Volume 191 Issue 8

Implementing a hand hygiene program nationally requires a culture change Given the evidence supporting the dramatic efficacy of hand hygiene (HH) culture-change programs and use of alcohol-based hand rub (AHR) solution worldwide and locally,1-4 a national HH initiative has been launched by the Australian Commission on Safety and Quality in Health Care, with the support of all states and territories. Although some jurisdictions have already undertaken programs in this important area,2-5 including some impressive studies described in the supplement to this issue of the Journal,6-9 this national program, organised by Hand Hygiene Australia (HHA), aims to introduce a standard HH culture-change program throughout all Australian public and private hospitals. The aims of the program are to improve HH compliance, increase the use of AHR, and establish a common system of measuring the disease outcomes associated with improved HH that can be used by hospitals to compare their performance against national and international benchmarks. The HHA program has three crucial components. 1. Use of the World Health Organization’s “5 Moments for hand hygiene” program: Adoption and adaptation of the WHO’s 5 Moments HH culture-change program has been important, as it includes a standard HH compliance auditing tool that defines the five key moments at which hand-cleaning is required during patient care (Box).10 Although some Australian states previously had their own “home-grown” auditing tools, the HHA–WHO 5 Moments tool has the advantages of simplicity and validated clinical accuracy. Moreover, it allows HH rates in Australian hospitals to be compared internationally with rates in other hospitals that have similar health care systems. The HHA has developed detailed educational tools, including a popular website (http://www.hha.org.au). In close partnership with health departments in each state and territory, it has conducted multiple training workshops throughout Australia to implement the HH culture-change program, which is controlled and coordinated by the states. 2. Validation of HH compliance educators and assessors: Fundamental to obtaining accurate HH compliance data has been the development of a standard training and validation program for infection control practitioners and other health care workers responsible for HH culture change. The training program prepares them to accurately and reproducibly teach and measure HH compliance using the 5 Moments tool in their hospitals. This validation feature has been crucial to ensuring that all HH compliance data are accurate and comparable between hospitals and between health services in different states. 3. Measurement of hospital-acquired infections: A key reason for improving HH compliance among health care workers is to reduce the risk of nosocomial disease transmission, yet there has been no system in Australia for accurately measuring the incidence of these infections. An important outcome measure for the HHA program is the monthly reporting by all Australian hospitals of the rate of new hospital-acquired Staphylococcus aureus bacteraemia (SAB) infections. The number of SAB infections (methicillin-susceptible and methicillin-resistant) occurring more than 48 hours after hospital admission is standardised against hospital activity (occupied bed-days and patient separations [discharges]). Although the relationship between nosocomial SAB infections and HH practice is not exactly defined, it is estimated that in Australia about 60% of SAB infections are probably directly related to poor HH.2,3 Thus, SAB data are likely to be a valid outcome measure for HH compliance. The SAB reporting system established by HHA is internationally unique and will potentially provide a useful template upon which any future expanded national system of nosocomial disease measurement could be based. The roll-out of the HHA program has progressed rapidly, with initial data submission by all regions commencing in early 2009 and subsequently ramping up quickly, to the extent that in the second audit period (July 2009), 168 hospitals submitted data. The National Hand Hygiene Initiative is an internationally unique culture-change program that will hopefully not only improve HH compliance and reduce the risk of nosocomial disease transmission, but also establish a standard system for accurately recording rates of key hospital-acquired infections. The HHA–WHO “5 Moments for hand hygiene”* HHA = Hand Hygiene Australia. WHO = World Health Organization. * Adapted from Sax et al.10

M Lindsay Grayson MD, MSc, FRACP · Philip L Russo BN, MClinEpid

Excessive maternal weight adversely affects all aspects of pregnancy and childbirth Weight and weight gain in pregnancy used to be an obstetric obsession, if not an oppression. Belief that weight restriction could prevent pre-eclampsia made scales the most feared instruments in antenatal clinics,1 causing some women to resort to fasting before their next appointment. Nearly 20 years ago, the routine use of scales started to diminish, in the same way as it had begun — without good evidence.1 Attention shifted to the weight of the offspring, and achieving birthweights within the 3000–4000 g bracket, which are associated with better perinatal outcomes.2 Evaluations of the resulting guidelines for weight gain in pregnancy2 (recently revised)3 also centred on birthweight, with less attention to more substantive perinatal and infant outcomes.4 The evaluations also showed that only a minority of women achieve an ideal weight gain;4 many gain more than is recommended, and excessive gain is most frequent in those who are overweight already.4 In the meantime, the childbearing population has changed considerably: growing in age, growing in weight, and growing in the expectation that none of this matters too much. In this issue of the Journal, two articles address different aspects of weight and pregnancy. Callaway and colleagues surveyed women about the preconception weight management advice they received, their self-perception of weight before pregnancy and their success with weight reduction.5 Jeffries and colleagues conducted a randomised controlled trial of an intervention to limit maternal weight gain during pregnancy.6 Callaway et al found that many women enter pregnancy blissfully unaware of their excessive adipose tissue,5 and presumably also of its effects on pregnancy. The study by Jeffries et al revealed that regular self-measurement of weight was effective in reducing pregnancy weight gain only in women who were overweight, but not obese, at the start of pregnancy.6 While it is disappointing that Callaway et al found that pre-pregnancy medical advice to lose weight was rare,5 one wonders how often doctors are rebuked for not acknowledging that “big is beautiful”. Alternatively, they may be constrained in their advice by their own body mass, or by simply not knowing how to translate weight reduction advice into meaningful action for their patients. Despite being innovative, the medical profession is often not an avant-garde movement known for tackling issues that do not fit within the routine framework of history, examination, diagnosis and treatment. It was only after obstetricians turned away from maternal weight control that fertility specialists turned to it,7 although their concern was more with achieving conception than with pregnancy and infant outcomes. Undoubtedly, the obesity pandemic has hit women of reproductive age particularly hard.8 The critical mass needed to initiate the menarche now comes earlier, but anything thereafter — from conception to pregnancy, childbirth, and perinatal outcome — up to the health of the next generation, is a different matter.9 An extensive body of literature, already overweight itself, testifies to the deleterious effects of excessive weight on conception rates (natural and assisted), pregnancy complications (mostly, gestational diabetes, pre-eclampsia and operative delivery, but also others), and fetal wellbeing (with increased rates of miscarriage, congenital malformations, stillbirth and perinatal death). Yet, the issue is not only the increased frequency of so wide a range of problems. It is also the weight-dependent increase in the challenges of diagnosis and management, not to mention the inherent complications of treatments, all of which add further fuel to the fire. Increased risks of fetal malformations are accompanied by greater difficulties of visualisation on ultrasound. Increased rates of late fetal death are compounded by reduced perception of fetal movements and the inadequacy of clinical examinations, including ultrasound and cardiotocography, in oversized individuals. Increased caesarean section rates are accompanied by greater challenges in gaining access to airways and the epidural space; increased operating times; greater blood loss; and a range of postoperative complications, including excessive bleeding, thromboembolism, impaired wound healing, wound dehiscence, urinary tract infection, and longer time to recovery. None of these ameliorate what is already common in obese mothers postpartum: failure to initiate and sustain breastfeeding, and postpartum depression, which have their own effects on giving infants who have survived earlier assaults a healthy start in life. Motivation on the part of pregnant women to protect their baby from unhealthy lifestyles and not to transmit these across generations is rarely lacking, but this is often an underutilised window of opportunity. It suffers from two main problems. First, and contrary to the wealth of evidence on the effects of obesity on pregnancy from its inception to its aftermath, there is remarkably little evidence on what can be done about it, as Jeffries et al noted.6 Second, the 9 months of pregnancy is too short a time for much to be achieved, especially for those at greatest need. Weight loss during pregnancy is not recommended. Recycling adipose tissue provides energy but few building blocks for fetal development, while the resulting ketoacidosis may harm the fetus. Re-introducing the terror of the scales (although worth considering for women who are unaware of their weight5) is probably not a solution. First, its effectiveness is limited, as Jeffries et al found.6 Second, although it reduces rates of fetal macrosomia and postpartum weight retention,4 it is too little too late for almost anything else. Third, it has the potential of adding insult to injury, victimising those who need ongoing support and assistance rather than repetitive lectures. Attention certainly needs to shift to preconception care, but further than preconception and fertility clinics.5,7 Too few attend them;5 half of all pregnancies are unplanned;5 and, when planned, there is usually too little time to produce substantial change. Contraception care may be better if it includes the question “what about afterwards?” and anticipatory guidance on the importance of weight, folic acid supplementation and planned pregnancy before instead of after stopping contraception. Like other pandemics that have hit maternity care in the past few decades, such as advanced maternal age and caesarean section rates, the obesity pandemic has roots that are deeper and longer than the 9 months of pregnancy.7,10 Digging them up will require more innovative strategies than we have witnessed thus far.

