Volume 183 Issue 6

When will Australians be able to count on receiving health care that is safe? The Oxford English dictionary defines safety as “freedom from danger and risks”, and there is little doubt that the question of safety is foremost in the minds of many Australians on admission to our hospitals. These concerns were heightened when, 10 years ago, the Quality in Australian Health Care Study (QAHCS) revealed that admission to hospital was associated with a 16% risk of an adverse event, including permanent disability or death.1 In the years that followed, public concerns about hospital safety were reinforced by a series of sensational scandals involving patient care at the King Edward Memorial Hospital in Perth, Western Australia (1999),2 the Canberra Hospital in the Australian Capital Territory (2000),3 and Campbelltown and Camden Hospitals in New South Wales (2002).4 Not surprisingly, all these incidents had common characteristics:3 compromised patient safety not detected by sentinel event reporting; suboptimal clinical governance; health care professionals, who, frustrated by inaction after internal reporting of adverse events, brought the matter to the attention of politicians; and, finally, all incidents provoked one or more independent inquiries.3 There is little doubt that, pari passu with these scandals, the public’s trust in hospitals and doctors has taken a pounding, as has the perception of the profession’s ability to regulate itself. And now, in 2005, we have the Bundaberg Hospital scandal in Queensland. Not surprisingly, this incident shares most of the features of the preceding hospital scandals. But it is also different — it reaches into the hearts of the Medical Board of Queensland, Queensland Health and the Queensland Government. The Bundaberg Hospital incident might revolve around the performance of Dr Jayant Patel, but it is in fact a symptom of an affliction affecting health care Australia-wide. In 2003, Patel was appointed as a surgical medical officer at Bundaberg Hospital and subsequently promoted to Director of Surgery. Over the following 2 years, he operated on about 1000 patients, of whom 88 died and 14 suffered serious complications.5 A clinical review has since found that Patel directly contributed to the deaths of eight patients and “may have exhibited an unacceptable level of care in another eight patients who died”. The report noted that although “in the comfortable majority of cases examined, Dr Patel’s outcomes were acceptable . . . [he] lacked many of the attributes of a competent surgeon”.6 All this may not have happened had the 2003 registration of Patel by the Queensland Medical Board been more rigorous. An in-depth review would have uncovered that Patel was placed on probation for 3 years in 1983 for “gross negligence” in his practice at Rochester Hospital in New York State; that in 2000 the Oregon Board of Medical Examiners in the United States restricted the scope of his surgery; and, in 2001, under threat of having his licence revoked in New York State, he instead obtained permission to surrender his licence to practise.7 The subsequent questioning of Patel’s performance at Bundaberg Hospital did not emerge from a clinical governance system but from concerns of individual doctors and nurses about his surgical performance and prowess. It was a letter from the nursing staff about this matter which, when tabled in Queensland Parliament, resulted in the establishment of a Commission of Inquiry headed by Anthony Morris QC. In the meantime, Patel left the country unimpeded. Inquiries are established to ascertain the facts, to learn from the events, to provide a catharsis for stakeholders, to hold people and organisations accountable, to reassure the public that something is being done, and to serve the interests of governments.8 It was hoped that the Morris Inquiry with these tasks and terms of reference9 would have shed light on: Patel’s appointment to Bundaberg Hospital; the role of the Queensland Medical Board in assessing, registering and monitoring overseas-trained doctors deemed to be necessary for areas of need; the role of federal, state and territory governments and the clinical colleges in these processes; systems to ensure accountability and monitoring of appropriate performance of individuals and clinical services; and systems to receive, process and resolve complaints about clinical performance or services. Now, with the termination of the Inquiry on the grounds of perceived bias, the public and the profession will have to wait.10 But, despite this, answers to these issues will have to be unearthed. They are not only pertinent for Queensland — they have national implications. We have had report after report11-13 on quality and safety, and bodies devoted to safety and quality such as the Australian Council on Healthcare Standards, the Australian Council for Safety and Quality in Health Care, the National Institute of Clinical Studies and, more recently, the NSW Clinical Excellence Commission. And the list goes on. Yet we continue to suffer hospital scandals affecting lives and limbs, which, for all we know, are only the tip of the iceberg. Ten years after the QAHCS and 5 years after the establishment of the Australian Council for Safety and Quality in Health Care, we still have no nationally accepted framework for clinical governance to ensure the safety and quality of Australian health services or the means to comprehensively monitor these indices.14 Based on QAHCS outcomes, 25 patients die each day in our hospitals from preventable adverse events and another 22 suffer preventable permanent disability (Dr R M Wilson, Director, Northern Centre for Healthcare Improvement, Royal North Shore Hospital, St Leonards, NSW, personal communication, 2005). Whether, 10 years after QAHCS, being treated in Australian hospitals still results in the same number of preventable human tragedies, we simply do not know, and this ongoing vacuum is an indictment of our health ministers and organised medicine. The time has long passed for Australia’s political leaders to abandon their leisurely bureaucratic approach to quality and safety15 and to insist on fast-tracking a national program that ensures quality and safety for all Australians accessing health care. It can only be hoped that the Bundabueg Hospital scandal will prompt out political leaders to act more decisively. In tandem with the dismantled Morris Inquiry, there is a wide-ranging Inquiry into the health system in Queensland, instigated by the Queensland Premier in April this year. This Inquiry, driven by two eclectic working groups, both headed by Peter Forster, issued an interim report at the end of July which is not flattering of Queensland Health.16 It is depicted as a gigantic dysfunctional conglomerate with a corporate centre that is more concerned with performance indicators, revenue generation and cost control, than with people. It appears to be preoccupied with tortuous decision processes and ineffective workforce management systems, and with workforce planning that is not linked to service delivery. In short, its command-and-control ethos has resulted in a chasm between administration and front-line health services. In the field, Queensland Health’s focus on cost containment and revenue raising has caused concern, frustration and even anger among clinicians who “feel undervalued and marginalised from a system which does not allow them sufficient time to undertake teaching and research, where they face ever increasing patient loads . . . [and] have limited ability to influence the way the health system is run”.16 There is an even deeper reason for clinicians’ discontent — Queensland is an impoverished health care state! It has the lowest number of doctors per head of population in Australia and is critically dependent on overseas-trained doctors, who now account for nearly one in four doctors in Queensland.16 But there is more. Queensland’s average recurrent expenditure on health is the lowest in the nation, and in 2002–03 its recurrent expenditure on public hospitals was 20% below the national average, and this is despite the greater geographic dispersion of health care facilities in Queensland. And to top off this bleak picture, the remuneration of hospital-salaried medical staff is the second lowest in the country.16 These telling statistics might be trumpeted by politicians and bureaucrats as reflecting good fiscal management, or blamed on the politically convenient federal–state health divide. But others may see it as an inhumane and unnecessary capping of the health budget. Whatever the rhetoric, the impoverishment of the Queensland health system cannot be sheeted home to Queensland Health. It lies squarely with the Queensland Premier and it will be interesting to follow the Queensland Government’s response to the final report of the Forster Inquiry, which is due at the end of this month. But the response will not require rocket science. There is a dire need for Queensland Health to be dragged into the 21st century by a restructuring of its monolithic and disconnected organisation into more diverse and discrete health structures. These should be open, transparent and, most importantly, connected to local communities and to clinicians empowered to make decisions about health care delivery. Queensland could do no worse than to emulate the clinician-led ongoing reform of NSW hospitals.17 Queensland is also in dire need of a boost to its health budget. It also needs to consider attracting clinicians to work in Queensland hospitals — by making its recruitment and retention packages for salaried staff competitive with those of other states, and by providing incentives for clinicians to work in non-metropolitan areas. The reward system does not have to be all monetary. It could include innovations such as a program of continual professional development and refreshment of non-metropolitan doctors through regular periods of secondment to major metropolitan centres. An attitudinal change to the role of visiting medical officers in public hospitals might also help. Despite having more medical schools than any other Australian state or territory, Queensland will be dependent on overseas-trained doctors for some time to come.18 There is a risk of some of these doctors not being suited to the local culture and practice expectations, or not having the necessary skills.6 Their continuing professional and cultural development needs to be met by structured programs involving the clinical colleges, as well as regular monitoring and constructive feedback. It’s time to cease the apparent neglect of overseas-trained doctors, not only in Queensland but nationwide.19 In a recently released book, Patient safety: achieving a new standard of care, there is a simple statement: “Americans should be able to count on receiving health care that is safe.”20 So should all Australians, whether in provincial Queensland or elsewhere.

