Volume 196 Issue 6

Innovative approaches can give more Australians access to pain management. The burden of chronic pain in the Australian community cannot be ignored. The results of the Bettering the Evaluation and Care of Health (BEACH) program suggest that almost 20% of general practitioner consultations relate ...

Timothy J Semple MB BS, FANZCA, FFPMANZCA · Malcolm N Hogg MB BS, GrDip(PM), FFPANZCA

Inadequacies persist in pain management Pain in patients has long been underestimated, and sufferers poorly served and stigmatised by previous health care approaches which have lagged behind the advances and recommendations of the time. Undertreatment of acute pain in Australia has been discussed over the past 24 years in editorials1 and guidelines,2 as have proposals for improved treatment.2,3 Cancer pain is in a similar situation to that of acute pain, with 50% of adults4 and children5 being undertreated, despite effective treatment being possible for most patients. Patients with chronic non-cancer pain face a worse situation; they are frequently stigmatised,6,7 and a large majority do not gain “access to appropriate assessment and treatment of the pain by adequately trained health care professionals”.8 Absences of data on the prevalence of pain and the associated costs of treatment have conspired to make pain almost invisible as a national health priority. But epidemiological studies by Blyth and colleagues revealed that chronic pain has a prevalence in Australia of close to one in five,9,10 similar to the prevalence in the United States.7 However, a more comprehensive view of pain has finally emerged to address these problems. In Australia, a draft National Pain Strategy (NPS) was prepared with input from health care and consumer organisations, and finalised by more than 130 health care organisations, including medical colleges, consumer groups, insurers and work safety organisations, at the National Pain Summit in March 2010. The resulting NPS (http://www.painaustralia.org.au/the-national-pain-strategy/national-pain-strategy.html) is the first worldwide pain plan with goals and strategies to address inadequacies in pain management. In response to the NPS, the Queensland Government allocated $39 million to a Statewide Persistent Pain Health Services Strategy, the Western Australian Government developed a Spinal Pain Model of Care (and supported the formation of Painaustralia), and the New South Wales government indicated it would introduce a statewide pain management program. A key idea identified is the “underlying principle of chronic pain as a disease in itself”.7 This concept was initially proposed in 2004,11 based on evidence of nervous system changes in people with chronic pain, and of pain-related psychological and environmental changes. Brain imaging studies suggest structural and functional changes which are reversible if appropriate treatment can be applied.12 The International Pain Summit (IPS) (http://www.iasp-pain.org/Content/NavigationMenu/Advocacy/InternationalPainSummit/default.htm) developed a broad framework suitable for use by any country (http://www.iasp-pain.org/PainSummit/DesirableCharacteristics_Nov 2011.pdf). Perhaps the most important outcome of the IPS was the Declaration of Montréal on pain management.6 The 2011 council of the World Medical Association resolved that “people facing pain have a right to appropriate pain management” (http://www.wma.net/en/30publications/10 policies/p2). Also in 2011, the European chapters of the International Association for the Study of Pain developed a transnational document on the impact of pain (http://www.efic.org/index.asp?sub=YMQ39bfQ m3D8IA). Chronic pain is no longer relegated to the background, but is now considered a clinical entity in its own right, requiring specialised, multifaceted care that brings real improvements to patient wellbeing. But there is still some way to go before the Australian health system can deliver such improvements. The Australian NPS details the barriers to improved treatment in the current model of care. A multidisciplinary pain management network is proposed, with emphasis on the primary care level, but also on community care for information, education, self-help, and support. The NPS provides goals and 120 strategic actions, which include: destigmatisation of people with pain education for all health professionals on treating chronic pain as a chronic disease adequate management of acute pain to minimise the risk of it progressing to chronic pain a monitoring system (now introduced) for opioid prescriptions to reduce the risk of inappropriate use. These recommendations show that, in both acute and chronic pain, change is necessary, but also achievable, to deliver the best possible care.

Michael J Cousins AM, MD(Syd), DSc, FFPMANZCA

Drug subsidy recommendations should be informed by active assessment of current evidence and emerging treatments Decisions about which medicines should be subsidised by the Australian Government on the Pharmaceutical Benefits Scheme (PBS) are based on recommendations made by the Pharmaceutical Benefits Advisory Committee (PBAC) — an independent statutory body appointed by the government.1 The PBAC lists among its goals maximising the “value” that Australia derives from its health expenditure and “meet[ing] the health needs of the majority of the Australian community”.2 While the PBAC is generally thought to have in place good processes for working towards these goals, its decisions are increasingly contested by consumers, governments, clinicians and the pharmaceutical industry.3 For example, concern has been expressed about the PBS’s subsidisation of ranibizumab (Lucentis), a vascular endothelial growth factor (VEGF) inhibitor used for the treatment of wet age-related macular degeneration (AMD), when a far cheaper and probably equally effective alternative — bevacizumab (Avastin), a VEGF inhibitor listed for cancer but not for AMD — was available.4 The listing of ranibizumab, it was argued, was inconsistent with the goals of the PBAC and PBS because it is about 40 times more expensive than bevacizumab, and costs taxpayers over $200 million each year (second only to atorvastatin and rosuvastatin). A recent development has brought the issue to light once again: Bayer Healthcare and Regeneron Pharmaceuticals are, together, likely to seek PBS listing for yet another VEGF inhibitor, aflibercept (VEGF Trap-Eye), recently approved by the Therapeutic Goods Administration,5 to treat wet AMD. Although aflibercept has not been shown to have greater efficacy than ranibizumab, patients only need an injection every 2 months, compared with monthly for ranibizumab.6 But even if this did provide some benefit to patients and reduced the cost of therapy, which it is only likely to do by a small degree, it would still leave bevacizumab unlisted, and taxpayers would still be paying significantly more than they need to, overall, to cover the cost of treatment for wet AMD. One possible explanation for such a situation is that the PBAC currently relies entirely upon interested parties putting forward submissions for listing, rather than proactively seeking submissions in the public interest. In practice, this means that almost all submissions come from commercial sponsors, and the agenda of the PBAC is largely determined by the interests of the pharmaceutical industry. This is potentially problematic, because commercial sponsors are unlikely to go to the trouble of listing medicines for indications that are not commercially attractive. In theory, there is nothing to stop professional societies or consumer organisations from making their own submissions to the PBAC in the public interest. However, non-commercial organisations seldom have the resources and expertise to conduct and synthesise the research into clinical effectiveness, cost-effectiveness and the broader impacts of health technologies that is needed to make a case for PBS listing. But need this be the case? Some overseas agencies charged with health technology appraisal (eg, in the United Kingdom7 and Canada8) place more emphasis on setting their own priorities for health technology assessment than does the PBAC. We suggest that it may be possible to expand the role of the PBAC so that it has the power to, first, identify emerging or established pharmaceutical agents that might require evaluation on the basis of likely public interest (“horizon scanning”); second, invite professional societies to prepare submissions in these priority areas; and, third, provide the necessary financial and scientific support to these organisations so that they do not need to be burdened by prohibitive costs or legal liability. Orphan drug provisions, which allow the PBAC to waive submission fees for medicines that have no sponsor or are not commercially viable,9 go some way towards redressing the imbalance between commercial and non-commercial interests; but, even here, the onus is on professional and consumer organisations to initiate and prepare submissions. In this regard, it is noteworthy that, in Australia, efforts have been made to initiate horizon scanning for non-pharmaceutical health technologies through the Australia and New Zealand Horizon Scanning Network (ANZHSN), which makes recommendations to the Medical Services Advisory Committee (MSAC).10 Horizon scanning may: identify new technologies with major implications for the health system; control the adoption and use of technologies; and, identify underused technologies, as might be the case with the listing of bevacizumab for the treatment of AMD.10 Expanding the role of the PBAC would not be easy. It would probably require the establishment of a separate government-funded body that would conduct horizon scanning, make recommendations to the PBAC, seek submissions from relevant professional organisations and provide these organisations with the financial and administrative support that they would need to conduct or commission the necessary health technology assessments. A subcommittee of the PBAC, to whom the horizon-scanning body could make its recommendations, would probably also need to be formed. And even if such a mechanism could be established, questions would remain, such as: Who should set priorities for seeking PBS listings? What criteria should be used for prioritising potential listings (eg, novelty, financial impact, clinical impact, disease burden)? What processes should be used to identify areas of need (eg, specialty mapping, forecasting, public ranking exercises)? And how can such processes be inclusive and transparent?8,10 Such practical difficulties are evident in the non-pharmaceutical medical technology sector in Australia, where, despite the existence of a separate government-funded horizon-scanning body, the impetus for the MSAC to conduct a health technology assessment almost always stems from an application by a commercial sponsor.10 But, unless steps are taken in this direction regardless of such difficulties, the PBAC will be unable to reach its full potential as an agency committed to universal benefits and the systematic application of evidence-based decision making.11

