Issues
Volume 214 Issue 2
Perspectives
Demographics and performance of candidates in the examinations of the Australian Medical Council, 1978–2019
Australia has relied, for most of its history, on international medical graduates (IMGs) to supplement its workforce. Since 1978, IMGs applying for general registration to practise in Australia have usually needed to pass the examinations of the Australian Medical Examining Council, or since 1986, its successor, the Australian Medical Council (AMC). The AMC provides several pathways to registration by the Australian Health Practitioner Regulation Agency (AHPRA). The route now termed “the standard pathway” consists of a two‐part assessment including a multiple choice question (MCQ) examination followed by a clinical examination. While most IMGs are required to pass both examinations, since 2007, IMGs who qualified in the so‐called competent authority countries (the United Kingdom, Ireland, the United States and Canada) have usually not been required to sit these examinations.1 The examinations have sometimes provoked controversy and political responses in various forms.2,3,4 Partly in reaction to these, but mainly through an internal process of continuous improvement, their formats have been adapted considerably over the 42‐year period. The MCQ examination assesses “basic and applied medical knowledge across a wide range of topics,” and since 2000, its pass mark has been set using item response theory.5,6 The original clinical examination used short cases and viva voces; in 2004, this was replaced by a 16‐station objective structured clinical examination (OSCE). The standard of both examinations is set at that “of newly qualified graduates of Australian medical schools who are about to commence intern training”.6 The last account of the demographic features of candidates attempting the examinations and their performance was provided in 2010.5 Now, a decade later, there have been striking changes in both these parameters, which we document and evaluate in this article. A further aim was to identify some demographic or candidate factors that might influence examination success. Source of data De‐identified information about candidates who took the MCQ and clinical examinations of the Australian Medical Examining Council and AMC, from their inception in 1978 until October 2019, were provided by the Council. It included the country and year of primary medical qualification, gender, year of birth, years of first attempt and success, and number of attempts for each candidate. From this information, we calculated the numbers of candidates, numbers of attempts, the success rate per attempt, and the proportion eventually achieving success each year. To examine the contributions of individual countries, results were aggregated into decades. Countries of training were also consolidated into regions, according to the United Nations geographical regions report, last updated in 1999 (Supporting information, table 1).7 Ethics approval was obtained from the University of Melbourne Human Research Ethics Committee (ID: 1750338.3). Demographic features of candidates Over the 42‐year period, a total of 35 699 candidates from 153 countries sat the MCQ examination, 16 588 (46.7%) of whom were female (Box 1). The median age of all candidates at their first MCQ attempt was 32 years (interquartile range [IQR], 28–37 years; range, 20–73 years). The clinical examination was attempted by 20 494 candidates. Their demographic features were similar to that of the candidates for the MCQ. Box 1 shows the number of candidates for the MCQ and clinical examination for the top ten countries of primary medical qualification at each examination. The data for countries grouped by UN region are provided in the online Supporting information, table 1, and data for candidates from all individual countries (except those with very few candidates) are provided in the online Supporting information, table 2. South Asia was the region contributing most candidates, with just under half the total — predominantly graduates from India, Pakistan and Sri Lanka. Next in order were those from South‐East Asia and North Africa. Candidate performance From a low base until about the year 2000, there was a marked increase in candidates attempting each examination, reaching a peak in 2009 for the MCQ and 4 years later for the clinical examination (Box 2 and Box 3). Although the candidate numbers declined slightly after these peaks, they remained almost fourfold higher than in 2000. The pass rate at each attempt in the MCQ examination fluctuated, with most year‐to‐year variations not reaching statistical significance. However, overall pass rates per attempt increased over time, from a low of 28% in 1987 to a high of 66% in 2018. Some candidates showed great persistence: 86 attempted the examination ten or more times. As with the MCQ examination, the pass rate in the clinical examination increased between the 1980s and the 2000s, reaching a peak of 64% in 2007. However, between 2011 and 2012 it fell by more than 10%, followed by a further decline; and for the past 5 years (excepting 2019 when data were incomplete), it has remained just above 30%. Nevertheless, most candidates who persevered managed to pass after one or two further attempts. As with the MCQ, there were a few who found it much more difficult. Five or more attempts were made by 621 candidates (3.0%), 144 of whom have not yet succeeded. Pass rates by individual country are provided in the Supporting information, table 3. In the MCQ, during the past three decades, women had a higher pass rate per attempt and overall, although the magnitude of the difference (about 3%) was small (Box 4). In the clinical examination since 1990, women had both a higher pass rate and fewer attempts. In the most recent decade, the difference in pass rates was substantial (+12%). Box 5 and Box 6 show the pass rates in the MCQ and clinical examinations, respectively, graphed against candidates’ age and the interval (recency) since their medical graduation. There was a marked decline in success with both increasing age and interval since graduation; this was more marked in the clinical examination. While the number of candidates who were 55 years or older was small (245; 1.2% of total), their pass rate was one‐third that of candidates aged 20–29 years, and only 45% of the older group eventually passed. Commentary Before 2000, the number of IMGs attempting AMC examinations annually was usually less than 300 and never exceeded 600. However, between 2000 and 2018, candidate numbers increased more than threefold to an annual mean of 1003 during a period when the number of all Australians born overseas increased only from 4.5 to 7.3 million.8 Some factors likely to have contributed to the increase in candidates were removal in 1998 of the requirement to be an Australian citizen, and offering the computer‐delivered MCQ examination from 2005 in several centres outside Australia. A further increase in candidates for the MCQ examination resulted from the 2006 decision by the Council of Australian Governments that all IMGs with limited or temporary registration with the individual state medical boards should pass that examination. The peak in attempts at the clinical examination in 2013 followed the establishment of the National Registration and Accreditation Scheme in July 2010 and the requirement that limited registrants (non‐specialists) demonstrate progress towards full registration (including passing the AMC clinical examination where applicable). It is important to note that these data are specific to those sitting the AMC examinations. They give only a partial picture of medical immigration over this period. Firstly, they do not include IMGs who were registered as specialists by the various states, and subsequently by AHPRA on advice from specialist colleges. Secondly, until 1992 the Medical Acts in all Australian states allowed graduates from the UK (and usually Ireland) exemption from the need for further examination. For the next 15 years, generalists from those countries usually had to take the