Volume 181 Issue 11

Health statistics say we’re doing well, but our healthcare system is in crisis; we need more than just another report Australians have never enjoyed such good health as they do now. Our life expectancies reach well beyond the biblical ideal of “threescore and ten”, and we rank among the top four in the world’s longevity league.1 However, there is a caveat: the poor health and short lives of Indigenous Australians continue to be a blot on the nation’s psyche. The quality of our healthcare also ranks highly. In a recent comparison of selected health indicators in five nations — Australia, Canada, New Zealand, the United Kingdom and the United States — our survival rates for breast, cervical and colorectal cancers were high, as were our performances in screening for breast and cervical cancer.2 Furthermore, Australia’s mortality rates for asthma and acute myocardial infarction were the lowest among the nations. Our vaccination rates for polio and influenza were exemplary, but the incidence of pertussis in Australia was the highest among the five nations.2 We could do better. Australia’s general practitioners also perform well.3 Most Australian adults reported being with the same doctor or place of care for more than 5 years, and most received appointments on the day they were ill, although after-hours access to primary care remains an issue.3 Core features of the patient–doctor relationship and communication also rated highly: 71% of patients related that the quality of the care they received was excellent; 71% felt that their GPs listened carefully; 73% believed that medical matters were explained in an understandable way; 63% were satisfied that their doctor spent enough time with them; and 61% claimed that their management plans had been clearly outlined.3 With all these good tidings, you may well ask why Australia’s healthcare is beset by a pervasive sense of negativism? Our citizens are losing confidence, troubled by long hospital waiting lists,4 increasing hospital access block,5 and crises such as those at the King Edward Memorial Hospital6 or at Campbelltown and Camden hospitals.7 Our doctors are also unhappy — battle-weary from working in resource-poor and unpredictable environments. Furthermore, there is a swell in public impatience with the inability of politicians to confront the chaos. Playing the cost-shifting and blame-shifting game is more their forte. The causes of discontent were sought in a recent survey of medicopolitical leaders (see Box), and the perceived problems fell predominantly in the domains of funding, organisation and bureaucracy. Indeed, even the Chairman of the National Productivity Commission concurs with these views. In launching the draft Review of National Competition Policy Reforms in late October 2004, he noted: “It is now generally accepted that Australia’s health system is beset by structural problems that require nationally coordinated action. But there is less agreement on the best way forward. An independent review of the whole system is needed to provide a roadmap for reform.”8 Another review? Please! Australia’s healthcare has had more reviews than The Lord of the Rings epic. Our citizens and healthcare professionals want solutions to the problems that they experience and which have been enunciated ad infinitum. The possibility of a National Productivity Commission inquiry into health has been temporarily deflected by the activation of a small taskforce in the Department of the Prime Minister and Cabinet. It will examine the operations of the Australian healthcare system to: ensure optimum efficiency and effectiveness of healthcare service delivery for all Australians across the primary, acute, rehabilitative and aged-care sectors, and, in doing so, clarify responsibilities; ensure best use of the funds all jurisdictions put into healthcare, as well as improve accountability and transparency in healthcare funding; and identify barriers to seamless service delivery for patients and recommend options to address them. The taskforce will present its report early in 2005. As its members contemplate solutions, they may well keep in mind that: We need more time. Modern healthcare reforms have drastically eroded time — time for care, time for teaching and time for learning.9 In an ageing society, we need to provide the means for healthcare professionals to spend time with people. We need greater efficiency. Given our limited health dollars, we need to spend wisely. We can no longer afford unnecessary duplication and waste. We need a greater investment in and coordinated strategies for preventive healthcare. Incentives for “good health” will yield dividends for the future.10,11 We must support our greatest asset — the healthcare workforce. Above all, the taskforce needs to remember the “public” in public service. In this year’s federal election, the public endorsed Coalition majorities in the House of Representatives and the Senate. Having placed such trust in the government, the public is now looking for political leadership in tackling the chronic problems in healthcare. They certainly don’t want yet another report to gather dust in the Council of Australian Governments archives. In this task it may be apt to recall the words of John F Kennedy: “Those who make small revolutions impossible will make violent revolutions inevitable.” Will we have three more years of political rhetoric or will there be purposeful reform? What is wrong with Australia’s healthcare system At a recent meeting, 36 high-level medicopolitical leaders representing all states and territories as well as selected clinical craft groups were independently asked “In one sentence what do you consider to be wrong with our health system?”. Thirty-four participated. The top three responses were: Funding (8 respondents) Lack of indexed funding; inadequate funding; funding inappropriately targeted or managed; maldistribution of government benefits in the community — “money in wrong place” mismatch between funding and expectations. Healthcare system organisation (8 respondents) Demand exceeds capacity; lack of same standards nationally; system is fragmented; poor coordination; access problems; compartmentalisation; system silos and the gap in between; duplication. Bureaucracy (8 respondents) Jurisdictional divides; duplication of function; mismatch between bureaucratic and patient priorities; faceless; costly and inefficient; poor coordination; poor forward planning.

Martin B Van Der Weyden MD, FRACP, FRCPA

Medical researchers have a moral responsibility to communicate their findings to the public There is no greater commitment than a government’s investment in the healthcare of its citizens. If we, as medical researchers and practitioners, are to preserve public trust and support for our scientific enterprise, we need to pay more attention to translating the benefits and grandeur of science into the common language of the general community.1 Although educators and journalists also communicate the achievements of medical science, doctors and scientists have a greater responsibility to increase the availability and salience of science to the public. I believe we can move further towards realising this goal by keeping several key questions in our minds. How have and how can biomedical breakthroughs benefit humanity? The development of vaccines and immunotherapies is at the top of my list of major medical advances that have changed humanity’s lot for the better. During the past year, the medical crises created by epidemics of Ebola virus and SARS have demanded the creation of new vaccines, which are now poised for clinical trials.2 Other developments in medicine include antibiotics to combat infection, organ transplantation to extend life, high resolution imaging that has reduced the number of invasive surgical procedures and, most recently, the global Human Genome Project, which is revealing secrets about the basis of life. In April 2003, the world simultaneously celebrated the 50th anniversary of Watson and Crick’s description of the DNA double helix and the International Human Genome Sequencing Consortium’s completion of the human genome sequence. However, the completion of the human genome sequence represented only the beginning in genomics research; it has led to the unveiling of a bold new vision for its future.3 Translating genome-based knowledge into health benefits will be a major focus of future genomics research. Virtually all diseases, with the exception of trauma, have a genetic component and an environmental component. One of the projected outcomes of the Human Genome Project is the development of personalised medicine. All patients who share the same diagnosis for a certain disease do not respond the same way to treatment. In some cases, we are already able to determine, based on genetic profiles, which patients will be responsive to specific drugs, and then to specifically deliver the most appropriate to eradicate the disease.4 We have entered a new era of multigeneration, population-based research. This will facilitate innovative genetic studies to identify the paediatric precursors of specific adult diseases, based on the comparative analyses of genetic profiles of children, their parents, and grandparents. Imagine the possibility of identifying genes in newborns responsible for cardiac disease, or diabetes, or arthritis, or specific cancers — and then managing and/or preventing the onset of these diseases. The overall improvement in quality of life would be extraordinary, and we are closer than you might think to achieving this goal. Many scientists have suggested the concept of newborn genetic “passports” in which the complete genetic profiles of newborns will be documented in medical files at birth. On the one hand, this sounds quite exciting, but the social implications are profound. As doctors and scientists, we must act now and we must act together to establish rigorous guidelines and boundaries for the use of genetic informatics with respect to: health insurance; genetic information and the workplace; genetic privacy and confidentiality; and, the forensic use of genetic information. Accordingly, the US National Human Genome Research Institute in Bethesda, Maryland, has developed the Ethical, Legal and Social Implications Research Program to ensure that genetic research is conducted in an ethically sound manner; that genetic technologies are integrated appropriately into clinical and non-clinical settings; that genetic information is correctly interpreted and appropriately used; and that health professionals and the public become more genetically literate.3 How important is advocacy in supporting the mission of research and addressing critical social issues? John Porter, former Illinois Congressman and Chairman of the US Subcommittee on Labor, Health and Human Services, and Education, stated: Since most members of Congress are not scientists, citizen scientists must individually inform, educate, inspire, and direct their representatives regarding public policy decisions affecting science.4 When Americans were polled by Research!America about who they believe should have the most influence on how government medical research funds are spent, they indicated that patients (first) and scientists (second) should have the most influence.4 (Research!America is a not-for-profit, membership-supported public education and advocacy alliance for medical and health research.) Scientists must continue to remember that it is a privilege to be engaged in research, and that the relationship between science and society is growing ever more intimate. The spirit of enquiry behind science is not self-sustaining — it is increasingly dependent on societal support. Thus, we have a moral responsibility to be good stewards of this support and to communicate our findings to the public in order to build on that trust and seek broad input. It is critical for greater success that advocacy groups work together for better healthcare and biomedical research. Typically, in the US, joint advocacy on many issues will involve the Association of American Medical Colleges (AAMC), research institutes, academic institutions, hospitals, state and local organisations, voluntary health associations, philanthropic foundations, individuals, and business and industry, as well as biomedical professional societies. As a representative of American scientists, I have valued opportunities to work closely with the US Congress. From 2000–2002, I was privileged to serve as President and Immediate Past-President of the Federation of American Societies for Experimental Biology (FASEB) — over 70 000 scientists speaking with one voice. Through directed advocacy effects of “acting now and acting together” we were successful in: doubling the NIH budget (1999–2003), from $13.6 billion to $27.2 billion; securing federal funding for human embryonic stem cell research; supporting genetic non-discrimination legislation to protect the use of private, genetic information (a work in progress); and developing debt-relief programs for physician–scientists to encourage this endangered species into the pipeline. What are the economic benefits of investing in research? Simply put by the Lasker/Funding First Foundation, “Investment in research saves lives and money”. Increases in life expectancy have contributed to national budgets. For example, in Australia between 1960 and 1999, longevity improved from 73.9 years to 81.8 years for females and from 67.9 to 76.2 years for males, at an estimated worth of $5.4 trillion.5 With respect to government support of biomedical research, the statistics when comparing the US with Australia were astonishing to me. I have recently learnt that in the 2000–2001 budget year, whereas the budget for the NIH was $17.8 billion, the Australian Commonwealth budget for health and medical research was a more modest $665 million.5 This represents a fourfold difference per citizen, with the US government spending about $130 per person and the Australian government about $33. I felt humbled, acquiring a more profound respect for my world-class Australian medical research colleagues, who, with truly limited resources, have made significant contributions to the field. Among these contributions are the discovery of lithium in treating bipolar disorder, as well as major advances in childhood diseases of spina bifida and sudden infant death syndrome. Australian researchers have also discovered a powerful secret to success — working collaboratively in interdisciplinary teams towards a common goal. Researchers around the world could all learn a lesson from Australian scientists; as the US budget for research begins to shrink, American scientists will have to adopt the Aussie philosophy in order to survive in the “business”. With competing demands on government resources, who will pay for tomorrow’s discoveries? I believe that projects leading to future discoveries will be paid for by creative partnerships between academic, philanthropic, corporate and government agencies. I also believe such projects should be guided by advocacy, led by scientists, to advance treatments and cures. We should always remember the wise words of Paul Rogers, Chair of Research!America: “Without research, there is no hope.”

Mary JC Hendrix PhD

The medical workforce needs of the Pacific islands, Papua New Guinea (PNG) and East Timor (see map) are vastly different from those of their richer neighbours such as Australia and New Zealand. In these developing nations, 50%–90% of the population live in rural areas (as opposed to 10%–15% in Australia). Their gross national product (GNP) is US$500–$2000 per capita, with 2%–5% of gross domestic product (GDP) spent on healthcare (compared with Australia’s $20 000 per capita, with 9.7% of GDP spent on healthcare). In Australia and New Zealand, there are about 2–2.5 doctors per 1000 population, while, in the Pacific, the ratios are about 20 times less, at 0.1–0.4. The age distribution of the population is also very different: 30%–40% of people are aged less than 15 years and only 5% are over 60 (compared with 20% under 15 years and 15% over 60 in Australia). The health of Pacific islanders is poor when defined according to standard indicators such as life expectancy at birth, infant and under-5 mortality, and maternal mortality (Box 1). The low ratio of doctors, nurses and other healthcare workers to the total population is unlikely to improve rapidly because of the lack of capacity for training. Today’s workforceThe current medical workforce in the Pacific region is made up of doctors who have been trained in a variety of ways: Locally trained graduates of Bachelor of Medicine and Bachelor of Surgery (MB BS) courses from the University of Papua New Guinea (UPNG) and the Fiji School of Medicine (FSM). Some of these doctors have also trained as specialists through local or overseas postgraduate training programs (see Kevau et al, page 608).1,2 Graduates from the Pacific Basin Medical Officers Training Programme (PBMOTP), which was run by the University of Hawaii in the Federated States of Micronesia from 1986 to 1996 (Box 2). The program trained 50 medical officers from Micronesia and 20 from Belau, the Marshall Islands and American Samoa. Most are now working in their own countries in the North Pacific region. Doctors from Pacific island countries who are employed in neighbouring countries on contracts that attract better remuneration, if not better hospital facilities, than that of their home country. Doctors from Europe, the Indian subcontinent, South-East Asia, or Australasia. Some are volunteers, some are associated with non-government organisations, and some are salaried members of the departments of health or universities in the countries in which they work. A small number are funded by overseas aid programs (eg, in East Timor). These doctors were the main providers of medical care until local training programs began. A handful have stayed on in specialties (eg, radiology, pathology) in which local trainees have not yet filled all the available posts or in remote hospitals funded by overseas aid or missions. Doctors from countries such as Cuba and China who have been sent to work in Pacific countries as a result of government-to-government discussions, but with little consultation with specialists in the Pacific region (local or expatriate). (This has occurred in East Timor and PNG.) The medical workforce in any Pacific island country represents a variety of attitudes and cultures as a result of doctors’ different backgrounds and training. For example, in Micronesia, there are 50 PBMOTP graduates with diplomas, six graduates with an MB BS from PNG or Fiji, and one with an MD from the United States (John Hedson, Chief Surgeon, Micronesia, personal communication). Knowledge and professional attitudes vary, despite the government classifying all doctors in the same way. There is reasonable mobility of specialists around the Pacific. For example, the Marshall Islands, Tonga, the Cook Islands and Fiji have all employed surgeons trained in PNG in recent years. Thirty per cent of doctors in Fiji are expatriates, as a result of the high attrition rate of local doctors — in the past 5 years, 40% of Fijian graduates have gone into private practice or left Fiji. Many Fijian doctors have gone to Australia or New Zealand, their residencies being supported by citing an “area of need”. As Australia is short of junior doctors and of doctors willing to work in rural and remote areas, governments and departments of health are only too happy to recruit well qualified overseas doctors to fill the local void, regardless of it being a case of “the rich robbing the poor” (see Baravilala and Moulds, page 602).5 Once these doctors leave their countries it is always difficult to return home. Medical salaries in the Pacific nations are not competitive with those in Australia and New Zealand (eg, the salary of a PNG doctor is about A$13 000–$30 000 a year). The longer a doctor spends working and training overseas, the harder it is to uproot the family, particularly if children are already established in school. There is, for example, no international school in the Solomon Islands. The first UPNG national graduate (Professor Sir Isi Kevau), who trained as a cardiologist and gained Fellowship of the Royal Australasian College of Physicians, has recently been knighted in recognition of his contribution to local medical school training and healthcare in PNG and for his sacrifice in making the decision to return home after living for some years in Sydney. Training the workforceUndergraduate training Scenario 1 Dr A did a 4-year specialist training program, one year of which was spent in Australia on a scholarship. His performance was impressive and his supervisors felt sorry for him having to return home to shortages, poor remuneration and fewer educational opportunities for his children. The consultants arranged a paid position and recommended he stay to study for a “Fellowship of the Royal College” — in their minds, a “real” qualification — rather than his MMed, a degree they knew little about. Dr A was smart and hardworking. After 4 years he gained his Fellowship, but by then he was more comfortable practising in Australia. He never returned home. His children were well educated and became Australians. Fiji, the Pacific islands and PNGThe predecessor of the FSM was founded in 1885.6 Until 1960, it was the only institution in the Pacific training doctors. Between 1951 and 1964, it also trained 16 national doctors for PNG before the Papuan Medical College was started in 1962 (see Kevau et al, page 608).1 Since the founding of its medical school in 1968, the UPNG has produced over 700 doctors, including 100 Pacific islanders and 50 expatriates. The attrition rate from the public service is about 50%.7 (Most of the doctors who leave the public service take up private or general practice or go to neighbouring Pacific countries. Some go into administration or politics.) The FSM commenced a 6-year MB BS course in 1982. The FSM is the principal medical school for the Pacific islands, and both undergraduate and postgraduate programs include a number of Pacific islanders. Together, the UPNG and the FSM have the capacity to produce about 120 doctors a year. In both institutions, courses based on problem-based learning have been adopted (see Duke, page 612).1,2,8 The majority of doctors working in the Pacific have been trained in the Pacific. However, the capacity of these countries to increase the medical workforce and improve doctor -to-population ratios is limited. There are not enough places in the two medical schools in the region and insufficient funds to recruit large numbers of doctors from elsewhere. Although the number of graduates is about half what is required, the available staffing and resources are stretched enough as it is and would be unlikely to be able to train more at today’s standard. Scenario 2 Dr B had the same experience as Dr A, but did return home. It was a difficult decision for him and his family after gaining his Fellowship. But he re-established himself back home, sent his children to the government school, was gradually promoted through the ranks of the local medical school and became an academic, one of the country’s leading doctors, and an inspiration to young national doctors. Workforce and training in East TimorEast Timorese doctors have been trained in Indonesian medical schools. After the vote for independence in 2000, the country’s infrastructure was destroyed by the departing Indonesians, although the hospitals were not damaged. There are currently 46 qualified East Timorese doctors, but only 23 are working for the government, with just 17 in clinical work. There are no practising local specialists. Non-government organisations staff some of the hospitals and health facilities in the provinces. Specialist care in East Timor is provided by a few doctors whose positions are funded by the Department of Health or by aid projects, such as those managed by the Royal Australasian College of Surgeons (RACS) and HealthNet (a Dutch non-government organisation, formerly CORDAid). The service provided is supplemented by visiting specialist teams (Box 3) (see Beckett, page 603).9 Postgraduate and specialist trainingSome of the benefits of running a local postgraduate program are that doctors-in-training work for most of the time in their own country, learn to diagnose and treat disease with the resources available, and are less likely to leave once qualified. Before the commencement of a local Master of Medicine (MMed) program in Fiji in 1997, only five of the 56 doctors who went overseas for specialist training returned. This led the FSM to believe it was training doctors for Australia and New Zealand! By contrast, local training, using external examiners, has been shown to encourage retention of doctors in the Pacific region, while still achieving a high standard. Scenario 3 Dr C was one of the first to graduate as a subspecialist. After working for a year on a low wage and feeling frustrated by constant shortages of essential items and equipment, she decided to go into private practice. For 2 years she continued to do some private specialty procedures, but gradually became less confident. She was not aware of the latest advances in her specialty and could not afford to attend overseas meetings. Ten years after graduating as a specialist, Dr C did only general practice. Her children were all well educated at private schools, but she never felt fulfilled. The local Department of Health felt resentful of the wasted investment in Dr C’s training. The main means of specialist training in both PNG and Fiji is university-run 4-year MMed courses. Both countries offer 1-year diploma courses in child health, obstetrics and gynaecology, and anaesthesia. Fiji also offers a surgery and medical diploma, while PNG offers a diploma in ophthalmology. Passage to the MMed course depends on a good grade at diploma level. Diplomates would be expected to be able to provide safe care in a rural district or provincial hospital. Since its inception in 1975, the MMed program at the UPNG has trained 132 specialists in medicine, surgery, child health, obstetrics and gynaecology, psychiatry, ear nose and throat, and ophthalmology (see Kevau et al, page 608).1 The program has successfully trained specialists from the Solomon Islands and Micronesia. In Fiji, diploma courses and MMed training were begun in 1997, with the first MMed students graduating in 2001. By the end of 2003, 74 diplomas had been awarded by the FSM (in anaesthesia, internal medicine, obstetrics and gynaecology, paediatrics, surgery, community and hospital practice), and 17 candidates had completed the MMed degree (in anaesthesia, internal medicine, obstetrics and gynaecology, paediatrics, and surgery). Of these graduates, 68 diplomates and 12 masters graduates were practising in Pacific island countries.2 About 10 medical officers trained under the PBMOTP have done a year of further training at the FSM to obtain a specialist diploma. A handful of these doctors have undergone further specialist training.4 Subspecialty trainingDuring the 1990s, PNG saw the need to train some of its general surgeons in surgical subspecialties. In 1994, programs in orthopaedic surgery, head and neck surgery and urology were started, with paediatrics and neurosurgery later added. These programs involve both in-country and overseas training for 2–3 years after obtaining an MMed and working as a general surgeon. Specialty associations in Australia have provided the trainers and hospital positions to support the program.10 Scenario 4 Dr D was a promising young specialist who, with the support of Australian aid, spent a year of training in Australia during his MMed course. This gave him a rewarding year of training and also provided him with a network of contacts and a desire to seek better remuneration. He finished his training back home and worked for a year as a specialist. Citing “area of need”, he was appointed to a general practice position in a remote hospital in Australia, and to this day works as a GP rather than in the specialty for which he was trained by his home country. A similar model was used to train orthopaedic surgeons in both Fiji and the Solomon islands through the support of Orthopaedic Outreach and the Australian Orthopaedic Association. Fiji’s experience of the specialist “brain drain” has led it to favour the PNG model of establishing a local subspecialty program rather than risk losing further specialists to Australia and New Zealand. Complementing specialist and tertiary health servicesVisiting specialist teamsDespite the improving standards of local specialists in the Pacific region, there is still a need to complement their skills and capabilities with the skills of visiting specialists. Teams visit one or two centres over a 2-week period, performing procedures on cases selected by the local doctor or specialist. Interplast,11 eye assessment and surgery teams,12 the Australian Orthopaedic Association and Orthopaedic Outreach have been performing this sort of work for some decades. In 1995, a Pacific Island Project was developed by the RACS to formalise Australian government support for visiting surgical teams.13 A similar program in PNG is the PNG Tertiary Health Services Program.7,10 The visiting teams treat patients using specialist equipment and expertise and pass on skills to local practitioners. They may also support local training programs. For example, a neurosurgeon on a 2-week visit may give undergraduate lectures and postgraduate teaching in neurosurgery course modules in addition to treating cases and handing on skills to a local subspecialty trainee.14,15 Sending selected patients overseasThe work of visiting cardiac teams led by Alan Gale and others has produced good outcomes in PNG and the Pacific. It has also resulted in improved nursing skills in intensive care.16,17 Although there are as yet no PNG or Pacific cardiac surgeons, much of the closed cardiac surgery is done by local surgeons during cardiac-team visits.10 Scenario 5 Dr E was a trained specialist providing a high standard of care until his marriage started to disintegrate. There was an acrimonious divorce and some violence. He was suspended from practice in the public health system and this resulted in many patients receiving suboptimal care until his case was heard and he was reinstated. It took over 2 years and the retirement of some opponents before he was reinstated and able to treat public patients. Although he was able to provide some specialist care in private practice, the majority of patients in need could not gain access to him. The funding available to send a small selection of patients overseas is limited. NZAid provides some funding for certain Pacific island countries. Rotary Overseas Medical Aid for Children and other groups arrange hospital care in Australia and New Zealand on a case-by-case basis. Although patients treated overseas derive benefit because they are usually selected on the grounds of being curable, the cost of treating one patient is often equivalent to the cost of bringing in a visiting specialist team for 2 weeks, who might consult on 50 patients and operate on 25. Using the Pacific workforce to provide specialist careDoctors and specialists in Fiji, PNG and the Pacific are well trained and already provide a broad range of services.9 Their abilities are limited only by lack of resources and supporting infrastructure. However, the remoteness of much of the population and the large number of patients mean that, in practice, their skills are only accessible to a small proportion of the population. Surgical MMed graduates from UPNG in 1999. From left: Simon Mete, Director of Medical Services Port Moresby General Hospital; Okti Poki, who qualified as Higher Surgical Diplomate in Paediatric Surgery 2004 after 2 years of training in Australia; Dudley Ba'aerodo, the surgeon on Malaita, Solomon Islands, who now has an RACS Rowan Nicks scholarship to train in urology; Lister Lun, surgeon on Manus, who also performs cardiothoracic surgery with visiting cardiac teams. The development of subspecialist training has enabled specialists in the Pacific to manage more complex conditions. A shining example of this is the development of paediatric surgery in PNG, where two surgeons, trained thanks to the enthusiasm of Paddy Dewan (Paediatric Surgery Coordinator, PNG Tertiary Health Services and Pacific Island Projects) and others, are now able to competently manage anorectal and other congenital anomalies. They make visits around PNG to perform specialist procedures, and earlier this year one also headed an RACS AusAid-funded team that visited the Solomon Islands. Two PNG-based specialists also made visits to Nauru to treat asylum seekers. As capabilities develop, Pacific island specialists will be the real experts in providing specialist care in their own countries. Aid programs will need to support them with the consumables and equipment necessary to use the skills with which they have been trained (usually with the help of AusAid funding). Future visiting teams will include specialists from PNG and the Pacific islands, as well as more narrowly trained Australasian specialists. However, as there will be a manpower shortage for decades, Pacific-based specialists will be limited in how much specialist care they can provide elsewhere. Visiting teams will comprise mainly Australian and New Zealand specialists for some time to come. 1 Population and health statistics for Australia, New Zealand, Papua New Guinea, East Timor and the Pacific islands* Country Population Life expectancy at birth (years) IMR† Under-5 mortality rate‡ MMR§/100 000 live births Doctors per 100 000 population Proportion of GDP spending on health (%) Spending per capita on health (US$) GNP per capita (US$) Australia 20 M 79 6 6 8 250 9.2 1741 19 860 New Zealand 3.8 M 78 6 6 7 220 8.3 1073 13 280 Papua New Guinea 5.1 M 54 73 102 370 7 2.3 27 580 Fiji 800 000 67 19 23 27 52 3.5 55 2 080 Solomon Islands 430 000 63 22 26 549 11 11.6 11 610 Samoa 175 000 68 22 27 70 38 5.8 91 1 440 Tonga 100 000 71 19 23 197 46 3.5 56 1 410 Vanuatu 200 000 61 38 49 68 10 2.5 29 1 110 Kiribati 93 000 63 54 74 225 15 12.7 94 980 Marshall Islands 53 000 66 63 92 na 43 4.6 85 2 270 Micronesia 120 000 68 20 34 226 46 9.1 171 1 960 East Timor 850 000 na 88 124 600 4 5.9 25 440 * Sources: World Bank, UNICEF, World Health Organization. †IMR (infant mortality rate) = number of infant deaths per 1000 live births. ‡Number of deaths in children under 5 years per 1000 live births. §MMR = maternal mortality rate. GDP = gross domestic product. GNP = gross national product. na = data not available. 2 Pacific Basin Medical Officers Training Program The Pacific Basin Medical Officers Training Program (PBMOTP) was a 10-year program (1986–1996) funded by US government aid and run by the University of Hawaii. It introduced an experimental 5-year problem-based learning course, with the first 3 years being spent in rural areas and community health clinics and the last 2 years being spent in urban hospitals. The program, which ran for a strict 10-year period because funding was limited, produced 70 doctors, 50 of whom were from the Federated States of Micronesia.3,4 These doctors had practical public health and clinical skills, but not as deep a knowledge of basic medical sciences and pathology as a graduate of the University of Papua New Guinea or the Fiji School of Medicine. Their degree would not be recognised in Australasia or the United States as an MB BS or MD equivalent. However, it is recognised for entry into postgraduate programs in Fiji. 3 Specialist surgical aid program in East Timor East Timor, a small country with a population of 850 000, is among the 10 poorest nations in the world (Box 1). It receives considerable support from donor countries such as the United States, Japan, Australia and Portugal. East Timor had an organised health service similar to that of the rest of Indonesia before the independence vote in 2000. After independence, East Timor had to rebuild its health service after almost all health infrastructure and records had been destroyed and experienced doctors had departed. Hospital services were reactivated in 2000 in the capital, Dili, by the International Committee of the Red Cross and in Bacau by Médecins Sans Frontières. These programs ended in mid-2001. Since then, the running of the national referral hospital in Dili has been assisted by Healthnet (formerly CORDAid), a non-government organisation. Specialist staff in the major disciplines of surgery, anaesthesia, obstetrics, paediatrics and internal medicine have been recruited by the East Timor Department of Health, Healthnet and an AusAid program managed by the Royal Australasian College of Surgeons (RACS). The RACS program is based primarily in Dili and provides a resident surgeon and anaesthetist and visiting specialty teams. Each month, a specialist surgical team comes to undertake procedures not normally performed by the resident general surgeon. Cases are selected on the basis of requiring specialist skills and having a chance of success in a situation of limited postoperative care and follow-up. Such cases include cataract removal by ophthalmology teams and repairs of cleft lip and palate by plastic surgery teams. Paediatric surgery teams have repaired imperforate anus in a number of children who previously had only a colostomy performed at birth. Visiting cardiac surgery teams have, to date, undertaken patent ductus repairs but not open heart surgery, even though rheumatic fever, with subsequent rheumatic heart disease and congenital heart disease, is common. Common procedures performed by visiting urologists are removal of bladder stones, prostatectomy, and repair of urethral strictures. Orthopaedic teams are involved in managing congenital disease (eg, club foot) and malunion or non-union of fractures in trauma victims. Patients with cancer usually present late, staging is based on clinical assessment and plain x-rays, and surgical treatment is limited. There are currently no East Timorese surgical specialists. The future specialist workforce in East Timor will be made up of a hotch-potch of graduates from training programs in a variety of countries. Part of the RACS program is to assist in developing specialist skills in-country. To obtain recognition of their specialist training, three East Timorese doctors are starting surgical training in the UPNG program (two in general surgery and one in ophthalmology). Other East Timorese doctors have gone to other countries, including the Philippines and Portugal, for postgraduate training. Anaesthetics in East Timor are mostly given by nurse anaesthetists. Australian anaesthetists have developed an appropriate 1-year program for nurses that includes a 3-month rotation to an anaesthetic teaching department in Indonesia. Perioperative theatre nurse education has been incorporated into this program, and two primary trauma-care courses using Indonesian-speaking doctors have been successfully conducted. The challenge in training the workforce in East Timor is to develop skills appropriate for the facilities available, the local disease mix, and health budgets for the foreseeable future. It has been an important policy direction for Ministry of Health planners to design a health service that is sustainable in the medium to long term with the level of expenditure likely to be available from their own resources and firm donor country commitment. These good intentions can be overwhelmed from time to time when some overseas aid teams arrive without the necessary language skills or interpreters and with minimal financial resources to provide the technical supplies they consume in the hospitals. The concept of specialist surgical aid programs providing tertiary care has been questioned as an appropriate priority in countries with underdeveloped health services. The conventional argument is that money would be better spent on clean water, vaccination programs and village-based health centres that deliver simple, effective services. We agree that supporting primary health services is important. Nevertheless, the community also gains from access to acute hospital care for common problems such as trauma, acute infections and obstructed labour. Relatively simple surgery requiring short hospital stays can restore patients to normal health and prevent much disability. Beyond this, tertiary surgical services — again with simple surgery and short stay for conditions such as cleft lip and palate in the young and blindness due to cataract in the elderly — can restore large numbers of patients to active and economic participation in their communities. The statistics from our visiting teams support this view.

