Letters

In reply

Lindy Willmott · Ben P White · Marcus Sellars

In reply

Cameron J McLaren · Greg Mewett

To the Editor: Close and colleagues raise some important issues in their article on voluntary assisted dying (VAD) and telehealth.1 For the most part, their four key considerations give good practical advice to clinicians trying to work around Commonwealth laws introduced for a substantially unrelated purpose. A scenario they do not address is where a patient has been assessed as eligible for VAD, and then needs to discuss with the doctor by telehealth the choice between having lethal medication administered to them, or taking it themself (self‐administration). This is already an issue in Western Australia, and will become an issue in Tasmania and Queensland; not so much in Victoria or South Australia, where this choice is essentially restricted by clinical criteria set out in the legislation. In the above scenario, it needs to be made clear to the patient that the doctor is not favouring self‐administration over practitioner administration, but has an open mind in talking through this choice by telehealth with the patient. Close and colleagues are right to caution against using telehealth to discuss the VAD medication protocol for self‐administration, but their advice to have such discussions in person is not particularly helpful when the doctor is remote from the patient. When self‐administration is chosen, Western Australian law requires written instructions to be provided to the patient by the doctor and the applicable pharmacist on how to prepare and take the lethal medication.2 It can be explained that these instructions will be provided as hard copy, with the doctor making clear that nothing said to the patient over telehealth should be construed as instruction on how to prepare or take the medication. When the pharmacist delivers the medication to the patient for self‐administration, as is the practice in Victoria and Western Australia, any question about the written instructions can be dealt with face to face, as part of the counselling of patients expected of pharmacists under guidelines issued by the Pharmacy Board of Australia.3

Richard SW Lugg

To the Editor: Kaur and colleagues propose the ABCD (abbreviated, brief, comprehensive, detailed) approach for older patients.1 Further to that, we propose extending the mnemonic to ABCDEF with E for efficiency and F for feasibility. This would make it more realistic. The Australian population is ageing. Older patients are often beset by numerous comorbidities. Innovative approaches to facilitate minimisation of hospitalisation and early discharge of frail older patients are urgently needed. Comprehensive geriatric assessment is advocated as the gold standard of managing older patients’ medical needs to improve quality of life. It requires specialist geriatrician assessment in geriatric evaluation and management wards. Unfortunately, a minority of older patients end up being admitted to geriatric evaluation and management units, whereas acute medical beds are mostly occupied by older patients where access to comprehensive geriatric assessment is poor.2 Further, the cost‐effectiveness of comprehensive geriatric assessment in specialised units remains unknown and its utility in reducing length of stay and avoiding readmissions is limited.3 The ABCD concept is intriguing. However, it is unlikely to resolve the dilemma of bed occupancy and length of stay of older patients unless the approach is sufficiently efficient and feasible. These elements conveniently extend the mnemonic to ABCDEF. By “efficiency” we mean efficiency in early recognition of their acute issues, establishing a multimodal approach of therapeutic interventions and discharge planning. “Feasibility” of utilising ABCD in various hospital settings must also be considered. Hospital in the home in appropriately selected patients is an example of efficient and feasible comprehensive geriatric assessment based on the ABCD approach.4 For the ABCD to be properly executed, E (efficiency) and F (feasibility) are integral to this approach. Timely access to specialist geriatric care along with improved delivery of primary care for older people are key issues that need to be concurrently addressed.5

