Volume 193 Issue 11

Objective: To assess the effectiveness of the Australian Medical Sheepskin in preventing sacral pressure ulcers (PUs), based on combined data from existing published trials.Design and setting: Data from two randomised controlled trials (RCTs) among Australian hospital patients and one RCT among Dutch nursing home patients were pooled, comprising a total population of 1281 patients from 45 nursing wards in 11 institutions. These data were analysed in two ways: with conventional meta-analysis based on the published effect sizes; and with multilevel binary logistic regression based on the combined individual patient data. In the multilevel analysis, patient, nursing ward and institution were used as levels and we controlled for sex, age, PU risk and number of days of observation.Main outcome measure: Incidence of sacral PUs.Results: Overall, the incidence of sacral PUs was 12.2% in the control group versus 5.4% in the intervention group with an Australian Medical Sheepskin. Conventional meta-analysis showed significantly reduced odds of developing a PU while using the sheepskin (odds ratio [OR], 0.37 [95% CI, 0.17–0.77]). Multilevel analysis gave an OR of 0.35 and narrowed the confidence interval by almost 50% (95% CI, 0.23–0.55).Conclusions: These analyses of pooled data confirm that the Australian Medical Sheepskin is effective in preventing sacral PUs. Multilevel analysis of individual patient data gives a more precise effect estimate than conventional meta-analysis.

Patriek J Mistiaen RN, PhD · Damien J Jolley MSc(Epidemiol), MSc, AStat · Sunita McGowan RN, MSc · Mark B Hickey BAppSc(Hons) · Peter Spreeuwenberg MSc · Anneke L Francke RN, PhD

Names are more than just labels used to identify diseases. They can be windows into the discovery, characteristics and attributes of the disease. Toponymous diseases are diseases that are named after places. Hendra, Ross River, Bairnsdale, Murray Valley and Barmah Forest are all examples of Australian places that have had diseases named after them. They all have unique and interesting stories that provide a glimpse into their discovery, history and culture. Because of perceived negative connotations, the association of diseases with placenames has sometimes generated controversy.

Ranil D Appuhamy BSc, MB ChB, MIPH · Jan Tent BA(Hons), DipEd, PhD · John S Mackenzie PhD, FASM, FACTM

This article reflects on 30 years of conducting the Melbourne Colorectal Cancer Study, a comprehensive, population-based investigation of colorectal cancer (CRC). The study had an incidence arm, a case–control arm and a survival arm, and contributed considerable knowledge about CRC risk, aetiology, prevention and screening. The incidence arm: confirmed high rates of CRC in Australia and the prevalent view that rates rise in first-generation immigrants from countries with low rates of CRC; and enabled the first report of high rates of colon cancer among Australian Jewish people and the first report of high rectal cancer rates anywhere. The case–control arm elicited: the contribution of family history, antecedent colorectal polypectomy and multiple antecedent stressful life events to CRC risk; the risk of rectal cancer in habitual beer drinkers; the first dietary risk score (emphasising the importance of a diet pursued over adult life that is high in foods of plant origin and fish, and low in fat and red meat); and the highly protective effect of regular aspirin use (stimulating much research globally, with the possibility of aspirin becoming an important preventive agent). The survival arm: found an adjusted CRC-specific 5-year survival rate of 42% among patients with CRC and 85% among matched control subjects; confirmed cancer stage as the most important single determinant of survival; and found that the survival rate among people with the earliest stage of CRC was only marginally lower than that of matched community control subjects, underlining the importance of early detection.

Gabriel A Kune MD, FRACS, FRCS

HIV will only be defeated when behavioural means of prevention become the basis of the global response For nearly three decades, the world has struggled to manage the vast human, social, economic and political impact of the emergence of HIV/AIDS. The history of the global HIV/AIDS pandemic is broadly divisible into two phases — before and after the introduction, in 1996, of effective antiretroviral therapy (ART). The first phase of the pandemic — from the earliest reported cases of HIV/AIDS in New York in October 1982 until treatments became available in 1996 — constituted nothing less than a public-health catastrophe. In many countries, notably the United States and South Africa, political leaders responded to the appearance of HIV/AIDS with a toxic combination of ignorance, prejudice and political cynicism directed at those in whom the disease had first appeared in industrialised countries — gay men, sex workers and injecting drug users. Only a few countries, including Australia, moved decisively during the 1980s to control HIV/AIDS and to prevent its spread into the general community. These pragmatic prevention strategies were based on rapidly accumulating evidence that simple changes in sexual and needle-sharing behaviour among young people, complemented by access to condoms and clean needles, dramatically reduced HIV transmission rates. By the mid to late 1990s, there was clear evidence from published studies that such strategies were effective in containing new HIV infection rates,1,2 and their success in Australia and a small number of other countries was undeniable. Yet almost none of these strategies were implemented on a sufficiently large scale or in time to reduce the impact of HIV/AIDS in regions and countries then largely unaffected by the problem. To put it mildly, an epic failure of leadership and political will to accept and act on scientific evidence turned a potentially containable problem into a pandemic that, by the late 1990s, was beyond control. Nature created HIV, but anti-prevention politicians and their associates created the HIV pandemic.3 The human consequences of the HIV pandemic, and the failure to contain the problem in the mid 1980s, are shocking. Since 1982, HIV has infected 60 million people, and there have been 25 million deaths from AIDS caused by HIV infection.4 The second, and much more encouraging and enlightened, phase of the HIV pandemic dates from 1996, with the development and introduction of highly effective ART. In almost all industrialised countries, access to this lifesaving treatment quickly became virtually universal. From the late 1990s, deaths from AIDS declined and HIV became a more manageable chronic condition. This in turn led to an abatement of the worst excesses of fear-mongering and a perceptible decline in HIV-related stigma and discrimination. The international response to HIV/AIDS was galvanised by two highly significant developments. Firstly, in 1996, the United Nations (UN) established UNAIDS, a specialised UN agency set up to provide strategic direction and to develop and oversee a coordinated international response to HIV/AIDS. Secondly, in 2002, the G8 countries (United Kingdom, US, France, Germany, Italy, Japan, Canada and Russia) established the Global Fund to Fight AIDS, Tuberculosis and Malaria. The Global Fund was charged with funding and supporting the large-scale distribution of ART in developing countries, especially African countries, which have been most grievously affected by the uncontrolled spread of HIV/AIDS. These two institutions — one handling strategy and politics and the other raising and disbursing money — have brought about tremendous improvement in the international management of HIV/AIDS. Since 2002, the Global Fund has sourced nearly US$20 billion from public and private donors,5 of which about US$10 billion has been applied to the subsidised distribution of HIV/AIDS treatment, care and prevention services in some 140 poor and developing countries. The Global Fund is now the major international financer of programs to eradicate mother-to-child transmission of HIV and to support harm reduction among injecting drug users. At the end of December 2009, programs financed directly by the Global Fund were providing ART to 2.5 million people.6 Together with ART distribution financed by the US under the President’s Emergency Plan for AIDS Relief, more than four million people in low- and middle-income countries now have access to ART, representing about 40% of those in urgent need. Sensible HIV strategies backed with large funding have begun to stabilise the spread of HIV/AIDS in most high-burden African countries. In Ethiopia’s capital, Addis Ababa, for example, the rollout of ART has led to a decline of about 50% in adult AIDS deaths over a period of 5 years.6 As the number of global deaths from AIDS has fallen, the number of those living with HIV has increased. There are now some 33.4 million people living with HIV infection.4 But, despite these advances, each year about 2.7 million people acquire HIV and about two million people die from AIDS, mostly within the developing world.4 Other regions have not responded as well as Africa. * Eastern Europe and Central Asia is one of the 10 regions defined and used by UNAIDS. The region includes Armenia, Azerbaijan, Belarus, Bosnia and Herzegovina, Bulgaria, Croatia, Estonia, Georgia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, the Republic of Moldova, Romania, the Russian Federation, Tajikistan, Turkmenistan, Ukraine and Uzbekistan. In Eastern Europe and Central Asia,* many national governments reject the lessons of how the spread of HIV can be contained through education and behavioural change. They oppose the widespread availability of condoms and the introduction of needle and syringe programs for those at highest risk of HIV infection. Consequently, rates of HIV infection in these countries are increasing at an alarming rate. In Eastern Europe and Central Asia, an estimated 110 000 people were newly infected with HIV in 2008, bringing the number of people living with HIV in the region to 1.5 million, compared with 900 000 in 2001 — a 67% increase over this period.7 Ukraine and the Russian Federation are experiencing especially severe and growing national epidemics. With an HIV prevalence of over 1.6% in adults, Ukraine has the highest infection level reported in all of Europe.4 So, as we mark the recent occasion of World AIDS Day 2010, the best that can be said about the state of the global fight against HIV/AIDS is that our successes have been relative. The world supported care and treatment for people with HIV/AIDS when effective therapies became available. During the boom conditions of the 1990s, it was relatively easy for the largest donors to put real financial resources behind the distribution of ART that saved millions of lives in the poorest countries. But economic times have changed. In October 2010, the Global Fund went to donors seeking some US$20 billion for the period 2011–13 so that the most urgent unmet need for ART in the developing world could be met.8 But, instead of US$20 billion, donors provided only US$11.7 billion. (Australia was one of the few countries that increased its support for the Global Fund.) In summary, the first phase of the HIV/AIDS pandemic was chaotic and lamentable. The second phase was encouraging and hopeful. We are now entering the third phase of the response. At a critical moment, transient economic difficulties in the donor countries threaten to jeopardise the great progress that has been made since the late 1990s. It would be appallingly callous and retrograde to take HIV treatments away from those whose lives have been saved thanks to the efforts of donors working through the Global Fund. We must not falter in our determination to provide universal access to care and treatment to all who still require it. The costs of ensuring universal access to ART by 2015 are, in the scheme of things, trivial compared with overall global development assistance budgets, not to mention expenditure on armaments and weapons, while the benefits are abundantly obvious. The third phase of the global response to HIV/AIDS must be dominated by a renewed commitment to behavioural prevention as the surest and most sustainable way to contain the pandemic. We can contain HIV by improving access to treatments and providing care to people with the disease. But HIV will only be defeated and eradicated when the lessons of behavioural prevention that we developed and applied in Australia two decades ago become the basis of the global response.

William D Bowtell BA(Hons)

Objective: To describe recent trends among men who have sex with men (MSM) in age at diagnosis of HIV in Victoria.Design and setting: Analysis of Victorian HIV surveillance data from (i) passive surveillance (2000–2009) and (ii) the Victorian Primary Care Network for Sentinel Surveillance (VPCNSS) (2006–2009). Age-trend comparisons were made using syphilis and gonorrhoea enhanced surveillance.Main outcome measures: HIV diagnoses, HIV testing and behavioural indicators by year and age group among MSM.Results: Following a period of sustained increase between 2000 and 2007, the median age at HIV diagnosis among MSM declined significantly, from 38.8 years in 2007 to 35.3 years in 2008 (P = 0.023), remaining at 35.9 years in 2009. Between 2007 and 2008, the median age of syphilis and gonorrhoea notifications also declined, from 40.6 to 36.0 years and from 32.3 to 29.3 years, respectively. The median age of HIV testing among MSM in the VPCNSS population remained constant between 2006 and 2009, at 33.0 years. Compared with older MSM, those aged less than 35 years were more likely to have never previously been tested for HIV (relative risk [RR], 1.36 [95% CI, 1.30–1.41]); to not know the HIV status of their regular partner (RR, 1.11 [95% CI, 1.01–1.21]); and to report inconsistent condom use with casual partners (RR, 1.07 [95% CI, 1.01–1.14]) and regular partners (RR, 1.07 [95% CI, 1.00–1.14]).Conclusions: Younger MSM in Victoria may be at increasing risk of HIV infection. Enhanced methods of monitoring HIV and sexually transmitted infection transmission in younger MSM are needed, as well as prevention messages to target this group, who may not fully understand their HIV risk.

Carol El-Hayek BSc, MEpi · Isabel Bergeri PharmD, MScEpi · Margaret E Hellard FAFPHM, FRACP, PhD · Alisa E Pedrana BBiomedSc(Hons) · Nasra Higgins MEpi · Alan Breschkin PhD · Mark Stoové PhD

Having two types of medical degree in Australia runs the risk of creating a two-tiered system Currently, all courses in Australia that qualify a graduate to undertake a medical internship are either a Bachelor of Medicine (BMed) or a Bachelor of Medicine, Bachelor of Surgery (MB BS). A bachelor degree is, by definition, an undergraduate degree, irrespective of whether the program has a graduate-entry pathway. While most medical professionals currently in practice gained their qualification by completing a 6-year MB BS, in recent times an increasing number of 5- and 4-year (graduate-entry) programs have been introduced.1 More recently, the University of Melbourne and others with graduate-entry programs have been planning to change their medical degrees to masters-level degrees that will be rebadged “Doctor of Medicine” (MD). This change will have significant implications for both medical education and the medical profession in Australia. In January 2009, the federal government phased out and then banned domestic full-fee-paying places for undergraduate programs in Australia.2 By changing its medical degree to a masters-level qualification, the University of Melbourne is able to circumvent this ban, and it has stated that it will be accepting about 30 domestic undergraduate full-fee-paying places from 2011.3 This move will restrict access to these places to students who are able to afford the $204 000 cost of completing the 4-year University of Melbourne MD.3 This is despite the recommendation of the Bradley review that higher education in Australia needs to be made more accessible to people from low socioeconomic backgrounds.4 Legislation is needed to ensure that both bachelor-level and masters-level medical degrees remain accessible to all Australians. In July 2010, the Australian Qualifications Framework (AQF) Council issued a consultation paper proposing a universal system for higher education coursework degrees that included certificates and bachelor and masters degrees. The paper also proposed that the nomenclature used to describe these degrees should be standardised so that, for instance, any bachelor course would have the title “Bachelor of ...” and any masters-level degrees would be called “Master of ...”.5 Under this system, a masters-level medical degree would be called a “Master of Medicine”, which more appropriately reflects the technical status of the degree. The University of Melbourne’s plan to label their masters-level medical degree as “MD” defies the AQF recommendation. In response, the Group of Eight Executive Director, Mr Michael Gallagher, has claimed that “the AQF is an important external reference but it has never been, nor should it become, a prescriptive regulatory tool”.6 The lack of regulation of degrees allows universities to overstate the academic level of their degree, creating an “arms race” in degree nomenclature. In fields other than medicine, the number of masters-level degrees using nomenclature that is inconsistent with the AQF recommendations is increasing, with the introduction of the Juris Doctor, Doctor of Physiotherapy, Doctor of Veterinary Medicine, and many more. It is important to acknowledge that the research MD already exists in Australia, and is regarded as a doctorate-level qualification equivalent to (or higher than) a Doctor of Philosophy (PhD). The introduction of a masters-level MD threatens to devalue the current doctorate-level MD in Australia for current and future holders of this research qualification. Having two types of medical degree in Australia runs the risk of creating a two-tiered system, ultimately leading to a divided profession. This is the most worrying potential consequence of introducing the masters-level MD degree in Australia. The age-old adage that “a doctor is a doctor is a doctor” is very much under threat. University strategies to differentiate themselves in the medical education market should not be allowed to take precedence over the integrity of the medical profession and Australia’s higher education system. As Australia addresses the need for consistency across qualifications, it is useful to consider how Australia’s educational structures fit with the changes seen internationally. Through their consultation paper,5 the AQF Council has in effect proposed a move towards the European Bologna Process, an initiative designed to enhance the quality of higher education in Europe and to promote convergence and harmonisation of higher educational systems and structures.7 This system is gaining recognition internationally, and American graduate schools have recently started moving in a direction compatible with the same goals.8 The Bologna Process divides higher education degrees into three cycles (levels) (bachelor, masters and doctorate), with a rough timeline for the duration of each cycle and progression between cycles. The Bologna Process has proposed benefits for mobility, recognition of qualifications, quality assurance, social cohesion and improving learning.9 The AQF Council’s consultation paper outlined a notional learning duration of 5–6 years to complete a bachelor degree together with a masters degree. Similar to the Bologna Process, the AQF considers bachelor degrees to be 3–4 years and masters degrees to be 1–2 years. This compares with the 5–6-year duration of undergraduate-entry medical courses in Australia.4 In recognition of the duration and cognitive input required for an undergraduate-entry medical course, European countries such as Spain are now awarding a masters degree, in addition to a bachelor degree, at the completion of a 6-year medical course.10 If this were implemented in Australia, it would negate the imperative for universities to change to postgraduate programs for perceived marketing advantages, allow medical graduates to receive the same recognition as other professions for similar notional duration of university courses, and ensure that medical graduates in Australia are all considered equally qualified by peers, supervisors, patients and members of the community. University-based medical education is on the brink of significant change. This brings with it a number of risks that require significant discussion and consultation so that the integrity of Australia’s medical education system can be maintained. Specifically, government legislation is needed to ensure that medical degrees remain accessible to all Australians. Further, the AQF must be given regulatory power to enforce its recommended nomenclature. The level of qualifications for medical graduates must be consistent to prevent future fragmentation of the profession.

Ross L Roberts-Thomson BMedSc(Hons) · Sam D Kirchner · Christopher X J Wong

This report summarises the presentations, discussion themes and outcomes of the National Forum: Assessment of Professional Behaviour of Medical Students held in Brisbane on 5 March 2010 The behaviour of doctors and medical students has received increasing attention in recent years, but its assessment has resisted straightforward integration into academic programs. Attempts to prevent the admission of the small number of students who are unsuitable for graduation and subsequent practice are yet to prove effective.1,2 National registration will require that virtually all Australian health professional students are registered with their respective national body;3-5 these students will therefore formally become members of their professions. The accountability thereby imposed on students and their schools will set new expectations for managing student behaviour in universities. In response to these issues, the Discipline of Medical Education, School of Medicine, University of Queensland (UQ) organised the National Forum: Assessment of Professional Behaviour of Medical Students, held in Brisbane on 5 March 2010. Participants confronted the conceptually and practically difficult problem of validly and reliably assessing the attitudes and behaviour of medical students as a component of their overall fitness to practise. ParticipantsThe forum was attended by 86 participants, including representatives of 13 Australian medical schools (from all mainland states), both New Zealand medical schools, Queensland Health and some of its public hospitals, the Medical Board of Queensland, the Health Quality and Complaints Commission of Queensland, the Australian Medical Council (AMC), medical student bodies, and other health professions. There were six presentations and two facilitated discussion sessions. Setting the sceneIn opening the forum, Professor Michael Keniger, Senior Deputy Vice-Chancellor, UQ, commented that issues relating to attitudes and behaviour are not restricted to medicine, and that an authoritative basis for a common approach is required, including the early detection of students who may pose problems later in their practices. The Commissioner of Queensland’s Health Quality and Complaints Commission,6 Professor Michael Ward, noted that although serious individual breaches of professionalism attract the most public attention, problems occur at two levels — the individual practitioner (often driven, arrogant and narcissistic) and the profession, which is immersed in a culture of silence. Failure at both levels has powered the “engines of external regulation”, including complaints commissions. Professor Ward suggested strategies that could be used to address these problems, including the avoidance of individual student selection “disasters”, the early identification of problem students, early responses to warning signs of aberrant practitioners, and individual remediation of both students and practitioners. Implicit in this is the need for the profession to raise “group intelligence”, deal with dysfunctional colleagues, and learn how to handle difficult conversations rather than turning a blind eye to poor practice. The AMC, the accrediting body for Australian and New Zealand schools, understands that measuring professionalism is less well developed than assessment in other areas, such as clinical skills and knowledge of biology and pathology, but it expects and encourages schools to monitor and assess student behaviour in a manner consistent with the principles of its recent publication for independent practitioners, Good medical practice: a code of conduct for doctors in Australia.7 The Chair of the AMC’s Medical School Accreditation Committee,8 Professor Michael Field, indicated that behaviour assessment is accepted as a routine element of medical education and that schools are required to develop robust processes overseeing student behaviour — incorporating clear standards and criteria, defined consequences of failure, and rules for progression. Schools should offer student support and counselling, and identify and deal with students whose lack of professionalism or impairment affects their ability and performance. AMC accreditation visits have revealed a wide range of approaches to assessing professional behaviour, and Professor Field noted that despite the expectation that schools establish professional behaviour committees, their processes have not always been accepted into the mainstream assessment practices of the schools. International experienceThe keynote address was given by Professor Maxine Papadakis, an academic physician and Associate Dean for Student Affairs at the School of Medicine, University of California, San Francisco (UCSF) and one of the United States’ pre-eminent researchers in the assessment of medical professionalism. She recounted the development at UCSF of the process for managing student behaviour. Dismissal can occur on the basis of sustained failure, indicated by “physicianship evaluation forms” issued by course directors or associate deans according to agreed patterns.9,10 Professionalism as a requirement for graduation is supported by large-scale studies showing that unprofessional student behaviour predicts disciplinary action as a registered physician,11,12 and that student professionalism ratings predict factors influencing patient care.13 Professor Papadakis urged a strong research effort to improve our expertise in remediation methods and underscored the deficiencies of professional culture by arguing for the reciprocal assessment of teaching staff by students. Current practice in AustraliaAssociate Professor Paul McGurgan (University of Western Australia) presented the results of a national survey on fitness-to-practise policies in Australian medical schools, a project conducted by senior medical students under his supervision (see Fitness-to-practise policies in Australian medical schools — are they fit for purpose?).14 The survey used the United Kingdom’s General Medical Council (GMC) categories of unprofessional behaviour for medical students,15 with a guiding assumption that fitness-to-practise policies should be developed in a nationally consistent way. Fifteen of the 19 Australian schools participated; 12 of these had fitness-to-practise policies, and six addressed all eight of the GMC’s best-practice criteria, but with variation in referral and remediation criteria. Seven schools excluded students during the 5-year study period, the most common reasons being persistent inappropriate attitude or behaviour (eight students) and criminal convictions (four students). The study revealed a lack of consistency across the schools, suggesting that a move towards a more collaborative approach is possible and should improve outcomes. Learning from other disciplinesAssociate Professor Lindy McAllister (UQ) described the development of the COMPASS system of assessing of student performance in the discipline of speech pathology.16 The instrument has high validity and reliability and is used formatively during mid-rotation evaluations and summatively during end-of-rotation evaluations. Students are assessed in clinical settings directly and on multiple occasions; the assessment includes four generic competencies — reasoning, communication, lifelong learning and professionalism, including behaviour — and seven occupation-specific competencies. An at-risk notification of grossly or persistent unprofessional behaviour may result in a student being withdrawn from a rotation and not permitted to return until agreed and monitored remedial work is completed. Student perspectivesTwo students from the University of Queensland Medical Society17 presented the society’s views on how student behaviour should be assessed. They described UQ’s personal and professional development interview process for students flagged as needing assistance — in any area, including attitudes and behaviour — as fair and equitable, yet daunting and stressful for some students, with some persistence of the (albeit incorrect) perception of a punitive, disciplinary and inquisitorial process. The students urged that satisfactory professional conduct be made a requirement for graduation, but called for better documentation of the rules and processes. They supported peer assessment, subject to the provision of adequate training, and a limited extension of behaviour assessment to social situations, where students are readily perceived as representatives of the school and the medical profession. They also pointed to social networking websites as possible settings for unprofessional behaviour. Future imperativesAssociate Professor Malcolm Parker (UQ) clarified the obligations of medical schools under the (at the time) imminent national registration scheme’s governing legislation.18 The statutory reporting requirements leave medical schools with the responsibility of directly managing student impairment that does not pose a direct risk of harm to the public and managing all student behaviour issues. He argued that assessment should be of actual, not simulated, behaviour, and that many instruments do not fulfil this requirement. He also questioned the possibility of remediating certain students, the appropriateness and effectiveness of purely academic sanctions (such as repeating rotations) for failure on professional behaviour grounds, and the continuing allegiance to strict confidentiality concerning students as they move into practice, which constrains any pre-emptive oversight by registration authorities. Participant perspectivesDuring the discussion sessions, participants raised the following issues and themes: The airline industry’s safety model includes training in how junior staff can convey critical information (in both senses of critical) to their seniors — a model that medical education must embrace more comprehensively. Unacceptable behaviour should be described objectively, rather than “diagnosing” personality traits and disorders in problem students. Although students with narcissistic personalities can conceal their behaviour from senior staff, students can often discern problems, highlighting the value of peer assessment. Peer assessment is valuable, but students’ sense of collegiality may minimise reporting rates. Administration staff are valuable sources of information, as they deal with behaviour that students would not always display to teachers. They provide formal reports on student behaviour in some schools. The responsibilities and scope of schools and students need to be clearly defined, so that judgements can be made reasonably and acted on. Some teachers are reluctant to critically assess students or junior medical staff for fear of terminating potential careers, but this may be changed by steady peer pressure over time. Students at younger ages may still be developing their “moral compasses”, but this can be accommodated by defining appropriate expectations for different stages and distinguishing these from criteria (such as honesty) that apply across programs. Simulated clinical scenarios may provide information on behavioural tendencies by seeking students’ responses in different contexts. Students should be positively encouraged to act professionally, and staff should provide feedback on good professional behaviour where appropriate. The main points raised by the speakers and participants are summarised in Box 1, and the actionable outcomes that were agreed on are listed in Box 2. 1 Assessing medical student professionalism: where are we now? The community expects doctors and other health professionals to behave appropriately. Failure at the levels of individual performance and the response of the profession have driven an increase in external regulation. The profession’s culture of silence about poorly performing peers reaches into student assessment and should be changed. A small number of students should not graduate and practise, on the grounds of their unsatisfactory behaviour. Admission processes do not effectively prevent these students from entering medical programs. Large-scale studies demonstrate that unprofessional student behaviour predicts later disciplinary action; student professionalism ratings predict quality of patient care. Under national registration, the Medical Board of Australia will not be responsible for assessing students’ professional attitudes and behaviour in medical schools; this will continue to be the responsibility of medical schools. The Australian Medical Council requires medical schools to support students and manage those who are impaired or demonstrate poor professionalism using clear standards and criteria, defined consequences of failure, and rules for progression. Descriptive behavioural criteria and accompanying standards are required for robust assessment; these can accommodate the moral maturation of students. Students strongly support assessment of professional behaviour, adequate documentation, and peer assessment with adequate training. The majority of Australian medical schools have fitness-to-practise policies and processes, but there is wide variation in referral and remediation criteria and processes. Assessment should arguably focus on actual behaviour, rather than behaviour observed during simulated situations, including formative and summative patient–student interactions, although simulations of various kinds can provide good teaching and feedback opportunities. Assessment should include feedback on positive as well as poor behaviour. Assessment should be accompanied by remediation, and adequate remediation requires further research. 2 Actionable outcomes of the National Forum: Assessment of Professional Behaviour of Medical Students 1. A forum report should be published in a major medical journal. 2. Representatives of the participants should write to the Medical Deans Australia and New Zealand,19 proposing that a trans-Tasman working group on the assessment of professional attitudes and behaviour be facilitated and supported. 3. The working group should define acceptable behaviour at different stages of a medical career; descriptors should be positive and inspirational. (The working group should also be involved in implementing outcomes 4–7.) 4. A nationally uniform approach should be adopted to align with the spirit and implementation of national registration and Good medical practice: a code of conduct for doctors in Australia.7 5. Further exploration and research should be undertaken in the areas of teaching professionalism, assessment processes and remediation. This includes collation of curricula in the related areas of ethics, law and professionalism. 6. Further academic articles should be published, covering descriptive and empirical work in assessment and remediation. 7. Any revision of the previously published position statement An ethics core curriculum for Australasian medical schools20 should more adequately address professional behaviour, its assessment, and its relationships with teaching ethics and law.

