Letters

In reply: The proportion of patients who, after being referred to specialist orthopaedic surgeons by general practitioners, are then listed for surgery, is around 20%–30%.1-3 In our trial, the diagnostic and management concordance between the physiotherapists and surgeon for this group was very high. It was also high for the 63% for whom evidence-based physiotherapy was appropriate. Management discordance occurred when surgical treatments that are controversial, and variously used by surgeons (as noted by Brand and colleagues), were recommended. It is important to note that the 74% agreement between the surgeon and physiotherapists in our trial was achieved under research conditions, with the physiotherapists screening independently. We suggest that the physiotherapist clinic be co-located with that of the surgeons, to facilitate further investigations, enhance the pathway to surgery and manage safety concerns. The advantages of a physiotherapist screening clinic are in (i) triaging out from waiting to see a surgeon, patients predicted to benefit from non-surgical interventions (including those not willing to consider surgery at the time) and (ii) triaging patients in to the appropriate non-surgical care. We agree that patients with degenerative, osteoarthritic conditions, for whom joint replacement surgery may be the eventual treatment, will be best managed through multidisciplinary care.

Leonie B Oldmeadow · Harvinda S Bedi · Hugh T Burch · Jenni S Smith · Edmund S Leahy · Miron Goldwasser

To the Editor: The concerns expressed by Byard and colleagues about “safe-sleeping messages”1 are based on the assumption that bed-sharing (mother and baby sleeping on the same bed surface) is intrinsically dangerous. While some case–control studies have shown increased mortality for young (but not older) bed-sharing babies of non-smoking mothers, more detailed studies have found excess risk only among parents affected by alcohol, extreme overtiredness, overcrowded housing, or where the sleeping environment was unsuitable, including prone or side sleeping, heavy bedding, waterbeds and sofas.2 Epidemiological studies support the safety of bed-sharing. For example, in Hong Kong and mainland China, bed-sharing is very common, but rates of unexpected infant death are extremely low. This implicates aspects of Western lifestyle and sleeping practices — including the V-shaped pillows (tri-pillows) highlighted by Byard et al, other suffocation and entrapment hazards, and maternal smoking — rather than bed-sharing per se. Bed-sharing is also the evolutionary norm, providing many opportunities for “mutual regulation” of maternal–infant physiology, including body temperature, sleep cycle and breastfeeding.3 Modern bed-sharing mothers may appreciate the more restful sleep and easier breastfeeding. Overnight sleep laboratory studies of bed-sharing and solitary-sleeping mother–baby pairs show that bed-sharing mothers are very aware of their baby’s presence, even in deep sleep, and move to avoid overlaying. Bed-sharing babies breastfeed more frequently, but with equivalent total sleep for mother and baby.3 Researchers note the rarity of unsafe prone positions among breastfeeding, bed-sharing infants.3 Other studies have shown increased rates and duration of breastfeeding among bed-sharing mothers and infants.4 For these reasons, bed-sharing has become more popular in Western cultures, with an Australian survey in 2000 finding around 40% of young babies bed-sharing for at least part of the night.5 As with other aspects of care, it is our duty as health professionals to discuss the risks, benefits and practicalities of bed-sharing so that parents can make an informed and safe choice. The Royal Australasian College of Physicians comments, “Co-sleeping or bed-sharing is common and associated with increased breastfeeding rates, longer and more restful sleep, and a protective posture and synchrony of mother with baby . . . All parents should be informed about how to safely co-sleep with their infants”.6 Safe bed-sharing recommendations are available from websites such as the UNICEF UK Baby Friendly Initiative.7

Sarah J Buckley

In reply: Our position on bed-sharing was not based on the assumption that it is intrinsically dangerous, but that there is an increased risk of mortality for bed-sharing babies of “parents affected by alcohol, extreme overtiredness, overcrowded housing, or where the sleeping environment was unsuitable” (to quote Buckley). These risk factors were not mentioned by the telephone health advice line quoted in our letter,1 which rather commented that mortality in bed-sharing babies was such a rare event that the caller should not worry about it — little consolation if a fatality occurred. We agree completely that parents need to be able to “make an informed and safe choice”, but this also requires informing them of potential dangers — which did not happen. Also, we do not agree that mothers are always aware of the presence of their babies, as reports of accidental suffocation during breastfeeding in bed clearly demonstrate.2,3 An informed decision is made when all the information has been provided, not just information that supports a particular point of view. Curiously, Buckley’s final point is to recommend a website for safe bed-sharing advice4 that states quite clearly (with italics): “the safest place for a baby to sleep is in a cot by your bed”. We concur.

Roger W Byard · Glenda Cains · Helen Noblet · Maxine Weber

To the Editor: Since graduating from medical school in 2004, I have dutifully read the Medical Journal of Australia. I was initially intrigued to read sporadic letters to the Editor in which authors, when commenting on current issues in medical education and clinical practice, referred to what happened “in our day”. Topics have included anatomy (eg, dissections), Latin and Greek lessons, teaching methods and hours worked. At times, I feel that the new generation of doctors, of which I am a part, must justify how we can work as medical professionals given our presumed inadequate knowledge. I believe that the skills I learned while at university have enabled me to successfully manage patients who not only have complex medical problems treated with numerous medications, but often require more support to be provided when at home. My training has taught me to solve problems and resource answers using multiple modalities and resources, at the same time keeping abreast of rapidly evolving medical theories and treatments. I do so while also facing the current economic challenges of rising insurance premiums, housing costs, and concerns about global warming. I did not learn Greek or Latin at school, but I did learn to touch type, design a database and formulate a spreadsheet. In my day, when electronic interfaces involved with patient care are changing rapidly, these skills have greatly enabled me for work in the 21st century.

Sara L Barnes MB BS

To the Editor: I am concerned that the Journal supplement “Early intervention in youth mental health”, published on 1 October 2007, may contravene the MJA policy on sponsored supplements. Item 9 of that policy (http://www.mja.com.au/public/information/instruc.html#Supplements) states: The supplement’s articles should not favour drugs/interventions/views/products of the supporting body to the detriment of other drugs/interventions/views/products. While many of the articles in this supplement are clearly scientific papers, a minority read more as advertorials and promote the interests of two of the supplement’s sponsors.1-3 The ORYGEN–headspace approach to adolescent mental health differs from the approach of other expert organisations, including the Faculty of Child and Adolescent Psychiatry of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) and the Australian Infant, Child, Adolescent and Family Mental Health Association.4 Both these organisations support ORYGEN and headspace in seeking to enhance mental health services and transition to adult services for adolescents, but not in the proposed “specialist youth-specific (12–25 years) mental health services providing comprehensive assessment, treatment and social and vocational recovery services”2 (Dr Phill Brock, Chair, Faculty of Child and Adolescent Psychiatry, RANZCP, personal communication). This arrangement does not fit with the way in which other service providers (education, juvenile justice, medicine) are organised, or with the legislative framework that protects the rights, welfare and safety of children (0–17 years of age). Children are not young adults, and child and adolescent mental health service models differ significantly from the traditional focus of adult mental illness. Most teenagers require a family-centred, developmentally appropriate, contextually sensitive, multimodal and systemic model that is less well developed in adult mental health services, including ORYGEN. In spite of claims to the contrary in the supplement, these different approaches are in competition for resources. ORYGEN and headspace have a product to sell (to government and to the medical and lay community). The publication of this supplement has provided them with a platform without presenting an alternate view.

