Leading Australian doctors and clinical researchers set new priorities

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)

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”.

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.

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.

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”.

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.”

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.