Malcolm H Parker MB BS, MLitt, MD · Jane Turner MB BS, FRANZCP, PhD · Paul McGurgan MB BCh, MRCOG, FRANZCOG · Lynne M Emmerton BPharm, PhD, MPS · Lindy L McAllister BSpThy, MA(SpPath), PhD · David Wilkinson MB BS, DSc, FRCP

Objectives: To describe current use and possible effects of Australian medical school fitness-to-practise policies (FTPPs), and to define and benchmark FTPP best practice.Design, setting and participants: A questionnaire-based study of Australian medical schools was conducted in August 2009.Main outcome measures: Use of FTPPs by medical schools; criteria used in FTPPs; remediation processes; numbers of students excluded for professional misconduct, reasons for exclusion, and year of study at time of exclusion.Results: The questionnaire was completed by 15 of 19 medical schools to which it was sent, and 12 schools reported using an FTPP. There was wide variation in the FTPP criteria used by individual schools, and use of an FTPP appeared to be independent of medical student registration with state medical boards and type of course entry. There were no apparent differences in medical student exclusion rates between schools with FTPPs and those without. The most common reason for exclusion was persistent inappropriate attitude or behaviour, including poor attendance, and most exclusions occurred by the third year of study.Conclusions: Most Australian medical schools use FTPPs, but these policies are variable and lack proven effectiveness. The variations in the numbers of students excluded by the different medical schools for unprofessional behaviour suggest discrepancies in the medical schools’ abilities to detect and manage students with problems in this area. Previous calls to develop a nationally consistent approach to the management of poorly behaving students should be addressed.

Paul M McGurgan MB BCh, MRCOG, FRANZCOG · Debbie Olson-White · Marie Holgate · Di Carmody RM, MPH

Objective: To evaluate the 2010 “Anatomy by whole body dissection” course, a 7-week elective course offered to senior medical students at the University of Sydney at the end of their third year.Design, setting and participants: In the 2010 course, 29 students divided into eight groups carried out whole-body dissections on eight cadavers over a 34-day period. Surgical trainees acted as demonstrators, and surgeons and anatomists as supervisors. The students were assessed by practical tests involving the identification of 20 tagged structures in four wet specimens before, during, at the end of, and 1 month after the course. In addition, students were asked to complete an anonymous feedback questionnaire about the course.Main outcome measure: Acquisition of topographical anatomical knowledge, and student feedback on the usefulness of the course.Results: A significant increase in topographical clinical anatomical knowledge was demonstrated among the participants and was maintained in the short term. The median pre-course assessment score was 8/20 (interquartile range [IQR], 4) and the median post-course assessment score was 19/20 (IQR, 1). This difference was statistically significant (P < 0.001). All students rated the course as “very good”, and unanimously recommended that the course be available to all students as part of the medical curriculum.Conclusion: Students’ knowledge of anatomy improved significantly between the pre-course and post-course assessments, and all students rated the course very favourably. This supports our view that dissection anatomy should be an integral component of medical education.

George Ramsey-Stewart MD, FRCS, FRACS · Annette W Burgess MBT, MEd, MMedEd · David A Hill MB MS, FRCS, FRACS

“I love the smell of a freshly opened textbook ...” Studying medicine in the internet age is fascinating, daunting and depressing. Fascinating because we can instantly YouTube anything — from clinical examinations and suturing techniques to recordings of laparoscopic surgery and lectures on any topic imaginable — and at any time. We can Google image-search anything from Janeway lesions and Roth spots to erythema nodosum and pancreatic panniculitis, granting us a wealth of experience in a mouse click. It’s daunting because the knowledge base already contains more information than a student can possibly hope to learn if we devoted a hundred lifetimes to the art. And it’s ever-growing. There is no pause, no rewind. Management regimens change and new drugs are born, and we will need to know them. And it’s depressing because we don’t know where to begin searching, or where to stop. We lack guidance because there is no guide. We seek mentors, yet even consultants struggle with the same problems.1 It’s so easy to feel as though you don’t know anything, to despair and burn out with learned helplessness. There is too much for us to learn, and with this wealth of information readily available, we find ourselves asking, “why bother?”. If someone needs antibiotics, we have the electronic Therapeutic guidelines to tell us which ones and what dose to use, and if someone has a hand fracture, we can just Google-search the bones before we call the orthopaedic registrar. Every computer has the internet (it is a “right”) and a staggering number of students spend much of ward rounds on their iPhones, fiddling with “apps” and browsing databases. I love textbooks though. I love the smell of a freshly opened textbook, the feel of its glossy cover and crisp pages, and how it makes me feel smarter just by purchasing it. When I’m in a bookshop, I could be anything ... if I just buy the right book. More than that though, I love the finite potential and predictability. Because I know the maximum number of pages, I am inspired. I can master this; I can finish this. There is a clearly defined goal, and I can achieve it. There are no links to other textbooks; just neat, discrete chapters. These points sit in stark contrast to the limitless electronic world in which a goal is seen as a boundary or wall; some kind of oppression. To me, these walls are comforting (which may make Steve Jobs at Apple cry). For one medical school, a shift away from electronic media back to textbooks resulted in dramatically increased test scores.2 It is interesting that this expansion of knowledge is coupled with a shrinking of attention span — what I call “TL; DR (too long; didn’t read)” medicine. To save us from the current deluge of facts, enterprising geniuses with short attention spans have united (briefly) to create a solution. Enter the era of X at a glance, Crash course: Y and Z made easy, aimed at the “if you can’t read it in one sitting, it must be beyond the required scope and thus not worth reading at all” mentality. Resources are rated as high or low yield, based on examination potential, and so receive a proportionate study time. This solution is not new. Physicians admit to glancing over articles, as there simply isn’t enough time to read multiple journals in their entirety (or that’s what I gathered from the abstract anyway).3 Nothing better combines the joy of the comforting boundaries, sense of accomplishment and relevant pearls than the pocket-sized medical book. These high-yield publications retain breadth, omit the unnecessary and, without much effort, give us the feelings of achievement that we so desperately long for and are denied by modern medical education. They are the quick-fix junk food of medical literature, and I need a hit. I learned electrocardiograms (ECGs) from The ECG made easy, like all good medical students. I shun large Robbins for mini-Robbins. The Oxford handbook of clinical medicine trumps Harrisons. The other day I saw a small Guyton and Hall and immediately resented all the time I wasted in first year reading the big one. And so, TL; DR: I like pocket-sized textbooks. Their easy-to-read, pocket-sized pages may make my world smaller, but they make it happier.

Nicholas M Beech BSc

I was honoured to be asked by the Editor of the Journal to contribute to the Power of One series — then a little perturbed when I read through examples of previous contributors. They all had such steady career goals and progress. My own pathway seems to have been much more winding and more tempered by personal life experience. School of Medicine and Dentistry, James Cook University, Cairns, QLD. Caroline M de Costa BA, MPH, PhD, FRANZCOG, FRCOG, FRCS(Glas), Professor of Obstetrics and Gynaecology caroline.decostaATjcu.edu.au AntecedentsI grew up in Sydney’s west, at a time when that area consisted mostly of bush and market gardens. My father, John Downes, was a physicist who was not able to attend university because of the Depression; while working in a bank, he undertook an external degree in science from the University of London. This gave him an enormous appreciation of the value of education, which he passed on to me; he would have liked me to follow him into pure science, although medicine was “acceptable”. He also taught himself Russian so that he could read relevant scientific journals, and when I was 11 he took me, my mother and my two brothers on a wonderful 8-month, low-budget trek across Europe, including former Yugoslavia, which was definitely not a tourist destination in those days. My mother, Dorothy, was unusual among the mothers of my school friends as she had a full-time job, in what would now be called special education. With an arts degree and qualifications in occupational therapy, she developed numerous employment and physical education programs for young adults with intellectual disabilities. Without ever specifically mentioning it, she showed me it was possible to do all this, run a household and still make cakes for school fetes. Despite, or perhaps because of, this background, my time at high school was far from smooth and eventually I left the public education system by mutual agreement. I was fortunate, somewhat later, to be given a second chance by an inspiring educator, Betty Archdale, and I was accepted into the final year at Abbotsleigh School. There, I took the New South Wales Leaving Certificate, taught by dedicated teachers who provided the grounding for everything I have done since. I thought I would like to be a doctor without knowing much about what was involved. I enrolled in medicine at the University of Sydney in 1963 at the age of 16, and, although I completed the first year, I dropped out, uncertain about where I was heading. I decided to travel again, and worked in a variety of menial jobs in Sydney to raise my fare to Europe, the centre of the world for my generation. I then discovered the possibility of signing on to a ship of the Swedish merchant navy, who would actually pay me to travel. In this way, over several years, I got to see North and South America and the Mediterranean, leaving the boat in Athens. Now that I have children of my own, I look back at my parents’ agreement for my embarking on this journey and understand the trepidation they must have felt. On the Crystal Sea I worked as a mess girl, and quickly learnt the value of being organised and getting a job done properly the first time. The captain made a meticulous inspection of my area every Saturday; if a speck of dust was detected, the whole thing had to be redone on Sunday. The Irish yearsFrom Athens, travel through southern Europe and the Middle East brought me to Jerusalem (then part of Jordan) where, among other jobs, I taught English in a Palestinian refugee camp near Ramallah. My experiences there, added to what I had seen in South America, decided me to return to medical studies, with the idea of working in a developing country, and in 1967 I was accepted into the Royal College of Surgeons in Ireland undergraduate medical school in Dublin. “Surgeons” was then (and is now) a wonderful institution, multicultural 20 years before the word was invented, and preferring students to have some life experience before studying medicine. From the very beginning, I loved the classes, the prospect of being a doctor, the atmosphere of the College, and Dublin life. I also, in my first year, became pregnant. I had no ongoing relationship with the father of my child. Abortion was by then legal in England, but I decided to continue the pregnancy and, in 1968, my beautiful son was born. There was an enormous stigma attached to “unmarried motherhood” in Ireland at the time that I was largely able to avoid, as my family did not live in Ireland and I was not Catholic. I was also greatly helped by many of my fellow students to cope with the demands of a small child, medical studies and earning enough to support my son. Some of the latter I did by writing articles about the lack of support for women in my position and the need for Irish women to have access to effective family planning services; this was the beginning of my writing career. It was at this time too that I realised that control of our own reproductive health is essential for women if we are to have fulfilling lives and bring up our (wanted) children to do the same; I also saw the need for more women doctors to be working in this area. The second wind of feminism was blowing across Europe and North America in the 1970s, although at first it was only a gentle breeze in Ireland. I was involved in a variety of political activities throughout my student years. In May 1971, I, with about 60 others, took part in a well remembered event in the fight for contraception in Ireland: the “contraceptive train” (Box 1). This was a day trip from Dublin to Belfast, where condoms, illegal in the Republic, were bought in the North and then brought back openly to Customs in the Dublin railway station. A blushing and highly embarrassed Customs officer looked at his feet as he asked me, “Miss, have you got any of them fings?” Charges against us were later dropped. The Irish Family Planning Association (IFPA) was established in the early 1970s and I have huge admiration for the doctors who put themselves forward to provide services that were both illegal and condemned by the very powerful Irish Roman Catholic Church. As a student, I was privileged to attend some of those first IFPA clinics. Meanwhile, every day in Dublin hospitals I saw women crushed by the burden of poverty and too many pregnancies. I had my obstetrics term in the venerable Coombe Women’s Hospital and was hooked when I saw my first breech birth — a difficult but successfully managed vaginal delivery. I wanted to be able to do that. I couldn’t help noticing that all the consultants were men, and although they were competent and caring, their attitudes to women were often patronising and paternalistic. Surgeons was a traditionally run medical school and in the first 3 years, all 17 women in the class of 120 sat at the front during lectures. By fourth year, we were considered mature enough to be distributed alphabetically among our male peers. As a “D” I was placed next to Alan de Costa from Sri Lanka; we married in 1972, have since had six children and now live in Cairns where Alan is a surgeon. (Sitting behind us in the class in “M” and “S”, others took similar steps.) Specialist training in Papua New Guinea, Ireland, England and AustraliaAlan and I qualified in 1973 and headed to Papua New Guinea (PNG), where we undertook internships at Port Moresby General Hospital with the first graduates of the University of Papua New Guinea medical school. This was a fantastic clinical experience. As well as medicine and surgery, I was able to practise some obstetrics under the direction of the late Dr Geoff Bird, whose enthusiasm for what he did reinforced my determination to specialise.1 In 1974 in Sydney, I passed Part One of the Membership examination of the Royal College of Obstetricians and Gynaecologists — only to be told that Sydney hospitals “never” took on women trainees in obstetrics. So we went back to Dublin and spent 3 years there; Alan trained in surgery and I in obstetrics and gynaecology (O&G) (Box 2). I was the first woman to be appointed as Assistant Master at “the Coombe” (really a registrar post but quite sought after), and I must say that I had enormous support from my male colleagues in those years. I also worked at the IFPA clinics; they were gradually becoming more widely known, although there were still clashes with the government and the Church. I often travelled back from England with a dozen intrauterine devices discreetly concealed in my bags for IFPA doctors. More and more, I was realising the importance of choice for women in their reproductive health care. Those Irish years were followed by further training in Birmingham. We then returned to Port Moresby as senior registrars. Again, the work was interesting and demanding, but PNG had gained independence since we had been interns, there were more local graduates and life was becoming difficult for expatriates. After 18 months, we returned to Australia and worked in the Kimberley region of Western Australia before settling in Sydney. Involvement in the sociopolitical aspects of obstetrics and gynaecologyBoth our practices were in western Sydney. Alan and I were involved in setting up our respective departments in the new Mt Druitt Hospital, and I also worked at Auburn Hospital. In both these hospitals there was a large population of recently arrived immigrant women, mostly from Middle Eastern countries, whose cultural and social views and expectations of childbirth were very different from those of Australian-born Anglo-Celtic women. The maternity and gynaecology services, although physically adequate, were not readily accessible to many of these women. I became involved in efforts to provide clinics directed at specific cultural and ethnic groups with female interpreters more readily available; I also carried out research into the views and beliefs around childbirth of ethnic women in western Sydney.2-5 In the early 1980s, there were several hundred male O&G specialists in Sydney and about seven women, most of whom were close to retiring age as they had been “allowed” to train when men went off to the war; after 1945, no more women were admitted to training. I found myself being recruited onto dozens of government committees as the token woman. It was also clear that if we were to have more women training as specialists, it was necessary to be involved with the Royal Australian College of Obstetricians and Gynaecologists (now the Royal Australian and New Zealand College of Obstetricians and Gynaecologists). I first became a member of the NSW state committee in 1984, spent 6 years on the Council (Box 3) and now, over 25 years later, still seem to be on several committees. There was plenty of support from the blokes though, and we now have a large intake of talented and enthusiastic young women (and men) every year into all branches of our discipline. Midwives — we can’t live without themOne of the most effective and interesting bits of committee work was the “Shearman Committee”, run under the benign dictatorship of the late Professor Rodney Shearman, which revolutionised the way maternity services were viewed and provided in NSW — and set an example for other states to follow. Consumers and midwives were shown by the “Shearman Report” to be important in the provision of high-quality pregnancy and intrapartum care — almost as important as medical practitioners!6,7 The concept of choice in childbirth began to be acknowledged as valid. I have always had great respect for the midwives I have worked with, have learnt a great deal from them and valued their judgement. It is disappointing to me that there are still turf wars between our two professions, when we should be seamlessly complementing each other in our work: midwives caring for women experiencing normal pregnancy and birth (the majority), and obstetricians dealing with emergencies and more complex cases. I am glad to say that in Cairns, possibly because much of our work is in remote areas and requires more responsibility in decision making, our relationships are generally excellent. The move to the tropical northPractice in Sydney, both public and private, was rewarding but Alan and I both hankered for a return to the tropical lifestyle and professional satisfaction we had experienced in PNG. In 1994, I undertook a locum for Professor Michael Humphrey in Cairns (after he told me “women won’t ever work in the country!”). I was tremendously impressed by the service Michael was setting up, including FROGS (Far North Regional Obstetric and Gynaecological Service), which sent specialists out to rural and remote communities and was particularly directed at caring for Indigenous women.8 I had already established a specialist gynaecological service at the Aboriginal Medical Service in Redfern, where I held clinics twice a week, so I was well aware of the multiple health problems facing Indigenous women.9 Locums in Cairns continued over the next 5 years while we maintained our practices in Sydney (Box 4), then in 1999 we made the permanent move north. I was employed by James Cook University (JCU), first as a senior lecturer; in 2004, I became the first female professor of O&G in Australia. That was the year we first had JCU clinical students in Cairns Base Hospital, which has become the second teaching hospital for JCU and has now produced five cohorts of young graduates, many of whom have stayed on to work in Cairns or elsewhere in rural Queensland. I am delighted that already several of my students have gone on to further training in O&G. As well as working at JCU, until 2008, I worked as an O&G specialist at Cairns Base Hospital and was actively involved in the outreach program, which has made a huge contribution to improving the health of women in a region the size of Victoria. I have also worked and taught in several countries in the region, including Nauru and Vietnam, and have returned to PNG as an external examiner.10 Although I still do some clinical work, I am now mostly involved in teaching, research and administration (Box 5). Empowering women — with accurate informationI have always felt that for women to be able to make informed choices about their reproductive health, they need good information. In 1989, I published my first book of heath care information for women, about sterilisation. Since I moved from private to public practice and my children grew up and left home, I have found more time to write, and the stable has grown to 12 books of information for women and several textbooks, including a manual for doctors performing caesarean sections.11 Through the internet I made contact again with a fellow Surgeons’ graduate, now back in the United States, Dr Michele Moore, and together we have published books in the US on caesarean section, hysterectomy, parenting after the age of 35 and other topics in women’s health, drawing on our professional knowledge but also on our personal experience, a combination that seems to ring true with many women readers. Abortion — law reform and improved servicesIn practice in Sydney I had not given much thought to abortion, as excellent clinics such as the Preterm Foundation offered good early abortion services, and late abortion using prostaglandins was becoming available as our methods for diagnosing severe fetal abnormality improved. I was aware that in 1996 the “Harradine Amendment” had made mifepristone unavailable to Australian women, but I hadn’t seen that as a particular problem in my own practice. However, in Cairns I realised that accessing safe abortion was much more difficult for women in rural and remote regions. In 2005, I attended the annual conference of the American College of Obstetricians and Gynecologists in San Francisco and began to understand the advantages that making mifepristone available in Australia held for all women. Since my own experience of unplanned pregnancy, I have always been pro-choice, even though I had not personally chosen abortion. I read widely about mifepristone use and the politics involved in its banning in Australia and came to the conclusion that action was necessary. In October 2005, the Journal published my article advocating the introduction of mifepristone into Australia.12 Immediately I found a large number of doctors, politicians and pro-choice advocates (mostly women but also many men) contacting me to agree with my recommendation. Late 2005 saw the rapid formation of a movement with great public support that in February 2006 led to a private members’ bill, sponsored cross-party by four women senators, and the overturning of the Harradine Amendment. Overturning the Amendment did not immediately bring about the introduction of mifepristone to Australia, as an application has to be made to the Therapeutic Goods Administration (TGA) for this, and the drug was controversial — more so here than anywhere else in the world owing to Harradine’s political manoeuvring. No drug company has yet been willing to make such an application. There exists a pathway for individual doctors to be approved to use in their own practices drugs that are available overseas but not available here — this is the Authorised Prescriber (AP) legislation. My colleague Dr Mike Carrette and I made such an application to use mifepristone in Cairns — it took time and the paper from many trees, but the TGA were extremely professional in their handling of what became a matter of considerable public interest. In April 2006 we received approval, and in July that year began to use the drug (initially with some apprehension in the face of such publicity). We have since demonstrated that it is a very useful addition to abortion practice and now more than 80 Australian doctors have AP approval. I look forward to the day when a drug company applies to market mifepristone nationally. There is still great variation between states in women’s access to abortion services, and this is an area I will continue to work in. Abortion must become part of mainstream Australian medicine; only then can we look at ways to lower what we know is a very high national abortion rate.13,14 ConclusionWhen I began my specialist training, there was no laparoscopy, no ultrasound, computed tomography or magnetic resonance imaging, limited fetal monitoring, no synthetic prostaglandins . . . the list could go on. There were also few women in the specialist workforce and there was a very hierarchical structure. I am pleased to have been involved in putting into practice many of the new developments in our specialty (Box 6). However, I am even more pleased to have been part of changes in attitudes among colleagues, midwives, nurses, administrators and women themselves that have brought about better reproductive health and greater input by women into decisions about their own health. Having control of their reproductive health is essential if women are to develop their full human potential. 1 Return of the “contraceptive train” from Belfast —Dublin railway station, May 1971 Caroline de Costa (then Downes) and Jerome, aged 3 years, with Customs officials of the Irish Republic. 2 Staff of Rotunda Hospital, Dublin, June 1975 Caroline de Costa: middle row, far right. 3 Royal Australian and New Zealand College of Obstetricians and Gynaecologists Council, 1992 Caroline de Costa: middle row, second from left. 4 In the operating theatre, Sydney, 1996 Caroline (second from left) and Alan de Costa operating in collaboration. 5 Cairns, 2006 6 Australian Medical Association National Conference, May 2010 — awarded the President’s Medal