Marc J N C Keirse MD, DPhil, FRANZCOG

Vulnerability to data manipulation is only one of many problems compromising the use of elective surgery waiting times to assess health system performance The recent controversy in Victoria over the manipulation of waiting lists in a number of public hospitals has focused attention again on the problems associated with a performance management system that is not underpinned by the collection and reporting of sound data. An independent audit of Melbourne’s Royal Women’s Hospital found that patients awaiting urgent or semi-urgent elective surgery whose waiting times were approaching the target for their category (30 days and 90 days, respectively [Box]) were reclassified as “not ready for care — patient initiated”. The reclassification ensured that category waiting time targets were not exceeded and that the hospital met elective surgery key performance indicators.1 Although at the time of the audit the hospital did not participate in the bonus scheme designed to reward hospitals for achieving targets, the state Minister for Health has since scrapped the bonus scheme.2 During the ensuing public debate, the Victorian Auditor-General and the Australian Institute of Health and Welfare (AIHW) both released reports highlighting the limitations of waiting times and clinical urgency categories as indicators of patient access to elective surgery and hospital performance.3,4 Taken at face value, waiting times for elective surgery appear to be a simple measure that can provide information about patient access to services, as well as hospital performance. However, the measurement of waiting times and interpretation of waiting times data are inherently complex. Because we currently measure only the period from the date of entry to the waiting list until provision of surgery, improvements in waiting times do not reflect the entire patient journey and may be negated by increases in the time spent waiting for primary care, diagnostic testing or specialist outpatient appointments. And although waiting times may tell us how long it takes for patients to move through one part of the care pathway, they tell us nothing about the quality of care received. Additionally, their use as performance indicators may provide a motive for data manipulation.5 The clinical urgency categories that have been used as part of the waiting-list management process also have important limitations. Patients are classified into three broad urgency categories (Box) by a largely subjective process with poor reproducibility between clinicians and across health services.6 While the intensity of clinical symptoms such as pain has been fundamental to assigning urgency categories, clinicians vary in how they assess these symptoms. In assigning urgency, clinicians may also consider non-clinical factors, but this occurs informally. Further, each urgency category is aligned with recommended waiting times that are not evidence-based.3 In recognition of the problems with jurisdictional variability, the AIHW has excluded urgency categories from its national reporting since 1999. These limitations make the current elective surgery categorisation system unsuited for one of its main purposes — stimulating improvement through benchmarking and the use of performance targets. Lack of reproducibility and vulnerability to manipulation, which are characteristics of some of the system’s access and performance indicators, limit the value of the information collected. This is one of an increasing number of instances where inadequate attention to data quality has compromised the important function of providing accurate information to guide service provision. If waiting times are to be a sound basis for the routine reporting of patient access to elective surgery or other health services, then they should be explicitly defined to provide a valid assessment of the time spent waiting for surgery, and measured in a standardised and unambiguous way. This approach has been advocated in Canada, where there has been a concerted attempt over the past 5 years to establish evidence-based waiting time benchmarks for specific procedures.7 Likewise, the categorisation of urgency needs to be underpinned by an explicit and standardised way of taking into account all factors relevant to a patient’s requirement for elective surgery. This has already occurred to varying extents in New South Wales, New Zealand and Canada. In NSW, recommendations for assigning specific surgical procedures to urgency categories have been developed and set in policy.8 NZ and Canada have both developed explicit, practical tools that help clinicians systematically prioritise patients for a range of specific procedures, such as joint replacement and cataract surgery.9,10 A clinical priority access system, while not without its controversies, has been used throughout NZ since the early 1990s. Some of the prioritisation tools developed by the Western Canada Waiting List Project have been used in elective surgery programs in several Canadian provinces. The challenges in finding reliable measures of health system performance are not unique to waiting lists. In every area of the health care system, problems result when data used to assess access, quality of care and safety are not based on appropriate measurements. The cornerstones of epidemiologically sound data are validity and reproducibility. The identification of measures able to produce valid, reproducible data is essential for credible assessment of health system performance and to drive long-term improvements. Current Victorian urgency categories for elective surgery Urgency category Desirable treatment time Category 1 Urgent: Has the potential to deteriorate quickly to the point where it may become an emergency Admission within 30 days Category 2 Semi-urgent: Causes some pain, dysfunction or disability Unlikely to deteriorate quickly Unlikely to become an emergency Admission within 90 days Category 3 Non-urgent: Causes minimal or no pain, dysfunction or disability Unlikely to deteriorate quickly Unlikely to become an emergency Admission some time in future (within 365 days)

Andrea J Curtis BSc(Hons), PhD · Johannes U Stoelwinder MD, FRACMA, FACHSE · John J McNeil PhD, FRACP, FAFPHM

Objective: To investigate the issues that confront women when addressing overweight and obesity before conception.Design: Questionnaire-based study of 412 unselected women in early pregnancy.Setting and participants: 255 women who attended a public, antenatal “first visit” clinic at a major urban obstetric hospital in Brisbane and 157 women who presented to a private obstetrician in Brisbane for a routine ultrasound scan during a 6-week period in 2006 were surveyed.Main outcome measures: Preconception health activities, prepregnancy body mass index (BMI), self-reported weight category, attempts to lose weight before pregnancy, and weight loss advice received before pregnancy.Results: Folic acid supplementation was reported by 56% of participants, and 53% attended a preconception health check. Of women who provided details of height and prepregnancy weight, 30% were overweight or obese before pregnancy. However, 23 of 65 women with a BMI in the overweight range categorised themselves as normal weight (36%), and only 8 of 50 women with a BMI in the obese range categorised themselves as obese (16%). As BMI increased, more women reported trying to lose weight (P < 0.001) and reported receiving advice regarding weight loss (P < 0.001). Prepregnancy weight loss was reported by 52 of 115 overweight and obese women (45%).Conclusions: Potential barriers to addressing overweight and obesity before pregnancy include poor uptake of routine prepregnancy health activities, inaccurate self-categorisation of weight, unsuccessful weight loss attempts and inadequate advice regarding prepregnancy weight loss.

