Volume 196 Issue 2

Is the 4-hour rule achievable — and beneficial — in our current system of health care? Albert Einstein is famously thought to have said that insanity is “doing the same thing over and over again and expecting different results”.

George Braitberg MB BS, FACEM, FACMT

Broader thinking is needed to restore mental health in a vulnerable population. It may well be that Australian Aboriginal culture, before significant European contact, provided conditions for mental health that the rest of the world would envy. Traditional Aboriginal culture has several factors that strongly reinforce good mental health.

Robert M Parker BA(Hons), BMed, FRANZCP

Assessing health status is only the beginning. Decisions to remove children from their biological parents are never taken lightly. Such decisions are reinforced by the growing body of evidence of the adverse short- and long-term outcomes of child maltreatment,1 which are increasingly seen to be mediated through the effects of abuse on early brain development.

Graham V Vimpani PhD, FRACP, FAFPHM · Susan M Webster MPHC · Meredith J Temple-Smith BSc, MPH, DHSc

The full content of this article is available by downloading the PDF.

The full content of this article is available by downloading the PDF.

Is canonical thinking inhibiting the flexibility and innovation required for expert clinical reasoning? The idea of clinical pathways was developed in 1985,1 with the intention of improving patient care and use of health resources. Since then, use of clinical pathways has proliferated, dominating clinical decision making in Australia and abroad. Important features of clinical pathways include a practical focus on the patient journey and a patient-centred multidisciplinary team approach.

Ralph K Nanan DrMedHabil · Alison S Poulton MA, MB BChir, MD · Bernard L Champion MB BS, BSc(Med), MMedEd

Proactive recognition and response, pre-emptive management Despite improvements in medical therapy and improved outcomes, patients admitted to acute care hospitals may suffer clinical deterioration and potentially avoidable morbidity. Recent reports show that patients admitted to hospital suffer cardiac arrests at a rate between 0.66 and 11.2 per 1000 admissions,1,2 and the approximately 80% mortality rate due to in-hospital cardiac arrests has not changed since the description of cardiopulmonary resuscitation more than 50 years ago.3,4 In this article, we review the epidemiology of in-hospital cardiac arrests and the evolution of the medical emergency team (MET) model to prevent them. In addition, we outline lessons learned from the MET model and the development of a national approach for recognising and responding to deteriorating patients. Finally, we contend that another paradigm shift is required to further improve patient outcomes via a more proactive and pre-emptive approach that includes improved detection and recognition of deterioration as well as structured management of patients who are at high risk of deterioration. The old paradigm: cardiac arrestWith introduction of cardiac arrest teams and Code Blue calls around 1970 came the first ubiquitous hospital protocol for escalating the care for deteriorating patients.3 This system is activated when a patient is pulseless and apnoeic, has no recordable blood pressure and is unresponsive. However, several studies published between 1990 and 2002 reported that in-hospital cardiac arrests were not sudden or unexpected, but were preceded by instability that was sub-optimally responded to.5-7 Up to 84% of patients had abnormal vital signs or new problems before cardiac arrest,5-7 and most were in asystole or had pulseless electrical activity.8,9 The current paradigm: METsIn 1995, the first description of the MET as a model for responding to patient deterioration was published.10 METs are composed of an intensive care, general medicine or emergency medicine registrar, and a critical care nurse. The advent of the MET delivered a mechanism for escalation of care earlier in the course of clinical deterioration than cardiac arrest. Criteria for a MET call are based on deranged vital signs and altered conscious state.10,11 A “staff member worried” criterion is often included to empower ward staff to call for assistance and bypass the traditional hierarchical model of escalation. Such criteria provide semi-objective thresholds for when ward staff should escalate care for deteriorating patients, and provide an expected and structured institutional response. The MET call is usually activated using a public announcement and pagers, and the team is expected to arrive within about 5 minutes. This system is the first patient-centred, organisation-wide system to be implemented across hospitals throughout the world. Over the past 16 years,10 METs have been introduced in at least 100 Australian hospitals.12 Although evidence of the effectiveness of METs is controversial,13,14 the MET model is currently the prevailing paradigm for identification of deteriorating ward patients and rapid escalation of care for them. Research into the characteristics and outcomes of MET patients has provided epidemiological data on deteriorating ward patients. In a MET-naive hospital, it was reported that 4.5% of ward patients fulfilled MET criteria on two separate days.15 Studies of mature METs report that 2.6%–5.6% of patients hospitalised for more than 24 hours receive MET review.16 Thus, about one in 25 ward patients will experience clinically significant deterioration. Research into MET patients has also shown that vital sign measurement is inconsistent and often incomplete, deterioration is variably recognised, and staff do not always activate a MET call when patients fulfil the criteria.17 In addition, activation is often delayed, and this is associated with increased mortality.18,19 Two surveys of ward nurses suggest that there is underappreciation of the significance of physiological derangements associated with MET criteria.20,21 A number of studies have reported that patients subject to MET review have a mortality rate of about 25%22-25 — higher than the 11% in-hospital mortality rate of patients admitted to intensive care units (ICUs),26 and much higher than the 2.5% in-hospital mortality rate for overall hospital admissions.27 Finally, about one-third of MET calls involve end-of-life care issues.24,25,28 These often occur out of hours, when parent teams are not in the hospital. As the patients are acutely unwell, they are often unable to participate in discussions regarding their preferences for active treatment, or conservative or palliative care. Accordingly, these decisions are typically left up to covering doctors, the MET and family members, and often need to be made expeditiously. A new paradigm: proactive, pre-emptiveThe MET model has emphasised the tenet that early intervention improves outcome (Box 1). Thus, the mortality of patients subject to MET review (25%) is lower than that of cardiac arrest patients (80%) but higher than that for patients admitted to ICUs. However, the MET model is reactive, as it requires a patient to deteriorate before it can be activated. We contend that a new paradigm is needed to promote a more proactive approach to recognising and responding to deterioration, and to provide a pre-emptive, structured, standardised approach to managing patients who are known to be at risk of deterioration (Box 2). This paradigm shift is supported by the National consensus statement: essential elements for recognising and responding to clinical deterioration,29 which describes the clinical systems necessary to provide appropriate care to deteriorating patients and the organisational supports needed to ensure that these systems operate effectively (Box 3). Predicting risk and preventing deteriorationNot all patients admitted to hospital will suffer a complication, but some will suffer sudden and unexpected deterioration. Increasing evidence suggests that patients can be risk profiled at, or even before, hospital admission. A hospital outcome predictive equation (HOPE) was recently developed using six variables that are associated with increased risk of death: age, sex, diagnosis at admission, emergency admission, aged care resident and inter-hospital transfer.27 In surgical patients, most postoperative complications are medical.30 It remains to be determined whether hospital-wide strategies or models of medical comanagement can improve patient outcomes based on such risk profiling. Similar criticisms were levelled at the MET model of care almost 10 years ago.31 Advance care planningAdvance care planning is particularly important in the context of the ageing Australian population, increasing numbers of comorbidities in hospitalised patients, and increasing complexity and intensity of medical therapies. Patients need to receive therapies that are beneficial to them, and do not cause significant harm or discomfort, and their wishes and choices regarding such care must be considered. Experience with the MET model suggests that many deteriorating patients receive suboptimal end-of-life care planning, and that this planning is done emergently by the MET. Advance care planning should be conducted when a patient is cognitively intact and able to contribute meaningfully to discussions, so that their preferences are known when deterioration is detected. In a recent trial, an advance care planning program improved the rate at which patients received preferred care, improved patient and family satisfaction, and did not increase patient mortality.32 Detecting and recognising early deteriorationImproved detection of deterioration requires tailoring of vital signs measurement to a level commensurate with a patient’s diagnosis, acuity, proposed treatments and change in status with time.29 In some patients, this may include the use of continuous automatic electronic monitoring systems that record observations and alert staff when trigger points are reached.33 Research shows marked variation in the quality and ease of use of vital sign charts.34 Enhanced design of observation charts has been associated with improved documentation of vital sign sets and recognition of deterioration.35 Improving management and follow-up of early deteriorationImproved training in the recognition of and response to early deterioration is needed. A multifaceted approach to this type of intervention — involving a newly designed observation chart, a track-and-trigger system and an education package — has been shown to be associated with increased MET activation, reduced unplanned ICU admission and reduced in-hospital mortality.36 Optimising the outcomes of MET patientsAs delayed MET activation worsens patient outcomes,18,19 research is needed to better understand the decision-making processes of ward staff with regard to escalating care for deteriorating patients. Specifically, it is important to understand the circumstances under which staff call their parent unit, as opposed to requesting external assistance. Auditing the clinical causes of MET calls may assist in the development of strategies to improve the outcomes of patients who fulfil MET criteria. The concept of “MET syndromes” has been raised,37 and it has been shown that sepsis, heart failure, pulmonary oedema and arrhythmias (especially atrial fibrillation) may be associated with about 50% of MET calls.38 Implementing checklists, guidelines or bundles of care for common causes of MET review may help to standardise management and improve outcomes of patients after a MET call has been activated. A simulation-based training course for MET members has been shown to be associated with improved team performance, but the effect of such training on MET patient outcomes has not yet been tested.39 ConclusionIn the 50 years since the components of cardiopulmonary resuscitation were described, outcomes of in-hospital cardiac arrest have changed little. The failure of cardiac arrest teams to substantially improve outcomes, in conjunction with research showing that cardiac arrests are often preceded by signs of deterioration, facilitated a paradigm shift to encourage detection and escalation of care before the onset of circulatory arrest. Although the effectiveness of the MET approach continues to be debated, METs have highlighted the need for even earlier detection and escalation of care for deteriorating patients. Another paradigm shift is now needed to improve prediction, detection and recognition of deterioration, and to optimise subsequent escalation of care. 1 Criteria for escalation of care and rates of mortality at various phases of patient deterioration Hospital inpatient27 Abnormal vital signs15 MET call22-25 Cardiac arrest1-4 Event rates (per 1000 admissions) — 138 10–50 0.66–11.2 Criteria for escalation Heart rate (beats/min) — ≤ 50 or > 120 < 40 or > 130 0 Systolic blood pressure (mmHg) — < 100 < 90 or > 200 0 Respiratory rate (breaths/min) — ≤ 10 or > 28 < 8 or > 35 0 Other — — Fall in conscious state or urine output Unresponsive In-hospital mortality rate 2.5% 14.6% Approx 25% Approx 80% 2 Phases of patient deterioration and strategies that may improve outcomes at each phase MET = medical emergency team. ICU = intensive care unit. 3 Essential elements for the care of deteriorating patients29 Clinical processes Measurement and recording of observations Escalation protocols Rapid response systems Communication processes Organisational prerequisites Organisational supports Education Evaluation and monitoring Use of new technology

