Volume 189 Issue 11

Bring on the debate, but let’s base it on evidence Not long ago, I received an email describing two different health care experiences: Two patients limp into two different medical clinics with the same complaint. Both have trouble walking and appear to require hip replacement. The first patient is examined within the hour, x-rayed the same day, and has a time booked for surgery the following week. The second sees his family doctor after waiting 3 weeks for an appointment, then waits 8 weeks to see a specialist, has an x-ray which isn’t reviewed for another week, and is finally scheduled for surgery a month later. Why the different treatment for the two patients? The first is a golden retriever. The second is a senior citizen. This tale of two treatments may seem to trivialise the gravity of a human experience, but it does serve to highlight the community’s prevailing unhappiness with our health service delivery: the untimeliness of access to doctors. As David Weatherall, Emeritus Regius Professor of Medicine at the University of Oxford, recently noted: . . . the work load of doctors today is such that good doctoring has become almost impossible, especially in an environment in which a medical supermarket mentality has been and continues to be generated by successive governments.1 In the face of medical workforce shortages, governments are looking to displace doctors with alternative health care providers like nurse practitioners (NPs), physician assistants (PAs), and other health professionals such as psychologists and pharmacists to relieve bottlenecks in health care delivery. Displacing doctors in this way, or “role or task substitution” as it is also termed, has been actively pursued in the United Kingdom and United States. In the UK, the number of NPs grew by 27% between 2004 and 2007 to over 47 000; NPs work in such diverse areas as general practice, emergency medicine, anaesthetics, surgery and endoscopy.2 In the US, there were about 69 500 PAs in 2007 and 140 000 NPs in 2004.3 Different strands of the US education sector are delivering courses to train these practitioners. There are university-based PA programs, and nursing schools now provide doctorates of nursing, in which candidates are purportedly trained in skills equivalent to those of primary care doctors, and practise using the title “doctor”.2,4,5 In light of these developments, an obvious question requiring clarification is: “What defines the role of these alternative practitioners?” One recent definition of NPs in an Australian context states: A nurse practitioner is a registered nurse educated to function autonomously and collaboratively in an advanced and extended clinical role. The nurse practitioner role includes assessment and management of clients using nursing knowledge and skills and may include, but is not limited to the direct referral of patients to other health-care professionals, prescribing medications and ordering diagnostic investigations. The nurse practitioner role is grounded in the nursing profession’s values, knowledge, theories and practices and provides innovative and flexible health care delivery that complements other health care providers. The scope of practice of the nurse practitioner is determined by the context in which the nurse practitioner is authorised to practise.6 The Canadian definition of an NP is almost identical.7 These definitions and the ascendency of NPs in the UK prompted the BMJ to run with a front cover (Box) questioning the difference between an NP and a doctor. PAs are starting to appear in Australia. Queensland Health is exploring the use of PAs through pilot programs in the areas of primary and emergency care at Mount Isa Hospital and at Cooktown Multipurpose Health Service, in cardiology at both Prince Charles and Princess Alexandra hospitals in Brisbane and at Specialist Connect, Brisbane for ear, nose and throat. In these pilot programs, two experienced US-trained PAs will be employed at each site to explore whether PA roles are valid in our health system in terms of productivity, quality of care, patient satisfaction, cost-effectiveness, PAs’ ability to work as part of a multidisciplinary team, and whether PAs provide a comfortable social and cultural fit within the Queensland health workforce. (Bronwyn Nardi, Senior Director of Workforce Planning and Coordination, Queensland Health, personal communication). A similar program is underway in South Australia, led by the state’s Health Department. The program is to pilot PAs in major metropolitan hospitals in Adelaide in paediatrics, anaesthetics and surgery.8 More recently, two US-trained PAs were seconded to the Department of Surgery at Queen Elizabeth Hospital in Adelaide to perform designated tasks (Guy Maddern, Jepson Professor of Surgery, University of Adelaide, Queen Elizabeth Hospital, personal communication). In addition to these initiatives, the University of Queensland (UQ) will inaugurate Masters and Diploma graduate programs in PA studies, and James Cook University will be starting an undergraduate program. All are scheduled to commence in 2009. The UQ program will provide broad generalised medical training with an emphasis on primary care, health maintenance and disease prevention, and medical, nursing and PA students will be taught together within the Faculty of Health Sciences to foster an ethos of team work (Peter Brooks, Executive Dean, Faculty of Health Sciences, UQ, personal communication). Nurses also have a defined path to follow to become NPs, including pursuit of a Masters degree, a designated period of clinical work and a final assessment by a multidisciplinary team of examiners (Ged Kearney, Federal Secretary, Australian Nursing Federation, personal communication). How should the medical profession react to these developments? Any discussions on doctor displacement will invariably raise the spectre of turf warfare.9,10 Be that as it may, there are questions that must be widely addressed and vigorously debated. It needs to be acknowledged upfront that the current medical workforce shortage is the outcome of successive past federal governments’ policies to cap the number of medical graduates. Doctor displacement is a solution to the resulting predicament, but no solution should sacrifice quality and safety. Becoming a doctor requires passage through an extremely competitive and rigorous selection process and indepth training in biomedical and clinical sciences to prepare for autonomous practice with its myriad clinical uncertainties. This is followed by a period of mandated, prevocational internship, followed by vocational training as prescribed by the clinical colleges. Doctors undergo 10–15 years of training to reach the stage of autonomous practice. Such rigorous training for doctors surely raises the question as to whether NP or PA programs will inevitably evolve into a truncated alternative route to working as a doctor, especially if their graduates were to be remunerated as independent, standalone clinicians. Importantly, will the advent of independent NPs and PAs effectively result in a two-tiered medical system in which some patients have access to lesser medical care than others? Most proponents of PAs and NPs stress the need for their obligatory involvement in teams focusing on multidisciplinary care, and this is commendable. But just how is this service delivery to be remunerated? Will remuneration be based on service provided by the team, or will individuals be remunerated for individual episodes of care? Who will decide what services can be provided by PAs and NPs and how they should be remunerated? Surely a bureaucratic and indemnity nightmare awaits! This approach will require the untangling of notions of parity — of cognitive and procedural services — and a political commitment to studies of the relative value of services provided by PAs and NPs and other members of multidisciplinary teams. Moreover, thorny problems such as these also touch on an overarching philosophical notion — that one of the primary roles of the doctor is to bring certainty to an undifferentiated illness, and to advise on and supervise an intervention or management plan.11 If this is a unique role for which medical graduates have been specifically trained, how is it to be brought to bear under the proposed new arrangements? Will doctors become mere service supervisors, or will their role continue to stress competence in diagnosis and treatment of individual patients? In any event, it is imperative that doctors are the team leaders. There is also an urgent need for consistent, reliable and agreed competency standards, as well as registered trade titles for PAs and NPs, regulated and supervised by multidisciplinary bodies and transferable between various jurisdictions. Interestingly, the evidence underpinning the effectiveness and cost-effectiveness of doctor displacement schemes and protocols is not particularly rigorous.2,3 Furthermore, there are intrinsic cultural considerations in health care delivery. Any programs of doctor displacement in Australia need to be underpinned by contemporaneous research to provide answers as to their relative efficiency and effectiveness, as well as patient safety and satisfaction. It would be unethical and unconscionable to introduce and sustain programs of doctor displacement without evidence from local research. Finally, the debate on whether we proceed with specific doctor-displacement programs will need to be cognisant of recent medical workforce developments. An impending “tsunami” of medical graduates from the recent expansion of our medical schools will soon flood our health care systems.12 Their education and role in health care delivery should not be compromised by developments in doctor displacement. The Australian Government response of using doctor displacement to alleviate workforce shortages must also take into account current acute and future projected nursing shortages.13,14 Thus, it is absolutely imperative that this entire debate be based on community requirements, rather than on the pursuit of vested interests or ideology-driven political agendas. So, bring on a wide-ranging debate about doctor displacement, but let us ensure that this is an evidence-laden debate — a debate that avoids the trenches of turf warfare. In this debate we need creative leadership from doctors.

Martin B Van Der Weyden MD, FRACP, FRCPA

Advocating for change at the 2008 AMSA National Convention and Global Health Conference The Australian Medical Students’ Association (AMSA) is the peak representative body for over 13 000 Australian medical students. In the course of its many and varied operations, the organisation hosts two major events each year — the AMSA National Convention (NC) and the AMSA Global Health Conference (GHC). The 2008 AMSA GHC and NC were held in Melbourne from 4–6 July (Box 1) and 6–13 July, respectively. These events were attended by around 1200 students, representing all 19 Australian medical schools. The GHC highlighted themes of health, conflict and the political process; culture, environment and society as catalysts for addressing health; international health policy and development; and Indigenous health and the human rights of marginalised populations. The GHC received generous support from AusAID and the Myer Foundation. With their help, AMSA was able to bring 25 students from the Asia–Pacific region (Box 2) to the conference to foster an exchange of skills, ideas and experience. With the theme of “desire, enquire, inspire,” the NC challenged delegates with provocative keynote sessions including: “HIV/AIDS: simply speaking”; “The euthanasia debate”; “Sports medicine: perspectives from both sides of the white line”; “The future of medical education”; and finally, “Mental illness and student wellbeing”. Every year, delegates to both events are challenged to become informed and active participants in building a sustainable, resilient health workforce for the future. Hence, the paramount issues at the NC and GHC in 2008 were training the future workforce, ensuring the mental and physical wellbeing of medical students and practitioners, and improving medical curricula with more education in Indigenous and global health. Training the future workforceSecuring the quality of Australian medical education in the face of increased student numbers is an ongoing challenge. The “Future of medical education” session provided an open forum to explore the nature of and solutions to this challenge. Dr Mukesh Haikerwal (general practitioner and former federal President of the Australian Medical Association [AMA]) described events that led to restrictions in growth of the medical workforce. These restrictions have meant that our health system now struggles to meet the needs of the community. He talked about the response to this shortfall — a rapid increase in the number of medical graduates, from about 1200 in 2002 to more than 3000 in 2012. These increases are purported to be a solution to Australia’s doctor shortage. However, as Dr Haikerwal pointed out, simply increasing the number of medical graduates delivered to hospitals is not enough to ensure the ongoing quality of the Australian medical workforce, nor will it solve the problem of doctor shortages in rural areas. Professor Steven Wesselingh (Dean, Faculty of Medicine, Nursing and Health Sciences, Monash University) went further by describing how both physical and human resources are strained under the requirement to maintain the quality of medical education that Australia is renowned for, while accommodating the influx of medical students. At this point, the panelists agreed that meeting the challenge of training these students was not an insurmountable task, but would require a great deal of innovation. Professor Wesselingh went on to talk about the Extended Rural Cohort (ERC) initiative at Monash University that allows students to apply directly to a medical course where they undertake the majority of their training in a rural setting. The benefits of ERC are twofold — the ERC makes use of a new training setting, and may see the students who train in this setting eventually return to practise medicine in a rural area, with a positive effect for the rural workforce. Professor James Angus (Dean, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne) focused on versatile education delivery methods, and the use of effective administration methods to ensure efficient use of resources. Mr Michael Bonning (AMSA President) discussed “Teaching on the run”, empowering today’s clinicians to be better teachers, and to optimise the quality of teaching delivered during time spent with medical students. Dr Alex Markwell (Chair, AMA Council of Doctors in Training) then spoke about medical schools adjusting to accommodate trainees, pointing out that the issue will move further along the continuum of medical education to impact on vocational training. Dr Markwell spoke about increased competition for specialist training places and the need for the government and colleges to address this issue now. A need for innovation in training the future medical workforce was apparent. Taking the training from its traditional setting and expanding the use of rural settings can buy some time. However, in the long term, it falls to programs like More Learning for Interns in Emergency, to foreshadow a significant paradigm shift in medical education. This will ensure a sustainable, quality education for medical students and junior doctors. Medical student wellbeingThe Honourable Jeff Kennett (Chair, beyondblue, the national depression initiative) highlighted the sixfold higher rate of suicide among medical practitioners compared with the community in general.1 He emphasised that the problem must be tackled early among students and doctors. The idea that doctors cannot be patients themselves is archaic, and AMSA urges medical students to visit a GP regularly to ensure their mental and physical health.2 The issue of bullying in the workplace is intimately linked to that of student wellbeing. A paucity of research exists to describe the extent of this problem in Australia. A report from Colorado Medical School found that 46.4% of students had been bullied at some time in medical school.3 Bullying behaviour breeds a culture of fear among medical students and trainees, many of whom are afraid to speak up for fear of career reprisal. Dr Sally Cockburn (GP and media personality, Melbourne) urged convention delegates to put an end to the cycle of a bullied student becoming a bullying doctor by speaking up about an issue that, until now, has largely been ignored. AMSA will release the results of the student wellbeing survey early in 2009. The results will describe the extent of this problem among medical students and guide interventions to put an end to bullying in the workplace. Optimising medical school curriculaIn the past decade, Australian medical curricula have undergone significant changes. This is a direct consequence of an increase in the number of medical students, the advent of graduate medical courses, resource shortages and an explosion of knowledge in new scientific fields. AMSA advocates for changes and inclusions to medical curricula, particularly in the areas of Indigenous and global health. Mr Tom Calma (Aboriginal and Torres Strait Islander Social Justice Commissioner, Australian Human Rights Commission) and Ms Pat Anderson (Indigenous Health Advocate, coauthor of the Little children are sacred report) gave an in-depth account of the future of Indigenous health in light of the Northern Territory Intervention and the national apology. Aboriginal and Torres Strait Islanders have a life expectancy 17 years shorter than other Australians. Delegates, as future doctors with an instrumental role in implementing public health policy, and as individual practitioners, were encouraged to gain an intimate understanding of the challenges facing Indigenous Australians. To this end, AMSA has advocated establishing in medical curricula nationwide core subjects in Indigenous health, covering aboriginal history, culture and kinship,4 as well as working towards initiatives that will see more Indigenous students enter medicine. Today’s medical students have an increasing appreciation for the globalised environment in which they live and will one day work. As the practitioners and policymakers of the future, students must be equipped with the skills to face the challenges of developing world health. Delegates at the GHC reflected on this requirement and, in response, AMSA has advocated for the inclusion of global health education in medical curricula. AMSA has also advocated for the Australian Government’s ongoing commitment to the Millennium Development Goals,5 as fulfilling these goals will go a long way towards improving the health of our future patient populations. The variety of issues covered at the 2008 AMSA NC and GHC reflects the diversity of the student population AMSA represents. However, delegates and medical students around Australia were united by a common mandate — to advocate for change. The 2008 GHC and NC enabled delegates, presenters and guests to work together to determine what that change should be, and to build networks that will enable us to meet these challenges in the future. 1 The 2008 Australian Medical Students’ Association Global Health Conference was officially opened by Vice-Chancellors Professor Glyn Davis AC (University of Melbourne, right) and Professor Richard Larkins AO (Monash University, left). Aunty Joy Murphy-Wandin (far right), delivered the traditional “welcome to country” address, which was followed by the opening keynote lecture presented by Sir Gustav Nossal AC (centre). 2 Three Fijian students, members of the Asia–Pacific delegation, perform a traditional islander dance at the 2008 Australian Medical Students’ Association Global Health Conference.

Carly M Fox BSc · Michael A Bonning BAppSci(Hons)

Objective: To determine what aspects of communicating and consulting with cancer patients are viewed as difficult and stressful by cancer specialists in Australia.Design, participants and setting: Anonymous, cross-sectional, Internet-based survey completed by 134 cancer specialists between June and August 2007. Participants, who were all members of the Clinical Oncological Society of Australia, included oncologists and palliative care specialists.Main outcome measures: Degree of difficulty perceived for various consultation tasks; level of stress reported during various practice-related situations.Results: Doctors had the most difficulty discussing high-cost drugs with patients they knew could not afford them, followed by topics relating to treatment failure. They had the least difficulty telling patients they had cancer or being honest about prognosis. The most stressful practice situations included having incomplete patient information to conduct the consultation and having a long line of patients waiting for a consultation. At least 62% of respondents reported experiencing some degree of stress in all the practice situations presented. There were differences in difficulty and stress experienced as a function of the doctor’s sex, age and clinical experience.Conclusions: Targeted, evidence-based guidelines and communication courses are required to better equip cancer specialists for providing non-directive advice about unsubsidised high-cost drugs and for offering different forms of hope in the context of treatment failure. Implementing small organisational changes — such as reducing interruptions during consultations and informing patients of the duration of their allocated consultation — may also help reduce stressful practice situations.

Aneta Dimoska BPsych(Hons), PhD · Afaf Girgis BSc(Hons), PhD · Vibeke Hansen BA(Hons) · Phyllis N Butow MClinPsych, MPH, PhD · Martin H N Tattersall MD, MSc, FRCP

In many settings, public reporting of health care outcomes still reflects the “name–shame–blame” culture that has permeated large areas of the health care sector for decades. A new approach to public reporting in Queensland, based on statistical process control, emphasises the dynamic nature of performance against specified outcome measures by focusing on the actions that hospitals are taking if their indicators vary from the average. The aim is for public reporting to contribute to, rather than detract from, the creation of an internal culture that emphasises rigorous investigation and improvement rather than merely assigning blame for problems.

Stephen J Duckett PhD, DSc, FASSA · Justin Collins GradCertHlthMgt · Maarten Kamp MHA, FRACP · Kew Walker BA(Hons)

Objective: To determine the core qualities that men value when communicating with general practitioners in primary care settings.Design, setting and participants: In a qualitative study using semi-structured interviews in non-clinical environments, 36 white Australian men drawn from the Florey Adelaide Male Ageing Study, stratified by age and marital status, discussed their help-seeking behaviour and health service use. Participants were from the North West Adelaide region. Interviews were conducted between January and November 2005.Results: The core qualities men value when communicating with GPs in primary care settings include the adoption of a “frank approach”, demonstrable competence, thoughtful use of humour, empathy, and prompt resolution of health issues.Conclusions: The core qualities men value when communicating with GPs are concordant with most key dimensions of a patient-centred approach, but not necessarily all. Adopting these qualities has the potential to enhance communication with and care of men in primary care settings.

James A Smith BAppSc(HumMovt)(Hons), BEd · Annette J Braunack-Mayer PhD · Gary A Wittert MB BCh, MD, FRACP · Megan J Warin PhD

To the Editor: Attending, as a “junior” outpatient rather than a Senior Physician, the hospital where I once worked has been a quantum change that has been both fascinating and instructive. There is a strict hierarchy among us out-patients. Having only my second intraocular injection makes me junior to the stout, slightly dyspnoeic man opposite, who is having his sixth. His status is increased by his wife’s attendance at the Cardiology Clinic. The elderly married couple nearby gain much prestige by having to leave their farm at 6:00 am and drive more than 150 km to the hospital. The rising cost of petrol is a worry, but while here they will take the opportunity to visit their married daughter who lives in the city near the hospital. Pride of place goes to the man who proved the doctors wrong — “They said I’d die two years ago and look at me now!” The staff do not escape scrutiny. Dr A is good but doesn’t talk much. Dr B is a lovely lady and her new hairdo is a big improvement, although the green dress is not quite right for her. Dr C is elderly and worried about his wife’s illness. Dr D is extremely good but is always running late. It’s best to get him, even if you have to wait. The appointment clerk on the left is more willing than the other clerk to give you the time and date you prefer for your next appointment. It is a new insight into the social dynamics of the hospital, even if it comes some years after I have retired from active duty. But clearly, all hospital administrators would gain much by spending six months as an anonymous outpatient.

