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Editorials

Musculoskeletal diseases Editorials 1 May 2023 Open Access

Introducing Australia's clinical care standard for low back pain

A new clinical care standard provides evidence-based guidance to help clinicians deliver best care for people with low back pain

Christopher G Maher · Aline Archambeau · Rachelle Buchbinder · Simon D French · Julie Morphet · Michael K Nicholas · Peter O'Sullivan · Marie Pirotta · Michael J Yelland · Leo Zeller · Nivene Saad · Elizabeth Marles · Alice L Bhasale · Christina Lane

Mja2 51915
Medical practices Editorials 3 April 2023 Free

Serious gaps in the investigation of sudden unexpected deaths in infancy in Australia

SUDI investigations should be led by coroners, supported by experienced paediatric pathologists Jeffery and colleagues examined how sudden unexpected deaths in infancy (SUDI) are investigated in Australia in a questionnaire‐based study,1 reported in this issue of the MJA. They unsurprisingly exposed gaps in the process and unsuitable approaches to investigating these deaths. As Jeffery and colleagues note, the definition of SUDI encompasses all cases in which an infant dies (or suffers a collapse that leads to death) before the age of twelve months, the death could not have been anticipated 24 hours earlier, and no medical cause is apparent. The SUDI definition includes all such deaths, whether they are subsequently explained or not, and thus encompasses sudden infant death syndrome (SIDS), a diagnosis that requires a complete investigation, including history, death scene investigation, and full autopsy. In the absence of generally recognised causes, the investigation of SUDI is a special situation: each case is a subject of research or a problem to be solved. Most cases in Australia fall within the purview of the police and the state coroner. While their questionnaire methodology had inherent limitations, Jeffery and colleagues found that police‐led investigation fell short of evidence‐based standards. Obvious problems are related to inadequate resources and the lack of a national approach to investigating unexpected deaths in infancy, including a national autopsy protocol. In some states, forensic institutions perform autopsies under the jurisdiction of the coroner. Only one employs a paediatric pathologist for this purpose, despite the fact that SUDI autopsy is a specialist procedure. Problems arise when pathologists without relevant specialist expertise overlook key aspects or misinterpret important findings; this can result in unsafe legal outcomes. In 1989, the late SIDS expert forensic pathologist Professor John Hilton discussed the fact that the investigation of SIDS is encumbered by unusual limitations.2 These limitations are pertinent to the study by Jeffery and colleagues, including ethical questions regarding consent for obtaining and retaining tissue, and difficulty in obtaining suitable control material for meaningful research. The specific causes of many cases of SUDI and SIDS remain unknown, despite the resources of 21st century science. Limitations to their investigation may play a role, but there are a number of plausible research hypotheses, especially that centred on the homeostatic control of breathing, arousal, and cardiac function.3 However, it is worrying that few neuropathological or neurotransmitter findings have been linked with SIDS risk factors.4 In contrast, the list of risk factors linked with infection‐based hypotheses (eg, the bacterial toxin hypothesis)5,6 is extensive,7,8 especially strong associations with prone sleeping and the type of sleeping surface.9,10,11 Achieving clarification may require, as demanded by Jeffery and colleagues, the implementation of core components of international standards, such as those recommended by the Kennedy Report,12 including a standardised autopsy protocol. Doing so would maximise the probability that the cause of death is elucidated, and ensure that risk factors are identified, parents and families receive immediate and ongoing support, and the consequences of incorrect diagnosis are avoided. SUDI investigations should be led by coroners, supported by experienced paediatric pathologists playing pivotal roles. A national database of SUDI data could also be helpful for research and monitoring standards, but this will require dedicated financial support.

Paul N Goldwater

Mja2 51884
Medical education Editorials 3 April 2023 Free

Distress and career regret in doctors: are we really that different to other professions?