Caroline M de Costa

I was the first in my family to be able to go to university, and like so many other students, I didn’t have any idea of what I wanted to be. However, the offer of a teacher’s college scholarship meant that this cane farmer’s son could afford to go to the University of New England (UNE), with its great system of residential colleges. Raised on a farm on Warregah (Box 1), an alluvial island in the Clarence River in northern New South Wales, I had attended Chatsworth Island Primary School, which boasted two or three teachers, depending on student numbers. The headmaster, Mr Woolley, was a fan of English grammar and, as a result, many of my postdoctoral students (and my daughters) have had to endure grammar lectures. National Health and Medical Research Council, Canberra, ACT. Warwick P Anderson BSc(Hons), PhD, Chief Executive Officer warwick.andersonATnhmrc.gov.au High school was in Maclean, two river crossings away. Country high schools were then, as ever, under pressure. I remember mathematics in second year needed to be taught in the headmaster’s garage. There were two pivotal moments at high school that led me into science; one involving a balloon and the other, the beach. In first year science, our teacher Mr Whelan asked us whether, in our opinion, air had weight. Of course we all said “no” — who could feel the weight of air on us! So he weighed a balloon deflated and then reweighed it inflated and, of course, the balloon had gained weight. This was such a simple lesson and I can still recapture the thought that I had then — that what seemed obvious was, in fact, wrong; a powerful message that has stayed with me. Then, in my final year of school, Colin Cork, our biology teacher, showed us how to see what all of us NSW coastal kids had seen, but not seen — that the shore between low and high tides was “understandable” on the basis of science, on the basis of the biology or the living flora and fauna and their interactions with this environment. We learned how plant and animal habitats were affected in understandable ways by their relative exposures to water, sun and the environment. In short, he showed that science made a familiar place for enjoyment also a place of understandable complexity and beauty. The cane gang that cut our crop for many years was from the local Aboriginal settlement on Ulgundahi Island, the next island to ours. They were dignified men. I remember my father saying to me that we were the luckiest cane growers in the district because this gang was the most reliable, hardworking and honest. The settlement was later moved to Maclean, the local town. My mother gave birth to my younger brother in Maclean hospital, sharing a room with an Aboriginal woman with whom she kept in touch. I remember being astonished when my mother told us that this Aboriginal mother was terrified that the authorities would come and take her baby away. I know now of course that this was the time of the Stolen Generation, but at the time it seemed unthinkable and very alarming to us. I am very grateful to my parents for their involvement with these Aboriginal people, and for the values they passed on to their children My first residential college experience at UNE was of eight “freshers” sharing a long dormitory without heating through an Armidale winter. There were frozen pipes in the mornings and a long, cold bus ride out to the university for breakfast. This was not an exceptionally conducive environment for studying, although I can’t blame the accommodation for the modest four bare passes I managed in my first year, one only after a supplementary exam in January. Fortunately, in second year I stumbled into the UNE subject, physiology, fell in love with learning about homoeostasis and integration of the body systems, and graduated in 1968 with first class honours. I will forever be indebted to Max Webster and the rest of the Physiology Department for such a stimulating learning environment. Beginning in researchMy interest in medical research as a power for good and for alleviating human suffering might be attributed, in part, to growing up in a small community where everyone knew everyone else, and knew all their trials and tribulations. In small communities, it is easy to understand that not everyone is born with the same opportunities, and that family circumstances and ill health or disability profoundly affect people’s start in life. In our small school and community, people with disabilities, ill health, bad luck or accidents were people we knew well and lived near. Undoubtedly, too, my father’s type 1 diabetes, which killed him at 51, had a significant effect on my career choices. How could it be that the failure of such a small and, on the face of it, simple gland could result in so much ill health, even when insulin was replaced by injection? Research in the past decade has shown us that early environment is crucial. So, it is very probable that my love of learning, a belief in fairness, in taking responsibility for one’s actions and in working hard and in helping others comes from growing up in a hardworking rural farming community, consisting largely of third- and fourth-generation immigrants from Scotland. The Chatsworth district was then almost entirely populated by 19th century Scottish immigrants. This may be pushing an argument too far, but the values of the Scottish enlightenment were strong in that society. I find it disturbing that now, in the 21st century, there is an apparent retreat from reason in many Western societies, and often a retreat from science. Many people seem to regard their own views and beliefs as being of equal value to any other, whether or not they are founded on any factual, scientific or logical base. There are many examples, such as the widespread use of such alleged therapies as homoeopathy, or the belief that crystals have magic healing powers. My father died when I was in my third year at university, but thanks to support from the War Widows Guild (established by Jessie Vasey), I was able to complete my Bachelor of Science degree with honours. I joined John Ludbrook, Professor of Surgery at the University of New South Wales, as a PhD student, and then transferred to the University of Adelaide with him when he became Professor of Surgery there. South Australia was in the throes of electing Don Dunstan as its state political leader, and the 3 years of my PhD and living in a postgraduate college in the great city of Adelaide at the end of the 1960s were memorable. John Ludbrook talked Francis Moore, Professor of Surgery at Harvard Medical School and the (then) Peter Bent Brigham Hospital, into taking on a science-trained Australian postdoctoral Fellow, and I had a marvellous time for two and a half years working on a wide range of research topics, eventually publishing 11 articles from that time. We invented a novel way of measuring pulmonary oedema,1 we set up a computer-driven postoperative fluid system for open heart surgery2 and we studied how best to maintain cardiac output during open heart surgery.3 I also worked with Cliff Barger, the legendary Professor of Physiology at Harvard Medical School, and this started me on my life-long interest in the pathogenesis of high blood pressure. Cliff and his postdoctoral Fellows, working with dogs that were integral parts of the laboratory group, showed that modest restriction of blood flow to the kidney resulted in a rise in arterial blood pressure within minutes; all the while the dogs were awake, although napping peacefully. The Fellows in Cliff’s group seem to have gone on to remarkable careers: Victor Dzau is now chancellor for health affairs at Duke University and president and Chief Executive Officer (CEO) of Duke University Health System, and Ed Miller is Dean and CEO of Johns Hopkins Medicine. Hypertension is a major health problem in both developed and developing countries. The World Health Organization estimates that it causes over seven million deaths each year.4 It has been estimated that almost a billion people world-wide have high blood pressure, with two-thirds of these living in developing countries.5 High blood pressure is not glamorous, but is a silent disorder and still largely of unknown cause and therefore hard to prevent. It is astonishing to think that for most people with hypertension, we still have no real understanding of what causes their blood pressure to rise. This rise is slow and incremental in most people and we rely on animal research for much of our progress towards understanding the pathogenesis. That the kidney is at the centre of causation seems likely. To maintain plasma filtration, and thus continued body fluid homoeostasis and life, ultrafiltration in the kidney requires blood pressure in the kidney’s glomeruli to be more than 15 mmHg higher than the oncotic pressure exerted by plasma proteins. That is, the blood pressure in the kidney matters, whereas for other organs it’s the flow of blood and its delivery of oxygen that is mainly regulated. To be teleological, it can be argued that there has been powerful evolutionary pressure to establish physiological control mechanisms that set overall arterial pressure in order to maintain just this glomerular blood pressure at the levels required. This reasoning can explain the results of experiments shown in Box 2 — when glomerular pressure was reduced by abruptly narrowing the supplying renal artery, arterial pressure soon rose and restored the renal arterial pressure beyond the narrowing, but at the expense of much higher arterial blood pressure overall.6,7 In 1974, after two and a half years in Boston, I longed to get back to Australia. I can still remember marvelling at the wonderful eucalypt forests during my first few months back, and the quality of the relations between ordinary human beings. I had not been sure where I wanted to come back to, so I wrote to both Paul Korner, Professor of Cardiology at the University of Sydney, and Derek Denton, founder of the Howard Florey Institute in Melbourne. Paul answered promptly saying “come”, I responded immediately saying “yes”, and arrived back only to be told that he had accepted a job in Melbourne as Director of the Baker Medical Research Institute and had invited me to come with him. The Baker Medical Research InstituteThe thought of moving to Melbourne was initially a jolt. For people from northern NSW, it was traditional to think of Melbourne as somehow inferior, if we thought about it at all. However, I liked Melbourne from the first day. It is a great place for health and medical research. This is due to the interplay of a number of factors — a critical mass of researchers, a certain spirit of genuine collaboration and a generally intellectual climate. I once heard Gus Nossal (previously, Director of the Walter and Eliza Hall Institute of Medical Research) offer an additional reason — that science was so strong in Melbourne because of the weather, which meant that inside activities were favoured over outdoor ones — while Michael Wooldridge (previously, Minister for Health) put it to me, that it was a legacy of Melbourne’s Scottish enlightenment founding fathers. Of course, Melbourne is not all about intellectual life. No other city in Australia, and perhaps anywhere, supports sporting events so much. For me, as a supporter of the Melbourne Demons, that has been mainly painful. Paul Korner’s time as Director of the Baker Institute, working with Jim Angus, Garry Jennings, Murray Esler and many others (some pictured in Box 3), building the Baker from a small, obscure institution to a major cardiovascular institute with highest quality research, was simply exhilarating. Not everyone warmed to Paul, who could be a fierce critic, but we all learnt so much from him and progressed so far under his guidance. The Baker years for me were the 7-day-a-week years, with dogs to look after that were chronically implanted with catheters and flowmeters; these were large animals that could very readily be trained to participate in experiments without stress. To understand blood pressure control, we need to study two systems that are both dynamic and that interact dynamically; the circulation of blood and filtration and reabsorption in the kidney. Using animals, particularly dogs and domestic animals in research, is controversial. For me, it was essential that we always thought about the welfare of the dogs, and this required a 24/7 commitment. Medical research is team research and I have been so fortunate over many years to have had such colleagues as Kate Denton and Roger Evans (pictured in Box 4; now both National Health and Medical Research Council [NHMRC] Research Fellows themselves), Michelle Kett, Robyn Woods and many others, as well as wonderful, dedicated research assistants and animal technicians. Monash and physiologyI left the Baker Institute in 1996 to become Professor of Physiology at Monash University. The Monash Department of Physiology has had an outstanding record in research and teaching since its inception. I felt that physiology as a discipline was changing, and many were challenging its relevance. The starkest demonstration came when the Harvard Department of Physiology was abolished in the 1980s. I believed then (and I still believe) that an understanding of how things work is physiology’s main game, and that this occurs both at the molecular level and at the integrative, whole human (or animal) level. The molecular bioscience revolution of the last 30 years or more continues to provide astounding insights into the way things work at the cellular and subcellular level. Now, the integrative sciences are resurgent, as we understand that in biology it is rare that “one plus one equals two” and that the answer changes anyhow, with time and environment! First work for the NHMRCMy first contact with the NHMRC came in the late 1980s, and began one morning before dawn when my home phone rang and the conversation went something like this: “It’s John Chalmers here, you old £&£$^&%$. I am just about to get on a plane in Adelaide for Canberra. It’s an NHMRC Medical Research Committee meeting today. I am going to set up an animal ethics committee, you’re going to be the Chair, and I want you to nominate who should be on the committee by the time of the meeting”. Well, like everyone else in medical research in the 1980s, I did what Chalmers (then Chair of the Council of the NHMRC) asked. I went on to serve for more than 7 years as Chair of the NHMRC’s Animal Experimentation Ethics Committee. I am proud of that work. The Australian code of practice for the care and use of animals for scientific purposes8 that we developed and introduced has stood the test of time, and we had excellent engagement with the animal welfare and rights movements. Although there were, of course, differences in our fundamental positions, I thank Hugh Wirth and Glenys Oogjees and their colleagues because it taught me that in public policy, engaging properly with those with different views is much better than not doing so. It provides better outcomes because it considers more diverse views, and is better in general because it builds human relationships. In Australia, there is now deep engagement between researchers who use animals and animal welfare and rights representatives. This benefits laboratory animals, researchers and society through better policies. I found myself debating Peter Singer, philosopher and bioethicist, on television, and occasionally running into pictures of myself labelled as an ogre at Melbourne street markets! Opportunity to reform NHMRC’s research approachesSoon after moving to Monash, Michael Wooldridge, who had recently become Minister for Health, asked me to be Chair of the new NHMRC Research Committee, amalgamated from the two previous NHMRC funding committees (the Public Health Research and Development Committee and the Medical Research Committee). He appointed an outstanding group of people to this new committee (pictured in Box 5). Despite some simmering concerns outside the NHMRC that either “soft science” would somehow take over decision making or that those “gene jocks” would get all the money, the newly merged Research Committee itself worked very well, as did the outstanding membership of the Council (Box 6). I would especially like to thank my two deputies Kerin O’Dea and Sally Redman for their guidance and support. As Research Committee Chair, I tried to be guided by what was best for all health and medical research, not any particular field or group. Some of the reforms we introduced included: The abolition of block funding of the big medical research institutes. Block funding of the biggest institutes had been a very successful policy during a building phase of Australian health and medical research, but I thought it had reached the end of its usefulness and was not well suited to where health and medical research was moving. Research was becoming more dynamic, more team-based and multidisciplinary. I felt that this required moving beyond the administrative constraints that block funding brought, and this also would provide a more open, transparent and competitive environment. Despite initial misgivings, the best institutes have since flourished, and it is encouraging to see the multitude of collaborations between these institutes, universities and hospital-based researchers. A more level playing field in NHMRC Research Fellow appointments; this has seen this scheme become stronger than ever, offering internationally outstanding researchers an opportunity to conduct full-time research in any area and appointments made on merit. A move away from the regional basis of funding, which had been managed through the Regional Grants Interview Committee (RGIC) system. This also involved the end of our interviewing system for grants, which I had personally enjoyed as an RGIC member. Many researchers were worried about the ending of interviews and the feedback that these could offer. On the other hand, one of the NHMRC’s supported outstanding social scientists remarked to me that the committee had been selecting grants on the basis of “performance art”, rather than science. Making NHMRC funding policies explicit. Until then, many policies were really case histories. The benefit of developing explicit written policies was that it led to the Research Committee thinking hard about all aspects of the funding schemes. Introduction of “one-line” grants, consisting of funding for support of both salaries and the direct costs of research, providing researchers and institutions with more flexibility in our system of support for the direct costs of research only. Introduction of the Program Grant Scheme; under this scheme, grants are awarded mainly as a record of achievement of the applicants, and are provided as large one-line grants. Introduction of Centres of Clinical Research Excellence, a one-line grant to clinical teams to develop careers and capacity in clinical research. Introduction of a special fellowship (the “Practitioner Fellowship”) for those who wish to keep on providing clinical care, but also to undertake clinical research. This is another rather unique scheme that continues to support some of our most outstanding clinicians in performing outstanding research. Introduction of a capacity-building one-line grant for public health and health services researchers. We realised that one of the problems with our health research sector was that these two fields had not had the opportunity to put teams together, unlike the biomedical sector, through the previous block funding system and the Medical Research Committee’s Program Grant system. Amendment and development of the Statement on Research, which aimed to address integrity in research. This statement would eventually become the Australian code for the responsible conduct of research,9 developed in the mid 2000s by a joint NHMRC, Australian Research Council and Universities Australia group that I chaired, and which was finally adopted in 2007. Being CEOI was appointed CEO of the NHMRC in mid-2006, at a time when the organisation became an independent statutory agency, separate from the Department of Health and Ageing, but still within the portfolio of the Australian Government Minister for Health and Ageing. Major tasks included establishing the organisation with its own support mechanisms (information technology, human resources, finance, etc), finding new premises (where we can conduct peer review, instead of in hotel rooms) and, with the support of the Minister, having a greater involvement in clinical and preventive matters through the establishment of a Health Care Committee and a Prevention and Community Health Committee reporting to the Council of the NHMRC (pictured in Box 7). We have also merged the previous National Institute of Clinical Studies into the NHMRC and are repositioning it as a major entity for the transfer, translation and implementation of clinical research knowledge. The NHMRC supports about 16 different funding mechanisms. Like our sister medical research funding bodies around the world, the NHMRC is buffeted by competing interests and views on how it should operate and what it should fund. Perhaps the most frequent argument is whether we should fund mainly basic discovery research, or only applied research with a clear benefit. The answer in my mind is “both”. Two Nobel Prizes by Australians are good examples of why. Nothing could have been more basic than Elizabeth Blackburn’s work on telomerase 30 years ago. Not only has this opened our understanding to one of the fundamentals of life, but our understanding of telomeres now seems set to help in cancer and in stress-related illnesses, among other areas of ill health. And then there are the Western Australians, Robin Warren and Barry Marshall, who undertook a brilliant piece of very applied research that provided not only a fundamental change in how we understand gastric disease, but resulted in rapid changes in how we treat it, both reducing patient suffering and cost to the system. The NHMRC is a body to both create knowledge and promote its uptake to improve health.10 I am very passionate about bridging that gap between the creation of knowledge and what happens in our health system — a system that too often is not based on science, and not based on evidence from research on what is best. I recognise that clinical judgment and experience are crucial parts of great health care. But science (and compassion!) should be the basis of how the system develops in the future. It is surprising how often science is able to be pushed to one side in all our society, if it is inconvenient. Or, indeed, subverted, as shown in the recent book Merchants of doubt: how a handful of scientists obscured the truth on issues from tobacco smoke to global warming.11 The NHMRC and the futureHealth and medical research is a great career for anyone who believes in the value of science in improving health, who maintains a life-long curiosity about biology and human biology, and who can handle the life-long uncertainty that comes with a research career — where will the next grant come from, will I be able to maintain creativity, am I using the best technique, where will my research take me intellectually? In Australia, health and medical researchers are well regarded. The public trusts that improvements in health will depend to a major degree on research. It looks up to the strong role models that some of our health research leaders have become through their research and through their activities in the public domain — people like Ian Frazer, Sir Gustav Nossal, Fiona Stanley, Stephen Leeder, Richard Larkins, and the many leaders of the Australian Society for Medical Research. The NHMRC will be 75 years old next year. I am proud to have been given the opportunity to contribute to its growth and to have helped in any small way for the NHMRC to achieve its dual role in discovery and application. This was spelled out neatly by Minister for Health, Billy Hughes, when, in delineating the NHMRC’s task, he told the inaugural Council meeting in 1936 that: “Research must be actively pursued and developed and as fast as new knowledge is acquired it must be applied”.12 The NHMRC will need to keep changing to serve the people of Australia and to ensure that what we offer patients improves, that how we prevent disease becomes more evidence based, and that we progress in research to push back the frontiers of knowledge to reveal the biology of health, and ill-health. For myself, I will be content if I have contributed new knowledge through my research and have helped ensure that the NHMRC is better able to do its job as a 21st century funding organisation. 1 On the farm Me (Warwick Anderson; back row, left), my father (front row, left) and Anderson uncles and cousins from Warregah. 2 Renal haemodynamic responses to renal artery stenosis in dogs Error bars on Day 2 show standard error of the mean change in aortic pressure, renal artery pressure and renal blood flow, over the 3 days of stenosis. The arrows indicate the beginning of stenosis. 3 Colleagues from the Baker Institute Left to right back row: Rosemary and Murray Esler, me (Warwick Anderson), Garry and Jan Jennings. Left to right front row: Judith Whitworth, Gavin Lambert, Heather and James Angus and Daine Alcorn. 4 Medical research is team research; the Monash Physiology and Baker Institute cardiovascular team, 1996 Left to right: Chiharu Tomodo, Katrina Worthy, Michael Stevenson, Kathleen Stevenson, Roger Evans, me (Warwick Anderson), Gary Ablett senior (Australian rules footballer, cardboard), Sharyn Fitzgerald, Jan Morrisson, Amanda Edgley, Amany Abdelkader, Simon Malpas, Fumihiro Tomoda and Goran Bergstrom. 5 The first National Health and Medical Research Council Research Committee, 1997 Left to right back row: Terry Nolan, Steven Holdsworth, George Van Der Heide, Robert Baxter, Ron Trent, Fred Mendelsohn, David Roder and John Finlay-Jones. Left to right front row: Nicos Nicola, Sally Redman, me (Warwick Anderson), Kerin O’Dea and Tania Sorrell. 6 The National Health and Medical Research Council of 1997–1999 Left to right back row: Geoff Duggin, Prue Ford, Celia Kemp, Richard Russell, Margaret Guilfoyle, John Delaney, Michele Kosky, Doris Zonta, David Adler, Lesley Barclay, John Catford, Michael Cousins, Bruce Armstrong, Ann Woolcock and John (Jack) Sparrow. Left to right front row: Don Chalmers, Stephen Leeder, James (Jack) Best, Judith Whitworth, Richard Larkins, Robert Wells, me (Warwick Anderson), Stella Clark and Andrew Wilson. 7 Current National Health and Medical Research Council members Left to right back row: Paddy Phillips, John Carnie, Ron Trent, Charles Guest, Jim Bishop, Rosemary Bryant, Anne Cahill Lambert and Aaron Geddes (for Jeanette Young). Left to right front row: Kerin O’Dea, Andrew Cuthbertson, Craig White, Sandra Hacker, me (Warwick Anderson), Barbara Patterson, Michael Good, Simon Towler and John Horvath. Absent: Jeanette Young, Cindy Shannon, Kerry Chant and James Best.

