Volume 208 Issue 5

Specialists need broader expertise in diagnosing clinical problems

Ian A Scott · Donald A Campbell

To produce a fit-for-purpose medical workforce, Australia needs streamlined training pathways in all medical disciplines

Roger P Strasser

Screening for cognitive impairment may lead to diagnostic and treatment plans that improve patients’ safety

Lorenzo Norris · Elizabeth L Cobbs

Interpreting epidemiologic evidence: connecting research to applications. 2nd edition

John R Attia

Medical schools require selection processes that reflect the type of doctor they aim to produce

Paul Garrud

Reducing the number of tobacco sellers would make it easier for smokers to quit After four decades of intense and innovative tobacco control policies and programs, Australian governments have achieved large reductions in population level smoking rates. The focus of this comprehensive approach has been to reduce consumer demand for tobacco products through high tobacco taxes, emotive mass media campaigns, graphic health warnings on packages, subsidised smoking cessation services and treatments, smoke-free public spaces, and bans on all forms of tobacco advertising.1 However, despite early calls for restrictions on the number and location of tobacco retail outlets,2 Australia is falling behind other jurisdictions in adopting polices that seek to limit the supply of tobacco products. In the United States, for example, both San Francisco and New York have adopted regulations that cap the number of tobacco retailers in each city district, responding to the high concentration of outlets in low income neighbourhoods. The disproportionate concentration of tobacco retailers in areas of greatest socio-economic disadvantage also exists in Australia, as highlighted in the report by Melody and her colleagues in this issue of the Journal.3 In Australia, however, no policies specifically aim to reduce the currently very high number of tobacco retailers. While no jurisdiction has yet to reduce outlet density sufficiently to assess the impact on smoking rates, there is strong evidence that having fewer retailers reduces the level of impulse purchasing of cigarettes. Canadian research found that one-third of smokers, especially younger smokers, would smoke less if they simply had to travel further to buy cigarettes.4 In an Australian study, the mere sight of tobacco retail outlets prompted impulse purchases, even in the absence of point-of-sale displays of tobacco products at the checkout counter.5 Continually resisting not only the urge to smoke but also to purchase cigarettes make it incredibly difficult for smokers to quit. Tobacco control policies that make it easier and also prevent relapse are critical for reducing the more than 18 000 deaths caused by smoking in Australia each year.6 Not only are tobacco retailers more numerous in low income neighbourhoods, tobacco retailers in disadvantaged areas are also less likely to comply with regulations regarding the retail display, sale, and promotion of tobacco in stores.7 Populations at greatest risk of taking up smoking, continuing to smoke, and suffering from the health effects of smoking are therefore not only exposed to more retailers, but are also afforded the least protection by tobacco control laws. Reducing the number of tobacco outlets could be achieved by several complementary policy options. The introduction of a substantive annual tobacco licensing fee in South Australia led to an almost 25% decrease in the number of retailers in that state.8 This is in sharp contrast to New South Wales, where very few tobacco retailers stopped selling after a no-fee tobacco retailer notification scheme was introduced.9 As would-be ex-smokers report frequent relapsing when they consume alcohol, banning tobacco sales in licensed premises would both reduce the number of tobacco outlets and support quitting smokers where they are most vulnerable.5 Such a move is unlikely to encounter substantial resistance, as tobacco sales appear to be of limited financial importance to bars and clubs.10 Other options include permanently banning retailers from selling tobacco if they have been convicted of selling to underage smokers, and offering incentives that encourage retailers to stop selling tobacco, such as a subsidised program to help them sell more fresh fruit and vegetables. In 2009, tobacco outlet density was described as the “new frontier for tobacco control.”11 Nearly 10 years later, Australia — in so many ways a leader in tobacco control — has yet to develop policies for reducing its high density of tobacco outlets. It is essential to challenge the existing retail sales environment, which sees tobacco sold ubiquitously alongside everyday household items. Framing tobacco retail policies as assisting former smokers to remain abstinent is entirely in line with the highly successful approaches Australia already employs to reduce the heath burden of tobacco use. Limiting the number of outlets that sell tobacco products, reducing the concentration of outlets, especially in disadvantaged areas, and limiting which outlets can legitimately sell tobacco products must be priority policy goals. It is time for Australia to break through the tobacco retail frontier and lead the way in regulating the supply of tobacco products.