Daryl A Jones FRACP, FCICM, MD · Nicola J Dunbar BSc(Hons), PhD, MPS · Rinaldo Bellomo FRACP, FCICM, MD

International innovations in health care may take considerable time to become widely disseminated into local Australian practice. Health systems throughout developed countries are being challenged to meet higher demand for access to hospital medical and emergency services. Patients of increasing medical and social complexity are presenting in ever greater numbers at a time of rising community expectations for safety, quality, value and timeliness of health care.

Harvey H Newnham MB BS, FRACP, PhD · Pieter De Villiers Smit MB, ChB, FACEM · Martin J Keogh GradDipCritCareNsg, GradDipManagement · Andrew M Stripp BBehavSc(Hons), MSc(ClinPsych) · Peter A Cameron MB BS, MD, FACEM

When “should not” becomes “must not” — how mandatory compliance with guidelines can threaten professional independence There is a proliferation of rules and red tape at all levels of society. In New South Wales, for example, the Department of Health has been generating around 70–100 policy directives a year. Among other things, such directives tell obstetricians when and how to deliver babies — compliance is mandatory, under threat of disciplinary action and loss of indemnity cover. One of the most prominent recent directives, PD2010_045 (Maternity — towards normal birth in NSW), requires a reduction in caesarean section rates to 20% by 2015,1 a target that is illusory and possibly dangerous. Others are worse. Policy directive PD2007_024 (Maternity — timing of elective or pre-labour caesarean section) states: The risk of respiratory morbidity is increased in babies born by caesarean section before labour, but this risk decreases after 39 completed weeks. Therefore elective or pre-labour caesarean section must not routinely be carried out before 39 completed weeks. These findings are supported by recent studies.2 This text is taken almost verbatim from a guideline of the National Institute for Health and Clinical Excellence (NICE) in the United Kingdom3 and, at the time, accorded with the relevant Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) guideline on the timing of elective caesarean section, the wording of which has since been softened slightly.4 However, there is one very substantial difference: the “should not” of NICE and RANZCOG became a “must not”. The NICE guideline was produced by a committee of 16 members, two of whom were obstetricians. Nicholas Fisk, then chairman of the Royal College of Obstetricians and Gynaecologists (RCOG) Scientific Advisory Committee, strongly criticised the outcome and stated that the committee “selectively interpreted” the facts to suit its case.5 Timing of elective caesarean delivery is a complex issue. There are factors (mainly related to pulmonary maturity) suggesting delay until 39 weeks’ gestation, and others (mainly related to unexplained stillbirth6,7) supporting the traditional timing between 38 weeks and 38 weeks and 6 days. A large randomised controlled trial (RCT) or a carefully conducted observational study employing propensity scoring would be required to provide a solid evidence base. For the moment it remains a matter of opinion, and RCOG, NICE and RANZCOG can, and should, express expert opinion and review the available evidence. Guideline committees and their products make an important contribution to improving clinical practice, and the voluntary work of countless individuals in this regard should not be denigrated. However, the situation may be altered completely once bureaucrats become involved. Changing the “should” of a College guideline to a “must” in a NSW Health policy directive has major implications. PD2007_024 effectively forbids doctors in NSW public hospitals to schedule routine elective caesarean section before 39 weeks. Anyone doing so risks disciplinary action and may forfeit their indemnity cover. PD2007_024 is not currently supported by high-level evidence, and even if there were solid data from a large RCT or a meta-analysis, it would be inappropriate to stipulate “mandatory compliance”. Evidence-based medicine has great potential to improve patient care, but it is a tool to inform clinicians, not an excuse to switch off one’s brain. As recently argued in the case of mesh use in pelvic reconstructive surgery,8 guidelines derived from a large RCT (or a valid meta-analysis of appropriate trials) are of limited use as a guide to the care of an individual patient if that patient is far off the trial sample mean in predictors of outcome. The Term Breech Trial9 is an excellent example. If there is a very high likelihood of an uncomplicated birth for an individual woman (eg, fast progress, small baby, previous normal births), a clinician may want to ignore the findings of the Term Breech Trial when deciding how to advise her. The process of starting with some initial information (probabilities of events of interest) and combining it with data related to an individual case or circumstance has been mathematically formalised by statisticians as “Bayesian updating”.10-13 Information from a clinical guideline, prevalence study or meta-analysis provides the “prior probability”, the data related to the individual case at hand are embodied in the “likelihood”, and the application of Bayes’ theorem13,14 gives the updated “posterior probability” on which a decisionmaker can act. This implies that even the best evidence in literature and guidelines can provide only prior probabilities. It is our job to adapt these to the clinical management of the individual patient, generating posterior probabilities that have been updated by the relevant particulars of the patient and processed by clinical intuition and common sense. However, in a trend that is encouraged by guidelines and policy directives, clinicians increasingly omit this updating process. Once a document — a seminal paper, a guideline, a policy directive — is published, it is likely to be interpreted cautiously (ie, as widely as possible) because of the litigious, risk-averse nature of our society. We do not particularise to the individual patient because our work environment strongly discourages doing so. Finally, even if a guideline is produced after an optimally diligent process and published so rapidly that it is up to date at its launch, it still freezes current best practice. Inevitably, today’s best practice will be obsolete tomorrow. Practice guidelines therefore have the potential to slow down progress, and unthinking adherence to such documents is unlikely to deliver the best outcomes to the greatest number of individuals. The expert system of our brains, employed in the assessment and treatment of the individual patient — and using relevant prior information from evidence-based sources — is a potentially superior tool when compared with the replication of a course of action outlined in a document issued by a government agency or professional body. It is time to reassert our professional independence.

