Volume 215 Issue 10

An approach for reframing palliative care has been designed to help improve the wellbeing of people with serious illness

Peter Hudson · Anna Collins · Mark Boughey · Jennifer Philip

Phasing out tobacco retailing is gaining traction as the natural next step in controlling the tobacco pandemic

Coral E Gartner · April Wright · Marita Hefler · Andrew Perusco · Janet Hoek

Current genetic testing guidelines may overlook patients with actionable mutations in high risk breast and ovarian cancer predisposition genes

Dilanka L De Silva · Paul A James · G Bruce Mann · Geoffrey J Lindeman

Fitzmaurice L, Donald K, de Wet C, Palipana D. Why we should and how we can increase medical school admissions for persons with disabilities. Med J Aust 2021; 215: 249–251.e1. https://doi.org/10.5694/mja2.51238. In this Perspective article, on page 250, the publication date for the Inclusive medical education: Guidance on medical program applicants and students with disabilities is incorrect. The sentence should read, “Beginning in 2019, MDANZ has been looking to support medical schools build ‘greater inclusivity within their culture, systems, and environment’, and published, in 2021, Inclusive medical education: Guidance on medical program applicants and students with disabilities”.

Chen VM, Curnow JL, Tran HA, Choi PY‐I. Australian and New Zealand approach to diagnosis and management of vaccine‐induced immune thrombosis and thrombocytopenia. Med J Aust 2021; 215: 245–249.e1. https://doi.org/10.5694/mja2.51229. Throughout this Perspective article, an incorrect acronym (“THSANZ”) was used for the Thrombosis and Haemostasis Society of Australia and New Zealand. The correct acronym is “THANZ”.

A 66-year-old man presented to a tertiary emergency department following a fall

Sophie C Burn · Akash Kalro

An older man presented with increasing pain the in right leg over 3 months, with no relief after femoral artery stenting

Genevieve Ho · Dedee F Murrell

The card from the vet was the nicest saddest thing anyone had done for us — a fiction piece based on my experience of working as a junior doctor after the death of my father

Isobel Yeap

Despite limits to its clinical value, the potential benefi ts for women should not be overlooked

Belinda E Kiely · Annabel Goodwin

Clinical breast examination can safely be omitted from breast cancer screening of women with BRCA1/2 mutations

Tamara Hettipathirana · Courtney Macdonald · Jing Xie · Kate Moodie · Chris Michael · Kelly‐Anne Phillips

A longer surveillance interval may entail an unacceptably increased level of risk of advanced neoplasia

Zaki Hamarneh · Charles Cock · Graeme P Young · Peter A Bampton · Robert Fraser · Fang LI Ang · Feruza Kholmurodova · Erin L Symonds

Phasing out retail tobacco sales would be favourably received by most Australians

Emily Brennan · Sarah Durkin · Michelle M Scollo · Maurice Swanson · Melanie Wakefield

Introduction: Type 1 diabetes presents significant challenges for optimal management. Despite intensive glycaemic control being the standard of care for several decades, glycaemic targets are infrequently achieved and the burden of complications remains high. Therefore, the advancement of diabetes management technologies has a major role in reducing the clinical and economic impact of the disease on people living with type 1 diabetes and on health care systems. However, a national framework is needed to ensure equitable and sustainable implementation of these technologies as part of holistic care. Main recommendations: This consensus statement considers technologies for insulin delivery, glucose sensing and insulin dose advice that are commercially available in Australia. While international position statements have provided recommendations for technology implementation, the ADS/ADEA/APEG/ADIPS Working Group believes that focus needs to shift from strict trial‐based glycaemic criteria towards engagement and individualised management goals that consider the broad spectrum of benefits offered by technologies. Changes in management as result of this statement: This Australian consensus statement from peak national bodies for the management of diabetes across the lifespan outlines a national framework for the optimal implementation of technologies for people with type 1 diabetes. The Working Group highlights issues regarding equity of access to technologies and services, scope of clinical practice, credentialling and accreditation requirements, regulatory issues with “do‐it‐yourself” technology, national benchmarking, safety reporting, and ongoing patient advocacy.

