Volume 190 Issue 2

Redressing the imbalance between community expectations and the capacity of the hospital system to meet them will require more than recommendations for prescriptive frameworks and practices Should a Martian dispatched to report on the state of Australia’s hospitals happen to land in New South Wales, the nation’s most populous state, his report would be pertinent and predictable: Public hospitals are severely stressed and sick. They are afflicted by bureaucratic inertia, and riven with mistrust, poor communication and bullying. To add to their woes, they are chronically under-resourced and understaffed. To the outsider, they appear to be a collection of islands, with health professionals on one island, and administrators, health boards and bureaucrats on others; all are surrounded by seas of silence. Their political masters are at a loss over what to do or where to turn and, in desperation, they resort to conducting inquiries when media reports of adverse hospital incidents become political millstones. In short, there is a pervasive sense of loss — loss of control, loss of direction, and loss of ownership by the hospitals’ serving health professionals, politicians, and the community they are meant to serve. The Martian is puzzled by this loss and the state of public hospitals. Is this harsh judgement reflective of an extraterrestrial mind, or is it accurate? The tenor of recent hospital-related media headlines or the frequency of high-level hospital inquiries may shed some light on this question. A sample of the former include: Packed hospitals cause 1500 deaths;1 Public hospitals on ‘brink of collapse’;2 Sick opt to walk out of hospitals — long delays in emergency wards;3 Loss of morale driving doctors out;4 Doctors seek cure for bullying;5 Minor cases clog hospitals;6 Longer wait for elective surgery;7 and Westmead doctors seek boss’s removal.8 As to high-level hospital inquiries, there have been no less than three in NSW in the past decade: the Walker Special Commission of Inquiry into Campbelltown and Camden Hospitals in 2003;9 a NSW Parliament Joint Select Committee (chaired by Revd Hon Fred Nile) convened in 2007 to conduct an inquiry into the quality of care of Jana Horska, who had a miscarriage in the emergency department toilets at Sydney’s Royal North Shore Hospital (RNSH);10 and, in 2008, the Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals, led by Peter Garling SC.11,12 This inquiry followed a coronial investigation into the death of Vanessa Anderson, a young patient at RNSH, following a head injury inflicted by a golf ball. In his findings on the Anderson case, NSW Deputy Coroner Carl Milovanovich noted that: There is little doubt that the NSW health system, while certainly staffed by dedicated professionals, is labouring under increased demand and expectations from the general public. Unfortunately, the same issues are invariably identified: not enough doctors, not enough nurses, inexperienced staff, poor communication, poor record keeping and poor management. These are systemic problems that have existed for a number of years and regrettably they all surface in the death of Vanessa Anderson ... it is almost impossible to avoid comment on the unfortunate repetition of the same systemic problems that continue to surface ... the Government of the day has the responsibility to provide adequate resources, training and staff to ensure the delivery of appropriate and timely medical services.13 In short, Coroner Milovanovich poignantly described a system failing because the demands on it exceed its capacity to deliver safe and quality services. On the same day that he delivered his findings, the NSW Labor Government announced the Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals (the Garling inquiry). In this issue of the Journal, Clare Skinner and her colleagues from the Hospital Reform Group provide a synopsis of the main recommendations of this inquiry.14 The Garling report is in desperate need of such a synopsis. In his opening statement, Garling is nothing if not disingenuous, nonchalantly noting that his report is “voluminous and detailed”. My copy of the report weighs nearly 3.5 kg! Leaving aside the 64-page “overview”,12 there are three substantial volumes comprising 1195 pages, accompanied by an incredible 139 recommendations.11 This represents the outcome of reviewing more than 1200 written submissions from more than 900 individuals and organisations, listening to more than 600 citizens in public hearings, making 61 visits to public hospitals, conferring with 27 peak bodies, and holding two conferences — and all in just 10 months.15 Notwithstanding the importance of such activities and the gravity of the resultant report, it provokes issues worth exploring. Inquiries serve multiple complex purposes, including learning, discipline, catharsis and reassurance.16 But an overriding purpose is to establish the truth and to recommend change, seeking to eradicate the shortcomings of the past by creating a more effective and efficient system. In some respects, reports of inquiries are like science. Science seeks the truth, but does not become science unless it is published, widely read, and widely accepted. Important to its reception and wide dissemination are the essential reporting qualities of focus, brevity, clarity and conciseness. These are hardly descriptors of the Garling report! One may well ask who has both the time and the stamina to read a report exceeding 1200 A4 pages. A further complication lies with the very people who are to be instrumental in implementing the recommendations. Hardworking health professionals, including those who have been swept up in the intense scrutiny of the system in which they valiantly try to operate, may be understandably sensitive to criticism and additions to their already burdensome workloads. Furthermore, most health professionals now support the principles of evidence-based medicine, with its taxonomy of levels of evidence. In contrast, the Garling report is based on broad consultation and represents the distillation of a constellation of opinions — the lowest tier in the levels of evidence. As such, it raises the spectre of the ancient Greek philosophical debate as to whether any consensus of opinion is necessarily synonymous with the truth.17 In any event, the report’s lightning rods for change are the 139 recommendations (many with extensive subclauses), and herein lies another problem. The recommendations are presented with no sense of priority and, curiously, are not costed. Finally, while acknowledging that policy formulation is easy and implementation is hard,18 the report is resoundingly silent on the details of implementation, beyond stressing the need for independence and auditing of the process. In this issue of the Journal, Stewart and Dwyer explore some of the conditions that have to be satisfied if the implementation of Garling’s recommendations is to cure the sicknesses of NSW public hospitals and, for that matter, hospitals nationwide.19 The report unearths little that is new in the Australian hospital system that has not been broached by publications in the Medical Journal of Australia over the past decade or so. It aims to increase the efficiency and effectiveness of the current system by way of recommendations directed at optimising health through prescriptive frameworks and practices. It offers little in the way of modifying community and hospital cultures that are trapped in the prevailing imbalance between community demands and expectations and the capacity of the hospital system to satisfy these demands. The Garling recommendations touch ever so briefly on this disconnect; but these cultures can only begin to be addressed more fully by communicating the essence of the report to both the community at large and to all health professionals. Furthermore, we need to move beyond treatment of the symptoms of hospital diseases and determine if there is a commonality of their root causes. This analysis would also inform culture change. For now, Garling’s recommendations need to be prioritised and scrutinised for their ability to actually deliver an improvement in the quality and safety of NSW public hospitals. It is imperative that these recommendations (which are essentially only suggestions) be evidence-based, reality-tested and rigorously debated by health professionals working at the coalface in broad consultative forums, such as the well attended NSW Health Ministerial Forum held in Sydney in December 2008. Will any of this satisfy our observant extraterrestrial Martian? Will the Garling inquiry make a difference to the cultures of health care? We need to know what the state apparatus thinks. As Skinner and colleagues note: “The response from the state government looms as very important, and is eagerly awaited”.14