Martin B Van Der Weyden MD, FRACP, FRCPA

Is it time to walk the line between overtreating indolent disease and undertreating aggressive disease? Few other health care issues in Australia have been as contentious as the diagnosis and treatment of early prostate cancer. Debate centres on two hotly contested but important issues: do prostate cancers diagnosed by an elevated serum prostate-specific antigen (PSA) level pose a significant threat to health, and if they do, can intervention alter the natural history of the disease? In this editorial, we consider the contribution that two recently published studies make to this debate, with a focus on survival and the role of surgical management. Study one: In the first study, Albertsen and colleagues presented an update of a retrospective cohort study first published in 1998.1 They estimated 20-year survival after clinically localised prostate cancer was treated without curative intent in 767 men diagnosed with this condition between 1971 and 1984. After a median of 24 years, the men’s current vital status was obtained and the contribution of prostate cancer to any subsequent mortality was determined by examining death certificates. Survival was assessed on a competing risk analysis, and stratified for age and tumour differentiation. The primary finding was that the risk of death from localised prostate cancer did not increase significantly with time from diagnosis — leading the authors to suggest that aggressive management of localised prostate cancer is perhaps unnecessary. The study also found that prostate cancer graded as Gleason sum 7 and above (moderately to poorly differentiated) is lethal. These results can directly inform our current debate only if the population studied is comparable to contemporary patients, and as these men were diagnosed in the pre-PSA era, there are major differences in this regard. Of the men in the cohort, 71% were diagnosed on the basis of surgical intervention for benign prostatic hyperplasia, either by transurethral resection of the gland or open prostatectomy. Both of these procedures sample the transition zone exclusively, where less than 25% of all prostate cancers originate. A relatively high proportion of these T1 tumours are true “transitional zone tumours”, which are well recognised to be smaller in volume and better differentiated, and to run a more indolent biological course. This is reflected in the finding that 33% of the cohort had cancers with Gleason sums of between 2 and 5 — well differentiated tumours. In contrast, significant or lethal prostate cancer with high Gleason sums is found predominantly in the posterolateral part of the prostate, the peripheral zone. Prostate cancer diagnosed after a finding of an elevated PSA level with sampling of the peripheral zone shows cancer with a Gleason sum of less than 6 in less than 5% of cases, with most cancer detected by PSA testing scoring 6 or 7 (moderately differentiated). Thus, this study cohort contained a high number of clinically insignificant prostate tumours that would be less likely to be diagnosed by needle biopsy. Any comparison with contemporary prostate cancer series detected by PSA testing is also confounded by the late age of diagnosis (median, 69 years) and the high rate of significant comorbidity in this cohort. Further, 42% of patients with clinically localised disease received some form of androgen deprivation therapy within 6 months of diagnosis (which was presumably continued until death), despite there being no evidence of disease progression. It is now becoming increasingly appreciated that hormonal therapy creates a disease in itself, which can contribute significantly to mortality from other causes (particularly cardio-vascular mortality from diethylstilboestrol).2 Despite its differences from more contemporary studies, the study by Albertsen and colleagues does offer striking insights into the biology of conservatively treated prostate cancer. Clearly, cancers graded Gleason 7 and above are lethal when managed conservatively, even in a population of sick elderly men. Conversely, at least up to 15 years of follow-up, cancers graded Gleason 2 to 5 run an indolent course, which suggests that in elderly and medically compromised men, a more conservative course can be followed. However, data from another series which is less contaminated with transition zone tumours suggested that low grade tumours can dedifferentiate and metastasise, which has particular relevance to men diagnosed at a younger age.3 Study two: In the second study under consideration, Bill-Axelson and colleagues directly addressed the second point of contention — can intervention alter the natural history of prostate cancer?4 Again, this was an updated analysis of a previously reported study. It was an elegant study premised on a beguilingly simple hypothesis that: by removing prostate cancer that is confined to the gland via radical prostatectomy, metastases can be prevented; by preventing metastases, death from prostate cancer can be reduced; and by reducing death from prostate cancer, overall survival is improved. Radical prostatectomy is the surgical removal of the prostate and seminal vesicles by dividing the prostate at the bladder neck and urethra, and suturing a vesicourethral anastomosis over the catheter. It has been performed by open abdominal surgery and, more recently, by a minimally invasive laparoscopic or robotic approach. In Bill-Axelson and colleagues’ randomised controlled trial, 695 men with clinically localised prostate cancer were allocated to either radical prostatectomy or “watchful waiting”. In both groups, hormonal therapy (medical or surgical castration) could be introduced at the discretion of the treating physician. Mean age at diagnosis was 64 years, and mean serum PSA level at diagnosis was 13 ng/mL. Median follow-up was 8.2 years. Importantly, this study is more representative of the era in which PSA testing is used to detect prostate cancer. Diagnosis was by contemporary sextant, ultrasound-guided needle biopsy of the peripheral zone, and only 11% of diagnoses were at transurethral resection of prostate, although a higher proportion had palpable disease than a modern series might. In this study, 77% of cancers were T2 (organ-confined) prostate cancers. In contrast to the Albertsen study, 77% of tumours were graded Gleason 5 to 7, and only 13% were graded Gleason 2 to 4. Nearly half (48%) of Bill-Axelson and colleagues’ cohort had a PSA level greater than 10 ng/mL at diagnosis. In all, this cohort of patients represents a somewhat more advanced disease group than would be representative in Australia in 2005 (where PSA testing is now more prevalent, and more cancer is being discovered in the 4–10 ng/mL PSA range). Nonetheless, the results presented by Bill-Axelson and colleagues are instructive, underscoring the biological truth of the study hypothesis. In men treated with surgical intervention, the incidence of metastatic disease and risk of death from prostate cancer was significantly reduced compared with those who were managed by watchful waiting. This led to a significant reduction in all-cause mortality, providing evidence for the first time that radical intervention for localised prostate cancer can deliver a real health benefit. This health benefit was highest in men younger than 65 years of age, with 19% of watchful-waiting patients compared with 8% of patients treated with surgery dying from prostate cancer at 10 years. Although the study authors remained cautious, suggesting further research needs to be done before introducing an immediate change in clinical practice, their results were impressive in terms of metastatic rate (14% in the surgery group versus 23% in the watchful-waiting group) and local progression of prostate cancer (64 in the surgery group versus 149 in the watchful-waiting group, showing a 25% risk reduction in local progression in the surgery group at 10 years). Further, 177 of the patients in the watchful-waiting arm versus 110 in the surgery arm received hormone therapy, with a median time to hormone therapy treatment of 4 years. So, now that Bill-Axelson and colleagues have shown in a randomised controlled trial that surgery for prostate cancer saves lives, do we have all the answers? Would that this were so. These data are extremely important in guiding men about the relevance of PSA testing, the risk of death and risk of metastatic and local progression from untreated histologically significant prostate cancer. However, the injudicious application of prostate testing has opened a Pandora’s box. We have seen an explosion in diagnosis of potentially insignificant non-life-threatening prostate cancer. There is now a strong push in the United States to have the PSA cutpoint for prostate cancer biopsy lowered from 4 ng/mL to 2.5 ng/mL or even lower.5 Some suggest all men have a prostate biopsy at the age of 50 years. The PSA test is good, but not great. It doesn’t help us differentiate between the indolent and dangerous prostate cancer. Gleason histology grading does help as a differentiator. But what is the cost–benefit balance of making a diagnosis of indolent microfocal Gleason 6 prostate cancer in a 78-year-old man with a PSA level of 6 ng/mL? We can take comfort in the proven knowledge that surgery is indicated for younger men with at least 15 years of life expectancy. However, a more judicious approach in managing older men with comorbidities will be needed. Countering this, newer technical developments in prostate cancer surgery, including laparoscopic and robotic radical prostatectomy, will further improve outcomes for men by reducing the morbidity of the operation and improving cancer control.6-8 Perhaps the next big question (and answer) in prostate cancer surgery has been articulated by Klotz.9 They are conducting a program of active surveillance with regular PSA testing and repeat biopsy, with surgical intervention with curative intent if there is cancer progression, in men with defined low-risk prostate cancer. This approach may help us to reduce unnecessary treatment in men at low-risk of disease progression. Eventually, an improved molecular understanding of the biology of these cancers will help us to predict precisely long-term outcomes in patients with prostate cancer and, thus, to decide on the most appropriate management for each individual patient.

Anthony J Costello FRACS, MD · Niall M Corcoran MB, AFRCSI · Scott Van Appledorn MD

Results of a recent Australian trial suggest it is time to stop equivocating about screening and treatment The 1998 consensus guidelines on the management of gestational diabetes mellitus from the Australasian Diabetes in Pregnancy Society emphasised that, “due to a lack of good quality randomised controlled clinical trials in the area of [gestational diabetes mellitus], these guidelines are based on what is a reasonable consensus of informed opinion in Australasia”.1 The clear benefits of treating women with gestational diabetes according to these guidelines have now been demonstrated by the Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS).2 This study randomised 1000 women with gestational diabetes to either routine antenatal care or to an intervention that comprised home glucose monitoring, review by a diabetes educator, dietitian and physician, and insulin therapy if glycaemic targets were not met. Serious adverse perinatal outcomes occurred in 1% of the intervention group versus 4% of the routine-care group (adjusted relative risk, 0.33 [95% CI, 0.14–0.75]). The percentage of infants who were large for gestational age was lower in the intervention group (13% v 22%), with no increase in those who were small for gestational age. Although induction of labour was more common in the intervention group (39% v 29%), rates of caesarean delivery were similar (around 31%). Measures of maternal quality of life were more favourable in the intervention group. To prevent one serious perinatal outcome, 34 women needed to be treated. The 1998 guidelines were equivocal in regard to screening for gestational diabetes, allowing either for universal screening or for selective screening based on clinical risk factors in relatively low-risk populations. In the light of the findings of ACHOIS, we believe that universal screening should now be accepted and implemented. There are multiple arguments in favour of this approach: Most women with gestational diabetes have no symptoms, and many have none of the classic risk factors associated with gestational diabetes.3 Screening based on risk factors adds an extra complexity to busy routine clinical practice and may lead to some women failing to undergo appropriate testing. Furthermore, ACHOIS patients were relatively “low risk”, being predominantly of European background, with a mean age of around 30 years, and a mean body mass index of around 26 kg/m2. Many would not have been tested based on risk factors. Nonetheless, the benefits of treatment were impressive. The precise level of hyperglycaemia that carries increased pregnancy risk remains to be defined. ACHOIS used as its inclusion criterion a 2-hour venous plasma glucose level on oral glucose tolerance testing ≥ 7.8 mmol/L but < 11.0 mmol/L. The women included in the study had a median fasting glucose level of 4.8 mmol/L and a median 2-hour glucose level of 8.6 mmol/L. The current Australian criteria suggest fasting and 2-hour cut-offs of ≥ 5.5 mmol/L and/or ≥ 8.0 mmol/L, respectively, for the diagnosis of gestational diabetes.4 To avoid the confusion which could occur if multiple sets of criteria were promulgated, we suggest that the diagnostic thresholds for gestational diabetes should not be revised until the blinded prospective international epidemiological study HAPO (Hyperglycemia and Adverse Pregnancy Outcome) reports its results, which are expected by mid-2007.5 Screening for gestational diabetes also offers benefits from a public health viewpoint, at a time of increasing prevalence of obesity and type 2 diabetes.6 Screening allows identification of women with undiagnosed type 2 diabetes and those at increased risk of developing this condition in the future. Detection of gestational diabetes has the potential to benefit not only the women involved, but also their children, through intervention.7 Preventing progression from gestational diabetes to type 2 diabetes is already considered cost-effective.8 Introduction of routine screening for gestational diabetes clearly carries cost and resource implications. The number of women diagnosed with gestational diabetes will increase, and appropriate provision must be made for their care. In ACHOIS, the intervention group received care from a multidisciplinary team, which generally comprised a dietitian, diabetes educator and physician, in addition to the obstetrician and midwives. This level of care is congruent with the 1998 Australasian guidelines, but may be difficult to implement on a large scale across Australia. Other models of care may be required, with increasing involvement of midwives, general practitioners and other health care providers. There is some evidence to support the efficacy of such treatment protocols.9 However, the ACHOIS data2 suggest that something more than “routine antenatal care” is required for optimal outcomes in this patient group. Therefore, less intensive models of care should be rigorously evaluated rather than promoted ad hoc on the basis of potential cost savings. The extra costs involved in providing optimal care for women with gestational diabetes are likely to be far outweighed by savings due to reduction in adverse perinatal outcomes. Evidence and recommendations on gestational diabetes Treatment for gestational diabetes substantially reduces adverse perinatal outcomes and improves maternal quality of life. Optimal proven treatment for gestational diabetes includes review by a diabetes educator, dietitian and physician, with insulin used if glycaemic targets are not achieved. Screening for gestational diabetes should be offered to all pregnant women. Maternity service providers should ensure that adequate resources are devoted to the detection and treatment of gestational diabetes.

H David McIntyre FRACP · N Wah Cheung PhD, FRACP · Jeremy J N Oats DM, FRCOG, FRANZCOG · David Simmons MD, FRACP

Objective: To assess the value of cusum analysis in hospital bed management.Design: Comparative analysis of medical patient flows, bed occupancy, and emergency department admission rates and access block over 2 years.Setting: Internal Medicine Services and Emergency Department in a teaching hospital.Interventions: Improvements in bed use and changes in the level of available beds.Main outcome measures: Average length of stay; percentage occupancy of available beds; number of patients waiting more than 8 hours for admission (access block); number of medical patients occupying beds in non-medical wards; and number of elective surgical admissions.Results: Cusum analysis provided a simple means of revealing important trends in patient flows that were not obvious in conventional time-series data. This prompted improvements in bed use that resulted in a decrease of 9500 occupied bed-days over a year. Unfortunately and unexpectedly, after some initial improvement, the levels of access block, medical ward congestion and elective surgical admissions all then deteriorated significantly. This was probably caused by excessive bed closures in response to the initial improvement in bed use.Conclusion: Cusum analysis is a useful technique for the early detection of significant changes in patient flows and bed use, and in determining the appropriate number of beds required for a given rate of patient flow.

Claire M Burns RN, BNursing · Cameron J Bennett MB BS, FRACP · Colin T Myers MB ChB, FACEM · Michael Ward MB BS, FRACP

Objective: To identify the relative importance of extrinsic determinants of doctors’ choice of specialty.Design: A self-administered postal questionnaire.Setting: Australian vocational training programs.Participants: 4259 Australian medical graduates registered in September 2002 with one of 16 Australian clinical colleges providing vocational training programs.Main outcome measures: Choice of specialist vocational training program; extrinsic factors influencing choice of program, and variation by sex, age, marital status and country of birth.Results: In total, 79% of respondents rated “appraisal of own skills and aptitudes” as influential in their choice of specialty followed by “intellectual content of the specialty” (75%). Extrinsic factors rated as most influential were “work culture” (72%), “flexibility of working arrangements” (56%) and “hours of work” (54%). We observed variation across training programs in the importance ascribed to factors influencing choice of specialty, and by sex, age and marital status. Factors of particular importance to women, compared with men, were “appraisal of domestic circumstances” (odds ratio [OR], 1.9), “hours of work” (OR, 1.8) and “opportunity to work flexible hours” (OR, 2.6). Partnered doctors, compared with single doctors, rated “hours of work” and “opportunity to work flexible hours” as more important (OR, 1.3), while “domestic circumstances” was more important to doctors with children than those without children (OR, 1.7). In total, 80% of doctors had chosen their specialty by the end of the third year after graduation.Conclusions: Experience with discipline-based work cultures and working conditions occurs throughout medical school and the early postgraduate years, and most doctors choose their specialty during these years. It follows that interventions to influence doctors’ choice of specialty need to target these critical years.