Wendy L Lipworth MB BS, MSc, PhD · Ian Kerridge MPhil, FRACP, FRCPA · Richard O Day MD, FRACP

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

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

Carl von Baeyer explores realistic pain assessment when self-report conflicts with observation and context. Self-report measures of pain intensity provide important primary outcomes in randomised trials of pain-relieving interventions. Scores from numerical ...

Carl L von Baeyer PhD

Opioid use is increasing, and not just for chronic conditions or cancer Global concern about the prescribing of opioid analgesic medications (particularly oxycodone) for chronic pain is growing. In this Journal in September 2011, Roxburgh and colleagues examined the rise of oxycodone and morphine prescribing and the harm associated with opioid use.1 In the accompanying editorial, Hall and Farrell argued that this suggests that most prescribing of opioids was for chronic non-malignant pain.2 We tested this assertion using general practitioner prescribing data linked to the problem under management, and examined the characteristics of the GPs who prescribed opioids and the patients who received these prescriptions. We analysed data from the Bettering the Evaluation and Care of Health (BEACH) program (detailed methods are described elsewhere3). For the period April 2010 to March 2011, we examined encounters at which opioids were either prescribed or supplied directly to patients. We then measured changes in opioid and oxycodone prescribing rates over the past decade and extrapolated these results to all Medicare GP service items claimed nationally.4 While Roxburgh and colleagues1 reported dispensing rates as measured by the Pharmaceutical Benefits Scheme (PBS), BEACH data measure GP prescription and supply actions. Using the international Anatomical Therapeutic Chemical classification,5 we defined opioids as “N02A” and oxycodone as “N02AA05”. We determined the statistical significance of differences by non-overlapping 95% CIs. In the 2010–11 BEACH data year, at least one opioid was prescribed or supplied at 4666 of the 95 839 encounters (4.9%) recorded from 892 GPs (93.1% of the 958 GPs who participated in that year). There were a total of 5350 opioids prescribed (5237; 97.9%) or supplied (113; 2.1%) by the GP at the 4666 encounters. From this point, we shall refer to them all as being prescribed. Compared with encounters at which no opioids were recorded, those at which an opioid was prescribed were four times more likely to be claimable through workers compensation (6.8%; 95% CI, 5.7%–7.8% v 1.7%; 95% CI, 1.5%–1.9%), and more likely to be long or prolonged consultations (10.0%; 95% CI, 8.8%–11.2% v 7.8%, 95% CI, 7.2%–8.4%). Opioids were prescribed at a rate of 3.7 per 100 problems managed, accounting for 5.8% of all medications prescribed or supplied by participating GPs. There was no significant difference in opioid prescribing rates for male and female patients. Opioid prescribing was rare for young patients, rose significantly for patients aged 25–44 years, peaked among 45–64-year-old patients and stayed almost as high in older age groups. Opioid prescribing was significantly less for patients new to the practice, possibly because of their younger age (results not shown) or GP reluctance to prescribe opioids at an initial consultation (Box 1). Commonwealth Health Care Card holders had a significantly higher rate of opioid prescribing than other patients; this rate was even higher than for patients aged 65 years and older, suggesting that age was not the only contributing factor. While the prescribing rate for opioids did not differ with the age group of the GP, male GPs prescribed significantly more opioids per 100 encounters than did females (Box 2), adding to previous research evidence showing that female GPs prescribe fewer medications than males.6 Malignant neoplasms accounted for only 3.5% of opioids prescribed, and chronic non-cancer conditions for a further 43.9%, so a significant proportion were prescribed for conditions classed as non-chronic.7 Almost 60% of prescriptions were for musculoskeletal problems. The higher prescribing rate by male GPs may reflect their higher management rate of musculoskeletal problems when compared with female GPs.6 Back problems accounted for over a quarter of all opioids prescribed and was the most common individual problem for which opioids were provided. About one in 10 opioids prescribed were for osteoarthritis, provided at almost one in five occasions of osteoarthritis management. Less than 7% of opioids prescribed were for generalised multisite pain, but 72.7% of generalised multisite pain managements had an opioid prescribed (Box 2). The most common opioids prescribed were combinations of paracetamol with at least 30 mg codeine (the minimum amount for classification as an opioid). Extrapolation suggests that there were over two million prescriptions for the year, nationally. The next most common opioid was oxycodone, followed by tramadol (Box 2). Over the past decade, the total prescribing rate for total analgesics remained steady4 but the prescribing rate for opioids rose from 3.8 per 100 encounters in 2000–01 to 5.6 per 100 in 2010–11; this was particularly the case for oxycodone (up from 0.3 prescriptions per 100 encounters to 1.5 per 100 over the period). Extrapolation suggests GP prescriptions for opioids almost doubled (from 3.83 million to 6.65 million), while the number of oxycodone prescriptions increased almost sevenfold (from 0.26 million to 1.73 million). These increases reflect both the increased prescribing rate and the increase in the number of GP visits claimed through Medicare in recent years. Our results show that Hall and Farrell were correct in their assertion that chronic non-malignant pain accounted for a far greater proportion of opioid prescriptions than did malignant neoplasms.2 However, we have also shown that a significant proportion of opioid prescriptions are for problems classified as non-chronic. The classification of a problem as non-chronic does not preclude it being chronic in some patients (although it is not usually chronic), nor does it preclude involvement of severe pain over an extended period. 1 Opioid prescribing at Australian general practice encounters by patient characteristics (based on weighted data) Patient characteristics Patients at opioid encounters Patient characteristic opioid prescribing rate per 100 encounters (95% CI) Total encounters 4666 5.6 (5.3–5.9) Sex (missing data, 44) Male 2572 (44.4%) 5.8 (5.4–6.3) Female 2050 (55.6%) 5.4 (5.0–5.7) Age group (missing data, 30) 0–14 years 6 (0.1%) 0.1 (0.0–0.1) 15–24 years 152 (3.3%) 2.0 (1.6–2.3) 25–44 years 1154 (24.9%) 6.1 (5.5–6.6) 45–64 years 1729 (37.3%) 7.7 (7.1–8.3) 65–74 years 734 (15.8%) 6.7 (6.1–7.3) ≥ 75 years 860 (18.6%) 6.5 (5.9–7.0) New patient to practice (missing data, 56) 213 (4.6%) 3.4 (2.8–4.0) Commonwealth concession card (missing data, 304) 2753 (63.1%) 8.2 (7.6–8.7) 2 Opioid prescriptions or supplies (n = 5350) at 4666 Australian general practice encounters (based on weighted data) A: Characteristics of general practitioners prescribing opioids GP characteristics Opioid prescriptions GP age- and sex-specific opioid prescribing rate per 100 encounters (95% CI) Sex (missing data, 0) Male 4150 (77.6%) 6.1 (5.7–6.6) Female 1200 (22.4%) 4.2 (3.8–4.7) Age group (missing data, 17) < 35 years 275 (5.2%) 6.1 (4.6–7.7) 35–44 years 889 (16.7%) 5.1 (4.4–5.7) 45–54 years 1686 (31.6%) 5.4 (4.9–5.9) ≥ 55 years 2482 (46.6%) 5.9 (5.4–6.4) B: Health problems managed with opioids Health problem Opioid prescriptions % of this problem treated with an opioid Back problem* 1449 (27.1%) 37.9% Osteoarthritis† 517 (9.7%) 18.4% Generalised multisite pain 351 (6.6%) 72.7% Fracture† 205 (3.8%) 20.3% Prescription—all† 198 (3.7%) 6.9% Malignant neoplasms—all‡ 187 (3.5%) 10.7% Sprain/strain† 147 (2.7%) 10.5% Migraine 108 (2.0%) 18.1% All musculoskeletal 3114 (58.2%) 17.3% Chronic non-cancer conditions§ 2350 (43.9%) 4.1% C: Main opioids prescribed or supplied Opioids Opioid prescriptions Estimated number nationally in 2010–11 Paracetamol/codeine (30 mg)¶ 1730 (32.3%) 2 130 000 Oxycodone 1406 (26.3%) 1 730 000 Tramadol 864 (16.2%) 1 060 000 Buprenorphine 427 (8.0%) 530 000 Morphine sulphate 371 (6.9%) 460 000 Fentanyl 252 (4.7%) 310 000 Dextropropoxyphene/paracetamol 180 (3.4%) 220 000 * Includes back symptom/complaint, low back symptom/complaint, back syndrome without radiating pain and back syndrome with radiating pain. † Includes multiple International Classification of Primary Care – Version 2 (ICPC-2) or ICPC-2 PLUS codes (see appendix 4 of Britt et al3). ‡ Includes all malignant neoplasms except of skin, for which only melanomas are included. § Chronic conditions are defined as in O’Halloran et al.7 ¶ Paracetamol and codeine combinations with less than 30 mg codeine are not classified as opioids.

