Letters

To the Editor: This year marks 10 years of successful operation of the Sydney Medically Supervised Injecting Centre — Australia’s only supervised injecting facility (SIF). It is one of 90 such facilities globally, with SIFs operating in eight different countries for up to 25 years. Legislation to lift the trial status of the Sydney centre was passed in the lead-up to the recent New South Wales state election, nearly a decade after the centre opened. Despite not having explicitly supported the centre while in opposition, at the Centre’s 10-year anniversary event on 6 May 2011, the newly elected Liberal–National coalition government signalled its willingness to contribute to bipartisan support of the centre. While the Sydney SIF has survived this transition into institutional “adulthood”, operation of the only other SIF in the English-speaking world, located in Vancouver, Canada, remains a politically sensitive issue. Indeed, the Supreme Court of Canada is currently deciding whether the right to establish and operate a SIF lies with the provincial or the federal government. The Australian and Canadian SIFs have much in common: both have a history of politicisation, both were established under trial conditions, and both have been subject to rigorous independent scientific evaluations. They have each contributed much to the large body of evidence showing the benefits provided by SIFs to individual drug users and to surrounding communities. Specifically, SIFs have been shown to reduce numbers of deaths from drug overdose,1 reduce numbers of ambulance call-outs2 and hospital admissions, improve client outcomes,3 enhance referral to drug treatment programs,4 improve public order (eg, by reducing injecting drug use and syringe disposal in public locations),5 and be cost efficient.6 No adverse consequences have been associated with their operation. There is widespread support for SIFs. This includes many Australasian specialist medical colleges as well as the Australian Medical Association and many scientific and research institutions. The majority of the Australian population also support SIFs, as shown in the recent National Drug Strategy Household Survey.7 Yet despite this, and the continually accumulating evidence showing the public health benefits of SIFs, the idea of establishing new facilities remains politically charged in the Australian context. In Melbourne, a local council recently urged the Victorian state government to consider establishing a SIF in an area with entrenched, street-based drug use. However, this was swiftly rejected, and calls for SIFs in other Australian states have been similarly refused by state governments. Indeed, the current legislation in NSW precludes the operation of any additional SIFs. But for the Sydney SIF, it appears that the repeated political hurdles which characterised its first decade of operation have finally diminished. In this single instance at least, the scientific evidence on SIFs has prevailed. Editor’s note: Ironically, after this letter was accepted for publication, the New South Wales Christian Democrat Fred Nile (Member of the Legislative Council) gave notice of intention to submit a Bill to close down the operation of the Sydney Medically Supervised Injecting Centre. No further details are available at time of going to press.

Marianne E Jauncey · Ingrid A van Beek · Allison M Salmon · Lisa Maher

To the Editor: A report in the Weekend Australian earlier this year described an increase in oxycodone-associated deaths, in parallel with an increase in prescriptions for the drug, sometimes known as “hillbilly heroin”.1 These increases are likely to reflect a change in doctors’ prescribing behaviour. Strong opioids were traditionally prescribed for cancer pain, often in the terminally ill, but since the 1980s they have been increasingly used for treating chronic non-cancer pain, despite an absence of new evidence of effectiveness or of whether opioids provide net benefit or harm to patients in this setting.2 Cancer patients are likely to die from their illness before the opioids have a chance to injure them, but patients with chronic non-cancer pain are not, and this is where oxycodone-associated deaths are more likely to occur. A contemporary view is that chronic non-cancer pain should be regarded as “a disease entity”,3 but equating a symptom with disease means that the patient becomes the sole arbiter of whether he or she is ill. The prescribing doctor has no means by which to objectively determine treatment outcomes. The notion of chronic non-cancer pain as a disease entity is based on neuropathological changes described as “central sensitisation”, which may result from nerve damage or from persistent peripheral nociceptive input.3 The concept is not intellectually challenging where there is objective evidence of either nerve damage or injury to somatic or visceral structures. Now, however, when medically inexplicable pain follows injury that may be so subtle as to be unassociated with any discernible abnormality, central sensitisation is invoked as the explanation du jour, without a critical assessment based on anatomical and physiological principles. Prescribing opioids in this setting may have inadvertently contributed to the reported increase in oxycodone-associated deaths. Guidelines exist for prescribing oral controlled-release opioid analgesics for chronic non-cancer pain.4-6 They advocate a signed patient–doctor agreement covering, among other things: the necessity for a single prescriber; a recommendation for all drug dispensing to be from the same pharmacy; no replacement for lost, stolen or destroyed prescriptions; and a requirement for consent for random urine and blood screens. However, these are just guidelines, not mandated, and there are no Australian data on compliance with them. Based on international data,7 the guidelines are likely to be more honoured in the breach than the observance. I advocate that a signed patient–doctor agreement should be mandatory in Australia before the prescription and dispensing of opioids for chronic non-cancer pain. This should be sighted by Pharmaceutical Benefits Scheme authorities before such dispensing is authorised, and a copy should be held by the dispensing pharmacy. A review of prescription guidelines for opioid analgesics in chronic non-cancer pain might reduce the epidemic of prescription drug misuse4 and mortality.

Mark S Awerbuch

To the Editor: In his thought-provoking editorial in the May issue of the Journal,1 Tait made reference to an apparent recent improvement in the life expectancies of Indigenous Australians by citing a 2010 Australian Bureau of Statistics (ABS) report entitled The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples, Oct 2010.2 In this report, the life expectancy for Indigenous Australians was quoted as 67.2 years for males and 72.9 years for females, compared with 78.7 and 82.6 years for non-Indigenous males and females, leaving a “gap” of 11.5 years and 9.7 years, respectively. These figures are from 2005–2007 (which includes the 2006 Census year), and are quoted again in this year’s update report from the Australian Institute of Health and Welfare.3 At first glance, they appear to be a startling improvement on the figures from 1996–2001, which quote (as late as 2005) Indigenous life expectancies of 59.4 and 64.8 years for males and females respectively, representing a “gap” of about 17 years for both.4 Unfortunately, the apparent improvement represents not a miraculous leap forward in Indigenous health care and outcomes, but rather a change in the methodology used to calculate life expectancies around the time of the 2006 Census. The essence of the change was from an indirect to a direct demographic method of compiling life-expectancy estimates, which entailed correcting Indigenous death registration data before calculating death rates. The ABS anticipated the potential for confusion (not to mention premature celebration), and so included warnings that comparisons should not be made between published estimates of Indigenous life expectancies on their website and in subsequent reports, as well as producing a discussion paper outlining and justifying the changes.5 The October 2010 ABS report explicitly stated that: “Differences should not be interpreted as measuring changes in Aboriginal and Torres Strait Islander life expectancy over time”.2 As with any statistical analysis, the underlying issue is the quality of the data. As we continue to work to narrow the “true” Indigenous life-expectancy gap, we need to be mindful of the importance of accurate record-keeping, including the identification of Indigenous status, if future analysis of mortality statistics is to stand up to scrutiny.