Mary G Harris MPH, PhD, FCHSE · Paul H Gavel BEc, MEc · Jeannette R Young MB BS, MBA, FRACMA

Objective: To determine immunity to tetanus and diphtheria in the Australian population.Design and setting: Analysis, using double antigen enzyme immunoassays, of a representative sample of sera (1950 samples tested for diphtheria and 2884 for tetanus) collected opportunistically from Australian laboratories between July 1996 and May 1999.Main outcome measure: Immunity to diphtheria and tetanus, defined as negative (susceptible) when the antitoxin level was < 0.01 IU/mL, positive (immune) when it was ≥ 0.1 IU/mL, and low positive (partially immune) when it was in the range 0.01–< 0.1 IU/mL.Results: About 99% of children aged 5–9 years had diphtheria and tetanus antitoxin levels ≥ 0.01 IU/mL (immune or partially immune). Antitoxin levels declined with age and generally more markedly for diphtheria than tetanus. For subjects aged 50 years and over, less than 60% were immune or partially immune to diphtheria and less than 75% to tetanus. Men and women had similar diphtheria antitoxin levels, while women had lower levels of tetanus antitoxin compared with men of the same age, with the difference being most marked in the age group ≥ 70 years (37% v 60%; P < 0.001).Conclusions: Immunity in children appears to be good, but adults, especially older people, may not be adequately protected. Recent changes to the Australian Standard Vaccination Schedule should improve immunity in cohorts now aged < 50 years. However, additional efforts are required to protect those over 50 years (especially travellers), who are most susceptible.

Heather F Gidding BAppSci, GradDipEpidBiostats, MAppEpid · Josephine L Backhouse BRurSc · Gwendolyn L Gilbert MD, FRACP, FRCPA · Margaret A Burgess MD, FRACP

In late 1995, a treatment program for renal disease and hypertension was introduced into a remote Aboriginal community. Over the next 3.5 years, mean blood pressure levels were markedly reduced, renal function stabilised, and rates of both renal and non-renal deaths declined significantly. In 1999–2000, responsibility for the program was passed to the community’s local Health Board, which subsequently faced deficiencies in clinical information systems and a shortfall in funding. After the handover, the intensity of the program declined, and compliance with medicines fell. Blood pressures in the treatment cohort increased, renal function deteriorated, and rates of deaths from natural causes subsequently rose. From 2002 to mid-2003, the adjusted risks of renal and non-renal deaths in the treatment cohort were three and 9.5 times the respective risks of people during the first 18 months of treatment in the systematic phase of the program. Sustained vigorous activity, both in treatment of people already identified and in community screening for treatment eligibility, is required to maintain good results in any chronic disease program. Adequate resources and well supported staff are essential, and constant evaluation is needed to follow outcomes and modify strategies as necessary.

Wendy E Hoy FRACP · Srinivas N Kondalsamy-Chennakesavan MB BS, MPH · Jennifer L Nicol BSc(Hons), MSc(Stats)

Obesity is shaping up to be the major health care problem and one of the most frequent causes of preventable death in Western countries in the 21st century. Bariatric surgery is the only current treatment that has been shown to achieve major and durable weight loss. Major weight loss in the severely obese leads to total or partial control of a wide range of common and serious diseases, such as diabetes, heart disease and hypertension. Laparoscopic adjustable gastric banding is the most common type of obesity surgery performed in Australia. It is effective, relatively safe and minimally invasive. The blocks to broader application of bariatric surgery should be identified and resolved.

Paul E O’Brien MD, FRACS · Wendy A Brown MB BS, PhD, FRACS · John B Dixon MB BS, PhD, FRACGP

Privacy regulation in Australia, whether by federal or state legislation or other means, has provoked complaints from researchers. Its scope depends on defining the information it covers, the organisations it governs and the principles it applies. Regulation is inconsistent, and compliance can be complex (as illustrated by a hypothetical research example). National reform to achieve a realistic, balanced, publicly acceptable and consistent regulation is urgently needed, and has been recognised and recommended by recent reviews of the Commonwealth Privacy Act 1988 (Cwlth) by the Office of the Federal Privacy Commissioner and the Australian Senate.

Colin J H Thomson BA, LLB, LLM

New legislation passed in Victoria (the Serious Sex Offenders Monitoring Act 2005) extends the role of doctors in managing and treating sex offenders. This legislation is not based on a solid understanding of the research evidence on treatment of sex offenders or on their risk of reoffending. The legislation creates ethical and professional dilemmas for health professionals through the conflation of legal control of offenders with the medical management of disorders of sexual preference. There is a critical need for research and funding in this area, rather than ever more oppressive laws, if governments are to be serious about treating sex offenders, rather than simply incarcerating them.

Danny H Sullivan MHlthMedLaw, FRANZCP · Paul E Mullen DSc, FRANZCP · Michele T Pathé MD, FRANZCP

A 25-year-old man presented with macroscopic haematuria associated with a body mass index of 20 kg/m2 and a severe coagulopathy consistent with vitamin K deficiency. The diagnosis of a profound malabsorption syndrome secondary to coeliac disease was confirmed by small bowel histology and positive coeliac serology. Clinical recordA 25-year-old man presented to our hospital’s emergency department with frank haematuria and bilateral loin pain. He had been unwell for 10 days with abdominal pain and vomiting. Two days before presentation, he sought medical attention and was prescribed naproxen for the abdominal pain (he only took two of these tablets); he was on no other medications. Two years previously, a diagnosis of irritable bowel syndrome had been made by his doctor, based on a history of loose bowel motions over 2 years and a normal colonoscopy. 1 Angular cheilitis This image is similar to but is not of the patient described in this article. At the time of his hospital presentation, our patient had a body mass index (BMI) of 20 kg/m2 and appeared pale, but had no sign of bruising. He was apyrexial and well hydrated, with unremarkable cardiovascular and respiratory findings. Gastrointestinal examination revealed a red swollen tongue and angular cheilitis (Box 1). There was some mild left renal angle tenderness. Urinalysis revealed > 500 ×106 non-glomerular red blood cells per litre (normal range < 13 ×106/L) but no pyuria. Abdominal ultrasound performed on the day of review was unremarkable. Peripheral blood tests revealed normal electrolyte levels and renal function, with a coagulopathy reflected by an international normalised ratio (INR) of > 10 (reference range, < 1.4) and activated partial thromboplastin time (APTT) of 115 seconds (reference range, 25–38 seconds) (Box 2). These results were verified with repeat testing. Clotting factor studies revealed severe deficiencies in factors II, VII, IX and X. There were also deficiencies in iron, vitamin B12, and serum folate, vitamin A and vitamin E concentrations (Box 2). Vitamin D levels were normal, but the serum alkaline phosphatase level was twice the upper limit of normal. Results of other liver function tests were normal. Endomysial antibody test results were positive, and tissue transglutaminase antibody (IgA) levels were more than five times the upper limit of normal. A preliminary diagnosis of vitamin K deficiency, leading to a profound coagulopathy, secondary to a malabsorption syndrome from coeliac disease was made. Duodenal biopsies confirmed the diagnosis of coeliac disease (Box 3). Gastroscopy showed no gastritis or peptic ulcer disease. The duodenal mucosa appeared abnormal and was consistent with villous atrophy. No conclusion could be reached regarding the nonspecific abdominal pain the patient experienced on presentation. Inflammatory bowel disease was a differential diagnosis, but inflammatory markers were only marginally elevated (Box 2). Parenteral vitamin K was administered, and the prothrombin time reduced to 15 seconds (INR, 1.3) and APTT became normal within 24 hours. The macroscopic haematuria resolved. The patient was also given parenteral iron and vitamin B12 and oral multivitamin replacement. He was reviewed by the dietetic services and educated about coeliac disease. He also started a gluten-free diet. On clinical review 2 months later, he was feeling well and had put on 15 kg in weight (BMI, 26 kg/m2). Duodenal biopsies 6 months after the initial presentation revealed variable villous abnormality, consistent with partially treated coeliac disease. The vitamin deficiencies had all resolved, and clotting factor studies were normal. Endomysial antibodies had become negative, and tissue transglutaminase antibody levels (IgA) were within the normal reference range. Bone mineral density at this time was normal. Genotyping revealed the presence of the HLA DQ2 allele. DiscussionThe most common presentation of coeliac disease is diarrhoea (43%); other reasons for presentation include anaemia (8%), bone disease (6%), weight loss (6%), and abdominal pain (5%).1 The remaining 32% of patients are asymptomatic or present with vague symptoms. Delay in the diagnosis of coeliac disease is common (mean, 11 years).2 About 47% of patients will have been misdiagnosed, and of those with classical symptoms of coeliac disease, 59% have been misdiagnosed as having irritable bowel syndrome.3 The clinical diversity of coeliac disease is recognised, and disorders involving nearly every organ system have been described with this condition.4 Haematuria is an unusual presenting symptom of coeliac disease.5 The haematuria in our patient indicated a systemic bleeding diathesis due to malabsorption of vitamin K, with subsequent prolongation of the prothrombin time and APTT.6 In patients with untreated coeliac disease, the prothrombin time is prolonged (INR, ≥ 1.4) in about 20%,7 and the coagulopathy is usually asymptomatic,8,9 but corrects quickly with administration of vitamin K.10 In the long-term treatment of coeliac disease, a gluten-free diet is paramount and leads to resolution of the underlying small bowel villous abnormality. A partial histological response to a gluten-free diet may reflect poor compliance, accidental exposure to gluten-containing food products, or slow recovery. Our patient claimed close adherence to the diet and was provided with adequate education and dietetic review. Histological recovery can be delayed, with 35% of patients still showing features of coeliac disease up to 2 years after commencing a gluten-free diet.11,12 Failure to achieve histological recovery can occur in the absence of gluten.13 The use of serology tests as surrogate markers for histological resolution is controversial.14-16 Some coeliac patients with negative results for endomysial and tissue transglutaminase antibodies have persistent villous abnormalities, necessitating the use of biopsies to monitor the response to a gluten-free diet (as in our patient). On HLA genotyping, our patient possessed the HLA DQ2 allele, which is present in more than 90% of patients with coeliac disease, but in only 20% of the general population.17 Endomysial IgA antibodies have a sensitivity of 90% and specificity of 100%, tissue transglutaminase IgA has a sensitivity and specificity of 98%. Sensitivities for the IgG class endomysial and tissue transglutaminase antibodies are around 40%.18 Deficiency of IgA occurs in 1.7%–2.6% of coeliac patients, and these patients have negative results on IgA antibody testing. Total serum IgA levels should be tested together with IgG (endomysial, tissue transglutaminase) to improve the overall sensitivity of antibody testing.19 Our patient demonstrates the need to be aware of the various presenting features of coeliac disease, and reminds us that coeliac disease is often misdiagnosed. 2 Results of laboratory tests Investigation Result Reference range Haemoglobin 123 130–180 g/L White cell count 12.4 4.0–11.0 × 109/L Platelets 727 150–400 × 109/L Mean corpuscular volume 73 82–95 fL Mean corpuscular haemoglobin 23.3 24–32 pg Reticulocytes 74 10–90 × 109/L Differential white cell count Neutrophils 9.52 2.0–7.5 × 109/L Lymphocytes 1.48 1.0–4.0 × 109/L Monocytes 1.25 0.1–0.8 × 109/L Eosinophils 0.12 < 0.4 × 109/L Basophils 0.02 < 0.2 × 109/L Blood film Microcytosis with moderate hypochromasia, and small numbers of elongated cells. Neutrophilia with no left shift and thrombocytosis. CRP 22.4 1.6–8.7 mg/L ESR 14 5–12 mm/hour Alkaline phosphatase 249 40–129 U/L Tissue transglutaminase antibody 101 < 20 U/mL Serum folate 4.7 > 6.8 nmol/L Red cell folate Not measured Vitamin B12 93 132–857 pmol/L Vitamin A 0.1 0.8–3.1 μmol/L Vitamin D 38 30–110 nmol/L Vitamin E 4.9 > 18.6 μmol/L Ferritin 10 24–336 μg/L International normalised ratio > 10 < 1.4 Activated partial thromboplastin time 115 25–38 seconds Factor II 15% 50%–120% Factor VII 3% 50%–120% Factor IX 17% 50%–120% Factor X 5% 50%–120% 3 Duodenal biopsies A At time of diagnosis. There is severe villous abnormality associated with marked enterocyte damage (black arrows), in keeping with untreated coeliac disease. B After 6 months of gluten-free diet. There is partial improvement of the previous villous abnormality, but a moderate villous abnormality with associated crypt hyperplasia remains.