Hans Peter Dietz MD, PhD, FRANZCOG · Barrie J Stokes BSc, MMath

The formula for reform works, but is the next review already overdue? In 2008, we reported our review of the Sydney University graduate medical program.1,2 When the program was introduced 11 years previously, it was innovative, with emphasis on helping students to solve problems and to think critically about what they were learning rather than to memorise lists of facts. In 2005, the Australian Medical Council (AMC) reviewed the program and awarded the maximum 10-year accreditation. However, the AMC also suggested a number of actions, including reviewing the role of problem-based learning (PBL) in the final 2 years of the course, reviewing some areas of assessment, providing a renewal process that allowed for flexibility and innovation within the defined outcomes, and reviewing the complex system of committee structures. We made 730 recommendations in our 2007 review, incorporating the AMC’s suggestions and covering the provision of an initial scaffolding on which students could build knowledge, increased anatomy teaching and the creation of clear learning objectives. We now report on the impact of that review. The major changes implemented after the review are shown in Box 1. Eighty-five per cent of the recommendations have been implemented. Another 5% are currently being implemented; 2% are no longer relevant; and 8% have not been implemented (Box 2). The implementation of 85% of the changes was due to three main factors: the inclusive nature of the review process; the commitment of the dean; and the team chosen to implement the changes through a newly created Office of Medical Education. The first 9 weeks of the course became a foundation block that provides a scaffolding of basic facts and concepts on which students can build future knowledge. The foundation block provides learning activities and additional tutorial groups specifically for students from non-science backgrounds who initially find the course difficult. An additional Chair of Anatomy with specific responsibility for teaching was created, and the amount of anatomy teaching in the first 2 years of the course was increased from 50 to 170 hours. An additional appointment of an academic surgeon jointly for Surgery and Anatomy has enabled the return of whole-body dissection as a student elective.3 These new appointments have ensured that anatomy is now taught throughout the course. Students now have electronic access to detailed learning objectives and a core curriculum with clear links to the teaching program for each week. They engage more with medical librarians, critically evaluating information sources, developing and refining search strategies and learning database construction. A student guide provides a direct link for quick location of key databases and basic science resource materials. While PBL remains a core component of the medical program, clinical reasoning sessions, which have more clinical emphasis than the traditional PBL tutorial,4 have replaced PBL tutorials in the final 2 years. The artificial distinction that existed between the two clinical years has been removed so they have become fully integrated. The amount and sophistication of assessment has been increased. In formative assessments, students are able to see their progress in relation to that of other students. Grading, which was not in the original graduate program, now occurs in the last 2 years. The criteria for awarding honours on graduation have become more rigorous, with a higher standard and an increased emphasis on academic supervision. Students interested in pursuing a career in research may also do a concurrent Master of Philosophy degree, which requires intensive immersion in research during holidays and the elective term. Heads of disciplines have become more involved in curriculum matters. Academic staff from disciplines that were previously not well integrated into the curriculum now meet regularly, contribute more to teaching and have become more collegiate. This has re-engaged clinicians and reinvigorated some disciplines that previously had less involvement in the curriculum. The introduction of new material has depended on the leadership given by champions who have taken on these new areas. This was particularly applicable with regard to helping students to understand and critically review complementary and alternative medicine, to develop an awareness of the spiritual dimensions of health for some patients and to better understand the problems of people with a disability. Medical humanities has been strengthened; and the creation of the position of Associate Dean, International Health increased students’ exposure to a range of global health issues. Recommendations regarding the importance of Indigenous health throughout the course have resulted in some Aboriginal health care delivery concepts being incorporated into the teaching of communication skills. Students are now encouraged to become more involved with Aboriginal medical services. Student numbers are increasing (Box 3). The total number of students increased from 261 in 2007, to 299 in 2011, with international fee-paying students increasing from 34 to 66. Federal government funding arrangements have created the need for medical schools to take more international fee-paying students. However, a balance has to be struck between this need and the essential requirement to provide a high-quality program with good support and tutorial groups of an effective size. A medical curriculum cannot guarantee effective student learning and satisfaction if numbers increase without a commensurate increase in academic staff, support staff and upgraded facilities on campus and in clinical schools. This issue is not unique to Sydney Medical School. Medical student teaching is intensive, with emphasis on small group tutorials, one-to-one teaching and role modelling. Teaching cannot be separated from research, as research informs much of the teaching. However, adequate resources must be put into teaching so that it is supported just as research is supported. Areas in which changes to the University of Sydney graduate medical program still need to be made are shown in Box 4. Leadership is essential for creating and sustaining changes. Academic leadership has been a key factor in the implementation of the majority of changes recommended in this curriculum review. The leadership of the dean, the academic course coordinators and the associate deans of the clinical schools has been crucial in implementing the changes so far. The dean should be clearly in charge of the curriculum and the curriculum should be one of his or her obvious priorities. While day-to-day curriculum management is delegated, regular meetings between the dean and academic course coordinators to discuss key issues, rather than curriculum detail, are important. Where innovative recommendations have been implemented, there has been a clearly designated and committed leader for the new area. In some cases these leaders were recognised in advance, while in other cases leadership arose spontaneously. In contrast, recommendations that were not successfully implemented did not have a champion identified. Before introducing change to a medical curriculum, there should be wide consultation with students, faculty members, other teachers, professional bodies and community groups.5 In our experience, wide consultation with faculty members, listening to and incorporating their suggestions and giving them some responsibility for implementation effectively re-engaged them and were the crucial factors in successfully changing the curriculum. While the importance of factors such as leadership and wide consultation may seem obvious, we need to acknowledge their essential contribution to effective, sustained change. Attempts to change a medical curriculum without leadership at the highest level, identification of leaders for specific roles and wide, regular and frequent consultation are likely to be doomed to failure. It became clear when reviewing the curriculum in 2007 that 11 years is too long to wait. A medical curriculum is dynamic and needs to respond to changes in medicine, health regulations, educational thinking and society. More frequent review would ensure that the curriculum remains relevant and plays an integral part in shaping the future leaders in medical care. Medical education and health care delivery are not static, which is why curriculum revision must be a continuous process of renewal and response to change. 1 Key changes implemented after the 2007 review Simplified and strengthened governance Revised first 9-week foundation block Developed core curriculum with clear learning outcomes Increased basic science teaching Trebled anatomy teaching hours Increased written and clinical assessments Introduced grading in final 2 years Upgraded honours requirements Created more research opportunities Created optional concurrent MPhil degree Increased use of IT for teaching and assessment Added new areas to curriculum Increased emphasis on critical care and surgery teaching 2 Why some recommendations were not implemented Lack of funding Increased student numbers Difficulty in recruiting teachers Lack of effective collaboration with outside bodies 3 Local and overseas students admitted to Sydney Medical School, 2007–2011 No. of students Year Local International Total 2007 227 34 261 2008 226 36 262 2009 247 46 293 2010 222 53 275 2011 233 66 299 4 Areas of the University of Sydney graduate medical program still in need of change Refugee health Aboriginal health Equipping students for leadership Clinical teaching on ambulant and standardised patients Interprofessional learning Greater ownership by clinical teachers More involvement by recent graduates