Martin B Van Der Weyden MD, FRACP, FRCPA

Women pay more than men for health insurance in the United States. Much, much more. This issue might be hard for Australians, covered by Medicare and community-rated private health insurance, to understand. Women’s health floods the media in New York City, and you can learn a lot from the information provided — newspaper articles, television programs and advertisements. Pharmaceutical companies are allowed to advertise drugs on television, hospitals advertise in the newspapers, and doctors advertise on the subway. Women are prominent in ads for antihistamines, antidepressants, analgesics and heartburn treatment. Even the ads for Viagra, Cialis and Levitra are filled with smiling, contented women. I regularly read the New York Times. (What else would a university academic read while living in New York City?) The Times has had several recent articles detailing the problems women have with health insurance. One of these articles1 suggests that women insured with individual policies from health insurance companies pay between 22% and 49% more than men for the same policy. The data come from the companies’ websites. You might think it’s because women get pregnant. Many US health insurance policies specifically exclude maternity care or charge a significant extra fee for it. But, even excluding maternity care, health insurance is more expensive for women. The insurance companies argue this is based on actuarial data. Women go to the doctor more than men; they take more medication and are more likely to have regular check-ups than men; they have illnesses caused by pregnancy (some policies cover complications of pregnancy but not pregnancy itself); and they go to doctors for regular reproductive care (contraception, Pap smears, mammography). A quote by Mr Bykerk, a former executive of Mutual of Omaha, starkly demonstrates the differences in the US and Australian approaches to health care and health insurance: “If maternity care is included as a benefit, it drives up rates for everybody, making the whole policy less affordable”.1 In Australia, in terms of health care, we are all in it together. In the US, the land of opportunity and free enterprise, you are on your own. However, the US is not monolithic. In some states (New York included) it is illegal to have sex-based individual health insurance premiums, and insurance obtained through an employer is not sex-based. We must be very careful in Australia not to mimic this very negative aspect of the US health care system. It turns out that the same type of actuarial arguments were used to justify race-based insurance premiums in the US many years ago. There are many effects of this insurance system. Today I learnt, much to my surprise, while watching one of my 500 channels of cable TV, that uninsured women cannot get mammographic screening for breast cancer unless they pay. I’m not sure why this aspect of the US health care system surprised me more than other features. Just because it’s in the public interest to reduce the risk of morbidity and mortality from breast cancer doesn’t mean that the public here thinks the government should pay for it. Most of the people I speak to have similar views: “You should be responsible for your own health care and make provision”, “Why should the government pay for you?”, and “I don’t want the government interfering in my health care”. This is from the people I deal with here — educated, urban, slightly left-leaning academic folk. I’m not sure what the rest must think. St Vincent’s is my local hospital. On the TV news I learnt that it offers free mammographic screening for women without insurance. Unfortunately, they do only 250 of these mammograms a year because someone has to pay and, despite fundraising, 250 is all they can afford. This project was started by an uninsured woman who had breast cancer diagnosed by mammography, for which she had to pay out of pocket. The perceptive among you will instantly be wondering how she paid for her treatment. Answer: she got married 3 weeks after diagnosis and was therefore covered by her husband’s group plan! This would not happen in Australia, although of course we have Medicare and the public hospital system available for those without insurance. A major strength of the Medicare and BreastScreen programs in Australia is the ability to pursue such public health screening activities. Indeed, this is one of the best features of the Australian health care system, and you might say it is the role of a civilised society to provide this. On the other hand, one of the strengths of the US health care system as it relates to women is its massive commitment to research, both publicly funded and privately funded, and the rapidity with which new treatments are introduced and paid for. Studies such as the Women’s Health Initiative trial of hormone replacement therapy2 could have been done nowhere else. Although the results were negative, they clarified a very important women’s health issue. The funding available for breast cancer research in the US is staggering by Australian standards. Speaking as one who has done research (though not on breast cancer) for 25 years, the feeling that there is never enough research funding is deeply ingrained in me. Here in the US, the best cancer treatments in the world are available and almost all are developed here — it’s just that they’re not available to everyone. Although there are many aspects of the US health care system that Australians would not wish to imitate, we can learn from the US about the importance of adequate research funding for women’s health. We need to find better ways of increasing both public and private money for this purpose. As for the cable TV, I must admit I have 500 channels in Melbourne as well. I am busier at home and can’t make comparisons, but we do seem to follow the US in our TV programming. In which case, I have seen the future and it is bleak.

Jeffrey D Zajac MB BS, FRACP, PhD

Objective: To estimate costs of retrieval, transport and acute medical services associated with road crashes in northern Queensland from March 2004 to June 2007.Design, setting and participants: Case study of 696 people aged 16 years or older who had been involved in a road crash in the study area (all areas north and west of Bowen, excluding the urban areas of Townsville and Cairns) and had been admitted to hospital for a minimum of 24 hours after the crash. Data on mode of retrieval, acute care provided and total costs were obtained for each patient.Main outcome measures: Method of retrieval or transport; length of stay in intensive care unit (ICU) and/or hospital for each patient; costs of retrieval, transport and inhospital care.Results: Retrieval data were collected for 614 of the 696 study participants (88%). Most primary retrievals (446; 73%) occurred by road. More than half of interhospital transfers were undertaken by fixed or rotary wing services. Casualties in the study occupied a total of 6360 bed-days, of which 734 were ICU bed-days. The total retrieval, transport and acute hospital care costs of road crash victims in northern Queensland over the study period were calculated to be approximately $10.4 million.Conclusion: The costs associated with rural and remote road crashes in northern Queensland represent a considerable economic burden.

Teresa M O’Connor DPhSt, MPH · Heather A Hanks BMedSc(Hons) · Mark S Elcock MB ChB, FACEM, FCEM · Richard C Turner MB BS, BMedSc, FRACS · Craig Veitch DipAppSc(RT), BA(Hons), PhD

Objective: To explore the experiences of families with a baby with Down syndrome at the time of diagnosis, and their preferences for information and support in the early period after diagnosis.Design, setting and participants: A qualitative, interview-based study of 18 families living in Victoria with a child with Down syndrome born between 2002 and 2004 who had not been diagnosed with the syndrome before birth. Interviews were transcribed verbatim and interpretive content analysis was undertaken.Results: Parental coping with the unexpected diagnosis of Down syndrome in their infant was influenced by the time interval between birth and disclosure of clinical suspicion of Down syndrome, the level of certainty of the attending physician at the time of disclosure, and the time interval between disclosure of clinical suspicion and confirmation of karyotype. Initial uncertainty and a delay in the diagnosis were detrimental to parental coping, as was premature communication of the news. Perinatal complications increased parental anxiety regarding their child’s condition and future. Individual communication style of midwives and physicians was a powerful predictor of parental adaptation. Parental needs for support and information were facilitated through normalising postnatal care, ensuring privacy, and providing early access to peer support and up-to-date written information. Many parents would have appreciated access to a liaison worker.Conclusion: The experiences of parents in this study provide practice points for improving postnatal care with minimal changes to formal service systems.

Evelyne E Muggli MPH · Veronica R Collins PhD · Catherine Marraffa FRACP, FRCPCH

Objective: To explore the experiences of patients with acne, psoriasis or atopic eczema in their relationships with their treating doctors.Design: Qualitative study, using semi-structured interviews conducted between January 2004 and April 2005, thematic analysis and modified grounded theory methodology.Setting and participants: Participants were patients with acne, psoriasis or atopic eczema recruited from urban general practices and urban dermatology practices.Results: 62 semi-structured interviews were conducted. Reports of negative experiences with doctors treating participants’ skin conditions were common. Both general practitioners and dermatologists were reported as having poor comprehension of the psychological implications of skin diseases, being insensitive to their patients’ emotional suffering, and trivialising participants’ disease. Participants acknowledged that time considerations and other pressures may explain these apparent deficiencies. Some participants perceived their doctors as medical technicians and sought treatment for their physical skin disease, not for its emotional or social aspects.Conclusion: We recommend education for GPs about the psychological effects of skin diseases, and education for dermatologists and GPs on how to elicit and manage, or appropriately refer, these problems.