David A K Watters ChM, FRCSEd, FRACS · David F Scott MD, MS, FRACS

For more than a century, doctors who received training at the Fiji School of Medicine (FSM),1 the University of Papua New Guinea,2 or, more recently, the Pacific Basin Medical Officers Training Program3 in Pohnpei have been the mainstay of the medical workforce in Fiji and the Pacific island nations. Recently, an attempt has been made to make Fiji and its neighbours self-sufficient in medical personnel by enlarging the undergraduate student intake into the MB BS course from 50 to 70 and by establishing postgraduate specialist training programs at the FSM. However, these plans have largely been thwarted by the shortage of doctors in countries such as Australia and New Zealand, creating a vacuum that has resulted in an enormous “brain drain” of FSM graduates into those countries. Two political coups in Fiji, in 1987 and 2000, have only exacerbated the problem. Fiji School of Medicine students and consultant on rounds, Colonial War Memorial Hospital, Fiji. The size of the problemFiji has a population of about 850 000 people, and the other main Pacific island nations (excluding Papua New Guinea) have a total population of about the same size. Hence, a medical workforce is required for about 1.7 million people. The current intake into the MB BS course at the FSM is 70 students per year — or about one student per 25 000 people. By comparison, Australia, with a population of about 20 million people, has a total intake into medical courses of over 1200 per year — or at least one student per 17 000 people. The exact number of Fijian graduates from the FSM who end up working in Australia, New Zealand, the United Kingdom or the United States is unknown. However, between 1987 and 2002, a total of 510 doctors left the Fijian government health service (Fiji Ministry of Health, September 2004, unpublished data). During this time, the FSM produced 284 graduates for Fiji. Most of the doctor “drain” is to the abovementioned developed countries — so much so that a cynic might conclude that those countries are simply using Fiji and the other Pacific islands as a cheap training ground. To fill government vacancies, the Pacific island nations rely on expatriate doctors from Australia or similar Western countries, or from Asian countries such as China and India. Expatriate doctors have given excellent service to the people of the Pacific islands. However, there are problems with relying on expatriates for a medical workforce, including difficulty and cost of recruitment, language and cultural differences, and frequent mismatches in expectations between the doctors and the employing country. The morality of recruiting doctors from other developing countries whose needs are just as great as, if not greater than, those of the Pacific island nations is also obviously an issue. Are there any solutions?A lot more can be done within countries to develop incentives (and remove disincentives) for our graduates to remain in their home country rather than seek “greener pastures” abroad. For instance, the employment conditions of doctors should allow more flexible and attractive career paths for young graduates. However, the economies of the Pacific island nations will never be able to afford salaries competitive with those offered in developed countries. Appeals to national pride also tend to fall on deaf ears when the political elite are seldom good models of personal sacrifice for the good of the country. It has been suggested that any country that employs a medical graduate trained in a developing country should reimburse that country the cost of his or her training.4 This seems a good idea, but it is hard to see where the political drive will come from to force a country like Australia to reimburse Fiji the full cost of training, for instance, a specialist surgeon. Another suggestion is that the FSM should deliberately alter its curriculum to make its graduates less competent to practise medicine in a developed country. However, this would be absolutely counter to the philosophy of excellence in teaching that is at present a fundamental mission of FSM — as it should be. And the practice of medicine in the Pacific is not so different from that in a developed country as to really make this a feasible proposition. The first step must be for Australia and similar countries to admit there is a problem that must be addressed, and that it is morally unacceptable to actively recruit medical graduates from countries such as Fiji to make up shortfalls in their medical workforce resulting from their own poor forward planning. Once this is agreed, all the stakeholders should devise appropriate responses to assist the requirements of the developed countries for more health professionals, while not overly depleting Pacific countries of their doctors. A suggestion is to genuinely try to reduce the requirement for more doctors in Australia by utilising other health professionals in roles traditionally filled by doctors. Market forces cannot, and should not, be entirely removed when it comes to employing doctors. However, an unfettered market will usually lead to one party going out of business, and no one wants healthcare in the Pacific islands to go out of business.

Wame R Baravilala MRCOG, FRANZCOG, FACTM · Robert F W Moulds PhD, FRACP

How did I come to be in East Timor? That is the exact question I asked myself upon arriving in Dili, the national capital, with my husband Ben, our 2-year-old son Oscar and 6-month-old daughter Chloe in tow. It was very hot and humid and there was a real threat of a looming dengue epidemic from Indonesia. My anxiety for the health of our children was in no way eased when, a few days after our arrival, an Australian expatriate asked, “What sort of a place is this to bring kids?”. Main entrance to the Dili National Hospital I had been aware of a program coordinated by Eugene Athan, an infectious diseases physician, whereby Australian physicians could work at the Dili National Hospital. As an infectious diseases physician with an interest in medicine in developing countries, and having been assured of the political stability of the country, I put up my hand to go. Ben was able to take time off work to care for our children. After many months of planning, multiple vaccinations, and reassuring family and friends of our safety and wellbeing, we arrived in Dili in late January 2004. The Dili National Hospital is run by the East Timor Ministry of Health. The hospital medical staff consists of overseas visiting specialists, Indonesian emergency department doctors, and Timorese resident doctors working on the wards and in the outpatient department. There are no locally trained specialists — a major limitation to the long-term goal of having an autonomous Timorese hospital. I worked on the women’s medical ward for 2 months. While not arduous, the work was emotionally draining. In my first week, there were three postpartum deaths due to presumed sepsis. Like anyone, I found this difficult to deal with, but being there with my family, and still breastfeeding Chloe, made it even harder. My emotions were fuelled by the thought that one family now consisted of a husband without a wife, and four kids without a mum. The harsh reality of the estimated maternal mortality in Timor (around 800 per 100 000 live births) is that this family circumstance is not uncommon. Despite Portuguese being the official language, the majority of Timorese people speak either Tetum, Indonesian, or one of 16 indigenous languages. As my Tetum capabilities were limited to pleasantries, I relied heavily on certain hospital staff to interpret for me. Needless to say, taking an adequate history and communicating with the patients and hospital staff proved to be a challenge — like a combination of charades and Pictionary. The language barrier became even more difficult towards the end of my stint, when a Chinese medical team arrived that included doctors, a nurse and a translator. They had spent 6 months learning Portuguese, which, despite the best of intentions, was of no practical use to the majority of people at the hospital. One of the beaches within an hour’s drive of Dili. These were a favourite place for expatriates and United Nations staff to gather on Sunday afternoons. The hospital was serviced by hospital and national laboratories that performed basic testing, which was intermittently available and of variable standard. Malaria films were regularly performed, with frequent positive results. Biochemical tests, including tests for urea and creatinine, were not available during my stay. Minimal microbiological investigations (including tuberculosis smears, and serology for HIV, hepatitis B, hepatitis C and syphilis) were available. Pathology specimens were sent to Australia, with a 6–8-week turnaround time. The major medical problems I encountered at the hospital included tuberculosis, malaria, renal failure, heart failure, thyroid disease and hypertension. As all patients had varying degrees of malnutrition, I kept them in hospital for as long as possible, knowing that the hospital would provide nutritious meals. Of concern was the lack of a single positive sputum smear test for acid-fast bacilli during my stay. For whatever reason (be it deficiencies in collection, transport, processing, laboratory technique or reporting), all sputum smears were negative. Aware that this could not be accurate, I introduced antituberculosis therapies in patients for whom there was a high suspicion of tuberculosis based on clinical features and x-ray results. Of greater public health concern was the lack of mycobacterial culture and sensitivity testing facilities. A national tuberculosis control program has been established to monitor patients during treatment, but some patients did not complete their therapy and it is unclear whether drug resistance is a problem. It was hard to believe we were only a 1-hour flight away from Australia. Drug therapy options were limited to an essential drug list; however, even these, at times, were unavailable. Although we had previously worked in Africa, we found it difficult to comprehend that the national hospital of one of Australia’s close neighbours could have such limited resources. Despite their many hardships and difficulties, I was touched by the loving nature and strong sense of family among the Timorese people. They were very receptive to us as a family, but we certainly raised some eyebrows. For starters, I was working while Ben stayed at home with the kids, which many locals found amusing! Ben spent most of the time fighting off malaria and dengue-carrying mosquitoes and keeping the kids and himself cool by whatever means, including a staple diet of ice-cream for the kids and beer for himself. During weekends off, we were able to hire a car and explore many beautiful parts of the country. Having spent only a short period of time at the Dili hospital, I was grateful for the welcome I received and the warmth of the hospital staff. Upon leaving, I felt I had contributed to the health of my patients, and yet had a deep sense of sadness because it seemed that the healthcare system may worsen before it improves. So, were we foolish to take our kids to Timor? On the contrary — we believe that we took them to a place full of caring, loving and welcoming people who deserve the chance to live a better life.

Carolyn L Beckett MB BS(Hons), FRACP

I wanted to work somewhere exotic, experience a different lifestyle and contribute to health advancement in a developing country. So I was delighted when Australian Volunteers International offered both me and my partner, also a doctor, a 2-year placement (February 2002 to February 2004) in Makira Province, previously the Eastern Solomon Islands. The village of Gupuna, Ugi Island, farewells our touring team. Life in the Solomon IslandsThe Solomon Islands have a subsistence agricultural economy. Of a population of 450 000, 85% live self-sufficient lifestyles involving small-scale farming, fishing, fetching water, cooking on wood fires, building and weaving. Outside events, even major ones like terrorist attacks, seem far away. Life on fertile volcanic soil surrounded by the Pacific Ocean maintains Solomon Islanders in good health. They work hard physically and enjoy a diet rich in fruit, vegetables and fish. However, they increasingly seek to supplement their traditional diet with rice, flour, canned meats and instant noodles. Healthcare in Makira ProvinceThe major causes of death in the Solomon Islands are infectious diseases and perinatal conditions.1,2 HIV/AIDS has not yet had a significant impact there.1 Makira Province, with 33 000 people, had no doctor working either when we arrived or when we left. Kirakira, the provincial capital, has a small hospital with 86 beds — plenty for patients, with spare beds for relatives. Coping with the hospital’s unreliable medication supply was a challenge — sometimes it was well resourced, while at other times we struggled to manage, using the most suitable medication available at the time. People suffered for want of paracetamol, and died for want of oxygen. Nurses helped us manage patients with malaria, tuberculosis and congenital syphilis, as they knew more about managing these conditions than we did. The most common diagnoses of the 2322 patients admitted during our stay are shown in the Box. There is a national referral hospital in the capital, Honiara, where we could refer patients we were unable to manage in Kirakira. Together with specialist eye, reproductive health and tuberculosis/leprosy nurses, I established a program of touring the 34 clinics in the province to provide support to clinic staff and treat patients. Most clinics are in coastal villages, accessible by aluminium dinghy and outboard motor. As the villages may see no shipping for months, people must be totally self-sufficient. Clinic nurses manage most cases of malaria, pneumonia and gastroenteritis that are not managed at home. Under national policy, every village should be within 3 hours’ walk of a clinic, but the country’s economic situation has not enabled this policy to be fully implemented. Nevertheless, the patients I saw while touring were in remarkably good health. Common referrals to me were for back pain, hip pain, and dysmenorrhoea. It was difficult to advise the staff in the clinics that had no supplies and no means to transport patients. Australia is currently funding the purchase of solar-powered two-way radios for each clinic (radios must be solar-powered because supplies of consumables are unreliable). Trauma and related infectionsSkin and soft tissue infections, abscesses, joint and bone infections, and pyomyositis were common in Makira. These infections may be occupational hazards of subsistence farming, but young children and even neonates were affected. We drained copious amounts of pus under ketamine anaesthesia, but, unfortunately, we often had no suitable antibiotic treatment. We treated many cases, including osteomyelitis and septic arthritis, with oral doxycycline, erythromycin or chloramphenicol. There were about 12 motor vehicles in Kirakira, and the first-ever motor vehicle accident happened during our stay. A passenger in a utility tray was crushed against another vehicle. He fractured seven ribs on one side and nine on the other. We had no intercostal catheters to manage the haemopneumothorax, no intubation facilities, and no resources to evacuate him. Yet, amazingly, he survived with analgesia, oxygen, intravenous fluids and basic physiotherapy (“Hold your chest and blow hard!”). His high level of physical fitness, as a subsistence farmer, most likely saved his life. Non-communicable diseasesNon-communicable diet- and lifestyle-related diseases that are major causes of morbidity and mortality in Australia are only beginning to reach rural Solomon Islanders. We saw mouth cancers among betel-nut chewers, and liver and cervical cancers. Diabetes manifests with peripheral vascular disease, and hypertension with stroke. No myocardial ischaemia was diagnosed during our stay. Challenges and rewardsThe general standard of health and health services, despite the country’s economic difficulties, highlights the fine personal qualities of the people. Nurses continued working during periods when they were not paid. I recall one nurse who visited the hospital on a day when she was off duty. Noting that no nurses were working, she went home, put on her uniform, and returned to cover the day’s shift. As there was no stationery provided for health services, people carried exercise books for their health records. Patient-held records provide continuity of care from village health workers to visiting overseas specialists, and also give patients ready access to the information.3 We spent a memorable 2 years in the Solomon Islands, proving to me that overseas volunteer work is enriching and rewarding. It provides an opportunity to support colleagues in countries where healthcare staff are difficult to recruit and retain. Common diagnoses of patients admitted to Kirakira Hospital (excluding admissions for childbirth), Jan 2002–Dec 2003 Discharge diagnosis* Infants Children 1–5 years Children 5–15 years Adults Total Malaria 45 77 81 336 539 Skin infections, abscesses, cellulitis, carbuncles, impetigo 12 37 32 129 210 Trauma 0 9 37 82 128 Pneumonia 48 29 9 27 113 Gastroenteritis 11 17 0 13 41 Osteomyelitis, pyomyositis, septic arthritis 0 3 13 21 37 Tuberculosis 2 1 3 17 23 Cancer 1 0 0 19 20 * Not mutually exclusive.

Rosalie Schultz MB BS, MPH

The training of Papua New Guinean doctors began in the 1950s, when students were sent to the Fiji School of Medicine, graduating with a Diploma in Medicine and Surgery. The Papuan Medical College (PMC) was established in Port Moresby in 1962, training all health professionals, including doctors, nurses, x-ray and laboratory technicians. Medical graduates received a Diploma in Medicine and Surgery. In 1965, when the University of Papua New Guinea (UPNG) was established, the PMC became the Faculty of Medicine. The first medical students graduated in February 1973 with a Bachelor of Medicine and Bachelor of Surgery (MB BS); the first graduating class comprised four expatriates and only one Papuan. In September 1975, PNG became an independent nation. In 2000, with the restructuring of the UPNG, the School of Medicine and Health Sciences became responsible for training in nursing (postgraduate), dentistry, pharmacy, diagnostic imaging and medical laboratory sciences. PNG students are selected for medicine and health sciences on the basis of their results in a common foundation year at UPNG or Pacific Adventist University. Other Pacific islander students who meet the academic criteria enter the MB BS course directly. Approximately 40 students are admitted to the MB BS course each year. Health extension officers (allied health workers with administrative and basic clinical training), who, together with nurses, are responsible for much of primary healthcare, are trained at Divine Word University in Madang. In 1998, as part of a general restructuring at UPNG, a curriculum committee of the Faculty of Medicine articulated concerns that the traditional curriculum was focused on didactic teaching, that students were not actively engaged in learning and that clinical experience was compressed. The committee examined international trends in medical education and concluded that the most appropriate model was that of an integrated, problem-based curriculum. At a workshop in mid-1998, academic staff, together with senior clinicians from Port Moresby General Hospital and the Department of Health, defined the desired personal qualities, skills and knowledge for a UPNG medical graduate. These now form the basis of the undergraduate program objectives of the new curriculum. These objectives are clustered into five domains of learning: community health; individual medicine (prevention, diagnosis and management of illness); professional and personal qualities and skills; critical analysis and information management; and life-long learning and teaching skills. These domains provide the educational and administrative framework for the new MB BS curriculum, which was introduced progressively between 2000 and 2003. The curriculum is fully integrated and entirely problem-based, with 112 “patient and community problems” studied over the four years. The problems reflect the burden of illness and the health issues confronting PNG (Box). They open up important areas and impart relevance to teaching, rather than replacing didactic teaching. The group work implicit in a problem-based curriculum, the early clinical experience and the emphasis on independent learning skills have all contributed to improvements in student motivation and application, and students are more articulate and confident. Medical graduates in PNG practise in a resource-poor environment, lacking many of the basic diagnostic tests that are taken for granted in developed countries. There is no computed tomography scanner at Port Moresby General Hospital, and basic tests are often unavailable (eg, serum potassium measurement has been unavailable for several months). Graduates may also be posted, in their first year, to regional hospitals and rural areas where there is limited supervision (see Poka).1 They require good clinical diagnostic skills and must be competent to perform common clinical procedures. In years 4 and 5 of the MB BS program, students are required to admit a minimum of 97 patients, to present 45 of these patients to a senior clinician, to assess a minimum of 20 patients presenting to the emergency department, and to assess and treat more than 100 patients in their urban clinic rotations — these activities must be certified. Experience with procedures (a total of 245 in years 4 and 5) is also specified and certified. The first graduates of the new MB BS program are now working as resident medical officers. While it is too early to make a judgement on their performance, feedback has been very positive. The UPNG Faculty of Medicine and the achievement of national independence also provided impetus for the training of clinical and public health specialists. The options for clinical training were to send graduates overseas to obtain membership or fellowship of Royal or other learned Colleges, or to establish local training programs specifically designed to meet the needs of specialists working within PNG. The second option was chosen, and the Faculty introduced the Master of Medicine (MMed) in 1975. The MMed is the degree recognised by the Medical Board of PNG for registration as a specialist. The basic structure consists of two parts: 1 year with an emphasis on basic medical sciences, followed by a minimum of 3 years with an emphasis on acquiring knowledge, clinical skills and experience in the specific discipline. This basic structure has been maintained over the 30 years since its inception, although a research component has been added in recent years. By 1980, the first graduates in surgery, paediatrics, internal medicine and anaesthesiology were employed as fully qualified specialists, followed rapidly by graduates in obstetrics and gynaecology. Within a relatively short time, the MMed program has produced specialists in ophthalmology, otorhinolaryngology, pathology, dermatology and, most recently, medical imaging. A program in emergency medicine has also now been established. All the programs have been developed and maintained with considerable assistance and support from Australian institutions (learned Colleges and hospitals) and individuals. Standards of training have been set and are maintained by the mandatory participation of external examiners, many of whom are examiners for Australian Fellowship examinations. Almost 30 years after its introduction, the wisdom of the decision to embark on specialty training based within PNG is clear. One hundred and thirty two PNG clinical specialists have been trained, of whom 93 (71%) are working within the public health service (including the UPNG School of Medicine and Health Sciences). The program has trained 16 specialists from other Pacific Islands, including 10 from the Solomon Islands. Although most of our graduates have spent part of their training in Australian hospitals, their feet have, for the most part, remained firmly on PNG ground. All are “generalists” within their specialty, and able to function effectively and efficiently in a poorly resourced environment. However, some have also developed expertise in subspecialty areas, and UPNG has now introduced a Higher Postgraduate Diploma in the clinical and pathology subspecialties. The best indicator of the success of the MMed program is that PNG is approaching a situation in which all the available hospital specialist positions will be occupied by fully qualified and highly competent PNG doctors. PNG has also made an important contribution to the training of Pacific Islander specialists. However, nine PNG specialists and three (of 16) Pacific Islander specialists are known to be working outside their own country. While this does not represent a huge “brain drain”, the fact that five of the nine PNG specialists have left since 2000 is a cause for concern. The history of training public health specialists is more complex. Early postgraduates were trained overseas. In the early 1980s, UPNG introduced a Master of Community Health, primarily based on research, but this has recently been replaced by a Master of Public Health, based on coursework and supervised research. This commenced as a combined program between the University of Queensland and UPNG, with coursework being done in Brisbane, but it is now run completely by UPNG. It is probably too early to assess the outcome of this program. The financial and logistical support provided by AusAid, together with the National Department of Health and UPNG, has been central to the success of our undergraduate and postgraduate training programs in medicine and the allied health professions. The interdependence of the health professions is of particular importance in a country like PNG. Medical undergraduates gain experience of primary care in both urban and rural settings and learn to appreciate the importance of the contributions made by other health professionals. It may well be time to consider adding postgraduate training in primary healthcare to our specialty training options to ensure that all graduates have the opportunity to further develop their skills and contribute to the health of urban and rural communities. In addition, there is a major need to introduce continuing professional development programs for all health professionals to ensure that the achievements in basic and specialty training are maintained, consolidated and extended. Medical students in a “patient and community problem” tutorial, University of Papua New Guinea Sample problems (patient names are fictitious): Scenario 1 Gala Tobwagau is brought by his son to the emergency department at Port Moresby General Hospital. His son tells you that Gala is a subsistence farmer from Losuia, in the Trobriands, and that he has been visiting him in Port Moresby for about a week. Gala has been complaining of a headache for most of the time he has been in Port Moresby, but it has been getting worse over the last three days. He was convinced that his headache was due to sorcery, so he went to a traditional healer two days ago, but that has had no effect. Gala is about 40 years old and has only a few words of Pidgin and English. (Final diagnosis: meningococcal meningitis) Scenario 2 Lyn ToRobert, a 35-year-old accounts clerk in Kokopo, presents to her local general practitioner complaining of a lump in her right breast. She noticed the lump about nine weeks ago, while she was preparing for a traditional sing sing. She was rubbing coconut oil and other body decorations on her skin when she felt the lump. She has had lumps in her breasts before, around the time when her breasts get a bit swollen and tender just before her periods, but these always go away over a few days. She tells you that this one also feels different. (Final diagnosis: breast carcinoma)

Isi H Kevau MMed, FRACP, PhD · John D Vince FRCP, MD · Jean V McPherson FRCPA

There are some experiences in medicine that are hard to forget. Mine took place in my second year of residency (between November 1998 and January 1999) during my rural medicine block on the volcanic island of Karkar, in Madang, a maritime province of Papua New Guinea (PNG). The Gaubin Rural Hospital, run by the Lutheran Church, serves the island’s population of over 50 000 people. Karkar volcano (reproduced with permission of Hervé Sthioul). I was a relatively junior resident, having graduated from the Medical Faculty at the University of PNG in 1996 and spent 23 months training at the Goroka Base Hospital in the Eastern Highlands Province. One fateful afternoon, a health centre referred a pregnant nulliparous woman with prolonged labour and splenomegaly. She was in shock, her abdomen was tense and distended, and there was a distinct non-tender mass occupying the left lower and upper quadrants — was this the spleen? The central abdomen was tender, and no fetal heart sounds were heard. Pelvic examination revealed that the woman had severe cephalopelvic disproportion, which was not unexpected, as she was only 1.5 m tall. She had a minimal pelvic bleed. I resuscitated her and whisked her into the operating theatre to do an emergency caesarean section. I administered spinal anesthesia (there are no anaesthetists or general anaesthesia in rural PNG), then scrubbed and put on surgical shoes. The parietal peritoneum was tainted blue, heralding the presence of haemoperitoneum, and, sure enough, the peritoneal space was bubbling with blood — heaps of it. Certain that she had a ruptured uterus, I immediately felt for the uterus to examine the site and severity of the rupture, but, to my amazement, the fundus was small and well contracted and there was no fetus in the uterine body. There was, however, a huge, nasty, transverse wound on the uterine body. I was perplexed — where could the baby be? I tried to feel for the spleen and got the shock of my life when I felt the legs of the baby! The spleen wasn’t enlarged at all. The dead 3 kg fetus was removed. The uterus was sutured and a tubal ligation was performed. During recovery the outcome of the surgery was explained to her and she accepted the fact that she would no longer be able to conceive. Seven days later she was discharged. The health of women and children in rural PNG is still a significant problem that consumes most of a rural doctor’s day-to-day practice. A major issue for the training of doctors in PNG is the need for senior doctors to guide and assist resident medical officers with practical on-the-job training in patient management. This practice should be continued, encouraged and strengthened.

Harry Poka MB BS, DCH

The Papua New Guinea Institute of Medical Research (PNGIMR) conducts research into the priority health problems of the people of PNG to improve treatment, control and prevention of disease. PNGIMR research programs encompass vector-borne diseases (particularly malaria), respiratory diseases, sexual health, disease surveillance, infectious diseases and operational (health systems) research. There can be no doubt that this capacity for high quality, evidence-based intervention has had a very positive impact on health in PNG. National malaria treatment policy, development of filariasis and malaria control programs, and the development of a pigbel vaccine are but a few of the areas in which the Institute’s research has been translated into action. Postgraduate research officers at the PNGIMR. The success of the PNGIMR has been due to an uncompromising attitude towards excellence in science. A crucial factor in maintaining these standards is the training of young PNG research scientists. Currently, there is an acute shortage of postdoctoral PNG scientists who have an internationally competitive track-record of achievement and publication, the ability to attract competitive scientific funding, an interest in research areas of national health priority, and the potential to be research leaders of the future. Priority must obviously be given to training PNG graduates to fill these gaps. However, it is not sufficient to increase the number of people with postgraduate qualifications by simply allowing them to accept scholarships to work overseas — we must target our graduates’ development to the things that matter in PNG. PNG has two advantages in formulating a PNG-centred research training program. Firstly, the PNGIMR is already carrying out research of acclaimed international standard, focusing on PNG health problems. It has many externally funded scientific projects, solid international networks, a high-level publication record, and internationally recognised scientific supervisors. Secondly, the University of PNG (UPNG) is a fast-maturing academic institution with a strong appreciation of the value of research. In September 2004, the two institutions signed an agreement to pool their resources to address the shortage of PNG scientists. The key to developing PNG health-research scientists is to base their training firmly in PNG, in areas of national importance with long-term potential. The cornerstone of this strategy is using PNGIMR projects as a vehicle for UPNG postgraduate degrees. Our developing model sees graduate students (from UPNG or returning from overseas) being recruited by the PNGIMR and rotated through its laboratories to top up practical skills, then being attached to a project for honours research, under supervision of a PNGIMR scientist, while registered at UPNG. Students who achieve a high standard then register for a masters degree or PhD course, developing the same research themes. Although still focused on PNG, these students will also spend periods of time in overseas laboratories, learning relevant technologies and expanding their international networks. By the time they complete their PhD they will have built a firm foundation for a career in their chosen area of research and already be established in their PNG workplace. At this stage, they can be insulated for a few years from teaching and administration to develop their own independent program of research. An important assumption of this model is that it is not always necessary to go outside PNG to get well regarded postgraduate qualifications. As a researcher, the most important things about your PhD are the relevance and novelty of the project, the quality of the work done, the international reputation of your supervisors, and productivity in publishing peer-reviewed papers in international journals. In PNG we have all the components to excel in this area, and the collaboration between the UPNG and the PNGIMR is a landmark step in making a UPNG research PhD an internationally recognised and competitive qualification, with full relevance to the PNG context.

John C Reeder PhD

Sirus Naraqi, an inspiring and warm-spirited doctor with a deep commitment to bettering the lives of the underprivileged, died in Sydney on 18 August 2004, after a two-year illness. Sirus Naraqi spent much of his free time visiting remote areas of Papua New Guinea, providing medical treatment and giving advice to Baha’i communities. (Reproduced with permission from the Baha’i World News Service.) Born in Persia on 30 September 1942, Sirus Naraqi served as a general practitioner to the Persian army before emigrating to America in 1969. There he completed postgraduate training at the University of Chicago and the University of Illinois, followed by numerous consultant physician and academic appointments. Sirus used his interest in infectious diseases to express his strong humanitarian desire to serve in areas of greatest need, such as Papua New Guinea (PNG), where he took up the Chair of Medicine at the University of PNG in 1983. During his time at the university, he led major research projects on severe forms of malaria, snakebite and meningitis. His warmth and style were important in preparing junior colleagues for positions of leadership. Because of its research and educational programs, the university’s Faculty of Medicine achieved international recognition. In 1998, after Sirus had spent 15 fruitful years in PNG, the University of Sydney appointed him Professor of Medicine and Associate Dean at Nepean Hospital, Penrith. Sirus had a lifelong commitment to community service. This included continuing participation in public debate; work with the World Health Organization on tuberculosis, malaria and HIV/AIDS; research and rural health work in PNG; and promotion of international human rights, literacy, hygiene and nutrition for the underprivileged. He also held numerous positions of leadership within the Baha’í congregation. The Queen made Professor Naraqi a Commander of the British Empire in 1998 for his service to PNG. The entirety of Sirus — his personal and professional actions — was inspired and strengthened by his Baha’i faith, an inclusive belief that expresses the oneness of humanity and the permanence of the human spirit, and that considers work in the spirit of service to others as worship of God. As a former colleague in PNG said, Sirus was the embodiment of equanimity, graciousness, clarity and generosity. Sirus was treasured by many people. Medical students respected his generosity of spirit and his dedication to teaching and to the profession. He did not seek effect or popularity. He was a world citizen who gave respect spontaneously and received it in return. His academic colleagues delighted in his integrity, commitment, firm principles and intellectual capacity. He is survived by his wife Mitra and children Ladan, Naysan, Anisa and Gulita.

Stephen R Leeder

Child health will only improve when local structures are further strengthened, enabled and supported Most countries in the western Asia-Pacific region have made consistent gains in child survival over the past 25 years (Box 1).1,2 Notable exceptions to this positive trend are Papua New Guinea (PNG) and East Timor. Sadly, a static child mortality rate such as has occurred in PNG, where the population has doubled over the past 25 years, means that, in this new century, about twice as many children are dying per year as in the mid-1970s. The health inequities between Australia and its nearest neighbours are many, and breathtaking in magnitude. In this issue of the Journal, McGain et al (page 687) document 87 deaths from snakebite at Port Moresby General Hospital (PMGH) (the largest hospital in PNG) over a 10-year period.4 This hospital serves a population of about 500 000 people. By comparison, throughout the whole of Australia since 1981 there have been an average of 2.6 snakebite deaths per year.5 McGain et al point out that lack of antivenom is a major reason for the high mortality, and that the cost of antivenom in real terms is 40 times greater in PNG than in Australia. The reasons for this include a per-capita gross national income that is 2.9% of that in Australia,2 price mark-up with privatisation of overseas distribution from Australian suppliers, and an Australian government subsidy for antivenoms sold in Australian hospitals that does not apply elsewhere. It is not difficult to suggest some feasible solutions to this problem: an Australian government subsidy for overseas developing-country purchasers, and/or direct supply from the manufacturer to the PNG Department of Health. However, snakebite is just one small piece of a very large puzzle of poor child health outcomes in PNG and the Asia-Pacific, and lack of antivenom is only one factor in high death rates from snakebite. Other factors are more systemic: limited access to health services, limitations in the quality of health systems, inadequate manpower, and poor management and financing. These problems are greater in rural areas, where 85% of the population lives; they have a major impact on all causes of avoidable child mortality, and are more difficult to solve than the lack of snake antivenom. PerspectiveAt PMGH, for every child who dies from snakebite, more than 50 die from other conditions that have been eradicated or controlled in Australia. In a 12-month period in 2001–2002 there were 238 child deaths at PMGH, of which four were from snakebite. Of 195 deaths in which the cause could be certified, 29 were from measles, 35 from meningitis (about a third of which were caused by Haemophilus influenzae type b [Hib]), 14 from HIV, 7 from tuberculosis, 66 from pneumonia and 11 from acute gastroenteritis.6 Throughout PNG, about a third of Hib isolates are resistant to available antibiotics (principally chloramphenicol),7,8 and rates of HIV are rising rapidly. The persistence of these infections in PNG despite the existence of effective methods of prevention or control should be a cause for concern and action in Australia as well as in PNG. Two-thirds of all child deaths are associated with moderate to severe malnutrition. On the role of aid and economic developmentAustralia currently allocates $435 million in aid to PNG (representing 20% of Australia’s official development assistance and 0.26% of its gross national income9 — far short of the benchmark of 0.7% agreed to by rich nations at the Earth Summit in 1992, and only achieved by Scandinavian countries and The Netherlands10). Much of Australia’s aid is now tied to strengthening law-making and law-enforcement facilities and financial management, but a proportion is allocated to social services (principally health and education). Aid programs in PNG often find themselves “between a rock and a hard place”. Sustainable development cannot occur in an environment of poor governance. When existing systems are not functioning well, one outcome, sometimes occurring by default and sometimes by design, has been the development or evolution of “parallel projects”, which circumvent existing government structures to achieve a flow of services or information to the periphery. There is a tension between this project approach and the building of genuine long-term capacity (ie, the resources and structures that enable self-sustainability) within government programs. However, if inequity within PNG and between PNG and Australia is to be reduced, aid allocated to social services must be spent in ways that will strengthen local systems so that services reach the most marginalised communities. One example of this dilemma is the Women’s and Children’s Health Project, funded by the Australian government and launched in PNG in 1997 (funding will cease at the end of 2004). The project has allocated $10 million a year to improve child and family health services. Credit must be given for its achievements, such as improvements to the vaccine “cold chain” (previously a major limitation on the quality of vaccines distributed in remote areas) and training and capacity support in some rural areas. However, results have generally been disappointing. Only a small proportion of the aid money has filtered down to the villages and settlements where child mortality is highest. Much has been consumed by large infrastructure costs in Port Moresby. In an attempt to tick off activities as completed achievements, weak and sometimes frustratingly inefficient government systems have often been circumvented using a “parallel project” mentality, rather than taking the much slower approach of working with and strengthening existing local structures. In a thought-provoking but pessimistic review, Professor Helen Hughes, Senior Fellow at the Centre for Independent Studies, has argued that aid has failed the Pacific nations.11 She believes that aid has created an ambiguity of independence, an environment in which government funds are spent on consumption rather than economic development, elevated exchange rates, and provided fodder for political corruption. These factors, plus high tariffs, have hindered manufacturing for domestic markets and export of agricultural products; reduced employment opportunities, skill development and entrepreneurship outside the government sector; and encouraged dependent welfare states. A partial solution suggested by Hughes11 is to make receipt of aid conditional on achieving certain goals, under an agreement of mutual obligation. This would require removing aid from government budgets, with mutual agreement between recipient and donor countries on its use, mutual monitoring, and disbursement subject to regular account auditing. Successful examplesPapua New Guinea (PNG) needs human capacity to provide a quality health service. In some areas of endeavour, this has been achieved. The Paediatric Society of PNG is one example of the slow and successful development of indigenous technical and professional capacity. This is a story of committed engagement by many paediatricians over four decades, building on the foundation laid by the late Professor John Biddulph. Progress has been based on the principles of quiet example and mentorship, working together at the front line of healthcare and grappling with everyday problems. In the past decade there has been increasing development of a few subspecialty areas and extraclinical skills, such as public health, research, evidence-based understanding, policy development, advocacy and child health nursing capacity. Australian public hospitals and individual paediatricians have played key enabling roles in this development, and, in turn, their support has been greatly assisted by AusAID through the PNG Medical Officer, Nursing and Allied Health Professional program and its predecessors. The outcomes are impressive. Locally trained PNG paediatricians now provide services in most of the 20 provinces, and contribute substantially to all areas of public child health, policy and service delivery.12 The PNG standard treatment manual,13 along with the National Government Health Plan, is a blueprint for a quality child health service in a resource-poor setting, and has been reproduced in many other developing countries and in internationally adopted strategies. These advances have only been achieved through the work of vital national child health institutions, the PNG Paediatric Society and the Department of Child Health at the University of PNG, with aid projects providing background support at various stages. Limiting factors to progressDespite some successful programs, many activities in PNG have not resulted in health gains where they are needed. Support areas of the health service remain weak: health and human resources management at all levels, drug and vaccine procurement, distribution and stock management, and health financing. Primary care, the most essential form of healthcare in rural areas but the least robust and most vulnerable level of the health service, has suffered the most because of these deficiencies.14 There needs to be a similar concentration on building capacity and commitment in these areas, improving efficiency, and minimising waste of resources and squandering of funds.15 The beginnings of progress in some of these areas have occurred. Health management is stronger in some provincial health services and hospitals now than it was 10 years ago, partly as a result of structural reforms and support and mentoring for management capacity provided by the AusAID-funded Health Sector Support Program. More needs to be done, but sustainable change will only occur slowly, tailoring strategies to individual situations — an approach that is at odds with some aid projects, whose designers often propose a “one size fits all” formula for rolling out the latest Big Idea, with little critical evaluation of outcomes. Equity and conditionality as principles of aidConditional aid, as Hughes suggests,11 might be a useful strategy, providing direct funding to carefully selected high-priority areas, with an agreement that certain process milestones will be reached. Potential examples might be Australian government funding of Hib vaccine, conditional upon completion of the national supplemental immunisation activities16 and achieving coverage of over 80%; or subsidising the purchase of snake antivenom, nevirapine and ceftriaxone, conditional upon improvements in drug procurement and national distribution systems. A further condition to ensure commitment and sustainability would be the understanding that the PNG government would take over responsibility for funding after a mutually agreed period of time. These targeted interventions would have broad benefits to the health service, would enable the implementation of new (to PNG) and highly effective interventions, and would enhance equity within PNG and between our two countries. However, there are some risks with conditional agreements. The withholding of interventions if conditions are not met would continue to hurt the people who are innocent of any waste or corruption — nurses and doctors who struggle every day to provide good healthcare, and the patients who suffer from the effects of a lack of quality services. Support should be given to local training institutions rather than aid projects running unsustainable training programs. A portion of the aid budget could be provided to build key areas of capacity by financially supporting individuals or groups committed to collaboration in ways that are appropriate to Melanesian society. AusAID and the PNG Health Department are currently proposing a step in this direction by establishing a Capacity Building Service Centre, which will place more emphasis on engaging locally successful individuals to act as mentors, build capacity, and result in significant changes to external contracting. The approaches outlined above are complementary and would reduce inequity between Australia and its Pacific neighbours. In some ways, they would be a departure from some current large aid projects, whose economic benefits often spin back to the donor country, and whose resources are consumed by project infrastructure that duplicates government institutions. I can see little place in a country like PNG for health projects that are managed by overseas private consortia. International tendering for health projects in a country that has no structured health management organisations can scarcely improve equity. This model has worked better for some aid development projects, such as road and water supply contracts, in which local engineering companies have won contracts, thus contributing to local development, employment and economic growth. However, the idea that health aid should be corporatised in a country that desperately needs an effective public health system is fundamentally flawed. No easy answersThere are no easy answers to how Australia can best assist regional countries. Ongoing engagement remains necessary at many levels — between governments, professional societies, institutions, and individuals. Without this there can be no mutual understanding, which provides the basis for progress and is crucial for regional peace. Some of the best examples of success suggest that sustained, quiet and modest-budget collaboration by committed groups or individuals who treat each other as equals will be the most effective strategy. As yet I have not addressed the problems of child mortality in the worst-affected country in the region — East Timor. A sustained collaborative approach would be of great benefit to this small country (Box 2). The view of PNG as a “failed state” is wrong. Progress is being made in many areas. Now is not the time for Australia to abandon PNG or our closest Pacific neighbours, but to learn from institutions and areas that have achieved much, to support them to do more, and to tailor approaches to specific situations. Australia also has much to learn from Pacific countries — quiet persistence, patience and a sense of community are qualities that might help us have a more realistic view of what progress really means. 1 Trends in mortality in children under 5 years (per 1000 live births) in the Asia-Pacific region over the past 50 years1-3 * In a Demographic Health Survey (DHS) in East Timor in 2003, the mortality rate in 2003 among children under 5 years of age was estimated to be 107 per 1000 live births. Mortality rate estimates from the previous eras, represented on the graph, are also based on retrospective data from the 2003 DHS, so the accuracy of these trends is uncertain. Reliable data from previous years are not available. 2 Increasing East Timor’s capacity to meet its child health needs The problems of capacity in East Timor are even deeper than in Papua New Guinea (PNG), and the child health system is in a much more embryonic stage of development. Currently, there are no East Timorese paediatricians, which is a major impediment to sustainable progress, local leadership, autonomy and direction. However, collaboration between the East Timorese Ministry of Health, the University of PNG and the Royal Australasian College of Physicians (RACP) will hopefully see East Timorese doctors trained in child health, largely in PNG, with some additional clinical experience in rural hospitals in Australia, over the next 5–10 years. This will provide training in settings that are similar to those of East Timor, foster personal and institutional connections between two developing countries, promote a developing-country university as a regional centre for high-quality specialist training, and minimise the risk of “brain drain” that would exist if specialist RACP Fellowship training were done in Australia.