Jon N Jureidini

In reply: Dr Jureidini’s response to the “Early intervention in youth mental health” supplement is puzzling and idiosyncratic. He asserts some kind of impropriety on our behalf or that of the MJA — an assertion we strongly reject. All articles were peer reviewed by experts in the field, including the editorial,1 which is obviously and explicitly the authors’ point of view and therefore open to debate, which we welcome. Other articles Jureidini characterises as “advertorial” are genuine descriptions of new models of care.2,3 Far from selling a product, we are advancing legitimate clinical and scientific arguments, and describing active reforms in mental health. Our “interests” are the pursuit of better mental health care and outcomes for young Australians, pure and simple. No evidence is provided for the assertion that the models described are in competition for resources. headspace has been fully funded with a completely new allocation of federal resources, with no funding redirected from other programs to support it. Furthermore, the youth mental health reform model was selected by the Australian Government through a nationally competitive tender process, in which anyone with a different approach was free to put it forward; indeed, several other submissions were considered and rejected. Similarly, no resources have been diverted to create the ORYGEN model; it is simply a successful restructure of existing resources that is demonstrably better accepted and more effective. Evidence shows that young people and their families find services structured in this way much more user-friendly, and levels of access, engagement and retention are substantially increased over traditional models. One of us (P M) is a member of the Faculty of Child and Adolescent Psychiatry of the Royal Australian and New Zealand College of Psychiatrists (RANZCP), and neither we nor headspace are aware of any official position of the RANZCP that is inconsistent with or unsupportive of the headspace development. Most of the 30 new headspace services across the nation are being established in partnership with local child and adolescent psychiatrists and public mental health services. While many psychiatrists are supportive of and working within the headspace and ORYGEN models, a small subset have expressed a fear that strengthening the focus on adolescents and young adults will somehow disadvantage children. Where is the evidence to support this fear? We are wholly supportive of further investment and improvement in mental health services for children. Unnecessary division on this issue will hamper all progress and is against the interests of patients and families. We strongly agree that there is clearly unmet need in the 0–12-years age group, as well as a further need for preventive interventions beyond the clinical service system, which may in time reduce the surge of incident cases of adult-type disorders. We call on Dr Jureidini to put his efforts into increasing resources and developing innovative service models to improve the mental health of both children and young people, rather than engaging in sterile arguments over professional territory and distribution of existing resources that will benefit no-one.

Patrick D McGorry · Anthony F Jorm · Rosemary Purcell · Ian B Hickie

In reply: I welcome Dr Jureidini’s criticisms regarding the publication of the MJA supplement “Early intervention in youth mental health”.1 Dr Jureidini has two major concerns. First, a number of articles in the supplement are deemed to unilaterally advocate concepts arising from the ORYGEN–headspace program, with the suggestion that this exclusivity contravenes the MJA policy for publishing sponsored supplements. Second, he claims that the general framework of the ORYGEN–headspace program does not have the endorsement of professional bodies such as the Faculty of Child and Adolescent Psychiatry of the Royal Australian and New Zealand College of Psychiatrists (RANZCP). Eminent mental health experts reviewed the articles in the supplement and, interestingly, not one of these authorities raised the RANZCP’s misgivings. This could mean that propagation of the Faculty’s concerns in the psychiatry fraternity may be selective, or that the rationale for its position has not convinced psychiatrists at large. Dr Jureidini’s other concern — that the supplement favoured the ORYGEN–headspace approach at the expense of other interventions, views or products — reflects the very essence of supplements. The fundamental purpose of publishing research or commentaries is to enter information into the publishing–evidence–integration cycle, wherein the dissemination of evidence or ideas is intended to promote change by influencing other researchers, health care professionals, the public and, ultimately, policymakers. Indeed, the ORYGEN–headspace program must have influenced policymakers, as the federal government recently announced grants totalling $19 million to support the national roll-out of the headspace program, especially in rural communities.2 Even if the publication of the MJA supplement played little or no part in this political endorsement, I am content that it has, at least, fostered debate and may well play a part in improving mental health services for young Australians.

Martin B Van Der Weyden

To the Editor: Little is known about the epidemiology of respiratory syncytial virus (RSV) in arid, desert regions generally, and in central Australia in particular. We performed a 5-year retrospective study from 2000 to 2004, inclusive, of children aged less than 2 years who were admitted to Alice Springs Hospital and identified as having RSV infection. RSV was detected using direct immunofluorescence (Light Diagnostics SimulFluor; Millipore, Billerica, Mass, USA) on nasopharyngeal secretions. The test has a reported sensitivity of 92%.1 We extracted demographic data from case notes and obtained population data from the Northern Territory Department of Health2 and the Australian Bureau of Statistics.3 From case notes over the 5 years, we identified 173 eligible children with RSV infection. The annual incidence rate was 21.4 per 1000 children under 2 years old. The rate in Aboriginal children was 30.9 per 1000, and the rate in non-Aboriginal children 11.6 per 1000 (P < 0.0001). The monthly distribution of cases is shown in the Box. Cases occurred throughout the year, and in every month, but there was a peak in admissions from March to August, which covers the Australian winter. Because Alice Springs Hospital is the only large hospital in the region, and almost all children needing hospital admission for RSV infection will be admitted there, our incidence rates of hospitalisation for RSV infection closely approximate population rates. However, we may have under-estimated the incidence because we only included children in hospital with proven infection, so we may have missed children who were not tested, or whose immunofluorescence test results were falsely negative. There may have been selection bias regarding admissions. Nevertheless, we found that Aboriginal children were more likely than non-Aboriginal children to be hospitalised with RSV infection, a finding in keeping with the known high incidence of pneumonia and bronchiectasis in Aboriginal children.4,5 While the incidence of RSV infection peaked in winter in central Australia, infections occurred throughout the year, and the winter predominance was less marked than is the case in temperate Australia.6 These data provide valuable information about RSV infection in an arid, desert region and can inform decisions about active or passive immunisation against RSV infection in central Australia. Monthly distribution of admissions to Alice Springs Hospital of children aged less than 2 years with respiratory syncytial virus, 2000–2004* * Inclusive.