AMC examinations, but from 2007 they were again exempted (along with IMGs from Canada and the US) when the AMC introduced the competent authority pathway. The overall success rate in the MCQ examination increased significantly from the 1980s. The AMC made several changes over that time to increase reliability and fairness. One was altering question types to formats less dependent on English language skill; another was publication of annotated question banks to assist candidates in their preparation.5,6,9 From 2000, the pass mark has been set by criterion‐referenced methodology. A further refinement from 2011 was administering the MCQ examination in computer‐adaptive format, where the difficulty of items is adjusted in real time according to a candidate's performance, considered to increase fairness and precision.10 A factor likely to have contributed to the recent lower pass rate in the clinical examination (Box 3) is the removal of nearly all candidates from the competent authority countries. Up till 2009, UK graduates had the highest pass rate in this examination (Supporting information, table 3), and their removal from the pool would inevitably lower the overall rate. However, the decline since 2010 cannot be fully accounted for by this since competent authority candidates comprised less than 10% of the 2000–2009 total. Thus, other factors affecting the most recent cohorts of candidates (eg, the changing mix of parent countries) are likely to have contributed. Many IMGs must often overcome hurdles less likely to be faced by those from competent authority countries. These include adapting to an unfamiliar health system, developing fluency in English, preparing for the examinations while under time pressure from short‐stay visas, and needing to support themselves with sometimes long hours of work outside the health system.11 It is possible, though, that changes in the format or content of the OSCE have also contributed. The differences between the results for women and men in the MCQ should not be overplayed, since the magnitude was small. Others have found little gender effect in postgraduate written examinations in the UK and the US.12,13 However, the outperformance by women in the clinical examination, particularly in the past decade, is more striking. Those findings have been seen elsewhere. Women perform better than men in Step 2 of the United States Medical Licensing Examination.14 Female overseas‐trained doctors were twice as likely as males to pass the UK Federation of Royal Colleges of Physicians’ Practical Assessment of Clinical Examination Skills (PACES) at their first attempt.15 The PACES examination has many similarities to the AMC OSCE, with communication skills important for both. Female superiority in patient–doctor communication has been documented previously,16 and may partly explain the present findings. That performance in the MCQ deteriorated with both age and time since graduation is not entirely surprising: the examination tests knowledge in all domains of medicine, including some of the basic sciences. The longer since these were studied, the more difficult it might be to pass questions based on them, especially for IMGs who had practised as specialists in their original country. More unexpected was the much lower performance in the clinical examination by older candidates. Clinical experience might have been expected to give them an advantage, but this does not appear to have been generally so. We have been unable to find exactly comparable data from medical licensing examinations in other countries. A UK retrospective analysis observed that international graduates aged more than 37 years actually performed better in a postgraduate paediatric examination.17 However, a US analysis noted a negative correlation between age when first certified by the American Board of Internal Medicine and the American Board of Surgery and subsequent success in maintenance of certification examinations.18 Since 1978, these examinations have played an important role in informing the credentialing of generalist IMGs by state medical boards and now the national board. This article has documented substantial changes over the four decades in the demography of candidates, and some factors that were associated with their success in the examinations. The information will be of interest to health planners, but more particularly to those IMGs who have passed through the process and others who are contemplating it. Many rural health services still struggle to meet their workforce needs and rely heavily on doctors who have migrated to practise medicine here.19 Australia continues to owe a debt to its immigrant doctors. Box 1 – Multiple choice question (MCQ) and clinical examinations: numbers of candidates, top ten countries* Country of training 1978–1989 1990–1999 2000–2009 2010–2019 Total MCQ examination India 351 496 2619 2483 5949 Pakistan 32 113 1007 1838 2990 Sri Lanka 159 246 1005 1394 2804 Egypt 179 356 375 1171 2081 Bangladesh 16 99 777 1107 1999 Iran 32 34 664 1197 1927 Philippines 83 182 646 714 1625 China 4 219 641 745 1609 Myanmar 21 66 485 772 1344 Iraq 8 160 420 602 1190 Total all countries 1864 3859 12 722 17 254 35 699 Clinical examination India 190 392 1059 2074 3715 Sri Lanka 101 194 399 960 1654 Pakistan 13 59 342 1168 1582 Bangladesh 7 53 483 831 1374 Iran 8 27 263 688 986 China 0 109 398 475 982 Egypt 78 296 195 375 944 Myanmar 5 45 175 661 886 Philippines 11 104 198 507 820 Iraq 2 85 303 358 748 Total all countries 897 2588 5806 11 203 20 494 * By total number of candidates. Data are listed by the year each candidate first attempted the examination. Many candidates made multiple attempts. International medical graduates trained in the United Kingdom and Ireland were exempted from the Australian Medical Council examinations by most states until 1992. Since 1997, few candidates from the competent authority countries (UK, Ireland, Canada and the United States) were required to take the examinations. Box 2 – Number of candidates and success rate per attempt in the multiple choice question examinations since 1978, and total number of attempts by candidates each year* * Data for 2019 truncated at October. Box 3 – Number of candidates, success rate per attempt and total attempts in the clinical examinations since 1978, and total number of attempts by candidates each year* * Data for 2019 truncated at October. Box 4 – Influence of gender on examination success* Period Gender N Total attempts Total passes Mean (SD) attempts Pass total (%) Pass/attempt (%) MCQ examination 1978–1989 Female 568 1299 412 2.29 ± 1.84 72.5% 31.7% Male 1142 2431 817 2.13 ± 1.68 71.5% 33.6% 1990–1999 Female 1691 3279 1434 1.95 ± 1.57 84.8% 43.7% Male 2164 4275 1729 1.98 ± 1.71 79.9% 40.4% 2000–2009 Female 5438 8666 4813 1.59 ± 1.14 88.5% 55.5% Male 7287 11846 6192 1.63 ± 1.32 85.0% 52.3% 2010–2019 Female 8891 12238 7378 1.38 ± 0.86 83.0% 60.3% Male 8365 12041 6845 1.35 ± 0.85 81.8% 56.8% Clinical examination 1978–1989 Female 257 503 233 1.96 ± 1.58 90.7% 46.3% Male 543 1085 471 2.00 ± 1.47 86.7% 43.4% 1990–1999 Female 1156 2037 1084 1.76 ± 1.07 93.8% 53.2% Male 1432 2917 1243 2.04 ± 1.35 86.8% 42.6% 2000–2009 Female 2636 3662 2428 1.39 ± 0.82 92.1% 66.3% Male 3170 5036 2772 1.59 ± 1.08 87.4% 55.0% 2010–2019 Female 6150 9802 4535 1.59 ± 1.03 73.7% 46.3% Male 5053 9184 3132 1.82 ± 1.30 62.0% 34.1% * MCQ = multiple choice question; SD = standard deviation. * The Australian Medical Examining Council did not list candidates’ gender in a few instances during the first decade. Box 5 – Australian Medical Council multiple choice question (MCQ) examination, 1978–2019: pass rates versus (A) age and (B) recency (interval since graduation) in the year when candidates first attempted the MCQ (all countries combined)* Spearman rank order correlation: (A) r = −0.964, P < 0.001; (B) r = −0.983, P < 0.001. Box 6 – Australian Medical Council clinical examination, 1978–2019: pass rates versus (A) age and (B) recency in year when the examination was first attempted* * Spearman rank order correlation: (A) r = −0.950, P < 0.001; (B) r = −0.950, P < 0.001.