Lachlan J McIver

To the Editor: Since publishing its first national report on mortality data from 2009,1 the Australian and New Zealand Audit of Surgical Mortality (ANZASM) has provided coverage of surgical mortality in participating hospitals across Australia. In their recent article promoting the role of clinical-quality registries in improving the quality of health care in Australia, Evans and colleagues2 describe the importance of national registries, particularly in high-cost areas of medicine. Evans et al present the proposed national quality indicators from a 2009 Australian Institute of Health and Welfare report3 and categorise them as current national indicators, indicators requiring data development and those for which a suitable data source has not been identified or substantial development is required to operationalise the indicator. Indicator 36, “Independent peer review of surgical deaths”, is categorised as the third type. The rationale for this indicator stated that the template of the Scottish Audit of Surgical Mortality had been adapted for use in Australia by some states and territories. The report recommended that data from these sources be reported nationally, ensuring that methods of collecting the data would become standardised across the participating states and territories. We wish to highlight that this is now the case. The ANZASM is an independent, peer review audit process overseen by the Royal Australasian College of Surgeons (RACS) and funded by state and territory health departments. The audit is designed to identify and monitor improvements in the quality of surgical care through the collection and analysis of patient mortality data. It aims to improve the the delivery of safe, efficient and effective surgical care by identifying, improving and preventing system and process errors. The database is standardised across all sites. In January 2010, to ensure complete participation by RACS Fellows in this activity in all states and territories across Australia, participation was deemed a mandatory continuing professional development activity (Category 1, surgical audit and peer review). Feedback is provided to individual surgeons on their cases, and overall results are summarised in a de-identified manner as case-note reviews and annual reports that discuss system issues arising on a state and national basis. These issues are analysed further, and recommendations for quality improvement in surgery are disseminated by the ANZASM to the broader surgical community and the respective regional departments of health through its annual reports, case-note-review booklets and, more recently, through workshops and seminars.

Guy J Maddern · Julian A Smith · Wendy Babidge · Gordon S Guy

To the Editor: The research by Rosenwax and colleagues1 and Lowthian and colleagues2 published in the Journal highlights the need for increased capacity in end-of-life care within primary care to reduce the inappropriate use of acute health care services at the end of life. Providing high-quality care for people diagnosed with advanced chronic conditions is among the most complex challenges for general practitioners.3 GPs and other primary care providers are able to provide appropriate palliative and end-of-life care when they are well supported by relevant specialists.3 For patients to be well cared for in the community, it is also necessary for informal carers to have the strength, the will and the skill to provide such care, as well as timely access to support and medical care. The recent National Health and Hospitals Reform Commission’s report4 and the Australian Government’s National Primary Health Care Strategy5 both recognise the need to build “the capacity and competence of primary health care services”4 to support their dying patients. These documents make recommendations that begin to address the current difficulties of caring for these patients in the community. Of significance are recommendations for increased support for carers; improved shared-care arrangements; and better access to specialist palliative care, support and funding for advance care planning and improved access to primary health care professionals.4 This includes a commitment to address workforce shortages and improving out-of-hours access to medical care.5 Such recommendations are positive and will be helpful when they are fully realised. However, issues within primary care — both at the community and individual general practice levels — also need to be addressed. People for whom a palliative approach is appropriate need to be systematically and proactively identified in a timely way. Needs assessment and care planning should be undertaken to ensure that problems and preferences for care are identified and mechanisms are put in place to support such care. To promote optimal end-of-life care, a coordinated, multidisciplinary approach is as important in the community as it is in the hospital setting. Good communication and collaboration between primary care providers, the patient’s specialists and specialist palliative care providers are imperative. Also essential is an ongoing dialogue with the patient and family to enable a clear understanding of the goals of treatment and to proactively plan for likely adverse events. Routinely planning for likely scenarios will potentially reduce the use of acute services and encourage the provision of care in more appropriate environments.

Claire E Johnson · Geoffrey K Mitchell

To the Editor: The finding of Wilkinson and colleagues1 that the Undergraduate Medicine and Health Sciences Admission Test (UMAT) score and medical school performance are only weakly correlated came as no surprise. Another shortcoming of the UMAT process has been its inability to recognise the effects that failure in the test can have upon applicants. The Selection Committee for the School of Medicine at the University of Notre Dame in Fremantle rejected the UMAT from the outset. We considered its content to be arbitrary, and that there was no evidence to suggest that it could predict a medical student’s performance, let alone a medical practitioner’s sensitivity and empathy. My concern with the need for fairness and sensitivity in the selection process evolved from my experience of being approached by applicants to other medical schools who were distressed by their failure to pass the UMAT hurdle. What upset them most was that the UMAT literature claimed that one could not study for the test as it tested “aptitude”. Rejected applicants therefore felt that they intrinsically lacked the necessary personal characteristics to be a good doctor. The truth was that they had not performed as well as others in an idiosyncratic test, which included tests of “spatial orientation” and other arcane matters. At the University of Notre Dame, we recognise the great disappointment that unsuccessful applicants feel and counsel those who contact us. We reassure them that they can try again the next year, and are likely to have a better chance of success then. We never imply that they are not suitable to be a doctor. Medical educators can only expect students to possess fairness, empathy and understanding of the suffering of others if we demonstrate the same qualities to them. In the case of the UMAT — an experiment that has dominated medical student selection in Australia for more than a decade — those qualities have been lacking. I believe that the UMAT has left a scar on many unsuccessful applicants and on the perception of the Australian selection process that was used in many universities over those years. Let us remember that doctors’ responsibility to be caring, sensitive and humane extends beyond the consulting room.

Barry N J Walters

To the Editor: The Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study, a large, blinded, multinational study, showed an increased risk of adverse maternal and neonatal outcomes in relation to maternal glycaemia, at glucose levels below the current Australian criteria for diagnosing gestational diabetes mellitus (GDM).1 The International Association of Diabetes and Pregnancy Study Groups (IADPSG), an international consensus group, has proposed new criteria for the diagnosis of GDM.2 As a result, these new criteria have been adopted by the American Diabetes Association, which predicts a significant increase in the prevalence of GDM.3 The new criteria were discussed at the Australasian Diabetes in Pregnancy Society annual scientific meeting in 2010. Moses and colleagues accurately outline the increased prevalence of GDM if IADPSG criteria are adopted in Australia.4 An increased prevalence has implications for resource allocation, and the anticipated increase in workload can be managed by appropriate planning and exploration of alternative models of care. We surveyed attitudes to the management of GDM among general practitioners already involved in antenatal shared care programs in the Liverpool and Fairfield areas of Sydney (GDM is not currently part of the shared care program in this urban area, which has a high prevalence of diabetes). Around 120 GPs are enrolled in the antenatal shared care program in the Liverpool and Fairfield areas. Forty-six of these GPs attended an educational meeting at which the survey was distributed, and of the 46 (who all completed the survey), only seven believed that GDM can always be managed in the antenatal shared care program. Seventeen felt that, due to lack of time or lack of access to appropriate resources, GDM cannot be managed at all by GPs as part of shared antenatal care; eight of these 17 indicated that they never initiated insulin for patients with type 2 diabetes. Only two indicated that no up-skilling was required for them to manage GDM. These attitudes may be limited to GPs in urban practices. Whether the involvement of GPs in the management of GDM is appropriate is unclear, and the provision of supporting resources requires further review. Additionally, as determined by Moses and colleagues,4 the predicted increase would come from older women who are possibly more likely to have other comorbidities that make them less suitable for shared care.