Kerry J Goulston MD, FRACP · R Kim Oates MD, DSc, FRACP

To the Editor: By his deployment of ad hominem arguments, outdated or industry-sponsored research, comparison to an unrelated phenomenon, and a biased selection of case studies and research reports, I fear the pro-wind-industry opinions expressed by Chapman will only serve to exacerbate the psychogenic and sociogenic processes he laments.

Daniel Shepherd

To the Editor: I would like to add my perspective, after nearly 50 years of experience in Australian medicine, to the very welcome articles by Moynihan1 and Webber.2 A few months after Medibank (Mark I) was launched in 1975, a colleague and I wrote a satirical article called “How to rob Medibank blind”.3 We deliberately wrote this article anonymously, so that it could be judged on its merits, and not by its authors. It was picked up by the Sydney Sunday Telegraph and featured across its middle pages. The responses of the then Minister for Health, Ralph Hunt, and Australian Medical Association (AMA) president, Lionel Wilson, were, to paraphrase their words, “doctors are not like that!” This view was shared by Medibank architect, economist John Deeble, when I asked, 20 years later, why he and his co-architect Richard Scotton had designed “a mechanism with an accelerator pedal but no brakes”. They had, he said, not thought it necessary. Around that time, on behalf of the AMA, I advised on the restructuring of the Professional Services Review (PSR). I had been fortunate, meanwhile, to have chaired Professional Standards Committees of the New South Wales Medical Board, and to have sat on the bench of the NSW District Court Medical Tribunal, looking at alleged poor professional conduct. This opened my eyes to the small number of doctors whose standards were poor overall, and led to the Board’s performance assessment program. Many had also been investigated by Medibank or Medicare. Instead of having the PSR chasing illusionary and indefinable “over-servicing” by general practitioners (curiously, specialists were almost never investigated), I suggested peer review, whereby trustworthy, practising GPs or relevant specialists could advise on whether or not a doctor’s pattern of practice was inappropriate. This could be judged on an overall view of their work, much as was being done in the NSW Board’s Performance Program. Another decade later, as Chairman of the Doctors Health Fund (then the AMA Health Fund), I attended a small dinner in Melbourne with the chairmen of a few restricted membership funds and the then Minister for Health, Tony Abbott, who asked me to sit next to him. I asked pointedly how he could justify commercial corporations’ continuing to make profits for their shareholders out of Medicare benefits which were supposed to reflect the value of a doctor’s professional services. How could there be so much fat in the system that these corporations could cream off their substantial profits? His disappointing response was that it was too difficult to do anything about it. Webber is correct — both sides of politics are to blame.

Peter C Arnold

To the Editor: An ethical concern that was raised by Conway in his article supporting the freedom to practise in accordance with conscience1 related to the problems that arise when patients — specifically children — are unable to express a considered opinion on any conflict between their clinicians and their legal guardians about their best interests. Parents know their child best, are responsible for continuing care of the patient (including during any adverse effects of treatments) as well as of any other dependants. However, they may also be guided more by strongly held beliefs than by the views of clinicians on the best interests of their child. The law gives parents considerable rights and obligations to make decisions in the best interests of their children, but the law also recognises that children have rights, independent of the parents. When children are able to form and express opinions, these are considered; when they can’t, they are dependent on others to promote their interests. Within this legal framework of competing rights, the solution can only be a legal one, as occurred with the patient in Conway’s example.1 Clinicians have to be prepared to go to court to put their case for the best interests of the child, and then accept the legal decision with good grace, however personally distressing. This is just another example in medicine of the need for all to work with less than desirable outcomes. And one must always remember that not complying with a court order is an option — with consequences — that may seem ethically justifiable to a clinician or parent.

William R Adam

To the Editor: In a recent Opposing Views article, Conway claims that doctors should be able to practise according to their personal values,1 but the argument he uses is not persuasive. The ethical dilemma in the case is not characterised correctly. Autonomous choices can be made while treatment options, based on scientific knowledge, are available. If there are no medical options to improve the outcome — if we are at the very limits of medicine — there is no duty to provide anything other than palliation. In other words, the “do no harm” principle takes precedence over the duty to treat the patient according to his or her needs. Under these circumstances, refusing to “treat” is to practise with medical knowledge and the comfort of the patient (in Conway’s example, a child) in mind, regardless of the parents’ wishes. There is no ethical dilemma in that sense. In fact, the dilemma doctors have is not clinical, but a professional one created by the court order compelling doctors to continue futile treatment, causing unnecessary discomfort that obviously conflicts with the “do no harm” principle. Hence, Conway’s case does not support his argument. In addition, his argument may lead to the violation of patient wellbeing and of professional values. The moral problem related to defining a space for personal values in medical care is that they may conflict with professional values, legitimising discrimination. Then it would be nearly impossible to criticise doctors and institutions that refuse abortion, do not examine patients of the opposite sex on religious grounds, and refuse to operate on HIV-positive patients or to treat people with different political affiliations. It would be hard to call that kind of environment a “healthy diversity”. As well as defending the right to health, we should protect the professional value of non-discrimination to preserve trust between medicine and society. In fact, in order to “safeguard against abuses of power, error and exploitation in medicine”,1 we have already established universal professional codes, instead of leaving the stage to the relativity of personal values.