Leonie K Callaway MB BS(Hons), FRACP, PhD · Michael J O’Callaghan FRACP · H David McIntyre FRACP

Objective: To determine if regular weight measurement throughout pregnancy can reduce excessive gestational weight gain.Design: A randomised controlled trial.Setting: A tertiary obstetric hospital in Melbourne, between July 2007 and May 2008.Participants: 236 pregnant women recruited at ≤ 14 weeks’ gestation.Intervention: Women allocated to the intervention group were given a personalised weight measurement card, advised of their optimal gestational weight gain (based on their body mass index at the time of recruitment and the United States Institute of Medicine guidelines), and instructed to record their weight at 16, 20, 24, 28, 30, 32 and 34 weeks’ gestation. The control group were weighed at recruitment, but were not given instructions about regular weight measurement. All participants were blinded to the purpose of the study.Main outcome measure: Weight gain from recruitment to follow-up at 36 weeks’ gestation.Results: In the study population, there was a trend to less weight gain in the intervention group. The women in the intervention group experienced a mean (SD) per-week weight gain of 0.44 (0.173) kg compared with those in the control group, who gained 0.46 (0.156) kg/week (mean difference, 0.02 kg/week; 95% CI, − 0.02 to 0.07 kg/week). The intervention significantly reduced gestational weight gain in the group of women who were overweight but not obese at recruitment: those in the intervention group (20 women) gained a mean (SD) of 0.42 (0.153) kg/week and the control group (18 women) gained 0.54 (0.123) kg/week (mean difference, 0.12 kg/week; 95% CI, 0.03 to 0.22 kg/week; P = 0.01).Conclusion: Regular weight measurement in pregnancy was not found to be effective in reducing weight gain, except among women who were overweight but not obese before pregnancy.Trial registration: Australian Clinical Trials Registry ACTRN12607000272493

Kirby Jeffries · Alexis Shub MB BS, FRANZCOG, PhD · Susan P Walker MB BS, FRANZCOG, MD · Richard Hiscock FANZCA, GradDipMedStat · Michael Permezel MB BS, FRCP, FRANZCOG

Despite positive changes to doctors’ working conditions, the stresses have changed rather than disappeared In the late 1970s, as a medical student in the United Kingdom, I attended a lecture from the then Dean of the medical school, Professor Neil Kessel. I recall him looking around at the 200 students assembled, and informing us that “Four of you will commit suicide”. That was, as I recall, the extent of our education about doctors’ health. Now, 30 years later, true to Professor Kessel’s foreboding, and despite his writings1 and the contribution of many others to an increasing body of knowledge and education about issues of physician impairment,2 four of my then colleagues have taken their own lives. Horrific though these mortality statistics may be, we also need to be cognisant of the considerable rates of morbidity among doctors. There have long been arguments about whether it is the stress of the job or the susceptible personalities that we bring with us to the profession that cause doctors to become stressed or psychiatrically unwell, or to develop substance misuse disorders. While we may be able to do little about the personalities of those attracted to careers in medicine, it is imperative that the stresses of the job and workplace are recognised, and that efforts are made to reduce them. For each cohort of medical students and doctors in training, the stresses of the previous generation may be modified, but they don’t disappear, and new ones are added. In theory, it is no longer permitted for registrars to stay up all night and then work the next day. In 1998, with the belated recognition that a disturbed sleep–wake cycle was good for neither patients nor doctors, and the establishment of the Safe Working Hours campaign,3 such practices are no longer defensible. However, doctors in training are not less stressed than those of previous generations; the stresses are different and often more intense, overlaid with the need for greater accountability, and the increasing militancy and litigiousness of consumers.4 In this issue of the Journal, we welcome two articles and a letter about doctors’ health and wellbeing. According to Heredia and colleagues, the intern year remains stressful despite reductions in hours and improvements in conditions.5 Self-report showed that 50% of interns thought medical school prepared them well for internship and, for most, internship was what they expected; but structured questionnaires showed that nearly 60% of interns had low levels of job satisfaction and, alarmingly, 18% regretted having studied medicine.5 Likewise, Markwell and Wainer found high rates of low job satisfaction and compassion fatigue among doctors in training, with 17% saying that, if they had their time over again, they would not have chosen medicine as a career.6 In the developmental trajectory of a doctor’s career, each phase brings its own set of challenges, and dissatisfaction with medicine as a career also appears to be significant among more senior doctors. A 2007 survey of what was deemed to be a representative sample of consultants in the British National Health Service found that 18% planned to retire early (before age 55), 32% were estimated to have psychiatric morbidity, and 17% reported drinking hazardous quantities of alcohol.7 The personal toll on doctors who are stressed, suicidal, burnt out or misusing substances must be appreciated; the effects on workforce planning of doctors underperforming or planning to give up medicine are also significant. Markwell et al found that most doctors in training report that their consultants and hospital administrations are supportive; this is encouraging, especially as it is in contradiction to the clinical experiences of working in a doctors’ health program. Here, some of the worst stresses experienced by doctors during their training (and later in their careers) are not those imposed by the system or training program, but come from the unsympathetic and judgemental attitudes of some more senior colleagues, who still see going through an intensely stressful training program as a rite of passage, or as preparation for tough times to come. Some of this stress is particularly stressful because it is personal and directed at individuals. It behoves us to treat our more junior colleagues with the same compassion that we show our patients. Postgraduate training for doctors has moved away from the apprenticeship model, making way for competency-based curricula. Trainees are under more scrutiny, and the stress of assessment is continual, with such evaluation tools as 360-degree assessment (multisource assessment with contributions from peers, other health professionals and patients) portfolios and formal evaluations in the workplace. The final exit examination may be less of a hurdle, but this comes at the price of doctors in training frequently being caught in a complex system where training requirements often conflict with workplace demands. The job is certainly stressful, but, as has been humorously pointed out, we as doctors need to admit the burden that we carry and find appropriate channels to “unload our baggage”.8 Authors of the third article on doctors’ health in this issue, Nash and colleagues, pose — and promise to explore in a future article — the important question of whether psychiatric morbidity is a cause or effect of medicolegal processes. However, they do find that those who work long hours are more likely to be involved in current medicolegal matters.9 Healthy doctors are more likely to have healthy patients. In order to keep doctors healthy, the ongoing challenges include not only continuing research into a changing group of issues, but integrating education programs into both undergraduate curricula and the workplace, and tackling workplace issues that may in part be best considered at the occupational health and safety level.

Kym D Jenkins FRANZCP, MPM, MEd

Objective: To investigate the frequency of, and factors associated with, Australian doctors’ involvement in medicolegal matters.Design, setting and participants: Cross-sectional survey of Australian doctors (specialists, trainees and general practitioners) insured with the medical insurance company Avant. A self-report questionnaire was mailed to Avant members in September 2007 to gather data on their involvement in medicolegal matters. Information on psychiatric morbidity and alcohol consumption was also collected using the General Health Questionnaire and the Alcohol Use Disorders Identification Test.Main outcome measures: Occurrence and type of past and current medicolegal matters with which doctors have been involved.Results: Of 8500 doctors invited to participate, 2999 returned completed surveys (36% response rate). Sixty-five per cent of respondents had been involved in a medicolegal matter at some time, and 14% were involved in a current matter. The two most common types of medicolegal matter were claims for compensation and complaints to a health care complaints body. Doctors were more likely to be involved in medicolegal matters if they were male, worked in high-intervention areas of medicine (surgery and obstretics/gynaecology), and worked longer hours.Conclusion: Our study concurs with other studies in finding an association between medicolegal matters and being male, working long hours and working in high-intervention areas of medicine. Unlike other studies, we found no association between age and involvement in a current medicolegal matter. Our findings also pose the question of whether psychiatric morbidity in doctors is a cause or effect of the medicolegal process.

Louise M Nash BA, MB BS(Hons), FRANZCP · Patrick J Kelly BMath(Hons), PhD · Michele G Daly BSc(Hons), MSc · Garry Walter BMedSc, FRANZCP, PhD · Elizabeth H van Ekert BA, DipEd, MMedHum · Merrilyn Walton BSW, MSW, PhD · Simon M Willcock MB BS, FRACGP, PhD · Christopher C Tennant MD, MPH, FRANZCP

Junior doctors face specific pressures related to their professional stage and development and can be at risk of poor health. A confidential survey conducted in 2008 by the Australian Medical Association Council of Doctors in Training investigated the health and wellbeing of junior doctors. There were 914 completed surveys: 71% of junior doctors were concerned about their own health, and 63% about the health of a colleague. A majority of junior doctors met well established criteria for low job satisfaction (71%), burnout (69%) and compassion fatigue (54%). The early stages of a medical career are demanding, and the health and wellbeing of junior doctors must be a personal priority, as well as the responsibility of the medical profession in general, to ensure a healthy medical workforce in the future.

