Volume 185 Issue 11

The more things change, the more they stay the same Nearly 100 years ago, George Bernard Shaw, in the preface to his play The doctor’s dilemma, savagely attacked the medical profession for its direct personal and pecuniary interest in the treatment of patients and argued that doctors could not be trusted to act in their patients’ best interests.1 He observed that medicine was not driven by science but rather by patient demand and service. Nor was Shaw particularly impressed with medical science, noting that “medical science is as yet very imperfectly differentiated from common curemongering witchcraft”. In short, he argued that the medical practice of his time was mostly ineffectual and that doctors should advise patients that wellness is not attained through a bottle of medicine but through decent housing, clothes, food and clean air. The doctor’s dilemma was that providing this advice would jeopardise his already meagre income. Despite Shaw’s vitriolic criticism, doctors of that era enjoyed the respect of society because of their care and compassion — attributes poignantly captured by Sir Luke Fildes’ famous painting “The doctor” (1891), which portrays a pensive doctor sitting by lamplight at the bedside of a sick child, with her anxious father hovering in the dark background. It is tempting to speculate what Shaw would make of the medical profession in Australia if he were sitting in judgement today. He would note that health care has become an economic giant, consuming large chunks of our gross domestic product (GDP) each year. In the financial year 2004–05, this amounted to 9.8% of GDP, or $4319 for each Australian.2 And this will only increase with the ageing of our population, the increase in chronic disorders, and the public demand for new drugs, biotechnology, medical devices and sophisticated surgery. As a prominent Fabian, Shaw would enthusiastically endorse Australia’s Medicare scheme, with its ideals of universal and unfettered access to medical care and provisions for meeting its costs. But public health insurance comes with a price — the overwhelming bureaucratisation of medical care with regulations, red tape and incessant reviews of activities.3 It also means the dominance of politicians and public servants in health decisions, with the medical profession relegated to myriad special interest and lobby groups. Considering Shaw’s scepticism about medical science, he would welcome evidence-based medicine and marvel at medical research and the role it has played in reducing infectious diseases, in widening the scope of surgery and in providing sophisticated tools for diagnosis. And with stem cell technology and medical genomics on the horizon, the sky’s the limit. He would note that medical research has become entangled with industry. In 2003, biomedical research funding in the United States reached the astronomical figure of US$94.3 billion. Industry accounted for 57% of the funding, the three major contributors being pharmaceutical, biotechnology and medical device firms.4 With this level of involvement, the purpose of biomedical research has passed from being purely for the public good to being for the good of researchers, institutions and corporations.5 Critical to this process is the promotion of products to doctors through incentives such as “taking meals, gifts, trips and . . . joining company advisory boards and speaker bureaus . . .”.6 Shaw might also be taken aback by the complexity of the organisation of medicine. From a simple structure of general practitioners supported by physician and surgeon consultants, it has evolved into numerous silos of medical subspecialties, each with their own technical territory and professional and political purposes. Doctors now work as members of health care teams, and the doctor–patient relationship has shifted from paternalism to partnerships in which doctors are health and social advisors. The ready availability of information via the Internet has given patients more knowledge and control of their own health. Patients’ expectations have also changed. The success of medical research and medicine’s capacity to cure many illnesses have led to unrealistic expectations of what doctors can achieve. Furthermore, Shaw would be amazed at how health concerns have mesmerised modern society, fuelled mainly by hyped reports of cancer “breakthroughs”7 and the shroud-waving of epidemiologists about yet another lifestyle danger to health.8 Finally, Shaw would congratulate the medical profession for being consistently endorsed by the public as an ethical and honest profession9 and be comforted by doctors’ prosperity.10 In his day, doctors were “hideously poor” and were “offered disgraceful prices for advice and medicines”.1 However, Shaw would also detect undercurrents of discontent, and debate and dilemmas for doctors in several domains: Medical practice. The burden of bureaucracy has had an insidious impact on medical practice and the independence of doctors. Conforming to evidence-based and protocol-driven practice continually erodes the capacity for discretionary practice and dampens its intellectual challenge. These sources of discontent, along with pressure from patients and the need to keep up with rapid changes in knowledge, have eroded professional satisfaction.11 The dilemma for some doctors is whether to continue in clinical medicine, to retire prematurely, or to pursue other career options. The profession. Subspecialisation of medical practice has hastened the decline of the generalist and led to compartmentalisation and segmentation of the profession, with extra burdens imposed by accreditation, registration and calls for recertification. But more daunting is an emerging identity crisis: firstly, what is a doctor?, and secondly, what does a doctor do? The first question has spawned a spate of definitions of what constitutes a doctor12,13 and what modern professionalism means.14,15 The second question has prompted calls for devolving medical practice through task transfer,16 which Shaw, with uncanny prescience, foreshadowed: “There are cases that present no difficulties and can be dealt with by a nurse or student, at one end of the scale, and cases that require watching and handling by the very highest existing skill, at the other.” The dilemma for the profession is to decide whether to continue down the subspecialisation route or to encourage a return of the generalist. The profession also needs to decide how task transfer will evolve. Trust in doctors. Trust underpins the doctor–patient relationship and is critical to society’s acceptance of medicine as a profession. In the words of Jerome Kassirer, former Editor of the New England Journal of Medicine, “Patients must be able to trust that their doctors’ motives are not subverted by financial gain, that their doctors are recommending treatments that benefit them, and that their doctors are involving them in research projects for the right reasons. Their doctors must not only be at their sides, but on their sides.”6 The entry of industry into medicine has raised questions about its role in continuous medical education, scientific and professional meetings, and support for travel and research. In these relationships, perfunctory declarations of conflict of interest by doctors are seen as the panacea for any concerns about honesty and transparency, but mostly they amount to little more than window-dressing. The dilemma for the profession is whether to confront conflict of interest head-on or persist with its comfortable approach of tolerating many “shoulds” but not many “musts”.6 Leadership. The Royal College of Physicians’ (London) recent report on professionalism stressed the need for a common forum that speaks with a “unified voice”.15 Nowhere is this more applicable than in Australia, if the conflict between professional bodies of general practice is anything to go by.16 Indeed, there are questions about whether the professional organisation of Australian medicine and its regulatory and representative bodies are appropriate to meet our current challenges, which include inexorable subspecialisation, the ability to absorb the projected increased output of our medical schools, and the development of a functional e-health system.17 The dilemma for doctors is whether they will continue to allow multiple leaders of multiple organisations to pursue multiple interests, or whether they will insist on an effective common forum that is proactive and speaks with a unified voice. Shaw’s report card on the medical profession of his time was a harsh and bruising affair. One can only surmise what he would make of medical practice and doctors in Australia today. But, in many ways, the fundamentals haven’t changed. The doctor’s dilemma remains that of how to deal with personal and professional conflicts of interest in order to maintain a position of trust and independence.

Martin B Van Der Weyden MD, FRACP, FRCPA

A national strategy for meeting the particular health needs of refugees would provide a more comprehensive approach The profile of refugees being resettled in Australia depends on global geopolitical conflicts, representations from the United Nations High Commissioner for Refugees to the Australian Government, and Australia’s response. Recent years have seen an enormous shift within Australia’s annual refugee intake, with 70% originating from countries in sub-Saharan Africa.1 The Australian Government requires those migrating under its Humanitarian Program to undertake certain health checks before being issued with a visa.2 Additionally, since mid 2005, the Department of Immigration and Multicultural Affairs (DIMA) has been rolling out an additional medical check known as a predeparture medical screen (PDMS) in the few days before departure (Kathy King, Director, Special Health Projects, DIMA, personal communication). This medical check was introduced in response to significant numbers of cases of communicable diseases being identified among new arrivals. Conducted mainly by medical staff of the International Organization for Migration (IOM), it is largely a fitness-to-fly check, although it does include screening for malaria, measles–mumps–rubella vaccination, and empirical treatment for intestinal parasites. Although DIMA is expanding the geographical coverage for the PDMS, not all current humanitarian entrants are subject to this screening. In this issue of the Journal, a collection of articles and a letter on refugee health indicate a high prevalence of various conditions among recent refugee arrivals (Chih et al, Outpatient treatment of malaria in recently arrived African migrants; Tiong et al, Health issues in newly arrived African refugees attending general practice clinics in Melbourne; Martin and Mak, Changing faces: a review of infectious disease screening of refugees by the Migrant Health Unit, Western Australia in 2003 and 2004; Cherian et al, Severe Plasmodium falciparum malaria in refugee children despite reported predeparture antimalarial treatment). Some of the data were collected before the introduction of the PDMS, which may have lowered the rate of malaria and intestinal parasite burdens. However, recent experience in New South Wales has been that cases of malaria continue to be detected despite antigen testing overseas. The detection rate for HIV among this previously screened population reported here by Martin and Mak (page 607) is low (0.12%), but is not zero. Further consideration of whether to repeat routine HIV screening after arrival is warranted. Hepatitis B tests are only conducted in a minority of entrants,2 yet this disease has important personal and public health implications. It is apparent that the screening conducted overseas, no doubt under difficult circumstances, remains suboptimal. Additionally, conditions such as anaemia, schistosomiasis and vitamin D deficiency flagged in the articles are, appropriately, not screened for overseas, yet warrant early detection and treatment. At the same time, the risk to the public from various conditions must not be exaggerated, as this is potentially detrimental to attitudes about already marginalised people, as shown by Leask et al (page 591). The fact that refugees have considerable health care needs is well documented, and these needs vary with region of origin and other factors.3,4 Health care professionals in Australia may be unfamiliar with some conditions, and diagnosis might be delayed if these conditions are not detected in their asymptomatic stages through adequate screening. The principles of prevention and early intervention, our existing knowledge about refugee health care needs, and the additional evidence from the articles in this issue of the Journal justify a call for nationally coordinated, comprehensive health assessments to be offered to all newly arrived refugees. This need for comprehensive health assessments was highlighted in a recent report on refugee children.5 However, entire families in this setting have the same requirements, and a family-centred approach is needed. Health assessments must not only focus on infectious diseases, but should take into account the refugee trauma experiences of families and individuals, and assess physical, psychological and psychosocial needs. Sufficient attention needs to be given to oral health, nutrition, undermanaged chronic conditions, and the impacts of violence. Currently, each state and territory has a different model and varying coverage for postarrival checks, as shown by some of the reports in this issue. Some jurisdictions have centralised clinics in public hospital venues, focusing mainly on infectious disease screening (eg, Tasmania, Western Australia). NSW, with an annual intake of 4000 refugees who are dispersed widely across the state, has a state-funded Refugee Health Service with some clinical role but which also supports mainstream health services to assist refugees. Victoria has a different model again, with a focus on general practitioners in community health centres and private practice, supported by refugee health nurses. Sheikh-Mohammed et al (page 594) and Tiong et al (page 602) highlight the important role that GPs play in providing health care services to refugees. However, there are limitations to GPs being able to perform comprehensive assessments, including time constraints, the challenges of using an interpreter over the phone, and the need for specialised knowledge. The release in May this year of a new Medicare item number for refugee health assessments goes some way towards supporting GPs who take on this role.6 Unfortunately, the opportunity to link the release of this item number to targeted GP education was missed at the national level. Indeed, a system of “accredited practices” could even be envisaged, with key GPs linked into, and supported by, clinicians and public health staff experienced in refugee health. As with health care provision to other special-needs groups, there are debates about the need for mainstream versus specialised services.7 In locations with significant ongoing refugee settlement, a mix of models is likely to be needed. Publicly funded clinics offer a number of advantages, including centralised knowledge and strong links with key refugee agencies. Specialised health care services targeting refugees also provide important education and support to GPs and other health care staff. Whatever the model for providing health assessments, newly arrived refugees need help to overcome the barriers they face in accessing health care.8 Increased availability of DIMA-funded case workers and of volunteers will help refugees negotiate our complex health care systems.9 Community education about available health care services is also important. Mainstream health care services must be capable of providing sensitive, culturally appropriate care to these vulnerable groups. At the national level, there are a number of initiatives underway in refugee health in addition to the new Medicare item number. In response to issues similar to those raised in the articles in this issue, the Department of Health and Ageing has, over the past year, convened a working group on refugee health, with representatives from all states and territories. This group has made recommendations to the Australian Health Ministers’ Advisory Council, some of which aim to address issues raised by Tiong et al (page 602). These include the cost of certain medications, such as praziquantel for schistosomiasis, and the limited availability of some vaccines for catch-up schedules. Refugee health is a varied field crossing multiple disciplines and presenting complex issues. The development of a national refugee health strategy would promote greater direction, coordination and standardisation nationally. One aspect should be data collation and monitoring of disease detection prevalence across jurisdictions. National guidelines relevant to refugee health, some of which are already being developed, are required. Finally, although clinicians and others working with refugees do network informally, more formalised networks between these health professionals will aid communication and collaboration across borders.

Mitchell M Smith MB BS, MPH, FAFPHM

The dark storm clouds on the horizon at dusk are typical of the wet season in Sudan. On this particular day, the wind that normally heralds the daily drenching of our compound had abated. It almost seemed it was in reverence to Tik, an 8-year-old Dinka girl, walking home leaning on her father and using a stick to compensate for her stiff-legged gait. A simple leg wound for Tik had translated into 3 weeks of painful muscle spasms as a result of tetanus. After successful treatment with diazepam, antibiotics and nutritional support, she was going home to her tent in the refugee camp. Another tent in the camp sheltered severely malnourished children receiving food and medicine from a non-government organisation in this remote area of war-torn Sudan. Tik returning home after treatment for tetanus (pictured with Katherine Hale) Children like Tik are not alone. At the start of 2005, there were 19.2 million people “of concern” to the United Nations High Commissioner for Refugees (UNHCR).1 This included refugees, civilians who have returned home but still need help, people displaced internally within their own countries, asylum seekers and stateless people. Most refugees are fleeing war, famine or insecurity. Large numbers have recently returned home to Afghanistan, but refugee displacements have actually grown in Darfur, western Sudan. There are almost 7 million and 5 million people of concern in Asia and Africa, respectively.1 Afghanistan, Sudan, Burundi and the Democratic Republic of the Congo (DRC) are the top four countries in terms of numbers.1 Australia resettled about 13 000 refugees in the 2004–05 financial year.2 At least 1500 of these came from large refugee camps in Sudan, Guinea and Tanzania.3 Understanding the conditions in the refugee camps and the medical facilities available before arrival in Australia will help health care providers meet the needs of these new arrivals. Camp conditions and medical servicesRefugee camps are often set up in countries neighbouring the conflict (Box). They can be assembled with little forward planning and virtually no infrastructure. There may be geographical difficulties — the area may have minimal food, water and shelter.6 Health care in refugee camps is provided by local authorities, and may be supplemented by international non-government organisations (NGOs) such as Oxfam or Médecins sans Frontières. Basic clinics provide primary health care and medicine for common acute conditions such as malaria, respiratory infections and gastroenteritis. Diagnosis is primarily clinical, with fundamental laboratory services such as malaria films and tuberculosis smears a luxury. Clinics are run by nurses, clinical assistants (with 2–3 years’ training in medical diagnosis and treatment) or doctors. There may be expatriate staff. Conditions can be very basic and a clinic may consist of wooden support poles and plastic sheeting. Local staff are adept at diagnosing and treating common acute conditions, but have more difficulty with chronic diseases such as diabetes and asthma. For example, in a malaria-endemic area, there will rightly be a low threshold for diagnosing and treating malaria in a febrile child. Limited vaccinations are available in these countries (commonly BCG, oral polio, measles and tetanus toxoid, with others less so). Medications also vary in availability, quantity and quality. However, access to essential medicines provided by the NGOs is life-saving, and advances are being made in the ambulatory treatment of acute severe malnutrition with high-energy protein paste based on peanuts.6 An example from Meheba, Zambia Meheba is a refugee settlement in north-western Zambia. It was set up in response to an influx of refugees from Angola fleeing civil war in 1971. In 2001, the population was about 47 000, most of whom originated from Angola, mixed with smaller groups of Congolese, Burundians and Somalians. Imelda and Jane (pictured with their mother in the clinic at Meheba, Zambia) are 2-month-old twins. They were born in the camp to Mary, who had recently fled unrest in Angola. Mary’s husband had disappeared in the war. Their birthweights were 1.6 kg and 1.7 kg, respectively. Their gestation was unknown, but they were presumed premature. It was Mary’s third pregnancy and she had no antenatal care. Mary received nutritional supplements and the babies were fed expressed breast milk through a nasogastric tube for 6 weeks until they were able to suck adequately. They received close attention to their temperature control, prompt treatment of a respiratory tract infection, and vitamin supplementation. They weighed 2.8 kg and 2.9 kg and were well when discharged. With the death of one of the rebel leaders in Angola, in 2002, peace after three decades of civil war enabled repatriation of large numbers of refugees from Meheba, and its population fell to 13 000 in 2005.5 Health screening of entrants into AustraliaRefugees apply for refugee status at the local UNHCR office. If it is approved, their settlement in western countries, including Australia, is negotiated by UNHCR. Predeparture medical and character checks are mandatory prerequisites for the granting of permanent resettlement visas. A medical examination and the following medical tests are currently performed: Chest x-ray for tuberculosis screening (if over 11 years); HIV serological testing (if ≥ 15 years); Syphilis serological testing (if ≥ 15 years and from a camp); and Urinalysis may or may not be performed.7 The health checks are carried out by panels of doctors and specialists nominated by the Australian Government Department of Immigration and Multicultural Affairs (DIMA) in the country of departure. If the results of these checks are deemed satisfactory, a residency visa is granted and travel arrangements awaited. If a medical problem is discovered, then these entrants are subject to health undertakings, in which specified medical treatment on arrival in Australia is an obligation. Further predeparture medical screening 72 hours before departure for Australia was introduced in mid 2005 for refugees and some sponsored humanitarian entrants departing from eastern and western Africa, Egypt, Sudan and Thailand. It consists of a rapid malaria test and treatment, intestinal parasite treatment and measles–mumps–rubella vaccine if aged < 30 years. This is recorded on an electronic health manifest, which is made available to the local settlement service provider through DIMA.7 The success of this predeparture screening had not yet been fully evaluated. There continue to be anecdotal reports of major medical problems that have been missed (including malaria, HIV, tuberculosis and sickle cell anaemia), and communication to final health care providers (refugee health clinics and general practitioners) of what had been done is inconsistent. The timing and quality of the health checks are also variable. Entrants who have been sponsored by family or friends do not always benefit from the above screening. These entrants are not routinely enrolled into settlement services on arrival and thus provision of health care in Australia may be delayed. ConclusionHere, we have described life in refugee camps and highlighted differences in health care quality between developed and developing countries in terms of conditions, resources, diagnosis, treatment, patient expectations, and sophistication. Predeparture screening can potentially detect important medical problems. Medical providers for refugees in Australia need an awareness of these complex issues.

Katherine Hale MB BS FRACP · Nicholas J Wood MB BS, FRACP · Mohamud Sheikh-Mohammed MIPH, MHSc, DipMedLabSci

Objective: To report on perceptions about the risk of infectious diseases from new arrivals to Australia arising from a wider study of mothers’ attitudes to childhood vaccination.Design, participants and setting: Six focus groups on perceptions about the benefits and risks of vaccination with 37 mothers of children aged 5 weeks to 18 years, mostly conducted in middle-class areas of Sydney between 6 October and 15 December 1999.Main outcome measures: Mothers’ views about infectious disease risk posed by immigration as a major reason to favour immunising children.Results: The idea of immigration being the primary source of infectious diseases was striking, and arose among a number of participants in every group conversation. Mothers expressed their dread of new diseases “from overseas”, and a sense that there are “more germs nowadays”, mostly from increased immigration to Australia and international travel. Some perceived people coming from other countries as having more disease because of an innate susceptibility or through cultural practices.Conclusion: Recent media coverage about infectious diseases importation by African refugees not only feeds, but reflects, community concerns about new arrivals as a source of allegedly rampant infection threatening Australians. These concerns have little evidence base. Public health advocates need to be proactive with the media to provide sophisticated counter-messages that expose the underlying subtexts and educate the community about the true risks of infectious diseases.

Julie Leask PhD, MPH, DipAppSci · Mohamud Sheikh-Mohammed MIPH, MHSc, DipMedLabSci · C Raina MacIntyre FRACP, FAFPHM, PhD · Alexander Leask MPH, DipAppEpi, BAgSci · Nicholas J Wood MB BS, FRACP

Objective: To determine barriers that affect access to health care for refugees from sub-Saharan Africa resettled in Sydney.Design: Descriptive epidemiological study and survey.Participants and setting: Parents of newly resettled refugee children seen at a tertiary hospital paediatric clinic between 10 June 2005 and 19 May 2006.Main outcome measures: Socioeconomic indicators, health seeking behaviour, social barriers, and beliefs about health.Results: Parents of 34 of a possible 35 families (97%) agreed to participate. Barriers to accessing health care include language barriers, financial handicap, lack of health information, not knowing where to seek help, and poor understanding of how to access health services. Most refugee families established connections with community and religious groups soon after arrival in Australia.Conclusions: Our findings suggest that most refugee families are not totally isolated in Australia, but form early connections with cultural, social and religious groups of their own ethnic background. These groups provide an opportunity to deliver health education and health information that would improve their access to health services.

Mohamud Sheikh-Mohammed MIPH, MHSc, DipMedLabSci · C Raina MacIntyre FRACP, FAFPHM, PhD · Nicholas J Wood MB BS, FRACP · Julie Leask PhD, MPH, DipAppSci · David Isaacs MD, FRACP, FRCPCH

Objective: To describe the clinical features and management of African migrants recently arrived in Western Australia and subsequently diagnosed with malaria.Design, participants and setting: Retrospective case record analysis of African migrants aged ≥ 16 years with malaria referred to Royal Perth Hospital (RPH) from the WA Migrant Health Unit (MHU) between 1 March 2003 and 30 September 2005.Main outcome measures: Demographic variables; clinical and laboratory variables; Plasmodium species; antimalarial medications used and their efficacy.Results: 57 (3.5%) of 1609 adult African migrants screened at the MHU were diagnosed with malaria and referred for treatment. 52 were infected with P. falciparum, two with P. ovale, one with P. malariae, and one with both P. falciparum and P. malariae; the malaria parasite could not be identified in one individual. No patients had severe malaria by World Health Organization criteria. Most patients (53/57) were treated as outpatients with oral antimalarial therapy; four patients without severe malaria were admitted to hospital for treatment and observation. Atovaquone–proguanil was the antimalarial medication most commonly used (in 52/57), and treatment was well tolerated in most patients. Post-treatment follow-up was possible in 50 patients; all 27 of those who were followed for 4 weeks or longer were cured. Cure could not be concluded in patients with shorter follow-up periods. All follow-up blood films were negative for malarial parasites.Conclusions: Outpatient treatment of malaria in recently arrived adult African migrants appeared to be safe and efficacious in our cohort.