Richard A Joske

In Victoria, almost one in six registered medical practitioners were over 60 years old in September 2006. Knowing when to give up practice is an important decision for most doctors and a critically difficult decision for some. Normal ageing is associated with some cognitive decline, although brighter, better educated individuals may be less at risk. Mild cognitive impairment (MCI) is associated with higher rates of Alzheimer’s dementia. Medical practitioners with early dementia or MCI often lack the insight to accept that they are no longer able to practise safely. Doctors can accommodate cognitive decline by choosing to cease procedural work, allocating more time to each patient, using memory aids, seeking advice from trusted colleagues, and seeking second opinions. Medical Boards are responsible for protecting the public from unsafe medical practice. There are no agreed guidelines to help Medical Boards decide what level of cognitive impairment in a doctor may put the public at risk.

Robert G Adler PhD, FRACP, FRANZCP · Conn Constantinou MB BS

There is strong agreement in the medical profession and among academic commentators about why professionalism has become an important focus of medical regulation and education, and about the need to respond to serious instances of unprofessional behaviour among doctors and medical students. Admission processes which include interviews do not prevent the entry of a small number of students who behave extremely poorly. Fair, reliable assessment of students’ attitudes and behaviour is achievable, but the challenge of preventing the progress of students who behave poorly through academic assessment remains. A nationally consistent approach to the management of poorly behaved students within the academic program is vital in the interests of equity across programs and protection of the public.

Malcolm H Parker MB BS, MLitt, MHealth · David Wilkinson MB ChB, FRACGP, DSc

To the Editor: This letter of lament was prompted by a recently overheard complaint by a first-year intern to her colleagues that radiologists were not “obeying” her! Her comment led us to review her last five imaging requests (“orders”). After discussion with other radiologists, three of these requests were considered inappropriate. Major reasons for inappropriate imaging investigations are lack of knowledge, fear of litigation, inadequate supervision, patient expectations, and being unaware of or uninformed about risks of ionising radiation. Inappropriate use of diagnostic computed tomography is especially worrisome. The trend towards requesting inappropriate imaging continues despite the many articles on this subject in the medical literature.1,2 Many publications have promoted judicious use of imaging sources.3 It is regrettable that clinicians do not make use of radiological expertise when faced with a diagnostic/imaging dilemma. This is especially so in hospitals when radiologists are available 24 hours a day every day of the year! In private practice and general practice, radiologists are only a telephone call away! The issues of communications with radiologists and matters of courtesy have previously been aired in this journal.4 The diagnostic imaging pathways developed at Royal Perth Hospital (by Professor R M Mendelson) in conjunction with the Western Australian Health Department are available freely on the Internet.5 Monitoring of this site indicates that the free access has been taken up by many clinicians overseas but it remains underused by Australian doctors. The perceived difficulties in communication and access to advice or information can be corrected by use of the telephone, email and Internet. After all, the goal for all of us is to provide the best care for our patients. It seems to us that the word “order”, which has replaced “request”, for imaging may be responsible for the change in attitude of the referring doctors! We urge all clinicians and medical journals to reintroduce the word “request” when communicating with imaging departments and radiologists.

Turab Chakera · Makhan S Khangure

Friendly bosses, fair working conditions and positive specialty training prospects down under It is said that there is many a true word spoken in jest, and I’m beginning to understand why. In the United Kingdom, it is joked that once a doctor has worked in Australia, there is no turning back. The reasons may seem obvious — the famous relaxed Australian attitudes, escaping the stresses of the National Health Service (NHS), a temperate climate . . . but those are only the tip of the iceberg. I am now 10 months into my Australian adventure, and it is time to take stock of the differences between the two systems of medicine. Why is practising down under so attractive to us Poms? Back in August 2007, I was concluding my first year as a newly qualified doctor at a highly esteemed teaching hospital in Leeds in Yorkshire. Twelve months earlier, as a less sleep-deprived medical student, I had spent 2 months in Sydney on my medical elective at a central teaching hospital. The experience left a lasting impression, and as I stared blearily out of the window into the Yorkshire drizzle, I realised I was fated to return. Australia was to be my foreign sabbatical — a new medical experience separating my “foundation training” (intern and resident years). So here I am with my “year” rapidly running out, only to have applied for and successfully secured a further resident year at the same Sydney hospital. This will be accredited in the UK as the completion of my foundation training, which leaves me with a difficult decision. By January 2009, should I stay or should I go? The bread and butter of my resident job in Australia doesn’t differ much from what it would be in the UK. However, the terms and conditions are considerably different; paid overtime — an alien concept in the NHS that I find encourages better care and fosters goodwill within the workforce. This brings me to the effective use of time. I cannot begin to calculate how many hours in the UK are dedicated to the art (or is it skill?) of sexing up ultrasound requests or begging for computed tomography scans from radiologists who are desperately busy and whose services are overstretched. The system in Australia is more organised, with more staff and better access to resources. This cuts out the telephone histrionics and means that, in some hospitals, imaging can be performed and reported on the same day. Hierarchy comes into the equation as well. Consultants in the UK still resemble those in “Doctor in the House”, dressed in dark suits and followed by a quaking entourage of house officer, senior house officer and registrar. In Australia, the style is less formal but no less effective. I am on first-name terms with my boss, and am encouraged to seek advice, day or night. This is a refreshing change from the strict, intimidating chain of command back home. I cannot neglect to mention the impact on the morale of British junior doctors of the newly devised Modernising Medical Careers (MMC) scheme, and the fallout it has generated. MMC was heralded as the educationally sound way of training junior doctors and enabling them to secure training posts that would lead to consultancies. Major flaws in the Medical Training Application Service (MTAS — the area of MMC dedicated to the national appointment of junior doctors to specialised training) were uncovered last year. Criticism has focused on the system’s online technical problems, the marking and weighting of applications and the lack of training posts. Fear of unemployment is high, with government figures citing 32 000 applicants for 23 000 posts.1 The British media have been uncharacteristically sympathetic to the plight of doctors applying to the MTAS, playing on the public fear of hospitals devoid of doctors who have all emigrated to Australia as a result of a “shambolic” recruitment process. “Remedy”, an opposition group set up by doctors, reflected this fear by renaming MTAS “Moving To Australia Soon”. By May 2007, the MTAS was unceremoniously shelved after protests from the medical community, which provoked an independent inquiry. These are still unsettling times for junior doctors. It appears Australia prides itself on an open and systematic process for appointing junior doctors to training programs.2 However, there is a growing shortage of training positions as the numbers of Australian and foreign graduates increase. A similar situation may be faced in this country if the medical community does not learn from the UK’s mistakes. Australia must be wary of the blurring of political and professional agendas when it comes to allowing the government to instrumentalise the process by which junior doctors are trained. In February 2008, the British Home Office ended its tradition of allowing doctors from Australia and other Commonwealth countries to benefit from training in the NHS.3 This medical “iron curtain” has been drawn in response to the bottleneck of home-grown and foreign graduates competing for limited positions. I hope Australia won’t make the decision to follow Britain into the realms of curtailing training opportunities for foreign graduates. It breeds disillusionment and cuts short invaluable experience gained only by immersing oneself in a different medical system. Who knows what the future holds for me? At the moment I am more than happy working in Australia, with friendly bosses, fair working conditions and positive specialty training prospects.

Sarah C Armstrong MB ChB

Objective: To characterise the nature and impact of World Youth Day (WYD) 2008 on emergency department (ED) presentations at key hospitals.Design, setting and participants: Retrospective analysis of WYD pilgrims presenting to the EDs of St Vincent’s Hospital and Sydney Hospital, 9–23 July 2008.Main outcome measures: Frequency of pilgrim ED presentations; presenting complaint, Australasian Triage Scale category, diagnosis, admission to hospital and demographic characteristics.Results: 191 pilgrims presented at the two EDs during the study period, comprising 7.8% of all visits to these EDs. Pilgrims had a median age of 22 years, and most were international visitors. The female-to-male ratio was 1.7 : 1. The most common diagnoses were lower limb strain or sprain, infections, and acute asthma. Pilgrims presented with less severe illnesses (with lower triage scores), and were less likely to be admitted to hospital than other patients.Conclusions: The pilgrim caseload was small, and these presentations were less acute and less likely to result in admission than non-pilgrim presentations. Thus, the overall impact on the hospitals was very small.

Myles W H Smith · Gordian W O Fulde MB BS, FRACS, FACEM · Patricia M Hendry

Mass gatherings, such as World Youth Day (WYD) 2008 in Sydney, provide an opportunity for public health workers to gain emergency management experience. Communicable disease (mainly influenza) among pilgrims was the major public health issue during WYD. Public health workers also identified environmental health issues, resulting in hazard reduction measures being made to reduce falls. Other public health issues highlighted include training, communication, surge capacity, and health education. Lessons learned from planning WYD mass accommodation could be applied to emergency accommodation in the case of evacuation.

Jan Fizzell MB BS, MPH, FAFPHM · Paul K Armstrong MB BS, FRACP, MAppEpi

The current crisis in health and health care in South Africa results from a combination of factors: the legacy of apartheid; issues of poverty, income inequality and AIDS; and the more recent influence of neoliberal economic policies and globalisation. The legacy of apartheid has meant that both health and health care are skewed along racial lines, and 60% of health care expenditure goes largely to the 14% of the population who have private health insurance. A more equitable distribution of health care resources will result from the promised National Health Insurance, the details of which are still being debated. The AIDS epidemic in South Africa was exacerbated by the government not introducing antiretroviral treatment (ART) until the early 2000s. In 2005, it was estimated that more than 5.5 million South Africans were infected with HIV. Now all those with a CD4 count below 200 are eligible for ART. A better health service will not be enough to improve the health of South Africans. A whole-of-government approach is needed to address the persistent problems of poverty and inequality.

Gavin H Mooney MA · Diane E McIntyre BCom, MA, PhD

Recent publications have highlighted the impact of human rights violations, poverty and extraction of natural resources on the health status of the indigenous people of West Papua. However, the Australian medical literature has so far remained silent on this issue. Long-standing allegations of violence being perpetrated against Papuan civil society are supported by accounts given by West Papuan refugees involved in an Australian-based study. Health data collected by Médecins du Monde and other sources provide an insight into the poor health and lack of health care in the province, with high rates of infant mortality and morbidity, maternal mortality, and HIV/AIDS. Extraction of natural resources is causing major disruptions to the traditional livelihoods of indigenous Papuans, as a result of environmental degradation, mass displacement and an influx of migrant workers. Australian health professionals are urged to assist in remediating this dire situation, in keeping with our tradition of contributing to the health care of societies in our region.

Susan J Rees PhD · Remco van de Pas MD · Derrick Silove MB ChB, MD, FRANZCP · Moses Kareth

You can learn a lot about Australian medicine by living in New York, where I am currently on sabbatical at Columbia University Medical Center. The health care system in the United States is as exciting as it is complicated, as caring as it is apparently heartless, much better than Australians think and yet, in many ways, much worse. New drugs and new treatments appear here faster than in Australia. Medical research is a vibrant part of medicine here. Actually getting access to health care is the problem in the US. By the time you read this, Obama will have won the election. Everyone in New York knows this, but no one officially predicts it yet. In the West Village of Lower Manhattan, where I live, no one votes Republican and you can’t buy a McCain badge except one that is abusive. A rapid way to see the strengths and weaknesses of the US health care system is to analyse the policies of the candidates and the public responses to them. Mostly the promises are meaningless generalisations, pretty much like those of Australian politicians, only more showy. The candidates plan to invest in prevention, chronic disease management, better information technology and avoiding waste. Somehow they seem to know how to do this better than those running the system now. Their specific policies focus on insurance and payment arrangements. Most interested Australians probably know that there is no universal insurance in the US. Insurance here is a mixture of employment-based, personally organised and government-based insurance. There is a bewildering assortment of policies. If you are lucky enough to have a good job in a large, stable organisation (such as a university, hospital or large but still solvent corporation) you will get your insurance that way. It’s expensive, but in general covers everything you need for you and your family. It covers drugs, even expensive ones, including those that are not yet available in Australia, or are available but not under the Pharmaceutical Benefits Scheme. As it is part of a group policy, it often covers family members with chronic diseases, such as diabetes. This benefit won’t seem like much to Australian readers, but what you may not know is that health insurance is not community-rated here, as it is in Australia. Medicare (Australia) covers everyone for doctors’ visits, with a variety of additional costs depending on what your doctor charges. When Australians take out private health insurance cover, the insurance companies charge the same premium for everyone (apart from exceptions brought about by recent changes relating to the duration of insurance). They are obliged to insure you, even if you or a family member has a pre-existing illness. There may be a waiting period, but you can get insurance. By contrast, in the US, you may not be able to get insurance at all, or, if you can, it will be much more expensive. Senator McCain’s plan was to fix this with tax benefits. Here in the US, health cover obtained via your employer is not taxed (unlike private health insurance in Australia) and is considered pre-tax income. This effectively amounts to a government subsidy. McCain plans to make the money that is spent on health insurance taxable, but to compensate for this by giving everyone a $2500 tax credit. He claims that this will increase coverage and competition. He also promises to free up rules, allowing people to get insurance interstate. But those who don’t pay much tax or can’t afford insurance will get little or no benefit. Senator Obama, in contrast, will make insurance more available. Not, I should say, universal government-funded insurance. That concept is considered “liberal” (a very negative description in politics here) or even “socialist” (fatal for a candidate here). All negative responses to proposals for government-funded health care here are framed in terms such as loss of control to the government, long waiting lists and lack of choice of doctor, as if those are not major issues in the US already. Obama will not be supporting universal government insurance. He is planning a hotch-potch of increased employer-based insurance and various tax incentives or additional taxes. He would prohibit insurance companies from denying insurance on the basis of health or age (but it is not clear how he would stop insurance companies charging more for certain categories of patient). He would make insurance for children compulsory, although he doesn’t explain how the poor, or even middle class, would pay for it in the future if they can’t afford it now. He would extend the insurance available to federal employees to the general public and would subsidise premiums for low-income earners, as well as expanding Medicare and Medicaid for the elderly and the poor. This would be funded by tax increases, which the Republicans criticise as “spreading the wealth around” and “too much government interference”. Neither of these plans will be anywhere near as good as Australia’s Medicare. Australians may grumble about Medicare and our private insurance system, but its strength is that it covers everyone. This is a feature of a civilised society. The US spends over 16% of its gross domestic product on health care (predicted to rise to 20% by 2015), compared with Australia’s 10%. Despite this, over 46 million Americans are not covered by insurance or government programs and therefore have inadequate or no access to health care. How can this be? Americans want, and like to think, they have the best of everything, including health care. And in some ways they do. But they believe it is your individual responsibility to pay for it. In Australia, we take the opposite view — that it’s the government’s responsibility. There are strengths and weaknesses in both of these approaches. I am generalising, and realise that not everyone in either country thinks along these lines. However, using these generalisations, there is much we can learn from each other. Substantial government involvement in supplying universal health care is required, but so is a significant degree of individual responsibility. Both countries still have a way to go.