Alexandra L Markwell MB BS(Hons), BSc · Zoe Wainer BM BS, BHSc

To the Editor: The uniquely stressful nature of medical practice has been highlighted by many studies focusing largely on general practitioners, consultant physicians and senior hospital staff.1,2 Although overseas data confirm significant levels of stress and anxiety among junior medical officers (JMOs),3-5 few researchers have examined the cohort in Australia. Consequently, the JMO Welfare Study was initiated by junior doctors as a quality-improvement exercise to investigate aspects of intern life in Australia by quantifying levels of work-related stress, burnout and job satisfaction among JMOs. All interns in Western Australia and Queensland, together with interns working in nine primary allocation centres in New South Wales, were invited to participate in a retrospective, questionnaire-based observational study. The questionnaire, offered to doctors completing their internship in 2007 in WA and NSW, and in 2008 in Queensland, consisted of two sections. The first section contained questions with fixed response options, such as a 5-point Likert scale (Box), while the second section utilised the Professional Quality of Life (ProQOL) psychometric tool.6 The response rate was 39% (276/706), with respondents having a demographic profile similar to non-respondents. Sixty-six per cent of interns were registered as patients with GPs, although only half (53%) had visited a GP in the past year. Sixty-five per cent self-reported high levels of stress in the workplace, and 47% believed their workload was excessive. More than 90% of interns felt they were well supported by other clinicians and most enjoyed their work (82%). If given their time again, 18% conceded they would not study medicine. Using the ProQOL scale, researchers found 59% of surveyed interns had low levels of job satisfaction, 31% were susceptible to burnout and 23% were at risk of emotional fatigue. Despite the survey limitations of a low response rate and reliance on data collected in different years, the JMO Welfare Study demonstrates that the intern year is a stressful time for medical graduates employed in Australia. While interns appear to be well supported in the workplace, a significant proportion experience low levels of job satisfaction and are susceptible to burnout and emotional fatigue. Although it is impossible to remove the element of stress associated with work as a medical practitioner, these findings indicate a need for junior doctors to be adequately trained in stress management and provided with suitable support services, such as counselling. Responses to questions concerning internship (n = 276) in the national Junior Medical Officer Welfare Study SD/D NA A/SA I worry about the welfare of my colleagues because of working conditions 40% 4% 56% I work unsafe hours on a regular basis 67% 6% 27% Medical school prepared me well for life as an intern 32% 3% 65% Working as an intern was what I expected 21% 3% 76% My employer devoted adequate time to my education 32% 3% 65% I often cannot attend educational sessions due to my workload 39% 4% 57% I have had enough time to engage in self-education 65% 6% 29% I often consented patients for procedures I had never seen 25% 0 75% I often consented patients for procedures I did not know well 20% 1% 79% As an intern I was a valued member of the team 11% 6% 83% SD/D = strongly disagree/disagree. NA = not applicable. A/SA = agree/strongly agree.

Daniel C Heredia · Caroline S Rhodes · Suzanne E English · Dayna B Law · Anna C McElrea · Florian X Honeyball

Our public hospitals need medical leadership, and partnerships with medical schools can provide it There have been huge changes in medical practice over the past 20 years, including advances in the fields of cardiovascular disease, orthopaedics and cancer. Many of these were introduced through major teaching hospitals, before going on to influence associated hospitals and private practice. Continuing advances in medical research and technology (including information technology) in coming years will offer yet further opportunities to improve patients’ survival and quality of life. Recurring events with mismanagement of patients have undermined confidence in public hospitals — well publicised incidents in Bundaberg and Royal North Shore Hospital are recent examples. Before the 2007 election, Kevin Rudd promised that public hospitals would be taken over by the federal government if they were not “fixed” by the state governments within 12 months. The community has a right to expect health care with a commitment to excellence and safety. Would transferring responsibility for public hospitals to the federal government, as is now foreshadowed by the National Health and Hospitals Reform Commission (NHHRC), solve anything? The final report of the NHHRC,1 with its 292 pages and 123 recommendations, warrants careful analysis, but the big issues are lost in the detail. I applaud its proposed initiatives to strengthen primary care, mental health care, dental care, preventive strategies and Indigenous health. The big gap is the lack of realistic proposals to “rescue” public hospitals. Despite delivering constantly evolving services, our hospitals have been required to deliver more and more with their existing resources (except for some recent increase in federal funds), with their performance measured against metrics relating to diagnosis-related-group-adjusted “patient separations”, waiting list numbers and emergency waiting times. Quality of care, in which professionals take pride, has become a low priority. Clinical academics and other medical leaders with a commitment to evaluation of quality, and to research and innovation, have been pushed to one side. Statements by the NHHRC that quality, safety, research and innovation should be encouraged have no meaning if management of hospitals continues in the current mode. Are the problems really understood? Garling concluded in 2008 that the New South Wales health system is in a state of crisis — “It is the breakdown of good working relations between clinicians and management which is very detrimental to patients”.2 To varying degrees, the same applies in state after state, although Victoria’s situation is better, with hospital boards overseeing chief executive officers who are expected to make decisions and work with professional teams, rather than detailed management responsibility resting with health bureaucrats and their delegates, as is the case in many other states. In the 1970s and 1980s, Australia had some great university hospitals doing excellent work. The Austin Hospital in Victoria was, in 1966, the first to be established with academic leadership. From 1974, the Flinders Medical Centre in Adelaide was a model “joint” university hospital, but now functions largely as a community hospital. The fine Westmead complex in NSW, developed under guidance from the University of Sydney (from 1976) now suffers state bureaucratic interference. For all that, the medical schools of the University of Melbourne and the University of Sydney were rated among the world’s top 300 medical schools for research in clinical medicine in 2009, being ranked 37th and 59th, respectively3 — both higher than Cambridge University and the University of Manchester, two of the five medical schools in the United Kingdom recently recognised as leading academic health science centres overseeing large groups of hospitals. Four other Australian schools are in the top 200. The interim report of the NHHRC dismissed the concept of “university hospitals”4 as old-fashioned.5 The National Health and Medical Research Council, in its Draft Strategic Plan for 2010–2012, ignores the strong recommendation of its own international strategic review (the Zerhouni Review) that the government should ensure that at least a few competitively selected hospitals have sufficient funds and a mission statement that also supports patient-based research rather than minimising current costs at the expense of long term transformation of health.6,7 This recommendation reflects the pattern so well developed in the United States, Sweden, Finland, the Netherlands, Belgium, Singapore and, more recently, the UK. Despite generalities in the NHHRC final report about the importance of research, university medical schools are now to relate to their teaching hospitals through a new “competency-based” National Health Workforce Agency, and teaching hospitals are to respond to external advice from the National Institute of Clinical Studies (NICS) as to how to treat their patients.1 Valuable though NICS is, its currency is “evidence-based medicine” derived from past clinical trials, usually performed by teaching hospitals, that reflects previous experience rather than advancing knowledge. “Competencies”, the proposed basis for education, can also only be defined by looking at current patterns. Further, clinical governance, so central to the culture of clinical academics, is to be developed through “‘Clinical Senates’ at national, regional and local levels”.1 External control is seen as the answer! Surely we should by now have escaped the tyranny of distance and can learn from the experience of other countries tackling similar problems. Britain’s National Health Service (NHS) was, for years, centrally controlled by bureaucracies. Public disquiet grew as it became clear that the NHS was falling behind international standards of health care. Gordon Brown, as then Chancellor of the Exchequer, intervened over the Department of Health. The Cooksey review8 called for major redevelopment of clinical research to safeguard and advance the quality of services. An outstanding academic surgeon, Lord Darzi, was then appointed a life peer, becoming the Parliamentary Under-Secretary of State for Health, to review the entire NHS. His reforms secured medical leadership of the system at every level, with groups of hospitals led by medical schools.9 The changes have rapidly turned around the morale, culture and quality of services in British public hospitals. In 2009, only the fourth year of the reforms that began with the Cooksey review, an international panel recognised five large hospital groups led by medical schools — Imperial College London, University College London, King’s College London, Cambridge and Manchester — as exemplary in their health care delivery, deployment and education of health professionals, and commitment to quality, clinical research and innovation. The key to reform has been medical partnership in managing services for patients at every level jointly with health service managers, all accountable to medical school leadership. Clinical research with constant evaluation of health care10 is seen as the key to quality of services. Cost savings are now being realised with improved resource allocation, despite also meeting emerging challenges (E Byrne, formerly Vice Provost, University College London Medical School, personal communication, Aug 2009). Australia’s public hospitals should come under a new partnership between federal and state governments and the nation’s medical schools, following British and other international patterns. Each group of hospitals would be led by an appropriate Executive Dean working jointly with a senior health administrator, with hospitals being grouped on current patterns of association for teaching and intern and registrar rotations. Some hospital groupings in the UK are large (including up to 60 hospitals), but clearly work well. Governance and management are devolved in the joint clinician–hospital administrator pattern, with accountability to university leadership, safeguarding appropriate medical involvement. Kevin Rudd may choose to intervene over the “health establishment”, as Gordon Brown did. We stand ready to work with him in rapidly turning around a system in disarray.