Desmond T Chih MB BS · Christopher H Heath FRACP, FRCPA · Ronan J Murray FRACP, FRCPA

Objective: To identify the most common health issues diagnosed by general practitioners in newly arrived African refugees.Design: Descriptive study based on a purposive sample of six GPs to collate data from medical records of patients from African countries who had attended their clinics for the first time between 1 January and 30 June 2005.Setting: Two community health centres and two private general practices in metropolitan Melbourne.Participants: African refugee patients who arrived in Australia after 1 June 2004 and were seen by the six participating GPs between 1 January and 30 June 2005.Main outcome measures: Demographic characteristics, laboratory test results and final diagnoses.Results: Data were collected from 258 patient files. Most patients were from Sudan (57%) or Liberia (17%). Half were aged under 15 years. The most common health problems identified were inadequate vaccinations, nutritional deficiencies (vitamin D and iron), infectious diseases (gastrointestinal infections, schistosomiasis, and latent tuberculosis) and dental disease. Musculoskeletal, psychological and social problems were common in adults. 37% of patients were tested for latent tuberculosis, and 25% of these tested positive.Conclusions: African refugees require comprehensive health assessments for undiagnosed and untreated health problems. While most of the common diseases identified are non-communicable, if left untreated they will affect the long-term health and productivity of new settlers.

Albert C D Tiong MB BS(Hons), MAppEpi · Mahomed S Patel MB BS, FRACP, FAFPHM · Joanne Gardiner MB BS, DipRANZCOG, BTheol(MCD) · Rowena Ryan MB BS, FRACGP · Karen S Linton MB BS, DipRANZCOG, FRACGP · Kate A Walker MB BS, FRACGP · John Scopel MB BS, FRACGP · Beverley-Ann Biggs MB BS, FRACP, PhD

Objective: To document demographic characteristics and prevalence of infectious diseases in refugees and humanitarian entrants attending the Migrant Health Unit (MHU) in Perth for health assessment from 1 January 2003 to 31 December 2004.Design: Retrospective case series.Participants: All refugees and humanitarian entrants arriving in Western Australia on subclass 200 and subclass 202 visas who were invited to attend the MHU.Main outcome measures: Demographic details, results of Mantoux tests, and blood and faecal tests for infectious diseases and parasites.Results: WA accepted 2781 refugee and humanitarian entrants in 2003 and 2004; 2617 were invited to attend the MHU, and 2111 (81%) actually attended for screening. Over three-quarters arrived from Africa. Overall, 25% had a positive Mantoux test result, 5% were carriers of hepatitis B, and 5% had positive serological test results for syphilis. People arriving from sub-Saharan Africa had the highest prevalence of most diseases, with 8% having malaria, 7% schistosomiasis, 5% hookworm, and 2% strongyloidiasis.Conclusion: Disease prevalence varied greatly between refugees from different countries and was particularly high in those arriving from sub-Saharan Africa, the origin of most of Australia’s refugee and humanitarian entrants. These data support the need for refugees and humanitarian entrants from countries with high rates of disease to have access to a comprehensive postarrival medical assessment and appropriate follow-up health care. Health services must provide beneficial and cost-effective services that protect the health of both individual refugees and the wider community.

Jennifer A Martin MB, BAO, BCh · Donna B Mak MPH, FAFPHM, FACRRM

To the Editor: Predeparture screening and treatment for Plasmodium falciparum malaria is increasingly administered to humanitarian refugees from malaria-endemic areas immediately before resettlement in Australia. It is undertaken by the International Organization for Migration (IOM), under contract from the Department of Immigration and Multicultural Affairs (DIMA).1 Combination therapy (usually an artemisinin derivative in combination with another drug, or chloroquine) is used for both adults and children. The first dose (of what is usually a 3–5-dose treatment course) is supervised, and written documentation of the treatment should accompany the refugee to Australia.1 Giving predeparture antimalarial treatment has the potential benefit of reducing the incidence of malaria after arrival, as well as reducing the risk of local transmission in malaria-receptive areas of Australia. Onshore health assessments are performed in about 80% of humanitarian refugees resettled in Western Australia (A Thambiran, Medical Director, Migrant Health Unit, Perth, WA, personal communication). Between August 2005 and March 2006 — a period of increased offshore predeparture management of malaria (in line with DIMA/IOM policy in response, presumably, to the increasing burden of imported malaria in refugees coming to Australia) — 336 African refugee children were screened on arrival in WA. Thirty-two children (9.5%) with P. falciparum malaria were identified, of whom 20 (10 Burundian, eight Congolese and two Sudanese) had received predeparture antimalarial medications. Eleven children who presented in a 3-week period had all been treated at a single centre in Kenya with pyrimethamine–sulphadoxine and artesunate, according to sighted IOM documentation. Of the remaining nine children, some had transited through countries other than Kenya, but not all had complete documentation. Three children presented with malaria parasite loads ranging from 6% to 14% within 7–10 days of arrival in WA. One child had severe malaria (14% parasite load), was obtunded at presentation and required intravenous quinine therapy and resuscitation. Overall, 15 of the 20 children treated before departure required hospital admission, despite our selective non-admission policy for uncomplicated P. falciparum malaria. No child had long-term sequelae and all had parasitological cure at Day-28 follow-up. Possible explanations for these apparent failures of predeparture treatment include: (i) incorrect documentation of treatment; (ii) poor compliance; (iii) lack of supervision; and (iv) inactive or expired medication. Delays in departure must also be considered at assessment, as these allow potential re-infection — in this cohort, the time between treatment and migration was poorly documented. Subsequent clinical presentation in WA ranged from 24 to 31 days after treatment in Africa (in cases where documentation was available). As all children were not treated at a single centre offshore, these cases are likely to reflect more widespread and multifactorial issues about the effectiveness of predeparture antimalarial management. Another concern is the rise of multidrug-resistant strains of P. falciparum, particularly throughout sub-Saharan Africa and South-East Asia. Combination therapy with artemisinin derivatives is now recommended by the World Health Organization as first-line treatment.2 However, many of the patients in this cohort received treatment with pyrimethamine–sulphadoxine and artesunate, despite reported high levels of parasite resistance.3 IOM protocols are evolving in an attempt to reflect the rapidly changing multidrug-resistance patterns in these malaria-endemic regions.1 A recent Ugandan study reported high Day-28 cure rates with artemether–lumefantrine (despite a relatively complex dosing schedule) because of lower drug resistance.4 These cases highlight the continuing need for comprehensive and timely onshore assessment (including malaria screening), irrespective of predeparture treatment. P. falciparum malaria remains a major global cause of morbidity and mortality — there were an estimated 515 million clinical infections in 2002, with 70% occurring in Africa.5 P. falciparum has a significant case-fatality rate (up to 20% in cerebral malaria6), even when managed appropriately. It results in 1–2 million deaths each year,3 mainly of children, and about 18% of all child deaths in sub-Saharan Africa are directly attributable to malaria.7 Australia resettles more humanitarian refugees per capita than any other nation8 and many are from malaria-endemic regions. Predeparture antimalarial treatment should reduce the number of clinical episodes of malaria presenting within Australia, but the efficacy of this unproven intervention warrants prospective study. Importantly, documented predeparture antimalarial treatment should not distract health care providers from considering this potentially life-threatening infection in a febrile child recently migrated from a malaria-endemic area.

Sarah Cherian · Joanna M Fagan · Aesen Thambiran · Janet Geddes · David Burgner

The National Health and Medical Research Council Act 1992 (Cwlth) was amended in 2006 to streamline governance arrangements and help the National Health and Medical Research Council (NHMRC) to become a more responsive organisation and more effective at both acquisition and implementation of new knowledge. As part of the NHMRC’s plans for the future, we will implement the recommendations of the Investment Review of Health and Medical Research on policy- and practice-focused research, commercialisation, and recruitment of health and research professionals to the NHMRC. The NHMRC is also improving its process for selecting and supporting the best research across biomedical, clinical, public health and health services disciplines; and will develop, trial and introduce new forms of communicating evidence-based information.

Warwick P Anderson BSc, PhD

Research and publication misconduct is commoner than many believe, hard to detect and difficult to investigate, with institutions often being reluctant to take action. The first countries to set up formal systems for policing research misconduct were the United States and some Scandinavian countries. The US Office of Research Integrity (ORI) is a useful model for other countries; rather than conduct investigations, the ORI supervises the investigation by the respondent’s institution. The United Kingdom has taken more than 10 years to set up a national supervisory body — the UK Panel for Research Integrity in Health and Biomedical Sciences. Unlike the ORI, it has no statutory basis. It is too early to tell whether the procedures set up in the UK will work. The present trend for governments to encourage universities to link up with industry may lead to a culture of secrecy and confused accountability. In any country, including Australia, intent on policing research, it is only possible for editors, reviewers or readers to initiate investigations, not undertake them, as power lies in the hands of employers, research funders and regulatory bodies.

Harvey Marcovitch FRCPCH

Institutions investigating allegations of research misconduct are vulnerable to claims that their processes are inadequate or that they have an institutional conflict of interest. The Office of Research Integrity in the United States sets down standards for and reviews the adequacy of investigations of research misconduct by institutions; recognises that internal politics and the involvement of non-experts can lead to honest mistakes being regarded as serious misconduct; requires complainants and investigators to act “in good faith”; and reduces damaging publicity when complaints are misconceived or false. Australia needs an office of academic integrity to ensure that all complaints are thoroughly investigated; the investigative procedures meet international standards; fair processes are provided for complainants and respondents; and institutions are protected from claims of “cover-up” and institutional conflict of interest.

Bruce M Hall MB BS, FRACP, PhD

Research conduct in Australia and worldwide is mostly unaudited. The purpose of good research governance is to ensure integrity in research through accountability, transparency and responsibility. Institutional responsibility for research governance has been adopted by Monash University’s Department of Epidemiology and Preventive Medicine, providing clear lines of accountability for researchers as well as support and guidance. A research audit tool has been developed, identifying areas where practice could be improved especially among less experienced researchers; the most common adverse findings concerned research protocols and procedure manuals. The need for participant confidentiality, privacy and data security was found to be understood, and adhered to widely by all researchers. An evaluation of the effect of audit on researchers found that the process was well accepted.

Stephanie J Poustie MPH, CertCritCare, BN · David McD Taylor MD, FACEM · Andrew B Forbes BSc(Hons), MSc, PhD · Marina A Skiba BEd · Mark R Nelson MFM, FRACGP, PhD · John J McNeil MB BS, PhD, FRACP

Broader measures are needed to reduce road trauma related to mobile phone use The effect of mobile phone use on driving performance and safety has been a major focus of distraction research. Around 94% of Australians (19 million) own a mobile phone,1 and the capabilities of these devices are rapidly expanding. They can be used to talk, read and send text messages, download and play video clips from the Internet, navigate to chosen destinations, and perform other functions.2 When used while driving, they are capable of distracting drivers by taking drivers’ eyes off the road (eg, when reading a text message), taking their attention off the road (eg, when talking), and physically interfering with vehicle control (eg, when reaching to answer the phone while steering). There is converging evidence that the use of mobile phones while driving increases crash risk. A New Zealand study estimates that crashes involving mobile phones account for about 0.5% of all reported crashes there,3 and a fourfold increase in crash risk has been reported in some epidemiological studies, for both hand-held and hands-free use.4 This increase in risk is similar in magnitude to that associated with a blood alcohol concentration of 0.08%. Few epidemiological studies have reported data on the increased crash risk associated with driver exposure to other sources of distraction, although threefold increases in crash risk have been reported for young drivers who carry three or more passengers.5 However, it is not clear if this increase can be attributed solely to distraction. Controlled psychological studies, conducted mainly in simulators, have shown distraction-related decrements in driving performance with use of mobile phones that appear to underlie these increases in crash risk: impaired lane-keeping ability; poorer speed and following distance control; longer reaction times; missed traffic signals; a reduced useful visual field of view; and other related decrements.6 In determining the increased risk to the public of mobile phone use while driving, it is necessary to know the prevalence of this practice. Taylor and colleagues observed 17 000 drivers at 12 metropolitan road sites in Melbourne in October 2002.7 Overall, 1.85% of drivers (315) were observed using a hand-held phone. Older drivers had a significantly lower rate of use than middle-aged or young drivers. In this issue of the Journal, McEvoy and colleagues report a cross-sectional survey to explore the use and effects of mobile phones while driving for drivers in New South Wales and Western Australia.8 Participants were 1347 licensed drivers aged 18–65 years. While driving, around 57% of drivers had ever used a mobile phone (39% of these had used a hand-held phone) and 12% had written and sent text messages. The authors estimate that, for all drivers aged 18–65 years in these two Australian states, about 1% will have ever had a crash while using a mobile phone and, in the preceding year, around 3% will have taken evasive action to avoid a crash because of their phone use. Collectively, the authors of these articles conclude that, despite legislation that bans the use of hand-held phones in Australia, mobile phone use is prevalent among drivers, particularly younger drivers, and that it can result in adverse consequences, including crashes. There are certain driver and task characteristics that appear to moderate the effect of mobile phone use on driving performance and safety:9 the amount of time the driver engages in phone-related activity; the complexity of phone design and the phone task itself; current driving demands; driver experience and skill; and driver willingness to engage in phone-related activity. Countermeasures to mitigate the effects of distraction should take these into account. The Australian Mobile Telecommunications Association provides the following specific advice to mobile phone users to minimise the potentially adverse effects of distraction: use a hands-free phone; plan trips and make calls when stationary; avoid making calls in heavy traffic or poor weather conditions; avoid complex or emotional conversations; use message services to answer calls; pull over safely when stopping to make calls; use phone features to reduce the effort involved; never take notes, look up phone numbers, or read or send text messages while driving; tell callers you are driving when on the phone; and use the phone to call for help in emergencies.10 These recommendations appear to be sensible strategies if applied to hands-free phones, the use of which is presently legal. The use of hand-held mobile phones while driving is banned in Australia, although exemptions do exist for some drivers (eg, police). At a broader level, there is scope for further countermeasure development, and policymakers have many strategies at their disposal.2 These include: Data collection to better quantify mobile phone use as a contributing factor in crashes: enhanced police report forms to record mobile phone use as a potential source of distraction; regular mobile phone distraction exposure surveys; use of “black boxes” to record phone use in crashes; Education: publicity campaigns to raise awareness of risks, especially for hands-free phone use and text messaging; highlight factors that increase vulnerability to risks, especially driver inexperience; promote strategies for minimising distraction, especially the purchase of the most ergonomic hands-free phone types; and raise awareness of penalties for using hand-held phones; Training to address when, optimally, to expose learner drivers to hands-free mobile phone use; the least distracting methods of interacting with hands-free phones; self-awareness of the effects of phone distraction on driving; the training of passengers as co-pilots to manage phone use; Legislation and enforcement: prohibit learner and probationary drivers from using all mobile phones while driving; review exemptions and anomalies in existing legislation; improve effectiveness of police enforcement of current legislation; develop technologies to prevent phone use in vehicles moving at high speed; increase penalties; Phone design: improve ergonomic design of in-built and portable hands-free phones to reduce distraction — although it is possible that improved design and ease of use could promote increased phone use while driving, and as a consequence paradoxically undermine safety; Vehicle design: use intelligent on-board “workload manager” technologies to temporarily suppress calls and prevent access to phone functions and controls when distraction potential is estimated to be high; Fleet safety: as a duty of care, develop, implement and enforce company policies on mobile phone use while driving; Licensing: provide information on risks of mobile phone use while driving in licensing handbooks; test knowledge of these risks; design practical driving tests to identify, and prevent from being licensed, learner drivers who are incapable of compensating for the effects on driving of hands-free mobile phones; and Research: to further understand the theory, effects and mitigation of mobile phone distraction. Many of these have been adopted as recommendations in the recently released report of the Parliament of Victoria Road Safety Committee Inquiry into Driver Distraction.10 The use of mobile phones while driving will continue to contribute unnecessarily to road trauma in this country unless countermeasures such as these are developed, implemented and properly evaluated.

Michael Regan BSc(Hons), PhD

Objective: To explore the use and effects of using mobile phones while driving.Design: Cross-sectional survey.Setting: New South Wales and Western Australia, 20 October to 7 November 2003.Participants: 1347 licensed drivers aged 18 to 65 years. Data were weighted to reflect the corresponding driving population in each state.Main outcome measures: Mobile phone use while driving (hand-held, hands-free and text messaging); adverse effects of use.Results: While driving, an estimated 57.3% ± 1.5% of drivers have ever used a mobile phone and 12.4% ± 1.0% have written text messages. Men, younger drivers and metropolitan residents were more likely to use a phone while driving and to report a higher frequency of use. Enforcement of hand-held phone restrictions was perceived to be low (69.0% ± 1.5%) and an estimated 39.4% ± 2.1% of people who phone while driving use a hand-held phone. Half of all drivers (50.1% ± 1.6%) did not agree with extending the ban to include hands-free phones. Among drivers aged 18–65 years in NSW and WA, an estimated 45 800 ± 16 466 (0.9% ± 0.3%) have ever had a crash while using a mobile phone and, in the past year, 146 762 ± 26 856 (3.0% ± 0.6%) have had to take evasive action to avoid a crash because of their phone use.Conclusions: Phone use while driving is prevalent and can result in adverse consequences, including crashes. Despite legislation, a significant proportion of drivers continue to use hand-held mobile phones while driving. Enhanced enforcement is needed.

Suzanne P McEvoy MB BS(Hons), MAppEpid, FAFPHM · Mark R Stevenson PhD, MPH · Mark Woodward PhD, CStat

Will DrinkWise truly act independently to reduce alcohol-related harm? The Australian Government recently awarded $5 million to “DrinkWise” to educate the public about responsible drinking.1 DrinkWise is a putatively independent body that was originally funded by the alcohol industry, whose representatives occupy six of its 12 board positions.2 DrinkWise’s stated mission is to change the “drinking culture” of Australia; its slogan is: “Moderation is always in good taste”. According to its Chairman, Emeritus Professor of Medicine John Dwyer, DrinkWise will produce policy by consensus. Given the alcohol industry’s representation on its board, will DrinkWise be able to advocate policies that the industry finds unacceptable? There is reason to be concerned, because the alcohol industry does not have a distinguished track record in reducing alcohol-related harm in Australia. It strenuously opposed the introduction of random breath testing in the 1970s and 1980s,3 because it would reduce alcohol consumption — which it did, and in the process reduced road crash fatalities and injuries. In the early 1990s, the brewers and distillers opposed the innocuous and basic policy of including standard drink labelling on alcohol beverage containers4 so that consumers could assess their own alcohol intake. DrinkWise is the Australian incarnation of a series of similar alcohol industry-funded “policy” groups that have been established in North America and the United Kingdom in recent decades — the industry’s term for them is “social aspects organisations”.3 The policies that these groups have advocated provide a reasonable guide to what we may expect from DrinkWise. These are alcohol policies that are apparently plausible and have a high media profile, but are likely to have little effect on problem alcohol use or alcohol-related problems: namely, school-based education and mass media campaigns about “responsible drinking”, the “self-regulation” of alcohol advertising and promotion, and 24-hour alcohol trading as a way of reducing alcohol-related harm.5 The evidence is clear that these are ineffective ways of reducing alcohol-related harm.6 School-based education on alcohol has been extensively investigated. At best, it has very modest effects on alcohol use; at worst, it can encourage experimentation.6 Youth are a favourite focus for the industry, because young people are their future (and best) customers. In 2002, for example, underage Australian adolescent drinkers were estimated to have consumed $217 million worth of alcoholic beverages.7 Educational messages that portray drinking as an activity only for adults are double-edged when delivered to teenagers who often are in a hurry to assume adult status. Industry-funded advocacy groups have attempted to circumvent the inconvenient lack of evidence for the efficacy of their preferred policies by using some of the same tactics as the tobacco industry — trying to manufacture spurious controversies about the effectiveness of policies of which they disapprove while producing apparently authoritative but biased reviews of evidence in favour of the polices that they advocate. In the early 1990s, for example, The Portman Group in the UK tried to covertly commission critical reviews of a World Health Organization report on alcohol policy from academics it assumed would be hostile to the report.8 More recently, the International Center for Alcohol Policies has been accused of commissioning a selective review of the evidence on the effectiveness of school-based alcohol education, while ignoring critical peer review comments that it solicited on the document.9 Alcohol industry advocacy groups also like to emphasise the protective health effects of alcohol consumption in older adults.2 These benefits have been contested,10 and even if they exist, they are small, at best, and far smaller than the overall harm. Any such health benefits largely accrue to middle-aged men at risk of cardiovascular disease who drink in moderation, rather than to the many more numerous young adults who drink in risky ways.6 None of this should be surprising. The alcohol industry cannot afford to reduce the risky alcohol consumption that generates most of its profits. Conservatively estimated, two-thirds of all alcohol consumed in Australia (and 90% of that consumed by young men) is consumed in ways that put drinkers’ and others’ health and wellbeing at risk.11 Nor should we be surprised, given the $5.5 billion in tax revenue that alcohol generated in 2004–05,12 that the Australian Government supports policies that purport to reduce alcohol-related harm without reducing per capita alcohol consumption. How will we be able to tell if DrinkWise lives up to its claim of being an independent organisation that reduces alcohol-related harm in Australia? First, we would see DrinkWise advocating public health policies that are supported by evidence, rather than the plausible but ineffective ones favoured by the alcohol beverage industry (Box).6 These will include (but not be limited to) policies such as increasing taxation on the most misused forms of alcohol in Australia (namely, cheap cask wine); more effective enforcement of licensing laws that penalise hotels for selling alcohol to intoxicated customers; and reductions in the hours of alcohol trading in areas where drinking causes public disorder and violence.6,12 Second, over the next half decade we should see a reduction in per capita alcohol consumption and reductions in key indicators of alcohol-related harm. These would include a lower proportion of fatal and non-fatal road crashes in which alcohol is a contributory cause; fewer hospitalisations for alcohol-related accidents, injuries, and suicides, especially among young adults; and fewer liver cirrhosis deaths and hospitalisations. If instead we see high profile media and school-based education campaigns urging us to drink responsibly, and no reductions in any of these indicators of alcohol-related harm, then DrinkWise will prove to have been what many in the alcohol field fear it will be — an attempt by the alcohol industry to avert serious consideration of public health policies that will adversely affect their bottom line. Evidential support for strategies to reduce alcohol-related harm6 Strong evidence of effectiveness and cost-effectiveness Alcohol taxation: higher taxes for higher alcohol beverages Availability restrictions: Raising the minimum drinking age to 21 years Reducing outlet density Reducing trading hours Enforcement: Random breath testing with blood alcohol concentration < 0.05 g/dL Enforcing licensing laws Penalties for serving intoxicated customers Medium evidence of effectiveness and cost-effectiveness Screening for at-risk drinking in primary care Early intervention for problem drinkers Weak evidence of effectiveness School-based education Public service messages

Wayne D Hall BSc, PhD · Robin Room

Objective: To estimate the extent and cost of alcohol-related absenteeism in the Australian workforce.Design: A secondary analysis of select data obtained from 13 582 Australian workers (aged ≥ 14 years) collected as part of the 2001 National Drug Strategy Household Survey.Main outcome measures: Self-reported measures of alcohol-related absenteeism, illness or injury absenteeism and alcohol consumption categorised according to National Health and Medical Research Council (NHMRC) guidelines for short- and long-term risk.Results: The use of self-reported measures of alcohol-related absenteeism resulted in an estimate of 2 682 865 work days lost due to alcohol use in 2001, at a cost of $437 million. The use of self-reported measures of illness or injury absenteeism to determine the extent of absenteeism attributable to alcohol use resulted in an estimate of 7 402 341 work days lost, at a cost of $1.2 billion. These estimates are about 12 to 34 times greater than previous estimates based on national data. Low-risk drinkers and infrequent or occasional risky and high-risk drinkers accounted for 49%–66% of alcohol-related absenteeism.Conclusions: The extent and cost of alcohol-related absenteeism is far greater than previously reported, and more than half the burden of alcohol-related absenteeism is incurred by low-risk drinkers and those who infrequently drink heavily.