Becky Freeman · Suzan Burton

Objectives: To describe the retail availability of tobacco and to examine the association between tobacco outlet density and area-level remoteness and socio-economic status classification in Tasmania. Design: Ecological cross-sectional study; analysis of tobacco retail outlet data collected by the Department of Health and Human Services (Tasmania) according to area-level (Statistical Areas Level 2) remoteness (defined by the Remoteness Structure of the Australian Statistical Geographical Standard) and socio-economic status (defined by the 2011 Australian Bureau of Statistics Index of Relative Socioeconomic Advantage and Disadvantage). Main outcome measure: Tobacco retail outlet density per 1000 residents. Results: On 31 December 2016, there were 1.54 tobacco retail outlets per 1000 persons. The density of outlets was 79% greater in suburbs or towns in outer regional, remote and very remote Tasmania than in inner regional Tasmania (rate ratio [RR], 1.79; 95% confidence Interval [CI], 1.29–2.50; P < 0.001). Suburbs or towns in Tasmania with the greatest socio-economic disadvantage had more than twice the number of tobacco outlets per 1000 people as areas of least disadvantage (RR, 2.30; 95% CI, 1.32–4.21; P = 0.014). Conclusions: A disproportionate concentration of tobacco retail outlets in regional and remote Tasmania and in areas of lowest socio-economic status is evident. Our findings are consistent with those of analyses in New South Wales and Western Australia. Progressive tobacco retail restrictions have been proposed as the next frontier in tobacco control. However, the intended and unintended consequences of such policies need to be investigated, particularly for socio-economically deprived and rural areas.

Shannon M Melody · Veronica Martin-Gall · Ben Harding · Mark GK Veitch

Smoking rates in the Busselton community have declined and lung function has improved over the past 50 years

Arthur (Bill) Musk · Michael Hunter · Jennie Hui · Matthew W Knuiman · Mark Divitini · John P Beilby · Alan James

Objectives: To estimate the efficacy of selection tools employed by medical schools for predicting the binary outcomes of completing or not completing medical training and passing or failing a key examination; to investigate the potential usefulness of selection algorithms that do not allow low scores on one tool to be compensated by higher scores on other tools. Design, setting and participants: Data from four consecutive cohorts of students (3378 students, enrolled 2007–2010) in five undergraduate medical schools in Australia and New Zealand were analysed. Predictor variables were student scores on selection tools: prior academic achievement, Undergraduate Medicine and Health Sciences Admission Test (UMAT), and selection interview. Outcome variables were graduation from the program in a timely fashion, or passing the final clinical skills assessment at the first attempt. Main outcome measures: Optimal selection cut-scores determined by discriminant function analysis for each selection tool at each school; efficacy of different selection algorithms for predicting student outcomes. Results: For both outcomes, the cut-scores for prior academic achievement had the greatest predictive value, with medium to very large effect sizes (0.44–1.22) at all five schools. UMAT scores and selection interviews had smaller effect sizes (0.00–0.60). Meeting one or more cut-scores was associated with a significantly greater likelihood of timely graduation in some schools but not in others. Conclusions: An optimal cut-score can be estimated for a selection tool used for predicting an important program outcome. A “sufficient evidence” selection algorithm, founded on a non-compensatory model, is feasible, and may be useful for some schools.

Boaz Shulruf · Warwick Bagg · Mathew Begun · Margaret Hay · Irene Lichtwark · Allison Turnock · Emma Warnecke · Timothy J Wilkinson · Phillippa J Poole

Introduction: In December 2015, the Royal Australian and New Zealand College of Psychiatrists published a comprehensive set of mood disorder clinical practice guidelines for psychiatrists, psychologists and mental health professionals. This guideline summary, directed broadly at primary care physicians, is an abridged version that focuses on bipolar disorder. It is intended as an aid to the management of this complex disorder for primary care physicians working in collaboration with psychiatrists to implement successful long term management. Main recommendations: The guidelines address the main phases of bipolar disorder with a particular emphasis on long term management, and provide specific clinical recommendations. Mania: All physicians should be able to detect its early signs so that treatment can be initiated promptly. At the outset, taper and cease medications with mood-elevating properties and institute measures to reduce stimulation, and transfer the patient to specialist care. Bipolar depression: Treatment is complicated and may require trialling treatment combinations. Monotherapy with mood-stabilising agents or second generation antipsychotics has demonstrated efficacy but using combinations of these agents along with antidepressants is sometimes necessary to achieve remission. Commencing adjunctive structured psychosocial treatments in this phase is benign and likely effective. Long term management: Physicians should adjust treatment to prevent the recurrence of manic and/or depressive symptoms and optimise functional recovery. Closely monitor the efficacy of pharmacological and psychological treatments, adverse effects and compliance. Changes in management as a result of the guidelines: The guidelines position bipolar disorder as part of a spectrum of mood disorders and provide a longitudinal perspective for assessment and treatment. They provide new management algorithms for the maintenance phase of treatment that underscore the importance of ongoing monitoring to achieve prophylaxis. As a first line treatment, lithium remains the most effective medication for the prevention of relapse and potential suicide, but requires nuanced management from both general practitioners and specialists. The guidelines provide clarity and simplicity for the long term management of bipolar disorder, incorporating the use of new medications and therapies alongside established treatments.