David G Penington AC, DM(Oxon), LLD(Hon), FRACP

The National Health and Hospitals Reform Commission report has a focus on building on “the vital role of general practice”, to strengthen primary health care as the “cornerstone of our future health system”. The report proposes Comprehensive Primary Health Care Centres and Services that will deliver “one-stop” primary health care; but in health care, bigger is not always better. The biggest challenge for the reform process may well be bringing together the different cultures of the largely private primary health care services, funded by the federal government, and the public, primary and community health services, funded by the states and territories. The report pays little real attention to the reforms needed to address the social determinants of health. There is a clear need for action now on the report’s most urgent recommendations for Aboriginal and Torres Strait Islander health, mental health, dental health and services for rural and remote communities. Diversity is a great strength of Australian general practice, and we must not lose it in the rush to reform.

Michael R Kidd AM, MD, FRACGP

The National Health and Hospitals Reform Commission (NHHRC) report attempts to deal in the short term with hospital access block by funding more beds in emergency departments, while, over the longer term, reforms aim to improve hospital efficiency, transfer care of patients to non-hospital settings, optimise use of outpatient clinics, fund hospital activities on the basis of efficient cost, and improve governance and accountability. The single most potentially effective recommendation is the considerable investment in and expansion of subacute and non-acute services, which will free up acute-care hospital beds for urgent cases. Population-based chronic disease management driven by Primary Health Care Organisations can also reduce future hospitalisations considerably. What the NHHRC could have dealt with more fully is the need to: (i) prioritise clinical interventions and the need for hospitalisation using evidence of cost-effectiveness obtained from clinical trials and longitudinal patient data; and (ii) move quickly towards funding of all health care by one level of government. Even the most effective reforms will not have a significant impact on future bed demand if professional and public expectations remain unsustainably high and do not acknowledge the need to change the role of hospitals within a reconfigured health care system.

Ian A Scott FRACP, MHA, MEd

Standard and Droplet Precautions are considered adequate to control the transmission of influenza in most health care situations. Vaccination of health care staff, carers and vulnerable patients against seasonal and, eventually, pandemic influenza strains is an essential protective strategy. Management principles include: performance of hand hygiene before and after every patient contact or contact with the patient environment, in accord with the national 5 Moments for Hand Hygiene Standard; disinfection of the patient environment; early identification and isolation of patients with suspected or proven influenza; adoption of a greater minimum distance of patient separation (2 metres) than previously recommended; use of a surgical mask and eye protection for personal protection on entry to infectious areas or within 2 metres of an infectious patient; contact tracing for patient and health care staff and restriction of prophylactic antivirals mainly to those at high risk of severe disease; in high aerosol-risk settings, use of particulate mask, eye protection, impervious long-sleeved gown, and gloves donned in that sequence and removed in reverse sequence, avoiding self-contamination; exclusion of symptomatic staff from the workplace until criteria for non-infectious status are met; reserving negative-pressure ventilation rooms (if available) for intensive care patients, especially those receiving non-invasive ventilation; ensuring that infectious postpartum women wear surgical masks when caring for their newborn infants and practise strict hand hygiene; and implementation of special arrangements for potentially infected newborns who require nursery or intensive care.

Rhonda L Stuart FRACP, PhD · Allen C Cheng FRACP, MPH, PhD · Caroline L Marshall FRACP, PhD, GradDipClinEpi · John K Ferguson FRACP, FRCPA, DTMH

Pregnancy and delivery are critical times for women with bleeding disorders, with mothers, and possibly their affected infants, being exposed to a variety of haemostatic challenges. Management of women with bleeding disorders during pregnancy involves a multidisciplinary team including, but not limited to, an obstetrician, an anaesthetist and a haematologist. This consensus document from the Australian Haemophilia Centre Directors’ Organisation (AHCDO) provides practical information for clinicians managing women with bleeding disorders during pregnancy. Included are: the expected physiological response in pregnancy in such women; management of pregnancy, labour and delivery, as well as obstetric anaesthesia issues, postpartum care, and reducing and treating postpartum haemorrhage; and management of infants at risk of a bleeding disorder and of bleeding in neonates. The guidelines were developed after extensive consultation, face-to-face meetings and revisions. The final document represents a consensus opinion of all AHCDO members. Where evidence is lacking, recommendations are based on clinical experience and consensus opinion.

on behalf of the Australian Haemophilia Centre Directors’ Organisation

The release for public consultation of the draft Health Practitioner Regulation National Law 2009 represents a once-in-a-generation opportunity to ensure best practice in medical regulation. The draft law fails to build on the best aspects of existing state and territory legislation, particularly in regard to how allegations of misconduct, poor performance or impairment are to be handled. If adopted, this legislation has the potential to set back important improvements to professional regulation that have been implemented in Australia in the past 20 years. There are also legitimate concerns about mandatory reporting provisions and the likely increased cost of regulation. More time and more work are needed to get this new scheme right.

