Volume 183 Issue 11

A government report concluded that the cause of the recent cluster of illness affecting 57 people at Melbourne Airport was a “mystery”. On reviewing the evidence, I noted the appearance of a constellation of distinct psychogenic features (in the absence of an identifiable pathogenic agent or source), and non-specific symptoms not correlated with any particular illness, strongly suggesting a diagnosis of mass psychogenic illness. Given the time differential between the illness onset in the index case and the initiation of air sampling, and the added factor of the air-conditioning in the terminal being switched to exhaust mode, the possibility that a toxic agent was responsible for making some of the victims ill cannot be completely excluded. Future investigations of similar incidents should, in the absence of clinical or laboratory findings, consider the diagnosis of mass psychogenic illness. Failure to do so can engender avoidable confusion and unease among the Australian public. The issue of diagnosing collective psychogenic illness will continue to be a major public health challenge, exacerbated by widespread anxieties over the threat of chemical and biological weapons and fears of contamination.

Robert E Bartholomew PhD, MA

Australian hospitals need to be prepared to deal with mass casualties from terrorist strikes, including bomb blasts and chemical, biological and radiation injury. Injuries from bomb explosions are more severe than those commonly seen in Australian hospitals. In disasters involving mass casualties in urban areas, many of the injured make their own way to hospital, often arriving before the more seriously injured casualties. Major hospitals in Australia should plan for large numbers of undifferentiated and potentially contaminated casualties arriving with minimal warning. It is critical that experienced and trained senior medical officers perform the triage of casualties in emergency departments, with frequent reassessment to detect missed injuries (especially pulmonary blast injury). Hospitals require well developed standard operating procedures for mass casualty events, reinforced by regular drills. Preparing for a major event includes training staff in major incident management, setting up an operational/control unit, nominating key personnel, ensuring there is an efficient intra-hospital communication system, and enhancing links with other emergency services and hospitals.

Jeffrey V Rosenfeld FRACS, FRCS(Edin), FACS · Mark Fitzgerald FACEM · Thomas Kossmann MD, FRACS · Gim Tan FACEM · Michele Gardner RN, GD, FRCNA · Andrew Pearce FACEM · Anthony Joseph FACEM · Shmuel Shapira MD, MPH

The government has undertaken roles in disaster planning and coordination to complement hospital and workforce readiness Rosenfeld and colleagues1 make many excellent points about individual hospital preparedness for terrorism. However, the article fails to fully contextualise the overarching emergency management arrangements and the considerable work that all levels of government have undertaken to support individual hospitals, area health services, jurisdictions and the nation as a whole.2,3 Many of the activities they suggest are already in place in different states. These include chemical, biological and radiological (CBR) training and health student training; media management; and tracking and identification of patients. The following points expand on some of the areas touched on by Rosenfeld et al. Disaster planningHospitals have disaster plans in place that complement broader jurisdictional and national disaster plans. Some of these broader plans include the Commonwealth Government Disaster Response Plan,2 guidelines for the treatment and management of smallpox and anthrax,4 the Mass Casualty Transport Review, the Mental Health Disaster Response Plan,5 the National Response Plan for Mass Casualty Incidents Involving Australians Overseas,6 and the National Burns Plan (AusBurnPLAN).7 AusBurn-PLAN, in particular, can activate national assistance to an affected jurisdiction by moving medical teams in and redistributing patients to other hospitals to ensure that the most appropriate care is delivered. The National Medicines Stockpile8 was established in 2002 to provide specialised pharmaceuticals and equipment in response to terrorist acts or other health emergencies. In addition, states and territories can call on their own embedded stocks. The National Medicines Stockpile includes stocks of antidotes, antibiotics, personal protective equipment, ventilators and negative pressure units. Contingency plans have been developed to deploy these assets to an affected jurisdiction if a chemical, biological or radiation incident occurs. Another important asset in disaster planning is the planned National Trauma Centre at Royal Darwin Hospital (RDH), initiated in response to the first of the Bali bombings, in 2002.9 RDH responded effectively and appropriately to both the 2002 and 2005 Bali terrorist attacks, but the establishment of the National Trauma Centre at RDH with two specialised chairs (a Chair of Emergency Preparedness and Response at the Northern Territory Clinical School and a Chair of Trauma and Critical Care at the Menzies School of Health Research) will further enhance the overall response capability of Australia. Hospital readinessRosenfeld and colleagues believe that, currently, most Australian hospitals would not be able to “cope” with more than 10–24 seriously injured patients. It is not clear how this number was determined. A review of over 100 terrorist bombings with improvised explosive devices since 199610 showed that most of the live casualties had relatively minor injuries, with less than 15% having injury severity scores over 15. Tragically, in major terrorist events, many people die at the time of the incident, as was the case after the September 11 attacks in the United States — but 48 hours after the tragedy only 18 patients remained in hospital. Another review of 13 major terrorist attacks11 found that only 9%–22% of survivors were critically injured (injury severity score > 15). Most of the casualties received relatively minor injuries. We agree that the “walking wounded” can be inappropriately “up-triaged” and/or self-present to key trauma centres, leading to a potential loss of focus on severely injured patients who need resuscitation and life-saving surgery. Hospitals must have contingency plans to corral less-injured patients in advance of the arrival of ambulances bringing the more severely injured. In New South Wales, for example, disaster plans factor these issues in by ensuring that the more severely injured patients are directed to trauma centres by helicopter and ambulance and the less injured are corralled or transferred by bus to smaller hospitals. Testing health system response capabilityNo plan is effective unless tested periodically by practice drills. There have been extensive exercises at a jurisdictional and national level for a number of disaster scenarios that test hospital systems. Exercise “Supreme Truth”, held at the Royal Adelaide Hospital in 2003, practised and evaluated the response of a major public hospital to a mass casualty incident involving a CBR agent.12 Among its outcomes were improvements to the SA Major Incident Plan, the facilities for managing CBR events, and the interface with emergency services. National Counter Terrorism Committee exercises have been led by the Australian Government. Of particular importance is Exercise “Explorer”, held in 2004, in which a terrorist bombing scenario in Sydney’s central business district was formally tested at a purpose-built site at Holsworthy.13 Over 250 patients were formally triaged and treated by ambulance personnel and health teams at the site. The disposition of patients to appropriate trauma centres was successful. As part of the same exercise, the AusBurnPLAN arrangements were tested.7 Severe burn patients were identified for transfer to other states, and medical-team support was provided in a coordinated fashion to NSW. Hospitals were also tested recently in “Mercury ’05”, a national multi-jurisdictional counter terrorism exercise with a focus on mass casualties. Mercury ’05 demonstrated how emergency management arrangements can be activated in a disaster during the surge phase (the first 12 hours after a disaster) to enhance overall capacity when operating within a nationally coordinated framework. More exercises are planned for 2006 that will yield valuable lessons for hospitals. In addition, “table-top” exercises, such as the Emergo Train system,14 appropriately test hospitals’ ability to manage a sudden surge in casualties and ensure that the most critically injured patients receive timely resuscitation and life-saving surgery. CoordinationResponse to a disaster requires coordination between a range of professionals and across jurisdictions. The Australian Health Disaster Management Policy Committee (AHDMPC) has the ability to support health-system “surge” response, both locally and nationally. This cross-jurisdictional group was established by the Australian Health Ministers’ Advisory Council in February 2003. It is charged with identifying Australia’s level of preparedness to respond to the consequences of a terrorist attack or a naturally occurring disaster and to coordinate a national response in the event of mass casualties or outbreak of disease. The AHDMPC has now coordinated planning and response in relation to avian influenza, the Indian Ocean tsunami and the recent Bali bombings, and has conducted debriefing following the Madrid and London bombings. It has also undertaken a number of audits of Australia’s emergency response capability and will use the results of those audits and ongoing monitoring to identify and address gaps. WorkforceSenior clinicians in hospitals must accept emergency management principles as part of their core business. Emergency response training at the local hospital level can be factored into the functioning of all hospital training programs, and should be regarded as no different from training in resuscitation or other clinical management issues. All hospitals should undertake disaster preparedness drills at least twice a year. It is incumbent on all clinicians to add emergency preparedness to their range of clinical skills and to be aware of the disaster plans within their institution. The AHDMPC has also made workforce disaster preparedness a priority and will shortly review the Department of Health and Ageing and Emergency Management Australia’s National Disaster Medicine course and undertake a national stocktake of health emergency management courses. There is also evidence of growing interest in biosecurity and disaster-response training and education from other quarters. For example, a recent review of the Public Health Education and Research Program has recommended that capacity and expertise in this area be developed and made more widely available through a variety of universities.15 ConclusionDisaster management calls on the skills of many professionals and many areas of government. Steps taken over recent years, including the establishment of the AHDMPC, have enhanced cooperation and coordination between sectors. There is a need for continuous improvement and for testing improvement initiatives through ongoing exercise programs.

Mary Murnane · David M Cooper

If experimental conditions are not optimised, correct interpretation of results is difficult Many people throughout the world use complementary and alternative medicine (CAM). In the United States, for example, a survey of 31 044 adults aged 18 years or older indicated that 36% had used some form of CAM in the previous 12 months.1 This widespread use was one reason why, in 1998, the US Congress established the National Center for Complementary and Alternative Medicine (NCCAM) to conduct rigorous research on CAM practices. CAM includes the use of dietary supplements and other natural products; manipulative interventions such as massage; mind–body approaches such as meditation; energy interventions such as acupuncture; and whole medical systems such as traditional Chinese medicine. NCCAM’s mission includes disseminating authoritative information to the public and professional communities concerning which CAM practices are safe and effective and which are not. The use of dietary supplements and natural products is the most widespread CAM practice in the US.1 Thus, one initial approach taken by NCCAM was to sponsor large trials of supplements using doses representative of those commonly used.2 The rationale included the concern that if the common dose is unsafe, it would be important to alert the public. Moreover, these doses were often used in smaller, less well-controlled studies. However, NCCAM found that this is not an optimal research strategy. As NCCAM defines its priorities and strategies for the next few years,3 we recognise that reinvestigation and optimisation of customary procedures, especially dose, is needed if NCCAM is to make informed statements. Is optimisation of CAM interventions needed?It is tempting to accept that the widespread use of CAM signifies that these interventions, as customarily used, are beneficial and safe, and the only research needed is a confirmatory study of customary procedures. Over the past few years, we have recognised these assumptions are often incorrect, largely because of the placebo effect, publication bias, and the inherent complexity of clinical interventions. The placebo effect refers to psychological or physiological changes associated with inert substances or “control” procedures. Placebo effects can be substantial. In an NCCAM-sponsored study on major depression, sertraline (a drug licensed for treatment of depression) was effective in 49% of patients: 25% had full responses and 24% had partial responses. However, placebo was equivalently effective: 43% of patients responded (32% full and 11% partial).4 In a non-NCCAM study, arthroscopic surgery for osteoarthritis of the knee (a procedure used before then on 34 000 patients per year in the US) was no more effective than sham surgery.5 Given the ubiquity and strength of placebo effects, the effectiveness of some CAM practices, as with some other health treatments, may be, at least partially, due to that effect rather than to specific efficacy of the intervention. Publication bias results in negative studies appearing less often in the literature, so that reviews in some journals give an overly positive view of CAM effectiveness. In addition, the literature is unlikely to be conclusive because the manner in which an intervention is commonly used is unlikely to optimise the many factors that together could make an intervention successful. A good example of the difficulty of making correct choices is that of echinacea for the common cold. People could take echinacea for prevention or for treatment of colds; use any of three Echinacea species; take an extract of the roots, or the stems, or the flowers, prepared by any of three procedures; and use any of at least three doses. It is very unlikely that public use has identified the correct clinical indication and the correct echinacea formulation without these parameters being systematically evaluated. In this situation, even well-designed large trials6 may fail to show efficacy. Lack of efficacy of a CAM modality in a given study, coupled with uncertainty about optimal experimental conditions in that study, creates a serious problem in interpretation, and this has practical consequences. If the negative results pertain only to the particular study conditions, more work can be done in the expectation that a positive result will eventually emerge. If conditions are optimal and the results pertain to the intervention generally, the efficacy of the intervention could be more justifiably questioned. Early “negative” results present a particular challenge for CAM, given that some people are very sceptical of the field in general, and will seize upon early results of such trials as demonstrating that a CAM treatment is ineffective entirely. As we became more cognisant of the difficulty in correctly interpreting studies for which conditions were not optimised, we updated NCCAM’s website to address one of these issues: dose optimisation:7 If there are no data to suggest that the proposed dose is likely to give maximum efficacy, or if there are no data to identify the highest tolerated dose that can be tested, the applicant should evaluate a range of dosages to establish the appropriate dose for the study or clearly explain why the optimal dose cannot be established. Use of a suboptimal dose that is safe but ineffective does not serve the larger goals of the CAM community. Any given study can only draw conclusions concerning the dose that was tested. If that dose proves ineffective, the community may conclude incorrectly that all doses of the intervention are ineffective, and patients will be denied possible benefit from the intervention. Dose optimisation: evaluating a range of dosagesAn approach to dose optimisation is suggested by the idealised dose–response curves in the Box. The dose of the intervention rises from a low-dose X to a mid-dose Y to a high-dose Z. “Response” can be considered in terms either of efficacy or of toxicity. In this example, dose X is too low to result in either efficacy or toxicity. Dose Z is so high that toxicity as well as efficacy is seen. Y is an optimal dose, at which high efficacy but only modest toxicity is seen. These curves should hold for any intervention, not just for biologically active agents. Natural product regimens need to be optimised with respect to dose of material in each pill, the number of pills per day, and the number of days of treatment. Mind–body, manipulative, and other CAM interventions also require optimisation of the dose, frequency, and duration. Meditation, for example, is typically taught in group courses of a given length, with patients told to practise a certain number of times per day. There is little literature on the dose–response relationships between the length of training or the frequency of practice and clinical outcomes. Thus, part of NCCAM’s new strategic plan for mind–body research calls for studies to “optimize the timing, components, duration, and level of mind–body interventions to achieve health benefits”.8 For most interventions, NCCAM considers that the dose that is commonly practised in the community is likely to fall between X and Y and have low to modest specific efficacy. With this assumption, placebo-controlled phase I/II clinical trials of that intervention should start with the customary dose, then increase the dose until high efficacy, a plateau of efficacy, or intolerance in terms of toxicity or patient burden is observed. CAM practices often involve complex botanical substances in which the active ingredient is very dilute, or other interventions that can be time-consuming to deliver or practise. For CAM, “intolerance” could be an inability to swallow more product, drink more tea, participate in more classes, or devote more time to certain behaviour such as meditation, rather than the classic systemic toxicity of conventional drugs. If substantial specific efficacy is seen before intolerance, the conclusion will be that an “optimal” dose of the intervention may have been identified, one that is ready for testing in a larger clinical trial. Only if an optimal dose of the intervention is used can definitive decisions about the effectiveness of an intervention be made. Dose–response relationships for beneficial interventions

Jonathan Berman MD, PhD, FAAP · Margaret A Chesney PhD

When a prominent Australian politician, the then Premier of Tasmania, The Honourable Jim Bacon, publicly announced in February 2004 that he had lung cancer, he was inundated with well-wishing communications sent by post, email and other means. They included 157 items of correspondence recommending a wide variety of complementary and alternative medicines (CAMs). The most common CAMs recommended were meditation, Chinese medicine, “glyconutrients”, juices, Laetrile and various diets and dietary supplements. Although proof of benefit exists or promising preliminary laboratory studies have been carried out for a small number of the recommendations, no scientific evaluation has been performed for most of these treatments. Their potential benefits and harms are not known. Several recommendations were for treatments known to be useless, harmful or fraudulent. Bacon’s experience suggests that cancer patients may receive unsolicited advice to adopt one or more forms of CAM. Both patients and practitioners need access to authoritative evidence-based information about the benefits and dangers of CAMs.

Ray M Lowenthal MD, FRCP, FRACP

There has been a breakdown of the social constraints that limit the Absurd Twenty years ago, the late Petr Skrabanek, physiologist at Trinity College, Dublin, noted the rising interest in sectarian medical schemes (“complementary and alternative medicine”; CAM), and lamented the lack of a clear “demarcation of the Absurd” in medicine.1 He acknowledged that human irrationality, rather than being unusual, is an integral part of being human: “Even the greatest thinkers, Descartes, Berkeley, [and] Newton could not resist the overpowering pull of their own wishful thinking . . . ”.1 This principle, that irrationality is a normal human characteristic, is more functional than the stance that humans are exclusively rational. The Absurd has gained a degree of agency and respect in some quarters of society through the CAM movement. Many complementary practices long known to result from magical thinking and observational errors are regularly trumpeted to be effective —based on new studies. The Absurd has been aided and legitimised through economic, social, and political currents. The internal pull of the Absurd has coalesced with external currents, forming a critical mass for the CAM wave to be propagated through the social system. Observations on human isolation reveal how fragile is one’s hold on rationality. In isolation (intensive care, etc), we can perceive internally generated stimuli and interpret them as emanating from external sources. These anomalies can be controlled simply through human contact and familiar surroundings. We propose that, in a similar way, irrationality in clinical decisions and research is normally modified, neutralised, or controlled by feedback from surrounding colleagues. However, when irrational beliefs are shared with a surrounding community of sympathetic thinkers, errors become institutionalised. Thus are generated medical sects and cults that propagate the Absurd. What has pushed institutions into the Absurd?The guardians that usually keep the institution of medicine from reeling off into irrationality are social contracts built into medical science and ethical behaviour. The academic community guards the contractual borders of science, while laws and regulations encode our ethical system. For the Absurd to have advanced, there must have been some breakdown of these social guardians. Postmodernism has promoted breakdown and reorientation of structured forms of thought. One of its guises is language distortion — the redefinition and use of words to fit personal views. For example, alternative and complementary have been substituted for quackery, dubious and implausible. Another is the invention of integrative medicine — designed to leapfrog methods into practice without need for proof.2 In a recent commentary, one author redefined standard scientific indicators of efficacy as various biases.3 Postmodernism creates an atmosphere in which absurd claims are accepted more readily because they have simply been renamed. In the postmodern catechism, facts and science are artefacts of social constructions, and modern medicine expresses political hegemony over other, subjugated forms of healing,4 such as naturopathy and homoeopathy. Postmodern CAM also tolerates contradiction without need for resolution through reason and experiment, resulting in a medical pluralism. Various “schools” and philosophies of healing — each inconsistent with the others, such as chiropractic, homoeopathy, orthomolecular medicine, and traditional Chinese medicine — create a scientific multiculturalism. Implausible proposals and claims become tolerable and comfortable, and the CAM advocate’s burden of proof is shifted to disproof by the science community, which that community accepts without major objection. These are constructions designed for propagation of the Absurd. Medical teaching and practices reshape themselves in this atmosphere. Of 175 US medical school CAM courses, only four were found to teach critical analysis of absurd claims.5 Public institutions follow. The US National Library of Medicine’s MEDLINE abstracts some 30–70 journals largely devoted to CAM advocacy, and none devoted to CAM critique. The National Institutes of Health’s website refers only to advocates, such as chiropractic and acupuncture guilds. They exclude well known critical and objective web pages such as those found on Quackwatch (www.quackwatch.org). The new sociolegal order also shows breakdown of classical ethics. CAM followers declare it to be ethical to perform clinical trials on scientifically implausible treatments — merely because the treatments are popular.6 In the United States, legislatures pass Access to Medical Treatment Acts allowing previously unethical practices such as chelation therapy. In 2002, the Federation of State Medical Boards set new physician behavioural guidelines that allow physicians to refer to, and work with, unscientific practitioners.7 Outlier pseudomedical occupations such as acupuncture and naturopathy have gained licensure in several US states. As the borders of science and ethics broaden to accommodate these notions, the Absurd occupies its expanded social space. Evidence-based medicine (EBM), relying on results of randomised trials, should be a bulwark against the Absurd. However, the heterogeneity of clinical trial methods and designs, differing population bases, and varying endpoints often result in heterogeneity of outcomes. This has precluded systematic reviews of CAM methods from defining a line of inefficacy.8 EBM also does not include plausibility or consistency with basic science in its methods and reviews, leaving each to physician and patient interpretation. Moreover, there are no solid criteria for evaluating the quality of trials and reviews, especially for detecting erroneous, manipulated, and faked data.9 Thus, most CAM systems remain in an indeterminate limbo state, awaiting enough negative clinical trials to return consensus opinion to the state of decades prior. Can we demarcate the Absurd in science and medicine?Skrabanek recalled Bevan’s warning, also attributed to Galileo: “The aim of science is not to open a door to infinite wisdom, but to set a limit to infinite error”.1 If EBM fails to resolve the indeterminacy of dubious and absurd claims, routes can be found to re-establish borders, and limit error and infinite repetition of borderline results. The most promising in our opinion is to adopt Goodman’s suggestion for using a Bayes factor to express statistical results of reports on anomalous methods.10 Goodman suggested assigning to each P value several values for the prior probability of the null hypothesis being true, and calculating the posterior probability for each value using Bayes’ theorem. The results give the reader the choice of several levels of efficacy depending on the estimated degree of initial plausibility of the tested claim. A Bayesian guardian at the gate to determine which methods are plausible enough to be worthy of further study would at once help to clarify inconsistent trial results and create a saving in clinical trials expense. It would certainly have met with Petr Skrabanek’s approval.

Wallace Sampson MD · Kimball Atwood IV MD

My early research career has benefited greatly from chance and the right environment. It was not my intention to solve major problems in my postgraduate studies. I was simply interested in the possibility that a virus, discovered by Ludwik Gross in the United States, was involved in the pathogenesis of mouse leukaemia. Although I had no plans to work on immunological problems, I was very much influenced by lectures given by two giants in medical research — Peter Medawar (who, along with Macfarlane Burnet, was awarded the 1960 Nobel Prize for physiology and medicine for their contributions to immunology) and James Gowans (who was Professor of Experimental Pathology at Oxford). Both were responsible for elucidating the phenomenon of immunological tolerance and the function of recirculating small lymphocytes. Their expositions helped me greatly in my subsequent work on the immune system. Early years and how I ended up in medical researchMy parents were born in Paris in 1896. During the first World War, my father Maurice Meunier (English translation, Miller) was an interpreter for British forces in France. In 1919, he married and left for China to join a French bank in Peking. He spent some 22 years in China and Japan, eventually becoming manager of the Franco–Chinese Bank in Shanghai. In 1930, my mother (for health reasons) and my two sisters returned to France by boat. My mother found that she was pregnant, so, having been conceived in China, I was born in Nice, France, in April 1931. The following year we (my mother, my eldest sister Jacqueline, Jeanine and I) returned to China, but we were back in France again 3 years later, because of my mother’s delicate health, and to allow Jacqueline to receive a “good” education at a French boarding school. One year later, when we were on the verge of returning to China, Jacqueline was diagnosed with pulmonary tuberculosis. The four of us instead went to live in Lausanne, Switzerland, which at that time was the place where tuberculosis was supposed to be cured. On the outbreak of World War II, the family hurriedly moved back to Shanghai where, unfortunately, Jacqueline had a relapse of her disease and died in December 1940, aged 17, sadly a few years before the discovery of the anti-tuberculosis drug, streptomycin. In 1941, my father, believing that Japan would enter the war, decided that we should move to Australia. We took the last available cargo ship out of Shanghai and arrived in Sydney a few weeks before Pearl Harbour was attacked. From an early age, and having witnessed my sister’s illness, I wished I could study medicine. Even though I was 10 years younger than Jacqueline, I remembered well her doctor telling my mother how little was known about the body’s resistance to infection, and that intrigued me. In Sydney I went to a Jesuit school, St Aloysius. There, I became friendly with an Austrian boy from Vienna, Gus Nossal. Our paths were to cross in later years. Having achieved a maximum pass in my last year at school, I was accepted into Sydney University medical school. In those days, the course lasted 6 years, but after the 4th year, I did a year’s research. I pursued a Bachelors degree in medical science in Professor de Burgh’s bacteriology department at Sydney University, investigating an experimental model of virus infection. This experience gave me a taste for basic research. PhD studies: virus-induced mouse leukaemiaAfter passing my finals and doing an internship at the Royal Prince Alfred Hospital in Sydney, in 1957 I applied for a Gaggin Research Fellowship, advertised in The Medical Journal of Australia. It was sponsored by the University of Queensland, and offered a return fare to the United Kingdom and a salary for 2 years in a research institute. With this Fellowship in hand, I was accepted as a postdoctoral student for the PhD degree at the Chester Beatty Research Institute in South Kensington, London. I arrived in 1958 with no clear idea of what I might be doing. Many of the scientists at the Chester Beatty were involved in searching for new chemical carcinogenic compounds. Adding more compounds to an ever-growing list did not particularly interest me, as I preferred to use the experience I gained in my BMedSci year to work on some model in which pathogenetic mechanisms had to be elucidated. There was no space for me in the London laboratories, and I was sent to one of the two Chester Beatty satellites, “Pollards Wood”, in Buckinghamshire. It had a splendid Tudor-style mansion in which the rooms had been refurbished to first-class laboratories and offices. There, Dr RJC Harris was working on the development of sarcomas in turkeys, induced by the Rous sarcoma virus. This interested me. Instead of working in his group, he suggested that I might investigate the pathogenesis of lymphoblastic leukaemia induced in mice by what was presumed to be a virus recently discovered by Ludwik Gross. I was very pleased to do this. The only space available was in a shack and in part of a converted horse stable near other horse stables that had been converted to animal holding rooms. Six months after I arrived, Harris was offered the directorship of the Division of Virology of the Imperial Cancer Research Fund at Mill Hill, London. He packed up and left, leaving me without an immediate supervisor, but it was some consolation to acquire his animal space. In the late 1950s, Gross (at the Cancer Research Unit, Veterans Administration Medical Center, the Bronx, New York) had induced leukaemia in some “low-leukaemic” strains of mice by simply inoculating newborn mice with filtered extracts of leukaemic tissues from “high-leukaemic” strains of mice that spontaneously develop the disease at around 9 months of age. Repeating Gross’s observations using the Pollards Wood strains of mice might have taken months or years, and so I wrote to Gross asking him whether he would be kind enough to send his virus and the mice harbouring it. I was grateful that he did so. It was known at that time that acute lymphoblastic leukaemia in mice somehow involved the thymus, and that adult thymectomy prevented the disease from developing spontaneously in high-leukaemic-strain mice, and from induction by ionising radiation and chemical carcinogens in low-leukaemic-strain mice. As no one had hitherto investigated the role of the thymus in the leukaemia induced by Gross’s method, I thought that this would be a good topic for my PhD studies. I had many questions to answer. Why did leukaemia develop only when mice were inoculated with the virus at birth and not later? Could adult thymectomy prevent the disease in virus-inoculated mice? Could the virus multiply only in thymus tissue? What would happen if a normal thymus was grafted into virus-inoculated mice that had their own thymus surgically resected? I was soon able to confirm Gross’s initial work and, in addition, showed the following: Mice given the virus at birth did not develop leukaemia when thymectomised after weaning, but did develop leukaemia when grafted in later life with normal thymus tissue. Grafting normal thymus as late as 6 months after adult thymectomy still enabled leukaemia to develop. The virus could be recovered from the healthy non-leukaemic tissues of neonatally inoculated mice that had been thymectomised at around 6 weeks of age. All these findings led me to wonder whether the virus could multiply in tissues other than the thymus, and to test whether day-old mice inoculated with virus after neonatal thymectomy would develop leukaemia when grafted 2–4 months later with thymus tissue. From leukaemia studies to immune deficiencyNeonatally thymectomised mice grew well at first, but after weaning, many lost weight and died prematurely whether inoculated with virus or not. Adult thymectomy, on the other hand, had never shown any untoward effects such as weight loss, immune deficiency or obvious abnormalities. The onset of wasting and premature death after neonatal thymectomy led me to conclude, “that the thymus at birth may be essential to life”.1 Histological examination of the tissues of neonatally thymectomised mice showed a marked deficiency of lymphocytes in the circulation and the lymphoid tissues, and many wasted mice had liver lesions suggesting infection by a hepatitis virus. I might not have followed up these results had I not been aware of the brilliant work of two famous immunologists, Jim Gowans and Peter Medawar. Gowans had recently shown that, unlike thymus lymphocytes, circulating small lymphocytes were not short-lived cells, as had been widely believed — they were long-lived immunocompetent cells, recirculating from blood through lymphoid tissues into lymph and well equipped to initiate immunological reactions when appropriately stimulated by antigen. Medawar and his colleagues had proven that these lymphocytes were involved in rejection of foreign tissues. Clearly, my neonatally thymectomised mice, that had so few lymphocytes, must have been immunodeficient. So, I tested their immune competence by grafting skin from foreign mice and from rats and by testing their antibody responses to several antigens. The results were striking; unlike mice thymectomised as adults, which had been shown by many to be perfectly able to mount all types of immune responses, my neonatally thymectomised mice were immuno-incompetent. I concluded that during embryogenesis, the thymus would produce the originators of immunologically competent cells, many of which would have migrated to other sites at about the time of birth. This would suggest that thymus lymphocytes leaving the thymus are specially selected cells.2,3 As had to be expected, thymus grafting restored immunological potential to thymectomised mice, but when the thymus donor was foreign to the host, the latter was specifically tolerant of the donor’s tissue antigens. I therefore suggested that tolerance is established within the thymus by the deletion of potentially reactive cells (“selective immunological thymectomy”).3 I next turned my attention to adult thymectomy. It seemed to me that, as total body irradiation damaged the lymphoid system and its immune function, recovery following irradiation should be thymus-dependent. This was found to be correct.4 In those days, most immunologists considered the thymus a useless organ that had become obsolete during the course of evolution and acted simply as a graveyard for dying lymphocytes. They could not fault my data, but criticised my interpretation. The most valid criticism was that my mice, having been bred in converted horse stables, must have had so many intercurrent infections that the additional trauma of thymectomy made them immuno-incompetent. I was able to silence this criticism in 1963, when I obtained an Eleanor Roosevelt Fellowship enabling me to spend a year at the National Institutes of Health in the United States, at that time the only country where germfree mice were available. As neonatally thymectomised germfree mice were also immuno-incompetent,5 immunologists finally agreed that the thymus did have an immune function. However, it was not clear whether it produced all the body’s lymphocytes, then widely believed to function as a single homogeneous population, or whether it influenced the lymphoid system by some unidentified humoral mechanism. Back in AustraliaIn 1965, I was invited back to Australia by Gus Nossal, who had just been appointed director of the Walter and Eliza Hall Institute of Medical Research in Melbourne, to succeed Burnet. I was to lead a new laboratory at the Institute, and Gus had kindly chosen the brilliant young Graham Mitchell, who had just graduated with first class honours from the University of Sydney Veterinary School, as my first PhD student. Our first task was to understand how the thymus contributed to the pool of immunocompetent recirculating small lymphocytes. To achieve this, we investigated how various cell types might restore immune functions to thymectomised mice and what happened to these cells. At that time no “CD” (cluster designation) markers were available to trace cells, and the fluorescent-activated cell sorter had not been invented. We therefore used genetic markers (H-2 disparate strains of mice) and anti-H-2 sera to follow the fate of the injected cells. By the use of such markers, we were able to show how thymus-derived cells and bone-marrow-derived cells interacted in the formation of antibodies (Box 1).6-9 The data in these classical papers established unequivocally for the first time that: (i) thymus-derived cells (later known as T cells, short for “thymus-derived” and coined by Ivan Roitt in London) could be activated specifically by antigen; (ii) they were not the precursors of antibody-forming cells; (iii) they were essential to help, through some form of collaboration, other lymphocytes derived from bone marrow (later known as B cells, short for “bone marrow-derived” cells, also coined by Ivan Roitt) to respond to antigen by producing antibody; and (iv) the mammalian equivalent of the avian bursa (that had been shown by various investigators to have a unique function in antibody formation) was the bone marrow. As to the mechanism of interaction, I made various suggestions, notably that T cells would “focus” cells’ antigen onto specific B cells, or that T cells might secrete antigen-non-specific pharmacological agents. How did the immunological community react to our findings? There was complete surprise, of course, but there was also disbelief when I presented these results at meetings held in the US and Canada in 1968. I was accused of “complicating things”, but the commonest and quite valid criticism of our view of how T and B cells collaborated was that two rare clonally individuated cells would never find each other. The most sarcastic criticism came from Bede Morris, then the Professor of Immunology at the John Curtin School of Medical Research in Canberra, who likened B and T cells to the first and last letters of the word “bullshit”! In spite of all this scepticism and criticism, Graham and I persevered in our work. It was urgently necessary to re-examine a multitude of immunological phenomena and diseases of immune aberration in terms of the two-cell system — tolerance, memory, autoimmunity, immune deficiency, genetically determined unresponsive states, mode of action of immunosuppressants, among others. Within 2–3 years, the entire immunological community jumped on the bandwagon, and since then, hardly an article has appeared in any immunological journal without mentioning the words T or B cells. Over the years my work with colleagues has attracted prestigious awards (Box 2). The two I appreciate most are the Copley Medal from the Royal Society and the Prime Minister’s Prize for Science. I treasure the former because it is the highest award granted by the Royal Society, and the oldest, the first medal being awarded in 1731. It is also a scientific award for outstanding achievements in any branch of science and previous medallists have included Charles Darwin, Francis Crick and Albert Einstein. I treasure the Prime Minister’s Science Prize because it is a distinctly Australian Prize and is, at present, the highest award that is given here. What does the future hold?In 1971, Macfarlane Burnet stated, “None of my juniors seem to be worried as I am by the fact that the contribution of laboratory science to medicine has virtually come to an end”.10 Burnet would be greatly surprised and pleased by the technological breakthroughs, such as transgenic technology, and novel experimental approaches, such as gene targeting, that have given us so much new knowledge in immunology. Although we can employ numerous strategies to allow better survival of transplanted tissues, to deal with various forms of immunological aberrations, and to produce new vaccines, we still have much to learn, in particular, how to apply the fundamental knowledge obtained from our bench work in clinical situations. I am thus in full agreement with the scientific philosopher Karl Popper, that “the deeper our learning, the more conscious, specific and articulate will be our knowledge of what we do not know, our knowledge of our ignorance”.11 1 Development and migration of T and B cells Haemopoietic stem cells originate in the bone marrow (and in the yolk sac and liver in the fetus) and are disseminated in the bloodstream. Some that have already differentiated to lymphoid stem cells reach the thymus where they differentiate to T lymphocytes that migrate out to circulate in the blood and lymph and to colonise the T-cell-dependent areas of the lymphoid tissues. B cells differentiate in the bone marrow and migrate out to colonise the B-cell-dependent areas of the lymphoid tissues and to circulate in blood and lymph. 2 Principal awards received Encyclopaedia Britannica (Australia) Award, 1966 Gairdner Foundation Annual International Award; Toronto, Canada, 1966 Scientific Medal of the Zoological Society of London, 1967 Paul Ehrlich-Ludwig Darmstaedter Prize; Frankfurt, Germany, 1974 Rabbi Shai Shacknai Memorial Prize; Jerusalem, Israel, 1978 Elected Foreign Associate for the United States National Academy of Science, 1982 International St Vincent Prize; World Health Organization, 1983 Sandoz Prize for Immunology, 1990 Peter Medawar Prize for the Transplantation Society, 1990 Croonian Prize, Royal Society; London, 1992 J Alwyn Taylor International Prize for Medicine; London, Ontario, Canada, 1995 Copley Medal, Royal Society; London, 2001 Prime Minister’s Prize for Science; Australia, 2003