Trevor Duke MD, FRACP, FJFICM

Your position never gives you the right to command. It only imposes on you the duty of living your life so that others can receive your orders without being humiliated. Dag Hammarskjöld, UN Secretary-General, 1953–1961 awarded the Nobel Prize for Peace I grew up in Canberra in the 1920s and ’30s, then, as now, a planned and favoured town awash with politics, politicians and public servants. Although interested in these dynamics, our caring, skilled family doctor was the person who most impressed me. John James FRCS was our community’s quiet medical leader, later recognised through the John James Medical Centre, now part of Canberra’s teaching hospital system. My parents were typical of their time. My father had emigrated from Britain in his teens and served in France in World War I. He was a public servant with the Federal Capital Commission (which from January 1925 was responsible for the planning and development of Canberra). He had a vocational flair for amateur theatricals of music hall and comedy genre. My mother was a capable homemaker. We became aware of the Great Depression just about the time my sister was born. My parents combined to have our large yard supplement our pantry. Mother became a genius in food preserving with the Fowler Vacola steam preservation kit, providing a great variety of foods. As children, my sister and I had warm and strong emotional, social and aspirational support, but our choices for our futures were our own. My parents offered two aphorisms: “Hard work is not lethal” and “Loyalty and fairness are necessary for success”. I have not found either to be wanting. In choosing a career, medicine held no competitor for me, although I dallied momentarily with veterinary science. I experienced the grief of three of my school classmates succumbing to diseases that now rarely cause death: poliomyelitis, mastoiditis and diphtheria. Polio returned to the class several times, and, although not lethal, it was damaging beyond reason, both physically and psychologically. Polio, in particular, marginalised those it affected. I felt that more could be done to alleviate this unfairness. “The effect of a teacher may be infinite”My undergraduate days during World War II were spent at the University of Sydney and at St Vincent’s Hospital, Darlinghurst. I commuted daily on the on-time “red rattler” (today we say “if only”) and travelled between campuses on the tram. Hospital life as a student was immensely fulfilling, and I matured among competitive peers. Two of my tutors made these days particularly memorable: Justin Markell, the meticulous, kindly physician in outpatients, and Douglas Miller, later Sir Douglas Miller, who became a leader in neurosurgery and President of the Royal Australasian College of Surgeons. Both encouraged and taught a careful approach to physical examination, diagnosis and patient care. They provided a sound basis for my future clinical endeavours. I became a junior resident at Marrickville District Hospital in 1947. At that time, 18 months to two years after graduation saw most graduates enter general practice. I also aimed to do so. Marrickville Hospital was general practitioner oriented, with specialist honorary staff drawn from Royal Prince Alfred Hospital. These included role models like the late Sir Thomas Greenway, a charismatic, thoughtful and instructive physician, and Frank Mills, a friendly, insightful surgeon who had made his reputation in Changi and Sandakan in World War II. He visited his patients often and always left a dusting of his knowledge on the junior staff. Looking further afieldAfter 18 months and still attracted to general practice, it was time to move forward. Two positions presented themselves: one for a medical officer on Macquarie Island, the most southerly point of Oceania in the Australian Antarctic Basin; and the second, for Medical Superintendent at Collinsville, a small coal mining town in north Queensland. My colleague Bob Allison and I applied for both and were interviewed together by the Antarctic pioneer, Phillip Law, in front of the dying embers of the log fire in the common room of the (old) University Club in Phillip Street, Sydney. Bob went to Macquarie Island and I to Collinsville. As the only doctor in town, I enjoyed 18 months of rich clinical experience. Post-term obstetric deliveries, head injuries, critically ill children, motor vehicle accidents and accidents involving horses all hastened my clinical maturity. I remember a young jackeroo with a perinephric abscess after a nasty horse-related accident. As we were stranded by floods at the time, a surgeon in Mackay took me through the operative steps by phone. All ended well. The community was full of reliable, loyal Aussies with enormous hearts. They were openly friendly and had a great bank of skills, and gave their local doctor the comfort often absent today. An outbreak of croup in some young children was the most formidable of my experiences. They desperately needed steam inhalation, but I was a little nonplussed as to how to supply it. One father spoke with his boss at the mine workshop, who rapidly produced a large galvanised watering can with four arms, each capped with a watering-can rose. Placed on a primus stove, this device effectively dispensed steam to four mosquito-netted cots simultaneously. Problem solved! Surgeon by serendipityI was no longer sure that I wanted to pursue general practice and planned to undertake postgraduate work in the United States. I applied for several positions and was appointed to a rotating internship at Albany Medical College, New York State. At my request, it included a term of psychiatry. I arrived to take up my appointment in 1950, just as the Korean War began. Given my previous surgical experience, I was promptly moved from psychiatry to surgery. The experience was life-changing. As the American surgical residents were drafted to Korea, I was promoted after six months, subsequently accepting the offer of five years’ graduated surgical training in the Halsted tradition at Albany Medical Center. William Halsted had been Foundation Professor of Surgery at Johns Hopkins University in Baltimore, and laid the basis for graduated surgical training. This proved to be five years of restricted finances, but top professional fulfilment and growth. My workday would start with 5.30 am ward rounds (before the chief arrived at 7.30 am), followed by a day in theatre, then admissions and lab work before falling into bed. How much more civilised work practices are today. I was embarrassed when my previous senior resident returned from Korea to be my junior, and his view “c’est la guerre” was most generous and the basis of a long friendship. My training was predominantly in general surgery (with much exposure to thyroid surgery) and included my introduction to clinical investigation, which initially centred on bleeding varices and the monitoring of serum ammonia concentration.1 A three-month exchange with the Women’s Clinic at Johns Hopkins in Baltimore allowed me to work under the dynamic Richard Te Linde, Head of the Gynecology Department. Another privileged memory was witnessing the early development of cardiac surgery, as Alfred Blalock, under the watchful eye of cardiologist Helen Taussig, performed his “blue baby” procedure for tetralogy of Fallot and for alleviating the effects of congenital cardiac defects.2 My final 18 months were spent in Albany in thoracic surgery at the time of its greatest development, as the pump oxygenator was introduced. These five years were shared with a global workforce from 27 nations including Japan and Germany. The chiefs of medicine and surgery offered opportunity and education to all, hoping to heal wounds from World War II. This global experiment was clearly ahead of its time, and resulted in many firm international friendships. Being Australian was a significant plus, as Australia was popular after its Pacific role and genuine friendliness to US troops. In 1953, I married Mary Jo, whom I met in the operating room at Albany Medical Center. She has been my loyal supporter and valued confidante since. Return to Australia — spreading my wingsI returned to Sydney in 1955. Many doors were initially closed, but, with recommendations from mentors, I was eventually employed by Frank Rundle, Director of the Unit of Clinical Investigation at Royal North Shore Hospital (RNSH). After six months I received a full-time research fellowship with clinical responsibilities in my areas of interest, giving me the opportunity to be involved in thyroid surgery and studies; isotopes and cancer chemotherapy; a prospective database for thyroidectomy; and ultrasound of the breast. Thyroid clinic: I worked with Rundle in his multidisciplinary thyroid clinic and helped develop an animal experimental facility. This brought me into contact with Ian Monk, a cardiothoracic surgeon, who, with a pump expert, Viv Ebsary, was exploring open-heart surgery.3 The use of animals for experiments caused significant angst, especially when clandestine activity was required — such as transporting anaesthetised sheep by wheelbarrow to a ground floor angiographic facility for experimental studies. From such humble beginnings, the entire unit later evolved to become the Wellcome Laboratories. Rundle was a perfectionist, demanding that our every activity be of the highest safety and quality. The preoperative checklist was instituted (now indispensable in modern risk management) to ensure nothing was omitted in preparing patients. Every operative step was to be as haemostatic as possible,4 and postoperative care empathic and supportive. These requirements became expected of all who worked or trained in what later became the University of Sydney Academic Surgical Unit at RNSH. Cancer chemotherapy: A grant from the NSW State Cancer Council in 1958 enabled me to spend four months with cancer specialists Joe Burchenal and David Karnofsky (known for the Karnofsky Performance Scale for assessing terminally ill patients) at Memorial Sloan-Kettering Cancer Center in New York. I returned to initiate the provision of cytotoxic therapy at RNSH, which later established a formal medical oncology unit. Even then, the need to embrace randomisation and the careful accrual of evidence was seen as crucial.5-7 Thyroid database: On leaving the United States in 1955, I had been encouraged by my surgical mentors to embrace the computer age and “develop a prospective databank to record progress and results” — “outcome” as a word was still aborning. Our first cases at RNSH were accrued in 1957 and, over time, we honed the database into a useful clinical and research resource. All thyroid and parathyroid surgical procedures by the Endocrine Surgical Unit at RNSH are recorded, and at my retirement in 1988 numbered 10 000 entries. Intrathoracic goitre: During the period of compulsory mass x-ray surveys for pulmonary tuberculosis in Australia between 1948 and 1975, many people were diagnosed with intrathoracic goitre. A prevalence study we conducted in metropolitan Sydney in 1953–1956 showed that intrathoracic goitre occurred in 1/5040 subjects examined (compared with 1/750 with active tuberculosis and 1/3500 with lung cancer) (Box 1). Unexpectedly, the prevalence of intrathoracic goitre was about three times greater among people born in England (then the main source of immigrants) than in those born in Australia.8 Diagnosis of intrathoracic goitre improved with the introduction of computed tomography scanning, as did the safety of operative procedures. We used a surgical approach based on embryology — a transverse incision in the lower neck (a collar incision) — delivering the goitre into the neck, which, with appropriate control of vascularity, resulted in minimal sternal splitting and avoided a transthoracic approach.9 This technique was refined over time with much input from surgical colleagues Alan Poole and Leigh Delbridge (and the surgical registrars) and particularly our anaesthetist Bruce White. Superb scrub and bedside nursing helped to ensure success. This led to a rethink in the treatment of recurrent goitre and provided leadership in optimising total thyroidectomy for nodular goitre, now a widely accepted procedure despite earlier controversy.10-13 Breast ultrasound: A visit to RNSH in 1962 by George Kossoff (who with David Robinson in 1961 built the first ultrasound scanner at the Commonwealth Acoustic Laboratories) led to another fortunate and fruitful long term collaboration — ultrasound of the breast (Box 2). Surgery — academic and vascularIn 1961, Academic Clinical Units were established at RNSH, with the support of Sir John Loewenthal, then the Chair of Surgery at the University of Sydney. I was appointed Senior Lecturer in Surgery and subsequently became the inaugural Professor of Surgery in 1974. I believed, like Osler (quoting John Henry Newman), that: “An academical system without the personal influence of teachers upon pupils, is an Arctic winter.”18 Students were involved as far as possible in all unit activities, and teaching students and residents in the operating theatre became a major thrust of our program, although initially we were limited by a lack of full-time teachers.19,20 Graham Coupland was appointed senior lecturer in surgery in 1967 and was as great a friend and associate as I could have hoped for. With fellow surgeon Harry Cumberland, and encouraged by Douglas Piper, Professor of Medicine, he refined the investigation and surgical treatment of peptic ulcer, for which their preferred procedure was highly selective vagotomy.21 Coupland’s untimely death in 1982 came at a time of unit growth, as we taught exceptional undergraduates, trained bright young people of integrity, and produced quality surgery and research. Vascular surgery was developed by Douglas Tracy with my assistance.22 However, with his departure to the University of New South Wales in 1961, this specialty grew very demanding of those remaining — Ray Hollings, myself, and later Graham Coupland. Ruptured aneurysms, which require immediate surgery, became the bête noire of our social and family life. At that time, pagers, which were the size and weight of a house brick, only emitted an alarm, and a telephone call determined the reason for the call. In 1977, RNSH agreed to the appointment of a full-time academic vascular surgeon, Michael Appleberg, an excellent leader who took the department through to substantial strength in surgery,23 research and training. A stream of overseas and domestic visitors and interactive visits between the RNSH unit and overseas units promoted clinical and research strengths (Box 3). RetirementAll these activities have provided a springboard for continued enjoyment of life after I retired from academia in 1988. Elected President of the Royal Australasian College of Surgeons in 1989, I have travelled extensively in Australia and New Zealand. This experience has reinforced my perception that the exceptional compassion and service given in war are still given in peace. Australasian surgery and surgeons stand high with me. I was asked to report on quality assurance in clinical management to the Australian Government Department of Health,24 and now follow with interest the progress of the Australian Council for Safety and Quality in Health Care. As Chair of the working party developing the Clinical Practice guidelines on the management of early breast cancer25 and as a member of the board of the National Breast Cancer Centre (1995–2003), I have found it very satisfying to see women empowered to handle a life-threatening disease. Working with the Cancer Council Australia and the Clinical Oncological Society of Australia to develop the Australian Cancer Network has, since 1994, also kept me happily in contact with clinicians and consumers in promoting better cancer care. I have also maintained a clinical interest through surgical assisting. I have more time to “smell the roses” and travel with Mary Jo to see friends and enjoy our grandchildren in the United States, with side trips to Europe. I read more, but am unable to keep up with all the good books that are published. I also have time to think over the contrasts between then and now and what is to come. Surgery in 1947 was more uneven than today. There were top-level surgeons who performed to their level. A good deal of surgery, however, was done in small hospitals across the community, and too frequently exploratory laparotomy was performed for an obscure diagnosis. The limitations were primarily in training and diagnostic technology. The idea that doctors “owned” the patients was diminishing, but still prevalent. This limited patients in obtaining a second opinion, when perhaps it should have been embraced. I have observed changes and been pleased to have the opportunity to be involved, and sometimes been supportive in promoting change. Strong academic units centred in training hospitals across Australia have, together with the Royal Australasian College of Surgeons and specialist surgical societies, embraced strong mentoring and graduated and proficient training. The quality of surgery and hospitals has been improved by these educational and vocational developments. Australian patients have access to surgery of the highest quality. The future for surgery should know no limits, with increasing precision of diagnosis, limited wounding associated with surgical access, and developments in pharmacological and genetic interventions. Surgeons will be expected to understand and fully explain the complexities of many new approaches to treatment, some of which will not be operative surgery. The psychosocial aspects of surgery will reinforce the benefits patients should enjoy from the science and art of surgery, in which the level of trust between surgeon and patient must remain inviolable. I am delighted that opportunity for betterment for patients expands apace. Fortune has indeed smiled on me. As I look to the future, remembering colleagues, nurses, students and patients, I remain aware that I have gathered a posy of other men’s flowers and only the ribbon which binds them is mine (Sanskrit). 1 Age distribution of intrathoracic goitre detected by mass x-ray surveys for tuberculosis (1953–1956) Source: Reeve et al8 2 Development of breast ultrasound imaging — from weather maps to quality images Initial attempts to develop breast ultrasound involved many women volunteers and a bistable waterpath machine, which provided linear, sector and compound scans. Sonograms were initially derived through a water bath in contact with but above the patient. Water sometimes spilled (Figure A), or leaked (Figure B), saturating staff and patients, but not dampening their enthusiasm. Technology (Figures B and C) rapidly improved the quality of sonograms, and, in 1974, the patient’s comfort (Figure C). With Kossoff and his associate, Jack Jellins, ultrasonographer Kaye Griffiths and her team, surgical registrar Bruce Barraclough, and sonograms from our volunteers, we were able to determine the “normal” sonographic appearance of the breast. It was hard going until Kossoff introduced “grey-scale” contrast into sonography,14,15 which allowed tissue contrast and better identification of breast disease, a principle later applied to virtually all tissues16 and “leading to the widespread adoption of ultrasound throughout the world.”17 Ultrasound now plays a significant role in breast cancer diagnosis — no more wet shoes and soaked patients! A. CAL Closed water bag breast echoscope (1966). The bag was lowered onto the chest, and the transducer moved through the waterbath. Coupling with the skin was incomplete and the breast compressed. B. CAL Open water bag breast echoscope (1968). This method allowed for improved coupling to the breast and removed the problem of compression of tissue. The breast floated freely in a water bath. C. CAL Open water tank breast echoscope (1974). A new approach, patient prone and breast freely floating, thus eliminating the need for coupling drapes. (Photos courtesy of George Kossoff.) 3 International Surgical Week — International Association of Endocrine Surgeons, Hong Kong 1993. Back row: Joe Tjandra (Melbourne), Tom Reeve, Leigh Delbridge (Sydney). Front row: Raj Nambiar, Abu Rauf (Singapore), Martin Liepins (Riga, Latvia).

Tom Reeve AC, CBE, FRACS, Emeritus Professor of Surgery, The University of Sydney

At seventy-seven it is time to be in earnest Samuel Johnson — A journey to the Western Isles of Scotland Nothing about my life has been planned, including medicine. When, to my surprise, I obtained one of the rare scholarships then available to the University of Sydney after the Leaving Certificate, I asked my father what I should do. “Medicine”, he said, “that’s a good career for a woman”. So, despite having no sciences and braving the fierce opposition of my Latin teacher, I obeyed. Nor did I know, even after graduating, what field of medicine to aim for, having spent much of my undergraduate years at Arts lectures and playing bridge. After doing the odd locum and a bit of general practice, I married a naval aviator and had six children. This removed me from medicine for 13 years. Returning to Sydney from Perth (following the fleet) and being short of money, I went to Royal North Shore Hospital (RNSH) and asked to do a refresher course by attending outpatient clinics. Although feeling like a middle-aged frumpish housewife, I was treated by each of the senior consultants, all men, with the utmost courtesy. I have honoured RNSH ever since. It was not easy to get a job. I worked first at Grosvenor Diagnostic Centre, assessing children with intellectual disability. The medical officers were at the fringe of a revolution in genetics, constantly learning about recently discovered syndromes and how to identify these as the underlying causes of the conditions in the people we saw. Yet, we were not esteemed by the medical profession, who referred to us as “guardians of the waiting list”, because we assigned priority to those most urgently in need of the few residential care places available. Our chief concern, however, seemed to be for the parents, and how to reconcile them with the pain of accepting that their children were “different”. From institutions to community careWhen my husband was posted to Melbourne, I worked in a large institution in Victoria, which taught me a lot about institutions and the danger of just accepting what occurred in them. I remember admitting a teenage boy, clinging to his tearful mother. She was at last persuaded to leave, too soon to notice that his bed had no pillow. I asked for one, but the busy charge nurse’s reply was, “I won’t allow pillows in my ward. They might fight with them or smother themselves”. Of course, we were understaffed, the few staff we had were overworked, and the residents had little supervision. So little, in fact, that one girl wandered out of her ward one night and fell into an uncovered hole containing a steam pipe — she was scalded to death. When I recollect this tragedy, I find it hard to accept the pious phrase “the dignity of risk”, which is too often used to justify neglect of people in residential care. Returning to Sydney, I was lucky to be at the start of the deinstitutionalisation program in New South Wales, but soon realised that this was not to be an easy path. Among the first people to move were a group from a large institution on Peat Island. They moved into a small cottage in Hornsby, and soon the neighbours were complaining, not because of discrimination, but because of the frequent noisy quarrels among the four residents about who should do the dishes! Human nature is no different whatever the IQ level. This same quartet looked marvellous — dressed for the first time in dinner jackets and evening gowns — for their first formal, a ball in Hornsby. As I grew older, I became interested in exercise and nutrition. I started to jog in the streets near where I lived, embarrassing my children and husband. It felt so good that I wondered how exercise would work for people with a disability. I obtained a Master of Public Health degree by doing a simple research project on this subject. Then RNSH allowed me to start a health promotion clinic for adults with developmental disability. This was soon enhanced by the arrival of a dietitian, Lyn Stewart, and an exercise physiologist, Caroline Bruce, and we became very busy. It was obvious to me that my colleagues, using nutrition and exercise, improved health faster than I did. Caroline also organised the people into teams and they went for trips at weekends, playing indoor cricket and soccer, and returned with amazing stories of their hijinks. This was a time of fanatical adherence to the philosophy of normalisation — all people with disabilities should live in the community, whatever their special needs, and participate in all community activities. Our staff struck some unrealistic expectations, including carers who refused to be involved in our sports programs, one proclaiming, “We’d rather our residents sat at home all day and never exercised, than take part in segregated activities.” We ignored these thought police, and took one group ourselves for their first sight of snow to luxurious quarters donated by a generous hotelier. At breakfast they sat down to silver and snowy table linen. “Oh look!” said one delighted young man, “we are going first class!” A trip to the snow Royal North Shore Hospital Health Promotion Clinic for Adults with Developmental Disability enjoying a weekend in the mountains. Latin and the logic of epidemiologyThe best teacher I ever had was a Dominican nun, Sister Anselm. She made me love Latin as much as she did. I later took the same delight in epidemiology, the closest thing I have found to thinking in Latin. This prompted my postgraduate studies in public health, completed with a part-time scholarship (awarded to promising public servants in the enlightened practice of the day). I applied epidemiology to the little-studied burden of disease in our patients, in whom I noticed diverse chronic and complex health problems. I obtained a Research and Development Grant from the Commonwealth Department of Community Services and Health for the first population study of health disorders in people with intellectual disability. This showed that, of a random sample of 202 adults with intellectual disability, each had an average of 5.4 medical disorders, half of which had not previously been detected.1 Colleagues in Victoria and Queensland reported that these findings supported their argument for specialised health clinics in those states. Not so enlightened were authorities in NSW, who closed the RNSH Health Promotion Clinic, in the face of many objections. The Department of Community Services’ mys-terious decision ended what was, as far as I know, the first health promotion clinic of its kind in the world. Since then I have tried unsuccessfully to reopen this clinic. An attempted retirementAt that stage, RNSH enforced retirement at the age of 65 years. I was a bored, cross, retired person, so I leapt at the chance to work for a while at Stockton Centre, a large NSW institution for people with intellectual disability. The enlightened administrator at the time, Lorraine Yudaeff, asked if I could find someone to assess the nutrition of the residents. I recruited Lyn Stewart, who had worked with me at RNSH. Lyn ran a tape-measure over some emaciated residents and recommended an enriched diet. This resulted in another study showing that 69 of the multiply-disabled residents in this 550-bed institution were severely underweight, with low levels of vitamin D, iron and folate. They were given a diet with increased caloric density for 12 months, with significant improvements in weight, in serum calcium and vitamin D levels, and in haematological indicators.2 We succeeded in increasing the weight of some very hungry people, but not without protest: one carer said we had ruined the quality of life of an adult resident who now weighed more than his previous 20 kg. He required two people, instead of one, to lift him, and was considered too heavy to take on outings, as they had no hoists. However, the noble staff of Stockton rose to the challenge. Several residents now verge on the overweight, not underweight! As a result of this work, there is now a policy of screening the nutritional and swallowing status of all people with intellectual disability in residential care in NSW. Microarrays — miniaturised assay systems allowing the structure and expression of thousands of genes to be evaluated My mentors and medical detective work I first met Professor Gillian Turner as her locum at Grosvenor. Gillian is now known internationally as a geneticist and has done the fundamental work on identifying the Fragile X syndrome, the most common inherited genetic cause of intellectual disability. This work began when Gillian was a medical officer at Grosvenor and introduced me to the intellectual fascination of dysmorphology and genetic disease. I enjoyed being a medical detective and identifying syndromes. The explosion then occurring in genetics is about to recur, with new technologies such as microarrays (Figure) that will make diagnosis more accessible. Given that a diagnosis can make all the difference to prognosis and treatment of associated physical disease or behavioural phenotype, a group of people much ignored by medicine will be taken more seriously in the future. I once excitedly asked Associate Professor Aidan McElduff (Endocrinologist) in the corridors of Royal North Shore Hospital whether a patient I had referred to him could have Kallman’s syndrome. Aidan looked surprised and said he supposed she could. This turned out to be the underlying aetiology. I was in awe of Aidan’s many qualifications and his far greater knowledge of medicine, but he has since become a mentor, a coauthor of published articles, a collaborator in studies on osteoporosis and hypogonadism, and an expert on the endocrinology of intellectual disability. Aidan once thanked me for introducing him to a new medical specialty, Intellectual Disability Medicine. Battling medical nihilismIt was generally considered inevitable that people with intellectual disability die young, which prompted Seeta Durvasula (Medical Lecturer in Developmental Disabilities, Centre for Developmental Disability Studies, University of Sydney), Wes Baker, Senior Planning Officer, Northern Sydney Health, and myself, to investigate mortality rates in a previously identified cohort of 693 people with intellectual disability in northern Sydney.3 We found that the death rate was five times higher than that of the general population of Sydney’s Lower North Shore.4 Furthermore, the causes of death were quite different from those in the general population, being predominantly respiratory disease and accidents. Seeta Durvasula recently presented data from this ongoing study at an international conference, showing that up to a quarter of these deaths were preventable. Contributory factors, such as inadequate supervision, delayed presentation and delayed diagnosis of illness, were identified. The challenge is now to reduce premature mortality and to treat remediable disease. The NSW Ombudsman is charged with the responsibility for reviewing all deaths of people with disabilities in care, looking at the causes and patterns of death and recommending ways of improving services to reduce early or preventable deaths. This important initiative has been noted internationally and may be replicated in Scotland. We also need to beware of medical nihilism. It is one thing to strive officiously to prevent the demise of an elderly person ravaged with disease. It is another thing to deny treatment to a young person with spastic quadriplegia who is enjoying life but swallows unsafely. I am reminded of a senior consultant with whom I discussed the need for supplementary feeding in some young individuals. “Why treat them”, he said, “aren’t they just vegetables?”. An international movement in intellectual disabilityI presented papers at meetings of the International Association for Intellectual Disability (IASSID) every four years, but found health professionals at these conferences often cowed by our non-medical colleagues, who considered us relics of the past, detested institutions. Encouraged by the then Australian President of IASSID Professor Trevor Parmenter (now Foundation Chair and Director, Centre for Developmental Disability Studies, University of Sydney), a Dutch physician Professor Heleen Evenhuis and I formed the Health Special Interest Research Group of IASSID. This Research Group now has yearly international meetings, and its achievements include developing health targets for adults with an intellectual disability.5,6 These targets address conditions that are highly prevalent, easily identified and amenable to available treatments (eg, regular assessments of hearing, especially if communication problems exist, and of dental and ocular health). The targets have been accepted by IASSID and presented to the World Health Organization for ratification. The future: developmental disability medicineA medical specialty will be established in this field. In The Netherlands, such specialists already exist, while, in the United Kingdom, psychiatrists who have specialised in learning disability are often attached to multidisciplinary teams working with people who have learning disabilities. It is clear, too, that doctors with such specialist knowledge must collaborate with nurses, psychologists, dietitians, speech pathologists, physiotherapists and occupational therapists. If it is possible to have multidisciplinary teams in aged care, such teams should also be available for people with disabilities. Of Australia’s total population, 1.86% have an intellectual disability.7 Thus, this group of people constitutes a population about the same size as our Indigenous population. In my opinion, a specialist clinic at each teaching hospital in Australia is required to support general practitioners caring for people with intellectual disability. In Victoria and Queensland, at least, university-affiliated academic centres for developmental disability provide government-funded medical services. In NSW, the Centre for Developmental Disability Studies at the University of Sydney is not so funded, but has helped me to establish a medical clinic with two other doctors, funded by billing Medicare. Our six-month waiting list illustrates the level of unmet need. Australians with disabilities —predominantly receiving pensions and with no political clout — are caught in a dysfunctional system. Formal responsibility for health and other services has largely passed from the federal to the state governments, with further buck-passing between health and social service departments within the states. Yet, much of their healthcare rests with GPs, funded by the federal government. I was founding chair of the NSW-based Association of Doctors in Developmental Disability (ADIDD), which lobbied for people with disabilities and their need for specialised health services. As it became obvious that this was a national problem, we have now formed the Australian Association of Developmental Disability Medicine (AADDM), which aims to establish national standards in healthcare delivery, lobby federal politicians, issue policy documents and position statements, and, eventually, train specialists in this field. I am lucky to have been present at the beginning of a new branch of medicine. I hope that advances in genetics will eventually lead to a therapeutic revolution for people born with intellectual disability. Meanwhile, we need more medical champions for this vulnerable but silent minority. Receiving an award Member of the Order of Australia (AM) in 2004, receiving the award from Her Excellency Professor Marie Bashir, Governor of New South Wales (left).