Alaa Alghamry · Joseph C Lee

In reply

Paven Kaur

To the Editor: In August 2020, the South Eastern Sydney Public Health Unit, located in New South Wales, Australia, received a statutory laboratory notification of an elevated blood lead level of 0.34 µmol/L in a preschool‐aged child recently diagnosed with autism. This was above the 0.24 µmol/L level requiring notification under the Public Health Act 2010 (NSW). The test had been requested by the child's paediatrician due to concern about the child’s recent consumption of an oral Ayurvedic medicine prescribed by a naturopath. Our environmental health officers undertook a home lead assessment, during which a soil sample and the Ayurvedic medication sample were taken for heavy metals analysis. The soil lead concentration was 160 mg/kg. The medication was labelled Manasmithra Vatika (MV), manufactured in India (Box). Analysis revealed that it comprised 0.96% lead by weight. The naturopath indicated that they had prescribed the medication to other child and adult patients, some of whom were seeking treatment for autism. Most consultations were conducted online and the prescriptions were purchased online. We were concerned about the risk of lead toxicity in the naturopath’s other patients who had been prescribed MV, and mounted a public health investigation in order to inform patients of their risk, to advise them to cease use of the medication, and to identify the extent of the problem. The naturopath provided a list of 28 patients (13 children) to whom they had prescribed the medication. We directly followed up the 12 NSW patients (other than the index case), asking whether they had taken MV, and, if so, in what dosage and over what period. We advised those who were taking MV to immediately cease its use, and to seek blood lead level testing through their own doctors. We asked patients to provide us with any remaining MV for lead analysis. Five patients provided MV samples; analysis showed lead content of 0.74–0.96% (mean, 0.81%) by weight. Four patients had an elevated blood lead level ranging from 0.30 to 0.68 µmol/L (reference interval, < 0.24 µmol/L). A fifth patient, whose blood lead level was undetectable (< 0.1 µmol/L) had ceased taking the MV at least 3 months before measurement. Based on these findings, we initiated a multi‐agency investigation involving NSW and Australian government regulatory bodies. Action taken against the naturopath by the Australian Health Practitioner Regulation Agency and NSW Health Care Complaints Commission prohibited them from treating medical conditions, such as autism. The naturopath voluntarily ceased prescribing MV and immediately contacted their patients to inform them of the lead adulteration of the preparation. The NSW distributor of the MV medication was investigated by the NSW Health Pharmaceutical Regulatory Unit and the Therapeutic Goods Administration, leading to the distributor ceasing to import the adulterated MV. The Therapeutic Goods Administration issued a public warning regarding the presence of lead in MV preparations generally, without naming an implicated brand or source.1 Lead exposure in children can be linked to reduced intelligence, and behavioural and developmental impacts.2,3 Ayurvedic medicines are formulated and prescribed based on ancient Indian texts. Although they are herbally based, Ayurevedic texts also provide for formulation with heavy metals including lead.4 Their use has been associated with elevated blood lead levels in patients.5 The public health investigation and subsequent multi‐agency intervention we have described prevented ongoing exposure of patients to a lead‐contaminated herbal product. As a result of this investigation, we suggest: ▪ health practitioner awareness be raised regarding the risks of recommending or prescribing unregistered, imported medications; ▪ clinicians consider testing for blood lead in patients who have consumed unregistered, imported Ayurvedic medications; ▪ public health professionals be engaged in the investigation of patients with elevated blood lead levels in the absence of an occupational source; ▪ community awareness be raised regarding the risk of consuming unregistered, imported Ayurvedic medications; and ▪ a multi‐agency response is required to effectively address prescribing of unsafe complementary medications by unregistered health professionals. Box – Manismithra Vatika tablets provided by a patient with an elevated blood lead level