Jacques FA Miller AC, AO, MD(Hon), PhD, DSc

Growing up in a medical household with a father who was a consultant physician, the idea of becoming a doctor was with me as early as I can remember. As a teenager, however, deeper thinking about life led me away and then back to medicine. I was fascinated by the wide diversity of human personality, and was an avid reader of biographies. One that influenced me greatly was that of Sir James Mackenzie1 (pictured, Figure 1). He was an Edinburgh graduate who became a general practitioner in Burnley, Lancashire in the second half of the 19th century. From clinical experience, he became keenly interested in the way the heart behaved in arrhythmia. He developed the application of the smoked drum polygraph to interpret the venous waves in his patients’ necks and their relationship to various forms of arrhythmia. As his findings eventually became recognised, he moved into the limelight. He moved to London, practised in Harley Street, headed a new cardiac department at The London Hospital (Figure 2), was knighted, and became the father of clinical cardiology. He was never as happy as he had been as a country family doctor, a role to which he finally returned in Scotland. I was fascinated by the story of how he applied science to resolve problems in a very human context. During my 2nd and 3rd years at Melbourne University medical school, I was confronted with huge masses of information to be reproduced in examinations — particularly in anatomy. Physiology, on the other hand, offered, under “Pansy” Wright, an opportunity to explore ideas. (Wright was Professor of Physiology and the enfant terrible of anti-establishment Australian academia — later Sir Douglas Wright AK, Chancellor of the University!) Nearing the end of my 3rd year in 1950, I was aware that my grasp of science was too shaky to enable me to distinguish fact from the arrogant assertion then so common among clinical teachers. I jumped at the chance of a scholarship to Oxford, offering 2 more preclinical years and 3 years of clinical education at the Radcliffe Infirmary. The years in EnglandLife as an undergraduate in Oxford was all I had dreamt of. There were opportunities to explore ideas of every kind among able people. On arrival in Oxford, I was told by the Professor of Anatomy that I could forget most of the topographical anatomy taught in Melbourne, just study his book The tissues of the body,2 and go anywhere library reading led me. Lectures, he told me, did not matter! Tutorials were a great experience, encompassing independent learning and critical discussions with a tutor who was a senior scientist. Perhaps the most memorable teaching I ever experienced was Howard Florey lecturing on general pathology, covering topics such as inflammation, tissue regeneration, cancer, immunology and responses to infection. There were many other fascinations at Oxford — music, theatre, and sport. My College in Oxford (Magdalen) was second in the intercollegiate “summer eights” (rowing). In my 2nd year, after a major falling out between the several “public school” factions and others, and dire predictions of disaster in the next intercollegiate contest, I was asked to become captain of the boat club. I spent every afternoon over five terms rowing. I missed many classes, but learned a great deal about building a team amid conflict and dissent. Clinical education in Oxford again offered a great clinical experience in an environment where conventional wisdom could be challenged and innovative ideas (such as treating haemophilia with animal Factor VIII produced there in the laboratory, and new approaches to managing severe poliomyelitis, or multiple sclerosis using tuberculin) were being explored. After graduating, I married an Oxford medical graduate whose clinical years had been spent at The London Hospital. We had four children over the next 8 years, and my wife committed herself to bringing up our children rather than pursuing her own career. Our marriage was to last for 26 years. A career in medicineMy early resident positions in Oxford led to an exciting 6 months as senior resident at the Hammersmith Postgraduate School, with challenging discussion of cases before leaders such as John McMichael, who headed medicine with a commitment to advance practice based on research, and John Dacie, who was an inter-national figure in haematology. On gaining membership of the Royal College of Physicians (MRCP), I accepted a Junior Lecturer position at The London Hospital in 1957. There I found a very different environment. There were many outstanding senior clinicians, but the academic medical unit was stuck in a time-warp, grounded in views on renal disease formulated in the 1930s. Recent research on renin and angio-tensin was regarded as a passing fad of no relevance to human disease. However, the position offered great clinical experience and a major commitment in clinical teaching, along with an isotope laboratory for measuring red cell survival in renal failure. I was fascinated by experimental reports on erythropoietin as a regulator of red cell production, thought to be produced by the kidney. I set about devising an assay, using hyper-transfused rats, assessing erythropoiesis with Fe59. After 6 months, my boss, Professor Clifford Wilson, asked what I was doing. I told him about erythropoietin and he sensibly asked me to prepare a literature review. Three months later, I asked him what he thought and he replied that he “did not really believe in humoral factors in disease”. However, by then I was successfully assaying erythropoietin in several forms of anaemia. He relented and let me get on with it! The publication of my first independent research paper in The Lancet in 1961,3 reporting absence of elevated erythropoietin in renal anaemia, led to an offer of a research fellowship in Boston with Ted Astwood (the man who had first isolated adrenocorticotropic hormone) at the New England Medical Centre. A year of full-time research in Boston, seeking to isolate erythropoietin, was exciting, and exposed me to first-class people. After returning to The London Hospital in 1963, I was appointed Consultant Physician at the age of 33, and gained research facilities supported by the Medical Research Council. Life as a teaching hospital consultant, with clinical duties, teaching and research, was challenging. I established the hospital’s first haematology clinic which grew rapidly. As my National Health Service appointment was part-time, I succumbed to urging from colleagues to begin private consulting in Harley Street. This practice grew like Topsy. While it involved dealing with many interesting people as patients, and was highly remunerative, it was not what I wanted to do with my life. I could never find sufficient time to do justice to my developing research on control of platelet production or to keeping my teaching fresh and vigorous. In 1966, I visited Australia for the first time in 16 years, attending an International Haematology Congress in Sydney. I seriously thought about returning to Australia and to academia. In 1967, Carl de Gruchy, Professor of Medicine at St Vincent’s Melbourne and renowned author of Clinical haematology in medical practice,4 approached me with the offer of a post as his first assistant, at a salary about half that of my London income. While I also considered a comparable post in Oxford, the lure of Australia was strong. Colleagues at The London Hospital suggested I must have been in need of psychiatric help to think of resigning, but at the end of 1967, my family and I shipped out to Melbourne. An academic career in MelbourneMy next 2 years at St Vincent’s Hospital were splendid, with time for research, for teaching and clinical practice. I completed an Oxford doctorate with research on megakaryocytes. However, when Carl unexpectedly resigned, I was appointed Professor of Medicine. The hospital at that time was staffed primarily by generalists, as honoraries. The few salaried specialists who provided diagnostic services were not regarded as part of the senior staff of the hospital. For St Vincent’s to become a modern teaching hospital, providing appropriate tertiary services, education and postgraduate training, there was a great need for development of clinical specialties nurtured by research. A real challenge! As an “outsider” in a tight-knit Catholic hospital, tackling this was not an easy task. Although the University of Melbourne was in dire financial straits at that time, I finally got agreement to make two new academic appointments — one in gastroenterology, and the other in endocrinology. Development of specialties, with research facilities initially within my unit, became the pattern for change. Hospital grand rounds, of the calibre of those at Hammersmith, were part of my vision. Resistance by vested interests — those who had previously controlled the destiny of the hospital — was inevitable and had to be lived with; but some senior honoraries who had experience of leading centres in the United States and the United Kingdom were strongly supportive. At the end of 1972, following Whitlam’s election victory, it was clear that Medibank would bring a new pattern of health care delivery with many opportunities for the public sector. Money became available for developing community health centres. In the preceding year I had become Chairman of the university’s Board of Social Studies and saw a health centre, with cross disciplinary collaboration, as both a useful community service and an opportunity to provide a new environment of undergraduate teaching in primary health care. When I formed a planning group, the Victorian branch of the Australian Medical Association (AMA) was outraged, and I was “declared black”. I was brought before hospital authorities and castigated for involving St Vincent’s in what was deemed to be a socialist experiment which would inevitably be involved in doing abortions and other wicked things! However, I had accepted the challenge and was not going to let go. I thanked both for their views and continued on my way! The state Liberal government would only approve the clinic if it had a fee-for-service doctor, complying with AMA demands. This was agreed. By mid-1975, after many battles, the clinic was built and opened within a high-rise housing estate near the hospital, managed by the local community. It had strong input from the Royal District Nursing Service, and social workers were integral to its team. Its doctor had just completed a PhD in my laboratory. To this day it provides service to its low-socioeconomic-status community with many immigrant groups. Deanship and what followedIn 1976, returning from a sabbatical year in laboratory research in Oxford, I became Deputy Dean of the Faculty of Medicine and was also recruited to chair the National Blood Transfusion Committee of the Red Cross. In 1978, I became Dean of Medicine, succeeding Sir Lance Townsend, but continued as Professor at St Vincent’s, with patients, research and teaching. I embarked on seeking to transform medical education from its preoccupation with peddling facts to a process of teaching students to think, to solve problems and to understand broad clinical responsibilities. Quality of teaching mattered enormously and needed attention. A critical decision by the faculty to change the curriculum to reflect these objectives was won on a vote of 57 for and 55 against, after two recounts, in a meeting attended by many faculty members who had not been near the university in years! From that point reform rolled on. The faculty needed change. Its resources were concentrated in the older, established departments rather than in those growing in research and doing new things. Again, vested interests were strong, but with persistence we shifted resources to clinical departments with strong research and away from anatomy and some other pre-clinical departments that justified their “wealth” on historical decisions and a large teaching load of questionable quality. The AIDS challengeThe National Blood Transfusion Service was an amalgam of independent state fiefdoms. It badly needed better decision making and regulation to safeguard standards, but this was strongly resisted by state directors unwilling to concede any authority. In my last meeting (February 1983), at which I announced my intention to retire, the news of AIDS cases linked to the use of fresh cryoprecipitate for haemophilia was reported in the New England Journal of Medicine.5 I relayed this to the council of the National Health and Medical Research Council (NHMRC), on which I then served, and was asked to set up a committee to advise on possible public health implications. Ian Gust, a virologist from Fairfield Infectious Diseases Hospital, Melbourne, joined me and played a key role in all our activities. Ron Penny of St Vincent’s Hospital, Sydney, who diagnosed the first Australian case of AIDS, covered immunology, and others contributed in further areas. As the story unfolded over the following year, there was great public fear of the unknown, and great potential threats to the male homosexual community. The gay community welcomed discussions early on, but a decision by the Sydney Blood Transfusion Service to exclude gay donors led to protests and cries of discrimination. We established good links with the Centers for Disease Control in Atlanta, Georgia, and benefited from weekly, if not daily updates on developments in the spread of AIDS and the search for its cause. The challenge was to ensure the crisis was handled objectively, on the basis of evidence as it became available, and that rational safeguards were put in place to minimise spread. The NHMRC provided funds to support research, but we resisted pressure from the Sydney gay community for them to control our research, as we could not accept their view that the disease was primarily a social or political problem. A huge amount of my time was devoted almost daily to press interviews to ameliorate scare stories of a “new black death about to sweep the world”, and also to oppose inappropriate moralistic haranguing of gay people, which threatened serious social disruption. Applying experience in epidemic control was essential. As evidence moved strongly to a viral cause, liaison with research laboratories in Paris and the US through Ian Gust became enormously important. Development of a national network of viral laboratories was supported, and when testing became possible, Australian Factor VIII concentrate was shown to be contaminated. Matters came to a head late in 1984, when three Queensland babies were shown to have died following transfusion from a single donation by a gay man. A National Health Ministers Summit was called by Neal Blewett (then federal Minister for Health). Our committee was expanded and renamed the AIDS Task Force (Figure 3). A second advisory committee, the National Advisory Committee on AIDS (NACAIDS), chaired by Ita Buttrose, was established with special responsibility for advising the public, for liaising with affected community groups and with Neal Blewett’s office, which maintained close links with the gay community. That committee channelled valuable support to the gay community in their development of very important “safe sex” education programs. Neal Blewett’s national leadership was critically important in gaining government support and funding. Our advice continued to be sought on containment of risk, and we made preparation for widespread testing for the HIV virus as soon as it became possible. In May 1985, we became the first country in the world to test every single blood donation for HIV. I had many memorable meetings with special interest groups. The gay community feared the consequences of being found to have a positive test, and repeated attempts were made to have the task force wound up over 2 years. The telephone used to ring at 6 am almost daily, with requests for comment on the latest story from Australia or overseas. Maintaining public dialogue was important for preventing inappropriate behaviour and to get the public to see the problem as a virus which could be handled rationally, rather than as a gay plague. A different challengeIn 1984, another public issue became a challenge. I was asked to chair a Committee of Inquiry into Rights of Private Practice in Public Hospitals. This arose from a heated dispute between the federal government and the AMA, and withdrawal of specialist services over the introduction of the new Medicare. The committee included Dr Brendon Kearney of South Australia representing government, and Dr John Cashman, a private radiologist nominated by the AMA. We had a protracted chase to get data from the federal government which purported to show excessive private use of pathology and radiology facilities in public hospitals. In reality, the rapidly expanding use of such services was outside the public hospitals, but the advisors who developed the legislation thought control could only be achieved in public hospitals. Apart from gaining access to the necessary data, public hearings across the country over 4 months, attended by the AMA and many specialist groups as well as by government, played a part in gaining a fragile consensus which largely defused the dispute. Finding common ground was the key. Oversight of diagnostic testing in hospitals was a reasonable expectation of government, and was finally agreed. After a general election at the end of the year, Prime Minister Hawke intervened to resolve the remaining issues with New South Wales surgeons and made available new funding to update equipment in public hospitals. My role when first appointed to the task had been damned by the Victorian AMA on the grounds of being a known “left-winger”, but in the end I received an apology and was later invited to address an AMA National Conference on the role of the profession.6 Two weeks after completing our inquiry, I remarried — a haematology colleague, Sonay Hussein, who still shares my life. By the end of 1986, I was so busy with AIDS issues that I stepped down as Dean of Medicine, continuing as Professor of Medicine. My last research paper was published in 1989.7 Life as a Vice-ChancellorEarly in 1987, I was appointed to be Vice-Chancellor of the University of Melbourne from the start of 1988. Before I took up the appointment, however, John Dawkins became Minister for Education with an agenda for radical reform. He was dismissive of what he termed “ossified old universities” and, at the end of the year, announced his intention to create the “unified national system” of higher education. While there was no doubt need for reform, the model of central ministerial control had many dangers, including those inherent in research policies which were to be shaped according to perceived national priorities. I was surprised to find fellow Vice-Chancellors reluctant to speak publicly about what many agreed privately was wrong with many aspects of the Dawkins reforms. While there was a good case for several major institutes of technology being upgraded to universities, a Commonwealth Tertiary Education Commission review of efficiency and effectiveness in higher education in 1986 had advised against combining the university and advanced education sectors.8 Other good aspects of that report had been incorporated into the Dawkins package, but when I declared myself as supporting some of these, Dawkins was outraged that I had publicly opposed others, particularly those relating to research and amalgamations. A review of research policy was finally agreed, which led to many improvements and additional funding for research infrastructure which currently continues. Other public issues laden with controversy included an attempt to regulate university education in terms of “competency skills”, and principles guiding relative funding of universities. Mobilising public opinion was the key to successfully resisting some of the Dawkins changes. By 1990, the University of Melbourne had moved into strategic planning and adopted objectives and principles in its own reform agenda. Seeking excellence in its teaching, research and public contributions ran counter to the prevailing political preoccupation with equity and equality. We were regularly under attack. One issue in Victoria during this time was the proposed replacement of most external assessments of secondary education by what were termed “common assessment tasks” — work done independently by students (Figure 4) — to be used in university selection. This was led by left-wing teacher groups, outraged by talk of striving for excellence in education. We threatened to introduce our own entrance examination. I led much of the public debate, supported by a group of school principals, which finally achieved rational compromise. Changes at the University of Melbourne were widespread. We concentrated on the quality of teaching, of supervision of research training and of academic management. Finally, a School of Graduate Studies was established to provide a collegial environment for graduate students, comparable in many ways to what I had experienced in Oxford. Getting a common commitment across the University to take pride in the quality of our work was the key to success. When Peter Baldwin (Dawkins’ successor as Minister for Higher Education) introduced “quality” as a major issue for the federal government, we came up “smelling of roses” in the first review.9 Life after Vice-ChancellorshipExpecting to move into a placid retirement at the age of 65, I was asked by the Premier of Victoria, Jeff Kennett, to lead a review of illicit drug policy at the end of 1995. Deaths from heroin overdose and open trafficking in the streets were both escalating. I headed a group of outstanding individuals with widely varied expertise. The challenge was the need to see drug dependency as a health problem to be handled through education and treatment rather than moralistic preaching and the law. While strong legal sanctions for the trafficking industry were appropriate, education was critical in prevention. Finally, when our 70-odd recommendations were unanimous, I addressed the first ever public joint sitting of both houses of the Victorian Parliament. We thought most of our recommendations would be adopted, but after a state election, with very strong lobbying by conservative politicians and the media, political support waned. National trials of new forms of treatment were implemented. A proposal for a multi-state heroin treatment trial was supported by the Kennett government, but subsequently stopped by Prime Minister Howard. Limited reform, with improvement of services, was achieved and, subsequently, a national policy was adopted for diverting arrested drug users to counselling rather than to courts in the first instance. A repeat review of illicit drug policies, including proposals for heroin injecting facilities, was undertaken in 1999–2000 after election of the Victorian Bracks government, but public and political reaction was a virtual rerun of 1996. National contributions to the drug debate were made through chairing the Capital Cities Lord Mayors’ Drug Advisory Committee 1997–99, and as keynote speaker in the NSW Parliamentary Summit which preceded the establishment of the Kings Cross heroin injecting facility. The College of Physicians was supportive of the changes sought.10 Challenges continue. These now mostly centre on improving support for and management of research in bodies I have chaired and seeking to bring the benefits of medical research to the community through commercialisation or other appropriate public means. Perhaps the most fulfilling have been the great growth and achievements of Cochlear Ltd as a public company and the creation of the new Melbourne Museum in its controversial new modern building. The host of challenges which have come my way over the years have presented many opportunities to contribute to the development of medicine, of education and of the community. Bringing about change has frequently involved conflict, but change would not have been achieved if popularity was what drove me. It has been a real privilege to work with outstanding colleagues at every stage and to have had such a variety of interesting and often exciting challenges — they still come! 1 James Mackenzie. © Royal College of General Practitioners Archives. 2 The London Hospital, circa 1950s–1960s. © The London Hospital. 3 Transmission of AIDS by blood transfusion hit the headlines in 1983 and 1984. The AIDS Task Force was seen as the bulwark of defence for the community. Illustration by J Spooner, reproduced with permission from The Age, Melbourne. 4 The "Common Assessment Task" was seen by its advocates as largely taking the place of external examinations in Year 12 for selection into universities. Illustration by P Nicholson, reproduced with permission from The Age, Melbourne.

David G Penington AC

Innovation, fitness to practise and medical education as a discipline were the themes of a recent colloquium Medical education is currently under the spotlight both in Australia and internationally. It is, for example, influencing and being influenced by major global initiatives such as the International Campaign to Revitalise Academic Medicine (a collaboration of medical academics seeking to secure a vibrant future for academic medicine) and the recent Productivity Commission’s report on Australia’s health workforce, which highlighted the need for more responsive education and training.1,2 New medical schools are being established, with some seeking to develop innovative programs and access perceived niche markets.3 Some of these issues were debated at a conference in March 2005 hosted by the Committee of Deans of Australian Medical Schools.4 It was against this background that the School of Medicine at the University of Queensland hosted the first Australian National Medical Education Colloquium in August 2005. Innovation, fitness to practise and medical education as a discipline were the themes of the 2-day Colloquium. It brought together over 120 participants from Australian medical schools, who were challenged to consider future directions for medical education. Plenary sessions were delivered by Ron Harden (Director, International Virtual Medical School [IVIMEDS], and former Professor of Medical Education, and Director, Centre for Medical Education, University of Dundee); Thomas Aretz (Director of Education, Harvard Macy Institute, Harvard Medical School); Merrilyn Walton (Associate Professor of Ethical Practice, University of Sydney); and David Prideaux (Professor of Medical Education, Flinders and Griffith Universities). Priority directions for medical education identified by plenary speakers were student-centred learning, adaptive curriculum, teaching innovations, systems approach, academic medicine, fitness to practise, and medical education research. Student-centred learningHarden highlighted the importance of student-centred learning as being pivotal to thinking about learning and teaching. He suggested our medical education programs need to see the student at the centre of the learning process, with a futuristic option that includes learning becoming personalised through “blended learning” — a mix of e-learning and face-to-face study — and truly individualised programs. IVIMEDS, a worldwide partnership of leading medical schools, is an example of an organisation working to develop e-learning opportunities in medical education. IVIMEDS includes a bank of learning objects (eg, x-ray images, decision-making scenarios, videos), curriculum maps, virtual patients, and guided learning that is responsive to the learning needs of individual students and is an example of what is called an “adaptive curriculum”. Adaptive curriculumAn adaptive curriculum modifies and personalises learning by designing teaching and learning experiences geared to the specific needs of individual students. As Harden explained, the concepts of “just for me” learning and “just in time” learning are accommodated by technology — when the learner is ready, the teacher will appear via technology. Programs such as IVIMEDS provide the framework and resources for this type of learning to be further developed. Teaching innovationsInnovations in medical education extend to curriculum, technology, assessment and professionalism. The curriculum model of the future should be student-centred, problem- or task-based, integrated, interdisciplinary, interprofessional, community-based and elective-driven, with core and student-selected components. The goal is systematic, outcome-based education.5 But how is this ideal to be achieved? And how do we move beyond a list of motherhood statements? Curricula are already becoming blended, using different technologies that allow students to access learning opportunities for what they need to know and when they are ready to learn. Technology will continue to be an important aspect of future medical education, with simulation a key feature.6 To keep pace with curriculum changes, assessment must move beyond multiple-choice tests of knowledge and multistation tests of “pretend” clinical skills using simulated patients. There is increasingly a need to assess aspects of professional behaviour and competence within the health system. Portfolio assessment may be one way to do some of this, but we have a long way to go before we can be sure we are graduating truly competent doctors with the necessary professional behaviour. Systems approachAretz stressed the need for medical education programs to prepare graduates who are responsive to both the needs of the health system in which they will function and the needs of the patients they will treat. Currently, medical students spend most time in teaching hospitals, but they will eventually work in the commun-ity, where most patients present and are treated. Aretz challenged delegates to prepare interns who are immediately ready for the workplace and have the prerequisite skills and knowledge required by the health system and the consumers of health services. The future of medical education was presented from global, system, institutional and individual perspectives. Global perspectiveWith the mobility of the health professional workforce, changes — including international accreditation, increased competition between medical schools, and increased cybermedicine — seem to be the way of the future. Global alliances for teaching resources and assessment are efficient, as is developing new assessment technologies, including consortia for practical clinical examinations, simulators and web-based clinical evaluation systems. There is a need to develop a global perspective such that equivalent standards across countries and medical schools are defined, including mechanisms for global standards, accreditation and curricula. System perspectiveMedical schools increasingly require their students to have an understanding of the evolving health industry structure from all levels, including self-care, nursing, general practice and specialist areas. The system works through partnerships between all components, such as academic institutions, biomedical research centres, the insurance industry, government, regulators and health care providers. Users of the medical school product, including health systems and patients, require and demand input into how medical education works. Institutional perspectiveMedical school programs will probably increasingly seek differentiation. Some will focus on interprofessional education (in which students in various health professions, such as medicine, nursing, and allied health, learn together); others will be for profit; and some will develop niche markets (eg, providing accelerated pathways to a particular speciality). A key challenge for medical programs is appropriate reflection of the health system they serve so that medical training mirrors actual health care delivery patterns and recognises non-traditional training sites. Faculty development plays an important part. Multidisciplinary teaching teams can be developed so that centres and institutes, rather than traditional medical disciplines, are the organisational framework for creating integrated curricula that cross traditional departmental lines. Individual perspectiveMedical schools should be educating for capability, so that indi-vidual learning tested once is insufficient and competence requires repeated demonstration. The ability of individuals to adapt to change, generate new knowledge and improve their performance and professionalism is as important as specific knowledge and skills. Academic medicineMedical schools and health systems need to recapture the educational mission by protecting time for teaching and faculty development. Academic medicine must be fully engaged with its real stakeholders — the health system and the patient. The International Campaign to Revitalise Academic Medicine has presented a range of provocative possibilities.7 Fitness to practiseAccording to Walton, fitness to practise is an issue with which all medical schools are currently grappling. There is still debate about what it really means, what its components are, what we are currently doing well, and what we need to do much better. Overall, we are probably handling the issues of knowledge and clinical skills quite well. However, there was broad agreement that we have a long way to go in terms of attitudes and behaviour. How can we define them, develop them in our students and then assess them? Medical education researchPrideaux challenged Colloquium participants to embed medical education research into academic medicine. In order to validate the effectiveness of new teaching approaches, medical education research must emphasise appropriate methodology. “Very little research is undertaken of our teaching programs in medical schools, and that which is done is usually methodologically unsound”, said Prideaux. Current problems with medical education research include no clear focus or standards, no strong evidence base, little research in key areas, methodological confusion and inappropriateness, poor design, wrong questions, atheoretical approaches, and reduced generalisability. He challenged delegates to make robust medical education research an integral part of their school service. SummaryThe Australian National Medical Education Colloquium provided a productive forum for medical educators to meet and to discuss and debate important contemporary issues affecting Australian medical schools. None of us know what the future will hold, and some of the possibilities discussed at the Colloquium were futuristic indeed. We would be wise to keep an open mind, to focus very much on competence and fitness to practice, and to develop a strong evidence base, as we travel this important path.