Barbara Depczynski · Vincent W Wong · Hamish D Russell · Nicole Opie

To the Editor: Contrast induced nephropathy (CIN) is one of the most important and frequent complications of invasive coronary procedures.1 We have previously reported a multicentre randomised trial comparing use of iso-osmolar and low osmolar contrast agents (iopromide and iodixanol, respectively) in patients with pre-existing renal impairment.2 The overall proportion of patients developing CIN by Day 7 was around 25%, and there was no statistical difference between the different contrast media. There have been few prospective randomised controlled trials to determine the late effects on renal function and outcomes in relation to dialysis and mortality in patients who developed CIN after invasive coronary procedures. We report here on the long-term follow-up of patients enrolled in our initial study. Of the original cohort of 191 patients, 21 were excluded because of lack of follow-up information. We divided patients into two groups based on whether or not they had initially developed CIN, defined as an absolute increase in the serum creatinine concentration of at least 44 μmol/L or by a relative increase of at least 25% from the baseline value on Day 2 or 7 after exposure to the contrast media. The primary end point was persistent renal impairment, which we defined by these same criteria for serum creatinine, and alternatively, by an absolute reduction in estimated glomerular filtration rate (eGFR) of at least 10 mL/min/1.73 m2 (accounting for the coefficient of variation of creatinine and also the age-related decline in GFR3-5). The secondary end point was a composite of death and need for dialysis. Median length of follow-up was 43 months (interquartile range, 31–48 months). Latest serum creatinine results were available from physicians, hospital records or private laboratories for 157 patients. Significantly higher proportions of patients who had CIN at baseline showed evidence of persistent renal impairment compared with patients who did not have CIN at baseline, based on both serum creatinine results (20/40 v 31/117; P = 0.006) and eGFR (22/40 v 28/117; P < 0.001). Mortality was determined for all 170 patients by direct contact or from the national death registry. A significantly higher proportion of patients who had CIN at baseline (2/41) compared with those who did not have CIN (3/129) needed dialysis (P = 0.60). Twelve patients who had CIN at baseline had outcomes of death, dialysis or both, compared with 32 in the other group (P = 0.57). Multivariate analysis showed CIN at Day 2 or 7 was an independent predictor of persistent renal impairment (odds ratio, 3.31 [95% CI, 1.39–7.86]; P = 0.007). Age, diabetes mellitus, sex, hypertension, body mass index, contrast type and baseline eGFR were not predictive. This long-term follow-up showed that CIN after invasive coronary procedures is associated with increased risk of persistent renal dysfunction in patients with pre-existing renal dysfunction. Physicians should be alert to this complication.

Akash Dhawan · Devang Parikh · Ibrahim Shugman · John French · Hisham Hallani · Clyne Fernandes · Craig P Juergens

To the Editor: Comparing Australian medical school policies regarding conflict of interest (COI) to their United States counterparts, Mason and Tattersall1 conclude that within Australia there is “a need for improved self-regulation”. The authors are applauded for highlighting this important aspect of medical education and organisational practice; however, the comparisons made fail to acknowledge a number of contextual differences that undermine the conclusions drawn. First, significant cultural differences exist between Australia and the US with respect to historical market practices and commercial sponsorship within the tertiary education sector.2 The persistent failure of self-regulation in the US recently culminated in the passing of the Physicians Payment Sunshine Provision, which now mandates transparent disclosure of all (> $10) payments, gifts and sponsorships, and imposes significant penalties for failure to report.3 Arguably, it is this changing legislative landscape that has encouraged US medical schools to develop more robust COI policies, rather than a proactive commitment to manage COI. Second, unlike in the US, most of Australia’s 20 medical schools sit within publicly funded universities, where central policy regulation of COI prevails. Mason and Tattersall’s1 suggestion that each school have its own COI policy without reference to the overarching university’s COI policy is flawed, particularly in a wider academic environment where industry sponsorship of education and commercialisation in research are increasingly encouraged as a desirable strategy to supplement falling levels of Commonwealth resourcing. Third, despite the lack of policies in Australian medical schools, positive performances with respect to COI in the curriculum were noted,1 demonstrating that lack of policy does not necessarily hinder appropriate curriculum content. Finally, on becoming doctors, medical students are bound by their professional codes of practice, codes of ethics, organisational policies and state and federal legislation, which outline the obligation to act within the recognised standards of the profession.4 While medical schools have a significant role to play in preparing future doctors to effectively recognise bias and appropriately manage COI,5 their ability to enforce more rigorous standards than those that apply within the professional community at large is doubtful. The adequacy of current professional codes is a matter for further debate. Medical schools exist within the wider context of the university, the community and the overarching political and legal landscape that governs their resourcing and practices. These factors must be taken into account when judging the actions of medical schools. To present Australian medical schools as lacking1 on the basis of a decontextualised comparison with US schools may be overly simplistic.

Eleanor Milligan · Allan W Cripps

In reply: The medical community in Australia regulates itself through various non-binding codes and guidelines, but these have not been shown to reduce industry influence on doctors or medical students. In contrast, the existence of institutional policies can limit the influence of industry, resulting in medical students and doctors who are less influenced by industry marketing.1,2 University conflict-of-interest (COI) policies must reflect the context in which they exist, but it is unlikely that a general university policy covering all faculties could address the specific challenges presented by medical student education. Policy development, while difficult, is possible, and the University of Melbourne is scheduled to complete a policy framework covering staff and students in health-related degrees this year. Arguably, it was the failure of the medical profession in the United States to self-regulate that led to the legislative changes that stimulated the recent COI policy advances in US medical schools. This could also occur in Australia. Despite the logistical difficulties of developing effective self-regulation within medical schools, there are increasing societal expectations that COI be dealt with effectively. If we ignore this sentiment, we risk the imposition of perhaps excessive and punitive legislation. Medical schools should embrace their influential position, and act now to demonstrate their leadership.