Kenneth J Pidd PhD · Jesia G Berry BHSc(Hons), GDPH · Ann M Roche PhD · James E Harrison MB BS, MPH

I have had a long and interesting life. I have been doubly fortunate in that most of the rewarding activities came into my life not through my own endeavours but by being presented to me, often quite unexpectedly. My first choice of a career came from seeking vocational guidance while in secondary school. I was advised to become a psychologist. Having no other aspirations, I set off in that direction and, in due course, gained admission to the Faculty of Arts at the University of Sydney, hoping to gain an honours degree in psychology. All went well until my second year — in 1942. By then, the Second World War had become pressing, and I found myself being interviewed by an army recruitment officer. He told me that, with my university background, if I were to join the infantry I might be rapidly promoted. The alternative was radar and coastal artillery. Radar sounded more interesting, and turned out to be very active as well. In 1942 and 1943, the Japanese I class submarines sank 175 000 tons of shipping and drowned some 350 sailors in the waters around Sydney. Our job was to locate the submarines. Things happened quickly. At one stage, Sydney had only one 10 cm radar station and I was for a time the most senior soldier running it. After some time the war moved north. On the wayIn the military, one learns to be a little devious. After 2 years, I manoeuvred myself into the Australian Army Psychology Service and, in time, achieved the rank of Warrant Officer 1st Class. I was doubly fortunate: my immediate senior officers were both learned and helpful — they became Professors of Psychology after the war. Wide experience and expert supervision achieved the curious result that, with no formal qualification, by the end of the war I was performing the duties of the Clinical Psychologist at 114 Australian General Hospital, the principal interservice psychiatric hospital. Here I saw my first battle casualties. To make amends for my training deficiencies, I was given the title “Psychometrist”. Consulting the Oxford dictionary, I discovered that psychometrists had the power of divining — from physical contact with an object — the qualities of any person or thing that had been in contact with it. Although this would indeed have been a very useful talent, I had to acknowledge that I did not possess it, but no one seemed to mind. Working as a psychologist showed me that doctors had most of the professional power. Therefore, I decided to do medicine and become a psychiatrist. On the way through, I discovered that many doctors believed that only those who were unable to make a living in any other branch of medicine, or who were hopelessly dependent on alcohol, became psychiatrists. At that time, the solution was to prove that one was a “real” doctor by acquiring the Membership of the Royal Australasian College of Physicians. For that reason, many psychiatrists in my generation have the hard-won FRACP after their names. The immediate postwar yearsLooking back now, it is interesting to reflect on the medical world in New South Wales 60 years ago. There was one university — the University of Sydney — and its Faculty of Medicine had one Professor of Medicine, one Professor of Surgery and one (part-time) Professor of Psychiatry. Consider their numbers now! There were many roles to be filled. Within a few years, I found myself a Lecturer in Psychiatry in the Faculty of Medicine and a Member of the Board of Studies, Lecturer and Examiner for the degree of Master of Arts in Clinical Psychology in the Faculty of Arts. Additionally, I had become a Member of the Advisory Board of the Institute of Criminology at the University of Sydney. In those days, to be on the teaching staff of three faculties at once was a little unusual. Getting aheadMy entrance into the Australian and New Zealand College of Psychiatrists was atypical. In the 1960s, David Maddison created the College virtually single-handedly. For some time, I had examined with him in clinical psychiatry for the University of Sydney’s Diploma of Psychological Medicine. David Maddison rang me one day and said he wanted me to be a Censor of the College. Having the psychopathology of the only child, it does not occur to me to join things, and I pointed out that I was not a member of the College. David said, “Yes you are”. The next day, I paid my subscription, and a few days later I was in the College, and a Censor. There were many committees to join, and each would have a story to tell if there were more space. Their titles will have to suffice (see Box). The essence of it was that there was much to be done and I did my best to be as active as possible. In 1997, I received the College’s Medal of Honour, an award rarely given. It was awarded not only for my services to the College but also for being an “ambassador” for the College. The Law FoundationIn 1960, David Maddison’s brother, John, was the NSW Attorney-General. He rang me one day and invited me to join the Law Foundation of NSW. It sounded interesting, so I joined, and, in time, I found myself chairing it. This meant chairing a group comprised of the Attorney-General, the Head of the Bar and of the Law Society and one or two other worthies of similar status. It was an interesting experience for a psychiatrist and taught me a lot during my 20-year membership of the Foundation. There was no shortage of problems to be dealt with. Representatives of the articled clerks came to see me, and complained that some of them were receiving little instruction and were instead being used as lowly paid messenger boys. The solution was to set up the College of Law in Sydney, which is still going strong. There were other problems. My experience as a witness had shown me that, while the great body of judicial officers were intelligent and committed to their duties, there were some unfortunate exceptions. For example, in the District Court of NSW, I found myself giving evidence before a judge who did not raise his head from the bench. When finally he lifted it he said, “Bloody bullshit”. The only possible answer was “May it please Your Honour”. He replied, “Thank you, doctor”, and put his head down again. The Chief Justice of the day was manifesting clear evidence of dementia, but no one was doing anything about these and other problems in an important system. I persuaded the Law Foundation to set up the Judicial Commission to deal with such problems, and, from 1997 onwards, gave occasional lectures to the Educational Division of the Commission. Back to the servicesOne Friday afternoon in 1964, Bill Deane-Butcher, from a nearby office, came to talk to me. I knew he was Head of Royal Australian Air Force (RAAF) Reserve Medicine. He said, “We’ll be at war with Indonesia over the weekend. The mirages have gone to Darwin. You have service experience, and we want you in the RAAF this weekend.” And I was. I was on the active Reserve for the next 17 years, with service in Malaya and Vietnam. I became Senior Consultant in Psychiatry to the Director General of Air Force Health Services, with the rank of Group Captain — certainly an improvement on my army career! Once more, I learned a lot about many things and about myself. Vietnam, with its jump mines, left me with an enduring hatred and contempt for those who advise war and bring it about. There is no shortage of such people now. Something newIn the early 1980s, I received another memorable phone call, this time with an unusual invitation. It was the NSW Minister for Corrective Services, asking me if I would like to be a part-time Commissioner of Corrective Services. There had been much trouble in NSW prisons, culminating in the 1978 Report of the Royal Commission into NSW Prisons,1 in which Justice Nagle recommended the creation of such a position. As my work at the RAAF had been settling down and my advancing years made it unwise to fly in very fast highly manoeuvrable aircraft, and as I had never been a Commissioner of Corrective Services before, I could not resist the invitation. It turned out that I had a particular advantage. The common language used in the lower ranks of the army was exactly the same as that spoken by the prisoners. This made my communication with them much easier, since I spoke it as a native. On one occasion, I was in what was then the maximum security wing at Long Bay Gaol, housing 90 prisoners. The prisoners told me that heroin was much cheaper there than it was on the street and that they were all using it. They shared one syringe and one needle, and I was aware that HIV was spreading rapidly in the outside world. I went to the Minister and suggested that we start a methadone program and distribute clean needles and syringes. He was appalled at my suggestion, and when my 1-year term was up, he told me he would not reappoint me. When my job was advertised, I applied for it, was interviewed by the appropriate committee and chosen by it. The Minister did not welcome me, but I stayed for another year to make my point, and then resigned. On another occasion, to achieve a necessary result, I broke the law. During a visit to the NSW female correctional centre at Mulawa, I encountered a woman sitting with her shirt hitched up and her trousers pulled down. She had a single-edged razor blade in her right hand and was cutting deeply into her abdomen, with considerable loss of blood. There was a brief conversation. “That’s not a good thing to be doing, why are you doing that?” “There’s a baby in there and I’m going to get it out.” “Is there any way that I can persuade you to stop?” “If you send me to Rydalmere Psychiatric Hospital, I’ll stop.” In those days it was necessary to get the services of two psychiatrists, each of whom signed a Schedule 3, before a person could be moved from a prison to a psychiatric hospital. Both the Minister for Corrective Services and the Minister for Health were involved. The median time for a transfer under these conditions was about 6 weeks. This seemed excessive in the circumstances, so — unlawfully — I signed a Schedule 2 and sent her off immediately, the bleeding having been staunched. (A Schedule 2 required the signature of only one psychiatrist, but could not legally be used for the transfer of prisoners to a psychiatric hospital.) Soon after this, my good friend, Bill Cramond, who was Head of Mental Health at the time, contacted me and said that the NSW Cabinet wanted to know exactly what I had to say about breaking the law in this way. Part of my reply was unprintable, and the rest was to say that I had the choice of standing before them with a dead woman and a dead baby, or signing the wrong piece of paper. I had chosen to do what I did, and, presented with the same dilemma in the future, I would do the same again. If they did not like it, we would have it out on talkback radio, television and the newspapers. I heard no more. The game went both ways. At one time, we had a former Chief Magistrate and a former Minister for Corrective Services in custodial care for breaking the law! One of the biggest problems with the prison system was that the officers and prisoners had each other stereotyped as villainous creatures, and there was something close to open warfare between the two populations. The 1978 Royal Commission into NSW Prisons noted that, in 1942, there had been a substantial upsurge in prisoner unrest in NSW, “leading to a dramatic increase in breaches of prison discipline. There were several serious assaults on officers.”1 As a result, between 1965 and 1976, prisoners regarded as intractable were sent to a special unit at Grafton. They were welcomed with a “reception biff”, which consisted of a beating about the back, buttocks, shoulders, legs and arms by two or three officers using rubber batons. In 1970, there was a systematic flogging of a large number, if not all, of the prisoners in Bathurst Gaol. In 1974, the prisoners rioted and burned the gaol down. The antipathy that resulted was strong, and our principal task was to break it down and help each side (prisoners and officers) to see the other more as they really were. We started a special unit in which the very “heavy” prisoners (those with power in the prison population social structure) and prison officers mixed freely and enjoyed some pastimes together. To that we added a psychologist and a female governor. In those days, that was something like appointing a woman to head the Anglican and Catholic churches. My greatest day in corrections occurred when, on one occasion, I was sitting in the office of the Governor of the special unit and two heavy prisoners came in and addressed her by her first name. “Isabel, Christmas is coming and we can’t get any boots for Santa Claus. Can you help us?” “You’ll be right, boys. I’ll make sure that you do.” “Thank you, Isabel”, and off they went. This was a long way from the Grafton “biff” to which heavy prisoners had been sent to teach them who was “boss”, as described in the Royal Commission report. More than once, when there was a fierce riot raging in a prison and I was there with my brother Commissioner, Frank Hayes, the heavies reassured us that they would make sure that nothing nasty happened to us — and, indeed, nothing ever did. They recognised that we were trying to be just to both sides. In the end, we had a 6-week strike, with no prison officers working at all. The heavies said there would be no trouble in the gaols, and there was none. This was a significant communication, as their cooperation meant that the administration could run on for many weeks without any prison officers present and that the officers’ strike did nothing but harm their own interests. Other thingsDuring the second half of the 20th century, I had observed that there were many excellent psychiatrists in private practice but that the field had shown little indication of becoming organised, as academic psychiatry and public psychiatry had done. This moved on when I met Paul Ramsay, who then owned a small private hospital I was using. We formed a close and comfortable working relationship that led to the building of the Northside Clinic, a sizeable private psychiatric hospital that was opened in 1973. The psychiatric services were managed by my practice, in which there were some 15 or more psychiatrists and associates. We taught students and were recognised by the University of Sydney as a teaching establishment. We also had registrars, which was of special interest to me, as I had held the first registrar position in psychiatry in Australia in 1956. It was called “psychological medicine” at the time. It all went well, but, by 1999, after one partner had behaved improperly, I decided to concentrate on other things. Protecting the publicThere was another problem that troubled me. In the 1980s, psychiatrist Harry Bailey was practising deep sleep therapy at Chelmsford Private Hospital, Sydney, with a completely unacceptable number of consequent deaths. There were other improprieties as well. I was hearing about this in my consulting room, for it was widely known. There was no sign of the statutory bodies — the coroners, the Health Department, the Medical Board — taking action, even though many of the patients were transferred from Chelmsford to public hospitals and died there. Disturbed by it, I obtained the details of the death of a particular patient, and — supported by a professor of pharmacology and a senior physician — had the relevant information laid before the prosecuting authorities of the day with a charge of manslaughter in mind. Before anything could happen, the patient’s body was shipped overseas, as she came from another country, and the case collapsed. I felt that I could do no more, but then Merrilyn Walton — now Professor Merrilyn Walton — turned up in Sydney to establish the Health Care Complaints Commission. We conferred, and identified 18 deaths that should never have occurred. Dr Bailey was asked for his responses to each of these — seriatim. He suicided and, in his suicide note, blamed me by name for his death. Subsequently, I was an expert attached to the Royal Commission into Deep Sleep Therapy conducted by Justice Slattery. Those who wish to learn more about these matters can consult the Report of the Royal Commission into Deep Sleep Therapy.2 As a consequence of this activity, I was asked to investigate the management of Ward 10B at Townsville Hospital. The ward had been run as a “therapeutic community”, a popular concept decades ago. The essence of it was that an institution of this kind should be run by those in it rather than by the ordinary management team, such as psychiatrists and the like. As might be imagined, chaos reigned, and there was an inquiry to which I became a part-time consultant. I have always done my best to ensure that patients are treated competently and sympathetically. This has led to an interest in euthanasia. The notion that someone dying in agony, unrelieved by palliative care, should be made to go the full distance when they beg for death is repugnant to me. Much more could be said about this. It led to my involvement with a poor fellow in Darwin seeking to terminate his life when no other psychiatrist could be persuaded to become involved in the matter. It was a very public situation. I received both an award and hate mail. And nowIn my eighties, I find myself sitting on the Mental Health Review Tribunal and enjoying it. I have been there since its establishment under the Mental Health Act 1990 (NSW). The only problems are the vagaries of the Act and the traffic encountered in getting to some venues. I have had a good time with excellent friends, family and people to help me. My occupation has been interesting and I am still going strong. Who could ask for more? Awards, appointments and publications Awards Service medals 1939/45 War Medal Australian Service Medal (Second World War) Vietnam Service Medal (Vietnam War) Member, Order of Australia, 1983 Medal of Honour, Royal Australian and New Zealand College of Psychiatrists, 1983 Honorary Life Member, Faculty of Medicine, University of Sydney, 1994 Reserve Forces Decoration, 1996 Gold Star Award, Voluntary Euthanasia Society of New South Wales, 1998 Part-time consultancies Royal Commission into the Use and Effects of Chemical Agents, 1985 On Australian Personnel in Vietnam, 1985 Carter Inquiry into Ward 10B at Townsville Hospital, Queensland, 1990 Royal Commission into Deep Sleep Therapy, NSW, 1990 Adviser to Commission of Inquiry into Workers Compensation Common Law Matters (NSW), 2001 Previous appointments Member, Psychologists’ Registration Board of NSW, 1989–1996 Chair, Board of Practice Standards, Royal Australian and New Zealand College of Psychiatrists, 1990–1997 Chair, Clinical Practice Advisory Committee, Royal Australian and New Zealand College of Psychiatrists, 1990–1997 Chair, Inquiry into Psychosurgery (NSW Government), 1996–1997 Chair, Medical Committee (Poisons Act 1996 [NSW]), 1973–1992 Member, Legal Representation Committee considering the rights and needs of the mentally ill, 1977–1987 Member, Ministerial Advisory Committee inquiring into mental health services in New South Wales, 1987 Consultant Psychiatrist to the Health Insurance Commission, 1989–2005 Visiting professorships and lectureships in Malaysia, New Zealand and all Australian states except the Northern Territory Publications Writing has been one of my pleasures. My first publication was in the school magazine of my intermediate high school — a satirical additional chapter for the book we were obliged to study for the Intermediate Certificate. I am still at it: I have 170 articles in the medical and legal literature, eight chapters in books, and three books to my name. In addition, I edited the journal Modern Medicine for 22 years.