Apakasimaka Dede · David Isaacs · Paul J Torzillo · John Wakerman · Rob Roseby · Rose Fahy · George Clothier · Andrew White · Paula Kitto

To the Editor: We report the serendipitous finding of non-Hodgkin’s lymphoma in a patient with adrenal Cushing’s syndrome. A 62-year-old previously well man (body mass index, 22 kg/m2) was referred to our institution with newly diagnosed type 2 diabetes, hypertension and dyslipidaemia. Clinical findings included oral thrush, bilateral severe pitting lower limb oedema, lower limb proximal myopathy, kyphosis, and increased abdominal girth (waist circumference, 92 cm), raising suspicion of Cushing’s syndrome (Box 1). Biochemical assessment revealed normal electrolytes, an unsuppressed early morning cortisol (following 1 mg dexamethasone), urinary free cortisol 6475 nmol/day (reference range, 0 – 250 nmol/day), and undetectable adrenocorticotropic hormone levels. Twenty-four-hour urinary catecholamine was normal. His testosterone level was 3.2 nmol/L, and dehydroepiandrosterone sulfate level was normal. Abdominal computed tomography showed a right adrenal mass that measured 3.1 × 2.8 × 3.4 cm (density, 36 Hounsfield units). Thoracic spine x-rays revealed wedge compression fractures at T-10 and T-11. Bone densitometry showed T-scores of − 3.3 at L2 – 4 and − 2.3 at the right femoral neck. Total body fat (18.5 kg; 33%) was higher than the recommended range for age and sex (13%–25%). The patient had a laparoscopic right adrenalectomy. Surgical excision was complete. Post-operatively, blood glucose and blood pressure returned to normal. Histopathology revealed an adrenal cortical tumour with atypical features, including a preponderance of eosinophilic cells, small numbers of clear cells, prominent nuclear pleomorphism, large nucleoli and occasional mitoses (Box 2A). However, the proliferation fraction (Ki67) was low and there was no necrosis. There was no large vessel invasion, although a single area of small vessel invasion was present (Box 2B). Unexpectedly, the adipose tissue adjacent to the adrenal gland was infiltrated by a diffuse large B-cell non-Hodgkin’s lymphoma (Box 2B). This was confirmed by positive CD20 immunohistochemistry. Bone marrow biopsy was normal. [18F]Fluorodeoxyglucose positron emission tomography (FDG-PET) scan showed increased uptake in the right adrenal bed only. The patient was treated with six courses of CHOP chemotherapy (cyclophosphamide, doxorubicin, vincristine and prednisolone) in combination with rituximab. A repeat FDG-PET scan 1 month after chemotherapy was clear. We speculate that lymphoma progression was suppressed by the coexistent steroid-producing adrenal tumour. The decision to treat the non-Hodgkin’s lymphoma was, in part, based on reports of progression of haematological disease following treatment of Cushing’s syndrome.1,2 Although histopathological examination of the tumour revealed some features suggestive of adrenocortical carcinoma, the distinction between adenoma and carcinoma can be difficult. In patients with recurrent or metastatic adrenocortical carcinoma, partial response has been reported using a combination of cylophosphamide, vincristine, cisplatin and teniposide.3 Two of these agents were used to treat our patient’s lymphoma. 1 Patient appearance at presentation, with obvious kyphosis and abdominal swelling 2 Immunohistochemistry A: Right adrenal tumour composed of enlarged pleomorphic cells with prominent nucleoli. B: Adrenal cortex (on right) with tumour showing focal vascular invasion (centre), plus adjacent non-Hodgkin’s lymphoma (on left).

Lai Y Wong · John Moore · Debbie Hill · Phil Brenner · Warick Delprado · Jennifer Turner · Joanne Taylor · Lesley Campbell · Jerry R Greenfield

To the Editor: We agree wholeheartedly with Skull and Nolan’s call for a lifetime immunisation register to enhance monitoring of coverage, provide a clinical support service and provide data for program evaluation.1 An expanded register could also provide information on the vaccine coverage for childhood diseases that may increasingly affect adults (such as varicella and measles), for immigrants who may receive childhood vaccines after childhood, and for occupational groups (eg, influenza vaccine for health care workers). However, we note some policy implications that need to be addressed before such an expanded register could be implemented. In August 2007, at a La Trobe University seminar on human papillomavirus vaccination, the 180 participants (mainly students and staff of La Trobe University) were asked to fill out a survey that included a question about the acceptability of a lifetime vaccination register. Of the 154 who responded, 8.5% were not in favour of such a register and another 8.5% declined to answer that question (unpublished data). This suggests that there may be significant barriers to the implementation of a lifetime register. Principal among the concerns cited were the implications for privacy, which were also noted by consumer groups.2 As with the existing Australian Childhood Immunisation Register, people will need to be aware of what data are being collected (including policies for data retention), their choice to opt out, and a clearly defined purpose in gathering the data (in particular, that the data will not be used in a punitive manner). People will also need to be assured that there are unambiguous policies governing access to the register and penalties associated with breaches of confidentiality. These concerns have led to the suggestion that a private health record should be developed instead,2 but such a record would be unlikely to be adopted widely and could not be used for monitoring or program evaluation. Development of an expanded register could also present potentially significant logistical problems. We would suggest a staged approach, beginning with expanding the current childhood register to include adolescents of school age and elderly people. Incentives to improve vaccine coverage in these groups could be modelled on the current General Practice Immunisation Incentives Scheme, which provides service incentive payments, outcomes-based payments and immunisation infrastructure funding. Many Indigenous Australians are currently covered through Aboriginal-controlled community health organisations. With the consent of those organisations, data could be absorbed into a national register. Later stages of implementation might see the inclusion of special groups (such as post-splenectomy patients and immigrants) and people receiving occupation-related and travel-related vaccines. The register could eventually be expanded to encompass the full Australian population. The current redevelopment scoping study for the Australian Childhood Immunisation Register3 is due for completion in 2008. We support enhancing the current central register, but clearly defined policies to protect privacy are required to address public concerns.

Allen C Cheng · Carmel M Hobbs · Priscilla M Robinson

In reply: We welcome additional dialogue on the important issue of developing a whole-of-life immunisation register in Australia. As with introduction of any register, logistics and concerns about privacy must be carefully considered, and a stepwise approach may well be appropriate. However, it is important to note that a non-acceptance rate of 8.5% derived from a small and potentially non-representative survey of seminar attendees does not necessarily represent a significant barrier to implementation of such a register.

Susan A Skull · Terrence M Nolan

To the Editor: I congratulate Haslam on his excellent overview of the role of empathy in medicine.1 He rightly reminds us that empathy is not vague or ill defined; rather, its presence improves clinical outcomes, and it can be both learned and lost. I would go further and argue that empathy is not an optional extra but a clinical competence essential for sound medical practice, no matter what our specialty. All clinical practice requires a doctor–patient relationship, the core skill of which is empathy. I wish to draw readers’ attention to a time-honoured but, in Australia, somewhat neglected educational activity where empathy is the major focus — that of Balint groups. In London in the 1950s, Hungarian-born psychiatrist Michael Balint and his wife Enid developed a unique method for studying the doctor–patient relationship.2 A Balint group is an experiential, small-group educational activity in which practising clinicians meet regularly to discuss their own doctor–patient interactions. The focus is on the emotional content of the doctor–patient relationship; the group’s primary task is to describe and empathise with both the doctor’s and the patient’s experience. Participants’ learning, therefore, is based on real-life situations they have encountered in their practices. A rationale for this kind of training is that all doctors tend to have habitual responses to certain clinical situations. Although these responses can be strengths which doctors bring to the care of some patients, they can also limit their capacity to help other patients. In certain situations, limits to doctors’ capacities for empathy may be unhelpful or even harmful to patients. A growing body of research suggests Balint-group training increases: practitioner sensitivity to hidden patient cues;3 the proportion of the consultation spent listening to the patient;4 practitioners’ experience of wellbeing during the consultation;3,5 practitioners’ sense of control in their work situation;5 and practitioners’ work satisfaction.6 At the same time it decreases: practitioner burnout;3,5 and unnecessary prescriptions,3 referrals5 and tests.5,6 In many countries today, Balint-group training is used in undergraduate and postgraduate education, most often in general practice training, but also in psychiatry, paediatrics, obstetrics and gynaecology, and internal medicine. At an international level, the vibrancy and energy of Balint-group work is reflected in the 26-year-old International Balint Federation (http://www.balintinternational.com). The Balint Society of Australia (http://www.balintaustralia.org), formed in 2005, joined the Federation in 2007.