Paul R Mason · Martin Tattersall

To the Editor: In their recent article on unintentional child drowning deaths, Petrass, Blivitch and Finch refer to the “limited detail within both police reports and findings” for South Australian cases of drowning.1 Since 2005, South Australia’s Child Death and Serious Injury Review Committee (CDSIRC), which I chair, has considered the circumstances and causes of all child deaths in SA. The legislation governing the CDSIRC’s work quite rightly precludes the publication of individual details of children’s deaths, but, since 2005, the CDSIRC’s annual report has given a summary of the circumstances and causes of drowning deaths for children in each year. Children drown in a variety of circumstances — in fish ponds, rivers, lakes, dams, buckets of water and in boating accidents — but the greatest number, especially among those under 4 years of age, drown in backyard swimming pools.2 In these incidents, time and again I read about failures of supervision, gate closure and adherence to pool fencing regulations and the maintenance of this fencing. Although the extent and nature of supervision may be of academic interest, the prevention of childhood drowning would best be served by the ongoing promulgation of well researched public health campaigns, such as those delivered by the Royal Life Saving Society — Australia and Kidsafe Australia, and attention to legislative changes that will ensure the regular inspection and maintenance of swimming pool fencing. The CDSIRC’s review of child drownings in SA is based on the detailed information obtained by SA police from witnesses present at the time of the event. This almost always provides a great depth of detail that enables the identification of the key risk factors present in the circumstances of the death. It is unfortunate if this information was not available to Petrass and colleagues, but it is incorrect to infer that such information is not collected in SA. The CDSIRC’s annual reports are available from its website.3 Similar reports are produced by child death review committees or teams in Queensland, New South Wales and Victoria.

Dymphna Eszenyi

In reply: Information made available by South Australia’s Child Death and Serious Injury Review Committee is similar to that in other Australian states that have a Child Death Review Committee; all produce an annual report of circumstances related to child deaths, including child drowning. While we are aware of these reports, for our study of child drowning, individual case details were required that cannot be extracted from compiled summaries in annual reports. By contrast, the National Coroners Information System (NCIS) provides access to original documents for individual drowning cases. Details for South Australian child drownings in the NCIS database were very limited, although at no point in our article did we infer that this information is not collected in SA; rather we stated that that coroners findings were only available for 38.1% of cases in the NCIS, and that autopsy and toxicology reports are not routinely uploaded.1 Further, the recently revised position paper of the National Drowning Prevention Alliance (NDPA) states that neither a single device nor a single solution can prevent child drownings, and recommended that caregivers, aquatic facility owners, managers and operators use “layers of protection” to aid in child drowning prevention.2 We certainly agree that the ongoing promulgation of well researched public health campaigns is an important layer in the prevention of child drowning, although, to date, no published studies have investigated the effectiveness or rigorously evaluated Australian aquatic death prevention campaigns (such as Keep Watch, Kids Alive — Do The Five, SafeWaters and Play it Safe by the Water). However, the NDPA did identify that supervision is the one layer that should be ever-present, regardless of what other layers are used.2

Lauren A Petrass · Jennifer D Blitvich · Caroline F Finch

To the Editor: A review by Harper and Lefkovits favoured increased use of prehospital thrombolysis (PHT) for the management of ST-elevation myocardial infarction (STEMI).1 The acknowledged importance of early reperfusion and the ready application of PHT make this a sound recommendation for settings that are remote from percutaneous coronary intervention (PCI) centres. However, the recommendation of using PHT for patients presenting within 2 hours of symptom onset in metropolitan areas is more controversial. Recent enthusiasm for this strategy has been buoyed by the 5-year data from the randomised CAPTIM study that compared PHT with primary PCI.2 This French study, conducted from 1997 to 2000, was prematurely terminated after recruiting 840 of the planned 1200 patients. There was no difference in the primary composite end point at 30 days. A post-hoc analysis subsequently reported that among the 460 patients randomly assigned to PHT or PCI within 2 hours of symptom onset, there was a trend towards lower mortality among those receiving PHT (2.2% [five patients] v 5.7% [13 patients] at 30 days; P = 0.058).3 By 5 years, an additional eight patients receiving PHT and 12 patients receiving primary PCI had died, resulting in a P value of 0.04 for mortality difference.2 This result reflected one component of a composite end point in a post-hoc subgroup analysis from a prematurely terminated, underpowered trial. Harper and Lefkovits comment that French registry data support the CAPTIM findings. However, data from a more than 10-fold larger Swedish registry do not.4 Important to the successful implementation of PHT is the transport of patients directly to PCI centres where early angiography can be performed if required. However, PCI and fibrinolysis do not make good bedfellows — a lesson learnt through the counterintuitive results of facilitated PCI trials, which showed no benefit and some harm when offering thrombolysis as a prelude to PCI.5,6 This adverse interaction is ameliorated if PCI is deferred for 3 to 24 hours after thrombolysis; however, there is a real risk that early PCI will be overused when STEMI patients arrive rapidly at a staffed PCI facility after receipt of PHT. We need stronger evidence than currently exists to be sure that, in metropolitan settings, the temptation for zealous application of PCI after PHT does not effectively result in over-application of a facilitated PCI strategy, with untoward consequences. In metropolitan regions, the current focus on reducing delays from onset of symptoms to percutaneous revascularisation should remain. Based on the evidence to date, PHT may be a cost-effective but not clinically superior alternative for reperfusion, and should be encouraged as the strategy of choice in circumstances when logistic or resource constraints limit ready access to primary PCI.

David B Brieger

To the Editor: In their article on the decline of infectious syphilis in the Australian Indigenous population from 2005 to 2009,1 Ward and colleagues conclude that it “might be the right time to move toward the elimination of infectious syphilis from remote Indigenous communities”. They note that another previously endemic sexually transmitted infection, donovanosis, has almost completely disappeared from Australia as a result of an elimination program.2 I strongly support their call to action and believe that syphilis can, and should, be next. It is likely that, outside of the small number of communities who have been able to implement a coordinated screening program, the decrease in syphilis in remote areas is an unintended benefit of the use of azithromycin for genital chlamydia and trachoma, and amoxicillin for gonorrhoea. Syphilis is only transmissible to sexual partners for a few weeks during the primary phase (when a chancre is present) and during the secondary phase (when mucocutaneous lesions may be present). Although syphilis is highly infectious during these stages, the relatively short duration of infectiousness partly explains why it is less common than other bacterial sexually transmitted infections. Because the painless ulceration of syphilis is easily ignored by men, or may go unnoticed by women with genital lesions, the diagnosis and treatment of latent (ie, subclinical) disease has been the main focus of syphilis control in remote areas. This approach has had only a limited effect on reducing the incidence of infectious syphilis. Indeed, as latent disease detection and treatment improves, there may be a paradoxical increase in the incidence of infectious cases because latently infected individuals become susceptible to new infection again after treatment.3 Therefore, detection and treatment of all cases of early, infectious syphilis must be the aim of an elimination program, but it will be extremely difficult to achieve this in a remote or rural setting using current diagnostic strategies that almost exclusively rely on serological testing. Serology is still the mainstay of syphilis diagnosis, despite the development of sensitive and specific polymerase chain reaction (PCR) tests for Treponema pallidum. Multiplex PCR tests that can also detect herpes simplex and donovanosis have been used to diagnose genital ulcerative disease in remote areas of Australia,4 but not to screen asymptomatic individuals. The validation of a syphilis PCR test that can be used to identify early, infectious syphilis should be a research priority — one that could be carried out as part of an Australian Government-funded, centrally coordinated but locally implemented, targeted syphilis elimination program.