Mark J Ferson · Sinead Flanigan · Toni Cains

To the Editor: Self‐collected vaginal samples are as effective as clinician‐collected cervical samples for detecting underlying cervical intraepithelial neoplasia grade 2 or higher (the target lesion of cervical screening) using polymerase chain reaction‐based oncogenic human papillomavirus DNA assays.1 However, the use of self‐collection within Australia’s cervical screening program is currently restricted to women who are underscreened or never screened (at least 2 years overdue, so 4 years since their last Pap test), aged ≥ 30 years and refuse a clinician‐collected sample. This is because, at the time the current policy was developed, self‐collection was believed to result in a small loss of sensitivity. Accredited laboratories are not permitted to test samples that do not meet these requirements. VCS Pathology (part of the Australian Centre for the Prevention of Cervical Cancer) was the first laboratory to receive regulatory approval to process self‐collected samples. Here we report the reasons for rejection of samples received between February 2018 and 30 June 2021, which is important given that about one‐third (34%; 2166/6234) of samples received could not be processed (37.4% in 2018; 37.9% in 2019; 34.1% in 2020; 22.8% in 2021). The three most common reasons were that the person was not sufficiently overdue (54.1% of rejected samples; 18.5% of all samples); that the wrong type of collection device was used (17.3% of rejected samples; 5.9% of all samples); or that the person was < 30 years of age (11.2% of rejected samples; 3.8% of all samples). Other reasons included delayed sample receipt (5.2% of rejected samples; 1.8% of all samples), presence of symptoms (3.0% of rejected samples; 1.0% of all samples) and multiple reasons (combination of above factors: 6.6% of rejected samples; 2.3% of all samples) (Box). The implementation of self‐collection, while known to be highly acceptable to many women who will not accept a speculum examination for screening,1,2 has been problematic in Australia to date.3,4 The eligibility restrictions and strict laboratory requirements have created unintended barriers for practitioners and potential participants, as demonstrated by both the sample rejection rate and low overall numbers compared with the eligible population (< 1%).3 The recently announced mainstreaming of self‐collection, by making it a choice for all screening participants using on‐label tests, should overcome many of these barriers5 and improve program equity and participation. Successful implementation will depend on timely education, communication and change management. Box – Proportion of 6234 self‐collected samples received that were unable to be processed, by reason and year of receipt (VCS Pathology, February 2018 to the end of June 2021) * Incorrect collection device refers to wrong swab type or media. † Other reasons include duplicate samples, and pregnancy (which was initially an exclusion criterion).

Julia ML Brotherton · David Hawkes · Marion Saville

To the Editor: In March 2021, the federal Parliament introduced a bill to legalise the use of the reproductive technology known as mitochondrial donation in Australia.1 Mitochondrial donation would be offered initially at a single trial clinic and, eventually, it would be made more widely available. The aim is to provide at‐risk women with the opportunity to have a genetically related child who is unlikely to develop maternally inherited mitochondrial disease. Legalising mitochondrial donation would have meaningful benefits for such women. However, as the bill currently stands, its implementation raises unresolved ethical and legal issues. Access will predictably be mediated by geographic, financial, medical and informational considerations. These include the location of the initial trial clinic, any out‐of‐pocket costs to prospective parents, and health professionals’ awareness of mitochondrial donation. Existing barriers to genomic testing, genetic counselling, and assisted reproductive technologies will also affect access. These barriers, including long waiting times and limited Medicare coverage for some genetic services, should be minimised. Mitochondrial donation requires donor oocytes. This raises questions about how oocytes will be procured and how many should be apportioned to mitochondrial donation relative to other procedures that may require fewer eggs to achieve a live birth. One crucial issue is whether oocyte donation for mitochondrial donation should require specific consent from donors. One option is to use oocytes donated for assisted reproduction generally, without requiring consent for their use in mitochondrial donation specifically. The first study of mitochondrial donation to yield a live birth took this approach.2 However, we believe this strategy fails to acknowledge the legitimate reservations some donors may have about the use of their oocytes in this novel reproductive procedure. Securing specific informed consent would protect donors’ wellbeing and autonomy as well as protect public trust in medicine. At a minimum, specific consent should be required in the trial stage. This could also generate important data on the views of a critical group of stakeholders (the oocyte donors) and on what impact, if any, requiring specific consent would have on oocyte supply. Mitochondrial donation also prompts a reconsideration of the ethics of sex selection. The Australian Government has signalled that it may provide parents with the option of implanting only male embryos.3 Since mitochondrial DNA is inherited through the maternal line, this would minimise any effects on the descendants of children born via this technique. However, this use of sex selection sits uneasily with Australia’s legal prohibition on, and moral reservations regarding, non‐medical sex selection. Both male and female embryos would receive identical mitochondrial DNA and face the same risks from the procedure; sex selection reduces risks only to that child’s descendants. There is also a concern that offering sex selection would lead parents to believe it is medically indicated, creating a sense of pressure to select male embryos. As sex selection raises serious concerns without promising clear benefits, we think there are problems with offering it in this context. Legalising mitochondrial donation raises numerous ethical issues, including access, oocyte donor consent, and sex selection. While mitochondrial donation carries important potential benefits, these issues need careful attention to ensure that its implementation in Australia is ethically robust.