Neville D Yeomans · Jillian R Sewell · Philip Pigou · Stuart Macintyre
We need a model of health and aged care services that adequately supports Australians with dementia
Australian services for people with dementia are fragmented, challenging to navigate and hard to access The coronavirus disease 2019 (COVID‐19) pandemic has led to reflections around reforming Australia’s health care system.1 In view of future reforms, this article is intended to provoke policy and clinical discussion regarding what an effective, efficient model of service delivery meeting the needs of people with dementia and their families may look like. The opinion presented here belongs to the members of the National Health and Medical Research Council (NHMRC) National Institute for Dementia Research Special Interest Group in Rehabilitation and Dementia. For the purposes of this article, we define a model of service delivery as the systemic framework through which services are organised, accessed, funded and delivered. Services in Australia for people with dementia are inadequate Dementia is the leading cause of disability, the second leading cause of death in Australians aged over 65 years, and the leading cause of death in women in Australia. In 2020, it is estimated that Australia will spend $8.1 billion on health care and $3.8 billion on social services for people with dementia, with a further $6.1 billion in lost productivity and earnings.2 Australian services for people with dementia are often fragmented, challenging to navigate and hard to access.3 It can be difficult for people with dementia to obtain a diagnosis, there are limited health and social services for early dementia, including post‐diagnostic support, and existing services are often poorly coordinated.3,4 Services face workforce shortages and gaps in worker knowledge and skills related to dementia.5 People with dementia and their care partners have called for support and information after diagnosis; flexibly delivered services that support their quality of life, including meaningful activity; and inclusion in decision making.6 A philosophical and societal shift in thinking is required: from provision of care to enablement, where people living with dementia are empowered to continue to direct their own lives.7 We are not meeting the human rights of people with dementia to health care Australia does not currently meet the human rights of people with dementia to timely and accessible health services of appropriate quality or to participation in health care decisions.4,6 The right to quality health care is affected by the variable delivery of best‐practice dementia care by memory clinics,8 acute hospitals,9 primary care,10 and community and residential aged care,11 perhaps because the role of each of these is unclear. Australia’s systems and context Australia has a long‐standing commitment to a universal health system and to long term care for older people. The health and aged care systems were developed largely in isolation from one another and have failed to resolve conflicts around medical and social models of care for older people. Health care systems are slowly adapting to this era of chronic disease and population ageing,12 but person‐centredness and integration within and across acute, primary, community and residential aged care systems remain a challenge.11 Principles underpinning models of service delivery for Australians with dementia Members of our group reviewed principles underpinning services such as the Department of Health Aged Care Sector and the Council of Australian Governments National Disability Insurance Scheme. 13,14 We reached a consensus that the following principles should apply to models of service delivery for dementia that: has an overarching objective to maintain positive health and wellbeing of people with dementia, their care partners and families; recognises dementia as a disability, consistent with the World Health Organization Convention on the Rights of Persons with Disabilities, and promotes autonomy, social participation and rehabilitation; takes into account the cognitive disability of people with dementia in accessing support and being a partner (along with their families) in planning care through supported decision making; is delivered by a multidisciplinary workforce who have knowledge and skills around dementia; is accessible for all people with dementia and care partners; is ongoing, cost‐effective and economically sustainable; is needs‐based, not capped according to central budgets; is integrated for seamless experience for people with dementia and care partners, within and across primary, acute and subacute health care, aged care and social services; and is evidence‐based. Review of possible models of service delivery for dementia We identified models of service delivery for dementia and other chronic conditions based on input from our broad authorship group and searching the peer‐reviewed and grey literature. These models are described in the and considered in terms of fit with the principles above. We included care pathways even though these are not a model because they are often used to improve service access and integration. In addition, we map the models of service delivery to our health and aged care funding systems, illustrating the limited integration across systems (Box). Learnings from these models: The self‐directed approach places the needs of the person with dementia centrally but may require processes to ensure supported decision making. Information is also needed regarding the risks and benefits of self‐management versus budget holding or service provider management, integration with health care, and consideration of costs. Case management improves outcomes for the person with dementia and could be flexible and needs‐based if sufficient workforce and integration across systems could be achieved. However, it would require a significant investment of resources. Strengths of the primary care chronic disease management model include equity and familiarity of access, and care coordination by a trusted health professional or practice team. Weaknesses include the limited amount of treatment (ie, current cap of five subsidised allied health consultations per year), limited dementia management skills in some general practitioners and practice nurses, and often poor integration with aged care. Shared and stepped care models may be able to be adapted to combine the strengths of the primary care chronic disease and specialist approaches, but integration of aged care services would be essential. Stepped care may not be the best fit for people diagnosed with dementia in other settings (eg, hospitals or residential care facilities). A specialist team approach with a skilled workforce is well equipped to provide evidence‐based care, although this is unlikely to be made universally accessible (eg, in regional areas) and may be cost‐prohibitive. Navigator and care pathway approaches may increase access to services, but do not improve the type or amount of supports or treatment available. None of the models of service delivery that we identified in Australia or overseas appear to sufficiently meet the principles above. There is no clear recognition that dementia is both a social and a medical issue. Australia has moved strongly in the direction of recognising the rights of people with disabilities including social participation but there is limited appreciation of this need in respect to most models for dementia. Recognition of dementia as a disability is only apparent in the self‐directed care model. The models also do not sufficiently consider the needs of the person with dementia and care partners together. Barriers to all the current models are the poor dementia knowledge and the tendency to stigmatise people with dementia by many health and aged care professionals.15 Next step: investment in model development We need to combine desirable elements in the primary care chronic disease management, case management, and specialist multidisciplinary care models. Having a system with a point of entry through primary care could maximise accessibility. Having a dementia and aged care specialist (eg, dementia nurse or case manager) working with GPs would bring the required skills and knowledge. A close partnership with a specialist multidisciplinary team (in person or using telehealth) would assist with diagnosis, ongoing support and management of complex cases, with possibly the most complex cases being managed by the specialist team. There needs to be investment to develop a model that is accessible, integrated and effective in meeting the needs of people with dementia. Our service delivery model needs to be co‐designed with people with dementia, their care partners, health, aged care, and state and federal government stakeholders, including treasury departments. Public health, social equity and human rights principles should underpin model design. Research is needed to explore proposed models and their elements with current recipients, service planners and providers. Methodologies may include service mapping; gap, risk and unintended consequence analysis; and economic modelling. Potential models will then need to be tested in a coordinated series of pilots and rigorous health system trials building towards national implementation. History has shown that piecemeal demonstration pilots and practice improvement projects will not bring about large‐scale change. Australia’s last National Framework for Action on Dementia 2015–2019 has just lapsed.16 Our new framework should include the development of a model of service delivery that considers accessible pathways to diagnosis and effective and seamless ongoing support of health and wellbeing throughout the course of dementia. Box – Current service funding structures and service models for Australians with dementia GPs = general practitioners; NDIS = National Disability Insurance Scheme; NGOs = non‐government organisations; PHNs = primary health networks.