John S Lubel BDS, MB BS, MRCP · Louise M Burrell MBChB, MD, FRACP · Vicki Levidiotis MB BS, FRACP, PhD.

Alfred Grauaug, known to everyone as “Fred” or “Freddy”, will be forever remembered as the pioneer of neonatal medicine in Western Australia. Fred was born in Vienna, Austria, on 11 August 1935, but grew up in Sydney, where he attended Sydney Grammar School and the University of Sydney, graduating in 1960. His postgraduate training included several years at the Royal Alexandra Hospital for Children, Sydney, and the Princess Margaret Hospital, Perth. When he arrived at King Edward Memorial Hospital (KEMH), Perth, in 1968, neonatology was not yet a subspecialty of paediatrics, and babies were cared for in “special nurseries”. Under Fred’s leadership, there was rapid progress to a fully equipped neonatal intensive care unit, which today has become one of the largest and best in the world. Fred was the first Director of the Neonatal Unit at KEMH. He held this position from 1968 to 1997, after which he continued as a neonatologist at KEMH and the nearby St John of God Hospital. His appointment by the University of Western Australia as a Senior Lecturer and subsequently Associate Professor in Neonatology was the first academic appointment in that specialty in the state. He was the first to use ventilators for respiratory problems in premature babies in WA. He established the first neonatal transport system, the first retinopathy of prematurity screening program and the first neonatal intensive care nursing course in Australia. He was a founding member of the Asia and Oceania Perinatal Society, and held positions on state, college and hospital committees. Before he knew of his illness (metastatic adenocarcinoma of the lung), Fred announced that his retirement from KEMH would be on 30 June 2005, two months before his 70th birthday. He would be one of the few intensivists to have continued working full-time in this demanding role at this age. Fred was known for his dedication, vision, energy, drive, determination, resilience and success. Fred valued multidisciplinary and multicultural clinical teams. Although he had a strong commitment to work, he managed to preserve a balance between work and the other aspects of his life. He was passionately involved in the Medical Association for the Prevention of War, of which he was State President for a time. With his wife Heather, he was an active supporter of the arts. Fred died on 13 July 2005. He will be sadly missed by the medical, nursing and other staff of KEMH and St John of God Hospital, by paediatric colleagues around Australia, and by his countless patients and their families. He is survived by Heather and their children David, Richard, Elizabeth, William, Emma, Michael, Alexandra and Sally. Fred’s first wife, Anne, died in 1978.

Karen N Simmer FRACP, FRCPCH · Jeffrey Tompkins FRACP

This case describes refeeding syndrome associated with volitional oral nutrition in a patient with chronic alcoholic abuse admitted for detoxification. Refeeding syndrome is an under-recognised and undertreated condition1-5 of severe, acute electrolyte, fluid-balance and metabolic abnormalities in chronically malnourished patients undergoing renutrition. Refeeding syndrome was first described in Japanese prisoners during World War II.6 Since then, it has been described in patients being refed after hunger strikes, starvation after being lost, chronic alcoholism, anorexia nervosa, malignancy, kwashiorkor and marasmus and in obese patients who have had duodenal switch operations.4,5 Reports conflict over whether it is more common following parenteral7 or enteral tube4 nutrition, but descriptions following volitional oral refeeding are less frequent. In people in a chronically starved state, insulin secretion is reduced in parallel with low carbohydrate intake. Fat catabolism predominates, and free fatty acids and ketone bodies replace glucose as the major energy source. If starvation is severe, body stores of phosphate, potassium and magnesium may be depleted, although serum levels are often maintained.3-5 With refeeding, there is a shift back to carbohydrate metabolism and an increase in insulin levels. Insulin stimulates the movement of phosphate, potassium and magnesium into the cells, leading to a fall in their serum concentrations.2 In addition, tissue anabolism increases cellular demand for phosphate, glucose, potassium and water.1 Hyperphosphaturia may occur with alcoholism,7,8 and thiamine, required for the intracellular transport of glucose, may be depleted.9 The principal biochemical hallmark of refeeding syndrome, as seen in this case, is severe, acute hypophosphataemia that usually occurs within 3–4 days of refeeding.2,3,10 This is often associated with hypokalaemia, hypomagnesaemia, sodium and fluid retention, thiamine deficiency and hyperglycaemia. Phosphate is the body’s major intracellular anion.4 Daily oral phosphate intake is about 1000–1400 mg, the major sources being meat, poultry, eggs, cereals and dairy products.4 Wine contains little phosphate.11 Phosphate is found in phospholipids, nucleic acids, adenosine triphosphate and 2,3-diphosphoglycerate in red blood cells. It is important for intracellular buffering, enzymatic phosphorylation, glucose metabolism, nervous system conduction and leucocyte function. Hypophosphataemia-induced depletion of 2,3-diphosphoglycerate in erythrocytes results in a left shift of the haemoglobin/oxygen dissociation curve, increasing haemoglobin affinity for oxygen and predisposing to local tissue hypoxia.1,2,4 However, the clinical manifestations of refeeding syndrome are varied and non-specific (Box 3). Potentially life-threatening sequelae include acute cardiac failure, respiratory failure, Wernicke’s encephalopathy, sepsis and acute renal failure. Sudden cardiac death has been reported in two chronically malnourished patients experiencing acute hypophosphataemia after initiation of total parenteral nutrition.12 Although non-specific, we believe the constellation of symptoms and signs observed in our patient is typical of refeeding syndrome. Most importantly, acute, severe hypophosphataemia not present on admission was noted 4 days after oral refeeding with a ward diet. The presence of a serum phosphate level of 0.15 mmol/L in our patient represents extreme hypophosphataemia. (The lowest published level we are aware of in a patient who survived is 0.07 mmol/L.11) Given the “low normal” value on admission and the patient’s risk factors for refeeding syndrome, the serum phosphate level should have been monitored more closely during the first few days of admission. We did consider several differential diagnoses. Although hypophosphataemia is commonly seen in sepsis,14 clinical and haematological evidence suggested that the patient’s respiratory infection had largely resolved by Day 4. Acute respiratory alkalosis may also cause hypophosphataemia,15 but was unlikely in this case, in view of the normal serum phosphate level on admission. Severe hypokalaemia was already being corrected by intravenous replacement from the day of admission. The development of paraesthesiae, myalgias, groin candidiasis, diarrhoea and sinus tachycardia (which may have indicated incipient cardiac failure4,9) was consistent with the diagnosis of refeeding syndrome.4 Unfortunately, the creatinine kinase level was not measured to exclude rhabdomyolysis. Cerebellar signs may have been secondary to alcoholic degeneration or mild Wernicke’s encephalopathy. Management of refeeding syndrome includes slowing of caloric intake, correcting electrolyte and metabolic abnormalities, monitoring fluid balance and treating complications. Thiamine and B-complex vitamins should be prescribed prophylactically before refeeding.4 Interestingly, the early administration of intramuscular thiamine for chronic alcoholism may have protected our patient against Wernicke’s encephalopathy secondary to refeeding syndrome. Ideally, patients at risk of developing refeeding syndrome should be identified and a prophylactic low-caloric low-carbohydrate dietary regimen implemented.3 Initially, 85 kJ per kilogram of body weight per day, with a generous protein allowance (1.2–1.5 g protein per kilogram of body weight per day), has been suggested.4,13 Caloric intake can then be gradually increased over the following 1–2 weeks, ensuring that clinical and biochemical parameters are closely monitored.4,12,13 It is important to note that most current recommendations are based on parenteral or enteral tube nutrition. Protocols are not well developed for volitional oral refeeding. However, “slow” refeeding in these patients could be achieved by providing a similar low daily caloric intake with reduced food portions. Ideally, an experienced dietitian should be consulted.4 In our case, a dietitian was not available on site, and, given the prompt correction of electrolyte abnormalities and absence of acute cardiac failure, no change to diet was made. Levels of serum electrolytes, urea and creatinine should be monitored at least daily in the acute phase. Prophylactic phosphate and potassium supplementation is often required at the time of refeeding in high-risk patients. Phosphate replacement is recommended if serum levels are below 0.3–0.5 mmol/L3,4,10 or if the patient is symptomatic. As oral replacement at these levels is often inadequate, intravenous replacement is advised.7,10 Complications of overzealous intravenous phosphate replacement may include hyperphosphataemia, hypocalcaemia, tetany, hypotension, hyperkalaemia, hypernatraemia, renal failure and metastatic calcification.2,10 Although successful intravenous regimens based on patient weight and serum phosphate levels in intensive care settings have been described,15 these are often complicated and impractical for ward patients. Terlevich et al10 described the use of 50 mmol intravenous phosphate over 24 hours in 30 ward patients with refeeding syndrome and normal renal function. Twenty-eight patients safely achieved a serum phosphate level above 0.5 mmol/L within 72 hours. We used 42 mmol intravenous phosphate over 36 hours to normalise serum levels in our patient. While less aggressive than the protocol described by Terlevich et al, it was deemed sufficient given that the patient was largely asymptomatic and that serum phosphate levels were improving. Intravenous phosphate was dispensed on site in 14 mmol aliquots, and prescribing this amount over 12 hours simplified the dosing regimen. Clinical diagnosis of refeeding syndrome requires a high index of suspicion.1 Its hallmark of acute, severe hypophosphataemia in chronically malnourished patients after refeeding may occur even in patients who are largely asymptomatic and orally fed. Prevention of morbidity and, in some cases, death requires careful management of diet, vitamin intake and electrolyte and fluid balance. Lessons from practice Refeeding syndrome is a potentially lethal condition in chronically malnourished patients undergoing renutrition. The syndrome is under-recognised and undertreated. Electrolyte levels should initially be monitored daily in at-risk patients, as acute, profound hypophosphataemia may develop even in asymptomatic patients. Regimens for volitional oral refeeding are not well developed, but a prophylactic low-caloric (85 kJ per kilogram of body weight per day), low-carbohydrate diet has been advised. Prophylactic thiamine, phosphate and potassium supplementation is often required for at-risk patients. Patients with serum phosphate levels below 0.3–0.5 mmol/L or symptoms of hypophosphataemia require intravenous phosphate replacement. 1 Serum electrolyte levels over the first 8 days after admission Day Electrolyte Reference range 1 4 8 Potassium (mmol/L) 3.6–5.1 2.4 3.5 3.9 Calcium (mmol/L) (corrected for serum albumin) 2.25–2.58 2.27 2.60 2.60 Magnesium (mmol/L) 0.74–1.03 0.71 0.69 0.70 Phosphate (mmol/L) 0.80–1.50 0.84 0.15 1.56 2 Serum phosphate levels over the first 8 days after admission* * Dotted line indicates the direction of change only (no data were available for Days 2 and 3). 3 Clinical features of refeeding syndrome4 Clinical feature Possible mechanisms Cardiovascular Acute cardiac failure Fluid retention (secondary to carbohydrate intake1,2,4 and hyperinsulinaemia9), arrhythmias, cardiomyopathy1,2,4 Arrhythmias, sudden cardiac death3,12 Electrolyte disturbance1,2 Respiratory Respiratory failure Diaphragmatic myopathy2,8 Neurological Seizures, paraesthesiae Electrolyte and/or metabolic disturbance,1,4 cellular hypoxia secondary to reduced 2,3-DPG and ATP Wernicke’s encephalopathy Thiamine deficiency1,2,13 Gastrointestinal Diarrhoea or constipation Electrolyte and/or metabolic disturbance,4 intestinal atrophy following malnutrition13 Haematological Sepsis Leukocyte dysfunction, hyperglycaemia, acid–base disturbance1,4 Haemorrhage Thrombocytopaenia,2,9 platelet dysfunction9 Haemolytic anaemia Depletion of erythrocyte ATP, resulting in increased cell membrane rigidity1 Metabolic Hyperglycaemia4 Glucose ingestion4 Acid–base disturbance1,4 Impaired phosphate renal buffering2,12 Renal Acute tubular necrosis Rhabdomyolysis4 Musculoskeletal Myopathy Depletion of muscle ATP,1,9 electrolyte disturbance1 Rhabdomyolysis Impaired production of phospholipid cell membranes causes sarcolemma dysfunction1,2 ATP = adenosine triphosphate. DPG = diphosphoglycerate.

