Volume 218 Issue 4

Australian skin cancer registries need to sensitively capture data on race and ethnicity to improve skin cancer outcomes for people with skin of colour

Ayooluwatomiwa I Oloruntoba · Michelle Rodrigues

Until we have strategies to reduce the barriers of video consultations, Australia needs long telephone consultations

Feby Savira · Eva Yuen · Anna Ugalde · Katherine Graham · Anna Peeters

Recent advances in critical care relevant to a broad range of clinicians

Yasmine Ali Abdelhamid · Adam Deane · Rinaldo Bellomo

A man in his thirties presented immediately on return from a one-month trip to Europe with widespread pustular lesions, tender lymphadenopathy, fever, and headache

Adam Stewart · Sanmarie Schlebusch · Susan Vlack · Jamie McMahon · Mitchell Sullivan · Alyssa Pyke · Krispin Hajkowicz

A 65-year-old woman presented to the emergency department with asymptomatic plaques on her left medial thigh

Katina J Selvaraj · Thomas J Stewart

Does pregnancy change a person’s medical values and preferences?

John J Bockxmeer · Casey M Haining · Andrea Atkinson

Comprehensive testing, monitoring, and treatment in primary care could save hundreds of Australian lives each year

Lien Tran · Benjamin C Cowie

Encouraging public compliance with measures that limit community transmission would benefit everyone, with only minor inconvenience

Gwendolyn L Gilbert

Universal screening would be cost-effective only if the test cost is low and people receive appropriate clinical management

Yinzong Xiao · Margaret E Hellard · Alexander J Thompson · Christopher Seaman · Jess Howell · Nick Scott

Having received three COVID-19 vaccine doses was associated with much lower likelihood of hospitalisation or death

Robert J Ellis · Cameron RM Moffatt · Luke T Aaron · Greta Beaverson · Khin Chaw · Corinne Curtis · Rhett Freeman‐Lamb · Deborah Judd · Khadija Khatry · Yee Sum Li · Terry Nash · Bonnie Macfarlane · Karen Slater · Yudish Soonarane · Mark Stickley · Satyamurthy Anuradha

Improving the collection of neurosyphilis surveillance data and integrating neurosyphilis incidence data into syphilis reports may enhance our understanding of the epidemiology of neurosyphilis

Ei T Aung · Marcus Y Chen · Christopher K Fairley · Jason J Ong · Eric PF Chow

Management of young-onset dementia needs to be age-appropriate and multidisciplinary