Christopher M Harrison BPsych(Hons), MSocHlth · Janice Charles BA, MSc(Med) · Joan Henderson BAppSc(HIM)(Hons), PhD(Med) · Helena Britt BA, PhD

Knowing if a patient is Indigenous can be key to improving their care An article published in 2010 in the New England Journal of Medicine advocated the collection of data on the race and ethnic groups of patients by medical practices in the United States. This was part of an initiative to computerise medical records and broaden the collection of demographic data. The authors suggested that such data could be used to detect health disparities, optimise the effectiveness of quality improvement interventions, and generate more reliable data on quality of care and outreach to patients. According to the authors, the “most common and strongest objection” was that doctors (and other practice staff) believed that “knowing a patient’s race and ethnic group is, or should be, clinically irrelevant”.1 Doctors are motivated by quality of care,1 but in this US initiative, there is an incentive for the data collection in the form of additional reimbursement. In Australia, incentives have been introduced for doctors to improve the management of infectious and chronic disease among Indigenous Australians (eg, payment for additional immunisations for children, access to health assessments at an earlier age and programs to improve access to medicines).2,3 However, these incentives have generally had limited uptake.2,3 This has been attributed to a failure to collect information on whether or not patients are Indigenous. In 2009, using a combination of an analysis of the available literature and de-novo qualitative research, we examined strategies for improving the identification of Indigenous people in general practice in order to facilitate the uptake of new measures associated with the Closing the Gap objective.4 Three issues emerged from discussions with general practitioners that have important implications for improving the identification of Indigenous patients in general practice. First, there was a clear consensus that the poorer health status of Indigenous patients indicated a need to improve their medical care. Second, in order to convince clinicians and overcome resistance to identifying Indigenous patients, the relevance of identification to quality of care needs to be demonstrated. Third, the experienced clinicians interviewed for our report could not provide any examples demonstrating how identifying Indigenous patients had improved medical care. In part, this last issue seemed to arise from the way clinicians conceptualise quality of care. Campbell and colleagues proposed a model of quality of care with two dimensions — access and effectiveness.5 Access means availability, accessibility, affordability and acceptability while effectiveness is operationalised as the processes of interpersonal and clinical care. Interpersonal care relates to the interaction between health care providers and their patients. Clinical care relates to the technical aspects of care.5 This distinction is also reflected in guidelines developed in the US to address disparities in health.6 Our research indicated that one of the barriers preventing clinicians from making the link between identifying their Indigenous patients and and quality of care is that they tend to focus on effectiveness of care rather than access to care. For example, in focus groups, none of the clinicians talked about access to additional or modified health services as a reason for identifying Indigenous patients, even though this is a cornerstone in reducing health disparities.4 However, at case study sites, we found that clinicians who did associate identification with accessing specific services or applying different sets of clinical guidelines were more confident and willing to ask patients about their ethnicity. Focusing on awareness of health services specifically available to Indigenous people, the rationale underlying these services and the associated incentives resulted in significant increases in completed health assessment for Indigenous people.4 Making the link between the collection of identifying data with quality of care is also important from the perspective of the community. Consultation with the community has revealed that, while many community members were prepared to identify as Indigenous, they did not see this information as relevant to the quality of care they received.7 Understanding that they might directly benefit from information provision was seen as further incentive for patients to identify as Indigenous. Not surprisingly, displaying promotional material in practices (including Indigenous flags etc.) significantly improved Indigenous identification. Knowing a patient’s ethnicity can help orientate clinicians to a range of issues and health service options that they might not otherwise have considered. Ensuring that identification results in improved care requires that this information (like any other aspect of a patient’s social history) is considered a starting point for enquiry that reflects the clinical and interpersonal imperatives of any interaction. Increasing the willingness of doctors to enquire about ethnicity will require a doctor more easily making the link between knowing a patient’s ethnicity and his or her quality of care. While this will involve improving doctor and patient awareness, it will also require having systems in place that enable information about ethnicity to contribute explicitly to improved quality of care.