Murat Civaner

To the Editor: In his Opposing Views article, Travis claims that fee- for-service (FFS) “provides the best transparency, accountability and incentive for everyone”.1 However, FFS models reward volume and intensity, rather than quality of outcomes. Evidence suggests that FFS results in increased numbers of patient visits, investigations and procedures,2 which contribute to inflation in the cost of health care.3 Further, an FFS model is “transparent” only on a most superficial level, because doctors are paid for the number of items they deliver. What matters most is transparency about whether the care being delivered to patients is in those patients’ best interests. Patients do not have the same grasp of technical information as their doctors. They assume, with justification, that most doctors perform their clinical practice not primarily to serve their own incomes, but patients’ best interests. Regardless, it is undeniable that the reward structure associated with an FFS system provides powerful incentives for delivering more services, with clinicians subsequently inducing increased demand for medical services.4 On the other hand, the problem with purely salaried providers is that they are more likely to underservice their patients, with an increase in the length and a decrease in the number of consultations.2 Clearly, neither of these payment systems is optimal for driving quality or efficiency in resource use. The ideal outcome from health care reform would be one in which the focus is on delivering high-quality, efficient care to patients, rather than high-quantity care. In designing the optimal payment structure, the aim should be to align the incentive with the quality and appropriateness of the care that is delivered — to reward doctors for their efforts to provide good health outcomes for patients.3 Our current health system provides much lower rewards for the doctors who practise much of our preventive care (general practitioners and physicians) than it does for procedural specialists. This may not be the most cost-effective strategy, and part of the debate about how doctors are paid should be directed at this imbalance. There has been experimentation with “capitation combined with pay-for-performance” or “shared savings” models, which are promising attempts to find the best balance of incentives for cost control and quality improvement.5

Matthew H R Anstey · Stephen P Gildfind

To the Editor: In 2009, we calculated that an estimated 50 405 prison inmate separations occurred in Australia in the 2007–08 financial year,1 and argued that the significant mortality risks associated with release from custody necessitated accurate and routine dissemination of such information. We believe this is still required, and that reporting the most current estimate of inmate separations may help facilitate better through-care and post-release health service provision. Our previous estimates have been used to contextualise discussions of prisoner health,2 estimate the number of post-release deaths,3 and advocate for needle and syringe programs in Australian prisons.4 Consistent with the approach detailed elsewhere,5 we estimated the number of inmate separation episodes occurring in Australia for the financial year 2008–09, using benchmark data from public documents on the website of each state and territory government department responsible for prisons. We attempted to obtain the total (ie, sentenced and on remand) number of inmates released from prison in 2008–09. This figure was available for Victoria (5458), South Australia (4489) and the Northern Territory (3078). For New South Wales, data could only be obtained for separations of sentenced prisoners (8941). To adjust for separations of prisoners on remand in NSW, we assumed that separations of sentenced prisoners comprised 38% of all separations, reflecting the ratios of separations in other jurisdictions. Hence, the total estimated number of separations in NSW was 21 468. Adding this to the other three figures gave a total of 34 493 separations in four jurisdictions that collectively hold 63% of the national prisoner population. A multiplier of 1.59 (1/0.63) was applied to this figure to produce a national estimate of 54 751 prison separations in 2008–09, each of which is associated with a significant increase in risk of death. Our estimate represents an 8.6% increase on the estimate from the previous financial year. This substantial increase suggests that routine reporting of actual incidents of separation, as well as numbers of unique individuals released from prison, remains vital to the provision of adequately scoped and resourced post-release health and welfare services in Australia.

Kristy A Martire · Sarah Larney

To the Editor: Significant mortality and morbidity occur among pedestrians involved in road traffic incidents.1 The National Road Safety Strategy 2001–20102 aimed to achieve a 40% decrease in pedestrian fatalities in Australia through road safety measures, including urban speed limit reductions. To assess the impact of such measures, we examined the long-term mortality trend in pedestrians presenting to an inner Sydney major trauma centre and determined whether incident location was a predictor of major trauma (defined as in-hospital mortality, intensive care unit admission and/or Injury Severity Score > 15). We identified 1944 trauma registry records of adult patients admitted to Royal Prince Alfred Hospital between 1992 and 2010 as the result of a pedestrian incident within the hospital’s catchment area, excluding transfers from other facilities (Box 1). Incident locations noted on clinical and ambulance records were classified as city or suburban according to current City of Sydney local government area boundaries. Population data were obtained from the Australian Bureau of Statistics. From 1992–1994 to 2007–2009 (population data for 2010 were unavailable at time of analysis), the age-adjusted mortality rate fell from 6.25 to 2.31 per 100 000 population (Box 2), a relative decrease of 63% (incidence rate ratio [IRR], 0.94; 95% CI, 0.91–0.98; P = 0.003). Negative binomial regression analysis showed that the reduction in mortality was statistically significant for incidents in the city (IRR, 0.91; 95% CI, 0.86–0.96; P = 0.01) but not suburban areas (IRR, 0.96; 95% CI, 0.92–1.00; P = 0.09). Multivariable logistic regression showed the odds of major trauma were 70% higher for suburban incidents than city incidents after adjusting for age, sex and time of presentation (after hours and weekends) (adjusted odds ratio, 1.7; 95% CI, 1.1–2.6; P = 0.02). The decrease in pedestrian mortality appeared most prominent after 2003, around the time the urban speed limit was reduced from 60 km/h to 50 km/h, and to 30–40 km/h in areas with high pedestrian activity.3 The 10 km/h speed limit reduction alone is estimated to have resulted in a 6% decrease in pedestrian fatalities.4 However, the trend appears to be limited to city incidents, with an annual reduction of 10% in the city versus 3% in suburban areas (Box 1). The observed improvement in outcomes, particularly in the City of Sydney, is likely a result of speed-limit reductions, drink-driving laws and improvements in clinical care. However, more needs to be done to protect pedestrians in suburban areas. 1 Baseline characteristics and outcomes of pedestrian incidents City (n = 883) Suburban (n = 1061) P Male 561 (47%) 625 (53%) 0.04 Median age (IQR) 34 (24–53) 46 (29–67) < 0.001 Median ISS (IQR) 4 (2–9) 5 (4–17) < 0.001 ICU admission 124 (11%) 241 (19%) < 0.001 Median hospital length of stay, days (IQR) 3 (1–9) 5 (1–13) < 0.001 Major trauma* 175 (20%) 336 (32%) < 0.001 Deaths 32 (4%) 76 (7%) 0.001 Crude mortality rate (95% CI)† 1992–1994 2.1 (− 0.4, 4.7) 1.5 (− 0.03, 3.0) 1995–1997 1.2 (− 0.6, 3.0) 2.3 (0.4, 4.4) 1998–2000 0.9 (− 0.6, 2.4) 2.0 (0.2, 3.8) 2001–2003 1.6 (− 0.3, 3.6) 1.5 (− 0.03, 2.9) 2004–2006 0.3 (− 0.5, 1.2) 1.3 (− 0.09, 2.7) 2007–2009 0.3 (− 0.5, 1.2) 0.9 (− 0.2, 2.0) Annual change over 18 years‡ − 10% − 3% IQR = interquartile range. ISS = Injury Severity Score. ICU = intensive care unit. * ISS > 15, requiring ICU admission, and/or death. † Rate per 100 000 population among adult pedestrians averaged over 3-year periods. ‡ Calculated using the formula: change (%) = (P1/P01/n − 1) × 100 where n is number of years observed − 1, P1 is the final average rate and P0 is the initial average rate. 2 Age-adjusted mortality rate per 100 000 population for adult pedestrians, 1992–2009* * Age standardised to Australian Bureau of Statistics 2006 census data (bars represent 95% confidence intervals).