Samantha M Loi · Monica Cations · Dennis Velakoulis

To the Editor: A recent survey found that 65% of Australians choose cremation over burial, and that, in the context of the coronavirus disease 2019 (COVID‐19) pandemic, cremations could be increased fourfold.1 It seems appropriate to look at the various roles of the medical practitioner in approving cremations. The first crematorium was built in England in 1878.2 Medical practitioners were at the forefront of the movement in Australia, and argued that cemeteries were already overcrowded and in disrepair, that a fear of being buried alive was common, and that cremation was a hygienic way to dispose of the dead when it was still believed that cemeteries were a source of disease in the living.2 The first Australian crematorium was established in Adelaide in 1903, after which progress halted due to ongoing debate;3 however, objections were overcome and many were constructed in the interwar years (Box 1). The most cogent reason for rejecting cremation was that it could be employed to hide homicides. The contrary argument was that having a medical practitioner verify the cause of death would both prevent undetected crime and advance medical knowledge.4 To provide for this verification step, each Australian state and territory introduced legislation setting out a process for the approval of cremations. Where the cause of death is suspicious or unclear, permission is withheld and referral made to a coroner. In Queensland, Tasmania and Victoria, any medical practitioner who did not complete the death certificate may issue a cremation permit (Box 2). In the Australian Capital Territory, New South Wales and Western Australia, only government‐appointed medical referees may issue a permit. Some states and territories also require assessment of cremation safety, verifying that there is no implanted battery‐operated device, which may explode and damage the cremator, and that the deceased has not received radioisotopes, which may create a public health risk during cremation. At the Public Health Unit, we manage the appointment of medical referees for the NSW Ministry of Health. As part of the review of the effectiveness of our procedures, in 2020 we developed a short questionnaire to identify reasons why medical referees may refuse permission to cremate and to seek suggestions for improvement to this administrative process. We emailed it to a 10% random sample of NSW medical referees (n = 77) and received 46 responses (60%). Of these, 29 respondents (63%) had served in the role for more than 15 years, nine (20%) for five to 15 years, and five (11%) for less than five years. The number of permits issued in the previous 12 months ranged widely: 25 had signed zero to ten, and at the other extreme, two provided estimates of 780 and 1200 permits. This large variation is most likely related to varying demands on medical referees by local funeral directors. The reasons for rejecting applications included inconsistencies in the forms (ten), incorrect or unclear cause of death (seven), a reportable death (four), uncertain identity of the deceased (one), and a retained battery‐powered device (one). No suggestions for improvement were made, but three respondents suggested we provide some medical referee training — we have undertaken to develop an online education module. Although roles differ between Australian jurisdictions, medical practitioners have an important responsibility for verifying that a body is suitable for cremation, a decision that they must make independently of the practitioner who certifies the cause of death. Box 1 – Woronora Crematorium, Sydney, constructed in 1934* * Courtesy of Woronora Memorial Park. Box 2 – Roles of medical practitioners in approval of cremation under current legislation for each Australian state and territory State or territory Legislation Final approver of cremation Name of permit Comments Who assesses cremation risk Australian Capital Territory Cemeteries and Crematoria Regulation 2003 Medical referee, a medical practitioner appointed by the Director‐General Certificate of medical referee The medical referee must view and be satisfied with the “Certificate of medical attendant” The “Certificate of medical referee” must state that there is no medical reason why the remains should not be cremated New South Wales Public Health Regulation 2022 Medical referee, a medical practitioner appointed by the Secretary Medical referee's cremation permit The medical referee must be independent of the applicant and of the medical practitioner who attended the deceased A medical practitioner must provide cremation risk advice concerning battery‐operated implanted devices and radioactive treatment Northern Territory Cemeteries Act 1952 Crematorium manager Cremation permit A permit can only be issued by the cremation manager if the certificate provided is signed by two medical practitioners stating that death was due to natural causes No reference to assessment of cremation risk Queensland Crematorium Act 2003 Independent doctor Permission to cremate (independent doctor) The independent doctor is a doctor who has not signed the cause of death certificate or the “Cremation risk certificate” Any other medical practitioner may complete the “Cremation risk certificate” South Australia Burial and Cremation Act 2013; Burial and Cremation Regulations 2014 Registrar of Births, Deaths and Marriages Cremation permit Registrar of Births, Deaths and Marriages must consider the “Death from natural causes certificate of second doctor” Second doctor certifies that there is no reason why the body of the deceased should not be cremated Tasmania Burial and Cremation Regulations 2015; Burial and Cremation Act 2019 Medical practitioner Cremation permit The medical practitioner who issues the permit must not be a partner, employee or relative of the medical practitioner who issued the medical certificate in respect of the deceased person The medical practitioner who signs the permit must be satisfied that any implanted medical device has been removed Victoria Cemeteries and Crematoria Act 2003; Cemeteries and Crematoria Regulation 2015 Registered medical practitioner Certificate of registered medical practitioner authorising cremation The registered medical practitioner is someone who is not the medical practitioner who completed the notice in respect to the death of the deceased The funeral director must take note of any battery‐operated implanted device mentioned on the “Medical certificate of cause of death” Western Australia Cremation Act 1929; Cremation Regulations 1954 Medical referee, appointed by the Governor Permit to cremate The medical referee must not issue the certificate of cause of death or be in partnership with the medical practitioner who does so The “Certificate of medical practitioner” covers battery‐operated implanted devices and radioactive treatments

Mark J Ferson · Reannon Johnson · Toni Cains

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has changed the doctor–patient relationship. The technological revolution that is telehealth has brought undeniable benefits to patients, including greater access and convenience, and more control and empowerment through self‐care.1 There are high satisfaction ratings for patients utilising digital health care technologies.2 Unsurprisingly, there has been an increased uptake in the use of online prescription, referral and medical certificate services where a pre‐existing doctor–patient relationship is not always present.3 In our experience, there is an increasing digital incursion on the traditional general practice consultation. General practitioners are being pressured by their patients to issue prescriptions4 and referrals outside of scheduled consultations. Presumably to preserve the doctor–patient relationship and potentially business interests, we have seen GPs acquiesce to these patient requests, often with little to no consultation. This is occurring despite previous research showing that consumer demand is a driver of unnecessary tests and treatments.5 This non‐contemporaneous doctor–patient interaction exacerbates the demand for fast, convenient health care delivered how and when patients dictate. In this instance, ensuring consumer satisfaction is potentially at odds with ensuring good and safe patient outcomes. There are risks of engaging with this type of instant medicine. Increased accessibility to, and demands made of, GPs increases their workload burden2 and precipitates cognitive overload. This emerging expectation of doctors to engage in asynchronous interactions with patients, outside of consultations, creates what we term a “digital fourth wall”. Patients can access their GP in an inherently one‐sided encounter, with doctors given little time and opportunity to reciprocate. Our concern is that the impersonal nature of this doctor–patient interaction may beget a diminution of professional responsibility towards the patient and suboptimal treatment and diagnosis. Striving for a mutually acceptable outcome through shared decision‐making processes will ensure that duty of care to the patient, based on GPs’ best clinical judgment, is not compromised. This may mean saying “no” to a patient, despite what we observe to be the natural inclination of many GP colleagues to acquiesce to increasing digital demands. The medico‐legal risk, and responsibility for patient care, ultimately rests with the GP. Despite appearances, novel innovations in technology do not always lead to health improvements.

Michael Tran · Katrina Anderson