Francis J Bowden

To the Editor: Recently, Professor Hoy argued for the full inclusion of Aboriginal and Torres Strait Islander people in the Australian Health Survey (AHS), including the measurement of clinical variables and the proposed sample repository.1 Although much of the argument is plausible, several points were overlooked that make it untenable overall. First, the current study design arose with input from at least five Indigenous representative bodies, including the National Aboriginal Community Controlled Health Organisation.2 They identified social and cultural issues as priority areas to be addressed — correctly so, as the underlying causes of health disparity are located in these domains, not primarily in the clinical and biomedical aspects of the AHS. The input from these major national bodies cannot be ignored. Second, yes — there are concerns that “the stored samples and their results might be somehow misused”.1 These concerns are legitimate and well founded in historical and contemporary experiences of Indigenous people. The argument for applying “current scientific and epidemiological knowledge, methods and safeguards”1 to the use of information held in the AHS is correct as far as it goes, but ignores equally important Indigenous knowledge and methodologies, Indigenous intellectual property issues, the principles of “ownership, control, access and possession” of Indigenous information,3 and certain aspects of the United Nations Declaration on the Rights of Indigenous Peoples. This position is therefore inconsistent with the National Health and Medical Research Council guidelines on values and ethics in Aboriginal and Torres Strait Islander health research, particularly as they relate to “survival and protection”.4 Third, denying Indigenous people control over how their health information is used by mainstream research institutions prevents accountability of researchers to communities. Using and publishing this information requires review by relevant experts, in this case Aboriginal and Torres Strait Islander community representatives. Biomedical expertise alone is insufficient to enable effective peer review and, at worst, it risks promoting destructive policies that ignore social, cultural and political realities for Aboriginal people and Torres Strait Islanders. Aboriginal people and Torres Strait Islanders rightly feel that they have been one of the most researched groups in history. And yet, even with this background of decades of being constantly studied, researched and examined, it seems that there is still not enough information being collected. Wellbeing is “grounded in the respect given to people, and the control afforded to them, in their daily lives”.5 Sometimes it’s up to Aboriginal and Torres Strait Islander people to identify what is important in Aboriginal and Torres Strait Islander health: it’s our health!

Kevin G Rowley · Alister H Thorpe

In reply: I thank Dr Rowley and Mr Thorpe for their response.1 It is hard to justify exclusion of any Australian from opportunities to participate fully in important initiatives on the recommendation of bodies whose membership sometimes has no direct link to the persons affected. There is no other population group in Australia to whom this applies. Medical and clinical approaches should complement initiatives to address critical social and cultural issues; they are not in competition nor mutually exclusive. The inclusion of health measures in the adult (but not youth) components of the Australian Health Survey (AHS) acknowledges that there is much to be learned and remediated clinically. Any interpretation of the deliberate exclusion of Indigenous youth from the “measures” elements of the survey is unsettling. There is more, not less, to be learned from this group. Their exclusion deprives policymakers of robust evidence that could improve health status. It condemns enquiry to the current sidestream method of short-term research projects on small pockets of people. These sometimes yield results of dubious generalisability and cause ongoing competition for the impossibly stretched research dollar. Alternatively, is it implied that Indigenous parents are less able to make sound decisions on their child’s participation or that the minors are less likely to cooperate? I suggest that the matter of participation in the AHS be aired through general media channels, as well as those with an Indigenous focus, such as “Living Black” (SBS television) and Imparja television, and through local Indigenous radio stations and community networks. With a developed sampling frame for Indigenous people, dialogue about elements of the examination should at least be conducted with the specific individual tribal groups or communities, if not with the targeted individuals (the preferred option). Subsequently, the whole issue of representation to policymakers in Indigenous health matters might be re-examined on a national basis.