NHMRC National Institute for Dementia Research Special Interest Group in Rehabilitation and Dementia
Rethinking pharmacological venous thromboembolism prophylaxis in minimally invasive gynaecological procedures
Although VTE risk in minor gynaecological procedures is low, a systematic approach to prophylaxis is necessary
Esther MC Johns · Alex Ades · Pavitra Nanayakkara
Putting the “good” into Good Clinical Practice
Current Good Clinical Practice guidelines are bureaucratic and should align with less burdensome examples of international trial policy
Tanya Symons · Steve Webb · John R Zalcberg
Medical education
How to use imperfect tests for COVID‐19 (SARS‐CoV‐2) to make clinical decisions
If we had a test that was both 100% sensitive and 100% specific for COVID-19, we would have no false-positive and no false-negative results
Katy JL Bell · Fiona F Stanaway · Les M Irwig · Andrea R Horvath · Armando Teixeira‐Pinto · Clement Loy
Editorials
The role of mathematical models in developing policies for controlling COVID‐19 transmission
Models must be supported by a range of qualitative and quantitative assessments and tools to translate their projections into policy
Allen C Cheng
Health and climate change MJA–Lancet Countdown report: Australia gets another failing grade in 2020 but shows signs of progress
At the end of 2019 and into 2020, catastrophic fires in Australia consumed homes, lives, wildlife and land. Just as the fires subsided, Australia, like the rest of the world, faced another emergency — the COVID‐19 pandemic.1 It is instructive to reflect on lessons from the health disasters of the past year. Following publication of The Lancet Countdown on health and climate change,2 the Medical Journal of Australia (MJA)–Lancet Australian Countdown on health and climate change was published in December 2020.3 This annual report on health and climate change in Australia is in its third year and comprises the efforts of five Australian institutions, in collaboration with University College London, facilitated by a partnership between The Lancet and the MJA.3 All three reports make sobering reading.3,4,5 2019 was Australia’s hottest and driest year on record, with average temperatures 1.52°C above normal and mean rainfall 40% below the 30‐year average before 1991.3 Australia’s 2019–20 bushfires burned 10 million hectares, directly killed 33 people and destroyed more than 3000 homes.6 Smoke engulfed major capital cities, including Sydney and Melbourne, and smoke exposure caused an estimated 417 excess deaths and over 3000 hospital admissions.3,7,8 The catastrophe laid bare how extreme heat is a severe health risk.9 The ecological damage of the bushfires was enormous;6 almost 3 billion animals were killed or displaced, and natural systems of biodiversity and species were harmed, perhaps irreparably.6 Severe storms and floods followed the fires, bringing further damage. Insured losses from disaster events totalled AU$3.7 billion in 2019, with bushfires accounting for $2.2 billion, although the total costs of the so‐called Black Summer fires could be much higher.3 The devastation of the bushfires led the Australian Government to establish the Royal Commission into National Natural Disaster Arrangements. The final report of the Royal Commission in October 2020 identified climate change as a major driver and acknowledged the risk of increasing extreme weather events.6 However, the Royal Commission’s scope was limited to disaster management (mitigation, preparedness, response and recovery) and did not discuss root causes of climate change such as the fossil fuel industry’s grip on Australia’s energy infrastructure, economy, political will and public discourse. Australia has no decisive national plan to address climate change and its health consequences.3 The Australian Government is a signatory to the Paris Agreement, but has declined to affirm net zero carbon emissions by 2050 — or by any date — unlike the UK and the EU; China has also committed to this goal by 2060. Unlike this inadequate approach to the climate crisis, Australia’s response to COVID‐19 was rapid and effective, despite facing the pandemic while the last bushfires still burned.10,11 Strong community engagement with public health measures enabled effective management of the first and second waves, making Australia’s, together with those of New Zealand and parts of Asia, among the more successful responses to COVID‐19.12 Key to this success was the valuing by governments of science and data to guide decision making. The pandemic forced politicians from across the Australian political divide to prioritise the evidence and expertise of the medical, scientific and public health communities over the voices of conservative commentators, business leaders and politicians. Tough political decisions were made for the sake of the nation’s health. This bipartisan, science‐based approach is a model for the future management of climate change, if implemented alongside an appropriate national plan. Australia’s First Nations people, who are at increased risk of poorer health outcomes than the general population in a pandemic, have provided exceptional leadership in their response to COVID‐19, resulting in low rates of virus transmission thus far.13,14 The country’s Indigenous populations are also disproportionately vulnerable to future climate change natural disasters.6 Since the traditional owners of Australia’s land are effective, resilient caretakers of the country and experts in land and fire management, the Royal Commission recommended federal, state and territory governments learn from and engage with their expertise.6 As another initiative capitalising on local expertise, The Lancet Countdown’s regional report in partnership with the MJA has led to improved performance indicators for climate change. For example, the Australian Countdown reports3,4,5 developed the wildfire (bushfire) indicator, which the Countdown is now adopting globally. These data have encouraged more direct engagement with Australian policy makers and health professionals, and provided direct funding guidance to Australia’s National Health and Medical Research Council (NHMRC), which is expected to translate into funding changes in 2021.15 