Warwick P Anderson

“... the current may turn towards the [medical] schools of the great nations of the south ... the Africander, the Australian, or the New Zealander may reach a development before which even ‘the glory that was Greece’ may pale” The influence of Sir William Osler on medicine is still apparent nearly 100 years after his death. Here, I examine what he knew about Australia, which Australians he met and how this enriched their personal and professional lives, and his influence on Australian medicine in general. Sir William’s grandfather, Edward Osler, was the father of Featherstone (William Osler’s father) and brother of Benjamin, whose children scattered to the United States, South Africa and Australia.1 Indeed, Harvey Cushing, the contemporary eminent neurosurgeon and Osler’s biographer, stated that he had met a man of the Australian branch of the Osler family who looked so like William Osler in “figure, stature, gesture, feature, and shape of head ... that he might have passed as a younger brother”.1 William Osler was born on 12 July 1849 in Upper Canada (now Ontario), the eighth of nine children.1 He was educated at church schools, where the Rev W A Johnson introduced him to what became his favourite book, the Religio medici of Sir Thomas Browne, and he searched the surrounding countryside for organisms and fossils to explore with the microscope. He next came under the spell of Dr James Bovell, a friend of Johnson’s and an enthusiastic microscopist, who taught at Osler’s school and practised medicine in Toronto. Bovell’s personality so imprinted itself on Osler that he always wrote “James Bovell” when testing a new pen or doodling.1 After finishing school, Osler initially followed his father into divinity, but switched to medicine at the Toronto School of Medicine. This was followed soon after by his first publication, on the subject of discovering organisms with the microscope, at 19 years of age.2 Two years later, on Bovell’s advice, he went to McGill University in Montreal where he met Dr Robert Palmer Howard, who taught medicine and surgery and stimulated Osler’s interest in pathology and searching the medical literature — interests that remained with him for life.3 The influence of these three men — Johnson, Bovell and Howard — was so great that Osler later dedicated his magnum opus, The principles and practice of medicine, to their memory. After graduating from McGill in 1872, Osler travelled to London and worked with physiologist John Burdon-Sanderson, in whose laboratory he noted the aggregation of platelets (previously thought to be bacteria) in 1873.3 He travelled to Germany where he met Rudolf Virchow, then to Austria where he saw dermatologist Ferdinand von Hebra, pathologist Carl von Rokitansky and others at work. When Osler returned to Montreal in 1874, he worked briefly in general practice until he was appointed Lecturer then Professor of the Institutes of Medicine at McGill University (Box 1). There he set about revitalising medical training by teaching physiology and histology through the use of the microscope (providing microscopes at his own expense). He started a journal club and began referring students to German and French publications. He wrote on the comparative pathology of parasites, smallpox, Addison’s disease, pernicious anaemia and other topics, and used his pathological experience as a foundation for his clinical acumen. There were no Australian associations during this period of his life. Osler’s appointment in 1884 to the Chair of Clinical Medicine at the University of Pennsylvania in Philadelphia was equally bereft of Australian connections, but was important in establishing his stature. He gave the Gulstonian lectures to the Royal College of Physicians of London in 1885, speaking on Malignant endocarditis; he wrote on chorea and cerebral palsy; and he continued “preach[ing] the gospel of clinicopathology, showing equal interest in the dead and living”.3 Osler accepted the position of Professor of the Theory and Practice of Medicine at Johns Hopkins University in Baltimore in 1889, at the age of 40. In 1892, he published his classic textbook, The principles and practice of medicine, and only when this task was complete did Grace Revere Gross (widow of a Philadelphia surgeon) agree to marry him. Their son Edward Revere was born on 28 December 1895. The British Medical Association (BMA) held its annual conference in 1897 in Montreal, and on 1 September, Osler gave an address on British medicine in Greater Britain,4 where he took the opportunity to give an historical account of the influence of British medicine on its colonies. He predicted that a future meeting of the BMA might be held in Australia, where there were few local graduates and most were of “English, Scotch and Irish colleges”. He described the Australian population as “more homogeneous” and “thoroughly British”. Osler had evidently read Australian and New Zealand medical journals, as he was surprised “with the monotonous similarity of the diseases in the antipodes to those of Great Britain and of this continent”, although he noted the frequency of reports “of parasitic affections and snake-bites”, which were unusual in the northern hemisphere. He commented that the medical profession in Australia was not as regulated as elsewhere because of “the absence of the military element” and was disappointed at the state of medical ethics, which he surmised from his reading.5 “In the large Australian cities, differences and dissensions seem lamentably common”, he said, attributing this to the 3- or 4-yearly reappointments in hospitals that involved soliciting votes.4 He quoted Dr Ferdinand Batchelor (Box 2), President of the 1896 Intercolonial Medical Congress, who was critical of the “managers of the hospitals [who] knew little, and at times seemed to care less, about the medical school”.5 Osler was scathing about the situation in Melbourne, described by Batchelor, where the election was in the hands of the “subscribers” and “election tickets were put out, and cards soliciting votes for [doctors] were found in hotels and bars and railway stations and in cabs”.5 He was however optimistic that the current may turn towards the schools of the great nations of the south. Under new and previously unknown conditions, the Africander, the Australian, or the New Zealander may reach a development before which even “the glory that was Greece” may pale.4 In July 1900, Osler travelled to London, where he attended the Royal College of Surgeons centenary celebrations at the hall of Lincoln’s Inn. A young Australian, Dr Henry Newland (Box 3), newly qualified in surgery, was invited to attend and was seated four chairs away from Osler at the banquet.7 On discovering Newland’s interest in neurosurgery, Osler advised him to study under Dr Harvey Cushing in Baltimore, which he did.8,9 Also in 1900, Osler published a monograph, Cancer of the stomach, with his former student Thomas McCrae.10 In the first chapter of the book, they write: Our colleagues in Australasia have demonstrated the same thing. The mortality figures [for cancer of the stomach] for Victoria for the years 1870–84 show an increase at about the same rate as in England ... They cited two Australian journal references,11,12 and continued that a similar trend also occurred in New Zealand, giving references to New Zealand journals.13,14 Osler was appointed Regius Professor of Medicine at Oxford University in 1905, and in 1907 made his usual transatlantic trip to the US. He visited there so regularly that “it had become a saying in Oxford that the Oslers often spent their week-ends in America”.1 On 3 October 1907, he addressed the students at St Mary’s Hospital in London on The reserves of life.15 He stressed that medical training “is in only three subjects — science, art, and the knowledge of men”. Halfway through the lecture, he deviated from his notes to verbally attack St Mary’s bacteriologist and immunologist Sir Almroth Wright (Box 4), saying: Stop your ears with the wise man’s wax against the wiles of that Celtic siren, Sir Almroth, who would abolish Harley Street [London’s centre of private medical practice] and all that it represents. Osler knew that Wright was cynical of clinical methods and clinicians and “ridiculed the crudeness of methods which faced disease armed with knives and drugs ...” Wright believed that “the physician of the future would be an immunisator”.17 Osler was aware of Wright’s sojourn in Sydney and his development of typhoid vaccine, to which he referred in his lecture. In spite of this disagreement, Osler and Wright remained friends, visiting each other at home,16 and Osler urged the use of typhoid vaccination of the troops in World War I.3 In April 1909, while travelling around Europe, Osler was asked to see a sick Australian in Rome, who “suddenly became severely purpuric from haemorrhaging blood vessels, turning plum-colored everywhere except under one patch of skin where he had put a mustard leaf”.3 This man, described by Osler in The Lancet,18 died 15 minutes later. Osler theorised that a reaction involving the capillary wall allowed blood to leak out, which he postulated to be an anaphylactic reaction. Osler was a keen traveller — he went about visiting friends, attending conferences, seeing historical places, and searching for books. This made him sensitive to accents, and he developed the habit of writing about them during his voyages. He carried this manuscript, titled The voice, with him from 1893, making additions as he went and promising an article on the topic for The century magazine, which remained unfinished.19 In his notes, he described a 56-year-old Scotsman who had lived in Australia for about 35 years and “except in a few words, the Scotch had been rubbed off his tongue”. Osler’s own speaking voice was described by his friend, Canadian neurosurgeon Wilder Penfield, thus: “he never had an accent that one could identify”.20 This was perhaps unsurprising in a man who lived for 35 years in Canada, 21 years in the US, and 14 years in England. Golden and colleagues suggest that Osler had “a cultivated speech ... what today might be called mid-Atlantic”.19 In February 1911, Osler was invited by his brother Sir Edmund Boyd Osler to visit Egypt and the Nile Valley. As usual, Osler was able to make a good mix of vacation, history and medicine. He enjoyed the pyramids, the Sphinx, various tombs and the Egyptian museum, and was impressed by the beauty of the mosques. He took time to visit the Kasr El Aini Hospital, where he saw “many things I had read of but had never seen”. Here he also met Dr Frank Madden (Box 5), an Australian surgeon at the hospital.22 Osler was invited to give the Silliman lectures at Yale University to a lay audience in April 1913. He spoke about The evolution of modern medicine, describing how religion and medicine grew out of magic, saying “among native Australians today it is still deliberately cultivated”.23 He was obviously aware of the Aboriginal witchdoctor with the power to heal or kill. Osler’s reading about Australia and awareness of its culture prepared him for meeting Leslie Cowlishaw (Box 6) in 1916, when Cowlishaw was officer-in-charge of invaliding in England. The two quickly struck up a close friendship, as Cowlishaw was already an established collector of medical books and could discuss medical history. Osler was perceptive enough to understand the Australian psyche, labelling Cowlishaw the “bibliophile from the bush”.24 There are six letters from Osler to Cowlishaw in the archives of the Royal Australasian College of Surgeons, mentioning Cowlishaw’s purchasing of books, and thanking Cowlishaw for sending him a book and for correcting an article Osler had written. Osler felt very comfortable with Cowlishaw and offered him hospitality, writing: ... come when you can — give a few days notice as I am much away — stay the night. There are many things in my collection to interest you. (7 March 1916) I am devastated to miss you ... Do come to us direct your next leave. (8 August 1917) In another note, Osler writes: “... come here for a rest and bibliographic browse when you come back — I am struggling with my catalogue ...” Osler’s influence added fuel to the fire of Cowlishaw’s enthusiasm for medical history and book collecting, to the extent that Cowlishaw acquired the biggest collection of rare medical books in Australia, which was sold to the Royal Australasian College of Surgeons after his death in 1943 for the now ridiculously low sum of £2750. Cowlishaw followed Osler’s example of not only collecting but also writing medical history. In Cowlishaw’s address on Some early printed books: their authors and printers, he presented a scholarly account of early printing presses and early medical books, many of which were in his possession.25 Cowlishaw acknowledged Osler’s guidance in this article, quoting him on three occasions. This publication was of sufficient historical merit to be referenced by Thornton in his major reference on the history of medical books and collectors.26 Thornton credits Cowlishaw with the statement that the first book in English on medicine was written in 1485 — quite an honour for an Australian, and one that shows the depth of Cowlishaw’s knowledge. In 1936, Cowlishaw wrote an authoritative account of the first 50 years of medicine in Australia, describing the First Fleet surgeons and giving brief accounts of D’Arcy Wentworth, George Bass, William Redfern (the first Australian medical graduate), Henry Cowper (the first postgraduate diplomate in Australia) and William Bland (the first Australian to publish in The Lancet and author of the first postmortem study to be published in the medical press in Australia).27 He also urged a philanthropist to donate money for a historical medical library, as Osler had done. In the Jackson Lecture of 1937, Cowlishaw gave an excellent account of Galen’s life and experiments.28 In his address to the 1937 meeting of the Australasian Medical Congress, Cowlishaw described how Osler made medical history alive and relevant by including it in his medical lectures, getting students to look up and read to the class the original description of a disease, and by having old books available for browsing.29 He also gave what is arguably the best account of medical historians through the ages, appealed for someone to edit a book of Australian medical history, and urged the teaching of medical history to medical students on a voluntary basis. Osler was not unaware of Australia, as he had relatives living here and had read about the country’s Aboriginal culture, the state of the teaching hospitals, and the role of subscribers in hospital appointments. He read Australian and New Zealand journals in his quest for illness trends, and compared them with those of Europe. He made special mention of treating Australian patients and advised Newland about his career. He enjoyed his meetings with Cowlishaw on book collecting and medical history. The expression “bibliophile from the bush” indicated a good understanding of Australian expressions, perhaps learned from other Australian doctors or patients whom he met; but such meetings have not been recorded. 1 William Osler, October 1881, during his Montreal period Reproduced with permission of the Osler Library, McGill University. 2 Ferdinand Campion Batchelor (1850–1915) Batchelor was born on Norfolk Island, where his father was the Anglican chaplain. He was educated in England, then apprenticed to a medical practitioner in Essex. He later attended Guy’s Hospital Medical School in London, practised in England, then migrated to New Zealand and settled in Dunedin. He started in general practice, before specialising in obstetrics and gynaecology. He was “a man of commanding presence and of a dynamic personality”. He was President of the Intercolonial Medical Congress held in Dunedin in 1896. He served in World War I, at the age of 65 years, and was sent to Egypt but was invalided back to Dunedin, where he died. A Batchelor Memorial Medal was struck to commemorate his contributions to New Zealand medicine.6 3 Henry Simpson Newland (1873–1969) Newland was a University of Adelaide graduate who did his postgraduate surgical training in England and Baltimore (with Harvey Cushing), returning to Adelaide to practise as a surgeon. He enlisted in the Australian Imperial Force in November 1914 and was appointed to the 1st Australian Stationary Hospital on the Greek island of Lemnos. With the closure of that theatre of war, he was sent to England, then France. He operated at the 3rd Australian Casualty Clearing Station in France, where he met Cushing again. Newland returned home to Adelaide, where he had a busy general surgical and neurosurgical practice.7 4 Almroth Wright (1861–1947) Wright graduated in medicine from Trinity College, Dublin, in 1883. He was interested in experimental work and visited pathologist Julius Cohnheim in Leipzig, Germany, and physiologist Michael Foster at Cambridge University. The latter proposed him for the position of demonstrator in physiology at the University of Sydney; Wright took up this appointment, demonstrating from 1889 to 1891. He was known as the “Irish windbag” and clashed with T P Anderson Stuart, the head of the faculty. Wright went on to become the Professor of Bacteriology at St Mary’s Hospital in London. He was against women being given the right to vote, but was instrumental in setting up the Medical Research Council. He described the role of calcium in coagulation, developed typhoid vaccine, and was a founder of immunology. He also taught Alexander Fleming, who discovered penicillin.16 5 Frank Cole Madden (1873–1929) Madden was born in Melbourne and graduated in medicine from Melbourne University in 1893. He worked at the Melbourne Hospital before travelling to London, where he eventually became medical superintendent of the Hospital for Sick Children, Great Ormond Street. He then moved to Cairo, Egypt, where he was a surgeon and teacher at the Kasr El Aini Hospital, and eventually Dean of the Faculty of Medicine at the University of Cairo. He wrote The surgery of Egypt, was interested in tropical surgery and schistosomiasis, and was awarded the Order of the British Empire for his services during World War I. He was a conscientious man, and committed suicide on 26 April 1929, probably as a result of the stress of politics between university, Egyptian and British governments.21 6 Leslie Cowlishaw (1877–1943) Cowlishaw was born into a wealthy family and educated at Sydney Grammar School. He started his book collection in 1906 after graduating in medicine. He worked in general practice in Cooma, New South Wales, where he met and married Jessie Garnock. He enlisted with the Australian Imperial Force in 1914 and served in Egypt and Gallipoli. After the war, he had a general practice in the Sydney suburb of Hornsby, before moving to Lindfield. With Robert Scot Skirving and Herbert Moran, he started the Section of Medical History and Literature of the NSW Branch of the British Medical Association in 1925. He became an honorary lecturer in medical history at the University of Sydney in 1931.24 Leslie Cowlishaw in World War I uniform. Reproduced with permission of the Royal Australasian College of Surgeons.