Jeffrey D Zajac MB BS, FRACP, PhD

Like most children, I had heroes, and the heroes I chose have in certain ways shaped my life. The first was fighter pilot Douglas Bader, who lost both legs in an aircraft crash but talked his way back into the Royal Air Force and became one of its most decorated pilots in World War II. I knew his life story by heart because, as a small child, I had polio and spent much of my childhood unable to walk, so I read instead. My second hero was cricketer Don Bradman. Being flat on my back in splints over a period of years, I spent a lot of time listening to the wireless and grew very fond of cricket. Bradman retired very shortly after I was born, so I never saw him play. What was important to me was that not only was Bradman the best, he was Australian. My other great hero just happened to be a woman, the scientist Marie Curie. But she was a hero not because she was a woman, wife and mother, but rather, because she triumphed over poverty and adversity to become one of the world’s greatest scientists. So, from quite early on, I was fiercely Australian, fascinated by the notion of research, determined that handicap was a challenge rather than an impediment, and very familiar with the inside of hospitals. And so I studied medicine at the University of Melbourne (Box 1). HospitalsMy residency at the Royal Melbourne Hospital (RMH) shaped the rest of my career. I worked at the RMH with some outstanding physicians, including Jock Frew, Ken Fairley, Tom Hurley and Margaret Henderson. But the most important influence was a term spent in the Clinical Research Unit affiliated with the Walter and Eliza Hall Institute of Medical Research and headed by Ian Mackay, who encouraged me to think about research. At this time (1968–1971), the RMH Residency (the living quarters for resident medical officers) was a lot of fun and the work ethic and sense of responsibility for patients extraordinarily strong. If you had a problem, you simply rang the Residency and a resident would come and help, whether he or she was on duty or not. None of us ever had enough sleep. Life outside work and study presumably went on (I do remember watching the landing on the moon), but those junior years were when I most enjoyed medicine. My membership exam for the Royal Australasian College of Physicians (RACP) was held in Adelaide. At the party afterwards, Jim Lawrence suggested that, as I was thinking of becoming a nephrologist, I spend a year at the Queen Elizabeth Hospital (QEH), where he was Head of the Renal Unit (Box 2). At the time, the QEH had the only renal unit in Adelaide, and we looked after all nephrology patients in South Australia and the Northern Territory, as well as Broken Hill in New South Wales. I have a vivid memory of a young man with post-obstructive polyuria who passed 50 L of urine daily (thought to be a world record!) and our efforts to keep him hydrated and in electrolyte balance. He made the sleepless nights worthwhile. Thanks to an RACP scholarship, I then spent a year in France at Hôpital Tenon from 1973 to 1974 (Box 3) working with Liliane Morel-Maroger, a renal immunopathologist. While there, I became enamoured of French language and culture, particularly cinema and opera — Placido Domingo was the tenor-in-residence at the Paris Opera that year. My stay in Paris was followed by a year in London at Guy’s Hospital (Box 4) with Stewart Cameron, again working in immunopathology. I took full advantage of the theatre, ballet and opera, Glyndebourne, the Chelsea Flower Show and the tennis at Wimbledon, and came back to Australia with great reluctance. By then, in the mid 70s, feeling I was well trained in renal medicine but less so in medical science, I decided to pursue a doctorate at the Howard Florey Institute (directly opposite the RMH), opting to work on blood pressure — particularly on mechanisms of adrenocorticotropic hormone (ACTH) hypertension in sheep. My PhD supervisor John Coghlan was a splendid mentor who encouraged me to become involved with the Australian Society for Medical Research. Eventually I became the Society’s first woman president. It was the beginning of a lifelong interest in research policy. A couple of years later, I was back at the RMH as an outpatient physician (with Ken Fairley) and nephrologist (with Priscilla Kincaid-Smith).1 The unit Priscilla had built from scratch was rightly regarded as a leading international centre, with a huge and very varied clinical load. I continued to do research at the Florey, while at the same time developing a rat model of ACTH hypertension at the hospital and, more importantly, beginning work on glucocorticoid hypertension in humans. Over the years, we were able to disprove the perceived wisdom that glucocorticoids raise blood pressure through salt and water retention and to show that the mechanism actually relates to nitric oxide deficiency and excess reactive oxygen species. This had major implications for the design of synthetic glucocorticoids for clinical practice. Further, we assembled evidence implicating glucocorticoid abnormalities in some forms of essential and renal hypertension, suggesting a broader role for steroids in raising blood pressure. This work was recognised by the Smith Kline & French Award of the International Society of Hypertension in 1984. I rarely found my gender to be a problem in medicine. My peers judged people on whether they were good doctors rather than other criteria, and I was lucky in that my own professional colleagues tended to be generous about giving women a go. One example stands out. When I was pregnant with my daughter Emma (now making movies in Hollywood), the Medical Officers Award did not contain any provision for maternity leave and so all I had was a couple of weeks of annual leave. This was balanced by the fact that my male colleagues at the RMH Renal Unit were all very supportive, both during and after my pregnancy. When I returned as a new mother, they took turns, over a period of 6 months or more, to do all my night and weekend work. One highlight of these years was a short sabbatical at the Medical Research Council Blood Pressure Unit at the Western Infirmary in Glasgow. It was a highly productive few months that set up a number of lifelong friendships and collaborations. I did physiological studies on glucocorticoid effects in normal subjects (or more correctly, staff of the Unit). This involved putting in cannulae and starting infusions around midnight. I used to rug up against the Glasgow sleet and snow and follow the blood stains into Casualty, the rest of the place presumably being closed for security reasons. After putting in the drips, I would doze for a few hours on a trolley until the experiment proper began, around 4:00 am. The Scots were enormously hospitable and I managed to road-test a variety of single malts. The only downside was the rugby. Watching Scotland v Ireland in January at Murrayfield, with all the excitement of kicking for touch in the mud, made me wish I was back in sunny Australia watching Mark Ella. My view of the dismal game was shared by my host, who kept standing up and yelling futilely at both sides to “run the ball”. University of New South WalesIn 1991, I joined the University of NSW (UNSW) as Professor of Medicine at St George Hospital in Sydney. It turned out that I was the first woman to be appointed Head of a department of medicine in Australia. I started out thinking that the main task was to recruit good people, and finished by thinking it was almost the only task — if you get that right, other things follow. These were very enjoyable years in which we worked to promote a research culture in the hospital. One particular highlight was the establishment of a successful renal transplant program. At this time, again with strong support from my male colleagues at UNSW and St George Hospital, I became the first woman to chair the Medical Research Committee of the National Health and Medical Research Council (NHMRC). I enjoyed enormously the chance to help shape the nature and extent of the national research agenda and my first glimpses of how policies were formulated in practice. Funding for research was increased and the biomedical and public health efforts were reintegrated. We instituted a variety of changes to better match research funding schemes to the overall national research strategy. A particular highlight was the development of partnerships with other funding bodies, notably Juvenile Diabetes International and the Wellcome Trust. Australians gained about 20 years’ life expectancy in the course of the 20th century, and about half of that is estimated to be a consequence of research.2 Research is absolutely fundamental to health care and, in an ideal world, would be fundamental to health policy. Department of HealthWhile chairing the Medical Research Committee of the NHMRC (1994–1997), I spent a considerable amount of time in Canberra, and when I stepped down from that position I was approached about another role, as Commonwealth Chief Medical Officer (CMO). I became the first woman to be CMO. In the event, I very much enjoyed the job and enjoyed living in Canberra. The Australian Capital Territory combines all the advantages of city and bush life and is very different from the mythical location regularly featured in the media in the eastern states. Having signed the “Official Secrets Act”, I am not at liberty to reveal the really interesting bits about my time in the Department of Health, but I did learn very quickly to admire the professionalism and work ethic of the Australian Public Service. In all my jobs I have worked with smart people, and certainly doctors work hard, but the quality that sets a good bureaucrat apart is not just intelligence and hard work, but also excellent judgement. Certainly, in stark contrast to the perceived wisdom outside Canberra, the work ethic was strong and the workload immense. One morning early on in my term, the Department of Health Secretary, Andrew Podger, drove me to our Senate Estimates hearings. On the way I chatted about my plans for the afternoon. He seemed to think my afternoon would be spent in Estimates, so I showed him my program where it said “Senate Estimates 9–11”. He smiled slightly and explained that the finishing time was 11:00 pm, not am! The particular barrow I chose to push during my term as CMO was evidence-informed policy, a counterpoint for the bureaucratic interest in evidence-based medicine. The work was extremely varied. As CMO I had executive responsibility for two divisions (the Office of NHMRC and the Public Health Division) and for all medical professional matters. I was one of the three members of the Vos Committee, commissioned by the Treasurer to determine how the Goods and Services Tax (GST) would apply to health, education, religion and, surprisingly, used cars. I was later publicly reviled for determining that tampons were a sanitary product (thus attracting the GST), not a medical device, and people doing feminist studies still send me angry letters. I chaired a committee for Defence and Veterans’ Affairs on the health effects of the deseal/reseal program in F-111 aircraft, which meant climbing over one at the Royal Australian Air Force (RAAF) base at Amberley to see for myself and left me with a great respect for the RAAF. I chaired an interdepartmental committee on quarantine and another on biotechnology. A tangible outcome from the former was the blending of two forms (customs and immigration) into one, to the delight of many arriving travellers. We promoted a reform agenda at the World Health Assembly and contributed to major policy initiatives relating to the National Health Priorities, quality and safety, and medical research. The theme for me was promoting consistent use of research and evidence to assist policy development. The Pharmaceutical Benefits Advisory Committee had long been regarded as a world leader in the use of evidence for rational prescribing, and the Medical Services Advisory Committee was set up to introduce a similar evidence base into provision of medical services. However, it was less clear that the same rigour was being applied to developing new policies in other areas. Health policy questions are influenced by the political context, particularly health system financing, local culture, community values, and history and geography. Realistically, the best we can hope for is that policy is informed by research and evidence. Policymakers often look for evidence to justify policies developed on other grounds, rather than using evidence to develop policy. As one former state Chief Health Officer put it, “we want evidence-informed policy, but what politicians want is policy-informed evidence”. Some years ago, the satirical magazine Punch (now sadly extinct) ran a competition for the most misleading advice to foreigners. A number of entries, as you might expect, gave misleading advice on how to behave at the cricket, most of which unhappily has come to pass, but the winning entry said “Try the famous echo in the British Museum reading room”. Misleading advice has even more serious consequences in health care and health policy. An example is the advice to parents, from Dr Spock and others, to sleep babies on their stomachs, on the basis of zero evidence, when this in fact increased sudden infant death syndrome. Not all health policy development requires systematic review of the available evidence: for example, equity of access and universal health coverage are self-evidently desirable policies. The difficulty, of course, is that we all want access, quality and affordability. In practice, we can pick any two. John Curtin School of Medical Research (JCSMR)I was very ambivalent about leaving the Department of Health, having thoroughly enjoyed my time there, but, given my background and interests, the Directorship of JCSMR was an offer I could not refuse. It had an outstanding reputation for medical science. The old JCSMR building was very extensive. I spent my first week wandering around meeting people and then discovered I had entirely missed one wing. Armed with directions, I made my way into the previously undiscovered lab and held out my hand to a woman in a white coat, saying “Hello, Judith Whitworth”. “No”, she said, and went back to work. At my interview, I was clear that the School needed to join the national competitive grant scheme, to engage further with the Australian medical research community, to design and build contemporary laboratories, to re-engage with clinicians, and to attract a medical school to Canberra. Before I took up the job as JCSMR’s first female director, I was given a copy of Machiavelli’s The prince. His 15th century view may be politically incorrect, but it contains insights that are as true now as then. The one maxim that stood out for me was that, in trying to effect change, you will have lukewarm support, at best, from those who will benefit and vigorous opposition from those who will not. Another aphorism I took to heart was variously ascribed to Edith Cavell and Harry Truman: you can do anything as long as you don’t care who gets the credit. In the event, these things have come to pass and, more importantly, the School has continued to make cutting-edge and important discoveries. International HealthDuring my stint as CMO in the Department of Health, one of my tasks was to take the Australian delegation to the World Health Assembly in Geneva (Box 5). On the first occasion, I had only recently joined the Department of Health and was still very “wet behind the ears”. Happily, the team (from Health, AusAID and Foreign Affairs) were all highly skilled, and my main tasks were sitting behind the flag, making interventions from prepared briefs and eating and drinking for Australia. At one point in the debate, a question came up about quarantine. I was hazy on our position and so, in the best bureaucratic tradition, I tried to pass the buck, asking our people who was in charge of human quarantine. “You are!”, they said in unison. Weakly I asked what it meant and one junior officer helped me out, explaining that I had the power to close the borders but I couldn’t pat the sniffer dogs, because they belonged to another department. We used the vehicle of the annual Australian speech to the World Health Assembly to advocate for research on health practice and health policy. At that time, despite some very notable World Health Organization research successes, there was little evidence of a strong research culture within the organisation, or of a valuing of research by member states at the Assembly. Perhaps as a consequence of these interventions, I was invited to chair a consultation on the role of the WHO’s Advisory Committee on Health Research (ACHR) and then to join the Committee. I am now in my second term as Chair, the first woman and first Australian to hold that position. The role of the Committee is to provide the Director-General with advice in relation to research. The ACHR is committed to a leadership role for WHO in the use of evidence from research to inform decisions about prevention, practice or policy in health and to bridge the “know–do gap” (ie, turn knowledge into action). The research culture in the WHO has changed substantially in the past decade. Established programs such as TDR (Tropical Diseases Research) and HRP (the Human Reproduction Programme) continue to perform strongly, but strength has also been built in health systems research (Alliance for Health Policy and Systems Research). One very promising initiative is EVIPNet (the Evidence-Informed Policy Network), which seeks to promote the systematic use of health research evidence in policy making, focusing on low-and middle-income countries and promoting partnerships at country level between researchers, policymakers and civil society. Also in the present decade, WHO ethics and guidelines review committees have been instituted and a clinical trials registry established. A code of conduct for research is being developed. Most excitingly, WHO is developing a research strategy that looks both to position the organisation as a standard setter and to use its stewardship role and convening power to promote and foster research relevant to the needs of low- and middle-income countries. Currently, I also co-chair the WHO/International Society of Hypertension Liaison Committee. The 1999 guidelines on hypertension3 have been cited over 2000 times, and the 2003 statement updating those guidelines in key areas4 has been cited over 400 times. ConclusionMy life in medicine has been fortunate. I have moved from a focus on individual patients to populations and policy, and from medical research to research for health. Medicine has been good to me. And my philosophy: today’s research is tomorrow’s prevention, practice and policy. 1 Graduation, University of Melbourne, 1967 2 Queen Elizabeth Hospital Renal Unit, Adelaide, 1972 Back row (L–R): Graham Rowe, David Miller, Napier Thomson, Bim Biswas. Front row (L–R): Judith Whitworth, Jim Lawrence, Geoff Burfield. 3 Hôpital Tenon, Paris, 1973 4 Guy’s Hospital, London, 1975 5 Addressing the World Health Assembly, Geneva, 1998