Parker J Magin PhD, DPD, FRACGP · Jon Adams MA, PhD · Gaynor S Heading BA, GradDipHSS(MSS), PhD · C Dimity Pond MB BS, PhD, FRACGP

Objective: To seek the views of patients attending general practice about doctors’ interactions with the pharmaceutical industry and their wishes for disclosure of this information.Design, setting and participants: 906 patients attending three general practices in metropolitan Sydney during October –November 2007 completed an 18-item anonymous survey exploring their perceptions of doctors’ competing interests.Results: Most patients (76%) were unaware of any relationship their doctor may have with pharmaceutical companies. Patients wanted to know if their doctor obtained any benefits in cash or kind from the pharmaceutical industry (71%), financial incentives for research participation (69%) or sponsorship to attend conferences (61%). Most agreed that disclosure of competing interests by doctors is important (84%), believing this disclosure would help patients make better informed treatment decisions (78%). Eighty per cent of patients stated that they would have more confidence in their doctor’s decisions if interests were fully disclosed, with strong support for verbal disclosure during the consultation (78%).Conclusions: Patients are currently not aware of their doctors’ competing interests but do want to know of doctors’ interactions with the pharmaceutical industry, indicating that disclosure of competing interests would improve their confidence in doctors’ decisions.

Martin H N Tattersall MD, FRCP, FRACP · Aneta Dimoska PhD · Kevin Gan LLB

Objective: To characterise the demographic and psychosocial circumstances of women contacting Victoria’s largest public pregnancy advisory service (PAS).Design and setting: Audit of PAS electronic records for the 12 months from 1 October 2006 to 30 September 2007. De-identified data were extracted from a comprehensive electronic database used for recording consultations.Main outcome measures: Summary statistics and measures of association.Results: During the 12 months, 5462 women contacted PAS; records were created for 3827 women, and data were available in more than 80% of records for 77% (13/17) of items. Over half of the women receiving pregnancy support from PAS (60%) were 18–29 years old; 12% lived outside the metropolitan area; 51% held a health care card, and smaller percentages faced housing, financial, or drug and alcohol problems; 16% reported violence, but 71% described partners as involved and supportive. Most (79%) made contact within 2 weeks of discovering pregnancy, and 72% were referred by a general practitioner. Later gestation at contact was associated with younger age (P < 0.001), having a health care card (P < 0.001), and living outside the metropolitan area (P < 0.001). The most common reasons for seeking abortion were the desire to delay pregnancy (23%) and family completion (18%); 42% already had at least one child. Twenty-three women reported that the pregnancy was the result of rape. Ten per cent had mental health problems, and smaller numbers faced access barriers and had special needs.Conclusions: This PAS responds to demand from women with diverse social and personal circumstances. Findings provide evidence for policy, prevention and service development.

Heather J Rowe BSc(Hons), PhD, MPHAA · Maggie Kirkman BA(Hons), PhD, MAPS · E Annarella Hardiman BSA, MSW, MAASW(acc) · Shelley Mallett BAppSci, BASoc, PhD · Doreen A Rosenthal BA(Hons), PhD

In this 21st century, we will need to better analyse the outcomes of our spending on newer and more expensive anticancer drugs, particularly through postmarketing assessment, to ensure that these investments are justified. Evidence-based medicine is only as good as the evidence available, and we advocate for more independently designed and funded trials that concentrate on the minimum effective dose and duration of therapies to reduce toxicity to patients and to control costs. There is a place for governments to provide funding for these studies in the public good. Although improving survival over standard care is the gold standard for proving the efficacy of a new therapy, surrogate endpoints such as early biological marker changes, functional imaging changes or earlier measures such as progression-free survival must be investigated to enable drug therapies to be discontinued earlier if they are ineffective. Studies searching for the presence of biological targets must be funded to exploit the potential advantage of targeted therapies. Treatment guidelines are best written by experts who are independent of the pharmaceutical industry. Existing databases should be linked to better monitor the outcomes of new therapies. Privacy safeguards are important, but privacy legislation may need to be modified to serve the greater public good from the information gained from linking databases.

Ian N Olver MD, PhD, FRACP · Ian E Haines MB BS, FRACP, FAChPM

The final report of the Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals was published on 27 November 2008. The report acknowledges the challenges facing the New South Wales health system, including increasing numbers of patients, rising treatment costs, workforce pressures, and the breakdown of working relations between clinicians and management. Many of Commissioner Garling’s 139 recommendations formalise aspects of clinical care that should and could be happening now if the system were better managed, including better supervision and training of junior staff. Commissioner Garling recommends that change should be driven by clinicians “from the bottom up”, but does not adequately describe how this should happen. Implementation of the report’s recommendations that will require strong leadership and continuing consultation with clinicians and the community.

Clare A Skinner BA(Hons), MB BS, MPH · Jeffrey Braithwaite MIR, MBA, PhD · Brad Frankum BMed(Hons), FRACP · Ross K Kerridge MB BS, FRCA, FANZCA · Kerry J Goulston MD, FRACP

Public hospital clinicians across Australia will relate to the problems described in the Garling report and endorse most of the recommendations to bring the system “back from the brink”. Implementation is feasible but requires substantial culture change, which must re-engage clinicians and stem the flow of desertion to the private sector. It must also address the fundamental causes of the current crisis. Key recommendations involve a substantial change in governance, with a transfer of many areas of the New South Wales Department of Health’s responsibility into four board-governed statutory authorities, where equal partnership between clinicians and managers will exist. Of Garling’s “four pillars of reform”, the greatly expanded role for the current clinician-led Greater Metropolitan Clinical Taskforce is a strong indication of the seriousness with which the Commissioner viewed the clinician–manager divide (which he likened to the Great Schism of 1054). The major omission in implementation is a failure to adequately address the loss of local accountability in hospitals since the abolition of area health service boards. Major change can occur without additional funding, but without substantial new money from the Australian Government, the public hospital system will not be pulled back from the brink. A better opportunity for true partnership of such importance between state and federal governments may not come again before it is too late.

Graeme J Stewart AM, FRACP, PhD, FRCPA · John M Dwyer AO, MB BS, FRACP, PhD

Objectives: To describe rates of occurrence of falls, injuries and fatalities to horse-racing jockeys in Australia.Design and setting: Retrospective analysis of data on race-day falls from stewards’ reports provided by the Principal Racing Authority of each state and territory of Australia, August 2002 – July 2006.Main outcome measures: Fall, injury and fatality incidence rates; comparison with overseas rates.Results: There were 3360 jockey falls from 748 367 rides. Falls occurred at a rate of 0.42 per 100 rides in flat races and 5.26 per 100 rides in jumps races. In flat racing, 54.6% (1694/3101) of falls occurred before the start of the race and 11.1% (344/3101) of falls occurred post-race. The 34.3% (1063/3101) of falls that occurred during flat races resulted in 61.7% (516/836) of the injuries sustained. In jumps racing, most falls occurred at a jump and 9.7% (25/259) of jockeys who fell were transported to hospital and/or declared unfit to ride. There were five fatalities resulting from falls during the study period, all in flat racing. Fall and injury rates were comparable with those found in the United Kingdom, Ireland, France and Japan.Conclusions: Being a jockey carries a substantial risk of injury and death. Although rates of injury in Australia are not exceptional by international standards, there can be improvement to safety standards in the Australian racing industry.