Gin S Malhi · Tim Outhred · Grace Morris · Philip M Boyce · Richard Bryant · Paul B Fitzgerald · Malcolm J Hopwood · Bill Lyndon · Roger Mulder · Greg Murray · Richard J Porter · Ajeet B Singh · Kristina Fritz

Research into pharmacological and non-pharmacological therapies, including precision medicine approaches, fuel hope to reduce the proportion of patients with uncontrolled seizures

Piero Perucca · Ingrid E Scheffer · Michelle Kiley

To the Editor: Cullen and colleagues are to be congratulated on their most recent contribution to the assessment of emergency department patients presenting with possible acute coronary syndrome.1 The ability to safely reduce length of stay for a larger proportion of patients compared with the ADAPT study, pending external validation, is promising.1 The timing of the article also presents an invaluable opportunity to remind all clinicians that despite the progressive improvements in accelerated diagnostic pathways for chest pain, not all chest pain is cardiac. Accelerated diagnostic pathways, when used incorrectly, run the risk of introducing cognitive dispositions to respond such as availability bias (where a clinician may choose a diagnosis that is more familiar, such as acute coronary syndrome), omission bias (doing something easy and omitting something hard, such as ordering serial troponins instead of a computed tomography aortogram) and Sutton’s slip (settling on the most obvious interpretation of the problem).2 The potential for error is further compounded by error-producing conditions inherent in busy emergency departments, such as overcrowding, narrow time windows for assessment, surge phenomena and multiple transitions of care (eg, movement to short stay).3 It is pleasing to see that additional features were utilised in stratifying patients compared with previous accelerated diagnostic pathways.1 High-risk features such as prolonged duration and recurrence of chest pain as well as syncope may also be present in aortic dissection.4 It is possible that a patient presenting with an aortic dissection could be deemed low risk with criteria such as those in the ADAPT accelerated diagnostic pathway.5 Troponin levels do not provide a safeguard, as evidenced in a previous case where a 75-year-old woman was discharged home after two normal troponin test results only to die later the same day from progression of a type A aortic dissection.4 Aortic dissection is a lethal cardiovascular emergency that boasts significant morbidity and mortality.4 It has been astutely described as the “subarachnoid haemorrhage of chest pain”.4 Although it is rare and sometimes difficult to diagnose compared with acute coronary syndrome, clinicians are urged to include aortic dissection in their initial assessment of chest pain before implementing an accelerated diagnostic pathway.

Joe-Anthony Rotella

To the Editor: We read with interest Mendelson and colleagues’ article regarding the underutilisation of computed tomography colonography (CTC) for colorectal cancer detection in Australia.1 The authors state that “CTC is less accurate in the diagnosis of small or diminutive polyps … However, in the context of symptomatic patients, this is not relevant”.1 This overlooks the importance of detecting small adenomas as well as flat, right-sided colonic lesions such as sessile serrated polyps. It is well established that the early detection and treatment of these lesions reduces interval colorectal cancer.2 To state that these are “not relevant” in symptomatic patients is inaccurate. High definition white light with the aid of chromoendoscopy tools such as narrow band imaging in optical colonoscopy (OC) has significantly improved the ability of endoscopists to detect diminutive and subtle lesions. CTC has a markedly limited ability to detect small and flat lesions when compared with OC.3 The authors reference phase 2 data from the National Bowel Cancer Screening Program, stating that “the great majority of OCs (about nine in ten) were normal”. However, polyps were detected in 34.9% of participants.4 The authors appear to define normality as the absence of a cancer or advanced adenoma (one in ten colonoscopies). We argue that the detection of any adenoma is important and is not “normal”, as it highlights a cohort of patients at risk of colorectal cancer and requiring ongoing polyp surveillance. We also question the authors’ suggestion that a negative CTC obviates the need for OC in lower risk patients with positive faecal immunochemical test results. OC provides the opportunity to detect and treat a range of polypoid and non-polypoid colonic pathology and although a negative CTC may help exclude a cancer, it does not address the range of other potentially morbid or precancerous causes of occult faecal blood. Given these limitations, a cautious approach should be adopted if CTC is to be used as an alternative to OC in all lower risk patients.