Wendy E Hoy

To the Editor: Although Indigenous males are twice as likely and Indigenous females are half as likely to report being diagnosed with osteoporosis compared with their non-Indigenous counterparts,1 data on the interracial differences in osteoporotic risk factors are limited. Our study of 276 patients attending a tertiary hip fracture unit in Western Australia over a 5-year period is the first to report differences in common risk factors for hip fracture between Indigenous and non-Indigenous patients. Our data showed a lower likelihood of vitamin D deficiency and polypharmacy but higher likelihood of diabetes mellitus, renal disease and alcohol use among Indigenous patients with hip fracture compared with non-Indigenous patients. Using the local orthogeriatric database, we identified 46 Indigenous and 230 randomly selected non-Indigenous patients aged ≥ 45 years who were transferred to a hip fracture unit following surgery for a minimal-trauma fracture at Royal Perth Hospital from July 2005 to June 2010. High alcohol use was defined as alcohol intake exceeding guideline recommendations,2 and polypharmacy as the use of more than five medications. We used a laboratory cut-off of 25-hydroxyvitamin D (25-OHD) < 50 nmol/L to indicate a low vitamin D level. Indigenous status was self-reported during admission. We compared data for Indigenous and non-Indigenous patients using the Mann–Whitney U and Pearson χ2 tests. We used logistic regression (SPSS version 17; SPSS Inc, Chicago, Ill, USA) to examine the association between Indigenous status and the predictor variables. Our study was exempted as a quality assurance activity from formal ethics review by the Royal Perth Hospital Ethics Review Committee and the Western Australian Aboriginal Health Information and Ethics Committee. Risk factors among the two groups are shown in the Box. The most common risk factors among Indigenous patients were antihypertensive use, high alcohol use and diabetes. In the final multivariate model, Indigenous patients with hip fracture were significantly more likely to have diabetes and renal disease and to report high alcohol use, but significantly less likely to have a low vitamin D level and polypharmacy, after adjustment for age, sex and rural residency. These well described risk factors contribute to fracture risk through two mechanisms: falls and secondary osteoporosis. Diabetes-related complications such as visual impairment, stroke and peripheral neuropathy can increase fracture risk.3 In renal dysfunction, osteoporosis is related to cortical thinning and uraemic osteodystrophy.4 Excessive alcohol intake at a young age among Indigenous people may affect peak bone mass.5 The effect of alcohol on liver cirrhosis, cognition, falls due to intoxication and peripheral neuropathy may contribute to fracture risk. Risk stratification will be more robust if these results can be cross-validated in other institutions. Associations between hip fracture and risk factors in Indigenous patients compared with non-Indigenous patients at Royal Perth hospital, July 2005 – June 2010 Variable Indigenous (n = 46) Non-Indigenous (n = 230) P* Crude OR Adjusted† OR (95% CI) Continuous (mean [SD]) Age at hip fracture‡ (years) 81.4 (9.1) 82.3 (9.4) 0.58 0.99 1.03 (0.96–1.10) 25-OHD level (nmol/L) 59.9 (30.2) 40.9 (18.6) < 0.001 – – Categorical (no. [%]) Women 29 (63%) 161 (70%) 0.35 1.11 2.52 (0.51–12.31) Non-metropolitan 42 (93.3%) 38 (16.6%) < 0.001 70.37 70.32 (14.43–342.59) Low vitamin D level§ 15 (38.5%) 142 (69.6%) < 0.001 0.27 0.26 (0.07–0.91) Prior fracture 9 (19.6%) 52 (22.6%) 0.65 0.83 0.42 (0.09–1.90) High alcohol use¶ 19 (41.3%) 10 (4.3%) < 0.001 15.5 13.25 (1.89–92.92) Diabetes mellitus 21 (45.7%) 41 (17.8%) < 0.001 3.87 8.19 (2.02–33.18) Renal disease 16 (34.8%) 21 (9.1%) < 0.001 5.31 6.12 (1.29–29.05) Polypharmacy** 18 (39.1%) 137 (59.6%) 0.01 0.44 0.17 (0.04–0.72) Antihypertensive use 26 (56.5%) 118 (51.3%) 0.52 1.23 2.75 (0.70–10.76) 25-OHD = 25-hydroxyvitamin D. OR = odds ratio. * Mann-Whitney U or Pearson χ2 test. Level of significance: P < 0.05. † Multivariate logistic regression. ‡ Minimal-trauma fracture. § 25-OHD level < 50 nmol/L. ¶ Alcohol intake exceeding guideline recommendations.2 ** > 5 drugs.

Michelle M Y Lai · Nicholas G Waldron

To the Editor: The number of vulvoplasty or labioplasty procedures rebated by Medicare Australia has more than doubled over the past 10 years;1 in the United Kingdom, a similar trend was observed in the National Health Service (NHS) (Box).2 Recent media debate in Australia highlights this as a concerning problem.3 The community assumes that surgical operations are clinically effective treatments performed for identifiable pathological features. In the context of female genital cosmetic surgery (FGCS), there is a blurring between disease and dissatisfaction, the latter being at least partly informed by cultural pressure about physical appearances. In addition, there is an absence of evidence on clinical effectiveness,4 and an apparent lack of commitment to monitor adverse events. This raises the question of how clinicians justify referring women for FGCS. A recent audit of referral letters for labioplasty in an NHS gynaecology clinic in the UK (University College London Hospitals project no. 03/0173) offers interesting insights. Of the 48 letters reviewed, the mean age of the women referred was 25 years (range, 9–50 years). Complaints about genital appearance were identified in 34/48 (71%) of letters (eg, embarrassment about undressing in public changing rooms). Physical discomfort was mentioned in 23/48 (48%) letters (eg, difficulty with activities such as cycling). Sexual problems were mentioned in 21/48 (44%) letters (eg, a reluctance to engage in sexual relationships). In two of the letters, the referrers mentioned disparaging comments by previous sexual partners, and one mentioned harassment by other girls at school. Alarmingly, a further seven letters (15%) alluded to concerns being flagged by the girls’ mothers. Only 77% of referrers reported examining the patient. A third of referrers judged the labia to be “normal”, yet nevertheless requested surgery for their patients. Pejorative language such as “leathery in appearance” or “pendulous and elongated” was used in 12 (25%) of the letters. Medical training may cover basic vulval anatomy, but detailed study of morphology is not included. This knowledge gap would have been less problematic in the past. However, in recent years, where intense marketing of FGCS5 is contributing to soaring demand, medical practitioners may not be sufficiently informed about female genital anatomy to assess and advise women about their concerns. Reasons for the increasing prevalence of female distress about genital appearance are likely to be complex and rooted in social and cultural changes. In the absence of identifiable diseases, referral for operations may not be the most appropriate way of managing women’s body insecurities. Labioplasty and vulvoplasty operations rebated by Medicare Australia1 and covered by the United Kingdom National Health Service2 over the past 10 years* INR = international normalised ratio. * Graph shows abbreviated, not daily, data. Intervals are weekly up to Week 9, then vary according to when INR was measured.

Rebecca Deans · Lih-Mei Liao · Naomi S Crouch · Sarah M Creighton

To the Editor: Animal and human studies confirm the view that colonisation by non-typeable Haemophilus influenzae (NTHi) of airways already damaged by inhaled toxins initiates a second major pathway of damage in chronic obstructive pulmonary disease (COPD). This provides a framework for novel and effective management strategies for this condition, which has previously been considered to be a self-induced disease of elderly people for which nothing can be done.1 Acute exacerbations of COPD are recognised as critical determinants of acute and long-term outcomes. They represent a shift within the bronchus of the balance between two pressures — colonising NTHi and protective recruitment of phagocytic cells — that favours the bacteria and results in an inappropriate and excessive inflammatory response. A novel oral vaccine that reduces acute exacerbations in COPD is currently undergoing an advanced clinical trial in 21 centres across Australia. Oral immunotherapy with enteric-coated inactivated NTHi enhances the efficiency of mucosal immune protection (Box). In a rodent model, specific T cells, derived from stimulation of Peyer’s patches by orally administered NTHi, enhanced clearance of bacteria from the bronchus by recruiting and activating phagocytes.2 In mice co-infected with NTHi and influenza virus, oral administration of NTHi abrogated the increase in levels of both bacteria and virus, suggesting NTHi is a final common pathway for both viral and bacterial infections.2 In humans who smoke, seasonal increase in circulating specific T cells was significantly augmented after oral immunotherapy with NTHi, blocking access of inhaled NTHi into peripheral airways.3 These data support a mechanism whereby NTHi increases physiological protection based on aspiration of bronchus content into the gut. Qualitative2-4 and quantitative2,3 sputum analysis showed that protection was correlated with a reduction of all pathogens and a significant 3-log fall in NTHi, as expected from specific activation of a non-specific clearance mechanism (phagocytosis). In COPD, T cell-recruited neutrophils within sputum undergo a phenotypic change characterised by longevity and enhanced phagocytosis, maintained by autocrine loops.2 Early clinical trials4 of oral immunotherapy showed reductions in the frequency and severity of exacerbations, with consistent decreases in antibiotic usage of more than 50%. A potent and well characterised NTHi isolate with broad cross-protection in screening assays has now been developed for use as the vaccine HI-164OV (unpublished data). Phase II clinical studies of the vaccine have shown it is safe and effective3 and resulted in significant reductions in exacerbations treated with systemic corticosteroids (63%) and hospital admissions (90%)5 among patients with severe COPD taking best-practice treatment. Phase IIb trials are now underway. Evidence of IgE antibody to NTHi in both COPD and treatment-resistant asthma predicts broader clinical value for oral therapy with HI-164OV, through its capacity to prevent inhaled bacteria (allergens) penetrating into small airways.3 Enhancement of mucosal immune protection by oral immunotherapy with enteric-coated inactivated non-typeable Haemophilus influenzae1 Aspiration of bronchus content (including bacteria) into the gut (1) stimulates Peyer’s patches (3) to release T lymphocytes that “home” to the bronchus (4). T lymphocytes — directly or indirectly — secrete cytokines and chemokines that augment recruitment and activation of phagocytes (5). Phagocytes reduce the colonising load of bacteria in the damaged bronchus mucosa. Ingestion of inactivated non-typeable Haemophilus influenzae (2), as a vaccine, augments this protective loop.