Matthew Oliver · Michael M Dinh · Susan Roncal · Soufiane Boufous · Bernardino Branco · Christopher M Byrne

To the Editor: Tenofovir disoproxil fumarate is a nucleotide analogue reverse transcriptase inhibitor that is used in Australia as first-line antiviral treatment for HIV infection.1,2 Tenofovir may be nephrotoxic, particularly affecting proximal tubular function.3 We report a case of tenofovir-associated Fanconi syndrome, which demonstrates the need for vigilance in patients taking tenofovir. A 17-year-old rurally residing boy with perinatally acquired HIV infection presented to a tertiary referral hospital with renal impairment. His serum creatinine level had been normal 4 years previously. He had had severe leg pain and weakness for over a year, and was unable to mobilise without a walking frame. Because of his illness, he had stopped studying. He had commenced antiretroviral therapy in 1996, when he was 3 years old, and at presentation was taking tenofovir plus emtricitabine and lopinavir plus ritonavir. Follow-up with his local clinician was intermittent. The patient’s HIV viral load was undetectable, and he had a CD4 count of 0.62 × 109 cells/L. His serum creatinine level was 150 μmol/L (reference interval, 60–110 μmol/L) and his estimated glomerular filtration rate (eGFR) was 52 mL/min/1.73 m2 (normal value, > 90 mL/min/1.73 m2). He had all the features of Fanconi syndrome — hypophosphataemia with renal phosphate wasting, glycosuria, aminoaciduria, a reduced serum uric acid level and proteinuria (1.93 g/day). He also had hypokalaemia and acidosis, and his urine tested positive for β2-microglobulin. Histological analysis of a renal biopsy specimen showed proximal tubular abnormalities (Box). In addition, he had severely reduced bone mineral density, elevated bone turnover markers and vitamin D deficiency. The patient’s tenofovir therapy was ceased, he was started on an alternative antiretroviral regimen, and he was given phosphate, potassium, bicarbonate and calcium supplementation plus vitamin D and calcitriol therapy. Two months later, his serum creatinine level was 130 μmol/L, his eGFR was > 60 mL/min/1.73 m2, and his proteinuria, glycosuria and aminoaciduria had resolved. His leg pain and weakness resolved within another month. He has since been able to recommence full-time study. The persistent biochemical and renal abnormalities in this patient may have been a result of delayed recognition of Fanconi syndrome leading to prolonged illness. Risk factors for tenofovir-associated nephrotoxicity include a GFR of less than 90 mL/min/1.73 m2, use of nephrotoxic medications, comorbidities (eg, diabetes and hypertension) and use of some protease inhibitors. Patients on tenofovir should be screened at least 6-monthly for eGFR, serum phosphate levels, proteinuria and glycosuria.4 Three-monthly testing is also suggested in the initial year, due to the occurrence of tenofovir-associated nephrotoxicity without risk factors.5 Urinary protein to creatinine ratio is usually increased in tenofovir-associated nephrotoxicity, and tests for some urinary proteins may be useful in subtle cases of the condition.3 Testing for albuminuria (a marker of glomerular disease) and sole reliance on eGFR are insufficient for detecting tenofovir-associated tubular dysfunction.3 Due to potential renal toxicity, optimal outcomes for patients on tenofovir require careful monitoring of patients and close liaison between treating practitioners. Renal biopsy specimens showing proximal tubular abnormalities in a patient with tenofovir-associated Fanconi syndrome A: Prominent changes of acute tubular necrosis (haematoxylin and eosin stain; original magnification, × 4). B: Acute tubular necrosis with proximal tubular eosinophillic inclusions (arrows) representing giant mitochondria visible by light microscopy (haematoxylin and eosin stain; original magnification, × 10).

David M Gracey · Mangalee Fernando · John Ziegler · Christopher P White · Jeffrey J Post

To the Editor: Participation by patients in cancer clinical trials is low. Doctors’ reluctance to participate in clinical trials has been reported as a key barrier to recruitment.1 The Physician Orientation Profile (POP) examines doctors’ attitudes to and behaviour regarding randomised clinical trials.2 In the context of a 2010 cluster-randomised trial to assess the impact of a consumer-friendly cancer clinical trials website (http://www.australiancancertrials .gov.au), we asked medical oncologists to complete the POP and identify barriers they faced when recruiting patients to trials. The option of providing a comment on barriers identified was included. The sociodemographic characteristics of the 28 medical oncologists who participated in the trial and the barriers to recruitment reported are shown in the Box. Twenty-one doctors reported that they faced barriers when recruiting patients to clinical trials. The most common barriers identified included poor organisational infrastructure, insufficient time, slow and bureaucratic ethics approval processes, and lack of staff (medical oncologists and clinical trials coordinators). This was associated with the feeling that it is too hard to do trials. However, in contrast to studies reported during the 1990s in the United States and the United Kingdom,1,2 we found that doctors were strongly supportive of clinical trials. A high proportion gave answers consistent with the attitudes of “researchers” (practice guided by published data) rather than “clinicians” (practice guided by clinical experience). For example, if there was uncertainty about treatment, most saw this as an opportunity to do a randomised trial (26 of 28), and most believed that clinical trials were central to a medical oncologist’s practice (24 of 28). We acknowledge our small sample size and the likelihood of selection bias. However, the doctors in our study were experienced in recruiting patients to clinical trials and had firsthand knowledge of barriers to recruitment in the Australian medical system. Our findings suggest that, rather than negative attitudes of doctors, issues regarding organisational infrastructure, staffing, time and ethics approval processes are now significant barriers to recruitment of patients to cancer clinical trials. The participating doctors’ comments about the challenges of ethics and governance processes are consistent with recent publications which highlight that multisite studies are under threat because of onerous ethics review and regulatory requirements.3,4 These issues are also addressed in the first rec-ommendation of the Australian Government’s Clinical Trials Action Group report, which is “to improve the timeliness of ethics and research governance review”.5 Our results support the importance of this recommendation. Australian medical oncologists’ sociodemographic characteristics and barriers to recruiting patients to trials (n = 28), 2010 Number* Sociodemographic characteristics Mean age (years) 48 Men 20 Location New South Wales 17 Victoria 11 Practice type Mostly salaried 10 Mostly fee-for-service 9 About equal 9 Barriers to recruitment One or more barriers 21 Poor organisational infrastructure (eg, “Lack of support to employ clinical trials staff”) 11 Lack of time 9 Lack of access to clinical trials due to geographic isolation 8 Difficulty identifying eligible patients 4 Trials competing for the same patients 2 Lack of awareness about ongoing trials 2 Preference for a particular treatment arm 0 Other† 11 No barriers 7 * Data are numbers unless otherwise indicated. † Examples of comments provided for other barriers: “Hopeless, slow ethics in NSW — central ethics has not helped. Average time to get trials going exceeds average working life of trials coordinators!! It is TOO HARD to do trials. The logistics and lack of infrastructure is a major barrier” “Bureaucratic ethics and governance requirements” “Profound delays in ethics approval” “Lack of resources and man power to put more clinical trials in our treatment centre. Sometimes forgetting about ongoing trials if I am not the principal investigator and sometimes not aware of ongoing trials outside our centre” “Lack of additional medical oncologists” “Insufficient clinical trials coordinators — constant overload of staff means we have to keep halving study accrual”