Margaret Kelaher BScPsych, PhD · Amy Parry BA, DipPH · Susan Day BA, PhD · Yin Paradies MMedStats, MPH, PhD · Ian Anderson MBBS, PhD

To the Editor: A “real world” study of smoking abstinence caught the attention of Australian media recently, who primarily focused on the commentary that “cold turkey” was the most successful approach for quitting smoking. Alpert and colleagues1 assessed the effects of nicotine replacement therapy (NRT) alone and/or in combination with behaviour counselling in 787 adult smokers from Massachusetts who had recently quit smoking. The participation rates at baseline and waves 2 and 3 were 46%, 56% and 68%, respectively. At each follow-up, almost one-third of participants reported that they had relapsed. Relapse rates were similar, regardless of NRT participation. This contradicted the higher quit rates seen with groups given NRT compared with the placebo or control groups reported in meta-analyses.2-4 Among previously heavy smokers, the lowest relapse rate was in those who received NRT and counselling; and among previously light smokers, the relapse rate was the lowest among those who did not receive NRT or counselling. In both groups, those who received only NRT had the worst relapse rates, a finding which reinforces the importance of adjunct counselling. Participants in the Alpert et al study1 self-reported NRT use. Quit status was not validated biochemically, which fails the Russell Standard5 of criteria applied to smoking cessation trials. Information on NRT dose, adherence, administration technique and reasons for shorter courses (eg, side effects, cost or perceived lack of benefit) were lacking. The longer term impact of NRT cannot be deduced from this study. The quality and quantity of psychological support received by each participant group was also unknown. It is unclear whether the study was adequately powered, given the small numbers of patients who completed a recommended course of NRT. Moreover, differential loss to follow-up threatens the study’s internal validity. Multiple attempts are often necessary before a smoker can successfully quit. Repeated yearly access to courses of NRT, as allowed under the Pharmaceutical Benefits Scheme (a 12-week supply of patches is allowed each year for clients entering a comprehensive smoking cessation support program), may confer a benefit in the longer term. There is no evidence for the effectiveness of cold turkey cessation, especially in moderate to heavy smokers. Nevertheless, those determined to quit without pharmacotherapy or additional support should be encouraged to try cold turkey cessation.

Johnson George

“Blunderburg” revisited is a very well written review of an important, well researched and well written book, Deadly healthcare, which describes Dr Jayant Patel’s disastrous term at Queensland’s Bundaberg Hospital. The review notes that the former Federal Health Minister Michael Wooldridge pointed out that Dr Patel ...

John A Buntine

To the Editor: The editorial by Seibel1 was timely, given the promotion in February last year by the New South Wales Agency for Clinical Innovation of an osteoporotic refracture prevention model of care. The evidence presented by Seibel is compelling — osteoporosis is a serious, undermanaged and preventable problem, and there are no more excuses for not instituting refracture prevention protocols in major teaching hospitals. Not only do these programs work to prevent further patient morbidity and mortality, but they are cost-effective in reducing the burgeoning public hospital costs associated with recurrent fractures and hospital admissions. We question the delay in implementing such programs. One cost analysis showed that treating 214 patients saved $156 713 and reduced hospital stays by 270 bed-days over a 2-year period (John Van der Kallen, Rheumatologist, Hunter New England Local Health District, personal communication). More than 10 years ago, we demonstrated that minimal trauma fractures were inadequately managed and preventable, and outlined a cost-effective clinical pathway for monitoring and treating these patients when they presented through the emergency department.2-5 Had this program been instituted by the medical administration at that time, there would have been a saving over a 10-year period of more than $2 million by one major Sydney teaching hospital alone. Despite much talk and “hype” on the part of medical and allied health professionals, medical administrators and government agencies, nothing has eventuated. Unless there is an injection of funds from health departments and a willingness from hospital administrators to implement such programs, we believe that “nothing” will be what continues to happen.

David Spencer · Graydon Howe · Nicholas Manolios

To the Editor: In Australia, when melatonin is requested in doses higher than those available in preprepared formulations, in different dosage forms, or for people under 55 years of age, private prescriptions and extempora-neous preparations are often used. There is evidence of efficacy of melatonin in shiftwork-related sleep disorders, jet lag, circadian rhythm disorders, and for older people with chronic insomnia, but not for insomnia generally.1-3 There is concern over increasing use of melatonin in children, but no current data exist for actual melatonin usage patterns in Australia. In September 2010, we conducted a 2-week prospective drug use audit of melatonin prescriptions dispensed to patients by Australian compounding pharmacies. All pharmacies of the Professional Compounding Chemists of Australia (PCCA) (n = 153) received audit forms and explanatory information sheets, followed up by two telephone calls. The audit form requested patient details, the melatonin prescription, prescriber, dose amount and formulation prescribed, directions on prescription, and purpose of medication. This study was approved by the Human Research Ethics Committee of the University of Sydney. Forty-one pharmacies completed 228 audits, a response rate similar to recent pharmacy-based surveys.4 Also, 42 pharmacies estimated melatonin prescriptions in the audit period without completing patient details. The demographic details of respondents (Box) were similar to those in a previous survey of Australian compounding pharmacies.5 A total of 1463 melatonin prescriptions were reported as dispensed in the 2 weeks by 83 pharmacies (17.63 per pharmacy). In the detailed audit, the median age of people for whom melatonin was prescribed was 12 years; 56.4% (128/227) were male; the average dose prescribed was 4.3 mg ± 2.5 mg (range, 0.5 mg–20 mg); the most common reason for prescribing melatonin was to help sleep in cases of attention deficit hyperactivity disorder (ADHD); and paediatricians were the most common prescriber (43.0%; 96/223). Analysis of the non-responders showed that responders were not different to non-responders in age, sex, years of experience or pharmacy prescription volume. Extrapolating the results, 70 132 prescriptions (17.63 × 26 × 153) are estimated to be compounded in the 153 compounding pharmacies annually. This staggering figure does not include non-PCCA pharmacies, compounding hospital pharmacies, melatonin purchases without prescription (generally via the internet), or Circadin (Neurim Pharmaceuticals) prescriptions. Circadin was not included in our study as it was introduced in mid 2010 and there had been only a few sales by September 2010, and it is approved only for people over 55 years of age with primary insomnia. In conclusion, we found that melatonin was frequently dispensed, with many cases of off-label use, to both adults and children, particularly for insomnia in children with ADHD and autism. Melatonin has limited long-term safety data, and the long-term effect on gonadal development, particularly with high doses, is unclear. The efficacy and safety of melatonin in children will only be established through well designed trials of high methodological quality and sufficient sample size. Melatonin prescription details for 227 patients Demographic details of patients and prescribers Proportion or mean ± SD (range) (n = 227) Details of patients for whom melatonin was prescribed Age (years) 22.8 ± 20.9 (1–83) Age bracket 0–2 years 1.4% 3–5 years 10.1% 6–10 years 32.0% 11–18 years 19.6% 19–34 years 8.7% 34–55 years 19.6% > 55 years 8.2% Male 56.7% New prescription 29.1% (42.3% using > 6 months) Details of prescribers (from 227 audit forms*) Type of prescriber General practitioner 41.4% Paediatrician 43.2% Sleep specialist 5.7% Psychiatrist 4.8% Other specialist 3.5% Reason for prescription† Primary insomnia 26.4% Secondary insomnia 14.5% Jet lag, travelling, shift worker, CRD 12.8% Help sleep in children with ADHD 24.2% Help sleep in children with autism and behaviour problems other than ADHD 19.4% Anxiety, trauma, stress and sleep problems 3.5% Sleep problems related to pain and cancer 0.8% Sleep problems related to other comorbidities (gastro-oesophageal reflux disease, Grave’s disease) 0.8% Unsure of reason 0.8% Dose (mg) (n = 213) 4.3 ± 2.5 (0.5–20) Total amount prescribed for liquid formulations (mL) (n = 99) 55.2 ± 53.2 (5–300) Total amount prescribed for solid formulations (number of capsules, tablets, troches) (n = 123) 72.9 ± 37.9 (15–300) Repeats authorised (n = 221) 2.3 ± 2.1 (0–10) Prescription duration (months) (n = 200) 7.9 ± 9.7 (0–60) Formulation prescribed† Tablets 3.5% Capsules, slow release capsules 49.7% Liquids (suspension, oral, sublingual drops) 43.5% Troches 2.6% CRD = circadian rhythm disorder. ADHD = attention deficit hyperactivity disorder. * Some data missing on one record of 228, so 227 used for tabulation. † Percentages may not add to 100% because of some missing data, and some patients may have reported two reasons.