Judith A Whitworth FTSE, DSc, MD, PhD, BS, FRACP

The association between smoking and lung cancer is now an accepted fact. Every day, doctors base management decisions on cardiovascular risk calculated using the Framingham equation. It is because of such findings and practical implications that the British doctors study and the Framingham Heart Study from the United States are among the world’s best known longitudinal studies. The stories of these landmark studies in the fields of epidemiology and public health have already been told;1,2 but longitudinal researchers have also been at work in Australia, with implications for our particular population and the wider world. We selected just a few of these (Box 1) — studies that have already demonstrated some longevity and which we judged would be of particular interest to our readership — and interviewed some of their key investigators. What are their stories? How will they make their mark in medicine? The Australian Diabetes, Obesity and Lifestyle Study (AusDiab)Interviewee: Professor Paul Zimmet“How many Australians suffer from diabetes? How many new cases are diagnosed annually? ... How many people have complications of diabetes that are threatening to their vision or even to their life? ... These are not questions from ‘Trivial Pursuit’ nor is the answer to each of these questions readily available”, wrote Professor Paul Zimmet in the Medical Journal of Australia in 1985.3 At that time, Zimmet was frustrated that there had been little research into the growing problem of diabetes in Australia. Even Papua New Guinea, then one of the poorest countries in the world, had better diabetes data. Zimmet’s involvement in the epidemiology of diabetes had begun a decade earlier when, in 1975, he had gained funding from the US National Institutes of Health (NIH) to conduct a diabetes prevalence survey on Nauru, a Central Pacific island. The President of Nauru, Hammer DeRoburt, had invited Pincus Taft — his Australian physician and a colleague of Zimmet’s — to the island because he thought diabetes was a problem on Nauru; he was right! Zimmet and Taft’s survey found the highest prevalence of diabetes in the world — about a third of the adult population were affected.4 With further NIH funding, Zimmet and his team were able to survey other Pacific countries and Mauritius, and also, in 1985, to set up the International Diabetes Institute (IDI) in Melbourne as a World Health Organization collaborating centre for the epidemiology of diabetes. “It was really that NIH funding which allowed me to create the institute and establish the framework and the infrastructure that was then able to do AusDiab”, said Zimmet. In 1996, Australia’s health ministers agreed that diabetes would become one of the national health priorities. Spearheaded by Dr Michael Wooldridge, the then federal Minister for Health and Aged Care, the National Diabetes Strategy was launched in 1998. Arising from (but only partly funded by) the Strategy, the Australian Diabetes, Obesity and Lifestyle Study (AusDiab) was commissioned, with Zimmet and Professor Timothy Welborn as the lead investigators. AusDiab was a population-based, cross-sectional survey of the national prevalence of diabetes and associated risk factors in people aged 25 years or older. The study involved an initial household interview, followed by a biomedical examination that included an oral glucose tolerance test, and questionnaires. It was conducted between May 1999 and December 2000 in 42 randomly selected districts in the six states and the Northern Territory of Australia. “It was akin to an army exercise”, said Zimmet. Team members would go in advance to work out logistics of transport, motels and meals, as well as to identify suitable study centres, which might be schools, town halls or local bowling clubs. Blood sugar-level tests were done immediately on site at a mini-lab, and blood samples were then sent by car or plane to the main lab for other testing and storage. In the initial cohort, 11 247 people attended the biomedical examination. The most alarming finding was that almost a million Australian adults had diabetes — equating to 7.4% of the adult population and a 300% increase since 1981.5 A further 16.3% had pre-diabetes, and there was a 60% prevalence of overweight and obesity and a high prevalence of untreated hypertension. Further funding, now with Professor Jonathan Shaw from Melbourne as co-investigator, allowed a 5-year follow-up study of 6537 participants in 2004–2005. This determined, among other things, that about 100 000 adults in Australia develop diabetes each year; that is, about 275 people every day. AusDiab is the largest national study of diabetes in the world. To ease ongoing funding concerns and to provide critical infrastructure, the IDI has recently merged with the Baker Heart Research Institute in Melbourne. There is no longer any argument that diabetes is a global epidemic with devastating human and socioeconomic effects. However, Zimmet says other questions related to diabetes now need answers, such as “Will preventing type 2 diabetes prevent cardiovascular disease?” Bettering the Evaluation And Care of Health (BEACH)Interviewees: Associate Professor Helena Britt, Associate Professor Graeme MillerEach year in Australia, more than 100 million general practice services are provided to about 85% of the population — to the tune of about $4 billion in Medicare payments.6 What really happens in these consultations? What is being diagnosed? In whom? And how is it being treated? Although Medicare statistics can provide some information about general practice services, it is data from the Bettering the Evaluation And Care of Health (BEACH) program that have been able to inform health care policy and clinical practice by answering these questions. Now in its 11th year, the BEACH program is a continuous national study of general practice activity in Australia — the only such study in the world — conducted by the Australian General Practice Statistics and Classifications Centre, a collaborating unit of the University of Sydney and the Australian Institute of Health and Welfare. Since its inception in 1998, 100 000 encounters between general practitioners and patients from a random, changing sample of 1000 GPs have been added to the BEACH database each year. The database now includes details of more than a million encounters. The BEACH program has provided independent data about a range of often controversial topics, including consultation length, payment structures, doctors’ prescribing practices, and adverse drug events, to various stakeholders, including researchers, educators, government departments and agencies, pharmaceutical companies and health care professional organisations. The program has produced 23 books (freely available for download from the BEACH website) and about 100 articles published in recognised journals. Most recently, the group has reported on the prevalence and patterns of chronic disease in Australia, finding that one in four Australians suffer from two or more chronic conditions.7 When asked to comment on the program’s impressive productivity, Associate Professor Helena Britt was quick to point out that: “What makes the productivity level so high is a fantastic team of excellent health services researchers”. There were also many years of methodological development and validation before BEACH was launched. “We didn’t land on the BEACH without preparation. It did take 20 years to get to that point ... and some more from [Emeritus Professor] Charles Bridges-Webb before that.” Between 1978 and 1990, Britt, a research psychologist by training, worked in the University of Sydney’s teaching and research general practice. The practice, run by Bridges-Webb, used a continually evolving data collection system that was based on his work in the 1960s and 70s with patient-based data collection from all general practices in the Victorian town of Traralgon. In 1990, the team successfully secured funding from the National Health and Medical Research Council (NHMRC) and the General Practice Evaluation Program for the first national study of general practice for more than two decades, and for a comparative study of rural and metropolitan general practice. These studies were reported in supplements to the MJA. Thanks to their distinctive covers, they became known as the purple report (Morbidity and treatment in general practice in Australia 1990–1991) and the green report (A comparison of country and metropolitan general practice).8,9 Some very lean years followed these two studies, with the team only managing to stay together by taking on smaller jobs from different groups, such as doing quality research for clinical trials for pharmaceutical companies, and, from 1993, by offering (for a fee) the method they’d developed as a quality assurance option to about 4000 GPs, thus gaining further evidence for and experience in using their method. Then, in 1997, with growing interest in how new drugs were being used in clinical practice, the team managed to “stitch together” sufficient funds from government and other sources, including the pharmaceutical industry, to launch the BEACH program the following year. Since the launch of BEACH, funding has remained mixed and uncertain, being renegotiated with all involved parties on an annual or biennial basis. In 2004, the government contribution to funding was withdrawn and, in 2006, there was a real concern that the program would be forced to close. However, this fear was not realised, as the government’s contribution to the program was re-established in mid 2007.6 Why does the BEACH team keep persisting in its efforts despite the ongoing funding challenges? According to the Centre’s Medical Director, Associate Professor Graeme Miller: “It’s a commitment to the importance of general practice, and of reliably describing general practice to justify what it’s doing and its place in the health care system”. The Blue Mountains Eye Study (BMES)Interviewee: Professor Paul MitchellDoes smoking cause blindness? What effect does visual impairment have on daily living? Observing the impact of eye disease on individual patients might explain why a clinical ophthalmologist would develop an interest in epidemiological research. The notion becomes even less surprising when one learns that Australian legend Professor Fred Hollows is one of two mentors whom ophthalmologist Professor Paul Mitchell credits with inspiring him to develop the Blue Mountains Eye Study (BMES) — the first large Australian population-based study of eye disease. Mitchell says that it was Hollows who talked him into doing an MD in Newcastle, New South Wales, in the 1980s, to research the prevalence of and risk factors for diabetic retinopathy. His other mentor is US-based Professor Ron Klein, who began (and still runs) the Wisconsin Epidemiologic Study of Diabetic Retinopathy in 1979 and the Beaver Dam Eye Study in 1987. When the two met at a diabetes conference in Australia, Klein invited Mitchell to the US to see how the Beaver Dam Eye Study had been done. It was after being appointed to the University of Sydney’s Department of Ophthalmology in 1990 that Mitchell designed the initial BMES to study visual impairment and common eye diseases in a representative older Australian community sample, and obtained NHMRC funding. Study participants were identified in two postcode areas in the Blue Mountains region, west of Sydney. The area was ideal because of the residents’ demographic similarity to the overall Australian population (for most characteristics); and its geographical separation from Sydney meant that publicity could be well targeted. In the first wave of the study (BMES-1), 3654 residents aged 49–97 years were examined during 1992–1994, with Mitchell personally conducting the eye examination for all participants. There have since been 5-year and 10-year follow-up studies, and an extension study in 1999–2000 of further residents who became eligible to participate (BMES-E). A 15-year follow-up study is currently underway. Since 2001, the BMES has been incorporated into the research activities of the Westmead Millennium Institute’s Centre for Vision Research in Sydney. When asked about the study’s highlights, Mitchell nominates the finding that visual impairment has an impact on quality of life that is similar to that from most major systemic conditions, and doubles the need for earlier institutionalised care; it is also associated with about an 80% risk of increased mortality. Further, the BMES was among the first studies in the world to demonstrate the link between smoking and blindness (now a warning on cigarette packets sold in Australia and elsewhere) (Box 2).10 Among the most important of more than 300 papers published from the study, Mitchell includes a New England Journal of Medicine report of the link between using inhaled steroids and developing cataracts.11 According to Mitchell, one of the core strengths of the BMES is the collection of objective data. All eye photographs are graded using standard protocols developed for the Beaver Dam Eye Study, which allows for the independent assessment and pooling of data from the BMES with data from other national and international cohorts. A further strength is that, right from the start, the BMES was designed to be much bigger than “just an eye study”. A wide array of data was collected and then expanded upon in the follow-up studies, including fasting blood tests, various detailed questionnaires, and hearing assessments, with the project also extending into genetic studies. Ever looking forward, Mitchell believes that a valuable area for future investigation is a possible link between basic vascular signs in the eye and systemic events, particularly cardiovascular events, stroke and mortality. “The eye is the only place you can see vessels — microvascular vessels — naked”, said Mitchell. “These microvascular signs are quite important for a whole range of diseases, and can now be imaged very easily without dilating the pupil and assessed automatically with computer programs.” The Busselton Health StudyInterviewees: Dr Digby Cullen, Associate Professor Alan James, Professor Bill MuskWho should benefit from a community-based study? Most obviously, “the general population”, but Busselton-based GP Dr Kevin Cullen, who founded the Busselton Health Study in 1966, nominated the community itself. One of the study’s five original aims specified that the study should “provide a community service in the detection, treatment and prevention of disease and in the education of a population”. For more than 40 years, and persisting beyond Dr Cullen’s death in 1994, the study’s dedication to the people of Busselton, a picturesque coastal town in the south-west of Western Australia (Box 3), has been returned in kind. This has not only been in terms of study participation, but also in enthusiastic ongoing support, fund-raising and volunteering. As an example — at one time, the local milkman was delivering bottles of glucose solution for the recipients to drink before blood testing for diabetes on the same day.12 The Busselton Health Study is now one of the longest running epidemiological research programs in the world. The predominantly Anglo-Saxon adult community of Busselton Shire took part in cross-sectional health surveys every 3 years from 1966 to 1981, with surveys of all schoolchildren each following year. A “hiatus” for a few years was followed by several surveys of special groups; and, in 1992, a specific family-based genetic study was conducted. In 1994–1995, 5500 surviving participants from the early surveys were successfully recalled. In 2005–2007, an NHMRC project grant enabled a further study of a randomised sex- and age-stratified sample of adults and of all schoolchildren, followed by studies of chronic airflow obstruction and sleep apnoea, with ongoing studies of diabetes and healthy ageing in “baby boomers”. So far, a total of around 16 000 people have been studied at least once. The earliest descriptive reports in Australia of the prevalence of common diseases including asthma and other lung problems (the study has always had an emphasis on respiratory disease), diabetes and coronary heart disease are those from the “population laboratory” of Busselton. Numerous papers have been published: interviewees Professor Bill Musk, Associate Professor Alan James and Dr Digby Cullen (son of Kevin) nominated research describing the decline in lung function related to asthma and cigarette smoking,13 and genetic studies into asthma14,15 and haemochromatosis16 as their recent favourites. From the community perspective, there has always been a policy of providing feedback to survey participants, with recommendations made to seek medical advice from the family doctor if indicated. Dr Digby Cullen said, “We have made an attempt to create a therapeutic community in Busselton and to a significant extent I think we have been successful ... certainly, when you look at the health statistics of Busselton, there is good evidence for a creation of a therapeutic community with, for instance, very low rates of smoking in the population — about 12% in our most recent survey”. In addition, the prevalence of coronary artery disease has been shown to be lower in Busselton than in the nearby state capital, Perth. What of the future? Since 1966, Busselton has grown sixfold from a small town with a population of about 5000 to one of around 30 000, as people, particularly retirees, have moved into the area. However, the population has remained relatively stable, ethnically and socioeconomically speaking, and wine growing, tourism and farming remain the main industries. The Busselton genetic resource is in international demand. Associate Professor James said, “We’re now matching the phenotypes that we have collected in Busselton with genotyping in our own studies and with an expanding number of international collaborators; there’s plenty of scope for genetic epidemiology to go from strength to strength in Busselton”. Regardless of how the study develops, the community focus will persist. Professor Musk said, “We very much feel the community around us and behind us. All of us worked with Kevin Cullen briefly or for various times before he died. He instilled in me, and I’m sure in plenty of other people, that our first duty was to the community. We plan to keep that, as a mantra, if you like, into the future”. The Dubbo StudyInterviewee: Professor Leon SimonsWho among us will live to a ripe old age, physically well and mentally able? In the 1980s, when Associate Professor Leon Simons of St Vincent’s Hospital, Sydney, decided to conduct a longitudinal study, he was aware that older age groups had been relatively neglected in research studies up to that time. He also realised that by studying “survivors”, some characteristics of healthy “long-livers” might be identified. The decision to embark on the Dubbo Study of the Health of the Elderly — now known more simply as the Dubbo Study — was preceded by a raft of other decisions. Initially a neurophysiologist, then a lipid clinician–researcher, Simons followed the 1980s evolution in his field by retraining as an epidemiologist while on sabbatical in Jerusalem. Simons’ Israeli mentor, Professor Yechiel Friedlander, remains a collaborator to this day. A key decision was where to locate the study. Simons said, “We selected Dubbo [a major regional centre in NSW, home of the renowned Western Plains Zoo] in reverse, after working out the size of the town we needed — a community of 35 000 to 40 000 people”. Another decision was what data to collect. At the time, there was much data available in the form of aggregated health statistics — how many people each year go to hospital, how many go home, how many die — but not much was known about the people themselves. “We decided to study what is loosely called ‘healthy ageing’ but with a focus on cardiovascular disease risk factors, because they were a little bit more controversial — did what we knew in middle-aged people also apply to senior citizens?” said Simons. “And when you study the elderly, you open up a Pandora’s box of sociology.” Thus, the Dubbo Study came into being as a prospective, longitudinal community study of the health of all non-institutionalised residents of the Dubbo local government area who were born before 1 January 1930. The cohort, first examined in 1988, was composed of 2805 residents (1233 men and 1572 women) aged 60 years or older. Initial study aims included identifying patterns and predictors of mortality, hospitalisation and the need for residential care. As well as extensive biomedical investigation, including a resting electrocardiograph, peak expiratory flow measurement, and blood testing for lipid and glucose levels, there was also to be a social science investigation of healthy ageing and health service use. Cardiovascular diseases and dementia were conditions of special interest. Subsequent data collections were made in 2000 and 2002–2003 as part of the Study of Assets and Health Dynamics Among the Oldest Old (AHEAD) investigation; and there has been continuing “cold pursuit” of death, hospitalisation and residential care data. Pragmatically, Simons’ favourite reports are those most recently published17 or currently in preparation. Our favourite may be the 2005 article which reported that having a “green thumb” (daily gardening) can guard against dementia.18 Less than half of those in the original cohort are still living, making further active data collection unlikely. Nevertheless, more papers are on the way to add to the 50 already published. Today, as the shape of Australia’s population pyramid changes to reflect our ageing population, there is heightened interest in healthy ageing and the provision of health care and other services to our older citizens. Over the next 10 to 15 years, as the most resilient of the cohort retire to their gardens, Simons anticipates that the Dubbo Study’s database will continue to be accessed and continue to contribute to our knowledge of ageing. Tasmanian Longitudinal Health Study (TAHS)Interviewees: Associate Professor Shyamali Dharmage, Professor John Hopper, Professor E Haydn WaltersHow do childhood factors affect adult-onset asthma? How do issues around the time of puberty influence the risk of breast cancer? When a disease “runs in the family”, is it because of environmental or genetic reasons? Today, the Tasmanian Longitudinal Health Study (TAHS) is attempting to answer these questions and more. However, very different questions were at the forefront when the study began in the late 1960s. The study, originally known as the Tasmanian Asthma Survey, was the brainchild of Dr Heather Gibson, a pioneering doctor working with the school medical service in Tasmania. Professor Haydn Walters, one of the current TAHS team, said: “At that time, the main interest was in how much asthma and how much other respiratory morbidity there was in young children, and what the risk factors were”. The baseline study in 1968 surveyed all 8500 schoolchildren in Tasmania who were born in 1961 and were then 7 years old. Particularly novel for the time were the lung function tests performed on all of these schoolchildren, known as probands. The probands’ brothers, sisters and parents were also surveyed, taking the total number of participants at the time of original survey to 45 900. Follow-up studies were conducted in 1974, 1979, 1992 and 1996, often involving a specific subset of the original participants. The first time that blood samples were collected from participants in the TAHS was in 1996, from a relatively small sample of families. The aim of the current and next phases of the study is to investigate the total original cohort of 45 900. Ninety per cent of the probands have now been traced, with 80% of them participating in a recently completed follow-up study. The sibling follow-up is underway, with 70% traced so far, and 60% of them participating in the study. The TAHS researchers are seeking to collect blood samples from all probands and siblings for genetic testing, to tease out the different effects of “nature” versus “nurture”. Today, the original probands are around 47 years of age, and include such prominent figures as a Deputy Lord Mayor and leading medical researchers. The TAHS researchers say their most cited article to date is one published in the BMJ in 1994. It reported that only one in four probands who had asthma in childhood continued to have asthma at age 32, and that one in 10 probands who didn’t have asthma as a child developed it later on.19 Among more recent interesting findings, the TAHS found that, for girls, being overweight at 7 years of age triples the risk of developing adult-onset asthma.20 The TAHS is unique internationally because it is the world’s largest and longest running respiratory health study. However, because of the population-complete nature of the cohort, the length of follow-up and the opportunities for a general health study, research is now extending to other areas such as breast cancer, eye disease and social science. As TAHS team members say, on the one hand, “It’s now a very rich dataset in terms of early life exposure ... and the original questionnaires asked about symptoms rather than diagnosis — a real strength from a research point of view”. On the other hand, “In terms of a cohort, the group are now starting to get very interesting because they’re getting older. They’ve gone through the healthy part of their life and now the major diseases are starting to emerge”. In keeping with the study’s original respiratory focus, the TAHS will enable the study of lung ageing. Although the TAHS was originally (and, essentially, still is) a Tasmanian study, 30% of the original probands now live outside Tasmania — mostly on the eastern Australian mainland in Victoria, NSW and Queensland — and, as current TAHS team leader Associate Professor Shyamali Dharmage explained, the study now involves a national collaborative family of researchers. But the TAHS has always been a family study. As Professor John Hopper, a long-standing TAHS team member, said, “The thing that differentiates this from a lot of other longitudinal studies is that it involves families, and its strength is that Australian families tend to know where each other are. The next stage will be to study the offspring”. Wittenoom cohort studiesInterviewees: Professor Nick de Klerk, Associate Professor Lenore Layman, Professor Michael Hobbs, Professor Bill MuskWhat would you do if you could see an accident waiting to happen that would hasten the deaths of hundreds of people? In 1948, Dr (later, Professor) Eric Saint, who had emigrated from the United Kingdom to Australia, was horrified by dust levels in the crocidolite (blue asbestos) mine and mill at Wittenoom in the Pilbara region of Western Australia, more than 1000 km north of Perth (Box 4). Saint wrote to the head of the WA Health Department advising that the mine would produce the greatest crop of asbestosis the world had ever seen. Unfortunately, responsibility for any decision to halt mining in the area rested with the Department of Mines, and the Health Department could only stand on the sidelines in frustration. Tragically, in time it became clear that there was another even more lethal health risk to the workers and residents of Wittenoom. The first Wittenoom-related case of mesothelioma was diagnosed in 1960,21 shortly after the initial suggestion of a link between exposure to crocidolite and mesothelioma.22 However, the Wittenoom mine continued to operate until 1966 when, ironically, it was closed for economic rather than health reasons. The mine may have been losing money then; today, the loss in life continues. In the mid 1970s, when it became apparent that an epidemic of asbestos-related disease was emerging in Wittenoom workers, Australian researchers began a cohort study. Mine workers’ employment records, giving detailed information about the identity of the workers, their length of employment and the duties they performed, were made available to the research team. Although only several hundred people were employed at any time, about 7000 workers (mostly men) had passed through the mine or mill over the years. Most worked for only a few months; many were post-war migrants, several hundred of whom returned (and were traced) to Italy. Resulting studies have reported that asbestos-related diseases, particularly malignant mesothelioma, lung cancer and pneumoconiosis, continue to be the main causes of excess mortality in the former blue asbestos miners and millers of Wittenoom. Further, mesothelioma appeared much earlier in these people than had been seen after exposure to other types of asbestos in UK industrial studies. By the early 1980s, people who had lived in the town of Wittenoom without working in the mine or mill were also developing asbestos-related disease at an alarming rate. In the 1950s and 60s, crocidolite tailings had been spread around the town as a cheap gravel and sand substitute. Professor Bill Musk said, “They brought the crocidolite in from the gorges and laid it around the township to counter the dust or the mud, depending on whether it was raining or not. So everybody living in town was exposed”. Professor Michael Hobbs continued, “The school playground had been layered with asbestos tailings as a better surface for children to be running about on, rather than hard dirt”. Thus, a residents cohort study involving more than 4500 former residents of Wittenoom, including Indigenous residents, was embarked upon. Intervention and other studies have continued in that group to this day, giving, as Associate Professor Lenore Layman said, “some support and comfort to people who live with this terrible fear about their children getting mesothelioma”. Together, the Wittenoom studies have provided evidence that (unlike with smoking) the risks of mesothelioma do not diminish with increasing time since exposure. Most importantly, Professor Nick de Klerk says that dose–response curves were able to determine, once and for all, that, “When it comes to blue asbestos, there is no such thing as a ‘safe’ level of exposure”. The evidence from these studies has influenced asbestos policy in Australia, assisted in legal deliberations, inspired a hit song by Australian rock band Midnight Oil (“Blue sky mine”), and even led to Wittenoom becoming a designated contaminated site that has been literally wiped off the map. However, asbestos is still being used in developing countries around the world. Hobbs said: “The first world has sort of recognised the dangers of asbestos and stopped using it. I think we have a moral obligation to go on pushing this barrow to make sure that our colleagues in China and India are equally armed with the information they need to try and stop things happening there. Because, if not, whereas we’ve seen hundreds of cases of mesothelioma, they will see thousands”. Women’s Health Australia (WHA)Interviewees: Professor Julie Byles, Professor Annette Dobson“I am woman, hear me roar; in numbers too big to ignore ...” proclaimed the lyrics of Australian-born Helen Reddy’s song “I am woman”. The song won Reddy a Grammy Award in 1973 and is now famous as the anthem of the Women’s Movement. But how much did we really know then about ordinary women’s lives and the influences on their health? In 1985, after much lobbying, Prime Minister Bob Hawke’s government committed to forming a National Women’s Health Policy. The Policy, which would provide a framework and planned strategy to improve the health of women in Australia, was to incorporate a wide perspective — recognising that women’s health was much more than just reproductive and sexual health. In the early 1990s, a tender was put out by the federal government for a national longitudinal study on women’s health — one that could collect scientifically valid information relevant to the development of health policy and practice, and that would enable women to gain greater power over shaping the nature of health care. On seeing the advertisement for the tender, a group of researchers from different academic disciplines (including medicine, sociology, psychology and statistics) met over coffee in Newcastle, NSW, and decided to put in a submission. Thus began Women’s Health Australia (WHA), also known as the Australian Longitudinal Study on Women’s Health. The study’s overall goal was (and still is) to clarify relationships between women’s health and a range of biological, psychological, social and lifestyle factors. Professor Annette Dobson said: “We’ve never claimed to have just one clear hypothesis. Rather, what we felt was needed was enough power in the study to be able to address new questions as they emerged. We did have some concrete examples of the sorts of hypotheses that could be answered, but we didn’t say this was a study to address this or that question. We were saying it’s a study to look generally at factors that influence the health of women”. Extensive surveys have been mailed at regular intervals to a national sample of thousands of women in three different age cohorts (18–23, 45–50 and 70–75 years at baseline in 1996). These age groups were chosen because they represented times before which major changes could be expected in women’s lives; so, for example, there would be baseline data for young women before most of them had babies. Further, the women were recruited from the national Medicare database, allowing a link to health services data. More than 41 000 women (14 792 young women, 14 200 middle-aged women and 12 624 older women) responded to the baseline surveys in 1996;23 and now, about 10 000 completed questionnaires are received each year. Over time, themes explored have included health-related behaviour (eg, diet and exercise), time use (eg, paid and unpaid work, and leisure), life stages and key events (eg, childbirth, divorce and widowhood), violence against women, and chronic disease. Because WHA does not focus on a specific exposure, disease outcome or social problem, publications are highly diverse (http://www.alswh.org.au/public.html). Dobson said, “We’re contributing to the story of the health of Australian women”. There is sustained work on overweight, obesity and physical activity, and in the unfashionable area of incontinence. Professor Julie Byles said, “We’re dispelling the myth that incontinence is just a condition for older people”. WHA is also one of the significant studies of ageing in Australia. In addition, there are add-on studies and collaborations. WHA has passed the 10-year mark and is currently funded to last the desired 20 years. However, the researchers see possibilities for expansion and extension. Byles said, “We have found that the cohorts’ experiences are likely to be different as they age, so we have put a suggestion to the Department [of Health and Ageing] that we recruit a new young cohort — precisely because of those differences”. The WHA study has certainly fulfilled Reddy’s command that women not be ignored. And, to make sure of it, Byles would like the study to “hang around” at least until the older women reach the milestone age of 100. Australians advancingThese eight longitudinal studies, all conducted “on our selection” (to borrow an Australianism from Steele Rudd), have already contributed much to our knowledge of diseases in Australia. Although they cover disparate topics and range in cohort size from several thousand to many tens of thousands of participants, there are some common elements to their stories: committed investigators who are capable of thinking into the future; dedicated and often longstanding research teams; sustained support and enthusiastic participation from the community; and the need to endure and persist through periods of extreme funding uncertainty. A striking feature of these longitudinal studies is their capacity to produce valuable results with relatively little funding overall — many of those interviewed said that their work had been conducted on “the smell of an oily rag”. Reports from the studies have been published in prestigious high-impact journals, such as Nature, the New England Journal of Medicine and the BMJ, as well as high audience-impact journals, such as the MJA, thus influencing discourse, attitudes and policy. These Aussie battlers are rightfully proud of their achievements, as are we. Despite some successes, none of the researchers are content to rest on their laurels. All are eyeing a future for their studies, carefully watching the emergent literature for new ideas that may be a natural fit for their study populations. Many are actively engaging productive collaborators in cutting-edge areas, like genetics, and seeking a greater international contribution through the integration and comparison of their data with those of others. Both of these advances are enabled by making their data available online. Does a longitudinal study have a natural lifespan? Maybe, but all our interviewees are more concerned that it will be a lack of funding rather than relevance or researcher interest that sounds the death-knell for their study. If these studies are stopped too soon, we will all miss out on “the gold coins at the end of the rainbow”. As Miller (from BEACH) said, “Enough of the past must be seen before we can begin to predict the future with any certainty”. To achieve sustainability, many argue that a different kind of funding is needed than that usually available to epidemiological researchers. Hopper (TAHS) said, “The work is generally funded by project grants, scientific project grants, but what is needed is core funding”. Several interviewees said there needed to be some sort of formal research policy providing long-term support to cohort studies. Whatever the lifespan of their own study turns out to be, most of the researchers want a future that is better for all longitudinal study investigators. WHA has published a practical guide to conducting longitudinal studies — how to store data, track people, manage collaborators and more.24 Dharmage (TAHS) dreams of establishing a supportive collaboration of longitudinal researchers, all helping each other forward. What will be the next great Australian longitudinal study? Zimmet (AusDiab) says the time is ripe for Australia to establish a comprehensive longitudinal national health survey, conducted every 5 years, which would give an idea of the burden of disease and the opportunity to monitor interventions. Hopper sees a future where the historically fostered culture of institutionalised non-cooperative research groups is turned on its head. “Even now, the concept of having national cohorts that are run as resources for the general scientific community is becoming more and more established. The general thinking is growing — not just in Australia but internationally — that these resources are precious, that they need to be open and accessible to a wide range of research; and that people who do research using these resources need to put that data back into the resource so that others can build on it.” Australian longitudinal research is making its mark in medicine at home and beyond. With renewed commitment, vision and adequate ongoing resources, we hope that these stories, and others like them, will continue. 1 On our selection: characteristics of some Australian longitudinal studies Study title Location Year of initiation No. in baseline cohort(s) Funding* No. of publications† Study website Initial funding Total funding The Australian Diabetes, Obesity and Lifestyle Study (AusDiab) National 1999 11 247 $1 500 000 $2 600 000 80 http://www.diabetes.com.au/research.php?regionID=181 Bettering the Evaluation And Care of Health (BEACH) National 1998 na $1 200 000 $11 000 000 53 http://www.fmrc.org.au/beach.htm The Blue Mountains Eye Study (BMES) Blue Mountains, NSW 1992 3654 $163 819 $7 255 400 332 http://www.cvr.org.au/bmes.htm The Busselton Health Study Busselton, WA 1966 5008 £6000 > $7 600 000 > 250 http://www.busseltonhealthstudy.com The Dubbo Study Dubbo, NSW 1988 2805 $250 000 $400 000 51 http://www.dubbostudy.org Tasmanian Longitudinal Health Study (TAHS) National 1968 45 900 nd $4 000 000‡ 30 — Wittenoom cohort studies Wittenoom, WA 1974 11 684 $50 000 > $4 000 000 100 http://www.sph.uwa.edu.au/go/research-programs/oee/schools-and-centres/schools/school-of-population-health/projects#asb Women’s Health Australia (WHA) National 1995 41 616 $3 500 000 > $18 000 000 252 http://www.alswh.org.au na = not applicable. nd = data not available. NSW = New South Wales. WA = Western Australia. * Amounts shown are estimates and may not include institutional funding for costs such as investigator salaries or postgraduate students, and may comprise a mix of federal funding, support from trusts and industry, and in-kind support from various states and territories. Total funding is an estimate of funding received so far. † Number of published (or in press) articles in peer-reviewed journals only. See study websites for details of other publications. ‡ TAHS funding information is only available since 1992. 2 Macular degeneration Neovascular macular degeneration in the right eye of a 71-year-old woman who smoked heavily. 3 Busselton, Western Australia At nearly 2 km, Busselton’s iconic jetty is the longest in the southern hemisphere. 4 Wittenoom miners Underground Wittenoom miners having a lunch break in a dusty crypt room.