Robert L Clancy · Margaret Dunkley

To the Editor: The Australian state of Queensland has one of the highest rates of melanoma and non-melanoma skin cancer in the world.1,2 Solar ultraviolet (UV) radiation is the most important environmental risk factor,3 highlighting the need for sun safety education and skin cancer screening among outdoor workers in Queensland. Many such programs are currently in place, including the Sunsafe Workplace Program developed by the University of Queensland in collaboration with the Queensland Skin and Cancer Foundation in 2007. In August 2010, we attended an outdoor workplace in Brisbane, with extensive sun safety policies already in place, to perform free voluntary skin checks on employees. Of 55 people invited to participate, 39 accepted. Of these, 36 were male, the median age was 35 years (range, 19–62 years), and 28 were of British and/or Irish ancestry. Eighteen participants reported spending 5–8 hours a day outdoors mid week and 20 reported the same at weekends. Six reported that at the start of summer, they never tanned and always burned, and 31 reported burning first, then tanning. Nearly half reported having had more than five painful sunburns in their lifetime. Despite these results, only a third of participants (13) reported wearing sunscreen, less than half (17) reported wearing a hat, and two-thirds (26) reported wearing sunglasses more than 50% of the time. Of the 39 participants, we referred one to his general practitioner for management of two non-melanoma skin cancers. About half of the participants reported having had formal skin checks before. Of these, one had previously had melanoma and five had non-melanoma skin cancers, and 10 had one or more suspicious naevi removed in their lifetimes. The main reasons given for not having had a previous skin examination were fear of skin cancer diagnosis and difficulty attending appointments during working hours. We found that providing easy access to free on-site skin examinations reduced interference to the work day, made appointments more accessible (both physically and financially), and enabled us to provide personalised information about participants’ skin and skin cancer risks and reassure those who had been anxious about receiving skin cancer diagnoses. We found that workers were relieved when told they had nothing suspicious presenting on the day, and that they seemed less anxious about seeking skin checks in the future. Despite many public awareness campaigns on skin cancer and the establishment of sun safety programs in the workplace, we found there is still room for improvement. Although clinical guidelines do not currently recommend routine skin cancer screening for the general population,4 the success of our visit leads us to encourage workplaces that are exposed to solar UV radiation to consider providing on-site skin examinations for employees, as well as ongoing sun safety education. We believe such services can help to break down barriers that prevent people from seeking medical assessment and management, and can help to spread the safety-in-the-sun message.

Nicola C Douglas · Laura Baillie · H Peter Soyer

To the Editor: In their report on the findings in Hope v Hunter and New England Area Health Service,1 Mahar and Burke suggest that some of the judge’s reasoning “may reasonably cause apprehension for clinicians relying on the peer professional practice defence”.2 In her Editor’s Choice, Katelaris mirrors this apprehension.3 But the judge’s findings are not nearly so troubling. Mahar and Burke state that “the court considered ... that because the defendant had completed much of his training in the United Kingdom and the United States, the evidence that he gave was not necessarily indicative of professional practice in Australia”. However, the judge had said: Without at all intending any criticism of Associate Professor Haertsch [expert witness for the defendant] ... his practice was in accordance with what he had learnt in his training in Edinburgh, Scotland and in Michigan, USA which was not, of itself, evidence as to peer practice in this country.1 The judge’s point was not about the defendant having trained overseas — the judge made no mention of where the defendant had trained. The judge was concerned about the expert witness who was testifying as to what extent the technique used by the defendant was peer practice in Australia. In doing this, the expert witness described how he conducted this sort of procedure, drawing on his overseas training. Quite reasonably, the judge regarded this as “not, of itself, evidence as to peer practice in this country”. Also, Mahar and Burke state that because the same expert witness had consulted a colleague about her practice concerning ganglion excision, the “court noted that this witness ... was in sufficient doubt to consult another practitioner” and “this may have partly informed the court’s decision to reject the expert’s evidence for the purposes of the defence”. However, the judge had said: I also consider it telling that Associate Professor Haertsch appeared to be in sufficient doubt about the matter that he thought it was necessary to consult Dr Gschwind for her views and for details of her practice concerning ganglion excision. I infer from the fact of such consultation, together with the fact that Associate Professor Haertsch has only operated on little rice grain sized ganglia ... that he has not had the same breadth of experience as Associate Professor Connolly [expert witness for the plaintiff] as to what constituted widely accepted professional practice ... concerning the excision of a half centimetre sized ganglia of the type that the plaintiff had presented for removal. In this regard I prefer the evidence of Associate Professor Connolly to that of Associate Professor Haertsch.1 Seen in context, it is hard to draw the conclusion that the testimony of the expert witness “was discounted because ... he consulted a colleague about her views on the case”.3 If the consultation with a colleague discounted the testimony, it was a very minor factor.