Marion Lustig

To the Editor: I note the concern expressed by Byard and Matthews about the safety of three-wheel strollers.1 Surely a safer method of control would be for the brake to be on at all times other than when the stroller is in use? This could be done by having a lever that had to be held in position by the user in order to move the stroller. Should not this be required in the safety standard?

Charles Bridges-Webb

To the Editor: Russell and colleagues recently wrote an open letter to the new Minister for Health.1 In response, we call for the Minister to champion the cause of Indigenous health. Dear Minister,Russell et al raise a number of pressing issues directly relevant to the health portfolio.1 However, of all the challenges that face you, perhaps the greatest is reversing the neglect and extreme health disadvantage experienced by Australia’s Indigenous people.2 Although the task is daunting, and detractors may argue that there are no evidence-based solutions, 150 years of collective experience from across the globe provides compelling support for real investment in the spheres of water, sanitation, housing, education, employment and primary health care to reverse health disadvantage. Tragically, while these basic necessities are taken for granted by most Australians, they remain a dream for many Aboriginal and Torres Strait Islander peoples. The greatest public health gains during the previous two centuries resulted from ensuring that communities had sustained access to clean water, adequate sanitation and appropriate housing.3 It is astonishing that these basic rights should remain on the unresolved agenda of a highly developed country. To our shame, these basic direct health determinants are not yet guaranteed for Aboriginal and Torres Strait Islander Australians.4 Relative poverty, absolute poverty and social exclusion all have a major impact on health.5 In Australia, relative poverty denies many Indigenous communities access to housing, education, transport and other societal benefits. It would be naïve to argue that this inequitable distribution of Australian resources has not been a major determinant of the poorer health of Indigenous Australians.6 The recent Auditor-General’s report on whole-of-government Indigenous service delivery arrangements clearly indicates that current approaches are inadequate and fall short on service delivery.7 There is therefore a critical need for decisive direct investment in basic infrastructure and its maintenance in Indigenous communities, along with comprehensive primary health care. This must extend to equipping and developing individuals and communities through a major investment in education and creation of employment opportunities that engages the community and is developed in true and equal partnership with respected Indigenous leaders and communities You may argue that many of these health determinants fall beyond your direct sphere of accountability. You may choose to point to the small-scale success stories, particularly in Indigenous primary health care. However, as Minister for Health and Ageing, you will continually be confronted by the direct evidence of the deleterious results of these health determinants on the life expectancy and health of Indigenous Australians.8 The time is ripe for a bold national leader to champion this cause in the corridors of power. We encourage you to become that advocate among your Cabinet colleagues. The challenge is yours. Will you have the courage and moral fortitude to make your mark on Australian history?

David N Durrheim · Mark Wenitong · Clare Huppatz · George Rubin

To the Editor: The academic success of the rural clinical schools (RCS) program is clear: community-based clinical placements in rural Australia are able to produce graduates that are academically indistinguishable from tertiary hospital-trained peers.1,2 The effect of the RCS program on the workforce is yet to be established. Eley and Baker recently identified early career choices by Queensland RCS graduates.3 Western Australian RCS students spend an entire academic year in the country. Here, we provide the first data on the return of WA RCS graduates to rural internship positions relative to the intern year cohort as a whole. Based on two cohorts entering postgraduate year 1 (PGY1) positions in 2004 and 2005, 14 of 28 WA RCS graduates have requested and completed the one rural rotation that is permitted during their intern year. Given the limited rural rotations available in WA, some sought rural experience as far afield as Queensland and New South Wales. The substantive uptake of rural experience by RCS interns is in contrast to the intern cohort as a whole (Box). In 2004 and 2005, the three WA tertiary allocation centres placed 135 and 131 interns, respectively. As WA has no whole-year rural internships, a subset of the urban allocation included a 3-month rural rotation. The distribution of graduates of the RCS was different to that of graduates from other programs (χ2 = 7.0693; df = 1; P = 0.008). RCS students were more likely than other graduates to take a rural rotation (odds ratio, 3.1). Furthermore, ongoing postgraduate contact with the RCS cohort has identified that 23 of 28 graduates have chosen to undertake at least some time in the country during their PGY1–3 years. There is also early indication that graduates will sign up for a rural vocational training pathway (3/28). Interestingly, only a small proportion of these graduates are from a rural background (5/28). Our data suggest that rural practice is seen as highly desirable postgraduate clinical experience by WA RCS graduates. These results provide initial evidence that the WA RCS program will increase the rural workforce. Aggregate of 2004 and 2005 rural clinical school (RCS) interns versus non-RCS interns: comparison of postgraduate year 1 (PGY1) intern location choices RCS (n = 28) Non-RCS (n = 238) Total (n = 266) Expected tertiary allocation centre PGY1 internships (statistically even distribution) Urban-only internship 20 174 194 Rural rotation during internship 8 64 72 Actual tertiary allocation centre PGY1 internships (actual distribution) Urban-only internship 14 180 194 Rural rotation during internship 14 58 72

