Volume 196 Issue 4

Quality regulation of medical devices is essential to ensure that safe and effective devices and procedures are available for use in the health care system. This not only helps protect patients, but also the companies that manufacture and sell these devices. For a variety of reasons, medical device regulation in Australia and internationally has been under increased scrutiny in recent years. In Australia, a number of reviews have ...

Stephen E Graves MB BS, PhD, FAOrthA · Guy J Maddern MD, PhD, FRACS

The Sydney Gay and Lesbian Mardi Gras has been an annual event on the streets of the city since 1978. The original purpose of this and other gay pride events in Australia and elsewhere was a public protest at negative social attitudes and antihomosexual legislation, and as part of an international day of action. It has expanded, in parallel with many other such events around the world, to become a festival to celebrate lesbian, gay, bisexual, transgender and intersex (LGBTI) culture. However, it retains elements of political activism...

Ruth P McNair MB BS, PhD, FRACGP · Tonda L Hughes PhD, MSN, FAAN

Standing up for science. The international scientific credibility of Australian tertiary education institutions is being undermined by the increasing number of pseudoscientific health courses that they offer. Many universities teach therapies without a scientific basis to their students within their health care curricula, including homeopathy, iridology, reflexology, kinesiology, healing touch therapy ...

Alastair H MacLennan AO, MD, FRCOG, FRANZCOG · Robert G B Morrison OAM, BSc, PhD

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

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

Ray Moynihan explores dilemmas over public access to records on professional misdemeanours These days, it seems technology starts to answer the questions it raises, even before we’ve had time to properly formulate them. As social media and sophisticated software force previously unimagined forms of transparency deep into the fabric of our lives, asking where to draw the line between professional privacy and the public right to know feels somehow old-fashioned. Yet, the answers will affect the future of health care, its massive workforce and the population at large. Australia’s new national register of over half a million health professionals now offers the possibility of searching someone’s entire track record with one click. The extent to which we embrace this new opportunity is the subject of an emerging debate that’s likely to generate a lot more attention. A powerful piece of investigative journalism from the new Global Mail outlet has laid out some of the groundwork for this debate, citing examples of past egregious conduct which fails to appear on practitioners’ current registration records.1 One case involved a nurse being repeatedly violent to nursing home residents; another featured a pharmacist moving large amounts of flunitrazepam, popularly known as a “date rape” drug; a third involved a doctor using cocaine with, and making sexual advances to, a receptionist and being convicted of criminal charges. As the Global Mail made clear, there is no legal requirement for past suspensions or reprimands — even for serious misdemeanours — to be part of the current registration record of a practitioner. What the new law does require is transparency about ongoing restrictions on a provider’s registration — which is, of itself, a major improvement on the old situation where many adverse findings were effectively secret. “The level of trust in regulators needs to be high”, says Joanna Flynn, chair of the Medical Board, one of the 14 boards that sit within the new Australian Health Practitioner Regulation Agency, in an interview. “If it looks as if we’re hiding anything it could diminish that trust.” She points out that the new register’s site also has links to external legal databases with previous decisions of courts and tribunals, though these can be difficult to track down. As to the question of whether everything in a practitioner’s track record should be easily available at the push of one button, “that’s for a wider debate”, Flynn told me. The new agency’s chief executive officer, Martin Fletcher, agrees. “I think there’s an important debate to have about transparency. There’s no right or wrong answer”, he said when I interviewed him, adding that the register is in place to protect the public, not punish practitioners. The clear tension here is between professionals wanting to protect their reputations and move on from past problems, and the public wanting to make the best decisions about who they want to care for them. “The debate is live, fraught and controversial”, said Ian Freckelton SC, a barrister and law professor at Monash University with long experience on health tribunals, in my interview with him. He says community expectations have changed significantly in the past decade, and there is a need to balance complex issues of privacy, rehabilitation, access to information and informed decision making by patients — which can be more complex still when involving a practitioner’s individual health condition. “This is something we’re just forming our views on.” There does seem to be an informal consensus about the need for a formal public consultation on the extent of transparency on the new national register. Should there be full one-click transparency of the entire track record, or should practitioners’ entries be cleared of problems they have demonstrably overcome? “We believe in rehabilitation”, said Merrilyn Walton, when I interviewed her. Her default position is full transparency, but with the opportunity for material to come off the registration record on a case-by-case basis. A former consumer watchdog and now board member for the new registration agency, she told me in her capacity as professor of patient safety at the University of Sydney that she’d like to see widespread public consultation: “We need to talk about this”. There seems little doubt we’ll soon be doing a lot more talking about the merits and limits of one-click transparency.

Ray N Moynihan BA

A recall of breast implants from a French manufacturer has highlighted a low data capture rate — and considerable room for improvement — in Australia’s registry. Breast implants have long been a subject of media hype and controversy. Despite the debate surrounding the use of silicone prostheses in the 1990s, demand continues virtually unabated. Although Australia has a registry of breast implants, it has recently become clear that it contains insufficient data ...