Kerry J Breen AM, MB BS, MD, FRACP

Clinical record A 4-month-old girl was referred to an ophthalmology clinic in May 2008 for assessment of a left convergent squint (esotropia). First noticed 3 weeks previously, the squint had become increasingly prominent. The child’s parents had also noted increased watering of the eyes, ascribed, by the child’s paediatrician, to congenital nasolacrimal duct obstruction. The infant was born preterm (at 36 weeks’ gestation), and had a history of congenital hypothyroidism and a perimembranous ventricular septal defect. There was no family history of glaucoma, and no history of intrauterine infection or birth trauma. Examination confirmed left esotropia. The infant’s eye movements were full, implying a concomitant squint. Her pupils were reactive to light, and with no afferent defects. She was photophobic when her pupillary light reflexes were tested. Aversion to light prevented assessment of visual function. There was tearing (epiphora) in both eyes. The corneas were mildly cloudy and appeared enlarged (buphthalmos); the horizontal corneal diameter measured 13.0 mm in the right eye and 12.5 mm in the left (Figure). A more detailed examination was performed under general anaesthesia. Intraocular pressure (IOP) was elevated at 27 mmHg in the right eye and 28 mmHg in the left (IOP reference range [RR] for an infant under general anaesthesia, 5–14 mmHg).1 The angles were open, and the optic nerve cup-to-disc ratio was increased bilaterally (0.6; RR for infants, < 0.4). Bilateral primary congenital glaucoma was diagnosed. Treatment began immediately with topical ocular antihypertensives and oral acetazolamide, and bilateral trabeculotomy was performed in a staged manner over the next month. At follow-up 13 months after diagnosis, ocular antihypertensive agents had been discontinued, and IOP was acceptable (16 mmHg bilaterally). Horizontal breaks in the basement membrane of the corneal endothelium (Haab striae) were present. Although visual outcome could not be assessed until the child was older, acuity (measured using Teller Acuity Cards) was subnormal bilaterally and worse in the right eye (20/380) than in the left (20/190). To treat amblyopia, the left eye is currently being patched for 2 hours a day. The patient will be reviewed at regular intervals to assess visual function and measure IOP. This case of primary congenital glaucoma (PCG) illustrates the typical clinical features of this condition, which, if untreated, results in blindness. In this case, the infant was referred to our ophthalmology service by a general paediatrician, who was reviewing her for thyroid and cardiac disease; neither of these conditions has a known association with congenital glaucoma. The difficulty in recognising PCG lies partly in its rarity; PCG has a reported incidence of 1 in 30 000 live births in Australia.2 Congenital glaucoma can also be mistaken for a number of common, benign conditions: conjunctivitis, corneal injury, in-turning eyelashes from associated conditions such as epiblepharon (a congenital anomaly in which a fold of skin lies across the lower lid margin), or, as in this case, congenital nasolacrimal duct obstruction. The significance of our patient’s squint is uncertain, although most likely it was a result of her deteriorating visual function. The pathophysiology of PCG appears to be dysgenesis of the trabeculum or its surrounding structures, which results in impaired aqueous outflow and increased intraocular pressure (IOP).3 The conventional outflow path for aqueous humour is shown in the Box. Elevated IOP results in breakdown of corneal endothelial function and an influx of aqueous humour into the normally anhydrous corneal stroma. Prolonged elevation of IOP results in excavation and undermining of the neural and connective tissue of the optic disc, and the development of optic neuropathy. The first clinical signs of PCG include the triad of blepharospasm, photophobia and excessive tearing. Progressively, the corneas become oedematous, lose clarity, and, if untreated, may become opaque. Elevated IOP in an immature eye also results in progressive enlargement of the cornea and sclera, known as buphthalmos (“ox eye”). Potential for corneal enlargement generally ceases when the child reaches 3 years of age, although scleral enlargement can increase beyond this age.3,4 The horizontal corneal diameter in full-term newborn infants averages 9.8 mm; a corneal diameter greater than 11 mm is enlarged.5 A horizontal corneal diameter greater than 12 mm in a 12-month-old child suggests abnormality.6 Progressive enlargement of the cornea may also result in horizontal breaks in the basement membrane of the corneal endothelium (Descemet membrane), known as Haab striae.3 Lessons from practice Congenital glaucoma is a sight-threatening differential diagnosis in an infant who presents with watering eyes. Key clinical features of congenital glaucoma are a cloudy cornea, excessive tearing, blepharospasm, photophobia and an enlarged globe. In infants, corneal size is a surrogate marker of intraocular pressure. Enlargement and asymmetry in corneal diameter requires further investigation. Patients with suspected congenital glaucoma require urgent referral to an ophthalmologist. The mean age of diagnosis is 4.4 months.2 Severe disease is occasionally observed in neonates, although in its early stages PCG tends to have few signs. An urgent referral to an ophthalmologist is required if tearing is associated with photophobia or blepharospasm; the cornea is hazy; or the eye or cornea is enlarged or asymmetrical. It is important to distinguish PCG from congenital nasolacrimal duct obstruction: infants with the latter also have excessive tearing, but, in contrast to PCG, the cornea remains clear, there is no enlargement of the globe and no photophobia or blepharospasm. Nasolacrimal duct obstruction is common, typically innocuous, and frequently resolves spontaneously within the first 12 months of life. It can be safely assessed and managed by the primary-care physician. Diagnosis of PCG relies on IOP measurement. The patient is usually assessed under general anaesthesia, not only to aid IOP measurement, but to permit accurate measurement of corneal diameter and thickness, detection of refractive errors, viewing of the angle structure and a detailed examination of the optic disc. Surgery is the first-line treatment for PCG. The two most common procedures are goniotomy and trabeculotomy, both of which involve microsurgical dissection of the trabecular meshwork, with the aim of increasing aqueous outflow. Ocular antihypertensive agents are an important adjunct to surgery, and are often used as a temporising measure. Screening for amblyopia and correction of asymmetrical refractive errors are undertaken until the child’s vision is developmentally mature to ensure the best visual outcome achievable for the child. Lifelong follow-up is often required. With modern treatment, a visual outcome of better than 6/15 is achieved in up to 79% of cases of PCG; whereas, if untreated, this condition carries an exceedingly poor visual prognosis.3,7 Normal production and outflow of aqueous humour Aqueous humour is produced by the ciliary body and passes from the posterior chamber through the pupil into the anterior chamber. Its outflow path includes the trabecular meshwork, Schlemm canal and the episcleral venous system. The proposed pathophysiology of primary congenital glaucoma is dysgenesis of the trabecular meshwork.

Adam K Rudkin BM BS, BJuris, BA(Hons) · Jwu J Khong MB BS(Hons), MMed · Theresa M Casey MB BS, FRANZCO

To the Editor: We wish to call for the removal of scheduling and legislative barriers in Australia that prevent easy access to naloxone for administration by peers to people suffering from a heroin overdose. Use of illicit opioids, typically heroin, remains the major cause of illicit drug-related mortality in this country, with at least one accidental opioid overdose currently occurring each day.1 Although population levels have not reached those seen during the peak in the late 1990s, geographically localised and transient increases in overdoses are evident.2 Death from heroin overdose typically occurs some time after use. In many cases, other people are present, and there is considerable scope for intervention to prevent death.3 Yet, in more than 70% of cases of fatal overdose, there is no intervention, and, where action is taken, calling an ambulance is seldom the first strategy, resulting in even greater risk of death.3 Opioid substitution treatment (with methadone or buprenorphine) is the mainstay of overdose prevention in Australia. Other interventions implemented here include outreach services and education for injecting drug users about the risks of overdose and how to respond to it.3 In 2000, Lenton and Hargreaves summarised the evidence for distributing the opioid antagonist naloxone for administration by peers to prevent deaths from heroin overdose. They concluded that an Australian research trial was needed.4 However, in 2001, the Australian heroin market was disrupted, heroin use and overdoses declined, and the trial did not proceed. Since then, emerging international evidence has demonstrated that injecting drug-using peers, family members and outreach workers can successfully administer naloxone to reverse heroin overdose — with few, if any, adverse effects.5 By December 2008 in the United States, 52 programs distributing naloxone for administration by peers were operating in 17 states, with over 1000 documented overdose reversals resulting from these programs.5 Most concerns about the intervention — such as the possibility of unsafe naloxone administration, reintoxication or more risky drug use — appear to have been unfounded, and naloxone administration by trained peers has been shown to be a remarkably safe intervention.5 In our view, the international evidence clearly indicates that increased naloxone availability will prevent many cases of fatal overdose, that conducting a trial in Australia is now unnecessary, and that naloxone should be made available without delay to be administered by peers in cases of opioid overdose. Careful monitoring and evaluation should be a part of this process. We call on all Australian states and territories to immediately enact Good Samaritan legislation to legally protect laypeople using naloxone in emergency situations. Naloxone should be reclassified from a Schedule 4 (S4) drug (available only on prescription) to S3 or S2 to make it available over the counter. As naloxone is no longer under patent,5 there may be little financial incentive for a drug company to pursue rescheduling. However, it could be rescheduled in Australia under provisions that allow state health authorities, professional associations or the National Drugs and Poisons Schedule Committee to initiate the process. Heroin overdose deaths are preventable. We need to take action now to enable peer-led intervention to reduce this serious outcome.