Helen P Beange AM, MB BS, MPH, FAFPHM

A doctor graduates from “blow in” to full-blown artist 1 Barramundi dreaming Sail form, 1400 mm high kiln-formed glass. I seem to be able to ‘think in glass’ and saw this vivid image in my mind before I went on to execute it in glass. 2004 has been a gratifying year for me. Solo international exhibitions in Dubai and Hong Kong; group shows in Australia and overseas; some interesting architectural commissions; and, some proposals for major international projects accepted. A piece acquired by the Ebeltoft Museum of Contemporary Glass in Denmark and another presented by the Governor of New South Wales, Marie Bashir, to the President of China; even a prize in a Queensland fine arts competition. A gratifying year for a glass artist, indeed, but an unusual year for a doctor. How did all this happen? My life began with 20 unbroken years of full-time institutional education, culminating in 1976 with graduation from the University of New South Wales (MB BS). I had chosen to study Medicine with what I now see as probably typical teenage arrogance and ignorance — when faced with an application form for the “rest of my life”, I ticked the boxes for Medicine, Law and Arts, without any real understanding of what any of those choices might entail. I pronounced that I sought a career where I could help people, continue learning and work anywhere in the world. Once begun, Medicine became my life. My choice was unquestioned; I proceeded with no thought of any alternatives. I loved it! In third year, I married Barbara, a fellow medical student. Not having to pursue the dating game, we had plenty of time and energy to devote to Medicine. For the next three years we spent much of our “spare time” in casualty departments and outpatient clinics, improving our clinical and practical skills. A major teaching hospital was the setting for my intern year, but I found myself craving a smaller, more personal environment, and moved on to a district hospital where junior doctors were expected to perform more procedures and accept greater responsibilities. A couple of years later I was lured into an entrepreneurial general practice partnership and lasted three months before accepting that this style of practice was anathema to me. Next came the toughest 18 months of my life. I established a general practice from scratch. I did it the hard way — forgoing all offers (including office equipment, an ECG machine, a nurse for one day a week and having my surgery painted) from pharmaceutical companies, pathology services and the like. I set up a no-frills, old-fashioned practice. One day, sitting at my desk, looking at the wall, I thought: “Well, here I am. I’ve made this practice viable. In 40 years, I can still be sitting here looking at the same wall.” That night I told Barbara that I wanted to sell up and travel. She took about three seconds to agree (even though she was in the middle of a paediatric intensive care term). That night I jumped off the merry-go-round. Although I didn’t know it, I would not get back on. I had dabbled in various arts and crafts over the years of my childhood and even university. I tried many media (including painting, drawing, pottery, leatherwork, copper enamelling and basic printmaking), but none held my interest once I had reached a level of basic competency. When I commenced general practice, I enrolled in a stained glass course at TAFE. The initial class was an epiphany. The moment I picked up a glasscutter and scored my first piece of glass, I knew something important had happened. It was akin to falling in love. I became obsessed with glass and spent any quiet hours between seeing patients drawing designs for windows. When the practice bell rang, I would reluctantly gather up my coloured pencils and be a doctor again. I filled our house with windows and started making them for friends and family. I found that I had an aptitude for the medium and was able to visualise the completed image in glass to begin with. I seemed to be able to “think in glass” (Box 1). I began to fantasise about running a little leadlight shop (instead of a general practice) and becoming a craftsman. This may have been sublimation for a frustrated earlier plan to become an orthopaedic surgeon. Orthopaedics had attracted me because of the variety of problems faced and the innovation and manual ingenuity it demanded. However, I found I could not accept either the requirement that I work overseas to qualify to work in my own country or, what seemed a necessity, to “step on the heads” of friends and colleagues to attain any one of the few available positions. Just before that defining moment when I had literally seen my future on the practice wall, I had faced mortality. I had the tragic misfortune to be involved in an unsuccessful attempt to save the life of my closest friend at that time. He had been stabbed and died, despite my best efforts as part of the resuscitation team. The wall that we construct in order to do the job that emergency medicine demands was breached. I suddenly knew how quickly life could be over. I began to dwell upon the things that I wanted to do but had not yet done and decided that it was time to stop postponing my gratification. So, I sold my practice and we went to Germany, bought a big motorbike and rode off on a great adventure. On our return, I decided to give glass a try. That was 22 years ago. My self-understanding and my feelings about that decision have evolved over the subsequent years. At the time, I talked it over with peers and mentors and received differing opinions. My colleagues told me I was mad to throw away all those years of study. How things change! At our last reunion dinner, I was awarded a prize for “best career choice”. My mentors, who were of my father’s generation, had a very different perspective. Most had a regret: the unwritten novel, unfinished canvases, missed opportunities. One observation was pivotal: “You have a choice. Before you tie yourself down with a mortgage, kids at private schools, the pool and a Volvo, give it [glass art] a try. If It works — wonderful. If it doesn’t, you don’t have to go to your grave regretting what might have been. So, get it out of your system.” The concept that my trial was to be temporary was paramount to my being able to consider it. Practical and emotional support from my parents, and particularly my wife, made it possible. As one of the few people on the planet to have choices, I also felt a genuine responsibility not to waste the opportunity. Becoming a glass artist was a long, difficult journey. I started at the bottom (again) and travelled alone. Going back to college to complete a visual arts degree would have been an easier, quicker path to a new career, but I was tired of institutional learning. I worked briefly as a glassblower, took courses in colour and design, life drawing and various technical methods and set up that small leadlight studio I had fantasised about (Box 2). I soon discovered that there was much more to the medium of glass art than tulip-pattern front doors and was launched onto a steep learning curve. Invitations to master classes in Germany and the USA led to dramatic improvements in my skills. Gradually, over 20 years, I evolved into a glass artist in my own right (Box 3 and Box 4). Every day, working away in my leadlight studio, two thoughts recurred. The first was that, eventually, I would be discovered to be having too much fun and it would have to stop. The old adage “If you find a job you love, you will never work another day of your life” turned out to be absolutely true. The second was that I agonised over leaving Medicine. I felt guilty about having had the benefit of a free university education, and wondered whether the time I had put in had in any way repaid my debt to society. I worried that my medical skills were waning and about how difficult it might be to regain them. I feared that I had failed my family’s expectations. Although working with glass gave me a level of satisfaction that practising medicine had not, my internal debate continued as these thoughts recurred for years, often on a daily basis. It helped that I was able to bring medicine into my work in a variety of ways: a privileged body of knowledge, much of the visual imagery that appears subconsciously in my work and the capacity to research what I do not yet know. And, instead of ministering to the body, I like to think that my work provides succour for the soul (Box 5). Simultaneously, in those early years, I experienced great difficulty in defining myself. I needed to call myself something. I knew I wasn’t an artist, although I didn’t really know yet what makes an artist. I also knew that it would be impertinent to call myself a craftsman, given my beginner’s skills. My dilemma was not aided by the stained glass fraternity, who labelled me a dilettante and a “blow in”. In time, these attitudes changed and some time later I was elected President of the Australian Association of Glass Artists. Recently, all these old, resolved identity problems came rushing back to me when I was compelled to join the non-practising medical register. Twenty years on since stopping work as a doctor and charting another course in life, I finally feel relaxed about calling myself an artist. (I know I am an artist — because I am receiving more critical acclaim and making less money than ever!) However, all this time, I have had in the back of my mind that I am still a doctor and had chosen to maintain full registration. I was surprised by how much this change in registration status bothered me. Although I no longer seriously entertain the idea of returning to clinical practice, I felt something stirring within when the door back (which remained ajar despite having receded further and further away) seemed to have closed on me. Even now, I rationalise that, if I really needed to, I could requalify. So, it would appear that I still have not abandoned the idea, as unlikely as it is. Medicine is a tough habit to shake! 2 Me and my kiln My current studio is much more spacious than earlier workplaces. 3 This land or Song of the magpie dawn Architectural installation, The Galeries Victoria, Sydney. 6 m x 2 m kiln-formed glass. Most of my work is based on Australian geological, social and mythological landscapes. 4 The magic carpet 500 mm x 600 mm kiln-formed glass Recent solo exhibitions in Dubai and Hong Kong have inspired me to address designs based on other cultures, still utilising my own styles and techniques developed over the past 20 years. 5 The Bungle Bungles Giant curved form, kiln-formed glass. Purchased by a doctor. I maintain links with the medical profession through collectors and commissions.

Marc D Grunseit MB BS

If you walked into my surgery in the inner-Brisbane suburb of Highgate Hill, you could be forgiven for thinking you were in an art gallery — paintings, my own works, hang on all the walls (Box 1). Am I a doctor? Am I an artist? I am both. When I left high school, I thought seriously about studying art, but logic prevailed and I found myself with a medical degree. After 6 years at university in Brisbane and three years of hospital work in Townsville, I travelled to Europe. In Belgium, while walking one night in a moonlit field, I was momentarily aware of the presence behind me of generations of European artists with whom I felt an intense personal affinity, including Michelangelo, El Greco, Vermeer, Van Gogh and Picasso. Perhaps it was the result of having immersed myself in art-filled galleries and churches; perhaps it was because I was so far from home. Whatever it was, I experienced a powerful sense of transcendence that took my breath away. And, for whatever reason, at that moment I felt very strongly that I would paint and would become known as an artist. It took some time to realise this grand vision of mine. I studied fine art at Townsville TAFE and then Seven Hills College (now part of Griffith University) while working in various general practices. Then, I set about establishing my own practice and having four children. For 10 years, I drew and produced only occasional works. After I turned 40, everything changed, and I found myself fired by a passion that I felt almost powerless to control. It was as if pictures had been accumulating inside me for years, and the backlog had reached a point where they had to be expressed. Each evening after work, when my family was in bed, I would begin painting — pouring my thoughts, visions and various “unconscious conclusions” onto canvas. I’d get by with little sleep — often three to four hours a night. It was one of the most stimulating and exhilarating times of my life. Painting energised me and charged my soul. Over the next 10 years, I held 10 solo exhibitions in Brisbane and Sydney and painted eight minor series, as well as “one-offs” (Box 2). Over this same decade, I continued to work in my practice, finishing work around 2 pm and employing other doctors to see the rest of the patients. My concurrent practice of medicine gave me many ideas to use in my art. For example, a patient waxed lyrical about her nephew’s wedding just when I was painting some women in white dresses. I decided to make them the bridesmaids and my exhibition “Tying the knot” was born. Each painting in the exhibition represented something people might bring to a marriage, from company and consolation, friendship and family, jealousy and acrimony, even alimony. Because my nights were so creative, I was glad to be sensible Dr Byth by day. Earning money by practising medicine gave me the freedom to paint whatever I liked, as I did not have to necessarily sell paintings (although this happened). Having studied medicine and having to deal with the body and its function on a daily basis, I feel at ease with the artistic “discussion” of the flesh, sex and sexuality, and I’ve used this knowledge freely in some of my exhibitions. Being a doctor adds credibility to this artwork, and even humour. After seeing my exhibition about the uterus, fertility and the power of female sexuality (“Up front, On view”), a patient joked as she had her Pap smear done: “So, whose cervix are you painting tonight, Dr Byth?”. My love and practice of art has helped me become aware of the broader social picture in medicine. “Normalising” illness, helping patients to become focused on good health outcomes and minimising the impact of setbacks have been some of my main patient management tactics in general practice. I know that painting provides me with relaxation at the end of a hard day’s work. It’s therapeutic for this doctor. When I begin each canvas, I have no idea what I will be painting. But I know that I’m a logical person; capable of working something from A to B — I guess this is the bedrock of medicine. Similarly, a painting represents thousands of small decisions (brushstrokes), each one dictated by what has gone before. Each and every painting “happens” when I am lost in this open-ended process. I paint almost exclusively in acrylics, beginning with an abstract colour field in which the painting gradually shows itself; I’m often surprised by the distance travelled between the final form and the original. The final painting will usually represent something I’ve been trying to say but for which I’ve often had trouble finding words. In my depths, there is a fount of ideas that are a mystery to me; their nature is unpredictable. I am able to give substance to these concepts in my paintings. In my art, I feel as though I can express many ideas and many layers of perception simultaneously and without discomfort, even though some of them are contradictory. For example, in Head of the river (Box 3), the composition of the painting separates “them” (over by the river) from “us” (our school) and lends weight and excitement to the picture. (Some boys, however, are completely uninterested.) As with medicine, I think I will never stop learning and developing in my art; I enjoy spending time with other artists in workshops, exchanging ideas and refining techniques. I think I’m a very Australian artist — my work has its roots in the land and people of this country and in what I’m doing. I began by painting Australian landscapes with my own perceptions and style. I love the messy edge of town where things are left behind, like wilting tennis courts, Hills hoists and car bodies (Box 4). In my early days, I used a lot of collage. Then, I did a series on Australians and sport called “Recreations”. Seeing lots of mothers and babies in my practice inspired the exhibition “Modern Madonnas”. Small fish swimming across and within some of the paintings in this exhibition gave them a dreamy quality (Box 5). Love of the sea, and in particular the coast of northern NSW, has led me to depict Cook Island and Fingal Head in many of my paintings (Box 6). I’ve painted schools and children, as my own children have been educated (Box 3). And, after a friend’s sudden cardiac death, a series of 12 black drawings evolved using stethoscopes, electrocardiograms and some religious imagery — heart beats representing life, followed by the stark silence of death. I want people to know that I am a three-dimensional person, not just a doctor. I hang my less confronting paintings in the surgery, and I enjoy having my patients tell me every day how much they enjoy them. Not only my patients, but also relatives of patients, other doctors, art lovers, people off the street (and even drug reps!) have bought my paintings off the walls. When I sell a painting, I replace it with another. My general practice has evolved over the years. As the elderly have died, younger families have moved into the area. Migrants and students are ever present, and more residential units mean more young people who work in the city. I love this variety. But I have had to meet other, more challenging changes: accreditation and continuing education requirements, as well as computerisation and the business aspects of practice. After about five years of painting nightly, two of my “right-hand helpers” at the surgery moved on, and I decided to return to full-time work for a while. As a result, I’ve painted a little less in recent years, but still manage two or three nights a week. Medicine and art, my two passions, have always intertwined, shaping my life. I can’t imagine practising medicine without my art or creating art without my medicine. The real skill (which I know I don’t always get right) is to strike a balance between them: the logical, precise and ordered thinking of medicine and the unstructured, unpredictable and creative flow of art. Together, they help me to appreciate the beauty of each moment and give me the practicality and resilience to get on with life. 1 My waiting-room (and art gallery) 2 Night duty 3 Head of the river 4 Renovations 5 Mother and child 6 Surfer

Susan Byth MB BS

A doctor–artist discovers that her art and her medicine may be not so different after all . . . 1 What the doctor prescribed Tubes of oil paint (not for ingestion). Last year, after 20 years in hospital practice as a paediatrician, researcher and clinical geneticist (and a daily witness to lives unravelled), I took six months’ leave to paint full-time. Institutionalised, I needed some time “out of captivity”, in exile from the medical cocoon. The conformity of the hospital system was suffocating me. I found little there to nurture the soul or guard against dampening of the spirit. I needed time to reclaim my individuality. Doctor, heal thyself . . . my prescription, my antidote: art, in hefty doses (Box 1). I have always been passionate about art, but, as the daughter of immigrant parents, I knew that I was destined for university. Art school was not really an option. I studied music and medicine simultaneously. My internship completed, I promised myself that I would try to incorporate the practice of art into my life as a doctor. I enrolled in a series of night art-classes — in life drawing, watercolour and oil painting, ceramics, leadlighting and mosaics. I fell into training programs in paediatrics and genetics, and then a doctorate. There were stints abroad, working in Houston and Manchester — my time, gobbled up. The study of undergraduate and postgraduate years proved a stark contrast to the creativity of my childhood days. Childhood. I remember lying on my stomach in the change room at a dance studio in Adelaide on a Saturday morning, busily drawing in my scrapbook as I waited for my ballet class to start — pink stockings, black leotards, hair pulled back; the softness of ballet slippers, shininess of ribbons, smell of sawdust; the big mirrored room; standing at the barre. Equally vivid is my memory of sitting on the laundry floor at home, having unwound balls of Turkish rug wool with my mother and cutting the lengths of richly coloured yarns. Making knots, one by one, I watched with wonder as, from humble threads, a rug magically materialised. Recollections of my mother at “work” in the kitchen — a feast for all the senses. The agility, the deftness, the sheer brilliance of it all dazzled me. All that creativity, bursting at the seams. I had already been painting seriously for seven years before my six-month sabbatical, and had held several solo exhibitions. I thought of art and medicine, my two great passions, as diametrically opposed — a dichotomy — and looked forward to stuffing my now “free” days full of artistic pursuits (Box 2). The degustation menu included abstract painting, printmaking, sculpture, and a course in professional practice for artists. It was a time of experimentation and renewal, revelation, unpredictability, self-directed learning, unexpected experiences, serendipitous discoveries and precious slivers of enlightenment. 2 Works-in-progress for the solo exhibition “Hieroglyphs and heartbeats”, April 2003 Left: Free-falling through my grandmother’s whispers. Oil and beeswax on board, 1.2 m x 1.5 m. Right: Mapping my own landscape. Oil and beeswax on board, 1.2 m x 1.5 m. When I paint, everything rests on intuition. There are no preliminary sketches, no navigation points — just me and the bare surface. What transpires is unknown, and I have learned to trust in that. It is like a dance, like music. There are many stories I could tell about this time: of being duped by one gallery owner and well treated by another, and of shocking indifference to trespass and violation after some of my paintings were vandalised with shards of glass on Jewish New Year. Here, I will share with you two stories — “Sitting duck” and “Of intimacy and interplay”. Each story, in different ways, shows how my time out of captivity has dispelled forever any misconception about the cleavage between art and medicine. Sitting duckJust before preparing for a group exhibition, “Sitting duck”, I was asked to be an expert witness for a family suing a hospital for allegedly negligent care of their son. He had become quadriplegic after surgery for scoliosis. I trawled through reams of medical reports, deeply affected by the accounts of the denouement of an able-bodied teenager to a ventilator-dependent quadriplegic adult. The words, the terminology, the descriptions in the reports were all so sterile, so lacking in compassion. Was I truly part of this fraternity? Sitting duck. My original intention was to create three sculptures (a new artistic pursuit for me), all light-hearted and frivolous, a celebration of my release from medical confines into the playground of creativity. I had very clear ideas about the works. One was to be a plaster cast of my torso and arms, with paintbrushes in either hand — the brushes of my conductor. The second was to be a hardened, hollow, shell-like, three-dimensional form of my torso modelled from an old T-shirt smothered in oil paint from my wiped brushes. This was to be gaily mounted on a plinth, with all the colours from my palette smeared irreverently on my own outer surface. The third was to be a transparent hollow form of my head, filled with empty tubes of paint, in playful acknowledgement of those six short months when paint, not medicine, was uppermost in my thoughts. However, the final sculptures bore no resemblance to their points of origin. The pieces took control, imposed their own will and directed me, a mere player in their grander scheme. 3 Winter 2003 Freezing cold in a garage as Ken Bowrey applies alginate, and we wait for it to cure. I can’t see, I can’t hear, and I can just breathe. My senses are all diminished. Ken makes body parts for film and television. Look carefully in the background and you’ll see some body parts . . . Unwittingly, the young man’s tragedy became the catalyst for the creation of sculptures that ushered me through a process that paralleled his own. Entrusting myself to strangers, I became my own palette. I was bound in fibreglass. My head was cast, and a mould made from it in a freezing-cold garage in mid-winter (Box 3). Unable to move, see or hear, my own vulnerability sensitised me to that of others. The sculptures developed their own integrity and autonomy. They became about altered and lost senses, loss of the recognisable self, fragility, vulnerability, dissociated states, disembodiment, about ability and disability, and the loss of self-expression. So much for light-heartedness and frivolity! I was outside comfort, outside what I knew. A sitting duck. I learnt that this is when self-discovery happens. All three pieces had morphed into an exploration of quadriplegia, its inertness, muteness and isolation. Disability, such an indelible mark on life, challenges and makes us rethink our own mortality. The first sculpture affected me the most. I wanted to mould the T-shirt into a form resembling my torso, harden its external surface, and then remove the inner stuffing. It sounded simple enough. Despite my research at hardware stores and dry cleaners, and a foray to the beach to collect a backpack full of sand (for the stuffing), the garment simply refused to be hardened. All my attempts were thwarted. While battling with the sculpture’s stubbornness, I temporised by sewing closed the neck and sleeve openings, filling the garment with cotton wadding, and arranging it into a shape that I liked. I left it propped on a chair. I was still determined, somehow, to harden the exterior. The next morning, I was confronted by what seemed to be another presence in the room, a palpable living, breathing thing, slumped on its chair, silent and motionless. Keen to photograph it outside in natural light, I unlocked the back door and lifted the torso on its chair. With the chair raised, the torso tumbled towards me — a moment of astonishing poignancy. I had just identified with quadriplegia in a very intimate way, through an inanimate object. How does that happen? 4 “Slumpy” Slumpy, relegated to his own room, with screens drawn around and a hospital blanket overlain. Autumn leaves are sprinkled on a bare palette (no paint for the artist), which doubles as a hospital food tray (Slumpy has lost his appetite). For days afterwards, the torso was so confronting, and the symbolism so potent, that I could not look at it. I had to move it to another room. (Isn’t that what society does with the disabled?) Each time I tried to reposition it, it defied me and would slump, just like a flaccid quadriplegic. I never did harden the exterior. I left it as it was (Box 4). Affectionately, I named the torso “Slumpy” in an attempt to diffuse the gravity of what it had come to represent. A year later, I still find him unnerving. What do we do with the parts of ourselves or of someone close to us that, through mental illness, malformation, accident, physical deformity, burns, or paralysis, are no longer recognisable to us? What is it like to look back at your own image and not recognise it (Box 5)? How do we incorporate this into our concept of self? Of intimacy and interplayA large part of my practice of genetics involves caring for disabled children and distressed parents. Pattern recognition is quintessential to syndrome diagnosis and requires a highly developed visual memory. It is not uncommon to see children over many years, to review and research, go back and look again, to interrogate the literature and databases, before a correct diagnosis is eventually made. This process, perhaps more so than in other medical disciplines, mirrors the artistic process, where constant questioning and reworking is the norm, and intellectual curiosity is crucial. In retrospect, it seems no accident that I was drawn to this subspecialty, the practice of which rests on many of the same skills that I employ as a practising artist. Like a metaphor for life, painting is about the search for relatedness and connectivity. I liken the process to standing in front of a mirror, completely naked, all flaws exposed. There is push and pull, tension, uncertainty. Images are lost and refound. Slowly, a painting starts to speak, as paint breathes life into the work. This marks the beginning of a dialogue, after which the painting itself directs my mark-making. From this, intimacy develops. The process echoes the way in which we ourselves form connections with others. Think of the vulnerability of our patients — medicine, too, is steeped in intimacy. 5 My own death mask The positive plasticine mould of my head. I cannot recognise myself in it at all — it isn’t lifelike; somehow neutered. I am forced to confront my own mortality. I will never forget my amazement when, on two separate occasions, a woman stood in front of one of my paintings and wept. Then there was the time when a small child, less than two, carried in his mother’s arms, looked at one of my paintings, pointed jubilantly, laughed out loud and exclaimed “woo WOO!”, having recognised a dog in the imagery. Relatedness and resonance. Touching another soul. How can marks on a surface do that? There are both similarities and contrasts between painting and doctoring. Putting on armour, for example. Sometimes work feels like that: steeling oneself for the day ahead, the bureaucracy, the demands and deadlines, the difficulty of yet another undiagnosed child. Sometimes painting is like that too — hurtling myself at a canvas only to be spat out, ricocheting backwards to the opposite side of the studio, then rolling my sleeves up for the next advance and flinging myself back again, the canvas unrelenting, with me solely accountable. The clinical practice of medicine demands adherence to rules and regulations; there is a dictated way of thinking, order, structure and logic. Unpredictability and experimentation, factors pivotal to the practice of art, might be seen as the antithesis of medical thinking, yet both are paramount in medical research, where advances often depend on novel ways of seeing and thinking. The practice of medicine, so laden with pathos, grief, love, regret, sadness, joy, struggle, tragedy, courage and humility, has informed me as an artist from the very beginning. In turn, creativity fosters new and different ways of seeing, broadens my understanding, nurtures me, assuages my soul, deepens my compassion, and heightens my empathy (Box 6). I believe that I am a better doctor for all this. So, for all my years of bearing witness, painting is, for me, part catharsis and part desire to give something back. On returning to work, my first memory is of a profoundly dry mouth, my heart beating outside my chest as I stand in the corridor, unable to open the door to my office. Back in captivity. “Doctor, schmoctor”, I tell myself, “we are all our own works in progress”. 6 At work in my studio

Lesley C Adès MD, FRACP, CG (HGSA)

Frederick Grant Banting (1891–1941), the Canadian Nobel laureate responsible for discovering insulin, had a less familiar side. As an artist he exhibited under the name Frederick Grant.1,2 Having enjoyed art at school,3 he took up painting again in 1920, as a relaxing way to fill in time between patients in his struggling medical practice in London, Ontario. He later wrote: “My happiest hours of this period were spent thus trying to copy pictures mostly from old magazines or books.”1 In the long gaps between patients, he also read the medical literature, which gave him the idea for his research. Within 3 years, he had isolated insulin and received the Nobel Prize.2 Throughout his life, art continued to be his favourite form of relaxation. As his confidence and skill as an artist grew, he began to paint the Canadian landscape. In the late 1920s, Banting’s introduction to the Canadian artists known as the Group of Seven provided him with encouragement that had a lasting influence on his work, and forged lifelong friendships for this enthusiastic amateur. Banting was intending to retire from medical research at 50 to paint full time, but his plans were foiled by his accidental death, at 49. (Paintings reproduced with permission from the Estate of Nelson Banting, Alliston, Ontario).

Joanne C Elliot

Joe Cinque's consolation. A true story of death, grief and the law. Helen Garner. Sydney: Picador, 2004 ($30, 328 pp). ISBN 0 330 36497 9. IN 1997 A YOUNG WOMAN gave her boyfriend a large dose of Rohypnol and heroin. As a result she is now a graduate in law with a special interest in criminology, and he is dead. She was found guilty of manslaughter and sentenced to 10 years’ imprisonment. The usual complex arithmetic surrounding sentencing set her free less than three years after being sentenced. The circumstances of the killing were complex and bizarre and the author has examined them carefully. It occurred in a maelstrom of late-adolescent turmoil, drug taking and disturbed group processes, filled with denial. If you wish to discover the details buy the book — it is very good value. Garner questions the legal processes which can produce such a result, as well as curiosities such as the preventing of the two Crown psychiatrists from examining the defendant. The law is imperfect but getting better. At the beginning of the 19th century there were more than 220 statutes containing the death penalty, and judicial interpretation had expanded the list to more than 350 capital offences. Children were hanged with some frequency, on one occasion 10 in a row. Not until the Criminal Evidence Act of 1898 were accused persons permitted to give evidence in their own defence. Most improvements were made in the teeth of firm legal opposition. One must keep up the pressure and Helen Garner is doing this here. Is such an outcome morally wrong? Morality is a system of approvals: there will be as many moralities as there are groupings in society. There is no empirical way of establishing which is to be preferred. Those who argue that morality must be founded on religious beliefs should remember that until relatively recently the Christian church thought it morally right to burn alive those who did not believe that the Earth was the centre of the universe and was orbited by the sun. The best we can do is to examine every proposition put to us and this thoughtful book does just that. John H T EllardPsychiatrist Balmoral Beach, NSW

John H T Ellard

Three dog night. Peter D Goldsworthy. Melbourne: Penguin, 2003 (340 pp). ISBN 0 6708 9398 6. I THINK UNLESS A JOURNEY is bumpy and uncomfortable you haven’t really travelled far from home. In his latest book, Three dog night, Goldsworthy sure does “good travel” according to my requirements. In this lyrical, and strangely suspenseful, novel we accompany three doctors who travel — literally into the desert, and figuratively into the untidy and impolite world of death and erotica — to a place that unnerves, but surely tantalises, us all. The title refers to the number of dogs you need to sleep with in the desert at night to keep warm. Martin, the protagonist psychiatrist, has a head full of Latin names and is obsessively in love with his impenetrably beautiful but physically flawed wife, Lucy. She is also a psychiatrist and a specialist in pain management. Lucy is a “trophy wife” and Martin is bringing her home to Adelaide (think churches and zoo murders) to show her off. He is particularly keen to introduce her to his oldest friend Felix, a grumpy old surgeon, who years ago turned his back on the Establishment and went bush to work with the Aboriginals, being initiated into the Japalarri people along the way. Felix is dying of hepatitis-related hepatoma that he contracted from a young boy who died as a result of his drunkenness. He is tormented by the boy’s death and seeks penance (or is it pain relief) from his friend’s subsequent agony. He also wants to travel into the desert to find a place to die, a sinkhole that is a special place for his Dreaming. In one last unbearable stretch of friendship he wants company. Martin and Lucy, armed with morphine, oxygen and a disappearing mask of propriety, accompany him on his journey, and nothing is the same again. Goldsworthy, in a book where too much metaphor is barely enough, has written a worthy and enthralling travel manual, peering under masks into the murky realms of the “id” below. Fortunately, he has done so with forgiveness. Christine HampshireGeneral Practitioner Balmain, NSW

Christine Hampshire

The secret cure Sue Woolfe. Melbourne: Picador, 2004 (444 pp) ISBN 0 3304 2124 7 Sue Woolfe, author of the widely enjoyed book Leaning towards infinity, dedicates this, her latest novel, “To a brother I never knew”. The dedication sets the tone of the book. In a fictitious Australian town, the central character, Owen, who has spent most of his life confined to his home and is completely mute, allows himself a month in the real world, posing as a hospital maintenance worker. From afar he falls in love with Eva, an exuberantly dressed but painfully shy laboratory assistant. Most of the book is a record of his outrageously voyeuristic attempts to spy on Eva and her scientist lover Gunther, whom he tries to discredit in order to replace him in Eva’s affections. These “spying” passages could make some readers uncomfortable, as it is difficult to know how much Woolfe expects us to suspend our disbelief. However, it is worth pushing through this to enjoy the book’s main themes. Each character in the story, however peripheral, harbours a secret — and, in some way, everyone is mute. This obvious metaphor forms a good canvas for Woolfe’s exploration of Asperger syndrome and, of course, that substance whose secrets have galvanised scientists since its discovery over 50 years ago — DNA. Why do people do science? The characters in this book have compelling reasons for their obsessive (and, in Eva’s case, illegal) pursuit of a cause and a cure for Asperger syndrome and, while you might have to suspend your disbelief a little more to swallow Woolfe’s conclusion, it is wonderful to believe that secrets can be known and silences broken. Ruth M ArmstrongDeputy EditorMedical Journal of Australia, Pyrmont, NSW

Ruth M Armstrong

Absence of coherence in the way Australia employs overseas-trained doctors is a problem for our healthcare system and for the doctors themselves In the 1880s, the head of the statistics unit of the Registrar-General’s office in London noted that the shortage of medical practitioners in England was such that there was “imminent danger” that qualified medical care might become “quite inaccessible to vast numbers of people”.1 This shortage was a direct outcome of the Medical Act of 1853, which prescribed strict criteria for the education and registration of medical practitioners. Its effect was to reduce recruitment into the profession because of more formidable courses while concomitantly phasing out unqualified practitioners.1 Now, at the beginning of a new century, we find that the predicament of Victorian England has become a global problem. There is a shortage of doctors worldwide, and Australia is no exception.2-4 OTDs must not be seen as a long-term solution to our doctor shortage. A number of factors have contributed to our doctor shortage. Prominent among these is federal government policy in the 1990s, which limited the number of medical school places in Australia, as all the while the Australian Medical Workforce Advisory Council maintained there was no shortage of doctors.5 Having miscalled policy, the federal government is now rapidly seeking to remedy its gaffe. Five new medical schools have recently been established6 and the number of bonded medical places (requiring graduates to work for a minimum period in districts of workforce shortage) in our existing medical schools has been increased by 234.7 The projected outcome of these initiatives is that the number of Australian medical graduates will increase from about 1200 in 2004 to about 2200 in 2014 (Warwick Hough, Director of Workplace Policy, Australian Medical Association, Canberra, personal communication). Whether this number will meet society’s demands a decade from now is anyone’s guess, but one thing is certain: Australia’s healthcare will be dependent on overseas-trained doctors (OTDs) for some time to come. Our increased dependence on OTDs is reflected by recent bureaucratic activity attending the government’s announced Strengthening Medicare package, with its additional 725 OTDs working in Australia by 2007.8 One consequence has been the generation of a report on OTDs submitted to the Medical Training Review Panel of the Australian Department of Health and Ageing in February 2004. It outlines a bewildering array of Australian policies and guidelines, and differing surveillance and stewardship of OTD programs. The report identifies: enormous inconsistencies in terminology; lack of national coordination in collection of data on OTDs; inadequacy of data held by different agencies and departments; differing entry points of OTDs controlled by different jurisdictions (eg, through the state and territory Areas of Need program or the federal Districts of Workforce Shortage program); a multitude of stakeholders, all focusing on their individual programs, with poor communication among themselves; doubts about the adequacy of assessment and supervision of OTDs entering Australian medical practice by medical boards and about the adequacy of the Australian Medical Council (AMC) examination. Finally, the report on OTDs found there were inadequate resources for orientation, ongoing training and supervision of OTDs, and suboptimal support for their families. Some progress has been made, such as the recruitment of OTDs through contracted recruitment agencies, reduced “red tape” in the assessment and recognition of OTDs, some flexibility in immigration arrangements to allow OTDs to stay longer,8 and fast-tracking of selected applicants to provisional registration and assessment by the AMC. However, the reality is challenging. The data on birthplaces of OTDs in the article by Birrell in this issue of the Journal () reflect the reality of the global village we now live in.9 Yet, while the backgrounds, knowledge and skills of OTDs are diverse, evaluations of competence may be bypassed when employing OTDs in Australia, and formal assessments of communication skills (as distinct from linguistic proficiency) and cultural awareness are not included in current assessments.10 This has the potential to compromise patient care. To facilitate an orderly integration of OTDs into the Australian healthcare system, McGrath () calls for a national body to establish uniform standards in licensure, to review and, where needed, to boost training resources and capacity. He argues that these are the minimum requirements to meet our duty of care to both the public and OTDs.11 We would also argue that recommendations by this body and coherent, relevant OTD data should be regular agenda items for the Australian Health Ministers’ Conference. Focusing on OTDs as the primary short-term solution to our doctor shortage has serious ethical and global implications. The “brain drain” of healthcare professionals from many developing countries compromises their healthcare systems and demoralises their healthcare workforces already struggling to cope with major public health problems such as HIV and malaria. It constitutes a major loss in financial as well as human capital — particularly as any remittances sent back by emigrants (estimated at US$72.3 billion in 2001 and the second-largest source of external funds for developing countries) are not necessarily reinvested in healthcare.12 Unless recruiting countries like Australia adopt policy options such as creative employment contracts that also subsidise the country of origin, it is likely that “borrowing” OTDs will continue to broaden the gulf between developed and underdeveloped countries. OTDs must not be seen as a long-term solution to our doctor shortage. The Australian Health Ministers’ Conference’s recent National Health Workforce Strategic Framework states: “Australia should focus on achieving, at a minimum, national self sufficiency in health workforce supply, whilst acknowledging it is part of a global market.”13 In the meantime, OTDs make a valued and essential contribution to our society and to the provision of healthcare to Australians. We should respect their contribution with the attention and care it deserves.