John H T Ellard MB BS, MRACP, DipPsyMed, FRACP, FRANZCP, FRCPsych, MAPsS

Looking back over my life, I am struck by how important chance has been. Chance creates opportunities — and my life has been abundant with opportunities. I have had the rare experience of changing careers several times. I have been associated with the birth of several new organisations and seen them become successful.1 My decision to study medicine was considerably influenced by my father, Kenneth Hetzel, a consultant physician at the Royal Adelaide Hospital, who became Dean of the Faculty of Medicine at the University of Adelaide (1953–1959). A greatly respected clinical teacher with a passionate interest in medical research, he was an inspiration to me.1 I graduated from the University of Adelaide at the end of 1944. Early in my course, I had enlisted in the Royal Australian Air Force, but after being diagnosed with pulmonary tuberculosis in 1945, I was unable to undertake military service. Many of my contemporaries did not return from war service. This left me with a strong desire to make the world a better place! As a student, through membership of the Student Christian Movement, I adopted a Christian commitment. This led me to a holistic medical perspective that I have consolidated with fairly extensive reading in philosophy and theology, with particular reference to the interaction between science and religion.1 My holistic perspective led to an interest in endocrinology, including “stress”. I became aware of the ideas of Hans Selye, who had first recognised the importance of the role of the adrenal cortex in the body’s response to stressful stimuli. This followed the earlier work of Walter Cannon, who established the role of adrenalin. Selye proposed the concept of “diseases of adaptation”, including essential hypertension as the result of “adrenal exhaustion”. I conducted an investigation of the adrenal cortex in hypertensive patients using a bioassay in mice for glucocorticoids (cortisol), which was a considerable challenge. The studies revealed normal adrenal function except in Cushing syndrome.2 There was considerable interest in stress at the time, and I had many requests for reprints! My finding was later confirmed by others. In 1951, I received a Fulbright Research Scholarship and proceeded to the New York Hospital Cornell Medical Center to work as a Research Fellow in Medicine under Professor Harold Wolff. He was leading a systematic study of physiological changes in a variety of organs and systems during different emotional states associated with stressful life experiences. I was assigned to study the endocrine (adrenal, thyroid) and metabolic systems. I believe I was the first to report an increase in cortisone secretion in humans associated with emotional states such as apprehension and exhilaration.3 These changes were accompanied by an increase in metabolic rate and other changes similar to those observed in physical trauma.4 After a period of training in clinical endocrinology at St Thomas’ Hospital in London, I returned to Australia in 1956 to become a Michell Research Scholar in the newly established Department of Medicine at the University of Adelaide under Professor H N Robson, the Foundation Professor of Medicine. In 1959, I was appointed Head of the Department of Medicine at the newly opened Queen Elizabeth Hospital (QEH) at Woodville, first as Reader and then, in 1964, as Michell Professor of Medicine. My point of view in practice, teaching and research was a holistic one embracing the whole person — body, mind and spirit. My clinical teaching also took account of the social environment in relation to the occurrence and management of disease. It involved the health care team and included the hospital chaplain. My clinical teaching paid special attention to the personal and social aspects of a patient’s illness. I emphasised to my students that there is both a “scientific diagnosis” of the mechanism of disease and a “personal diagnosis” of the personal and social situation of the patient, both diagnoses being equally important. My research team at the QEH included graduate students and was particularly focused on the pathogenesis of Graves disease (hyperthyroidism), which was shown to be an autoimmune disease.5 My interest in thyroid disorders led to my involvement (from 1964 to 1972) in studies of severe iodine deficiency in the Papua New Guinea (PNG) highlands in relation to goitre and brain damage (cretinism). Confronting the challenge of trying to improve public health in a developing country had a permanent impact on me. I was a member of the Foundation Council of the new University of Papua New Guinea (1965–1972) and assisted in the establishment of a university medical school from the previous Papuan Medical College, following the model in Fiji.1 The challenge of public health in AustraliaMy interest in public health arose from a number of factors. Firstly, although trained in internal medicine and endocrinology, I had a strong interest in psychosocial aspects of health and disease. This interest became explicit during my 3 years as a Research Fellow in New York studying the relationship between psychosocial stress and physical illness.1 Secondly, my experience in PNG stimulated my interest in the health services of developing countries, particularly when I first clearly recognised the importance of the organisation of health services. I was impressed with the very effective organisation of services in PNG, including the provision of services at village level through the Aid Post Orderly and the organisation at district and regional level, with the result that PNG had a major public health program embracing the whole country. The Director was Roy Scragg, from Adelaide, who provided visionary leadership over 12 years. Finally, Australian Frontier (1963–1972), established by the Australian Council of Churches, provided me with experience of a social mechanism for helping communities develop their own ways of dealing with social problems through promoting human values. Special health problems explored by Australian Frontier included the needs of migrants and Indigenous people, as well as elderly, young, disadvantaged, poor and disabled people — a good introduction to social medicine! In 1967, these experiences together led me to apply for and then be appointed to the Foundation Chair of Social and Preventive Medicine in the new medical school at Monash University, Melbourne. In teaching with a small, dedicated staff, we adopted the “ecological model” of health, which included human biology, environment, lifestyle and health services.1 This involved the discipline of epidemiology. I was particularly interested in bridging the gap between research and action. At Monash University, between 1968 and 1976, we conducted various epidemiological studies related to the rapidly expanding metropolis of Melbourne. We began with studies of suicidal behaviour and the management of traffic casualties. These were followed by studies of the mental health of students, the health and health behaviour of Indigenous people, the reproductive behaviour of Greek migrant women, and more general studies of women’s health.1 All of these projects required epidemiological data. Studies were carried out by a series of research fellows who completed higher degrees with the assistance of Tony Ryan, a Senior Lecturer who had recently had postgraduate training in epidemiology at the Harvard School of Public Health. These studies led at the time to innovations in the provision of community services — such as the Lifeline Service in Melbourne; an Aboriginal Health Service managed by Indigenous people in Alice Springs; interpreter services for Greek and other migrants in Melbourne hospitals; and improved services at the Alfred Hospital emergency department for traffic casualties and victims of self-poisoning. In addition, we developed a Community Health Centre in Prahran, following an earlier health survey that showed the need for both health and social services to be available at one site.6 This was a very hot political potato at the time (1973–1974), in the face of opposition from most of the local general practitioners and an Australian Medical Association resolution condemning me for the initiative! After an uncertain beginning, the centre became well established in meeting the needs of the people of Prahran. I became interested in the challenge of bridging the gap between epidemiological findings and their public health application, with particular reference to road safety campaigns. The first major success in this area was in 1971, when legislation was introduced to make the wearing of seatbelts compulsory. I developed my “wheel” model for the social learning process in relation to seatbelt legislation and then proceeded to apply it to the development of random breath testing (RBT) legislation (Box 1). The process begins with collecting and analysing epidemiological data, then disseminating them in suitable form through the media. This leads to wide public discussion. When a consensus emerges, a plan is designed to tackle the problem that has been defined by the data and the discussion. Political agreement is required before the necessary legislation can be passed. After the legislation has been introduced, the program is implemented and evaluated. Evaluation requires collection of new data, which then provide the basis for the next cycle. I used this model in relation to a series of public health issues.1 1 My “wheel” model, showing the social process involved in public health advancement in relation to blood alcohol levels and random breath testing legislation Much later, I was able to review subsequent data on alcohol consumption, which indicated that up to 1975 there had been a steady increase in national consumption to the level of 10 L per person per year. By 1997, this figure had dropped to 7.6 L. The fall began in 1983, which was after the adoption of RBT in Victoria (1979), South Australia (1981) and New South Wales (1982). There had therefore been a change in drinking behaviour after the introduction of RBT, and this change has persisted. Such a change in Australian drinking habits would not previously have been thought possible! The invitation to give the 1971 Boyer Lectures for the Australian Broadcasting Commission was a big shock! I chose the topic “Life and health in Australia”, which was based on the teaching and research work of the young Monash University department (Box 2).7 The lectures were later expanded into a book, Health and Australian society,8 first published in 1974, with two subsequent editions in 1976 and 1980. The first book of its kind, it was used as a student text for teachers, nurses, social workers, physiotherapists and medical students. I was pleased to discover it was also read by politicians! 2 “Life and health in Australia”, my presentation for the 1971 ABC Boyer Lectures The Boyer Lectures and the book, together with other press coverage of our work, introduced public health and epidemiology to the public in the form of major modern Australian epidemics such as traffic crashes, suicidal behaviour, coronary heart disease and cancer of the lung. In the 1970s, this was new information to the public and caught media attention. Public perceptions of epidemiology have expanded greatly since then, so that the media are now well aware of the discipline in relation to heart disease, cancer, the effects of Agent Orange, infectious diseases and many other problems. This greater public awareness has been very important for public health. Public health nutrition in AustraliaThe redirection of the Animal Nutrition Division of the Commonwealth Scientific and Industrial Research Organisation (CSIRO) to become the Division of Human Nutrition gave me a remarkable opportunity — unprecedented for a medical graduate — when I was appointed Chief and took up my position in 1976. In my plan, I proposed a study of the relationship between diet and “diseases of affluence” (particularly coronary heart disease and cancer) using a multidisciplinary approach involving epidemiology, behavioural science, nutrition, physiology and biochemistry. A staff of 80 enabled me to develop this approach. A book called The LS factor — lifestyle and health, written by Senior Epidemiologist Tony McMichael and myself, described research at the Division over a 10-year period (1976–1985). It covered areas such as diet; diet and cardiovascular disease; diet and cancer; alcohol and tobacco consumption; stress; and the development of preventive services.9 Our book has even been translated into Chinese! Iodine deficiency in PNGOur work in New Guinea, carried out in collaboration with the PNG Public Health Department, raised my awareness of the problem of iodine deficiency. This problem eventually took over my life after I formally retired from the CSIRO at the end of 1985. Combating iodine deficiency has been for me a great personal adventure in international health. It all began in 1963, when I was asked by the Editor of the Medical Journal of Australia to review an article by Terry McCullagh on the use of injections of iodised oil (Lipiodol) in PNG.10 This was new technology proposed to help control the severe goitre problem (Box 3) in remote villages in the highlands where iodised salt (the usual remedy for the problem) could not be easily introduced. An initial controlled trial carried out by McCullagh, at the request of the Director of Public Health, John Gunther, showed that one injection of iodised oil would prevent goitre for up to 3 years.10 However, in 1963, it was not known whether iodine deficiency was present in PNG. 3 Severely iodine-deficient mother and child, Papua New Guinea The mother has a large goitre and the child is also affected. Cretinism in a child can be prevented by correcting iodine deficiency before the onset of pregnancy.1 In due course, our laboratory studies in collaboration with the PNG Public Health Department revealed that there was severe iodine deficiency and that it could be corrected for up to 5 years by a single dose of Lipiodol.11 Apart from the very large and frequent goitres seen in the villagers, there were many severely brain-damaged people who were also deaf-mute and often had a squint and a spastic weakness of the limbs (Box 4). This condition (“cretinism”) was being reported at the time in similar remote mountainous regions of South America, India and China, and had been observed earlier in Europe.12 There was considerable dispute as to whether or not the condition was related to iodine deficiency. It had apparently spontaneously disappeared in various parts of central and southern Europe without any known correction of the iodine deficiency. After we had successfully demonstrated the long duration of the effect of a single iodine injection, I realised that with iodised oil we had the means to carry out a controlled trial (which would not have been possible with iodised salt) to see whether correcting severe iodine deficiency would prevent cretinism. After approval by the PNG Research Advisory Committee, the trial was set up in the Western Highlands north of Mount Hagen. In collaboration with the PNG Public Health Department, we began the trial at the time of the first census in 1966. Families were alternately given injections of iodised oil or saline. Over the next 3 years, follow-up assessments of brain damage in young infants were carried out without knowledge of which injections the mother had received (ie, double-blinded). Particular attention was paid to the motor milestones, such as age of sitting up and walking. Any evidence of deafness reported by the mother was confirmed by a simple tuning-fork test. This critical phase was undertaken double-blind with great skill and dedication by Peter Pharoah, an experienced PNG medical officer who was seconded to this work by the Public Health Department at my request. After more than 3 years of careful and laborious work, involving Pharoah in extensive climbing to reach the mountain villages, the code was broken. There was no doubt that mental retardation (evident in 26 cases in the control group) had been prevented by injection of iodised oil before pregnancy. In six of the seven retarded infants born to mothers treated with iodised oil, the mothers were already obviously pregnant when injected, and there was doubt about the birth date of the seventh infant. 4 A young Papua New Guinean cretin with squint, ataxia and mental deficiency After completion of the study, injections of iodised oil were given to 120 000 people in the highlands, and an iodised salt program was introduced. The report of this work was published in the Lancet13 and was duly accepted as definitive.14 The spontaneous decline in iodine deficiency in Europe has since been attributed to diversification of the diet, associated with economic and social development, and the use of iodine supplements.12 The finding clearly demonstrated, for the first time, that the cretinism observed was the result of fetal iodine deficiency in the first half of pregnancy. The trial also showed the effectiveness of prevention by correction of the deficiency before pregnancy. Unfortunately, although this form of cretinism is preventable, it is not reversible.12 Animal modelsDuring the 1970s, it became apparent to me that there was a great gap between our knowledge of the effects of iodine deficiency on brain development and its application in the developing world. More evidence was needed. One of the factors leading me to take the position at the CSIRO was the possibility of developing an animal model to confirm the effect of iodine deficiency on fetal brain development. This was duly done (for the first time) both in the sheep and the marmoset monkey over the period 1976–1985 by an excellent CSIRO team with past experience of trace element deficiencies in sheep.15 These animal studies indicated the significant effects of iodine deficiency on growth and development. The effects on the brain were part of a spectrum of effects including abortion and stillbirths as well as goitre, brain damage and growth retardation of the fetus. A new concept — the iodine deficiency disordersClearly, a new concept beyond that of “iodine deficiency and goitre” was needed to better reflect the increase in knowledge that had occurred over the preceding 25 years, particularly in relation to brain development. After much pondering and two stimulating visits to China, and with the sympathetic encouragement of colleagues, I proposed the epidemiological concept of “iodine deficiency disorders” (IDDs) to denote all the effects of iodine deficiency on the growth (and especially brain development) of a population that could be totally prevented by correcting the iodine deficiency (Box 5).16 This concept was rapidly adopted internationally — the term was even used in China without translation! My Chinese colleague pointed out that Confucius would have approved of the term, as it referred to the primary cause and would therefore lead to appropriate measures for control! International actionThe announcement by the World Health Organization of the global eradication of smallpox in 1980 encouraged me to raise the possibility of eradicating IDDs with available technology using iodised salt or iodised oil.16 In China (1981–1984) and Indonesia (1976–1981) I had seen the massive nature of the problem of iodine deficiency. The WHO subsequently estimated that there were two billion people at risk in 130 countries and recognised iodine deficiency as the most common preventable cause of brain damage.17 Preventive measures suitable for mass application (use of iodised salt or iodised oil) and simple methods of epidemiological monitoring and surveillance (salt iodine and urine iodine measurements) were available. However, there was great delay in applying existing knowledge on IDDs to preventive programs in areas of need — to the detriment of the many millions in developing countries who were suffering irreversible brain damage due to iodine deficiency. In a report to the United Nations (UN) Nutrition Subcommittee, I stressed my concern about the gap between knowledge and application. To help bridge the gap, I proposed that an expert consultative group of scientists and other public health professionals be established to help develop national IDD control programs in collaboration with the WHO and UNICEF.1 The International Council for Control of Iodine Deficiency DisordersThe decision to establish the International Council for Control of Iodine Deficiency Disorders (ICCIDD) was made in Delhi, India, in March 1985, when I put the proposal to a group of 10 consultants and advisers who were attending a WHO/UNICEF workshop on the control of IDDs in South-East Asia. This was followed by an inaugural meeting, supported by WHO and UNICEF, in Kathmandu, Nepal, in 1986 (Box 6).18 I became Executive Director, and later Chairman, of the ICCIDD. The ICCIDD now consists of a multidisciplinary international expert network of 700 endocrinologists, epidemiologists, nutritionists, public health administrators, technologists, communicators, economists and others from 100 countries, with a majority from developing countries, who are committed to helping national governments and international agencies develop national programs to eliminate IDDs as a public health problem.19 Since 1986, the ICCIDD has held a series of regional meetings with the WHO and UNICEF to foster the development of national control programs. The meetings have been attended by ministry of health representatives from countries in the region. I adapted my social process wheel model (Box 1) to the IDD elimination program.19 Particular importance was given to political will, which had been lacking in the past but had now been mobilised through the UN system, particularly the World Summit for Children, held in 1990. The outcome of the Summit was a declaration signed by 71 heads of state and eventually by 88 other governments. The declaration accepted a series of goals for the better health and education of children throughout the world, including the virtual elimination of IDDs by the year 2000. A report to the 1999 World Health Assembly (WHA) indicated that, of the 130 countries that had a significant IDD public health problem, two-thirds had introduced universal salt iodisation programs. Between 1990 and 1998, the number of countries with salt iodisation programs had increased from 46 to 93.17 However, there is a need to ensure the sustainability of this achievement. This depends on epidemiological surveillance with urine iodine measurements to confirm the absence of iodine deficiency. Sustainable elimination of IDDs is only possible if surveillance continues — recurrence can readily occur, and has indeed occurred.17,19,20 In 2001, the ICCIDD adopted a mandate for the future dedicated to the elimination of iodine deficiency as a cause of brain damage (Box 7).20 At the 2005 WHA, Canada and Australia proposed a resolution requiring countries to report to the WHA on the monitoring of their iodine deficiency elimination programs in 2007 and every 3 years thereafter. The resolution was adopted and provides the necessary political support for future sustainability of the programs. I believe the non-government organisation model is relevant to many other international health problems. A multidisciplinary group of concerned scientists and public health professionals can come together to define a problem and then develop a program designed to solve the problem in collaboration with UN agencies.12,19,20 ConclusionIt has been a great experience to assist in the development of a UN program to eliminate iodine deficiency — the most common preventable cause of brain damage. The program was made possible by targeted research that established the relationship between iodine deficiency and brain damage — research that included epidemiological study in the field in PNG and later studies in animal models. Rapid development of the elimination program was made possible by the effectiveness of introducing iodised salt as a population measure and the application of a simple laboratory method to determine urine iodine levels as a marker for iodine deficiency and to correct any deficiency in populations. A dedicated group of multidisciplinary professionals in the ICCIDD provided the scientific leadership in collaboration with national governments, the WHO and UNICEF, assisted especially by aid programs of Australia, Canada and the World Bank. I have been very fortunate, for more than 50 years, in the people I have been associated with — my family, friends and colleagues have always been a support and inspiration to me. 5 Iodine deficiency disorders by stage of human development16 Fetus Abortions Stillbirths Congenital anomalies Increased perinatal mortality Neurological cretinism (mental deficiency, deaf-mutism, spastic diplegia, squint) Hypothyroid cretinism (dwarfism, mental deficiency) Psychomotor defects Neonate Goitre Hypothyroidism Child and adolescent Goitre Hypothyroidism Impaired mental function Retarded physical development Adult Goitre Hypothyroidism Impaired mental function Iodine-induced hyperthyroidism All ages Increased susceptibility to nuclear radiation 6 Inauguration of the International Council for Control of Iodine Deficiency Disorders (ICCIDD), Kathmandu, Nepal, 1986 L – R: Basil Hetzel, Executive Director (Australia), John Dunn, Secretary (USA), and John Stanbury, Chairman (USA). Inset: the logo adopted by the ICCIDD emphasises the importance of the effects of iodine deficiency on the brain. 7 International Council for Control of Iodine Deficiency Disorders (ICCIDD) mandate, 2001 The vision of the ICCIDD is a world virtually free from iodine deficiency disorders, with national endeavours in each country to maintain optimal iodine nutrition, primarily through universal consumption of iodised salt. The mission of the ICCIDD is to advocate to governments, citizens and development agencies a priority commitment to normal iodine nutrition through a multidisciplinary approach that involves all relevant partners. The ICCIDD believes that country programs must be fully supported nationally for sustained success and will work with all partners and national entities towards that end.

Basil S Hetzel AC, MD, FRCP, FRACP, FFPHM, FAFPHM, FTSE

Despite all our efforts, the boulder is barely halfway up the mountain When I set up in practice at Kununoppin [Western Australia] in 1958, the hospital was administered by a teenage girl working 3 days per week, the bed average was 20 and if I had a problem, the Medical Department would solve it. Today, the bed average is 14.5, a number that includes 10 residents in the permanent care facility, the hospital administration requires 3.6 full-time employees and if ever I have a problem, the Medical Department has almost certainly caused it. — Dr John Radunovich, addressing the Country Medical Foundation in 1993, when country medicine was in danger of being “rationalised” by the government. Perhaps the problem of rural medical workforce in Australia is best represented by the Greek story of Sisyphos, King of Corinth. He was a mortal, an individualist and, like many rural doctors, disinclined to do the gods’ bidding. For interrupting one of Zeus’ amorous pursuits, Sisyphos was sent to the bottom of Hades as punishment, condemned to forever push a boulder towards the top of a mountain, only to have it roll down as he neared his goal, so he had to start again. For more than 70 years, Australia has been trying to solve the problem of a paucity of rural and remote doctors. We have not been helped by the vagaries of workforce planning, which most developed countries, including Australia, got wrong. Now there is a worldwide shortage of general practitioners, general physicians and surgeons (and nurses) and, as always, the rural areas bear the major brunt. In the past 20 years, a mass of descriptive research has been published, inquiries and conferences held, and programs put in place. A plethora of rural medicine organisations and institutions have been formed to implement them. But our boulder continues to roll back down the mountain, and we have to continually push it up. Fly-in/fly-out specialist services to rural towns have been in place for many decades, and are now supported nationally through the Medical Specialist Outreach Assistance Program. The Rural and Remote General Practice Program recognises the need for extra support for rural medicine, with programs for the recruitment of rural GPs and students, and programs for retention and succession planning. We have tried a variety of incentives with at least partial success. We have also reinvented many programs in a different form to be implemented by a new organisation. Truly, Sisyphos is an appropriate candidate for patron of Australian rural medicine. So where do we find solutions — in the rock, in the mountain, in Sisyphos, or in appeals to the gods to ease his eternal labour? The rockWe need to make Sisyphos’ rock smaller and smoother. The nature of general practice has changed. Many rural GPs are unwilling to take on the worries of business ownership. They prefer to go into a service environment that supports and rewards them, and allows them to use their skills and find their own balance between work, social and other priorities. The 1930s saw the rise of “collectivisation” in agriculture. In rural general practice, this is having its expression as integrated primary care, which combines individual and population health, with combined Commonwealth, state and local government funding sources. The New South Wales Government Integrated Primary Health and Community Care Services program is an example that shows promise of fulfilling the dual aims of providing a locally managed but state-supported base for GPs with a single integrated base for primary health care. GPs have the opportunity to retain their own practice, with clinical and professional freedom, while working directly with community-oriented nursing and allied health professionals. Crucial to the success of the project is a third governance structure, locally developed, which maintains the separation of the general practice from the state health department, but builds workforce and clinical care integration.1 Doctors who wish to continue in a traditional practice management structure have also been asking for assistance in management. The South Australian Government has, as part of its “Recognising the past — rewriting the future” program, funded the Rural Doctors Workforce Agency in SA to facilitate the availability of management and legal advice to rural practices.2 The mountainWe need to make the mountain smaller and the path easier. Government policies recognise the resource needs of rural practice and support programs that attract, recruit and retain rural doctors. These programs are spread across myriad administering agencies, from undergraduate programs such as rural clinical schools to relocation support and retention payments. All have had some success and need to be continued. However, on their own, incentives recognise the need without affecting the cause. Incentive programs need to take into account the work initiated by the Rural Doctors Association of Australia in defining the conditions necessary to run and sustain a viable rural medical practice.3 They also need to be matched with programs that reflect the environment of today’s doctors — a work environment that is attractive to the increasing number of women in medicine and general practice, that encourages a healthy lifestyle for doctors, and that educates communities to be more aware of doctors’ needs, as we educate doctors to be aware of patients’ needs. Overseas-trained doctors make up 35% of GPs in rural and remote Australia. Many have temporary registration in areas of medical need and have never had their medical skills assessed. Rural communities and medical regulatory bodies display ambivalent attitudes towards these doctors. But it is clear that medical services in rural Australia would collapse without them.4 The Australian Rural and Remote Workforce Agencies Group points the way forward: overseas-trained doctors “need to be viewed as colleagues and community members contributing to solutions — not outsiders contributing to problems”.5 SisyphosRural medicine is inextricably tied to generalism, but it is under extreme threat, as instanced by the following. Between 2000 and 2005, generalist doctors decreased by 1%, while specialists increased by 47%.6 Of Monash University medical graduates from 1980 and 1985, 50% were working in general practice 8 years after graduation. Of graduates from 1995, 33% were working in general practice 8 years after graduation.7 Only 4.9% of University of Queensland medical graduates from 1990 to 2004 are currently working in rural and remote Queensland.8 These figures support findings from NSW evaluation and exit interviews, which increasingly show cadets staying in rural areas but taking up specialties other than general practice.9 This march to specialisation is compounded by poor resource support for health sectors dependent on generalists. The states need to acknowledge that their rural hospitals are largely reliant on GPs providing services to the public health system. Primary medical care needs to be able to compete with the specialties on a more level playing field in terms of facilities, conditions of service, career structure and financial reward. The latter is increasingly important as more and more medical students graduate with large debts. At the macro level, there is a need to attract doctors into generalist careers. Beyond seeing rural general practice as a specialty requiring its own fellowship recognition is a need for young doctors to see advantage in general and rural practice. Undergraduate programs have had some success in achieving this aim. However, much of this is lost in the early postgraduate years, as new graduates are captured by hospitals and find exciting and rewarding alternatives. Eighty per cent of new doctors have not decided on their career choice before their PGY 1 year.10 There is a need to have challenging GP and rural GP terms incorporated into their early postgraduate training. The godsIn Greek mythology, the affairs of state were influenced by competing deities, exemplified today by government departments. However, their lack of coordination results in contradictory actions, such as Commonwealth programs to re-skill procedural GPs, while state health departments close down obstetric units and dismantle anaesthetic machines in those doctors’ hospitals. And even before the rural clinical school initiatives come to fruition, we dilute their possible effect by introducing similar programs for outer metropolitan regions. In Australia, there is federal government funding for mental health, diabetes, obesity and other chronic disease programs. These programs are laudable, but in rural areas there also needs to be a pool of primary medical care funding to effect prioritisation and provision of local health needs. Country doctors are intolerant of excessive centralisation and managerialism by state health departments. Increased respect from bureaucrats towards those working at the coalface will go a long way towards keeping them there. Many formerly involved country people feel alienated by state health departments which cannot provide them with GPs, let alone locally grown ones, but which at the same time reduce their opportunities to have a real say in the organisation of their health care. The shortage of doctors in rural and remote Australia has been and will probably always be a Sisyphean problem. We do not need any more questionnaire-based surveys of rural intention or one-off reviews that only add to the weight of Sisyphos’ rock. We do need a method to enable us to take a continuing and holistic overview of what is actually happening at the grass roots level in providing rural and remote communities with appropriate and safe health care. One possible process could be an independent Office of the Inspector of Rural Health Care. A comparable example is the state-based Office of the Inspector of Custodial Services, which is supported by legislation that enables direct reporting to parliament. The rural health inspector would monitor workforce, problems of coordination and red tape, and propose policy and mediation for getting individuals, government-funded organisations and sectional groups to see further than their own self-interest. Ultimately, we must ask the gods to move beyond our fragmented programs of the past 20 years and towards coordinated programs that address the major impediments to having a viable rural medical workforce.