Simon R Lenton · Paul M Dietze · Louisa Degenhardt · Shane Darke · Tony G Butler

To the Editor: On behalf of the Australian Association of Musculoskeletal Medicine (AAMM) and the Australasian Faculty of Musculoskeletal Medicine (AFMM), we would thank Briggs and Buchbinder for raising the topic of back pain as a National Health Priority Area (NHPA) for debate.1 The AAMM and its teaching arm, the AFMM, have been arguing for years that higher priority should be given to the management of low back pain, and we certainly support the arguments for making back pain an NHPA. We agree that back pain is a major burden on society, and that coordinated action that includes all stakeholders is required. Currently, members of the AAMM and AFMM are involved in contributing to the Australian Core Competencies in Musculoskeletal Basic and Clinical Science project,2 which aims to standardise the undergraduate teaching in musculoskeletal medicine around Australia. As well as supporting undergraduate initiatives, the AAMM and AFMM have been the significant providers of postgraduate education for doctors around Australia over the past 20 years, being engaged in activities that include the development of evidence-based guidelines and university-based postgraduate diploma and masters programs.3 It is then very disappointing to read disparaging comments about doctors with a special interest in musculoskeletal medicine. Briggs and Buchbinder assert that one potential disadvantage of making back pain a health priority is that it may provide “justification for those with . . . vested interests to promote clinically ineffective interventions”. The example they cite is a questionnaire survey of Victorian doctors in 2004, highlighting that a self-reported interest in low back pain or musculoskeletal medicine, or both, was strongly associated with back pain management beliefs and practices that are contrary to the best available evidence.4 The title of the Spine journal article4 is mischievous and misleading. The article implies that members of the AAMM have poorer knowledge about low back pain than doctors with no special interest in back pain. The real facts are that no attempt was made by the authors to specify what training or continuing medical education doctors had received, or whether they were members of the AAMM.

Victor J Wilk · Michael J Yelland · Michael B Oei

To the Editor: In the recent article by Briggs and Buchbinder, the authors propose that one advantage of including back pain as a National Health Priority Area (NHPA) is that it will increasingly encourage the management of back pain in accordance with best-practice clinical care guidelines.1 The emergency department (ED) is a key point of presentation for people with back pain. Research suggests that optimal management of low back pain incorporates multidisciplinary input, ensuring the provision of adequate analgesia and rational use of further investigations.2,3 On the basis of such data, we devised an interactive decision-support tool for completion by ED staff. The “Low Back Pain Assessment and Treatment” (LBPAT) guidelines were designed by a multidisciplinary team of nursing, medical, physiotherapy and pharmacy staff, based on accepted evidence-based standards of practice already in use.4 Use of these guidelines enables rapid assessment of “red flags” that may require further investigation and treatment. The guidelines include a flow diagram divided into three pain-management options for patients with mild, moderate or severe pain, with prompts for referral to physiotherapy and neurosurgery. The LBPAT guidelines indicate which imaging studies and blood tests may be required and when, as directed by findings. Information to assist discharge planning, including follow-up by a physiotherapist and general practitioner, and provision of information, is included. Once they were developed, we evaluated the effectiveness of the LBPAT guidelines in improving ED clinical practice. A retrospective case-record study of patients presenting to the ED and identified from International classification of diseases, ninth revision (ICD-9) codes (for back pain or low back pain) was undertaken before implementation of the guidelines (October–December 2006; 87 patients), immediately after implementation (May–August 2007; 96 patients), and about a year later (July–August 2008; 28 patients). Uptake of the LBPAT guidelines was only 47%–50% in both postimplementation periods. However, adherence to pain management guidelines improved significantly after implementation (59% [57/96] compared with 46% [40/87]; P = 0.02), and was maintained a year later (57% [16/28]). Use of aperients in patients who were coprescribed opiates was much improved in the period immediately after implementation (40% [27/68] compared with 16% [11/69]; P < 0.001) and 1 year later (70% [14/20]). Postimplementation data suggested a reduction in unnecessary blood tests (ie, no red flags requiring further investigation). For patients discharged from the ED, discharge planning and continuity of care did not improve immediately after implementation, but were greatly improved 1 year later. If back pain is included as an NHPA, use of a clinical decision tool such as the LBPAT guidelines is one potential method of preserving resources and improving patient outcomes in cases of back pain in the ED setting.

Stephanie K Vaughan · Julie L Gawthorne · Andrew S Finckh · Susan A Welch

In reply: The two preceding letters highlight that there are many stakeholders with an interest in back pain in Australia. Many craft groups are involved with the provision of postgraduate education and have contributed to the musculoskeletal core competencies initiative. Vaughan and colleagues describe promising results from using a clinical decision tool for acute back pain in an emergency department. On a national scale, implementation of such a tool in all emergency departments may significantly improve outcomes and reduce costs. Making back pain a national priority would provide unique opportunities to rigorously study these types of approaches. A timely illustration of our concern about vested interests potentially promoting ineffective or unproven interventions1 is the lively debate centred on the recently published United Kingdom National Institute for Health and Clinical Excellence guidance for the early management of persistent non-specific low back pain.2 The recommendation that injections of therapeutic substances into the back for non-specific low back pain should not be offered, as the evidence of effectiveness is lacking, led to the forced resignation of the president of the British Pain Society because of his refusal to denounce the guidelines he helped to formulate.3 To suggest that the title of the Spine journal article is misleading and mischievous is patently incorrect, as the title, “Doctors with a special interest in back pain have poorer knowledge about how to treat back pain”, simply summarises the main study findings.4 Based on 3831 responses from general practitioners in New South Wales and Victoria, collected in 1997, 2000 and 2004, doctors who reported a special interest in low back pain were significantly more likely to believe that patients with acute low back pain should be prescribed complete bed rest until the pain goes away (relative risk [RR], 1.89; 95% CI, 1.53–2.33); that they should not return to work until they are almost pain-free (RR, 1.55; 95% CI, 1.31–1.83); and that lumbar spine x-rays are useful in their work-up (RR, 1.36; 95% CI, 1.21–1.52). We also reject the suggestion that we made disparaging remarks about doctors with a special interest in musculoskeletal medicine. After adjusting for the presence of special interests in back pain, there were no important differences in back pain beliefs between those with and without a special interest in musculoskeletal medicine. While we cited a survey that found that Australian Association of Musculoskeletal Medicine (AAMM) members see a high caseload of patients with back pain,5 we made no claims about the knowledge base of AAMM members.

Rachelle Buchbinder · Andrew M Briggs

To the Editor: We thank Page and colleagues for their important article considering the sociodemographic correlates of antidepressant utilisation in Australia.1 We note that fewer than 15% of the young people in the study were prescribed fluoxetine, and almost 40% were prescribed sertraline. These rates of antidepressant use contrast with the available evidence on treating young people diagnosed with depression. A recent review examining the effectiveness of selective serotonin reuptake inhibitors (SSRIs) for depression among children and adolescents demonstrated that fluoxetine is the only SSRI with at least some evidence for effectiveness.2 Current clinical guidelines recommend that a young person diagnosed with a major depressive disorder who is to be prescribed an antidepressant should be given fluoxetine in the first instance.3,4 Reasons for the apparent lack of concordance with the guidelines might include treatment of disorders other than depression, or prescriptions for those who have already had an unsuccessful trial of fluoxetine. It would thus be of great interest to learn what proportion of young people are prescribed an antidepressant other than fluoxetine, and what proportion of young people prescribed an antidepressant are concurrently undergoing guideline-concordant psychological treatments, such as cognitive behaviour therapy. The data presented by Page et al draw attention to challenges faced by doctors providing treatment for young people experiencing depression, which include a lack of good evidence about the effectiveness of newer antidepressants for this age group. However, there is an opportunity to support better use of evidence in decisions made about treatment options for young people. The provision of high-quality, evidence-based information for patients and their carers to enable informed decisions is essential, and shared decision making offers a way to enable this.5 By improving the knowledge transfer between doctor and patient, antidepressant prescription can be more judicious.