Ann T Gregory MB BS, GradDipPopHealth · Ruth M Armstrong BMed · Tanya D Grassi MB BS(Hons), BSc(Vet)(Hons) · Bronwyn Gaut MB BS, DCH, DA · Martin B Van Der Weyden MD, FRACP, FRCPA

During the Middle Ages, uroscopy was an important tool for evaluating health, and medical practitioners often carried Johannes de Ketham’s urine wheel as a diagnostic aid. In honour of de Ketham, a modern urine wheel is presented, which may be a useful diagnostic tool for present-day physicians. Hippocrates, Aristotle and the ancient Egyptians inferred diagnoses from urine evaluation, but it was not until the Middle Ages that uroscopy reached diagnostic dominance. A major reason for its rise to prominence was the publication of Johannes de Ketham’s Fasciculus medicinae in 1491.1 This was the first illustrated medical book printed and is also among the most beautiful of such texts. The importance it places on urine evaluation is evident on page 1b, which depicts a urine wheel: a large circle surrounded by 21 thin-necked, urine-filled flasks (matulae) (Box 1). This wheel shows how the colour and consistency of urine could be matched to a diagnosis. Disease was thought to result from the imbalance of humours, reflected by urine colour. In the corners of the urine wheel, four small circles contain descriptions of the four temperaments: sanguineous, choleric, phlegmatic and melancholic. In an era nearly four centuries earlier than Laënnec’s stethoscope, three centuries before the first investigations into blood pressure and two centuries earlier than Hooke’s microscope, uroscopy became the most important tool in evaluating internal health of the human body — more highly valued than the pulse. Its use is depicted by a woodcut from the first Italian edition of de Ketham’s Fasciculus medicinae, showing a professor teaching diagnosis by uroscopy as different matulae are presented to him (Box 2). Although modern technology allows greater insight into the hidden clues of bodily functions, visual observation of urine is still useful. A contemporary urine wheel with diagnoses that might be associated with visually abnormal urine is presented in Box 3. 1 Urine wheel from the first edition of Fasciculus medicinae* * An English translation of de Ketham’s urine wheel is available at www.mhm.ku.dk/upload/urinposter.pdf.2 2 Professor teaching diagnosis by uroscopy 3 A modern-day urine wheel that contrasts de Ketham’s diagnoses (italics) with modern interpretations of urine appearance

Charles J Diskin MD

The 21 August 1937 issue of the Medical Journal of Australia contained two articles on a hitherto unknown disease affecting abattoir workers and farmers — Q fever (with the “Q” standing for query). The first of these was by Edward Holbrook Derrick, Director of the Laboratory of Microbiology and Pathology, Queensland Health Department, Brisbane, and comprised his meticulous clinical descriptions and subsequent experiments to isolate the causative organism.1 During his research, Derrick sought the help of Frank Macfarlane Burnet, and the second article by Burnet and Mavis Freeman from the Walter and Eliza Hall Institute of Medical Research in Melbourne described their identification of the causative agent.2 Research breakthroughs frequently involve scientific collaboration, and attributing credit for the results of such collaborations can be difficult. In the light of some new information about Derrick’s experiments, I believe that he may not have received sufficient credit for his contribution to the discovery of the organism responsible for Q fever. When the MJA articles were published, Q fever appeared to be a disease localised to a small area of south-eastern Queensland. However, within a decade or so, it was shown to be of worldwide significance. Edward Derrick’s laboratory notes rediscovered Edward Derrick in his laboratory in 1937 taking rectal temperatures of guinea pigs. The guinea pigs were housed in second-hand battery jars, with two to a jar. In January 1994, I was asked by Professor L W Powell, Director of the Queensland Institute of Medical Research, to examine some cardboard boxes containing books and papers packed by Derrick before he died in 1976, to see whether there was anything important that should be kept. The boxes contained out-of-date textbooks, letters, photographs, notes of experiments and other memorabilia. One small package wrapped in newspaper contained an old exercise book cover, 13.2 × 21.2 cm, in which there were seven files of brown paper. Each file was stapled with a split-staple in the top left-hand corner, and on the top right-hand corner they were labelled Q1 to Q7 and they were in numerical order. Further examination of these notes revealed that they were laboratory notes comprising case histories and the results of guinea pig experiments. Correlation with Derrick’s MJA article of 1937 revealed that they were the laboratory notes relating to seven of the nine patients on which the article was based, and it was apparent that these notes had not been read by previous biographers. (A more detailed account of my findings, together with more than 300 digital images of the original documents, has been lodged in the Library of the Queensland Institute of Medical Research, and the Herston Medical Library, Brisbane.) Who was Edward Derrick?When Derrick was appointed to the position of Director of the Queensland Health Department Laboratory of Microbiology and Pathology in Brisbane in mid 1935, his previous experience included a year at the Walter and Eliza Hall Institute of Medical Research in Melbourne as a cancer research scholar in 1921 and a year as a pathology assistant at London Hospital in 1923. In the intervening period, he had survived a bout of tuberculosis and worked mostly as a country general practitioner in Australia. The laboratory he was in charge of was primitive even by standards of the time. It had a small staff of four, none of whom had tertiary qualifications. However, as Box 1 shows, Derrick’s appointment as Director of this laboratory was the beginning of a long and distinguished career as a research scientist and administrator. It was only a month after his appointment that Derrick was asked to investigate the cause of an obscure fever affecting meatworkers in a Brisbane abattoir processing dairy cattle (workers at a nearby abattoir processing steers for the international market had not been affected). He immediately set to work questioning the clinicians who had been treating the patients. Edward Derrick’s Q fever investigationsThe patients Derrick described in his MJA article presented between September 1935 and November 1936. Five were abattoir workers, another two were dairy farmers, and another worked in sewage construction. By examining the patients almost daily, and visiting some of them at their place of work, Derrick was able to make meticulous descriptions of their illnesses. He began by excluding other known causes of fever common in coastal Queensland. His working hypothesis was that it was likely to be a rickettsial infection, although it differed from the known rickettsias in that the patients did not have a skin rash or a positive Weil–Felix reaction. To isolate the causative organism, he began inoculating guinea pigs with patients’ acute-phase blood and urine samples with the aplomb of an experienced researcher. The inoculated guinea pigs became febrile and developed enlarged spleens, and he recorded their febrile response. His studies were done during the Depression, which explains Derrick’s use of second-hand battery jars (the casing of early batteries), and his method of recording his laboratory results on the cheapest paper available. Some extracts from the laboratory notes I discovered are described and illustrated in Box 2. He transmitted the infection serially in guinea pigs, investigated its properties in relation to heat, cold, and filterability, and studied the effect of dilution on its potency. He showed, by challenge and cross challenge, that the “strains” isolated from different patients were the same. This led to the development of a diagnostic test, albeit a cumbersome one, based on guinea pig immunity. Derrick also tried to identify the source of the infection and the manner of its transmission to patients. He visited Patient 3, a dairy farmer, at his farm where he looked for ticks or sick animals. He inoculated milk and cream (both raw and diluted) from the dairy into guinea pigs (they died from sepsis, but did not develop fever). He thought the infection might be transmitted by a biting vector, because he could only transmit it from one guinea pig to another by injection of infected liver and spleen. He attempted to infect other laboratory animals, mice and a few rabbits, without success, and rats with limited success. Overall, the results were compatible with Derrick’s hypothesis that a rickettsia-like organism, rather that a virus, was responsible for Q fever. Collaboration with Frank Macfarlane BurnetAt this stage, Derrick sent material from his patients and his guinea pig experiments to Frank Macfarlane Burnet at the Walter and Eliza Hall Institute of Medical Research in Melbourne. Burnet was one of the most prominent medical researchers in Australia at that time, and he already had an international reputation. Derrick was an unknown researcher working in an obscure peripheral laboratory, and he needed assistance from someone with an up-to-date, well staffed laboratory who had scientific support in the international arena. At a follow-up of Patient 5 on 17 September 1936, Derrick took a blood sample and sent half the serum to Burnet. Burnet’s laboratory notes (courtesy of Mr Gavan McCarthy, Director, Australian Science and Technology Heritage Centre, University of Melbourne) on 1 October 1936 read “abattoirs fever apparently successful early passage but now appears to have been lost”.3 On 5 October 1936, Derrick sent serum from Patient 7 to Burnet, and on 12 October he sent spleen and kidney from guinea pig D6 (Patient 7). Burnet’s laboratory notes on 30 November 1936 read “Abattoirs fever. Virus grown consistently. No spirochaetes or rickettsia seen”. After studying Derrick’s notes and drawings (see Box 2), I have wondered whether this comment could be interpreted as the report of a “consultant” to a “referring doctor” who has asked, “Could you please examine this material. I think that it contains a living organism. I have looked for many organisms, but I think it is likely to be a rickettsia”. (I could not find any correspondence that might shed light on this speculation either in Derrick’s or in Burnet’s papers that refer to this period of time.) On 1 January 1937 after further testing on D6 material, Burnet recorded, “Abattoirs fever: positive transmission to rats and mice. Enlargement of liver and spleen. In a rather variable proportion of mice numerous rickettsia seen. Sub inoculation to guinea pigs gives typical fever with immunity. Rickettsia seen.” In later communications, Burnet said that on this day he was confident that he had positively identified the organism causing Q fever. Interestingly, Burnet sent samples of D6 material to Rolla Dyer, head of the Rickettsia section at the National Institutes of Health in Washington, DC,4 and it was this strain that made it possible to show that it was identical to the organism that Herald Cox from Rocky Mountain Laboratory, Montana, USA, had isolated from ticks. Box 3 gives a summary of the current understanding of Q fever. A self-effacing scientistWe may never know whether Derrick should have received more recognition for his part in the identification of a rickettsia-like organism as the cause of Q fever. We do know that Derrick was responsible for having the organism named Rickettsia burneti5 (later changed to Coxiella burnetii as a result of Herald Cox’s contribution), and it is interesting to speculate as to why he did not ask for his own name to be included. Derrick was known for his retiring and self-deprecating nature, so it is quite possible that he shrank from taking the credit. He also knew (or guessed) that he had to act quickly to get a name in print because the group from Montana was about to publish its results on the “Nine Mile agent” in ticks. Rather than entering an argument with the more forceful Burnet, he may have decided to name it after him so that the answer would be a quick “yes” to his suggestion. It is interesting that Q or Query fever still bears the name given to it by Derrick when he was investigating its cause, and strangely it is a disease that continues to puzzle researchers. However, there has been a proposal for a name change. A seminar presentation in French, published in 1951, argued strongly that Q fever should be renamed Derrick–Burnet fever,6 and a Google search reveals that the use of this name is not uncommon. I would support this name change. 1 Edward Holbrook Derrick, CBE, MB BS, MD (1898–1976) 1921–23: Sir John Grice cancer research scholar, Walter and Eliza Hall Institute of Medical Research, Melbourne. Pathology assistant, London Hospital 1924: Contracted tuberculosis and, abandoning plans to become a medical missionary, returned to Australia to fight the disease (his brother had died of TB), hoping the climate would be curative 1925–34: Locum general practitioner, mostly in small country towns in the eastern states of Australia. With his health restored, he began private practice in Brisbane in 1934 1935–46: Director of the Laboratory of Microbiology and Pathology, Queensland Health Department, Brisbane. Conducted the first research on Q fever, collaborating with Frank Macfarlane Burnet to identify the causative organism. Studied other infectious diseases in Queensland, being the first to isolate Leptospira pomona. Suggested the establishment of a research institute to focus on Queensland diseases, and chaired an advisory committee that set up the Queensland Institute of Medical Research (QIMR) 1947–66: Deputy Director, QIMR, and in 1961 became Director. Continued investigations of leptospirosis and scrub typhus, and set up a virology unit. Conducted studies on asthma incidence 1966–73: Director of the Queensland Asthma Foundation’s Research Bureau Awards include: CBE; the Commonwealth Department of Health’s Cilento Medal (shared with Burnet); Britannica Australia Award for Medicine; Medal of the Australian and New Zealand Association for the Advancement of Science; Honorary Doctorate of Science (University of Queensland) Publications: Almost half of his 128 scientific publications were published in the Medical Journal of Australia, which also published a Festschrift issue in his honour in 1967 Source: Doherty RL. Derrick, Edward Holbrook. Australian dictionary of biography. Vol 13. Melbourne: Melbourne University Press: 620-621. 2 What Edward Derrick’s laboratory notes revealed 3 Q fever Q fever is a zoonosis, the causative organism Coxiella burnetii occurring worldwide (except in New Zealand) in mammals, birds and ticks. C. burnetii is an obligate intracellular organism, first classified as a rickettsia. Recent studies and genome sequencing suggest that it is a γ-Proteobacteria, order Legionellales, but with characteristics in common with bacteria in the genus Rickettsia. Q fever infection in humans may be asymptomatic; or it may cause an acute illness (usually a flu-like illness, pneumonia, or hepatitis), or a potentially fatal chronic illness (predominantly endocarditis). C. burnetii is disseminated mostly as aerosols or fomites from animals, particularly parturient animals. It is highly infectious, affecting abattoir workers and farmers, as well as researchers and laboratory technicians. Australia is the only country with a Q fever vaccine. C. burnetii also forms spores (0.2 × 0.5 μm) that resist heat and desiccation, and persist for long periods.