Jane Nikles · Victor Lo · Jennifer A Giam · Bandana Saini

To the Editor: I have read two recent reports on neurocysticercosis in the Journal.1,2 After performing a literature search for Australian cases of neurocysticercosis (PubMed search, using the terms “cysticercosis”, “neurocysticercosis” and “Australia”), I found reports of 39 patients, and the reports of 33 of these patients were published in the past two decades. This suggests that the prevalence of neurocysticercosis in Australia is rising, or that it has been increasingly recognised and reported in recent years. As expected in a developed country, more than three-quarters of the patients were immigrants from neurocysticercosis endemic areas, and the remainder were Australian residents who had travelled to endemic regions. So, although it appears that Australia is free of locally acquired neurocysticercosis, it is possible that some immigrants who developed the disease while living in Australia were not infected overseas, because some of them developed the disease more than 10 years after they migrated from their home countries. The occurrence of neurocysticercosis among people returning from endemic areas to cysticercosis-free countries shows that cysticerci may remain asymptomatic for a long time in the nervous system or may become symptomatic years (or even decades) after infection.3 Indeed, certain forms of neurocysticercosis, including calcifications, chronic arachnoiditis, subarachnoid cysts and even spinal cysticerci may manifest a long time after infection. However, the single cysticercus granuloma causes symptomatic disease in the first few months after infection;4 this form of the disease occurs mainly in people who have not had previous infection and involves an acute inflammatory reaction to the implantation of one cysticercus in the brain parenchyma. At least seven of the immigrants to Australia with neurocysticercosis had this form of the disease, and some of them developed symptoms up to 3 years after arrival, suggesting local acquisition of the disease from a contact infected with Taenia solium. Unfortunately, case reports and case series of neurocysticercosis diagnosed in Australia do not include information on whether household contacts of diagnosed patients had been tested for carriage of Taenia. Increased awareness of the mechanisms of disease transmission for neurocysticercosis will help to reduce further spread of this zoonosis.

Oscar H Del Brutto

Objectives: To document and describe outpatient persistent pain management services in Australia.Design, participants and setting: Systematic survey conducted between 1 December 2008 and 31 January 2010 of 57 services providing outpatient care to adult clients with persistent pain, plus five specialised paediatric services throughout Australia.Main outcome measures: Service structure, including funding processes; activity, including client numbers, access to specialised services (inpatient care, pain relief interventions); waiting times; and use of allied-health-professional-based pain management programs.Results: Of 68 services identified, 57 participated in the study. The median waiting time from referral receipt to initial clinical assessment for a publicly funded outpatient adult pain management service was 150 days, compared with 38.5 days for a privately funded service (P < 0.05). There was substantial variability among providers in range of services offered, including provision and duration of allied-health pain management programs. The level of service provision for children and rural patients is notably lower than that reported for urban adult constituents.Conclusions: Persistent pain management services are currently unable to meet service requirements adequately, and waiting times are more prolonged for publicly funded than privately funded services. Greater service provision is required in rural areas and for children.

Malcolm N Hogg MB BS, GrDip(PM), FFPANZCA · Stephen Gibson BBSc, PhD · Amal Helou BHlthSc(Nursing), MM(PM) · Jacklyn DeGabriele BHlthSc(Nursing), GrDip(Midwifery) · Michael J Farrell BAppSc(Phty), MSc(Gerontology), PhD

Objective: To assess whether patients receiving opioid substitution therapy (OST) in general practice cause other patients sufficient distress to change practices — a perceived barrier that prevents general practitioners from prescribing OST.Design, setting and participants: A cross-sectional questionnaire-based survey of consecutive adult patients in the waiting rooms of a network of research general practices in New South Wales during August – December 2009.Main outcome measures: Prevalence of disturbing waiting room experiences where drug intoxication was considered a factor, discomfort about sharing the waiting room with patients being treated for drug addiction, and likelihood of changing practices if the practice provided specialised care for patients with opiate addiction.Results: From 15 practices (eight OST-prescribing), 1138 of 1449 invited patients completed questionnaires (response rate, 78.5%). A disturbing experience in any waiting room at any time was reported by 18.0% of respondents (203/1130), with only 3.1% (35/1128) reporting that drug intoxication was a contributing factor. However, 39.3% of respondents (424/1080) would feel uncomfortable sharing the waiting room with someone being treated for drug addiction. Respondents were largely unaware of the OST-prescribing status of the practice (12.1% of patients attending OST-prescribing practices [70/579] correctly reported this). Only 15.9% of respondents (165/1037) reported being likely to change practices if theirs provided specialised care for opiate-addicted patients. In contrast, 28.7% (302/1053) were likely to change practices if consistently kept waiting more than 30 minutes, and 26.6% (275/1033) would likely do so if consultation fees increased by $10.Conclusions: Despite the frequency of stigmatising attitudes towards patients requiring treatment for drug addiction, GPs’ concerns that prescribing OST in their practices would have a negative impact on other patients’ waiting room experiences or on retention of patients seem to be unfounded.