Denese E Playford · Harriet Denz-Penhey · Lesley Skinner · J Campbell Murdoch

To the Editor: The growing problem of tuberculosis in resource-rich countries has been recently highlighted,1 with immigration thought to be an important contributor. To assess a possible increase in incidence, we performed a retrospective case record review of all children who had tuberculin skin tests or who were diagnosed with tuberculosis at The Children’s Hospital at Westmead for 3 years from 2004 to 2006. This period included the establishment of a refugee clinic in May 2005, which routinely tests refugees by tuberculin skin testing. We compared our findings with published data from 1982 to 1991.2 Latent tuberculosis infection was defined as tuberculin skin test induration of ≥ 10 mm (regardless of prior BCG vaccination) and a decision by the treating physician to start isoniazid monotherapy. Proven active tuberculosis disease was defined as a child with a positive isolate of Mycobacterium tuberculosis from culture or positive polymerase chain reaction for tuberculosis or positive tuberculin skin test in association with a clinical picture strongly suggestive of active tuberculosis disease. The number of tuberculin skin tests performed increased through the study period (Box 1), largely because the refugee clinic saw 90 new patients in 2005 and 150 in 2006. The proportion of children with an increased induration response increased over the study period (Box 1 and Box 2). We observed an increase in latent tuberculosis infection, both in absolute numbers and in the proportion of the total caseload. The absolute number, but not the proportion, of cases of active tuberculosis disease increased during the study period. Over the same period, hospital admissions remained static at about 26 000 per year. Extrapulmonary tuberculosis was present in 12 of 23 patients (52%) with active tuberculosis, compared with 34% in the earlier study.2 There was no increase in tuberculosis meningitis. The active tuberculosis cohort ethnicity was consistent with the earlier study, with 22 of 23 patients of non-European origin, and 18 born outside Australia. The predominant ethnic groups were from Africa (eight, all born outside Australia) and the Indian subcontinent (four, two born outside Australia). Our finding of an increase in the proportion of patients with latent tuberculosis infection but not active tuberculosis disease is largely due to increased testing of refugees. It is reassuring that we did not find active tuberculosis. The United Kingdom has reported an increased incidence of tuberculosis in African immigrants.1,3 Australian immigration trends have shown a demographic shift, with increasing numbers of refugees from Africa.4 Although our study is likely to suffer from referral bias, it is the largest review of paediatric tuberculosis from a tertiary centre in Australia. Children very rarely transmit tuberculosis, but it is important to identify and treat latent tuberculosis to prevent progression to active disease.5 We believe our results are encouraging in showing a low incidence of active tuberculosis and indicate the need to screen refugees for latent tuberculosis to direct chemoprophylaxis. 1 Comparison data on tuberculosis among children, 2004–2006 Year Total TSTs performed Results available > 10 mm > 15 mm No. of patients commenced on isoniazid No. with active TB disease No Yes No Yes 2004 116 111 104 7 108 3 5 4 2005 257 247 202 45* 221 26* 25 8 2006 278 263 193 70* 215 48* 36 11 TST = tuberculin skin test. TB = tuberculosis. * P < 0.01 compared with previous year. The discrepancy between the total numbers performed and the cumulative numbers in the categorisation of response is due to patients not returning to have the TST read. 2 Results categorised by size of tuberculin skin test induration

Paul D Robinson · Dianne Dalton · Terri Cripps · Nicholas J Wood · Alison M Kesson · David Isaacs

To the Editor: I write to voice my objection to the use of the term “tsunami” by many in the medical education community when describing the massive increase in medical student numbers that has begun as a result of recent government initiatives.1-5 Although it is true that the government has opened the floodgates, as opposed to the water restrictions they applied in the mid 1990s, I believe describing this increase using the metaphor of a tsunami is a misnomer. I do not disagree with the potential for this phenomenon to wreak mayhem with the quality teaching and supervision of medical students and junior doctors and their access to adequate employment in both prevocational and vocational places. Nevertheless, I believe that we need to adopt a more accurate term to describe this impending event. A term I have heard on a number of occasions is that of the “rising sea levels” of medical graduates, which (although less dramatic) I think is more accurate, because this expression indicates that the change (likely a sea change) is going to be long-lasting, if not permanent, rather than a flash flood, as signified by “tsunami”. If we are going to continue to describe this impending increase as a “tsunami”, the only benefit I can see is that it may encourage us to learn lessons from the real event. As a result of the 2004 Boxing Day tsunami, a tsunami early warning system was put in place to alert citizens of an impending tsunami and give them a small window of time to prepare. A number of medical education groups, including the Australian Medical Association Council of Doctors in Training, have started sounding the alarm about the increase in medical students. It remains to be seen whether this warning will be heeded in time. One only has to look to the fiasco in the United Kingdom this year with junior doctor allocations to see what happens when adequate preparation is not made for impending change. Will a student who enters medicine in 2010 feel that, during their medical education voyage, they are receiving a quality education? And when they graduate, will they find a rich sea of prevocational and vocational opportunities? Or will they feel like a drop in the ocean of fellow graduates scrambling to gain a properly supervised training position?

Andrew W Perry

To the Editor: The Mandometer treatment for patients with eating disorders (Box 1), developed at the Karolinska Institute in Stockholm, was brought to the attention of the public and the profession in Australia through Norman Swan’s Health Report in 2003.1 Since then, 40 patients from Australia have received treatment using this method, 29 of whom were treated in Stockholm, seven in Melbourne and four in San Diego. In a randomised controlled trial, Mandometer treatment brought 75% of patients into remission in an average 14 months, with a relapse rate of about 10% during 5 years of follow-up.2 There are seven criteria for remission, including normal eating behaviour, normal body mass index (BMI) and physical parameters, and remission of psychiatric symptoms. Patients must have returned to school or work, be comfortable with their body weight, and have avoided binge eating and vomiting for at least 3 months. Patients fulfilling five of these criteria are considered in partial remission. Of the 40 (39 female) patients reported here, 27 patients (68%) were diagnosed according to criteria of the Diagnostic and statistical manual of mental disorders, 4th edition, with anorexia nervosa, seven (17%) with bulimia nervosa, and six (15%) with an eating disorder not otherwise specified. The median age of patients was 18.7 years (range, 10.7–39.3 years). On admission, they had been ill for a median period of 5 years (range, 1–25 years) and they had had up to 20 previous unsuccessful episodes of treatment (median, 3 episodes). Fourteen patients (35%) fulfilling five remission criteria have returned to Australia for follow-up, but have not yet returned to school or work. Eight patients (20%) are in full remission, 11 (28%) are in treatment, and seven (17%) withdrew from treatment before completion, some after only a few days. All patients who are treated in Stockholm and San Diego are followed up in Melbourne, and outpatient treatment is also offered at the Melbourne clinic. Of the 27 patients with anorexia, 16 have entered full or partial remission, with marked improvement in all parameters (Box 2). Six achieved remission and 10 partial remission in 220 (range, 129–257) and 220 (range, 168–570) days, respectively. The five anorexic patients who dropped out of the treatment had low BMI (11.3, 13.5, 13.8, 14.6 and 15.7 kg/m2), had been ill for 4, 5, 8, 14 and 25 years, and had had up to nine previous episodes of treatment. This report concerns severely ill Australian patients who had previously undergone many episodes of care. These preliminary results are encouraging, given the known resistence of these disorders to treatment.4,5 Although the outcomes reported here appear to be better, comparison with other methods used in Australia should be made in a randomised controlled trial. The Melbourne Mandometer Clinic is willing to participate in such a trial. 1 Mandometer treatment has four interventions 1. The patient re-learns how to eat using Mandometer, a computerised procedure that provides feedback during meals (Figure). In about 5–6 months, anorexic patients are able to eat a normal meal and perceive a normal level of satiety after practising eating gradually larger meals. Bulimic patients are similarly trained, but they are able to eat normal amounts of food from the beginning of treatment. After using Mandometer, patients are trained to eat socially. 2. Patients rest in warm rooms after each meal. Warmth has an anxiolytic effect and prevents compensatory hyperactivity and vomiting after the meal. 3. Physical hyperactivity is prevented by use of wheelchairs and warming jackets between meals. 4. Patients are trained to re-learn social skills. Manuals describing the details of treatment are used at all clinics. The patient can adapt her or his eating rate to a linear curve displayed on the monitor (A), because she or he sees her or his own eating rate emerging (B). At regular intervals, the patient rates her or his feeling of fullness on a scale that appears on the monitor (C) and adapts her or his ratings to an s-shaped curve (D). The axes have no numerical values during training. 2 Body mass index (BMI) and obsession, anxiety and depression scores in six Australian anorexic patients treated to remission and in 10 anorexic patients treated to partial remission Psychiatric symptoms were evaluated by the Comprehensive Psychopathological Rating Scale.3 Values are medians and ranges. There were no significant differences between the groups.