Milton G Roxanas MB BS, FRANZCP

“I would like an arrangement made with publishing houses in India and Australia to issue special editions of my text-book in those countries ... I have so many friends in both places, many of them men in official and teaching positions that the book would be adopted in the schools — as indeed it has been at Sydney ...” The first part of this article examined the life and medical influences of William Osler (Box 1) in the context of his Australian connections. This second part looks at his encounters with Australians in the final years of his life, and the influence and legacy he left on Australian practitioners and medical practice after his death. In 1918, the Oslers were still grieving the loss of their son Revere in the war the previous year. This catalysed Osler’s decision to bequeath his house to “Christ Church [College, Oxford] as a permanent home for my successors”, in the absence of any progeny.1 On 24 March 1918, Lady Osler wrote to Kate Cushing (Harvey Cushing’s wife): These wonderful pictures have just come from Major Fiaschi from the Australian hospital in Boulogne. He — Fiaschi — was once in Baltimore from Australia as a PG [postgraduate]. Perhaps you remember him — we often see him. He says he has sent some pictures to Dr Cullen ... This implies that when Piero F B Fiaschi (Box 2) worked with Harvey Cushing in Baltimore in the United States, he was introduced to William Osler and that he continued the friendship and visits after Osler went to Oxford.2,4 As the tide of war was turning in 1918, Osler was lecturing Canadian and American medical officers on postgraduate medical courses and preparing them for life after the war. In October of that year, Hugh Cairns (Box 3), an Australian from Adelaide, was introduced to Osler by A L Smith, the master of Balliol College, Oxford. Osler offered Cairns an appointment at the Radcliffe Infirmary for 6 months when he was discharged from the army, and then advised him to work for a Bachelor of Science in surgical pathology at Oxford, and subsequently to prepare for obtaining Fellowship of the Royal College of Surgeons.5 Cairns was a frequent visitor at the Oslers’ house, the “Open Arms”, and on 25 January 1919 was introduced to Harvey Cushing. Cairns attended Osler’s Saturday morning rounds at the Radcliffe Infirmary, which continued until Osler became ill with bronchopneumonia in December. Osler then developed empyema and died on 29 December 1919, at the age of 70 years. Cairns continued to visit Lady Osler, and she recommended him to Cushing for neurosurgical training. During 1926–1927, Cairns spent 12 months with Cushing at the Peter Bent Brigham Hospital in Boston. On his return to London in September 1927, Cairns set up the neurosurgical unit at the London Hospital and was instrumental in persuading Lord Nuffield (who was previously Osler’s car mechanic) to donate money to establish Nuffield chairs at Oxford University. Cairns played a major role in setting up mobile neurosurgical units in World War II,6 and was involved in the early trials of streptomycin and penicillin in treating cerebral infections. He became the first Nuffield Professor of Surgery at Oxford. Cushing’s biography of Osler was published in 1925, and Robert Scot Skirving (Box 4), a senior physician, was chosen to review it.8 After a delightfully thorough review, he ended by quoting a description of Osler from the biography: “He joyed with the joys and wept with the sorrows of the humblest of those who were proud to be his pupils”. Scot Skirving took it upon himself to write a short publication on the life of Osler for the Australian market.9 He praised Osler’s textbook, The principles and practice of medicine, as “absolutely sane, without faddism and with a perfect blending of scientific facts with their practical applications ...” His work was not without error however — for he writes that Osler died at 71 instead of 70 years. A physical connection between Osler and Australia exists in the form of a gavel (Box 5) that was donated to the Royal Australasian College of Physicians in March 1950 by Dr William C Gibson, a Canadian neuroscientist who worked with neurophysiologist John C Eccles in Australia and who had a notice on his office door that said, “If you think medical research is expensive, try disease”.10 This gavel is made from wood saved from Osler’s childhood home, the parsonage at Bond Head, Ontario, Canada. The history of similar gavels has been described and catalogued — it appears that Osler’s nephew, Dr Norman Gwyn, used wood from the Osler home to make paper knives for the family and gavels that he gave to various associations (although the one in the possession of the Royal Australasian College of Physicians is not mentioned).11 Osler’s approach to the practice of medicine was a balanced one, between the bedside clinical, the laboratory, and postmortem pathology. He bought microscopes for his students, performed postmortem examinations himself and was careful with therapeutics. He used to remind his readers of a sensible approach to pathological tests and their importance to the clinical situation. In an editorial accompanying a “Clinching the diagnosis” series in Pathology that posed the question, “what would Osler say today?”,13 James P Isbister (Box 6) concluded by writing, “In the Oslerian sense, it [the series of articles] will be a collection of problem-oriented reviews aimed at bridging the gap between clinical and laboratory medicine”. Written from the pathologist’s point of view, Isbister discussed the various approaches to interpreting pathology results, weighing possibilities and relating them to the clinical picture rather than viewing them in isolation — wise counsel at a time when doctors often spent more time looking at results than talking with the patient. In 1996, Dr Oleg Preda (Box 7) privately printed 500 copies of his book The master-word of Dr William Osler.14 In the preface, he writes: He [Osler] never claimed to have more than modest abilities which he organised and used properly. This knowledge he shared with others and along with the charm of his personality made friends of his colleagues of all ages and in all places. Preda edited many of Osler’s speeches, giving them modern, relevant titles, removing gender-specific language, and adding notes to abide with Osler’s wishes (eg, Osler’s handwritten request on his copy of A way of life to add a Sanskrit poem by the Indian dramatist Kalidasa to any future reprints of the address). He divided the book into a brief history of Osler’s life followed by four sections based on the principles by which he practised medicine and lived his life: (1) “Credo” contained his beliefs and philosophy; (2) “Study” referred to students, libraries and bedside reading; (3) “Work” outlined the need “to do what lies clearly at hand”, and relations among colleagues and nurses; and (4) “History” aimed to connect the past with the present. In this technological era of medicine, Preda’s book added humanity and philosophy to the technical aspects of medicine, and he was modest in printing a small number of copies at his own expense and giving these to friends instead of making them available to a wider audience of doctors and students. In 1999, Professor Michael O’Rourke (Box 8) wrote an editorial in the Medical Journal of Australia titled “William Osler: a model for the 21st century?”.15 The publication mentioned various aspects of Osler’s life and stressed his attitude to medicine, especially his enthusiasm, knowledge and ethics. Osler’s rejection of gossip endeared him to friends and foes, which helped unite the medical profession. O’Rourke referred to notes inside a copy of Cushing’s The life of Sir William Osler (held in the library of the Royal Australasian College of Physicians) in which Robert Scot Skirving wrote that James Linklater Isbister (Box 9) had met Osler twice and that “he [Isbister] was extremely impressed by his character and influence on the young”. O’Rourke reminded us that, “given the explosion of knowledge and the frequent intrusions from phone, facsimiles and email which frustrate our routine and challenge our equanimity”, we need to sit back, reflect and weigh knowledge, commonsense and ethics in our daily practice, as Osler taught and practised. A recently found letter from Osler to D Appleton & Co, publisher of The principles and practice of medicine, dated 18 February 1898, stated: I would like an arrangement made with publishing houses in India and Australia to issue special editions of my text-book in those countries ... I could even add if necessary a short supplement to the special edition dealing more fully with certain affections peculiar to those countries. I have so many friends in both places, many of them men in official and teaching positions that the book would be adopted in the schools — as indeed it has been at Sydney ...17 This led to the eventual release, in 1913, of a special eighth edition of his textbook for Australia, which was used in Australian universities.17 At that time there were three medical schools in Australia (Sydney, Melbourne and Adelaide), with a total enrolment of 957 medical students, while the number of doctors in the country was less than 3000. These numbers were sufficient for Butterworth & Co to publish a special Australian edition made up of American sheets.17 Unfortunately, Osler did not identify who his Australian friends were. Osler was keen for his book to have as wide a market as possible, as he used royalties from its sale to further his own book collecting. Osler’s influence on Australia was similar to that on other countries. The Australian edition of his textbook taught the principles of medicine to a generation of doctors. Those fortunate enough to visit or meet him took pride in the experience and were inspired to practise medicine with high ideals and humanity. His writings and timeless sayings (eg, “take heed to [your] education, and [your] reputation will take care of itself”) are often quoted because they have well articulated wisdom, even in this age of molecular medicine. His cautious attitude to medication (“man has an inborn craving for medicine”) is a constant warning to those practising polypharmacy. He also highlighted the need for continuing medical education by stating “it is astonishing with how little reading a doctor can practice medicine, but it is not astonishing how badly he may do it”. The employment of modern tests, be they chemical, imaging or pathological, do not lessen the need to be wise, well read, experienced, and compassionate towards the patient, in spite of the help given by computers and other technology. Australian doctors, medical teachers and writers continue to look to Osler’s guidance in applying his principles to modern medical practice. 1 Sir William Osler at Oxford, 1908 Reproduced with permission of the Osler Library, McGill University. 2 Piero Francis Bruno Fiaschi (1879–1948) Fiaschi was born in Windsor, New South Wales, second son of Thomas Fiaschi, a medical graduate from Florence, Italy. He graduated in dentistry from the New York College of Dentistry in 1903 and then in medicine from Columbia University in New York in 1905. He worked with Harvey Cushing in Baltimore and met him again in Abbeville, France, during World War I. He served in the Australian Army Medical Corps in Gallipoli, Egypt, France and the United Kingdom from 1914. Fiaschi was a pioneer in using saline for treating hypovolaemic shock in France. He became a urologist and venereologist and was associated with Sydney Hospital. In World War II, he was a medical inspector of prisoner-of-war camps in Australia.2,3 3 Hugh Cairns (1896–1952) Cairns was born in Port Pirie, South Australia. He started studying medicine at the University of Adelaide in 1912 but left to join the Australian Army Medical Corps. He served in Lemnos, Greece, where the Gallipoli casualties were taken. After the withdrawal from Gallipoli, he was repatriated to Adelaide to finish his studies, which he did in 1917. He then re-enlisted with the rank of Captain and went to the 2nd Australian General Hospital at Wimereux, France. In October 1918, he obtained leave to visit his father’s relatives in Scotland, and then used a letter of introduction to visit A L Smith, who in turn introduced him to Sir William Osler. Cairns was so upset at the death of his friend T E Lawrence (of Arabia) in a motorcycle accident in 1935 that he researched and advocated the wearing of crash helmets for motorcyclists. In 1945, he was called to treat the American General Patton, who had fatal spinal injuries from a motor vehicle accident. Cairns wrote on brain abscesses, head injuries, brain tumours, akinetic mutism, and cingulectomy for treating psychosis. He was appointed the first Sims Commonwealth Travelling Professor in 1947–48. He died from lymphoma of the caecum in July 1952.5 4 Robert Scot Skirving (1859–1956) Scot Skirving was born in Scotland, the son of a farmer. He travelled to Adelaide as a sailor on the Tantallon Castle and suffered from beri-beri on the return voyage, which influenced him to enrol in medicine at the University of Edinburgh. He graduated in 1881, in the same year as Thomas Anderson Stuart (the first Professor and Dean of the Faculty of Medicine at the University of Sydney) and Arthur Conan Doyle. He returned to Australia as a ship’s surgeon on the emigrant ship Ellora. After working in Queensland, in 1883 he was appointed medical superintendent of Sydney’s Prince Alfred Hospital (which received its Royal charter in 1902). He also served as honorary physician at that hospital and honorary surgeon at St Vincent’s Hospital. He was a lecturer at the University of Sydney and had a lecture theatre named after him at Royal Prince Alfred Hospital.7 Reproduced with permission of Ann Macintosh, Scot Skirving’s granddaughter. 5 Gavel at the Royal Australasian College of Physicians The inscription on the plate states “Made from wood saved from the birthplace of Sir William Osler after its destruction by fire. Made up by Mr Tom Jamisson. Osler’s cousin, Dr Norman Gwyn, provided the wood. Presented by Dr William Gibson of Canada, 22 March 1950”. Reproduced with permission of the Royal Australasian College of Physicians. 6 James Paton Isbister (1943–) Isbister is the son of two physicians (James and Clair). He graduated from the University of New South Wales in 1968 and, after residency at Prince Henry and Prince of Wales hospitals, specialised in clinical haematology, working at St Vincent’s Hospital in Sydney and the Royal Postgraduate Medical School of London. He was head of the Department of Haematology and Transfusion Medicine at Royal North Shore Hospital for many years and, while there, set up the first blood cell separator (apheresis) unit and first allogeneic bone marrow transplant service in Australia. He is currently Chair of the Advisory Committee of the Australian Red Cross Blood Service. He has written several books and many articles on haematology.12 7 Oleg (Alec) Preda (1941–) Preda was born in Russia. He graduated from the University of Sydney in 1972 and was a resident doctor at Royal Prince Alfred Hospital, Sydney Hospital and Hornsby Hospital in Sydney. He became a Fellow of the Royal Australian College of General Practitioners and was in general practice in the Sydney suburb of Castle Hill. He first became acquainted with Osler when, on expressing a wish to study medicine to the doctor conducting his physical examination before national service, he was urged to read Osler’s The student life. In his second year of medicine, he found Cushing’s biography of Osler in his local library, and reading it left a lasting influence on his life and work. Preda made a pilgrimage to all the places where Osler worked, visiting Toronto, the Wistar Institute in Philadelphia, McGill University and the Osler Library, Johns Hopkins University, and Osler’s house (the “Open Arms”) in Oxford. He viewed Osler’s brain at the Wistar Institute where it is held, and said “sadness came over me as I saw the gaps in the specimen where the greedy had debased this noble relic by cutting out portions of his brain” (Oleg Preda, personal communication). 8 Michael O’Rourke (1937–) O’Rourke graduated from the University of Sydney in 1960 and was a resident at St Vincent’s Hospital, Sydney, proceeding from anaesthetics to physiology and finally cardiology. He worked in the Department of Physiology at Johns Hopkins Hospital, before returning to Australia to become Professor (later Emeritus Professor) of Medicine at the University of New South Wales. His main interest is arterial haemodynamics, and he has written extensively, including several books, on the subject. He was instrumental in showing that arterial vasodilator drugs such as calcium channel blockers and angiotensin-converting enzyme inhibitors are superior to β blockers in treating hypertension. He is a Member of the Order of Australia (AM) and a member of the American Osler Society (Michael O’Rourke, personal communication). 9 James Linklater Thomson Isbister (1870–1936) Isbister was born in Scotland and went to school both there and in Adelaide, before graduating in medicine from the University of Adelaide in 1896. He worked at the Sydney Hospital before starting in general practice in North Sydney in 1898. He became an honorary surgeon and gynaecologist at the Royal North Shore Hospital in Sydney. In 1908, he spent a year travelling to London, Scotland and his ancestral origins in the Hebrides. He must have met Osler during this visit (as noted by Robert Scot Skirving), but there is no mention of this association in any other source. Isbister was described as a reserved, meticulous and saintly man. He was a foundation member of the Royal Australasian College of Surgeons.16 He treated Sister Mary MacKillop at the convent in Mount Street, North Sydney, and was the grandfather of James P Isbister (see Box 6).

Milton G Roxanas MB BS, FRANZCP

Objective: To describe the clinical features and laboratory findings in patients with definite red-bellied black snake (RBBS; Pseudechis porphyriacus) bites, including correlation with results of venom assays. Design, patients and setting: Prospective cohort study of patients with definite RBBS bites, recruited to the Australian Snakebite Project from January 2002 to June 2010. Main outcome measures: Clinical and laboratory features of envenoming; peak venom concentrations and antivenom treatment. Results: There were 81 definite RBBS bites; systemic envenoming occurred in 57 patients (70%) and local envenoming alone occurred in one patient. Systemic envenoming was characterised by local envenoming in 55 patients (96%), systemic symptoms in 54 patients (95%), anticoagulant coagulopathy with a raised activated partial thromboplastin time (aPTT) in 35 patients (61%) and myotoxicity in seven patients (12%). One patient required non-invasive ventilation for severe myotoxicity that resulted in muscle weakness. Three patients developed local ulceration. There were no deaths. Twenty-two envenomed patients (39%) received tiger snake or black snake antivenom, and administration within 6 hours of the bite was associated with normalisation of the aPTT. Eight patients (36%) had immediate hypersensitivity reactions to antivenom, including one case of anaphylaxis. The median peak venom concentration in 37 systemically envenomed patients with serum available was 19 ng/mL (interquartile range, 12–50 ng/mL; range, 3–360 ng/mL), which did not correlate with clinical severity. In 17 patients who received antivenom and had venom concentration measured, no venom was detected in serum after the first antivenom dose, including nine who were given one vial of tiger snake antivenom. Conclusion: RBBS envenoming caused local effects, systemic symptoms, anticoagulant coagulopathy and, uncommonly, myotoxicity. One vial of tiger snake or black snake antivenom appears to be sufficient to remove venom and neutralise reversible effects, but hypersensitivity reactions occurred in over a third of patients.

Andrew Churchman BM BS(Hons) · Margaret A O’Leary PhD · Nicholas A Buckley BMed, FRACP, MD · Colin B Page MB ChB, FACEM, MMedSci(Clin Epi) · Alan Tankel BSc, MB ChB, FACEM · Chris Gavaghan MB BS, FACEM · Anna Holdgate MB BS, FACEM, MMed · Simon G A Brown MB BS, FACEM, PhD · Geoffrey K Isbister BSc, FACEM, MD

Objective: To describe an in-depth analysis of the content and quality of stories about new cancer interventions in Australian media.Design and setting: Search of the Media Doctor Australia media-monitoring website for stories about newly reported cancer interventions, including drugs, diagnostic tests, surgery and complementary therapies, that had been collected from June 2004 to June 2009 and rated for quality using a validated rating instrument. A mixed-methods approach was used to analyse data and story content. Data from the website on stories about other new health interventions and procedures were compared.Main outcome measures: Differences in quality scores between cancer-related news stories (“cancer stories”) and other stories, and between types of media outlet; differences in how cancer was reported in terms of cancer type, morbidity, mortality, and in the use of hyperbole and emotive language.Results: 272 unique cancer stories were critically reviewed by Media Doctor Australia. Cancer stories had significantly higher scores for quality than other stories (F = 7.1; df = 1; P = 0.008). Most cancer stories concerned disease affecting the breast or prostate gland, with breast cancer appearing to be over-represented as a topic relative to its incidence. Pairwise comparisons showed statistically significant superiority for broadsheet newspaper stories over online stories (F = 12.7; df = 1; P < 0.001) and television stories (F = 10.7; df = 1; P = 0.001). Descriptions of morbidity and mortality were variable and often confusing in terms of numbers, time periods and locations. Literary devices including hyperbole and emotive language were used extensively, mostly by the researchers.Conclusions: While reporting of cancer in the general media is of low quality, many of the poorer aspects of content are directly attributable to the researchers. Researchers and journals need to do more to ensure that a higher standard of information about cancer is presented to the media.

Amanda J Wilson PhD · Billie Bonevski PhD · Alison L Jones FRCP · David A Henry FRCPE

On 8 June 2009, I started work as a locum gastroenterologist on the other side of the world and in a very different environment to the one I was used to. The inspiration for my visit came from an article in the careers supplement to the BMJ.1 A specialist trainee in infectious diseases wrote of his experiences working in Royal Darwin Hospital in the “Top End” of Australia’s Northern Territory. He described the hospital as modern and well equipped, but lacking a full-time gastroenterologist. On an impulse, I offered my services for 3 months, and my offer was accepted. I applied for a 3-month sabbatical — my first sabbatical — from my post of 18 years as a gastroenterologist at the Royal Victoria Hospital, Belfast, and a senior lecturer at Queen’s University Belfast, Northern Ireland, United Kingdom. I must confess that I wasn’t entirely naïve about life and work in Australia. I had previously worked at the Austin and Heidelberg Repatriation hospitals in Melbourne for 18 months in 1990–1991, and I had been back “Down Under” on holiday in 2007, visiting Sydney and Melbourne, as well as Uluru (Ayers Rock) and Port Douglas. Having enjoyed both my previous trips to Australia, I was keen to work there again, especially in the Top End with its particular challenges, not least of which is its remote tropical location, far from Australia’s major cities. After my impulsive decision, I had plenty of time to get used to the idea — negotiating my leave of absence and completing all the necessary paperwork for the Australian authorities took almost 2 years. With Australia’s NT designated as “an area of unmet need”, I was sponsored by the NT Government to obtain an advanced competency registration with the Australian Medical Council and a temporary residency visa for 3 months. I arranged to go during the European summer so that my wife and our two youngest children (who were on school holidays in July and August) could join me for a good part of the time. This also meant we would be in Darwin in the dry, winter season, when the daytime temperature is a comfortable 32°C with moderate humidity, and avoid the very humid wet season. On my first day at the hospital, I was given the role of general physician and put in charge of one of four admission teams, each consisting of a consultant, a registrar and one or two junior doctors. Each team was on duty for 24 hours one weekday per week, and one weekend day for three out of four weekends, and responsible for 15–30 patients at any time, with up to 15 patients admitted on a take-in day. The hospital has an excellent emergency department as well as a rapid assessment planning unit, which was used jointly by physicians and surgeons to assess their patients in the first 24 hours after admission. I soon discovered that there were three main categories of patients at Darwin Hospital: Aboriginal people from the Darwin area and much further afield; other local Darwinians, most of whom had moved to Darwin from other parts of Australia and South East Asia; and older, retired Australian tourists who come to the NT to escape the southern winter (the “grey nomads”). Patients from outside Darwin are brought in by air ambulance. The Royal Flying Doctor Service (RFDS) does not operate in the Top End of the NT, which has its own air ambulance service, but occasionally patients are flown to Darwin by the RFDS from Alice Springs or from areas of Western Australia and Queensland. It is often quicker to fly to Darwin than to one of the other major cities because of the immense distances involved. Although about 30% of the NT population are Aboriginal and Torres Strait Islander people, most living in remote areas, they make up a disproportionate 40%–60% of the patient population at the hospital. This reflects the relatively poor health status of Indigenous Australians compared with the non-Indigenous population. Their high level of diabetes, chronic renal disease, hypertension, heart failure and alcoholism is a disturbing fact, as is their lower life expectancy; the life expectancy gap at birth between Indigenous and non-Indigenous people is 12 years for males and 10 years for females.2 Furthermore, perinatal and infant mortality rates are two to three times non-Indigenous rates.2 My stay helped me to appreciate the complex reasons for this situation, which encompass social and economic as well as educational factors, not to mention the difficulties of delivering health care to remote communities. I greatly enjoyed the challenge of medical practice in a new environment. As well as the usual presentations of patients with neurological, cardiorespiratory and hepatic conditions, we were faced with cases of severe sepsis, tuberculosis, melioidosis (Burkholderia pseudomallei), rheumatic heart disease, severe complications of diabetes, meningitis and infected scabies. The radiological findings discussed at multidisciplinary meetings seemed to have been drawn from a textbook of septic complications. This contrasted with multidisciplinary meetings in the UK, which have been specifically set up to deal with patients with cancer. I rapidly learnt to prescribe ceftriaxone with or without gentamicin as the initial antibiotic regimen, which proved to be life-saving in many situations. My sabbatical coincided with the height of the swine flu outbreak; typically, six or more patients with this condition were admitted each day. The severity ranged from relatively mild to critically ill, with patients in the latter category requiring ventilation and intensive care. Darwin is soon to have its own medical school, but for many years it has functioned as a satellite centre for training students from the medical schools at James Cook University in Townsville, Queensland, and Flinders University in Adelaide, South Australia. I was hugely impressed by the high level of medical care delivered by all the staff in the hospital. Their dedication and professionalism were very evident and, in conversation, I became aware of a strong vocational motivation that elsewhere is becoming lost in an increasingly cynical world. Many of my colleagues relished the challenges of working in Darwin. They were all Australians but, with the exception of the senior physician, Dr Diane Howard, none were originally from Darwin. Their experience of medicine in the major cities in Australia, where they had previously trained and practised, was similar to mine in the UK. They looked upon their time in Darwin as something of an adventure, not dissimilar to my own experience. Of particular value were the hospital’s cultural awareness seminars, which enabled new staff to gain some understanding of the culture of Indigenous people. The key points that I gained from these seminars were an appreciation of the complexity and richness of Aboriginal culture, and the profound personal disruption for Aboriginal people that admission to hospital entails. Hospital admission is traumatic for anyone, but for people who live in small, isolated communities with strong family relationships, it is deeply disturbing and bewildering. First, they have to cope with being unwell, and then with being flown several hundred kilometres to a place which must seem alien in virtually every respect — uncomfortably cold air-conditioning, different food, a different language, and frightening procedures. I learnt that even small things like eye contact, which we regard as a polite courtesy when talking to another person, may be threatening and confrontational to Aboriginal people. Great efforts are made to bridge this cultural gap by providing interpreters and Aboriginal liaison officers, and by encouraging a friend or relative to travel with patients and stay with them at the hospital. These current efforts contrast with some of the misguided government interventions of the past, most notably in relation to the “stolen generation”, when Aboriginal children were removed from their families “for their own good”. I found that these events are still vividly remembered and resented. During my trip, I was fortunate in being able to visit a health clinic in Oenpelli (Gunbalanya), in West Arnhem Land, about 300 km from Darwin. I particularly noticed a mural in the clinic, prominently displaying the word “Reconciliation”. Coming from Belfast and having lived through “the Troubles”, I could not help thinking of the parallels with the situation in Northern Ireland, with our community also struggling with reconciliation — two cultures trying earnestly to understand one another and come to a working arrangement. Health care is often on the frontline of cultural divisions. In Northern Ireland, the health service served both sides faithfully and impartially and was undoubtedly a force for good. I sensed that the health services in the NT are in a similar position. I have now returned to my normal job in Belfast, facing up to old challenges and some new ones. On reflection, I consider myself very fortunate and privileged to have practised medicine in Darwin, to have been accepted so generously by new colleagues, and to have learnt so much from them and from the patients we cared for. I found it refreshing, humbling, often thought-provoking and at times inspiring. It is an experience that I and my family will never forget. Murals promoting Aboriginal health and reconciliation at the Oenpelli (Gunbalanya) Health Clinic, West Arnhem Land, NT (published with permission). I am dwarfed by one of the Northern Territory’s magnetic termite towers, with its accurate north-south alignment to control temperature.