Adrian T Fung MB BS · Janet Rimmer MB BS, MD, FRACP

Present-day public hospitals are often lacking in humanity, costing more and doing less, and run by executive staff with minimal clinical knowledge The current obsession with finding and punishing “Dr Death”, as Patel has been called, instead of dealing with the system that sponsored him, seems likely to ensure that, when the dust has settled, the status quo will prevail. The Bundaberg Hospital scandal is a symptom, and more attention needs to be paid to the underlying causes. Work is performed within systems and its quality is determined by the quality of those systems. People generally do what the system requires. With all the media mayhem, we should not forget that many able people work for organisations like Queensland Health. I believe that the current problems in Australian hospital systems have their roots in the “reforms” of the 1980s: the development of corporate structures and managerialist management systems.4,5 Corporate structures devalue clinical involvement, alienate hospital communities, diminish humanity, and result in a burgeoning corpocracy. The managerialist approach produces staff and bed shortages, long waiting lists and excessive bed usage.6 It concentrates on business plans and targets, and negative short-term financial objectives, producing perverse economic activity; managers are rewarded for “quick fix” solutions. This can result in inaction and deferral of work. For example, there are concerns about waiting lists for surgery and delays with specialist referrals.3,6 The period since the 1980s has also seen considerable politicisation of public services in Australia.7,8 This can result in bias, inappropriate appointments and excessive use of secrecy and spin. Good systems are designed deliberately to produce high quality work.9 By eliminating waste, delay and the need to redo substandard work, they achieve long-term cost effectiveness. All good hospital departments have leaders who are clinically competent, but they must also be just, transparent, energetic and committed. They have the ability to transform their staff into effective teams. Team “ownership” results in people working to improve systems instead of merely using those systems to further their own ends. When I was a junior resident medical officer in Townsville Hospital in 1960, the hospital was of intense interest to the local community, and this “ownership” was a strong incentive to hospital staff. In addition, the Medical Superintendent was a competent and active general surgeon. The hospital made remarkably efficient use of the resources available to it. I don’t remember there being any waiting lists. Contrast this with present-day public hospitals — they are likely to be isolated from their communities, lacking in humanity, costing more and doing less,10 and run by executive staff with minimal clinical knowledge. There are other problems besetting Australian hospitals. For example, many have been slow to adopt safe systems. New intravenous device technology has been demonstrated to reduce the risk of needlestick injury.11 Many hospitals are yet to define and mandate best practice for the use of intravenous devices — the major source of hospital acquired bacteraemias.12 Although the immediate costs of such initiatives may be considerable, the treatment of a potentially preventable blood stream infection that endangers life can cost tens of thousands of dollars, and an injury with a contaminated needle may lead to chronic illness, substantial economic loss and potentially shortened life. In addition, hospital systems have not capitalised on the advantages of information technology. Communication and the dissemination of knowledge are vital in the complex dynamic systems that are modern hospitals, and this requires efficient communication systems.3 Yet, hospital IT departments can become corporate empires dedicated to the control of computer hardware and software — they often seem to do more to inhibit communication than to facilitate it. Although the Morris Inquiry was clearly essential, its base cost has been estimated at about $6 million.2 In addition, compensation of those who may have been injured, and repair of those injuries, is likely to entail a substantial financial burden. Ultimately, this money has to come from the pockets of taxpayers and the Queensland economy, and is therefore unavailable for treating patients or educating children. This is quite apart from the moral and personal costs involved, and the damage to staff morale when a job is either not done or done badly. So, what can be done? Unfortunately, the culture of the managerialist corpocracy is so deeply embedded in public administration in Australia that no quick answer seems likely. And, according to the late popular historian Barbara Tuchman, when something fails, it seems humans are inclined to believe that the solution lies in doing it twice as hard.13 One thing that could be done now is to make central offices behave like coaches rather than controllers and judges. Good coaches are able to mould effective teams, they are expert at dealing with poorly performing players, and they themselves are expendable if the team persistently underperforms. In addition, really good coaches think of the longer term. Politicians and senior staff in central offices need to relearn the motto of the schools some of them attended: “cui servire est regnare” — to serve is to rule. Quality is always positive; we can only ever do better by having better systems and by learning how to make better use of them. This requires careful systems analysis and systems optimisation.9 A fundamental requirement is trust, and this demands justice and transparency. However, if we are to improve the quality, safety and economy of hospitals in the long term, we need an “idea whose time has come”, to quote Victor Hugo (http://www.geocities.com/Paris/LeftBank/9640/otherq). Like Maynard Keynes, who found a way to end the Great Depression, we can only hope that succeeding generations will be able to see more clearly the reality of things as they are. To create an enduring and worthwhile hospital system, public administration has to move beyond corporate structures and managerialist management approaches.