Martin B Van Der Weyden MD, FRACP, FRCPA · Mabel Chew FRACGP, FAChPM

Since the late 1990s Australian employers have recruited an increasing number of overseas-trained doctors (OTDs) to hospital and “area of need” general practice positions. While assessment standards vary by state and field of medicine, most OTDs are appointed without a formal assessment of their medical knowledge and clinical skills, with registration to practice being conditional only on their working in hospitals and “areas of need”. By comparison, formal assessment is required before an OTD can practise medicine in the United States, the United Kingdom and Canada. Most of these doctors hold temporary resident visas, but a minority are permanent residents who have not completed their Australian Medical Council accreditation examinations. In 1997–98, most OTDs arriving under temporary resident visas were from the United Kingdom and Ireland, and by 2002–03 this had dropped to under 50%; OTDs now come from a greater diversity of countries.

Robert J Birrell PhD

Australian healthcare is greatly enriched by its overseas-trained doctors (OTDs). There is no national approach to support the integration of OTDs into the workforce. The problem areas are well defined — the need for better information access; better orientation to our healthcare systems and the workplace; improving communication with patients and healthcare workers; standardised assessment of knowledge and skills; and education and training support —so, let’s get on with it.

Barry P McGrath MD, FRACP

Weeks after beginning its winding journey, a redirected letter finally finds its destination. In our eagerness to open it, we almost tear in half the neatly folded crisp white sheet that lists a series of results: angina, pass; asthma, pass; preeclampsia, pass; bulimia, fail, could not elicit history of vomiting; croup, pass. The list continues to a dispassionate conclusion that the candidate has demonstrated adequate knowledge at the examinations of the Australian Medical Council (AMC) to secure a passing grade. The accompanying card graciously thanks us for our tutoring 1 year ago. We stare wordlessly at the sheet, our joy obliterating its sterility. So far, he has fled state persecution, worked 10 years in a factory, and supported a family of four on a minimum wage. The iatrogenic death of his father served as a powerful impetus to return to his calling in life, medicine. Forty years old, he has juggled swimming and soccer lessons, school homework and, lately, running a small business to steal time to prepare for his own examinations. “I promised myself at my father’s bedside that I would go back to medicine. Every day in the factory, I used to dream about becoming a doctor again, but we needed that job to survive.” Now he will forever be known as an “AMC”. As we exuberantly write him a congratulatory note, a vision of his journey ahead involuntarily crosses our mind. As he begins his quest for a job, he will quickly learn that, although all foreign graduates seeking to enter the Australian medical system must take the AMC exam, the term “AMC doctor” automatically carries the connotation of inferiority. Irish, American and German doctors will be identified by country, while he and his peers from the developing world will be separated by an invisible, but distressingly tangible, line. Deeming himself unsuitable for the elite hospitals, he will apply instead to those considered more “foreigner-friendly”, their reputation earned not necessarily for their greater tolerance of foreign graduates, but because of their inability to attract the more aspiring. These hospitals too will first select local graduates before yielding the leftover spots to the AMCs. At the scant interviews he secures, he will be summarily discarded at some on account of his thick (yet understandable) accent and his slow (yet considered) speech. At others, he is unlikely to receive ticks in the boxes that say “team player”, “enthusiastic” and “makes good eye contact”, because he is unfamiliar with the buzzwords and gestures (although not the inherent concepts) that interviewers seek. His first job is almost certain to be in a hospital staffed largely, if not almost exclusively, by foreign doctors. Collegial support will be tentative, the focus being on surviving each day without raising the staff’s ire. He will be greeted cautiously, unaware of an unspoken probation, and he might only enjoy a few days’ grace before barbed remarks escape their loose restraint. Despite his commitment, he will be slow, never having had the benefit of observing local protocol as a student or a subintern. Despite having passed his exams, he will hesitate with most tasks, including the essential ones of documenting directions, checking blood tests and making a physiotherapy referral, because he is a stranger to them all. Some doctors and nurses might lend a kind and guiding hand, but he is more likely to (over)hear the following: “You are the resident — it’s your job!” “Why do I always end up with the AMCs?” “He might be a nice person, but he doesn’t have a clue!”. Occasionally, the remarks will be deliberately hurtful: “Excuse me, this desk is for doctors only!” “Why don’t they just go back where they came from?”. He is most likely to miss tutorials because of unfinished work, and, when he does get to one, he is the diminutive figure in the corner, too self-conscious to ask a legitimate question. He is the one you will see biting on a stale sandwich most evenings as he ploughs through piles of paperwork between braving phone calls to the registrar, irate at his inability to articulate a problem in 30 seconds. When the desperately needed interpreter is hours away, he will meekly announce his grasp of two other languages. Relief and gratitude on the part of the staff will be somehow inexplicably replaced by righteousness. “At least he can do that!” He will often wonder why his best attempts to contribute meaningfully seem antagonistic, why there is such a glaring lack of encouragement, and why he is finding this initiation harder than he had ever imagined. In a private wish list, he craves for a little more understanding and a little less hostility; then, scoffing at such imagined luxuries, he returns to face another day. Slowly, one unit then another shares the AMC burden, each one “preparing” the next, so that his perceived shortcomings always precede him. Soon he must think about the following year’s jobs. What should he do? Who knows him well enough to provide the references? Who are his role models? Should he follow the majority of his AMC peers and enrol in general practice training or should he make a concerted attempt to pursue a long-desired specialty? The obstacles seem magnified in advanced training. Even if he manages to enter a specialty program, who will supervise the children’s homework? Who in the hospital appreciates the needs of an older foreign doctor, also a son, father, husband and small business owner? The conflict between personal aspirations and life’s larger concerns routinely ravages his mind. In the course of our own training, we have been frequent witness to, and no doubt creators of, the hurdles that the medical community puts in the way of foreign medical graduates. These hurdles are not only academic, but also personal, based on our uninformed and unchallenged perception of their culture, education and work ethic. Every foreign graduate we have taught has understood the rationale for an Australian exam, but, after attaining the very standard demanded by the profession, it is the indignity of working in an unsupported and hostile environment as a second-class doctor that turns out to be the insurmountable hurdle. Although the issues surrounding foreign medical graduates are genuinely difficult and bear no glib resolutions, we suggest the following considerations. Integrate foreign medical graduates preparing for the AMC exam into hospitals by allowing them to observe educational seminars, outpatient work and grand rounds. Knowledge of local medical practice is far more accessible in this manner than by spending countless lonely hours in the library in search of assimilation. Access should not be limited to peripheral hospitals, which are often difficult to travel to and lack consistent teaching programs. Expand the educational program for foreign graduates by encouraging local physicians to teach. (With the assistance of just one other colleague, each of us spent just 2 hours a week to adequately address the exam syllabus.) It is crucial that program directors sanction such activity rather than be dismissive of its goals — a volunteer teaching program will enjoy success only if personal gain is sometimes set aside. Assign a specific mentor for foreign doctors at each institution. Such a mentor must be sensitive to the different goals and needs of foreign doctors compared with those of their local counterparts. Neither excessive pressure to conform nor total immunity from compliance with local standards should take the place of a deliberate process of integration. Practise what we preach. Medical students are taught from inception about the value of empathy and communication. We repeatedly examine their grasp of such skills, yet, once they are doctors, these skills are perceived to be an optional extra. Apply the open-ended question to foreign doctors: “Tell me how you feel.” Appreciate the worth of foreign doctors as a pillar of our increasingly cosmopolitan society. The very doctors we may deride will go on to serve entire populations, which the average Australian graduate is ill-equipped, and hence uncomfortable, to serve. The statistics on migrants, ageing populations and chronic illnesses do not bear repetition, but the overwhelming need to help our foreign doctors to help us take care of all our patients does. In medicine, the road is long for us all, but for the foreign medical graduate it is inevitably more winding and rough. It is our obligation to not abandon our colleagues along the way, but to seek to ease their journey with small, personal gestures and larger, administrative measures. While they tend our society’s sick, we must not deny them their own bruises that often lie just beneath the surface. It is only then that as physicians we can truly call ourselves healers.

Ranjana Srivastava MB BS(Hons) · Declan J Green MB BS(Hons)

To the Editor: Hays notes that international medical graduates on temporary residency visas are “an almost invisible workforce”.1 This invisibility results partly from a lack of data, but it also stems from a lack of coordination and consistency between agencies which do hold relevant data. In the main, these doctors hold conditional registration (rather than general registration) with state and territory medical registration boards. However, there are inconsistencies between jurisdictions in how data on conditional registrants are treated in relation to national medical workforce data collection (namely the annual national medical labour force surveys overseen by the Australian Institute of Health and Welfare [AIHW]), and in how statistics relating to this group are reported. Available data from four medical registration boards indicate that, in 2003, conditional registrations of overseas-trained doctors comprised over 10% of all medical registrations in Western Australia and Queensland (see Box). Percentages have increased since 2001 in WA, NSW and, to a lesser extent, in Queensland, while remaining steady in Victoria (2001 figures were WA, 8.2%; Qld, 9.3%; Vic, 6.5%; NSW, 2.3%).2-5 The invisibility of this group might be ameliorated to some extent if existing data on conditional registrants were reported and collated in a consistent manner. The AIHW is the obvious candidate to oversee such collation, and the question of why the state and territory medical registration boards do not provide the data to enable this to occur is a puzzling one. The primary function of medical registration boards is, of course, administration of registrations in their jurisdictions, and their workload has been increased by growth in conditional registrations, which involve time-consuming processing. In this context, it is perhaps understandable that the boards are not focused on the potential value of their data to medical workforce planning. If better use is to be made of the existing data for national medical workforce planning, the boards will need to commit to consistent and more detailed reporting practices for conditional registrants. This would probably occur easily if boards were convinced of the value of national medical workforce planning, and recognised the value of their unique contribution to it. It is a stated principle of national health workforce strategy that Australia should aim to achieve national self-sufficiency in its health workforce supply.6 If this is to be achieved, the numbers, characteristics and movements of international medical graduates on temporary visas must be monitored more carefully. All registrations and conditional registrations for overseas-trained doctors in four states, 2003 State Total registrations Conditional registrations* Western Australia2 6 854 718 (10.5%) Queensland3 12 531 1263 (10.1%) Victoria4 17 603 1115 (6.6%) New South Wales5 25 481 1211 (4.7%) * These include overseas-trained conditional registrants only. It excludes conditional registrants who are interns, who have passed all Australian Medical Council examinations or who are registered conditionally for health or disciplinary reasons.

Catherine M Joyce

Snow-capped Mount Kilimanjaro, in Tanzania, stands 5895 m (19 335 ft) high and is the highest mountain in Africa. The hike up the mountain, although considered arduous, is attempted by dozens of people each day. About one in four actually succeed. A few years ago, we set out to climb it, planning to get to the summit and down again in six days. We had pre-arranged an experienced guide and, rather than carrying tents, chose to stay in huts provided on the mountain. We hired some down-filled clothing and sleeping bags with the help of our guide — but, when offered crampons and ice axes for hire, we both laughed at the idea. “This is just a walk”, we joked, “not a real climb”. View of Mount Kilimanjaro (5895 m, 19 335 ft), Tanzania, from the road leading to the park entrance. It is two vertical miles higher than Australia’s highest mountain, Mt Kosciuszko. For years no one believed the early reports that a mountain near the equator had snow on its summit. The first two days of climbing were moderately hard and it became progressively colder. At one point, our guide spent some time talking intently to a colleague who was on the way down. He then explained that a group of hikers, two days ahead of us, had been climbing through a thunderstorm when a young American woman was struck by a bolt of lightning and killed instantly. She had literally “blown up”, with lightning bolts arcing down her body and out through her torso and limbs to the ground, leaving huge flesh wounds. This macabre event caused us some anxiety. Our guide thought she had been struck because she was wearing a red parka, believing that red objects “attract” lightning. We pondered whether there was some scientific rationale for red gear being more likely than other colours to attract lightning. Trying to warm up in the sun outside one of the huts on our rest day. We eventually reached the first hut and stayed overnight. Next morning was initially cold but comfortable. But then we struck rain, a strong wind blew up, and the chill factor sent the thermometer plunging. It became so unbelievably cold that we had to put on every piece of cold weather gear we had. This was our first sense of just how cold it can be at high altitude. As we sat on a rock to rest, one of us noticed a scrappy piece of red plastic on a bush and began to deride those nuisance climbers who “show a complete lack of respect for the beautiful mountain surroundings by leaving behind plastic rubbish to contaminate the pristine environment”. We then saw another piece of red plastic, then another, and soon realised that there were dozens of such pieces in a circle of about 10 m diameter. We then noticed a carefully constructed mound of rocks adorned with fresh flowers. It suddenly dawned on us that this must have been the spot where the young American woman had been blown apart by lightning. The rough rock memorial must have been constructed by her fellow climbers. We were both awestruck by the frightening power of lightning. We continued climbing fairly easily, and had decided in advance to spend an extra day at Horombo hut (at about 4000 m) to help us acclimatise. It was hard to watch our fellow climbers leave without us — people we had met in the first few days and who would probably reach the summit before us. As events unfolded, our decision to spend that extra day at Horombo set us up for life-theatening situations near the summit. On our fourth day, we reached the highest hut, Kibo, at 4700 m. The views were quite beautiful, with a pink sunset on neighbouring Mount Mawenzi and absolutely pristine clear skies. We had a small meal — no one has much appetite at altitude — and turned in for a few hours’ sleep before the final hike to the summit, with the aim of being there at dawn. We set off for the summit at about 12.30 am. It was a moonless night, but at that altitude the sky was filled with millions of stars that appeared so close we felt we could pluck them from the sky. Amazingly, the starlight was sufficiently bright to illuminate Kilimanjaro and adjacent Mount Mawenzi. It was unforgettably spectacular. We were climbing with our guide and a trainee guide on his first ascent. We felt fairly confident that this last section of the climb would not defeat us. We had both tried to get fit enough by running up and down 50 flights of hospital stairs three times a week, and had taken precautions to avoid altitude sickness — climbing slowly, drinking plenty of water, taking prophylactic acetazolamide, and taking the extra day to acclimatise. As we began, I was surprised to find that I was extremely breathless despite walking slowly. The snow was hard and, as we had not brought headlamps, we stumbled in the frozen boot marks of previous climbers. Recovering from each stumble required much energy and produced marked breathlessness. We found the climb extremely arduous, and experienced effort-induced nausea plus the bitter, penetrating cold. I felt certain that I would not make the summit. In lucid moments I cursed my oxygen-dissociation curve for its failure to “shift to the right” and be more generous in donating oxygen. The physical and mental struggle to reach Hans Meyer cave, a third of the way up to the summit push, was monumental. I had seen published photos of Hans Meyer cave (named after the first man to climb Kilimanjaro) — which show it as virtually dry. But we found the cave totally ice encrusted, with large icicles hanging down from its roof. The temperature was −20°C to −30°C. We rested briefly at the cave, which allowed me to recover somewhat. As we pushed on laboriously, we noticed the bright stars disappear and within a few minutes we were enveloped by cloud, strong winds, and then driving, icy snow. The blizzard made climbing treacherous and reduced visibility to almost zero. To our surprise, and alarm, virtually all of the other climbing groups had turned back. The only person who didn’t was obviously an experienced mountaineer, who rapidly passed us wearing crampons and swinging his ice axe rhythmically to cut steps in the snow. To see the other groups stop and then turn back made us a little concerned that we were taking a considerable risk in pushing on. Nonetheless, we were both determined to continue up the mountain. At this point, Mark, a cardiothoracic surgeon whose hands generally prove fairly useful in his profession, hadn’t been able to move or feel his fingers for some time and was convinced he had significant frostbite. This did not change his determination to continue the climb. He thought that, as he already probably had some frostbite, going on to the summit was unlikely to make it worse. It is hard to describe how much emotional effort was required to keep climbing. Taking each step required every bit of mental endurance and concentration. It would not have been so bad if we had crampons, but we only had boots and so we slipped a lot. And every slip was exhausting. Everything in our lives — our families, our professions and all our previous life experiences — faded into a vague, dark background as our whole world was reduced to the small space between our ice-encrusted eyes and the snow slope in front of us. Dawn began to break and we were able to see a little more clearly in the faint light through the billowing ice and snow. It was around this time that we had two frightening experiences. First, I lost my footing and began to slip backwards down the mountain. It crossed my mind, with surprisingly lucid mathematical precision, that my slide down the mountain may increase in velocity and end by my crashing at near terminal velocity into Kibo hut 915 m (3000 ft) below. However, I managed to roll over and, aiming for a large rock, slid feet first into it. This life-threatening event produced marked and unrelenting breathlessness. I recovered slowly, and we continued to struggle on up the steep slope towards the summit, kicking our boots as deeply into the snow as best we could to gain precarious footholds. Then the second frightening event occurred. Mark slipped and began sliding down the mountain. He frantically grabbed at a rock protruding from the snow and this stopped his fall. He hugged the rock above his head with both hands, his body hanging down, and his feet flailing helplessly, unable to get any foothold. Every effort to kick a hole in the snow to try to gain a footing caused the snow to just fall away down the slope. I tried to help him, but couldn’t do much. The guide retreated down to our position, kicked a foot hole himself and then helped haul Mark above the rock. Mark lay prostrate in the snow, unable to catch his breath for 10 minutes or so. He later described this sensation as what it must feel like to die of respiratory failure! The guide encouraged us to keep going if we wished, although he later confessed that on a number of occasions he had decided that neither of us could possibly make it to the summit. Doggedly, we pushed on. We reached the top at about 8.00 am. It was an anticlimax — we were unable to see much. Although the blizzard had eased off slightly we were still besieged by falling snow and mist. The only reason we realised we were at the summit was that there was a small sign welcoming us to the top of the mountain. With blue fingers, I am attempting to video at – 30oC without gloves. The video camera, laboriously carried to the summit, only worked for a few seconds in the cold, but that visual record of our achievement is very precious to us. We shook hands and joked with our guide. However, he was more interested in leaving the summit as quickly as possible, warning us that “the weather is going to get bad”. Mark remembers thinking at the time that this was a somewhat superfluous statement. It didn’t seem conceivable that it could get any worse! We hiked, slid, crab walked, and glissaded down the steep slope through the whiteout. It didn’t look like the same route that we had come up on — it looked even steeper and we both felt that our guide was completely lost, and that at any moment we would glissade over the edge of one of the cliffs. We had read that 10 people die on Kilimanjaro each year, some by getting lost and falling over ice cliffs, and we thought that the same fate was destined to befall us. Eventually, we reached Hans Meyer cave and began to feel that we would safely descend the mountain. What should have been a physically demanding, but easily manageable, hike turned out to be an unexpectedly dangerous adventure for us both. The disappointment at not being able to see the famous dawn view from the Kilimanjaro summit was minor compared with the sheer adventure of the experience, the knowledge that very few hikers made it to the summit that day, and the experience of two close friends struggling together against exhaustion, cold, fear, danger and disappointment. We were inexperienced mountaineers. But we were both able to help each other when we each faced danger, and we felt a very strong bond with each other. We felt an incredible sense of achievement because we had overcome all of the difficulties. Snowbound descent — this spot was totally dry and barren on the ascent. And we learnt some lessons: Get very fit by walking and running up stairs (not just on the flat) before undertaking a climb up Mount Kilimanjaro. Get professional advice on cold weather gear, especially modern thermal underwear, wind-resistant but “breathable” jackets, and good-quality down-filled gear. It can make the difference between being miserable or comfortable. (Many times as we climbed I said to myself that I would pay $10 000 to anyone who could have given me any of that gear, right there and then.) Take anti-altitude sickness precautions. Hire a reputable, experienced guide — inferior guides may not be primarily interested in getting you to the top — the earlier you turn back, the less work and less risk it is for them. And we did meet someone who could have died for lack of a good guide. As we descended through the storm, we found her stumbling along, severely hypothermic, disoriented and unable to speak. Her guide had let her set off up the mountain without gloves and other warm gear, and had not followed her into the storm. Hire crampons and an ice axe. We scoffed when we were offered crampons, but if we were doing the climb again we would undoubtedly hire these climbing aids, even though it is rare for Kilimanjaro climbers to strike a blizzard. Take digital cameras, including a video camera, with you, even though they are heavy and inconvenient to lug at such an altitude, and the exhaustion produced by climbing reduces one’s motivation to take photos. The resulting pictures are irreplaceable and worth every effort. A useful website is www.climbingkilimanjaro.com But, in the end, the experiences and rewards we gained from our adventure were such that neither of us could possibly have anticipated how much it would enrich us as individuals and friends.

Bruce W S Robinson MD, FRACP, FRCP · Mark G Edwards MB BS, FRACS, FRCS

Much has been written about false memories — memories that are a distortion of an actual experience, or a confabulation of an imagined one. Memory and its reliability or otherwise have profound implications for us all, not only in our daily lives, but clinically and medicolegally. How often does a medical negligence or misconduct allegation boil down to “he said, she said” evidence? And we have all experienced the mismatch of memories of events shared in the distant past by more than one person. This personal anecdote records the same event as recalled by two people. Quite fortuitously in this instance, objective contemporaneous evidence settled the disagreement. Being a borderline student in Chemistry I, my poor performance in the practical examination was enough to secure a fail mark and a repeat of first-year medicine. During my rerun of Chemistry, I consistently failed to identify the colours of certain metals when held in the Bunsen flame. The Ishihara chart confirmed partial red–green colour blindness. Four years later, in 1959, I bumped into a medical school colleague in Paris, and we visited an art gallery together. Throughout the ensuing 45 years, my memory has been that the gallery was the Louvre. I have a clear memory of our standing before an impressionist painting by Manet, with mainly blue to purple hues, of Paris in the rain. My companion commented how wonderfully the red roofs contrasted with the overall bluish colours. I asked, “What red roofs?”. I could not see them until she pointed them out, and was intensely disappointed by this aesthetic consequence of my red–green handicap. That night I recorded the unhappy event in my diary. I have since visited perhaps no more than two or three art galleries, and then only as a reluctant companion to my wife. Van Gogh’s bedroom in Arles Van Gogh’s bedroom in Arles (oil on canvas — Musée d’Orsay, Paris; photo RMN © Gérard Blot) — one of three versions of the same painting, and most likely the one I saw. This one, painted while Van Gogh was voluntarily confined to a mental asylum in Saint-Rémy, includes a self-portrait as one of the paintings above the bed. In a letter to his brother, Théo, Vincent wrote “. . . it’s just simply my bedroom, only here colour is to do everything . . .” Fast forward to 2002. By chance, I re-established communication with my student colleague, now a psychiatrist in England. I commented how she had been someone I had always remembered, in large measure because of our joint experience at the Louvre. She replied that our gallery visit had made its mark on her, too. In subsequent decades of lecturing, she had taken care, when preparing slides, overheads and PowerPoint presentations, to avoid colours that might be confusing to men like me. However, the painting had not been in the Louvre, she said, but at a museum of impressionist art near the Place de la Concorde. Furthermore, the red I had not been able to see in the painting was not Parisian roofs in the rain, but the red heads of birds! Quite fortuitously, at the time of this correspondence, I was transcribing my 1959 European travel diary into typescript. I quickly checked my entry for the day at the art gallery. Yes, my colleague was right: it was a museum at the Place de la Concorde, not the Louvre. (The museum was, in fact, the Musée du Jeu de Paume at the Place de la Concorde, which housed the collection of impressionist paintings of the Louvre before they were relocated to the Musée d’Orsay in 1986.) But the painting in question? No red roofs in a rainy Paris. No birds with red heads. It was the famous Van Gogh painting of his bedroom in Arles, with the large, red coverlet on his bed! I had been familiar with Van Gogh’s bedroom painting for many years before going to Europe. But my memory, over nearly five decades, remains of rainy red roofs. No matter that I have searched the catalogues of the Impressionists and have not found such a painting. No matter that I now know that the painting with the invisible reds was the Van Gogh pictured here, my memory remains undiminished — red roofs in the rain! I still “see” them clearly. As for my colleague, despite my presenting her with the contemporaneous evidence of my diary, she, in turn, “knows” that the picture was of birds with red heads!

Peter C Arnold BSc, MB BCh, BA

We have a fabulous country out there, with lots of people who will benefit from our skills I was tired of seeing myself in my patients — white, middle-aged, middle-class, menopausal women — the “worried well”. It was time for a change. Time to leave my renovated terrace in inner Sydney. Time to put down the glass of champagne, cancel the subscription to the opera, put in storage my five pairs of boots from the Manhattan winter sales, and head off to “the bush” for a seachange. The bush was not an unknown entity for me. Although I’ve lived most of my life in cities, mainly Sydney, I was born in rural Wagga Wagga, the daughter of the first university-trained vet to practise west of the Blue Mountains. I spent my preschool days with my father, flying in a Tiger Moth to attend cows in obstructed labour, and delighting in watching his whole arm disappearing inside the birthing cow. So, my idea of what it would be like working in rural and remote Australia was partly based on these early experiences. Nonetheless, some of my friends were a little sceptical, viewing this decision as a whim, a blip in my middle-class, ABC Classic FM-saturated life. How wrong they were! I have ended up embracing wholeheartedly this wonderful life, committed to spending the rest of my working days facing the challenges of being a doctor in remote Aboriginal communities. It’s not all fun and games, of course. For a multitude of reasons, the health of Aboriginal people, as we all know from media reports and journal articles, is much worse that that of other Australians. In remote areas, the people often do not seek help until the advanced stages of an illness. A person with a toothache may first present with a huge dental abscess and a fever; another, with an unchecked ear infection, may be first diagnosed with a cerebral abscess; a pregnant woman may wander in for her initial check-up at 38 weeks’ gestation; painful joints are more likely to be lupus or rheumatic fever than osteoarthritis; and chest pain in a 26-year-old man must be treated as a myocardial infarction until proved otherwise. Flying over Arnhem Land. Photo courtesy Dan Armstrong. But medicine in the Northern Territory has grown up with an infrastructure geared to remote communities and to Aboriginal health. Having always believed in a public health system in which treatment priority is determined by illness severity (as in emergency departments in public hospitals), I was thrilled to find that the Northern Territory delivers the type of healthcare I believe in. Requests for outpatient appointments are faxed to the specialist in charge of that department and “triaged”. A woman with cervical intraepithelial neoplasia (CIN) grade III will be seen before one with grade I, and a woman with a history of breast cancer with recent weight loss and low back pain will be seen within a week. No preferential treatment linked to income or social standing. Just the sickest are seen first. Exactly how public medicine should be. Working in Aboriginal health in the Northern Territory is like working in a big cooperative family. I have never known such a sense of collegiality, and a lack of competition between healthcare providers. Help is always at the end of a phone. An emergency evacuation is organised via the district medical officer on duty for that day or night. There may be some input from a registrar or specialist to fine tune the patient’s treatment before air evacuation, and, if the patient’s condition is unstable, a registrar may accompany the nurse on the flight and perform the necessary resuscitation procedures before evacuation. Each time I have accompanied a patient to the airstrip for a medivac, I have watched the plane take off with tears in my eyes and an embarrassingly “proud to be Australian” lump in my throat. Not just the feeling that at last the patient is in safe(r) hands, but the feeling that not many countries provide such a fabulous service. But what of the communities I have worked in, the life I now lead, and the medicine I now practise. My favourite community is in western Arnhem Land, and I will return to this community in January 2005 to take up a 12-month contract. My first job there was in the “Wet”, that time of year when the skies become more ominously black as the day progresses, and the thunderstorms and lightning displays make the 1812 Overture and the Sydney Harbour New Year’s Eve fireworks display seem like child’s play. When the heavens open, the rain buckets down and the temperature drops a welcome 10°C. And, in the “Top End”, this is the time when tropical diseases blossom, and any person with symptoms of pneumonia or explosive fevers with skin lesions is diagnosed as having melioidosis until proved otherwise. This disease has a reasonably high fatality rate (the books say 17%), and the causative organism lives in the soil in the rainy season, so anyone with a cough and high fever is pumped with intravenous ceftriaxone and immediately evacuated. On a single day in this community during the Wet, our patients included a man with suspected melioidosis (which turned out to be septicaemia from a staphylococcus pustule on his leg); a 9-year-old with a huge, hard tonsillar lymph node and a massive cavity in a nearby tooth (I suspected osteomyelitis); and a 21-year-old girl who, as a child, had miraculously survived a gigantic brain abscess that developed from mastoiditis (which in turn developed from an untreated ear infection). She presented with headaches and vomiting, probably associated with a blockage in the shunt extending from her brain to her belly. And to top it off, there was a 17-year-old girl with active (treated) tuberculosis that appeared to have spread to her kidneys. All these people had to be either evacuated (with limited places on the Aerial Medical Service plane) or flown on a charter plane to Jabiru and then taken by bus to Darwin. A nightmare to organise, but somehow it gets done. One of my most memorable experiences involved visiting an outstation that, in the Wet, could only be reached by a small twin-engine plane. I had asked the outstation nurse what supplies to bring — lunch? water? stethoscope? “Just water and stethoscope”, she said. “Keep it light. Forget about the lunch. Rebecca and Samuel [at the outstation] have a pack of about 60 dogs, and they’ve become unmanageable. In fact, Rebecca and Samuel have moved out into the humpy outside, as the dogs have taken over the house. If you bring your lunch, they’ll smell it and eat you and your lunch for starters.” “Righto”, I said, always casual in the face of impending disaster. And she wasn’t far wrong. We flew over the Arnhem Land escarpment, some of the most beautiful wilderness country I have ever seen, and as the plane skidded to a halt on the very short airstrip we were prevented from getting out by a mob of about 20 ferocious dogs, who obviously thought the pilot, nurse and doctor were their breakfast, lunch and dinner by air express. Rebecca finally managed to call them off and we set up the clinic on the veranda, tending to the needs of eight people with a variety of disorders — chronic obstructive airway disease, rheumatic heart disease (requiring monthly penicillin injections and regular echocardiography and cardiology review), newly diagnosed hepatitis B, a child with anaemia, hypertension, as well as the usual smattering of hypercholesterolaemia, worms and diabetes. For all those urban GPs out there who are feeling sluggish and jaded, I thoroughly recommend considering a seachange to rural and remote Australia. If your emergency medicine skills are somewhat rusty (mine were totally obsolete), head off to your local ED and spend a few months eating humble pie while interns and residents show you the latest ropes. Book into a few courses, such as emergency life support (ELS) and early management of surgical trauma (EMST). If you’ve decided that remote Aboriginal communities might be your cup of tea, practise communicating with your neighbours from non-English-speaking backgrounds. Or, better still, travel to a country whose language and culture is totally different from your own, get ill (but not too seriously), and experience at first hand how difficult it is to describe your symptoms to a doctor or nurse who doesn’t speak your language. We have a fabulous country out there, with lots of people who will benefit from our skills. My best advice to anyone who wants to see Australia, and is ready to experience new challenges and work with some of the most disadvantaged people in the world, is to pick up the ball, run with it, and, in the words of a famous running shoe company, JUST DO IT!