Rachel F Dear · Alexandra L Barratt · Martin H N Tattersall

To the Editor: I am disappointed by Williams and colleagues’ blinkered view on “conflict of interest”.1 Their focus is solely on that of influence by profit-making medical supplies companies, often loosely referred to as “big pharma”. However, many careers are made and lost by government-influenced appointments and funding. The careers of some doctors in government-funded positions may hinge on whether they support the health department stance on a particular guideline. Rarely have I seen a future promotion, government research funding, committee appointment or professorial sinecure listed as a conflict of interest. This, I believe, is the real elephant in the room.

Peter J McLaren

Most older people with memory loss do not have dementia. Those with mild cognitive impairment are at increased risk of progressing to dementia, but no tests have been shown to enhance the accuracy of assessing this risk.

Leon A Flicker MB BS, PhD, FRACP · Andrew H Ford MB ChB, FRANZCP · Christopher D Beer MB BS, PhD, FRACP · Osvaldo P Almeida MD, PhD, FRANZCP

Objective: To assemble what is known about the mental health of Indigenous Australians from community surveys.

Anthony F Jorm PhD, DSc · Sarah J Bourchier BPsych(Hons) · Stefan Cvetkovski MPH · Gavin Stewart BSc(Hons)

Objective: To assess whether emergency department (ED) overcrowding was reduced after the introduction of the 4-hour rule in Western Australia and whether any changes in overcrowding were associated with significant changes in patient mortality rates.

Gary C Geelhoed FRACP, FACEM, MD · Nicholas H de Klerk BSc, MSc, PhD

The first report on the 4-hour rule needs fleshing out.

Drew B Richardson MB BS(Hons), FACEM, GradCertHE

Do demographic changes alone explain our busy EDs?

Judy A Lowthian MPH, BAppSc(SpPath), LMusA · Andrea J Curtis BSc(Hons), PhD · Damien J Jolley MSc(Epidemiology), MSc, AStat · Johannes U Stoelwinder MD, FRACMA, FACHSE · John J McNeil PhD, FRACP, FAFPHM · Peter A Cameron MBBS, MD, FACEM

Substance misuse and intellectual disability take their toll.

Ernest M Hunter FRANZCP · Bruce D Gynther FRANZCP · Carrick J Anderson MB BS · Leigh-ann L Onnis GradDipPH · Jeffrey R Nelson PhD · Wayne Hall PhD · Bernhard T Baune PhD, MD, FRANZCP · Aaron R Groves FRANZCP

Build youth-centric services and they will come.

Elizabeth M Scott BSc(Hons), MB BS, FRANZCP · Daniel F Hermens BSc, GDipSci, PhD · Nicholas Glozier MB BS, FRANZCP, PhD · Sharon L Naismith MCN, DCN, CCN · Adam J Guastella PhD · Ian B Hickie MD, FRANZCP, AM

Why doctors and writers are on the same page.

Dawn Barker MB ChB, FRANZCP

Anthony Leong was born in Singapore in 1945 and graduated from the University of Malaya in 1969. He pursued postgraduate training in America, where he completed his pathology residency at the University of Washington, Seattle, between 1971 and 1973. In 1976, he migrated to Adelaide to continue his work in lymphoma and tissue processing, especially tissue staining and immunohistochemistry. He excelled in research and, in 1980, received a doctorate in medicine from the University of Adelaide, where he was Clinical Professor of Pathology from 1981 until 1996. From 1996, he dedicated most of his effort and time to the Asia–Pacific region, where he held a number of leading posts including Professor of Anatomical and Cellular Pathology at the Chinese University of Hong Kong and Honorary Professor of Pathology at the Post Graduate Medical Institute, Beijing. From 1999, Anthony was Professor of Anatomical Pathology at the University of Newcastle and Medical Director of the Hunter Area Pathology Service. He was a Fellow of the colleges of pathologists of Australasia, the United Kingdom and America, as well as an honorary Fellow of the Hong Kong and Thai colleges. He served as President of the International Academy of Pathology, Australasian Division in 1995–1996 and was the foundation President of the Asia–Pacific Society for Molecular Immunohistology in 2005–2006. He was also a founding member of the Society of Applied Immunohistochemistry and the International Society for Analytical and Molecular Morphology. Anthony’s most influential footprint was in the field of immunohistochemistry, where he left a great legacy of excellence in research and an unsurpassed love of pathology. He was a prolific author of over 370 original papers, reviews and book chapters, and more than 23 textbooks and monographs. He was a great teacher, a wise mentor and a wonderful leader, who was full of humour and interesting anecdotes. His favourite pastime was golf, and he was a proud member of the “four amigos” golf team at his local club. However, it is fair to say that his golfing never matched the dizzying heights of his academic record! Anthony passed away in late June 2011 after a short battle with cancer. He is survived by his wife Wendy and two children Trishe and Joel, both pathologists.