R G Peter Watson MD, FRCP(UK), FRCPI

What happened when a doctor on duty in the emergency department suddenly made the transition to “patient in Resus 2”? “I am not sure exactly why you would want to put your coronary arteries through a full day of paediatric anaesthetics ...” a colleague had written in an email I was perusing in the emergency department on the morning of New Years Day. Suddenly, and unrelated to the contents of the email, I developed extreme anxiety. Recalling that, years ago, frequent irregular ectopic heartbeats had created similar, less severe anxiety, I felt my pulse, expecting to find it irregular. My pulse was regular, but the rate was 120 beats/min. I walked to the tearoom, hoping that whatever it was would go away. Although I had no chest pain, the short walk convinced me I could not ignore the symptoms. I told a colleague I thought I had SVT. In seconds, I made the transition from “doctor on duty in the emergency department” to “patient in Resus 2”. Abbreviations Cath lab Catheterisation laboratory CCU Coronary care unit ECG Electrocardiogram IV Intravenous SVT Supraventricular tachycardia The anxiety worsened, which I attributed to my changed status. Unhelpfully, my ECG showed a left bundle branch block. I began to sweat, and developed mild chest discomfort. I also began to show signs of being a difficult patient. I insisted on having local anaesthetic for my IV line insertion (which is something I do for all my patients). My anxiety was far worse than the pain. I wanted midazolam, but received 5 mg morphine. We compromised about the benzodiazepines and I accepted 2.5 mg diazepam orally, though I knew that this would take 30 minutes to work. I took aspirin, glyceryl trinitrate and later enoxaparin without complaint. The oxygen mask caused claustrophobia and I insisted on nasal prongs. But as my discomfort and restlessness increased, the mask was put back in place — whether I liked it or not. I have seen many an anxious, restless, sweaty patient pull away at their oxygen mask shortly before their cardiac arrest and death, and it began to dawn on me that I might have something nasty going on. But the prospect of sudden death was not my main concern — what I wanted was treatment for my anxiety, which was far worse than my chest discomfort. Mobile phones are wonderful things. My brother chose this moment to phone from New Zealand to ask me if he should double his dose of sotalol to control his paroxysmal atrial fibrillation. (I’m not sure what advice I gave him, but I gather he is still alive.) Then my wife arrived, and best of all, she wheedled a further 5 mg of diazepam for me from some kind soul. The ambulance transfer to a city hospital was a bit of a blur — and that was just the way I wanted it. The city hospital was familiar, as 2 years earlier I had organised an attachment to see what went on in its cardiac catheter laboratory. My cardiologist wanted me in there again. I was not thrilled, but I felt I was on an unstoppable train. I was not particularly interested in hearing about the bad things that could happen there (which included death), and I signed the consent form without reading it. What I really wanted to know was how much midazolam I could have during the procedure. I was assured I could have “some”. A wardsman came to shave an area around the femoral artery and beyond. This also did not appeal. Being allowed midazolam before the shave seemed unlikely, so I closed my eyes, lay back and “thought of England”. Later, a sheepish and apologetic wardsman returned to tell me he had shaved the wrong side. (It was not as if he had chopped off the wrong leg, as some doctors have done.) More thinking of England. A nurse popped in during the procedure. I was to go to the cath lab immediately, and she had 5 mg diazepam for me. I tried to point out that, if I was going immediately, the diazepam wouldn’t have time to work. But I swallowed it anyway, bringing the total diazepam for the day to 12.5 mg. And I was counting. A small crowd had gathered at the cath lab, including a radiographer I had worked with elsewhere. Chlorhexidine in alcohol was used to paint my groin. The nurse doing the painting warned me that I would feel a burning pain if any of the solution reached sensitive parts of my nether regions. She was right! And she was ready! A syringe of sterile water was squirted on the affected area to relieve the burning. (I categorically deny that my continued complaints about the burning were because I liked having a woman squirt sterile water there — although I have considered having the procedure repeated, just in case.) After I had been draped — which restored some dignity to the proceedings — my cardiologist began to infiltrate local anaesthetic. I reminded him about the midazolam. He assumed that I was unhappy about the pain from the local, but I just wanted to be “out of it” while tubes were being put inside my heart. A milligram of midazolam and 25 μg of fentanyl were given intravenously. The fentanyl made me vomit. The benzodiazepines were working better than I thought, as the nausea and vomiting were not unpleasant — just embarrassing in front of an audience. And then I was dreaming. Not of angels greeting me at the pearly gates, not of a welcome from 30 naked virgins — my dream was all about shoes. As the beginnings of consciousness materialised, I seemed to be in two places at once. In one, there was this thing going on with the shoes; in the other, I was lying flat on my back surrounded by machines and people dressed in blue, one of whom was mucking around in my groin. It was a very strange dream indeed. I tried to will myself awake to get the business with the shoes sorted out. But as I awoke, it was the shoes that faded away and the people in blue who became more real. And I noticed that I had a fat lower lip. What had happened was this. The catheter placed in my femoral artery was fed into my left ventricle. Here, tickling an already irritable myocardium, it provoked ventricular fibrillation. During the 40 seconds it took to organise the defibrillator to shock me (Box 1), I presumably did what I have seen patients do as they have a cardiac arrest — I went into spasm similar to the tonic stage of an epileptic seizure. The seizure caused me to bite my lower lip. In 2004, in the columns of the MJA, I had indicated that if I had a cardiac arrest close to a defibrillator, I expected to survive.1 Nice to be proved right. The angiogram showed a single blockage of a coronary artery at a bifurcation (Box 2, A), which I was told might make stent placement difficult. I was also told I could expect to experience some (presumably ischaemic) pain during the procedure. My benzodiazepine level was such that I accepted this information with equanimity. I dozed as they fiddled; the procedure appeared to be a success (Box 2, B), and soon after nightfall I was back in the coronary care unit. I had received aspirin, clopidogrel, enoxaparin, heparin and abciximab, all to stop my blood clotting. A large hole had then been made in my femoral artery, from which I slowly and steadily bled. I was instructed to lie flat and not move my right leg. After replacing the saturated pressure dressing, the nurse applied pressure to the area for 10 minutes. Blood collected in various places. Those with knowledge of anatomy can imagine where these places were. For those without, they were around where the nurse had been squirting sterile water earlier in the evening. Cleaning up had to be done without my moving much. Periodically my bits and pieces got in the way and had to be flicked aside. (I closed my eyes, but I was no longer capable of thinking of England.) This cycle was repeated every hour for 8 hours. Finally, at 4 am, the bleeding stopped. I have never before had a nurse pay so much sustained attention to my groin — not even when I was a junior doctor. As day broke, I noted that I was alive. The previous day’s medication had worn off and I was fully awake. The groin pain was not sufficient to need treatment. All things considered, I was feeling pretty good. But that was easily fixed — I was given drugs: atenolol to slow the heart beat without actually stopping it; perindopril to lower the blood pressure while still keeping it measurable (a chronic cough allows the cardiologist to know that blood is still flowing); aspirin and clopidogrel (cardiologists feel sorry for gastroenterologists and try to add rare excitement to their lives — a patient with a dodgy heart and a stomach full of blood will do the trick); rosuvastatin (cardiologists favour functioning cardiac muscle over functioning skeletal muscle); and isosorbide mononitrate (the highlight of my hospital stay!). After swallowing the handful of pills, I was expecting indigestion, but what I got was a headache. I soon became a clock-watcher. I ensured I was given paracetamol every 4 hours. The headache sometimes became just bearable, but would not go away. I became aware of every beep, bang and noise in and around the CCU — and there were many. (Why is it that when I am giving anaesthetics, I can set the monitor alarms so that they go off only rarely, they mean something when they do, and I take notice of them — but when I’m in other hospital environments, alarms go off all the time, they mean nothing, and no one takes any notice?) The patient in the bed opposite commiserated — the racket coming from the nursing station at the change of shift reminded him of the noise made when he fed his raucous chooks. The next morning, full of nausea and headache, and with my heart being monitored by telemetry, I was moved from the CCU to an empty double room. Having a shower was my next big adventure. I had my left hand in a glove covering my IV line, I couldn’t flex my right leg at the hip, and I had ECG leads and wires going to a battery-operated telemetry box. I couldn’t find any soap. As I was not exactly dressed to go out looking for a nurse, I pressed a call button. I didn’t have my glasses on, and the button turned out to be for “emergency assistance”. Anyway, I was told that the only soap was in the liquid soap dispenser above the sink, some distance away from where I was supposed to be having a shower. A series of prolonged, complex, awkward and repetitive manoeuvres were required to get soap and water together where they were needed (which was pretty well everywhere). Sadly, there is no video clip of this dance. As the headache from my second isosorbide tablet was kicking in, a middle-aged man with chest pain was put in the next bed. I had to be careful what I said to him. He spent a good part of the time talking on his mobile phone. He was certain that his pain had nothing to do with his heart and said he was only there to keep his wife happy. I did not share his certainty as, through the curtains, I overheard him telling his story to his doctor. Later, he told me his pain was returning. I suggested that he press the call button, but it became evident that he was not going to do this. So I told him I needed some more paracetamol for my headache, and pressed my call button. Soon the nurses were taking ECGs and giving him glyceryl trinitrate. As night fell, I plotted how to organise sleep. Nothing seemed likely to happen in my room after 9.30 pm. After taking paracetamol and temazepam, I eventually drifted off. But before midnight, a nurse woke me. “Are you all right?” she asked. “No! I have a bloody headache and you have just woken me up”, I thought. “Yes”, I said. “Your heart rate is 140 on the monitor”, she said. The cause turned out to be a loose monitor lead. After this intrusion, I was unable to get back to sleep. I knew I could not have any more drugs until 1.30 am, so I asked if I could get out of bed. After wandering around in circles for a while, I came across a large bank of screens showing CCU and ward telemetry tracings. There were heart blocks, bradycardias, tachycardias, paced rhythms and evolving infarcts. I noted that I was alive and ticking, although that seemed a mixed blessing at the time. But what was my trace doing up there along with all the others? Were the gods punishing me for something I had written more than 20 years ago?2 So, what did I learn from being “on the other side”? Doctors are not immune from illness. Hospitals are dangerous places — avoid them if possible. Selected patients should be given benzodiazepines the moment they walk through the door. Those responsible for unnecessary hospital noise should be taken out and shot. And, after considering the alternatives, I can highly recommend ventricular fibrillation as a way of leaving this world. 1 Electrocardiogram showing cardioversion of ventricular fibrillation 2 Angiograms taken before and after placement of a stent A: Coronary arteries before the procedure, showing complete occlusion of the left anterior descending coronary artery. B: Coronary arteries after angioplasty and placement of a stent.

Michael J Mackay MB ChB, MHA, FACRRM

We reached the Zambezi escarpment after dark, unable to appreciate the panorama of wilderness that extended 50 or more kilometres to the opposing heights in Zambia, on the other side of the great river that was heading into Mozambique on its way to the Indian Ocean. It was 1972 and we were on our way to collect samples of blood from villagers who shared the Rhodesian (now Zimbabwean) side of the valley with all kinds of wild animals, vectors and parasites. On the top of the escarpment, as we were about to wind our way down into the darkness in our Land Rover, we learned of the return of another violent species to the valley — the freedom fighters from across the border. In what the military wing of the African National Congress of South Africa referred to as the Sipolilo campaign (after a town on the plateau near the escarpment), their soldiers had crossed the river in 1968 in the hope of recruiting villagers for revolution, but they had been discovered by local forces and then dispersed in a process that took lives on both sides, as well as in the hapless middle. As our headlights probed the bush, a camouflaged patrol of Rhodesian infantry appeared and signalled us down. “You should not go any further”, their officer advised, “the terrs are back and the roads might be booby trapped or mined”. I was with Michael Gelfand, Professor of Medicine at the University of Rhodesia, whose lined face, thin body and wispy, grey hair suggested enormous age to my youthful mind, though he was only 60. He was already a legend — son of Lithuanian refugees to South Africa, he had graduated from the University of Cape Town and made his way north to Rhodesia to be fundamental in developing the multiracial medical school in the capital, Salisbury. He was founder and editor of the Central African Journal of Medicine and a prolific writer on tropical diseases. Gelfand was also an observer and recorder of local Shona customs and appeared to be above the racial conflict that was emerging in his country. Though his registrar, I had never spoken to him about race. Perhaps strangely, it had never seemed to be an issue in the “black” Harare hospital in which the University was based. Gelfand, I reflect, set an unspoken standard — he was a kind man, knowledgeable and respectful of local traditions but, above all, absorbed in African medicine with a boyish enthusiasm that simply could not understand preferences for other branches of the profession. When he suggested I join him and the provincial doctor on a research foray, I thought I was made, and although it was a bit of a shock to come across the soldiers and their warning, there was never any question of our turning back. Our lust was up for blood and, I suspect, the old man believed he knew enough about the locals to be able to negotiate any difficulties. Nevertheless, as we descended into the valley in a lighted cocoon of tall grass that bowed before our bumper bar, we knew our wheels would be exerting pressure on the track and whatever might be primed beneath it, and we remained silent. We were going to survey the incidence of the nematode Wuchereria bancrofti by collecting blood samples from villagers. The samples would be examined back in Salisbury for the worm’s larval forms, known as microfilariae (Box 1). First observed by Otto Wucherer in Brazil in 1866, these larvae are released in their thousands from each female adult worm and can be observed wriggling among the blood cells of infected people. The larvae are the width of a white cell but 40–50 times the length. The long (4–10 cm), hair-thin adult worms, discovered by the English physician Joseph Bancroft in Queensland in 1876, live in the lymph vessels of victims, from where the females release the larvae, which make their way to the peripheral blood (Box 2). The adults particularly enjoy the comforts of the lymph vessels in the pelvis and groin, but when these vessels become blocked, the victim’s legs may swell with elephantine disfigurement (Box 3). The blocked vessels can also affect the scrota of the unfortunate, demanding an unusual service from a wheelbarrow. Our hunt was to take place at night because of the still unexplained phenomenon in which the microfilariae appear in the bloodstream after dark to rendezvous with their night-biting mosquito vectors. How they know when to emerge is as much a mystery today as it was in 1877 when first observed by Scottish physician Patrick Manson in China. The allied question of where they go during the day has no better answer than Manson’s original postmortem examinations, which revealed the “majority to be lodged in the blood vessels of the lungs”.1 How they know the time of day and their location, and how they maintain their position in the flow (given that they have no suckers) remains as unanswered as the question of why they feel the need to hide and waste so much energy doing it. The people in our first village had heard us coming long before we had noticed their cooking fires and they surrounded our vehicle with interest when they learned we were doctors and, I suppose, not soldiers. We explained our business and called for volunteers and soon had a long line waiting in the lights of the Land Rover, where we had established our “laboratory”. We took samples and looked for oedema in legs but had concluded that requests to bathe scrota in the limelight might be counterproductive. We did, however, assess the size of spleens as an indication of the prevalence of chronic malaria. All went well for an hour or more, until sudden screeching in the bush around us caused our line to disintegrate in pandemonium. People started yelling and ran to their huts to arm themselves with pots and pans, which they banged together as they disappeared clamorously into the bush. We three doctors were abandoned — immobilised and silhouetted in the lights of the vehicle. “We’re dead”, I thought, “the terrs have arrived”. I looked around for somewhere to run, but Gelfand held his ground. “Settle down. They’re not terrs, they are just elephants who have come after the grain stores in the village”, he explained to the naive Australian. Sure enough, his diagnosis was confirmed by trumpeting and crashing through the undergrowth as the herd surged for the corn. “Stay where you are”, advised the Professor, but the young registrar was consumed by stupidity and went to find an elephant for himself. It did not take long. A huge black shape crashed before his widened eyes. With the villagers in sustained conflict with the marauders, there seemed little prospect of controlled bloodletting, so we decided to pursue our research further down the track. An hour later, we arrived at the next village. The first village had been welcoming. The second was sullen. It was surrounded by a high brush fence and, in the moonless darkness, we heard it before we saw it. We heard the rhythm of drums: a mysterious, exciting, but ominous syncopation; an almost supernatural throbbing bass to the higher pitched cries of birds and monkeys. We drove up to the entrance to the compound and stopped the car, now to be more unnerved by silence. The drumming had stopped and all of nature seemed to be holding its breath. The villagers surrounded us in the darkness and the mood was unpleasant. Gelfand tried to communicate in Shona, but there was little reply. Something was going on in that village. Was it some kind of ancient animistic ritual? Was it some kind of new political ritual? Were there terrs in the village? In the crowd? The Professor was squeezing charm from inner reserves as he slowly backed us to the car. It was plain he was making a retreat, rather than an entreaty for participation in our worthy research, and we wasted no time piling in and waving farewell with ersatz cheer. We were very glad to get away and to be heading for the ranger’s hut on the river bank some kilometres distant, where we were going to spend the night. Relief, however, was limited by the realisation that there was only one track to the one white man’s hut in that direction and it was well known to everyone. The hut was on a grassy clearing about 25 metres back from the Zambezi River, opposite the entrance of the Luangwa River, which rises in northern Zambia. The water was black, wide and fast, but you could not meditate on it in the open. Although the sounds of the nightlife were enticing and the river bewitching, there were lions seeking dinner, hippos waiting to be annoyed and snakes to be insulted, not to mention the mosquito vectors of filariasis and the future prospect of needing a wheelbarrow. We retired to the hut, set up our screens and, in memory of our friends up the track, made sure the doors were locked, for whatever difference that might have made, then tried to go to sleep. We were glad to see the morning. Unanimously, we decided to curtail our field work that week-end and concentrate on our specimens back in the capital, but we did stop at a couple of villages on the top of the escarpment. We looked for clinical signs of filariasis but found none, although previous surveys had confirmed a high prevalence of microfilariae in that area. Relaxed in the open savannah of the plateau, we mused on the disease we had gone to survey. We would have been surprised to know that basic questions would remain unanswered 40 years later, despite an explosion of research of unimagined sophistication.2 Immunology was taking off in those days, and we might have expected an answer to why the microfilariae are able to nullify immune defences to the extent that millions of these motile, burrowing worms can be born, live and die in an infected person’s system for decades without causing much damage. A hundred years earlier, an editorial in the British Medical Journal had wondered that these “swarm(s)” of worms “should produce such a comparatively trivial amount of inconvenience”, but even today we are not much closer to the truth.3 We already knew adult worms had proven resistant to the one hopeful drug, diethylcarbamazine, since its discovery in 1947, but we expected a breakthrough. We would have been disappointed by the lack of any significant challenge to the adult worms in the next 40 years, apart from the extraordinary concept of perhaps being able to affect the adult by damaging bacteria that live symbiotically within it.4 Who would have thought each adult had its own dairy farm? In the 1970s, emphasis was on treatment of individual cases of elephantiasis. How do you manage the grotesque leg? We looked forward to the development of new drugs, but might have done better looking backwards. Considered a “new insight”, it is now believed that “basic hygiene, antibiotics and physiotherapy can slow, prevent, or in some cases reverse elephantiasis”.2 In 1846, however, even before the discovery of the worm, the English surgeon E Bascome had argued that elephantiasis was the result of repeated attacks of erysipelas.5 It now seems that reaction to secondary infection may be more important in blocking the lymph vessels than reaction to the worm. Prevention in the 1970s meant not being bitten by mosquitoes. We could not have foreseen the discovery that semiannual treatment of whole populations with our old friend diethylcarbamazine, and some newer drugs, can so markedly reduce the number of microfilariae that propagation is limited.6 Nor could we have anticipated the ease of diagnosis by measurement of filarial antigen in drops of blood on blotting paper.2 Had we known of these advances, it would have been surprising to know that, despite them, the prevalence of the disease is increasing in some parts of the world, thwarting the concept of eradication. Indeed, the World Health Organization now maintains that over 120 million people are affected worldwide.7 The battle is being lost, not only because of interruption to prevention programs by civil strife but also because of the proliferation of breeding sites resulting from inadequate sewerage in the sprawling suburbs of the developing world. Musing on the complexities of tropical disease, we were enjoying our journey across the plateau on the way back to Salisbury when one of the plateau’s residents invaded our cabin. I had no idea the wasp-like insect was a tsetse fly or I might have better understood Gelfand’s eagerness to dispatch it. Alas, the fly was undeterred by his flailings, and dived on his jaw, provoking a physical response almost as quickly as the emotional. The whole side of the Professor’s face reddened and swelled, from ear to mouth and brow to mandible. Fortunately there were no further anaphylactoid reactions, as we had no medicines, but when the Professor announced it was a tsetse fly I really began to worry. I had driven through Mozambique earlier that year and been intrigued by the Portuguese attempts to limit the spread of the fly by disinfecting vehicles in sheds of corrugated iron. Why? To limit the spread of sleeping sickness. Oh my goodness, there was no effective treatment for that disease either, so I watched the Professor all the way back to Salisbury, hoping his drowsiness was not significant. The Professor recovered, and now that I am almost 10 years older than he was then, I really do understand the physiological rather than pathological attributes of an afternoon nap. As I finish writing this reminiscence in Papua New Guinea as a leader of a team of young postgraduates from James Cook University who are as fascinated as I was by the mysteries of tropical medicine, I remember Michael Gelfand with great fondness. I am sure he enjoyed sharing these mysteries with the young as much as I am doing today. 1 Microfilariae of Wuchereria bancrofti Photo courtesy of Wayne Melrose. 2 Life cycle of Wuchereria bancrofti Reproduced with permission from the Centers for Disease Control and Prevention, Atlanta, Ga, USA. 3 Elephantiasis case from the Western Province of Papua New Guinea Photo courtesy of Wayne Melrose.