Simon M Holliday FAChAM, FRACGP, FACRRM · Parker J Magin PhD, FRACGP · Janet S Dunbabin PhD · Ben D Ewald MClinEpid, PhD · Julie-Marie Henry RN, DipAppSc(Nursing) · Susan M Goode BSc(Hons), DipMgmt · Fran A Baker BMath · Adrian J Dunlop PhD, GradDipEpi

Objective: To describe values of serum prostate-specific antigen (PSA) in older men without diagnosed prostate cancer, categorised by age and country of birth, and to describe self-reported prostate cancer screening. Design, participants and setting: A cohort study (the Concord Health and Ageing in Men Project) involving a representative sample of 1434 eligible ...

Melisa J Litchfield BAppSc, MPH(Hons) · Robert G Cumming MB BS, MPH, PhD · David P Smith BA, MPH, PhD · Vasi Naganathan MB BS, FRACP, PhD · David G Le Couteur FRACP, PhD · Louise M Waite MB BS, FRACP, PhD · Fiona M Blyth MB BS(Hons), FAFPHM, PhD · David J Handelsman MB BS, FRACP, PhD

Objectives: To test whether a summative workplace-based assessment (WBA) is feasible and acceptable for international medical graduates (IMGs). Design, setting and participants: A 6-month trial with 27 IMGs from teaching hospitals in Newcastle, Australia. IMGs were assessed by 65 trained assessors from different disciplines, using blueprinted ...

Balakrishnan R Nair AM, FRACP, FRCP, GradDipClinEpi · Michael J Hensley MB BS, PhD, FRACP · Mulavana S Parvathy MB BS, FRACGP · Deborah M Lloyd BA(Hons), DipEd, PhD · Brooke Murphy BA, MA, BLegStud · Kathy Ingham DipPractMgt, DipTrainAssess, DipBusMan · Julie M Wein DipBusMan · Ian M Symonds DM, FRCOG, FRANZCOG

Findings from a Queensland coronial inquest highlight the complex clinical, ethical and legal issues that arise in end-of-life care when clinicians and family members disagree about a diagnosis of clinical futility. The tension between the law and best medical practice is highlighted in this case, as doctors are compelled to seek family consent to not commence a futile intervention. Good communication between doctors and families, as well as community and professional education, is essential to resolve tensions that can arise when there is disagreement about treatment at the end of life.

Sean Lawrence MB BS, FACEM · Lindy Willmott BCom, LLB(Hons), LLM · Eleanor Milligan PhD, BA(Hons), BSc · Sarah Winch BA(Hons), PhD · Ben White LLB(Hons), DPhil · Malcolm Parker MB BS, MHealth

Futility assessments, which are unavoidable in end-of-life settings, need to be procedurally fair. This necessitates communication between health professionals and substitute decisionmakers regarding the decision to define treatments as futile. The common law test for whether treatment should be withheld or withdrawn is the best interests test. A futile treatment is not in any patient’s best interests. While it is rare for the law to disagree with a futility determination made by health professionals, if a determination has been made without consultation and fails to reflect the patient’s best interests, the courts will overturn it. The best regulatory regimes provide for a balance between the powers of health professionals and substitute decisionmakers to make decisions for incompetent patients, and for clear and efficient dispute resolution. The Queensland law and its requirement for consent to withhold or withdraw futile treatment represents a good model of futility determination, with clear powers given to substitute decisionmakers and health professionals. Disputes concerning the treatment of incompetent patients automatically trigger the appointment of the adult guardian as the decisionmaker, and there are avenues for appeal.

Cameron L Stewart BEc, LLB(Hons), PhD

The recent 100-year anniversary of the Flexner review and the release of the Australian Medical Education Study have stimulated vigorous debate about the role of bioscience knowledge in medical education. Two critical questions define debate in this area: does bioscience learning assist in educating medical students to become competent doctors, and, if so, what are the most effective teaching and learning methods to facilitate this outcome? There is tacit acceptance that specific bioscience knowledge is critical for the development of clinical expertise; however, there are few empirical data to support this notion. Two differing theories have been proposed to describe the role of bioscience learning in the development of clinical reasoning skills — the “two-worlds” model and the “encapsulation” model. A series of studies provides support for the encapsulation model. Some medical programs are now integrating bioscience teaching into the clinical years of the course. Evidence of the effectiveness of this on outcomes, such as improved clinical reasoning, is inconclusive.

Geoffrey J McColl MEd, PhD, FRACP · Justin Bilszta BAppSci(Hons), PhD, GradCertUniTeach · Stephen Harrap MB BS, PhD, FRACP

Might science need philosophy for a precise and complete understanding of pain? We were invited to reflect upon brain–mind–pain interactions and to opine on whether modern neuroscience adequately considers pain phenomena and experience. One might suggest that adequacy is not a particularly lofty goal in this respect. However, if we were to consider whether ...

Michael A Thacker PhD, MSc, FCSP · G Lorimer Moseley BAppSc(Phty)(Hons), PhD

The winners of the MJA Dr Eric Dark Creative Writing Prize were announced at the inaugural Dr Eric Dark Memorial Dinner, held at the Fairmont Resort in Leura, New South Wales, on Saturday 10 March 2012. The prize is sponsored by Varuna, the Writers’ House and “Doctors Who ...”, a Varuna initiative to nurture creativity, innovation and advocacy in the medical profession. Named in memory of Dr Eric Dark (1889–1987), Australian general practitioner and public health activist, the MJA’s new writing competition obviously inspired many of our readers: there were 110 entries based on the theme of “splendid isolation”, with a very high overall standard. We needed all the help we could get from the creative writing experts at Varuna and our new literary editor, Dr Leah Kaminsky, to come to a final decision! The winners were Dr Susan Fox, a GP from Daylesford, Victoria, in the medical practitioners category, and Australian National University medical student Paulina Wojciechowska in the medical students category. Both winners attended a 2-day writing workshop at Varuna, led by Dr Hilton Koppe and Dr Kaminsky, on the same weekend as the dinner. The medical practitioners prize also includes a 1-week residential writing retreat at Varuna. We thank our external judges and, of course, those of you who shared your stories and insights with us. Keep writing and watch out for the announcement of next year’s competition. MJA editorial staff congratulate the winners: (L-R) Dr Tania Janusic, Dr Annette Katelaris, Dr Susan Fox, Paulina Wojciechowska, Dr Ruth Armstrong, Dr Astika Kappagoda. Eric Dark (painting): inspiring doctors to create, innovate and advocate; pictured with “Doctors Who ...” panel members Dr Michelle Cahill and Dr Hilton Koppe.