Amy E Jeeves MB BS, BMedSci(Hons), FRACS · Rodney D Cooter MB BS, MD, FRACS

A window of opportunity for change The current health care reform process is remarkable for its lack of attention to private non-general practice (non-GP) specialist services. About 23 million ambulatory visits are made to non-GP specialists each year, and $1.6 billion of the Medicare budget flows to these services. For the patient, effective collaboration between his or her various health care providers is essential for safe, high-quality care. This is particularly so when the patient is consulting more than one non-GP specialist. An individual with type 2 diabetes, for example, might be seeing an endocrinologist, a nephrologist, a cardiologist and perhaps others, in addition to his or her general practitioner and allied health providers.1 The final report of the National Health and Hospitals Reform Commission (NHHRC) noted the key role of non-GP specialists in the shared management of care for patients with complex and chronic health needs, and recommended improving access to a more comprehensive and multidisciplinary range of primary health care and specialist services in the community through the establishment of Comprehensive Primary Health Care Centres and Services, available for extended hours.2 However, the current reforms are concerned almost exclusively with public hospital, general practice, community and primary care services. While GP Super Clinics may provide consulting facilities for visiting medical specialists, there are currently only 64 implemented or planned across Australia, and there is no formal requirement or policy incentive for functional integration between non-GP specialists and members of the primary health care team working in the same GP Super Clinic.3 So is there a problem? Potentially, yes. The vast majority of non-GP specialists in private practice are highly skilled, committed practitioners. Nevertheless, the lack of a comprehensive policy framework means that access to private specialist services is determined largely by market forces. This is most apparent in the geographical maldistribution of the medical workforce, with relatively few non-GP specialists choosing to work outside metropolitan areas. Moreover, almost no improvement in specialist–population ratios in remote and rural areas is expected over at least the next 8 years.4 Even in metropolitan areas, there is a tendency for private specialists to practice in affluent areas, limiting the choice available to patients in more deprived areas, whose mobility may be reduced by poverty or disability. And yet it is in socioeconomically deprived areas that patients are more likely to suffer multiple chronic diseases.5 It is striking that about 80% of general practice consultations but only 27% of non-GP specialist appointments for ambulatory care are bulk billed.6 The average gap between the fee charged by a non-GP specialist and the Medicare benefit received by a patient who is not bulk billed is $46.12. A recent Australian Bureau of Statistics (ABS) survey found that about 10% of Australians referred to a non-GP specialist delayed or did not keep the specialist appointment because of cost.7 Unlike in general practice, there are no Medicare incentives for non-GP specialists to bulk bill for most consultations. The Medicare Safety Net helps, but it is clear from the ABS data quoted above that up-front billing can exceed the cash reserves of many patients. A further potential problem with the lack of a policy framework for private non-GP specialist services is the risk of lapses in quality and safety. All medical practitioners in Australia are required to provide evidence of participation in continuing professional development at the time of annual registration but, unlike the accreditation process for general practices, there is no requirement for the quality review of non-GP private specialist practices, with the exception of imaging providers and laboratories. Lapses in the quality of non-GP specialist care are likely to be rare, although few rigorous data exist, but when they occur the implications can be disastrous.8 A more common threat to quality and safety may be lack of timely communication with the patient’s general practitioner following every consultation by another specialist.9 This can have major ramifications for a patient with complex care needs. There is very little point in a doctor seeing and advising a patient without communicating with the other health practitioners involved in his or her care. Radiologists, pathologists and non-medical health practitioners who provide Medicare-rebateable services following referral are required to supply a report to the referring doctor, and it seems reasonable for such reporting to be universally expected of all referred services. No systematic data exist, but general practitioners report frequent frustration at the lack of timely communication from other medical colleagues.10 These difficulties are further compounded by failure to implement the NHHRC’s recommendation of strategies to assist patients living with complex health problems to adopt a single general practice as their “health care home” responsible for continuity and coordination of care.2 So what is required to address these problems? Medicare Locals are currently being rolled out across Australia, replacing Divisions of General Practice, and will be required to work with local clinicians — including Lead Clinician Groups and presumably individual specialists — “to identify and remedy service gaps and breakdowns in service integration and coordination”.11 However, their ability to bring about change at regional level will be limited without a national policy framework that includes provisions relating to non-GP private specialist practice. General practitioners receive incentive payments for bulk-billing concession card holders and children. For reasons that are not clear, other specialists only receive bulk-billing incentives for telehealth consultations. A Medicare incentive for non-GP specialists to bulk bill consultations and other services for concession card holders and children would help to address the financial barrier faced by many patients. Such an incentive would also help redress the potential differential in revenue for specialist practices between affluent and deprived communities. A bulk-billing incentive would be more socially just than the current Extended Medicare Safety Net (EMSN) which, on the ABS evidence cited above, fails 10% of referred patients. A review published in 2011 found that some 53% of EMSN benefits were distributed to the 20% of the population living in Australia’s most socioeconomically advantaged areas, whereas the 20% living in the most disadvantaged areas received only 3.7% of benefits.12 Medicare rebates should be contingent on a report being provided for all referred medical services, not only pathology and imaging services. It will become easier to ensure that such reports are accessible to all treating health professionals once the impediments to a national personally controlled electronic health record are overcome. Incentives are required for all health practices, not just general practices, imaging providers and laboratories, to undergo regular accreditation. The present Australian health reform process provides a window of opportunity to develop and implement policy changes relating to private non-GP specialist practice, ensuring that the considerable public funding flowing to this sector of the health system achieves the most effective and equitable contribution to the nation’s health.

Tim P Usherwood MD, FRACGP, FRCP

“When you have seen one AHSC, you have seen just one AHSC” — Academic Health Sciences Centre, National Task Force Final Report1 Australia’s health system is struggling to meet demand and expectations. Demand is driven by an increasing burden of chronic non-infectious disease associated with ageing.2 Expectations of cutting-edge care for all are set by the public and by government.3 Meeting these demands and expectations will be possible only with substantial effort in research and education as part of health service delivery. Separation of funding for research and education from the delivery of patient care diminishes the opportunity for mutually enhancing integration, and for expenditure efficiencies.4,5 Recognising the importance of evidence-based clinical practice in quality and efficiency of health care delivery has been a driver for the creation of academic health sciences centres (AHSCs) in the United Kingdom6 and Canada.1 Australian commentary on AHSCs7 has emphasised an absence of government leadership in establishing AHSCs in Australia. It is critical to the success of AHSCs as a tool for optimal health care delivery that they are inclusive, and that they set performance benchmarks in service delivery, education and research, while neither aspiring to elitism, nor separating their activities from the provision of health care itself. In early 2010 and 2011, a group of Brisbane hospital, university and community health care practitioners, administrators, educators and researchers had several meetings to consider the feasibility of establishing an AHSC. They recognised that some integration of education and research with service delivery was already occurring. A successful example of this was a hospital-based research program that had led to the development of cervical cancer vaccines,8 which had led to development of research facilities. This and other similarly successful programs were facilitated by leadership from individuals; however, an environment that encouraged activity by all practitioners was seen as likely to result in better outcomes in education, research and service. The meetings concluded that providing such universal support would improve health care, and further noted that failure to combine the three domains could be wasteful. Several barriers to integration of education and research with service delivery were identified, which could be resolved by using a partnership model between local research institutions, public and private health care providers and educational facilities. Emphasising a partnership meant moving from a workplace focus to integrated management and service delivery structures across boundaries between primary and tertiary health care, and between education and research. The partnership model was chosen because governance was identified as key to realigning the purposes of hospital and academic institutions.9 Although it was hoped that merging many of the partners’ processes would occur with time, it was agreed that incremental changes in leadership and management structure could usefully start the process. These changes would be prioritised in terms of their potential to have a positive effect on health outcomes and resource efficiency. Developments in health and hospital reform and the release of a National Health and Medical Research Council position paper on designation of Advanced Health Research Centres in 2010, to which the group provided comments, helped launch the Diamantina Health Partners (DHP) in mid 2011 as an AHSC. This partnership brought together the University of Queensland (UQ) PA-Southside Clinical School, UQ Diamantina Institute, UQ general practitioner partners, research and teaching components of the Queensland University of Technology (QUT), the newly created Translational Research Institute (TRI), and health service delivery units from the Princess Alexandra and Mater Hospitals. The partnership is a functional (not legal) one, with relationships and governance determined by a signed memorandum of understanding (MOU). The MOU covers the following issues relating to governance: The DHP board is entrusted to explore options for the best organisational vehicle for the DHP (which in time may become a separate legal entity). Sufficient internal resources will be committed by the partners as appropriate to achieve outcomes, with each (except the TRI) making an initial financial contribution for the development of the DHP. Financial contributions may be varied by mutual agreement of the board. The initial financial commitments of the DHP are the costs of a senior administrative consultant and workshops for strategic developments. All income remains with the participating entities. The board is to formulate and control administrative and strategic development. Mission and visionThe major aim of the DHP is to integrate research, teaching and training with clinical service delivery, to enable internationally benchmarked, quality health care to be delivered in a timely and cost-effective manner. We recognise that complete integration is not realistic, but believe that mutually beneficial strategic decisions at university and hospital levels will facilitate achievement of the vision. Initially, we will align the strategic goals and plans of DHP stakeholders with expectations of patients using DHP services, for which we established six principles of development (Box 1). Planning coordination is pivotal to the success of the DHP, and we believe education of clinical staff in research will encourage critical evaluation and application of new ideas and therapies in clinical care — skills to improve hospital performance in key performance indicators relating to efficient use of health care infrastructure (Box 2). Staff discussions about conjoint appointments facilitating teaching, research and clinical services are underway between the partners. Current situationOne of our most pressing problems is engagement and representation in the DHP, which we are using our committee structure, reporting system, discussion groups and user groups to address. Early success in engagement is evident in collaboration on draft proposals and in facilitation of clinical research (by building clinical trial enrolments into performance indicators of service providers and departments). Engagement success is also seen in the teaching of medical, allied health and nursing students about clinical research methods, and by facilitating encounters between clinicians and basic researchers. Engagement is important from the strategic and survival perspectives of the DHP, and various strategies to benefit health and working environments are being planned. The ability to address new barriers is also crucial to success. Another issue is that although the DHP board needs to have strategies in the best interests of the DHP, some partner representations on the board will be necessary, at least initially. The long-term aim is to have the right mix of people and skills acting in the interests of the DHP. An appropriate policy for membership of the board and its committees is being developed, as is a structure for successful implementation of DHP strategy into practice. Clear governance lines between the board and the partners will be necessary. Lastly, board diversity needs to be considered. The increasing number of women who are clinical academic leaders in Queensland will help achieve a balance of sexes. Care must be taken not to change organisational structure unless changes are clearly linked to improving health outcomes. Areas under consideration include harmonisation of job descriptions and salaries between employment agencies, transparency of data and information technology services, and standardisation of intellectual property and commercialisation management. Setting research and policy priorities is underway. An evident failure to deliver the vision espoused in the original 2010 proposal for health reforms threatens the existence of AHSCs, as federal funding for research, education and health remain separated. It is expected that the DHP will be politically independent and the board will be accountable for policy delivery and efficient use of public funds. The outstanding issues to be resolved by the DHP board are engagement; structural and policy “levers” it can use to influence institutional strategies; and ensuring strong alignment between the DHP and its individual components. SummaryMany have asked “what is the benefit of the DHP over the current situation?” We believe that the responsiveness of research to community health needs and the balance of research and teaching outcomes in academic institutions can be improved, and stronger incentives to integrate research outcomes into clinical practice can be provided. The DHP is thus set up differently to a clinical research centre. The aim of our DHP is to improve health outcomes by means of coordinated excellence in teaching, research and clinical care. Technical efficiencies and excellence in care mean that financial efficiencies will occur. Joint clinical, research and teaching initiatives are underway, and plans are being developed to teach future clinical staff the science of clinician-directed, rational use of medical resources. These include pathology, imaging services, pharmaceuticals and patient referrals, assisted by published expert guidelines. There are significant administrative and personnel issues to surmount, but planning for integration has begun, and plans for turning research outcomes into clinical care plans are already emerging. 1 Six principles of development The Diamantina Health Partners (DHP) will work towards: 1. A joint governance structure promoting a coordinated effort towards better health care. The DHP governance structure is based on a partnership — a non-incorporated joint venture. This structure enables partners to honour obligations to other entities. Functional integration is supported through joint appointments and creation of joint activity streams. 2. Jointly determined key performance indicators (KPIs) in patient care, education and research. Traditional measures of research focused on publications and of teaching based on student assessment were felt not to provide an ability to measure relevant contributions to health outcomes or “quality”. 3. A jointly agreed strategy for improving health care, focused on health and wellbeing. 4. Administrative processes aimed at accelerating dissemination of research-based evidence into clinical practice. 5. Collaborative use of public resources with public accountability. Cost-effectiveness is part of DHP strategy. Collaborations that ensure the best use of public resources and public accountability are encouraged. Reporting towards KPIs that relate to measurable health improvements will be introduced. 6. Common drivers encouraging development and improvement of clinical innovation, training and health policy. Proven strengths on the DHP campuses will be used as exemplars for setting aims and employment standards at an international level. 2 Clinical issues that could be improved with better linked education and research Role of emergency department for multiple attenders and for people with chronic conditions Bottlenecks in internal medicine discharges and the primary–secondary health care interface Providing health care for areas of high medical need, such as bariatric surgery versus a proliferation of obesity clinics in tertiary hospitals Use of expensive pharmacotherapies that have not been proven to meet clinically relevant end points, and which may cause high rates of adverse drug events New research tools such as genomics for predictive management of disease or response to drug therapies, streamlined by information gained from health services research in a particular health district