Peta L Hitchens BAppSci(Equine), MVPHMgt · C Leigh Blizzard PhD · Graeme Jones MMedSc, MD, FRACP · Lesley M Day BSc(Hons), MPH, PhD · James Fell BEd, MPhil, PhD

Objective: To characterise injuries sustained in basketball and netball that result in hospital admission and to compare the profiles of injury between the two sports.Design and setting: Population-based retrospective descriptive epidemiological study using data from the National Hospital Morbidity Database, July 2000 to June 2004.Participants: Patients discharged from a public or private hospital with basketball or netball codes as the “activity when injured”.Results: There were 5090 basketball-related hospital admissions (mean patient age, 22.2 [SD, 10.7] years; 71.5% male) and 4596 netball-related admissions (mean patient age, 26.3 [SD, 10.9] years; 88.9% female). Fractures were the most common injury (46.8% [2384] of basketball-related and 29.5% [1358] of netball-related admissions), with the forearm and hand or wrist the most common fracture sites. The participant-based forearm fracture hospitalisation rate (5 + years age group) peaked in the 5–14-years age group. Anterior cruciate ligament rupture was the most common diagnosis, accounting for 760 (16.5%) netball-related admissions (mean [SD] age, 26.7 [8.4] years) and 354 (7.0%) basketball-related admissions (mean age, 25.5 [7.9] years). Achilles tendon injury accounted for 732 (15.9%) netball-related admissions (mean age, 35.2 [7.5] years) and 381 (7.5%) basketball-related admissions (mean age, 35.8 [7.8] years).Conclusions: The high rates of anterior cruciate ligament rupture and Achilles tendon injury resulting in hospital admission and their long-term consequences impact extensively on the individual and the community. The common injuries sustained in basketball and netball were strongly age-related.

Louise Flood MB BS · James E Harrison MB BS, MPH, FAFPHM

Objective: To determine the prevalence of elevated troponin levels after a marathon, and test for an association with reduced renal clearance.Design, setting and participants: Prospective observational study of entrants running the full (42 km) 2007 Perth Marathon, Western Australia.Main outcome measures: Elevated troponin levels (≥ 0.1 μg/L) after the race; pre- and post-race survey data, and biochemical parameters.Results: 27% of runners (92/346) enrolled in the study, of whom 88 (96%) completed it. Most were men (71%; 65/92); mean age was 43.1 years (SD, 9.8 years; range, 25–64 years) and mean body mass index (BMI) was 24.1 kg/m2. Raised troponin levels were seen in 32% of participants (28/88), the highest being 1.4 μg/L. The strongest predictor for developing elevated troponin levels was a decrease in weight (odds ratio [OR], 2.15; 95% CI, 1.27–3.65). Creatinine increase was also associated with elevated troponin levels (OR, 1.03; 95% CI, 1.01–1.06), but pre-race estimated glomerular filtration rate, age, sex, BMI, training factors, marathon experience and race time were not. Most runners (99%; 87/88) had elevated levels of ischaemia-modified albumin after the race.Conclusions: Troponin level increases were common among marathon finishers. The strongest predictors were weight loss and an increase in creatinine levels, suggesting that reduced renal clearance is an associated factor. Further study is needed to determine the clinical significance of these findings, and to understand the mechanism.

Kelley M Hubble MB BS · Daniel M Fatovich MB BS, FACEM · Jonathon M Grasko MB BCh · Samuel D Vasikaran MD, FRCPA

Henry Handel Richardson’s 1929 novel Ultima Thule, the third volume of The fortunes of Richard Mahony, portrays the final years of Mahony’s failed 19th century colonial venture and the psychological challenges he faced. The novel graphically describes the onset and evolution of younger onset dementia, modelled on the author’s own experiences with her father, who died of general paresis of the insane. The issues on which Richardson focuses, including Mahony’s depression and suicidal despair, the difficulties of understanding behavioural change without a diagnosis, the impact of parental dementia on young children and the spouse, and the importance of person-centred care in dementia, remain relevant today.

Brian M Draper MB BS, MD, FRANZCP

Final exam: a surgeon’s reflections on mortality . Pauline Chen. London: Souvenir Press, 2008 (xv + 267 pp). ISBN 978 0 28563 811 2. Although it is more than 40 years since I graduated, reading A surgeon’s reflections on mortality revived memories of my own undergraduate and postgraduate years. Replete with detailed recollections of the author’s initiation into medicine and specialist practice, this is more than a trip down memory lane. At its heart resides a concern that many will, as was the case with the author, find challenging and unsettling. Pauline Chen uses narrative and reflection to tell us of her transition from a frightened and anxious medical student to a compassionate transplant surgeon. The stories reveal a maturation process that inevitably leads her to evaluate the agendas that direct her life as well as her clinical practice. The journey brings her face to face with her own mortality and the realisation that to become a good doctor she needs to prepare for her “final exam”, namely her own death. The book ultimately confronts the issue of end-of-life care and, somewhat bravely, the author suggests it is not the disease process, place of death or service delivery but a doctor’s fear of and aversion to dying that influences outcomes. This, she asserts, is “the most difficult and fundamental human obstacle in changing end of life care.” Not everyone will agree with this conclusion, but the issues raised within the book cannot be summarily dismissed. Is it the art or the science of care that matters most? According to Ken Wilber, a transpersonal psychologist of some repute, the crucial ingredient is not the doctor’s bag with all its tricks but the holder of that bag. In “doctor speak”, this can be translated as “physician heal thyself”. Chen invites us to heal.

Michael P Barbato

On speed: the many lives of amphetamine. Nicolas Rasmussen. New York: New York University Press, 2008 (ix + 351 pp). ISBN 978 0 8147 7601 8. Amphetamines are highly topical in the Journal — recent articles have discussed the controversies of prescribing them for attention deficit hyperactivity disorder, and their associations with violence in emergency departments and criminal offending. This book situates current concerns about stimulant use in a historical context and, in doing so, crosses swords with the pharmaceutical industry. But Rasmussen also has insights into the past roles of military medicine and social concerns that might be exploited to increase market share for drugs that are sold for “aspirational” goals. The author’s background is in history and philosophy of science. His book is at times irritating, particularly with repeated and unconvincing efforts to calculate past consumption of stimulants in the United States. These quibbles are minor, however, for the scope of his work is provocative and applicable to other areas in which social mores and medicine interact. His premise — that amphetamines have been marketed and remarketed for dubious indications and social woes, rather than for medical problems — is appealing and his research painstaking. However, most intriguing is the discussion of marketing, of efforts to rebrand addiction as habituation, and of the evolution of life problems seen as warranting psychopharmacological intervention. Rasmussen makes a good case that patent medicines and their promises have been supplanted by amphetamines and related drugs. This is a well referenced and easily read book, which reminds the reader that uncritical acceptance of drug marketing is unwise. The book is not as tendentious as the works of David Healy or Peter Breggin, and for that is all the more compelling. Nevertheless, any doctor will be challenged by the ease with which novel drug indications are accepted and by the shifts in prescribing patterns, which remain so similar. Moral panics about drugs are reinvented by every generation, and Rasmussen admirably provides the historical setting for current anxieties about stimulants. Melbourne, VIC