Max Kamien MD, FRACP, FRACGP · W Ian Cameron DRANZCOG, FRACGP, FACRRM

Many voices proposing innovative strategies — which way forward? Australia is considered by much of the world as the “great outdoors”, with tourists travelling from afar to see our landmark deserts, rainforests and other natural wonders. Yet we are, in fact, an urbanised nation, with fewer and fewer Australians living outside capital cities. And with the shrinking of our rural population, a growing problem has emerged: increasingly noticeable disparities in health outcomes, with people in the bush generally doing less well than those in the cities. Over the past decade or so, a range of initiatives have been implemented to try to address the dwindling rural health workforce. To gain some insight into how these initiatives are progressing, we interviewed leaders from key medical organisations with a specific interest in rural health care (Boxes). They shared with us not only their medicopolitical views, but also their personal experiences in rural and remote practice. Despite much effort, the workforce and health care picture painted is still one of a parched landscape which, in places, is becoming progressively drier. Without much “rain” forecast for the next 10 years, the leaders we interviewed advocated a raft of further innovative strategies which, if introduced sooner rather than later, may help to avert the deepening rural health care drought. Solving the workforce shortageRecruitment: the role of exposureAll experts agreed that recruitment into rural and remote practice is a key problem, exacerbated by a national medical workforce shortage. In response, there has been a recent proliferation of new medical schools, and development of rural clinical schools and university departments of rural health. However, there will be a time-lag of 10 years or more before any real effect is seen in the workforce. Until then (and afterwards), exposure to rural and remote practice early on in medical careers, from student years onwards, is seen as the key to long-term recruitment into rural and remote practice. Not just exposure per se, but supported, positive and continuous exposure. Royal Australasian College of Surgeons (RACS) Representative: John Graham Roles: Elected Councillor, RACS; previously, rural representative to Council, RACS (2000–2006) and Chair, Divisional Group of Rural Surgery, RACS (2004–2006) (also, Co-chair, Rural Specialists’ Group, Rural Doctors Association of Australia) Alma mater: University of Sydney, 1972 Discipline: Vascular and renal access surgeon Location: Lismore, New South Wales, since 1992 Childhood: Born in Sydney, primary school in Singapore and high school in Sydney “I was the second resident ever to come to Lismore and I knew that if ever an opportunity came to go to the country that it was something that I could really encompass and that I would enjoy doing.” John Graham, Elected Councillor, Royal Australasian College of Surgeons (RACS) and, previously, rural representative to the RACS Council, said, “We know, for instance, from the figures that have come from James Cook University in Cairns, that if you can get your medical students into a rural training program early on, then you’re likely to retain more of them in rural practice”. And the opportunity for rural exposure can only increase, with the need to accommodate the training and early career needs of increasing student numbers. David Campbell, President of the Australian College of Rural and Remote Medicine (ACRRM), is also a director of a regional clinical school in Victoria, which has already been “oversubscribed” by students. Students see a rural placement as an opportunity to “suck it and see”, and to experience the breadth of skills that rural doctors have. Furthermore, Campbell said “the smart ones” also understand that the rural setting is a better training environment. “They’re not going to be standing at the back of a group of 20 people at a major teaching hospital in the city; instead, they’ll be dealing one to one with clinicians.” Graham, and Ross Maxwell, President of the Rural Doctors Association of Australia (RDAA), warned that the “exposure” plan can fall down when graduates who have had rural exposure as medical students enter the workforce. Graham extolled the value of rural rotation in the prevocational years of training. David Rivett, Chair of the federal Rural Reference Group of the Australian Medical Association (AMA) and New South Wales AMA Board representative for rural NSW, agreed, saying that the “hub-and-spoke” model, in which a rural hospital has an urban linkage and affiliation, helps “expose” doctors in the early years of their medical careers. However, rural rotations should be given due recognition. “There’s an intrinsic, inbuilt feeling in a lot of tertiary hospitals that rural practice is not second rate, but even third rate”, he said. Maxwell pointed out two other common, important problems with some rural rotations — being too short to allow the doctors to feel as though they belong and, even worse, traumatising relatively inexperienced doctors by sending them out to single-doctor towns without support. Exposure to rural practice has long been a part of general practice training in Australia. Chris Mitchell, Chair of the National Rural Faculty of the Royal Australian College of General Practitioners (RACGP), says that a lot of people, including him, ended up in rural general practice because they found they liked it during a mandatory rural term in their early postgraduate years. The two specialty college representatives we interviewed would also like to see some sort of mandatory training in the rural setting as part of specialty training programs. However, Paul Bauert, Chair of the Rural Taskforce of the Royal Australasian College of Physicians (RACP), flagged some obstacles. “There’s been a great deal of resistance to it [the mandatory rural term] from the Division of Paediatrics and Child Health trainee committee, and there’s been an absolute resistance to it from the RACP adult divisions from both the Fellows and the trainees.” Graham said that, although there is no mandatory training term for surgery, registrars who take up a rural-based training position go home with both the benefit of exposure to rural and remote practice and an RACS logbook that is better than they can achieve elsewhere. Marketing: the big picture versus the bottom lineOpinions varied as to how rural and remote medical practice should be marketed to students and new graduates. Mitchell said the lifestyle and clinical satisfaction of rural general practice should be promoted across the whole journey of general practice. “We’re doing it in a piecemeal kind of way, but we’ve got to be targeting schools, medical students, prevocational registrars and also, of course, vocational registrars.” However, Maxwell saw a problem in pushing a career in rural practice purely on flexibility, mobility, a great lifestyle and wonderful practice, when the time commitment is often very full-time. “We really need to make sure that rural medicine has a very good professional profile, so that we can then attract people who may otherwise consider being specialists”, he said. Further, Maxwell saw a need to compete with other opportunities for doctors. Since reviewing salary packages and making them more attractive, Queensland has been successful in recruiting enough doctors to exceed the set target. “The fact is that, before, they weren’t competing; so, of course, they weren’t going to attract doctors — if you won’t compete, you’ll never win”, he said. Training conundrumsTraining for rural and remote practice carries the dual challenges of training the right people and training them in the right way. Mitchell believes that the current general and rural training streams for vocational training for general practice in Australia require urgent review. In his opinion, the rural training stream, with its rules, regulations and restrictions, is far less appealing to Australian graduates than the more flexible general pathway. Although about 40% of registrars in the general stream have an interest in rural training, no incentives or rewards are directed towards the general pathway. Mitchell adds, “We’ve got to provide incentives for those people who train in rural areas, and those incentives should increase with increasing remoteness, not only financial but also in terms of increased educational resources and increased support”. The extra year of skills training in the rural stream will soon be recognised by a rural health Fellowship rather than the existing Diploma. But there is competition. From as early as 2007, there may be an alternative path to a rural general practice via a Fellowship offered through the ACRRM. Campbell said the ACRRM’s position is that the best training environment for rural practice is “in rural areas by rural doctors” and that the RACGP model, in which rural practice is an “add-on”, is the wrong model. Instead, the ACRRM’s 4-year program involves “immersion” in rural medicine. Doctors will be able to train in a variety of environments relevant to rural practice, including a hospital environment, and will be able to complete requirements in any order they choose. Although most training will be based in the rural environment, it is anticipated that ACRRM Fellows will also be able to work as generalists in urban practices. Rivett said the specialist colleges also need to train more generalists. “There’s a dearth of general physicians and general surgeons, who are core people to provide high-quality services aside from your rural GP. It can’t all go on the heads of rural GPs.” Bauert concurred that physicians practising in rural and remote areas will need to be trained as generalists, rather than as subspecialists. Rivett added that these generalists will need to be buttressed and given career support. “If you’re a generalist for 10 years, maybe you can go back and get a step up to become a gastroenterologist or cardiologist, or whatever. That rural time will be given some recognition and give you some precedence in the system.” According to Graham, from the beginning of 2008, the new RACS training program will select trainees directly into the specialties. We may have to work towards having rural surgery as its own specialty “and, if you like, buy slots in each of the other training programs”. “Difficult, untried, but necessary, if we are to train people with the broad exposure necessary for work in rural surgery”, he said. With the specialist colleges becoming more and more sub-specialised, Bauert believes the ACRRM’s original proposal to look after all doctors who were going bush, not just GPs, could work well. The ACRRM could be an overarching body, taking on the mantle of responsibility for trainees and supporting Fellows from all colleges. “You could have an ACRRM member, who may be a Fellow from a different college, providing support and most of the supervision, and then you would have regular video links with your formal supervisor — a Fellow of your own college, in a nearby centre or hospital”, he said. Campbell has an even broader vision. He believes that if we can support and start to champion the rural environment as an ideal medical training environment, it has the potential to change the way health services are delivered across the nation by restoring the role of the generalist, “if we get a large enough cohort of doctors being trained in rural practice, with the range of skills that rural doctors have got”. Maxwell came to a similar conclusion; he said that while we are yet to see if rural clinical schools can help address the workforce problem, if nothing else, they will hopefully give a generation of graduates an experience which leads to a more generalist practice. Australian College of Rural and Remote Medicine (ACRRM) Representative: David Campbell Roles: President, ACRRM (also, Director, East Gippsland Regional Clinical School, Monash University, Bairnsdale, Victoria) Alma mater: University of Adelaide, 1978 Discipline: Rural general practice Location: Lakes Entrance, Victoria, since 1983 Childhood: Adelaide (“a big country town”) “For as long as I can remember, I wanted to go into rural practice because I saw that as probably the only opportunity within the profession to develop and retain a whole range of skills.” Overseas-trained doctorsThe Australian rural workforce now relies heavily on international medical graduates. No longer considered as temporary solutions, in some towns, overseas-trained doctors (OTDs) have become part of the community. Much progress has been made in terms of their initial assessment; however, orientation, support and supervision are further challenges that have yet to be adequately met. Rivett pointed out that if a supervisor is the OTD’s employer, he or she may have a vested interest in not reporting problems, for fear of losing a valued employee. “The supervisor needs to be a more independent person, actually supposed to sit in with them for some hours on a regular basis. And for that to happen, it would need to be properly funded”, he said. Further, in terms of support, OTDs do not have the same “network of mates” to ring for advice; Rivett said they need to be given an artificial network to support them. Graham suggested that overseas-trained surgeons ought to first spend time in a larger hospital close to their designated practice location, so that they understand the Australian hospital system and network with the surgeons with whom they are going to be relating. Retention: essentialMaxwell said the health care system in most rural communities is relatively fragile — very much dependent on a small team of people with the right skills mix. Sustaining this requires constant regeneration of the workforce, which is proving to be a challenge. Apart from not bringing young Australians into rural medicine in anything like adequate numbers, older doctors who have broad experiences and procedural skills are being replaced by a cohort of doctors who may not have those skills. Graham’s greatest fear is that, if 35% of our rural surgical workforce retire in 5 years, as has been suggested, the surgical workforce will be depleted before the problem starts to be addressed. Thus, there is a current urgency to retain as many rural and remote doctors as possible over the next 10 years. Rivett advised increasing grants for the retention of ageing rural doctors: “. . . generous retention grants or tax breaks to try and keep those people in the workforce till we get new people there”. More generally, most of the leaders we interviewed identified similar elements that can help lead to longevity of a doctor’s career in rural medical practice, including a reasonable workload, access to a local hospital and having a variety of work, including procedural work. Adequate cover and improved locum support were stand-outs, for both professional and lifestyle reasons, as was recognition, both professional and financial, of their efforts. Rivett suggested that GPs and specialists be provided with locum support to go to a tertiary centre for some months to up-skill in any area they choose. Also, they should have a “leg up” if they want to go back to that tertiary centre at some time to further their career. He thought state governments could, fairly easily, overcome the “indemnity barrier”, where hospital administrators have vetoed planned up-skilling because of concerns about the adequacy of medical indemnity provisions. Although the rural lifestyle is often touted as one of the desirable things about rural practice, it can be a drawback when workforce shortages lead to long hours and difficulty in taking leave. Rivett said there should be an agreed core number of doctors for each rural location, a number that allows people to have a lifestyle. “Generation X and Y certainly don’t want to work the crazy hours that us dinosaurs have worked in the past”, he said. If a town needs four doctors for them to have a reasonable lifestyle, and if patient numbers are not sufficient for a fee-for-service Medicare Benefits Schedule income to support them, then subsidies are needed so that the town becomes an attractive place to work. Mitchell works in a well staffed general practice of “part-timers” in a town of 7000–8000 people. There are usually between four and five doctors working at any one time; they are all involved in the after-hours roster, and they cover their own leave. “Family friendliness” was seen as crucial, as was access to educational services. Maxwell said that although only about 30% of GPs in rural and remote areas are women, compared with more than 50% nationally, most young doctors moving to rural Australia are women, and Mitchell pointed out that nearly 60% of new medical graduates are women. Hospital obligations are very difficult to fulfil when there are no facilities to assist doctors with families — what do you do if you get called in to deliver a baby while you are out shopping with the kids? Mitchell said we need both adequate on-call allowances and adequate leave provisions for visiting medical officers (VMOs); these issues apply to specialists as well as to VMO-GPs. Workforce efficienciesInformation technology (IT) was generally seen as a potential tool that is yet to be fully utilised, particularly in the clinical setting. Rural-based physician trainees can link in with their training program in Melbourne, and Bauert has used IT to link with doctors in a smaller hospital, providing supervision and finding out what may turn up at his hospital over the next few days. Mitchell’s practice routinely keeps copies of high-quality evidence-based guidelines on its server to assist in quick searches for relevant information. Maxwell thinks that remote doctors would have stronger drivers to use IT. However, it seems that IT use in clinical practice is still struggling with some fundamental teething issues. Despite its huge potential as a workforce solution, there has not been a commitment to providing the required IT infrastructure, or an appropriate fee structure for the time and expertise involved. For example, there is no system to pay for specialists or rural doctors to give or receive opinions over the phone or electronically. Campbell pointed out that there are international models which we should consider adopting. “There’s a really good model in Alaska being run now, whereby small, isolated rural health teams are provided with what they call an IT cart — where the health worker can do an ECG, do spirometry, take a photograph of a tympanic membrane of the ear, load that onto the system, and then send an email to the clinicians back at the base hospital, who will then give them a report about that patient. Now, it’s not real-time, but they get a report within a few hours and they are able to deliver care in that way. It works extremely well.” Developing the role of practice nurses has helped to take some of the pressure off doctors. However, while there was strong support for health care teams headed by doctors, this did not extend to health care workers replacing doctors. Rivett recalled an instance where a nurse practitioner was sent by the state government into a country town to help the solo GP. The GP’s practice was decimated to the point where he left town; the nurse practitioner left some months later, and the town was left with no primary health care worker. Bauert is aware that remote area nurses supported by visits from district medical officers have sustained remote communities in the Top End of the Northern Territory, but his personal feeling is that the level of care cannot be the same as if there were a full-time GP or viable general practice service there. Nevertheless, all agreed that task substitution or, at least, collaboration rather than competition, remains a way of keeping the doctor’s workload tolerable. For example, Graham said surgeons in rural towns could be supported in their on-call commitments by appropriately trained GPs. Rural Doctors Association of Australia (RDAA) Representative: Ross Maxwell Roles: President, RDAA (also, South West Area representative, Queensland AMA Council; and Board member, Health Workforce, Queensland) Alma mater: University of Queensland, 1982 Discipline: Rural general practice Location: Dalby, Queensland (on the Darling Downs), since 1989 Childhood: Rural Queensland “I grew up on a sheep and cattle property 50 km west of Winton. Fantastic childhood, spent a lot of time working the property with my mum and dad.” Economic incentives matterRemuneration was perceived to be a huge barrier to the recruitment and retention of rural and remote doctors. Although all representatives were aware of oft-proposed geographic provider numbers, in the main they preferred rural incentive and retention packages. Bauert pointed out that Darwin has recently been experiencing the “Vortex to Queensland”, achieved not via geographic provider numbers, but through location allowances and incentives — the further from a major centre, the higher the incentive. Maxwell reminded us how industry copes with a workforce problem; for example, the mining industry — if they want a workforce in a certain area, they provide the economic and professional conditions that will attract the workforce. They make the incentives clear and specific and they present them up-front. Maxwell reasoned that the argument for geographically determined enhanced Medicare rebates had foundered around the question of whether the intrinsic intellectual content of consultations in rural and remote practice is different. However, GPs who work out bush do feel there is a context around what they do that is different — because they manage not just the primary kind of care, but also hospital-level care and serious emergencies. Another key difference between metropolitan and rural practice is the additional on-call commitment without any extra financial incentive, and with accompanying family and general lifestyle issues. Mitchell did not consider rural and urban practice to be very different. “When you look at BEACH [Bettering the Evaluation and Care of Health] data, the vast majority of work done by rural GPs and city GPs is very similar. I’m not suggesting that there isn’t a need for procedural competence in certain contexts of rural general practice, but those contexts are basically confined to working in RRMA [Rural, Remote and Metropolitan Area classification] 4 and 5 towns, where there is a hospital appointment. There are about 1000 proceduralists out there, but about 5000 rural general practitioners.” He saw the remuneration problem as applying to both rural and urban general practice. “It’s certainly just as difficult a specialty as any other”, he said. The key problem, as he saw it, is that the reward for general practice is “pathetic” compared with the financial reward for some other medical specialties. “This is affecting the choice that medical graduates make when they’re coming through with a huge HECS [Higher Education Contribution Scheme] debt”, he said. Keeping rural communities aliveAlthough some rural communities, particularly those on the coast, are growing, many others are crumbling, experiencing the progressive loss of infrastructure. Bauert believes that the rural GP is really the “glue” that can hold a lot of remote communities together. Rivett thought a GP in a town would be vitally important in maintaining an aged care facility and in allowing people with chronic diseases to be cared for in the community, without having to shift to a city location. Although Mitchell did not want to suggest that rural GPs are not a linchpin in their community, he did consider that communities need more than GPs; they need an entire infrastructure. “It’s very challenging for rural communities when they lose their GP, but it’s also very challenging for the GP to remain in a rural community that’s losing its school, that’s lost its accountant and its bank and all of the infrastructure that allows it to function.” Mitchell saw the plight of dying communities as irreversible without investment. “What is required is a proper resourcing of these communities and a push to get people in other careers going to the bush, like bankers and accountants.” There also needs to be better and more equitable resourcing of education, as well as health. “We balance a lot of issues in terms of schooling — like balancing physics to English. Well, I think we need to really look at some sort of balance for rural origin versus city students, as well.” Going further, he asked: “Is there any real reason why government departments have to be in completely overcrowded cities? There are lots of regional centres crying out for that sort of capital investment.” Australian Medical Association (AMA) Representative: David Rivett Roles: Chair, AMA Rural Reference Group (federal); New South Wales AMA Board representative for rural NSW Alma mater: University of Melbourne, 1972 Discipline: Rural general practice Location: Batemans Bay, NSW, since 1975 Childhood: Mostly spent in Melbourne and Adelaide, with 2 years in Switzerland “Holidays in Deniliquin, NSW, as a 10–12-year-old, playing in irrigation ditches and being chased by sheep and cattle was enough to give me a love of the country.” Exploring models of health care deliveryHub-and-spokeBauert thought the “perfect world” of rural health care delivery — a good hub-and-spoke model, involving programs like the Medical Specialist Outreach Assistance Program, in which specialists go out to remote communities several times a year, providing support to the district medical officers, GPs, nurse practitioners and Aboriginal health workers — was shattered by the poor funding arrangements for such outreach programs. Although largely from a single source (the federal government), money for various programs seems to be inefficiently doled out from separate “buckets”, instead of being centrally administered, with considerable “wastage” as various federal and territory bureaucrats decide how best to distribute it. Also, conditions under which practitioners can access the money are not determined by practising doctors, but seem to be engineered by bureaucrats to show accountability. Rivett concurred: “If you look at the Specialist Outreach Assistance Program, it’s a great concept, poorly funded and poorly administered.” He said specialists are providing a great service, but not getting proper support; for example, they may not be being funded for travelling expenses. Maintaining small rural hospitalsThe steady decline and loss of rural hospitals and access to procedural services were of major concern to all leaders we interviewed. Campbell said that the decline is not necessarily linked to the viability of a rural town. “It seems to be an independent process really, related to lack of funding support and lack of adequate training for people with the skills to be involved with those services.” Hospital services are being repeatedly downgraded, or not upgraded to match the growth of towns. Doctors leave centres when frustrated about not being able to get rostered time off or time to attend training courses, having too many commitments, or lack of access to theatres — whenever there is a financial crisis, theatre lists are cut back. The problem may lie in the different goals held by health bureaucrats compared with health practitioners. Rivett put it bluntly: “If you want to be a successful bureaucrat, you’ve got to have an underspend in your department’s budget for the year. That’s how success is measured. Not what [health-related] results you achieve, but how well you do at saving dollars.” Campbell has found trying to provide a medical service in an environment where the nearest hospital is 40 minutes away extremely difficult and costly. His practice has self-funded a very large three-bay emergency area to deal with the “things that turn up at the door”. A state-run community health facility in the same district shuts its doors at 8 pm. Campbell has waged a long, unsuccessful campaign trying to convince the Victorian state government to direct more resources to his town. “I’ve famously been told by one health minister, when I said that Lakes Entrance was the largest town in the state without a hospital, ‘Well, not for long, we’re going to close some’.” Whatever the cause of the hospital closures, Rivett said that he would like the next Council of Australian Governments agreement with the states to lock in rural hospitals where they are, prevent further downgrading, and look at federal funding to maintain rural health care. “We need some sort of buttress and a guarantee that these facilities will be available into the future”, he said. “There’s got to be some vision from health bureaucrats as to what’s going to happen in rural health care in years to come. You can’t just have patients getting flown 100 km for treatment all the time. It affects their families enormously.” Primary care infrastructureCampbell does not think that the model of the doctor-owned practice is necessarily suitable for rural practice in the future, particularly small town practice. Why would anyone want to put some capital input into something that is going to lose value as time goes by, rather than gain value? “Local government or state government or maybe universities could own the infrastructure and actually take responsibility for managing the practices, and just provide an opportunity for doctors to come in and do their job without having to worry about capital input or the management side of things”, he said. Mitchell also thought it was important to have “easy entrance, gracious exit” sorts of models, whereby the practice infrastructure is owned by a third party. Mitchell’s view was that what the community needs is health services and, while throwing dollars at doctors will help, it will not necessarily address the lack of services for rural communities. “We actually need to look at some other models. I really think that we need some primary care infrastructure to be built, so that rural GPs can be working at the centre of teams”, he said. Extended practice teams should be made up of nurses, advanced nurses, medical assistants and allied health workers, all working under the delegation of GPs. “The reality is, whether you’re talking about city general practice or rural general practice, it has been starved of funds for infrastructure investment. It is far more efficient in my view to deliver community health services through general practices than it is through a side-wing on a public hospital.” Mitchell added that we also need a primary health care strategy, to allow for strategic rather than ad-hoc investment of resources, with all organisations involved. “I think we need to stop the fixation that we’ve got on secondary and tertiary care in Australia and seriously start investing in primary health care facilities. And, in particular, we need to do that in rural areas”, he said. “There are flexible ways to set up your services, but it does take a lot of effort to find your way through all of these things. At the moment, our practice has to find the program that we can slot into, like cardiac rehab and pulmonary rehab. What we need is a system-wide approach that doesn’t rely on [individuals’] enthusiasm.” Royal Australian College of General Practitioners (RACGP) Representative: Chris Mitchell Roles: Chair, National Rural Faculty, RACGP; Vice-President, RACGP; (also Chair, North Coast GP Training, New South Wales) Alma mater: University of Newcastle, 1986 Discipline: Rural general practice Location: Lennox Head, NSW, since 1991 Childhood: Born in Brisbane, grew up in Hobart “I got sent up here as my first basic GP term . . . came up and basically just fell in love with rural general practice.” Matching services to needs, and supply to growthSeveral of the doctors expressed frustration at the difficulty of getting government to invest adequately in growing communities. Mitchell said one of the issues particularly facing coastal areas is population growth that outstrips the supply of doctors and health services. Much of the population growth is in the over-65-years age group — people who require a lot of care. Graham said that regional hospitals identify strongly with one another. “Although we seem similar to a small metropolitan hospital, there is a quantum leap between the resources we have and the resources they have.” He said the major problem that regional hospitals face is funding the work they are able to do and expected to do, leading to bed shortages and theatre closures, with more than 50% of rural surgeons reporting that they consider their working environment to be fragile. An associated, important issue is that the medical community that practises in the country is generally not involved in the governance of its own resources. Graham also said that being part of a larger health area can cause its own problems. Despite differing needs, hospitals can find themselves competing with other hospitals in their area for funding. “There was a time when we felt that the needs, for instance, of Lismore would be considered in terms of the Lismore surrounds, but now we’re all tied in the one big area. We do keep spending money at a higher rate than Coffs Harbour or Tweed or Port Macquarie, and so there’s sort of a move to try and downgrade us and build them.” He acknowledged that a greater political imperative may be at work — “swinging seats” may be influencing funding distribution. Campbell said that the issue of economic viability of rural health services is based on a false premise. “If you’re talking about equitable delivery of services then you shouldn’t really be inserting comments of viability as well. I mean, you’ve got to understand that perhaps sometimes these services, per capita, are going to cost a bit more in rural areas.” The critical role of governmentThere was much frustration with fragmentation of health funding and with bureaucracy. Campbell said, “underpinning all of our issues is the problem with the Commonwealth–state funding structure”. He said that when teasing out all problems, the brick wall “we run up against” is the Commonwealth playing off against the states or vice versa. Mitchell said, “I think I understand the frustrations of the Commonwealth when they throw money in and the state government pulls it out. I also understand the frustration of the state government providing services under their signature that could be done much more cost-effectively in a community setting”. Fighting aside, Campbell said the problem is the fairly piecemeal approach to issues at both federal and state level, which represents a “band-aid” approach without any major affirmative policy initiatives to address the issues at either level of government. A very stark exposition of the state–federal divide in health care delivery in a small rural community is having a hospital sitting at one end of town, which is funded by the state, and a general practice (funded fee-for-service by Medicare) sitting at the other end. How can towns, instead of having two competing and not always complementary systems, actually have one health system which works really well? Mitchell personally thinks it would be really sensible if the “federals” took it over and stopped funding the state for some rural health services. As an example of inefficiency, he considered that, rather than having four or five different on-call services run by various practices in a small town, it would be far more appropriate for the doctors to be delivering their services in the safety of the hospital facility, using the infrastructure that is already there, while continuing to bill Medicare for their services. Maxwell believes that, rather than there being any political conspiracy to not support rural health care delivery to the fullest degree, what looks like inactivity may actually be inertia and the fact that people “see the world in the context of their own street”. He regards it the work of organisations like the RDAA to try to remind politicians and bureaucrats that they have to have policy constructs that are workable and will deliver services in rural Australia. We wondered if this problem could be overcome by specific representation, and asked several of the leaders whether they thought a Federal Cabinet Minister for Rural Health could assist in implementing specific rural health policies. Most had not considered the idea, but Campbell was open to the suggestion. “To do something meaningful for rural health, there may need to be someone with a focus solely and wholly on improving rural health and education for rural health, unaffected by the needs and the power of the metropolitan or centralist driven policy”, he said. Royal Australasian College of Physicians (RACP) Representative: Paul Bauert Roles: Chair of Rural Taskforce, RACP; Council of Division of Paediatrics and Child Health, RACP (also, President, Northern Territory AMA; Federal Councillor, AMA; NT representative, Australian Doctors’ Fund) Alma mater: University of Queensland, 1977 Discipline: Paediatrics Location: Darwin, NT, since 1977, with periods away for training and family reasons Childhood: My father was in the army; I got used to moving between different locations and changing schools “I was attracted to rural practice by a sense of adventure, something different.” Prime Minister, I think you should . . . When we asked the leaders which two problems they would advise the Australian Prime Minister to address to improve the rural health situation, there were some consistent priorities. Almost all raised Indigenous health. For example, Bauert said, “Until we decrease the disparity between access to health by Indigenous people compared with non-Indigenous people, Australia as a nation isn’t going to grow. If we can do that, we as a country would become a little more supportive of rural communities and more, if you like, compassionate”. Campbell said, “The major issue with regard to rural health in Australia is Aboriginal health. The first thing I would do is set up state-based systems of community control for delivery of Aboriginal health services, appropriately supported on an equitable basis”. Mitchell said, “The preoccupation with Indigenous health is essential. The problems, in many ways, are similar; they’re just far worse for Aboriginal communities”. Among other key recommendations were: an affirmative action policy to ensure equitable provision of infrastructure for rural communities, including access to local hospitals that provide a comprehensive range of services and integrated primary care facilities; and making general practice a career-of-choice again, via recognition and reward for general practitioners. There was also a call to be more attuned to the voice of the people in rural Australia, and in particular, the voice of the rural medical community. Graham said, “Really, at the end of the day, the medical community reflects the needs of the community at large”. Breaking the droughtIn speaking with these leaders in rural health, we were struck by their different but equally innovative responses to the rural health care crisis, many of which they have implemented in their own practices: responses that often rely on the goodwill of those directly involved and which are not necessarily sustainable. Thus, not surprisingly, nearly all the leaders we spoke to called for the systematic application of strategies not only to increase the rural workforce but also, just as importantly, to ensure ongoing health care delivery in rural and remote Australia. Now that we have heard these many voices, it may be time to seek unity on a strategic direction forward. Underpinning Australia’s rural health care crisis is the concept of access. As Campbell put it, “I think we can directly equate health status to access. We know that where we improve access, we improve health. There’s no doubt about that”. The key strategies proposed by these leaders for improving access include: a hub-and-spoke model for secondary and tertiary care; the sustenance of small rural hospitals; the recognition of general practice (including rural practice) as a specialty in its own right; and the development of an innovative, collaborative primary health care infrastructure. Our Prime Minister, John Howard, has said of the current drought affecting Australian farmers, “When the bush suffers, all Australians feel their pain”. While our government can only wait with other Australians for rain to fall on the land, they can and should act now to promote the flow of health services to our rural heart, otherwise it will go into terminal failure. In the land of the “fair go”, it is time to decide upon and implement the best strategies on offer, in the interests of equality and better health for us all.