Jennifer H Martin FRACP, PhD · David E Theile MB BS, FRACS · Ken K Y Ho MD, FRACP, FRCP(UK) · Ian H Frazer FRCPE, FRCPA, FAA

To the Editor: In reply to my critics whose letters were published in the 20 February issue of the Journal1-4 after the publication of my article “What is wrong with Medicare?”,5 I would ask them to look broadly at Australia’s health care dollar and how it may be misspent. It is clear that the percentage of practitioners who wilfully set out to defraud Medicare, Veterans’ Affairs, workers compensation and other forms of insurance is relatively small. However, the current structure of Medicare, which is the result of poor policy decisions, allows inappropriate practice, as well as inefficiency and cost-shifting. Inertia in health care reform will continue to diminish our ability to deliver a first-world standard of care into the future. My critics would do well to consider this.

Tony D Webber

To the Editor: Non-surgical cosmetic procedures have rapidly increased over the past 15 years, and although there are no reliable figures for Australia, there was an eightfold increase in such procedures in the United States between 1997 and 2010.1 Practitioners in the cosmetic field are seeing more frequent complications (eg, burns, scarring) from laser treatments that have been performed by untrained or inexperienced operators, including beauty therapists. These treatments are often performed as walk-in procedures in shopping centres. A cosmetic surgery report to the New South Wales Minister for Health in 1999 outlined a number of issues with laser use in Australia.2 More than 12 years later, very few of these issues have been addressed. There are more regulations on the sale and use of laser pointers in Australia than there are for lasers in health care. The Australian/New Zealand Standard 4173:2004, Guide to the safe use of lasers in health care, limits and classifies lasers used for medical purposes according to the degree of hazard. The Standard recognises that all personnel using and handling lasers should have training appropriate to the task they perform.3 Queensland, Western Australia and Tasmania have some regulations regarding medical grade lasers, but there are currently no regulations enforcing the Standard in other jurisdictions. There is also no industry standard for the necessary skills, qualifications and training for use of lasers, or regulation of these. National guidelines for the use of medical grade (Class 3B and 4) lasers need to be developed urgently and should address several issues to protect consumers: Medical grade lasers should only be sold to medical practices where the operator can be observed by a doctor at least some of the time, and complications can be discussed with the doctor. Medical practices should be licensed under the relevant Radiation Act in each jurisdiction (eg, Radiation Control Act 1990 in NSW) and listed on a website. All users of the laser in each licensed practice should be registered and individually licensed. National guidelines for accredited laser-safety courses should be established, ensuring adequate training and certification for obtaining a licence.