Danny H Sullivan

To the Editor: A 50-year-old man presented with gynaecomastia and galactorrhoea, reporting diminished libido and energy over 12 months. Previous medical and psychiatric histories were unremarkable. The patient had a tender increase of the right breast tissue. His testes appeared normal. He had markedly elevated prolactin levels (410 μg/L; reference range [RR], < 15 μg/L) and decreased testosterone levels (5.6 nmol/L; RR, 10–33 nmol/L); results of other biochemical tests were unremarkable. Pituitary magnetic resonance imaging (MRI) showed a microadenoma. Cabergoline 0.5 mg twice weekly was commenced. One year later, the patient had normal prolactin (8 μg/L) and testosterone (14 nmol/L) levels. His libido and sexual function had improved — he claimed his “mates are envious”. MRI demonstrated no changes to the tumour. He was lost to follow-up. Five years after his last review, the patient re-presented with his estranged wife, who was concerned about changes to his behaviour after starting cabergoline. He had engaged in excessive casino and horse-racing gambling, resulting in financial losses (> $100 000), and excessive libido had led to hypersexual activities and divorce proceedings. His prolactin levels were normal (10 μg/L), but testosterone levels were low (8 nmol/L). Cabergoline was ceased. On review 3 months later, the patient’s change in behaviour was dramatic. All gambling and hypersexuality issues had ceased, and divorce proceedings were on hold. His prolactin levels had increased (78 μg/L); testosterone levels were unchanged (8 nmol/L). No changes were seen on MRI. Pathological gambling has been reported in patients with Parkinson’s disease who take dopamine agonists — particularly pramipexole but also cabergoline (4.5% of published cases).1 Most were also prescribed levodopa.1 A minority had concomitant hypersexuality.1 The prevalence of pathological gambling in patients with Parkinson’s disease has been estimated at 6.1%, compared with 0.25% in age- and sex-matched controls.2 There has been one published case report of pathological gambling (but not hypersexuality) following use of a dopamine agonist (cabergoline 0.25 mg weekly) for prolactinoma.3 However, the dose of cabergoline normally used in Parkinson’s disease is higher (0.5–6 mg/day).4 Normalising prolactin levels usually leads to increased libido and vitality, but not pathological gambling and hypersexuality. Our patient had not engaged in these activities before commencing cabergoline, and there was no personal or family history of psychiatric illness. Moreover, his testosterone concentrations during treatment ranged from low to low–normal, never high. His Naranjo score was 6, indicating a “probable” adverse drug reaction.5 No reduction in tumour size was seen, raising the question of a partial non-functioning pituitary adenoma. Cabergoline-induced pathological gambling and hypersexuality are probably under-reported, and physicians should consider screening for these in patients treated with dopamine agonists.

Henrik Falhammar · Jennifer Y Yarker

To the Editor: A 77-year-old woman with a history of idiopathic long-QT syndrome (presumed genetic) presented to hospital with a storm of defibrillator shocks from her implantable cardioverter defibrillator (ICD). She had a single-chamber Guidant Ventak Prizm VR, model 1850, and a Guidant ventricular lead, model 0148 (Guidant Corporation, Indianapolis, Ind, USA) implanted 12 months earlier after an episode of syncope. The lead had been implanted by left subclavian venous access. The patient’s postoperative course and responses to routine questioning indicated that the device was functioning normally. After presenting with device discharges, a 12-lead electrocardiogram showed oversensing suggestive of lead dysfunction. Stored electrograms from the defibrillator showed artifactual signals that were typical of lead disruption. These signals had triggered inappropriate detection of ventricular arrhythmia and subsequent device shocks (Box 1). The pacing threshold and lead impedance were normal. On close examination of the patient’s chest x-ray, a line of radiolucency was detected within the lead between the first rib and clavicle. At reoperation, the lead was extracted with minimum difficulty and the site of the insulation break was detected (Box 2). A new lead was implanted and the patient was discharged home well. Subsequent follow-up was uneventful. Lead failure can occur any time after implantation of an ICD, and should be suspected when patients present with inappropriate ICD discharges.1 This case illustrates oversensing as a result of the lead’s insulation being disrupted by crush compression between the first rib and clavicle. Alternative implantation techniques, such as cephalic vein cut-down or extrathoracic axillary vein puncture, have been suggested for venous access to avoid this complication.2 1 Stored electrograms from the patient’s implantable cardioverter defibrillator showed artifactual signals had triggered inappropriate detection of ventricular arrhythmia and subsequent device shocks (arrow) 2 Implantable cardioverter defibrillator lead after extraction showing the break in the insulation (arrow)

Chin V Hiew · James W Leitch

To the Editor: Accidental ingestion of foreign bodies is common in children. Most pass through the gastrointestinal tract spontaneously,1 but some, such as magnets and batteries, can cause serious problems. We treated three children, aged 4–11 years, who ingested magnets that caused multiple bowel perforations. All three children presented with abdominal pain and vomiting, and were initially treated for gastroenteritis as the history of ingestion was not available. Plain abdominal films were subsequently used to make the diagnosis of foreign body ingestion. The ingested objects were later found to be pieces from magnetic construction toy sets. The first patient was an 11-year-old child with autism. An initial laparoscopy revealed marked dilatation of the small bowel and interloop adhesions. Subsequent laparotomy revealed several magnets (rods, rings and balls) in adjacent loops of the small bowel (Box, A), as well as necrosis and 13 perforations of the small bowel. Segmental resection was performed with a defunctioning ileostomy. During surgery, radiography was performed to ensure that all foreign bodies were removed before closure of the abdomen. The child made a good recovery, and the ileostomy was closed 3 weeks later. The second patient was 4 years of age. An abdominal x-ray revealed a cluster of foreign bodies in the right lower quadrant of the abdomen, with a small gap between the fourth and fifth foreign bodies. A laparoscopy revealed a cluster of magnetic rings (Box, B) perforating the small bowel and the caecum. Two of the rings were on the caecal side and four were on the small bowel side, with an intervening fold of mesentery — the gap on the x-ray. The magnets were retrieved through a minilaparotomy, and the caecal perforation was oversewn. The third patient was a 5-year-old who presented with similar symptoms and x-ray findings. Laparotomy revealed an area of pressure necrosis underlying the magnet and causing perforation of the jejunum, which was repaired by segmental resection and primary anastomosis. As ingestion of foreign bodies is usually not witnessed, a high index of suspicion is required for correct diagnosis.2 Of confirmed cases, 50% of patients remain asymptomatic.3 Fewer than 10% of cases require intervention, and about 1% require surgery.4,5 Ingestion of multiple magnetic objects in children is particularly serious, because of their tendency to aggregate in the bowel and compress intervening tissue, and should be treated aggressively. These cases demonstrate the harmful consequences of magnets in toys. More stringent regulations on the use of magnets in toys — especially in toys for children younger than 5 years — and measures to increase public awareness of this issue are needed. Clusters of ingested magnets in children A: Magnets in loops of the small bowel. B: Magnetic rings perforating the small bowel and caecum, showing intervening fold of mesentery and bowel wall (arrow).