Anthony P Morton MD, MS, MScAppl

Recently, we published an outline of concerns about the opening of Australia’s first religiously affiliated medical school. A litany of spirited responses followed. Michael M Daube Professor of Health Policy, Division of Health Sciences, Curtin University of Technology, GPO Box U1987, Perth, WA 6845. m.daubeATcurtin.edu.au To the Editor: Kerridge et al1 raise a number of concerns about religiously affiliated medical schools in general, but about the University of Notre Dame in particular. The implications to be drawn from their article are that the establishment of the University of Notre Dame medical school is of itself a cause for concern, that insufficient thought has been given to the ethical and other issues inherent in the establishment of a medical school of this nature, and that the Australian Medical Council (AMC) accreditation processes are inadequate by virtue of the inability to consider matters beyond the adequacy and quality of medical education. The AMC has already noted2 that its processes enabled it to raise questions about religious and related ethical issues with the University, and that they did so. As Director General of Health in Western Australia through the period of Notre Dame’s development of the medical school concept and accreditation, I observed at first hand the integrity of the Notre Dame application and the rigour of the AMC processes. Far from being given insufficient attention, the matters raised by Kerridge et al were discussed locally (not least between the University and staff of the WA Department of Health), and with the AMC. The AMC also discussed these issues independently with the Department, as well as with the University. The AMC’s decision to provide accreditation, albeit subject to clearly specified requirements, may not please some, but this should not be cause to imply fault in the process or the protagonists. It is unfortunate that Kerridge et al have not looked at the beneficial aspects of the development of a new and innovative medical school in Western Australia that will complement the University of Western Australia’s more traditional strengths. It is fair game to criticise religiously based institutions when there is evidence that they seek to impose their mores on the rest of society, but not when they bring in new ideas, new funds, and new and much-needed places for medical students — and when they and the accreditation processes have been at pains to avoid the sins of which they are accused. --> George Larcos Nuclear Medicine and Ultrasound Physician and Senior Clinical Lecturer, Westmead Hospital and University of Sydney, PO Box 533, Wentworthville, NSW 2145. nglATimag.wsahs.nsw.gov.au To the Editor: Kerridge and colleagues1 live in an anaemic world ruled by relativism. They agree that everyone is entitled to an opinion, but they believe that there is no right or wrong and so rationalise dissimilar views by accepting all and dismissing none. In contrast, Christian doctors understand that there is an ultimate truth and, in an environment of love and forgiveness, minister to patients and teach students according to God’s design for His world. Kerridge et al question whether the medical curriculum within a newly created medical school in Australia can be appropriate, given its Catholic affiliation. They seem to argue for the application of knowledge in a moral vacuum and miss the point that moral values enhance (rather than detract from) the value of knowledge. It is also evident that this moral compass cannot come from human beings. In a sense, it is amusing to see the self-contradiction and entanglement inherent in ethicists’ faulty logic. On another level, I hope that the Centre for Values, Ethics and the Law in Medicine at the University of Sydney is not funded by taxpayer dollars. --> Paul A Komesaroff Physician, Department of Medicine, Monash University, Alfred Hospital, Commercial Road, Prahran, VIC 3181. paul.komesaroffATmed.monash.edu.au To the Editor: The article by Kerridge et al1 raises important issues about the establishment of Australia’s first religiously based medical school at the University of Notre Dame. The authors draw attention to the need to consider the adequacy of the education provided in relation to accepted standards of medical practice, whether equitable access will be provided to potential students, and whether academic freedom and tolerance will be guaranteed to the levels required by the Australian public. The article is presented in a careful, measured and balanced manner. In essence, it concludes that the onus is on the University to show that it is both sensitive to these concerns and able to satisfy them. The accompanying comment from the Australian Medical Council (AMC)2 acknowledges the problems and indicates that there are several key points that remain to be resolved, namely: “concerns over the theological context of the medical course”, the need to “develop a process for handling potential conflicts over the inconsistency between the medical school’s teaching program and the canonical statute defining the purpose of the University”, and the possibility that “students of some backgrounds may perceive themselves to be effectively discriminated against on the basis of their own religious conviction (or lack thereof)”. It is arguable that these issues are so important that the commencement of the course should not be contemplated until they are resolved. Most readers would see this debate as unremarkable and would assume that it would lead to a negotiated compromise. However, the reply by the University3 is alarming. In spite of the importance of the questions, the public acknowledgement by the AMC that there are key unresolved issues and the obvious public interest in the subject, Professor Bower, speaking on behalf of the University, simply states that “we do not see a need to respond to this article”. In fact, this is a potent response in itself, which may be taken to suggest a lack of openness to criticism and an unwillingness to engage with philosophical or ethical perspectives that vary from those promoted by the University. It is neither the right of the AMC to proceed with accreditation nor that of the University to press doggedly ahead with its agenda independently of public accountability. There are both ethical and legal issues that need to be addressed, and the community is entitled to a full and unqualified assurance that questions raised in serious debate are satisfactorily answered. Both bodies must serve the interests of the wider community and operate according to the standards demanded by it. It may be that the issues raised can or have been satisfactorily addressed. If so, the public is entitled to know how this has occurred; if not, it would appear that further steps need to be taken before accreditation comes into effect. --> Edward D Watt Dean (retired), Faculty of Arts, University of Western Australia. lifewaATq-net.net.au To the Editor: In their articles on the new University of Notre Dame Australia (NDA) medical school, Kerridge and colleagues1 and Frank and Walters2 have revealed rather more than they may have intended. We are told by Kerridge et al that Australia’s “secular, pluralist society” is in favour of “diversity of beliefs and values”,1 and by Frank and Walters that “the Australian Medical Council supports diversity”.2 But the authors reject diversity in favour of their firm commitment to a particular, positive, proselytising version of medical ethics, from which no deviation should be tolerated in Australian medical education. They list their “concerns” about the NDA medical course. The two lists are almost identical, and contain no surprises. There is no doubt in their minds about what NDA medical students are likely to be taught about termination of pregnancy, contraception, assisted reproductive technologies, embryo research, and what one article delicately labels “end-of-life care”.1 Whether this will be so remains to be seen. Statements from NDA convey hints that what their medical students get in practice may be no more than a Catholic-lite version of medical ethics, at most. If so, our authors may turn out to have less to worry about than they fear. But running through their list of “conncerns”, we may reasonably ask them to specify what it is that every medical student must be taught about the matters they men-tion in order to meet the requirements of a “secular, pluralist society”. For example, will they be satisfied if NDA promises that its medical ethics lecturers will teach that: there is no ethical objection to terminating a pregnancy even where there is no medical indication, either maternal or fetal, for the termination; there is no ethical objection to cutting off food and fluids from an unresponsive patient in a stable condition with the intention of hastening the patient’s death. I do not deny that some doctors agree with the values and beliefs that, the authors suggest, reflect a “secular, pluralist society”. But their opinions are not beyond reasonable dispute. They represent a particular standpoint in medical ethics. Other doctors, and other people, disagree. On these matters there is no such thing as an impartial position. There is no justification, therefore, for demanding that every Australian medical school comply with one particular standpoint in teaching its students, or risk losing accreditation. --> John E Murtagh Adjunct Professor of General Practice, Department of Community Medicine and General Practice, Monash University, 867 Centre Road, East Bentleigh, VIC 3165. murtaghATbigpond.com To the Editor: As a Foundation Professor of the University of Notre Dame’s Graduate School of Medicine, I would like to add a comment to recent writings on the subject of a religiously affiliated medical school.1,2 In the process of accepting my honorary appointment, I looked into the issue of possible religious bias in the curriculum and was eventually reassured and convinced that there was no cause for concern. The subject of theology, presented by Peter Black (Lecturer in Theology, University of Notre Dame), is not based on Catholic dogma but is essentially a reflection on the spirituality of illness and its impact on people. My understanding is that, to date, the students seem to be comfortable and impressed with the subject and the teacher. It must also be appreciated that the students will disperse to a wide spectrum of experienced clinical teachers of various persuasions who will carry out bedside and office teaching in a similar way to that of all other medical schools. One wonders what all the fuss is really about! It is worthy of reflection that the time-honoured model that guided our ethical standards was the Hippocratic Oath and, subsequently, the Declaration of Geneva.3 The enshrined principles are virtually synonymous with basic Catholic teaching and, indeed, with that of most other religious groups.4 It would be most appropriate for the Australian Medical Council to conduct an evaluation of the Notre Dame students at the end of this year. It might also be interesting and appropriate to evaluate the messages emanating from teachers of bioethics in other medical schools, some of whom tend to promote quite opposing and unbalanced viewpoints. From first-hand experience and the comments of aggrieved students, I suggest there are other causes for concern, especially in view of the multicultural background of students studying medicine in Australia. For example, to ridicule students for their beliefs — especially for their belief in God — is a terrible dereliction of reasonable teaching responsibilities. I feel confident that the medical students of Notre Dame will enjoy a balanced curriculum, especially with people of goodwill supervising the course. --> Robert G Batey Area Director, Drug and Alcohol Clinical Services, Hunter New England Area Health Service, Locked Bag 1, Hunter Region Mail Centre, NSW 2310. robert.bateyAThunter.health.nsw.gov.au To the Editor: I wish to congratulate Bower for his amazingly clear, concise and unemotive response to the article on religiously affiliated medical schools in this country.1 Having a great respect for the University of Sydney and its Centre for Values, Ethics and the Law in Medicine, I was disappointed in the article that was designed to stimulate debate on a subject that is clearly of major interest but not necessarily of major concern.2 I am disappointed because the article suggested that bodies (churches) responsible for the foundation of our original university system might now have problems in delivering unbiased and appropriate medical education. This approach to stimulating debate seems, at best, mischievous and, at worst, ill-informed. The response was a gem, and I again commend the author for taking such a positive stand. --> Ian H Kerridge,* Rachel A X Ankeny,† Christopher F C Jordens,‡ Wendy L Lipworth§ * Director, †Senior Lecturer, ‡Researcher, §PhD Student, Centre for Values, Ethics and the Law in Medicine, Blackburn Building, University of Sydney, NSW 2006. iankATicpmr.wsahs.nsw.gov.au In reply: All Australians have a legitimate interest in the education of health professionals. In our article1 we outlined some of our concerns — shared by the Australian Medical Council (AMC)2 — about several features of the current University of Notre Dame program, including compulsory theology courses and procedures for student selection. However, the public’s interest extends beyond the purview of the AMC’s accreditation process. For example, how will the introduction of religiously affiliated medical schools affect access to a full range of health care services and accord with the broad range of needs, values and beliefs in Australian society? Because we seek to foster critical reflection and further public discussion on this and other questions, it does not follow (as Daube suggests) that we seek to dismiss benefits that may arise from the establishment of religiously affiliated medical schools. Nor does it follow (as he also suggests) that we are impugning the integrity of the AMC’s accreditation process. New ideas, new funds and new places for medical students may go hand in hand with the imposition of religious mores on secular society. We can applaud the former and question the latter. Daube implies that we must choose between applause and criticism, but this is simply not true. Murtagh welcomes the upcoming AMC evaluation, but reassures us on the basis of his own personal reflections and impressions that there is no cause for concern. However, his experience is confined to the students in the medical program. The concerns we have raised extend to other groups likely to be affected by the Notre Dame curriculum, including (a) people in rural areas who may not be able to access the full range of health services because of the religious convictions or limited training of their local general practitioner, and (b) potential medical-school applicants who choose not to apply to Notre Dame. We also note that ridiculing people for their religious beliefs (or indeed, lack thereof) is unacceptable not only in education, but in any context. The commitment to an ultimate truth that is defined in religious terms, as affirmed by Larcos, is fundamentally what is at issue in the establishment of religious medical schools in Australia. We would be the first to agree that the pursuit of knowledge can not and should not occur in a moral vacuum. However, we challenge his implication that religion has some kind of monopoly on morals and values. Any secular, liberal society also rests on moral principles, such as tolerance of difference, and values, such as respect for human life, freedom and equality. Watt suggests we reject diversity in order to advance a monolithic bioethical, educational and health care agenda. This is an odd reversal indeed. To reiterate the central issue: many religious institutions are explicitly doctrinaire. We wish to open a public discussion about the potential problems created when such institutions take on the function of medical education. As we stated in our article, none of the problems we have raised are insurmountable, but all should be acknowledged and addressed. Along with Komesaroff, we are therefore disturbed by the University of Notre Dame’s decision not to take up the Journal’s invitation to respond to our article — even as an issue “for debate”. --> ©The Medical Journal of Australia 2005 www.mja.com.au PRINT ISSN: 0025-729X ONLINE ISSN: 1326-5377 To the Editor: Kerridge et al1 raise a number of concerns about religiously affiliated medical schools in general, but about the University of Notre Dame in particular. The implications to be drawn from their article are that the establishment of the University of Notre Dame medical school is of itself a cause for concern, that insufficient thought has been given to the ethical and other issues inherent in the establishment of a medical school of this nature, and that the Australian Medical Council (AMC) accreditation processes are inadequate by virtue of the inability to consider matters beyond the adequacy and quality of medical education. The AMC has already noted2 that its processes enabled it to raise questions about religious and related ethical issues with the University, and that they did so. As Director General of Health in Western Australia through the period of Notre Dame’s development of the medical school concept and accreditation, I observed at first hand the integrity of the Notre Dame application and the rigour of the AMC processes. Far from being given insufficient attention, the matters raised by Kerridge et al were discussed locally (not least between the University and staff of the WA Department of Health), and with the AMC. The AMC also discussed these issues independently with the Department, as well as with the University. The AMC’s decision to provide accreditation, albeit subject to clearly specified requirements, may not please some, but this should not be cause to imply fault in the process or the protagonists. It is unfortunate that Kerridge et al have not looked at the beneficial aspects of the development of a new and innovative medical school in Western Australia that will complement the University of Western Australia’s more traditional strengths. It is fair game to criticise religiously based institutions when there is evidence that they seek to impose their mores on the rest of society, but not when they bring in new ideas, new funds, and new and much-needed places for medical students — and when they and the accreditation processes have been at pains to avoid the sins of which they are accused. George Larcos Nuclear Medicine and Ultrasound Physician and Senior Clinical Lecturer, Westmead Hospital and University of Sydney, PO Box 533, Wentworthville, NSW 2145. nglATimag.wsahs.nsw.gov.au To the Editor: Kerridge and colleagues1 live in an anaemic world ruled by relativism. They agree that everyone is entitled to an opinion, but they believe that there is no right or wrong and so rationalise dissimilar views by accepting all and dismissing none. In contrast, Christian doctors understand that there is an ultimate truth and, in an environment of love and forgiveness, minister to patients and teach students according to God’s design for His world. Kerridge et al question whether the medical curriculum within a newly created medical school in Australia can be appropriate, given its Catholic affiliation. They seem to argue for the application of knowledge in a moral vacuum and miss the point that moral values enhance (rather than detract from) the value of knowledge. It is also evident that this moral compass cannot come from human beings. In a sense, it is amusing to see the self-contradiction and entanglement inherent in ethicists’ faulty logic. On another level, I hope that the Centre for Values, Ethics and the Law in Medicine at the University of Sydney is not funded by taxpayer dollars. Paul A Komesaroff Physician, Department of Medicine, Monash University, Alfred Hospital, Commercial Road, Prahran, VIC 3181. paul.komesaroffATmed.monash.edu.au To the Editor: The article by Kerridge et al1 raises important issues about the establishment of Australia’s first religiously based medical school at the University of Notre Dame. The authors draw attention to the need to consider the adequacy of the education provided in relation to accepted standards of medical practice, whether equitable access will be provided to potential students, and whether academic freedom and tolerance will be guaranteed to the levels required by the Australian public. The article is presented in a careful, measured and balanced manner. In essence, it concludes that the onus is on the University to show that it is both sensitive to these concerns and able to satisfy them. The accompanying comment from the Australian Medical Council (AMC)2 acknowledges the problems and indicates that there are several key points that remain to be resolved, namely: “concerns over the theological context of the medical course”, the need to “develop a process for handling potential conflicts over the inconsistency between the medical school’s teaching program and the canonical statute defining the purpose of the University”, and the possibility that “students of some backgrounds may perceive themselves to be effectively discriminated against on the basis of their own religious conviction (or lack thereof)”. It is arguable that these issues are so important that the commencement of the course should not be contemplated until they are resolved. Most readers would see this debate as unremarkable and would assume that it would lead to a negotiated compromise. However, the reply by the University3 is alarming. In spite of the importance of the questions, the public acknowledgement by the AMC that there are key unresolved issues and the obvious public interest in the subject, Professor Bower, speaking on behalf of the University, simply states that “we do not see a need to respond to this article”. In fact, this is a potent response in itself, which may be taken to suggest a lack of openness to criticism and an unwillingness to engage with philosophical or ethical perspectives that vary from those promoted by the University. It is neither the right of the AMC to proceed with accreditation nor that of the University to press doggedly ahead with its agenda independently of public accountability. There are both ethical and legal issues that need to be addressed, and the community is entitled to a full and unqualified assurance that questions raised in serious debate are satisfactorily answered. Both bodies must serve the interests of the wider community and operate according to the standards demanded by it. It may be that the issues raised can or have been satisfactorily addressed. If so, the public is entitled to know how this has occurred; if not, it would appear that further steps need to be taken before accreditation comes into effect. Edward D Watt Dean (retired), Faculty of Arts, University of Western Australia. lifewaATq-net.net.au To the Editor: In their articles on the new University of Notre Dame Australia (NDA) medical school, Kerridge and colleagues1 and Frank and Walters2 have revealed rather more than they may have intended. We are told by Kerridge et al that Australia’s “secular, pluralist society” is in favour of “diversity of beliefs and values”,1 and by Frank and Walters that “the Australian Medical Council supports diversity”.2 But the authors reject diversity in favour of their firm commitment to a particular, positive, proselytising version of medical ethics, from which no deviation should be tolerated in Australian medical education. They list their “concerns” about the NDA medical course. The two lists are almost identical, and contain no surprises. There is no doubt in their minds about what NDA medical students are likely to be taught about termination of pregnancy, contraception, assisted reproductive technologies, embryo research, and what one article delicately labels “end-of-life care”.1 Whether this will be so remains to be seen. Statements from NDA convey hints that what their medical students get in practice may be no more than a Catholic-lite version of medical ethics, at most. If so, our authors may turn out to have less to worry about than they fear. But running through their list of “conncerns”, we may reasonably ask them to specify what it is that every medical student must be taught about the matters they men-tion in order to meet the requirements of a “secular, pluralist society”. For example, will they be satisfied if NDA promises that its medical ethics lecturers will teach that: there is no ethical objection to terminating a pregnancy even where there is no medical indication, either maternal or fetal, for the termination; there is no ethical objection to cutting off food and fluids from an unresponsive patient in a stable condition with the intention of hastening the patient’s death. I do not deny that some doctors agree with the values and beliefs that, the authors suggest, reflect a “secular, pluralist society”. But their opinions are not beyond reasonable dispute. They represent a particular standpoint in medical ethics. Other doctors, and other people, disagree. On these matters there is no such thing as an impartial position. There is no justification, therefore, for demanding that every Australian medical school comply with one particular standpoint in teaching its students, or risk losing accreditation. John E Murtagh Adjunct Professor of General Practice, Department of Community Medicine and General Practice, Monash University, 867 Centre Road, East Bentleigh, VIC 3165. murtaghATbigpond.com To the Editor: As a Foundation Professor of the University of Notre Dame’s Graduate School of Medicine, I would like to add a comment to recent writings on the subject of a religiously affiliated medical school.1,2 In the process of accepting my honorary appointment, I looked into the issue of possible religious bias in the curriculum and was eventually reassured and convinced that there was no cause for concern. The subject of theology, presented by Peter Black (Lecturer in Theology, University of Notre Dame), is not based on Catholic dogma but is essentially a reflection on the spirituality of illness and its impact on people. My understanding is that, to date, the students seem to be comfortable and impressed with the subject and the teacher. It must also be appreciated that the students will disperse to a wide spectrum of experienced clinical teachers of various persuasions who will carry out bedside and office teaching in a similar way to that of all other medical schools. One wonders what all the fuss is really about! It is worthy of reflection that the time-honoured model that guided our ethical standards was the Hippocratic Oath and, subsequently, the Declaration of Geneva.3 The enshrined principles are virtually synonymous with basic Catholic teaching and, indeed, with that of most other religious groups.4 It would be most appropriate for the Australian Medical Council to conduct an evaluation of the Notre Dame students at the end of this year. It might also be interesting and appropriate to evaluate the messages emanating from teachers of bioethics in other medical schools, some of whom tend to promote quite opposing and unbalanced viewpoints. From first-hand experience and the comments of aggrieved students, I suggest there are other causes for concern, especially in view of the multicultural background of students studying medicine in Australia. For example, to ridicule students for their beliefs — especially for their belief in God — is a terrible dereliction of reasonable teaching responsibilities. I feel confident that the medical students of Notre Dame will enjoy a balanced curriculum, especially with people of goodwill supervising the course. Robert G Batey Area Director, Drug and Alcohol Clinical Services, Hunter New England Area Health Service, Locked Bag 1, Hunter Region Mail Centre, NSW 2310. robert.bateyAThunter.health.nsw.gov.au To the Editor: I wish to congratulate Bower for his amazingly clear, concise and unemotive response to the article on religiously affiliated medical schools in this country.1 Having a great respect for the University of Sydney and its Centre for Values, Ethics and the Law in Medicine, I was disappointed in the article that was designed to stimulate debate on a subject that is clearly of major interest but not necessarily of major concern.2 I am disappointed because the article suggested that bodies (churches) responsible for the foundation of our original university system might now have problems in delivering unbiased and appropriate medical education. This approach to stimulating debate seems, at best, mischievous and, at worst, ill-informed. The response was a gem, and I again commend the author for taking such a positive stand. Ian H Kerridge,* Rachel A X Ankeny,† Christopher F C Jordens,‡ Wendy L Lipworth§ * Director, †Senior Lecturer, ‡Researcher, §PhD Student, Centre for Values, Ethics and the Law in Medicine, Blackburn Building, University of Sydney, NSW 2006. iankATicpmr.wsahs.nsw.gov.au In reply: All Australians have a legitimate interest in the education of health professionals. In our article1 we outlined some of our concerns — shared by the Australian Medical Council (AMC)2 — about several features of the current University of Notre Dame program, including compulsory theology courses and procedures for student selection. However, the public’s interest extends beyond the purview of the AMC’s accreditation process. For example, how will the introduction of religiously affiliated medical schools affect access to a full range of health care services and accord with the broad range of needs, values and beliefs in Australian society? Because we seek to foster critical reflection and further public discussion on this and other questions, it does not follow (as Daube suggests) that we seek to dismiss benefits that may arise from the establishment of religiously affiliated medical schools. Nor does it follow (as he also suggests) that we are impugning the integrity of the AMC’s accreditation process. New ideas, new funds and new places for medical students may go hand in hand with the imposition of religious mores on secular society. We can applaud the former and question the latter. Daube implies that we must choose between applause and criticism, but this is simply not true. Murtagh welcomes the upcoming AMC evaluation, but reassures us on the basis of his own personal reflections and impressions that there is no cause for concern. However, his experience is confined to the students in the medical program. The concerns we have raised extend to other groups likely to be affected by the Notre Dame curriculum, including (a) people in rural areas who may not be able to access the full range of health services because of the religious convictions or limited training of their local general practitioner, and (b) potential medical-school applicants who choose not to apply to Notre Dame. We also note that ridiculing people for their religious beliefs (or indeed, lack thereof) is unacceptable not only in education, but in any context. The commitment to an ultimate truth that is defined in religious terms, as affirmed by Larcos, is fundamentally what is at issue in the establishment of religious medical schools in Australia. We would be the first to agree that the pursuit of knowledge can not and should not occur in a moral vacuum. However, we challenge his implication that religion has some kind of monopoly on morals and values. Any secular, liberal society also rests on moral principles, such as tolerance of difference, and values, such as respect for human life, freedom and equality. Watt suggests we reject diversity in order to advance a monolithic bioethical, educational and health care agenda. This is an odd reversal indeed. To reiterate the central issue: many religious institutions are explicitly doctrinaire. We wish to open a public discussion about the potential problems created when such institutions take on the function of medical education. As we stated in our article, none of the problems we have raised are insurmountable, but all should be acknowledged and addressed. Along with Komesaroff, we are therefore disturbed by the University of Notre Dame’s decision not to take up the Journal’s invitation to respond to our article — even as an issue “for debate”.