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

The Primary Health Care (PHC) working group of the Department of General Practice of Maastricht University in the Netherlands was founded in 1998 specifically to introduce students to patient care, research and education in primary health care settings outside the Netherlands. Rural health care in Australia is appealing to international medical students because of its unique setting. In the past 5 years, 42 medical students from Maastricht University have pursued a medical elective in rural Australia, supervised by the PHC working group. Doctors and coordinators in primary care clinics across Australia have welcomed and supervised students from Maastricht and exposed them to the reality of rural health care. Future collaboration with other Australian primary care clinics is welcomed.

Jochen Cals MSc · Peter Joyner DRCOG(Obst), FACRRM · Robert J Tuffley FRACGP, DRANZCOG · Geert-Jan Dinant MD, PhD

In an 1823 lecture to medical students on the principles and practice of surgery, London surgeon Sir Astley Cooper raised many issues still discussed among doctors today, including: the importance of studying anatomy; factors leading to what would now be called “adverse events”; and the possible legal consequences of making errors. Cooper stressed the need for open communication between doctors and patients. Cooper practised surgery during a period when old medical guild controls were breaking down and before new professional regulatory bodies had developed. Cooper’s lecture suggests that the important principles that underpin competent, caring professional practice endure today.

William Coote MB BS, FRACGP, BEc

Helicobacter pylori is established as a cause of peptic ulcer (PU). Less well recognised is that an epidemic of PU began around the middle of the 19th century, reached a peak at the turn of the century, and is now on the wane. As the epidemic developed, the risk of PU increased in successive generations throughout life. Then the epidemic diminished in successive generations. The risk of gastric ulcer (GU) was highest in people born around 1885, while the risk of duodenal ulcer (DU) was highest in those born about 10–30 years later. H. pylori infection offers an inadequate explanation of the PU epidemic. Although the epidemic coincided with a major rise in cigarette smoking, PU then declined in spite of an increased incidence of smoking. None of the other possible causes of ulcer (non-steroidal anti-inflammatory drugs, stress or diet) satisfactorily explains the epidemics of GU and DU and their asynchronicity. The best, but inadequate, explanation for the epidemic is the coincidence of the acquisition of a new potent strain of H. pylori in childhood and the uptake of smoking in adult life.

John M Duggan MD, FRACP, FRCP · Anne E Duggan MHP, FRACP, PhD

The past is another country: they do things differently there. Hartley LP. The go-between1 One indulgence accorded to those of us in our senior years is the ability to reflect on life’s circumstances many decades ago and compare them with those of today. My recollections of medical practice, as the son of a surgeon, stretch back to my schooldays. A lasting memory is of the many gifts, the so-called “grateful patients”. Glassware, silverware, bowls, paintings and books were the permanent items; flowers, Scotch and home-made delicacies the temporary ones. These often came from patients who had paid my father’s full fees, but more often from people for whom he had reduced his fees (generally people he considered to be impoverished) or whom he didn’t charge at all (mostly friends, ministers of all religions, colleagues and medical students). I remember other courtesies. He would never see patients who lacked a detailed letter from their general practitioner, and his replies were equally detailed, often complemented by a telephone call. Asked for a second opinion, he gave it to the patient and the GP and allowed them to decide whether surgery should be done by the first surgeon consulted or by himself. He was available, day and night, to advise GPs baffled by obscure clinical presentations. If asked, he would accompany a GP to a patient’s home. This joint visit had formal rules, including rules about who entered the room first and who exited last. When surgery was needed, he invited the GP to assist. His reputation relied on the success of his surgical interventions and on the opinions of the GPs who saw his work at close quarters. Those were the 1940s and 50s: a long time ago. What would my father have made of today’s intraprofessional relations? I doubt that he would even have understood commercialism, mercantilism (including advertising and self-promotion) and competition policy. Even if he had, would he have thought that they could ever apply to the practice of medicine? Sir Robert Menzies, born a decade or so before my father, commented about the universities in language my father would have applied to medicine: Are the universities mere technical schools, or have they as one of their functions the preservation of pure learning, bringing in its train not merely riches for the imagination but a comparative sense for the mind, and leading to what we need so badly — the recognition of values which are other than pecuniary?2 (my emphasis) Today, Australian doctors jealously hold onto their patients. Many GPs will not share an after-hours roster because they are worried that their colleagues might poach their patients. GPs no longer phone a patient’s former GP to let him or her know that the patient is now attending their practice and to obtain information that could be useful in the patient’s future care. GPs no longer write comprehensive referral letters to consultants. Today, letters of referral are notoriously inadequate.3 Specialist physicians now often arrange to manage referred patients on a regular basis, without sending them back to the referring GP for follow-up. The next time the GP sees the patient is when the patient asks for a new referral to the physician in question, who is now the patient’s specialist — no longer the GP’s consultant — and is, of course, not available after hours. Specialists now rarely refer patients back to their GP with the advice that they see another physician with a special interest in their problem, instead referring them directly — leaving the GP out of the loop. The explosion of knowledge in each field means that care is more “expert”, with more assured results, than in my father’s day. But it comes at a cost. If the patient’s condition worsens after-hours, the GP has to manage without feedback from the specialists. Where once we could discuss with our pathologist or radiologist colleagues just which tests or studies should be done on a particular patient, now the briefest of request forms, containing minimal clinical information, suffices for the laboratory technician or radiographer to perform the requested investigations and for the pathologist or radiologist to interpret the results. When we doctors attend a multi-doctor practice as patients, we will often be seen by a doctor we don’t know, who is not aware that we are colleagues. Even if the request form is marked Dr rather than Mr or Ms, we become just another first name called out by the nurse or radiographer. With billing now separated from the delivery of the service, we are frequently charged fees. Many doctors now charge their colleagues not just the Medicare rebate, or even the Medicare schedule fee, but their full, private fee. Why have things changed so much? Politicians after Menzies have persuaded the public — our patients — that medical services are like any other commodity. Each service has a government-designated value. Competition policy applies to the medical practitioner as much as to the television repair man or motor mechanic. Advertising and marketing are commonplace. Many doctors no longer own their practices, but are employed by profit-seeking enterprises beholden to shareholders. What once were thought of as being reasonable professional fees to cover a doctor’s training, skills, experience and equipment are now commercial fees expected to deliver a healthy profit to remote shareholders. Universal medical insurance (Medibank/Medicare) began the pro-cess. Once we all had to pay our levy and were “covered” for medical expenses, we began to insist on passing the rebate on to our colleagues for their formerly free medical services. This also relieved us of the burden of having to deliver a “grateful patient” at Christmas or on some other suitable occasion. It was not too difficult to persuade our treating practitioner to bill us for the rebate. Practice costs have also risen incommensurably with Medicare rebates. Increasing demands such as standards in occupational health and safety, sterilisation procedures, building and fire regulations, management of patient records, confidentiality procedures, and responsibility for following up on advice to patients are all worthy in themselves, but have combined to create an intolerable financial burden for solo practitioners and small group practices. The expensive practice manager has become an essential. Flourishing malpractice litigation has resulted in “procedural” GPs and some specialists having to charge much higher fees than those rebated by Medicare, and patients, even if they are colleagues, must bear the financial cost. There are those who say that doctors should be treated no differently from other patients. This might stem from a loathing of privilege of any sort (what the Russians call protektzia) or a reluctance to place additional pressure on treating doctors by burdening them with the knowledge that they are treating a colleague. Doctors, we know, make poor patients; furthermore, one interpretation of Murphy’s Law states that, if something might go wrong, it will go wrong when the patient is a doctor! In the United States, some legal experts even contend that it is illegal for doctors to reduce their fees for colleagues.4,5 With the commercialisation of medical practice, many of the courtesies formerly extended between colleagues have disappeared. The remaining septuagenarians might regret these changes, but that is of little practical moment. What does matter is what now confronts Australian patients seeking care from GPs and appropriately recommended specialists. In theory, Australia has one of the world’s highest standards of care in our “centres of excellence”. But the reality for most Australians, even for many of the minority with private health insurance, is based on a changed ethic. Financial self-interest has come to all but dominate medical practice, even inside hospitals, where it once played no role. Cui bono?* Not the patient’s. * For whose benefit? It is no longer “worth it” for GPs to do house calls or visits to nursing homes, to assist at their patients’ operations or to be available after hours. It is no longer worth it for GPs to acquire a diploma in a special field of interest: patients insist on attending a registered specialist. It is no longer worth it for GPs to spend time phoning specialists to discuss their patients’ problems. Cui bono? Not the patient’s. It is in the interests of specialists to offer continuing care to patients rather than to refer them back to their GPs. It is in the interests of specialists to refer patients to other specialists, bypassing the referring GP. This sets up a new pattern of inter-specialist referrals that, in turn, benefits all specialists, leaving the GP out of the management loop. Cui bono? Not the patient’s. It is in the interests of hospital-based specialists to have patients opting to be admitted as private patients, enabling them to raise fees for their services. It is in the interests of hospital management to have this additional source of income. Cui bono? Not the patient’s. The professional courtesies of the 1940s and 50s might seem old-fashioned today. But if, back in those days, we had asked my father, “Cui bono?”, he would have had no hesitation in replying “The patient’s!”

Peter C Arnold BSc, MB BCh, BA

To the Editor: Schattner’s call to resurrect history-taking and examination as the dominant means of clinical diagnosis1 is analogous to advocating a return to cave-dwelling and spear-hunting for food in the era of houses and supermarkets. Even the most ardent supporters of history and examination would acknowledge that they can be grossly inaccurate, in possibly up to 30% of cases.1 Clearly, without using further diagnostic tools, there would be an unacceptably high rate of missed, incorrect or delayed diagnoses with associated morbidity, mortality and financial costs to the patient, hospital and community. Therefore, there is an urgent need to challenge the “politically correct” and entrenched paradigm of history and examination as the initial approach to diagnosis and management. In my approach to acute abdominal pain, I have long since abandoned using the stethoscope to ruminate over the meaning of mysterious bowel sounds in favour of liberal use of computed tomography (CT) scanning. Gone are the days of inspection, palpation, percussion, auscultation and operation. This often arouses considerable opposition from traditionalist colleagues who are concerned about the cost and radiation dangers of abdominal CT. But their criticism ignores mounting evidence that the modern CT scan is rapid and accurate for nearly all conditions that require emergency surgical treatment.2 In every study comparing the accuracy of CT scans with history and examination, CT wins hands down.2,3 The CT scan takes the guesswork out of diagnosing the cause of abdominal pain and, most importantly, reduces the need for laparotomy procedures that frequently produce negative results. Similar conclusions could be drawn regarding the use of CT scans in head injury or the use of chest x-rays in acute respiratory conditions. Perhaps the new clinical paradigm should be “scan first and talk later”. So, why do some clinicians continue to routinely promulgate the sacred and arcane ritual of taking a history and doing an examination, which, as diagnostic tools, are clearly second-rate. Cost is not a valid excuse, as there is no reason for patients to accept second-best care. The explanation may lie in blind adherence to ancient dogma that has been unchallenged since Hippocrates. Failure to accept that history and examination have severe limitations; to actively embrace newer, more accurate diagnostic tools; and to revise established clinical paradigms may relegate clinicians to the relevance of dinosaurs outside museums of ancient history. At the risk of medical heresy, I would suggest that the obituary notice for history and examination as the dominant diagnostic tools may be long overdue.

Kenneth Wong

In reply: Wong writes eloquently, and seems utterly convinced of the merit of the “testing first” medicine that he preaches. Yet his arguments are flawed and his system, appalling. Young physicians not wearing a white coat are a fairly common sight in hospitals these days. Without a coat, they no longer have a convenient means of carrying around essential tools such as a flashlight, reflex hammer or ophthalmoscope. Indeed, if all they have to do is automatically order computed tomography (CT) scans, they will not need such tools. It is exactly to oppose these negative trends in medicine that my article was written. What I was trying to say was not that history and examination should replace modern imaging, but rather, that the decision about whether and when to order a test, and what test to order, should more than ever be based on skilful verbal and physical contact with the patient. Careful interpretation of basic clinical data such as the proneness of the patient to develop certain conditions (“pre-test probability”), the behaviour of symptoms over time, and the results of very simple laboratory tests are also immensely valuable. Most of this information can only be gleaned from patient–physician communication.1 Would Wong’s approach to acute abdominal pain (do a CT scan first and then let the diagnosis sort itself out later) hold water in cases of acute gastroenteritis, renal colic, peptic ulcer, acute hepatic congestion, incarcerated hernia or Henoch–Schönlein purpura? All these not uncommon causes of acute abdominal pain can be confidently identified by their typical history and findings and successfully treated with no resort to imaging, which may be not only redundant but also costly and hazardous.2,3 An additional downside of imaging without forethought is that it is fraught with false negative findings (eg, early diverticulitis or pancreatitis) and false positive findings (eg, “incidentalomas”) that often result in diagnostic confusion, lost time and more unnecessary testing.4 When the indirect benefits of patient–physician communication and examination are also taken into account, the integral value of the clinical paradigm is even more strongly re-affirmed. Medicine is a humanistic profession. Patients experiencing pain, distress or uncertainty look up to the physician who talks to them, touches them, comforts them and is sensitive to their plight.5 Even the best, latest-generation CT scanner would never be able to do that.