Ruth M Armstrong BMed

“The baby’s breech, come quickly.” The midwife’s voice was sharp and squeaky. She had already hung up the phone. My head, muddled with sleep, began to pound. I staggered out of bed, stripped off my pyjamas and dragged on an old shirt and jeans, pulling my straggly hair into a rough ponytail. I grabbed my jacket on the way out the door. Outside, the mist enveloped me in stillness. An early morning frost had coated the windscreen with ice. I scraped it with my hand, but it was stuck tight. I turned the car’s heater on full, put the windscreen wipers on to maximum and pulled out of the driveway. With my head out the window, I could just negotiate my way between the gum trees lining the road. The mist swirled kaleidoscopically in the headlight beams. My eyes began to water, and I wiped them with fingers numb from the cold. As I finally reached the highway, I pushed down harder on the accelerator, trying not to spin my tyres on the icy bitumen. In the birth room of the tiny rural hospital, Matildhe was emitting short, low moans in between loud pants. Julie had got Matildhe’s legs up in stirrups, but she was lopsided on the bed. I pulled her buttocks to straighten her up. I noticed my hands were shaking as I took up position between Matildhe’s legs. She smiled briefly at me with her mouth but her eyes were fixed on the wall behind me. The baby’s buttocks were visible, with thick bottle-green meconium oozing out of the anus. There was no one else to call for help; the other GP in town was on holiday. Julie was the only nurse on duty for our small country hospital, and this baby was coming soon. Julie was an experienced midwife but I doubted she had delivered many vaginal breech babies in the past 20 years or so. The only breech birth I’d ever seen was when I’d been called in to observe as a medical student; I had been one of twenty or so people in the room. I shuddered. “You can push, Matildhe”, I said, trying to stop my voice from trembling. My mind was a muddy puddle. My eyes were fixed solely on Matildhe’s perineum; everything in my peripheral vision was blackness. I could hear Julie murmuring words of encouragement to Matildhe, but I couldn’t see her. Phrases came to me from deep within, the voices of professors and tutors long gone: Hands off the breech Keep the back up Let the body hang when you see the nape of the neck I heard each of these slowly and clearly intoned in a deep and authoritative voice. I uncurled my thumbs from where I was clenching them under my fingers. Matildhe continued to pant and moan as I coaxed her through the birth. I followed the voices in my head, leaving my hands off except to assist the delivery of the baby’s arms, and ensuring its back was uppermost in the birth canal. At one point, I heard Julie murmur to me, “I can’t find the heartbeat”, as Matildhe pushed, shrieking. I clamped my teeth together, biting down hard. I now held the baby’s legs in my hands, with its head still inside Matildhe. Its blue feet hung down limply over my wrists, lolling to each side. “Come on”, I said to Matildhe. “Another push.” I placed forceps on the baby’s head, but an image came to me of a different manoeuvre I remembered from the textbooks. I placed my hand tightly over the baby’s face, my middle finger in its little mouth, my ring and index fingers on its cheeks. “Come on baby”, I cried. Finally the baby’s head slipped free of Matildhe’s vagina. I held it in my hands, willing it to take a breath. “We have to take your baby for a bit of breathing help”, I said to Matildhe. She nodded, her eyes closed, her face still. The baby was cold in my hands and rapidly turning white. I wiped it down with a towel and began the resuscitation. My hands were shiny with sweat and vernix; it was hard to get a good seal on the facemask. “Is Matildhe okay?” I called to Julie. “Bit of bleeding over here”, Julie replied. “Can I give some extra oxytocin?” I took a shallow breath before I began to bark orders at Julie for more drugs. “Your baby’s a bit flat”, I said gently to Matildhe as I continued the resuscitation. I had already started pumping the baby’s tiny chest with my index and middle fingers, trying not to break its ribs as I pressed down quickly, again and again. With the ventilation mask slipping off the baby’s tiny face with every puff of oxygen, I grabbed a small tube to insert into its lungs. My hands were shaking so much, it was hard to hold the baby’s head still to see the vocal cords. I tried once, twice, three times. Each time, the baby’s chest failed to rise as I pumped oxygen down the tube. I tried for a fourth time. My fingers felt numb. My chest was heavy. I could feel Matildhe’s eyes on us. Please, I willed. Finally, the tube was through the cords. Something shifted in the room. A flick of the baby’s eyelid. A slight movement of a tiny fingernail against the resuscitation cot. The baby had a heartbeat again. “The bleeding’s slowing”, called Julie. “Matildhe’s blood pressure is holding and her pulse is settling.” I breathed out the air I’d been holding in tight against my heart. “You have a baby boy”, I said finally to Matildhe. She smiled. “Will he be okay?” she asked, craning her head towards the resuscitation cot. “We need to wait”, I said quietly. “But he’s okay for now.” At the nurses’ station, I struggled to write my notes. Despite the blood pumping hard through my arteries at my wrist, the pen wouldn’t move on the page and my sentences didn’t make sense. I found myself staring into space on several occasions. The retrieval team were kind on the phone, asking me to repeat myself over and over. They said it would be three hours until they arrived. I paced back along the long, empty corridor to the birth room, with the sound of my footsteps bouncing off the sterile walls. Matildhe was cradling her son’s head in her hands. He was lying peacefully. “Thank you”, she said. “Thank you for everything.” As I walked outside the hospital entrance into the morning, the air opened up around me. The sun was shining through the clouds, sending rays of light high into the sky. Magpies cawed to each other across the bitumen. The window of my car was still open. I wound it up and drove home, watching the sunlight dance over the defrosting ice crystals on the windscreen.