Glynis A Johns MB BS, DPH, MPhil

Despite leadership roles being critical, we persist with outmoded models of organisations and pay inadequate attention to developing individual leaders and new models of leadership within the medical profession. New forms of leadership are required. Among many important roles, leaders are called on: to enhance the meaningful identity of a profession; to create effective linkages with other healthcare professionals and stakeholders, as well as with healthcare system managers; to interpret complexity so that their institutions and followers can operate successfully in uncertain times; and to consistently model ethical behaviour.

S Bruce Dowton MD, FACMG, FRACP

Doctors’ concerns in 2004 look remarkably similar to those they were expressing more than a century ago Doctors often yearn for the good old times when governments didn’t interfere and economic security was matched by an unfettered freedom to practise their skills, but did these times ever exist? Delving into the Australian Medical Journal (AMJ) from 1870 to 1879 suggests that the medicopolitical issues confronting the profession have changed very little. Medicine today is more sophisticated, but the politics is not and has lost a certain character-forming robustness. Premises of Dr William R Pugh, surgeon and oculist, 131 Collins Street, Melbourne, circa 1865. © State Library of Victoria. The political issues confronting doctors in the 1870s included: The number of doctors entering the colonies with questionable overseas qualifications and uncertain language skills, and the failure of medical boards to control this;1 Poor remuneration for general practitioners and control of doctors’ remuneration by health funds (lodges and friendly societies);2 Specialist intrusion replacing general practice;3 Inadequate funding of the public and charity hospitals;4 Competition from pharmacists and alternative medicine;5 and Litigation, an unfair legal system and poor expert witnesses.6 It sounds familiar! The qualified doctorIn 1870, Australia had medical schools in Melbourne and Sydney. A reputable British degree was a prized qualification, and England was fondly referred to as “home”. Medical Acts governed the registration of doctors, a privilege which was jealously guarded. In 1873, there were 469 registered practitioners in Victoria with degrees from 48 universities, “not to speak of 10 who hail from no College at all, but by good luck were practising in the colony before 1853”.7 Valid proof of 3 years of equivalent study was enough to gain entry to the Medical Register, but there was doubt that medical boards were able to adequately check overseas qualifications. Frequent stories appeared of unlicensed medical practitioners being prosecuted, as did editorials calling for better screening of international medical graduates, exemplified by the case of Dr Myers, of the University of Lima, Peru, who rated an entire editorial, as he was accused of “sneaking into the profession”.8 The editorial castigating Dr Myers and the Medical Board was a gentlemen’s tiff compared with a stinging editorial in August 1875 on American degrees:9 “. . . the Americans who do everything in a hurry, educate their doctors in their usual fashion”, implying that a fat fee to an American university could purchase a pass in a fast-tracked medical degree. This, in turn, was mild compared with the disdain shown towards Chinese degrees and to those of Asian descent who attempted to gain access to the Register. The comments from an 1875 editorial10 would today earn a trip to the Anti-Discrimination Tribunal: “Because they speak in an unwieldy tongue and because any system of medicine they may have studied is at the opposite extreme of intelligence” and “. . . whenever an opportunity has been afforded them of submitting their medical knowledge to a reliable test, they have shown an incompetence . . .” The failure of the Medical Board of Victoria to protect the public from overseas-trained doctors of dubious quality caused great agitation. Criticism in an editorial using the subtle genre of the time expressed the view that “The Medical Board . . . is, in reality, only the mockery of an authority. They have no option in registering the most objectionable holder of a valid qualification and . . . what they know to be the most insufficient evidence of a proper medical education.” Have these all-too-similar sentiments been more gently expressed in our own medical and popular press of late? Remuneration of GPs“A person will go to a specialist and joyfully give a guinea . . . while the poor half guinea of the general practitioner is uniformly begrudged”, lamented an AMJ editorial from April 1876. The standard fee for a GP consultation was 10 shillings, but most GP visits were house calls. This period saw the rise of the medical clubs and friendly societies. GPs were invited to tender a competitive price and were paid by the club, essentially a health insurance fund. To ensure a busy practice, the price competition was fierce. As the price of general practice was driven down to meet the demands of the funds, GPs complained frequently about their poor remuneration.11 There were several attempts to form cartels to stand up to the clubs and bring the prices up, but doctors would always break ranks and offer to undercut their colleagues to ensure the security of their own practices.11 Attempts to improve GP remuneration usually failed because of lack of political unity. Successive Medical Society presidents expressed great concern about the emphasis on low cost, high volume medicine, which meant that it was “impossible that they [doctors] can devote sufficient time to each individual case. They must hurry along . . . and this continued hurry must lead to a kind of practice unsatisfactory alike to practitioner and patient.”12 State remuneration of “medical men” was considered a “disgrace”. The vaccination fee of 2s 6d “was ludicrously inadequate”,13 and state health officers were “mocked by their paltry salaries”.13 Compassionate discounting in private practice was common, but many GPs felt their charity was abused by the wealthier who could afford to pay. Informed financial consent was the subject of an editorial in November 1875:15 “Patients are often obtuse on the fees for operations and it is better there be no misunderstanding afterwards”. However, the popular press often made reference to high medical fees. Such a story in The Argus, a Melbourne newspaper, so raised the ire of one GP that he was moved to write In reply:16 “Of the 30 medical men residing there [Collins Street, Melbourne’s equivalent of Harley Street in London] . . . and [who] visit their patients in expensive vehicles, drawn by thoroughbred horses, driven by fat coachmen in gay livery, seven have no carriages at all, and eight drive but one horse, and their coachmen are not in livery . . . albeit I have no carriage and cannot quite make ends meet.” Doctors and their cars in the 1870s! The specialist and the generalistAn 1878 editorial entitled “Special practice” stated: “There is not much left for the General practitioner to do in these days of specialism; at least there is not much the public think he can do. Every organ of the body is appropriated by those who give their attention to regional diseases so that the general practitioner is looked upon as a kind of pathological poacher if he extend his treatment greatly beyond catarrh, colic or fever. In surgery, especially, he is forbidden to meddle, and there are certain instruments which it is a kind of professional crime for the average [GP] surgeon to use.”3 Public sector fundingThe public (or charity) hospitals were chronically underfunded. Outpatient waiting rooms were crowded with patients waiting many hours to be seen. There was a need for more public hospitals, and the decade saw the completion and opening of the Alfred Hospital in Melbourne. It was initially a free hospital, but it wasn’t long before a debate started about the merits of increasing its income by taking in “pay patients”. As the charity hospitals received minimal government funding, there was continued and strident criticism of those patients who could afford to pay for their hospitalisation but took advantage of the free system. The question of paying patients in public hospitals was a vexed one, with lessons we could learn from today. The medical profession was divided, as it gave a competitive advantage to the full time clinicians and honorary specialists at the hospital. An editorial entitled “Pay hospitals” in March 1877 summed up the position well: “It is a mistake to endeavour to associate gratis patients and pay patients under the same roof. So far as we know, wherever the experiment has been tried, it has failed . . . the difficulty continually arose, of pay patients complaining they did not receive attention and accommodation sufficient to distinguish them from the gratis patients, while these latter were of the distinct contrary opinion, that the pay patients were unfairly preferred.”17 Melbourne Hospital circa 1870. At that time honorary medical staff were elected every 4 years by the hospital’s subscribers. Doctors expended considerable effort and expense to win these prestigious positions.14 © State Library of Victoria. Competition for honorary posts was fierce. Appointment was by elections, the voters being the subscribers to the hospital; such ballots were a cause for much angst and legal action after the results became known. Petty jealousies abounded between doctors, and tension existed between the hospital administrators and the medical staff over budget control. The Melbourne Hospital’s budget was saved in the nick of time by a zealous administrator who publicly called the medical staff to account in no uncertain terms for their over-prescribing of meat extracts as dietary supplements, thereby nearly breaking the pharmacy budget. In May 1878, the whole medical staff of the Sydney Infirmary resigned because of dissatisfaction with the conditions at the hospital: “Week after week it has been found necessary to turn away applicants for admission there, partly for want of room . . . there are many instances in which patients cannot be properly treated at the infirmary at all.”18 Access block in the 1870s! The competitionThree groups provoking the ire of the profession in the 1870s were pharmacists, homoeopaths and quacks, a basket into which all other alternative healthcare providers also fell. The prescribing pharmacist caused the most concern, and some doctors were most rigid in their views. One GP was fined for refusing to attend to a child who had been kicked by a horse because a pharmacist had already applied some sticking plaster to the child’s head! Pharmacists drew this comment in an 1876 editorial: “They [the public] seem to entertain a belief that a knowledge of drugs implies a knowledge of disease and he who can compound and dispense can also prescribe.”11 How did the medical profession fight this competition? They considered dispensing medicines and charging for their own drugs. Doctors insisted on charging a consultation fee when issuing repeat prescriptions, and this was a source of frequent public complaint. These complaints particularly aggrieved the profession, which felt that there was some intellectual property in the potions and mixtures that they designed to treat various diseases — intellectual property which then stayed profitably with the pharmacist.19 Patent medicines, which promised a cure for everything from alcoholism to scurvy, were also a problem, particularly when promoted by snake oil merchants. However, it was humbling to see one of the major academic tussles of the day was a written war between The Lancet and the AMJ on the benefits of intravenous ammonia for the treatment of snakebite, a cure promoted by a Professor George Halford, one of Melbourne’s leading academics. Homoeopathy was especially hated by the profession. This hatred was fired by the repeated attempts by homoeopaths to gain admitting rights to the Melbourne Hospital and to set up special homoeopathy units. This was a move as fiercely resisted then as it would be today. Homoeopathy was described in an AMJ editorial in 1877 as “an irrational heresy” and homoeopaths were described as “immoral, dishonest and promoting a system of charlatanry”.20 The homoeopaths were well organised and very adept at answering public criticism and mobilising their supporters. The public seemed to find no shortage of cash to pay their homoeopath or herbalist, but were very reluctant to pay their GP, a source of serious irritation to the profession.21 “Quacks” encompassed a wide range of practitioners, and even included the odd member of the profession whose views did not match the thinking of the day (which seemed rather rigid despite proud claims that it was consistently evidence-based). Certainly, unqualified practitioners abounded, as did cures using cupping, blistering, electricity, patent medicines, chiropractic techniques, and herbal medicines. The disdain of the profession towards all of this was evident, and doctors bemoaned the general public’s support of alternative therapy, as shown in an 1871 editorial: “A sympathetic public would be up in arms to protest against the inhumanity of repressing a benefactor of mankind who got his knowledge of disease from nature and who, like a poet, had not been licensed to practise, but had been born with a diploma.”22 Medicolegal problemsOur profession’s dim view of their legal brethren was not shaped in recent times. Doctors in the 1870s felt hounded by an unfair, biased and poorly administered legal system. Most of the AMJ issue of November 1871 was devoted to the unjust nature of a verdict for malpractice against a doctor who missed a fractured neck of femur.6 The patient was awarded damages of £230. The opinion of the AMJ was: “It is hardly possible to imagine a verdict more unjust, or more directly contrary to all the facts as they were presented.” A public fund was set up to help the defendant pay the damages, medical defence organisations not being available at the time. The AMJ was scathing about the expert witnesses who testified against their colleagues, especially as they were of the view that the whole unjust action was begun after a doctor consulted for a second opinion implied the treatment by the initial surgeon was defective and so “encourages the belief in the patient’s mind that there has been neglect in her (first) attendant.” Doctors were frequently in court as witnesses and experts but were also exposed to the rigours of a jury in the Coroner’s Court. Deaths frequently resulted in coroner’s cases, and the outcomes of these cases were extensively reported in the popular press. Manslaughter charges against unfortunate practitioners were not uncommon. An editorial in the May 1875 issue of the AMJ called for coroner’s juries to be replaced by expert panels so medical men could be tried by their peers, who more fairly understood the complexities of medical practice.23 Court fees paid to expert witnesses were low and their experiences were unpalatable: “That a medical man should be kept in attendance for a whole day at a court of justice, and probably bullied into the bargain, and then, for all this trouble and annoyance, get a paltry pound, was monstrous.”13 This was a litigious age and legal actions against medical practitioners reported in the Journal made spicy reading, with actions for slander and libel being not infrequent. Lessons from the 1870sThe politics of the time was robust and intemperate, not ruled by genteel Victorian manners. Consider these quotes from the AMJ in 1871:24 “The autocrat who rules Geelong hospital . . .” “The committee of the Alfred Hospital are a very paltry one” and “Some opposition can be expected from an unimportant section of the profession which makes up in obstreperousness and bad language what it lacks in numbers and intelligence”. How better to end than with an obituary in the all-too-plain language of the day, expressing regret at the passing of a Melbourne specialist, who died on holiday in England: “For, although as a contributor to the sum of medical knowledge, Mr Whitcomb cannot be said to have taken a prominent position, he had practised long and successfully in this city . . . and at the Medical Society dinners . . . could be relied upon . . . to take part in the more convivial division of the festivities”. It seems the secret to successful practice in the 1870s was very similar to today’s — work hard, look after your patients, control your own fees and stay out of court. A little advertising didn’t go astray even in those times, and many speeches deploring medical men appearing in the press to announce their latest breakthroughs and triumphs were disdainfully reported. Ego was never far from the surface, often manifested as professional pride. Doctors tempered their independence with compassion and were more caring than commercial, as well as irascible, difficult to lead and organise, contemptuous of government and very opinionated. What has changed? Alfred Hospital circa 1875. Nosocomial infections were never as rife at The Alfred as at Melbourne Hospital. In the 1880s the Herald newspaper advocated that people carry cards reading “If any accident should happen to me do not on any account take me to the Melbourne Hospital”.14 © Alfred Hospital Archives.

David Molloy FRANZCOG

Has academic medicine lost its leadership role? Many of us believe academic medicine is in crisis.1-3 Tugwell, Professor of Medicine at the University of Ottawa, has written of the need to “bring people together to debate whether the existing structure of academic medicine is still fundamentally sound and, if not, to propose alternatives to it”.1 Editor in chief of the Journal of the American Medical Association, DeAngelis, recently wrote that “the traditional 3-legged stool of academic medicine comprising education, patient care, and research is broken. The education leg is currently being held together by peanut butter and bubble gum combined with the unselfish persistence of faculty dedicated to teaching”.2 The other core roles are also under threat. Much medical research today is done outside academic medicine, for example in institutes of biotechnology and biomedicine. And most clinical service, even in teaching hospitals, is provided by non-academic doctors. Perhaps what really makes academic medicine unique and important and risks being lost is the “added value” or synergy that exists when the three traditional roles are combined effectively — that is, the extra value and quality of teaching provided by the best clinicians and researchers; the special relevance of research defined and driven by the needs of the healthcare system; and the innovation and excellence in service when it is informed by that research. Our view is that: We have lost sight of the reality that teaching the next generation of doctors is a core and essential activity of academic doctors, vested in us by society;4 We are failing to strike the appropriate balance in research, with too much emphasis on basic biomedical research at the expense of clinical, applied and health services research;3 We have forgotten the essential values of altruism and social responsibility;5 and We are at risk of becoming irrelevant to the healthcare system through a failure to drive innovation and excellence in clinical practice across the system, resulting in indefensible variations in practice and outcomes. In response to concerns such as these, in June 2004 a group of leading medical journals, including the Medical Journal of Australia, convened a working party of medical academics to promote and revitalise academic medicine. We met for 4 days near London to define an agenda for the next 12 months, and attended a plenary meeting with about a hundred invited stakeholders from around the world. Why is academic medicine failing?1-3 The reasons are multiple and complex. Loss of leadership must rate highly, with the accompanying loss of focus and vision. The values of academic medicine have similarly become diluted. A major concern, reported by all members of the working party, is the apparent decline in interest in academic medicine as a career. The world has changed profoundly in the past few decades, for example with the rise of patient interest groups, intense pressures on healthcare systems, and the ever-expanding availability of new technologies, but it seems the discipline of academic medicine has not changed with it. What is to be done? First, we agreed that an international campaign is needed about this issue, combined with a global debate. We need to acknowledge that there is a crisis and a need for change. The International Campaign to Revitalise Academic Medicine (ICRAM) is under way, with a website at www.bmj.com/academicmedicine. We want your views and participation. The working party believes we need a new vision for academic medicine. We need a clear definition of academic medicine and a clear iteration of our values — what we stand for and what we want to achieve. As part of this, the place of academic medicine within medicine, the healthcare system and society needs to be clarified. The working party acknowledged that the debate about academic medicine needs to be evidence-based wherever possible. Ioannidis and colleagues have published an initial synthesis of available evidence and defined a research agenda:3 Problems: What are the problems with academic medicine across different settings and countries? Capacity: What factors influence career choice and are responsible for the declining numbers of doctors choosing academic medicine as a career? Indicators: What are reliable indicators of quality, impact and outcomes in academic medicine research, teaching and service? Impact of industry: What are the relations between academic medicine and its funders, particularly the pharmaceutical industry, and how should they be optimally regulated? Patients: Does academic medicine work for patients?3 Five task groups have been formed to deal with the key issues of vision and values, training and careers, analysing the evidence, stakeholder liaison, and communication. The convenors of these groups meet monthly as a steering group for the working party. A series of regional and stakeholder advisory groups are also being formed to ensure we have broad input from a wide range of interests. Details will be posted on the website soon. With two articles recently published in the British Medical Journal, launching the campaign and presenting an initial analysis of the evidence,3,5 our work is well under way. We are drafting articles on a new vision for academic medicine, the role of academic medicine in global health, and training and career options. We recently met with the World Health Organization and the World Federation for Medical Education. A mechanism for receiving submissions to the campaign will be established. What does this mean for Australia? We are the two Australian members of ICRAM. Once ICRAM’s business plan is available, we intend to write to the Chief Medical Officer and to the Committee of Deans of Australian Medical Schools, formally introducing them to ICRAM and its work, and seeking their involvement. We hope to secure support for a national meeting to explore the issues on a national scale, and to develop strategies to respond. It is early days. The ICRAM working party cannot do this alone. We need engagement with, and involvement from, a wide range of professional bodies. We believe this is a vital task and are committed to it. We hope you will join us.

David Wilkinson DSc, FAFPHM · Robyn L Ward PhD, FRACP

What’s needed in medical education are new and big ideas, coupled with a dose of investment In the 18th century, doctors had no particular qualifications and their education was gained as an apprentice to a master. Maybe this wasn’t such a bad idea — students today find themselves increasingly on the fringe of a system that has lost its enthusiasm for imparting wisdom to its young people, despite this imperative being enshrined in the Hippocratic Oath. The UK’s General Medical Council still has high expectations of medical schools: early contact with patients; patient-centred communication skills; courses rich in ethics, culture and ethnicity; and more training taking place in the community. It champions curricula that produce caring, knowledgeable, confident and competent medical graduates who have a broad understanding of health and disease in individuals, their families and society. . . . emphasising teaching over research in their portfolio can be professionally life-threatening for academics But in the UK today there seems to be a growing gap between aspiration and action: the universities, the National Health Service (NHS) and the government don’t seem to support the laudable goals of the General Medical Council. While it is often difficult to measure the success of medical education, there is only so much neglect it can tolerate — squeeze it too hard and standards will drop. In both the UK and Australia, governments want more doctors trained, but the strategies do not extend much beyond numbers and throughput. There is money for new places in medical schools — in the UK, Labour has invested substantially in the NHS in recent years, and the number of students accepted in medical schools has increased from about 4800 in 1999 to almost 7000 in 2003.1 This has been achieved by increasing the size of existing schools and by establishing new ones, such as the University of East Anglia and the Peninsula Medical School in south-west England. Additional sites for medical training have been created in association with existing schools (eg, Durham with Newcastle, Derby with Nottingham). But there is a dwindling pool of both clinical and pre-clinical academics to teach the eager new recruits. Teaching seems to be moving off the mental map for doctors working in a health service that, they feel, has pushed them to the edge. The human side of medicine is what makes working in the NHS tolerable; it can be rewarding to spend time with patients and students without the need to race back to the lab to inject some more rats or write another grant application. Good relationships and appreciation of effort can help too — many consultants and general practitioners feel they are in exile within the NHS, doing cut-down versions of the jobs for which they trained. Teaching does not fare well in such an environment. We have new contracts for consultants and GPs that encourage careful tallying of hours worked and quality targets met. Many find this “policing” approach demoralising; it is only through professionalism, goodwill and belief in its value that teaching will flourish. Juggling clinical work, research and teaching is difficult enough. But when teaching lacks mechanisms equivalent to those that identify and reward excellence in practice and research, it is relegated to a distant third place. Disturbingly, emphasising teaching over research in their portfolio can be professionally life-threatening for academics. While two-thirds of the income of medical schools reflects the numbers of students they teach, the remainder is determined by scores in the Research Assessment Exercise (RAE).2 Several research-intensive medical schools approached the 2001 RAE by a thorough purge of dedicated teachers in order to boost the institution’s average rating for excellence in research. Despite being obliged, almost immediately, to rehire limited numbers of teachers to meet their education responsibilities, some of these same medical schools are already sharpening their knives for more academic cutbacks in the run-up to the 2008 RAE. The less ruthless medical schools emerged from the 2001 RAE with financial penalties and have since cast staff adrift more slowly. Nevertheless, it’s possible that this obsession with research-based income will implode. Sooner or later the General Medical Council will decide that things have reached such a point of neglect that medical education needs dedicated investment — not just in buildings, but in teachers and medical courses. In the meantime, the next generation of medical academics and teachers is shrinking. To train all the extra students in the system, the UK probably needs about 1000 more clinical academic posts by 2006.3 This won’t happen while the new NHS contracts attach financial rewards to service in preference to teaching. These problems are not unique to the UK. Australian medical schools face similar pressures, and teaching often comes out second best. The spirit of curriculum reform has led to more graduate entry, more problem-based learning, and now strategies to get medical graduates into rural and remote Australia. Yet, Australia is also short of graduates, and recent increases in medical student numbers will only partially redress the short-sighted cutbacks of the early 1990s. One hopes the Australian Health Workforce Advisory Committee’s push for a more integrated approach to workforce planning will produce a commitment not only to boost numbers, but to ensure appropriate funding of courses to maintain the high reputation of Australian medical graduates. Governments are becoming increasingly hard-nosed about the money they invest in training medical students, and there is a burgeoning international transfer market. Australian medical graduates are an attractive product in this global marketplace. Governments want their graduates to stay. The Scottish Executive, for example, questions why it should educate so many English students when they are inclined to return “south of the border” on graduation. This market mentality needs a few more rules; there needs to be an international commitment to high standards and agreements to maintain investment locally rather than trying to poach quality graduates trained at some other country’s expense. Despite the difficulties, there are some impressive developments in undergraduate education in the UK. The new medical schools are alive with enthusiasm and energy,4 and are pursuing models of medical education that build on previous innovation, such as Australia’s Newcastle model. Nevertheless, what’s needed in medical education are new and big ideas, coupled with a dose of investment. Where are the current icons in medical education? In the past the likes of Abraham Flexner argued passionately for practical and interactive education, while James Mackenzie introduced the novel concept of teaching by general practitioners. Without passionate and committed teachers, medicine will decline. Then, any number of state-of-the-art laboratories, industrial partnerships, novel genes and science parks won’t be able to rescue it.

David P Weller MPH, PhD, FRACGP, FAFPHM · Richard F Heller MD, FRCP, FRACP, FAFPHM · Konrad Jamrozik DPhil FAFPHM, MFPH

This is an extraordinary opportunity and very exciting, say the Deans of the new medical schools With so many changes in medical education in the past decade in Australia and overseas, we might have expected a period of consolidation and stability. Not so, for seven new Australian medical schools are now at various stages of development. Except for the James Cook University medical school in north Queensland, which opened in 2000, these are the first new medical schools in Australia in 30 years. We talked to the Deans of the five schools which are closest to opening to find what has been happening and what they hope to achieve. The schools are marked by their differences, not only from most of our established medical schools, but also from each other. These differences lie not in their curricula and courses, which incorporate many recent reforms in medical education, but in the ways the new schools are structuring themselves and harnessing resources for delivering the curricula, as well as in their priorities and the specific qualities they wish to foster in their graduates. What are the new schools and why are they needed?First to open was the Australian National University (ANU) in Canberra, which enrolled its first students in 2004 and is taking over the Canberra Clinical School facilities from the University of Sydney. Griffith University and Bond University on Queensland’s Gold Coast, and the University of Notre Dame Australia in Fremantle, Western Australia, plan to take their first students in 2005, the University of Wollongong in 2006, and the University of Western Sydney in 2007. A medical school at the proposed Sydney campus of the University of Notre Dame has been announced, but its exact status is unclear. We interviewed the Deans of Medicine at ANU, Griffith, Bond and Notre Dame. At Wollongong, the Dean of Medicine, John Hogg, was yet to assume full-time duties, and we spoke instead to Don Iverson, Dean of the School of Health and Behavioural Sciences, who has overseen the planning of the new medical school, and to key faculty members. As the Western Sydney school appointed its Dean, Neville Yeomans, in October 2004, and had yet to develop the details of curriculum, location and student numbers, it was not included in our survey. The new schools are fostering diversity, bringing their programs to an even broader range of institutions than the traditional “sandstone” universities. The ANU is one of Australia’s “group of eight” research-oriented, capital-city-based universities (and the last of these to open a medical school), whereas the other four universities are regional, and two are private — the Catholic University of Notre Dame and Bond University (the former having some Commonwealth-subsidised places, but the latter being “entirely free of government subsidy and influence”, said Chris Del Mar, Bond). The new schools are also bringing an academic presence to the medical community in regions where this has previously been lacking. The schools are small, with intakes about, or even slightly below, 80 students per year — sometimes deemed to be the “critical mass” to sustain a medical school (Box). But small size may have advantages (“the Dean might even know your name”, said Paul Gatenby [ANU]). All the new schools lack the traditional departmental structure. They emphasise collaboration, and are harnessing teaching and learning resources in innovative ways from within their universities, their local communities, around Australia and internationally. “The emergence of the new schools is clearly being driven by workforce issues”, said Judy Searle (Griffith). They have a commitment to fill particular workforce needs, local or national. Because of their responsiveness to local needs and dependence on local resources, each school is unique. Courses and curricula: no need to reinvent the wheelThe new schools are incorporating the recent reforms in medical education. All will provide curricula with problem-based, self-directed learning; horizontal integration between disciplines; vertical integration between basic and clinical sciences; early exposure to patients; and increased emphasis on communication skills, ethics, and personal and professional development. However, the new schools “are not reinventing the wheel”, said Iverson (Wollongong). All are obtaining a curriculum from an established medical school and modifying it for local conditions: Griffith from Flinders University, Notre Dame from the University of Queensland, the ANU and Bond from the University of Sydney, and Wollongong from a UK medical school. Iverson explained that Wollongong has turned overseas as it plans a model he believes is new to Australia — a community-based medical school, which conducts most of its clinical teaching in the community rather than in hospitals. This model is most developed in the United Kingdom. Four of the new schools will also follow the lead of Flinders, Queensland and Sydney in offering a 4-year graduate-entry program, creating a more equal balance between graduate and undergraduate medical programs in Australia. Bond will offer a 5-year undergraduate course, but this will be similar to the graduate-entry program, preceded by a “science-heavy, case-based first year” to bring school-leavers up to the necessary level, said Del Mar. The new graduate schools are also adopting the now almost universal criteria for graduate entry — grade-point average in a first degree, performance in the GAMSAT (Graduate Australian Medical School Admissions Test) and interview. The differences from established graduate schools will be in the details: for example, whether all criteria must be satisfied individually or may be combined, and, in particular, the content and weighting of the interview. For instance, at Wollongong, the planned weighting reflects the school’s aim that 30% of its students should come from a rural, regional or remote background. In addition, the ANU has a pathway whereby high-achieving school-leavers enrolling at the university in other disciplines may be interviewed and guaranteed a place in the medical school when they graduate, provided they pass the GAMSAT. Entry criteria at Bond are similar to those at other undergraduate schools, comprising the UMAT (Undergraduate Medicine and Health Sciences Admission Test), school academic achievement and interview. Fees are about $45 000 per annum, and Bond, like the other new medical schools, is actively seeking support for scholarships, particularly for Indigenous students and those from East Timor. Delivering the course: do we need a full deck of cards?As new initiatives, the schools have the luxury of first choosing a curriculum and then devising the best way to deliver it, unlike older schools which had to impose new courses onto pre-existing structures. In keeping with the principle of integrating the disciplines, the schools are not setting up traditional discrete departments. Nor do they expect to derive all their expertise and resources from within the medical school. Instead, they are drawing on the resources of the parent university and, where necessary, forming collaborations with other institutions, locally and further afield. For example, at Griffith, which already has many health students (especially in physiotherapy), the medical school will be one of 11 schools, including dentistry and pharmacy, consolidated into a new Health Group. Within this group, academics will be organised into “discipline clusters”, said Searle. The medical school will draw on clusters in the Health Group and the Science Group for subjects such as biochemistry, physiology and microbiology. This has the added advantage of allowing cross-fertilisation, said Searle. Where more specialised expertise or resources are required, the school is appointing academics who report directly to the Dean (eg, in molecular pathology, anatomy and paediatrics). The university has pre-existing excellent “wet” anatomy laboratories, and the school is setting up a pathology laboratory and museum. Bond, which lacks other health courses, is following the principle of obtaining expertise through appointments direct to the school — many part-time — and providing resources through collaborations with other institutions. For example, Bond will rent pathology resources from the Queensland University of Technology, and, for anatomy, the University of Queensland laboratories for a week of intensive dissection to complement prosected specimens, computer simulations and high-fidelity medical imaging. Bond is also keen to collaborate with nearby Griffith medical school. Clinical teaching: doing more with lessAvailability of patients for clinical teaching is an increasing concern for medical schools in developed countries, as hospital stays become shorter, patients in hospital tend to be sicker, and, at the same time, courses increasingly require early patient exposure. How will the new schools meet this challenge? All are looking at new ways of accessing patients and more efficient ways of conducting clinical teaching, as well as collaborations to make best use of available resources. Perhaps most innovative is Wollongong, which plans a community-based medical school, where 80% of exposure to patients is in the community rather than in hospitals. This will include general practices, specialist rooms and community clinics, such as diabetes and sexual health clinics. “The school will use a good portion of its budget to offset the income lost by clinicians through taking students, as well as providing an academic rank commensurate with clinical experience”, said Iverson. Furthermore, community clinicians are an untapped resource — only about 15% of general practitioners in the region, and even fewer specialists, take students into their practices, and the local clinical community is enthusiastic about the plan. Notre Dame is enlisting private and outer metropolitan hospitals to avoid overlap with the established medical school at the University of Western Australia. A bonus is the different casemix. “Exposure to patients in the tertiary system alone gives a distorted view of medicine,” said Bower. “Clearly we need tertiary hospitals for areas such as acute psychiatry, major trauma, some paediatrics. But the casemix at private and outer metropolitan hospitals gives a brilliant experience of the sort of medicine faced by most medical practitioners, as opposed to ‘super’ specialists in tertiary hospitals.” Elsewhere, overlap seems inevitable, and schools are collaborating. Bond will share six of Griffith’s seven hospitals, having established together that there are enough student places. At present, Gold Coast hospitals accept around a hundred overseas students on electives (mostly from Europe), but will reduce this to make way for Australian students. Where overlap occurs, clinical teaching will be modified to meet the needs of the two student bodies. There is also a move for students to learn basic clinical skills not on patients, but in simulated environments — clinical skills laboratories, using models, simulated patients, and clinical teaching associates. These methods are used particularly for intimate physical examinations, such as breast and pelvis, but are also being applied to a wider range of skills. For example, Bond will have some experiential learning on the wards in Years 2 and 3, but will teach basic clinical skills predominantly “in-house” in clinical skills laboratories. A concern raised by several of the Deans is the need to improve teaching in the clinical placement years, which have traditionally been regarded as an “apprenticeship”. Searle sees a need for a better scientific underpinning in Years 3 and 4 of the course, and is investigating how to provide a core academic spine to the curriculum. In addition, Griffith is considering how to “do clinical teaching better”. For example, the “1-minute preceptor” is a strategy for clinical teachers to make the most of teaching time through effective assessment of the learner’s needs, instruction and more efficient feedback. An innovation at Notre Dame that Bower believes is unique in Australia is a weekly clinical debriefing tutorial, guided by a clinician, in which students reflect not on clinical content but on the doctor–patient interactions and the impact of the experience on themselves. This aims to put flesh on the “reflective practitioner” and to inculcate a culture of doctors caring for their own health. The Deans commonly felt that clinical teachers require better support and training. “A lot of curriculum reform has put clinicians offside, but clinicians are our best asset”, said Searle. “We need to use them ‘smarter’ and make sure the university provides adequate administration support.” Wollongong is ensuring the quality of its clinical teachers by setting up medical teaching programs. Unfortunately, most of the medical schools (with the possible exception of Wollongong) cannot properly reimburse clinicans for time with students. Information technologyInformation technology (IT) has facilitated the design of the new schools and is central to delivery of their curricula. Indeed, Bond will be using the Sydney problem-based course live — Sydney’s web interface, which includes formative assessment, was a criterion for its choice. The schools are exploring the further potential of IT. For example, the ANU school will be the university’s “guinea pig” for advanced IT presentations (such as generating three-dimensional “virtual reality”), with the university’s latest facility for this housed in the medical school. Its uses include training in procedural skills, such as inserting intravenous lines. Griffith will integrate IT resources, including interactive programs, into its course. The schools will also be teaching students how to make more efficient use of IT, such as personal digital assistants, in clinical practice, with the proviso, said Bower, “never to make patients feel they take second place to the electronic apparatus”. Assessment: an international endeavourAssessment, like other areas of medical education, is also becoming more collaborative. The new schools are typically joining international assessment consortia, which provide banks of assessment items and allow comparison between schools. For example, the ANU belongs to a Hong Kong-based consortium, and Wollongong will join a similar UK consortium. Assessment serves a range of functions, and the Deans emphasised the importance of differentiating these and tailoring each assessment task to the desired function. In general, the new schools will emphasise formative assessment (a learning tool) and will use summative assessment only when required (such as accreditation for progression to the next stage and ranking). For instance, Notre Dame will have “lots of formative assessment” in Years 1 and 2 and a single, summative examination at the end of each year. Similarly, Griffith will have a major barrier at the end of Year 3 to ensure students enter the pre-internship year with adequate competence. Searle believes assessment should reflect “real-world” requirements; Year 4 assessment is “around the sorts of behaviour and performance they will need as junior doctors”, she said. Indeed, the new curricula typically include a professional and personal development theme, which includes communication skills, procedural skills and other aspects of fitness to practise. These are assessed as academic endeavours against predetermined requirements. In this way, the schools are ensuring their graduates are equipped for practice with more than just scientific knowledge. Further changes in assessment are mooted. Del Mar praised the North American system of a national licensure examination, although he considers this approach may be too radical for Australia at present. School-specific goalsNot surprisingly, all the Deans are ambitious to produce “quality graduates” who will be in demand for postgraduate training. But they are distinguished by their specific goals for their graduates. For example, Iverson hopes that 60%–70% of Wollongong graduates will choose general practice, and the rest specialist practice, not in capital cities, but in rural, regional or remote areas. Strategies to achieve this include: recruiting people with “strong ties to regional, remote or rural areas” (initially through aggressive recruitment of professionals already established in a rural or regional area); ensuring the curriculum reflects clinical situations common in general practice and a full range of the procedures possible in general practice; and providing as many general practice placements as possible throughout the course. At Notre Dame and Bond, the goals for medical graduates reflect the particular philosophies of the universities. All Bond students, including medical students, are required to study four core subjects — business and entrepreneurship, IT, communication (community advocacy rather than the one-to-one communication skills usual in medical programs) and law and ethics. This reflects Bond’s origins as a private university funded by the entrepreneur Alan Bond and a Japanese consortium. Del Mar hopes that the resulting Bond-specific attributes in organisation and administration will create “future leaders in medicine”. Notre Dame aims to produce graduates who will fill areas of unmet need and appreciate the Catholic values of compassion, respect and service. All students study philosophy, ethics and theology. The theology course is being modified to increase its medical relevance, with more emphasis on human spirituality, belief systems and their significance in life than on the gospels. Although Catholic ethics will be taught, the requirement is to understand, not necessarily to espouse, them. Bower wished to put to rest the canard that the Catholic ethos will affect education about some topics. “Our students will be exposed to all the information necessary to talk to their patients in a non-judgemental, respectful and ethical manner about any sensitive issue, such as abortion, contraception and end-of-life decisions. For example, if a woman asks one of our graduates about contraception, they would talk about it in relation to her needs and circumstances. They would not say it is an immoral act, which is the Catholic doctrine. That in itself would be unethical.” Notre Dame is also trying to instil the concept of medicine as a vocation with a service component, and students are expected to perform voluntary work for the practices providing clinical placements. “This has further educational value”, explained Bower, “as students learn about themselves, the practice, and their interactions with others.” Searle and Gatenby have specific goals for their schools as well as their graduates. Both wish their schools to take leadership roles in medical education and to develop strong research programs (see next section). In addition, “developing a regional identity and providing an academic focus for the local clinical community is also a major goal for Griffith”, said Searle, who wishes to improve healthcare in south-east Queensland. Research and the tripartite model of academic medicineAlthough all the schools wish their teaching to be informed by scholarship, they differ in their emphasis on research and their attitudes to the tripartite model of academic medicine, which combines excellence in teaching, research and clinical practice. For the ANU, research is a priority and a selling point. The school wishes to take its place within the strongly research-based university — the only Australian university consistently ranked among the “top 50” universities in the world — and to capitalise on its strengths in anthropology and sociology. Its strategy is to enlist staff from the ANU research schools to teach, supervise student projects, and contribute to developing the faculty. Gatenby believes that “enquiry-based learning can really only occur in the context of a research-rich university. While it is possible to teach medicine in a TAFE, I do not know whether it is desirable.” Griffith also wishes to develop a research agenda. “That is why we are an academic institution”, said Searle. “The appointments we make should provide leadership in research as well as around teaching and learning.” Griffith proposes to link with existing strengths and fill the gaps, particularly in translational research and research into health outcomes in primary care and the community. Searle also wishes Griffith to be known as “a strong protagonist of evidence-based practice in medical education”. A frequent criticism of the changes in medical education is that they have not been rigorously evaluated. Searle believes that, as randomised controlled trials of the new courses are not possible, medical education must look to evaluative methods from other disciplines, such as psychology. She hopes that the register for longitudinal follow-up of medical students, which is being set up by the Committee of Deans of Australian Medical Schools, may answer some of the questions. A lack of resources for basic science research is a current problem at some schools. To overcome this, Notre Dame is developing research partnerships with other institutions (eg, through part-time appointments). It will also pursue research in areas requiring less infrastructure, such as primary healthcare and epidemiology. The Bond school is not yet undertaking research, but sees itself capitalising on the university’s strengths in applied research; it will provide seed money and statistical support for research by clinical teachers as well as university academics. For Wollongong, research is less of a priority than ensuring a high-quality medical education. Iverson believes Wollongong graduates will be as clinically competent as those who went to more research-intensive schools. However, Wollongong’s community-based school is an experiment in medical education, which they hope will yield objective evidence of its educational and economic effectiveness. Even the Deans with a strong research commitment have reservations about embodying the traditional tripartite model of academic medicine in all staff. Both Gatenby and Bower emphasised that it is not necessary for each academic to be a stellar performer in all three domains, as long as the organisation as a whole meets its obligations. “With the pressures of today it is impossible for an academic to excel at all three. The polymath academic is a dying breed”, said Bower. Perhaps this is revealing what was once covert — he was taught by some excellent researchers who were awful teachers. “We need to move to the North American model, where a member of staff can elect to follow either a research tenure track or a teaching tenure track — although the latter has to be informed by scholarship.” ConclusionIf Australia’s older medical schools are the “department stores” of medicine, providing graduates for many different purposes, then the new schools may be the “boutiques”. They are pioneering new ways of delivering a medical education and aim to produce graduates with qualities unique to their schools. How successful they are in providing for Australia’s future medical needs will be followed with great interest by politicians, practitioners and patients. Characteristics of five new Australian medical schools* Australian National University Griffith University Bond University University of Notre Dame Australia University of Wollongong First intake 2004 2005 2005 2005 2006 Type of course 4-year graduate 4-year graduate 5-year undergraduate 4-year graduate 4-year graduate Student places per year 92 88 ~65 80 80 Commonwealth- subsidised (HECS) 80 (includes 5 MRB, 11 BMP places)† 80 (includes 3 MRB, 6 BMP places)† 0 50 (includes 3 MRB, 7 BMP places)† 72 Fee-paying domestic 0 8 ~55 30 0 Fee-paying international 12‡ 0 ~10 0 8 * Information was not available from the University of Western Sydney or the proposed University of Notre Dame in Sydney. †Publicly funded places created under the Medical Rural Bonded (MRB) Scholarship Scheme and the Bonded Medical Places (BMP) Scheme carry a requirement for 6 years’ work in rural areas and areas of workforce shortage, respectively. ‡Approved places, not all filled in 2004. HECS = Higher Education Contribution Scheme.