Ami Schattner

To the Editor: Your thoughtful editorial comment1 in the 21 August issue laments that the essence of the art of our profession was potentially diminished recently by the report of a working party of the Royal college of Physicians of London.2 My medical dictionaries and textbooks are curiously silent on the notion of an “art of medicine”, so I went to “the source” and discovered that “Life is short, and the Art long” comes from quotes of popular Latin authors as “Ars longa, vita brevis” — in turn from Hippocrates’ original Greek,3 A native Greek-speaking medical colleague of mine points out that the Greek word used in the quote implies “long through to the end” — presumably the end of one’s career or the end of one’s life. So we (and Hippocrates) are evidently referring to a rather grand concept of the art of medicine, not just a narrow view implied by the term “judgement”, as proposed by the working party. I see judgement as being but one of many essentials of the art of our profession, and agree with Van Der Weyden’s assertion that the proposed use of the term “judgement” in place of “art” is indeed reductionist and should be rejected.

C Ross Philpot

To the Editor: I agree with Van Der Weyden’s quotation from Osler: “The practice of medicine is an art, based on science.”1 In my medical training in the 1960s, I was taught that medicine was both an art and a science — perhaps more the former than the latter, given that the technological age was not yet fully upon us. It saddens me that there is now an almost inexorable trend towards the use of advanced technology in medicine and away from human interaction between doctors and patients. I do not believe in reducing humans to mere numbers on a pathology results form or images on a computer-driven x-ray monitor. This is what helping patients “judge” which path to take “through the indeterminacies” back to health1 suggests. Gordon expressed similar sentiments in an earlier article:2 The arts, humanities and social sciences act as a counterbalance to the relentless reductionism of the biomedical sciences . . . [M]edicine will attract students who are interested in the biomedical sciences, many of whom are particularly good at processing and memorising information. Unless they have adequate time for reflection, such students may ultimately adopt a dogmatic or overly technical approach to clinical practice . . . As a “doctor” — in the sense of a modern version of an ancient healer — I accept that my role is “to cure sometimes, to relieve often, to comfort always”.3 There is cold comfort if we lose the “art” of medicine.

Norman Shum

A recent editorial discussed the issue of interactions between doctors and pharmaceutical companies (MJA 2006; 185: 299-300). The reactions ranged from agreement to offence. To the Editor: I would like to congratulate Tattersall and Kerridge on their recent editorial covering the issue of industry influence in medical education.1 Like the authors, I was dismayed on seeing the Australian Medical Association statement to the press regarding the recently revised Australian Competition and Consumer Commission guidelines for disclosure of industry support. Industry supports medical education because it pays, and we would be well advised to remain aware of this basic fact. It amazes me that anyone could subscribe to the view that doctors need industry freebies to remain informed of new therapeutic options in this age of electronic media. We are constantly inundated with information — the issue is to choose reliable, unbiased data. As a rule, industry-sponsored sources of information should be regarded as potentially biased and therefore suspect. In my view, direct industry sponsorship of continuing medical education activities is inappropriate and should not just be regulated, but abolished altogether.

Hans Peter Dietz

To the Editor: Tattersall and Kerridge make the argument that any interaction between industry and clinicians must, of necessity, compromise the decision as to the appropriateness of the particular treatment prescribed.1 The more common situation is that interactions do exist, and this is covered by a process of disclosure of, for example, honoraria or shareholdings. However, this situation is also inadequate, in that the extent of the potential for influence is not disclosed (eg, the size of the honoraria, or the volume of shares held in the company). This is also relevant when it comes to evaluating potential conflicts of interest in medical publications. As the authors note, the health care industry is complex, and interactions do occur between clinicians and industry. In this situation, full and frank disclosure — rather than the mere indication that a relationship exists — is far more appropriate.

Charles M Fisher

To the Editor: I am critical of the article by Tattersall and Kerridge.1 In my opinion, the article comprises a series of pompous announcements from an ivory tower, which hint without actually saying that doctors who attend educational symposia organised by pharmaceutical companies, and who subsequently order the product, are acting improperly. As I see them, the facts are quite otherwise. Medical practitioners have an obligation to do their best for their patients by giving them the most appropriate treatment available, and to keep up to date with their profession. Both these objectives can be achieved by educational symposia organised by the research-based pharmaceutical companies, which introduce new concepts in medicine as well as new products. Research-based pharmaceutical companies play a major role in the development of modern therapeutics through the introduction of new drugs. The development and manufacture in commercial quantities of life-saving compounds in the future, such as, for instance, the new biological agents and the new anticancer drugs that we need so urgently, would not be possible but for the pharmaceutical industry. One cannot imagine this important work being done by other agencies, such as the universities or the government. The Australian Government, in fact, sold its own pharmaceutical company (Commonwealth Serum Laboratories, now CSL Ltd) some years ago. Doctors attend educational symposia run by pharmaceutical companies so as to obtain information that will be useful for their patients, not because they can get a few free drinks and a dinner. The suggestion to this effect is offensive. I note that one of the authors is Director of the Centre for Values, Ethics and the Law in Medicine. I would value his opinion on doctors who advertise directly to the public, such as the eye surgeons who advertise repeatedly on talkback radio, and the promoters of alarming cardiovascular articles that predict catastrophes if one does not apply to the sponsors of the program. To criticise doctors for prescribing products promoted at educational symposia while allowing these other examples to flourish without criticism is, to my mind, hypocritical.

Ian S Collins

To the Editor: A new trend of doctors appearing in television advertisements is emerging in this country. This has occurred with some impetus over the past year, and now involves not just everyday medical practitioners, but highly regarded public figures. The ethical implications of such advertisements are worthy of some thought. There has been no formal discussion regarding these issues, and the New South Wales Medical Board does not cover it specifically within the Code of professional conduct.1 This has allowed medical practitioners to participate in the advertisements with no guilt about the possible ethical flaws of their actions. This is perhaps a premature response, as there are several areas where the ethics are potentially questionable. The first is the creation of a conflict of interest. The idea of a doctor being sponsored by a drug company is covered, to some extent, by the Code.1 As is well understood, a medical practitioner must declare to a patient any financial dealings he or she has with a company involved in the treatment of that patient.2 For the described commercials, the drugs are invariably over-the-counter general medications, like analgesics or vitamin supplements. A medical practitioner may recommend these frequently, and it would be difficult to explain to each patient the nature of the doctor’s connection to the drug company while maintaining the high level of integrity and trust expected within modern practice. Then there is the nature of the advertisements themselves. Medical practitioners can be seen advocating specific products for use by their patients, their families and sometimes even themselves. They display their medical qualifications as a reason for consumers to trust them, playing on the esteem and regard in which doctors are still held in large parts of the community. This is a big risk to take, especially when considering the questionable benefit of some of the treatments being advocated. I believe that the practice is poor for the public image of doctors and, even if ethically tolerable, it may be prudent for it to be openly frowned upon by the profession. However, the profession may consider it completely acceptable. What is lacking is a frank and open discussion on the ethics involved.

Adrian M J Pokorny

To the Editor: I would like to comment on two articles that appeared recently in the MJA. “Doctors behaving badly?”1 was an anticlimax. It was not, as would be expected, an exposure of misconduct by doctors, but dealt with the potential conflict of interest that occurs when they interact with the pharmaceutical industry. No evidence of doctors “behaving badly” was provided, yet a solution to this potential problem was proposed — “disclosure” (ie, yet more paperwork), accompanied by a disclaimer that this was unlikely to work. This is an important issue, but the content of the article cannot justify such a misleading title. I can only assume it was the result of editorial intervention, in which case there is some hypocrisy at work, given that the inside front cover and the outside back cover of the same issue of the Journal are taken up with full-page drug advertisements, and within, a $10 000 prize was offered for the best original research article published in the Journal (sponsored by a drug company). The second article, From the Editor’s Desk “Tilting at titles”,2 which cited the dreaded Australian values, suggested that titles such as “doctor” should be trashed altogether and replaced by an introduction such as “Hello. I’m Jean Smith. I am a urologist and together we will confront your prostate problem” — a statement that is unlikely to give great confidence to the average digger. Doctor Samuel Johnson put this argument to rest in 1775:3 What is implied by the term Doctor is well known. It distinguishes him to whom it was granted, as a man who has attained such knowledge of his profession as qualifies him to instruct others. A Doctor of Law is a man who can form lawyers by his precepts. A Doctor of Medicine is a man who can teach the art of curing diseases. My concern is that there appears to be an editorial assumption that doctors are preoccupied with titles and are willing to treat patients unethically for a few glasses of Kooyong Pinot Noir and a good feed. This might be good press, but not in the MJA. Perhaps some disclosure is required. To return to Johnson: There are but two reasons for which a physician can decline the title of Doctor of Medicine, because he supposes himself disgraced by the doctorship, or supposes the doctorship disgraced by himself.

Padraic J Grattan-Smith

In reply: We agree with Dietz that unbiased sources of information about new therapeutic options are increasing, and many are available electronically. Virtual Mentor, the American Medical Association’s ethics journal, has suggested reducing drug company influence on doctors’ prescribing by stopping companies paying for continuing medical education,1 and the Australian Competition and Consumer Commission is exposing this issue. Fisher recommends full and frank disclosure of links with industry, but he does not state to whom these disclosures should be made. The revised Royal Australasian College of Physicians guidelines recommend that employing hospitals create a Conflict of Interest Committee to receive employees’ declarations, and to advise when a duality of interest may be construed as a conflict of interest.2 The Box shows the disclosure statement that one of us displays in his consulting room, copies of which are sent to referring doctors when letters are written about patients. Grattan-Smith felt the title of our article was misleading. However, the title is stated as a question precisely because the assessment of professional behaviour, and particularly the assessment of possible conflicts of interest, is a matter of considerable dispute. It is clear that the relationships that doctors have with industry may constitute bad behaviour in the eyes of some, including the editorial writer in the Sydney Morning Herald.3 We do not, as Fisher suggests, contend that interaction with the pharmaceutical industry inevitably compromises prescribing decisions, but agree with him that full and frank disclosure, rather than the simple notification that a relationship exists, offers at least some reassurance that the possibility of influence is being acknowledged and managed. Collins asserts both that we hinted that doctors who attend educational symposia organised by pharmaceutical companies and subsequently order the product are acting improperly, and that doctors attend such meetings for the free food and wine. We do not believe that either statement is correct, and accept that the choices that doctors make to attend such events are generally motivated not by gluttony, but by a range of complex factors, including a desire for education, clinical feedback and professional collegiality. Nothing in the interaction between doctors and the pharmaceutical industry is simple. Although the editorial from the Sydney Morning Herald suggests that avoidance is the simplest response to this dilemma, we would argue that such a complex issue requires a complex response and that support for adequate disclosure should be a necessary (but insufficient) component of the medical profession’s response, if it hopes to maintain the high regard in which it is held by the Australian public. Example of a disclosure statement displayed in the consulting room and enclosed with letters about patients Disclosure of interests that might influence my prescribing and treatment of cancer patients Pharmaceutical companies I have received no honoraria or financial support for more than 10 years from pharmaceutical companies for: serving on advisory boards consultancies providing patients' data relating to drug use enrolling patients in a clinical trial speaking at a company-sponsored event During the past 10 years I have not: received financial or other support from pharmaceutical companies for my research activities or staff received travel, registration, accommodation or other support from pharmaceutical companies for me or my staff to attend regional, national, or international conferences or meetings received research support from pharmaceutical companies received personal gifts from pharmaceutical companies attended company-sponsored meetings, launches of new drugs I am not a principal investigator on trials supported by pharmaceutical companies. I do invite eligible patients to consider entry on some pharmaceutical company sponsored trials, but I derive no personal financial benefit. I do not accept free samples of drugs from pharmaceutical companies. I do not welcome visits from representatives of pharmaceutical companies. Martin Tattersall

Martin H N Tattersall · Ian H Kerridge

In reply: Grattan-Smith is obviously concerned about “Doctors behaving badly?” as an appropriate title for the editorial by Tattersall and Kerridge.1 He is also agitated by my column From the Editor’s Desk “Tilting at titles”.2 The editorial’s title was not the result of Machiavellian machinations — its creation belongs entirely with the editorialists. Grattan-Smith may not feel that accepting pharmaceutical company largesse is bad behaviour, but the public sees it otherwise, as evidenced by the unprecedented coverage of the “Roche affair” in The Australian,3,4 the Sydney Morning Herald,5 and the BMJ.6 The public comments were not flattering: “the gluttony of the whole thing was mind blowing”3 and its defence by doctors was “in poor taste and displays the supreme arrogance of the privileged”.7 The public and most doctors expect the relationships between the pharmaceutical industry and doctors to be open and transparent. We believe this to be the case with the pharmaceutical advertisements in the Journal, and the MJA/Wyeth Prize. Our advertising policy prevents pharmaceutical companies from placing advertisements within or adjacent to articles that might have relevance to the drug being advertised. Wyeth generously donates $10 000 each year to the authors of the best original research published by the Journal on the understanding that Wyeth has no input to the selection process. Research has already been independently peer reviewed for publication before being considered for the prize, and the winner is decided by the Journal staff and the members of our independent Content Review Committee. Grattan-Smith’s concern with my column was its questioning of the title “doctor”, which apparently is now a source of confusion for patients in busy hospitals. He cites Samuel Johnson’s concept of a doctor and quite rightly so. Physicians of his time had every right to call themselves Doctors. They were graduates from Oxford and Cambridge who pursued a long, formal and inflexible course. It began with a Masters in the liberal arts, proceeding through the Licentiate and then a Doctorate in Medicine by dissertation.8 These doctors were the epitome not only of scholarship but also of elitism. Those with moderate means were barred from pursuing medicine at Oxford and Cambridge, as were non-conforming Protestants and Roman Catholics. It took the Scottish medical schools in Edinburgh and Glasgow to break down the English citadel. In our times, the use of the title “doctor” by medical practitioners is a privilege granted by the community and the state, and has to be earned and sustained by open professional conduct. A closeted freebie of “a few glasses of Kooyong Pinot Noir and a good feed” is what most of the public perceives as doctors behaving badly, and it is perception that counts.

Martin B Van Der Weyden

A 26-year-old woman accidentally swallowed a 15 cm long spoon during a “laughing attack”. The spoon was removed from the stomach with a single lumen gastroscope (with great difficulty).

Bernard R Beldholm MB BS · Alice U Lee MB BS, FRACP, PhD

MondayHe’s a dead man. Balloon pump. Recurrent VTs. Frequent defibs. Still conscious! Stupid wife I hate this rude bitch. No respect for me. No respect for my husband. No respect for his life. I can see it in her eyes TuesdayShe knew what was coming the moment I looked at her. Spoke to her anyway. She knows he’s a dead man. But still refuses to listen Who does she think she is? Telling me what to do. She won’t even give him a chance WednesdayAnother defib. Can’t stand to look at him. Let her watch the defib. See what she’s doing to him. He cried out. Gave her a pointed look She won’t even look at him. Won’t acknowledge him. Won’t acknowledge his right to live. Not even when he cried out ThursdayAnother defib. I wish he’d die He looks worse today. I’m losing him. Why won’t she help him? FridayAnother defib. Cracked it. Took her into my office Another shock. Cracked it. Will give it to her in her office She begged me “I can’t lose him” “What will I do without him?” “My life for 40 years” “Give him his life back” She begged me “I can’t save him” “I can’t shock him any longer” “I can’t hurt him any more” “Give him his dignity” SaturdayShe looks into my eyes. Holds my hand Tells me she can’t save me I already know I squeeze her hand Thank you She looks into my eyes. Holds my hand She’s letting me go I squeeze her hand I love you

Ailin Mohajeri

Generally, a hospital has one Director, but during the filming of several scenes of this year’s blockbuster Superman returns at Thomas Walker Hospital (“Rivendell”) in Sydney, there were two! Equipped with a medical background and psychiatric qualifications, I continued to be responsible for the smooth running of the psychiatric hospital, while Bryan Singer, of X-Men fame, took charge of the movie. In the main, there was no confusion about our identities and roles among hospital staff, patients, actors and film crew, but there were a couple of exceptions. Early in the piece, when entering the hospital gates, I was accosted by one of the film’s security guards. “I’m the Director”, I explained. “And I’m Superman”, replied the disbelieving, portly guard. Another time, my wife visited the hospital to watch a scene being shot and announced on arrival that she was “the Director’s wife”, which floored a second security guard, as Bryan Singer is openly gay. There are differences, of course, between a hospital director and a movie director. In this case, Mr Singer boasted an artistic temperament, an entourage of doting attendants, a wonderfully appointed caravan in which to unwind, and reportedly a $30 million salary for making the film. I offered a milder manner, loyal but not fawning secretarial staff, my office as my sole retreat, and a considerably smaller salary. Although happy with my lot, subconsciously, along with other staff, I craved a part — hero, villain or mere extra — in the movie, but Brandon Routh, Kevin Spacey and co. had these sewn up. Undeterred, I wore a hired Superman outfit under my suit for the duration of the filming and was ever ready to strut my stuff. “I’m the Director and Superman” would surely be hard to top, in one’s medical career and in life.

Garry J Walter MB BS, PhD, FRANZCP

On 28 March 2006, the World Health Organization Global Alliance against Chronic Respiratory Diseases, comprising 41 national and international organisations, was launched in Beijing. In 2005, four million people died of chronic respiratory diseases, and chronic obstructive lung disease is the fifth leading cause of death worldwide. Chronic obstructive pulmonary disease accounts for about 7% of the total burden of illness in Australia. I’ve come to visit him in his garb of house arrest — flannelette pyjamas from Kmart — he stands, greets me, hitches up his pants, exhausted, sits and speaks in tiny bursts: “Today is a good day! This morning I could do up my buttons without getting too much out of breath!” Each night the moon drags the tide an inch closer to the shore. Each day he cuts and glues balsa to shape model ships, perhaps today a papyrus raft to bear the brief message of his soul. He drove trucks for years, smoked, took dex and Coke for extra miles, and now sniffs oxy for the loo. He’s my age: The front door prison grille swings shut. I wave goodbye for both of us.

Stephen R Leeder AO, PhD, FRACP

Until recently, iodine deficiency had been prevalent for centuries in a number of landlocked mountainous regions of the world.1,2 The Himalayan region3 and the Bernese region of Switzerland4 were especially known for severe endemic goitre as a result of this deficiency. Since the 1920s, the prevalence of goitre has fallen with the widespread use of iodised table salt.4 Many different human and animal inborn errors of metabolism can cause congenital goitre.5-12 It has been shown to occur in animals such as Syrian hamsters, bongo antelopes, Dutch goats, Afrikander cattle, merino sheep, mice, fox terriers, pigs, Abyssinian cats, and horses.5-12 However, we could not find any studies reporting congenital goitre in monkeys. Here we report multinodular goitre occurring in wild rhesus monkeys in the Nilgiris (Blue Mountains) in the state of Tamil Nadu, southern India (Box). It is possible that these animals developed goitre because of a genetic defect. However, research has shown that livestock can develop iodine deficiency disorders (IDDs) due to an iodine-deficient diet, and may require the addition of iodised salt to their food.13 Thus it is possible that the multinodular goitre observed in Nilgiri rhesus monkeys is the result of low iodine levels in their mountain environment. Further investigation is necessary to establish the exact reason for the goitre. A literature search failed to identify any studies of endemic goitre in humans living in the Nilgiri region, although a 2003 policy note issued by the Government of Tamil Nadu states that goitre is prevalent in some of its districts.14 Tamil Nadu has been aggressively pursuing eradication of goitre by various means, including raising awareness of IDDs, encouraging its people to demand iodised salt, and educating salt retailers to sell only iodised salt.15 If the disorder in the rhesus monkeys is indeed caused by iodine deficiency, they could serve as a model for naturally occurring multinodular goitre and would form a natural resource for studying this major thyroid disorder in humans.

Biji T Kurien PhD · Jobin T Kurien

Five months in Cambodia restored my perspective I knew very little about Cambodia before I landed at the airport in Phnom Penh. I imagined luminous green rice paddy fields, smiling brown faces, and the perfect antidote to my disillusionment with medicine after only 2 years working in the Australian public health system. My medical resident jobs had seemed to require more secretarial ability than clinical skills, and hours were lost begging for an urgent investigation or trying to secure an outpatient appointment within the next 6 months. I wanted to witness the power of basic medical treatment — to save lives with a course of penicillin, to save sight with a few doses of vitamin A. I had teamed up with a small Australian non-government organisation called Awareness Cambodia and agreed to take on the task of establishing an outpatient medical clinic in the rural province of Kampong Speu. I had 5 months in which to do it. The van ride into Phnom Penh from the airport was enough to trigger a surge of panic as I tried to digest a series of confronting images. A mother clutching her very young baby with one hand and, with the other, manoeuvring her motorbike through a sea of traffic; a barefoot boy with a swollen belly, his naked younger brother in tow, begging at a busy intersection; pre-pubescent girls in make-up and pyjamas loitering outside ramshackle wooden brothels. The brutal realities of living in a developing country hit me hard in the face. The next few weeks were spent doing the necessary groundwork around Phnom Penh and Kampong Speu, visiting the local hospitals and established clinics. From what I could see, a bed in a public hospital was no more than a bed in a cheap guesthouse. Only the intensive care unit had any equipment — a few oxygen tanks and perhaps one functioning cardiac monitor. To my horror, I discovered that it was not uncommon to use blocks of ice for postoperative analgesia (applied, for example, directly over a patient’s midline abdominal wound), and that, because of sheer lack of staff, the patient’s families performed almost all of the nursing duties. Hospitals run by foreign non-government organisations were so overloaded that patients would literally have to win a lottery to receive care in these hospitals. In the clinics I attended it was rare to see a doctor listen to a patient’s chest before prescribing three antibiotics for a chest infection, and intravenous (IV) drips were consistently the favourite therapy among Cambodians, who believed that they could cure anything from a headache to a sore toe. It was not unusual to see an IV pole protruding through the window of a passing car, or held up by a devoted parent as the family rode home on their trusty motorbike. In a corner of Phnom Penh, I discovered a network of pharmacies stocked wall-to-wall with the latest broad-spectrum antibiotics and a never-ending stream of patients buying them, without prescription. In the countryside, Western doctors had to compete with village doctors, some of whose remedies were like something out of a bad fairytale. A colleague told me that she asked why a child in one village had a glass eye and was told that the eye had been used in a concoction to cure the child’s mother of a serious illness. I personally remember a woman with scabies who was non-compliant with the standard topical permethrin treatment, opting instead to pour hydrochloric acid on her wounds to take away the itch. I faced different problems in my interactions with the government health centre that we planned to work with. The centre appeared to have all the fittings required for a clinic, including a wealth of power outlets, light fittings and taps, but there was no electricity or running water. Instead of being glad that we were providing doctors and free medicine, our initial proposal for a fortnightly outpatient medical clinic for the villagers in Kampong Speu province was met with hesitation because of fears that it would increase the workload of the health centre staff. As they only earned US$18 per month, out of necessity, they ran their own private clinics in the afternoon. We ended up having to supplement the government workers’ salaries before we were allowed to provide our free service to the villagers. To save myself from jumping on the next plane back to Australia I had to focus on small goals and achievements. I began to take pride in our clinic and the fact that when we examined patients we spent a good 10 minutes with them, instead of the usual 2 minutes. We checked people for anaemia with simple laboratory tests, and we gave them vitamin supplements and treated them empirically for worms — but it was a far cry from what I had imagined. The sickest patients, who needed our help the most, were the hardest to treat. A 21-year-old man with pancytopenia readily comes to mind. We referred him to the local hospital because he could not stand up and was bleeding from his gums. But his family could not afford the blood transfusions he needed, let alone the hospital costs and the further investigations required. He ended up relying on herbal remedies and died six weeks later. It was not uncommon to find families falling deep into debt trying to save their loved-ones, often to no avail. Other families would put their sick relatives in a hut on the outskirts of the village and leave them there to fend for themselves — out of sight, out of mind. Nothing was easy. If we decided to refer a patient to the local hospital or to Phnom Penh, we needed to spend the next few hours working out the logistics of finance for transport, meals, compensation for lost income, and a carer for the six or seven children left behind. Ethical dilemmas emerged on a daily basis. An elderly woman presented with fatigue and occasional per rectal bleeding and, on examination, was slightly pale. In Australia she would have been on the next colonoscopy list. In Cambodia this would mean a long trip to Phnom Penh to the only public hospital that performed colon-oscopies. But who was going to pay for the colonoscopy? And, more pertinently, what would we do if we found something? Was it ethical to submit an otherwise well 70-year-old woman to an abdominoperineal resection or partial colectomy when she might not survive the operation? Was it worth sending her family deep into debt? Or was it more ethical to treat her anaemia with iron tablets and improve her quality of life? Working in Australia was beginning to seem like a dream. But having said all this, I will never forget one woman’s smile as we helped to secure an operation for her granddaughter’s cleft palate, and I still treasure the bowed thanks from the villagers for making them feel better, if only by turning up every week, listening to their problems and giving them our time. My 5 months in Cambodia may not have unfolded as I expected, but I do not regret it. I learnt that I am lucky to live in a country where I, and my patients, have access to free health care and where I can practise medicine with the knowledge that there are good referral systems in place. I thought I would go to Cambodia and change people’s lives, but instead when I went there it changed mine. The experience gave me perspective, not only in my medical practice but in all aspects of my life. My time in Cambodia has helped me see an abundance of resources and opportunities that I couldn’t see before.