Susan E Fox MB BS(Hons)/BA, FRACGP, FACRRM

Every morning I wake just to hear him get up and head for the bathroom. Then I fall back to sleep. Somewhat later, I wake up again. I hear him leave the bathroom and go down the stairs. Slowly. No reason to rush. Like on thin ice of a lake, one step after another. Just to make it to the other side. I fall back to sleep. When I wake again, I know it’s time for him to leave the kitchen. He does. I can hear the clonking of the dishes as he clears the table, and then the door slightly creaks. Steps across the hallway. Another creaking door opens and closes. He’s in the lounge: it’s time for the news. Later, after I have finally emerged from my bedroom, he will enumerate to me the famous people who died last night. But now I fall back to sleep and continue along twisting hospital corridors, through half-open hospital rooms. I burst into one after another. Where is she? She was here just a second ago, just then, before I woke up! I look for her in the empty beds and gurneys. Sometimes I find her. But she’s there less and less often. They say it is normal. She will be nearest for the first six months. And then not. I am still in my dream, bubbled in, when the phone starts. I pretend I’m asleep. He pretends he cannot hear it. It rings for a few minutes. When it ceases, I know there have been too many interruptions and I will no longer meet her today. Leaving behind the rusty twilight of the corridors, I struggle out of bed. When I see him, we both choose not to mention the phone. In an undertone, we make remarks about recent political unrest in some faraway countries. “What will it be?” we ask, trying to avert eyes from her picture on the left, just by the vase with pansies. Then it’s the phone again. We knew we would not be able to get away for long. It is now like some new law of nature. They ring us. A procession of acquaintances, friends and relatives. They check on us, give advice we never asked for, enquire about our daily routine. Some of them behave like they are bringing a special message. They say, “She came to me in a dream last night. She looked well. Your mother looked happy”. I know they mean unlike that day in the chapel, supine and dressed up by foreign hands from the funeral home because it is no longer our tradition to prepare our loved ones ourselves for their last journey. They tell me things as if they were some long forgotten details. What a great nurse she was. Not the fastest but so well organised that she’d always finish everything before everyone else. How patients wanted her to be their nurse. How they said, “Sister, I hope you are making my injections today”. And how she stayed in a boarding house and was afraid of mice. “I know, I know”, I answer. But what I really want is to be able to smell her hair. I go and sniff her pillow, but every day the scent becomes vaguer and vaguer. The phone rings again. He and I look at each other. “Why don’t you answer, this is your house now”, my father tells me. It is. The phone angrily buzzes as I walk out of the room. When he isn’t there, I sieve through clutter assembled on her side of their bed. There is a small urn with ambers, because they’re supposed to take away any pain you have. I try warming up a few golden pebbles in my hands but everything stays the same. There is also a basket with dried petals for better sleep. I sneak them out to my room — if I could dream for longer, I might get to see her more often. Then there is a porcelain elephant with a lifted trunk. It seems incredible that it’s no longer needed. I catch him dusting it when he thinks I’m out. I too wait. I feel that if only I could stay motionless for long enough, she will change her mind and come back. “The human was not meant for inaction”, voices in the receiver tell me. “To survive, one needs to keep busy. This is the only way.” In the evenings, we sit in front of the TV. He dozes off and wakes up to the sound of his own snoring. I work through a pile of photocopies from my Anatomy colouring book. Over and over again, like a madman, I colour the brain, the parts that failed her when we needed them to work. The parts where the blood leaked out and gave her a big scare, and neither of us were with her. The parts that gave her such a headache. The headache so big that they call it “thunderclap”. Like a loud clap of some large hands from above to announce that your time has come. Days are always fine. It’s like she went to work. At night I’m back in there again, when we hovered at her ICU bed like scared birds whose hatchling had fallen out of the nest. “Let us leave her rosary in case she wakes up when we aren’t there.” “Let us leave her some cookies in case she wakes up hungry.” “And the eyeglasses, why didn’t we think of that, if she wakes up and cannot see, she’ll be petrified.” One morning I fall asleep to wade through the brown dusk of a cave. I feel she’s somewhere around, but cannot tell her apart from the other silhouettes that populate it. They corner me in and stare. Then they drag me inside a cube as dark as a fucking Rosetta Stone: “You have to stay here. You are not meant to wander around”. I fight them tooth and nail. I will not be locked up! Never will it happen! The muddy darkness around me shifts with uncertainty, and then I feel her by me and can smell her hair. As if I had any bargaining power, I declare, “I will stay put as long as I have to, providing she holds my hand through all this time”. It is allowed. They put me in the cube but I get to clutch my fingers around hers. I sit in complete darkness. My senses tell me nothing except that my hand is out there with her, in a brownish grotto. “I don’t even get to dream”, he says when I tell him. It’s the phone again. They ask me about my dreams. I fear they will be like him, a bit envious of my little dark box. “I wish there was something to tell”, I reply. “How is he?” they ask. “He walks”, I answer. Kilometres of footpaths daily. I know he is trying to remember. He had no way of tearing her away from the cold claws of the other side; he had no way of stopping her from slipping through, all blue on her lips, and face, and arms. But now he will save her. He will pick up every memory of her that lingers in the parks and cul-de-sacs, pin the pieces together and turn them over in his head so many times that they will finally hold strong. He will close his eyes when the spring wind blows from the mountains, and she will be in it just the same as years ago when he would meet her on her way back from work, shivering from cold in an unbuttoned trench coat. He will listen to footsteps echoing on the pavement; a slightly uneven gait, yes, just like hers when she was in a hurry. He will labour like an ant in the infinity of mazes; he will not forego any avenue, will check every nook, collect every grain of sand and drag it back home. The doctors may have had to let her go, and it was not up to him to do anything. But this is the part that rests in his hands. And this time it will be different. She will not end as long as he goes on. I sometimes see him meandering around alleys of the cemetery and trails of neighbouring hills. I now know it. We are both dragging our own stones on our own ropes attached to our own necks. These are our private stones; we will guard them with our lives. Only we and no one else can rid us of them. When I look at him through the knots of twigs and their fresh sprouts, I know he sees me. He knows I see him. We gently alter our routes so that they don’t intersect. The weather is clear. Wind caresses my cheeks. I close my eyes and test how far I can walk without seeing. In the darkness I create.

Jeremy Bunker, MB BS, FRACGP, was born in Swindon, England, on 10 August 1957 and came to Sydney at the age of 2. Educated at Epping Boys High School, he completed Year 12 in 1975 and, as an accomplished pianist, initially studied at the Sydney Conservatorium of Music. During this time, Jeremy decided he wanted to pursue a medical career and enrolled in medicine at the University of New South Wales. He obtained a first class honours degree in 1983 and was awarded the University Medal, the Wallace Wurth Prize for General Proficiency throughout the Medical Course, the Paediatrics Staff Prize and the Australasian Faculty of Occupational Medicine Prize. Jeremy’s broad interests and genuine liking of people made general practice a natural career choice. After completing his residency at the Prince of Wales Hospital, he set up practice in 1986 in Ultimo with his friend and colleague Dr Kathleen Burns. In 1994, Jeremy attained Fellowship of the Royal Australian College of General Practitioners. First as a general supervisor in 1992 and then as a medical educator in 1996, Jeremy became involved in the Royal Australian College of General Practitioners Training Program, where he helped mentor many registrars in both the science and art of general practice. Over the next 15 years, Jeremy took on many academic and leadership roles in general practice. In 2003, he left the Ultimo practice and was appointed the foundation Director of Training at the Sydney Institute of General Practice Education and Training, which later became GP Synergy. At this time, he also joined the General Practice Unit at Fairfield Hospital as Staff Specialist, where he pursued his interests in chronic disease management and the integration of health service delivery. At a local level, Jeremy served as Chair and as Director of the Central Sydney GP Network. In 2010, he received the RACGP award for Best General Practice Research Article in the Australian Family Physician Journal. Jeremy’s wit, extraordinary facilitation skills, humility, openness and compassion made him a truly exceptional educator. He died in Sydney of lung cancer on 4 May 2011, and is survived by his partner Max, and his children Sophie, Tim and Amelia.

Elizabeth K Marles

EVER WANTED an update on rheumatoid arthritis (RA) without having to wade through pages of complex science or a heavy hardcover volume? If so, then Fast facts: rheumatoid arthritis is for you. This adjunct to core knowledge for the non-specialist covers all the requisite points in the smallest possible space. Blending the necessary content ...

Phillip C Vecchio

Persistent pain is a complex and multidimensional condition, so the solution should also be multidimensional, say doctors who specialise in pain medicine.

Amanda Bryan

There’s a great tradition of doctors who also write, says Dr Peter Goldsworthy, who divides his time equally between general practice and writing.

Sophie McNamara

Dr Luke Murtagh recently completed pain medicine training at Royal Adelaide Hospital. He is now qualified in both pain medicine and anaesthesia

Cate Swannell

After completing his medical training in Sydney, Associate Professor Roger Goucke practised as a general practitioner in Papua New Guinea, South Korea, Vanuatu and the UK. He then returned to Western Australia to train in anaesthetics. During the 1990s, his focus became pain medicine, and he was a key player in having it classified as a specialty. He currently works in the department of pain management at Sir Charles Gairdner Hospital in Perth and is a clinical associate professor in the school of medicine and pharmacology at the University of Western Australia.

Amanda Bryan

It can happen so easily. A staff member in a medical practice is asked to archive some old files in an awkward back cupboard. As some of the files start to fall, she reaches out to stop them and hurts her back

Kath Ryan