Volume 209 Issue 4

Newborn screening for spinal muscular atrophy may help avoid delays that might threaten the integrity and equity of access to therapy

Hugo Sampaio · Bridget Wilcken · Michelle Farrar

A certification process by an independent organisation will help tackle the threat that predatory journals pose to the intellectual community

Peter L Munk · Tyler M Coupal · Wilfred CG Peh

Network meta-analysis helps determine which treatments are viable options and which are not, but its interpretation to inform clinical decision making remains a challenge

Bram Rochwerg · Romina Brignardello-Petersen · Gordon Guyatt

A 62-year-old man with a history of bee allergy presented with severe eye pain one day after being stung in the eye by a bee

Andrew Olivo Payne · Elaine Chong

Management for psychiatrists, 4th edition

Gin S Malhi

We need to train our rural medical workforce in deeper mental health care skills

Molly Shorthouse · Louise Stone

Monoclonal antibody-based therapies are improving outcomes for patients with a range of cancers

Ian N Olver

Farmers who are younger, experience financial hardship, or are isolated are at particular risk of drought-related stress

Emma K Austin · Tonelle Handley · Anthony S Kiem · Jane L Rich · Terry J Lewin · Hedda H Askland · Sara S Askarimarnani · David A Perkins · Brian J Kelly

Relative survival for patients with B-cell non-Hodgkin lymphoma improved significantly with the introduction of rituximab

Fraser Wright · Greg Hapgood · Aravi Loganathan · Nathan Dunn · Shoni Philpot · Julie Moore · Peter Mollee

There is considerable potential for improving awareness of the health effects of smoking

Emily Brennan · Kimberley Dunstone · Melanie Wakefield

Time is ticking: administrative delays to undertaking low risk health research need to be minimised

Holly Foot · Ian A Scott · Grant M Russell · Neil Cottrell · Nancy Sturman · Christopher R Freeman

Bronchiectasis is gaining recognition as an important chronic lung disease of increasing prevalence

Simone K Visser · Peter Bye · Lucy Morgan

Integrating exercise into routine cancer care: guidance for health professionals

Prue Cormie · Morgan Atkinson · Lucy Bucci · Anne Cust · Elizabeth Eakin · Sandra Hayes · Alexandra L McCarthy · Andrew Murnane · Sharni Patchell · Diana Adams

To the Editor: As Clay-Williams and colleagues,1 we have also experienced frustration at the time-consuming, expensive2 and protracted processes required as a prerequisite before undertaking research involving identified patient data across Australia. Ironically, in the case of clinical quality registries, we collect data designed to measure quality of care so that patients may benefit from improved clinical processes. Yet, the system conspires to delay and undermine these efforts. There are lessons we have learned in developing clinical quality registries that deal with some governance issues identified by Clay-Williams and colleagues. They describe developing a legal agreement, which 21% of hospitals refused to accept. The Southern Eastern Border States (SEBS) Committee was developed with representatives of health departments from Victoria, New South Wales, Queensland and South Australia to streamline and prevent duplication of legal agreements.3 We worked with a SEBS Committee representative to develop special clauses and conditions to include in the Medicines Australia Clinical Trials Research Agreement schedule, subsequently endorsed by the SEBS Committee. Participating sites, both public and private, recognise and routinely accept this agreement. This same committee, or one with a similar construct, could determine nationally whether research is low risk to address the confused and contradictory advice given by ethics committees. We agree that standardisation of forms and processes is required — participating sites should not be permitted to introduce their own forms, causing confusion to researchers and introducing additional delays. A national information portal and repository for protocol amendments which governance officers can access to review or approve changes would be welcomed. However, while Clay-Williams and colleagues recommend that there should be no requirement for principal investigators to be employees of the participating site, we believe that for clinical quality registries, having a local principal investigator provides a vital link between researchers and local staff. As previously suggested,4 limits should apply on an acceptable time period to provide a definitive determination on study conduct within an institution, as occurs in Europe with clinical trials.5 It is unacceptable that this process lasts more than 60 days. As researchers usually have no capacity to have an impact on institutional authorisation processes, greater accountability should vest with governance offices. The current costly and dysfunctional system is stifling research in Australia.