Kerrie A Lawson PhD · Mabel Chew FRACGP, FAChPM · Martin B Van Der Weyden MD, FRACP, FRCPA

Is there something wrong with the way CPR is presently practised? “That doctor — he should be sacked!” An elderly gentleman was talking about me, and he was doing it on the local television news! My crime was to make the observation in a letter to the MJA that “. . . regular involvement in cardiopulmonary resuscitation (CPR) makes me wish the technique had never been introduced.”1 I had waved a red rag in front of bulls. To disparage CPR creates fury in those who, professionally or otherwise, see it as the reason for their existence. My wife had warned me that I would be painted as the bad guy, and, when this happened, my daughter asked cheerfully, “Is Daddy going to be like Pauline Hanson?”. My first inkling of the coming storm was on the Monday the Journal appeared. A Perth radio personality wanted to interview me. I was not told that, immediately before me, he would be interviewing the head of St John’s Ambulance in Western Australia. “Doctors Give CPR Shock Treatment” was the headline in The Australian. A flurry of phone calls from journalists followed. The local paper picked up the story, and over the next few days a local general practitioner, the local ambulance chief, a surf-lifesaving identity and an editorial in the paper all attacked my purported position. I had several conversations with the medical superintendent of the hospital where I was working: I was free to express an opinion in the MJA, and I was not being reprimanded — as some in the media wished. But, he indicated that he was going to publicly distance the hospital from my remarks, and reaffirm hospital policy — to commence CPR in an emergency whenever a person has stopped breathing or has no pulse. (I am grateful to this medical superintendent, who expended time and effort publicly defending the hospital, and defending me for opinions which — like those expressed here — are mine alone, and not those of the hospital.) The local television station made the topic their main story, and repeatedly replayed the clip of the elderly gentleman who had survived two cardiac arrests and wanted me sacked. The story finished with the words, “Dr Mackay declined to be interviewed”. I did not know I had been invited. Someone had received and declined the invitation for me! An advanced healthcare directive Should I have my cardiac arrest while going about my duties in the emergency department — immediate defibrillation please! And maybe a whiff of oxygen. (If I don’t survive, I will be quite surprised.2) Should I arrest in the hospital dining room, forgo the mouth- to-mouth (I am squeamish about these things). I may (grudgingly) accept some chest compression, until the defibrillator arrives. But if you have not got me back after three shocks — call off the circus. Go back and finish your lunch. If I arrest in the street, you will do what you will. But I won’t be happy. I doubt you will be able to get a defibrillator to me quickly enough. If I arrest at home, I know it will be very difficult for you to do nothing. But it will be 15 minutes before the ambulance arrives. And to end up brain damaged on a ventilator is something I do not want. (But if you are clever enough to call the ambulance so that I arrest after it arrives, by all means use the defibrillator.) When I am in a bed in a hospital ward “old and grey and full of sleep”, do not use your hands to commit violence upon me — use them to comfort me. I became a member of a hospital cardiac arrest team in 1973. Formally or informally, I have been part of such teams ever since. Two things I have learnt from this: there are things I do to patients that I do not want done to me; and, an advanced healthcare directive can never be found when you want one — so I hope I will be forgiven for placing mine here (Box). I would have attended at least a couple of hundred cardiac arrests. My guess is that, sadly, only a dozen or so of these people survived to leave hospital. (A meta-analysis of 39 studies involving 33 124 out-of-hospital cardiac arrests has shown a survival rate of 6.4%.3) Some of the survivors I remember well. While one middle-aged man was telling me about his chest pain, I noticed the cardiac rhythm on the monitor change to ventricular fibrillation. I charged the defibrillator as he continued to talk. I waited until he lost consciousness and then shocked him. In seconds, he was asking me what happened. Such episodes are not unusual in emergency departments (or in the back of ambulances). Of the vast majority who have not survived, I have a clear memory of only a few. I was visiting a patient at his home. He was telling me about his “gallbladder pain” when he had a cardiac arrest. His wife phoned an ambulance while I began resuscitation. When the ambulance arrived, his wife and I had a pink patient with small pupils. At that time ambulances did not carry defibrillators. By the time we arrived at the hospital, which was only a hundred yards away, the patient was blue, his pupils were fixed and dilated, and he could not be revived. It is difficult to maintain effective and continuous external cardiac massage while loading and unloading an ambulance, and while the ambulance is in motion. An editorial in the MJA in 2003 bemoaned the fact that “cardiac arrest is more successfully treated in Chicago or Heathrow airport, on an American Airlines or Qantas jet, or in a Boston post office, than in the vestibules, corridors or general wards of Australia’s premier hospitals”.4 A review of 28 cardiac arrests occurring at the Melbourne Cricket Ground (MCG) revealed a quite extraordinary survival rate of 71%,5 compared with a 3% survival rate from out-of-hospital resuscitation reported, at about the same time, in metropolitan Melbourne as a whole.6 Each minute from the onset of ventricular fibrillation to the use of a defibrillator results in a 10% reduction in survival.7,8 Thus, there is every reason to encourage anything that can shorten the time between the onset of cardiac arrest and defibrillation.9 But there is a big difference between the population of the MCG and that of a general hospital ward. The former has been able to get to the MCG, whereas the latter may be unable to get to the bathroom. Patients in a general medical ward may have failing hearts, lungs, kidneys and brains; they may be dying of cancer, they may be failing to respond to treatment for severe infection, or they may be otherwise very unwell. Most MJA readers will be familiar with the following scene, which takes place regularly in hospital wards. The curtains are barely closed around the bed of an elderly woman; two people are taking it in turns to rhythmically compress her chest; three doctors are attacking her oedematous limbs with needles, unsuccessfully attempting to insert them into veins; a fourth is poking around her groin trying to cannulate her femoral vein; and a fifth has a laryngoscope in her throat. But on this occasion, I notice something rather unusual (though I have seen it before). As I ventilate her lungs through the endotracheal tube, her eyes are wide open, her pupils are small, she blinks, she seems to be looking straight at me. Someone remarks, “She has a dying heart”. Eventually, we allow the rest of her to follow. In the past, nurses used experience and common sense when deciding not to use CPR in most patients when they died. Now, they are expected to start CPR on anyone who collapses and does not have a “not-for-resuscitation” order. This order is supposed to be discussed with the patient. This exceptionally difficult task may fall to the most inexperienced doctor on the ward. The results of CPR in this ward population are likely to be poor, even if immediate defibrillation is available (which it is not10). If cardiac arrest in a general medical ward is to be treated, could management be limited to prompt defibrillation, oxygen by bag and mask, and little else? The management of out-of-hospital cardiac arrest seems particularly prone to controversy. During the 1990s, ambulances regularly arrived at emergency departments carrying patients on whom cardiac massage was being performed. Subsequent discussion with relatives revealed that many of these patients had not had a witnessed cardiac arrest. They had been found dead. It was treating these patients that made me wish that the technique of CPR had never been introduced. In the five years since I wrote those words (and while the notes for this piece were gathering dust), it has become accepted that “. . . survival for the victim of cardiac arrest not resuscitated by a determined trial of advanced cardiac life support at the scene is negligible and not improved by further emergency department efforts”.11 Ambulance officers now have authority to cease resuscitation at the scene when it has clearly failed. This has reduced the incidence of futile resuscitation being performed in ambulances, which then has to be continued for a respectable period of time in the emergency department. But it may not prevent futile resuscitation efforts being performed in patients’ living rooms. An 85-year-old woman may phone “triple 0” after finding her husband collapsed on the floor. She may be advised to commence CPR. Sometimes, mightn’t it be quite reasonable for her to disregard this advice, and, when the ambulance arrives, to ask the paramedics to let her husband remain undisturbed? One hundred and five paramedics, emergency nurses, and emergency physicians who regularly took part in CPR were asked at what point they would like CPR stopped if they were the patient.12 Ten per cent did not wish to have CPR started at all; and only 3% wished to complete a full CPR protocol based on standard American Heart Association guidelines. Does not this suggest that there might be something wrong with the way CPR is presently practised? I was explaining to an elderly woman that her dying brother would be unlikely to last the hour. I asked if she wished to be with him when he died. Her husband turned to her and said, “ No. You don’t want to be there when they put the paddles on.” The assumptions behind this remark startled me. Should cardiopulmonary resuscitation be a futile deathbed ritual — a secular last right? There are many ways to die. To die without fuss, here one minute gone the next — that is the best.

Michael J Mackay MB ChB, MHA, FACRRM

How can we restore some semblance of sanity to a world spinning out of control? Some years ago now, Terry Gilliam (of Monty Python fame) produced something of a screen gem, enigmatically entitled Brazil. It was set in some indeterminate period in the near future, at which we now seem to have arrived. The world of Brazil was a world out of control — a world in which the infrastructure of daily living had become so complex that it required the intervention of a quasi-supernatural being when things went wrong in the lives of its inhabitants. Played (brilliantly) by Robert de Niro, this being descends (like Superman) from nowhere to rip open the offending section of wall — behind which there pulsates an incredibly complex, almost organic, mass of wires, tubes and other assorted technological viscera — “fix” the problem and then disappear once more. While immensely grateful, the mortals whom he has thus aided are none the wiser as to how he has effected this minor miracle, which leaves them very much at his mercy the next time the system fouls up. This threat is never far off, as the more complex things are the more often they go wrong. It would be possible to run a society with such a quasi-supernatural saviour at hand, assuming, of course, that some terrible mishap does not befall your hero. The gamut of potential mishaps must be extensive: kryptonite, alien forces, death rays, evil geniuses, or even the appearance of a Bizarro-quasi-supernatural being. But, in Brazil, hero de Niro did not succumb to any of these. He succumbed to paper. Yes, you heard me: paper. One day, he is walking along a road when a wind springs up. A piece of paper blows up against his leg, then blows away. Then a second, then a third — before a veritable barrage. Some of these papers are whisked away, while others adhere to his flailing limbs as he struggles to free himself. Soon he is trapped, struggling to breathe in this swirling, smothering maelstrom. But the onslaught of the paper is relentless, torrential, unforgiving. Soon, his struggles falter, and he drops to his knees. We sense that he has lost the battle. His struggling figure wanes, the paper begins to disperse, and soon there’s nothing left where de Niro once stood. He has been utterly subsumed — drowned and obliterated — by paper. Any of this sound familiar to you? It should. Simply substitute “computerisation” for “complex infrastructure” and “red tape” for “paper”. But what is red tape? Red tape consists of the requirements of a complex bureaucracy. How is it manifest? As documentation. Why is it seen as necessary? In order to prove that we are doing what we say we are doing. But to whom are we demonstrating this proof? Ultimately, to a bunch of lawyers, whether they are the hired guns of a litigious patient or the hired “suits” of a government department. Our society is drowning. It is on the verge of being utterly subsumed by the complexity of its own systems. Anyone who doesn’t realise this is ready for a wake-up call. This is that call! Litigation was originally put in place to protect the rights of the individual, but it now oppresses the very people it was sent to protect! Every day around the world, billions of ordinary citizens — from doctors to nurses to accountants to engineers to shopkeepers to craftsmen to fishermen to you-name-it — spend a substantial part of every hour devoting themselves to the documentation of their job as opposed to its execution. And with every year that passes, the level of documentation becomes more exacting, more oppressive, more intrusive, less conducive to the effective management of the job and, perhaps most damaging of all, insidiously undermining of trust. Everybody out there is hurting. A patient of mine who runs a small woodwork workshop for children (in which no child has ever been injured) told me that he now finds himself paying out $15 000 a year in insurance to an insurer he had to hunt for interstate. A well-known fishing identity from Sorrento, near Melbourne, speaking on a local radio station, said that he spends half his working day on dry land filling out government forms. Another of my patients, a family accountant, has to drop all of her loyal, regular, small clients because the documentation requirements of even the simplest transaction have placed the cost of her accounting services out of reach of these people — the very people for whom she set up her business in the first place. On a macro scale, in my opinion, the productivity of modern society has been virtually halved by the requirements of documentation (while the consumption of paper has sextupled). The situation is no longer sustainable. As a society, we can no longer afford the luxury of mistrust. Yes, it’s nice to have the right to sue, but the other side of that coin is that each of us must expend half of our working lives in efforts to prevent others from suing us. Ironically, the exponential rise in documentation that was supposed to protect us from such litigation has failed miserably. We are being sued more than ever before. At a recent risk management seminar I learnt that the United States experience of capping damages is that it doesn’t work and that lawyers simply launched more actions so as to bring their total income back to what it was before the capping. We need to create legal systems that virtually exclude lawyers entirely (eg, the New Zealand system of compensation for medical mishap), and we need to limit their numbers quite sharply — as it seems to me that each lawyer will fill the litigious airspace available to him or her. And, we need to become aware of the price we pay for each so-called “right” we claim. Moreover, we need to trust one another more. The world is spinning out of control, and nobody is yelling: “Stop!” “The Brazil Project” is about doing just that. It is about bringing these issues into the public eye in a balanced fashion, without compartmentalising them to the point of meaninglessness. It is about calling a moratorium on worthless documentation — ie, any documentation that is not essential to the actual running of a particular enterprise. It is about loosening the stranglehold of lawyers, whom we ourselves have aided and abetted with our actions. It is about recognising that there is another way of conducting our society — a way based on trust rather than adversarial acquisitiveness. My intention is to make The Brazil Project a functioning reality — not an institution bound by meetings and minutes and mission statements, but a loose association of like-minded individuals whose aim it is to restore to the world some semblance of sanity. This will take time, effort, energy, faith, determination and, yes, some money. As a 70-hour-per-week medico, I can’t do it alone (although success in this venture would probably render me a 35-hour-per-week medico!). If you are interested in joining me in this endeavour, please contact me. I do not pretend to have all the answers, nor am I entirely certain of the way to proceed, but there has to be a better way, and I believe the first step in achieving a better way is a cry of protest. The more voices that join in this cry, the better it will be heard.

Ron Elisha MB BS

Objective: To determine (i) whether people advertising themselves on a dating website were more likely to be smokers than members of the general population; and (ii) whether attractive advertisers (those whose ads were viewed most often) were less likely to smoke than all advertisers.Design: Comparison of the number of advertisers who smoke with survey data on national smoking status.Setting: “RSVP”, Australia’s largest web-based dating site (455 196 members on 12 October 2004).Participants: 132 176 advertisements accessed on 10 February 2004.Main outcome measures: Smoking status; and “votes” for advertisers’ attractiveness based on how often visitors to the site accessed individual advertisements.Results: In every age group, there were higher proportions of women smokers among the advertisers than in the general population (P < 0.05), and this was also the case for men aged 50 years and over. There was a higher proportion of non-smokers in the “Top 100” men or women advertisers aged 20–29 years (82%) compared with total RSVP advertisers in this age group (67%) (P < 0.001). 85% of the men and 78% of the women in the two “Top 100” groups were non-smokers, with only 2% of both sexes claiming to be regular smokers.Conclusions: Compared with the general population, a higher proportion of women and older men who advertise themselves on a dating website are smokers. Smokers may be perceived as less attractive.

Simon Chapman PhD · Melanie A Wakefield PhD · Sarah J Durkin PhD

Publications on climate change and the health of populations are burgeoning,1,2 and the relationship between climate change and government actions continues to provoke heated international debate.3,4 Climate is well known to affect the mental health of individuals.5,6 In addition, and of relevance to governments, the relationship between a sense of health and well-being and voter behaviour has been examined.7 However, although it is recognised that climate can affect voter turnout, and elections have been disrupted by inclement weather,8,9 the link between climate and government change has hitherto received no attention in the international literature. MethodsUsing a quasi-semi case–control study design (sans controls), I studied interim results of the October 2004 Australian federal election and weather patterns on election day to test the hypothesis that there is a relationship between weather and voter behaviour, and that it is significant enough to have an electoral impact. I obtained information about the electorates in which the sitting party was replaced from the website of the Australian Broadcasting Corporation.10 The weather predicted by the Australian Bureau of Meteorology for voting day in the electorates which changed hands was obtained from a national newspaper.11 ResultsIn general, voters across Australia enjoyed fine weather on election day (9 October 2004). There was a swing of over 3% to the incumbent Liberal Coalition Government.12 However, the swing was not uniform, nor in one direction. Thirteen of 150 electorates changed party (Box). For three of the five electorates with a swing to the Labor Opposition sufficient to change hands, the weather was not fine, and indeed was predicted to worsen during the day. This weather pattern contrasts dramatically with electorates which recorded a swing to the Liberal Coalition Government sufficient to change hands. In six of these eight electorates (75%), the weather was fine. In the remaining two, the weather was forecast to clear during the day. DiscussionThis study suggests that weather on the day of an election may influence voter choice. However, the limitations of the study do not allow a causal statement. The limitations include the assumption that fine weather is universally welcome, the small sample size, and the imprecision of weather records. Nevertheless, the findings of the study may have relevance to electoral campaigning — and therefore to political and subsequently population health outcomes. Possible improvements to the study include use of a historical cohort design, in which weather data are collected for each electorate on serial election days and compared between electorates which changed party and those that did not. The method could be adapted for international comparisons, and the hypothesis tested over time in other electoral systems. Subsequently, if the findings are very strongly suggestive, and resources and technology emerge to facilitate it, researchers could randomise similar electorates to receive “usual” weather or “enhanced” weather. This could answer definitively whether weather, and what weather, wins votes. Importantly, a proven relationship between climate and government change would stretch the horizons of scholarship. Incumbent governments could research and use evidence-based physical and spiritual interventions to exploit the vast campaign resource potentially provided by fine weather. Conversely, parties in opposition seeking office could develop behaviour-change strategies to convince key voters that although they think the weather is fine, it is only a matter of time. In any event, this research highlights the possibility for the diverse disciplines of meteorology, medicine, social psychology, political science and demography to explain electoral success — an outcome with potentially major impacts on health. Forecast weather in electorates that changed party in the Australian federal election, 9 October 2004* Electorate Sitting party Forecast weather Swing ALP gain Adelaide (SA) LIB Fine 1.9% Cunningham (NSW) GREEN Partly cloudy 0.8% Hindmarsh (SA) LIB Fine 1.0% Parramatta (NSW) LIB Becoming cloudy 1.9% Richmond (NSW) NAT Isolated showers later 1.9% Liberal gain Bass (TAS) ALP Fine 4.7% Bonner (QLD) ALP Fine 2.4% Braddon (TAS) ALP Fine 7.1% Greenway (NSW) ALP Fine 3.7% Hasluck (WA) ALP Clearing showers 3.6% Kingston (SA) ALP Fine 1.4% Stirling (WA) ALP Clearing showers 3.6% Wakefield (SA) ALP Fine 1.9% * Electoral information was obtained from www.abc.net.au/elections/federal/2004/results/changing.htm10 (accessed 10 Nov 2004), and forecast weather from the Bureau of Meteorology (published 9 Oct 2004 in The Weekend Australian11). ALP = Australian Labor Party. GREEN = Australian Greens Party. LIB = Liberal Party. NAT = National Party. NSW = New South Wales. QLD = Queensland. SA = South Australia. TAS = Tasmania. WA = Western Australia.

Rosemary Aldrich BA (Comm), MPH, FAFPHM

Objective: To describe the spectrum of oxygen-delivery methods.Design: Clinical audit.Setting: Medical wards of a tertiary referral teaching hospital in August 2004.Participants: 98 medical patients receiving supplemental oxygen.Results: Of the 98 patients, 40 were not receiving oxygen by customary methods. In classifying the patterns of oxygen delivery, we describe the transcephalic, submental, and (inadvertent) rectal approaches, as well as lachrymal insufflation and the “Venturi cravat”. We also describe novel oxygen-weaning methods, including the half-wean, reverse wean, and placebo wean.Conclusions: Many patients receive oxygen by unconventional methods. We postulate that this is evidence of a renewed interest in the historical routes of oxygen delivery.

John R Attia MD, PhD, FRCPC · Balakrishnan R Nair FRACP, FRCP · Stephen R Mears DipIM · Karen I Hitchcock BA, MB BS

Christmas for us this year will be the usual 20-minute ferry trip across the azure waters from Townsville to nearby Magnetic Island (known locally as “Maggie”), while being entertained by frolicking dolphins. On arrival we will head straight to Alma Bay, blessed with its golden sands, Dom Perignon-clear waters and vibrant coral reef. My wife and I, however, still cling to the nostalgic concept of Christmas bedecked with snow, a thundering fireplace, allergenic mistletoes, an inviting bowl of punch, and a real Christmas tree bought as a last-minute bargain in the Arctic cold of Newcastle upon Tyne. Temperatures at Christmas time in the northern hemisphere at any distance from the Equator are cold. Indeed, the temperature in Bethlehem at the time of the birth of Jesus Christ has been argued to be about 7°C.1 As we are experienced in looking after sick newborn babies, we have been impressed every year by the fact that, in depictions of the nativity scene on Christmas cards we receive, the newborn Jesus is almost always naked. There is good evidence that maintaining a normal temperature is one of the basic tenets of newborn care.2 We therefore undertook a study to either confirm or refute our impression that the newborn Jesus was indeed not clothed at birth. MethodsThe National Gallery in London houses one of the world’s great collections of European paintings. We accessed its website3 and typed the words “the nativity” into the search box. The Nativity at Night, by Geertgen tot Sint Jans, late 15th century. © National Gallery, London, UK. The Nativity, by Piero della Francesca, 1470s. © National Gallery, London, UK. ResultsOur search yielded 25 “hits”. Of 25 paintings listed, two were not of the Nativity, and three paintings of the Nativity did not show the newborn Jesus clearly. Close analysis (independently by each author) of the 20 remaining paintings yielded the following. Clothing and other means of protection: The newborn Jesus was naked in 11 paintings, lightly clothed in seven, and moderately clothed in two. The newborn Jesus had a halo in eight paintings. Birth size: The newborn Jesus was large for gestational age in 11 paintings, appropriate for gestational age in six, and had a premature look in two. Clothing of Mary, Joseph and onlookers: Mary was thickly clothed in all 20 paintings. Joseph was also thickly clothed in all of the 19 paintings depicting him. There were 56 onlookers (angels were excluded, as the authors only deal with mortals in their clinical practice) in 14 of the paintings; 47 were thickly clothed and 9 moderately clothed. Position of the newborn Jesus: On the floor in 12 paintings, in Mary’s arms in four, and in a cot or basket in four. In summary, the newborn Jesus was either naked or lightly clad in 90% of the Old Master paintings of the Nativity, was large for gestational age in 55% of the paintings, and placed on the floor in 60% of the paintings. DiscussionWe postulate that Jesus would have been hypothermic at birth, and very much so if also premature, had he been born on 25 December in a place with a temperature of 7°C. There might, of course, be other explanations. The newborn Jesus being naked and placed on the floor may have a number of meanings. One, pragmatic interpretation is that he was born a normally formed, healthy baby, as evidenced by his being large for gestational age in 55% of the paintings. However, this explanation is thrown into doubt by two which depicted Jesus as being born small for gestational age or preterm. Another potential meaning, more symbolic than pragmatic, is that he was born into this world without any earthly possessions. In similar vein, to the unscientifically inclined the halo and the pedigree of Jesus’ birth might suggest a neutral thermal zone, making the ambient temperature irrelevant. One obvious explanation is that the painters got it all wrong — it may have been warmer than we are assuming. However, all of the Old Masters painted Mary and Joseph as wearing winter clothing, and 47 of 56 onlookers (84%) were in winter clothing and the remaining nine were moderately clothed. An attractive explanation is that Jesus was not born in winter.1 In Luke 2.8, the Bible states: “Now there were in the same country shepherds living out in the fields, keeping watch over their flocks by night.” Keeping flocks in the field was common practice from April to September, but in the cold and rainy winter months shepherds took their flocks back home to shelter them. The Bible contains further evidence against December as the month of Jesus’ birth: “And it came to pass in those days that a decree went out from Caesar Augustus that all the world should be registered . . . So all went to be registered, everyone to his own city. Joseph also went up from Galilee, out of the city of Nazareth, into Judaea, to the city of David, which is called Bethlehem . . . to be registered with Mary, his betrothed wife, who was with child. So it was, that while they were there, the days were completed for her to be delivered. And she brought forth her firstborn Son . . .” (Luke 2: 1–7). The Roman rulers would have regarded taking a census in winter as impractical and unpopular. A census would have been more likely after the harvest season, around September or October, when the weather was good and the roads dry to facilitate travel.1 Accordingly, Christ’s birth would have been in September, when the temperature would allow the shepherds to tend their flocks by night, and also allow the newborn Jesus to be, as observed in our investigations, only lightly clothed or not swaddled. Finally, 25 December as the date for Christmas was decreed in the 4th century ad by Pope Liberius, possibly to compete with pagan festivals celebrating the winter solstice.4 Come Christmas Day this year, when we are sipping our chilled chardonnay under the clear sapphire sky, we will not be able to help but wonder whether Jesus might yet have been born on 25 December, but in . . . in Maggie (or should that be Magi?) Island, adjacent to the glorious tropical coast off Townsville, north Queensland, by the Great Barrier Reef.