Charles Cope

To the Editor: A 12-year-old boy presented to a regional emergency department with a 3-day history of progressing bilateral conjunctival injection, fevers (39°C), a widespread erythematous bullous rash, and superficial erosions to his lips, oral mucosa and urethral meatus. The patient was admitted to hospital for management of Stevens–Johnson syndrome (SJS). Initial treatment included intravenous f luids, intravenous ceftriaxone and oral azithromycin before transfer to a tertiary referral hospital. The patient had not taken any oral medications or over-the-counter therapies. He had no preceding viral symptoms. However, 2 weeks before onset of symptoms, he had received vaccination against varicella-zoster virus. On Day 1 of admission, intravenous immunoglobulin (Intragam P, CSL, Melbourne, VIC; batch numbers 3740600696, 3740500668, 3740600690, 3740600679) was administered at a dose of 1 mg/kg and repeated 20 hours later. On Day 2, oral prednisolone therapy (1 mg/kg/day) was initiated and continued for 5 days, and antibiotics were administered for 8 days (cefotaxime [50 mg/kg] and azithromycin [10 mg/kg]). Mycoplasma pneumoniae serological testing of blood samples taken on admission was negative. Bilateral conjunctival ulcers were managed with topical chloramphenicol eye ointment, topical 0.5% prednisone, lubricant drops and normal saline washes. The patient developed further areas of bullae and erosions to his cheeks and ears (Box). He also developed palmar papules, and dusky finger tips and toes. Skin bullous lesions were managed with daily sterile aspiration, and erosions were managed with silver-impregnated silicone dressings (Mepilex Ag, Mölnlycke Health Care, Gothenburg, Sweden). The patient’s rash and fevers abated, and he was discharged on Day 12 with advice from the dietitian and physiotherapy-assisted mobilisation. Sequelae at 2 months included cutaneous post-inflammatory hyperpigmentation. SJS after varicella infection has been reported,1,2 and a single case after varicella vaccination was included in a case series of six possible cases of SJS after vaccinations.3 SJS after medication use or infection with M. pneumoniae is well documented; however, cases where no clear cause can be documented result in increased parental anxiety. This case of SJS was preceded by varicella-zoster vaccination performed as part of school protocol. In the absence of any other obvious cause, it has been reported to alert practitioners of the possibility of a link (Therapeutic Goods Administration adverse drug reaction no. 291111). Patient with Stevens–Johnson syndrome after varicella vaccination

Elizabeth M Christou · Orli Wargon

To the Editor: Neal and Irwig1 argue that more precise measurement of blood pressure using ambulatory blood pressure monitoring is unlikely to deliver the clinical and economic benefits that could be achieved by switching to a risk-based strategy, such as that advocated by the National Vascular Disease Prevention Alliance.2 Moreover, they question: do you need to “know your numbers”? However, all risk-based strategies are based on numbers for blood pressure and various lipid parameters. Furthermore, despite a wealth of evidence that numbers-based approaches reduce cardiovascular events, I am not aware of any randomised controlled trial demonstrating the superiority, or even the equivalence, of a strategy based on 5-year absolute risk for cardiovascular prevention. Is a strategy based on 5-year absolute risk best for the individual patient? Clinicians treat lifetime risk,3 taking into account family history and, for women, the prospect of pregnancy. A low 5-year risk is not sufficient justification for withholding treatment of elevated lipids or blood pressure. Although the 44-year-old, male non-smoker without diabetes and with a systolic blood pressure of 170 mmHg may have a 5-year cardiovascular risk of 5%, clinicians will investigate and provide aggressive blood pressure treatment to reduce his lifetime risk. Treating according to the numbers will ensure that the choice of therapy offers the greatest risk reduction. Clinicians treat individuals, not populations. Management of the individual patient with cardiovascular risk is neither exclusively numbers-based nor exclusively risk-based, but a combination of the two approaches. We should use the approach that works best for the individual patient.

Duncan J Campbell

To the Editor: The prevalence of obesity in Australia is increasing, with a quarter of Australians currently obese and two-thirds overweight.1 The fast-food industry is particularly implicated in this, because it offers cheap, high-calorie and low-nutrient food and employs branding that can alter taste preferences.2 Despite considerable lobbying from health groups, Australian governments have not elected to regulate the fast-food industry, instead leaving it to self-regulate. Predictably, a recent industry self-regulatory initiative aiming to decrease advertising to children failed.3 Suggested methods of regulating the fast-food industry have included taxing unhealthy foods, limiting advertising to children, and mandatory nutritional labelling. However, recent research has suggested a more creative solution. Instead of restricting the industry, perhaps the effective branding strategies of fast-food companies could be used for health promotion. It has been shown that children prefer food in McDonalds-branded wrapping over the identical item in plain wrapping.2 Even typically healthy items, like milk and carrots, are preferred when given McDonalds branding. New research has taken this idea a step further and shown that the branding of a fun, health-themed television show can be used to make healthy foods more appealing.4 These findings may motivate a new population-level strategy to reduce obesity. Established fast-food brands could be given incentives to apply their branding to healthy items. This would allow the fast-food industry to contribute to a healthier food environment, while avoiding the market restriction of taxation. Another option is to establish a government-funded enterprise that uses fast-food marketing to sell healthy items. Costs of such ventures may be outweighed by future reductions in health spending. With regard to obesity, perhaps it is time we started looking on the outside of the box for the solution.

Dugal B S Smith

To the Editor: The past decade has seen significant change in the management of major haemorrhage, including earlier and more aggressive use of fresh frozen plasma (FFP). Australian guidelines now advocate high ratios of FFP to packed red blood cells (PRBC) from the outset of resuscitation.1 Preparation of one unit of FFP for every two units of PRBC is recommended. This approach is supported by a recent meta-analysis demonstrating a reduction in organ failure and mortality with high FFP : PRBC ratios.2 In Australia, 40% of major trauma incidents originate in rural areas,3 some distance from tertiary or even secondary care. Initial resuscitation often falls to general practitioners (with no blood bank) or aeromedical services. In a 2010 international survey of 29 aeromedical services conducted by the Royal Flying Doctor Service (RFDS) (Western Operations), the seven responding Australian services reported difficulty accessing blood products. Only three had immediate access to PRBC, although all could obtain it within 45 minutes. None could obtain FFP without delaying departure, and only four had access within 45 minutes. This difficulty in obtaining blood products, particularly FFP, was evident in an analysis of major haemorrhage management by the RFDS (Western Operations). Of 7585 patients transferred in the 2009–10 financial year, 610 (8%) had a diagnosis that put them at risk of major haemorrhage; of these, 58 (9.5%) demonstrated physiological derangement predictive of requiring massive transfusion and did receive transfusion in flight. However, the FFP : PRBC ratios fell short of accepted standards (Box), particularly in patients originating from non-regional hospital locations. As logistical difficulties with storage and preparation render FFP impractical in remote Australia, alternative sources of coagulation factors must be explored. European groups have proposed replacing FFP with freeze-dried factor preparations (fibrinogen concentrate and prothrombin complex concentrate),4 which are currently available in Australia. These are easier to store, transport and deliver, and may be safer and more efficacious than FFP.4 Evidence that tranexamic acid significantly reduces mortality in trauma-related haemorrhage5 has been met with a guarded response in Australia. The study was conducted in developing countries with limited access to blood products and its applicability here has been questioned, although it may be highly applicable to remote and regional areas where FFP is scarce. Ongoing research and the planned Australian Massive Transfusion Registry will contribute further to the debate. When devising major haemorrhage strategies, however, it should be remembered that managing bleeding in Melbourne and managing bleeding in Meekatharra (in remote Western Australia) are two very different prospects. Ratio of fresh frozen plasma (FFP) to packed red blood cells (PRBC) in patients at risk of requiring massive transfusion, 2009–10 Origin of patient All patients (n = 58) Regional hospital (n = 35) Non-regional hospital (n = 23) Mean number of FFP units delivered: In referring hospital 0.9 1.3 0.3 During transport 0.2 0.3 0.1 Mean number of PRBC units delivered: In referring hospital 2.5 3.3 1.3 During transport 1.8 1.6 2.0 Overall FFP : PRBC ratio 1 : 3.9 1 : 3.1 1 : 8.3