Julian Koplin · Esther Lestrell

To the Editor: We congratulate Wright and Versteeg1 for their timely article outlining Australian and international experience of patient enrolment in general practice. Missing from the debate, however, is any reflection on the Practice Incentives Program – Indigenous Health Incentive (PIP‐IHI), a voluntary general practice enrolment of Indigenous patients intended to improve chronic illness care. Here, to offer transferrable lessons for informing the rollout of the Voluntary Patient Enrolment scheme (called MyGP),2 we draw on findings from the Sentinel Sites Evaluation — based on administrative data from the Department of Health and more than 700 interviews with Aboriginal health services and general practice3 — and submissions made to the PIP‐IHI review by key stakeholders in 2019.4,5 First, the lack of existing clinical information system capacity to record if a patient was registered with the PIP‐IHI hindered its implementation. Of particular concern were the separate spreadsheets developed to manage patient registration. Short term gains from developing parallel systems did not advance systematic development and use of follow‐up and recall systems in the longer term. Thus, investment in patient registration systems that advance clinical information systems is required. Second, a perception that the PIP‐IHI rewarded paperwork but did not improve clinical outcomes was a disincentive for participation. Administrative requirements were widely considered too burdensome, particularly, annual patient registration that required practices to determine whether patients were previously registered or had duplicate registrations. This resulted in low patient re‐registrations, limiting the potential for the measure to provide longer term community benefit. Hence, to improve participation, the administration burden must be minimised, with flexible, simplified one‐off registration procedures that enable patients to change general practices. Last, given that patients registered for the PIP‐IHI were expected to have a diagnosed chronic disease, it is notable that Tier 1 or Tier 2 payments reflecting continuity of care and planned review were not triggered for about 30% of patients.6 A substantial proportion of PIP‐IHI‐registered patients were either not regularly attending general practices or the practices were not billing for care in a way that triggered payments. Practice staff attributed this to inadequacies in their recall and reminder systems and to difficulties in contacting patients for recall and in getting them to attend a follow‐up appointment. Therefore, incentives need to encourage better care, not just enrolments.

Jodie Bailie · Alison Laycock · Ross S Bailie

In reply

Michael Wright · Roald Versteeg

To the Editor: We congratulate Backholer and colleagues for their article.1 This is a timely, powerful call to action. One in six Australians live with a hearing condition, a proportion that is set to rise as our population ages. However, prevalence also increases with longer exposure to loud noise and is higher in Indigenous and lower socio‐economic status populations. As audiologists, researchers and consumer advocates, we believe that taking a social determinants approach is the best way to significantly improve health and wellbeing. Historically, approaches to hearing health in Australia have been device‐centric.2 With the Roadmap for Hearing Health,3 collaboratively created by the sector and the federal government, there is an opportunity to change direction. To date, with the notable exception of initiatives in Aboriginal communities,4 hearing health has not been approached through the lens of the social determinants of health. We are currently working to change this. Physical and digital spaces determine the experience of hearing conditions5 to such an extent that interventions for accessibility can have as much impact on wellbeing as health interventions. Across all specialties, we encourage clinicians and researchers to forge connections with the disciplines of architecture, town planning, acoustic engineering, communications, and technology, to name a few. The HearMe report,5 which combines lived experience narratives with expertise from far beyond the health sector, was a first step in this direction. The work of the Obesity Collective is to be commended for taking a similar approach to an urgent public health issue (www.obesityaustralia.org). We live in a hearing society, making a person’s hearing status itself a determinant of health. People living with hearing conditions face stigma, discrimination and access barriers, including to health care. As highlighted by Backholer and colleagues,1 the coronavirus disease 2019 (COVID‐19) pandemic was a great disruptor and accelerator, showing us that rapid, society‐wide transformation is achievable. A world that is fulfilling, accessible, inclusive and respectful for people living with hearing conditions is possible if we centre the diversity of lived experience and commit to action on the social determinants of hearing health across the life course.