Australia’s leading medical and nursing bodies have recognised climate change as a health emergency.8 Governments of states and territories have committed to zero net carbon emissions by 2050, with climate change adaptation plans incorporating the health sector and investment in renewable energy.3,16 With the unprecedented disasters of 2020, public sentiment in Australia has shifted, as more people realise climate change is here now, with impacts for all. In November, the Climate Change (National Framework for Adaptation and Mitigation) Bill 2020 was introduced into the Australian federal Parliament by the independent Member of Parliament Zali Steggall, with wide public support, including from the Australian Medical Association and more than 100 major businesses.17 The outcome of the 2020 US election and the environmental platform of the incoming administration of Joe Biden coincides with a more positive stance in Australian politics towards addressing climate change.18 In the MJA–Lancet Countdowns,3,4,5 Australia embraced the importance of local data, local experts and local stories. A regional China Countdown report is also being published in parallel this year,19 and in 2021, there will potentially be Countdown collaborations for the EU, South America, the US, and Small Island Developing States. Looking forwards, Australia should as a priority establish a National Health and Climate Change Centre within the Australian Government Department of Health to develop a National Plan for Health and Climate Change with real‐time monitoring. As well as preparing to manage climate‐related health sequelae, Australia’s health sector should commit itself nationally to zero net carbon emissions by 2040 in line with the National Health Service in the UK, preferably with the states and territories responsible for implementing evidence‐based interventions.20 Reducing unnecessary medical tests and procedures will serve to reduce carbon emissions, health care costs and harmful outcomes.21 Research funded by the NHMRC and the Medical Research Futures Fund should guide better ways to efficiently reduce the carbon footprint of Australia’s health care services. Australia has an obligation under the Paris Agreement to submit enhanced nationally determined contributions by the end of 2020. We recommend that the Australian Government agree to a target of a 50% reduction in carbon emissions by 2030, which is what is likely required to limit global warming below 1.5°C.3,4,5 The Australian Government needs to recognise that fossil fuels are no longer a sound investment and join with other jurisdictions that are committed to shifting completely to renewable energies to make that sector the most cost‐effective for jobs and energy security. In Australia the crises of 2020 were unprecedented, shocking and predictable. We remain hopeful all Australian governments will aspire to the leadership shown nationally with the COVID‐19 pandemic and effectively deal with climate change now, understanding the major health risks of neglecting this issue. We anticipate health and corporate leaders, as well as leaders across other sectors, will continue to drive change. Interrogating successes and failures nationally in the MJA–Lancet annual Australian Countdown provides a robust model for monitoring and positive change. The flow on benefits to health and wellbeing, the economy and society from such change will be enormous. This article is co-published in The Lancet.22
Nicholas J Talley · Fiona J Stanley · Tamara Lucas · Richard C Horton
Is the UCAT appropriate for selecting undergraduate medical students?
Non-academic personal qualities are also desirable in doctors: higher mental abilities, empathy, ethics, creativity
David A Powis · Don Munro · Miles R Bore
Research
Modelling the impact of relaxing COVID‐19 control measures during a period of low viral transmission
The consequences of removing some restrictions may not be apparent for more than two months
Nick Scott · Anna Palmer · Dominic Delport · Romesh Abeysuriya · Robyn M Stuart · Cliff C Kerr · Dina Mistry · Daniel J Klein · Rachel Sacks‐Davis · Katie Heath · Samuel W Hainsworth · Alisa Pedrana · Mark Stoove · David Wilson · Margaret E Hellard
The change from UMAT to UCAT for undergraduate medical school applicants: impact on selection outcomes
Objectives: To assess whether the change from the Undergraduate Medical and Health Sciences Admissions Test (UMAT; 1991–2019) to the University Clinical Aptitude Test (UCAT) for the 2020 New South Wales undergraduate medical degree intake was associated with changes in the impact of sex, socio‐economic status and remoteness of residence, and professional coaching upon selection for interview. Design, setting, participants: Cross‐sectional study of applicants for the three NSW undergraduate medical programs for entry in 2019 (4114 applicants) or 2020 (4270); 703 people applied for both intakes. Applicants selected for interview were surveyed about whether they had received professional coaching for the selection test. Main outcome measures: Scores on the three sections of the UMAT (2019 entry cohort) and the five subtests of the UCAT (2020 entry); total UMAT and UCAT scores. Results: Mean scores for UMAT 1 and 3 and for all four UCAT cognitive subtests were higher for men than women; the differences were statistically significant after adjusting for age, socio‐economic status, and remoteness. The effect size for sex was 0.24 (95% CI, 0.18–0.30) for UMAT total score, 0.38 (95% CI, 0.32–0.44) for UCAT total score. For the 2020 intake, 2303 of 4270 applicants (53.9%) and 476 of 1074 interviewees (44.3%) were women. The effect size for socio‐economic status was 0.47 (95% CI, 0.39–0.54) for UMAT, 0.43 (95% CI, 0.35–0.50) for UCAT total score; the effect size for remoteness was 0.54 (95% CI, 0.45–0.63) for UMAT, 0.48 (95% CI, 0.39–0.58) for UCAT total score. The impact of professional coaching on UCAT performance was not statistically significant among those accepted for interview. Conclusions: Women and people from areas outside major cities or of lower socio‐economic status perform less well on the UCAT than other applicants. Reviewing the test and applicant quotas may be needed to achieve selection equity.