Louise Young MPsychEd, PhD · David Wilkinson MBChB, FRACGP, DSc

Objective: To determine whether grand rounds are becoming less common in Australian hospitals.Design and participants: Between November 2003 and April 2004, we surveyed 88 clinicians with educational responsibilities in Australian hospitals. A written questionnaire evaluated whether grand rounds were held and how frequently; the structure and percentage of attendees; and the perceived value of grand rounds with regard to education, professional development and general characteristics.Results: Clinicians in 73/88 hospitals completed the survey (83% response rate). Of the 73 respondents, 63 reported that their hospitals continued to hold grand rounds, and most considered them to be valuable in the areas surveyed. Grand rounds were more common in larger hospitals, public hospitals, and those having junior medical officers. The proportion of clinical staff regularly attending grand rounds was estimated to be 10%–50% by most respondents.Conclusion: Grand rounds continue in the majority of hospitals and are considered valuable for educational and professional reasons. There may be scope for improving attendance at grand rounds by greater emphasis on the specific needs of attendees.

Richard Tarala FRACP · Alistair W Vickery FRACGP

Factors to be considered in planning our medical workforce to meet future needs include: Need for outcomes-based curricular designs in medical schools and postgraduate training. Shortening the length of medical training. Improving career flexibility to permit professional reinvention. Developing awareness within the profession about how innovation happens.

S Bruce Dowton MD, FACMG, FRACP

Exploring the “norms” or principles of bioethics, health law and international human rights is central to personal and professional development courses of contemporary medical schools. Despite the increasing popularity of using the insights of fine art and literature (particularly through resources such as the New York University Literature, Arts and Medicine Database1), how these dovetail with the former objectives remains something of an academic puzzle. Further, curricula use of the medical humanities often meets with scepticism and disinterest from exam-oriented students. Teaching application of principle through medical humanitiesThe Personal and Professional Development course at the Australian National University Medical School has taken a unique approach. The course aims to teach not just the relevant norms or principles of bioethics and health law, but to encourage their consistent and practical application throughout a medical career, despite personal, collegial and institutional obstacles. This process may be linked to a tradition of scholarship known as virtue ethics, as its aim is character development rather than intellectual recall of abstract rules.2 I have argued in a previous publication that medical humanities has “normative” (or “principle-developing”) aspects, particularly when linked to a process of reasoning that strives to achieve coherence between laws and fundamental social virtues, such as justice, fairness and respect for human dignity.3 This process of reasoning is designed to give students the capacity not only to critique and weigh compliance with such norms or principles, but to assist in developing them, be they derived from ethical, legal or human rights traditions.4 Over the first 2 years of the course, each fortnight four students are required to develop and present a collaborative half-hour PowerPoint analysis of a staff-selected contentious issue in bioethics, health law or international human rights. These include the standard components of bioethics and health law, but many of the presentations relate to a major theme of this course — that, while corporate globalisation may enhance efficiency and innovation, its “lobbying” principles and strategies may be having a major adverse impact on current health policy and on the foundational medical virtue of loyalty to the relief of patient suffering.4 In addition to using selected online resources and nominated experts, the students are required to incorporate in their presentations imaginative insights and arousals of conscience gained from examples of fine art, including visiting a nominated work of art at the National Gallery of Australia. Thus, in addition to the well accepted works from the medical humanities canon (eg, Edvard Munch’s Death in the Sickroom [Nasjonalgalleriet, Oslo, c. 1893] and George Tooker’s Corporate Decision [private collection, 1983]), students are asked to consider, with expert guidance from the gallery staff, selected works from the National Gallery of Australia; for example, John Longstaff’s Motherless (1886), Anselm Kiefer’s Twilight of the West (1989) and George Lambert’s Chesham Street (1910) (Box 1). Bill Viola’s The Passions and medical, personal and professional development trainingThe course recently took advantage of a relevant temporary exhibition. Between 29 July and 6 November 2005, the National Gallery of Australia exhibited a collection of architectural video installations, The Passions, by the artist Bill Viola. Viola’s art uses actors in slowed video performance of narrative moments eliciting heightened emotions, disturbances of consciousness and a search for meaning in the face of tragedy. His art provided a good example of how our students are encouraged to use the medical humanities to incorporate, within their conscience, career-long respect for implementing principles of bioethics, health law and the international right to health in the face of challenges, such as those posed by corporate globalisation. This approach goes beyond suggesting that such works merely heighten clinical observation skills.5 It attempts to enhance professional loyalty and normative thinking toward individual patients in the face of the unique contemporary pressures created by corporate globalisation. Such contexts include tragic narratives involving: breaking bad news to a couple (Viola’s Dolorosa shows the grieving faces of a man and woman [Box 2]); assisting a mother and her daughter grieving about the death of their son and brother (Emergence depicts the dead Christ emerging from a tomb and being laid to rest by two distressed women [Box 3]); or watching relatives view the body of a loved one who has just been removed from life support6 (Observance displays a procession of 18 people slowly taking turns to confront a disturbing sight and expressing and sharing emotions [Box 4]). Viola’s The Passions were developed, primarily from a tradition of Christian iconography, during a residency at the Research institute of the J Paul Getty Museum in Los Angeles in 1998. Viola’s Emergence, for example, draws upon Descent from the Cross by Rogier van der Weyden (1435, The Prado, Madrid, Spain). His work, Observance, has artistic roots in The Four Apostles by Albrecht Dürer (1526, Alte Pinakothek, Munich). The use of such representational narrative paintings for private devotion was a dominant feature of 15th century art. Such treatises instructed the laity to participate empathically in the picture, to become a meditative “co-sufferer”. The medieval artist, as does Viola, strove to overcome complacency in matters of spiritual development, the art arousing heightened emotions which could then be harmonised in prayers for forgiveness and by redemptive grace.8 Viola’s exhibition also draws on Hindu and Zen spiritual traditions. This is particularly evident in his depictions of hand “mudras”, and in Five Angels for the Millennium, a video projection with stereo sound in which five large simultaneous videos depict the human shape distorted in light, fire and water within a darkened, cloistered space, with accompanying sound crescendos as the human forms gradually appear (Box 5). This evocation of the meditative human spirit may also resonate with our students who commence each personal and professional development session with a five-minute, staff-directed relaxation exercise, lacking overt religious elements. A medical version — “Five Angels for the Medical Millennium” — could shape the following particular resonances for students studying the pressures on patients from corporate globalisation: the recrudescence of scholastic dogmatism and lack of local industry support, which is inhibiting stem cell research; the regulatory panics over pharmaceutical patents associated with emergent infectious disease; persecuted whistleblowers nonetheless leading quality and safety in an increasingly privatised health care system; the frequently blasted expectations associated with lucrative artificial reproductive technology; and the uncertain legitimacy and health care values of entrepreneurs directing public health policy through the principles and strategies of corporate globalisation. The task of discerning and then assisting the fallen angels among this collection, those least likely to enhance the foundational professional virtue of loyalty to the relief of patient suffering, seems a worthwhile challenge to the conscience of many medical students and health professionals. ConclusionBy so viewing an exhibition such as Bill Viola’s The Passions, it is hoped that one practical, normative outcome of the emotional resonances evoked in our students may be to encourage them to challenge the role of corporate multinationals in setting global public health policy, while at the same time appreciating their contributions to efficiency and innovation. They could then begin to play a medical regulatory version of Hermann Hesse’s eclectic, nation-ruling and character-shaping “Glass Bead Game” (from the Nobel Prize winning novel of the same name). In the novel, student monks in a fictional country of Castalia are taught to play an extremely complex game in which aspects of diverse intellectual traditions are interwoven. Strategic “Renaissance-type” thinking could suggest: Constitutional, lobbying and professional regulatory measures countering profit-driven moves to dismantle universal health services and medicines delivery systems9 in favour of user-pays health savings accounts10 and medicines savings accounts;11 Trade agreement provisions facilitating improvements in socially responsive, cost-effectiveness evaluation of allegedly “innovative” pharmaceuticals before government reimbursement;12 and Educational strategies assisting capacity building in this area by teaching students to have pride in Australia’s role in promoting the public good of cost-effectiveness evaluation by the Pharmaceutical Benefits Advisory Committee in the context of its social justice origins and the multinational corporate pressures upon it. 1 Chesham Street George Lambert, Chesham Street, 1910. Oil on canvas. National Gallery of Australia, Canberra. 2 Dolorosa Bill Viola, Dolorosa, 2000. Colour video diptych on two freestanding hinged LCD flat panels. © Bill Viola. Photo: Kira Perov. 3 Emergence Bill Viola, Emergence, 2002. High-definition video rear projection on a wall-mounted screen. Commissioned by the J Paul Getty Museum, Los Angeles. © Bill Viola. Photo: Kira Perov. 4 Observance Bill Viola, Observance, 2002. Colour high-definition video on plasma display mounted on wall. © Bill Viola. Photo: Kira Perov. Medieval devotional works were created in an intellectual climate that emphasised the instructional value of the vices, as well as the virtues. The traditional seven capital vices are: superbia (pride), ira (anger), invidia (envy), gula (gluttony), lusuria (lust), cupidita (greed) and accidia (sloth).7 Many works in Viola's The Passions likewise resonate with this tradition, particularly Observance (above) where such vices appear in expressions shared between those passing each other to observe a person who has died. Viola's work from this perspective might encourage medical students to present reflections as if these people were delegates of the World Trade Organization discussing enhanced regimes of intellectual property rights; or chief executives of a multinational pharmaceutical company considering the profit outcomes of a research and development strategy, or how to alter a nation's public health system to maximise their organisations' financial growth. 5 Five Angels for the Millennium Five Angels for the Millennium, 2001 (detail, from left to right: Departing Angel, Fire Angel and Birth Angel). Five channel video projection with stereo sound. © Bill Viola. Photo: Kira Perov. What imaginative “normative” resonances do these images have for medical students when loyalty to the relief of patient suffering is considered in the context of the challenges produced by corporate globalisation?

Thomas A Faunce BA/LLB, BMed, PhD

David J Tiller,* Rick McLean,† Bruce C Harris‡ * Head, Department of Renal Medicine, Royal Prince Alfred Hospital, Missenden Road, Camperdown, Sydney, NSW 2050; and Visiting Professor, School of Rural Health, University of Sydney; † Associate Dean, ‡ Program Coordinator, School of Rural Health, University of Sydney, Dubbo Campus, Dubbo, NSW. dtillerATmed.usyd.edu.au To the Editor: Your column in the 5 September issue of the Journal1 was exquisitely timely. Four days later, a seedling from the original Hippocratic tree from the island of Cos was planted in the grounds of a clinical school of the Medical Faculty of the University of Sydney (Figure) — not in proximity to the jacarandas of Camperdown, but rather to the river red gums near the School of Rural Health in Dubbo! The School of Rural Health is the newest of Sydney University’s clinical schools, having been funded as part of the Regional Health Strategy in 2000. The story of how the Hippocratic seedling came to Dubbo is wonderful. About 18 months ago, two of us (B H and D J T) were discussing what shade trees should be planted around the new clinical school (summer in Dubbo is hot), and the matter of the Hippocratic tree arose. We discovered that it was a European plane tree and made an initial approach to the National Library of Medicine in the United States (who, as stated in your column, had grown a tree from a cutting of the original), but this was unsuccessful. However, Dr John Boulas, a Greek-born Sydney-based urologist colleague was soon to depart for the Olympics in Greece and, as luck would have it, undertook to contact an urologist colleague in Greece who looked after the prostate of the mayor of Cos. This was duly done, and within a couple of months, two seedlings from the original tree arrived at customs in Sydney and spent 3 months in quarantine at the Royal Botanic Gardens. After that time, having been declared free of disease, one was brought to Dubbo to acclimatise. The official planting took place on 9 September and was officiated over by John Anderson, previous Deputy Prime Minister, who played a major role in the Australian Government’s commitment to fund the Regional Health Strategy in 2000, and the new NSW Minister for Health, John Hatzistergos, whose parents came from the island of Cos! To close the loop, both Mr Anderson and Mr Hatzistergos are University of Sydney alumni. The university’s motto (“sidere mens eadem mutato”) means “same learning under different stars”, indicating its links to the universities of Oxford and Cambridge. Perhaps the School of Rural Health motto should be “same learning under the same tree”! In any situation, the links to the history of medicine are firmly established, and medical students will have the opportunity to reflect on the tradition of medicine before their taking of the Hippocratic Oath or its modern equivalent. Wanted: a few more modern-day Hippocrates to teach under the tree. Apply within.

David J Tiller · Rick McLean · Bruce C Harris

Peter M Brooks Executive Dean (Health Sciences), University of Queensland, Royal Brisbane Hospital, Edith Cavell Building, Herston, QLD 4006. p.brooksATmailbox.uq.edu.au To the Editor: Van Der Weyden raises an interesting issue in his recent column From the Editor’s Desk.1 It has long been known that the collective noun for academics is “an absence of”! He is absolutely correct in pointing out that research is valued far more than teaching. That is the reality of current university funding and is at risk of becoming more so, given the research assessment exercise currently being introduced by the federal government.2 This raises the whole issue of profess-orial titles. In a world where elitism is considered not politically correct, we should perhaps dump these titles entirely. I have long yearned for a system like that in the United States, where an individual enters the academic stream at the level of Assistant Professor, progresses to Associate Professor and then Professor (finally being offered tenure after winning the Nobel Prize). This leads to the situation where the “professorial denominator” is not used — individual academics (like other staff) are introduced as “Doctor”. In Australia, many Associate Professors drop the “Associate”, and most “clinical” title holders seem very keen to add their academic titles to their private practice shingles and letterheads. I have often considered doing an economic analysis of the annual value of a title to a doctor’s practice (which I suspect is considerable), and charging appropriately. A decade ago, the then President of the Royal Australasian College of Physicians and myself, as Honorary Secretary, decided to replace professorial titles with “Dr” in all College mail-outs. This lasted about 6 weeks, with a veritable flurry of responses pointing out that we had failed to address these Fellows appropriately. What Van Der Weyden highlights are the real pressures currently on academic medicine, and the need for real debate in the medical community about the worth of academe and the absolute essential building blocks — research, learning and ser-vice — of any credible health system.

Peter M Brooks

We need a vision to attract funding increases, and it must come from the research community Some time ago, a federal Health Minister met with a group of medical researchers who argued passionately for more funding of medical research. As they left, the researchers overheard the Minister say, in an aside to his adviser, “even if we give them what they ask, they will just want more”. This real political comment is indicative of an enduring tension between medical researchers and government — perhaps an enduring tension between all who seek more of the taxpayers’ funds from governments faced with a plethora of competing community demands. This tension is echoed in the outcome of a 2002 survey of health and medical researchers reported in this issue of the Journal by Shewan and colleagues.1 These authors reveal that about 90% of respondents believe that adequate funding was very or extremely important to their research role, but only about 10% felt that the current level of research funding was adequate. This accords with current campaigns by the Australian Society for Medical Research,2 Research Australia3 and the Association of Australian Medical Research Institutes4 to increase government funding. But to increase funding to what purpose? Following the Wills Report in 1999,5 the federal government doubled National Health and Medical Research Council (NHMRC) funding for medical research to almost $480 million in 2004.6 Although NHMRC funding is only a proportion of our total medical research funding, it is the major component. After this increase, the NHMRC undertook a number of new activities (eg, Public Health Capacity Building Grants, Centres of Clinical Research Excellence) and funded project grants more fully. However, the major change that the extra funds allowed was the introduction of new, large and flexible Program Grants. These are competed for on the basis of achievements over the previous 5 years, and allow teams of researchers to be much more strategic in their research plans. The new funding also allowed the NHMRC to attend to things which were unpopular in some quarters; for example, abolition of block funding of independent medical research institutes. Now, in 2005, NHMRC future funding projections are again flat, and the government shows little inclination for “more of the same”; that is, to increase the NHMRC budget for the sake of it. Researchers hoped that the recent Grant Report,7 which examined the implementation of the government’s doubling of NHMRC funding, would spark a further increase in funding from the government, but this was not to be. There is also increasing competition from countries which can either support Australia’s best researchers more lavishly (eg, the United States) or which are rapidly increasing their national funding (eg, China, Singapore, and the European Union). There is no common view on what increased Australian funding for medical research is needed for. Ask individual researchers and they will forcefully articulate their individual cases. Depending on who they are, they may point to the need to strengthen health services research to provide an evidence base for turning policy into practice in the health system. Others may call for a robust research effort in established infectious diseases (eg, Ross River fever) or in new ones that are potential threats (eg, new forms of influenza), or for research into public health measures to combat these threats. Others may advocate research into problems of chronic diseases that are sometimes seen as less urgent but, in fact, account for the overwhelming majority of the burden of disease locally and internationally, even in poorer countries. For example, it has been pointed out recently that 80% of deaths from chronic diseases involve people living in low- and middle-income countries.8 It seems that until a strong “story” emerges from the research community for the need for extra funding, nothing much will happen. The medical research leadership needs to work together to articulate what extra funding will provide for Australia. “More of the same, but better” is unlikely to succeed — the medical research community needs to come forward with a vision. One interesting finding in the study by Shewan and colleagues was a divergence in views between researchers at medical research institutes and universities.1 University researchers felt significantly more strongly that the infrastructure available for research was inadequate, and were also significantly more satisfied with the excitement of discovery in their research work. The medical research institutes enjoy some advantages in that they now receive direct infrastructure funding from the NHMRC and also from state governments; do not pay fringe benefits tax; don’t have to teach undergraduates; and often have magnificent, government-funded research labs. Now, universities are adopting an internal research institute model (eg, the University of Queensland’s Institute for Molecular Biosciences, and Monash University’s Institute of Medical Research) so that they too have a two-tiered system. Still, most health research emanates from universities, and university-based researchers need to follow the example of the independent institutes and organise themselves more effectively. To return to my original theme, the medical research community needs to develop a plan that will convince government that the pursuit of research and its translation into treatments, equipment and services contributes to a more innovative and productive economy. An important part of this plan will be to keep our most talented younger researchers working here for the good of Australia. Talented young researchers often see themselves as global citizens, able to find work easily anywhere around the world. There must be good funding methods that support the best research, from molecular genetics through to health services research, and the best young researchers, so that we are constantly adding zest and the yeast into the system! The young are much more likely to challenge orthodoxies and hunt out new approaches — Peter Doherty and Barry Marshall were both young when they made their ground-breaking discoveries that led to their Nobel prizes. New ideas and well supported arguments can work, as shown by the federal government’s response to the Wills Report in 1999, and the Victorian and Queensland governments’ responses through their innovation initiatives (the Science, Technology and Innovation Initiative for Victorian, and Smart State for Queensland). Governments need to take a long-term view, and to regard research funding as an investment, to set strategic goals and commit to the long term. They also need to develop comprehensive policies that encourage private and philanthropic investment in research in Australia, which, compared with that in the US, is but a drop in the ocean. This will keep the mobile health research workforce here, working to make Australian health research vibrant and productive, and contributing even more to national health and wealth. It is up to the research community to come up with innovative directions. The NHMRC itself will need to take a much stronger leadership role in developing exciting and innovative strategies suitable for the 21st century and justifying the community’s hopes and trust9 in health research.

Warwick P Anderson PhD

Objectives: To investigate the perceptions of Australian health and medical researchers 4 years after the Wills Report recommended and led to a substantial increase in health and medical research funding in Australia.Design, setting and participants: A telephone poll of 501 active health and medical researchers, conducted between 28 April and 5 May, 2003.Main outcome measures: Researchers’ views on the adequacy of funding, infrastructure and support, salary, community recognition, the excitement of discovery and research outcomes such as publication and patenting in research.Results: Research funding was the most important concern: 91% of researchers (455/498) viewed funding as “very” or “extremely” important to their role, but only 10% (52/500) were “very” or “extremely” satisfied with the level of funding. Research infrastructure and support were seen as “very” or “extremely” important by 90% of researchers (449/501), while only 21% (104/501) were “very” or “extremely” satisfied. Researchers in medical research institutes were significantly more likely to be satisfied (27% [56/205] “very” or “extremely” satisfied) with the level of infrastructure and support than those working in universities (15% [41/268] “very” or “extremely” satisfied; P = 0.001). Among the factors that motivate researchers, the excitement of discovery stood out in terms of both high importance and satisfaction. Publications were viewed as more important research outcomes than patenting or commercial ventures.Conclusions: Funding and infrastructure support remain overwhelmingly researchers’ greatest concerns. University-based researchers were less satisfied with infrastructure and support than those in independent medical research institutes.

Louise G Shewan BA(Hons), PhD · Andrew J S Coats DM, DSc, FRACP · Jane A Glatz BSc(Hons), PhD, MBA · Christine C Bennett FRACP, MPaed

The Helicobacter story illustrates some of the human hallmarks of revolutionary research Not so long ago, peptic ulcer disease played havoc with people’s lives. Its sufferers endured chronic and debilitating pain and ran the risk of a life-threatening gastrointestinal haemorrhage or ulcer perforation. Throughout most of the 20th century, the conventional wisdom was that peptic ulcer disease was caused by gastric juice corroding vulnerable mucosa; the dictum “no acid — no ulcer” ruled the day, and neutralisation of gastric acid was the mainstay of management (Box 1). Fixed in this belief, gastroenterologists and surgeons vigorously argued the relative merits of different medications and surgical procedures in reducing gastric secretion, while research addressed the influence of “associated” factors such as social status, smoking and stress on gastric secretion and mucosal resistance. Marshall and Warren, 1984. Reproduced from Helicobacter pioneers.3 By the turn of the century, all this was relegated to medical history by the groundbreaking research of two Australians, Barry J Marshall and J Robin Warren. They scuttled the prevailing acid-mucosal model by showing that peptic ulcer disease is an infectious disease caused by Helicobacter pylori. For this research, Marshall and Warren who, “with tenacity and a prepared mind, challenged prevailing dogmas”,1 were awarded the 2005 Nobel Prize for Physiology or Medicine. The story of their research journey is well known. But its essentials are worth repeating because they illustrate some of the human hallmarks of revolutionary research. These include: being at the right place at the right time, and seeing what other people had seen but thinking what nobody else thought;2 the role of serendipity; a passion for research that abandons personal safety with self-experimentation; and the inevitable resistance of the medical establishment as research undermines current dogma. Being, seeing and thinkingAs part of the physician training program in the 1980s at Royal Perth Hospital in Western Australia, registrars were encouraged to pursue a research project. In 1981, Marshall found himself in such a position as he commenced a rotation in the hospital’s gastroentero-logy service. His boss, Dr Tom Waters, suggested that he talk to Dr Robin Warren, a pathologist at the hospital, about the mucosal spiral bacteria Warren had observed microscopically in some gastric biopsies. Marshall was intrigued and, on reviewing the endoscopic and clinical details of 25 patients exhibiting these mysterious bacteria, found that they were associated with endoscopic diagnoses of duodenal ulcer (n = 2), gastric ulcer (n = 7), gastritis (n = 12), and erosions and scars (n = 4). But there was no consistent clinical pattern. A literature review revealed that these mucosal organisms had been noted intermittently for at least a hundred years, but there were no clear patholo-gical or clinical patterns.3,4 Marshall and Warren decided to explore the significance of the spiral bacteria by gathering more clinical material and by attempting to culture the organism from gastric mucosa obtained at endoscopy. Marshall and Warren were at the right place: members of the Royal Perth Hospital gastroenterology service were prepared to provide such specimens and members of the hospital’s microbiology department were willing to freely provide people and resources for the culture quest. It also was the right time. Apart from the happy meeting of an enthusiastic registrar unencumbered by dogma and a more senior person who had an observation waiting to be explored, flexible endoscopy had become a widely used clinical procedure and provided the means to obtain fresh specimens for research. The presence of mucosal gram-negative bacteria (initially thought to be a Campylobacter-like organism3) was soon confirmed, but all attempts at their culture were unsuccessful. On taking stock, in late 1981, Marshall discussed his progress with two senior members of the Royal Perth Hospital gastroenterology service, Tom Waters and Chris Sanderson. The latter, in true Australian (laconic) style, advised: “Barry, you should stop buggerising around and do a proper study!”3 And so, a prospective study of 100 patients, with the investigators blinded, was born, and the next characteristic of revolutionary research satisfied: thinking and addressing what other people presumably had not thought about. Marshall believes his relative inexperience helped him think in an original way about the bugs in the biopsies. “If the dogma is incorrect, it’s better to know nothing about it.” (Marshall, personal communication, October 2005.) The 100-patient study aimed to pursue the following questions: is the organism present in the normal stomach? can it be cultured? can its presence be correlated with the type and severity of abnormal gastric histology? how is it related to patients’ symptoms and disease status? Marshall and Warren may not have known it, but their journey to Stockholm had begun. Serendipity plays its partThe attempt to culture the elusive organism proved fruitless until religion entered the saga. The gastric mucosal specimens for culture were treated as routine faecal specimens or throat swabs: if at 48 hours no unusual organisms were seen, the culture plates were discarded. In 1982, the Easter holidays occurred from 9 April (Good Friday) to the end of 12 April (Easter Monday). The busy weekend technicians were preoccupied with an outbreak of methicillin-resistant Staphylococcus aureus in the hospital and presumably did not get around to examining the culture plates on Saturday. On the next working day, Tuesday 13 April, small transparent colonies of H. pylori were present.3 Marshall and Warren now had tangible evidence to advance their research. The first solid dataThe 100-patient study was completed by May 1982 and its outcomes were seminal.3,4 Of the 100 patients who had undergone endoscopy, 65 had gastritis, and there was a strong association between gastritis and the presence of the spiral organism. The latter were found in all patients with duodenal ulcer and 80% of patients with gastric ulcer. In contrast, their presence was rare in patients with non-steroidal drug-related ulcers. The bacteria could be cultured, and were a new genus with features of both Campylobacter and Vibrio species. (They were subsequently shown to be H. pylori, but that is another story.) Resistance from the medical establishmentIn January 1983, to stake their individual legitimacy in the evolving H. pylori story, Warren and Marshall submitted two separate research letters outlining their preliminary data to The Lancet. Publication was delayed, as Robin Fox, an editor at The Lancet, wanted to know why there were two separate letters. These were eventually published in June of that year.5 Locally, an abstract outlining preliminary findings of the 100-patient study was not accepted by the Gastroenterological Society of Australia for presentation at its annual conference (Box 2), and difficulties attended the submission of the definitive paper of the 100-patient study to The Lancet in January 1984. Once again, the journal’s Editor-in-Chief, Ian Munro, was challenged — this time because he was not able to find reviewers who would agree on the importance of the paper. Munro sent Marshall a “temporising letter”, after the first round of review advising Marshall the he believed that The Lancet should publish the paper and that he was trying to find reviewers who would agree with him (Marshall, personal communication, October 2005). The paper was published in June 1984.6 An accompanying editorial noted in classical reserved style: “If the authors’ hypothesis of cause and effect should prove valid this work is very important indeed.”7 Self-experimentationAt the end of 1982, Marshall had left Royal Perth Hospital and taken up a senior registrar post in general medicine and gastroenterology at the Fremantle Hospital in Western Australia. Again, he was at the right place with the right people. The staff at the hospital were aware of Marshall’s research at Royal Perth Hospital and encouraged him to continue at Fremantle. These included Ian Hislop, head of gastroenterology, David McGechie, a microbiologist with excellent laboratory facilities, and the pathologist, Ross Glancy. At Fremantle Hospital, Marshall and his colleagues showed that bismuth salts (which had been used to treat gastritis and peptic ulcer disease for many years) killed H. pylori in vitro; and, in clinical studies, that bismuth cleared H. pylori but the infection would recur unless metronidazole was added to the regimen. Yet during this time, Marshall was frustrated with The Lancet’s seeming procrastinations and his own failure to develop an animal model for the disease. Possibly because of these frustrations, he decided to infect himself with H. pylori. He asked Hislop to perform a gastric biopsy on him and then ingested a pure culture of H. pylori (109 organisms). All was well for 5 days, but then he developed halitosis, morning nausea, and recurrent vomiting of acid-free gastric juice. A gastric biopsy on Day 10 showed severe acute gastritis and many H. pylori (Box 3). The symptoms spontaneously resolved after 14 days, but Marshall’s wife, Adrienne, had had enough and demanded that he immediately commence antibiotics or “be evicted from the household to sleep under a bridge”.3 The Medical Journal of Australia connectionAfter the 1984 Lancet paper came out, Marshall received a call from the then MJA editor, Alistair Brass. He congratulated Marshall on the Lancet paper, but suggested that, next time he published, it might be closer to home. In a recent interview with the Journal, Marshall noted that he had always planned to submit his initial work to The Lancet, but has no objections to publishing in Australia: “If it has a local flavour I send it to the MJA.” (Marshall, personal communication, October 2005.) And so it came to pass that the account of his self-experimentation8 and observations on the in-vitro sensitivities of H. pylori and further clinical correlates9 were submitted to this Journal and promptly published. In a citation analysis performed by the MJA to celebrate its 90 years of publication, these two articles ranked second and third among the Journal’s 10 most cited articles.10 Marshall and Warren join four other Australian born Nobel Laureates in Physiology or Medicine: Howard Florey for his discovery of penicillin, MacFarlane Burnet and Peter Doherty for immunology, and John Eccles for neurobiology. Marshall and Warren’s achievement is made more extraordinary by the fact that they performed all their ground-breaking work not in well endowed and cloistered medical research institutes, but in the orderly chaos of hospitals. And their attempts to convince medical orthodoxy were not smooth: as noted by their Nobel Prize citation, they challenged prevailing dogmas with “tenacity and a prepared mind”.1 The Helicobacter story, and the journey to this particular Nobel prize, doubtless benefited from great timing, the right people and places, original thinking, serendipity, tenacity and passion. But the outcome is unarguable: Marshall and Warren have irrevocably changed clinical practice and have alleviated much human suffering. 1 Advertisement from the MJA, 1957 2 Letter from the Gastroenterological Society of Australia* * Reproduced from Helicobacter pioneers.3 3 Silver stain of Marshall’s gastric biopsy on Day 10 after ingesting Helicobacter pylori Epithelial cells have rounded up in shape without intracellular mucin, and have many closely adherent black H. pylori organisms. Reproduced from Helicobacter pioneers.3