Robin A Cooke MD, FRCPA, FRCPath

A 1978 case report in the Journal described a 25-year-old man with disseminated osteogenic sarcoma whose metastases regressed after treatment with diet and intensive meditation. Thirty years later, there has been no recurrence of his cancer, and a recent pneumonectomy for chronic bronchiectasis revealed mature cancellous bone in the resected lung. The man is otherwise well. (MJA 2008; 189: 663-665) Clinical recordA man who is now 58 years old was diagnosed in 1974, at the age of 24, with histologically confirmed high-grade osteogenic sarcoma of the right femur (Figure, A). His right leg was amputated in January 1975. Histopathologically, the tumour was described (in a 1994 review of the case) as follows: “The tissue is replaced by a cellular malignant spindle cell tumour forming osteoid and bone and having a disorganised pattern of proliferation . . . confirming the diagnosis of a high grade endosteal osteosarcoma (osteogenic sarcoma).” In December 1975, widespread bony and pulmonary metastases were diagnosed. Despite being told in March 1976 that he had only 2–3 weeks to live, the man survived until September that year, when he underwent three cycles of palliative chemotherapy with vincristine, adriamycin, cyclophosphamide and dacarbazine, as well as brief palliative radiation therapy. He elected to discontinue these therapies as his condition deteriorated further. The patient then consulted prominent psychiatrist and hypnotherapist Dr Ainslee Meares, who reported his case and his subsequent remarkable recovery in the Medical Journal of Australia in 1978.1 When Meares first saw the patient, he had visible bony tumours protruding from his ribs, sternum (Figure, B) and iliac crest, and was coughing up blood containing small spicules of bone (Figure, C). Meares taught him how to meditate, and both he and the patient felt this was a key component in recovery, although he also adhered faithfully to a vegan diet and tried many alternative therapies, including massage, acupuncture, faith healing and others. The patient recovered and returned to full-time work, founding and running self-help groups for people with cancer, but had persistent reminders of the original illness. Presumably related to immunosuppression from chemotherapy, he developed pulmonary tuberculosis in June 1978, and was treated for this condition for 12 months. This progressed to cavitation and severe bronchiectasis, causing repeated bouts of pneumonia and persistently elevated erythrocyte sedimentation rate (ESR). Chest x-rays in November 1989, 15 years after the patient’s diagnosis and subsequent recovery, showed evidence of previous tuberculosis and ongoing bronchiectasis, with a left hilar mass compressing the left upper lobe bronchus by 50%. Views of the lumbar spine and pelvis, taken at the same time to investigate ongoing back pain, showed abnormalities initially thought to represent progressive metastatic disease. The report noted “progressive metastatic disease with large osteoblastic deposit right ilium, sacrum, and invasion into L5”. That report was amended 4 days later, after comparison with films from 1978, to state “The appearances in the body of L5 . . . are those of metastatic disease but this appearance is essentially unchanged”. A thoracic computed tomography scan performed a few days later showed evidence of previous left lung tuberculosis. With no further treatment, the patient’s condition remained stable. X-ray images of the chest, pelvis and lumbar spine in 1993 were unchanged from 1989. Lung function testing in 1996 and 1999 showed satisfactory function, with an FEV1/FVC (forced expiratory volume in 1 second/forced vital capacity) ratio of 2.56 L/3.40 L. Indeed, the patient was well enough to go trekking in Nepal for three weeks in 1999 to a height of about 16 000 feet above sea level. However, two episodes of left lower lobe pneumonia in 2004 and chronic bronchiectasis resulted in referral to a thoracic surgeon with a view to pneumonectomy. Noting the patient’s chronically elevated ESR, indicating ongoing sepsis, and recurrent chest infections, the surgeon recommended left pneumonectomy while the patient was still young enough to tolerate the surgery. In December 2004, pneumonectomy was performed. As the patient had relied on elbow crutches since the original leg amputation, it was hoped that a minimally invasive approach might preserve chest wall skeletal structure and musculature, but because of widespread adhesions and tuberculous scarring, this was not possible. A complicated 5-hour pleuropneumonectomy was performed, with the pericardium being opened to enable access to the pulmonary veins, precipitating a short period of intraoperative ventricular fibrillation. Macroscopic pathological examination showed a small, collapsed, scarred left lung. The lung parenchyma was abnormal, and bronchiectasis, cavitation and scarring were widespread, but there was no obvious tumour. Microscopic examination showed severe bronchiectasis, but there was no evidence of mycobacterial infection. The report noted that “palpation of lung parenchyma deep to the hilum reveals a rock-hard consistency, impossible to section with a knife. Using a saw, horizontal cuts . . . reveal a centrally located bony mass 35 × 30 mm about, surrounding the bifurcation of the left main bronchus.” Histopathological examination of decalcified sections showed “a bony mass surrounding and incorporating large central bronchi and neurovascular structures. Much of the bone has a mature cancellous appearance with normal appearing osteocytes, and mature fat within the intertrabecular spaces. In addition there are foci of coarse sclerotic and heavily calcified bone which are devoid of viable osteocytes. No viable tumour is present.” After steady postoperative recovery, the patient returned to full-time work and remains well. DiscussionOsteosarcomas are rare malignant tumours of the skeleton characterised by formation of immature bone by tumour cells. At the time of this patient’s diagnosis, osteosarcoma was a devastating disease with very low survival rates.2 Most patients died within a year of diagnosis. Management centred around limb amputation, with palliative chemotherapy and radiation therapy for recurrences. Over the past 30 years, management has improved dramatically. With the use of limb-sparing surgery, induction and adjuvant chemotherapy, and surgical excision of metastases, survival rates of around 60% can now be expected for patients presenting with localised disease.3-5 There are limited data examining long-term outcomes among patients recovering from osteosarcoma. A few articles have reported long-term follow-up, including surveillance for recurrence,6 the development of other cancers,7 and cardiac toxicity from chemotherapy agents.8 Metastases have been known to develop as long as 14 years after diagnosis.6 While there is a report of spontaneous regression of a pulmonary metastasis that developed 5 years after treatment for osteosarcoma,9 the fate of regressed secondaries has not been well documented. Today, pulmonary metastases are often resected, but this is while the tumour is active. In this patient’s case, the lung was resected, for other reasons, 30 years after the original diagnosis, and incidentally, a large piece of mature cancellous bone was found surrounding the left main bronchus. This presumably represented bone formation by a long-since regressed secondary tumour, similar to the bone found in the primary tumour at the time of amputation. It is clear from the 1978 report that large sections of the externally visible osteogenic secondaries were resorbed as the cancer regressed. This was most obvious on the patient’s chest wall (Figure, D). However, some spinal and pelvic bone formed by the secondaries appears to have remained intact after tumour disappearance, as illustrated by the fact that x-rays taken of the spine and pelvis 15 years after diagnosis and recovery were identical with films of 11 years earlier and by the presence of bone in the resected lung. It is interesting to consider the possible factors involved in this man’s remarkable recovery. Spontaneous remission is a possibility, although exceedingly unlikely at such an advanced stage of disease, and its coincident timing with a wide range of self-help measures adopted by the patient makes this explanation even more improbable. Certainly, the patient had widespread disease from which recovery, even today, would be very unlikely. Although the patient received a short course of palliative chemotherapy and radiotherapy to his lumbar spine, it is unlikely that this would have been curative with such widespread metastatic disease. Meares and the patient attributed the remarkable recovery to intensive meditation,1 and it is true that the patient meditated from 3 to 5 hours daily after developing secondaries. He still regularly meditates and teaches others with cancer to do so. His fastidious adoption of the Gerson diet10 for 3 months, followed by adherence to a plant-based wholefood vegan diet may also have played some part. Such a lifestyle approach, incorporating meditation and a vegan diet, has recently been shown to cause significant modulation of gene expression and biological processes associated with tumour growth.11 Apart from illustrating the value of maintaining hope in the face of apparent hopelessness, this case shows that, long after tumour regression, metastatic lesions from osteosarcoma may contain significant amounts of residual bone. Even in the absence of tumour, these bony deposits may cause health problems in their own right, depending on their location. Our understanding of such unlikely survival continues to improve with the recent demonstration that modifiable lifestyle factors affect gene expression in patients with cancer.11

George A Jelinek MD, FACEM, DipDHM · Ruth H Gawler MB BS, MGPPsych, FACPsyMed

In the early 1970s, the Burns Unit at the Royal Children’s Hospital in Melbourne was suddenly faced with the management of a number of children presenting with extensive full-thickness burn injuries. This prompted a renewal of interest in the use of fresh pigskin as a temporary cover for burn wounds. While early debridement and split skin autografts offer the best form of wound coverage, this approach is limited in massive burns by the lack of donor sites available to obtain split skin for grafting. The aim of temporary cover of burns sites with pigskin is to reduce excessive fluid loss, act as a barrier against burns wound sepsis, protect the wound from mechanical trauma, and help control pain. Plans to obtain pigskin were made with some degree of urgency. The State Research Farm at Werribee agreed to supply a pig to the hospital, on a weekly basis, for harvesting of a large split skin graft taken from one side of its body. This would be performed under anaesthesia by a member of the surgical staff. We were also informed that these were valuable “pathogen free” pigs and were to be returned alive and intact (minus, of course, the split skin from their side) to the research farm after the procedure. All that was needed to complete the plan was an anaesthetist. I was selected for the task not on the basis of any experience, skill or knowledge, but primarily because of my junior status within the Department of Anaesthesia. In addition, it seemed that all the other members of the Department had suddenly developed an intense interest in vegetarianism, animal rights, Judaism or any other cause they could find that would preclude them being selected. Having no knowledge of pig anaesthesia, I consulted what literature I could find on the subject and gleaned the following: Pigs can never be considered fully fasted for anaesthesia. They always have a potentially “full stomach”, with its attendant risk of vomiting and aspiration under anaesthesia. If fasted in an enclosure, they will eat their faeces if hungry. After all, they are pigs. Pigs have excellent veins in their ears, suitable for cannulation and intravenous induction of anaesthesia. A clear airway may be difficult to maintain in a pig. Manoeuvres such as chin-lift and jaw-thrust are problematic, and endotracheal intubation is made difficult by the airway taking an acute, almost 90° turn just beyond the vocal cords. There was limited information on how pigs react to anaesthetic agents commonly used in humans. Two points were of concern: Pigs are susceptible to malignant hyperthermia, not only in association with anaesthetic agents but even with significant exercise and stress. Landrace pigs are particularly susceptible to stress, and risk becoming “roast pork” if sufficiently stressed. Pigs are much more sensitive than humans to non-depolarising muscle-relaxant drugs. These drugs need to be titrated carefully to avoid the need for prolonged positive-pressure ventilation. Armed with this knowledge, I prepared an anaesthetic machine, some intravenous equipment, drugs, masks and intubating equipment in the animal laboratory operating room. This room was on the first floor at the rear of the hospital and it was here, on the first morning, that I nervously awaited the arrival of the attendants with my first “patient’’. When they failed to arrive in the operating room and I was called to go to the goods delivery laneway at the back of the hospital, it suddenly became apparent to me that my role was to be larger than I had anticipated. In the laneway was a panel van and beside it were the driver and his assistant, both anxious to get my signature for the delivery of a pig. I peered into the back of the panel van and was confronted by my first view of my patient — a snorting, smelly, very grubby pig with an excess of oral and nasal secretions and weighing about 100 kg. His aggressive stance and demeanour indicated clearly that there would be no cooperation with any medical procedure. My approach to pig anaesthesia required a hurried revision. There was no way this pig was going to proffer me one of his ears, with its excellent veins, and allow me to establish intravenous access and then administer drugs to render him more compliant. The only possibility was to somehow get the pig to turn round and present his buttocks to me at the open window at the back of the panel van. Sweet talking and cajoling failed, but shoving and prodding finally got the buttocks within range and I prepared for action. Using a stabbing motion, reserved for intramuscular injections into violent and uncooperative adults, I plunged a hypodermic needle deep into the nearest buttock and emptied my preloaded syringe of 1 g ketamine — hopefully into a gluteal muscle — before quickly moving to a safe distance away. The pig was angered by this assault, but the ketamine soon took effect and he fell on his side, adopting an air of sweet repose, although snoring loudly, indicating some degree of airway obstruction. Much haste was now required. Four able bodies, myself included, quickly lifted the unconscious pig out of the panel van and placed him on a sheet on the ground. He was then rapidly hosed down before being transferred to a clean sheet. By lifting the sheet at each corner, we carried our snoring pig hurriedly into the hospital. The noisy, obstructed, breathing pattern intensified as we ascended the stairs to the animal laboratory. Appalled at the thought of having to assist breathing en route with mouth-to-snout ventilation, we quickened our pace. I was greatly relieved to finally get the pig onto the operating table, where I was able to deliver 100% oxygen via a conical face mask, suction the nose and pharynx, and thus restore a clear airway. I deepened the anaesthesia by adding halothane to the oxygen delivered from the anaesthetic machine and then placed a large intravenous cannula into one of the pig’s superb ear veins. I then attempted to intubate the trachea. This proved very difficult, and after multiple attempts I finally succeeded by using a malleable wire and then passing a cuffed endotracheal tube over the wire. My greatest fear throughout the procedure was that the pig would develop malignant hyperthermia. The thought of my patient becoming roast pork kept me nervously vigilant. The skin harvesting went well, and after emergence from anaesthesia the pig was transferred, in a somewhat dazed state, uneventfully back into the panel van and home to Werribee. Flushed with success and now armed with a proven approach, we prepared for the next pig to arrive the following week. On its arrival in the back of the panel van, I was confronted with a new pig and a new problem relayed to me by the lone driver. En route to the hospital from Werribee and passing through Footscray, the driver’s assistant noted that the pig was trying to climb out of the open window at the back of the panel van. The van was stopped and the driver and his assistant attempted to push the now almost fully extruded pig back into the panel van. Unfortunately, the pig fell out onto the ground, injuring the leg of the assistant driver, and then escaped into suburban Footscray. The assistant was taken to a local hospital while the driver, with help from some local council workers, eventually got the pig back into the van and finally to my care. In response to this incident, the State Research Farm sternly warned us they would send no more pigs unless we sedated them before departure to ensure the health and safety of the driver, his assistant, the panel van and the pig. How best to sedate a pig for a journey across Melbourne in a panel van? Clinical pharmacology was in its infancy in the 1970s, and conclusions drawn from human studies and applied to animals were risky. What was needed was a drug that would calm the pig and take away its desire to escape but not sedate excessively. At that time there was much interest in the anaesthetic literature in the drug droperidol. Droperidol had been used to treat severe agitation in psychotic patients. It was said to produce marked tranquillisation and sedation, allay apprehension and provide a state of mental detachment and indifference while maintaining a state of reflex alertness. Just what we wanted in our pigs! However, there had been some disturbing reports of the drug causing a state likened to a “locked-in syndrome”, with marked inner turmoil experienced by the patient despite the external appearance of calm. There was no time for trials, and we reasoned that, if the pig did indeed feel locked in, this would make unruly behaviour even less likely. Droperidol was in fact given on only one occasion: 10 mg intramuscularly 30 minutes before departure to the hospital. The pig arrived calm and awake, even tranquil. We, however, remained apprehensive, being unsure what this pig was really thinking. We anaesthetised three pigs in total and the harvested skin was used as temporary skin cover to good effect. It was said that the children’s appetites improved, even to the extent that one child reportedly “would now eat almost anything”. This is, of course, purely anecdotal and I find it difficult to attribute this observation to the nature of the temporary skin cover used. Soon after these three successful anaesthetics, a Surgical Research Fellow arrived at the hospital keen to start a research project on oesophageal atresia, using piglets as an animal model. Unfortunately, being now regarded as the pig anaesthesia expert in the hospital, I once again found myself seconded to the animal laboratory to anaesthetise pigs. These, however, were piglets, weighing only about 8 kg each, and were much less of a challenge. In fact, it soon became almost a pleasure to anaesthetise these happy little piglets. They were small enough for me to carry to the operating theatre in my arms. If they squealed or struggled, which usually occurred only when I started to anaesthetise them, they would immediately become quiet if, with one hand, I held them upside down by their hind legs. Then with my other hand I would place the anaesthetic mask over their snout and anaesthesia induction would take place calmly. The induction was so calm and smooth I have at times been tempted to try this technique on uncooperative small children. As with adult pigs, intravenous cannula placement in the ears was easy and endotracheal intubation difficult. I anaesthetised 10 piglets in total, with only one untoward event: one piglet had a short episode of profound hypoxaemia and appeared to have a somewhat “cerebral” grunt for the first 24 hours after surgery, but then reverted to behaving in a normal piggy way. The research study on the piglets did not produce any breakthroughs in surgical practice, but did demonstrate that pericardium is probably not a suitable material to bridge the gap in the oesophagus when repairing oesophageal atresia. There was very little science in my pig anaesthesia experience either, except for one important observation that sadly remains little known even today. I discovered that when piglets were adequately anaesthetised (ie, did not respond to surgical stimulation), their curled tails became straight. I took it on myself to call this the “Mullins sign”, with the hope of making a name for myself in the paediatric porcine anaesthesia literature. But despite quite brazen self-promotion of this sign over the past 30 years, the Mullins sign has failed to receive due recognition. With the acceptance of this article for publication by the MJA, I can now say with a mixture of pride and humility that the Mullins sign is finally “in the literature”.

Geoffrey C Mullins MB BS, FANZCA

A 76-year-old woman reported a fishbone stuck in her throat, but no foreign body was identified. Eight weeks later, she experienced a transient ischaemic attack, and a stingray barb was subsequently removed from the right common carotid artery. To our knowledge, this is the first report of the migration of an ingested stingray barb. Clinical recordWhile holidaying in Queensland, a 76-year-old woman presented to an emergency department, reporting a fishbone stuck in her throat after a meal of snapper. A neck x-ray showed a vague 1 cm linear opacity. She was referred to an ear, nose and throat surgeon who performed a laryngoscopy and rigid oesophagoscopy under general anaesthesia. This revealed bruising to the right hypopharynx without mucosal trauma, but no foreign body was identified. The patient was discharged the following day, and subsequently returned home to Victoria. Two weeks later, the patient presented to her local doctor with ongoing dysphagia. A repeat x-ray of her neck showed a linear area of calcification of up to 1cm in length on the lateral film among patchy areas of calcification in the thyroid cartilage and carotid bifurcations (Box 1, A and B). No further action was taken. Six weeks later, the patient re-presented reporting transient left facial droop, left arm weakness and paraesthesia that resolved completely after 10 minutes. She also reported persistent dysphagia, a painful lump on the right side of her neck, and weight loss of 5 kg since her trip to Queensland. An urgent carotid duplex ultrasound examination revealed a linear foreign body traversing the right common carotid artery, 2 cm proximal to its bifurcation. The patient was transferred to our hospital. She was fit and her only comorbidities were hypertension, hypercholesterolaemia and anxiety disorder. On examination, she had raised blood pressure (165/70 mmHg) and was in sinus rhythm. There was a palpable mass in the right anterior triangle of the neck, with no audible bruit. Neurological examination was unremarkable. A computed tomography scan with intravenous contrast medium confirmed the presence of a 34 mm linear foreign body traversing the right common carotid artery, with a surrounding soft tissue mass consistent with a haematoma. There was no extravasation of contrast medium (Box 1, C). A small filling defect, consistent with an adherent thrombus, was noted on the intravascular segment of the foreign body. The patient underwent exploratory surgery with awake, regional anaesthesia, which permitted continuous neurological monitoring. This enabled safe distal cross-clamping of the internal and external carotid arteries and proximal cross-clamping of the common carotid artery before the foreign body and the traumatised carotid artery were manipulated. A 1 cm segment of the right common carotid artery (which was 2 cm proximal to the carotid bifurcation and included the foreign body) was resected and an end-to-end anastomosis with 6-0 Prolene (Ethicon, Piscataway, NJ, USA) was carried out. The foreign body was subsequently identified as a stingray barb (Box 2). There was no neurological compromise during or after the surgery. A Gastrografin (Bayer AG, Berlin, Germany) swallow fluoroscopy study undertaken 1 day after surgery showed no leak of contrast from the pharynx. The patient was discharged 4 days after the surgery, had recovered by 6-week follow-up, and was well at a 12-month review. DiscussionForeign bodies that migrate from the pharynx and oesophagus into the neck are often reported;1-7 most common among adults are fishbones.1,2 To our knowledge, this is the first report of the migration of an ingested stingray barb. The harpoon-like structure of the barb facilitates its migration in one direction, similar to observations in cases of migrating saw-toothed fishbones.3 Stingray injuries are common in tropical regions of Australia;8 envenomation is a concern in acute injuries, due to the necrotising properties of the venom, and pseudoaneurysm of the superficial femoral artery is a reported complication of this.9 It is not surprising that envenomation did not occur in our patient, as the stingray barb may have been lodged in the snapper for some time, and any remaining venom was probably destroyed during cooking. Previously reported cases of foreign bodies migrating into the common carotid artery were not associated with an ischaemic cerebrovascular event.4-6 In a case reported in 1958, the foreign body (a needle) was extracted directly by endoscopy;4 two other cases required open exploration and cross-clamping of carotid arteries.5,6 Ingested foreign bodies that migrate outside the pharynx and oesophagus are difficult clinical scenarios to diagnose. Migration may occur within 24 hours of injury.1 Investigation usually begins with an x-ray to locate the foreign body, but this is not entirely sensitive, even for fish bones.2 Although stingray barbs have been reported to be radio-opaque on x-ray,10 they may not be detected as stingray skeletons are cartilaginous and the spine contains vasodentine.11 In our patient, the stingray barb was visualised as a radio-opaque body in the x-ray, but the findings were uncertain because of calcification in the thyroid gland and carotid arteries. When a foreign body is seen on x-ray, an oesophagoscopy showing oedema, bruising or abrasion should raise suspicion of a migrating foreign body.7 Computed tomography is the investigation of choice, and should be performed as soon as possible to prevent catastrophic complications of migration into structures of the neck.1,2 1 Radiographic findings from a patient who ingested a stingray barb A,B: X-rays 2 weeks after the patient reported a fishbone stuck in her throat, showing linear area of calcification in the lateral film (arrow). C: Computed tomography scan after the patient experienced a transient ischaemic attack, showing linear foreign body (arrow). 2 Stingray barb removed from common carotid artery

Desmond C C Gan MB BS, BMedSci · Ravi L Huilgol MB BS, FRACS · Mark J Westcott MB BS, FRACS