Huy A Tran · Glen E M Reeves · Frederick W Hetherington

Walter Lowen was born in Vienna on 10 March 1916 and spent his childhood in Lwow, Poland. A national junior table tennis champion, Walter contributed to Poland’s bronze medal at the Swaythling Cup world championships in London in 1935. Religious persecution in Europe spurred his migration to Australia in July 1939, a few months before he was due to complete his medical degree at the University of Lwow. In 1940, Walter was accepted into medicine at the University of Melbourne and, in 1941, he married Sima, whom he had met en route to Australia. Walter still pursued table tennis, winning the Australian singles title in 1948 as well as many state singles titles. In 2000, he was inducted into the Table Tennis Victoria Hall of Fame. Walter graduated in 1945 and undertook his residency at Launceston General Hospital. In 1948, he returned to Melbourne, where he practised as a general practitioner in Reservoir and Ashburton. In 1958, he moved to The Alfred Hospital, Melbourne, where he trained in radiology and, in 1961, he gained Fellowship of the Royal Australasian College of Radiologists. He then developed his diagnostic expertise at the Melbourne Radiology Clinic in female infertility, obstetrics, and thoracic and renal radiology. During this time, he published papers on medullary sponge kidney disease, cavitating pulmonary metastases and radionuclide placental localisation. Walter’s obstetric and gynaecological imaging expertise led to his appointment as Director of Radiology at Royal Women’s Hospital, Melbourne, between 1962 and 1975. From 1976 until his retirement in 1994, he continued sessional work at Royal Southern Memorial Hospital, Bairnsdale Regional Hospital and Preston and Northcote Community Hospital. After he retired from medicine, Walter concentrated on his family and competitive bridge. As a Grand Master, he helped Victoria win the open teams event at the Australian National Bridge Championships in 1972. Walter remained intellectually sharp until he died peacefully, aged 94, in Melbourne on 11 January 2011, survived by Sima and their three children Richard, Mark and Norma. Walter was inspirational and generous to many, and is remembered with affection as a gentle giant.

Richard J Lowen · Mark Lowen · Norma Gilbert

Whiplash: evidence base for clinical practice. Michele Sterling, Justin Kenardy. Sydney: Elsevier 2011 (xv + 197 pp, $77.25). ISBN 9780729639463. WHIPLASH is a controversial, but widely accepted, “diagnostic” term that describes a putative causal mechanism for a constellation of symptoms that are generally not underpinned by recognisable pathology. This reference book has the stated aim: “to bring together current knowledge of the whiplash condition that will allow all stakeholders involved in the management of patients with whiplash, from clinicians to policy makers, to gain greater understanding of this condition”. Whiplash research is important, as up to 50% of people with this condition do not recover fully and up to 30% remain moderately to severely disabled. The editors of this book, Michele Sterling (associate professor of physiotherapy) and Justin Kenardy (professor of psychology), are both from the University of Queensland, and have both made significant contributions to the university’s Centre of Clinical Research Excellence in Spinal Pain, Injury and Health. They are well positioned, therefore, to comment on contemporary work in their fields, particularly as considerable research concerning whiplash arises from their institution. They have also attracted contributors from a spectrum of disciplines including neurosurgery, psychology, physiotherapy, rehabilitation, epidemiology, engineering, economics and law. The book comprehensively elucidates contemporary research, particularly in the fields of physiotherapy and psychology. However, as it observes, there is little or no evidence to guide the clinician who is managing the whiplash patient. There is virtually no evidence that confirms a link between symptoms and pathology, and there is also very little established evidence-based management. The chapters on law, compensation and insurance are worthwhile reading for medical practitioners involved in the medicolegal aspects of whiplash. A series of case studies is also included. The book is recommended for scientists involved in physical and psychological rehabilitation research into whiplash. It confirms the paucity of evidence related to the whiplash construct. However, it does not assist the clinician who is interested in providing evidence-based whiplash management.

David G Vivian

The integrated medical curriculum . Raja C Bandaranayake. London: Radcliff Publishing, 2011 (xvii + 128 pp, $43.50). ISBN 9781846195105. THIS MAY BE a timely addition to medical school bookshelves, as so many new medical schools are engaged in curriculum development. Written by a respected Australian medical educator, the book promotes an integrated approach, and then attempts a comprehensive coverage of issues concerning design, implementation, assessment and evaluation, and blending theory with practice. The strength of the book lies in the international experience of the author who has, among other things, worked as a senior academic at the University of New South Wales in Sydney and the Arabian Gulf University in Bahrain. The final two chapters are the most valuable, where this experience is used to describe common pitfalls, and four case studies highlight the lessons learned from well intentioned, but not always successful, attempts to redesign a medical curriculum. However, the case studies are not analysed in great depth and appear almost as a postscript. It may have been better, as in a problem-based curriculum, to present case studies as the lead-in to each chapter, with the analysis combining theory and practice to demonstrate lessons learned about integration. Other strengths of the book are: the commentary on integrated vs integrating curricula, a perceptive issue (Chapter 1); the brief but accessible history of curriculum integration (Chapter 2); the discussion on the advantages and disadvantages of integration (Chapter 5); and the list of evaluation questions to consider (Chapter 7). The major weakness of the book is the relatively scant presentation of a theoretical basis for integration, and methods for achieving, assessing and evaluating integrated learning. Some recent research literature is also not cited, particularly in integrated and workplace-based assessment and evaluation methods. Further, little is said about qualitative evaluation, which may be the stronger approach to exploring how learners perceive and gain from different curriculum approaches. The material is probably of more value to less experienced educators, who should be able to follow the links to the literature and expand their reading. I would suggest that readers work backwards from the final two chapters to the earlier discussions of emerging issues.

Richard B Hays

The human face is like no other part of the anatomy. It presides over some vital biological functions like eating and breathing, but it is also home to that other human essential — the personality...

Amanda Bryan

I enjoy the challenge and variety in oral and maxillofacial surgery. Treatment involving the facial and jaw region is functionally important and highly visual. Our specialty can make significant facial changes, to provide dramatic and sometimes life-changing improvements. We also have something unique in medicine; an understanding of the worlds of medicine, surgery and dentistry...

Amanda Bryan

Where do you want your personal and professional life to be in 2 years? Or in 5 years? And how are you going to get there? Many doctors aspire to a bigger and better practice, financial security and more time for themselves. Yet, they don’t have a business plan to help them achieve those goals...

Kath

Professor Michael Levy’s interest in the health of prisoners was sparked the very first time he visited a prison, when he was a board member of the then NSW Corrections Health Service in 1994. “From the first moment that I got engaged in this issue through a committee prison visit, there was just something that lit up in me”, he says...

Sophie McNamara

Why did you decide to train in this specialty? When I initially studied medicine I was planning to specialise in surgery but I discovered that I particularly liked working on the head and neck, and cranial and facial area, and maxillofacial surgery offered me a unique opportunity to work in just that region. I also liked the fact that the work is not monotonous — it ranges from minor oral surgery to quite extensive maxillofacial procedures. What do you like most about your training so far? This specialty offers a unique opportunity to train and work across two different disciplines: medicine and dentistry. The training has been well structured and the consultant-led teaching approach in theatre was excellent. The training is also consistent between New Zealand and Australia, which has allowed me to travel between the two countries during my training. What do you dislike or find challenging? As part of the training I had to complete a second professional degree. In my case, my second degree was in dentistry and while I was studying I was not getting paid, so financially it was a big struggle compared to other surgical specialties. While completing the three extra unpaid years at university, I worked as a locum doctor. What’s next? I plan to move to Melbourne to do a fellowship year at the Royal Melbourne Hospital and Royal Children’s Hospital, subspecialising in my area of interest, orthognathic (jaw) surgery. Then, after 15 years of training, I hope to get my first real job as an oral and maxillofacial surgeon.

Amanda Bryan