John S Whitehall FRACP, MRCP(UK), DCH

We present a case of an older patient who sustained dental trauma during a break-and-enter and assault at his home in Broome, Western Australia. Cruelly nicknamed “Fatso” from a young age, our patient was an 80-year-old gentleman who lived on his own in a care facility, in close proximity to individuals in similar circumstances. Despite weighing 800 kg and being 5 metres tall, the patient was able to mobilise on all four limbs, and was self-caring apart from receiving a daily meal service similar to that of “Meals on Wheels”.1 The assailant sat on top of the patient, who bravely fought back by biting the assailant’s knee. This caused damage to the patient’s teeth. He was unable to mount a more vigorous response, as it was a cool night, which rendered him more lethargic than usual. The patient was a vague historian, but there were no noticeable complaints of pain or any behavioural change. Blood tests were not performed because of the difficulty of penetrating the patient’s extremely tough skin. The patient made a remarkably swift and uncomplicated recovery, restarting his normal high-protein (mostly whole-chicken) diet after a brief period of observation. This was in stark contrast to what followed for his assailant, whose history we also briefly present.2 He was taken into clinical custody, where it was discovered that the patient’s tooth had penetrated his knee joint capsule, as well as causing several deep irregular lacerations. The assailant required a prolonged hospital admission after developing fever and septic arthritis. Despite repeated attempts to culture the assailant’s blood and joint aspirates, the cultures did not grow any organisms. To assist in his treatment, the hospital’s Infectious Diseases Department requested swabs from Fatso’s mouth, teeth and tongue to attempt to identify the likely cause of the infection. This was achieved during a home visit, with specially modified swabs (see Box) and a degree of trepidation. The mouth swabs grew Aeromonas hydrophila and Trichosporon asahii, consistent with the predominantly gram-negative and fungal microorganisms expected. The organisms were found to be sensitive to meropenem, vancomycin and ciprofloxacin. These findings were used to tailor the antibiotic therapy for the assailant. The assailant made a slow and difficult recovery, with ongoing fever and joint inflammation. He was transferred to a metropolitan hospital for further treatment. The patient generously cooperating in helping determine effective treatment for his assailant

Samuel J Fitzpatrick MB BS · Amanda L Thomas MB BS(Hons)

Robert “The Prof” Bedford provided medical services in South Australia for over 20 years, despite having no medical qualifications In the early 1980s, a national newspaper ran a feature soliciting nominations for “the most boring town in your state”. The winner for South Australia was the Eyre Peninsula township of Kyancutta. This generated the expected reaction from parochial inhabitants, who came up with a long list of interesting aspects of the district, including the notable and exciting fact that the township straddles the Eyre Highway, that great semitrailer-populated road connecting the west of the Australian continent with the east. Doubtless much of this list was facetious, but Kyancutta does in fact have a fascinating history, however dull it might have seemed by the end of the 20th century. It was the home of one of the earliest inland meteorological reporting stations; it had Australia’s fifth officially recognised aerodrome; and it housed an outstanding and unique natural history museum. All this, and much more, was the work of one man, Robert Bedford, who was known to three or more generations of farming families as “Beddie” and “The Prof”. Thirty or so years ago, when the boring town award arrived, there were still many older people in the central Eyre Peninsula who could recount stories of treatment, operations and consultations by “The Prof”. Once it was known that he had medical skills and was prepared to use them to assist his farming neighbours, he dealt with a never-ending stream of broken bones, dislocations, gunshot wounds, boils, carbuncles, scalds and burns, snakebites and fevers. He is even recorded as having treated burns with skin grafts. So many medical problems came his way that, with the aid of his wife, Hilda, he eventually set up a cottage hospital. The tyranny of distance ensured that he remained the first choice for local medical problems and emergencies, but Bedford was conscious of his limitations, and communicated frequently with nearby practitioners and metropolitan specialists. He referred patients whenever it was practicable; this being a term to be interpreted with regard to the sometimes vast distances involved, the vagaries of the weather, the primitive vehicles traversing equally primitive roads, and a rattly train service whose main function was to transfer wheat and barley, with passengers being of secondary importance. Such conditions meant that the transfer of patients did not occur very frequently in the earlier years. Like many other rural medicos then and now, he had a veterinary practice as well. It might have been assumed that he was medically qualified, even if not of professorial status, but simple enquiries reveal that, though widely consulted for injuries, illnesses and even obstetrics (he is recorded as having successfully delivered 99 infants from 98 confinements), Robert Bedford was not a doctor. Nor was his original name Bedford; he was born Robert Arthur Buddicom and changed his name to Bedford when he left England for Australia in 1914. In some accounts, his departure is described as “hasty”, implying a scandal, but all that could be found to support a scandal was a court case for alleged misrepresentation on a prospectus for a proposed telephone company. It is just as likely that his widely expressed pessimism about the future of England motivated his move. Bedford was born in Shropshire, in 1874, to a landowner family. He was educated at Charterhouse School and was a science scholar at Oxford University, where he qualified with a Bachelor of Arts degree in 1897. After this, he worked in marine biology in Naples, Italy, and then served as a curator of the Plymouth City Museum and Art Gallery, where he founded and edited a journal, Life. From 1906 to the time of his migration, he worked as a demonstrator and lecturer at the London Hospital Medical College (now Barts and The London School of Medicine and Dentistry). He was clearly a talented, cultured and widely educated man when he took up wheat farming in the remote district of South Australia where he was to spend the rest of his incredibly active and productive life. In 1919, he attempted to enrol as a medical student at the University of Adelaide, but he wanted to attend courses at the Royal Adelaide Hospital on his own terms and according to his own timetable. Not surprisingly, this was unacceptable to the medical faculty, and Bedford returned home disappointed, but with as good a collection of up-to-date textbooks purchased in Adelaide as would have graced the shelves of any reputable practitioner of the time. As long as anyone needed him, he was prepared to help, even when a full-time doctor set up practice in the nearby town of Wudinna. In fact, he remained on good terms with that doctor, and they frequently assisted each other and enjoyed games of bridge and musical evenings together with their wives. Farming, operating a flour mill, running a general store and acting as the local doctor and vet should have been enough to occupy anyone; but not so for this restless renaissance man. Radio station 5RB took to the airwaves in 1924, a railway refreshment room was opened in 1925, and in 1928, the Bedford store also became the official post office. In 1929, he decided it was important to set up an inland weather reporting station as an aid for the airlines, which were by then flying across the country from coast to coast. He bought his own barometers and wind gauges, but his observations were so accurate that the Bureau of Meteorology supplied further instruments and set up Kyancutta as an official weather station. His inspiring personality drew in neighbours to help build an all-weather aerodrome, which became an essential refuelling point for east–west flights across the country. In the 1930s, Robert’s interest in aviation was continued by his son, Bill Bedford, who continued to evacuate medical patients from areas as distant as Coober Pedy in the north of South Australia and Cook on the trans-Australia railway line, until an ambulance plane was stationed at Whyalla in 1965. Robert Bedford and one of his fossil fish In 1929, among his many interests and occupations, Bedford opened the Kyancutta Museum and Library to house his personal geological and palaeontological specimens, which he had collected locally and interstate on numerous self-funded trips, as well as specimens sent from collectors elsewhere in Australia. He examined and excavated meteorite craters in southern and central Australia, and published descriptions of these meteorites and tektites, mainly in his own Memoirs of the Kyancutta Museum. In 1939, he sent five specimens of fossil fish collected from early Devonian limestones in New South Wales to the Natural History Museum in London. These specimens formed the basis of an article published by Dr Errol White, then the fossil fish expert at the British Museum, who named one of the newly described fossils Williamsaspis bedfordi in Robert’s honour. Unfortunately, because of wartime disruptions at the Museum, the article was not published until after Bedford’s death. Other fossils on which Bedford worked included the ancient Cambrian archaeocyathid sponges from the Flinders Ranges. Described by his daughter as quietly spoken and peaceable, but capable of flying into a sudden rage, Bedford must have been a difficult man to argue with. The “establishment” certainly did not like him. He engaged in an acrimonious debate on geological matters with Sir Douglas Mawson (Newton Luscombe, personal communication), and the South Australian Museum opposed his admission to the Museums Association of Australia and New Zealand. His action in sending meteorite and fossil specimens to the British Museum may have been a reaction to the ill feeling that existed towards him among local geologists, and it certainly did nothing to ameliorate that antipathy. He was a prolific correspondent with dignitaries, scientists and institutions in Australia and abroad. His mind was constantly active and he involved himself wholeheartedly in local politics and as a member of the Australian Wheatgrowers Federation, for whom he drafted a constitution. He had visions of his little town of Kyancutta becoming a major regional centre, but this was not to be. The weather reporting station continued to function and, now operated by his grandson, is still an official Bureau of Meteorology observation and reporting station. The cottage hospital has long gone, its function being taken over by a hospital at Wudinna, established by the Bush Nursing Society, and which later became the Central Eyre Peninsula Hospital. The museum was closed shortly after World War II and its contents were dispersed. A series of models of his ingenious mechanical inventions ended up as toys for his grandchildren. Some of his medical books have been donated to a project for a museum at the University of Adelaide Medical School, which has still to see the light of day. Robert Arthur Bedford died on 14 February 1951. His contributions to geology and palaeontology have now been recognised by the scientific world, and his museum is named in historical studies. He was well aware of his limitations and did not publish any medical articles, so his legend as a medical practitioner remains only in the memories of those he helped. Such memories are mostly now extinct, but they are still, no doubt, associated with the inherited possessions of his descendants and with the folklore of the region. There is talk of a biography to expand on the memoir published by his daughter, Sylvia Laube, but, until then, this note may serve as a tribute to an amazing man, scientist, inventor, entrepreneur and original thinker, and a well loved bush doctor. He is buried in the Kyancutta cemetery, and his epitaph reads: “He laboured in his sphere as those who live in the delight that work alone can give”.

Michael Sorokin MB BCh, FRCP(Ed)

“Child deaths are falling, but not quickly enough to reach the target.” “Most maternal deaths could be avoided.” The Millennium Development Goals Report, 20101 “Where we are now in terms of health service delivery should be measured against where we have come from and not where we ideally should be. A lot of progress has been made.” Mary L Nannono, Permanent Secretary at Uganda’s Ministry of Health, 20082 The Millennium Development Goals (MDGs) report published in June 20101 shows that the targets to reduce maternal and child deaths will not be met, particularly in sub-Saharan Africa. Uganda is an east African country committed to achieving MDG 4 (the goal to improve child survival) and MDG 5 (the goal to improve maternal health). In recent years, there has been much work to improve Ugandan antenatal and neonatal care, scaling up emergency obstetric care services and child health policies. However, progress remains slow and, at current standards, Uganda is unlikely to attain the MDG 4 and 5 objectives (Box).3 Why has there been insufficient progress? What happens when mothers and children come to hospital? I am an Australian doctor training in paediatrics under the Royal Australasian College of Physicians. I also intend to train in anaesthesia. I decided to take a year-long break from the training scheme to do humanitarian aid work in a developing country, and I am now coming to the end of a 6-month sabbatical in Uganda. This personal perspective on paediatric and obstetric care provision in Uganda aims to illustrate some of the stumbling blocks in practice that are limiting progress towards the MDGs in maternal and child health. My time in Uganda was divided between the obstetric operating theatre of the National Referral Hospital in Kampala, and responsibility for a paediatric ward in rural Uganda at a not-for-profit mission hospital, run jointly by the local Catholic diocese and an international non-government organisation. Every morning on arrival at the obstetric theatre I was greeted by women waiting, lining up in the entrance hall or lying on plastic sheets on the floor of the ward, contracting in pain. All needed emergency caesarean sections. However, each woman waited in turn for her operation or spontaneous delivery, whichever came first. When her turn came, the patient would walk into theatre and struggle onto the operating table with minimal assistance, pausing only for a grunt or grimace during a contraction. My first day at the Kampala hospital theatre was particularly disappointing — six emergency caesarean sections resulted in two fresh stillbirths, one macerated stillbirth and two admissions to the special-care baby unit. We hand-ventilated one baby for an hour because there was no mechanical ventilator. Later that afternoon, the baby stabilised on continuous positive airway pressure, but died overnight. My colleagues and I decided to undertake a 1-month audit to review maternal and neonatal outcomes: were there avoidable delays for emergency caesarean sections, and could anything be done about them? The maternal mortality rate in my sample of 435 was 1%, the stillbirth rate was close to 7% (equivalent to the hospital’s 1968 rates14) and mothers waited on average for 5 hours for the emergency procedure. Reasons for delays included staff unavailability, a lack of running water, a non-functional autoclave (and hence no sterile drapes and gowns), and no spinal needles or drugs for spinal anaesthesia. As a result of the audit, the hospital expedited the building of two new obstetric and gynaecological operating theatres and undertook to ensure that highly qualified and experienced staff ran them. Mothers are advised to bring a delivery pack when they come to hospital — not a dressing gown, slippers and baby clothes, but their own cannulae, sterile swabs, suture materials and 10 packets of sterile gloves, in case the hospital supply runs out. During my second week, a woman in her seventh pregnancy joined the section queue. Her indication for surgery was obstructed labour at 38 weeks gestation, with a “poor obstetric history” that translated as six previous stillbirths. She waited patiently in line but when it was her turn there were no gloves in stock and she had brought only one packet. She waited while women with gloves had their procedures. Her blank emotionless expression when the surgeons told her over the drapes that her baby was stillborn will remain with me forever. How can this hospital function as a comprehensive emergency obstetric care provider when caesarean section priority relates to the number of gloves the patient can supply rather than the underlying urgency of surgery? My responsibility for a 23-bed children’s ward (often with two to three patients per bed) in rural Uganda also brought me many challenges. At this hospital, one difficult day started with a mother in obstructed labour who delivered her baby with shoulder dystocia. During our attempt to resuscitate the baby, there was a power failure and, as there was no fuel for the back-up generator, the oxygen concentrator did not work. The oxygen cylinders were empty, so there was no oxygen in the hospital. Sadly, we were unable to save the baby. The same day, a 4-day-old twin died of jaundice because our phototherapy machine was broken and the parents could not afford to travel to another hospital. Then the mother decided to discharge herself from hospital with her surviving twin, also jaundiced and on intravenous antibiotics, and consult a traditional healer. I remember a 3-year-old patient referred from a larger regional centre to our rural hospital for a blood transfusion because there was “no blood available”. The child’s haemoglobin level was 2 g/dL and she was in severe respiratory distress. I was confused by the cross-match form and unit number noted in her case notes, yet the clearly documented reason for transfer was “no blood available”. The mother reported that, while she and her daughter were at the regional centre, another child, as sick as her own, had arrived whose need for the blood, already crossed-matched for our patient, was decided to be the more urgent because his or her mother could contribute money. As health care practitioners, we make decisions that are generally evidence based and (hopefully) in the patient’s best interests. A premature neonate, with a gestational age of 27 weeks, had been labelled a “fighter” after surviving 3 days on only a whiff of oxygen. This was going to be a success story for Africa — the survival of a premature baby. One night, a 6-month-old boy presented in severe respiratory distress when the oxygen concentrator was away being repaired and the only oxygen cylinder that wasn’t empty (it was one-quarter full) was with the fighter, who hadn’t tolerated a trial on room air. Reluctant to take oxygen away from her, I told the mother of the boy that I had done all I could. He died 3 hours later and I could hear the mother wailing from my room. The next day, the condition of the fighter on oxygen therapy suddenly deteriorated and I was unable to revive her. Had I made the wrong decision? Hindsight is a torment for one’s conscience. However, the oxygen dilemma prompted us to adapt the oxygen tubing so that two children could receive low-flow oxygen at the same time. When I received my first Ugandan arrest call, I ran to the bedside. Almost 5 minutes after I arrived, the suction and some monitoring equipment appeared. Oxygen was not available until later and we also had to wait for resuscitation drugs. The outcome was poor, both for the patient and my confidence. After my third resuscitation call, I didn’t run any more. I walked “mpola mpola” (slowly, slowly) with the rest of the team — arrests are difficult to manage without basic equipment, and usually fatal because of delayed treatment. So far I have painted a somewhat bleak picture, but there were good days and successes. A 6-week-old girl was brought in severely malnourished, weighing 2 kg with sepsis and malaria. The good Samaritan who had picked her up as a newborn from the roadside after the mother abandoned her was feeding her cow’s milk. After antibiotics, antimalarials and commencing our formula feeding program, the child gained weight and even started to smile. Also heartening, and something that has constantly amazed me, is the resilience and good humour of the staff, who do their best with what is available. However, when I read in the local newspaper that the World Health Organization’s Making Pregnancy Safer program is to be extended, and more mothers will be encouraged to give birth in hospital, I remember all the critical events that I have witnessed. Surely this advice will not lead to improved outcomes while there is such a disparity between demand and supply, between concept and reality. Reliable running water and electricity; hospital supplies like basic disposables, oxygen, and blood for transfusion; and adequate staffing and staff training are essential requirements for emergency obstetric and paediatric care. My story highlights that if basic hospital facilities were improved and some systemic delivery deficiencies overcome, more progress towards the MDGs 4 and 5 in Uganda and all of sub-Saharan Africa would be made. Ensuring that 90 per cent of African mothers and newborns have access to the essential interventions already written into policy would cost a very affordable US$1.39 per capita.15 What are the Millennium Development Goals for maternal and child health and where does Uganda stand in achieving them? Millennium Development Goal (MDG) 4 aspires to a global target of a two-third reduction by 2015 in the mortality rate of children aged under 5 years. For Uganda, this means a decrease to below 56 deaths per 1000 live births; however, the rate only declined from 186 to 135 deaths per 1000 live births during the period 1990 to 2008.4 Globally, neonatal mortality accounts for 38 per cent of deaths in children aged under 5 years; hence, a substantial reduction in neonatal deaths is necessary if this goal is to be attained.5 A 2006 Ugandan survey reported a perinatal mortality rate (comprising the stillbirth rate and early neonatal mortality rate) of 36.3 per 1000 pregnancies.6 This amounts to 44 500 newborns dying and 45 100 stillborn babies each year.7 Childbirth is the time of greatest lifetime risk of mortality for a mother and her baby. Intrapartum complications account for an estimated 42% of the world’s 358 000 annual maternal mortality rate (MMR). Sub-Saharan Africa contributes 57% to the world’s annual MMR.8 The first target of MDG 5 is to reduce the MMR by three-quarters before 2015, equivalent to a reduction to 131 deaths per 100 000 live births in Uganda — the estimated MMR is currently 435 deaths per 100 000 live births.9 A 2005 study estimated the MMR at 645 deaths per 100 000 live births at the National Referral Hospital, my workplace.10 Many obstetric and newborn complications can be prevented or successfully managed with prompt interventions. The Lancet Newborn Survival Series demonstrated that skilled clinical care could effect a reduction in neonatal mortality rates of up to 72 per cent.11 Timely identification and management of childbirth complications is paramount, and while more mothers and newborns die during this period than at any other, coverage and quality of care often remains inadequate in resource-limited settings.12 It is also important to note that with gross under-reporting (deaths at home or en route to hospital are often not recorded), the true figures are undoubtedly substantially higher. However, Uganda’s slow progress towards MDGs 4 and 5 has put the spotlight firmly on maternal and child health delivery. The government has responded by developing a national roadmap to accelerate the reduction of maternal and child mortality and morbidity. It has been placed high on the political agenda and, with the country’s upcoming elections in February 2011, all major political parties in the country are promising to make maternal and child health a priority. In addition, the World Bank in May 2010 released a new 5-year action plan to help poor countries reduce their maternal and child deaths. Uganda is one of the sub-Saharan African countries targeted. There is hope that, with time, Uganda will achieve the aim of the United Nations 2009 global consensus on maternal, newborn and child health: to have “every pregnancy wanted, every birth safe and every newborn and child healthy”.13 “All needed an emergency caesarean section. However, each woman waited in turn for her operation or spontaneous delivery, whichever came first.” “My responsibility for a 23-bed children’s ward (often with two to three patients per bed) in rural Uganda also brought me many challenges.” Communication, Ugandan style!

Katie M Moynihan MB BS, DCH

To the Editor: A patient of mine recently reported that she had had a busy week, with the death and funeral of her sister. The woman had died with lung cancer at the age of 77, after having smoked tobacco for 61 years from the age of 17. On further enquiry, I was informed that the woman had “smoked all day and all night”, at the rate of 60 to 80 cigarettes per day. People could hardly stand to visit her home because “the house was always full of smoke”. Two different brands were used, including packs of 40. She had required oxygen therapy for the past 12 to 18 months and was severely disabled by breathlessness. She would “chain smoke”, with one cigarette behind each ear and one in her mouth. Rather than light them with a match or cigarette lighter, she would light her next cigarette from the butt of the one she was just finishing. At an average of 70 cigarettes every day for 60 years, the total intake amounts to around 1 500 000 cigarettes. At, say, 50c for each cigarette, this equates to a cost of $35 a day or $12 775 for a single year. A principal reason for taking the trouble to offer this anecdote for publication is that this is the greatest number of cigarettes I have ever heard of being smoked by any one person.

C Ross Philpot

Mr D Duck presented with a painful neck and underwent cervical facet and foraminal injections under computed tomography control. He looks happy with the result, which proves that interventional radiology is not quackery.

Derrick G Selby · Claudio Coscia

An emergency department audit of horse-related injury presentations alerted researchers to a hitherto uninvestigated source of childhood harm: non-equine horses. A search for the term “horse” in the database of the South Australian Injury Surveillance and Control Unit was performed for presentations of horse-related injuries to a paediatric emergency department of an Australian tertiary teaching hospital over a 5-year period. After all equine-related episodes were extracted, the remaining presentations were herded together and conclusions were jumped to. When legitimate science and research technique failed, poetic licence was prevailed upon.

John A Craven BSc(Hons), FRACP, FACEM · Jacquie K Schutz BM BS, FRACP

An 82-year-old man presented to the emergency department with abdominal pain and vomiting. An abdominal computed tomography scan showed a whirl sign around the superior mesenteric vessels (Figure, arrow), suggestive of small bowel volvulus. A whirl is formed by the afferent and efferent loops of the volvulus, with the central portion consisting of tightly twisted bowel and mesentery.1 The latter create swirling strands of soft tissue shadow within a background of mesenteric fat attenuation, giving the appearance of a hurricane on a weather map. Caecal and sigmoid volvulus can also give rise to whirl signs. Laparotomy confirmed mid-gut volvulus with 360° rotation. The patient had an uneventful recovery following derotation of the mesentery.

Debasish Debnath · Peter Frecker

Rock music may be bad for your knees as well as your ears Clinical record In May 2009, a 17-year-old woman in the dance floor audience at a rock concert was performing “air guitar” — a form of dance and movement in which a performer mimes to rock or heavy metal guitar music, commonly requiring enthusiastic jumping and leaping about a “stage”. While performing a manoeuvre involving a jump into the air, she landed awkwardly on her right leg. She noted immediate intense right knee pain with obvious patellar deformity. An ambulance was called, and a dislocation of the right patella was diagnosed. Under methoxyflurane inhalation, ambulance officers reduced the dislocation by manoeuvring the knee into full extension. On arrival at the emergency department, the patient complained of pain “everywhere” in the knee. There was no obvious swelling or deformity of the knee joint. There was tenderness over both the medial and lateral collateral ligaments, with minimal patellar tenderness. She had full painful range of movement. Radiological examination of the knee showed a joint effusion with lateral subluxation of the patella. There was a 2 mm ossicle lateral to the lateral femoral condyle, which may have represented an acute avulsion fragment. A compression bandage was applied, and the patient was discharged with analgesia and crutches, with follow-up to be undertaken with her general practitioner. The patient re-presented to the emergency department 36 hours later with a painful and swollen knee joint. After discussion of treatment options with the patient and her mother, a decision was made to proceed to arthroscopy. At arthroscopic debridement, a tense haemarthrosis was released. A bleeding point was identified at the patellar attachment of the torn medial patellofemoral ligament. A synovectomy of the affected area was performed, and haemostasis of the local bleeding vessel was achieved with diathermy (Box). There was minor chondral damage about the medial patellar facet. Other joint structures were intact and there was no fracture. The patient had an uncomplicated recovery with routine postoperative care. At 3-week review, she was able to walk comfortably unaided. There was minimal effusion and she had a full range of movement. She was prescribed a muscle-strengthening program and referred to a physiotherapist, and she made a full and uneventful recovery. DiscussionDislocation of the patella is an injury more commonly seen in young athletes and usually spontaneously reduces at the time of injury.1 There has been no report in the medical literature of a knee injury sustained during a musical performance. Although the literature describes several maladies attributed to guitar playing, such as wrist injury,2 overuse injury to the digits,3,4 and irritation of the skin secondary to exposure to the instrument’s surface,5-7 there are no reports of an acute physical injury due to guitar playing. There is a single internet report of an acute injury sustained while playing a guitar-like instrument — an avulsion injury of the lateral condyle of the left femur, incurred while playing the video game Guitar Hero.8 An internet search using Google found numerous reports of acute injuries attributed to the performance of air guitar. The Chicago Sun-Times reported an unspecified back injury to the reigning Chicago Region Air Guitar champion,9 while the winner of the United States Air Guitar regional competition in Brooklyn “rocked so hard during a daredevil performance that doctors had to amputate a toe she broke during the gig”.10 There are also reports of a knee injury as a result of jumping from a height during a performance and an ankle injury sustained after jumping from speakers.11 There has even been a report of death due to air guitar — a student in Singapore fell to his death from a building when he was “jumping up and down on the bed placed against an open window while mimicking a rock guitarist”.12 Our case suggests that injuries due to the performance of air guitar are a source of previously unrecognised and unreported morbidity and demonstrates that, even though the instruments used in air guitar are imaginary, the injuries sustained are quite real. Rock music may be bad for your knees as well as your ears. Arthroscopic photograph of the knee joint Diathermy-treated bleeding point within the medial patellofemoral retinaculum (arrow).