Jessica Vitkovic · Caitlin Barr · Bamini Gopinath

To the Editor: With great interest we read the article by Weise and colleagues,1 which presents the results of a retrospective cohort study that found higher age‐standardised rates of potentially preventable hospitalisation in people with intellectual disability in New South Wales compared with the general NSW population. Given the great health inequality of people with intellectual disability, we acknowledge the authors’ effort to conduct this valuable study. However, after reading the article, we were left with two questions. First, to be able to interpret the results of this study, a clear description of the population characteristics of both groups is indispensable. Information about parameters such as age and sex of both populations and about the design of the database is of crucial importance. The absence of this information makes it difficult to get a good picture of the population studied and any limitations or biases that need to be taken into account. We recognise that this type of data is not always easy to collect, especially when working with large population databases. Given its importance for interpretation purposes, we see this as a crucial point of attention for future research. Second, in this study, potentially preventable hospitalisations were identified using the definition in the National Healthcare Agreement, progress indicator 18.2 However, in addition to this definition, the circumstances and the exact reason for hospital admission have not been explored, which makes it difficult to conclude whether all hospital admissions could actually have been prevented in clinical practice. Further research would therefore be of great added value to unravel the significance of the study findings by exploring the differences in the rates of potentially preventable hospitalisations to guide possible future reforms of primary and community health care. In conclusion, the article provided us with important knowledge about the rates of potentially preventable hospitalisation of people with intellectual disability. However, the questions mentioned above need to be answered and further research should be conducted to allow a good interpretation of the results.

Karel L Wel · Lydia Kleinjan · Marleen J Leeuw

In reply

Janelle C Weise · Preeyaporn Srasuebkul · Julian N Trollor

TO THE EDITOR: Multisystem inflammatory syndrome in children (MIS‐C) or adults (MIS‐A) is a rare but severe systemic inflammatory syndrome,1 with an epidemiological peak occurring 4–6 weeks after severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2) outbreaks.2 Also known as paediatric inflammatory multisystem syndrome temporally associated with SARS‐CoV‐2, MIS‐C is the subject of active surveillance across paediatric centres.3 The peak age for the syndrome is 9 years,1 although cases have been reported in adults.4 We report, to our knowledge, the first Australian case of MIS‐A, diagnosed 2 months into the SARS‐CoV‐2 Delta outbreak in New South Wales, with 60 075 coronavirus disease 2019 (COVID‐19) notifications in the period 29 June to 4 October 2021.5 A 42‐year‐old woman presented with 7 days of subjective fevers, myalgia, light‐headedness, abdominal pain, nausea, palpitations and non‐pleuritic chest pain. Presentation occurred 27 days after acute COVID‐19 pneumonitis, confirmed by polymerase chain reaction and serology testing. The acute illness was mild, requiring neither oxygen nor hospitalisation, and the patient recovered fully 72 hours before onset of this new symptom complex. She was unimmunised against SARS‐CoV‐2. The patient was febrile (38.2°C), with tachycardia (114 beats per minute) and hypotension (79/56 mmHg) but no respiratory distress. She had bilateral conjunctival injection, a widespread blanching macular rash (Box), and oedema of the hands bilaterally. There was no lymphadenopathy or oral mucosal change. Investigations revealed significant inflammation, with a raised C‐reactive protein level (119 mg/L; reference interval [RI], ≤ 4 mg/L), lymphopenia (0.5 × 109/L; RI, 1.0–4.0 × 109/L), thrombocytopenia (74 × 109/L; RI, 150‐400 × 109/L), neutrophilia (12.2 × 109/L; RI, 2.0–8.0 × 109/L), deranged liver function tests (alanine transaminase, 160 U/L; RI, 10–35 U/L), and hypoalbuminemia (20 g/L; RI, 35–50 g/L). Her D‐dimer level was raised (2.34 mg/L; RI, < 0.5 mg/L), as was her brain natriuretic peptide level (1660 ng/L; RI, ≤ 125 ng/L); troponin and creatine kinase levels were normal. Blood and urine cultures were negative, and anti‐streptolysin O and anti‐DNase B titres were not raised. No echocardiographic evidence of myocarditis was seen, and there was no coronary artery dilatation. The patient responded to two doses of intravenous immunoglobulin (2 g/kg each) following 48 hours of inotropic support (metaraminol infusion then low dose noradrenaline). Aspirin (3 mg/kg daily) was administered, as well as intravenous antibiotics for 72 hours while cultures were pending. MIS‐A was diagnosed on the basis of current case definitions,6,7 although the patient also fulfilled criteria for probable toxic shock syndrome, as described in other case series.8 Adults and adolescents with MIS‐A typically present with multisystem involvement, often incorporating myocarditis, shock and gastrointestinal features,4,9 whereas younger children present more commonly with a Kawasaki disease‐like illness.9 Given the absence of specific diagnostic markers, the overlapping phenotype with toxic shock syndrome and the poor sensitivity of cultures and serological markers for these alternative diagnoses, such differentials must be carefully considered in the early phase of illness. Nonetheless, clinicians should be aware of MIS‐C or MIS‐A in patients presenting with shock, mucocutaneous changes and/or gastrointestinal symptoms, even without preceding symptomatic SARS‐CoV‐2 infection. Prompt treatment with intravenous immunoglobulin and/or steroids is essential to minimise long term morbidity from coronary artery dilatation.1 Although rare, further cases of MIS‐C and MIS‐A are anticipated following increasing COVID‐19 case notifications in NSW and Victoria. This letter was published as a peer‐reviewed Accepted Article (prior to structural editing and typesetting) on 14 October 2021. Box – Bilateral conjunctival injection (A) and diffuse blanching macular rash (B) in an adult with multisystem inflammatory syndrome