Martin B Van Der Weyden MD, FRACP, FRCPA · Ruth M Armstrong BMed · Ann T Gregory MB BS, GradCertPopHealth

Religious or spiritual values often influence health care decision-making by patients and their families, particularly in times of crisis. Though religious values might seem to be irrelevant where continuing treatment is judged to be “futile”, such clinical assessments should instead serve to open a dialogue about values and beliefs. The six major religious traditions in Australia have some similar values and principles about death and provision of care for the dying, but differ in their processes of ethical reasoning, cosmologies, and key moral concepts. Engaging with religious traditions on the common ground of basic values (such as human dignity, care, the sacredness of human life, non-violence, compassion, and selflessness) promotes negotiation of the manner in which care is provided, even where conflicts exist.

Rachel A Ankeny PhD · Christopher F C Jordens PhD · Ian H Kerridge MPhil, FRACP, FRCPA · Ross Clifford MA, MTh · Rod Benson BMin(Theol), MA

The longest life might not be the best life An articulate 52-year-old woman recently telephoned me. “Give the ‘smoking kills’ line a rest”, she urged. “I’ve smoked for 30 years. I have emphysema. I am virtually housebound. I get exhausted walking more than a few metres. I have urinary incontinence, and because I can’t move quickly to the toilet, I wet myself and smell. I can’t bear the embarrassment, so I stay isolated at home. Smoking has ruined my life. You should start telling people about the living hell smoking causes while you’re still alive, not just that it kills you.” The call crystallised for me some diffuse unease I have long felt about some underexamined fundamentals in the entire public health enterprise. Here is how I see it. We are all going to die. Advanced age is easily the strongest predictor of death. Nearly half of all deaths in Australia occur in a hospital.1 These three truisms have acquired profane, almost unutterable status in contemporary health care debate. Each is banal in isolation, and they remain banished from polite discussion as indecent reminders of the pathos of the human dust-to-dust destiny, occasionally insisting to be heard amid the unbridled optimism of the scientific legacy. Huge energy is invested in avoiding their mention. Perhaps the most unabashed manifestation of this denial is the spamming American Academy of Anti-Aging Medicine which boasts 11 500 members in 65 nations,2 and unblinkingly speculates about the virtues of people living to the age of 120 and possibly as long as 170.3 The decadence of such a first-world cosseted vision, in times when more than a billion people live on less than $1 a day and another 1–1.5 billion live on $1–$2 a day,4 37.8 million mostly young people are infected with HIV,5 and one million still die of malaria each year, would be remarkable were it not for the values it shares with mainstream health politics and the media-fuelled public expectations which sustain it. Today, anyone bold enough to suggest pausing to question the unrequited battle and conquest metaphors which dominate the politics of health, risks being branded a medical heretic or even an apologist for involuntary euthanasia of the aged. The dominant medical motto for our age might well be “never say die”. Recently, following on from Richard Nixon’s declaration of war on cancer in 1971, the current head of the United States National Cancer Institute, Andrew von Eschenbach, caught the spirit of George Bush Junior’s all-conquering Zeitgeist, and challenged America to “eliminate suffering and death from cancer” by 2015.6 In Sweden, it is government policy that the road toll should strive to reach zero,7 not merely to fall. If you scratch the surface of the human genome project, unstated assumptions about eternal life are not hard to find in the pitch to the often elderly biotech investors. Single-issue health organisations often talk of research that might one day eliminate their diseases. The recent announcement of an imminent vaccine for cervical cancer8 is self-evidently a wonderful thing. Here is a near-to-fully translated research advance that promises to end the collected misery, pain and indignity that millions of women would otherwise suffer over the years. The eradication of smallpox and the predicted departure of wild polio from the planet are astonishing achievements. So why not conquer everything else? In wealthy nations today, there are few causes of death that cannot boast a non-government agency and a research focus dedicated to eradicating the offending disease. Health agencies’ mission statements are purged of anything that even hints that a point might be reached when an organisation might be content with a certain incidence of deaths from their cause. Defeat is anathema to medical progress when it comes to death. Plainly, there is much to admire in all this. If the go-for-gold death eradication scenarios played out for each preventable cause, a huge number of young and middle-aged lives would be saved. But if no one died from cancer, was ever killed on the roads, or died from any given cause now subject to ever-onward mortality reduction targets, what would take their place? If the death toll from late-age cancer plummeted, if heart disease became something permanently able to be postponed, would this be progress? Which causes of death would increase when others declined? What would we die from? Isolated from the wider “if not death from X, then what?” question, advances against deaths from particular diseases may be pyrrhic victories if all it means is that cause-of-death deckchairs are being shuffled on life’s Titanic, only to sink around the same time. In at least six of the cases investigated in which patients died after being admitted to Sydney’s Camden and Campbelltown hospitals in 2001, the patients were aged over 80. Several others had serious diseases likely to cause their deaths, sooner rather than later.9 Yet, an unexamined assumption in much of the outcry was that something was inherently wrong in very old or very sick people dying in hospital this month rather than in the next 6.10 The discourses of shameful government neglect, of un-Australian inequitable health service provision in low socio-economic areas have steamrollered the now endangered discourse of the innate decency of the “good innings”. The “rule of rescue”11 — the imperative people feel to rescue identifiable individuals facing avoidable death — similarly permeates health policy and resource allocation. Tucked deep away in the Productivity Commission’s 2005 report on the Economic implications of an ageing Australia,12 are examples of a very different kind from today’s never-say-die epic, hinting at a lament among experienced doctors for times when: . . . pneumonia, the old man’s friend, came to visit, that was regarded as quite a good outcome. That is not acceptable to the community anymore. There is a great tendency to do significant interventions in the very old . . .; Older people are able to undergo operations and procedures that previously were denied to them. For example, 10 years ago, 75-year-old people often were not dialysised if they had chronic renal failure, but this would be a common occurrence now.12 While there are ideological imperatives stoking apocalyptic visions of unsustainable ageing populations,13 it is true that the elderly consume hugely disproportionate health care resources, particularly in the last years of life where up to 40% of health care expenditure can occur.14 If the health care costs for 25–29-year-olds are indexed at 100, those expended on the 65–69 years age group are 387.6, and those aged 85–89, 614.2.12 Moreover, hospital separations in those aged 65 and over grew from 26% to 33% between 1991 and 2001, with the growth being only minimally explained by the growing number of aged people in the population.12 The director of the US Hastings Center, Daniel Callahan, has written of the deeply ingrained “pathology of hope”, and its beneficiaries in the pharmaceutical, diagnostic and medical industries.15 Together, these fuel exponential health care expenditure in ageing populations. Callahan’s heretical proposal is that civil society should supplant medicine’s present open-ended goal of prolonging life at all costs with a radical refocusing on quality of life and the compression of morbidity during a decent life span. He writes: The average person in good health in the developed countries of the world . . . already lives long enough to accomplish most reasonable human ends. A medical policy that could assure those now being born that they could live as long . . . and healthy lives as their parents, should be perfectly acceptable . . . This ideal of steady-state life expectancy at its present level would establish, happily, a finite and attainable goal: Enough, already. Average life expectancy in Australia has risen from 51 for men and 57 for women at the beginning of Federation, to 78 and 83, respectively, today.16 Australia’s non-Indigenous population has the world’s fourth highest life expectancy after Japan, France and Switzerland. As a nation, we are near to being the healthiest in the world, with the exception of the national shame of the poor health status of our Indigenous population. Increasing longevity in the last 30 years reflects success in many areas, but particularly in preventing and treating heart disease, declining disease caused by reduced smoking in men and big reductions in motor vehicle and child injury deaths. These and other major preventable causes of death kill Australians early, often well before their retirement, still causing tens of thousands of person-years of life lost (PYLL) before age 75. Indeed, the PYLL concept enshrines the idea that years of life lost after 75 do not “count”, not entering into national calculations of the national state of health. A hallmark of a civilized society is valuing life at all stages, and not simply when its citizens are in the peak of their economically productive powers. The revulsion that many expressed at news of the study sponsored by Philip Morris (which advised the Czech Government that early deaths of smokers each saved $1227 on health care, pensions and housing17) is an index of these values. However, the corollary is not to hold the door of life open unquestioningly and indefinitely, regardless of the quality of such life or the costs of doing so. A recent systematic review of the rate of functional decline in older people in the US has shown a significant reduction in this decline in the past 3 decades, suggesting some success in compressing morbidity (ie, delaying the onset of illness) through both disease prevention and medical care.18 However, the demographic wave of people entering old age will mean that the number of people who are disabled, dependent and living with reduced functionality through multiple chronic conditions will grow to be larger than ever before.19 With this trend compounded by the rapidly growing obesity epidemic,20 we seem likely to see an unprecedented prevalence of disability in ways that may have not been previously anticipated in modelling. The number of people with Alzheimer’s disease in Australia (presently around 200 000) is expected to reach 580 000 by 2050.21 Death, and particularly early death, is typically privileged above suffering in the formulae used by health planners to set priorities. Health ministers boast about disease survival rates all going in the right direction, but spare relatively little thought about how to reduce the burden of chronic disability in the living. A reorientation that saw improvements in quality-of-life indices like chronic pain, immobility, isolation, sensory impairment and depression as being just as, if not more, important than the slavish pursuit of prolonging lives, would see a major rechannelling of research and expenditure. National audits of the morbidity arising from such quality-of-life-eroding variables deserve more attention and public policy discussion. The medical specialties that would benefit from such a reorientation would include pain management, public health efforts dedicated to keeping people physically and mentally active, and efforts at improving the much-discussed Bhutanese-inspired concept of “gross national happiness”.22 More importantly, considerations of such qualities of life would force the health and medical enterprise to engage more with others sectors like financial and residential planning and ergonomic design to facilitate greater independence for the aged, rather than focusing so much on simply keeping people alive in old age. And we need to embrace “Enough already”.

Simon Chapman PhD

Public debate is required if families are required to fill the gap left by hospitals which now only “care” for the illness and not the patient I told myself I would write this article as I was dragging my 8-year-old’s drip behind her at 3:30 am when she decided it was time to go for a walk in the semi-lit hallway of a paediatric teaching hospital. My daughter has severe autism, intellectual disability and suffers from epilepsy. Although I am probably a little better informed than most, given my experience in the field of bioethics and health law, I am a lay person. Thus, my description of events will be in terms that are perhaps not medically accurate, and from my own perspective. Having discussed my experience in a non-statistically-rigorous fashion, as a lay person does, with several others who have recently been hospital inpatients or whose relatives have been inpatients, I find that my impressions are uniformly shared. My discourse should not be interpreted as a criticism of the staff of the hospital, whom I found to be as accommodating as conditions allowed. I would also like to make it clear that my concerns should not be dismissed as a commentary on the nursing aspects of my daughter’s hospital admission. They are intended as a critique of the direction of the way hospital services are generally delivered, and this — as is well understood — is the result of many contributing factors. Before her hospital admission my daughter had had a urinary tract infection that had been treated with various antibiotics. Nonetheless, she kept vomiting up anything that passed her lips as well as having occasional bouts of diarrhoea. Her temperature remained very high. Her eyes were sunken, and she was pale and weak. It was fortunate that one of my daughter’s therapists decided to accompany me to the emergency department. She stayed with me from 11 am until 3 pm. Had she not done so, I don’t know how I could have gone to the toilet or obtained anything to eat. My daughter cannot communicate readily, does not understand the concept of hospital, and would have been distraught at being left in an unfamiliar environment with unfamiliar faces, and at dealing with the shock of having an intravenous line inserted. It is not possible to explain these things to her. Fortunately, humane staff in the emergency department permitted me to use a hospital phone to call my husband, otherwise this would have been an impossibility. (Even if I had one, mobile phones cannot be used, and a public phone was some distance away.) I was provided with a plastic bag in case my daughter vomited. When she did, I did not know where to dispose of the bag. I imagined that I should not put it in an ordinary rubbish bin. I wandered out of my daughter’s cubicle and asked a nurse, who directed me to a bin for infectious waste. Later in the day, a Red Cross volunteer provided me with a cup of tea and a sandwich. Having spent most of the day in the emergency department, and being intermittently assisted by helpful and polite medical, nursing and administrative staff, my daughter was admitted to the general medical ward. My daughter could not move herself from the trolley to the bed so nurses did this and then departed. The job of straightening the bed was left to me. I was then given most useful advice from the mother of an infant in the next bed who had been in the hospital for some time. She told me that there was a toilet for parents, but if the queue was too long, the nurses sometimes let you use the toilet for the children. As I shortly discovered, the parents’ toilet was nauseating. The bin in the toilet seemed not to have been emptied for some time and was overflowing. No one told me there was a shower. It became clear, although no one mentioned this, that the tasks of toileting and cleaning my child, as well as making her bed and eventually feeding her, were reserved for me. I was asked to collect all of my daughter’s urine and a specimen of her faeces. Again, for a host of reasons, I had thought that this was a nursing task. I did not feel confident about doing this and this was not because it was distasteful, although I must admit I wasn’t thrilled about it. It was more because I was not familiar with where things were kept, and how to get my daughter to urinate into the container that was placed in the toilet. It also took me some time to realise that collecting the urine was not now for the purposes of testing but just to see how much she was passing. I was therefore also unsure of what to do if the faeces contaminated the urine. It is well known that hospitals are not places that are conducive to sleep unless you are so unwell that staying conscious is the challenge. Consequently my daughter was able to sleep for most of the night, but I was not. An older nurse helped me set up a single “sofa bed” for myself. By morning I had a headache, was coughing and sneezing (not related to the hospital stay) and was exhausted. A lovely nurse popped in to provide advice about parking fees, the family resources centre, use of the internet and the room on the floor available to parents. While my daughter was asleep, I chanced using the accidentally discovered shower, hoping she would not wake in the meantime, and found it to be in a similar state to the toilet. During the morning, the paediatric consultant ordered an ultrasound of my daughter’s renal system and appendix. This eventuated by about 4 pm. While waiting in the x-ray department, my daughter was sitting on my lap when she had an episode of diarrhoea. Luckily her 20-year-old sister was present so I was able to find someone to give me a towel to try to clean my daughter and myself. My daughter was provided with a surgical gown. My jeans were not the best. Fortunately, the ultrasound was normal. At around 5 pm, a charming doctor payed us a visit and said we could either stay another night or leave. I asked her what she would do in our position. She advised that the intravenous fluids had probably provided my daughter with some stability and she was more likely to begin eating at home than in hospital. That being the case, my response was that the hospital would have to put me in chains to keep us there. My daughter is now fine. I am left wondering why it has come to be, amid the continual structural reforms, that health professionals have time to attend to equipment and defined clinical tasks, and not to people. Indeed the most “care” I received was from the Pink Lady who volunteers her services one day a week. The time devoted by health professionals to personally tending to my daughter would have amounted to a matter of minutes. Parents come into a hospital already worn down by worry. They are tired. They do not expect that the responsibility for care will be left to them. I have discovered that my experience is not confined to paediatric hospitals, nor indeed to the public hospital system. One woman told me that she paid professional carers to look after her mother day and night while in a private hospital. Another said she had been so shocked at the lack of personal care that she and her sister stayed on to look after their mother. In another instance, a woman in her 80s described having to make her own bed with an intravenous line in tow, and being regularly left sitting in the shower unable to move after major surgery. Is this a failing of our health care institutions, or just what we should come to expect? While I have no wish to be inflammatory, some of the problems I have mentioned are clearly matters that should return to the province of hospital staff. Basic issues of cleanliness on the ward cannot be a responsibility of patients or their relatives. Failing to attend to an elderly patient left sitting in a shower is frankly disrespectful. Insofar as my daughter has special needs, I felt some additional care was taken in the mechanics of her treatment. By this, I mean three nurses were on hand when she was injected with gentamycin, and a specialist was called when a young doctor failed to insert the intravenous line after several attempts. The woman taking meal orders did try to be flexible in getting the kitchen to produce food to meet my daughter’s idiosyncratic tastes. Otherwise, there seemed to be no cognisance of the fact that some effort needed to be made to engage her and gain her confidence. Nor was there any recognition of the difficulty I faced in leaving her side for short periods. In regard to some of the other issues, such as the extent to which families are expected to look after their loved ones in hospital and to which inpatients are required to fend for themselves, there is clearly need for public debate. Changes of this magnitude should not be introduced by stealth or attrition. If we are moving towards a system in which care from families is routinely required, then this ought to be made clear. At least then we may be better prepared.

Bebe Loff PhD

A radiologist presents examples of discourtesy between doctors and suggests a return to good manners and professionalism In 2004, I presented a poster of my musings on my professional experiences as a radiologist at the hands of medical colleagues. While I felt very strongly about its contents, I thought it would provide a little amusement among the scientific works at the meeting of the Royal Australian and New Zealand College of Radiologists. To my amazement, it struck a chord with many delegates — obviously, I was not alone in seething about discourtesy, which seemed rife, between professional colleagues. Most doctors (and their medical indemnity organisations) agree that patient rudeness and aggression are an increasing problem, and there is discussion on strategies to deal with these. Insufficiently debated is what I believe to be an increasing trend to discourtesy between referring clinicians and radiologists and between radiological colleagues. There are international and Australian codes of ethics regarding behaviour between colleagues.1-3 However, my literature search for references to practical day-to-day courtesy between colleagues revealed mainly concerns as to whether it was polite to bill fellow practitioners for services rendered!4 It would be easy to dismiss interprofessional rudeness as a facet of the decline in good manners in the general community. However, I consider that loss of courtesy between colleagues reduces directly the quality of patient care, and also the enjoyment of one’s working life. The complexities of modern medicine mean that no one doctor can be a “jack of all trades”. However, a lack of respect for the unique skills of another branch of medicine, and an unwillingness to admit some ignorance of these skills and to request advice, result in behaviour such as the following: An x-ray packet was returned to the radiologist with the terse instructions “RE-REPORT” pinned to the packet. In a telephone conversation to the radiologist who had reported a normal result on breast ultrasound examination, a general practitioner said “I ordered you to do an FNA [fine needle aspiration] and I expected it to be done. In future, when I order an FNA, it will be done.” After requesting a large number of examinations without consulting the radiologist, a country GP wrote: “Do not return patient to . . . until all tests ordered have been performed.” I sometimes feel that doctors have a desire to appear powerful in the eyes of patients. This may have resulted in the handwritten note from a GP, presented to me one morning (Box 1). Fear of litigation is always with us, and it is tempting to try to share the blame, but there is no excuse for the following outburst: A surgeon opened a telephone conversation to the radiologist with the words “I have told this patient to sue you to hell”. Colleagues are always going to make mistakes, and one day it is going to be you! One-upmanship is never helpful (Box 2). Short, friendly, personal letters or phone calls (even in this age of impersonal emails and text messages) are still the better way to point out a colleague’s error. Certainly, a fax received at the reception desk, and available for all to read, causes severe angst in the recipient (Box 3). And last, but not least, bullying in the playground or the workplace causes untold distress. Remember, you were a junior hospital doctor once! As a first step towards achieving a more pleasant work environment, the medical colleges should encourage debate on maintaining good manners and professionalism between their fellows. After that, it’s over to you and me! 1 Note from a general practitioner to a radiologist This note was presented by a patient when she arrived for an ultrasound examination 2 days before her scheduled appointment. 2 Report from a radiologist to a general practitioner This report was sent by a radiologist who investigated the patient and reviewed films taken at another radiological practice 2 years previously. 3 Fax from an endoscopist to a radiologist After the suggested endoscopy, the endoscopist faxed back the radiologist’s report with this handwritten comment.

Jane L Nuttall FRCR, FRANZCR

The golden rule is to treat your fellow medicos as you would wish to be treated When I was a medical student in the 1950s, we learned about medical etiquette, which our teachers then confused with medical ethics. There were rules governing the relationships between doctors, especially about “pinching” each other’s patients. And consultants were supposed to meet the patient and his or her general practitioner and give an opinion, not take over the patient. Being asked to treat a colleague, or a member of their family, was regarded as the ultimate professional accolade, and charging a fee was not an option. The same principles applied to nurses, medical students and clergy. Since then, the organisation of medical practice has become more complex. There are many more doctors and specialties. Doctors involved in the care of a patient may not know each other, or even understand each other’s main task or daily work. Some do not even trust each other. For example, recommendations in radiology and pathology reports for further, more expensive tests are in most cases sound medicine, but, in areas of medicolegal phobia or fierce competition, some GPs are sceptical of the underlying reasons. They forget that two minds are usually better for patient safety than one, and see themselves as the patient’s personal doctor who knows what is good for that patient. Radiologists and pathologists are regarded as part of a service industry. They should provide what they are asked for, neither more nor less. The combination of personal distance resulting from relative anonymity together with authoritarian personality traits is the probable underlying psychopathology behind the crass examples cited by Nuttall in this issue of the Journal1 . Anonymity is also a major reason for the vast difference in courtesy between hospital discharge letters written by registrars and those from consultants in private practice. My pet hate is the registrar who replies to my detailed letter for admission, addressing me as “The LMO” (local medical officer). Medicare also changed the courtesies doctors displayed to each other. One reason for using it was that it was “free”, and the other was the convenience for the doctor-patient in not feeling obliged to say “thank you” with an expensive present. Doctors also became more militant about being paid their due worth. Even medical students were charged full fees, and this has spelt the death knell for the Hippocratic rules governing lifelong obligations between teachers and learners. Medical students also absorb many of their future attitudes and behaviours from their teachers. Medical craft groups tend to judge other doctors according to their own standards. This results in “bad-mouthing” of other doctors, which is one of the more unedifying features of modern medicine.2 Even specialist writers of problem-based learning modules subconsciously tend to begin their scenarios with a patient “stuffed up” by a GP and rescued at the 11th hour by the clever consultant at the “Royal Excellent Hospital”.3 The golden rule of medical relationships is to treat your fellow medicos as you would want to be treated. This would be more likely if doctors of all persuasions were to meet more often and learn something of each other’s views and daily tasks. Members of the medical profession are a team fighting a battle against mental and physical disease and disorder. Courtesy comes from the habit of giving credit and thanking others for their contribution to the wellbeing of a patient. I was particularly moved by a letter to a journal from an orthopaedic surgeon who remarked that, after having performed 1200 hip arthroplasties, he had received his first letter of feedback from a GP, informing him that the operation had revolutionised the life of a patient.4 My fantasy would be to dine out once a year with each of the doctors and their support staff who have contributed to the management of my patients. The Federal Treasurer could contribute to the quality of patient care and the reduction of medicolegal cases by making such events tax deductible.

Max Kamien MD, FRACP, FRACGP, FACRRM

Professional discourtesy to radiologists does not enhance patient care In this issue of the Journal, Nuttall describes some interactions between radiologists and their colleagues which suggest professional discourtesy.1 We do not know the individual circumstances of these, but we do know that collaboration, communication and courtesy are critical aspects of professionalism that will help to promote the quality use of diagnostic imaging. The patient and all other professionals involved are direct beneficiaries of such good conduct. It is of concern to the Royal Australian and New Zealand College of Radiologists (RANZCR) and to many radiologists that they have become distanced, not only from patients, but also from their medical colleagues. Workforce shortages, pressure on film reporting, and remote reporting arising from technological advances may all contribute. The distance and limited direct interaction may help explain some of the examples of discourtesy described by Nuttall. This is an issue not only in Australia and New Zealand, but internationally.2 Professionalism is not a new word to readers of the Journal — it has been canvassed in editorials and other articles and is strongly embedded in the day-to-day lives of medical practitioners. It is nonetheless something that we must continue to reflect upon and not take for granted. It is a trait that we must explicitly support and promote among medical students, trainees and colleagues. The roles defined for specialists in the CanMEDS (Canadian Medical Directions for Specialists) framework3 — the basis for a current curriculum development project at RANZCR — include those of communicator and collaborator. The specialty of radiology is fuelled by communication and collaboration. The decision to request an imaging study acknowledges that there is a clinical question requiring additional information before it can be answered fully. Imaging is now so embedded in modern medicine, that its impact on patient care is often overlooked and even taken for granted. Interventional radiology has revolutionised some previously complex open surgical procedures, all aimed at improving patient care and wellbeing. However, at present, the expertise of radiologists is not being utilised effectively in the Australian health care system. This is because the referral process requires a specific test to be requested, instead of enabling the radiologist to recommend the most appropriate diagnostic test in the clinical situation. Furthermore, the almost complete reliance on written reports by many clinicians diminishes the radiologist’s ability to interpret complex imaging studies in consultation with the relevant clinician. “Professional values and responsibilities” is a strand of the Learning, Education and Professionalism (LEAP) program, a framework for continuing professional development which is being piloted across Australian specialist medical colleges, including the RANZCR. The program was developed with reference to the literature on medical professionalism,4 and breaks down professionalism into three components — relationships and accountability, advocacy and equity, and education. Underpinning these concepts is the Quality Use of Diagnostic Imaging Program, which is being undertaken by the RANZCR with funding from the Australian Government Department of Health and Ageing. A central tenet of this program is to “recognise the role of consumers, diagnostic imaging providers and referring practitioners in attaining quality use of diagnostic imaging and involve them through collaboration, consultation and partnership and multidisciplinary activities.”5 Each individual, whether as patient, referrer or radiologist, has much to gain and nothing to lose from a commitment to quality diagnostic imaging embedded within clinical investigation, treatment and management, and with communication that is polite, professional and informative. It is encouraging to observe in Nuttall’s article the personal and professional value that can be derived from presentations at scientific meetings. Scientific and medical expertise is a vital part of our professional role. So also is the capacity to advocate for good and appropriate care for patients. This requires overt communication and collaboration, and Nuttall has highlighted examples where the contrary has occurred.