Manjunath B Siddaiah-Subramanya · Peter Borzi

To the Editor: The recent case report by Chow and colleagues raises questions about the causal link between black cohosh use and hepatotoxicity.1 The authors state that the patient had no history of “significant alcohol consumption”, but a presumably related adverse drug reaction report available from the Therapeutic Goods Administration reveals her alcohol use was “3–4 units [of] alcohol per day, [with] 1–2 alcohol-free days per week”.2 Alcohol misuse is a known risk factor for severe liver disease, as is gastric bypass surgery for obesity,3 also in the patient’s history. Unfortunately, because histological examination of the liver 6 weeks after first presentation found no recognisable residual hepatocytes, the diagnoses of alcoholic steatohepatitis, non-alcoholic fatty liver disease and non-alcoholic steatohepatitis cannot be excluded. Without this, the specific conclusion of the liver biopsy that the “Massive hepatocellular necrosis [was] associated with herbal medication”2 cannot be substantiated. The patient “was not taking any other medications, including other herbal preparations”, but the use of multivitamins was disclosed,2 without further information on ingredients, indication, dosage and duration of use. Notably, an overdose of vitamin A can cause severe liver disease. Finally, discontinuation of black cohosh failed to reduce the patient’s bilirubin levels, suggesting ongoing liver cell destruction by the as-yet unknown agent. Chow et al state “Extensive investigations to exclude other causes of acute liver failure gave negative results”.1 It is unclear whether rare liver diseases were excluded, notably herpes infection, which has been reported to cause severe herpetic hepatitis. Nor was polymerase chain reaction testing performed for hepatitis viruses. The authors mentioned other published case reports of hepatotoxicity potentially linked with black cohosh.1 A recent assessment of 42 cases by the European Medicines Agency (EMEA) concluded that most were insufficiently documented, or were otherwise inappropriate for analysis.4 A case in the United States initially described as “probable” (> 1000% of the recommended dosage of black cohosh), based on the report that the patient “did not drink alcohol or use illicit drugs and was not taking any medications”, was later corrected.5 The patient testified under oath that she drank wine regularly and used other drugs, and a US court judged there was no evidence to establish that black cohosh had caused her liver disease.6 There is no apparent credible evidence that black cohosh caused liver failure in the patient described by Chow et al.1 A daily alcohol consumption of 30–40 g should be considered principally in any causality assessment. In addition, idiopathic reasons, rare or unclear liver diseases, and other medications should be considered as possible causes. Even in patients with liver disease who consume little or no alcohol and have no exposure to other toxic agents, the cause of the disease remains unclear in up to 30%. In view of this, reliable and sufficient reporting of adverse drug reactions is a necessary precondition to any reliable assessment of causality.7

Belal Naser · Eckehard Liske

To the Editor: The case reported by Chow and colleagues of liver failure associated with the use of black cohosh1 requires comment regarding causality. The case has also been the subject of an adverse drug reaction report by the Therapeutic Goods Administration (TGA), and a possible causality has been proposed.2 At presentation on 23 May 2006, the patient was aged 50 years (TGA),2 not 51 as stated by Chow et al.1 Her bodyweight was 88 kg (TGA)2 after gastric bypass for obesity.1 She had been taking black cohosh (20 mg daily) intermittently for 3 years. The subsequent temporal course is essential for assessing causality. According to the TGA report,2 the patient increased the dose of black cohosh to 40 mg daily on 31 March 2006 and stopped taking it on 31 May 2006. The case report describes a 2-month history of lethargy, nausea and arthralgia,1 obviously reported at first presentation. Back calculation shows symptom onset around 23 March 2006. Thus, symptoms emerged 1 week before the dose increase, suggesting a lack of temporal, and hence causal, association. The patient had several risk factors for severe liver disease.1 Risky use of alcohol for women is defined as more than seven standard drinks per week or more than three drinks on a single occasion.3 The patient had a daily intake of 3–4 units of alcohol, with 1–2 alcohol free days per week (reported by the TGA),2 rendering her at some risk of alcoholic liver disease. Moreover, gastric bypass with partial resection reduces gastric mucosal alcohol dehydrogenase and consequent gastric ethanol metabolism. In combination with rapid gastric passage of alcohol into the jejunum, this leads to high blood ethanol concentrations, another risk factor for liver disease. Risk factors for possible non-alcoholic steatohepatitis and cirrhosis are obesity and gastric bypass. Other causes were not excluded, including Wilson’s disease (by 24 h urinary copper measurement), hepatitis E, herpetic liver disease and infection by varicella zoster virus, parvovirus B19, parainfluenza virus, adenovirus and cytomegalovirus (by assessing for a change in IgG titre after disappearance of IgM). The marked hepatic mononuclear infiltrate is compatible with some viral infections. Certainly, various herbal products may cause liver disease. A good example is kava,4 but not black cohosh.5,6 The European Medicines Agency examined 42 cases of liver disease with a suspected association with black cohosh, and found that only four patients had some grades of causality.5 Reassessment showed that two of these patients had herpetic hepatitis, one had autoimmune hepatitis, and the fourth was not assessable.6 Further studies are necessary to show clearly whether black cohosh is potentially hepatotoxic.

Rolf Teschke

In reply: Teschke questions the temporal sequence in our reported case1 by raising an ambiguity in dates. We wish to clarify: when the patient first presented on 23 May 2006, lethargy, arthralgia and nausea had been present for only about 3 weeks. This was well after the dose increase in black cohosh in March 2006. As such, the dose escalation definitely preceded the patient’s symptoms and liver failure. To further explore causality would require rechallenge with black cohosh, which we consider dangerous and unethical. Other unlikely causes of liver failure raised by Teschke, although theoretically possible, were not evident. The clinical course and histological findings in the pretransplant biopsy and explanted liver categorically excluded alcoholic cirrhosis and non-alcoholic steatohepatitis as causes of the liver failure. We also reiterate that there was no previous history of liver disease or other medication use. Increasing numbers of case reports are being published showing evidence of hepatotoxicity in patients taking black cohosh. Two well documented cases of seriously deranged liver function in patients taking black cohosh, which resolved on ceasing its use, have just been reported.2 Teschke concedes that four other cases have been reported where some causality between black cohosh and hepatotoxicity was evident.3 Neither Teschke nor Naser and Liske offer any reassurance on the long-term safety or lack of toxicity of black cohosh by referencing any properly conducted safety study. Certainly, there is recent in-vitro and in-vivo evidence in a rat model that black cohosh is toxic to hepatocyte mitochondria and impairs oxidative phosphorylation, resulting in apoptotic hepatocyte death.4 It is notable that, based on available evidence, the Australian Therapeutic Goods Administration requires preparations containing black cohosh to carry a warning of potential liver toxicity, stating that “there appears to be an association between the use of black cohosh and liver damage, but that it is very rare”.5 Furthermore, in the United Kingdom, the Medicines and Healthcare Products Regulatory Agency stated, “Warnings regarding rare adverse reactions in the liver should be added to the product information for black cohosh for both licensed and unlicensed products”.6 Government authorities in Europe3 and Canada7 have raised similar concerns. Long-term studies as well as further animal studies would be welcome in this area.

Elizabeth C-Y Chow · Marcus Teo · John A Ring · John W Chen

To the Editor: The article by Eley and colleagues clearly articulates challenges and solutions for providing quality undergraduate medical education in rural locations.1 Simulation-based education (SBE) also helps meet the challenge of providing quality rural medical education. Simulation is an ethical means of supporting the development of technical and non-technical skills relevant for safe and competent clinical practice. SBE can be used creatively to prepare, supplement and enhance rural clinical placements. Simulation is often used to support learning of clinical events that occur infrequently, such as medical emergencies. These simulations are immersive, placing the clinician in a scenario that reflects the physical, psychological and social fidelity of a real work environment. Similarly, immersive simulations can be used to acquire competence in common examination and procedural skills. Hybrid simulations include combinations of simulators (eg, benchtop models) and actors (simulated patients) in quasi-clinical environments.2 Simulation facilities are increasingly available in rural locations. In Victoria, Gippsland Medical School has a simulation centre with a range of clinical environments including reception, consulting rooms, a fully equipped ward and an emergency room. We provide graduate-entry medical students with an opportunity to develop clinical skills in simulation, aligning scenario complexity, content and context with their learning in real clinical settings. Scenarios are often based on real patients’ experiences, exploring more than just the technical skills the student is learning. Preliminary evaluation suggests this sequencing of skills development, authentic scenario creation and immersive simulations for commonly occurring clinical encounters maximises learning in real clinical settings. We have had strong local community engagement, evidenced by the easy recruitment of simulated patients and support from medical practitioners who teach our students in clinical settings. We are exploring a range of simulated rural clinical placement activities for the remaining years of the curriculum. We believe this approach will relieve some pressure on clinical placements, as students are well prepared to learn in such settings. Additionally, clinical nurse educators have taken on teaching roles in the simulation centre, relieving pressure on medical practitioners. There are limitations to SBE. Specialist facilities are required, teachers and actors need to be trained, and curricula need to be developed and evaluated. However, our experience locally, and the rapid growth of SBE internationally, suggest that this approach to delivering high-quality medical education has relevance in all settings.