Saibai Island is the closest part of Australia to another country. Lying in the Torres Strait, off the tip of Cape York Peninsula, Queensland, the mangrove-rimmed mudflat is only 4 km from Papua New Guinea (PNG) — a mere 20 minutes in an outboard dinghy, but a journey from poverty to plenty in terms of health care for residents of the palm-thatched village of Mabaduwan, PNG, north of Saibai. Mothers bring their sick children to the primary health care centre in Saibai, and who can blame them? Once a dinghy beaches, a Rolls-Royce service is triggered. One mother recently brought her 1-month-old daughter to Saibai because she was sleepy and not feeding well. The carer in Saibai noted a full fontanelle and telephoned the administrative centre in Thursday Island, about 120 km away, at the tip of the Cape. A helicopter was sent to retrieve the mother and infant to Thursday Island, where hydrocephalus was suspected and advice was sought from the regional centre for neonatal care in north Queensland, in Townsville, about 1500 km south. The centre dispatched a retrieval team of doctor, nurse, incubator, ventilator and backpack of medicines to Thursday Island in a twin-engine King Air of the Royal Flying Doctor Service (RFDS). Thursday Island, however, is too small for a landing strip, so fixed-wing planes must land on nearby Horn Island, where passengers catch a bus to a jetty and then a barge across a fast-flowing strip of water to Thursday Island. Medical evacuations are facilitated by a small helicopter, which is based on Horn Island and hops back and forth. The retrieval team left Townsville as night fell, were helicoptered back and forth from Horn Island in the middle of the night and returned to Townsville just before dawn. They had confirmed the large fontanelle, floppiness, an unreactive left pupil, and a sluggish right pupil, and initiated ventilation for respiratory failure. In Townsville, ultrasonography revealed a massive lesion in the left cerebral hemisphere, which was confirmed by magnetic resonance imaging to be a tumour. Meanwhile, the mother, who spoke very little English and whose life to that day had been spent in rural simplicity, was plunged into the luxuries of our modern Parents’ Unit next to our busy intensive care ward: lamp-lit hut with split bamboo floor was exchanged for electric lights and carpet; wood cooking fire for microwave; sleeping mat for huge, sprung, blanketed mattress; tropical heat for refrigerated “comfort”; nocturnal silence for the cut, thrust and whistles of intensive care battle; and family and friends for armies of strangers contending at all hours. Worse, the trees near the beach had been replaced by a strange contraption, more like a well, and there was no sea water with which to clean herself. We wondered why she had chosen to sleep with the lights on until we realised she did not know how to turn them off. Why did she sleep on top of the bed, or was she sleeping on the carpet? We soon learned that she had no idea how to use the microwave and stove and, in any case, had no coins to turn them on so we, of course, provided food. Why did she devour the fruit and leave everything else? We learned she was ravenous for sweet potato and cassava and perhaps a piece of fish. We thought she might like to go outside, but she was terrified to leave the ward. The acres of parked cars and the traffic on roads running in all directions contrasted with the carless, unpaved pathways between huts in Mabaduwan. Not surprisingly, her mental health began to disintegrate, and she became so fearful she would not even go to the toilet unless accompanied by a nurse. We needed to talk to her — to explain things and get permission for the surgery —but were confounded by her dialect. Late on the Friday afternoon of her admission, we rang our translating service, the health clinic at Mabaduwan, the Saibai clinic, people who allegedly knew her husband on Saibai, her embassy, and various consulates to no avail, but as luck would have it, someone discovered a distant “cousin” who had a boy in our paediatric ward who had worked his way to Townsville from Mabaduwan in a similar manner. The cousin spoke English. Conversation about the apparent diagnosis, the remote chance for surgery, the risks of anaesthesia, and so on, was tricky and took quite a while, supplemented as it was with such basic information as how to use the bathroom, and reassurances that we were bringing a change of clothing. In the end, we convinced ourselves that the mother understood matters and agreed to surgery. Surgery revealed a fleshy mass infiltrating the brain, with necrosis and haemorrhage. Frozen section showed malignant glioblastoma. As much tumour las possible was removed, the wound closed and the baby returned to the ward, still ventilated. After the surgery was completed, conversation became even trickier as we tried to discuss the contending kindnesses of continuation or withdrawal of high-tech support. There was no doubt about mother’s continued retreat into herself. Ultimately, it was widely agreed to withdraw high-tech support and “let nature take its course” and, while the cousin was rallying a few friends to support the mother, we began to explore the ways of transporting mother and the baby’s corpse back to her village. She was adamant that she did not want to be separated from her daughter’s body, and we were keen to preserve what remained of her stability. It was clear that mother and daughter should travel together — one should not go with the luggage. Problems accumulated with each phone call. No commercial airline would even think of transporting a mother with a corpse in her arms. Discreetly wrapped? No way! How about in a small crib? Not on your life, mate. I tell you, we can’t sell a ticket to a corpse. Well then, how about doing us a favour and transporting the corpse free of charge in the luggage if we really have to do it that way? No chance — it is all tied up with regulations and corpses can only travel with the assistance of a qualified undertaker and in a proper casket. A funeral director was asked how much it would cost to transfer one small corpse to Saibai. At least $3000, was the reply which, we figured, was probably about 3000 times the mother’s accumulated wealth. Was there any chance the RFDS would take mother and corpse on a back load to Thursday Island? Its King Air is the only plane based in Townsville, and constant demands from the living relegate those of the dead to the bottom of the list. Moreover, there were certain rules about transporting corpses. What if we kept the baby alive, to be extubated on Thursday Island? Would the commercial airlines consider carrying a baby being discretely hand-ventilated by a nurse? It was not as if we were asking for room for our whole transport team and equipment. After all, that equipment is all we have and it, too, needed to be on call in Townsville for the needs of the living. At least the airlines considered this question, but later phoned to express regrets that other passengers in the small regional plane might be challenged by the phenomenon. Sensing it might be easier to transport the living than the dead, we postponed the extubation, which took a bit of explaining. Mother seemed to follow the logic, and phone calls to Saibai and Mabaduwan began to prepare for the possibility but, as night fell on the second day of fruitless organisation, there was no apparent answer to the problem. We hoped something would “turn up” in the morning. It did. The RFDS plane had been dispatched to pick up two adult patients in Cairns and bring them back to Townsville. Cairns is about halfway between Townsville and Thursday Island, and there was time to put in a “mercy” diversion to Thursday Island. The old problem of transporting corpses remained and it was very good the baby was still alive. We still did not want to be separated from our transport incubator for the journey, which was likely to take about 10 hours, and sent one of our experienced nurses to ventilate the baby by hand. It was not clear how we would get the baby from Thursday Island to Saibai but wondered if she could go with one of the regular field trips to those islands. On the other hand, perhaps the baby could be extubated on Thursday Island and mother and corpse could return to Saibai in some kind of unofficial way, for which the Torres Strait is renowned. As our time was limited, medical staff on Thursday Island agreed to meet our team on Horn Island from where the baby would be helicoptered to the hospital for extubation. This would be very helpful, but would involve four hops of the helicopter: to pick up a doctor or nurse from Thursday to meet the patient on Horn, to take her to the hospital and then return to base. Off flew our little group — up the coast over the Great Barrier Reef, then over the flat scrub of the Cape with its single four-wheel-drive track, determinedly heading for the tip where it would join the shore of the Gulf of Carpentaria, which had been receding from the west. Almost 3 hours after take-off, mother, baby and ventilating nurse alighted on red-soiled, sparsely treed Horn Island in the azure flows of the Torres Strait, to breathe the heavy, hot, watery air of the tropics. Mother was instantly at home. Nurse began instantly to perspire. Oddly, mother sighed “trees”. Did you not see any in Townsville, the nurse asked? Not one, said the mother, though the hospital is surrounded by them. Meanwhile, concerns had risen in the staff at Thursday Island when it was learned the child was returning for extubation at that hospital while her father and other family members were gathering on Saibai to see her before she died and to be with her when she did. It seemed heartless to pass a corpse on to the family and budget constraints joined the meltdown. A helicopter would be employed to return the baby and her mother from Horn to Saibai, and a nurse and experienced paramedic would go with her to continue hand ventilation. That helicopter was waiting on the airfield when our team arrived and in the hot haze of Horn, the child was passed from nurse to nurse and continued the journey home. Our team returned to Cairns. At about 4 pm, father was reunited with daughter but, taking her up, would not pass her on to anyone. He appeared to have been consumed by an isolating grief that excluded and even blamed his wife. Everyone was alarmed and no one really knew what to do, but time was passing and the helicopter needed to return before dark. With the sun low, the family gathered around the child and the tube was removed in expectant hush . . . but death did not follow. Stillness was punctuated by weak gasps that strengthened, quickened, and went on and on, all night, and into the morning when the family wondered if it would be all right to head off for Mabaduwan so the girl could see her grandparents. Something did expire that night — the bitterness of the father. In a transformation judged by the night nurse to be the most moving she had ever witnessed, father, mother and family were reunited. It was “the proudest moment” of the nurse’s career. At about 10 am, the dinghies were fired up and the family returned home, but I knew nothing of these latter events when, 2 days later, I took a call from the primary health care worker in the village in PNG. In broken English he explained the baby was now crying loudly, waving its arms and demanding food, and wondered if I had further advice? My English broke in reply. In retrospect, this medical venture had involved multiple sea trips, six helicopter flights, two ambulances, two long-haul plane retrievals with special staff on overtime, several days of life-supporting intensive care, neurosurgery, anaesthesia, medicines, laboratory investigations, social-work support, interminable phone calls, accommodation, meals, and changes of clothing . . . all for free. In return, a small girl lived for 6 months.

John S Whitehall FRACP, MRCP(UK), DCH

On the eve of the fourth anniversary of the Boxing Day Tsunami, I could not help but reflect on the moment that this catastrophic event reignited my childhood vocational passion in the exact location where it had originated — Matara, Sri Lanka. A sense of anguish grips my weary soul For as a young child, my vision seemed clear But in my youth, soured was my lofty goal To vanquish my poor sick brethren from fear Left my island home for a richer land Forgot the advice of a nun so stern Exams and selfish ambition to hand My heart grew heavy, my mind started to churn Then disaster on a scale unseen before Waves of destruction strike my island home Trying to save kindred from death so raw I was transformed by the human spirit shown Then I heard a familiar angelic sound Twas my nun asking, had I my purpose found?

Suran Fernando MB BS, PhD, FRACP

A 69-year-old man presented with a 3-week history of intermittent interscapular dull ache, complicated by small volume haemoptysis. Contrast-enhanced computed tomography of the thorax showed no evidence of pulmonary embolism, but demonstrated a well circumscribed lesion, 10 mm in diameter, in the right bronchial tree (Figure, A), leading to suspicion of a neoplasm. Using flexible bronchoscopy, we successfully removed a whole macadamia nut (Figure, B) that was obstructing the bronchus intermedius at the level of the right middle lobe orifice. Additional history obtained after the procedure revealed an aspiration event 3 weeks before admission. The patient reported having tripped while walking upstairs and concurrently eating a handful of macadamia nuts, resulting in a coughing spell that lasted the better part of the night.

Stefan Buchholz · George R Rudan

A 57-year-old overseas tourist presented with confusion and deteriorating vision in her right eye. She had a known history of poorly controlled diabetes and an involuted left eye. No further history was obtainable. Examination of the right eye demonstrated a dislocated crystalline lens, and long-standing tractional retinal detachment. I performed a B-scan ultrasound of the right eye. When doing this investigation, I often tell patients that “It’s like when you are having a baby”, but this time I was surprised by what I saw! The dislocated crystalline lens and funnel tractional detachment formed an amusing but apt image (Figure).

Neil S Sharma

Objective: To estimate the effect of day of the week on the odds of being discharged alive from an intensive care unit (ICU).Design: A longitudinal analysis of risk of discharge by day of the week.Setting and patients: 4569 patients admitted to the ICU of St Thomas’ Hospital, London, from 2002 to 2006.Results: The odds of being discharged alive were lowest on the weekend and literally climbed during the week.Conclusion: Our results show a frightening pattern of discharge from an ICU ward, most likely caused by a complex web of specialist availability and patient demand.

Adrian G Barnett BSc(Hons), GStat, PhD(Maths) · Nicholas Graves BA(Hons), MA, PhD(Econ) · Ben S Cooper BSc, MSc, PhD · Rahul Batra BS, MD · Jonathan D Edgeworth MB BChir, BSc, PhD

The snow-dome effect with three continuous positive airway pressure (CPAP) machines in action. We describe a novel use for continuous positive airway pressure (CPAP) to decrease levels of daytime sleepiness without the need for concomitant use of a CPAP mask. We used CPAP machines to create a snow-dome appearance in our hospital’s annual Christmas decorations competition. CPAP therapy is the currently recommended treatment for moderate to severe obstructive sleep apnoea. Treatment is applied by a CPAP pump (air-pressure generator), which is transmitted to the patient’s upper airway via tubing and a CPAP mask. All CPAP masks have an exhalation port to prevent rebreathing. Modern CPAP machines reliably generate a pressure of 20 cm H2O, but can generate slightly higher pressures to partially compensate for living at high altitude. The Prince Charles Hospital is located in Brisbane. The climate is subtropical. The Sleep Scientists’ office window measures 112 cm wide by 104 cm high, with a 9.5 cm internal recess. A plastic sheet was adhered to the sides of the window frame, except at the top right corner — to act as the exhalation port. Tape was applied to provide additional reinforcement to prevent billowing out while the CPAP machines were in use. It also gave the appearance of a timber window frame. Cardboard was used at the bottom to provide a solid support and create an entry for the CPAP tubing. Beanbag balls (small polystyrene spheres of 4 mm diameter) were poured into the recess between the glass window and plastic sheet. They were blown about by three CPAP machines to give the appearance of a snow dome. The central CPAP machine produced a maximum pressure of 55.4 cm H2O — achievable using the original Vortex CPAP machine; the CPAP machines at each corner generated pressures of 22.9 and 21.3 cm H2O, respectively. The three CPAP machines used to create the snow-dome effect. The Vortex blower is centre, with modern CPAP machines on either side. The theme was “I’m dreaming of a white Christmas”. The Stanford Sleepiness Scale (SSS) is a subjective measure of momentary daytime somnolence ranging from 1 to 7, with 1 indicating minimal daytime sleepiness and 7 representing difficulty staying awake.1 In our single-centre crossover study, SSS scores of spectators were noted to reduce to 1 (alert, wide awake) when the CPAP snow dome was on. SSS scores returned to the participant’s baseline soon after the CPAP snow dome was turned off. (Yes, the CPAP has to be actually on for this clinical effect.) We suspect the treatment effect will be somewhat blunted in colder climates where it snows, but await clinical data from other centres.

Tim Young MB ChB, GradDipClinEpi, FRACP · Cheryl Scott BSc, RPSGT · Rebecca McLachlan BAppSc(Hons)

Objective: To determine the association, if any, between male-pattern hair loss (baldness) and serum 25-hydroxyvitamin D (25-OHD) levels.Design and participants: A cross-sectional study of 296 healthy middle-aged and older men.Main outcome measures: Degree of baldness was independently assessed by two researchers using the Hamilton–Norwood scale and serum 25-OHD was measured in all men.Results: Classification of the degree of baldness by the two researchers showed a high level of agreement (κ = 0.93). Forty-eight per cent of men had no hair loss or mild frontotemporal recession, 15% had predominant vertex loss, and 37% had significant scalp and vertex loss. After data were adjusted for potential confounding factors — including age, month of 25-OHD measurement, exercise levels, use of sunscreen, skin type and frequency of outdoor hat wearing — no significant differences in 25-OHD levels between these groups was detected (P = 0.60).Conclusions: The degree of baldness does not appear to influence serum 25-OHD levels. The high prevalence of baldness in older men does not explain sex differences in 25-OHD levels. Other novel hypotheses are required to help determine whether baldness serves any physiological purpose.

Mark J Bolland MB ChB, PhD · Ruth W Ames NZCS · Andrew B Grey MD · Anne M Horne MB ChB · Barbara H Mason BSc · Greg D Gamble MSc · Ian R Reid MD

It is said the medical profession should learn from the aviation industry, which has a much better safety record. This is possibly because pilots get a mandatory 8 hours’ sleep. They also have to rest between shifts, for longer than the hours worked. Pilots do everything in duplicate to ensure accuracy. Most importantly, the pilots know that if their passengers are going to die, they are going to die too. So, I think it is high time that medicine looks into emulating the aviation industry. Next week, after rewriting my 11th revision for the MJA until 3 am, I am going to walk into my outpatient clinic at 12 pm (after my mandatory sleep-in) and tell my patients I was following safety regulations. Perhaps I should make an announcement on the hospital paging system: Ladies and gentlemen, this is the doctor speaking — we apologise for the short delay. We’re about 3 hours behind schedule but hope to make up some time through the day ... I like the idea of having equal, if not longer, hours of rest after every shift. It means that when I am on call on Saturday and Sunday, I can take the next 2 days off. (Golf or tennis? The more I think about it, the more exciting it is.) What about doing things in duplicate? Next time I check a pulse and find that it is 72 beats/min and regular, I will confirm it only after I have my registrar check it too. I can hear her saying, “right wrist flexed and pronated, radial pulse checked, 72 per minute” — and my reply, “Roger”. When we get into a plane, we are told where we are going, how long it will take, and exactly what time we will get off the plane. I think this is an excellent idea. Imagine telling a patient: Mr Nair, you are going to the preoperative ward now to prepare for your surgery. Afterwards, you will be in the intensive care unit for 24 hours, and then stepped down to postoperative care. You will be leaving us in 7 days at 12:30 pm. Your surgeon will be —, assisting him will be —, and the anaesthetist will be —. To look after your comforts in the ward, we have the lovely Nurse — ... Not everything is done better in aviation than in medicine though. For instance, all airline passengers (possibly except those in the front with the free French wine) are expected to exit the plane in the same condition as they entered. In medicine, we expect that they will leave in better condition. In this regard at least, the airlines should learn from us. Once on the plane, there is the flight safety routine before departure. Imagine, during your first day at the hospital, watching a nurse demonstrating how to use a defibrillator. Having watched her do this once, you are then supposed to do it yourself the next time there is a cardiac arrest! I am not sure whether, in the panic of a “water landing”, I can even put on the life vest the way they have shown me. Why can’t airlines certify passengers before we board as able to don the life vest, with recertification required every 6 months? The seatbelt demonstration is another aviation routine that we do not need to emulate. Who does not know how to do up a seatbelt? (After all, I managed to drive myself safely to the airport so I could park in the ridiculously expensive car park.) If you don’t know how to put on a seatbelt, should you really be travelling? In medicine, we believe in evidence and scrutinise everything carefully. We do not take anything for granted. In flying, when requesting an exit seat (to more comfortably accommodate your obesity, osteoarthritis and sciatica), you are asked, “In the event of an emergency, are you willing and able to assist other passengers?” You agree, and they give you the seat. This is like believing the man with cirrhosis and delirium who lies about his alcohol intake! I often wonder whether that fat man in the exit seat could even fit through the emergency exit, let alone help anyone else. Should we have a limit on the body mass index for exit seats? Should we have a stress test or fitness test before the seat allocation? Then there are the oxygen masks. We do not tell chronic bronchitis patients, “In the event of your oxygen levels dropping, a mask will drop down above you” — we just give it to them. What about this idea of fitting your own oxygen mask before helping others? Just imagine if all doctors treated themselves first and then looked after the young, old and disabled. We are far more altruistic in our profession! There is one final thing to consider in which flying is far superior to medicine: the airport lounge. If you are a frequent flyer with a gold or platinum card, you enjoy special privileges. If you are a frequent attender in the hospital, should you also have a special area for waiting, depending on your status? If you are a gold or platinum patient, unlike those with silver cards, you should not have to wait in the emergency department for 24 hours to get an inpatient bed. I think it is time to review the whole thing. Clearly, we in medicine are good at some things; others, they do better in aviation.