Lizbeth M Kenny FRANZCR · Fiona Pacey

Objective: To describe the epidemiology and clinical features of box jellyfish envenoming in the Top End of the Northern Territory and, in particular, confirmed stings from the major Australian box jellyfish, Chironex fleckeri. Design: Prospective collection of clinical data and skin scrapings or sticky-tape tests for nematocyst identification from patients presenting to Royal Darwin Hospital and remote coastal community health clinics in the Northern Territory, spanning 10 950 km of coastline; analysis of tidal, weather and seasonal data. Patients: All patients with jellyfish sting details recorded between 1 April 1991 and 30 May 2004. Main outcome measures: Demographic and clinical features, use of C. fleckeri antivenom, and associations between weather, seasonal and tidal factors and confirmed C. fleckeri stings. Results: Of 606 jellyfish stings documented, 225 were confirmed to have been caused by C. fleckeri. 37% of C. fleckeri stings were in children, 92% occurred during the “stinger season” (1 October to 1 June), 83% occurred in water 1 m or less deep, and 17% occured while victims were entering the water. Stings were least common on outgoing tides (P < 0.001) and commonest between 15:00 and 18:00 (P < 0.001) and on days with wind speed less than that month’s average (P < 0.001). Nearly all victims experienced immediate pain, but this could often be controlled with ice; only 30% required parenteral narcotics and 8% required hospital admission. Cardiorespiratory arrest occurred within several minutes of the sting in the one fatal case, involving a 3-year-old girl with only 1.2 m of visible tentacle contact. C. fleckeri antivenom was given to another 21 patients, none of whom had life-threatening features at the time they were given antivenom. Conclusions: Most C. fleckeri stings are not life-threatening; patients who die usually have cardiopulmonary arrest within minutes of the sting. The potential benefit of antivenom and magnesium under these circumstances remains to be shown, but a protocol with their rapid use is recommended if cardiopulmonary arrest has occurred. Unfortunately, this is unrealistic for many rural coastal locations, and the priority remains prevention of stings by keeping people, especially children, out of the sea during the stinger season.

Bart J Currie FRACP, DTM+H · Susan P Jacups BN, MPH

Quotes from MJA contributors in 2005 It is unusual to find mention of beavers’ living arrangements in a physiology journal but, according to Swain, there are similarities between beaver pond levels and blood glucose levels. A beaver must maintain a constant water level in its pond for the proper functioning of its lodge, just as we must maintain our blood glucose levels within a defined range to ensure, among other things, brain function.1 The beaver controls the water bed by changing outflow over the dam and inflow from the stream beds, just as insulin controls glucose leaving the blood and entering tissues, and, among other things, glucagon affects glucose release from the liver. Analogy and metaphor may be figurative rather than scientific forms of communication but they can nevertheless help us, our students and our patients, to integrate new information by drawing on similarities with prior knowledge. Swain’s engaging beaver pond analogy of blood glucose control is a quiet and gentle one. As you will see in the following selections, this year’s MJA contributors have used a variety of analogies and metaphors (sometimes unwittingly) to try to get their point across. As well as creating a bridge to understanding, these devices inject unexpected and welcome humour into the generally dignified world of medical publishing. You asked for it . . .“Attached is my assessment of the manuscript. It’s a bit like panning for gold — you have to go through a lot of sand to find the gold.” “This is a weak study, well executed. Unfortunately, a great coat of paint does not make up for a deficient underlying structure.” “This is a naïve exercise in stamp collecting without any attempt to ascertain the origin and value of the stamps.” The medicalisation of peer review“The whole paragraph is a case of malignant pharmacological speculation syndrome.” Picture this . . .“The commercialisation of medical patents is but a small tile in the mosaic of Australian innovation . . .” “Epidemiological data provide a window through which theories of causality may be viewed.” “Seeding grants don’t sprout, pilots don’t fly.” Accidentally“ . . . patients [are] falling through the cracks in the Northern Territory.” “We give . . . the incidence of this complication according to medical litterature.” “This is a simply aweful paper.” UnderstoodNot infrequently, the MJA receives manuscripts that challenge the existing scientific dogma or confront our social sensibilities. In such circumstances, it is not unusual for the editors to make certain of the rigour of a manuscript with an additional cycle of peer review. As expressed by one expert reviewer . . . “I will state the obvious. You’ve got a hot potato on your hands. The idea of piercing its skin several times with the fork of extended peer-review will ensure that the thing is less likely to explode when placed in the microwave of public scrutiny.”

Ann T Gregory MB BS, GradCertPopHealth

During the Australasian Antarctic Expedition of 1911–1914, Douglas Mawson and two companions, Belgrave Ninnis and Xavier Mertz, undertook an ill-fated mapping journey. Ninnis died when he fell down a crevasse, together with the sledge carrying most of their food supplies, and later Mertz became ill and died. Only Mawson returned. In 1969, Cleland and Southcott proposed that Mertz died of vitamin A toxicity and Mawson suffered from the effects of hypervitaminosis A because, with little food left, they were forced to eat their surviving dogs, including the liver. This hypothesis was supported by Shearman in 1978. After re-evaluating this hypothesis, I propose that Mawson and Mertz suffered from the effects of severe food deprivation, not from hypervitaminosis A, and that Mertz died as he was unable to tolerate the change from his usual vegetarian diet to a diet of mainly dog meat. I also suggest that Mertz’s condition was aggravated by the psychological stress of being forced to eat the dogs he had cared for for 18 months.

Denise Carrington-Smith BA(Psych), MSocSc(Archaeology)

From the 1930s to the 1960s, Royal Newcastle Hospital was the centre for innovation in Australian health care. Many of the innovations were driven by a visionary medical superintendent, Chris McCaffrey, and the staff he appointed. Among the reforms he introduced were: an overarching emphasis on efficiency; the appointment of salaried specialist staff, now widespread; the unit record system for medical records, now universal; a domiciliary care service, now established in most of Australia; and an emphasis on audit and quality studies, now largely abandoned in the form pioneered in Newcastle. These innovations were vigorously opposed by organised medicine and barely tolerated by the health bureaucracy. They are unlikely to be replicated in the current environment where hospitals are run by managers in a culture dominated by budgetary considerations.

John M Duggan AM, MD, FRACP · Peter I A Hendry AO, MB BS, MD(Hon), FRCPA

The Presidents of the colleges told us that what does not kill them makes them stronger Australian and New Zealand College of Anaesthetists (ANZCA) To serve the community by fostering safety and quality patient care in anaesthesia, intensive care and pain medicine President: Michael Cousins Professor and Head of Department of Anaesthesia and Pain Management, Royal North Shore Hospital, Sydney, NSW Medical degree: University of Sydney (1963) Wants to be remembered for: Founding the Faculty of Pain Medicine; creating taskforces on key issues (eg, perioperative medicine); fostering research (eg, ANZCA Foundation). Year of inauguration of college: 1992 (previously, Faculty in College of Surgeons) Current number of fellows in Australia: 2900 Australasian College of Dermatologists (ACD) Refulgent in tenebris (They shine resplendent in the dark; ie, They succeed in difficulties) President: Anne Howard Head of Dermatology Unit, Western Hospital, and Dermatologist in private practice, Melbourne, VIC Medical degree: University of Melbourne (1975) Wants to be remembered for: Making the college attractive for women and younger doctors, and improving its transparency. Year of inauguration of college: 1966 Current number of fellows in Australia: 300 Australasian College for Emergency Medicine (ACEM) President: Andrew Singer Clinical Director of Emergency Medicine, Canberra Hospital, ACT Medical degree: University of Sydney (1984) Wants to be remembered for: Strengthening the training program; improving the perception and status of emergency medicine. Year of inauguration of college: 1983 Current number of fellows in Australia: 700 Royal Australian College of General Practitioners (RACGP) Cum scientia caritas (With scientific knowledge and tender loving care) President: Michael Kidd General Practitioner; Professor and Head of Department of General Practice, University of Sydney, NSW Medical degree: University of Melbourne (1983) Wants to be remembered for: Acting with integrity; supporting education and mentoring; and creating leadership and training opportunities. Year of inauguration of college: 1957 Current number of fellows in Australia: Over 11 000 have FRACGP (over 7500 financial members) Royal Australasian College of Medical Administrators (RACMA) Let us progress in unity by working together in harmony President: Philip Montgomery Area Executive Director - Royal Perth Group, North Metropolitan Area Health Service, Perth, WA Medical degree: University of Western Australia (1977) Wants to be remembered for: Leading a team that provided contemporary educational programs; conducting the hospital “orchestra” to deliver a good product; and having a sense of humour. Year of inauguration of college: 1968 Current number of fellows in Australia: 400 Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) Ab umbris ad lumina vitae (From shadows to the light of life); and Excellence in women’s health President: Kenneth Clark Obstetrician and Gynaecologist, Palmerston, New Zealand Medical degree: University of Otago (1981) Wants to be remembered for: Having vision and honesty; trying to ensure the College has a future and is not emasculated because of complacency and lack of forward thinking. Year of inauguration of college: 1978 Current number of fellows in Australia: 1300 Royal Australian and New Zealand College of Ophthalmologists (RANZCO) Ut videant (That they may see) President: Allan Rosenberg Ophthalmologist, Sydney NSW Medical degree: University of Sydney (1974) Wants to be remembered for: Being a pair of safe hands, who looked after ophthalmology and also medicine. Year of inauguration of college: 1965 Current number of fellows in Australia: 700 Royal College of Pathologists of Australasia (RCPA) Medicine is pathology President: Vincent Caruso Director of Pathology, Western Diagnostic Pathology, Perth, WA Medical degree: University of Western Australia (1973) Wants to be remembered for: Dealing with the professional issues fairly; bringing a commonsense approach to the management of the College; and listening to the Fellows and trainees. Year of inauguration of college: 1956 Current number of fellows in Australia: 1800 Royal Australasian College of Physicians (RACP) Hominum servire saluti (To serve the health of our people) President: Jill Sewell Deputy Director, Centre for Community Child Health, Royal Children’s Hospital, Melbourne, VIC Medical degree: University of Melbourne (1971) Wants to be remembered for: Passing on wisdom; thinking broadly and including a wide variety of people; looking after patients and colleagues well; sticking at things (“enough ripples can make a wave”). Year of inauguration of college: 1938 Current number of fellows in Australia: 7600 Royal Australian and New Zealand College of Psychiatrists (RANZCP) Ex veritate salus (Out of truth [or understanding] comes health [or wellbeing]) President: Julian Freidin Psychiatrist, Alfred Hospital Homeless Outreach Psychiatric Service, Melbourne, VIC Medical degree: University of Melbourne (1981) Wants to be remembered for: Turning the College into something much more functional, useful and externally focused. Year of inauguration of college: 1963 Current number of fellows in Australia: 2100 Royal Australian and New Zealand College of Radiologists (RANZCR) Lumen afferimus morbis (We cast light on disease) President: Liz Kenny Senior Radiation Oncologist, Royal Brisbane and Women’s Hospital; and Medical Director of Cancer Services, Central Zone Queensland, QLD Medical degree: University of Queensland (1980) Wants to be remembered for: Making a difference, both to individuals with cancer and to cancer care at the state and national level. Year of inauguration of college: 1949 Current number of fellows in Australia: 950 Royal Australasian College of Surgeons (RACS) Fax mentis incendium gloriae (The torch of the mind is the flame of glory) President: Russell Stitz Colorectal Surgeon, Brisbane, QLD Medical degree: University of Queensland (1966) Wants to be remembered for: Improving the influence of surgeons in surgical care in the public hospital system; increasing the role of newer surgical subspecialties in the College. Year of inauguration of college: 1927 Current number of fellows in Australia: 3600 The Presidents of the medical colleges in Australia and New Zealand could be excused for feeling besieged. The colleges, as the bodies responsible for training and accrediting medical specialists (and setting and maintaining standards for general practitioners), are being challenged by many factors, including medical advances, the medical workforce shortage and societal changes. The latter include the growing “culture of suspicion”, whereby professionals are no longer trusted to regulate themselves, and increasing government oversight. In the past 10 years, the colleges have been scrutinised by the Australian Competition and Consumer Commission, the Australian Health Workforce Officials’ Committee, the Australian Medical Council and the Productivity Commission. At the same time, they have to counter longstanding negative perceptions held by some of the public, and even the profession, that they are conservative “closed shops” run by GOBSAT (“good old blokes sitting around tables”), and that they have enormous power and are interested only in maintaining income. We interviewed the Presidents of the 12 medical colleges to find out about their recent challenges and how they are responding to them. Although the colleges (with the exception of the College of General Practitioners) also have jurisdiction in New Zealand, we focused on Australia. Solving the workforce shortagesAlmost all the Presidents believe there is a shortage of specialists in their field or, at the very least, a maldistribution (eg, urban versus rural–regional). The problem will only worsen with the ageing of both patients and practitioners, increasing workforce feminisation and cultural change, with younger doctors unwilling to work the traditional long hours. For the Presidents of the College of Physicians (Jill Sewell) and the College of Radiologists (Liz Kenny), providing sufficient workforce is their college’s greatest recent challenge. It is “a moral and ethical obligation”, said Michael Kidd (President of the College of GPs). However, opinions vary as to how this can best be achieved and who carries the ultimate responsibility — the colleges or government. For the Presidents, there is a natural tension between providing more specialists and maintaining the professional standards that are fundamental to their organisations. The most obvious approach is to train more specialists, and several years ago the Australian Medical Workforce Advisory Committee (AMWAC) set targets for increasing the number of trainees in many specialties and subspecialties. Providing more training positionsFor colleges that cannot place all suitable applicants, creating more training positions is a vexed issue, as other stakeholders are involved: these positions are traditionally in public hospitals and financed by the state governments, with the colleges responsible for their accreditation. Not only is adequate funding required, but the colleges demand adequate educational value. The situation is not helped by the move of many doctors from the public to the private sector, particularly in specialties such as pathology and radiology. Several Presidents talked of working hard and “knocking on every door” to meet or exceed AMWAC targets for positions. President Vincent Caruso says the College of Pathologists has lobbied state and federal governments with limited success. The College has tapped into the private sector to fund a number of training positions either fully or with support from the federal government. The College of Surgeons, in particular, blames government for a shortage of advanced surgical training positions. “We think it is morally reprehensible that, earlier this year, 130 people were in this transitional position [awaiting advanced training posts]”, said the President, Russell Stitz. “We are keen to look at integrating basic and advanced stages. Politically that is difficult because health departments want people at the basic training level to fill their service requirements.” Attracting more traineesOn the other hand, colleges that cannot fill all their training places see the need for their specialty to be made more attractive to junior doctors. “Recruitment is a key issue for colleges of obstetricians and gynaecologists around the world”, said President Kenneth Clark. Indemnity must be kept under control and negative lifestyle portrayals avoided to encourage recruitment. The College of Psychiatrists has developed a recruitment package to encourage medical students to consider psychiatry as a career. However, President Julian Freidin does not feel that solving the psychiatric workforce shortage is the College’s responsibility alone, as it does not control all the workforce and financial levers. “The College is talking with the government about significant issues that deter students — all training positions are hospital-based, in acute settings that can be highly pressured, and psychiatry is less well paid than other branches of medicine.” The youngest specialty, emergency medicine, has also not reached AMWAC targets as quickly as expected, said its President, Andrew Singer, for similar reasons: “the pay structure, with most employed as staff specialists at lower pay than, say, procedural specialists; and perceptions that the work is difficult and high pressure”. However, some Presidents see the problem arising further upstream, from past government decisions limiting “the pipeline” of medical students. With the recent proliferation of medical schools, numbers will increase, but there will be a long lag before any effect is seen on workforce numbers. Reducing training timeMost Presidents dismiss the suggestion to reduce training time as being neither practicable nor a solution to workforce shortages. “If you just rush some people through faster, you will help for a couple of years, but you are still on the same conveyor belt”, said Sewell. Training has traditionally been time-based, with a certain number of years required in a registrar position before a barrier examination. Although some colleges are planning to move from a time-based to a competency-based program (see Training programs), they do not feel this will allow any substantial reduction in training time because of the amount of material that needs to be covered and the nature of rotations. Many colleges defend the length of their program because of a desire for their fellows to be generalists. For example, according to Michael Cousins (College of Anaesthetists), an anaesthetist in a country hospital must be able to cope with a wide range of patients and situations. Freidin also pointed out that there is a large service component during training. “Over the 5 years that psychiatrists work as registrars, they spend only a short time training. They are working to keep the state system from falling apart.” Recruiting overseas-trained doctorsThe medical workforce pressures mean that Australia relies heavily on overseas-trained doctors. All the colleges have procedures, in conjunction with the Australian Medical Council (AMC), to assess the suitability of these doctors to practise in Australia. Kidd summed up his college’s position, which is typical: “Any doctor recruited to work in independent practice anywhere in Australia should be at the level of a Fellow of the College and should either have attained that Fellowship, be judged by the College to have had equivalent training and assessment, or be working under supervision towards meeting the Fellowship standard”. However, the colleges find assessing overseas-trained doctors a challenge. There is “such a difference between qualifications on paper and actual competencies of practice”, said Kenny. And the procedures of some colleges have been criticised as overly slow, onerous and even anticompetitive. A range of other schemes allow overseas-trained doctors to practise in Australia without ever coming into contact with a college, and required standards vary between schemes and also between different states and territories. Cousins elaborated: “In states such as Queensland, it has been possible to employ overseas-trained doctors in career medical officer positions and to allow them to practise de facto as specialists, without going through the college process”. The colleges want to see standardisation of procedures and requirements across colleges and jurisdictions. The federal government has asked the colleges to define rapid assessment pathways, particularly for areas of need, and to identify appropriate overseas qualifications. A continuing concern in this process, according to Cousins, is indemnification against claims of discrimination against particular overseas programs. Task substitutionAnother suggestion that might help relieve medical workforce pressures is to transfer some tasks of doctors to other health professionals. Indeed, the Productivity Commission proposed a multiskilled “generic” health worker in its recent position paper on issues affecting the health workforce.1 While Presidents such as Sewell felt there was merit in “skills transfer and better use of the health workforce in a broader way”, all stressed the need to maintain quality of care. For example, Allan Rosenberg of the College of Ophthalmologists contended that, “with adequate training, substitution of certain tasks is possible, but only a doctor has a holistic approach to treating the patient as a whole person”. For the College of Obstetricians and Gynaecologists, task substitution is probably their greatest recent challenge. Their President, Clark, said the College is not anti-midwife. “It is perfectly reasonable for women to have other care options. What they must have is immediate access to specialist care.” Some colleges strongly support the development of health care teams headed by doctors. The College for Emergency Medicine sees itself as a leader, having “embraced advanced nursing roles and brought allied health staff into non-traditional areas in the emergency department”, said Singer. Similarly, public sector psychiatry is very open to the idea of clinical teams with a psychiatrist as “the leader who has the best ability to integrate the biological, psychological and social”, said Freidin. Kidd would like to see dedicated GP nurses in every general practice. Kenny believes in “role evolution”, and is evaluating its potential together with the radiographer and medical physicist professional bodies. In addition, many specialist colleges are willing to share workload with appropriately trained GPs. For example, the College of Dermatologists sees that GPs, including those working in specific skin cancer clinics, fill a need in the detection and management of skin cancers. Yet, a concern for many is the potential for task substitution to create a two-tier system, whereby some Australians receive a lower level of care than others. For example, the College of Anaesthetists wishes to maintain Australia’s pre-eminence for low anaesthetic mortality. “The general public expects not to die undergoing anaesthesia for a routine procedure”, said Cousins. Moreover, many Presidents pointed to a shortage of other workforce in their respective fields (eg, nurses and biomedical scientists), limiting the potential for task substitution. Responding to government oversightThe Presidents are generally philosophical about currently increasing government regulation, seeing it as “a fact of life that will not go away” (Stitz). Some also described benefits, such as increased interest in funding training posts and in ensuring supervisors have time for training. But there is no doubt that this regulation is a challenge that demands considerable time and resources. The ACCC reviewThe review of the colleges by the Australian Competition and Consumer Commission (ACCC) originated in the widening of the Trade Practices Act 1974 in the mid-1990s to include the medical profession. The ACCC began investigating allegations that the College of Surgeons was in breach of the Act by restricting entry to advanced training. The implication was that the college was a “closed shop”, inflating specialist incomes by limiting competition. To avoid legal action, the College applied for authorisation of its conduct, which can be granted if the ACCC is satisfied that the public benefit outweighs any detriment caused by the lessening of competition. In 2003, this authorisation was granted for 4–6 years, subject to the College making reforms to increase transparency, accountability, stakeholder participation and procedural fairness of its processes. Stitz believes the situation is now largely resolved. “The end result is we have robust processes, and jurisdictional representatives on all our major educational committees. But we are having a bit of trouble with the resources needed to service the ACCC requirements for timely accreditation of hospitals and assessment of overseas-trained surgeons.” The ACCC then turned its attention to the other colleges and began a joint review, with the Australian Health Workforce Officials’ Committee (AHWOC), of the extent to which college processes for selection, accreditation and assessment incorporated the general principles of the College of Surgeons’ authorisation. Several other Presidents mentioned going out of their way to make contact with the ACCC and trying to work “within the rules”, believing the recommended changes were desirable. Sewell (Physicians) said: “They are wanting us to do certain things slightly differently. Many we have been trying to achieve anyhow, such as working more closely with the [government] jurisdictions about the distribution of the training workforce and our educational processes”. Others, such as Freidin (Psychiatrists), feel there is no suggestion their colleges are restraining trade — they have been “caught up in the general review”. The ACCC–AHWOC report on the colleges earlier this year observed that many had implemented, or were intending to establish, approaches similar to ACCC recommendations, but that implementation was in its very early stages and varied between colleges.2 The colleges were invited to assess their progress individually. AMC accreditationIn the past 5 years, the colleges have also been scrutinised by the Australian Medical Council (AMC), which has long accredited medical schools and their curricula. In 1998, the AMC was invited by the federal government to develop processes to accredit the college programs for specialist medical training, continuing professional development and assessment of overseas-trained doctors. The AMC has been reviewing the colleges at the rate of one or two a year since 2001. The Presidents described the AMC reviews as exhaustive: “It was a major evaluation, with face-to-face meetings and site visits relating to our entire educational and examination program”, said Cousins. The College of Physicians underwent the process in 2004; Sewell considered it “a really important opportunity to look at everything we do educationally”. Those still to be reviewed are anticipating the challenge. Anne Howard (College of Dermatologists) commented that the review (scheduled for 2007) is “a good opportunity to work out our curriculum and make sure we have the correct selection, training and assessment processes. But it will be fairly time consuming and expensive, especially for small colleges like ours, because they want a lot of material”. Similarly, Philip Montgomery of the College of Medical Administrators (scheduled for 2008) said “the most important challenge for us is making sure that all our processes and the quality of our education program are such that we get full accreditation”. Reinventing themselvesThe soul-searching prompted by this intense scrutiny is no doubt a factor in many of the recent changes made by the colleges to their processes, educational programs and governance. Training programsA major role of the colleges is to oversee vocational training in what has been traditionally a time-based, master–apprentice system. Several Presidents highlighted changes to the underlying philosophy of their programs. For example, the College of Anaesthetists has “modularised” training and is adapting these modules for distance education. Both the College of Physicians and the College of Radiologists are moving to competency-based rather than time-based programs. Kenny said the College of Radiologists is putting enormous effort into curriculum development. “With the help of professional educators from the University of NSW, we are looking at a project that articulates the skills and competencies we expect of our trainees and graduates. These will be part of the actual training program and will be assessed.” She believes that defining required competencies could also have benefits in assessing overseas-trained doctors and task substitution. The College of Physicians intends its planned competency-based program to increase flexibility, as “trainees will be able to demonstrate their competencies at their own rate”, said Sewell. (The College has allowed part-time training for many years.) Not all colleges have complete responsibility for training in their specialty. For the College of GPs, a major crisis was the loss of the contract for vocational training in 2002. GP training is now overseen by a government-owned company and contracted out to regional consortia, which include the College, to be performed to College standards. Another exception is the College of Medical Administrators, which includes, as its basic qualification, a university masters degree in public health or administration. Montgomery explained: “We used to run the program itself and set the curriculum and examinations, but it was a little antiquated. The universities are very good at running these masters programs, and the courses are available”. In fact, the Committee of Deans of Australian Medical Schools has suggested to the Productivity Commission that universities should have a “major role” in vocational training.3 Overwhelmingly, the Presidents thought this was not practic-able. Many questioned where the universities would get the required teachers, as all their fellows are already involved in college programs. Sewell saw benefit in “working together with universities around specific skills and specific courses”, but “would not want to see a wholly parallel system of university vocational training which competed with the colleges. We are not that big a pond”. She also pointed out that “as clinicians provide an enormous amount of teaching to medical students (often unpaid) as well as to vocational trainees, there is considerable expertise in medical education outside the universities”. Continuing professional developmentTraditionally, continuing professional development (CPD) for college fellows is a voluntary program comprising lectures, seminars and conferences. However, a number of colleges feel more is required, such as making CPD compulsory and introducing audit components. The College of Surgeons is keen for its Fellows to participate in external audits, such as the national breast cancer audit, and is supporting the roll-out of a binational audit of surgical mortality. The College of Obstetricians and Gynaecologists is the most demanding: “For the last decade we have required adequate compliance with our continuing education program, which includes compulsory practice review. We can — and do from time to time — remove the Fellowship”, said Clark. His college has also led a national project on CPD — the LEAP (Learning, Education and Professionalism) framework. This includes practice review and is being trialled by other colleges under the auspices of the Committee of Presidents of Medical Colleges (CPMC) (see below). “We have now reached a joint belief at CPMC level that this is the way we should be going. We are trying to counter the position that it is an optional extra”, Clark continued. Nevertheless, while other Presidents support CPD, most are dubious about the value, or even the possibility under their by-laws, of making Fellowship contingent on revalidation. GovernanceTraditionally, colleges have been run by councils of their members, plus a smaller executive. There are moves to create smaller, more business-oriented governing bodies. In addition, the ACCC is pushing for governing bodies to include representatives of other stakeholders — trainees, the government jurisdictions and the community. The College of Ophthalmologists moved 2 years ago from an executive council to a board run along the lines of corporate law. Rosenberg believes they are “ahead of the pack”. “We were looking at ourselves long before the ACCC review. The aim was to make changes to work within the law and look after our fiduciary interests, while retaining the collegial feel. We have pretty well followed the AHWAC and ACCC recommendations. We try to prevent crises by being proactive.” Many colleges now have trainee repres-entatives on their federal or state councils or other committees. The move to include community representatives has been slower, and those appointed tend to have other desirable expertise. The GPs have just appointed the first layperson to council. “She is bringing a strong background in financial management, strategic planning and corporate governance, as well as the layperson’s perspective”, said Kidd. The College of Physicians has longstanding relationships with several consumer organisations but has not involved them in council. Sewell believes “they do not want to sit on a lot of committees, as there are not enough of them. They want to be involved when significant policy decisions are being made”. The colleges are also beginning to involve the government jurisdictions, particularly in educational planning (eg, the College of Physicians has an AHWOC representative on its educational strategy implementation board). However, the ACCC–AHWAC report in July 2005 called for more progress in involving the jurisdictions in decisions affecting the workforce.2 Committee of Presidents of Medical CollegesIn the face of the pressures, some Presidents see a particularly important role for their professional association, the Committee of Presidents of Medical Colleges (CPMC). “The Colleges have tended to be their own little worlds and to act in isolation”, explained Clark. “We need to be supporting each other more, and looking after the smaller and weaker colleges. We have been slow to share teaching and staff resources.” Some Presidents also believe the CPMC needs to move from being just about information-sharing to being a body in its own right. The smaller colleges particularly appreciate the CPMC. According to Howard, “The meetings are terrific, with a real feeling of cooperation. We are looking at what sort of training modules we can help each other with”. Montgomery said, “The CPMC is a collaborative body, and very good for networking with other colleges, learning from each other and keeping up to date. It is particularly useful in being able to communicate directly with the Department of Health and Ageing and the peak bodies around Australia”. On the other hand, some groups have criticised the CPMC as too timid and too agreeable with government, and some colleges may continue to put their own case. What of the future? On being President . . . . We asked the Presidents whether, with all the demands, they have time for a private life. “Of course”, they all replied. Yet most acknowledge that the college workload is immense, especially in the larger colleges, where it could be full-time and may involve at least one day a week travelling. In addition, all still have “a day job”, although many have reduced their hours. Essentials seem to be a supportive partner and the ability to get by on very little sleep (one President gets up at 04:00 to spend 3 hours on college work before their regular job). Kidd described it like an athletic event — he makes a conscious effort to attend to exercise and diet, take time out, and achieve balance. Why have they volunteered for this role? For all, it seems the climax to a long period of service to their college, and a typical response was “wanting to give something back to the profession”. The term as president is mostly 2 years, because, as many said, that is as long as a person can stand. After that, according to one, they ”will be able to kick up their heels”. The Presidents do not expect the pressures on the colleges to abate. However, they do believe that government and public misperceptions need to be corrected. “There is a belief that the colleges have enormous power and are interested only in income”, said Cousins. “We are training, examining, and professional standards organisations. An incredible number of people give vast amounts of time and energy to the colleges. They do it because they believe in the importance of postgraduate education and want to maintain current standards. And they do it for free. It would cost millions to pay for the activities of our college.” Nevertheless, they agree that responsiveness and transparency are needed. “The colleges have to be mindful of what is happening outside themselves and make sure that the community wants and values the specialists they produce”, said Freidin. As Caruso said about CPD, they need to demonstrate their integrity to the public. “It has to be not just done, but seen to be done.” Yet, several Presidents warned that increasing government regulation could alienate the people on whom specialist training, and ultimately health care, depend. Stitz explained: “We are comfortable with government processes that ensure that professional people behave appropriately and that define the broad parameters of educational excellence. But once the parameters are defined, we should be allowed to get on and do the work we are trained to do”. From our interviews, it was clear that the current pressures are challenging not only the colleges, but also the Presidents. Their role has a considerable impact on their lives (Box). Yet, just as responding to the challenges may ultimately strengthen the colleges, so to do the Presidents regard their once-in-a-lifetime role as an enriching experience — they spoke of it variously as an honour, a privilege, and a wonderful opportunity to meet inspiring people and to make a major contribution to their profession and health care in Australia, and “the best job in the world”.