Barbara Griffin · Graeme L Horton · Lisa Lampe · Boaz Shulruf · Wendy Hu
Research letter
The short to medium term benefits of the Australian colorectal cancer screening program
In Australia, colorectal cancer is the second most frequently diagnosed cancer and one of the most common causes of cancer‐related death.1 Evidence that bowel cancer screening reduces mortality through early detection and treatment2 led to the introduction in 2006 of the Australian National Bowel Cancer Screening Program (NBCSP), offering faecal occult blood testing. The NBCSP has been progressively rolled out, from covering those aged 55 or 65 years in 2006 to screening every two years for all Australians aged 50–74 years by 2020.3 During 2016–17, 41% of people invited to participate in screening did so.4 A recent review of the NBCSP found that the risk of death from colorectal cancer was lower for invitees, and that those who had cancer were diagnosed at an earlier stage of disease.5 In Australia, jurisdictional cancer registries do not collect data on surgery‐related morbidity. However, the Binational Colorectal Cancer Audit (BCCA) (https://www.bowelcanceraudit.com) has collected information since 2007 on the diagnosis, management, and outcomes of surgically managed Australian and New Zealand patients with colorectal cancer, as well as whether patients were identified by the NBCSP. BCCA data are voluntarily collected by 435 registered surgeons at 138 participating hospitals across Australia and New Zealand, covering about 24% of newly diagnosed cases of colorectal cancer in 2019.6 We sought to determine whether patients with surgically managed colorectal cancer diagnosed through the NBCSP have better post‐operative outcomes than those diagnosed in other pathways. We undertook a cross‐sectional analysis of de‐identified BCCA data for patients aged 18 years or over who underwent surgery in Australia for colorectal cancer during January 2007 – December 2018. Outcome measures were inpatient and 30‐day mortality; surgical complications; medical complications; return to theatre; and hospital length of stay. We undertook binary logistic regression to assess associations between screening and binary outcomes. The association with length of stay was assessed in ordinary least squares linear regression models. The Monash University Human Research Ethics Committee (project, 19327) and the BCCA Operations Committee provided ethics approval for our study. Of 23 310 cases of colorectal cancer in the database, we could include 15 630 cases with data on cancer type and screening status in our comparison of demographic and clinical characteristics. A larger proportion of patients identified by the NBSCP than of otherwise identified patients were men (58% v 54%); their mean age (64 years, standard deviation [SD], 7 years v 69 years; SD, 14 years) was lower, and larger proportions had American Society of Anesthesiologists (ASA) scores in the low risk range (77% v 59%), were from lower socio‐economic status areas, had presented for elective surgery (96% v 85%), had less advanced cancer stage disease (stages 0–II: 69% v 63%), and underwent minimally invasive surgery (80% v 66%) (Box 1). Data on adjusting variables and outcomes were available for the 11 366 cases included in our logistic regression models. NBSCP‐detected patients were less likely to have post‐operative surgical (adjusted odds ratio [aOR], 0.83; 95% confidence interval [CI], 0.69–0.99) or medical complications (aOR, 0.75; 95% CI, 0.59–0.94); their length of stay was also briefer (adjusted mean difference, –1.56 days; 95% CI, –2.06 to –1.06 days). Post‐operative mortality and return to theatre rates were similar for screened and other patients (Box 2). Our analysis of BCCA data indicates that, in addition to the lower long term mortality associated with the NBCSP,5 short term post‐operative benefits are also evident that should be taken into account when promoting the program. Our study reinforces calls to improve participation rates in the national screening program by eligible participants to optimise the value of this critically important initiative. Box 1 – Demographic and clinical features of 15 730 patients who underwent surgery for colorectal cancer in Australia, 2007–2018, by diagnostic pathway Identification of patients Characteristic Total NBSCP Other P Number of patients 15 730 1357 14 373 Age at surgery (years) Mean (SD) 69 (13) 64 (7) 69 (14) < 0.001 Range 18–100 50–75 18–100 50 or under* 1556 (10%) 77 (6%) 1479 (10%) 51–60 2433 (15%) 385 (28%) 2048 (14%) 61–70 4192 (27%) 651 (48%) 3541 (25%) 71–80 4473 (28%) 244 (18%) 4229 (29%) over 80 3073 (20%) 0 3073 (21%) Missing data 3 0 3 Sex 0.003 Women 7142 (45%) 563 (42%) 6579 (46%) Men 8586 (55%) 792 (58%) 7794 (54%) Missing data 2 2 0 American Society of Anesthesiologists score < 0.001 1–2 (low risk) 9205 (60%) 1000 (77%) 8205 (59%) 3–5 (high risk) 6033 (40%) 294 (23%) 5739 (41%) Missing data 492 63 429 Socio‐economic status (IRSD quintile) < 0.001 1 (most disadvantaged) 2470 (16%) 224 (17%) 2246 (16%) 2 2385 (16%) 221 (17%) 2164 (16%) 3 2957 (20%) 278 (22%) 2679 (19%) 4 3107 (21%) 288 (22%) 2819 (20%) 5 (least disadvantaged) 4153 (28%) 282 (22%) 3871 (28%) Missing data 658 64 594 Cancer type 0.50 Colon 11 287 (72%) 963 (71%) 10 324 (72%) Rectal 4443 (28%) 394 (29%) 4049 (28%) Operative urgency < 0.001 Elective 13 457 (86%) 1310 (96%) 12 147 (85%) Emergency 999 (6%) 11 (1%) 988 (7%) Urgent 1248 (8%) 36 (2%) 1212 (8%) Missing data 26 0 26 Cancer stage < 0.001 0 (cancer in situ) 699 (5%) 92 (7%) 607 (4%) I (local disease) 3728 (24%) 535 (41%) 3193 (23%) II (local disease) 4689 (31%) 278 (21%) 4411 (32%) III (nodal spread) 4437 (29%) 347 (26%) 4090 (29%) IV (metastatic disease) 1625 (11%) 42 (3%) 1583 (11%) X (not identifiable) 121 (1%) 16 (1%) 105 (1%) Missing data 431 47 384 Operative approach < 0.001 Minimally invasive surgery† 10 498 (67%) 1082 (80%) 9416 (66%) Open 5140 (33%) 269 (20%) 4871 (34%) Missing data 92 6 86 IRSD = Index of Relative Socioeconomic Disadvantage (Australian Bureau of Statistics); NBSCP = National Bowel Cancer Screening Program; SD = standard deviation. * National screening program participants are aged 50 years or more. † Laparoscopic, hybrid, conversion of laparoscopic, robotic and transanal total mesorectal excision. table#t1 tbody td:nth-child(n+2) P. Pleft { text-align: center; } table#t2 tbody td:nth-child(n+2) P. Pleft { text-align: center; } Box 2 – Logistic and linear regression analysis of the association between screening and outcomes for 11 366 patients with colorectal cancer, Australia, 2007–2018 Identification of patients NBSCP v other Outcome NBSCP Other Univariate regression: OR (95% CI) Multivariate regression: aOR* (95% CI) Number of patients 843 10 523 30‐day mortality† 2 175 0.14 (0.02–0.44) 0.31 (0.05–1.01) Surgical complications‡ 171 2494 0.82 (0.69–0.97) 0.83 (0.69–0.99) Medical complications§ 89 1889 0.54 (0.43–0.67) 0.75 (0.59–0.94) Returned to theatre 52 658 0.99 (0.73–1.31) 1.02 (0.75–1.37) Mean difference (95% CI) Adjusted mean difference* (95% CI) Length of stay (days), mean (SD) 7.27 (6.17) 9.62 (8.02) –2.34 (–2.90 to –1.79) –1.56 (–2.06 to –1.06) aOR = adjusted odds ratio; CI = confidence interval; NBSCP = National Bowel Cancer Screening Program; OR = odds ratio; SD = standard deviation. * Adjusted for age, sex, socio‐economic status, screen category, cancer type, American Society of Anesthesiologists score. † Within 30 days of surgery. ‡ Abdominal/pelvic collection, anastomotic leak, entero‐cutaneous fistula, wound dehiscence, wound infection, sepsis, ileus, small bowel obstruction, urinary retention, ureteric injury, splenectomy, post‐operative haemorrhage. § Including chest infection, cardiac complications, deep vein thrombosis, pulmonary embolus.