Magenta B Simmons · Michaela R Willet · Sarah E Hetrick

To the Editor: In their editorial commenting on our viewpoint article on Team Care Arrangements (TCAs), Harris and colleagues acknowledge a number of problems with TCAs and a lack of evidence for their effectiveness. However, they state that “the idea of team care still has merit” and that although there is “ample room for improvement in the current process”, they “cannot agree with Hartigan et al’s radical prescription to replace TCAs with patient summaries”.1 This seriously misrepresents our article. We did not suggest that TCAs should be replaced by patient summaries. We stated: “There are many elements in the solution to this problem, but one of primary importance is the development of a comprehensive patient summary”.2 Among these elements could be the one suggested by Harris et al — registration of patients in a shared database. However, a shared database would avail little if the patient information contained therein is not sufficiently comprehensive to permit development of well considered treatment objectives and priorities. The essential issue is whether TCAs are an improvement on the coordination that occurs under the traditional referral system. Coordination exists along a spectrum. At one end, it can be rigidly structured, with all participants having right of veto over action by any of the others. At the other end, it can be fluid and unstructured, with decisions over who should be involved in any particular management issue left to the good judgement of participants. By electing to impose on general practitioners a coordination model at the rigid end of this spectrum, the architects of TCAs appear to assume that GPs are usually unwilling, or cannot be bothered, to consult with other health professionals and must be made to do so. This is a massive assumption that demands very strong evidence. What is the evidence? And even if there were evidence, is coercion the answer? There is no doubt that coordination in care of patients with chronic illness is important and that it can be improved. However, improvements must be based on evidence and be practical. TCAs are neither.

Paul A Hartigan · Tuck Meng Soo · Marjan Kljakovic

In reply: We accept the clarification by Hartigan and colleagues of their article’s intent,1 and agree with the importance of good-quality information in electronic databases, especially if the information is to be exchanged. Unlike Hartigan et al, we do believe that Team Care Arrangements (TCAs) have some merit, as they provide structure for planned care and help coordinate access to multidisciplinary care provided over a period of time within the complexity of the current health system. However, they have not been very effective in developing trusting relationships and encouraging better communication between general practitioners and providers outside the practice because of a variety of systemic barriers. In our editorial, we suggested some alternative strategies.2 Although the paperwork and complexity of current requirements could be reduced, we cannot see that coercion is involved. Both patients and providers can choose to enter freely into TCAs and the requirements are for communication and consent, not for “right of veto over action”.

Mark F Harris · Bibiana C Chan · Sarah M Dennis

Davidson’s essentials of medicine. J Alastair Innes, editor. Edinburgh: Churchill Livingstone Elsevier, 2009 (xii + 861 pp). ISBN 978 0 7020 3001 7. Davidson’s essentials is intended as a portable mini-textbook of medicine, primarily for medical students, for reference and reading while “on the move”. Although portable electronic formats such as PDAs may be good for reference purposes, they can be difficult to read or study from. Likewise, many existing handbooks use a list-based presentation that is not suitable for the novice learner seeking basic comprehension. Thus, Davidson’s essentials is a useful contribution that generally achieves the stated goals of its editor. It is a multi-authored work, but good editing means chapters have a consistent style and easy readability. A very useful feature is a one-page summary of the examination features for each organ system. This is a valuable learning tool that relates the presentation of each system to the examination of the actual patient. Indeed, each of these summary pages would make a good educational poster. The photographs are in colour and are generously sized. Tables and diagrams are used judiciously, and are educational rather than exhaustive. This is an excellent little textbook, but is by no means perfect. It fits easily into a bag, but is just a little too large and heavy to carry in the pocket. The chapter on emergencies and critical care is not long enough to give more than a cursory outline of shock, organ failure and resuscitation. Likewise, the discussion of geriatric syndromes is far too short for my liking. The last chapter gives sample OSCE (objective structured clinical examination) questions, but too few to be really useful; the book would not suffer if this final section were omitted. This book is definitely value for money, given the price of comparable handbooks. I recommend this for medical students beginning clinical work; allied health workers working in an unfamiliar area may find it useful for reference.

James Macdonald

Setting the alarm for bed-wetting Bell and pad alarm therapy appears to be an effective treatment for nocturnal enuresis in children, according to Australian researchers. Designed to condition the child to recognise a full bladder, the alarm sounds when the sleeping child releases urine onto a pad. A questionnaire was sent to 240 affected children and their parents, and results showed that the initial response rate to bell and pad therapy was 84%, with a relapse rate of 30%. Better outcomes were associated with female sex, shorter duration of treatment, the child’s willingness to use therapy, and a lack of diurnal symptoms. The success rate of repeat therapy was high (78%) and the average length of repeat treatment was 10 weeks. The authors comment that their findings may help clinicians identify children who may need different approaches to treatment. J Paediatr Child Health 2009; 45: 405-408 H. pylori and gastric cancer Treatment for the eradication of Helicobacter pylori appears to reduce the risk of gastric cancer, say Italian and US researchers. The association between gastric cancer and infection with H. pylori is well established, but the effect of eradication treatment has previously not been clarified. In a meta-analysis of six studies involving over 6000 patients in areas with a high incidence of gastric cancer, 1.1% of treated patients developed gastric cancer, compared with 1.7% of untreated patients. A pooled analysis of all the studies comparing eradication treatment for H. pylori to no intervention or placebo revealed a relative risk of 0.65. The authors conclude that, because of the high incidence of gastric cancer worldwide, even a small decrease with H. pylori eradication treatment will have major benefits. Ann Intern Med 2009; 151: 121-128 VTE and travel: what are the risks? There is considerable conflict between published studies about the real risk of venous thromboembolism (VTE) associated with travel. A US meta-analysis that included data on 4055 cases of VTE has confirmed the association and suggested a dose-response relationship between travel time and risk of VTE. Compared with non-travellers, the meta-analysis showed that travellers had an overall pooled relative risk of 2.0 for VTE. When differences between selection criteria for control subjects were accounted for by excluding control patients who had been referred for VTE evaluation, the relative risk rose to 2.8. Additionally, an 18% higher risk for VTE was observed for each 2-hour increase in travel time. The authors comment that the heterogeneity of study design not only makes comparisons and pooling of data difficult, but also highlights shortcomings in the understanding of basic principles of research design. Ann Intern Med 2009; 151: 180-190 “Blindness” to fungal spores Ever wondered why your respiratory system doesn’t react to the allergens and antigens contained in the thousands of fungal spores (conidia) you breathe in with each lungful of air? A group of European researchers appear to have found the answer, which lies in the presence of a surface layer on the dormant conidia that masks its recognition by the immune system and prevents an immune response. Using a number of fungi that can be opportunistically pathogenic, including Aspergillus fumigatus, they conducted in-vitro assays and in-vivo murine experiments. The surface “rodlet layer” of the conidia is composed of hydrophobic proteins bound to the cell wall, and is immunologically inert, failing to induce activation and maturation of dendritic cells or alveolar macrophages, or to activate helper T-cell immune responses. The authors comment on the exciting possibility of generating rodlet protein-based nanoparticles containing therapeutic substances, which could be transported through the body without recognition by the host immune system. Nature 2009; 460: 1117-1121 Overweight kids Despite national policies for the detection and management of overweight and obese children, it appears that screening for these children, followed by a short period of counselling in a primary care setting, may not be of benefit. Australian researchers conducted a randomised controlled trial involving over 200 overweight or obese children aged from 5 to 10 years. Participants were identified through measurement of body mass index (BMI) by their general practitioner, and placed into intervention and control groups. The intervention consisted of four consultations over a 12-week period, which aimed to create change in nutrition and physical activity, along with educational materials for the family. No significant improvements were observed in BMI, physical activity, or nutrition in the intervention group compared with the controls at 6 and 12 months. Despite the limitation of a smaller number of participants than planned, the authors comment that the trial suggests international policies on childhood obesity recommending GP surveillance and a brief period of counselling are not likely to be successful in the fight against obesity. BMJ 2009; 339: b3308 Dr Tanya Grassi, MJA

Ann Gregory

Med J Aust 2009; 191 (8 Suppl).