Stuart A Gillon · Cem R Kibar

To the Editor: An evaluation of 3390 prevocational progress assessment forms in New South Wales suggested that the assessment instrument appears unable to detect underperforming doctors, and may not aid their professional development.1 Similarly, Queensland interns undertake five terms per year and, in each of these, they are assessed against 11 items in three domains: clinical competence, communication, and personal and professional skills. The purpose of the assessment is to identify underperformers and subsequently to help improve their performance. However, there is limited literature on the psychometric properties of the instruments used. Our study aimed to evaluate the construct validity and reliability of the instrument as a measure of interns’ performance. We performed principal component analysis (PCA) of the assessment items from all 72 interns who completed the five assessment forms during their intern year of the University of Queensland (2005 to 2007), working in one teaching hospital. A reliability test was performed using generalisability theory, which measured the variation in scores due to differences in performance between interns. It is generally expressed as a G coefficient ranging from 0 to 1 (no reliability to perfect reliability). Supervisors assess interns using the rating scale: “requires substantial assistance”; “requires further development”; “consistent with level of appointment”; “performance better than expected”; “performance exceptional”; or “not applicable or not observed”. Supervisors’ ratings were coded from 1 to 5 for the data analysis. Our examination of the assessment forms found that the mean of the skill items ranged from 3.69 to 4.16 (SD, 0.31–0.41). PCA identified only one factor from the 11 assessed items, and it explained 71% of variance in scores. The loadings of the coefficients ranged from 0.80 to 0.93 (Box) and the G coefficient was 0.16. These data show that the instrument in this setting only measures a single global work performance factor, has low reliability, does not discriminate well between interns, and does not differentiate well between the different domains and assessment items, raising the question as to whether it is fit for purpose. The assessment program should be able to assess all these required attributes of junior doctors as outlined in the Australian Curriculum Framework for Junior Doctors in order to work safely in Australian hospitals and other health care settings.2,3 Other assessment methods involving direct observation, such as the mini clinical evaluation exercise4 and direct observation of procedural skills,5 could be integrated into the assessment to enhance its validity, but would require trained assessors and substantial time commitment for development and delivery. Domains, assessed items, descriptive statistics and factor loading of principal component analysis of the assessment instrument used on 72 graduates Domain Skill items Mean (range) SD Factor loading Clinical skills Knowledge base: demonstrates adequate knowledge of basic and clinical science 3.72 (3.00–4.40) 0.33 0.84 Clinical skills: elicits and records accurate, complete history and clinical examination 3.87 (2.80–4.60) 0.37 0.90 Clinical judgement/decision-making skills: applies knowledge base and clinical findings; organising, synthesising and acting on information 3.88 (2.80–4.80) 0.39 0.90 Emergency skills: acts effectively and, when appropriate, acknowledges own limitations and seeks help 3.79 (3.15–4.40) 0.34 0.76 Procedural skills: performs procedures competently 3.70 (3.20–4.40) 0.38 0.72 Communication skills Patient and family: interacts effectively and sensitively with patients and families/caregivers 4.07 (3.40–4.80) 0.33 0.79 Medical records/clinical documentation: provides clear, comprehensive and accurate records 3.92 (2.80–4.60 0.41 0.88 Personal and professional skills Professional responsibility: demonstrates appropriate attitudes and behaviour, including punctuallity, reliability, honesty and self-care 4.15 (3.20–5.00) 0.34 0.85 Teaching: demonstrates commitment to learning, reflective thinking, and teaching others 3.69 (3.20–4.40) 0.34 0.80 Time management skills: organises and prioritises tasks to be undertaken 3.97 (3.20–4.60) 0.36 0.89 Teamwork and colleagues: works and communicates effectively within a team 4.16 (3.20–4.80) 0.31 0.93

Jianzhen Jenny Zhang · David Wilkinson · Malcolm H Parker · Andrew Leggett · Jill Thistlethwaite

To the Editor: Kimble and colleagues have implied that the main strategic intervention to reduce the risk of dog bites is the education of dogs, owners and children, which is the equivalent of claiming that the most important way to prevent road accidents is for people to drive..

Katina D'Onise · Ronald L Somers

To the Editor: Since the publication of Knight and colleagues’ case report on the topic, five more patients have presented with burns caused by Grevillea pyramidalis ssp. leucadendron, or maangga berry.1 Traditionally, these berries have been used by Aboriginal Australians for tattooing.1 As in the cases described by Knight and colleagues,1 these burns were sustained by Indigenous children aged 8–11 years in northern Western Australia and required specialist burn care. Two patients sustained 1.5% total body surface area, deep partial-thickness burns to their left forearms, which required surgical management. Three patients presented with superficial partial-thickness left forearm burns, which were managed non-operatively via telehealth. Four of the five patients were only referred to the state burns unit 7 days after the initial injury, and one patient was lost to follow-up. Management of these patients’ injuries was limited by compliance issues. Grevillea seeds can be responsible for deeper burns, which require surgical intervention, and superficial burns, which can be treated non-operatively. In this series, the burns occurred in Indigenous children with darker skin, which often has poorer scar outcomes. This demographic, coupled with compliance issues and late referral, make grevillea seed burns a difficult clinical entity to treat. Community education and health staff awareness is imperative in helping us provide optimal treatment in the future.

Joseph Luo · Tania McWilliams · Fiona Wood

To the Editor: We welcome the article by Williams and colleagues on conflicts of interest in clinical guidelines,1 and agree that such conflicts can undermine trust in guidelines, compromise patient care and skew health care spending. One challenge in managing conflicts is the lack of evidence that disclosure minimises their impact. For example, research at the United States Food and Drug Administration found that, despite disclosure, for every committee member with a conflict, there was a 10% greater likelihood of the meeting favouring the drug reviewed.2 Recusal (self-disqualification) is also problematic, especially in Australia where there may be a relatively small pool of experts available. Given these problems, we are concerned that some of the recommendations made by Williams and colleagues lack supporting evidence and fail to adequately address conflicts of interest. One of their recommendations, a tiered system within guideline panels limiting those with conflicts to contributions regarding the nature of the disease under discussion, for example, ignores what we know about the way that conflicts of interest operate. Research has shown that this apparently innocuous element of guideline development is not immune to influence, as conflicts of interest can influence how disease is defined, leading to broader disease definitions and lower treatment thresholds.3 A second recommendation was that guideline developers declare that “any benefits received have not influenced their professional opinion”. But surely this misses the real danger of such conflicts, which is not that of making deliberately biased decisions. Rather, the issue is that professional opinion may be unconsciously swayed by conflicts.4 Finally, they suggest an exclusion period of 3 years between receipt of industry support and involvement in guideline development. But no evidence is provided to ensure that this is “sufficient time for the conflict to have lost its potential for ‘undue influence’”. Without supporting evidence, the choice of 3 years, rather than 4 or 2 and a half, appears arbitrary. We need more research into the way conflicts of interest operate, and perhaps we need to seek a fresh pool of experts who, while less experienced, may be significantly less conflicted.