Anthony J Pease · Sofianos Andrikopoulos · Mary B Abraham · Maria E Craig · Brett Fenton · Jane Overland · Sarah Price · David Simmons · Glynis P Ross

Widespread adoption of high value cancer care practices during the pandemic will benefit cancer care delivery into the future

Vivienne Milch · Rhona Wang · Carolyn Der Vartanian · Melissa Austen · Debra Hector · Cleola Anderiesz · Dorothy Keefe

To the Editor: Burrell and colleagues captured data from 77 hospitals containing 91% (n = 204) of coronavirus disease 2019 (COVID‐19) intensive care unit (ICU) cases during the first four months of the pandemic.1 Overall mortality (n = 30, 15%) for mechanically ventilated and non‐ventilated patients in this study was lower than other published data. In contrast, overseas reports have indicated mortality rates for patients with COVID‐19 admitted to ICUs of 40%, 44%, 60% and 70% in the United Kingdom, China, Italy and the United States, respectively.2 Evidence indicates that within developed countries, mortality rates associated with COVID‐19 vary according to physiological parameters but also markedly according to location.3 Low ICU bed occupancy and the distribution of cases across a large number of institutions1 has positively influenced Australian COVID‐19 mortality rates. Less obvious is the role and effect of critical care nurses. ICU nurse to patient ratios in Australian units were 1:1 and 2:1 for 77.8% and 7.5% of ICU days, respectively.1 Mortality is affected by local practice3 and in countries where ratios of 1:6 or more are common,2 mortality rates in ventilated patients can exceed 80%.4 Globally, point‐of‐care pandemic practice in ICUs has involved fewer critical care nurses, variously supported by redeployed nurses without critical care qualifications or experience. Critical care nurse expertise augments pre‐emptive rather than reactive strategies for ICU patient management. In the study by Burrell and colleagues, invasive ventilation was instituted for 119 (58%) patients: 79 (66%) of these on day 1, increasing to 94/113 (83%) by the end of week 1.1 Eighty‐five (42%) patients were able to be supported with either non‐invasive ventilation, high flow oxygen therapy or supplemental oxygen, monitored and managed by critical care nurses. Within an ICU model of care, critical care nurse staffing levels, skills mix, advanced practice functions and level of education ensure the high quality and safety of care delivery. Australian critical care nurses are expert clinicians with advanced education, training and experience who directly influence patient outcomes at the micro (patient and family), meso (unit or organisation) and macro (policy) level.5 Clearly elucidating workforce issues and composition is critically important for documenting models of care and associated outcomes in critical care.

Rochelle Wynne · Caleb Ferguson · Patricia M Davidson

In reply

Aidan JC Burrell · Tessa Broadley · Andrew A Udy

To the Editor: We read with interest the study by Black and colleagues1 on the effectiveness of a pro‐active risk factor management strategy based on absolute cardiovascular disease risk score compared with usual care, in a rapid access chest pain clinic setting. The study suggested that such a strategy significantly improved 5‐year cardiovascular risk scores; however, we would consider some caution before reaching such a conclusion. Although the authors point out several potential sources for bias in their study, there is an additional one that has not been highlighted. In the results, the authors state that “the increase in use of guideline‐based therapies was similar in the two groups,” yet do not go on to explain the differential effect as to why the blood pressure and lipid profiles decreased in the interventional group only. We suggest that the reason for this lies in a fundamental difference between the groups selected. The interventional group at baseline was receiving proportionately greater amounts of lipid‐lowering and anti‐hypertensive therapy: 56% and 30% higher, respectively, than in the control arm. These higher treatment rates may explain the lower blood pressure, the lipid profiles observed and, consequently, the improved final risk scores in the interventional arm. Also, as the authors pointed out, almost a third of eligible patients approached declined to participate and is therefore an important source of potential selection bias. We also note that the offer of referral to a public smoking cessation service was limited to those in the intervention group. National guidelines recommend this strategy as part of standard care,2 and hence we question whether this intervention should truly be considered to deviate from best practice or usual care.