John Court · Cecilia E K Bergh · Per Södersten

To the Editor: Senna is widely used in laxatives, but the results of its misuse are not inconsequential. We describe a 36-year-old woman admitted with hypercalcaemia and renal failure. She had a 6-year history of anorexia nervosa and ingestion of 50–100 senna tablets daily for weight loss. Examination revealed clubbing of the fingers and toes, a body mass index (BMI) of 17.7 kg/m2 and postural hypotension. Laboratory findings on admission are shown in Box 1. Results of autoimmune studies and protein electrophoresis, and the serum angiotensin-converting enzyme level were normal. Parathyroid hormone-related peptide was absent. She had a bland urinary sediment, trace proteinuria (150 mg/24 h; reference range, < 150 mg/24 h) and a urine pH of 5.0 (physiological range, 4.5–8.0). Computed tomography scans did not detect malignancy or infection, but showed bilateral medullary renal calcifications. Renal biopsy confirmed extensive nephrocalcinosis and the absence of primary glomerular disease. A skeletal survey showed prominent periosteal reaction and new bone formation at the ends of long bones (Box 2, A). A bone scan revealed increased tracer uptake in a pattern consistent with hypertrophic osteoarthropathy (HOA; Box 2, B). Interestingly, bone mineral density (BMD) scans showed increased lumbar and femoral T scores (1.2 and 1.3, respectively). Four years later, the renal failure, clubbing and HOA persisted despite a reduction in senna intake. Low urine volume is a prerequisite for urolithiasis, but hypercalcaemia is the key requirement for nephrocalcinosis.3 The suppressed parathyroid hormone level and elevated serum calcium level excludes primary hyperparathyroidism and made familial hypocalciuric hypercalcaemia unlikely. The serum and urine biochemistry was inconsistent with thiazide diuretic use or renal tubular acidosis. Hence, exogenous calcium is the likely cause of hypercalcaemia. Each of the senna (calcium sennosides) tablets the patient ingested contained 12.5 mg of calcium. Chronic ingestion, in addition to dehydration (with low calcium excretion) and a low BMI may contribute to a vicious circle of calcium phosphate retention, renal failure and nephrocalcinosis. Indeed, hydration increased her calcium excretion to 6.23 mmol/day and normalised her serum calcium and phosphate levels after a week. The association between finger clubbing and senna misuse, and the reversibility of finger clubbing, were reported in 1975.4 Several reports have followed, but only one noted concurrent HOA on plain x-rays.5 We believe that our report is the first to show the extent and distribution of HOA related to this disorder. It remains unknown whether HOA is reversible with abstinence from senna. Patients with anorexia are also more likely to have a low BMD, and the increased BMD scores seen in our patient might be the result of metastatic calcification or periosteal new bone formation. Neither could be conclusively proven. The development of nephrocalcinosis in anorexic patients is more common than is generally appreciated. Clubbing and HOA are useful clues to senna misuse, and BMD measurements should be interpreted with caution in this setting. 1 Biochemical parameters on admission before treatment Parameter Patient value Reference range Serum concentrations of: Sodium (mmol/L) 139 135–145 Potassium (mmol/L) 3.2 3.5–5.0 Magnesium (mmol/L) 0.74 0.80–1.50 Chloride (mmol/L) 102 95–107 Bicarbonate (mmol/L) 24 21–30 Urea (mmol/L) 8.6 2.5–7.8 Creatinine (μmol/L) 166 40–120 Albumin (g/L) 28 35–45 Corrected calcium (mmol/L) 2.93 2.20–2.60 Ionised calcium — pH adjusted (mmol/L) 1.51 1.14–1.29 Phosphate (mmol/L) 2.58 0.80–1.20 25-hyroxyvitamin D (nmol/L) 23 55–108 Parathyroid hormone (pmol/L) 1.0 1.1–7.7 Rates of: Creatinine clearance (mL/min) 20 90–150 Urine sodium excretion (mmol/day) 28 40–100 Urine potassium excretion (mmol/day) 29 50–140 Urine calcium excretion (mmol/day) 1.56 2.0–7.5 2 Ankle x-ray and full bone scan

Andy K H Lim · David H Hooke · Peter G Kerr

To the Editor: The editorial by Woollard and Newman1 discussing the best management of stable coronary artery disease is welcome and timely, but we believe their conclusions undervalue the benefits of optimal medical therapy. The authors correctly point out that the early trials comparing surgery with medical treatment did not include aspirin, β-blockers or lipid-lowering drugs in the medical treatment group. Clearly, the benefits of these treatments have been so dramatic as to make these original trials irrelevant to current practice. After reviewing trials comparing percutaneous coronary intervention (PCI) with coronary artery bypass graft (CABG) surgery and discussing their limitations, the authors conclude that: The best interpretation of currently available data is that, for patients with severe coronary artery disease, the more invasive procedure with a longer recovery time (CABG) has a better long-term clinical outcome and is more cost-effective than the less invasive fast-recovery procedure (PCI). We believe this conclusion is only appropriate for those patients in whom an adequate trial of medical therapy has failed to achieve sufficient relief of anginal symptoms. Based on current evidence, including that from the MASS II2 (comparing medical therapy with both CABG and PCI), COURAGE3 (comparing PCI with medical therapy) and AVERT4 (comparing intensive lipid-lowering therapy using atorvastatin with PCI) trials, we conclude the following about the management of stable coronary artery disease: Irrespective of whether patients under-go CABG or PCI (or neither), aggressive medical therapy combined with appropriate lifestyle measures is the means by which patients are protected from major adverse cardiovascular events. There is no evidence that either PCI or surgical treatment is superior to the current best medical treatment in preventing death or myocardial infarction. Patients with stable angina should be informed accordingly and be reassured that their symptoms are likely to abate or resolve with optimal medical treatment over a period of time. Intervention should be reserved for patients in whom an adequate trial of medical treatment has failed to relieve symptoms or in whom medication is poorly tolerated, and possibly for patients in whom satisfactory anti-atherosclerosis treatment targets cannot be achieved. Performing PCI and CABG in patients with stable angina consumes a significant portion of the Medicare budget. We believe many patients with absent or relatively minor symptoms consent to these procedures in the mistaken belief that their lives will be prolonged. Application of evidence-based guidelines would significantly reduce the number of interventions currently performed and make much needed resources available for prevention strategies and for selected patients with acute coronary syndromes in whom this expensive treatment has proven benefit. Lastly, we strongly support the implication by Woollard and Newman that patients should “undertake consultation with other providers” regarding treatment options — including medical therapy.