Kerrie A Lawson PhD · Ann T Gregory MB BS, GradDipPopHealth · Martin B Van Der Weyden MD, FRACP, FRCPA

Eleanor Dark (by Olive Cotton, 1945) © The Mitchell Library, State Library of New South Wales. The opposition that aspiring women doctors faced in the late 19th century was well summed up in 1881 by Professor Anderson Stuart of the University of Sydney’s Medical School: “I think that the proper place for women is in the home, and the proper function is to be a man’s wife, and the wives to be the mothers of our future generations”.1 Even when women were admitted to medical school in Sydney, the medical establishment still resisted, and there was a public furore in 1905 when Dr Susannah O’Reilly, fourth in her year, was denied a resident position at Sydney Hospital. The Sydney newspaper, Truth, was moved to verse:2 The Lady Doctor’s come to stay, No matter what the men may say, And who should bar the right of way, To Dr Sue O’Reilly By 1911, there were 94 women registered as medical practitioners in Australia, and 14 lived outside the state capital cities.3 However, they left no known records of their experiences. Neve, in her history of Australia’s pioneer women doctors, notes “there appear to be no memoirs, diaries, or other papers from which could be gleaned recorded experiences or personal reminiscences”.1 One insight into the world of a woman general practitioner comes from a novel by Eleanor Dark (1901–1985) who “for over twenty years . . . was undoubtedly the best-selling serious novelist writing in Australia”.4 Eleanor Dark completed her first novel, Slow dawning, in 1926.5 It is about Valerie Spenser, a 25-year-old doctor, who establishes a medical practice in a (fictional) country town, Kawarra, where she had grown up. There was community prejudice against women doctors, and Valerie struggled to reconcile her career with her desire for a family. Eleanor Dark understood rural general practice and the difficulties of combining a career with family responsibilities. Her husband, Eric Dark, was a general practitioner in Katoomba from 1923 until 1970. A biographer wrote: “The telephone was the biggest interruption for Eleanor. It rang day and night and she could never ignore it”.6 In 1975 she told an interviewer: “My books have been written at intervals snatched from years as a housewife . . . it is impossible to keep a home going in Australia unless one is busy most of the time”.7 Dark’s most famous work is The timeless land based around the interactions between Australia’s first white settlers at Sydney Cove and the local Aborigines. She has been described as “a novelist of ideas. She felt strongly that, while women are the heart of the family system, they should have their own careers to match their abilities”.6 In Slow dawning, Valerie Spenser at 18 aspired to a life with “three main ingredients: ambition for healing and helping, worship of beauty in all its forms, and an overwhelming desire to love, to be loved by the man who was to be her mate”. Even at school, Valerie met preconceptions. A friend she told of her aspirations to train and work as a doctor, replied “Are you going to be a spinster lady all your days?”. When Valerie returned to Kawarra, a local worthy, gossiping to a friend, suggested “The practice of medicine must be death to the natural bashfulness and modesty of womanhood”, adding “these women doctors have no modesty and no morals”. The local chemist felt “Though she may be clever and all that, she’s too young and pretty. They might overlook her being a woman if she was forty-five and hard-faced”. Like most doctors of the time, Dr Spenser practised from her home. For housekeeping she engaged Mrs Gillogley who “had not been able to take this doctor-lady seriously before, but the imposing array of mysterious and deadly looking instruments converted her”. Valerie’s consulting hours were 9–10 am, 2–3 pm and 7–8 pm. There were numerous house calls every day, including to farms, and home confinements. Adenoids were removed at home. Valerie did her own “after hours”, and an evening at the local picture theatre might be interrupted by a message on the screen: “Dr Spencer wanted”. The MJA wrote on “The equipment of the general practitioner” in October 1924, noting: “Every medical practitioner finds it advisable to live in a house of good appearance. Corner houses are frequently selected, although the central situation is more important . . . It is usual for the practitioner to set aside a portion of his house for his professional work. A separate entrance, a suitable waiting room for patients and a consulting room with an antechamber adjoining for the examination of blood, urine and other excretions, are essential”. The article also lists equipment required in country areas. “The man in the country will, naturally, find it advisable to have . . . anaesthesia masks, ether drop bottle, a mouth gag and tongue forceps, emergency instruments including tracheotomy tubes, intubation tubes, blunt hooks, directors and aneurysm needles”, and “the midwifery bag should be properly equipped with axis traction forceps, uterine dilators, curette, suturing outfit, pelvimeter, douch [sic] can with attachments, the usual drugs, including chloroform or ether, dressings, gloves and antiseptic lubricant.”8 Kawarra had a population of 3000 and one other doctor, a Scotsman, Dr McCabe. He warned Valerie that “For a month of careful treatment patients will squirm at their doctor’s bill, but they’ll pawn the family Bible to pay a quack for his incantation”. He also observed that “The laity is apt to indulge in fervid party warfare on the subject of doctors”. Some of the wealthier locals attended the suave Dr Hughes in the next town and took pride in his “four guinea accounts” for home visits. It gave “a certain prestige to call in a doctor from a town some miles distant”. Valerie didn’t like Hughes, although when they first met “they talked shop for half an hour, as even the most incompatible pair of doctors will”. Valerie remembered having a teenage infatuation with Jim Hunter, the son of a prosperous local businessman and had hopes that the attachment might be revived. But Jim had fought in France in World War 1 and “the whole hideous proceeding had sickened and disgusted him. He came back believing in, desiring, thinking of, hoping for nothing on earth but peace, peace to the point of placidity — and the safe haven of work”. When Valerie returned to Kawarra, Jim was about to marry Kitty, a 19-year-old local girl. Kitty consulted Valerie before the wedding. Valerie had found, as a medical student, that many people felt “a working knowledge of one’s own body was ‘not nice’ ”. Kitty “at the age of nineteen, was almost as ignorant of everything pertaining to sex as a child of three”. She did understand “married people sleep in the same bed”. Valerie “a couple of times, made little clear diagrams” which evoked from Kitty “I do love Jim; but o-o-o-h.” Dr Valerie’s advice: “Don’t think of it as a dose of castor oil, Kitty”. A new doctor, Dr Owen Heriot, comes to Kawarra, despite the Sydney medical agent advising that the town could not support three doctors. Heriot was not deterred: “You know as well as I do that there’s still a certain prejudice against lady doctors. If one of the trio has to starve, she’ll be the one . . . if she can do a man’s work, and make a man’s money, she’ll have to take a man’s risks”. Life became difficult for Valerie. There was Jim’s marriage, unwanted propositions from Dr Hughes, and a falling off in her practice with the arrival of Heriot. She “was tired and unhappy and fighting and persecuted — and no one stood beside her. It was not the troubles themselves that could beat her — it was the solitariness in which she must face them . . . no one was ever meant to be lonely”. Valerie mused “I want real love, and marriage, and a couple of babies . . . I have my mental and physical needs and desires . . . must they be forced back, and repressed till they twist me into something horrible?”. On top of this, an accumulation of little things “tried her strength”. Mrs Gillogley “reported a leaking gas pipe connecting the gas heater; she reported the front-door bell out of order; she reported an incorrect milk bill. There was a hawker, with haberdashery — did Dr Spencer want any? The butcher couldn’t send an ox-tail, would steak do? The cord of the kitchen window was broken — a mouse had been in the pantry — the ice chest was leaking — the clothes line rusting — the best tray cloth had iron-mould on it . . .”. An MJA editorial in 1923 may have given some comfort to women doctors facing similar frustrations when it observed that: “In medicine women have revealed aptitude of no mean order”, and predicted that with “unity of purpose . . . the medical women of Australia will have little difficulty in breaking down the last remnants of the sex barrier which has impeded them for so long”.9 Heriot had been an army medical officer through the trench warfare in France. Valerie felt he was “a cynic, a sneerer, a disdainer of life”. However, when things became really difficult for Valerie, with rumours about her “goings on” with Dr Hughes and nasty gossip about some of her medical treatment, it was Heriot who understood and sympathised. “He realised the intolerable and unnatural restraints which convention thrust upon her . . . it haunted him that he had harmed his rival not through her incompetence but through her sex.” It is enough to say that Valerie and Heriot married. The fanciful romantic storyline in Slow dawning is only touched on here. Dark felt she went much too far, referring later to “my unspeakable Slow dawning” and admitting it was the only time she wrote “with the object of making money” by trying to appeal to “the addicts of popular romantic fiction”.6 However, this admission does not detract from the book’s description of general practice 80 years ago or its record of community attitudes to women doctors. Today, with the proportion of women in Australia’s general practice workforce rising from 32% to 35% between 1995 and 2000,10 and around 60% of general practice trainees being women,11 it is interesting to speculate how the impediments facing women doctors have changed over the last 80 years. In 2002, Kilmartin and colleagues conducted a structured qualitative study of 40 women general practitioners designed to rank “the 10 most important issues in their professional and non-professional lives”.12 The women described “enormous pressure . . . trying to balance professional and non-professional roles” leading to “stress, guilt, ‘burnout’ and ill-health”. Major issues articulated by the group included “achieving job satisfaction in general practice through mental stimulation, challenge and a variety of work”, “having time to nurture a quality relationship with a partner” and “having a strong sense of self-esteem and self-image, leading to autonomy and control over one’s professional life”. Valerie Spenser would probably have agreed had she participated in Kilmartin’s study. In the depths of her troubles, Valerie told herself that women “would climb at last to a height where they would perform not only the artistic or intellectual work to which their natures inclined, but the normal functions of wifehood and motherhood as well. A terrible fight, a slow one . . . generations it would take . . .”. For Valerie, the most important issue may have been what Dr Heriot called “a certain prejudice against lady doctors” doing “a man’s work”. This prejudice is a major theme in Slow dawning, reflecting Eleanor Dark’s assessment of community attitudes in the 1920s. While there is no suggestion in Kilmartin’s research of this attitude, some women doctors might question whether the “terrible fight” has yet been won.

Bill Coote MB BS, FRACGP, BEc

Death is a fearful thing. William Shakespeare (Measure for measure) It is well recognised that hospital autopsy rates have been declining for a number of years.1 It now seems to be almost an “accepted” fact that hospital autopsies are a procedure of the past, having been bypassed by newer and more effective technologies for evaluating illness and disease states. This is, of course, completely incorrect. Every study into autopsy practice has demonstrated the usefulness and necessity of a careful dissection after death to determine not only the true cause of death, but also the response of the patient to various treatment modalities. The autopsy is, and will always be, the ultimate audit of clinical practice.2 Following appropriately conducted autopsies, it has been consistently demonstrated that suggested clinical causes of death may be inaccurate and require correcting; unsuspected but significant conditions are often discovered; and unexpected effects of therapy and procedures may be revealed. The autopsy provides an excellent basis for teaching students the fundamentals of anatomy and the manifestations of disease. It also provides important information on the effects of newer drugs on normal as well as on diseased tissues.3-5 Given these well established facts, the obvious question is, “Why are autopsy rates in such decline?”. A short questionnaire to determine the status of the autopsy in your pathology department 1. When was the last time your head of department... a. Performed an autopsy? b. Observed an autopsy? c. Touched a dead body? d. Saw a dead body? e. Read about a dead body? (Scoring: 1–6 days ago, 5 points; 7–30 days ago, 4 points; 4–52 weeks ago, 2 points; 1–10 years ago, 0 points; > 1 decade ago, automatic fail) 2. Who teaches registrars autopsy techniques? a. Pathologists 5 points b. Other registrars 1 point c. Mortuary technicians 2 points d. What teaching? – 5 points 3. Do CPCs occur regularly? a. Yes 5 points b. No 0 points c. Don’t understand the question – 5 points 4. What is the average time for provisional and final autopsy reports to reach clinicians? a. 1–6 days 5 points b. 7–30 days 3 points c. 1–6 months 1 point d. 6 months to 1 year 0 points e. > 1 year – 5 points f. After retirement automatic fail 5. When was the last time an attending clinician was seen in the autopsy room? a. 1–6 days ago 5 points b. 7–30 days ago 3 points c. 1–6 months ago 1 point d. 6 months to 1 year ago 0 points e. > 1 year ago – 5 points f. Not recognised as such automatic fail and escorted out by security 6. When was the last time senior pathologists waxed lyrical about an interesting autopsy case? a. 1–6 days ago 5 points b. 7–30 days ago 3 points c. 1–6 months ago 1 point d. 6 months to 1 year ago 0 points e. > 1 year ago – 5 points f. Never automatic fail Interpretation of results. Frankly, if your score is anything less than 35 points, I would not be blaming clinicians for the fall in autopsy rates, but would be looking much closer to home. CPC = clinicopathological conference. Pathologists often complain that the responsibility for the alarming fall in autopsy rates rests squarely on their clinical colleagues. Clinicians’ palpable lack of interest and their obvious reluctance to ask relatives to give consent for autopsy are seen in a very unfavourable and disapproving light in the corridors of pathology departments the world over. However, it must be recognised that the lighting in many pathology departments is suboptimal, often due to their temporary or basement locations, and that such perceptions may not always be absolutely correct. For autopsies to be meaningful, there needs to be a clear understanding of the patients’ specific clinical issues. This means that contact and discussion between the treating clinicians and the supervising/autopsy pathologist needs to occur before, often during, and certainly immediately after autopsy examination. Accur-ate dissection with photographic and written documentation of abnormalities is essential, and reports need to be issued promptly, with presentation of findings immediately after the autopsy or at least at regular weekly autopsy rounds. Provisional and final reports, with clinicopathological correlations and clear gross and microscopic descriptions, are the responsibility of the pathologist. Failure to disseminate them in a timely fashion causes both the clinician and the pathologist to lose interest in the case. Once a month, a clinicopathological conference needs to be held for general hospital medical, nursing and ancillary staff and students to review interesting cases and to answer clinical questions.6 Does any of this occur? I would suggest that it often does not, and that this lack of support of autopsy practice from within the heartland of pathology may be one of the real reasons for clinicians’ lack of interest and the fall in autopsy rates. It has been observed that hospital-based pathologists, excluding those involved in paediatric/perinatal or forensic practice, do not even seem to like autopsies. Autopsies are considered to be technically messy and physically demanding and to detract from the more “scientific” and sterile world of histological and molecular pathology. In fact, they are sometimes seen as some sort of atavistic medical throwback, to be undertaken only by second-rate academics and those who are unemployable in the real world of 21st century anatomical patho-logy! Proof of the lowly status of the autopsy can be seen in the delegation of responsibility within hospital departments. All too often, the most junior registrar with the least training in anatomical pathology is designated to perform autopsies. The autopsy may even be undertaken in the absence of a consultant. Often it is a mortuary technician — one with many years of experience but no formal training, except in the “university of life and the school of hard knocks” — who teaches the unhappy registrar autopsy techniques. Registrars complain about how difficult it is to get consultants to review cases once dissections have been completed; and yet the literature maintains, and surveys have found, that “the necropsy is an invaluable investigation which is currently under-used”7 and that “most pathologists consider autopsies to be valuable and important for quality assurance in health care”.2 However, perhaps we should judge pathologists by what they do, rather than what they are quoted as saying? Could this be a scurrilous and unfair suggestion? Possibly. However, one way to assess the validity of these assertions would be to examine pathology department records to find out when the last time was that senior pathologists performed an autopsy examination by themselves. I would suggest that years might well run into decades. Perhaps the most impartial and unemotive way to assess this would be to use a scoring system to objectively determine a pathology department’s commitment to autopsy practice . . . And fortunately, one just happens to be available (see Box).

Roger W Byard MD, FRCPath

A ramble along the byways of medical history Scatology — the study of excrement — has long fascinated my co-author and me.1 Nevertheless, until our most recent discovery, even we would have conceded that the most dedicated coprophile would be hard pressed to find a link between dog droppings, medicine and Christmas. At the Nativity, despite the manger’s rural setting, was there a dog, let alone dog droppings, to be seen? Cows, goats, sheep aplenty and a camel or three, but Rover seemed conspicuously absent. Rudolph is a reindeer, not a red setter. And, over those 12 days of Christmas, our True Love trucked in a whole aviary of birds but, for some reason, never a dog a-barking. Perhaps this absence is related to the popular view that dog faeces rate towards the lower end of the general desirability scale. In Australia, many a local authority finds menace in every deposit of dog excrement2 — it seems that dog droppings are deemed a health hazard, despite a distinct lack of scientific evidence. Statistically, on an average walk in the park, you are far more likely to be killed or injured by dog bites,3 broken glass,4 or discarded syringes5 than infected by stepping in dog excrement. Slipping over and fracturing a hip is a potential hazard, but we have failed to find a report of the same; however, there has been a report of a fall involving a slip on puppy urine.6 Imagine our delight to find out — after meandering along little-travelled byways of medical history — that dog excrement has not always been so reviled and that it does have a prior, however slight, association with Christmas. An old surgical text, a pleasant surprise withinA little while ago, we purchased the fourth English edition of Laurence (more properly, Lorenz) Heister’s A general system of surgery, published in London in 1750 (Box 1). It was considered the first truly modern surgical text in the English language,7 and was the greatest surgical text of the 18th century, running to seven German, ten English and three Latin editions as well as being translated into Italian, French and Dutch. Profusely illustrated (by the standard of the day), Heister’s text combined practical surgical technique with sound anatomical knowledge, both of which he had gained by first hand experience. Who were its past owners? Were any of them practising surgeons? Alack, our copy of Heister is pristine in every detail with no markings to indicate prior ownership. Judging by its unsullied pages, this book was never used as an everyday reference by student or surgical practitioner. However, deep within its pages, there is one tantalising clue to suggest that at least one of the unknown previous owners of this book had intended on practising the art of surgery. That clue came in the form of a piece of interposita — that extraneous matter that tends to accumulate within the pages of a book (Box 2). An 18th century visitationThe piece of interposita in question is a single sheet of watermarked paper measuring 8 by 10 inches (255 by 210 mm) (Box 3). On holding the paper up to the light, a large watermark of the Pro Patria (“For the Fatherland”) type can be seen, indicating that the paper itself was probably produced in Holland at some time in the 18th century, but could have been used elsewhere, particularly in the United States.8 Our interposita was folded in four when we found it. On one side, in a series of ruled-off compartments, was a collection of ten recipes, mostly medicinal, neatly hand-written in ink. Its unsoiled nature, the fact that the writing and ink are the same throughout, and that there are no corrections, suggests that the piece was compiled at one sitting from sources already at hand. The intent, we presume, was to create a permanent document for future reference, an aide-mémoire kept for safety and ease of access in the standard surgical reference of the time. But, seemingly both the book and interposita were little used from that day to this. Although the author is unknown, we feel the evidence indicates he was a young, enthusiastic but inexperienced doctor of the later decades of the 18th century. In all probability he had just finished his apprenticeship and was about to embark on a career of his own. An established practitioner would not need recourse to such an aide-mémoire, having already acquired his own favourite nostrums. Our English Heister edition dates from 1750. From the fine, undamaged condition of the interposita, it seems unlikely it would predate this. We believe, most likely, it was made fresh and placed immediately within the edition. Several other pointers lead us to the conclusion that it does not post-date the end of the 18th century. Firstly, the writer routinely employs what is now an archaic form of the letter “s”, known as the long s located at the beginning or in the middle of words, while the modern s form, the short or terminal s, appeared at the end. Secondly, the writer uses what are now obsolete spellings. For example, he spells the word “garlic” with a “k” — garlick. The k had been dropped from English usage by the turn of the 19th century. The Oxford English Dictionary records a usage of the k-less form in 1796 and constantly thereafter. Likewise plaister is an antique variant of plaster. But we have left our strongest evidence till last — the recipes themselves. Amusing the patient while Nature takes its courseIn all, the interposita lists ten recipes — eight medical: Plaister for Cuts or Wounds; Recipe for Eye water; A good recipe for the piles; An infallible recipe for the Dropsy; A cure for an obstinate cough; The famous American recipe for the Rheumatism; Bitters, and Bitters [a second variation]; and two culinary: Recipe for little cakes; and, for a plum pudding. Of course, to our minds, such recipes, in particular that for an “infallible” cure for dropsy, would seem to be nothing but fanciful imagination. But what else could a young and inexperienced practitioner have relied upon at a time when no satisfactory alternatives existed? They are good examples of what Voltaire (1694–1778) described as the art of amusing a patient while Nature takes its course. An “infallible recipe” for dropsy would have to wait upon William Withering’s ground-breaking An account of the foxglove and some of its medical uses, published in Birmingham in 1785. The effect of foxglove was to quickly consign such ineffectual remedies to the dust-bins of history. Our writer noted “the famous American recipe for the Rheumatism” and recorded “£100 has been given for the Recipe”. Would you have paid such a price for a recipe which combined garlic(k) with gum ammoniac (a foetid plant resin) into boluses (large round pills) to be taken twice a day with strong sassafras tea? Both bitters recipes are based on Peruvian bark (genus Cinchona), which was introduced to Europe in 1640; however, the plant which produced it was not known to botanists until 1737.9 But, with Christmas (and dog droppings) uppermost in our minds at the moment, and medicine ever-present, let us turn our specific attention to another recipe in this collection. Dog turd, medicine and ChristmasWe do not refer to the recipe for a plum pudding (although we do think the experience of “one large nutmeg” could well be overpowering, capable of evoking strong emotions, just like dog turd), but rather to that to help haemorrhoids (Box 3). The recipe begins, innocently enough, with oil of red roses,10 a volatile oil obtained from the distillation of the fresh flowers of the Gallica rose, Rosa gallica. Then comes frankincense,9 the ingredient with the ultimate Christmas connection: And when they [the Wise Men] were come into the house, they saw the young child with Mary his mother and fell down, and worshipped him; and when they had opened their treasures, they presented unto him gifts; gold, and frankincense, and myrrh. The Bible, King James version, Matthew 2: 11 Frankincense, otherwise known as olibanum, is the dried resin from trees of the genus Boswellia, known to grow in regions surrounding the Red Sea. It was highly valued particularly for its fragrance, and has been widely traded throughout the Near East for millennia. Topical application of frankincense to the colonic mucosa is reputed to have anti-inflammatory properties, but whether this can withstand rigorous scientific scrutiny is debat-able.11 The surprise appearance of dog turd, coming so soon after frankincense — a substance steeped in Christmas tradition and reverence — would no doubt jar most modern sensitivities to the core. Turd is an Anglo-Saxon word of ancient origin (proto-European), pushed aside from genteel conversation: “not now in polite use” as the Oxford English Dictionary quaintly puts it. Presumably, dog turd was included for the same “cleansing and purifying properties” that made dried “dogs’ dung” (also known as “pure”) desirable for dressing leather in the 19th century.12 However, as dogs do not suffer from haemorrhoids, we are slightly tempted to think it may have some mysterious power to suppress their appearance. The recipe is completed with honey, aloes Socotrine9 and egg yolk.13 In pharmacy, honey finds use as a demulcent which soothes inflamed mucous membranes. All aloes, in general, act as large-bowel stimulants, promoting the transport of material through the bowel lumen. Its inclusion here was probably to expedite bowel emptying. We doubt whether the author appreciated the minutiae of pharmacological niceties within the range of aloes. He probably specified the Socotrine form more because of availability or price. Egg yolk is slightly alkaline and has the virtue of not being readily broken down by acids or other electrolytes. We believe that in this preparation it was used to bind the active ingredients together. On balance, we feel that this recipe — in its day — would have found acceptance as “a good recipe for the piles”, easing the pain and discomfort of this common condition. However, we are not so sure about the desirability of dog turd as a medicinal ingredient today. 1 Frontispiece of Heister’s surgery text 2 A word on interposita Once a book has left the bookshop, been opened and presumably read, extraneous matter tends to accumulate within its pages. Strangely, for such a common occurrence (and as far as we can tell), this matter seems to lack a collective name. Thus, we would like to suggest the name interposita derived from the Latin — think of it as our Christmas gift to the English language. Interposita gets within books for a variety of reasons. For the greater part, it serves as a bookmark. Over our many years of borrowing public library books, we have encountered bus and rail tickets, envelopes, letters (some very personal), shopping lists and receipts, lottery “scratch-it” cards (in our experience, never with an unclaimed prize), photographs, string, rubber bands, hair pins, religious images (quite common), and once a condom wrapper (in a book on retirement planning!). Less frequently, interposita, as in our current report, may be related to the contents of the book itself, such as a newspaper cutting of a review. Among extraneous interposita, tobacco and cigarette ash were once quite common but not so much now. Thus, interposita can be viewed as miniature time capsules reflecting prevailing social attitudes and practices. Once, a doctor donated a carton of old medical texts to our university medicine history library. His wife reclaimed them very quickly. It seems she was in the habit of secreting bank notes within them, on the assumption neither her doctor husband nor anyone else for that matter was likely to consult these outdated tomes. Our local librarian tells me the strangest object found in a returned book was a partial denture — obviously someone really getting their teeth into the subject matter. 3 The interposita with the “recipe for the piles” enlarged