Simon Hew · Zaid SM Ardalan

In reply

Richard M Mendelson · Tom R Sutherland · Andrew F Little

Dr Karen Wayne was awarded a Medal in the General Division (OAM) in the Australia Day Honours

Cate Swannell

Curtin University has awarded Emeritus Professor titles to two members of their Faculty of Health Sciences for their distinguished service to the university. Emeritus Professor Errol Cocks is a Professor of Disability Research, who has an esteemed career spanning 50 years. He has provided visionary services and contributions to improve the lives of people with disabilities. He has worked across Australia and internationally, and delivered innovative leadership in service development, disability theory and research to enable people to achieve citizenship and inclusion in their communities. Emeritus Professor John Mackenzie is a Professor of Tropical Infectious Diseases. He was the founder and Deputy CEO of the Australian Biosecurity Cooperative Research Centre, which was a funded CRC initiative established at Curtin. He was also awarded the decoration of Officer of the Order of Australia for service to microbiology research. http://news.curtin.edu.au/media-releases/curtin-university-honours-new-emeritus-professors/ Ben (Willem) Mol has been appointed as Professor of Obstetrics and Gynaecology at Monash University and as Consultant Obstetrics and Gynaecology at Monash Health. Professor Mol’s research is focused on the organisation of multi-centric evaluative research in obstetrics, gynaecology and fertility. “My research is focused mainly upon everyday practices—my most important task is the stimulation and innovation of evaluative research in obstetrics, gynaecology and reproductive medicine,” Professor Mol said. After studying medicine at the University of Amsterdam, Professor Mol worked in the Department of Clinical Epidemiology and Biostatistics at the Academic Medical Centre, Amsterdam (AMC). In 1999 he obtained his doctorate with honours at the Faculty of Medicine, University of Amsterdam with his dissertation entitled Evaluating the effectiveness of diagnostic tests: tubal subfertility and ectopic pregnancy. Professor Mol trained as a gynaecologist at the University Medical Centre (Universitair Medisch Centrum) in Utrecht and from 2002 he was a senior researcher in the department of Obstetrics and Gynaecology at the AMC. From 2003 to 2007, he worked as a gynaecologist-perinatologist at the Maxima Medisch Centrum, in Eindhoven, and between 2007-2013 as Professor of Obstetrics and Gynaecology at the AMC in Amsterdam. https://www.monash.edu/medicine/news/latest/articles/world-renowned-obstetrician-and-gynaecologist-joins-the-monash-health-translation-precinct Monash Health surgeon Paul Cashin has been appointed as Adjunct Clinical Associate Professor at Monash University where he lectures Year 3 and 5 medical students. Associate Professor Cashin is a senior upper gastrointestinal (GI) surgeon and is Service Director of General Surgery at Monash Health, and Director of Medical Services at Jessie McPherson Private Hospital. His research focuses on the surgical management of benign and malignant upper GI disease. Beyond his teaching and research, Associate Professor Cashin holds a number of leadership positions, including Chair, Monash Health Antimicrobial Stewardship Committee and the Comprehensive Care Committee. He is also Clinical Lead, ICS OG Cancer Optimal Care Pathway Design Committee and an elected Board Member, Australian and New Zealand Gastro-Oesophageal Surgery Association. https://www.monash.edu/medicine/news/latest/articles/monash-surgeon,-researcher-and-lecturer-receives-academic-promotion Monash University PhD candidate Dr Edmond Kwan is the recipient of the prestigious Conquer Cancer Foundation Merit Award in recognition of his research into prostate cancer. A medical oncologist, Dr Kwan is a PhD candidate in the School of Clinical Sciences at Monash Health (SCS). Dr Kwan’s research group— the Prostate Cancer Therapeutics Laboratory—designed a blood test to accurately detect androgen receptor variants AR-Vs. This test can be performed more routinely than tests involving circulating tumour cells. “We found that a significant proportion of these patients with detectable AR-Vs in their blood still benefit from these effective therapies, and therefore we would recommend against clinicians using AR-Vs as a method of choosing ideal treatments for their patients,” Dr Kwan said. https://www.monash.edu/medicine/news/latest/articles/monash-phd-candidate-recognised-for-practice-changing-research-into-prostate-cancer Professor Raina MacIntyre, Dr Anita Heywood, Dr Holly Seale, Abrar Chughtai, Bayzidur Rahman, James Wood and Tony Newall, from the University of NSW have received the Council of Academic Public Health Institutions Australia (CAPHIA) 2017 team award for excellence and innovation in public health team research for personal protective equipment (PPE) research. This award recognises a research team that demonstrates an outstanding level of achievement in public health research. CAPHIA is the peak body that represents all major Australian tertiary education institutions teaching and researching public health. CAPHIA’s mission is to improve the public’s health by advancing public health education, research and service throughout Australia. https://med.unsw.edu.au/news/leaders-public-health-recognized-caphia-awards

Cate Swannell