Michael M Daube · George Larcos · Paul A Komesaroff · Edward D Watt · John E Murtagh · Robert G Batey · Ian H Kerridge · Rachel A X Ankeny · Christopher F C Jordens · Wendy L Lipworth

Preeti Sachdev,* Simon Chapman† * Postgraduate Honours Student, † Professor, School of Public Health, University of Sydney, NSW 2006. simonchapmanAThealth.usyd.edu.au To the Editor: Smokeless tobacco products (with the possible exception of Swedish “snus”1) are carcinogenic.2 They cause oral cancer, sometimes rapidly (within 7 years of use).3 A pinch of smokeless tobacco held in the mouth for 30 minutes delivers as much nicotine as 3–4 cigarettes.4 Sachet of smokeless tobacco In Australia, the sale of smokeless tobacco was first banned in 1986, in South Australia.5 Thereafter, all states enacted legislation outlawing its sale, and, in 1991, an amendment to the federal Trade Practices Act 1974 banned the manufacture, importation and commercial supply of the products.6 Nevertheless, permits to import smokeless tobacco for personal use were issued on application, and, in March 2002, an amendment to the federal Customs (Prohibited Imports) Regulations 1956 allowed importation without a permit of amounts up to 1.5 kg for personal use.7 Between September 2000 and March 2002 (when permits were still required for all importations), 2270 permits were issued, while between March 2002 and December 2004, a further 88 permits were issued for amounts exceeding 1.5 kg (Mr Tim Pulford, Australian Competition and Consumer Commission, Canberra [which administers permits], personal communication). Following observations of smokeless tobacco being sold in south Asian shops in Sydney, New South Wales, we sought to assess its availability. We selected 14 Sydney suburbs with large populations of residents from south Asia (defined as the Indian subcontinent), and surveyed all south Asian mixed businesses in the shopping precincts of these suburbs in March 2005. If no smokeless tobacco products were displayed, the person serving was asked if they had any “paan masala or guthka” (Hindi expressions for smokeless tobacco) for sale. Fifty of the 53 shops surveyed (94%) sold smokeless tobacco: 31 (62%) of these kept it under the counter, 14 (28%) on display behind the counter, and five (10%) on shelves accessible to consumers. No shopkeeper advised that sale of the products was illegal. The prevalence of “under the counter” storage suggests widespread awareness that it is illegal to sell the products. The federal Customs (Prohibited Imports) Regulations do not restrict the number of times a person may import up to 1.5 kg of smokeless tobacco for personal use without a permit. A typical sachet of guthka (Box) weighs 4.6 g, meaning that around 320 sachets could be legally imported for personal use. It would be entirely legal for a shopkeeper and each family member to import up to 1.5 kg on a daily basis if it was intended for personal use. Diversion of this into retail trade appears easy. The ease with which we were able to obtain smokeless tobacco suggests that the law prohibiting sale is not being enforced. The New South Wales Public Health Act 1991 empowers officers, such as environmental health officers, to investigate breaches of the Act. These officers should undertake surveillance of the readily identifiable shops in the manner that we did, confiscate the products being sold and warn that future sales will result in prosecution.

