. My first concern is that the earliest of those systematic reviews,2 which came to a very different conclusion from that of Bogduk, was published in 2001, well before he submitted his clinical update to the Journal on 16 July 2003. Yet, he does not mention that review, even though he was obviously aware of it, as evidenced by his letter to the journal Regional Anesthesia and Pain Medicine expressing concern with the methods underpinning the review.5 Even if Bogduk disagrees with the conclusions of that review, justification for excluding it from the evidence base of his recent clinical update seems warranted. Secondly, two more recent systematic reviews3,4 have come to conclusions very different from those of Bogduk on the role of radiofrequency neurotomy in treatment of lumbar zygapophysial joint pain. The first of those two reviews, from the Cochrane Collaboration Back Review Group, concludes: “There is . . . conflicting evidence for its [radiofrequency denervation] effectiveness for lumbar zygapophysial joint pain. There is limited evidence suggesting that intradiscal radiofrequency may not be effective in relieving discogenic low back pain. Further high-quality randomized controlled trials are needed, with larger patient samples and data on long-term effects, for which current evidence is inconclusive.”3 The second review concludes: “Current studies fail to give more than sparse evidence to support the use of interventional techniques [zygapophysial injections and radiofrequency denervation] in the treatment of lumbar zygapophysial joint-mediated low back pain. This review emphasizes the need for larger, prospective, randomized controlled trials with uniform inclusion and exclusion criteria, standardized treatment, uniform outcome measures and an adequate duration of follow-up period so that definitive recommendations for the treatment of lumbar zygapophysial joint-mediated pain can be made.”4 In summary, authors who knowingly exclude important relevant evidence from clinical updates should at a minimum justify the exclusion of that evidence. Given the collective weight of recent relevant systematic reviews, considerable doubt now exists about the role of radiofrequency procedures in the treatment of lumbar zygapophysial joint pain.

Adrian B Wenban

Nikolai Bogduk Director, Department of Clinical Research, Royal Newcastle Hospital, David Maddison Building, Newcastle, NSW 2300. mgillamATmail.newcastle.edu.au In reply: Although systematic reviews have identified three studies of lumbar radiofrequency neurotomy, they do not take into account technical errors in the procedure. Neither the study of Gallagher et al1 nor that of Leclaire et al2 used techniques that could coagulate the target nerves accurately, consistently, and thoroughly.3 Therefore, these studies are not a measure of the efficacy of the procedure when performed correctly and have no place in a systematic review. Nor are systematic reviews permitted to include complementary, observational studies like that of Dreyfuss et al.4 Yet, this study sets the benchmark for what outcomes can be achieved, if and when correct techniques are used. The “conflicting” evidence reported by systematic reviews arises because inaccurate surgical techniques are used. When studies using inaccurate techniques are eliminated, there is no conflict. The literature reduces to one controlled study5 and one complementary study.4 These were the studies that I cited in the clinical update on chronic low back pain.6 In the face of that literature, the conclusion that I proffered, and which Wenban has quoted, is valid. Zygapophysial joint pain can be relieved by radiofrequency neurotomy. Perhaps the extra words that are required are provided that correct techniques are used.

Nikolai Bogduk

Winston Chong Chair, Interventional Radiology Reference Group, Level 9, 51 Druitt Street, Sydney, NSW 2000. ranzcrATranzcr.edu.au To the Editor: I refer to the recent editorial on “Metformin and serious adverse effects”.1 I would like to highlight the position of the Royal Australian and New Zealand College of Radiologists (RANZCR) on the use of metformin hydrochloride when administering intravascular contrast media. The RANZCR has adopted an evidence-based approach in formulating its guidelines. The College guidelines on metformin hydrochloride and intravascular contrast media are available at <www.ranzcr.edu.au/open/policies/diagnostic_imaging/pol1_2.htm>. The current guideline is that there is no need for patients to stop taking metformin hydrochloride for 24–48 hours before administration of an intravascular contrast medium. Stopping or continuing to take metformin depends on the patient’s renal status, and the likelihood of inducing renal dysfunction when intravascular contrast is administered. If discontinuation is required, then the drug only needs to be stopped for 48 hours, commencing on the day of administration of intravascular contrast.

Winston Chong

Janelle C Nisbet,* Joanna M Sturtevant,† Johannes B Prins‡ * Endocrinology Registrar, † Renal Specialist Pharmacist, ‡ Director of Diabetes and Endocrinology; and Professor of Endocrinology, University of Queensland, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, QLD 4102. jprinsATsoms.uq.edu.au In reply: Chong’s letter highlights some important issues, and his points are well made. As we imply in our editorial,1 the evidence base on which to base guidelines and decisions is poor, which is one of the reasons that the guidelines differ widely between countries and organisations. Specialty-specific guidelines must also take into account practicalities. We elected to follow the more conservative end of the guideline spectrum in our suggestions, accepting that, in many circumstances, these would be difficult or impossible to follow. From a radiological perspective, it would require a significant change in practice to implement guidelines such as those we suggested, and the evidence base supporting such a change does not exist. Metformin is a short-acting drug and stopping it at the time of a potentially hazardous procedure will almost always be effective in preventing drug-related complications. Overall, the aim of our article was to raise awareness of the potential hazards of metformin use, and to encourage practitioners to follow available and relevant guidelines.

Janelle C Nisbet · Joanna M Sturtevant · Johannes B Prins