Mervyn D Cobcroft MB BS, FANZCA · Charles Pembroke-Corgi

Taking a risk and embracing opportunities may yield unexpected benefits I didn’t really know back then why I had to go, but something within me was pushing, and so, I went. I grew up in the United Kingdom and trained there in medicine. During my internship, I realised that I wanted to go to Africa for what were, then, a variety of ill-formed reasons. They included travel, adventure and an attraction to the notion of mission doctoring — doing “everything” while working in an underserved community. Without doubt I was, in part, naïve, but in 1987, straight after internship, I was on my way to Jane Furse Hospital in the black South African “homeland” of Lebowa, 3 hours’ drive north of Johannesburg. It was only later that I learned I had been employed after the other hospital doctors had left because of local violence. Vignette 1: the changing colours of Africa Awake. My first morning in Africa. The night before, my journey from the airport to the hospital had been a nightmare. In a decrepit truck, with companions who spoke no English. On rough roads, in a dense darkness the like of which I had never experienced before. It had taken hours and I had never felt more alien in my life. The scene that next morning, as I wandered across the mission hospital campus, is etched in my mind. The very light itself was different. A cloudless blue sky. Deep red earth carpeted with purple flowers that had fallen from the jacaranda trees. The pinks, purples and reds of the bougainvillea. And, of course, the smiling black faces of the nurses contrasting with their radiantly white uniforms. Yes, this was where I needed to be. I recall having said at my medical school interview that I wanted to do medicine because it offered me the opportunity to help people less fortunate than myself. I’m still not sure who cringed more — me, or the interviewer — but I did mean it. I enjoyed medical school and my internship in a district hospital in northern England, and had been accepted into a general practitioner training program in the Midlands. But first of all I was going to do a year in Africa. Vignette 2: on practising “grass roots” medicine Vusi was 22 years old and had been caught stealing. He was brought into our rural district hospital in poor shape, with a spear through his abdomen and lower chest — some punishment. However green I may have been, I was the only doctor available and so, with help from the nurses, I stabilised him in the emergency room before moving him, as quickly as possible, into theatre. I knew there were only two units of blood in the hospital that weekend. I intubated and anaesthetised him and handed over his care to the student nurse on duty. Then, scrubbed up and with a theatre nurse assisting, I opened his abdomen and repaired multiple small and large bowel lacerations and a liver tear. Vusi left hospital a week later and, in subsequent years, I was often greeted cheerfully by him as I moved around the village. Members of a local church celebrate the opening of a new clinic I had gone to Africa against the advice most teachers and mentors provided — “too risky”, “bad for your career” and “go later, do your training first”. But I went, and after a year I knew that if I wanted to make a real difference, to do something meaningful, to give, then I needed to stay. It seemed to me that those who only stayed for a year or two took more than they gave. I stayed for 12 years and regret not a moment. I gained extraordinary clinical experience, as the workload was so high and we had so few doctors. Within 18 months of arriving, I recall noting that I had seen almost every fracture covered by my orthopaedics textbook — and had become adept at their conservative management. I gave of my limited clinical training and skills, and I received more in return by way of experience. By staying on, as I learned more and more I was able to give more. Always, I received yet more in return. Vignette 3: from patients to protocols and programs Mhlambe watched me, disinterested, with a dull, glassy stare. Eighteen months old but very underweight, he had all the stigma of kwashiorkor — peeling skin, oedema, and thinned red hair. He had the worst type of malnutrition, kwashiorkor plus marasmus. Malnutrition was our second most common paediatric problem (gastroenteritis was the most common). Mhlambe prompted me to develop an evidence-based protocol for the management of malnutrition in place of the previous ad hoc approach, and mortality rates fell as a result.1 A few weeks later, Mhlambe was discharged well and went on to be treated for tuberculosis through another newly developed community program. He finished treatment successfully and his mother became involved in a women’s group developing a vegetable garden and making crafts, helping to address the underlying cause of Mhlambe’s admission — poverty. I spent most of my time at Hlabisa Hospital in KwaZulu-Natal, perched on top of a ridge looking down across the plains to massive forested sand dunes and the Indian Ocean coast. It was a 450-bed hospital with 10 000 annual admissions, serving a population of around 250 000. Usually we had about five doctors, sometimes up to around 10. At times, I was the only doctor available. Vignette 4: evolving research A lazy Saturday morning spent mulling over the events of the week. Obstetrics had been busy that week — I had done 15 caesarean sections, two vaginal breach deliveries and had successfully managed a shoulder dystocia. But I had also signed six stillbirth certificates on Friday. None of the bereaved mothers had been seen antemortem by a doctor and I could still hear their wailing. Something was not right. I wandered over to the obstetrics ward and made a list, from the maternity register, of all the perinatal deaths I could find in the previous 3 months. Then, on to the medical records office where I could obtain and examine the records of these deaths. I estimated the perinatal mortality rate to be about 60 per 1000 (about 10 times higher than the best in the UK at that time). Most of the cases had never been seen by a doctor and it was obvious that at least a third were associated with an error or omission in care. Without knowing it, and with no training, I was doing some health systems research. In response to my findings, I wrote some simple protocols, developed a training program for midwives and doctors in the hospital and village clinics, and visited all clinics monthly to implement the protocols and support the staff. I was doing public health medicine. Within a few months, perinatal mortality was significantly down and hardly any deaths were classed as avoidable. Most importantly, we embedded the changes into routine practice, disseminated our results through publication, and helped others implement similar programs.2,3 Completing one of the 2000 caesaean sections I did during my 12 years in Africa. It soon became obvious to me that clinical services, although very necessary in this environment, were insufficient if the goal was improved population health outcomes. Organisation, systems, processes, an evidence-based and protocol-driven approach to care — all within a population health ethos — are crucial too. In reality, there is no divide and distinction between clinical medicine and public health; each feeds off and complements the other. As we organised and strengthened the clinical service, so we organised and strengthened the community services. We worked hard to integrate the hospital with the clinics, and so to develop a truly engaged service. We also worked hard on priority, high burden diseases such as tuberculosis,4-6 sexually transmitted infections and HIV/AIDS. Vignette 5: engaging the community Petros, thin as a rake, was coughing, bent over, almost retching with the effort. We saw hundreds of cases of tuberculosis each year; the incidence had risen dramatically as the prevalence of HIV increased. A simple audit showed that only about 20% of diagnosed TB cases could be shown to have completed the prescribed 8 months’ course of treatment. Clearly, the practice of 4 months’ hospital admission followed by 4 months’ treatment through the village clinics was not working. First, we adopted a shorter and simpler 6-month drug regimen with admission for only 2 weeks. Then we developed community-based, directly observed treatment using village clinics, with community health workers and a wide range of lay people as supervisors. Documented treatment completion rates rose to over 80%.4 The benefits of community participation included managing an ever-increased disease burden, at lower cost, and with much improved outcomes.6 I went to Africa on an impulse and against all advice. In all honesty, I considered that I was a risk and had very little to give. But I gave what I could — myself, my time, and my commitment. I received so much more in return — extraordinary clinical experience and skills, a deep appreciation of the importance of public health medicine, a range of opportunities to develop clinical, research, and leadership skills, and the privilege of meeting a wide range of fascinating people. Research based on my observations blossomed and, over time, I published more than 100 papers. Seven years ago, I came to Australia as new opportunities and challenges presented themselves. Aspects of the transition were hard, while others were easy. My African experience certainly eased meeting the responsibilities of my appointment as Foundation Chair in Rural Health at the University of Adelaide, where I was instrumental in establishing the Department of Rural Health and the Rural Clinical School. There followed a stint in senior university management, and I am now preparing to take over as Head of the School of Medicine at the University of Queensland at the end of 2006. However, every 6 months I return to Africa to foster my ongoing research there, and for some reason it always feels like going home.

David Wilkinson MB ChB, PhD, DSc

We can put issues on the agenda, but perhaps not achieve reform For Thomas Wakley, the founder of The Lancet, an important function of his journal was to reform medicine, which he saw as full of incompetence, quackery, corruption, and nepotism. He wanted to reform as well as inform. But can journals reform? Can they lead? Are medical journals important for leadership in medicine? Or is this grandiosity on the part of editors? Aren’t journals there to follow, reflect, and comment rather than to lead? Most editors think that journals can lead Drummond Rennie leading us to the promised land of open peer review. Some years ago, I asked various editors if they could provide me with examples of where journals had shown leadership. All the editors — except one — came up with examples. JAMA had led on promoting a tobacco-free society, preventing nuclear war, drawing attention to the plight of the uninsured in America, promoting the control of violence, and encouraging research into peer review. The New England Journal of Medicine had led by describing and deploring the industrialisation of medicine, encouraging health reform, and drawing attention to the importance of conflict of interest. The BMJ had led on fighting tobacco and improving the standard of statistics in medical journals. The Lancet had led with reducing the risk of nuclear war and encouraging the internationalisation of medicine. The Medical Journal of Australia had led with campaigns on smoking, promoting reform of the World Medical Association, AIDS awareness, Aboriginal health, and traffic safety. The Canadian Medical Association Journal had shown leadership by publishing a highly influential series of articles on critical appraisal of scientific papers. One editor disagreed violentlyThe most interesting response came from Stephen Lock, my mentor and predecessor as Editor of the BMJ. He wrote: Stephen Lock, Editor of the BMJ, 1976–1991. There are no examples of where medical journals have led. Nor is it the journal’s role — which is to provide a forum for debate and to publish checked data. In fact, despite what editors say, I doubt whether any publication has done much leading — for instance, the Socialist landslide in [the British general election in] 1945 was probably due to the WEA [Worker’s Education Association] influence in the forces during the war rather than the Daily Mirror, while Ernest Hart’s [great editor of the BMJ in the 19th century, see below] successes owed more to the BMA parliamentary Bills Committee, and his numerous social contacts, than to the BMJ — and even Robbie Fox’s [great Lancet editor of the 20th century] often cited role in the introduction of the NHS was secondary to Moran’s [Lord Moran, Churchill’s doctor] leadership at the RCP [Royal College of Physicians] and in the Lord’s [House of Lords] debate. Think of the contemporary issues — AIDS, health reform in the USA, and the current NHS debate — and you’ll realise how little influence the journals are having, can have, or should have. What does follow-up tell us?One advantage of having asked editors for examples of leadership several years ago is that it is possible to take a longer term look at whether they were examples of leadership. I deliberately did not define leadership for those editors, but my working definition of leadership by a journal is that it achieves a change that would not otherwise have happened. Ironically, the best two examples of leadership from the list involve Stephen himself. Stephen, together with Drummond Rennie from JAMA and John Bailar, statistical adviser to The New England Journal of Medicine, played a central part in prompting the study of peer review. This process, which is fundamental to all of science not only in deciding which papers to publish but also in the giving of research grants, was largely unstudied until these three urged that it should be. There have now been five international congresses on peer review, and a body of research has been created. This has happened almost entirely within biomedicine, but its results are beginning to percolate into other areas of science. I cannot see that this would have happened without the leadership of Lock, Rennie, Bailar, and their journals. Similarly, the work to improve the quality of statistical reporting was led by Lock and the BMJ, together with other journals. The Lancet published an important series on statistics by Austen Bradford Hill, the BMJ published a series called “Statistics at Square One” (which later as a book sold more than 100 000 copies), and Lock and other editors involved statisticians in the peer review process. Many studies showed that the standard of statistics in medical journals was woeful — it is now better (although still far from perfect). This has an importance way beyond journals themselves. Bad statistics means false conclusions. Doctors and patients were thus being misled. Ernest Hart, Editor of the BMJ, 1867–1898, made use of his extensive social contacts to promote the issue of child protection. Can history furnish examples of journals leading? History can help us with trying to answer the question on whether journals can lead, and I want to examine a campaign of Ernest Hart, Editor of the BMJ from 1867 to 1898.1 Hart was a major public figure in a way that no BMJ editor has been before or since. He was highly controversial, believing that, “An editor needs, and must have, enemies; he can’t do without them. Woe be unto the journalist of whom all men say good things.” Hart tried to lead on many issues, but his most prominent campaign was against “baby farming” — giving infants (often bastards) to carers for money, knowing that the carers neglected and even murdered them. In Hart’s first year as editor, the journal carried a story on the inquest of four children who had all died under the care of the same “nurse”. The journal also published several leading articles on the subject. In 1868, Hart advertised in a newspaper as a father-to-be, offering money for adoption. He received 333 replies and identified Mrs X, who had seven malnourished infants living in her care in dreadful squalor. In the previous 2 years she had registered seven deaths of infants younger than 1 year. Articles in the journal led to questions in parliament. More cases were reported in 1870, and Hart formed with others the Infant Life Protection Society. He was also appointed chairman of the BMA’s Parliamentary Bills Committee in 1872. A bill was drafted and enacted in 1872. It proved to be a weak bill, and a much stronger bill was passed in 1877. The problem was not solved. In 1896, Mrs Dyer of Reading was executed for strangling her charges and throwing them into the Thames. The BMJ published a six-part series on “baby farming and its evils”. The child protection movement grew enormously at this time, and the National Society for the Prevention of Cruelty to Children was founded in 1889. Baby farming: infants (often bastards) were given to ”carers“ who neglected and even murdered them. Peter Bartrip in his history of the BMJ concludes: “The Journal did not singlehandedly cause the Infant Life Protection Act to be passed, but it undoubtedly exerted a powerful influence.”1 We can probably never separate out the role of the journal from broader influences, but journals seem to be good at putting issues onto the professional and public agenda. Evidence from media studies Hugh Clegg, Editor of the BMJ from 1947 to 1965 believed that: “A subject that needs reform should be kept before the public until it demands reform.” The question of whether journals lead or follow is similar to the question of whether the mass media lead or follow, and some in the new discipline of “media studies” have addressed exactly this question. The story of Watergate is often cited as a classic case of the media leading people on what to think. It was in June 1972 that five men broke into the campaign headquarters of the Democratic Party. The incident received extensive publicity from The Washington Post, but initially there was little public interest. Yet the press kept on, and by April 1973, 90% of the American population knew the word “Watergate”. In 1974, President Nixon was forced from office. Did the media depose the president? Clearly they did not do so alone, but they played a crucial role. Maxwell McCombs and Donald Shaw have developed the theory of “agenda setting”.2,3 This means that “We judge as important what the media judge as important.” Bernard Cohen, a political scientist from the University of Wisconsin, puts it this way: “The press may not be successful much of the time in telling people what to think, but it is stunningly successful in telling its readers what to think about.” This chimes with a saying of Hugh Clegg, Editor of the BMJ from 1947 to 1965: “A subject that needs reform should be kept before the public until it demands reform.” McCombs and Shaw analysed the 1968 presidential race between Richard Nixon and Hubert Humphrey to see if they could work out whether the media were leading or reflecting public opinion.2 They looked at nine print and broadcast media used by Chapel Hill residents and ranked stories by position and length. They considered five major issues: foreign policy, law and order, fiscal policy, public welfare, and civil rights. They then looked at how undecided voters ranked these issues, and found that they ranked them exactly the same as the media. The 1968 US Presidential election: Richard Nixon v Hubert Humphrey. But which came first: the media agenda or the voters’ agenda? There have been subsequent studies, and the general finding is that the media interest comes first.3 Later work suggests that agenda setting works best when people are interested in a subject but uncertain about what to think.3 For example, I own a dog and hence am interested in animal experimentation, but I am very uncertain about what the risks and benefits might be. Nobody, as far as I know, has conducted any studies like this with medical journals, but it might be that the findings can be generalised from the mass media to general medical journals. If so, journals can put issues on the agenda and do have some influence on how people think about them — a limited form of leadership. Evidence from campaigningJournals do sometimes consciously set out to lead, to make change happen. At the BMJ I was involved with campaigns to encourage explicit rather than implicit rationing of health care, promote an ethical code that could be used by everybody in health care, and revitalise academic medicine. All produced many fine words but none led to change. This may not be because journals cannot produce change, but because we did not conduct the programs well. The Institute for Healthcare Improvement in the US is running a campaign to reduce unnecessary deaths in hospital, many the result of medical error. The campaign is called the “100 000 lives Campaign”, and its slogan is “Some is not a number. Soon is not a time.” (Box 1). Before launching the campaign, the institute studied political campaigns, and identified six essential features: platform, measurement, communication, field, funds, and values. The start is a clear, scientifically sound, highly developed platform or message. Measurement is essential to know if the campaign is succeeding, and communication must be constant, two-way, and involve many different media. Impact will depend on signing up many people and institutions (creating a field force), and the 100 000 lives Campaign has signed up some 2000 hospitals. Funds are essential, but so are explicit values; the values of the 100 000 lives Campaign include “all in” but “staying on message”. I do not know of a medical journal that has campaigned so carefully, and perhaps a more important question than “Can journals lead?” is “What must they do to make change happen?” ConclusionMy cautious conclusion is that journals can lead, in limited ways (Box 2). They might follow the example of the Institute for Healthcare Improvement and more effectively campaign, but their main contribution may be less to try and achieve precise reform and more to put issues firmly on the agenda. In my years at the BMJ, we tried to lead by promoting evidence-based medicine, encouraging doctors and patients to work in partnership, reminding the rich world constantly of its obligations to the poor world, battling against research misconduct, hastening the flow of information to the developing world, securing the independence of medicine from the pharmaceutical industry, and promoting patient safety. History will judge if we have had any success. 1 The 100 000 lives Campaign A: The campaign poster B: Locations of hospitals in the “100 000 lives Campaign”. 2 A hypothesis on factors that might influence the ability of medical journals to lead One hypothesis, no more, is that journals will be most successful in leading when it is on a topic that is of direct concern to them and where they work together. The successful example shown is the registering of clinical trials. In contrast, the work of the rationing agenda group was not directly concerned with journals and involved only one journal: it failed.

Richard Smith MB ChB, MSc, FRCP

The presumption that fictional characters may have real diseases is nothing new. The description of mental illness is a constant feature in literary criticism, and with increasing frequency, descriptions of physical afflictions suffered by literary characters have been showing up in the medical literature. Various characters have even lent their names to medical syndromes — who doesn’t know that Pickwickian Syndrome derives its name from a character in Charles Dickens’ Pickwick Papers or that the Lilliputian Syndrome derives its name from the land of little people in Jonathon Swift’s Gulliver’s Travels?1 However, characters in children’s literature have been less well examined for physical maladies. Save for a recent article on head trauma in nursery rhymes,2 this area seems largely unexplored. We propose that children’s literature provides a wealth of descriptions of disease states; one only has to look. Consider the following as examples. Winnie the Pooh The tale of Winnie the Pooh, A A Milne’s good-natured but bumbling bear, seems on the surface to be a simple children’s story. However, examining Mr. Milne’s hero in a medical light casts a different shadow — that of a short, heavy-set, polyphagic bear. It is not difficult to appreciate the relative corpulence of Winnie the Pooh. In fact, it is well described. In Chapter 2 of Winnie the Pooh, Pooh becomes lodged firmly in the doorway of his friend Rabbit’s house as a direct result of his generous girth.3 Does he, however, have true truncal obesity? To test this theory, we measured the classic Pooh doll belonging to one of our daughters. The waistline measurement was found to be 37 cm; the hip circumference was 38.5 cm. This gives a waist to hip ratio of 0.96, well over the 0.9 necessary to define abdominal obesity. This got us thinking . . . Could Pooh be an early example of the metabolic syndrome? By World Health Organization criteria, he would also need to have hyperinsulinaemia and hypertension or dyslipidaemia.4 While it is difficult (if not impossible) to measure the fasting plasma glucose level and blood pressure of a fictional character, we do believe that Milne left clues for us to follow. The first is that Pooh is always hungry — the polyphagia of impaired glucose tolerance. The second is the very nature of his food — as everyone knows, honey-coated translated to Latin is mellitus. We think that Winnie the Pooh may be a very appropriate spokesperson for metformin. Humpty DumptyHumpty Dumpty sat on a wall, Humpty Dumpty had a great fall, All the king’s horses and all the king’s men Couldn’t put Humpty together again. So, what caused the massive trauma that apparently befell Humpty Dumpty? The classic image of this character is that of a large egg, which has fallen from a wall. However, the origin of this image is exceedingly unclear. Might it, in fact, be that Humpty Dumpty was actually not an egg, but rather a human with eggshell-like bones? We propose that Mr Dumpty actually suffered from osteopetrosis, a rare disorder characterised by impaired resorption of bone by osteoclasts.5 The resulting bone is exceedingly dense and can, in severe cases, crowd out haematopoietic cells. This results in exceedingly brittle bones, and affected individuals have frequent fractures, not infrequently from “great falls”. Also, with the displacement of the marrow, extramedullary haematopoiesis is common and frequently causes hepatosplenomegaly.5 Is it possible that Mr Dumpty acquired a distended abdomen as a result of organomegaly, producing a torso that was egg-shaped? Furthermore, the resultant anaemia may lead to pallor, causing the skin to assume a colour reminiscent of an eggshell. The possibility that Mr Dumpty represents the first described case of osteopetrosis is high, and should be investigated further. Goldilocks and the three bearsIn this classic tale, Goldilocks happens upon the three bears’ house. She samples all of their food, angrily rejecting their porridge as either too hot or too cold. Then, after finding the perfect bed, she falls into a deep sleep. These are all horribly inappropriate things to do in a stranger’s house. In this story, we appear to have hypersomnia, polyphagia, social disinhibition, and irritability — all strongly characteristic of the Kleine–Levin syndrome.6 This syndrome typically (though not always) occurs in adolescent males, and involves periods of hypersomnia followed by megaphagia. While Goldilocks does not exhibit the hypersexuality frequently associated with this disorder, she does display its characteristic irritability, confusion, and impulsive behaviour. As for the apparent reversal of the sleep–eat phase in this story, it is highly likely that Goldilocks had awoken from sleep immediately before the initiation of the tale. Little Boy BlueLittle Boy Blue, come blow your horn The sheep’s in the meadow, the cow’s in the corn, Where’s the little boy who looks after the sheep? Under the haystack, fast asleep. To conventional thinkers and many a child, this rhyme conjures up an image of a lazy little boy, dressed all in blue catching an ill-timed nap while his chores go unfinished. We suggest an alternative hypothesis. As individuals can change their clothing quite easily, it would be folly to record for posterity a rhyme based upon colour of the the garments of a small child. On the other hand, what if the “blue” represents some intrinsic property of the individual? We propose that Little Boy Blue was actually cyanotic, causing a bluish hue in his skin. Examining the rest of the data available in the rhyme, it would seem likely that Little Boy Blue was born with the rare Taussig–Bing syndrome (a ventricular septal defect located immediately below the pulmonary valve).7 This causes transposition of the great vessels and subsequent pulmonary hypertension. Severe pulmonary hypertension doubtlessly led to shortness of breath and fatigue, necessitating frequent sleep. The act of blowing a horn would undoubtedly decrease venous return by increasing intrathoracic pressure and causing a relative decrement in the forward flow of blood. It is not difficult to imagine that this would be unsettling to anyone with already compromised respiratory function, let alone a small child. Little Boy Blue was not lazy; he merely needed a cardiothoracic surgeon. Modern examplesRaggedy Ann is a well known red-haired character (as is her male counterpart, Raggedy Andy, who must be mentioned for the sake of political correctness). To even the most casual observer, Ms Ann does not appear to be the picture of health. Immediately noticeable is the straight, coarse, red hair surrounding a plump, round face. Further investigation and more careful physical examination reveal in Ms Ann more subtle signs of disease. Vital signs show Ms Ann to be hypothermic (in fact dangerously close to poikilothermic) and underweight. Further dermatological inspection shows her to have extremely dry skin. Neurological evaluation shows some degree of muscle flaccidity and perhaps even atrophy. Given these findings, it seems entirely likely that Ms Ann suffers from protein malnutrition, or more specifically, Kwashiorkor.8 Ms Ann is apathetic about this probable diagnosis (and everything else for that matter), which is also a symptom of the disease. The trend continues. Modern day characters exhibit modern day afflictions. A certain olive-colored, swine-loving amphibian host of a children’s television show appears to be suffering from a variety of maladies. His most striking feature is his greenish hue; but we should not overlook his obvious exophthalmos, absence of a visible nose, hyperkineticism, and loss of coordination. A MEDLINE search gives a possible unifying answer for this constellation of symptoms: exposure to nitromethane. As this chemical is a common synthesis intermediate in agricultural fumigants and biocides, it is likely that this unfort-unate’s pond was exposed. National Toxicology Program studies of toxicology and carcinogenesis related to nitromethane in F344/N rats and B6C3F1 mice show that this chemical can cause hyperactivity and loss of coordination; hepatomegaly; anaemia; increased methaemoglobin concentration; and exophthalmos along with olfactory degeneration.9 This character’s protuberant eyes and lack of nasal structures are self-evident. We postulate that his greenish hue is in fact a combination of anaemia and increased bilirubin level from methaemoglobinaemia, worsened by hepatic dysfunction. His anaemia may be severe enough to cause a peripheral cyanosis, with his jaundice and cyanosis combining to cause a greenish colouration. ConclusionWe believe we have made nothing short of tenuous arguments that nursery rhymes and other popular children’s literature are often thinly veiled references to chronic disease states. We advise physicians to become observant of the literary works that their children and grandchildren enjoy, and, if possible, to subject them to the rigour of evidenced-based medical analysis. This might be an activity that brings the whole family together.

Brown J McCallum MD · Stuart M Smith MD

Emergency department (ED) overcrowding is the most serious issue confronting EDs in the Western world.1 As a result, diversion of ambulances to another hospital has become commonplace. This is primarily due to access block — patients in the ED requiring inpatient care are unable to gain access to appropriate hospital beds within a reasonable time frame.2 A reasonable time frame is defined as up to 8 hours spent in the ED by an admitted patient.2 Adverse events associated with ED overcrowding and ambulance diversion have been reported. These include impaired access to emergency care, compromised clinical care, prolonged pain and suffering, and prolonged inpatient length of stay. These adverse events have also been linked to fatalities.3,4 To date, no studies have examined the mortality rate associated with ambulance diversion. I hypothesised that, during periods of ambulance diversion, patients in the ED would have a higher eventual mortality rate, because ED staff, stretched beyond their capacity, may not be able to provide safe care. Methods By placing "No Entry" signs at the point of ambulance entry, we could save thousands of lives each year. All periods of ambulance diversion at Royal Perth Hospital ED for the calendar year 2003 were studied. That year’s ED attendances numbered 51 885, with an admission rate of 43%. Of all attendances, 38.3% arrived by ambulance. The rate of access block during the study period was 30.7%. Each episode of ambulance diversion was recorded as day, date, start time, and end time. From this, the 1-hour period before ambulance diversion (pre-diversion) was determined. (This was considered to represent the period of greatest risk for patients). For comparative purposes, an identical time series was constructed for when the ED was not on ambulance diversion. For example, if the ED was on ambulance diversion on a Wednesday from 11:00–14:00, then the pre-diversion period was 10:00–11:00 and the comparative period becomes the Wednesday 1 week later, assuming that the ED was not on diversion during that period. If it was, then the preceding Wednesday was chosen as the comparative period. If that period was on diversion, then the Wednesday 2 weeks later was used, and so on. This was to allow for valid day-to-day comparisons, and to avoid seasonal variations. The record of each patient episode refers to the period (pre-diversion, diversion or the respective comparison periods) during which the patient arrived at the ED. To avoid duplication of patient episodes, once patients attended the ED, they remained in that defined episode. For example, if a patient arrived at the ED in the pre-diversion period and subsequently died, that death was attributed to the pre-diversion period (even though this patient may have still been in the ED during the diversion period). These data were linked with EDIS (Emergency Department Information System) and TOPAS (The Open Patient Administration System) for each patient attendance. TOPAS is an administrative computer system that, among other things, records patient outcomes, such as discharge or death. The outcome measure used was death. (Deaths were those deaths that occurred at any stage while the patient was in hospital, from the ED to the wards.) In this retrospective data-linkage study, data were analysed using SAS version 9.1 (SAS Institute, Cary, NC, USA). A negative binomial model was used because it is equivalent to the Poisson model. However, the Poisson model assumes that the variance and means are the same, whereas the negative binomial model does not make that assumption. Fit was assessed using deviance and χ2 tests. ResultsThere were 297 episodes of ambulance diversion in 2003. Paradoxically, the results show a statistically significant 28% reduction in patient mortality for patients attending the ED during periods of ambulance diversion (Box). DiscussionPatient safety, as measured by eventual mortality, appears to be positively enhanced by ambulance diversion. That clinical staff are able to meet the clinical and safety needs of their patients during ambulance diversion has profound implications. From my data, it is possible to calculate the number of lives saved by ambulance diversion. The difference in mortality (1.87% minus 1.34%) is 0.53%, which is equivalent to 29 of the 5445 patients; extrapolating this to an annual figure (0.53% of the 43% admissions of 51 885 annual attendances) means about 118 lives saved per year at our hospital alone. Nationally, there are about 4 million ED attendances per year. Assuming a national admission rate of 30%, there is potential for ambulance diversion to save 6360 lives a year in Australia. It is recommended that, to realise these safety gains, health authorities should steadily increase the prevalence of ambulance diversion. Further research is needed to examine the effect on mortality of increasing access block. As there is an almost linear correlation between access block and ambulance diversion,3 it is likely that increasing access block to 100% might result in three times as many lives saved. Episodes of ambulance diversion and patient mortality rates Period Number of patients Number of deaths P Incidence rate ratio (95% CI) Pre-diversion period (1 h) 8679 137 (1.58%) Comparative period (1 h) 7175 100 (1.39%) 0.34 1.13 (0.88–1.46) Diversion period 5445 73 (1.34%) Comparative period (not on diversion) 8245 154 (1.87%) 0.018 0.72 (0.61–0.95)

Daniel M Fatovich MB BS, FACEM

Reading my emails in the lead-up to the Christmas season, I find myself asking, Has everyone got a generous big brother out there, or am I the lucky one? I have reason to believe that somebody is watching me and knows every tiny detail about my health and wealth. Of the 60 or so emails I receive daily, only a few are from people who have no concern about my wellbeing. For example, there could be one from the Medical Journal of Australia asking me to review an article within 3 days. They could not care less if my wife is sick or my daughter has an exam. Then there is the last reminder from the College about my annual subscription fee. The bank manager emails me about my account, which is already overdrawn over the overdraft. The rest of the emails are from well wishers and fellow human beings. For example, there is one from a friend who is the orphan of an African cocoa and gold magnate. His father told him on his deathbed about the 5.6 million American dollars and gold deposits in a US bank. Now that he has turned 21 he is able to get hold of the money, with my help. All I need to do is start an account in Australia. With the 10% my brother is promising me from this deal, my financial worries will be over. I could retire early and even go to Ivory Coast to have a holiday and meet him. But things are not that simple. I have another friend in the Middle East who says he found my name through “top personnel in society and in aid groups”. He reassures me that the petroleum company he is working for is loaded. So he over-invoiced the company and has transferred 27.5 million dollars to a bank in the US. He would love to meet me in a neutral country like Spain to see how he can transfer the money to Australia. He will pay me 10% too. I have decided to take the second option, as I would like to go to Spain. I have asked him to organise my flights. I could take my wife with me too. An external auditor of a bank in Africa wants to have a partnership with me. He has found $95 000 in an account and would love to transfer it to Australia. If I send him my account number, the money can be transferred the next working day and I will receive 40% of the amount. He will look after the legal and banking issues. I wish we had banks like that here! Teaching and research are not well remunerated. My wife was keen for me to do some extra work. Fortunately, the following job offer came: “Requirements for work with us: age from 20 till 60 years, inhabitant of Australia, opportunity of Internet connection, opportunity to check email not less than 3 times a day, the bank account in Australia, the responsibility, accuracy and punctuality, knowledge of the basic purposes of household and office technical equipment”. It seems I have all the essential qualifications except being punctual. They will offer me the job straight away if I send them my bank details so they can transfer my commission without delay. It looks like they mean business, and the appointment process is nothing like where I work! Maybe I will wait till I come back from Spain. It’s amazing how word gets around. How did they know that I have erectile dysfunction? I do hope my doctor (or wife again) has not dobbed me in. It’s hard to understand why a drug that is supposed to help with erectile dysfunction is called “soft” Viagra. Another email is about plain Viagra — ordering it is fast and secure. A third email offers me a discount on these tablets. But I love the next email. It says if I try a certain drug I will forget all my failures in life. (Like the five attempts at the Fellowship?) Should I wait till I come back from Spain before ordering it? I am in a real fix. The cheaper version of the drug promises that all my dreams will come true and that I will win my game. I wonder if they know that I am not the sporty kind! It also promises to harmonise my feelings (whatever that means!). Even before I bought it I had an offer of refills. And how did they know I don’t have a PhD? A recent email reminds me that the only thing stopping me from getting a better job and better pay is not having a PhD. (No doubt my wife contacted them.) Apparently they found a loophole in the regulations, and if I send the money straight away, the PhD can be mine in 2 weeks. Moreover, no study is required, so I can go to Spain without any worries. The only thing they have not found out about is my baldness. I am still waiting for that email with the quick remedy. Hope it’s not a curly one! All these emails have restored my faith in humanity. I am thankful to you, my brothers (and sisters), for thinking about me and for your desire to help me. All my Christmases have come at once! Merry Christmas to all my correspondents. I look forward to a prosperous, healthy, funfilled and happy new year with your blessings.