Christopher J Ryan

To the Editor: The Journal recently drew attention to circumstances in which courts have not accepted professional opinions on standard of care required in negligence cases.1,2 These include opinions formed after consulting colleagues, from doctors trained overseas or unrepresentative of national peer professional practice. In a veterans’ entitlements case in 2004 (Linton and Repatriation Commission3), in which I was an expert witness for the Department of Veterans’ Affairs, the Administrative Appeals Tribunal did not accept an opinion on appropriate clinical management in the past from an expert whose memory of peer professional practice was contradicted by documents that were in use at the time in question, preferring the latter. However, contrary to the circumstances described by Mahar and Burke, the Tribunal did accept opinions from a doctor who consulted others and from me, even though I trained overseas. The Repatriation Medical Authority produces “statements of principles” that enumerate factors which connect veterans’ health to service under the Veterans’ Entitlements Act 1986 [Cwlth].4 Inability to obtain appropriate clinical management is a factor in many of these statements. Tribunals have relied on professional opinion to determine the appropriateness of clinical management received by veterans. In Linton and Repatriation Commission, a veteran claimed in 2004 that withholding corticosteroids during the 1970s constituted inappropriate management of asymptomatic hilar lymphadenopathy due to sarcoidosis.3 There was disagreement between expert witnesses. One expert, a graduate of 12 years and a newly qualified Fellow of the Royal Australasian College of Physicians (FRACP) in the early 1970s, believed that the veteran should have been offered corticosteroids. Another FRACP, who was 15 years younger and graduated in the mid 1970s, after consulting colleagues who had practised at the time in question, believed corticosteroids would reasonably have been withheld. Despite being trained in the United Kingdom, the Tribunal accepted evidence from me on three important issues.3 First, the Tribunal accepted that textbooks used in the 1970s may contain statements of what should have been done at that time to manage sarcoidosis. Second, the Tribunal accepted that, based on the textbook on which Australian physicians probably relied during the 1970s, patients with the veteran’s condition were unlikely to have been treated with corticosteroids owing to an expectation that the condition would resolve spontaneously. Third, the Tribunal accepted that early clinical trials of corticosteroids in the treatment of pulmonary sarcoidosis between 1967 and 1976 were inconclusive and gave doctors no reason to believe that steroids would alter the long-term outcome of the condition. In addition, a 2000 Cochrane review found that the long-term effect of steroids was still unclear.5 The Tribunal, therefore, found that the veteran’s condition was managed appropriately. Comparing the circumstances under which civil courts and the Administrative Appeals Tribunal have not accepted opinions on standard of care would reveal any systematic differences between the jurisdictions.

Hedley G Peach

To the Editor: By focusing on the observed low correlations between the Undergraduate Medicine and Health Sciences Admission Test (UMAT) and academic scores at the University of Queensland (UQ), Wilkinson and colleagues1 conclude that the UMAT is a poor predictor of medical student performance. Alternatively, one could focus on the very high mean and low variance grade point average (GPA) scores of the UQ student cohort and conclude that the use of UMAT scores was clearly very successful in identifying a high-performing group of students. However, before making any conclusions based on these data, we should draw on the vast literature that highlights common problems that significantly affect validity coefficients.2 Range restriction is one such problem, and Wilkinson and colleagues rightly used Thorndyke case 2 to correct for this in their UMAT scores. Although they achieved little change in observed correlation values, a recalculation using the mean standard deviation of the entire UMAT cohort for the period 2005–2009 actually takes the 0.14 correlation between Section 1 and Year 1 GPA to 0.27. Despite this considerable increase, Thorndyke case 2 only accounts for direct range restriction of the predictor (UMAT scores). However, in the context of medical student selection, there are other important sources of error that need to be accounted for in order to better appreciate predictive validity. First, use of a high cut-off on the high school examination score is very likely to add indirect range restriction on the UQ UMAT scores. This may be further attenuated by not including measures of non-cognitive ability (interviews). Second, selection on cognitive ability tests (UMAT and high school results) also creates range restriction on the largely cognitive criterion (GPA) that would further reduce observed validity correlations. The UQ study illustrates such restriction. Third, the unreliability of the criterion itself needs to be accounted for, especially when more subjective ratings are included, such as ratings of clinical performance. The problem of relatively small samples in selection studies is well documented.2 Given the evidence of extreme range restriction of predictor and criterion variables used in medical school selection research, more primary studies (followed by meta-analysis) are necessary before accurate conclusions can be made about the use of the UMAT, or of any other predictor used in this high-stakes selection context.

Barbara N Griffin

To the Editor: I spent my fifth-year medical student elective at Alice Springs Hospital and a remote Aboriginal settlement in the north-west of South Australia in the early 1980s. I organised this myself and came away with a fairly firm belief that the health of the Indigenous population in remote areas was unlikely to improve. Between 1995 and 2009, I visited remote Aboriginal settlements and hospitals in Darwin and Alice Springs as a specialist physician. Nothing I have seen in that time has changed the view I formed as a student. During my time in these settings, I have seen in the Indigenous population extreme examples of poverty, severe neglect of children and adults with disability, and examples of physical and sexual abuse. On occasions I have been threatened, and at times I have needed to be escorted for my safety. When staying overnight on settlements, I have been provided with secured accommodation. I have walked in fear of feral and diseased camp dogs and have been hurried along in my work to avoid cultural incidents. The article by Patel and colleagues explores some of the issues in this area as they affect medical student training.1 I think it is good that they have done so, but to dress it up with quasi-scientific methodology is unnecessary. My view is that it is not possible to provide or sustain health services of any reasonable standard in small and remote communities that have no economic basis for development and where the population is poor, poorly educated and has little prospect to share in this country’s fortune. There is a reason that we are failing to improve the health of the Indigenous population in remote areas, and that is that we cannot. It is an unrealistic expectation. This needs to be acknowledged, and we all need to move on.

Adrian N Winsor

To the Editor: In their editorial about risks to medical students in rural and remote placements, Peachey and McBain-Rigg stated: But there is a danger that, in focusing only on possible harms, we underestimate the power of difficult circumstances to enhance the very attributes that are required for the long haul in rural and remote practice.1 They referred to such issues as a “philosophical quandary” and went on to use a metaphor about a breaking bungee rope. The editorial conflated two important issues: safety and character-building experiences. The safety of visiting medical students and workers is not a philosophical quandary. Requirements of occupational safety are a practicable matter and a matter of law. Employers are required to assess and manage risks. The editorial’s authors are from Queensland, where the current relevant legislation is the Workplace Health and Safety Act 1995. Assistance is available from state workplace safety bodies, such as Workplace Health and Safety Queensland. Patel and colleagues made a good empirical assessment of adverse events that have happened to medical students in remote areas.2 Such an assessment could contribute to a safety management plan and system. Patel et al stated that “a ‘distressing’ incident does not necessarily lead to an overall negative placement and may in fact be a powerful learning experience”. They gave the example of a female student who was not met when she got off a bus at a remote community at 3 am, which concluded with the student’s words that the placement was a “good placement medically”. A worker might implicitly or explicitly approve of any risk that he or she is exposed to, but this does not relieve the employer of its obligations to the worker’s safety. Inviting readers to look on the bright side of safety shortcomings is not in the best interests of medical students, the permanent workforce or the population of rural and remote areas.

Andrew W Nielsen