A Jane Johnson · Wendy A Rogers

In reply: We thank Johnson and Rogers for their letter. A tiered system has benefits but is not foolproof; vigilance by panels is needed to ensure disease definitions are appropriate. Delphi methodology, which can make participants anonymous via use of a facilitator, may prevent the influence of senior panel members over more junior ones in this and other regards. Although declarations would not affect conflicts operating at a subconscious level, turning one’s attention to conflicts at the time of recommendations may lead to greater awareness in some panelists. Declarations have almost no cost. We welcome more research into the length of time that “cures” conflicts. Including less experienced but less conflicted people on panels is a reasonable suggestion, though significant industry relations begin during trainee years, and expert input is likely to be beneficial for authority and take-up. Conflicts are a thorny issue, with undeniable tension between a purist approach and pragmatic considerations, particularly in a small pond. Given the present lack of transparency, we should urgently trial proposals supported by logic or evidence, and look forward to guidance from the National Health and Medical Research Council.

Michael J Williams · Dev A S Kevat · Bebe Loff

To the Editor: The perspective by Williams and colleagues,1 based on analysis of guidelines hosted on the National Health and Medical Research Council (NHMRC) portal (http://www.clinicalguidelines. gov.au), highlights the need for a culture of transparency and disclosure to effectively manage conflicts of interest. With the current health reform agenda being dependent on the availability of clear and unbiased clinical guidance, the NHMRC continues to actively address this persisting challenge. In July 2011, new standards for guideline developers seeking NHMRC approval were released. The standards make it mandatory for guideline developers to publish all sources of funding for the guideline; to publish a complete list of all the people involved, including professions, organisational affiliation and role in the guideline development process; and to publish how potential competing interests are identified, managed and documented. A competing interest declaration must be completed by each member of the guideline development group.2 The NHMRC is committed to implementing management practices for improving transparency of the development of evidence-based health advice. We recently conducted public consultation on policies for identifying and managing conflicts of interest in relation to NHMRC committees and working groups who are developing guidelines. Submissions to the consultation will be taken into account for the finalised policies, to be released in 2012. The draft policies can be viewed at http://consultations.nhmrc.gov.au/open_public_consultations/conflict-of-interest. The NHMRC has also established the Australian Guideline Developers Network and holds national workshops to help guideline developers identify and manage issues, including conflict of interest, with the aim of reducing the variability in the quality of guidelines (http://www.nhmrc.gov.au/guidelines/nhmrc-initiatives-support-high-quality-clinical-practice-guideline-development). These strategies, combined, will strengthen the role of the NHMRC in supporting the translation of health research into trustworthy clinical guidance, in areas that will most benefit the health of the Australian population.

Warwick P Anderson · John McCallum

Despite the various functional tests and biomarkers available for evaluation of patients with coronary artery disease (CAD), we sometimes look for the reassurance of anatomical information by way of a coronary angiogram. However, as an invasive modality, it does carry some risks, and the proportion of patients with normal coronary angiograms has remained relatively stable at 15%. In recent years, the rapid development of computed ...

Gary Y H Liew MB BS, FRACP · Michael P Feneley MD, FRACP · Stephen G Worthley MD, PhD, FRACP

A 58-year-old woman presented with multiple extensive, necrotic ulcers on the proximal lower limbs (Figure, A and B). A diagnosis of calciphylaxis in the absence of renal impairment was made. Although non-uraemic calciphylaxis has been described previously, the pathogenic mechanisms and significance of documented risk factors are poorly understood. Multiple risk factors were identified in this patient, of which the most prominent is likely to have been severe and longstanding hypoalbuminaemia of unexplained cause. In addition, obesity, European ancestry, female sex, hypovitaminosis D, an elevated alkaline phosphatase level, non-alcoholic steatohepatitis, weight loss and use of steroids were all features of this case that have documented associations with calciphylaxis.

Raffaela Armiento · Ilana Gory · Peter J Jenkins · Catriona A McLean

Each year, over 1000 medical device incidents are reported to the Australian Therapeutic Goods Administration (TGA). The most recent published statistical reports from this scheme show 926 reports in 6 months (January–June 2009), of which 597 resulted in serious injury and 25 were associated with patient death. The 3 Fr peripherally inserted central catheter (PICC) is a medical device commonly used in infants ...

Joel M Dulhunty MB BS, MTH, PhD · Andreas Suhrbier BA, PhD · Graeme A Macaulay BEng(Med) · Jennifer C Brett BEng(Med) · Alexa V A van Straaten BA(Hons), MA, MPhil · Ian M Brereton BSc, PhD · Jillann F Farmer MB BS, FRACGP, FRACMA

Objective: To describe the frequency, characteristics and outcomes of reports of possible harms related to medical devices submitted to the Australian Therapeutic Goods Administration (TGA) using data made publicly available on the TGA website.Design and setting: A retrospective analysis, conducted in January 2012, of data made publicly available on the TGA website from January 2000 to December 2011.Main outcome measures: The number and nature of reports of medical device incidents, recalls and alerts.Results: Up to December 2011, 6812 incidents involving medical devices were reported to the TGA, although there were several periods where data were unavailable. Incidents were reported more frequently in later years, most often by device sponsors, and were often attributed to mechanical problems. 295 deaths and 2357 serious injuries have been related to incidents, with serious injury (597) highest in 2009. Most incidents involving medical devices were not investigated (47.5%), or, after investigation, no further action was taken (25.0%). During the same time period, there were 35 medical device recalls and 34 medical device alerts issued by the TGA, with no consistent increase over time.Conclusions: Despite TGA reform proposals, greater transparency is still needed. Issues that have not been addressed include patchy and conflicting data in the public domain and lack of explanations for the large proportion of uninvestigated reports. To maintain public confidence in the national regulatory system these problems need to be resolved.

Richard G McGee PGDipSurgAnat, MMed(ClinEpi) · Angela C Webster MMed(ClinEpi), PhD · Thomas E Rogerson BSc · Jonathan C Craig MMed(ClinEpi), PhD

In Australia, regionalised maternity care aims to ensure provision of the appropriate level of care to all women, through assessment of risk, referral and transfer. An important element of this care is providing high-quality, safe and accessible services to women and babies in rural and remote areas. For women who experience pregnancy complications, this means their needs may not necessarily be met by their local hospital. They may be admitted ...

Tim Badgery-Parker BSc(Hons), MBiostat · Jane B Ford BA(Hons), PhD · Mary G Jenkins RN, CM, MScM · Jonathan M Morris MB ChB, FRANZCOG, PhD · Christine L Roberts MB BS, FAFPHM, DrPH

Objective: To determine if the improvement in inpatient glycaemic control observed with basal–bolus insulin (BBI) over sliding-scale insulin (SSI) in the formal study setting translates to routine clinical conditions.Design, setting and patients: Cross-sectional study in which capillary blood glucose levels (BGLs) were prospectively measured four times daily for up to 8 days in 124 patients with type 2 diabetes admitted to a tertiary teaching hospital and treated with BBI between November 2008 and May 2010. Data from the BBI treatment group were compared with retrospective data from 96 patients treated with SSI between June 2001 and May 2006.Main outcome measures: Mean daily BGL; independent effect of insulin regimen on mean daily BGL.Results: Mean baseline BGL was not significantly different in patients receiving BBI and SSI (mean ± SD, 11.3 ± 4.1 v 10.6 ± 4.3 mmol/L; P = 0.23). After the first full day of therapy, mean daily BGL for patients receiving BBI was 1.6 ± 3.7 mmol/L lower than baseline BGL, and it remained 1.6–2.4 mmol/L lower than baseline throughout the study (P < 0.001). In contrast, there was no significant change in BGL for patients receiving SSI. Random effects regression analysis indicated that BBI was associated with a significantly lower mean daily BGL than SSI, independent of other variables (P < 0.001). The incidence of hypoglycaemia (BGL < 4 mmol/L) was significantly greater in patients receiving BBI than SSI (3.3% v 1.4%; P < 0.001), but there was no significant difference for severe hypoglycaemia (BGL < 2.8 mmol/L) (0.3 v 0.5%; P = 0.3).Conclusions: Under routine clinical conditions, BBI is effective and safe across a range of patients and appears to be superior to SSI. Clinical improvements reflected those seen in a strict formal study setting.