Annaleise R Howard‐Jones · Sam R Orde · Zoe Jennings

To the Editor: We congratulate Donovan and colleagues1 on their snapshot bedside audit of 850 inpatients with diabetes across 27 Queensland hospitals. The results in their audit identified current strengths and deficits in inpatient diabetes management. These efforts will be invaluable to the planning of future improvement interventions in Australia. Inpatient diabetes management centres on improving glycaemia, as measured by reducing incident hypo‐ and hyperglycaemia, in order to reduce the consequences of dysglycaemia. While auditing bedside practice is important, it describes only part of the picture of inpatient diabetes. The complementary counterpart that augments the value of such auditing is the process of glucometric assessment, which is being enabled by the introduction of point‐of‐care networked blood glucose monitoring in Australian hospitals, with the first hospital‐wide system instituted in 2019.2 Glucometry involves collecting all blood glucose measures for inpatients throughout an admission and calculating mean and threshold indices of glucose management, which assists bedside care as well as enabling virtual glycaemic care programs.3 The potential synergy between glucometric assessment and bedside practice audits arises when these audits identify a change in practice within a hospital. Any resulting changes in that institution’s glucometric trends will provide quantitative information about the value of that practice change. This will enable the widespread dissemination and adoption of those practices found to have the greatest beneficial effects on glycaemia, and will provide an evidence base for generating national standards.4,5 Similarly, after adjusting for differences and variability in patient populations, glucometric benchmarking enables comparisons to be made between hospitals.6 When cross‐referenced with differences in practice, as identified by audits such as the Queensland Inpatient Diabetes Survey (QuIDS),1 the effects of these differences may be determined and their independent value thus broadly quantified. We applaud the increasing national adoption of both electronic medical records and networked blood glucose monitoring, enabling future glucometric benchmarking.7 In the face of the ever‐increasing prevalence of diabetes in hospitals,8 it is crucial for all those involved in inpatient diabetes care to champion the twin quality procedures of auditing bedside practice and glucometric benchmarking. It is only together that these processes can best help us achieve optimal outcomes in hospital for people with diabetes.