Richard W Harper · Esther M Briganti · Brett H R Forge

In reply: We agree with Harper and colleagues that for most patients with stable coronary artery disease, prevention of death or other cardiac events is best achieved with medical treatment. Many patients and even some doctors are so impressed by the restoration of coronary blood flow achieved with angioplasty that they incorrectly assume it will provide a prognostic benefit. However, we do not agree that intervention should be reserved for patients in whom medical treatment has failed. It is unlikely that a trial comparing current medical treatment with coronary artery bypass graft (CABG) surgery for severe left main coronary disease will ever be performed, and current evidence favours CABG at least in this group. In addition, many patients with angina prefer a mechanical intervention to long-term antianginal medications, and why should they be denied that choice?

Keith V Woollard · Mark A J Newman

To the Editor: In Australia, the rising cost of the Pharmaceutical Benefits Scheme (a comprehensive system for subsidising prescription medicines for the whole population) has led to the Australian Government instituting a number of cost-saving strategies. One of these strategies is to encourage the use of generic medicines. However, generic prescribing is a contentious issue among Australian prescribers. The debate has centred on issues related to bioequivalence, quality and safety.1,2 Further, previous studies have shown that changing existing prescribing behaviour is difficult.3,4 To avoid the difficulty of having to change existing prescribing behaviour, education about the benefits of generic prescribing should be aimed at medical students, who are the prescribers of the future.5 To explore and evaluate senior (final-year) medical students’ perceptions of and knowledge about generic medicines and generic prescribing, we undertook a nationwide, web-based survey of senior medical students in Australian universities from 18 June to 18 September 2004. Of 1497 senior medical students in 10 universities throughout Australia, 400 (26.7%) responded to the survey. The first part of the questionnaire required students to select the correct bioequivalence limits allowed by the Therapeutic Goods Administration when comparing a generic medicine with a brand-name medicine. We compared responses to detect differences according to sex, graduate (students with a Bachelor or higher degree on entry to medical school) versus non-graduate status, and between the 10 universities using Fisher’s exact test. For the first question, six options were given, with the correct answer being 80%–125%. Most respondents (64%) did not answer the question, and only three (0.8%) answered it correctly. Responses to other individual questions in the web survey are shown in the Box. Seventy-one per cent of respondents (287) thought that they needed more information on how bioequivalence tests are conducted. More than 90% of respondents did not believe that generic medicines registered in Australia are equal in terms of quality and efficacy to their brand-name counterparts. A similar proportion of respondents thought that generic medicines would cause more side effects than brand-name medicines. Eighty-seven per cent highlighted pharmacists as one of the most important health care professionals to advise them on generic medicines. Almost 92% of respondents agreed that their future prescribing habits would be likely to be influenced by their senior colleagues and medical consultants. More than 60% believed that their respective university did not adequately cover the topic of cost-effective prescribing in their medical curriculum. Our survey clearly shows that medical students in Australia need to be better taught about issues relating to generic medicines and generic prescribing. Modifying existing curricula to include education about generic medicines will be a critical strategy towards promoting rational use of generic medicines by medical practitioners. Responses to questions assessing knowledge and perceptions of senior medical students in Australia about generic medicines and bioequivalence Responses P (Fisher’s exact test) Survey question/statement Strongly agree Agree Neutral Disagree Strongly disagree Sex Graduate status* University† All generic products of a particular medicine that are rated as “generic equivalents” are: therapeutically equivalent to the innovator brand product 66 (16.5%) 276 (69.0%) 18 (4.5%) 36 (9.0%) 4 (1.0%) 0.692 0.094 0.096 therapeutically equivalent to each other 4 (1.0%) 49 (12.3%) 23 (5.8%) 263 (65.8%) 61 (15.3%) 0.846 0.998 0.107 I have not been introduced to the issues of bioequivalence for generic drugs during my medical education 120 (30.0%) 153 (38.3%) 47 (11.8%) 69 (17.3%) 11 (2.8%) 0.703 0.893 0.010 I need more information on how bioequivalence tests are conducted for generic medicines 73 (18.3%) 214 (53.5%) 74 (18.5%) 34 (8.5%) 5 (1.3%) 0.036 0.572 0.195 A generic medicine is bioequivalent to a brand-name medicine 79 (19.8%) 270 (67.5%) 18 (4.5%) 30 (7.5%) 3 (0.8%) 0.574 0.943 0.827 A generic medicine must be in the same dosage form (eg, tablet, capsule) as the brand-name medicine 27 (6.8%) 106 (26.5%) 52 (13.0%) 196 (49.0%) 19 (4.8%) 0.751 0.677 0.152 A generic medicine must contain the same dose as the brand-name medicine 47 (11.8%) 171 (42.8%) 44 (11.0%) 126 (31.5%) 12 (3.0%) 0.919 0.905 0.048 Generic medicines are of inferior quality to brand-name drugs 148 (37.0%) 226 (56.5%) 20 (5.0%) 5 (1.3%) 1 (0.3%) 0.006 0.944 0.054 Generic medicines are less effective than brand-name medicines 151 (37.8%) 228 (57.0%) 19 (4.8%) 1 (0.3%) 1 (0.3%) 0.029 0.124 0.010 Generic medicines produce more side effects than brand-name medicines 148 (37.0%) 222 (55.5%) 26 (6.5%) 3 (0.8%) 1 (0.3%) 0.052 0.619 0.023 Generic medicines are less expensive than brand-name medicines 165 (41.3%) 215 (53.8%) 9 (2.3%) 9 (2.3%) 2 (0.5%) 0.190 0.154 0.072 Brand-name medicines are required to meet higher safety standards than generic medicines 112 (28.0%) 219 (54.8%) 42 (10.5%) 22 (5.5%) 5 (1.3%) 0.747 0.843 0.162 * Comparing graduate (those with a Bachelor or higher degree on entry to medical school) with non-graduate students. † Differences between the 10 universities represented.