Greg W Roberts BPharm, FSHP · Norma Aguilar-Loza BN(Hon) · Adrian Esterman PhD · Morton G Burt MB ChB, PhD · Stephen N Stranks MB BS

Objective: To examine the differential in cancer survival between Indigenous and non-Indigenous people in Queensland in relation to time after diagnosis, remoteness and area-socioeconomic disadvantage.Design, setting and participants: Descriptive study of population-based data on all 150 059 Queensland residents of known Indigenous status aged 15 years and over who were diagnosed with a primary invasive cancer during 1997–2006.Main outcome measures: Hazard ratios for the categories of area-socioeconomic disadvantage, remoteness and Indigenous status, as well as conditional 5-year survival estimates.Results: Five-year survival was lower for Indigenous people diagnosed with cancer (50.3%; 95% CI, 47.8%–52.8%) compared with non-Indigenous people (61.9%; 95% CI, 61.7%–62.2%). There was no evidence that this differential varied by remoteness (P = 0.780) or area-socioeconomic disadvantage (P = 0.845). However, it did vary by time after diagnosis. In a time-varying survival model stratified by age, sex and cancer type, the 50% excess mortality in the first year (adjusted HR, 1.50; 95% CI, 1.38–1.63) reduced to near unity at 2 years after diagnosis (HR, 1.03; 95% CI, 0.78–1.35).Conclusions: After a wide disparity in cancer survival in the first 2 years after diagnosis, Indigenous patients with cancer who survive these 2 years have a similar outlook to non-Indigenous patients. Access to services and socioeconomic factors are unlikely to be the main causes of the early lower Indigenous survival, as patterns were similar across remoteness and area-socioeconomic disadvantage. There is an urgent need to identify the factors leading to poor outcomes early after diagnosis among Indigenous people with cancer.

Susanna M Cramb BAppSc(Med Sci), Grad Cert(Sc), MPH · Gail Garvey BEd, MEd · Patricia C Valery PhD, MD, MPH · John D Williamson BA(Hons), GradCert(PublicHlth), MEpi(Clin Epi) · Peter D Baade BSc, MMedSc, PhD

Is hope or optimism required for dealing with cancer? We all have hopes and dreams. For people affected by cancer, these can be even more vivid. I (L R M) have seen many people who have taught me about the power of hope and the value of asking “What are you hoping for?” I was looking forward to playing in the next concert of the Corpus Medicorum (the chamber orchestra of the Australian Doctors Orchestra), but worried about how difficult my part looked. Then I heard that our soloist only had one lung! Sue, a professional tuba player and a non-smoker, was diagnosed with an aggressive lung cancer for which the treatment was a left pneumonectomy. Her surgeon, Phillip (P A), who happened to be a talented viola player, ran the Corpus Medicorum as a hobby, and could imagine what it might be like never to be able to play music again. No one knew if Sue would be able to play her tuba after surgery. She described how Phillip had made a deal with her; “If you can play afterwards, when you are well, you will come and play a concerto with my orchestra.” The night before her surgery she was still playing at 4 am, “in case this was the last time”. The day she got home from hospital, she waited until her family had tucked her into bed and left. Then she gingerly picked up her tuba, which weighed over 10 kg, and proved to herself that she could still play a single octave scale, if not very well. Eighteen months later, after four cycles of adjuvant chemotherapy and much hard work, Sue kept her side of the bargain: she played the very difficult three-movement tuba concerto by Vaughan-Williams brilliantly, sitting alongside Phillip as principal viola. As I played my clarinet, my thoughts strayed to the bassoon player I often sat next to in the orchestra. I hoped he might be inspired to stop smoking, instead of telling me he didn’t need to because he drank green tea. Our usual much-loved conductor of the orchestra had not been able to conduct, but was hoping to be able to come to the concert, since he had chosen the music and written the program notes. At 81, he had recovered from lymphoma but myelodysplasia was now robbing him of his energy, and he required regular blood transfusions. Everyone was delighted that he made it to the concert, sat in the front row, and got up and told the audience why and how he had constructed the program. He reduced us to tears of laughter by singing a folk song from his English childhood, “Training to be a village idiot”. He died just 2 months later. Many people describe how overwhelming and frightening it is to come into the cancer treatment centre for the first time and see so many sick people. But, over time, they come to appreciate that we are all in it together, with each person having their own stories of hopes and dreams. Health professionals often feel frustrated by patients and families whose hopes appear unrealistic, particularly the refusal to contemplate that the end of their life may be near. It is important to distinguish between hope and optimism. Hope has been defined as “a process of anticipation that involved the interaction of thinking, acting, feeling and relating, and is directed towards a future fulfilment that is personally meaningful”.1 Hope can be either generalised (with no specific goal) or particular (directed towards a specific goal), for example, our conductor hoping to be well enough to attend our concert.1 In contrast, optimism refers to having a generally positive outlook on life or “viewing the glass as half full”. The distinction between optimism and hope is that of agency — exerting control over one’s future. The classic definition of dispositional optimism is having a global expectation that good things will be plentiful in the future and bad things scarce. Optimistic individuals believe that their goals can be achieved in the face of adversity and will continue to try to attain the goals, but pessimistic individuals are more likely to give up.2 We know that the psychological coping style of people diagnosed with cancer is not associated with survival or recurrence rates.3-5 But this is not what people want to hear. The study by Schofield and colleagues demonstrating that a person’s level of optimism had no impact on their survival from locally advanced lung cancer attracted hate mail from patients around the world.4 When people with metastatic colorectal cancer on a phase III clinical trial were surveyed, neither the levels of hope nor optimism had any impact on overall or progression-free survival times, but those with high depression scores had significantly worse survival times.5 Other studies have suggested that lower optimism levels are significant predictors of anxiety and depression in patients with ovarian cancer and their caregivers.6 These studies are not intended to destroy hope, as some of the hate mail suggested. We know that maintaining some hope is very important to patients with cancer, but it is reassuring to be able to tell a distressed patient that they don’t need to be positive all the time. Having a bad day or a cry will not make the cancer grow faster. Patients can also be reassured that they need not feel guilty if they are not naturally optimistic, but depression needs to be detected and treated. We also know that the level of optimism among doctors varies. Perhaps not surprisingly, a study by Jennens and colleagues, which assessed knowledge about the benefits of palliative chemotherapy for metastatic lung cancer among doctors, showed that respiratory physicians were more like to be pessimistic about outcomes with chemotherapy, and medical oncologists were more likely to be optimistic.7 Oncologists need to be aware of their own levels of dispositional optimism and try to present a balanced view. It is important to be aware that patients with unrealistic levels of optimism, such as that displayed by our bassoon player, may be more likely to participate in risky behaviours, such as continuing to smoke after cancer treatment. Some studies also report that patients and caregivers may defer palliative care or refuse “do-not-resuscitate” orders because they equate this with giving up hope. Higher levels of hope and optimism are also reported to correlate with positive psychological changes or “post-traumatic personal growth” following a diagnosis of cancer.1 A desire to maintain hope and optimism are also described as powerful motivators to participate in phase I clinical trials, even when the chance of therapeutic benefit is low. While it is essential to ascertain that patients have sufficient understanding to give informed consent to participate in a trial, it is also important to respect that, for some people, part of their expression of optimism and hope is belief in a high chance of personal benefit. One study suggests that phase I participants with high levels of treatment-specific optimism have fewer symptoms of depression at the beginning and the end of treatment.8 Part of the art of oncology is to help people maintain hope about achieving goals that are important to them but also realistic; to hope for the best-case scenario but have a plan for the worst-case scenario. The recent model suggested by Kiely and colleagues is a useful tool for helping oncologists discuss potential survival times with specific treatment regimens in advanced cancer, in a way that is realistic but maintains hope.9 They found from an analysis of randomised controlled trials in metastatic breast cancer that the worst-case scenario for survival could be simply approximated as one-quarter of the median survival time reported in the trial, and the best-case scenario as more than three to four times the median. For some, like Sue the tuba player, playing music will be a goal in itself, but there are broader benefits. It has been shown that listening to music causes dopamine release onto the nucleus accumbens, an area classically thought to mediate reward perception and addiction. A recent review found that music interventions may have beneficial effects on anxiety, pain, mood and quality of life in people with cancer, and small beneficial effects on heart rate, respiratory rate and blood pressure were identified.10 When caring for people with cancer, a willingness to be flexible, to listen and to encourage realistic hopes can be just as important and rewarding as giving the right treatment to the right person at the right time. Be prepared whenever appropriate to do things like rearrange the chemotherapy dates to fit around special events and holidays. Encourage people to go out and live life as best they can, despite their cancer. Treat people as you would hope to be treated, and you will not go far wrong.