Rahul D Barmanray · Mervyn Kyi · Spiros Fourlanos

In reply

Peter Donovan · Benjamin P Sly · Gaurav Puri

To the Editor: I commend Wijeratne and Earl1 for drawing attention to the retirement issues faced by doctors. Psychological issues are compounded by the lack of legislative provision for doctors to progressively step down from the demands of full registration. Reducing workload is not a simple matter. The impediments to maintaining registration while reducing workload include recency of practice requirements and up to 73 hours per annum of continuing professional development (CPD) for physicians2 — far exceeding that of other health practitioners. Encore careers as described by the authors, while rewarding, could cause issues with the scope of practice requirements. Current guidelines around the definition of “practice of medicine”,3 unless changed, could find doctors practising medicine without a licence. Eighty‐eight per cent of doctors in a local medical association survey (131 respondents; response rate 27%) supported a step‐down approach, with 59% (of 113 respondents) supporting reduced CPD requirements.4 Many doctors see their profession as a calling and retain a strong desire to serve their communities both before and after retirement. Dignity and respect are key to effective transitions to retirement. Doctors often leave the profession on a sour note because their attempts to maintain registration in order to give back to their communities flounder under current regulations. There is despondency around the lack of recognition of their significant expertise and lack of regulator foresight in how to use the vast resource of senior doctors (eg, pandemics, fires, floods, community health needs). Australia appears to lag behind other countries in this regard. In the United States, states such as Pennsylvania offer retiring and retired doctors volunteer licences through their medical boards to volunteer their services for community health programs.5 The Australian Senior Active Doctors Association and the Australian Medical Association Queensland Senior Doctor Craft Group are working to achieve a step‐down approach.6 Other professions recognise and encourage the active participation of retired members; for example, retired lawyers in several states, including Queensland,7,8 can apply for free practising certificates to undertake pro bono work. In many cultures, “senior” is synonymous with wisdom, leadership and excellence. While retirement planning is important, so is addressing practices and regulations that undermine and limit the value that senior doctors can bring to their communities as they transition through the latter stages of their careers.

Geoffrey Hawson

In reply

Chanaka Wijeratne · Joanne Earl

To the Editor: As members of the Australian Rheumatology Association (ARA), we read with great interest the recent article by Russell and colleagues.1 The organisation has long been concerned that current training pathways and health care resourcing are resulting in a discordance between rheumatology health care supply in Australia and community needs. ARA believes the rheumatology workforce is in significant undersupply, ageing and largely focused in cities, and that our current training programs will not deal with these issues. A 2018 ARA survey of members found that 41% of respondents (of which 54.5% work at rural and remote clinics) plan to retire in the next 10 years.2 Our concerns are supported by Western Australian data3 reporting a critical shortfall of rheumatologists that trainee throughput will not address. However, accessing accurate national data has been difficult due to the issues outlined by Russell et al.1 For example, Australian Health Practitioner Regulation Agency (Ahpra) data suggest there are 441 practising rheumatologists in Australia, but the ARA is only able to identify 364 (including non‐members).4 In addition, understanding the community demand for care has been challenging, as this might be assessed through the surrogate of numbers of people on waiting lists, but there is heterogeneity of the referral acceptance guidelines and data collection processes. To this end, ARA has recently partnered with the Public Health Information Development Unit at Torrens University to define the rheumatology workforce in Australia, analyse interaction effects, and understand the relationships across public and private settings. This needs to be linked to disease prevalence data and geographic service area to understand supply and demand. We also need to understand the selection into the training process and pathways in order to drive policy addressing our suspected workforce problems. We strongly believe that any workforce planning research should engage and partner with specialty societies; for example, we believe that ARA is best placed to engage our members to aid understanding of their career choices and practice patterns. We encourage other specialty groups to follow suit and the Royal Australasian College of Physicians to consider their leadership role in this area.