Sasha Taylor · Farhad Salimi · Arul Earnest · Alexander G Heriot · John R Zalcberg · Susannah Ahern
Letters
Maintaining routine vaccination during the COVID‐19 pandemic
To the Editor: Restrictions and concerns associated with coronavirus disease 2019 (COVID‐19) have led to decreased routine immunisation coverage in many countries, including the United Kingdom1 and the United States.2 Australian data showing the COVID‐19 pandemic’s impact on vaccination coverage are not yet available, but it has disrupted services provided by the National Immunisation Program, which funds vaccination for children, adolescents, adults and special risk groups. In the face of ongoing COVID‐19 risk and restrictions, maintaining a resilient routine vaccination program is crucial. The COVID‐19 pandemic has heightened barriers to vaccination. Lockdown restrictions have affected immunisation service accessibility. Specifically, some clinics reduced face‐to‐face appointments in favour of telehealth3 or closed due to insufficient space and increased staffing and other requirements.4 Patients may have rescheduled appointments to avoid COVID‐19 exposure in waiting rooms, while school‐based programs have been disrupted by closures. Reduced consultations limit not only opportunities to vaccinate but also opportunities for health care providers to address vaccine questions and concerns and reinforce trust. Employment changes related to COVID‐19 may also exacerbate cost barriers for people at risk of under‐immunisation, such as migrants, international students, asylum seekers and refugees.5 To improve access, some jurisdictions have successfully established drive‐through vaccine clinics, and pharmacists in some states have been granted expanded permission to vaccinate children against influenza. However, some families may have delayed vaccines due to the COVID‐19 pandemic, and governments may need to consider additional resources for catch‐up vaccination and extensions or grace periods for “No jab, no pay” and “No jab, no play” policies. School‐based vaccination programs should be re‐established as a priority when schools reopen. Publicly available vaccination coverage data will not reflect COVID‐19‐related impacts until as late as December 2020. We recommend early release of more timely data to ensure service providers gain feedback on program performance. We also recommend awareness campaigns promoting timely National Immunisation Program vaccination or catch‐up. Information should be culturally and linguistically appropriate and should be developed through consultation and engagement with diverse communities, including Aboriginal and Torres Strait Islander communities. Australia’s immunisation providers are dedicated and adaptable, but we must now respond quickly to the challenges of COVID‐19 and remain vigilant to maintain routine vaccination coverage across the lifespan.
the Collaboration on Social Science, Immunisation (COSSI) Working Group
Sodium–glucose cotransporter type 2 inhibitors: managing the small but critical risk of diabetic ketoacidosis
To the Editor: We would like to highlight some points arising from the discussion by Hamblin and colleagues regarding euglycaemic diabetic ketoacidosis associated with sodium–glucose cotransporter type 2 (SGLT2) inhibitors.1 First, clinicians should be aware that this condition occurs not only in the perioperative context but also in systemically unwell patients with medical problems. Apart from the periprocedural insult, four categories of precipitating factors are recognised: intercurrent illness; dietary modifications (eg, prolonged fasting, very low calorie diet); medication changes (especially reducing or stopping insulin); and health system factors (eg, use in misdiagnosed type 2 rather than type 1 diabetes, and lack of patient education on the handling of SGLT2 inhibitors perioperatively).2,3,4 Second, diabetic ketoacidosis is more frequently reported with major surgery; for example, cardiothoracic, bariatric and abdominal surgery (postoperative ileus contributing). Third, clinicians should be aware that the current recommendations5 are based on low quality evidence and are potentially subjective. For example, the use of glycated haemoglobin levels < 75 mmol/mol (9%) as one factor to stratify lower patient risk, while intuitive, is not an unequivocal finding in the literature.4 We are in agreement that one should not overreact to capillary ketone levels in the perioperative period; these should be interpreted in conjunction with other acidosis markers (pH, bicarbonate and base excess). We differ regarding the authors’ statement that blood ketone testing is warranted only in unwell or symptomatic patients. In our clinical experience, we have encountered asymptomatic presentations with ketone levels > 2.0 mmol/L and acidosis before colonoscopy, despite the cessation of SGLT2 inhibitors on the day of the scheduled colonoscopy, necessitating deferral and inpatient treatment.6 Bowel preparation, diet modification and changes in diabetes medications are possible contributory factors for a minor procedure such as colonoscopy. Further, not all patients attend a pre‐assessment clinic and on the day of their procedure may be unable to recollect their diabetic medications. For these reasons, as recommended by the Australian Diabetes Society, it is prudent to check capillary ketones (using a single glucose strip) on admission for all patients with type 2 diabetes regardless of symptoms in the periprocedural period.5 Finally, in patients who have not held their SGLT2 inhibitors sufficiently or who have ketosis, the decision to proceed should depend on a nuanced appraisal integrating the complexity of the procedure, precipitating factors, and degree of acidosis.
Emily J Meyer · Venkatesan Thiruvenkatarajan · David Jesudason
Sodium–glucose cotransporter type 2 inhibitors: managing the small but critical risk of diabetic ketoacidosis
In reply
Peter S Hamblin · Rosemary Wong · Leon A Bach
Time for a clear national COVID‐19 strategy
To the Editor: Pandemic responses across the world have been highly reactive. However, there remain only three strategic options to managing coronavirus disease 2019 (COVID‐19): mitigation, suppression and elimination (Box).2 With the promise of efficacious new vaccines, mitigation is appropriately not considered as part of Australia’s national strategy. However, our stated goal of achieving “no community transmission” remains poorly defined and risks missing important distinctions between elimination and suppression.3 Effective elimination is dependent both on getting to zero local cases and then staying there, with any new transmission chains immediately halted. All jurisdictions of Australia have now achieved elimination over significant periods, even without articulating this as their strategy. By comparison to suppression, greater relaxation of restrictions may well be allowable under an elimination approach if vigilance is maintained, as New Zealand has demonstrated.4 Although the challenges of ensuring quarantine of returning travellers are well recognised, this is an essential aspect of maintaining elimination and increases in importance as distancing restrictions are eased. Australia’s current strategy appears to imply suppression, with some virus circulating but with case numbers at manageable levels. Whether suppression has been achieved can be monitored by maintaining an effective reproduction number of no greater than one, or equivalently by ensuring the epidemic curve of new community cases is not upsloping. Importantly, the reproduction number and the rate of new cases at any point in time are unrelated — we could have effective suppression and a reproduction number of one with daily case rates of five, ten or 50. Our definition of no community transmission appears to imply complete identification of transmission chains with no “mystery cases”, regardless of the number of new cases. These considerations are important in determining whether we have full visibility of the epidemic and effective contact tracing but do not determine the reproduction number. The rapid spread of the virus necessitates a public health strategy that is clear, robust and agile. Improved control combined with the increasingly clear seasonality of the virus5 suggest that control can be maintained throughout the summer. However, if vaccination has not been widely distributed before winter 2021 and we do not make clear choices, further major outbreaks remain likely. Box – Characteristics of coronavirus disease 2019 (COVID‐19) epidemic response strategies (Trauer et al) Elimination Suppression Mitigation Our definition No cases or transmission, except in quarantined arrivals Very low community case rates; limited transmission Higher case rates, but within health service capacity Key metric of success No locally acquired cases Effective reproduction number not exceeding one,* or a horizontal sloping epidemic curve of locally acquired cases Hospital and ICU occupancy within (expanded) capacity Accrual of significant population‐level immunity No No1 Yes, likely to take many months, with considerable morbidity and mortality Need for mobility restrictions and hygiene measures Mobility may return to near normal while cases and transmission remain at zero; vigilance essential; likely need for episodic restrictions if quarantine escape occurs Continuous need for high levels of restrictions; strong possibility of disruptive lockdowns given that community transmission persists Unpredictable Need for restrictions on international arrivals Extremely high, and increases as distancing restrictions are eased Moderate Less important Current appropriateness for Australian jurisdictions† Reasonable Reasonable Not under consideration ICU = intensive care unit. * The effective reproduction number becomes more difficult to quantify precisely as numbers fall. † Given an effective vaccine appears likely.