Linda R Mileshkin MD, FRACP, MBioeth(Mon) · Phillip Antippa MB BS, FRACS · Penelope Schofield BSc(Hons), PhD, MAPS

Could multidisciplinary team arrangements be making patient care inefficient and doctors uninvolved? A heading on the front cover of the Journal in 2011 (“Putting the love in — to patient care”) suggested that somewhere inside ...

Ian Charlton MD, MB BS, MRCGP

John Cawte had an extraordinary passion for the human condition that made him an innovator in the field of transcultural psychiatry. His mentors included anthropologist Margaret Mead and Kamilaroi Elder Bill Reid. His belief that doctors working with Indigenous people had to understand and respect the different cultural and spiritual belief systems of their patients — a given today — was revolutionary for its time. Born in Adelaide in 1925, John graduated from the University of Adelaide Medical School in 1949. From 1951 to 1963, he was Superintendent at Enfield Receiving House in Adelaide — an experience eloquently described in his memoir The last of the lunatics (Melbourne University Press, 1998). From 1955 to 1956, John studied community-based psychiatry as a Harkness Fellow at Johns Hopkins and Harvard Universities. In the early 1960s, John helped to establish the University of New South Wales School of Psychiatry and School of Public Health and Community Medicine. He held a personal chair in psychiatry and community medicine at the university until his retirement in 1991. Spending all his free time working in remote communities, John recognised earlier than most the important role of traditional healers, documented in Medicine is the law: studies in psychiatric anthropology of Australian tribal societies (University Press of Hawaii, 1974). In 1967, he developed the Arid Zone Project, establishing medical and community services centred around Bourke in western NSW. The project continued for 30 years and was a model for university–community partnerships. Through it, University of NSW academics, including Fred Hollows, formed warm relationships with Aboriginal leaders and developed holistic models of health and community services. In 1977, John founded the Aboriginal Health Worker, now in its fourth decade of national publication. An initiated member of the Warramirri clan from Elcho Island, he worked with the Elders to help record some of their healing practices — at their request — to promote cultural understanding. This project resulted in the publication of The universe of the Warramirri: art, medicine and religion in Arnhem Land (UNSW Press, 1993) and Healers of Arnhem Land (UNSW Press, 1996). In 1989, John was made an Officer of the Order of Australia, for his services to psychiatry and Aboriginal health. John died, aged 86, at Little Bay on 26 October 2011, and is survived by his five children and five grandchildren.

Rose Ellis · Max Kamien

Your guide to paediatric anaesthesia. Craig Sims, Chris Johnson. Sydney: McGraw-Hill 2011 (374 pp, $129.95). ISBN 9780071000222. THIS GUIDE aims to provide expert practical information across the breadth of paediatric anaesthesia without getting bogged down by details. The vast clinical experience of the editors (and their team of contributors) ensures that these aims are fulfilled in an informed, practical way. Chapters covering basic science and techniques relating to anaesthesia and resuscitation for children are complemented by others discussing anaesthesia for a comprehensive range of surgical subspecialities as well as for specific paediatric conditions. Care has been taken to include discussion of current issues that have generated controversy. The target audience includes trainees wanting a pithy summary of paediatric anaesthesia to inform their clinical experience and assist in preparation for exams. Both editors are examiners for the Australian and New Zealand College of Anaesthetists, which means they understand how high the bar is for those exams. The general anaesthetist with an interest in paediatrics wanting an easy-to-read update will also be well served. The book reads very comfortably, often with the tone of the consultant who has an interest in teaching, but the style does not allow for exhaustive explanation, detailed debate over alternative approaches or extensive referencing. However, it is sure to be stimulating for the career paediatric anaesthetist. The search for academic defensibility has led to some bloated, heavily referenced texts that often leave the reader wondering what they would actually do when confronted with a clinical scenario. The source of much clinical teaching is expert opinion, as a consultant works with a trainee. This volume gives expert opinion a voice. Neither online resources nor standard tomes on the topic address the needs of those this volume aims to assist. It is a great resource for trainees and anaesthetists with a paediatric interest and promises to be a springboard for discussion among paediatric anaesthetists.

Ian M McKenzie

Incorrect description of microbiological methods: In “Meningitis and pneumonitis caused by pet rodents” in the 20 February 2012 issue of the Journal (Med J Aust 2012; 196: 202-203), there was an error in the clinical record box. The third sentence of the fourth paragraph should have read: “After 24 hours of incubation, light growth of an organism was noted on blood and chocolate agars (Oxoid Australia, Thebarton, SA) which had been incubated anaerobically and in supplemental carbon dioxide.”

Lito E Papanicolas · Judith M Holds · Narin Bak

Data not correctly labelled: In “Emergency department overcrowding, mortality and the 4-hour rule in Western Australia” in the 6 February 2012 issue of the Journal (Med J Aust 2012; 196: 122-126), there was an error in Box 1 (page 123). Data under “Hospital 1” should have been shown as “Hospital 2”; data under “Hospital 2” should have been shown as “Hospital 3”; and data under “Hospital 3” should have been shown as “Hospital 1”. The sentences in the Results describing this data (page 124) should have read, “The relative mortality rates, and the absolute rate reductions for Hospitals 2 and 3 were similar for the last two periods, while Hospital 1 had less decline”, and “There was some evidence of heterogeneity of monthly decline (P = 0.03) within the three tertiary hospitals, with a smaller monthly decline in Hospital 1”. There was also an error in Box 4 (page 124). The open squares represent data for Hospital 1 (not 2); black triangles represent Hospital 2 (not 3); black diamonds represent Hospital 3 (not 1).

Gary C Geelhoed · Nicholas H de Klerk