Tieh-Hee Koh FRCPCH · Marion R Koh

Objective: To describe fall-related injuries due to pets in an older population.Design: Case series.Participants and setting: Patients aged 75 years and over presenting to the emergency department of a metropolitan hospital in northern Sydney over 18 months, with a fracture directly related to their pet.Main outcome measures: Type of fracture; circumstances of injury.Results: 16 cases (mean patient age, 81 years) are described; 13 (81%) involved women. Animals of five species were involved, with cats and dogs being the most common pet hazard.Conclusions: Pets are a potential environmental hazard in the occurrence of fall-related injuries in older people, with dogs and cats most likely to be involved. Women appear more likely than men to be injured.

Susan E Kurrle PhD, DGM · Robert Day FACEM · Ian D Cameron PhD, FAFRM(RACP)

Envenoming is rare in Australia — multicentre studies are needed to improve the tenuous evidence base Whether it’s the live snake that escapes in an emergency department or the farmer, bitten by a brown snake, who drops into his wife’s work to say he will be in hospital, and then collapses and has a seizure on arriving in hospital — bites and stings are a fascinating topic and the occasional envenoming presenting to hospital makes the local news. Unfortunately, the rarity of envenoming in Australia has meant the evidence base in clinical toxinology is tenuous, with considerable reliance on case reports and anecdotes of successful treatment. Although case reports can be essential in providing information about rare effects, more importantly they help to develop hypotheses for further studies. Randomised controlled trials (RCTs) of antivenoms are difficult to undertake in clinical toxinology because of the rarity of envenoming, the rapid course of life-threatening effects, and the potential for complete reversal of effects with antivenom. Funnel-web spider envenoming and major box jellyfish envenoming by Chironex fleckeri are two contrasting examples of such situations, with very different outcomes over the past 30 years following the introduction of their respective antivenoms. Despite the absence of an RCT of funnel-web spider antivenom, most people would agree that its introduction has prevented death in some cases and changed the outcome in many more cases over the past 25 years. It is highly unlikely that any ethics committee would now sanction an RCT, except perhaps to conduct a short n-of-1 trial, randomising patients initially to antivenom or placebo, and providing rescue treatment after 1–2 hours.1 The initial prospective study of nine successfully treated patients,2 another study demonstrating a significant reduction in hospital length of stay,3 as well as the fact that there have been no fatal bites since the introduction of funnel-web spider antivenom, provide more than single-case or anecdotal evidence for its efficacy. In contrast, the introduction of C. fleckeri antivenom has been somewhat different, with reported deaths despite the administration of antivenom, and continuing controversy about its use intramuscularly in the prehospital setting and in treating non-life-threatening effects.4 Recent animal work suggests that pretreatment with antivenom is not completely effective in preventing cardiovascular collapse and adds to the concerns regarding the efficacy of this antivenom.5 Irukandji syndrome has come to the attention of most Australians over the past few years, with at least one confirmed death from Irukandji syndrome in far north Queensland,6 and reports of significant numbers of cases in northern Western Australia in this issue of the Journal ().7 This has attracted significant media attention, threatened tourism in Queensland, and prompted the rapid introduction of untested treatments.8 Unfortunately, this appears to have overshadowed the far more lethal C. fleckeri envenoming, which continues to claim lives, with recent deaths of young children in far north Queensland. Treatment for C. fleckeri envenoming remains controversial, with concerns about the efficacy of antivenom,4 disagreement over the role of pressure immobilisation bandaging9 and non-evidence-based ongoing support for the potentially dangerous adjunctive treatment with verapamil.10 Recent animal studies provide evidence that pressure bandaging in C. fleckeri envenoming may increase venom discharge,11 and a review of the literature found no evidence for the recommendation of pressure immobilisation in major jellyfish stings.9 A recent animal study investigating treatments for C. fleckeri envenoming demonstrated that pretreatment with antivenom only prevented cardiovascular collapse in 40% of rats.5 The addition of verapamil did not prevent any deaths, supporting previous studies showing that verapamil worsens outcome in C. fleckeri stings.12 Another finding was that the addition of intravenous magnesium sulfate to antivenom, as a pretreatment, prevented death in 100% of cases.5 Future studies will need to further evaluate antivenom and the possible benefits of magnesium. However, it must be emphasised that early resuscitation is likely to be the single most important measure in severe C. fleckeri envenoming. Back on land, Australia is extremely fortunate to have some of the safest and most efficacious snake antivenoms in the world and the only commercially available snake venom detection kits for patient management. Despite this, the management of snakebite continues to be dominated by anecdotes and case reports, with limited information on antivenom dosing and redose timing. In addition, many snakebites occur in rural or remote areas, necessitating use of retrieval services and telephone advice. In this issue of the Journal, Yeung et al () report a retrospective study of severe brown snake envenoming in Western Australia, suggesting that larger overall doses of antivenom are required.13 Although the authors have moved to using 10 ampoules as their initial dose, their study does not provide conclusive evidence to allow absolute recommendations for antivenom dosing, particularly in other parts of Australia. However, it reinforces the problems with severe brown snake envenoming in rural and remote areas, and the need for sufficient antivenom being available for a first dose (at least five ampoules) for patients with suspected snakebite being retrieved to larger centres. The study by Yeung et al13 also provides the impetus for prospective studies of snakebite to define the initial antivenom dose and the need for further doses. Such studies are only possible if there is serial estimation of venom concentrations in blood to determine the antivenom dose required to completely neutralise circulating venom.14 Because of the rarity of snake envenoming, a multicentre study is required. The study by Currie () demonstrates just how uncommon snakebite envenoming is in Australia.15 Despite enrolling patients at a hospital that has large numbers of snakebite presentations, the study period required was about 10 years. Multicentre studies are currently being conducted throughout Australia, with collaborative research between clinical toxinologists and emergency physicians in more than 30 hospitals. In addition to answering questions about antivenom dosing, these studies will prospectively evaluate the effectiveness of pressure bandaging with immobilisation. Many questions remain about the use of snake antivenom. The treatment of and premedication to prevent snake antivenom reactions is still of concern. There have been three RCTs,16,17 but because of problems with small numbers and methodology18 many questions remain. Such studies are difficult in Australia because of the infrequency of administration of antivenom in single centres. Again, we need either large multicentre studies or, alternatively, studies conducted in rural tropical countries such as Papua New Guinea or Sri Lanka, where snakebite envenoming is common and a major public health issue. Collaborative work between these countries and Australia will both improve the care of patients and contribute to our understanding of snake antivenoms.

Geoffrey K Isbister BSc FACEM MD

Objective: Fatal snakebites at Port Moresby General Hospital (PMGH), Papua New Guinea (PNG), were examined to identify interventions that may improve patient survival.Design: Retrospective case series.Subjects and setting: Inpatients at PMGH who presented with snakebite, had evidence of envenomation, and died as inpatients between 1 January 1992 and 31 December 2001.Outcome measures: Number and cause of fatalities; ventilation bed-days; antivenom timing, dose and price.Results: 87 deaths occurred among 722 snakebite admissions to the intensive care unit (ICU). Of these 722 patients, 82.5% were ventilated, representing 45% of all ventilated ICU patients and 60% (3430/5717) of all ICU ventilator bed-days. The median duration of ventilation in fatal snakebite cases was significantly less than in non-fatal cases for children (3.0 v. 4.5 days) and adults (3.0 v. 5.0 days). The case-fatality rate for children (14.6%) was significantly greater than that for adults (8.2%). Sixty fatalities were examined in detail: 75% received blood products; 53% received antivenom (mostly a single ampoule of polyvalent), but only 5% received antivenom ≤ 4 hours post-bite. Major causes of death included respiratory complications (50%), probable intracerebral haemorrhage (17%), and renal failure (10%). Antivenom unit costs increased significantly over the decade; in 2000 an ampoule of polyvalent antivenom was 40-fold more expensive in PNG than in Australia on a gross domestic product (A$) per capita basis.Conclusions: Management of severe snakebite is a major challenge for PMGH. Improved antivenom procurement and use policies (including increased use of appropriate monovalent antivenoms), combined with targeted snakebite education interventions (community- and hospital-based), are key interventions to reduce the ongoing toll from snakebite.

Forbes McGain MB BS, DipObs · Ken D Winkel MB BS, PhD, FACTM · Aaron Limbo MB BS, DipAnaesth · David J Williams BSc · Gertrude Didei MB BS, DipAnaesth

Objective: To describe the epidemiology of snakebite in the “Top End” of the Northern Territory, and the envenoming syndromes of individual snake species.Study design: Prospective collection of clinical data and snake identity.Setting: Royal Darwin Hospital (RDH), a 300-bed tertiary hospital servicing a population of 140 000 spread over 522 561 km2.Patients: All patients with bites by confirmed snake species between September 1989 and March 2003, and all suspected snakebite cases between September 1989 and March 1998.Outcome measures: Incidence rates of definite snakebite and envenoming. Clinical features of bites from defined snake species.Results: There were 348 suspected snakebites over 8.6 years, with 114 aerial evacuations to RDH, 216 patients (62%) definitely bitten (23.2/100 000 per year) and 79 (23%) envenomed (7.6/100 000 per year). There were 156 bites from confirmed species over 13.6 years: 31 (20%) from western brown snakes (Pseudonaja nuchalis), with early collapse in 14 (45%), consumptive coagulopathy in 26 (84%) and 25 (81%) given antivenom; 21 from death adders (Acanthophis spp.), with neurotoxicity in 8 (38%) and 6 (29%) given antivenom; and 20 from mulga snakes (Pseudechis australis), with local swelling in 19 (95%), myotoxicity in 12 (60%) and 15 (75%) given antivenom. In 34 bites from less venomous species, there was no life-threatening envenoming. There were no deaths.Conclusions: Snakebite still causes morbidity in tropical Australia, but, with access to hospital and antivenom, deaths are rare. This study has enabled further definition of the envenoming syndromes of three highly venomous Australasian elapids.

Bart J Currie FRACP, DTM+H

Objectives: (1) To assess the number and severity of episodes of Irukandji syndrome in Broome, Western Australia. (2) To correlate demographic, seasonal, geographic and climatic features of Irukandji stings. (3) To assess treatment of Irukandji syndrome at Broome Health Service. (4) To assess the public health impact.Design and setting: (1) A retrospective analysis of jellyfish data forms and charts of 111 patients, identified from Broome Health Service Emergency Department with a discharge diagnosis of marine sting between 1 January 2001 and 1 July 2003. (2) Correlation between climate and Irukandji envenomation data.Main outcome measures: Number of patients with Irukandji syndrome; their demographic and environmental features; the clinical syndrome; treatment requirements.Results: 111 patients were prospectively identified with marine stings; 88 were identified with Irukandji syndrome. Non-Irukandji syndrome data were excluded for analysis. The “jellyfish season” extends from January to May, although stings occur all year round. Only 38% of patients had vinegar applied to the sting site before hospital presentation. Signs and symptoms were variable between individuals, with 20% having no signs of sting at all and welts found in 16%. Fifty per cent of patients were hypertensive at presentation. Distress was found in the majority of patients, with 90% requiring opioid analgesia (morphine equivalent: mean, 20 mg; median, 13 mg) and 17% requiring admission. There was one evacuation to Perth with cardiotoxic marine envenomation resulting in pulmonary oedema, which necessitated 4 days in intensive care. Stings were significantly more common when the ambient median temperature was greater than 28.3°C, after midday, on an incoming high tide and on windy days.Conclusion: The rate of envenomation in northern WA is likely to be the highest currently documented in Australia. There is syndromic variability when compared with the north Queensland experience. This implies different causative jellyfish species that are not yet identified. Stings in Broome can be severe and life threatening; there are significant commercial and public health implications as a result. Management at Broome Hospital is contemporary and effective.

Conrad J Macrokanis MB BS, FRACGP, BSc(Hons) · Nicole L Hall · Jacki K Mein MB BS, FACCHP, MAE

Objective: To investigate the doses of antivenom administered to adult patients with severe brown snake envenoming.Design and setting: Review of charts from Western Australian adult teaching hospitals, December 1991 to December 2001.Patients: 35 patients with severe brown snake envenoming, defined prospectively as afibrinogenaemia (< 0.3 g/L) after a bite by a brown snake (genus Pseudonaja).Main outcome measure: The dose of antivenom required to neutralise venom, defined prospectively as the dose of antivenom given before the return of detectable fibrinogen levels.Results: Of 88 patients with brown snake envenoming admitted over the 10 years, at least 35 had severe envenoming. Afibrinogenaemia persisted for 10 hours (range, 1.4–68 hours) after the first dose of antivenom; in four patients afibrinogenaemia lasted more than 24 hours. The dose of antivenom given before venom neutralisation ranged from one to 23 ampoules. In two-thirds of cases, venom was neutralised with five ampoules, and 89% had venom neutralised with 10 ampoules. Two patients died, and another had serious bleeding complications. Another patient died during the study period from intracerebral haemorrhage, but did not have fibrinogen levels measured.Conclusions: Patients received initial doses of antivenom too small to neutralise circulating venom, and remained afibrinogenaemic for prolonged periods, with serious consequences. The authors now use 10 ampoules as an initial dose in severe brown snake envenoming.

Justin M Yeung MB BS, FACEM · Frank F S Daly MB BS, FACEM · Mark Little FACEM, MPHTM, DTMH · Lindsay M Murray MB BS, FACEM · George A Jelinek MD, FACEM, DipDHM

A novel tagging technique has uncovered some surprising information about jellyfish behaviour If you spend any time at all in tropical Australia, especially in the water, you will know about box jellyfish. You will also know that they have a major effect on the way people use the water, that they are capable of killing humans within minutes, and that vinegar is the first aid treatment of choice.1 But did you know that they “sleep”? We certainly didn’t! About 12 months ago, we came up with a novel idea to try to track box jellyfish (Chironex fleckeri) using small ultrasonic transmitters (about 4 cm long and 12 mm in diameter). Using these for tracking marine animals is not new, but tracking jellyfish with them — that’s certainly never been done before. Normally, when tracking marine organisms (such as fish), you open the body cavity, insert the transmitter, suture the wound and let the fish go. With jellyfish, it’s not that simple. Firstly, jellyfish don’t have a body cavity (they only have two cell layers, an ectoderm and an endoderm, with a non-cellular layer, the mesoglea, between these). Secondly, suturing jellyfish is not easy. In fact, it’s impossible! After many failed attempts to attach transmitters, we finally struck upon a simple but effective method. We glued them on using histoacryl, a superglue used by surgeons. All you need to do is catch a box jellyfish without getting stung (an art in itself!), glue a transmitter to it (Box 1), release it, and follow it with an underwater directional microphone. You can then work out where they go and how active they are. In the last jellyfish season, we managed to track several tagged box jellyfish (Box 2), and came up with some staggering results. It seems that these jellyfish show marked diurnal behaviour. During daylight hours (from about 0600 to 1500), they moved in straight-line distances of about 212 m an hour. However, from about 1500 to 0600, they moved an average of less than 10 m an hour.2 During these periods of “inactivity”, the jellyfish lie motionless on the sea floor, with no bell pulsation occurring and with tentacles completely relaxed and in contact with the sea floor (Box 3). Shining lights on the jellyfish while they are inactive on the sea floor, or causing vibrations close by on the seabed, causes the animals to rise from the sea floor, swim around for a short period, and then fall back into an inactive state on the sand. If you have any interest in animal biology, this type of action in a lower invertebrate should immediately raise the question of “Why?”. We believe it is related to the way the jellyfish collect food. The box jellyfish is an active visual hunter of vertebrates. It has four sets of six eyes, some of which are image-forming with lenses and retinas, lying around the four facets of the bell (body) of the animal.3 Box jellyfish are also extremely active, with metabolic rates at least an order of magnitude greater than those of any other jellyfish we know of.4 So, at night — when vision is limited and you cannot see your prey or your predators (turtles for box jellyfish) — rather than burn a lot of energy swimming around, it makes a lot of sense to become inactive, decrease your energy used in locomotion and divert it to growth (these animals can grow at 2–3 mm across the bell per day). A really simple strategy, but one we had not thought box jellyfish used. All we need now is for someone to design a tag small enough to put on Irukandji box jellyfish (Carukia barnesi) — which are about as big as your thumbnail — and then we will really make some progress! 1 Attaching a tag to the most venomous marine creature in the world — it’s easy when you have the right glue! 2 A large box jellyfish with its tag attached, off in search of food 3 A tagged box jellyfish lying motionless on the sea floor — the first time this sort of behaviour has been recorded in jellyfish

Jamie E Seymour BSc(Hons), PhD · Teresa J Carrette BSc, MSc · Paul A Sutherland MSc

To the Editor: We report an unusual case of Ross River virus (RRV) disease in a 7-year-old child. The patient presented to her general practitioner with fever, rash and pain in the lower limbs. Swelling of the joints of the hands and left knee was found, with a widespread rash that covered the trunk, limbs and face. The rash comprised lesions of varying types, including maculopapular, vesicular and petechial lesions (Box). Rash in a child with Ross River virus disease The general practitioner transferred the patient to the state tertiary paediatric service. No antibiotics were given before transfer. On arrival at Princess Margaret Hospital for Children, Perth, the patient was unwell, with a fever of 38°C. A provisional diagnosis was made of septicaemia (probably meningococcal), and treatment was begun with intravenous ceftriaxone. Extensive investigations were performed, but results of all initial serological, polymerase chain reaction and culture investigations were negative. Rheumatology review was requested because of the prominent arthritic component of the illness. This revealed widespread polyarthritis, and the illness was felt to be a reactive or post-infectious process. The child’s family raised the possibility of RRV disease, as her grandmother had had this disease several years previously, and the child had stayed overnight at her grandmother’s home in a coastal lake area 2 weeks before disease onset. The area had abundant mosquitoes, as well as kangaroos, which are vertebrate amplifiers for RRV.1 Serological tests for RRV were performed 3 days after admission, and were negative for IgG and positive for IgM. Repeat serological testing during convalescence showed a fourfold rise in IgG titre (from 80 to 320), confirming the diagnosis of RRV disease. The patient’s rash decreased over several days. She had persistent synovitis in the left knee at review 3 weeks after admission. At review at 8 weeks all symptoms and signs had resolved, and she had full function. This case highlights the fact that, while RRV disease with severe symptoms and arthritic manifestations is uncommon in children, it nevertheless should still be considered in the differential diagnosis of children with a febrile and arthritic disease.1,2 This child’s illness appears to have been a reactive vasculitis and polyarthritis, which, while well recognised with other infections, is not well described in association with RRV disease in children. RRV arthritis is caused by joint infection, and treatment is currently based on empirical anti-inflammatory regimens. During the recent RRV disease epidemic in Western Australia, 1174 notifications for RRV disease were received between 1 October 2003 and 31 March 2004. Of these, 21 patients were aged 15 years or younger. Thus, while RRV disease is an infrequent illness in children, it does occur, and should be considered in the differential diagnosis of a child who presents with a febrile illness, rash and joint symptoms from an area with known autochthonous transmission of RRV.

Kynan T Feeney · Kevin J Murray · Amanda J Whittle · Gary K Dowse

To the Editor: Previous articles in the Journal have stressed the importance of making obesity prevention a public health research priority.1,2 Participation in physical activity is one important factor in counteracting increase in body weight.3 While recent studies have focused on environmental factors that influence walking (eg, presence of paths and trails, accessibility of destinations)4 and the possibility of environmental innovations to increase rates of participation, few studies have investigated participants’ perception and understanding of variation in physical activity in relation to environmental factors across the seasons. Our study aimed to examine how people perceive the impact of changes in ambient temperature and hours of daylight across the seasons on their rates of physical activity. We compared residents of the southern and northern hemispheres: a group of women from Sydney, Australia (n = 121; mean age, 19 years [SD, 2 years]), and a group of women from Trier, Germany (n = 109; mean age, 21 years [SD, 3 years]). Participants completed a brief written survey specifically designed for our study. The survey, using an “open question” format, asked participants to describe and explain any perceived changes in their physical activity during winter and summer. The majority of Australians and Germans perceived seasonal changes in physical activity (73.6% and 71.6%, respectively), with no significant difference between the two groups. These changes typically entailed a decrease in physical activity levels during winter (noted by 55.2% and 66.2% of Australians and Germans, respectively). A significantly higher number of Australians than Germans perceived a change from outdoor activities (eg, swimming) to indoor activities (eg, squash) between summer and winter (χ1 = 9.21; P = 0.002). Significantly more Germans than Australians perceived themselves to be affected by environmental factors (χ1 = 9.37; P = 0.002). These results support the contention that environmental changes are linked to changes in activity levels,5 and that more extreme climatic changes (such as those experienced by Germans compared with Australians) are associated with a greater perceived impact on levels of physical activity. Programs aiming to encourage greater participation in physical activity in winter need to challenge people’s perception of the impact of environmental factors by offering indoor opportunities for exercise, particularly to people from Germany. It appears that Australians are more aware of indoor opportunities for physical activity. Research into environmental factors that encourage or discourage walking4 needs to be taken into account when designing programs to enhance physical activity across the seasons. For example, constructing walking or cycling paths in the neighbourhood may encourage people to continue with indoor activities during the colder seasons by making the indoor venues more easily accessible.

Tanja Hechler · Josephine Y Chau · Sarah Giesecke · Silja Vocks

To the Editor: The articles in the General Practice issue are most interesting. Sadly, the articles on how general practitioners are paid1-6 have largely missed the point. It is not only how GPs are paid, but also how much that matters. No matter how ideal the incentive incorporated in the payment method may be, if the quantum is too little even the most idealistic GP will find it impossible to work in a professional manner. Payment here includes both direct personal income and the associated practice conditions. In most countries, changes in GP financing focus more on how to keep costs down than on rewarding quality. Green was the only author to address this issue, making the point that US family medicine organisations have recently changed from showing how good GPs can be to ensuring they are paid well enough to do that good work, and to provide incentives to encourage the next generation of family physicians.6 Since the introduction of the National Health Service (NHS) in 1949, the United Kingdom has gone through several cycles of declining incomes and conditions for GPs, followed by declining interest and recruitment, in turn followed by higher pay and conditions that attracted new recruits. Overall, UK GPs have been paid relatively well compared with their hospital specialist colleagues. It is no accident that the UK has developed the highest levels in the world of academic general practice, as well as research in practice, while the British taxpayers obtain the highest value from their overall health service.7 Currently, in Australia, the Journal classifieds confirm that there are vast discrepancies between expected salaries for specialist and GP services; perhaps there is a lesson for funding. Until salaries for GPs are similar to those for specialists, bright young medical graduates will prefer to work in higher-paying, hospital-based specialties. Merely altering the payment system will make little difference. The value potentially obtained from good primary care will remain out of reach unless the total resources put into this sector are increased.

James A Dickinson

To the Editor: Proposals to manage the shortage of general practitioners by recruiting and training overseas-trained doctors and funding new medical schools will take years to take effect and be enormously expensive. The crisis is with us now. Support for properly trained practice nurses by Medicare, either as a rebate or a salary, could rapidly ameliorate the shortage of GPs, and would deliver improved patient care. I do not refer here to nurse practitioners — that is a different issue. Practice nurses in many developed countries undertake routine GP tasks. Increasing specialisation requires GPs to have more time to evaluate patients. Nurses can complete an initial case summary: these are time consuming and are often missing. Nurses can measure blood pressure; perform Pap smears, breast examination, and vaccinations; counsel people (who will often reveal important information to a nurse); sterilise instruments; explain asthma plans and puffers; give simple dietary advice; and supervise diabetes protocols. This is not a second-class option — it will improve care: doctors who have worked with the system find it improves the quality of their practice and saves them a great deal of time to do other tasks. New and bridging courses for these nurses, a few of which exist, would rapidly produce a workforce happy to work from 9 am to 3 pm, or job share. They need Medicare support. The Minister for Health and the shadow minister may wish to consider this.

Sandy L A Reid

To the Editor: Poor adherence to therapy with asthma preventer medications is common among teenagers with asthma. This is often simple forgetfulness rather than active non-compliance. One of our adherent patients shared his secret with us — the alarm mode on his mobile phone. He set this to be activated twice daily to remind him to take his medicine. A recent survey by Newspoll showed that about 90% of teenagers aged between 13 and 19 years in Melbourne and Sydney have a mobile phone, most of them on a prepaid plan.1 We have subsequently recommended this reminder system to other patients, who have expressed interest in adopting the practice. This could be useful for all patients required to take regular medications. In the absence of a mobile phone, many household appliances (such as microwave ovens) have electronic timers that could be programmed to sound an alarm on a regular basis.

Gaudenz M Hafen · John Massie

Quotes from MJA contributors in 2004 Much that is written for the Medical Journal of Australia is never intended for print. Volumes of correspondence, for the editors’ eyes only, flow into our in-trays — notably reviewers’ forthright opinions and authors’ robust rebuttals. Paradoxically, at times these missives seem better written and more suited to publication than the related manuscript! Straightforward, simple and clear, concise and precise, they are an editor’s delight. This Christmas, as always, we want to wish our contributors “Happy reading and all the best for your writing in the New Year!”. In this vein, we share with you some of the most memorable manuscript-related remarks received this past year. They reinforce general words of advice often given to aspiring writers. Respecting the various authors (and protecting ourselves), these quotes — now in print — have been de-identified. Make your point“The act of writing down guidelines always promotes debate and criticism, but it is important to ensure that the debate moves forward rather than in circles.” “On reading this paper, I wondered whether I was losing my mind. This is for you to judge. I cannot see a coherent argument.” Time matters“The feeling obtained on reading this paper is that a lot of time and effort has been expended and many trees felled for no particular reason.” “I’m sorry that I’ve been slow with this opinion. I don’t think, however, that either science or medicine will be damaged by the delay.” “I happened to have some spare time this afternoon, so I have undertaken the review already (if there is a prize for most rapid review for the Journal, then I want to be considered).” Declare conflict of interest“It is tempting to give it [this manuscript] a glowing review, which it indisputably deserves, but some degree of bias might be alleged since, unless the paper’s authorship has changed since the last draft I worked on, I am one of its authors!” Aim high . . . . . . but temper hyperboleReviewer: “The final section of this article is somewhat evangelical...” Author: “The article’s ‘somewhat evangelical’ tone is part of a desire to make people notice the enormity of the task, to stimulate debate and, possibly, more effective action.” Be scientific“I do not think a show of hands at a conference is scientific evidence to support an argument.” “The statement that a result can be clinically important but not statistically significant is nothing other than wishful thinking.” Be fearless“I look forward to drawing swords against your referees.” Be yourselfWe like Letters to the Editor to be short — no more than 400 words in length. Sometimes reviewers’ well-intentioned suggestions can seem impossible to accommodate. One author responded with individual flair. Reviewer: “... Point 8. It would be useful to summarise the current . . . constraints . . . in a box so that non-Australian authors will understand what is being discussed.” Author: “In 400 words, mate? Your sense of humour is even better than the editor’s.”

Ann T Gregory MB BS, GradDipPopHealth

While shopping one evening at the local supermarket, I did a double take when I came across this startling item. Lethal viruses on sale to unsuspecting consumers!? As the product claims to be “premium quality” SARS, I am sure that if it actually did contain the SARS virus it would be enough to potentially kill thousands of people. SARS in a can (aka sarsaparilla) is made from carbonated water, sugar, caramel, flavours, food acid and a preservative. Strangely enough, sales of this product actually increased in New Zealand during the SARS epidemic, with a BBC news website reporting that some people were asking, “Is this a medicine for SARS or protection against SARS?”.1 In another report, a New Zealand spokesman for the manufacturer said that the company was not thinking of changing the name of the drink and was unlikely to do so if current sales trends continued.2 The company also used to sell Double SARS, but I understand that this product has been discontinued.

Guy D Eslick PhD, MMedSc (Clin Epi), MMedStat

A 68-year-old woman presented with cholelithiasis and common bile duct obstruction. Laboratory tests showed leukocytosis and raised serum alkaline phosphatase levels, but the eosinophil count was normal. Faecal microscopy was not performed. A roundworm (Ascaris lumbricoides) trapped in a T-tube Removal of the stones by means of endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy was unsuccessful because of difficulty catheterising and visualising the ampulla of Vater. After open cholecystectomy and exploration of the common bile duct, the sphincter of Oddi was dilated with bile duct dilators, and a T-tube was inserted before closure. After an uneventful postoperative period, the T-tube was removed 14 days after operation. A dead Ascaris lumbricoides roundworm was trapped in the T-tube. The patient was discharged 2 days later after receiving anthelmintic treatment. Abdominal ultrasound and stool examinations showed no abnormalities at follow-up after 1 month and 6 months. A. lumbricoides, the most common roundworm infecting humans, is endemic in areas where sanitation standards are poor. Adult worms normally reside in the upper gastrointestinal tract, but can migrate into any organ in the body, including the biliary tree (biliary ascariasis).1

Ilyas Baskonus MD · Gokturk Maralcan MD · Abdullah Serin · Necdet Aybasti MD

A 19-year-old man was referred to the outpatient department with a 3-month history of recurrent urinary tract infection and an x-ray showing a calcified ring-like structure in his bladder (Figure A). He had no relevant medical history and denied knowledge of any foreign body having entered his urethra. At cystoscopy, the ring-like structure (over 3 cm in diameter) appeared rather like a fried onion ring (Figure B). A lithoclast was used to fragment a dense layer of calcification, revealing a plastic sheath used to house electrical wire as the offending foreign body. Once the calcification had been removed, it was possible to extract the object with endoscopic forceps (Figure C). The patient was advised to avoid electricians.

Nathan Lawrentschuk MB BS · Paul A Kearns MB BS

An extravagant lifestyle in the 1970s often goes undetected by computed tomography scans — unless, of course, the spleen gives it away with its vascular perfusion.

Sam McCormack

The elegant simplicity of Indigenous dot painting, and how it belies a structural complexity within the story of each work, has long fascinated me. I began experimenting myself, but “dot doodles”, with no story, were unfulfilling. A request for artwork from the Day Procedure Unit at my hospital led to the idea of combining work and art. My workday revolves around human anatomy. As a surgeon, I must understand the spatial relationships of structures. I see the apparent simplicity of their position, and yet still marvel at the boundless complexity of their function and the developmental process that has led to their arrangement. A marriage of this art form and these subjects seemed logical, with the parallel of elegant simplicity and structural complexity allowing me to feel comfortable and respectful in using this method of expression.

Iain J Skinner MB BS, FRACS

This bone marrow smear was taken from a child after chemotherapy for acute lymphoblastic leukaemia. The marrow showed no residual leukaemia, and provided this photographic evidence of her steps towards remission.

Annmarie A Bosco · Giselle Kidson-Gerber

With the advent of semi-automatic defibrillators, public access to defibrillation has expanded like never before. Here we see an Adélie penguin at Mawson’s Hut, Cape Denison, Antarctica, being trained by Dr Geoff Couser to administer life-saving defibrillation therapy to a collapsed Weddell seal in the background.

Geoffrey A Couser FACEM

Our initial shock on seeing the sign in the foreground was alleviated when we noticed other nearby signs advertising motor spare parts!

Dhushan Illesinghe MB BS, MD, FRANZCP

A 22-year-old man presented to our accident and emergency department an hour after a motor vehicle accident. He had no history of seizures. On examination, he was alert, haemodynamically stable and his Glasgow Coma Score was 15/15. Both pupils were normal in size and reacted to light. His left eye was slightly protruded, and a rigid radio antenna about 12 cm long emerged from below the left lateral canthus (Figure 1). His visual acuity was normal, and he had no diplopia. Skull x-rays showed the antenna in the left anterior fossa (Figure 2). A computed tomography scan showed it traversing behind the left globe (Figure 3) as far as the left anterior cranial fossa, with the tip embedded in the region of the left sylvian fissure. There was minimal subarachnoid haemorrhage over the surface of the temporal lobe. The patient underwent emergency left frontotemporal craniotomy. At surgery, the antenna was seen to penetrate just lateral to the superior orbital fissure and reach the dura and the temporal lobe (the left sylvian fissure). The antenna was removed, and the patient was discharged from hospital several days later without any visual or neurological complications. Penetrating intracranial foreign bodies at low velocity characteristically enter via the orbital roof, the temporal squama or the cribriform plate. In this case, the antenna penetrated the orbital roof — one of the thinnest areas of cranial bone — without injury to the globe of the eye, or any neurological complications. We recommend that in cases such as this, with minimal external findings and normal neurological examination, simple external traction should be avoided.

Hossein Sanaei-Zadeh MD · Kamran Aghakhani MD · Mansour Parvaresh MD

This unfortunate patient was involved in a motor vehicle accident. Being an old car there were no airbags, and valve springs are obviously a poor substitute.

Sam McCormack

We were wondering how to describe the lesion seen on this magnetic resonance image. Vertebral “body” seemed appropriate.

Brad Milner

A woman presented with a “roaring” headache and claimed that she had been chased all day by a lion. After a thorough assessment, I advised her that there was no lion and that it was all “in her head”. A computed tomography scan confirmed the presence of the lion and the woman went home reassured.

Steven R Doherty MB BS, FACEM