James M Trauer · Ben J Marais · Romain Ragonnet · Julian Savulescu · Emma S McBryde
Letter
COVID‐19: estimated number of deaths if Australia had experienced a similar outbreak to England and Wales
To the Editor: Australia has had a remarkably successful response to coronavirus disease 2019 (COVID‐19), even considering the second wave experienced in Victoria. The Australian rate of COVID‐19‐related deaths of 35 per million population is 15–20 times lower than that observed in countries across Europe and the Americas.1 However, as the second wave in Melbourne has shown, it is important not to become complacent. Using all‐cause mortality data in England and Wales over the peak of the COVID‐19 outbreak in March and April 2020, we directly estimated the number of excess deaths that might have occurred if the outbreak in Australia had been of a similar extent to that in England and Wales. We estimated the relative risk of all‐cause mortality in England and Wales from the COVID‐19 outbreak by dividing the total deaths from all causes for weeks 11–21 in 2020 (9 March – 24 May) by the mean number of deaths for the weeks 11–21 averaged over 5 years (2014–2018) (limited to years when comparable Australian data were available). We calculated age and sex stratified relative risks as there are well documented differences in COVID‐19 fatality by age and sex.2 To estimate the baseline risk of all‐cause mortality in the Australian population, we estimated the mean number of deaths by age and sex for weeks 11–21 over the period 2014–2018. Finally, to estimate the total deaths that might have occurred if Australia had experienced a similar outbreak to England and Wales, we multiplied the baseline expected number of deaths by the age‐specific relative risks for men and women (Box). This resulted in an estimated additional 16 313 deaths in Australia: 9295 men and 7018 women. In contrast, by 26 May 2020 there had been 102 COVID‐19‐attributed deaths in Australia and 1365 excess total deaths from weeks 11 to 21 according to provisional mortality statistics.3 This enormous difference underlies the importance of Australia’s response using a combination of extensive testing and contact tracing, mandatory quarantine of people returning from overseas, and shutdowns to control community transmission. While acknowledging that these measures carry with them substantial social and economic harms, we wish to highlight the scale of the loss of life avoided. Further details of our methods and results are available in InSight+.4 Box – Estimating the relative risk (RR) for death in England and Wales during weeks 11–21 in 20201 and applying it to the Australian2 population (Stanaway et al) Age group (years) RR for death in England and Wales* Mean total deaths† in Australia, 2014–2018 Total expected deaths in similar outbreak‡ Estimated absolute increase in number of deaths§ Males 0–14 0.86 167.2 144.3 −22.9 15–44 1.06 864.0 916.7 52.7 45–64 1.46 2629.4 3844.7 1215.3 65–74 1.47 3111.6 4573.3 1461.7 75–84 1.62 4589.4 7461.7 2872.3 ≥ 85 1.73 5118.2 8834.2 3716.0 Total 1.57 16 429.8 25 774.8 9295.0 Females 0–14 0.92 127.2 116.8 −10.3 15–44 1.10 440.2 482.4 42.2 45–64 1.36 1670.0 2265.8 595.8 65–74 1.35 1960.6 2640.8 680.2 75–84 1.48 3714.8 5493.0 1778.2 ≥ 85 1.52 7591.6 11 523.9 3932.3 Total 1.46 15 504.4 22 522.7 7018.3 * Calculated as deaths in 2020 (weeks 11–21)/average deaths in the same period 2014–2018. † Weeks 11–21. ‡ Average deaths in Australia × RR. § If outbreak in Australia had been similar to the United Kingdom. Calculated as expected deaths minus average deaths. Data source: Office of National Statistics website. Deaths registered weekly in England and Wales, provisional. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/weeklyprovisionalfiguresondeathsregisteredinenglandandwales (viewed July 2020). The number of deaths for weeks 11–21 in the period 2014–2018 by age and sex were provided on request from the Australian Bureau of Statistics.
Fiona Stanaway · Les M Irwig · Armando Teixeira‐Pinto · Katy JL Bell
Full list of Australia Day Honours
Cate Swannell
A hospital‐wide response to multiple outbreaks of COVID‐19 in health care workers: lessons learned from the field
Kirsty L Buising · Deborah Williamson · Benjamin C Cowie · Jennifer MacLachlan · Elizabeth Orr · Christopher MacIsaac · Eloise Williams · Katherine Bond · Stephen Muhi · James McCarthy · Andrea B Maier · Louis Irving · Denise Heinjus · Cate Kelly · Caroline Marshall
What are people saying on social networking sites about the Australian alcohol consumption guidelines?
Benjamin C Riordan · Daniel T Winter · Paul S Haber · Carolyn A Day · Kirsten C Morley
Call for infant formula reconstitution uniformity and improvements in manufacturer feeding guides
Shelley Farrent · Brian Coppin · Scott Morris
COVID‐19 and residential aged care: priorities for optimising preparation and management of outbreaks
Georgia E Aitken · Alice L Holmes · Joseph E Ibrahim
PPE for your mind: a peer support initiative for health care workers
Tahnee L Bridson · Kym Jenkins · Kieran G Allen · Brett M McDermott
A guide for medical practitioners transitioning to an encore career or retirement
Chanaka Wijeratne · Joanne Earl