Mohamed Azmi Ahmad Hassali · Kay Stewart · David C M Kong

To the Editor: In a recent article, Youl and colleagues provided information about the ability of doctors to accurately diagnose skin lesions that they excise or biopsy.1 We wish to offer some comments about their comparison between general practitioners and skin cancer clinic doctors. First, in the study by Youl et al the behaviour of GPs and patients in mainstream practice was different from that of doctors and patients in skin cancer clinics, as indicated by the comparative frequency of whole body skin examinations performed (GPs, 30.4%; skin cancer clinic doctors, 73.2%).1 The study did not indicate the circumstances under which each decision to excise took place. Did patients become aware of a new or changing skin lesion and bring it to the attention of the doctor, or did the diagnosis result from a whole body skin check that might have revealed an earlier, previously unnoticed and more subtle lesion? It may be useful to separate basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) into histological subtypes, as early superficial BCC and intraepidermal SCC may be more difficult to diagnose than other subtypes.2 Second, the casemix of non-melanotic skin cancers in the two groups of doctors was quite different, with a BCC : SCC ratio of 1.1 : 1 for GPs and 2.1 : 1 for skin cancer clinic doctors. The difference in casemix was reflected in a study of our own3 in which we described the histology of 1247 lesions excised by doctors, including 76 lesions removed by one doctor in a designated skin cancer clinic. In an unpublished sub-analysis, we divided the results into two settings for comparison (Box). Like Youl et al, we found that the casemix of non-melanotic skin cancers was significantly different for the two groups of doctors (P < 0.001), but in our study the BCC : SCC ratio was much higher for skin cancer clinic doctors (4 : 1) than for GPs (0.6 : 1). We believe this most likely reflects an increased pick-up of BCC in skin cancer clinics, owing to the higher frequency of full body skin examinations and the consequent detection of lesions of which the patient is unaware. Third, the reported sensitivity and specificity in the study by Youl et al refers only to excised lesions. There is no information given about the lesions that practitioners decided not to excise. The sensitivity and specificity of skin examinations can only be determined if all relevant skin lesions are assessed, thereby giving an accurate representation of the number of true- and false-negative diagnoses. However, this would require multiple excisions, which would be clinically unacceptable. An important limitation of the study is that it does not assess or compare how many skin cancers each group of doctors missed. In conclusion, although the study by Youl et al provides comprehensive information about diagnostic accuracy, we do not feel — based on the information available — that a meaningful comparison between the two groups of doctors can be made. Comparison of lesion excisions in skin cancer clinic and general practice settings Mean patient age (years) Proportion of excised lesions that were malignant* BCC : SCC ratio Number needed to treat† Skin cancer clinic 56.5 76% (58/76) 4 : 1 (44/11) 4.7 (14/3) General practice 56.9 45% (512/1145)‡ 0.6 : 1 (190/305) 9.0 (154/17) BCC = basal cell carcinoma. SCC = squamous cell carcinoma. * BCC, SCC or melanoma. † Benign or dysplastic naevi excised per melanoma. ‡ There were 26 cases in which histology results were missing. All were in the general practice setting.

Clare Heal · Beverly Raasch

To the Editor: Youl and colleagues are to be commended for their research into the performance of special-interest skin cancer clinicians.1 However, the conclusion that the performance of general practitioners and skin cancer doctors in the diagnosis of skin cancer is similar is highly questionable. To truly compare the two groups and their diagnostic accuracy, it must be established that the participants were representative of the groups they are supposed to represent. The fact that the participating GPs were largely self-selected, perhaps on the basis of their personal interest in the subject, was a potential flaw that the authors acknowledge. Further, an examination of diagnostic accuracy should also take into account whether the lesions found were of similar type, size and stage. There was no determination of any qualitative differences (eg, in size or thickness) between the tumours seen and diagnosed by the two groups. When a patient presents, specifically, with a large, tender, hyperkeratotic squamous cell carcinoma (SCC), there is no real test of diagnostic skills. On the other hand, detecting a small early posterior-thigh melanoma or a superficial BCC on a whole body examination is a challenge. Overall, one would expect at least two to three BCCs to be diagnosed for each SCC found2 — however, in the study by Youl et al, GPs found a similar proportion of each type of lesion, suggesting that perhaps a large number of BCCs were not being detected at all in the GP group. The lower incidence of whole body examinations in the GP group suggests that a higher proportion of asymptomatic lesions may have been missed by the GP group and thus not included in their sensitivity/specificity data. This possibility could have been examined by noting the site of lesions found: identification and diagnosis of lesions in areas covered by clothing or footwear may be more likely on whole body examination. Although Youl et al reported that the diagnostic sensitivity for melanoma among skin cancer clinic doctors was twice that of GPs, a re-examination of the data with all of the above in mind may well reveal that skin cancer clinic practitioners are performing even better than suggested. That being said, the number of melanomas found per week by the skin cancer group (0.25 melanomas/doctor/week) in the study by Youl et al is much lower than in our own dedicated primary care skin cancer clinic (1.47 melanomas/doctor/week, based on audit data gathered between February and September 2007). Good medical care relies on accurate diagnosis and appropriate treatment, and the earlier the diagnosis is made, the less costly and less invasive the treatment and the greater likelihood of a cure. Surely we should all be working together — skin cancer clinic practitioners and GPs, alike — towards achieving optimum outcomes for our patients. To that end, a wider range of higher education in skin cancer medicine is being encouraged by the University of Queensland’s Master of Medicine program3 and the Skin Cancer College of Australia’s fellowship program,4 and bodies such as the Skin Cancer Society of Australia and the Royal Australian College of General Practitioners have been working together to introduce an accreditation process for those practising primary care skin cancer medicine.5,6

Jeffrey Keir

In reply: We thank Heal and Raasch, and Keir for their comments and suggestions. First, as acknowledged in our article, it is possible that general practitioners with an interest in skin cancer may have been over-represented in our sample. It is also the case that the comparison between GPs and skin cancer clinic doctors may have been affected by characteristics of patients attending each type of practice. Patients attending skin cancer clinics are self-selected (often worried about a specific skin lesion), while for those attending GPs in mainstream practice, skin lesions are more likely mentioned during a consultation for something else.1 Case selection, which helps increase diagnostic ability by Bayesian principles (improving pretest probability of malignant lesions), may thus be more likely for skin cancer clinic doctors than GPs.2 Our study represented a broad cross-section of skin cancer clinics, and the number of melanomas excised per doctor per week ranged from 0 to 1.7. The ratio of basal cell carcinomas to squamous cell carcinomas excised ranged from 0.1 to 6.0 for mainstream GPs and 0.8 to 8.0 for skin cancer clinic doctors. Whether clinical and histological features of skin lesions or the type of skin examination undertaken influence diagnostic accuracy was beyond the scope of our initial study. This question will be the subject of future analyses. It has been suggested that a limitation of our study was that it did not assess or compare the number of skin cancers each group missed. However, as specifically stated in our article, the aim of our study was to examine diagnostic accuracy of excised or biopsied lesions. To examine the sensitivity and specificity of all lesions (excised and non-excised) and of screening examinations would require a different study design. We disagree that meaningful comparisons between the two groups cannot be made from the data collected in our study. Our prospective study included over 11 000 skin excisions or biopsies from a large group of mainstream GPs and from doctors working in a variety of skin cancer clinics. One of the most important outcome measures of our study was the degree of accuracy of skin cancer diagnoses within the primary care setting. We have demonstrated that primary care practitioners, whether mainstream GPs or skin cancer clinic doctors, diagnose skin cancer with similar, high levels of accuracy. This is a reassuring result, particularly in a country with the world’s highest incidence of skin cancer.

Philippa H Youl · Peter D Baade · Monika Janda · Christopher B Del Mar · David C Whiteman · Joanne F Aitken