To test or not to test?
Population-wide prostate-specific antigen (PSA) screening for prostate cancer is not recommended in Australia, and new evidence does not warrant a change. So Smith and colleagues conclude, after reviewing the results of two large, randomised controlled trials — the European Randomized Study of Screening for Prostate Cancer and the prostate component of the US Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial. Thus far, it remains uncertain whether screening for prostate cancer lowers the risk of death from prostate cancer (→ Evidence-based uncertainty: recent trial results on prostate-specific antigen testing and prostate cancer mortality). What is more certain, as Barratt and Stockler explain, is that PSA testing definitely is associated with harms, including the side effects of subsequent treatment for prostate cancers that would never have been life-threatening, such as reduced erectile function and persisting urinary problems. They advise doctors on how to explain this information to their patients (→ Screening for prostate cancer: explaining new trial results and their implications to patients).
An Achilles heel
Clinical supervision is a vital part of postgraduate medical education. Yet it is the Achilles heel of our hospital system, say Hore and colleagues, with hospitals generally lacking either the resources or the motivation (or both) to ensure it is done properly. They offer some contentious suggestions, such as always having patients under the on-site supervision of a consultant (→ Clinical supervision by consultants in teaching hospitals). In a linked editorial, Forsyth notes that health authorities are increasingly recognising that support of education and supervision may lead to better health outcomes, and that the recent Garling report called for recognition of the importance of the role of the clinical teacher (→ Critical importance of effective supervision in postgraduate medical education).
A first in abortion law
A horse with a green tail? Having been promised that she would see such a wondrous creature, a 14-year-old girl was enticed into the London barracks of the Royal Horse Guards, to be raped by five officers. As de Costa recounts, the girl fell pregnant, and she and her parents sought the help of Dr Aleck Bourne, a consultant gynaecologist. The year was 1938, and “therapeutic” abortion was legal only if a woman’s life was in danger. Yet, Bourne considered termination was justified because of the risks to the girl’s physical and mental health. He performed a surgical curettage and then deliberately informed the police of his actions. The rest is history (→ The King versus Aleck Bourne).
Seeking a second opinion?
Patients who seek a second opinion from a medical oncologist are typically more educated, younger and female, say Tattersall and colleagues. They studied responses to a questionnaire completed by 77 of the 123 new patients seen at the Sydney Cancer Centre over a 2-year period who had stated that they were seeking a second opinion; this group represented a little over 5% of all new patients seen. Commonly stated reasons for seeking a second opinion were to obtain additional information or reassurance about recommended management. The second-opinion consultation resulted in a change, either in treatment or in the supervising oncologist, for 39 of the 77 patients (→ Second opinions in oncology: the experiences of patients attending the Sydney Cancer Centre).
Where lies the balance?
A man with Munchausen syndrome had at least 10 recent coronary angiograms in a long list of unnecessary, expensive and potentially harmful medical interventions. According to DeWitt et al, this less-than-ideal and costly exercise could have been prevented if a highly confidential notification program had been in place (→ Patient privacy versus protecting the patient and the health system from harm: a case study). Robertson and Kerridge say that citing cost savings as a justification for a notification program that would violate the privacy of mental health patients compounds the manifest injustice these patients already face in the health system. They propose a raft of other solutions, including structured clinical intervention (→ “Through a glass, darkly: the clinical and ethical implications of Munchausen syndrome”).
The incidental tourist
The first laboratory-confirmed human case of West Nile virus (WNV) infection in Australia is reported by Rogers and colleagues. A tourist from Israel spent much of his visit here in hospital being treated for encephalitis, returning to his home country for outpatient rehabilitation. Infection with WNV was diagnosed after discharge, after specific serological testing of acute and convalescent sera. WNV is an arbovirus that has caused large outbreaks of febrile illness, meningitis and encephalitis in Europe, North America and the Middle East. Rogers and colleagues explain why the risk of transmission in Australia from human cases is very low (→ Imported West Nile virus encephalitis in an Israeli tourist).
Another time . . . another place
No books, no tapes, no audio-visual aids, no seminars, no avant-garde philosophy will ever be subtitutes for the discipline of the bedside medicine — the one-to-one situation where tradition, humanity, art and science are blended.
Medical Journal of Australia — 1971
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