Balakrishnan R Nair FRACP, FRCP, GradDipClinEpi

As a first-year doctor working in a hospital, I have been chastised many times by grimacing patients in pyjamas about how I “don’t know how it feels” or that I’m “just doing this to torture them”. The second accusation is close to the truth for patients who abuse the public hospital system to get free drugs, hot showers, clean sheets and nurses to harass. The first accusation, however, has recently been laid to rest. I now patrol the wards and intervene with impunity. I have been dealt the great trump card of suffering and have been blessed, you might say, with the get-out-of-jail-free card of sympathy. I have done what very few men have ever done. I have given birth! — albeit to a 4.0 × 2.5 mm piece of calcium salt. Early one morning, I awoke with a strange urge to urinate, but had difficulty doing so. It wasn’t that I couldn’t get anything out — it was more that it hurt to get it out. I kept starting and stopping and wondering what in Zeus’ name was going on. Although the problem plagued me all day, I decided that I didn’t need to consult a doctor. I would diagnose myself. I made a mental checklist of symptoms. Urgency? Check. Burning? Check. Difficulty initiating a stream? Check. I felt like a pharmaceutical ad. I thought I had a urinary tract infection. Unfortunately, as I didn’t talk to a doctor, no one reminded me that urinary tract infections are incredibly rare in men and usually indicate cancer or some other form of horrible co-disease. So my prescription was to drink a lot of water and “borrow” some antibiotics from the emergency department (ED). (This is why hospitals don’t trust doctors to handle and dispense medications and instead leave that up to the nurses.) That night, during my shift in the ED, my symptoms continued and I became well aquainted with the toilets. I had just finished with a patient and sent him home when I sat down and felt a horrible ache in my left lower back. It was as if a body builder had ploughed his hand into my side, grabbed my kidney and squeezed it like a fresh tomato. Sweat broke out across my forehead. I got up and went to the bathroom, hoping somehow that it would relieve the pain. Alas! . . . nothing. Staggering back to a chair, I flopped into it ungracefully and, putting on a brave face, told my supervisor I had a pain in the back. Feeding a doctor a symptom is a wonderful thing. It’s like feeding a trained circus dog a biscuit. The symptom immediately unlocked an automatic pathway in her brain and, like a good doctor, she quickly rattled through a series of classic screening questions: Have you ever had back problems? Have you had this pain before? How would you describe the pain? How would you score the pain out of 10, with 10 being the worst pain you can imagine and zero being no pain? On and on she went. I answered as best as I could, but that hand in my back was squeezing tighter and tighter and I could feel my stomach contemplating sending my dinner back to where it came from. At some point, my supervisor’s visual system interrupted her brain. She stopped asking questions and, with a quizzical look, observed: “You’re sweating”. I nodded. “I feel like I’m going to vomit”, I gurgled. Fortunately, a nurse walked past and instantly diagnosed me as sick. She took my arm, led me to a bed and handed me one of the large cups used in the ED for catching stomach contents. I had always despised these cups. They embody all that’s wrong with letting non-medical people have input into how a hospital is run. Some bean counter must have found them on sale after a milk bar went out of business. He must have thought himself very clever for scoring thousands of cups on the cheap. However, I’m sure they cost the hospital more than they save. The logo on the side taunts ill patients with “SLURP, SLURP!” in bubbly pink and blue lettering. Luckily, I knew to avoid making eye contact with the cup. Lying down calmed my stomach enough for the nurse to roll me over for a shot of an antiemetic. For a while, I felt a bit better and thought things might work out, but unfortunately, the pain wouldn’t let me relax. I was sure that the body builder squeezing my kidney had noted my recent drug use and injected some steroids into his own rear. A few minutes went by and the pain escalated from crushing to nuclear. I broke down and staggered to my feet to tell the nurse that I wanted to cross the line and become a patient. This was a poorly conceived plan. Standing up immediately pushed my stomach into reverse and I promptly filled the SLURP! cup. Luckily, the nurse saw this, and, holding a fresh cup, rushed over like a widow with a coaster trying to protect her antique furniture from a foaming beer bottle. During a long period of mind-numbing pain, the nurse probed me for the usual patient demographics and produced what is known in the biz as a “large-bore needle”. The questions were quick and in themselves painless. However, the needle was less so. She missed my giant forearm veins twice. I thought I had always been nice to that nurse, but looking back through the haze of pain, I really can’t remember which nurse it was. There are a few who simply hate all doctors. Or maybe she resented having to put that first needle in my butt. So, I guess I could have deserved it. Fantastically, on the third attempt to get a vein . . . success! and with it . . . sweet, sweet morphine. When frail, elderly ladies who subsist on toast and ginger ale come into the ED with broken hips, we give them 1 mg morphine at a time, and 5–8 mg turns them into giggling school girls. When an average-sized man comes in after a knife fight, we give him 2.5 mg morphine at a time, and after about 15 mg he has to be fished off the ceiling with a broom. During my stay in the ED, they gave me 5 mg morphine at a time and it took 10 doses to make me feel human again. Apparently, that body builder had built up a tolerance by injecting more than just steroids. After being pumped with 50 mg morphine plus various other analgesics and antiemetics, I was finally able to relax. As I failed to diagnose, I had a kidney stone. It was not a fun night for me waiting for that rock to work its way through my narrow plumbing. But, as I was a “VIP” (ie, doctor), I received a couple of perks. First, I was put up in the sexual assault room, which comes equipped with its own ensuite bathroom and total privacy. When I pushed the nurse call button, she showed up immediately with morphine in hand. Well, I passed the stone completely a couple of days later and, although the pain returned occasionally during that time, it was nothing like the first attack. Overall, it was quite an experience and I learned a few things. For instance, I learned that, contrary to common belief, kidney stones are much worse when they are higher up. I was still in a pleasant, early morning stupor when I heard the unmistakable “ping” in the toilet bowl. I shook my head and thought “that was too easy”. I had expected to be balled up on a cold, tiled floor, screaming for the afterlife, as I gave birth to my little rock monster. Furthermore, all that time staring up at a white ceiling in a morphine-induced stupor had got me thinking. It’s a rough gig being a hospital patient, and I wasn’t even offered the food. About 10% of all people who enter a hospital never come out. So, I was lucky . . . this time. But I have to enter that hospital multiple times a week. So the next time you’re in the hospital and some fresh-faced doctor is inflicting a little pain on you in the name of improving your health, just think, that doctor may be me . . . and I do know how you feel! I also live in constant fear that, at any time, another illegitimate child may some day return to reduce me to tears.

Keiran K Tuck MB BS(Hons)

A 53-year-old woman presented with a 2-day history of epigastric pain. She had mild tenderness over the right upper quadrant and epigastrium, with no peritonism. A chest x-ray revealed free gas under the diaphragm (Figure, A; arrows). A computed tomography scan confirmed a large pneumoperitoneum but no hollow-viscus perforation; the uterus was filled with gas (Figure, B; arrow). On further questioning, the patient recalled that the pain began after she sat on the gas outlet of a pneumatic spa. She was managed conservatively and discharged uneventfully. Air introduced through the gynaecological tract is a non-surgical cause of pneumoperitoneum. Distension of the uterus with gas on imaging can be a clue to diagnosis.

Yu Xuan Kitzing · Sam McCormack

Thirty years ago, when general practice surgeries were attached to doctors’ houses, there was generally someone around to help in emergencies, even at awkward times. One Saturday morning, when I was working alone, a boy aged about 7 was brought in to the surgery by his mother. He needed a penicillin injection, and when I asked his mother if she could hold him, she said “The last time he had a needle it took three people to hold him, so I’ll wait outside”. I went upstairs to the house and enlisted the help of my veterinarian son, who was home for the weekend. “I’ll show you how to hold him”, I said. “We learnt how to hold all animals,” he replied. So I left him to it. In keeping with the fashion favoured by vets at the time, my son had long ginger brown hair, a beard and a bushy moustache. He pinned the child to the examination couch with two ginger-haired hands and grinned at him through his beard. Hypnotised by this spectacle, the boy didn’t move, breathe or make a sound. When it was all over, I took him back out to his mother, who had not seen my son enter the consulting room from upstairs. The boy said to her “Was that a bear?”. I didn’t disillusion them. Doubtless, they still tell the story about the odd assistants employed by the funny woman doctor in Brisbane.

Alison Miller MB BS

Well chosen artworks in the doctor’s waiting room can be an unwritten prescription for peace “Your blood pressure is up today” is a not uncommon doctor-to-patient line. If it’s a one-off reading — and as long as it’s not dangerously high — a general practitioner will usually take into account that the patient is somewhat stressed just by being there. Well meaning as they may be, posters in the doctor’s waiting room with urgent calls for immunisation against some threatened pandemic can start the blood pressure rising. The notorious poster showing an aorta being squeezed of a white, fatty substance is enough to make us bring up the porridge we had that morning. Recently, while waiting for someone in a colonoscopy area, I had little choice but to read a poster on the many diseases of the colon. It was not consoling by any means and would be better suited in a medical student’s study. Being an artist, it might be thought that I’m a little biased about what should hang on walls, but I speak from experience too. It’s nearly 20 years since my father-in-law died in a hospice. A memory that has stuck with me over the years was the comfort I found in a Monet print in the corridor just outside his hospice room. It was a painting that the soul could enter into and, for a few moments, escape the heaviness of his impending departure. More or less, that’s the good a painting can do in a waiting room. The healing process can begin in the mind, and where better to start than before a patient even says hello to the doctor. Artworks on the waiting room walls, whether prints or originals, are places that we can walk into and feel becalmed. Better still are paintings of local places such as beaches that are likely to strike a chord and evoke happy memories. Having appropriate works of art on your walls is, in effect, an unwritten prescription for peace for those who enter your doors. Indeed, why not go the extra mile by printing up miniatures of the paintings (with the artist’s permission) and handing one to patients as they leave, or sending it with any correspondence? This will reinforce the pleasant experience of the waiting room, which might then spread among their peers. Your surgery is but a few well chosen works of art away from being a much more enjoyable place for patients and staff. The Bluff (Mike Barr) Dune path, Victor Harbor (Mike Barr)

Mike Barr

To the Editor: With ageing and population growth, the number of people with disabilities is rising. By 2010, it is projected that 1.5 million Australians will have severe or profound limitations to core activity in the areas of self-care, mobility and/or communication.1 In 1976, the United Nations proclaimed that 1981 would be the International Year of Disabled Persons, with the aim of promoting the rights of all people with disabilities to participate fully in society and to enjoy living conditions equal to those of other citizens.2 Yet today, more than 30 years later, even in a country as affluent as Australia, families struggle to care for children with disabilities, ageing parents look after adult children, and middle-aged people have their lives put on hold while caring for partners or parents with disabilities. Every aspect of life is affected, including physical and psychological health, employment prospects, and the ability to take holidays and maintain social relationships. While the physical and emotional demands can never be underestimated, an added pressure is the huge financial impact on every family affected by disability. Homes are mortgaged, endless time is spent securing funds for essential equipment, and some individuals reluctantly share their plight with the media. The time is right to reform the disability sector. We need to shift from the current crisis-driven welfare approach to a planned and fully funded national disability insurance scheme (NDIS) that will underwrite sustained, significant, long-term improvements in meeting the needs of people with disabilities. The models for an NDIS already exist, with fully funded no-fault insurance schemes for people injured in the workplace and in car accidents in several states and territories. At a forum in October 2007, National Disability Services (the national industry association for disability services) supported the extension of coverage provided by road accident insurance schemes to new groups, a proposal that was endorsed at the recent Australia 2020 Summit.3 The NDIS could be funded from a number of sources, including a supplement to the Medicare levy, third-party car insurance or workplace insurance. The costs would be modest and the benefits significant, because an NDIS would be more equitable than current arrangements (whereby a few achieve multimillion-dollar payouts and many others in similar situations receive nothing), and would enable people with disabilities and their families to be in control, make choices and plan their lives with confidence.

Dinah S Reddihough · Bruce P Bonyhady

The phrase “cut to the chase” is thought to have originated as a script direction in early silent films which, after some romantic meanderings, would often climax in chase scenes.1 The phrase’s figurative meaning — to get straight to the point — emerged by the 1940s, and is very popular with MJA medical editors today when advising aspiring contributors. We like original submissions that are pithy and leave no doubt as to their intention. We happily share the following delightful observations received in Journal correspondence this year that relate to various aspects of medical publishing. Not one “beats around the bush” (but that’s another story). Introductions: how to charm an editorThe cover letters that accompany submissions to the Journal tend to follow a standard format. However, on occasion, one does stand out from the crowd: Author: I have not been [to] your beautiful country yet, let my words visit it first. (Editor’s note: This paper did not proceed to print in the MJA, as it did not meet Journal criteria for publication.) Methods: you’re not fooling meReviewer: Certainly the authors used both quantitative and qualitative approaches, but the mere conjunction of such approaches in the one study does not constitute a mixed-methods approach. By their demonstration, throwing flour, eggs and water in a bowl will produce pasta. Not unless some skill and care is applied, I’m afraid! Results: please explainReviewer: The comment about the average 22% overall growth in physician service provides no timescale for this growth. I certainly hope it is not annual or we will all be very busy. Discussion: enough is enoughReviewer: It is ... irritating to have studies call for [general practitioner] education, when GPs educate themselves silly, to, apparently, little avail. Is there no better way to change activity? Conflict of interest: pardon meReviewer: I wrote the reference I’m recommending, but it IS the best paper on the subject out of Australia. (Editor’s note: The “best paper” HAD won an award.) Conclusions: you asked for itReviewer: In direct answer to your question about whether this submission has “legs”, I believe it’s safe to say that if this submission were a dinner table, the guests would be eating on the floor. To the Editor: you’ve got to be kidding me!Author’s reply: I find it very hard to respond briefly (and politely) to a letter which, in misreading, misinterpreting and misquoting what I have written, sets me up as a straw man to be knocked down. End noteReviewer: I’ll stop this review before it’s longer than the worthwhile parts of the paper under consideration.

Ann T Gregory MB BS, GradDipPopHealth

Dissection. Jacinta Halloran. Melbourne: Scribe, 2008 (233 pp). ISBN 978 1 921372 12 4. Until 3 years ago, Dr Anna McBride was achieving her life’s ambitions: partner in a suburban general practice where she felt she did well for her patients, marriage to a successful architect, two healthy sons, a network of friends and relatives . . . Then 17-year-old Ben Feltham walked into her consulting room with a pain in his knee, a pain she failed for 7 months to diagnose as the osteosarcoma it proved to be. Now Anna awaits the mediation hearing in a negligence case brought by the young man’s mother. However, Dissection is no episode of the television series MDA in novel form. Halloran’s intentions are more complex: she wants to analyse what happens to the doctor’s persona following an accusation of professional negligence. Deftly she wields the sharpest of scalpels as she follows Anna’s daily life, at home and in her practice, over several months before the hearing. Guilt, remorse, anxiety and self-doubt are all exposed as Anna questions her decision to study medicine, her clinical knowledge, and her ability to combine her roles as wife and mother with being a “good” doctor. Halloran’s portrayal of Anna is both forensic and sympathetic — all readers, but especially other women doctors, will identify and empathise with her. Some particularly good passages come from Anna’s interactions with women undergoing pregnancy, miscarriage or menopause, which cause her to reflect on her own experiences of sex, motherhood and the gradual loss of fertility. Yet, Halloran’s touch is always light — this is a good Christmas stocking-filler and holiday read. A minor complaint: there is another, intriguing background story that I won’t give away, in which the characters might have been more fleshed out. Overall, though, a very good first novel, with hopefully more to come as Halloran, herself a general practitioner, explores other aspects of the medical life.

Caroline M De Costa

Round the red lamp. Arthur Conan Doyle. Robert J L Darby, editor. Chicago: Valancourt Books, 2007 (xxiv + 320 pp). ISBN 0 9792332 7 5. Certainly not in the 1890s, or at least, not with any sense of realism. Better known for his Sherlock Holmes series, Conan Doyle shocked Victorian England with his collection of short stories about medical matters, with its graphic descriptions of diseases and medical disasters, and a somewhat jaundiced view of his own medical profession. This was a view that did not sit well with the romanticised image of doctors at the time. From a modern physician’s perspective, this collection offers some intriguing insights: a wide range of physician and surgeon capabilities and personalities remain unchanged. Further, our view of our colleagues of 110 years ago may well be close to Conan Doyle’s. I found fascinating their knowledge, or lack thereof, of aetiology, diagnosis and management of diseases. Medicine practised day to day was notable, such as the preponderance of home visit-based practice, surgery as a spectator sport, and the lack of regulation or accountability (yes, quackery was even more widespread then than it is now!). The stories themselves vary quite a deal in subject, length and quality. The better of them draw complex characters (both doctors and patients), discuss difficult social and medical issues, and do not pull punches. Others are overly sentimental and simplistic, venturing back to the more traditional territory of medical fiction of that century. This patchiness would draw me to conclude this collection is more fascinating as a piece of medical history than as a work of great fiction. Yet there are some very entertaining stories that will resonate long after they are read, and may well cause a medical reader to reflect on what is the true role of the doctor. Who knows, I might start doing more home visits!

James A Best

As the Christmas holiday season approaches, many MJA readers may be feeling uncertain about the future. Will doctors be replaced by nurse practitioners, help lines and computers? Will we outlive our dwindling superannuation stashes? Will the Wallabies ever beat the All Blacks? In such times of uncertainty, humour can be a blessed refuge, which might explain the deluge of entries for this year’s Christmas Competition. Never before have we been forced to be so selective. Of course, the idea that you can clown around and still be a serious person is not new. If we all lived according to Nietzsche’s pronouncement that ... we should consider every day lost on which we have not danced at least once. And we should call every truth false which was not accompanied by at least one laugh we would probably have a lot more fun (as long as we ignored most of the other things he said). Some of this year’s entrants, such as Nair, who thinks the call for the medical profession to emulate the aviation industry might have gone too far (→ Flying and medicine: mutual lessons), and Young et al, who have put continuous positive airway pressure machines to a novel but thoroughly ridiculous use, obviously adhere to this philosophy (→ Blowin’ a blizzard in Brissie). Others, such as Kitzing and McCormack, remind us that too much frivolity where pressurised air is concerned can be dangerous (→ Pneumoperitoneum: a non-surgical cause), as can multi-tasking while tossing back festive fare (Buchholz and Rudan, “Foreign body inhalation: a nut in the tree”). As a research journal, we always look forward to your quirky studies, and this year’s entries did not disappoint. Bolland et al have failed to demonstrate a selection advantage to male-pattern baldness (who says medical journals don’t publish negative studies?) (→ Does degree of baldness influence vitamin D status?), and Barnett et al have demonstrated, with the aid of a multicoloured six-legged “spider”, that the odds of being discharged alive from a London hospital’s intensive care unit on the weekend are not good. (→ Hospitals are dangerous places) Uncertainty can also create opportunities for serious creative reflection. The devastation of the Boxing Day tsunami in his homeland caused Fernando to question whether he had fulfilled his true purpose in life (→ A sonnet to a doctor’s epiphany); Barr challenges the need for alarmist messages in doctors’ waiting rooms and suggests we replace them with carefully chosen artworks (→ The positive power of paintings); and Whitehall reflects on the extraordinary lengths he and his team went to in order to cushion the grief of a dead baby’s parents — and the miraculously unexpected outcome (→ No ticket for a corpse). Of course, situational humour is the bread and butter of the Christmas Competition. We enjoyed conjuring a mental image of Miller’s paediatric patient being restrained by a “bear” (→ Occasional assistance needed for general practice) and Tuck’s painful tale of self-diagnostic uncertainty (→ Kid stone: a tale of valour and writhing agony). The yearly ritual of the secret ballot revealed, however, that our favourite story by far was that of Geoffrey Mullins’ experience with porcine anaesthesia in a teaching hospital, which wins the written part of the competition (→ Pigs, burns and curly tails). We learned a great deal from this story, and are proud to be the first journal in the world to publish the Mullins sign, the use of which we hope will spare many piglets from awareness under anaesthesia. The winner in the image category is Neil Sharma, whose patient’s eye ultrasound demonstrated more than he bargained for (→ Baby in the eye?). It is Christmas after all and, Nietzsche aside, nobody can resist the appeal of a baby in a manger. Each winner will receive an Australian-themed hamper to enliven their Christmas celebrations. A final thought for troubled times: Uncertainty and mystery are energies of life. Don’t let them scare you unduly, for they keep boredom at bay and spark creativity. Robert I Fitzhenry If the pundits are correct, we can expect even more wonderful entries for next year’s competition. Now there’s something to look forward to! Dr Ruth Armstrong, MJA

Ruth Armstrong