Sue M Evans · John R Zalcberg · Ri Scarborough

In reply

Jeffrey Braithwaite · Robyn Clay-Williams · Natalie Taylor

To the Editor: In their recent article, Shulruf and colleagues1 concluded that prior academic achievement constituted the most effective means of predicting timely graduation. This outcome measure overlooks a more important graduate attribute: professionalism — the values and skills that the profession and society expects of doctors. This attribute is identifiable at admission, and it is possible to test for and select for this.2 When considering the desired outcome of satisfactory performance at junior medical officer level, the authors state that the “outcome of subsequent workplace performance, while important, is moderated by influences beyond the undergraduate environment”.1 This statement contradicts extensive literature suggesting otherwise. An erosion of vicarious empathy during medical education programs is well documented and is evident across other health care professions.3 Medical school education fails to consistently foster the development of advanced moral reasoning in medical students, with particular problems developing during the period of clinical immersion, when the influence of the “hidden curriculum” becomes evident to students.3 The above have been linked to the experience of burnout in students, which can manifest as professionalism lapses in both pre-clinical and clinical rotations.4 Papadakis and colleagues5 suggested that disciplinary action by a medical board was strongly associated with prior unprofessional behaviour in medical school. Most complaints against doctors are due to conduct, not competence. Many organisations have developed guidelines to ensure medical students adhere to professional standards. Academic and intellectual qualities alone cannot predict the ideal candidate for admission to medical school, and facets of professionalism such as moral orientation, resilience and self-control are acknowledged to contribute to one’s efficacy as a doctor. Furthermore, prioritising timely completion may promote students not seeking help, perpetuating poor performance in an effort to ensure timely completion. This perpetuates a workplace culture where people do not feel able to seek help, with significant repercussions as seen in the recent suicides of young doctors. Timely completion may indeed be predicted by prior academic success; however, attitudinal and behavioural factors are highly relevant at selection and throughout subsequent careers. An overemphasis on prior academic achievements may de-emphasise student characteristics associated with the development of professionalism.

Mark H Arnold · Jennifer Smith-Merry · Andrew S Lane

To the Editor: We are concerned about the emergence of antibiotic-resistant gonorrhoea in Australia. On 17 April 2018, the Commonwealth’s Chief Medical Officer Brendan Murphy released a statement about two cases of multidrug-resistant gonorrhoea that had recently been detected in Australia1 — at least one of these patients acquired the infection in Southeast Asia. These particular cases were similar to the one recently reported in the United Kingdom,2 where the patient was reported3 as having high level resistance to azithromycin and to ceftriaxone — the cornerstone of treatment. Also notable in that case was treatment failure using spectinomycin, with ongoing detection of the bacterium on throat swab. Treatment with intravenous ertapenem was successful. It should be of concern that gonorrhoea may only have the option of intravenous treatment, but the real problem here is that we may be on the precipice of untreatable gonorrhoea. With almost 750 000 short term resident returns every month,4 and over 200 000 of these being returns from Southeast Asia, the likelihood of repeated introductions is real. In the current context of rising gonorrhoea rates in Australia,5 further importation, transmission and spread of these resistant organisms will add substantial challenges to the disease control, especially in men who have sex with men and in Indigenous Australians. Such spread will incur significant health and health care costs for the sexual and reproductive health of Australians. There is an urgent need for all treating doctors to ensure that swabs for culture are taken for all symptomatic patients, as well as for those with an initial positive polymerase chain reaction result; for travellers to be aware of the risks of having unprotected sex; and for any multidrug-resistant patients and contacts to be referred for expert advice to ensure testing and treatment.

Brett Sutton · Mihaela Ivan

Bond University has become the fi rst in Australia to introduce emotional intelligence testing of potential medical students

Cate Swannell