Robert J Douglas BA, BAppSc(Dist), BM BS · Jason Ward BM BS, FRACS(Orth)

Does this colonic polyp not resemble a jelly baby?

D Brian Jones

Objective: Design, setting and participant: A mixed-methods, prospective, descriptive study of unsolicited mail sent directly to a general practice registrar in a private general practice located in rural north Queensland, collected between 1 March and 30 September 2010.Main outcome measures: The amount, by number and weight, of unsolicited mail items, and the proportion of each document read, in total and by category.Results: 196 items of unsolicited mail, weighing 19.85 kg, were received over a period of 7 months. The category with the largest number of mail items was pharmaceutical company correspondence (70; 36%), closely followed by medical tabloids and free journals (67; 34%). Medical tabloids and free journals made up the largest proportion of unsolicited mail by weight (15.49 kg; 78%). Of all 196 items, only 10 (5%) had more than half of their content read.Conclusions: Although small in size, this study suggests that a reduction in unsolicited mail to general practitioners in Australia would have benefits for GPs in terms of time management, environmental benefits, and reduction in frustration levels.

Amanda M Torkington MB BS, BSc · Robyn G Preston BA(DevS)(Hons), MHSc(HealthProm), PGCertDisasRefHlth · David T Brandts-Giesen BHlthSc(Podiatry), GradCertPHResEval

Objective: Design, setting and participants: A randomised single-blind controlled trial with a treatment duration of 3 days and a follow-up period of 4 days was conducted at a sauna in Berlin, Germany. Between November 2007 and March 2008 and between September 2008 and April 2009, 157 patients with symptoms of the common cold were randomly assigned to an intervention group (n = 80) and a control group (n = 77).Interventions: Participants in the intervention group inhaled hot dry air within a hot sauna, dressed in a winter coat, whereas participants in the control group inhaled dry air at room temperature within a hot sauna, also dressed in a winter coat.Main outcome measures: Area under the curve (AUC) summarising symptom severity over time (Days 2, 3, 5 and 7), symptom severity scores for individual days, intake of medication for the common cold and general ill feeling.Results: No significant difference between groups was observed for AUC representing symptom severity over time (intervention group mean, 31.2 [SEM, 1.8]; control group mean, 35.1 [SEM, 2.3]; group difference, − 3.9 [95% CI, − 9.7 to 1.9]; P = 0.19). However, significant differences between groups were found for medication use on Day 1 (P = 0.01), symptom severity score on Day 2 (P = 0.04), and participants’ ratings of the effectiveness of the therapy on Day 7 (P = 0.03).Conclusion: Inhaling hot air while in a sauna has no significant impact on overall symptom severity of the common cold.Trial registration: ClinicalTrials.gov identifier NCT00552981.

Daniel Pach MD · Bettina Knöchel CandMed · Rainer Lüdtke MSc · Katja Wruck Documentalist · Stefan N Willich MD, MPH, MBA · Claudia M Witt MD, MBA

To the Editor: Paul, the 2-year-old octopus of Oberhausen Sea Life Aquarium, Germany, gained celebrity status over the course of the 2010 International Federation of Association Football (FIFA) World Cup by predicting winners with surprising accuracy. In order to make a prediction, Paul was offered food from two separate containers, each one featuring the respective team’s flag. Whichever container Paul chose to eat from first was deemed to be the predicted winner. During the World Cup, Paul correctly predicted all of Germany’s results, as well as the eventual winner, Spain. In other words, this cephalopod made correct predictions eight times in a row. Suppose that before the beginning of the World Cup we hypothesised that Paul would correctly predict the results of eight football matches, including the grand final (H1). The null hypothesis (H0) would have been that Paul could not correctly make these predictions — that is, he was not psychic. Assuming a probability of 0.5 of correctly predicting a result (ie, a 50 : 50 chance), then the probability of predicting eight games in a row is 1 in 256 (1/28), or about 0.004. As Paul did correctly make these predictions, there is strong evidence to reject the null hypothesis. Using an exact 95% confidence interval to generate a prediction interval, the best we can say about the probability that Paul was psychic is that it is > 63% and ≤ 100%. Therefore, should we assume Paul was psychic based on P = 0.004, or has something else happened? The most likely explanation is that a type 1 error occurred — we rejected the null hypothesis when it was true, because a P value (significance level) of 0.004 still allows a chance finding of a statistical difference to occur in 0.4% of tests. Interestingly, in clinical practice we often accept P values that indicate less significant results than this (ie, P > 0.004 but < 0.05), so type 1 errors may occur more often than we realise. Of course, there are several problems with our analysis. First, we were already aware of the outcome when we conducted the analysis, so our probability for each successful prediction should have been 1 and not 0.5. This is an example of post-hoc probability analysis. Second, it was not an ideal scientific experiment because there was no control group, only one test was performed per match, there may have been differences in food preparation, and so on. Finally, it is not wise to conduct statistical analysis on implausible events, as this increases the probability of type 1 errors. We do not believe that Paul had psychic powers, but his predictions do serve as a good example that type 1 errors can never be ruled out, even with highly significant results.

Lydia M McGee · Richard G E McGee

The ethics of pediatric research. David S Wendler. Oxford: Oxford University Press, 2010 (337 pp). ISBN 9780199730087. AS HEAD of the Unit on Vulnerable Populations, Department of Bioethics, NIH Clinical Center, in the United States, David Wendler continues to contribute to the rich debate on issues surrounding ethical research involving vulnerable populations, including children, who cannot give informed consent. This particular work was written while Wendler was a Faculty Fellow in Ethics at the Safra Center for Ethics at Harvard University, and is the result of over 10 years of research. A balanced and engaging analysis of the justifications for the ethical acceptability of non-beneficial paediatric research is critical, if we are to undertake ethically sound translational research in vulnerable populations to improve medical care. Scholars in clinical research ethics and, potentially, clinicians engaged in paediatric research should find this book of interest and value. Each well structured chapter includes brief summaries of the arguments presented in the chapters immediately preceding and succeeding it. Wendler is particularly helpful when he explores the ways in which concepts such as “social value”, “human interests and causes”, “wellbeing” and a “better life” influence the moral status of non-beneficial paediatric research. Additional diligence is called for by all parties where substitute consent is required. This topic could have received further critique as part of the two insightful and extended chapters on the contributions of participants. Acknowledging the shared responsibilities of clinicians, researchers, substitute decisionmakers, bioethicists, human research ethics committee members, regulators and publishers in ensuring good clinical research practice is essential for a sound examination of key issues. The book is relevant to an Australian audience, with reference to comparative regulatory frameworks here, the US, Canada and elsewhere. The book is well within reach of most budgets and would be a worthwhile addition to medical and social science libraries.

Jennifer M Fleming

The pen & the stethoscope. Leah Kaminsky, editor. Melbourne: Scribe Publications, 2010 (x + 223 pp). ISBN 9781921640735. “Medicine is my lawful wife and literature my mistress; when I get tired of one, I spend the night with the other.” This quote from Anton Chekhov, perhaps the most famous doctor–writer, appears in the flyleaf of The pen & the stethoscope, a collection of stories by doctor–writers. Despite my misgivings about presenting fiction and non-fiction in the same volume, this is a seamless set of narratives by doctors, from varying specialties, who are also accomplished writers. It demonstrates that we, as doctors, have moved beyond the 19th century and Chekhov’s need to separate our scientific and humane selves in the clinical setting. Leah Kaminsky, herself an award-winning author and practising family physician in the United States, has assembled an international cast of doctor–writers who illuminate issues such as the challenge of ageing, suicide of a colleague, and guilt at failure but also success in medicine. We are treated to an insightful exploration of the thoughts and feelings of doctors in their daily work. The point of view of patients and their loved ones is also elaborated with great skill. Ethan Canin, in his exquisite tale, “We are nighttime travellers”, details the disintegration of a man and his marriage over many years, and his final very moving redemption. In “The checklist”, Atul Gawande details a doctor’s simple but ingenious idea that has saved lives. “Do not go gentle”, by Irvin Yalom, is an account of a psychiatrist who can identify with his patient who hoards the letters of a long-lost lover. Oliver Sacks, in “The lost mariner”, writes about a neurological conundrum with his usual fluidity and flair. Jacinta Halloran, in “Finding Joshua”, exposes every doctor–mother’s fear that a demanding job will not leave enough time for her children. I enjoyed reading The pen & the stethoscope. The stories are well written, thought provoking and appealing to both doctors and lay people. Medical students may find these narratives particularly enlightening. I recommend this collection as a good addition to the Christmas holiday reading list.

Sue Ogle

Chilli, chicks and heart-attacks — the misadventures of an intern by Dr Manju Mendis. Sanjaya Senanayake. Colombo, Sri Lanka: Perera Hussein Publishing, 2010 (269 pp). ISBN 9789551723118. If the secret of novelistic success is to write about what you know, then I am more than a little worried about Sanjaya Senanayake. The author, an infectious diseases physician at the Canberra Hospital who already has two popular medical texts to his credit, has thrown away his evidence base in this rollicking and licentious account of the intern year of the handsome Dr Manju Mendis. Set in the elite St Ivanhoe hospital, there is priapism, onanism and near-miss bestiality — and that is just the opening chapter. We meet the execrable surgeon Professor Monty Bonkzalot, who supplements his income by operating on pets in the hospital after hours, the pulchritudinous television journalist Fabulus Hipz, the culturally confused Lucky King, and the billionaire Pik Freiman, who finds true love in his ninth decade. Dr Mendis stands by and lets a deeply unpleasant woman die, he kills another by inflicting pain to a gouty foot, fails to report a murder and, after sleeping with Hipz, provides her with information that has Bonkzalot sacked. He exposes the career-long lies of “physician to the stars” Spider Croquet and ultimately falls in love with a beautiful sex-worker. The blatant racism that this accentless, locally born son of Sri Lankan parents experiences along the way is met with swift and cruel remedy. It’s all good fun — think Bollywood meets Scrubs — and an exercise in wish fulfilment that will be appreciated by any young doctor who has suffered at the hands of egomaniacal consultants. The relentless punning will annoy many readers, some of the dialogue doesn’t quite work and, although they have made J K Rowling billions, I would have dropped the ubiquitous adverbs. But if you are looking for the material for a screenplay that explores the issues faced by contemporary second-generation South Asian professionals, this would be a very good place to start.

Francis J Bowden

Sex, lies and pharmaceuticals. How drug companies are bankrolling the next big condition for women . Ray Moynihan. Sydney: Allen & Unwin, 2010 (256 pp). ISBN 9781742370187. SEX SELLS, as does the implication of a good scandal, so the title alone should generate some sales of Australian investigative journalist Ray Moynihan’s latest exposé of Big Pharma’s marketing machine. Building on the success of his earlier work, Selling sickness, Moynihan here teams up with Dr Barbara Mintzes (Assistant Professor in the Department of Anesthesiology, Pharmacology and Therapeutics at the University of British Columbia in Canada) to disassemble the story behind “female sexual dysfunction” or FSD. The story of FSD is traced through an investigative journalist’s eyes, from the revolution in sexual medicine in the late 1980s, through the launch of the now infamous phosphodiesterase type 5 inhibitors, to today. Along the way, with the benefit of hindsight, the authors assemble the jigsaw pieces of pharmaceutical company influences on researchers and clinicians to paint a picture of a series of disorders being created by the very industry which then fortuitously provides the panacea. Moynihan and Mintzes are no strangers to highlighting the effects of pharmaceutical company promotion and largesse. While it could be argued that this work is part of a sustained attack on the industry, Moynihan takes great care to emphasise the usefulness of pharmaceuticals for some women who have a sexual disorder. The main theme is that these women form a small minority — not 43% or similar figures quoted by proponents of such medical treatment — and that many non-drug therapies are as effective as drugs, if not more so. Sex, lies and pharmaceuticals is very readable, and its target audience is consumers, not health professionals. Its main aim is to encourage consumers (or patients) to ask questions of their doctors to gain an understanding of the diagnosis with which they are being labelled, and for which they are subsequently treated. It is $30 well spent to see what your patients may be reading and to question “Where did those useful diagnostic tools really come from?”.

Greg Kyle

101 top tips in medicine: cynical and otherwise. John Larkin. Oxford: Radcliffe Publishing, 2010 (131pp). ISBN 9781846193989. JOHN LARKIN is a consultant physician and rheumatologist from Glasgow and, if his writing is anything to go by, is clearly not someone who will ever be accused of taking himself too seriously. His self-described absence of any superior qualifications, testimonials or, indeed, literary merit appear to make him perfect for this “cynical” take on hospital life in the follow-up to his 2005 debut book, Cynical acumen. 101 top tips in medicine is an on-call-style book, but with the sort of home truths we would only have previously expected from the “Fat Man” in the satirical novel The house of God by Samuel Shem (pen-name of psychiatrist Stephen Bergman). The 101 top tips are divided into categories — cynical, survival, clinical, career and miscellaneous — although the majority have the wry, tell-it-how-it-is style that Larkin does so well. Included are a number of practical day-to-day tips to help you through internship and early residency years, as well as those classic gems that are generally only offered by senior doctors after you’ve learnt them the hard way. Everything from “don’t answer a telephone if it’s not for you” to “always touch a bed before sitting on it” is explained and justified (a hand is far easier to wash than pants, after all). While you’d be hard pressed to call this a “medical text”, it’s the only one I’ve ever been able to sit down and read from cover to cover. Anyone will be entertained by Larkin’s anecdotes and the liberal use of footnotes that provide a humorous narrative style, but the intended audience is clearly medical students and junior doctors. This book would make a great light read for any junior doctor (or consultant whose sense of humour is still intact) or gift for a fresh graduate.

Daniel J Scherer

Voting in this year’s Christmas Competition was akin to picking the daily double, with two main categories emerging from the field — “humorous” and “true stories.” Apart from the need for clarification about the number of votes allowed per person (thwarting any attempts at race fixing) and comments about the much needed upgrade for a new voting “box” (the current one has survived three office moves since 2001), the voting proceeded quickly and without incident. Once again, all entries were of very high quality and reached the finish line unscathed — with two winners (by a nose). In the humorous category, “The hidden menace of non-equine horses” by John Craven and Jacquie Schutz won the day. The paper fills an important gap in the scientific literature and will no doubt have you recounting some of your own childhood encounters with this beast in its various guises. True stories are often sobering but some of them, such as Katie Moynihan’s heart-wrenching account of her experiences working in Uganda, need to be told. Along with the author, we hope that some of the human stories behind Uganda’s slow progress towards reducing maternal and child mortality will raise awareness of the country’s dire shortage of basic hospital facilities, and the very small amount of money that would be required to provide relief: much less than the average Australian spends on the Melbourne Cup! Our great thanks to all who entered this year’s competition. We know there are more stories and pictures out there and look forward to your future entries as you feel spurred on to take up the challenge and bolt to the finish line next year, for a chance to win not a cup but a basket (of goodies) for your Christmas table.

Alison Williams

Did you know that when a manuscript is sent out for peer review, experts may elect to provide comments for the editor’s eyes only? Although we have sometimes shaken our heads in frustration when advice given to the editor (“Do not publish!”) does not match that offered to the authors (“A promising report, indeed ...”), thankfully, more often than not, the content is fairly congruent and includes further information that enlightens, entertains or otherwise stimulates us. We feel particularly privileged when contributors share their personal stories. Once again, at Christmas, we’d like to share a few comments that caught our eye this year. From the more sobering to the humorous, we hope you’ll find something thought-provoking among the batch provided. A doctors’ health journal?We all may know that many doctors do not have their own general practitioner. Members of the Journal’s Content Review Committee meet on a monthly basis to discuss, among other things, the most recent issues of the Journal. During one meeting, a participant commented: “The closest many of us [that is, doctors in general] get to seeing a GP is reading the MJA”. Public stationsFrom various submissions, apologies and requests for extensions, we are aware that several of our very valued contributors required medical attention this year. One expert shared this timely experience that was relevant to reviewing a paper related to the practice of medicine: “I recently had to go to the emergency department of a large teaching hospital. The doctors and nurses were kind to me but the place was like Euston Station and my visit there ranks as one of my bad life experiences — and I am medically qualified.” On location“I see you [the MJA] are in Clarence Street [in Sydney]. My parents bought me a bike there for my 17th birthday (1986) and I am ashamed to admit that I still ride it, although it has largely retired (2005), to ride down to check the surf on summer holidays.” Editor’s note: We think this was probably Clarence St Cyclery, founded in 1975. Quality publishing“I’ve written more than I usually do to the authors in the hope this places a bomb under them to write something that is more worthy of the MJA. As it stands, their current version could make it in the Women’s Weekly or page 3 of the Sun. (Probably showing my age with that last line — I guess the Sun doesn’t do Page 3 anymore. Not that I ever looked at Page 3, I only know this from what [name of esteemed professor] tells me ...).” Recipe for success“Thankyou for the opportunity to review this entertaining manuscript. A mix of science, fashion and a tinge of plausibility was evident which is, of course, the basis of many a Cochrane review.” The essential ingredient “I’m wondering whether you’ve had the time (or the inclination) to watch a new reality [cooking] show ... I came across a re-run yesterday when the cricket match was boring me to tears ... For the starter course, they [an amateur chef team] served a risotto of lobster with vanilla and truffle ... You will note [from the website transcript] that no truffles are listed on the [ingredients]. In its place is truffle oil ... I thought the quote of the show was, ‘Where were the truffles?’ ... Well, this in a nutshell, is what’s wrong with [this manuscript]. Where were the truffles?” The MJA looks forward to receiving more of your “truffles”, be they formal or informal, next year and beyond.

Ann T Gregory MB BS, GradCertPopHealth

Registration Good medicos are burning with desire, To take on board advances they require, Devoting leisure moments to pursue Such literature that enters their purview. They front up to hear lectures after work, To bone up on some therapeutic quirk, So expertise and insight may be gained, And professional standards be maintained. Continued education brings rewards, And favour of the state medical boards Without whose benefit good doctors fear They’re likely to be tossed out on their ear. Well, not infrequently, they feel they must, Pursuant to their academic lust, Convene with keen like-minded personnel, At some prestigious convention hotel. They choose a choice location for this spree, Where shopping is most likely duty-free, Then as they doze or contemplate or learn, They plot deductions from their tax return. The program planner usually provides Relief from lectures and relentless slides, Allowing those who feel at all inclined, To swan off on excursions and unwind. Thus one encounters doctors of renown, Who while relaxing let defences down, And herewith is a brief manifesto Of doctors, some of whom you surely know. This resumé of medicos indeed, Should satisfy an all-consuming need, So patients may be able to rejoice, In visiting the doctors of their choice. Herewith in verse maybe for the first time, The healing arts and artists caught in rhyme. Appear on stage to be viewed and discussed, The ones to whom our bodies we entrust. Final session (After Noel Coward’s I went to a marvellous party) For some obscure reason I’m here for the season Of medical rorts, With doctors who venture To convention centre In grand plush resorts. The new qualifiers And old frequent flyers Arrive in their hoards, The healing profession To make an impression, On medical boards. It cost quite a bit But I have to admit It was worth every cent, I’m not a cheapskate And I’m pleased to relate That I’m glad that I went. Yes I went to a lovely convention, A junket, a real jamboree, The doctors turned up to sip and to sup, And much of the noshing was free. Benevolent caring drug houses Fell over each other, what’s more. Such elegant samples they took from their shelves, The drugs into which all the avant-garde delves, And which they agreed to try out on themselves, I couldn’t have loved it more! It was such a super convention, The doctors committed to learn. You know what I mean, The more they could glean, The more they’d be likely to earn. They didn’t need too much note-taking, With printed handouts by the score, Then discounted textbooks were offered for sale, All quite up to date in the latest detail, And others available on the e-mail, I couldn’t have loved it more! It was such a way-out convention, No lawyers or newshounds allowed, Although I admit, When musing a bit, A few had got in with the crowd. You have to watch out for intruders, You need a firm hand at the door, Insurers were handing out membership slips, Detailers were offering quite useful tips, And promised to upgrade old computer chips, I couldn’t have loved it more! It was such a stunning convention, With double projection of slides, Intelligent folk, Enjoying a joke, Occasional funny asides. The visiting firemen were splendid, Imported from somewhere offshore, Presenting their work with a practised aplomb, It’s easy to tell from the accent where from, It had to be either a Yank or a Pom, I couldn’t have loved it more! It was such a friendly convention, The women were out on spree There’s no way of stopping, The ladies when shopping, When everything is duty free. Some menfolk had joined in the outing, When finding some lectures a bore. A sort of wine buff, I examined the range, Of duty-free liquor and some of it strange, And picked up a discounted carton of Grange, I couldn’t have loved it more! It was such a first-rate convention, And nobody wanted to stop, Although one or two, Perhaps me and you, Declared it was over the top. We ambled along to the rostrum, Displaying such esprit de corps, Then off we all went with a friendly handshake, To boast of the hardships that we undertake, And let patients know what we do for their sake, I couldn’t have loved it more!

Leonard Green MRANZCR, FRACR, OAM