Penni L Blazak · Kim Greaves

In reply

James A Black · James E Sharman · Thomas H Marwick

To the Editor: “Patients often suggest a ‘social meeting’ after you have treated them. It’s a slippery slope” — quote from an Australian medical student.1 A review published in The Medical Journal of Australia of what constitutes misconduct in health professional–former patient sexual relationships highlights the variation between different health professional codes and the repercussions.2 The article notes the lack of national guidance or codes of conduct for health professional students regarding this or similar professional boundary issues.2 The lack of knowledge on this and other professionalism dilemmas faced by students led to the Professionalism Opinions of Medical Students (PoMS) study.1 We obtained ethics approval from the University of Western Australia (Ref. RA/4/1/9278) to conduct the PoMs study using a mixed methods approach with a validated online survey1 to triangulate how the Australian public (n = 503), qualified doctors (n = 809), and medical students (n = 2602) viewed a range of professionalism dilemmas that medical students may encounter. Participation was voluntary and anonymous. Medical students were informed about the study through their medical school. Doctors and the public were informed about the study using media and social media resources. The surveys were closed when recruitment had plateaued. One of the scenarios asked for respondents’ opinions on how acceptable it would be for a medical student to embark on a romantic relationship with a former patient, and if student participants had encountered a similar situation. To determine whether unconscious bias influenced participants’ opinions, there were two randomly administered versions with female or male protagonists (no same‐sex version was included). The scenario is described below: A male/female medical student bumps into a 25‐year‐old woman/man at an evening concert. The student had taken her/his history and performed an abdominal examination in the emergency department a fortnight ago when she/he had attended with abdominal pain. The pair get chatting and the woman/man invites the student back to her/his flat for “somewhere quieter for a drink”. The male/female student accepts the invitation. How acceptable is this student’s behaviour? Almost 4% of medical student respondents (n = 84) reported encountering a situation similar to the one described. Using the χ2 test to compare the responses, there were significant differences in how the three demographic groups viewed this scenario. Notably, more than 50% of the public (n = 237), compared with more than 37% of the students (n = 896) and 29% of the doctors (n = 215) who completed this section of the survey considered this behaviour as acceptable (P < 0.001), regardless of the gender of the protagonist. Doctor participants were the only group to have no gender bias for the acceptability of the protagonist’s behaviour. Medical students’ opinions were intermediate, but were significantly influenced by their stage in the course. Survey participants in the early years of the medical course expressed opinions that aligned more with the public’s responses (478/1099, 43%), but the responses of students in the later years of the course were closer to the views expressed by qualified doctors as to how acceptable they considered the behaviour to be (412/1195, 34%; P < 0.01), supporting the concept of professional identity formation. The PoMS results demonstrate that medical students encounter patient sexual relationship dilemmas and are often unsure about how to manage this — a situation compounded by a lack of national guidance or codes of conduct. We endorse the suggestion that governing bodies provide clearer guidance to health professionals,2 but also advocate that health professional students are provided with explicit guidance on this and on how to apply the other behavioural expectations of good medical practice3 as a student.

Paul M McGurgan · Katrina L Calvert · Christine M Jorm

To the Editor: The Standing Committee on Social Policy and Legal Affairs recently completed its inquiry and final report into family, domestic and sexual violence in Australia.1 This comprehensive report made 88 recommendations to inform Australia’s next National Plan to Reduce Violence Against Women and their Children (National Plan). The report explores violence victimisation in diverse communities (eg, Indigenous people, people with a disability). However, consideration of women involved in the criminal justice system is conspicuously absent. Many women involved in the criminal justice system are victim‐survivors of family, domestic and sexual violence. Estimates suggest that between 70% and 90% of women in prison in Australia have been victims of violence.2 In addition, our previous research found that women released from prison are 16 times more likely to die from violence compared with women of the same age in the Australian population.3 However, the only mention of women involved in the criminal justice system as victim‐survivors in the report is in the subsection discussing Indigenous people which acknowledges that Indigenous women experience disproportionate levels of violence victimisation and incarceration. While Indigenous women should be a priority group for violence prevention, and are over‐represented in prisons in Australia, this was a critical missed opportunity to address the over‐representation of victim‐survivors in the criminal justice system. For many Indigenous and non‐Indigenous women, their offending is connected to previous experiences of violence victimisation.2 Victim‐survivors are also being funnelled into the criminal justice system due to inappropriate criminal justice responses to family and domestic violence.4 As noted in the report, the current National Plan (2010–2022)5 has not been successful in reducing violence against women, and as such, this type of violence remains a prominent and all too common issue in Australia. Women involved in the criminal justice system should be among the priority groups for national violence prevention strategies. The next National Plan should address the health and social needs of these women, which are often drivers of both criminal justice involvement and violence victimisation (eg, mental health, housing, financial independence). Trauma‐informed criminal justice responses that recognise the impact of traumatic experiences on health and behaviour, such as pre‐arrest diversion to mental health or family violence services,6 are also needed. Without this, women who are victim‐survivors of violence will continue to be criminalised due to a misunderstanding of the impacts of family, domestic and sexual violence on their health, lives and behaviour.

Melissa Willoughby · Stuart A Kinner