Helen I Keen · Claire Barrett · Catherine Hill

To the Editor: In their study examining the suicide deaths of 3027 young Australians during 2006–2015, Hill and colleagues1 reported that nearly 60% of cases had experienced mental health problems during their lifetime, and around 75% of deaths were of young males. We would like to draw attention to another important statistic within these data. Specifically, 4.6% of males who died by suicide in Australia had a diagnosis of autism spectrum disorder (ASD). This is alarming, considering that the prevalence of males with ASD in Australia is estimated to be only 1.3%.2 For males in the study age range (ie, 10–24 years), the prevalence ranges from 1.2% to 3.3%, with the highest prevalence in the 10–14 year bracket. Nonetheless, the apparent high incidence of suicide by males with ASD is consistent with recent research indicating a three‐ to nine‐fold increased risk of suicide among people with ASD compared with the general population.3,4 The increased suicide risk in ASD may be explained by the high incidence of comorbid psychiatric disorders among this population.5 Indeed, in one national cohort study from Denmark, over 90% of people with ASD who attempted or died by suicide had another comorbid mental health condition.3 In addition, it is important to note the low rate of suicide reported among females with ASD (0.4%). This finding is inconsistent with large international studies that report significantly increased incidence of suicide among females with ASD compared with females in the general population, with rates similar to or exceeding that of males with and without ASD.3,4,5 Females with ASD may be underrepresented in the data presented by Hill and colleagues due to lower recognition of ASD among females or to diagnostic overshadowing, whereby ASD is overlooked in favour of other more apparent psychiatric diagnoses (eg, anxiety, borderline personality disorder, depression). Finally, we highlight the fact that there is no systematic procedure or requirement in Australia for asking about or reporting ASD diagnoses within the emergency department or hospital admission systems. Plausibly, ASD is inadequately captured in data concerning health and mental health profiles, health service system access, suicide attempts and deaths in Australia.

Darren Hedley · Mark A Stokes · Julian N Trollor

In reply

Nicole TM Hill · Patrick D McGorry · Jo Robinson

To the Editor: The incisive editorial by Dudley and Lin1 should serve as a clarion call for the development of “more robust strategies with targeted, customised approaches … evidence‐based interventions and peer‐reviewed evaluations”. Their sobering editorial highlights the immense challenges that need to be overcome to affect the growing suicide rates underscored by Hill and colleagues.2 They point out that transgenerational trauma and socio‐economic disadvantages increase suicide in Indigenous populations and call upon collaborative governmental support to address the problem. Intriguingly, although prevalence is higher in moderate to severely disadvantaged youth, the statistics among the least disadvantaged youth are not lagging far behind.2 This suggests that there are likely additional commonalities, such as mental illness, which features in at least half of all such suicide (> 55%).2 It is in light of this confronting reality that we raise the additional need for in‐depth knowledge and mechanism‐informed targeted treatment to avert suicide. It is concerning that one‐third of parents and carers are inadequately informed of mental health services available for mentally ill youth, impeding access to appropriate services,1 which clearly needs to be addressed. But simultaneously, it is important to identify more specific interventions and discern when and how to apply them effectively. This requires a reconceptualisation of suicide as a process, which involves both broad factors within the social environment and specific changes within cognitive and emotional processing networks within the brain.3 Mental illnesses, such as depression, have an impact on the latter by creating a cognitive drive that can be modelled as sequential steps that emerge from a faulty appraisal system to engender feelings of defeat and entrapment that increase hopelessness.3 It is because of these poorly understood antecedents4 and lack of rescuing factors that suicidal ideation ensues3 and is intensified to ideation or intent by additional motivational factors before being converted volitionally to planning and attempting suicide.3 The latter alters neural network connectivity, and further increases the likelihood of future suicide.5 Such deeper insights are needed to provide a framework for targeted preventive interventions. Therefore, we strongly resonate with the authors’ demand for targeted evidence‐based interventions and urge that in addition to these much‐needed initiatives, our energies should also be invested in mechanism‐based research.

Gin S Malhi · Erica Bell · Zola Mannie

In reply

Ping‐I Lin · Michael J Dudley