Health departments should support the professional training they require and show that their employees are valued The COVID‐19 pandemic has again focused attention on the mental health and wellbeing of doctors, particularly those in training. An earlier meta‐analysis (54 studies during 1963–2015 that included a total of 17560 trainee doctors) found that 21–43% (pooled estimate: 28.8%) had symptoms of depression during residency.1 The cross‐sectional online survey of Australian orthopaedic trainees in late 2021 reported by Kollias and colleagues in this issue of the MJA2 found even higher rates of distress and burnout: 39 of 88 respondents (44%) met the Physician Well‐Being Index criterion for distress (a short 7‐item measure); 55 (63%) had experienced burnout during the preceding 30 days. Those who reported distress were more likely to regret having chosen medicine as their career.2 How concerning are these findings? Survey rates of various indicators of poor wellbeing (distress, depression, burnout) derived from nationally representative population‐based surveys are generally 30–50% lower than reported for doctors,3 leading to the conclusion that poorer wellbeing is more frequent among doctors than other adults. However, there are reasons why junior doctors should have better mental health than other workers,3 including the fact that they often enjoy socio‐economic advantage,4 are by definition well educated, have successfully negotiated early adulthood (when most chronic mental illness emerges), and have a vocation with purpose and minimal likelihood of unemployment. One explanation for the discrepancy is that single occupation surveys have important limitations. Most have relatively low response rates (38% in the study by Kollias and colleagues2), raising the problem of respondent bias producing a “grumpy worker effect”. A United Kingdom meta‐analysis found rates of distress in single occupation studies to be fairly consistent at one‐quarter to one‐third of respondents across a broad range of professions, significantly higher than rates for the general adult population.5 The authors concluded that being recruited to “stress surveys” may lead to selection bias or over‐reporting, and that this problem is shared by many occupations.5 When we examined rates for various professions derived from repeated national representative surveys in Australia with very high response rates (greater than 90%), the prevalence rates of mental ill‐health were in the range 4–22% in 2019, and 8–22% in 2020;6 the prevalence was lower for doctors, with higher rates of pay and life satisfaction, than for the other professions examined (lawyers, engineers, accountants, nurses and midwives, and teachers).6 Over the past few years, even before COVID‐19, professional bodies in Australia have reported similarly low morale, burnout, and job dissatisfaction among emergency service workers,7 architects,8 and teachers.9 So are doctors any different to other professionals? We do differ in two key ways: the length and depth of our apprenticeship, and who pays for our professional training. Medical schools in Australia have changed radically in recent decades: thirteen of twenty‐one medical programs are now graduate entry degrees, often providing accelerated four‐year, instead of five‐ or six‐year, programs. To compete internationally, most graduate programs provide MD qualifications, cramming into these shorter courses a research project that once required an extra year. Recording “learning experiences” and continuing workplace assessment fill students’ days, while professionalism, communication, and ethics courses compete for time with pre‐clinical and ward‐based learning, with (at my university, at least) extensive attendance requirements. As a result, medical students are older when they graduate and have acquired more debt than earlier generations;10 more have competing family and parental responsibilities than younger undergraduate medical students, and less of the downtime many older clinicians had when they were studying. The number of medical graduates in Australia increased from 2733 in 2010 to 3637 in 2019 (33% over nine years).11 Career progression in many specialities is slowed by bottlenecks, while other areas, including general practice and psychiatry, struggle to fill training roles. Nevertheless, in 2019 more final year students wanted to pursue surgery as a career than any other speciality except “adult medicine”, and only one final year student wanted to work in addiction medicine!11 After graduation, junior doctors face a mixture of excessive and conflicting demands. The social connections and support that help deal with long and stressful work hours are undermined by training rotations to far‐flung hospitals and frequent early year job changes. We do not know the ages of the surgical trainees in the survey by Kollias and colleagues,2 but most were probably in their thirties. Career regret and jealous glances at schoolfriends in professional careers, often fully qualified and many earning six‐figure salaries in their late 20s, and paying their personal trainers more per hour than a junior doctor receives, are understandable. Given the similar rates in other professions, distress and career regret are likely to affect a minority of trainees. However, the authors of a new meta‐analysis of longitudinal studies12 suggested that increasing resources and reducing work demands for junior doctors would improve their work engagement and clinical care. The same may be true for students, who may also need guidance about career pathways and community needs. After demanding weeks in hospitals, a junior doctor's weekends are regularly spent preparing for expensive exams (and paying HECS debts), unlike most other young professionals who have had protected study leave and for whom exams are paid. Surely it is time that health departments act like good employers, and fund and support the professional training they require and show that their employees are valued?

Nicholas Glozier

Mja2 51875

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