Debra F Nestel · Robyn A Hill · George T Somers · Christopher A Browne

To the Editor: We read with interest the article by Griffin and colleagues,1 which provides valuable insight into the practice effects of coaching on medical school selection tests. As senior clinical students, we have watched with more than a passing interest the introduction and growing popularity of coaching courses in recent years. What was once regarded as a costly, unnecessary and potentially disadvantageous exercise has, in recent years, given rise to a flourishing industry. As the authors point out, alternative selection tests such as the Undergraduate Medicine and Health Sciences Admission Test (UMAT) and entry interviews were devised in part to overcome the socioeconomic bias associated with using matriculation results alone.2,3 Ironically, these overpriced coaching courses are often available only to those from higher socioeconomic backgrounds, jeopardising the equity of access that the tests aimed to improve. At many independent high schools, in fact, attendance at coaching courses is now often the norm, in contrast to schools from lower socioeconomic backgrounds. Many students now opt to undertake coaching for fear of “missing out” on what may potentially be an edge obtained by other prospective students. It is the psychological comfort provided to students that they have done some preparation that marketers of coaching courses have been exploiting, as evidenced by the finding from the Australian Medical Students’ Association Medical Education Survey in 2006 that 70% of students felt better prepared for the UMAT as a result of coaching.4 In light of this, data provided by Griffin and colleagues thus provides welcome reassurance that expensive coaching courses may provide little or no benefit in relation to UMAT or interview outcomes. Although their study reported a slight increase in interview scores on the second attempt at entry to medical school, what was not discussed by the authors was the students who undertake coaching before resitting either an interview or the UMAT. While they mention that a proportion of students resit the UMAT, there was also no discussion on the effect of simply repeating the UMAT. Further analysis of the effects of repetition and coaching on candidates who resit the UMAT or interview would circumvent the limitation of directly comparing coached and non-coached groups that are unlikely to be equivalent, given that coaching is voluntary and may be linked with personality, ability and socioeconomic factors. It would be interesting to observe what effect, if any, coaching might have had on these candidates’ results. This might provide further evidence in support of the authors’ findings.

Christopher X J Wong · Ross L Roberts-Thomson

To the Editor: In addition to its well established link with rickets and osteoporosis, vitamin D deficiency has been associated with increased risk of autoimmune, malignant and cardiovascular disease.1 Marginal deficiency occurs at serum 25-hydroxyvitamin D [25(OH)D] levels of 25–50 nmol/L and frank deficiency at levels < 25 nmol/L,2 but there is some evidence that levels < 80 nmol/L3 or even < 110 nmol/L2 could be suboptimal. In Australia, vitamin D deficiency is most frequent in nursing home residents, dark-skinned veiled women, and residents of southern latitudes.2 However, those who are instructed to habitually minimise sun exposure following a diagnosis of skin cancer may also be at particular risk. We recruited patients with a history of non-melanoma skin cancer, who were not taking vitamin D or calcium supplements, from outpatient dermatology clinics at Royal Prince Alfred Hospital, Sydney (latitude, 33° south). Ethics approval was obtained from the Sydney South West Area Health Service and University of Sydney ethics committees, and all participants provided written informed consent. Serum 25(OH)D levels were measured by radioimmunoassay (DiaSorin, Saluggia, Italy)4 in both late summer (February 2006 or 2007) and late winter (August 2006), with participants completing a 2-week diary detailing daily sun exposure and sunscreen application before each measurement. Twenty-five participants (12 men, 13 women; mean age, 64 years; range, 44–78 years) completed both assessments. We found a significant reduction in mean 25(OH)D levels in winter (summer, 69 ± 3.4 nmol/L; winter, 59 ± 6.2 nmol/L; P < 0.05). In summer, all but one participant had 25(OH)D levels > 50 nmol/L, and eight had levels > 80 nmol/L. In winter, 12 participants had 25(OH)D levels < 50 nmol/L, two had levels < 25 nmol/L, and only three had levels > 80 nmol/L (Box). Hence, using the accepted target value of 50 nmol/L,2 12 participants (48%) were vitamin D-deficient at the end of winter, compared with one (4%) at the end of summer. In summer, the mean reported daily sun exposure was 1 hour (range, 10 min–2.5 h), comprising 40 minutes of off-peak (before 11 am or after 3 pm) and 20 minutes of peak exposure. In winter, the mean daily exposure was also 1 hour (range, 20 min–1.5 h), comprising 30 minutes each of both peak and off-peak sunlight. Volunteers reported wearing sunscreen during about 50% of their summer sun exposure and 27% of their winter sun exposure. Despite mean reported daily sun exposure falling within recommended guidelines, half of our participants were vitamin D-deficient at the end of winter, with almost all demonstrating reductions in winter 25(OH)D levels. Our findings suggest that vitamin D deficiency may be much more prevalent than expected in these patients, and that vitamin D supplementation might be indicated for this group, at least during winter. Vitamin D levels in summer and winter 25(OH)D = 25-hydroxyvitamin D.

Anna-Marie McCombie · Rebecca S Mason · Diona L Damian

To the Editor: I read with interest the article by Hardie and Critchley, in which the authors attempted to measure attitudes towards both Australia’s current health care system, and shifts to greater public or private funding of health care.1 The article’s finding that pro-public funding attitudes were greatly favoured over pro-private funding attitudes may in fact be more of a reflection of the leading nature of the authors’ pro-private statements than of the true attitudes of the 800 study participants. Most Australians, regardless of their views on public versus private funding of health care, would be unlikely to support the statements “Australia should adopt a private, user-pays system like they have in the [United States]” and “The very best health care should be available only to those who can afford it”.1 The results are certainly not consistent with the findings from the 2007 Ipsos Health Care and Insurance study2 — a survey with more than 5300 participants and a solid 20-year history, which is supported by governments (Commonwealth and state/territory), private providers and industry associations. This study found that just over half of respondents (52%) supported full government funding of Australia’s health care system, while 42% opposed such a funding approach. In fact, more than 20% of respondents “disagreed a lot” with the proposal that “All hospital and medical costs should be met out of government revenue — the taxes we all pay — people should not have to pay anything directly”.2 The Ipsos results suggest there is still significant diversity of views on how Australia’s health care system should be funded and, importantly, these results do not support the conclusion of Hardie and Critchley that Australians “overwhelmingly favour a more socially responsive public health system, funded by the public purse”.