Balakrishnan R Nair FRACP, FRCP

Objectives: To determine whether weather conditions affect emergency department (ED) attendance and admissions from the ED.Design and setting: A retrospective observational study in a large metropolitan ED.Main outcome measures: ED attendance (total and via ambulance) and admissions to hospital from ED, as a function of weather variables.Results: On warm, dry, sunny and good weather days there were significantly more ED attendances in total than there were on cool, rainy, dull and bad weather days, respectively (P ≤ 0.001). There were significant correlations between ED attendance and temperature (r = 0.36, P < 0.001), rainfall (r = − 0.20, P < 0.001) and hours of sunshine (r = 0.17, P = 0.001). Attendance via ambulance was not affected by weather variables. Admissions from the ED were positively correlated with temperature (r = 0.15, P < 0.01) and negatively correlated with rainfall (r = − 0.12, P = 0.02).Conclusions: As there is a clear relationship between weather conditions and ED attendance, incorporating meteorological forecasting into emergency medicine training may improve ED scheduling. To improve the morale of ED staff coping with an onslaught of patients on good weather days, the ED environment should simulate sunny weather, with swimming pools, sun lamps, palm trees and Beach Boys music.

Daniel K B Ou MB BS · The-Phung To BPharm, MClinPharm · David McD Taylor MD, MPH, FACEM

The public image of psychiatry could be better. Just three of the perceptions held by the community are that psychiatrists are loopy, that their treatments are ineffectual, and that the profession is too removed from mainstream medicine. Turning around such strong public opinion is no easy task, and possibly unachievable. Or so I thought until earlier this year. Saturday 21 May dawned a crisp and clear day, albeit a little breezy. A quick shower and breakfast, then I was out the door with my son Adam for his Under 8 soccer match. After a wind squall midway through the first half of a gripping encounter, one of Adam’s team mates, Brad, suddenly clutched his right eye and began to scream, then ran towards his mother on the sideline. The match was temporarily suspended, and parents from both sides formed a huddle around Brad and his distraught mum, the sense of helplessness profound. Little did anyone know that, over 20 years ago and before commencing psychiatry training, I had spent a term at Sydney Eye Hospital and that, despite limited opportunities since, I still fancied my skills in this area over the next person. I decided to intervene. Brad’s right eye was swollen and watering profusely. “Is the pain worse when you blink?” I enquired. Brad nodded, sobbing. Without further ado, I gently pulled his right upper eyelid towards me by its lashes and slowly everted it. The sight of the lid’s inflamed inner conjunctival surface caused some parents to step back, others to look away and many to wince, but my focus was now on a speck of dirt, trapped under the lid, that beckoned, seductively, “Garry, I’m yours”. Without averting my gaze, I requested a clean tissue and an onlooker obliged by inserting one into my free outstretched hand. A deft dab saw the foreign body gone and Brad once more a “happy camper”. For the hero, of course, the trick on such occasions is to give the impression that these actions are all in a day’s work by making no fuss, by politely shrugging off backslappers, and by quickly resuming one’s previous activities. Accordingly, when the game restarted, I was the first to recommence barracking: “In there, Adam!”, “Defence! Defence!”, “Nice tackle Kevin!”, and so on. At the same time, I was very mindful of the sorts of conversation taking place nearby: “They say he’s a psychiatrist.” “Surely not?” “Yep, a shrink.” “You don’t say . . . Wow!” Now a psychiatrist’s self-esteem and the public image of a profession should never hinge on a fortunate turn of events, as occurred during Round 7 of the 2005 Under 8 Ku-ring-gai District Soccer Competition. Nevertheless, while I do not pray that a gale blows during every soccer game in which my son plays, I confess to now following the weather forecast more closely and to not minding the occasional stiff breeze on match days. I even keep a box of tissues handy. I have also recently reminded myself how to reduce a dislocated shoulder. Just in case.

Garry J Walter PhD, FRANZCP

The must-have health guide. 2nd ed. Margaret Stearn. Oxford: Heath Press, 2005 (vi + 378 pp). ISBN: 1 903734 75 4. Anyone with young children or familiar with children’s literature will know there has been an explosion in the number of books about bottoms. Titles such as The day my bum went psycho and The bugalugs bum thief (the latter by Tim Winton no less) are on high rotation in most school libraries. UK physician Dr Margaret Stearn’s The must-have health guide perhaps represents an expansion of this publishing phenomenon into the area of consumer health. As the title page advises, the book focuses not on respectable medical conditions such as diabetes, but on “life’s embarrassing problems”. Its concerns are the floppy, the spotty, the leaky, the smelly and the discharging. Hiccups, blushing, bad breath, snoring, shaky hands, and shyness are the only topics covered that don’t directly relate to breasts, bottoms, genitals, blemishes of skin and appendages, or urination. Surprisingly, even after 35 years of women’s magazines covering every aspect of sexual anatomy, function and disease, genital conditions still constitute the bulk of embarrassing health problems, at least according to Stearn. Alphabetically organised by problem, from acne to wind, the information (including treatment), is fairly detailed, readily comprehensible, and eminently practical. Unlike most self-help guides The must-have health guide is evidence-based, providing frequent references. Each problem entry concludes with a list of contacts. While most of these are UK based, they all have web addresses. The tone of the book is English in a rather brisk, no-nonsense but not unfriendly way. It’s a little like having a very knowledgable aunt in a thick tweed skirt and sensible shoes, a slight twinkle in her eye, ever ready with practical advice. For instance, in the “small breasts” section Stearn provides extensive information about breast implants, but reminds us that small breasts are “just as functional as large ones, get less droopy, are a kilo less to carry around and are good for sports”. The book is also studded with more whimsical pieces of information. Did you know, for example, that a study of male Mensa members showed they had thicker body hair than average, and the most intelligent had hairy backs? For those embarrassed by crab lice, faecal incontinence or urinating during sex — and let’s face it, most of us still are — this is an extremely helpful guide. Simon C CowapGeneral Practitioner Newtown, NSW

Simon C Cowap

Beyond borders. McGraw-Hill’s guide to health placements. Hamish Graham. Sydney: McGraw-Hill, 2005. (xiv + 98 pp $19.95). ISBN 007471552 6. It is not that often that a small book delights me as much as this one did. There was, I found, much to enjoy. Written by a senior medical student, the proceeds go to Médecins Sans Frontières, and it is all about health science students and health professionals undertaking successful placements overseas. I am surprised at how many of my medical colleagues have never worked or studied overseas. As somebody who has globe-trotted excessively I suppose I have a biased view, but I believe you can tell who has been overseas, and how it has touched them — usually in a positive way. Travel and work overseas is not without risk of course. When doctoring in Africa most medical students I knew of had a fine time, but there was a tragic death (from a car crash), an occasional case of malaria, plenty of gastro, and one very embarrassing case of gonorrhoea. Most of these risks, and a range of others, are at last touched on in this pocket-sized book, providing a wealth of useful information in a very lively and friendly format. I particularly liked the many quotes that seek to inspire travel. Scattered throughout Beyond borders are a series of case studies that students and doctors will find very useful, prompting them to think carefully about what they face, without seeking to dissuade them from embarking on a very likely life-changing experience. Well done! David WilkinsonDeputy Head, School of Medicine University of Queensland, QLD

David Wilkinson

A bloke’s guide to keeping it up down under. A sexual health guide. Beth Quinlivan. Melbourne: Ibis Publishing, 2005 (175 pp). ISBN 1 920923 96 9. Hmm, I thought, Hmm, I thought, when I received A bloke’s guide to keeping it up down under to review. What is a woman doing writing on this topic and, what’s more, a woman about whom I know nothing? A quick search of the Internet revealed that my not knowing about Beth Quinlivan reveals more about me (and my rather provincial life) than her presumed anonymity. As a medical journalist for the BRW and the Financial Review, Quinlivan has ample justification for writing on men’s issues. Add the cooperation of psychologist, Michael Young, and you have both writing skills and a genuine knowledge of men’s sexual health issues. At the outset they reveal a conundrum — despite the available plethora of (at times quite candid) information on sexual issues, men’s sexual health is not improving. The authors propose that information alone does not equate to an education — “the real key to improving men’s health”. With that I agree, and although this almost pocket-sized book cannot result in “an education”, it goes a long way towards providing a succinct and relevant body of information for the average Aussie bloke. As an educational tool for men and their partners it succeeds. Although small in size it is big in content and, more importantly, has a certain degree of street savvy in terms of content and layout. It is well organised in a series of chapters starting with basic male sexual anatomy and physiology and then progressing through the four major pelvic issues of sexual dysfunction, male cancers, STDs, and fertility. It is perhaps not surprising that erectile dysfunction gets its own chapter, since Viagra has ensured its status as the male disorder of the last decade; but it’s disappointing that BPE/BPH (Benign Prostatic Enlargement; Benign Prostatic Hypertrophy) doesn’t get a guernsey. It is noteworthy that dotted throughout the book are competent warnings on issues rarely mentioned elsewhere. For example, the need for urgent action when a priapism occurs, the need for care in the controversial issue of hormone therapy in the older male, and the “brave new world” problem of clinics that advertise (and dupe men into believing that only they have the answers). Although the book has a good array of diagrams, I felt there could be more, especially in the early chapter on anatomy. As well, there is no index, an essential element of any book. In the discussion on circumcision, there is no mention of the possible scarring and deformity of the glans penis and shaft. As well, it would have been helpful if the relative incidence of the “pros and cons” of circumcision were added, an important element for discerning real risks and benefits. A lot of thought and effort has created a quality book that I hope will become a companion for a lot of men. Beth Quinlivan (with Michael Young) deserves much praise. Denis J CherryMedical Director Perth Human Sexuality Centre, WA

Denis J Cherry

The essential guide to herbal safety. Simon Mills, Kerry Bone. Missouri: Elsevier Churchill Livingstone, 2005 (xvi + 684 pp). ISBN 0 443 07171 3. With the dramatic growth in the use of herbal medicines, consumers and practitioners alike need to access reliable information on the safety and efficacy of herbal medicine. The essential guide to herbal safety is extremely topical and fills a considerable gap in the literature. This is an outstanding reference text on herbal safety that deals not only with a range of critical issues (safety monitoring of herbal medicines, herb–drug interactions, quality control), but also provides a series of exemplary monographs on herb safety. The text brings together contributions by acknowledged experts in the field. The safety monographs contain useful information on the current regulatory status of each herb in selected jurisdictions. The LD50 data for various extracts of the herb serve to highlight the relative risk represented by different extract forms (water, ethanol, etc) and the role of individual phytochemical constituents. Categories descriptive of known toxicity in pregnancy and lactation are provided for each herb. I would have liked the authors to provide similar toxicological categories or grades for general consumers, however this would have required substantial input by clinical toxicologists. Overall, the text is extremely well researched, integrating various data sources. It is an excellent book to have in hand and will undoubtedly become an important resource. At just over $100, The essential guide to herbal safety represents outstanding value. Alan BensoussanDirector, Centre for Complementary Medicine Research University of Western Sydney, NSW

Alan Bensoussan

The fetal matrix. Evolution, development and disease. Peter Gluckman, Mark Hanson. Cambridge: Cambridge University Press, 2005 (xiv + 257 pp). ISBN 0 521 54235 9. This is a remarkable book by two authors who have both worked at the very top of fetal and perinatal biology for decades. They hypothesise that much of adult chronic disease can be explained by a series of predictive adaptive responses made by the fetus during intrauterine life. By these responses, triggered by changes in the intrauterine environment, the fetus attempts to change aspects of its growth and development in a way that may favour postnatal survival. In a sense, the intrauterine environment is taken to be a predictor of life outside the womb, which may well be very different from the fetal prediction. It is put forward that these interactions of gene and environment are ultimately responsible for many of the health problems of adulthood including obesity, hypertension, diabetes and the vascular consequences of atherosclerosis, stroke and myocardial infarction. The story does not require an in-depth understanding of either genetics or fetal physiology. In fact, the authors gently introduce some of their concepts with basic information about reproduction and the influence of genes on embryonic development, before developing their ideas in greater detail. The narrative writing style is easy to follow and there is an extensive bibliography for anyone interested in further study in this field. The book ends with a discussion of how a better understanding of these concepts might help to prevent adult disease, and the possibilities that may exist from manipulating both the prenatal and postnatal environments. While some of this is speculative, the authors develop a compelling argument for governments to fund research in the field of developmental biology. They argue strongly that there needs to be a “big science” approach, with the funding of long-term studies that begin long before pregnancy and continue into adulthood. If the authors are correct, this kind of investment may also pay dividends for other scourges of modern civilisation such as breast and prostate cancer, and Alzheimer’s disease. This work has the potential to be recognised as a landmark publication that influences scientific thinking for decades. It should be of interest to anyone who is involved in any aspect of human medicine and biology, particularly those working in the field of perinatal medicine. David A EllwoodProfessor of Obstetrics and Gynaecology The Canberra Hospital, ACT

David A Ellwood

Allen E Gale Physician (Allergy), Adelaide Aerobiology Laboratory, PO Box 401, Hindmarsh, SA 5007. agaleATagale.com.au To the Editor: I have had increasing pain in my right hip over recent years, which now appears to have been caused by pressure from the lateral wing of the bucket seat in my car. The use of the right leg for both the brake and accelerator (my car is an automatic) explains why the pain is unilateral. The discomfort, which became intolerable recently when I was on holidays and driving an automatic hire-car with stiff bucket seats, was relieved by sitting on a roll of towelling! The diagnosis was finally confirmed by ultrasound. The report revealed that “a small amount of fluid was present in the greater trochanteric bursa. Pain was accurately localised to the bursa over the greater trochanter . . .”. My wife has suggested an appropriate name for the condition — “bucket seat bursitis”. She has already discovered that only three modern car manufacturers offer a flat seat as an alternative to bucket seats. I have now had the offending bucket seat wings removed at modest cost without disfiguring the seats. I wonder how commonly this condition occurs and why the old bench-type seats were replaced by bucket seats?

Allen E Gale

Joseph M Rey Professor of Child and Adolescent Psychiatry, University of Sydney, Sydney, NSW. jmreyATbigpond.net.au To the Editor: Yet another report has been published highlighting the parlous state of mental health services in Australia and the plight of the mentally ill and their families.1 In the words of Mr Keith Wilson, Chairman of the Mental Health Council of Australia, they are the “untouchable and untouched”,2 the pariahs of Australian society. Summarising the findings of the report is unnecessary, as the issues (poor access to services, lack of continuity of care, and a dwindling workforce among others) have been much in the public eye and are all too familiar to most medical practitioners. More important is whether this report will succeed in generating change for the better where scores of others have failed. The difference this time is that consideration has been given to a Commonwealth Solution:2 the Commonwealth government taking over the management and funding of these services across Australia. As state governments have made such a mess of mental health services and have repeatedly failed to sort out the well known problems, that seems an attractive option. This solution would stop passing the blame between the states and the Commonwealth, would reduce cost-shifting, may standardise (if not improve) care across Australian jurisdictions, and may result in more adequate funding. There might be light at the end of the tunnel after all. The counterbalance is that having the Commonwealth in charge of mental health services will pose new problems, least of which is the creation of a parallel health bureaucracy. One of the few achievements of the past 30 years has been the “mainstreaming” of mental illness; that is, bringing psychiatric disorders out of the asylums and into the general health services and hospitals. If the Commonwealth takes over, demarcation disputes between mental health and general health services are likely to flare up, especially in emergency departments and hospital wards. Because general health services are themselves stretched and under-funded, clinicians and administrators will be tempted or even forced to push mental health patients out of the general hospitals and try to unload anyone with psychiatric problems, whether physically ill or not, into the Commonwealth-run services. “Mental illness is no longer our responsibility”, many relieved administrators and clinicians will say. Endless arguments and meetings will ensue about where these Commonwealth-run services should be located and where patients with both mental and physical illness belong. The only way to avoid this retrograde leap would be for the Commonwealth to take over all health services — too simple and rational a solution to be adopted. As the report eloquently depicts,1 mentally ill people and their families are desperate. In that context, any change can be perceived as better than nothing, certainly better than the hopelessness that currently pervades these services. Such a solution may also be tempting to a stretched and demoralised mental health workforce.3 Can the Commonwealth be more effective or enlightened than the states? The Commonwealth’s track record of compassion, of emphasising individualism, the survival of the fittest, does not augur well for its ability to care for the mentally ill. By and large, psychiatric patients are neither the “fittest” nor the best equipped people to compete in a free marketplace. The Commonwealth does have a track record of expediency. In that context, it is not too far-fetched to imagine the now empty refugee detention centres being reconditioned into outback psychiatric facilities for the severely disturbed. “This is a provisional but necessary measure to meet the urgent need for more psychiatric beds” will undoubtedly be the words used by the incumbent health minister. We may even be blessed with a “Pacific Solution” to mental illness.

Joseph M Rey

Jim Siderov Senior Pharmacist, Cancer Services, Austin Health, Studley Road, Heidelberg, VIC 3084. jim.siderovATaustin.org.au To the Editor: Acetylcysteine (Mucomyst [Bristol-Myers Squibb, Melbourne]) is a mucolytic agent commonly used as adjuvant therapy for patients with abnormal, viscid or inspissated mucous secretions in such conditions as chronic bronchopulmonary disease. It is administered as fine nebulae, and its adverse effects in this form are minimal. Patients may observe an initial slight odour, or stickiness on the face after nebulisation. When acetylcysteine is nebulised using a normal nebuliser it produces a dense mist. One of the less well known adverse effects of the medication was recently observed at a major teaching hospital, when an acetylcysteine cloud activated the hospital’s fire alarm! Medical, nursing and pharmacy staff need to be aware of this potentially embarrassing situation. To help alleviate the problem, acetylcysteine can be administered via a jet nebuliser, similar to that used to administer the antimicrobial pentamidine. The jet nebuliser uses an air or gas stream to break liquids up into smaller particles, decreasing the droplet size and thus eliminating the dense mist.

Jim Siderov

A 62-year-old woman presented to the emergency department with a persistent cough and severe abdominal pain. Computed tomography showed the rare condition of a spontaneous rectus sheath haematoma on the right side (Figure A). The patient commented that her husband had been suffering the same symptoms for days, and that he was taking warfarin therapy. Six hours later, he presented to the same hospital with a matching rectus sheath haematoma on the left side (Figure B), and required blood transfusion. This completed a “marriage of inconvenience”, but did bring them closer to marital bliss — they shared a room in hospital, although in separate beds! Spontaneous rectus sheath haematoma is very rare. Coughing can rub the inferior epigastric artery or its perforating branches against the free posterior edge of the rectus sheath. Clinical suspicion should be raised in the elderly patient taking anticoagulant therapy. To our knowledge, this is the first reported case of simultaneous presentation of rectus sheath haematoma in family members. Computed tomography scans of matching rectus sheath haematomas in a married couple.

David James FRACGP, GradDipSurgAnat · D Ong Hii FRACS · Nathan Lawrentschuk MB BS

A middle-aged man with type 2 diabetes was brought to hospital with a history of loss of consciousness for an unknown period of time. He had refractory hypotension and hypoglycaemia. A magnetic resonance imaging scan showed an infarct in the splenium of the corpus callosum (Figure). The splenial infarct resembled a “boomerang”, which is characteristic.1 Strokes involving the splenium of the corpus callosum are associated with hypoperfusion,2 and can be seen in association with metabolic changes such as hypoglycaemia, hyponatraemia, hypernatraemia, and renal failure.1 Magnetic resonance image: axial FLAIR [fluid-attenuated inversion recovery] sequence, showing boomerang-shaped signal hyperintensity in the splenium of the corpus callosum.

Jeyaraj Durai Pandian MD, DM · Robert D Henderson MB BS, FRACP

A 25-year-old woman with clinical depression was referred with vague epigastric pain and early satiety after meals for 6 months. Abdominal examination revealed an indentable J-shaped mass in the epigastrium. A barium meal examination was subsequently carried out. The image shows a whorled, stippled mass occupying the stomach, forming a ‘J’ shape. The most likely diagnosis was a trichobezoar. Bezoars are of different kinds and commonly include hair (trichobezoar), vegetable fibres (phytobezoar) or medications (pharmacobezoar). About 90% of bezoars are encountered in women, and about 10% of these patients have a psychiatric disorder. The patient underwent exploratory laparotomy with gastrotomy and removal of a large hairball, which had an extension into the duodenum.

Guneesh Dadayal MB BS · Dipesh D Duttaroy MB BS, MS · Sashidhar Yeluri MB BS, MS

During routine colonoscopy we were surprised to find this sign of peace produced by colonic mucosal folds (see Figure). The image was produced with a Pentax EC-3870FK2 video colonoscope.

Richard H Riley FANZCA · Richard Sallie MD, FRACP

The explosion in psychiatric neuroimaging research has led to the establishment of stressful and dark neuroimaging laboratories in which young researchers sweat in front of computer monitors performing laborious and tedious imaging analysis. These conditions have contributed to the development of a new psychiatric syndrome, described below. Diagnostic criteria“Lesionnaire’s syndrome” predominantly affects younger researchers examining magnetic resonance imaging (MRI) scans of the brain. These researchers: (a) Work in large institutions; (b) Have a fixed belief that volume change in a brain structure causes schizophrenia; (c) Feverishly spend hours tracing brain structures to prove this belief; (d) Alter their beliefs if their attempts are unsuccessful and begin work on a different brain structure or new method; (e) Attribute negative findings to “methodological limitations”; (f) Begin to see non-brain images in brain scans on which they are working. The diagnosis may only be made if the patient satisfies criterion (f) and any three of criteria (a)–(e). The diagnosis cannot be made if the MRI scan has revealed an organic disorder. Case reportA 38-year-old psychiatrist had spent hundreds of hours tracing hippocampal volumes on MRI scans. He would lock himself in a darkened room, staring at a computer monitor, often listening to ’80s music in an attempt to relieve the mind-numbing tedium of the repetitive tracing behaviour. After tracing scans for 4–5 years, he revealed to his colleagues that he had discovered religious images — in particular, a vision of the Crucifixion (Box). He was successfully treated with complete tracing abstinence, but has had episodic relapses of his delusional visions, during which he has been heard to cry out “Maybe if I trace a few more it will reach statistical significance”. In order to ensure that the syndrome was related to the tracing behaviour rather than the music, a further trial was undertaken. Fortunately, re-exposure to ’80s music outside the imaging laboratory did not lead to a relapse in his symptoms.

Dennis Velakoulis MB BS, FRANZCP · Christos Pantelis MD, MRCPsych, FRANZCP · Mark Walterfang MB BS, FRANZCP

Making films from bone marrow aspirates is often a challenge for haematologists and oncologists in training (particularly oncologists). This aspirate taken from a child’s ilium ended up looking more like a femur.

Anthony R Herbert MB BS, BMedSc

Anyone who regularly writes or reviews for the MJA will know that, halfway through this year, we launched ourselves into the world of electronic submission and peer review. If the editors were catapulted kicking and screaming into the orbit of our new system, we can only imagine how our contributors feel. However, as we all adjust to the thin atmosphere and weightless state up here, we have to admit that it is a fine thing to have all the manuscripts “virtually” at our fingertips. Like astronauts viewing the world from afar, we can see the overall shape of things and can zoom down on the detail at the stroke of a key. Hopefully, this small step for the editors will be a giant step for the speed and efficiency of the MJA. Perhaps because of this innovation, there were slightly fewer submissions for this year’s Christmas Competition than in previous years. However, the quality was very high (undoubtedly both tenacity and a sense of humour are assets in the new submission process). Encouragingly, the contributors came from a range of medical specialties — surgeons, psychiatrists, anaesthetists, physicians, emergency physicians, a corgi and even a geriatrician among them — proving that you can teach both the old and a dog new tricks. For judging this year, the entries were posted on the outside south-western wall of “The pod” (see picture), an oval corrugated structure which functions as the MJA’s boardroom and space probe. Such public placement, under the joint scrutiny of our communications manager and librarian, precluded the usual tricks such as vote tampering, multiple voting and ghost voting. As usual, every entry received at least one nomination, reflecting the eclectic tastes and diverse interests of the MJA staff. In the image category, there was much support for the symbolism of Velakoulis et al’s iconic MRI “findings”, and the sheer freakishness of James and colleagues’ account of an elderly couple’s matching flank haematomas. However, the prize (two bottles of premium Australian wine) goes to Riley and Sallie, for “Finding inner peace”, an important colonoscopic image that should be sent without delay to all world leaders. Entries in the written category, which also carries a prize of two bottles of wine, were, on the whole, disturbing. Among the offerings were studies on the health benefits of ambulance diversion (Fatovich) and the impact of the weather on emergency department attendances (Ou et al), and dissertations on the disease states of popular characters in children’s fiction (McCallum and Smith) and the contents of Nair’s inbox. Ultimately, we were most moved by Cobcroft and Pembroke-Corgi’s earthy account of the medicinal and other uses of dog poo in history, not the least because of the co-author’s excellent nose for a good story. We sincerely thank those who forged boldly into the inner worlds of their imaginations, then into the unknown territory of online submission to enter the competition. As for the rest of you, we like to think that there are other images, ideas, observations and stories hovering out there in cyberspace or languishing in a hitherto undiscovered folder in our new system. Log on and send them in for next Christmas. To infinity and beyond!

Ruth Armstrong BMed