Preeti Sachdev · Simon Chapman

Chris E Rissel Clinical Associate Professor, School of Public Health, University of Sydney, Level 9, King George V Building, Missenden Road, Camperdown, NSW 2050. crissATemail.cs.nsw.gov.au To the Editor: The editorial by Sharman about exercise and air pollution1 makes the point that cars contribute substantially to air pollution, and air pollution is known to have adverse health effects. Therefore, Sharman posits that exercise, which is unequivocally good for human health, is best done away from sources of air pollution. This “common-sense” maxim to avoid air pollution when exercising is superficially reasonable as far as it goes, but is a very weak response to the health and social problems generated by motor vehicles or the need for increased levels of physical activity in the population. With only half the Australian population achieving adequate levels of physical activity,2 recommendations to patients to be more physically active are essential. To simultaneously promote exercise and then put a health warning on this physical activity effectively undermines the recommendation. Part of the difficulty in judging the actual risks from air pollution and benefits of physical activity is that the science of pollutant exposure is not well understood at the individual level. It is not currently possible to say that exercising in a particular environment will have a net negative effect. Thinking laterally, perhaps physical activity even boosts the immune response in a way that helps the body resist adverse effects of air pollution? Perhaps only under more extreme conditions would outdoor activities need to be curtailed. One body of relevant research that Sharman did not consider is the research on pollutant exposure by travel mode, which clearly indicates that car drivers and passengers have pollutant exposures at least twice that of pedestrians walking on the same street.3,4 The longer people sit in cars, the greater their exposure to air pollutants, not to mention the increased risk of obesity.5 Therefore, a highly sensible approach is to recommend to patients that they avoid travelling in cars, particularly if the patient is sensitive to air pollutants or if traffic is congested. The most obvious common-sense solution to reduce air pollution and increase individual and population levels of physical activity is to recommend to patients that they replace short car trips with walking or cycling. As little as two 15-minute active transport trips per day can achieve recommended levels of physical activity to maintain health. It is possible to change travel behaviour, and this is a far better recommendation for all patients than telling them not to exercise near traffic.

Chris E Rissel

Louis A du Plessis Former Senior Lecturer, School of Applied Science, Riverina–Murray Institute of Higher Education, Wagga Wagga, NSW (retired). eldupeATbigpond.com To the Editor: Health professionals in the Sydney Greater Metropolitan Region have been found to be less aware of air pollution and its health effects than are patients susceptible to such effects.1 Therefore Sharman’s brief review of the harmful effects of air pollution is welcome.2 In offering advice on how to minimise the exacerbation of pollution-induced harm by exercise, Sharman concentrates on the spatial distribution and temporal variation of traffic. The advice is sound for the metropolitan population, but incomplete for non-metropolitan residents exposed to smoke from burning biomass. Australia’s National Environment Protection Measure defines limits for inhalable particulate matter suspended in ambient air (PM10). The NSW Department of Environment and Conservation operates a network of monitoring stations to measure PM10 and other pollutants, and posts the results daily on its Internet site <www.epa.nsw.gov.au/index.htm>. The National Environment Protection Measure requires environmental authorities to work towards reducing the number of days on which PM10 exceeds the daily limit to no more than 5 days per year. This goal is far from being realised in some places. One such place is Wagga Wagga, NSW, where monitoring of PM10 started on 11 April 2001. From that date up to 6 July 2005, the city experienced 118 days on which PM10 exceeded the limit, as well as many days of pollution near but below the limit. In the same period, monitoring stations in the Sydney Greater Metropolitan Region registered between 11 and 33 days of excess PM10. Of the 118 days of above-limit PM10 in Wagga Wagga, 30 occurred in the period from 30 October 2002 to 26 January 2003, when there were severe bushfires in south-eastern Australia. Most of the rest had a cause that is very evident in the surrounding countryside in autumn — the burning of paddocks to prepare them for sowing. Rural residents’ health is worse than urban residents’ health for many reasons, but biomass burning is not widely recognised as one of them. The Australian Medical Association’s Rural Reference Group, which is being convened to improve rural health,3 may wish to add environmental health to its agenda. There are two steps that the Group could take to lessen the effects of smoke from burning biomass. The first is to acquaint rural doctors with information such as that presented by Sharman. The second is to persuade the Department of Environment and Conservation and NSW Health to issue rural health warnings based on the continuous, real-time output of PM10 monitors in regional centres.

Louis A du Plessis

James E Sharman Postdoctoral Research Fellow in Cardiovascular Physiology, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Brisbane, QLD 4102. jsharmanATsoms.uq.edu.au In reply: As emphasised in my editorial, regular aerobic exercise is to be encouraged, as it is of undeniable benefit to health.1 The crux of the intended message was for people to undertake an exercise program, but not near busy roads. There was no suggestion to curtail outdoor activities. Although the effect of traffic pollution on an individual is not well understood, there are many hundreds of scientific papers consistently finding that whole automotive pollution, or components thereof, damage biological tissue and promote disease.2 The World Health Organization recognises urban air pollution as a major risk to human health, with exposure to particulate matter alone accounting for an estimated 800 000 deaths a year globally.3 Would it be ethical to confine this information to the annals of scientific literature, or should some attempt be made to inform those who may be unknowingly and unnecessarily exposing themselves to veritable risk? People should have access to all the available information so that they can make an informed decision on where to exercise. Not only is it common sense, but it is entirely reasonable to suggest that people would be better off avoiding exercise alongside roadways congested with traffic. Quite separate to the question of exercising beside busy roads, but equally important from a health perspective, is the issue of persistently high ambient levels of particulate air pollution in certain regions. The air quality problem encountered in Wagga Wagga is exacerbated by geographical and climatic factors that encourage entrapment of air pollution, owing to a temperature inversion layer that is particularly apparent during winter. Other cities, such as Launceston, Tasmania, suffer the same fate and, in both cases, smoke from domestic wood-heaters is thought to be the biggest contributor to poor air quality. What are people to be told regarding exercise in these regions? It may be reasonably argued that habitual exercise in such environments would be detrimental to health, but it would be a very poor public health outcome if people were advised to stop exercising. In the affected areas mentioned, community education programs have been in existence for years, but these appear to be of limited value, as daily air pollution limits are regularly exceeded,4 as highlighted by du Plessis. Although unpopular, the answer lies in stricter regulations to clean the air, such as banning wood-heaters and tighter monitoring of rural burning.

James E Sharman

Killing me softly. Voluntary euthanasia and the road to the peaceful pill. Philip Nitschke, Fiona Stewart. Melbourne: Penguin, 2005 (xi + 354pp). ISBN 0 14 300303 8. For any doctor who has followed the euthanasia debate in Australia over the past decade, Killing me softly will provide some personal insight into the psyche of the leading protagonist for the pro-euthanasia argument, Dr Philip Nitschke. In this book, written in a semi-autobiographical style, Nitschke narrates his journey as one of an activist-in-waiting, in search of a cause, who stumbles upon a cause célèbre. That cause arrives in the form of the Northern Territory’s Voluntary Euthanasia legislation. Dr Nitschke himself is very critical of the medical profession and how he perceives our role in the end-of-life decisions of our patients. He describes himself as being possibly “the most harassed doctor in the country” and as the “chosen walnut . . . to be . . . crushed by the sledgehammer of the thought police”, but seems to see himself as the saviour of the sick and dying. As you might expect with the first-person narrative of an extreme view, opposing or moderating opinions are articulated only for the purpose of contradicting them. Nonetheless, the issues he raises are certainly of enormous relevance to many doctors and patients. It is his solution with which you might take issue. It is the very complexity of this ethical territory that stops governments from being able to formulate legislation to govern end-of-life decisions. During my Presidency of the AMA, I argued, against some fierce opposition, to invite Nitschke to the 2002 AMA National Conference to participate in a policy debate on end-of-life decisions. This was based on the belief that good policy can only be formulated when the breadth of opinion is directly canvassed. The lively and at times passionate discussion on the conference floor demonstrated the ethical and practical dilemmas many doctors face in providing compassionate care for the dying patient. Whether you agree or disagree with Nitschke’s arguments for physician-assisted suicide or for the development of a “peaceful pill”, you are likely to agree or disagree strongly. I do not believe any doctor could read this book and remain impartial to its contents. Kerryn L PhelpsAdjunct Professor in Public Health and General Practice University of Sydney Former President, Australian Medical Association

Kerryn L Phelps

New skin Eight children with serious burns have gained very high quality skin in a short time without any need for further grafting — courtesy of fetal skin. Swiss researchers developed a skin-cell bank from one fetal skin biopsy (4 cm2 skin) taken after a pregnancy termination at 14-weeks’ gestation. They then developed fetal skin-cell constructs from collagen sheets. Paediatric patients who were candidates for autologous skin-grafting had successive constructs applied to their burn sites at every change of dressing for up to 3 weeks. Complete skin closure was rapid, occurring in about 15 days. There was little hypertrophy and no retraction of the new skin. Further, over time, total recovery of mobility was documented, especially in the hands and fingers. The skin-cell bank developed by the researchers is capable of producing several million skin constructs. Lancet online Best foot forward? Which patients with diabetes should receive ongoing podiatry care? Australian researchers have challenged the traditional teaching that it should be every patient. McGill and colleagues say this ideal is impossible in the real-life setting as no health care system is sufficiently resourced for such a universal approach. They suggested podiatry should instead be provided to those patients at highest risk of foot ulceration, and estimated the number needed to treat (NNT) in order to prevent one ulcer per year in a cohort of 250 patients with diabetic neuropathy compared with 222 patients with diabetes but no neuropathy, followed for an average of 2 years. In of order risk: history of previous ulceration or amputation: NNT = 7; decreased pressure sensation: NNT = 18; decreased vibration sensation: NNT = 45; and, no neuropathy: NNT = 367. Intern Med J 2005; 35: 451-456 Take two Mars bars? Mars (the “chocolate” company) is seeking pharmaceutical partners to help it develop compounds synthesised from natural cocoa flavanols into prescription drugs, according to an editorial in the Lancet. Although preliminary research with cocoa flavanols had indicated several potential beneficial health effects — including reduced platelet aggregation, enhanced endothelial function, and antioxidant effects — variations in cocoa processing and flavanol content have made it hard to translate these early findings into tangible clinical benefits. Further, most chocolate confectionery products do not contain doses that are even likely to be beneficial. Lancet 2005; 366: 608 Green cities are lean cities A clean, green environment could help to promote physical activity and weight loss, suggest European authors. They drew upon data about the health, housing and the surrounding environment of 6919 city-dwellers in a range of European countries. Compared with people living in clean, green environs, people living in areas with more graffiti, litter and dog mess, and less visible vegetation and greenery, were less likely to be physically active and more likely to be overweight. The authors say that as well as considering individual factors that facilitate or hinder increased physical activity and weight reduction, we should also pay attention to environmental ones. BMJ online Younger and younger Mayo clinic researchers warn that, as our young adult population ages, there may be an exponential increase in the overall occurrence of non-melanoma skin cancer. They examined the incidence of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) between 1976 and 2003 in people younger than 40 years of age living in one county in Minnesota, USA. The overall age-adjusted incidence of BCC was 25.9 per 100 000 young women and 20.9 per 100 000 young men; the incidence of SCC was similar for men and women at 3.9 per 100 000. Over the time period studied, there was an increase in BCC diagnosed in young women. Further, the proportion of BCCs found on the torso increased from 18.9% in 1976-1979 to 50% in 2000-2003 — an increase related, possibly, to outdoor tanning and tanning bed use. The researchers also found an increase over time in SCC in both women and men. We may need to redouble our efforts in preventing skin cancer in the very young. JAMA 2005; 294: 681-690 Smoking teens Which teenager is going to take up smoking cigarettes? Canadian researchers say it is more likely to be an adolescent who had an enhanced susceptibility to environmental tobacco smoke in childhood. They measured salivary cotinine levels, a measure of the amount of nicotine entering the bloodstream, in nearly 200 young schoolchildren with an average age of 9 years. At follow-up at least two years later, 44% of these children (now with an average age of 13 years) had become smokers. The smoking teens were more likely to have had higher concentrations of nicotine when first studied. It was suggested that efficient absorption of nicotine from second-hand tobacco smoke may have rendered these adolescents susceptible to nicotine-seeking behaviour. CMAJ 2005; 173: 377-379

Ann Gregory