Melanie Cheng MB BS

Objective: To collect contemporary accounts of celebrity use of complementary and alternative medicine (CAM), to aid clinicians in determining which CAM treatments patients are likely to use.Design: Articles published during 2005 and 2006 reporting celebrity use of CAM.Results: 38 celebrities were found to use a wide range of CAM interventions. Homeopathy, acupuncture and Ayurveda were the most popular modalities.Conclusions: There may be many reasons why consumers use CAM, and wanting to imitate their idols is one of them.

Edzard Ernst MD, PhD, FRCP · Max H Pittler MD, PhD

The first Australian I ever met was a delightful lady doctor, recently qualified, who arrived in the wee Fife village of Kincardine in which my father had been the general practitioner for 17 years. She was to be his locum during his long and eventually fatal illness. Dr Patricia Hodgson (née Richardson) as a resident medical officer at Royal Adelaide Hospital (RAH) in 1937. (Photograph courtesy, Michael Holt, Assistant Archivist, RAH Heritage Office.) Her name was Pat Hodgson and she had just married when World War II broke out. Her husband, Guy, was a merchant seaman. His services were required on the very hazardous trans-Atlantic passage to keep Britain supplied with food and arms. Pat was certainly not going to sit at home in Adelaide while her newlywed was risking all on the other side of the world. At least she would be able to see him from time to time as he reached the eastern end of his voyages. As the ships most often docked in Liverpool or Glasgow, she was delighted to find a medical job in Scotland, within relatively easy reach of either port. Scottish villages were not used to lady doctors in the 1940s. They preferred middle-aged to elderly males clad in suits and spats and smelling of tobacco and surgical spirit — or even non-surgical spirits — rather than perfume. My father, having been carted off to hospital, had no say in the appointment. To get a locum at all in wartime was an unusual privilege, as most of the young medicos who normally cut their teeth on such jobs were in the services. The population of this small mining and farming community could not have been cared for by the neighbouring doctors, who were getting on in years and lived at some distance. Pat had to be accepted. Being only in my early teens at the time, I was not privy to the full impact that a large and vibrant Aussie woman had on the town. I am sure there was a considerable redistribution of the complaints usually seen in the surgery, and one can only imagine the boggling that eyes went through when first she paid a home visit to an unsuspecting patient with a painful set of piles. But the fresh air she brought with her was the first breeze of the winds of change about to overtake the professions in the postwar years. She became the most popular locum we had ever had. It wasn’t just Pat who awaited Guy’s visits eagerly. My family rejoiced as he bore two large cardboard boxes, bound by marvellously concocted string knots, up our steps every 3 months or so. These contained the miracles of America’s non-rationed society: the Hershey chocolate bars, the cans of Spam and, on one occasion, an entire case of Limburger cheese. This was a new experience in our household. Nothing so exotic had ever entered our doors — nor so quickly been banished to the outside laundry. The stench pervaded the waiting room and led to a downturn in surgery attendance. When we eventually screwed up the courage to get past the smell, we were surprised to find the taste so acceptable. Pat’s eyes twinkled from the depths of deep sockets above generous cheeks. Her figure was similarly cheerfully ample. In spite of rationing, Pat’s proportions failed to diminish. When she eventually returned for a visit before returning to Australia, she had put herself on a diet. This proved to be so successful that she was unrecognisable when I opened the door to her. Apparently, she used this to great advantage when she was interviewed, as so many returning passengers were, on the wharf at Fremantle. “Look,” she cried, “I left here a 12-stone dumpling. Now I am a 7-stone weakling. Send more food parcels, the Brits need them!” The village never really recovered. My father’s practice, sold after his death, was bought by another lady doctor. Unfortunately not endowed with a taste for cigarettes, whisky and good humour, that practitioner had more rigid views about life, death and the way to salvation.

Thomas F Sandeman MD, ChB, FRANZCR

During the early 1950s, I completed 2 years of hospital resident training in general and obstetric hospitals in Sydney, which in those days allowed for very little sleep! As a young graduate I had a desire to experience the responsibilities of patient care firsthand before attempting an extensive program of postgraduate training in orthopaedic surgery in the United States and United Kingdom. There was time, however, to get married before starting out as a solo general practitioner in Wellington, in central-western New South Wales. Clinical demands were arduous: the patients had high expectations and, at the same time, seemed to have great confidence in the practical judgement of their doctors. As a young graduate, this caused me to feel a degree of “professional anxiety”. As time moved on, my wife and I settled into the busy routine of general practice, with help and advice from the older, more experienced local practitioners. My obstetric work quickly increased, which meant blood work, cross matching and Rh typing — all part of our antenatal routine. One particular experience shows how the circumstances of 50 years ago influenced one’s actions. An “elderly” primipara (in those days, 32 years old was considered elderly) was easily delivered of a beautiful boy — her pride and joy. Initially all seemed well, but after the first few days, no meconium had been passed and the baby appeared to be distressed, with abdominal discomfort. I became concerned and phoned the paediatric surgeon at the Children’s Hospital in Camperdown, Sydney, for his advice. Feeling that there was clinical evidence of a developmental bowel obstruction, he too was anxious about the baby’s condition. At that time, no air-ambulance or helicopter rescue services were available in the area. The road ambulance could not be arranged and would take too long anyway. I thought of trying to charter a light aircraft from Dubbo, and phoned Dubbo airport. But the weather was most unsettled, and no charter flights were operating. The airport official explained how a Royal Australian Air Force training squadron had been grounded by the bad weather over the state. Was there any other option? The baby’s parents were so very anxious — they would agree to any suggestion to expedite the transfer of their child to the Children’s Hospital. While I pondered the situation, suddenly a new voice came on the phone line — he announced he was an ex-Royal Air Force (RAF) World War II fighter pilot, and, being an emergency, he offered to fly us to Sydney despite the weather. The flight would be in a De Havilland Chipmunk — an open-cockpit, two-seat RAF light training aircraft — if I was game! I agreed to be at Dubbo airport with the baby as soon as possible. We wrapped the small baby warmly, safely protected in a cane basket. The plane’s second control column was removed, enabling me to carefully place this important bundle away from the wind, set snugly between my legs in the instructor’s seat. In no time, we took off in the drizzly afternoon weather, passing through the overcast gloom and flying above full cloud cover. I found the experience exciting, and when comparing this with my later years of instrument flying in similar meteorological conditions, it’s clear that our pilot certainly demonstrated his expertise. Flying into Sydney airport was a relatively simple exercise in those days, compared with the hectic jet traffic, radar and intense air traffic control that are the norm today. While flying over the Blue Mountains on the approach into Sydney, above partly broken cloud, our pilot asked me through the intercom, “How far past the hills do you think? My dead reckoning indicates a further 10 minutes before commencing descent to Sydney.” I got a fleeting view of a long line of Katoomba street lights, confirming our pre-descent position. An ambulance was awaiting our medical emergency at the airport and raced us to the Children’s Hospital. I found this ambulance ride even more hectic than the air trip! Sadly, despite expert urgent surgery, multiple developmental bowel obstructions proved too much for the infant’s survival. The return flight holding this sad little bundle was not easy. Before take-off, interested kind folk kept asking to see the small baby in the basket. Happily, later, while I was studying overseas, news came that the bereaved mother had given birth to a healthy, bonny boy. Now in my retirement years, I constantly worry about young country mothers experiencing the return of isolation, the deterioration of country hospitals and the lack of medical expertise. Despite modern road transport and air travel facilities, political priorities continue to result in few improvements being made to these serious problems in the country. In the past, limitations to rural services were accepted as a fact of life. Every effort was made to compensate. Rural medical services must not now deteriorate because of political neglect.

Anthony H Hodgkinson MB BS, FRACS, FAOrthA

Objective: To review whether watching football increases the population cardiac event risk in New South Wales.Design: Analysis of hospital admissions for acute myocardial infarction, other cardiovascular disease, and other acute injuries at the time of two stressful sporting events in NSW in 2005: the Sydney Swans playing in the Australian Football League (AFL) Grand Final, and the Socceroos’ penalty shoot-out in their World Cup qualifying match against Uruguay.Results: There were no increases in any of the studied admission events at the time of, or in the days immediately following, these football matches.Conclusions: Australians appear to be resistant to acute stressors associated with watching sporting events, possibly due to higher rates of motivational deficiency disorder (MoDeD) than in European populations.

Adrian E Bauman PhD, FAFPHM · Hidde P van der Ploeg PhD · Tien Chey MAppStats · Gary Sholler FRACP

It was the mid 1950s in Newcastle, a time of world unrest from the expansion of communism, and balloted national conscription by birthday. To supplement the meagre income of a second-year resident (a princely sum of 12 pounds, 5 shillings for a 70–80 hour week), I would go and examine the “nashos” (national conscripts) for their induction into the army, when the work was available. It paid as much as two or three pounds for a couple of hours’ work. Towards the end of such a session, in a small break, I leaned back in the chair and stretched. In came a gangly, sinewed youth, ambling slowly forward. “Name?” I asked in a quiet voice. “Kev Browwwn.” Hearing’s OK — tick. “Good health?” “A’reckon.” A quick physical confirmed no flat feet, hernia or haemorrhoids. Grade A-1. Coming to the last item — “Stand on that line” I instructed, while filling in the form and pointing behind my back. “Read the lowest line you can see on the chart on that wall.” It’s 6/5, better than 6/6. A long pause — did the chart fall off? — no. I turned to have a closer look at the youth’s face — crystal clear eyes in deep sockets, slowly squeezing into a line, reminding me of Gary Cooper in his Oscar-winning role as sharpshooter Sergeant York. “Ahh — ’m gettin’ it . . .” Then in a great tumble: “W J Pettigrew, Government Printer.”

Henry Kan BSc, MB BS

Objective: To study drug prescribing by brand name versus generic name in an Australian teaching hospital.Results: Overall, 53% of drugs were prescribed by brand name. Brand names were preferred when they were shorter and easier to remember and spell, when there was only one brand on the market, and when the brand name ended in an x.Conclusion: Doctors might be encouraged to prescribe generically if generic names were devised using the same principles marketers use for devising brand names.

Jonathan Bromley MB ChB · Nicholas A Buckley MD, FRACP

To the Editor: “Out of the blue”, I received a personal message from a retired nursing sister of a children’s hospital, who had earlier written to the MJA1 describing “a cluster of neonates [who had] simultaneously turned blue” in the 1950s. Her letter to me followed one of mine in the Journal, describing methaemoglobinaemia (MetHgb) in infantile keto-acidosis, where the cyanosis responded rapidly to diabetic control alone.2 Rare as MetHgb is, it has previously been recognised as a presentation of infantile acidosis.3 The cause of the colour change in the neonate cluster “was traced to dye from the hospital’s brandmarks on a batch of new cotton nappies (which had been washed before being marked)”.1 The dye was understood to have been “absorbed into the infants’ circulation via their raw umbilical areas”. As it turns out, nappy dyes have been incriminated in MetHgb.4 The POISINDEX® System (Thomson Micromedex, Denver, Colo, USA) revealed that the aniline group is among the compounds capable of causing MetHgb through any portal of entry, even intact skin (Stephen Gibbins, Poisons Information Specialist, Victorian Poisons Information Centre, Melbourne, personal communication). Another textile ink, aminophenol, may also lead to the disorder.5 Other common causes of MetHgb are given in the Box. Causes of methaemoglobinaemia (MetHgb) MetHgb can be genetic, through faulty haemoglobins or cytochrome deficiency. On exposure to appropriate exogenous toxins, heterozygotes tend to be particularly susceptible, as are infants per se without any such trait.4 Nappy dyes have been incriminated.4 In the United Kingdom between 1961 and 1980, the most common industrial causes of acquired MetHgb were chloroaniline, p-toluidine, nitrobenzene, nitrochlorobenzene, nitrates and amines — frequently by dermal exposure. Nitrates, nitrites in food, local anaesthetics (particularly benzocaine), and other medicinal agents, such as chloroquine, dapsone, para-aminosalicylic acid and resorcinol, have also been implicated.5,6 Aniline dyes were discovered in the 19th century and found useful for inks and for dyeing leather, which they penetrate as they do living skin. They were also used in wood stains, textiles, and oriental rug-making. Because aniline dyes are not indelible and are toxic, they are being superseded by chrome dyes. The hospital linen room concerned1 reports that they now apply dry, colour-fast pigments using heat-pressed or stamped “transfers” (Administrative Officer, Metropolitan Linen Services, Brisbane, personal communication). It is not possible to confirm what the “Baby blues”1 dye was — aniline or other. Nor can we now establish whether the dusky colour of the babes was due to absorbed dye circulating passively. Circumstantially however, MetHgb would seem to have been a likely possibility.4 In differential diagnosis, when cyanotic infants or adults without cardiorespiratory signs are encountered, we should not forget MetHgb, drugs and chemical toxins. In patients with MetHgb, the blood will be “chocolate-brown”; and yes — do remember to take a sniff for that exhaled acetone.2

Ivan Cher

Quotes from MJA contributors in 2006 Journal style incorporates many elements — for example, defined formats for abstracts, specified subsections for different article types, the obligatory statistical results; and, at the “micro-level”, a particular use of punctuation and capitalisation, and of preferred words or phrases. However, journal style is but one aspect of writing style. In Strunk and White’s classic guide, The elements of style, White devotes a chapter to the broader aspects of writing style: “style in the sense of what is distinguished and distinguishing”. Here, warns the famous “little book”, we leave the solid ground of what is correct, or acceptable, in the use of English. A writer will find no satisfactory explanation, no infallible guide to good writing, and no inflexible rule by which to shape his or her course. “He [or she] will often find himself steering by stars that are disturbingly in motion.” After all, “Who can confidently say what ignites a certain combination of words, causing them to explode in the mind?” At the MJA, we are principally interested in the novelty and clinical relevance of our contributions, but we are also intimately concerned with all matters of style, firstly Journal style but then, more generally, writing style and the impact on readers. We would like to share with you the supernovas, some style-related, that passed through our ever-expanding galaxy this year. All creatures great and small“I’m well aware of the likely costs to me of publication of this letter, so on reflection I’ve decided that while I’m prepared to be hung for a sheep, it’s not worth it for a lamb (ie, a shorter letter). I would therefore like to withdraw my submission.” “This particular tome is a dog’s breakfast (think: pack of feral canines) of a production that doesn’t warrant publicising . . .” Cruising“The inertia of the socio-economic system means that, as for [an] ocean liner, we cannot expect to be able to turn it around more quickly in future than we can now.” Americana“The article will need to be ‘cleansed’ of some North American terms or concepts to make it more comprehensible to down-under readers. I don’t believe the Mafia control our waste disposal services here, unlike New Jersey, although they are welcome to them.” EntitlementsReviewer: “If this article is to be an update, the subjective comments and flowery language should be removed.” Author’s response: “The reviewer is entitled to [his/her] personal aesthetic but there is no requirement in general or specifically in the Journal’s Instructions to Authors for any scientific article to be written in dull and lifeless prose.” First impressionsWith the current information overload, an author needs to grab the readers’ attention during their first quick perusal of an article. Some inadvertently send the wrong signals, as one reviewer noted. “Ronald Reagan advised us (among other things) never to begin a speech with an apology. The present version of the manuscript is testament to the effect of not heeding Reagan’s advice. By excessively emphasising their non-support of several issues in the Introduction, the reader is left wondering whether the article is of any significance at all. By the time the reader reaches the Results, he or she would have been met with so many of the authors’ caveats about the study that I wouldn’t be surprised if readers were to put the article down without going any further.” Limitations unlimitedPeer reviewers encourage authors to acknowledge the limitations of their study, and occasionally, they point out that the authors have gone a little overboard in this duty. Rarely is this advice given in such a spectacular fashion as follows. “Think of this in terms of medical publishing’s answer to The Gong Show. It is traditional for us to hand authors a large stick and ask them to hit themselves repeatedly over the head — a process we affectionately term ‘describing the limitations of the study’ — at which point the editors bang the gong to put an end to the spectacle and assign the performance a score. Usually this bloody demonstration takes place AFTER the authors have performed their dance routine. “In the manuscript’s present form, the authors start hitting themselves just as they’re called on stage to perform. They inflict so much punishment on themselves that they become extremely dazed, resulting in a predictably lacklustre dance performance, after which they engage in more self-punishment. In fact, the present version of the manuscript is written in such a manner that the limitations tend to overshadow the findings — akin to the authors adding glass shards on the club head to inflict more pain. As scores are dependent on their performance of the dance, the authors don’t earn themselves extra points for the extra round of savage clubbing they receive.”

Ann T Gregory

1 Café-au-lait spots with “coast of Maine” appearance 2 Computed tomography scan of the thorax showing multiple rib lesions A 46-year-old man presented with generalised bone pain which had been present for approximately 15 years. His past history was significant for a precocious puberty, with full development of secondary sexual characteristics by 9 years of age. His adult height was 165 cm. Physical examination showed multiple café-au-lait spots with typical “coast of Maine” appearance (Figure 1). Routine laboratory tests gave normal results, except for levels of inorganic phosphate (0.71 mmol/L; reference range, 0.81–1.45 mmol/L) and alkaline phosphatase (286 U/L; reference range, 31–93 U/L). A chest x-ray showed multiple ill-defined radiolucent lesions in the ribs. A computed tomography scan of the thorax showed multiple expansile lytic rib lesions, with a peripheral rim of calcification consistent with polyostotic fibrous dysplasia (Figure 2). The coexistence of precocious puberty, café-au-lait spots and polyostotic fibrous dysplasia constitutes the McCune–Albright syndrome.1 The pathogenesis involves mutation in the Gsα gene located at chromosome 20q13.2-13.3. All cells carrying this mutation manifest dysplastic features. This case highlights the importance of history and physical examination in establishing a correct diagnosis, which in this case was missed for several years.

Mehdi Hamadani MD · Lubna Chaudhary MD

At the MJA we are constantly delighted, fascinated and amazed by the submissions we receive. Our Christmas contributions this year did not disappoint: the range of articles reflects the journey through medical life from the fresh-faced idealism of the medical student to the world-weary demeanour of the experienced physician. For some, the journey involves an attempt to transform the lives of others. Many new doctors set out enthusiastically with a desire to help people and change the world with their new-found knowledge. But as Cheng points out, in her eye-opening account of Medicine along the Mekong, sometimes the world just reaches out and changes us. Our journey as Australians often takes us to distant lands, like Dr Pat Hodgson who touched a Scottish village and a future doctor with her humour and vitality during World War II, (→ Sandeman). We are armchair travellers too — sports enthusiasts in danger of injury when watching football on the lounge with a beer or two (→ Bauman et al), but ultimately we give it a go, hoping it will be “orright mate”, even if it involves transporting a seriously ill neonate in an open aircraft, as Anthony Hodgkinson did in the 1950s (→ Hodgkinson). Living in a global society, the onslaught on our daily lives of the cult of celebrity and commercialism is represented by both Ernst and Pittler (Celebrity-based medicine), and psychiatry’s answer to Superman, Garry Walter (The Directors). As with all travellers’ tales there are stories that make us laugh — sometimes so hard that the cutlery is in danger (→ Beldholm and Lee) — and those that help us realise that sometimes there is little left to do but accept that we are powerless and finally let go, a theme touched on by both Leeder and Mohajeri. But ultimately a decision was made by our intrepid MJA staff and, although every submission received at least one mention, there were two that shone in the judges’ opinion. Bromley and Buckley’s x-tremely interesting research on the x-factor in prescribing of medications in hospital was a clear winner, along with Mohajeri’s moving poetic description of a patient’s final journey through the eyes of a medical student. These lucky winners will each receive a Christmas hamper with compliments of the MJA. We would like to thank all our fellow travellers who contributed to the competition this year, and ask that more of you join us on the journey next year. Do send us your ideas for next Christmas — we always want more presents to open!

Tanya Grassi