Michael H Armitage

In reply: We are intrigued by the discrepancy between our findings1 and the 2007 Ipsos study results2 noted by Armitage. We took a psychometrically rigorous approach to measuring the public’s preference for health care systems. If our pro-private statements seem “leading”, then the pro-public statements (“Australia should adopt a collective social health system supported by higher taxes as is done in some Scandinavian countries”, “I would be willing to pay higher taxes to improve Australia’s health care services”) could be similarly construed. Armitage reports that 52% of the Ipsos sample supported (and 42% opposed) full public funding of health care. If we apply this support–oppose dichotomy (ie, per cent above and below the scale mid-point) to our own data, a striking 70% of our sample support (and 30% oppose) greater public funding, while just 7% support (and 93% oppose) more private funding. This is consistent with other Australian studies showing a preference for health and medical research being conducted in public, as opposed to private, settings.3-5 We cannot directly compare our methods and results with the Ipsos survey because, ironically, when we tried to access this research supported by “governments ... private providers and industry associations”, we were advised by Ipsos that the report is not publicly available.

Elizabeth A Hardie · Christine R Critchley

To the Editor: Arnold is correct to question whether the New South Wales reportable misconduct legislation will be effective,1 because it relies on doctors making a judgement about whether a colleague has flagrantly departed from accepted standards of professional practice. Doctors have a high threshold for referring to medical boards, in part because they perceive the system to be adversarial rather than recognising that individual and system factors can combine to create poor professional performance. Also, medical boards have no direct ability to modify the workplace circumstances to make them more supportive of a poorly performing doctor. Poor performance has multiple causes, including mental and physical illness, cognitive impairment, substance misuse, professional isolation, and personality disorders.2 Flagrantly poor performance is rare, but research shows that the prevalence of poor performance is about one in a hundred doctors per annum.2 Many of these doctors are amenable to local remediation, provided there are properly promulgated procedures. The United Kingdom and some states in the United States have developed systems for assessing poorly performing doctors that require directors of medical services to manage complaints locally. In the UK, the National Clinical Assessment Service is available to support medical directors in more complicated cases. Consequently, the number of referrals to the General Medical Council has decreased, but the number of doctors being reviewed has increased to the number that would be expected from research.3 Doctors reviewed by medical boards in Australia do not reach the predicted prevalence levels, and boards’ processes seem slow by comparison with what can be done locally. It is a moot point whether Dr Jayant Patel would have been reported under the new NSW legislation, because some of his colleagues appeared not to have thought that he flagrantly departed from accepted standards. The real problems in Bundaberg were that there were no local mechanisms for health professionals to raise their concerns. For almost 2 years, the director of medical services at the hospital took no direct action.4 Queensland Health is developing local processes that will be administered by directors of medical services supported by a clinical performance support service.5 The evidence against relying solely on medical boards and in favour of local procedures for managing poorly performing doctors is now incontrovertible. Currently, many poorly performing doctors are not being identified and offered remediation, and patients are being left at risk. These are important issues for the National Health and Hospitals Reform Commission.

James A Dunbar · Prasuna Reddy

In reply: The opinion expressed by Dunbar and Reddy that: “The real problems in Bundaberg were that there were no local mechanisms for health professionals to raise their concerns” ignores the many real difficulties (canvassed in my editorial)1 confronting any member of staff who tried to raise their concerns within that institution. Local mechanisms cannot play their part if the institution’s senior staff do not wish to implement them. The ability of and, indeed, encouragement for all staff, regardless of seniority, to report their concerns directly to the medical board, bypasses all local deterrents. Our medical boards have the experience needed to sort out the major from the trivial, the genuine from the frivolous, incompetence from impairment. Dunbar and Reddy continue: “The evidence against relying solely on medical boards and in favour of local procedures for managing poorly performing doctors is now incontrovertible.” This is a straw man. No one, to my knowledge, has made any such suggestion. What I support is: (i) a direct avenue for someone local to report to the medical board; (ii) diligent and sensitive enquiry by the medical board; and (iii) if needed, the cooperative implementation of remediation by the local entity and the medical board.

Peter C Arnold

Caffeine caution before and during pregnancy CARE Study Group researchers based in the United Kingdom suggest that sensible advice for women contemplating pregnancy would be to reduce their caffeine intake from all sources before conception. Further, once pregnancy is confirmed, they should make every effort to stop or markedly reduce caffeine consumption.1 The researchers had conducted a prospective longitudinal observational study in 2635 pregnant women, finding that maternal caffeine consumption was associated with an increased risk of fetal growth restriction and that the risk increased with increasing amounts of caffeine consumption. The researchers said that although the overall size of the reduction in birthweight — for example, of about 60 – 70 g for caffeine consumption of more than 200 mg/day — may be seen as small, it could nevertheless affect perinatal morbidity and mortality in an already compromised fetus. More than 60% of the caffeine consumed by participants in the study was from tea, and only 14% from coffee. The authors of an accompanying editorial concurred that pregnant women should be advised to reduce their intake of caffeine products during pregnancy; however, the women should not replace caffeine-containing beverages with drinks containing alcohol, or soft drinks loaded with sugar.2 1. BMJ 2008; 337: a2332 2. BMJ 2008; 337: a2316 Check-ups by the dozen Group appointments are being trialled in general practices in the Canadian province of British Columbia in an effort to address a critical shortage of doctors. The groups typically involve 12 to 15 patients with a common condition (such as diabetes, heart disease, hypertension or arthritis), one doctor and one nurse, and last for about 90 minutes. The concept, developed in the early 1990s by Colorado physician Dr John Scott, is proving popular both with patients, who enjoy the support of others with similar health problems, and doctors, who are finding the experience professionally satisfying. Group appointments seem to be revenue-neutral, being neither a money-maker for doctors nor a money-saver for governments. CMAJ 2008; 179: 1111-1112 Whole ovary transplanted A 38-year-old woman who had two children and normal ovarian function donated an ovary to her identical (monozygotic) twin sister who had undergone premature menopause at 15 years of age. The recipient’s first menstruation in 22 years occurred on Day 101 after transplantation, and after 11 regular menstrual cycles, the recipient fell pregnant. A healthy baby girl was born at term, and both mother and baby are doing well. The ovary was transplanted intact using a microvascular technique, in which the donor’s ovarian veins (3 mm in diameter) were anastomosed to the recipient’s ovarian veins and the donor’s ovarian arteries (0.5 mm in diameter) were anastomosed to the recipient’s ovarian arteries. Whole-ovary microvascular transplantation is technically more challenging than the more usual ovarian cortical grafting, but could result in a longer duration of graft function. N Engl J Med 2008; 359: 2617-2618 Beware of burnout in intensivists Australian intensivists are at high risk of “burnout syndrome”, according to a recent survey. Shehabi and colleagues invited all 324 intensivists listed as practising in Australia on the Australian and New Zealand Intensive Care Society database to take part in a web-based survey about their work, workload and risk of burnout. The workload reported by the 115 survey respondents was high, with most managing more than two new admissions and an average of two lengthy family conferences per day; about one in four respondents managed more than nine ventilated patients at a time. Survey respondents also had considerable administrative and locum clinical duties. Although most intensivists reported high job satisfaction, 80% had signs of psychological stress and discomfort, 42% showed signs of emotional exhaustion and 32% experienced negative feelings and cynicism about their professional activities. The researchers said these emotions placed a large proportion of respondents at significant risk of both burnout syndrome and depressive illness. They called for leaders, managers and policymakers within intensive care to focus on the prevention, early identification and management of burnout among critical care practitioners. Crit Care Resusc 2008; 10: 312-315

Ann Gregory