Letters

To the Editor: The recent report by the Multicentre Australian Colorectal-neoplasia Screening (MACS) Group1 offered some intriguing findings. Participation in bowel cancer screening was lower than expected, despite a range of tests being offered. In addition, people offered a choice of different faecal occult blood tests (FOBTs) were less likely to participate than those not offered this choice. The accompanying editorial by Salkeld and colleagues concluded that “Informed consumers making smart choices about screening . . . would be a public health success”.2 We believe the available evidence indicates otherwise. As the MACS Group study showed, participation in FOBTs was lower than in the Australian Government FOBT pilot program,3 and participation in screening by colonoscopy was lower than for other studies, including our recent Australian study.4 They suggested this may be because local general practitioners were not engaged in the project. Our study was designed to address this issue, and concluded that involvement of GPs had a small, non-significant effect on participation rates and no effect on response to invitation.4 This is not to say that involvement of GPs is undesirable. The MACS Group study found participation in FOBTs of 27.4% when only an FOBT kit was provided and a significantly lower participation when a choice of four screening modalities was offered, with an FOBT kit provided (18.6%, P = 0.03). These data confirm the findings of a large multicentre study from the SCORE2 Working Group.5 In that study, participation in FOBT was 30.1%, while participation in either FOBT or flexible sigmoidoscopy, when a choice of the two was offered, was 27.1%. The authors did not offer this analysis, but the difference was again significant (P = 0.015, two-tailed Fisher’s exact test). The editorial by Salkeld et al suggested that the Australian bowel cancer screening program should incorporate decision-support systems to allow informed choice of screening options. The “choice paradox” reported by the MACS and SCORE2 studies argues against this. Further, there is no evidence that decision support improves rates of participation in screening, and some explicit evidence that it has no effect.6 This should not be troubling. At this time, most colon cancer screening is still performed after consultation between patient and doctor, and in this setting informed choice is possible and desirable. Decisionmakers such as the Australian Government Department of Health and Ageing use a different process, which is explicit and quantitative,7 in determining screening policy. With the evidence available, the Australian mass-screening program should offer and evaluate a single test modality.

Douglas R Taupin · Mike Corbett

In reply: Taupin and Corbett contend that the “choice paradox” reported by the MACS Group study argues against decision-support systems to allow informed choice of screening options. That would be true if the purpose of informed choice was simply to increase participation in screening.1 Our point is that the purpose of informed choice is to support an ethical basis for individuals’ decisions about screening.2,3 This can occur within the single-test modality (faecal occult blood tests) of the national screening program. It would be desirable to have decision-support systems embedded in a doctor–patient consultation. But this may not be feasible in terms of screenee access to a general practitioner, nor affordable for the Australian Government — hence our call for a self-directed decision-support system as an adjunct to a doctor-guided system. This is one way of applying the principle that patients should be given unbiased information on the benefits and harms of screening that enables them to make an informed choice about their own participation in screening.4

Glenn P Salkeld · Jane M Young · Michael J Solomon

To the Editor: We read with alarm the skin cancer clinic profile published recently in the Journal.1 This article publicly states what has been privately suggested for some time — that doctors in skin cancer clinics provide a service no better than the average Australian general practitioner. Surely, if these doctors are calling themselves skin cancer “experts”, the aim of their practice should be to reduce the skin biopsy rate. This is obviously not the case. They report a consultation to biopsy ratio of 1.79. Thus, 56% of all their consultations result in a skin biopsy. The biopsy to treatment ratio of 3.1 is also very high. In addition, they report that only 32% of all biopsies yield a non-melanoma skin cancer. This figure indicates either no additional diagnostic ability on the part of the skin cancer clinic doctors compared with the average Australian GP (who, according to a recent retrospective study, can clinically diagnose a basal cell carcinoma 34% of the time2) or an effort to maximise income. Similarly, the article describes a number needed to treat (NNT) of 28.6. This means that for every 29 benign lesions excised and sent for histological examination to exclude melanoma, only one melanoma is detected. The authors concede that this figure is equivalent to that observed in mainstream general practice. We therefore question the motives of doctors at these clinics in presenting themselves as skin cancer “experts”. However, perhaps the greatest indicator of their seeming intent to maximise financial gain can be demonstrated by an analysis of skin flap item numbers. The article indicates that the total number of excisions was 8055, of which 116 were melanomas and 4709 were non-melanoma skin cancers (ie, 4825 cancers were excised). If one assumes that a suspicious or benign mole biopsy is never closed with a skin flap repair (standard clinical practice), then, of the 4825 skin cancers excised, 2651 (55%) were closed with a flap procedure, and of these, 55% were either “complicated” or “site-specific” flap repairs. There were only 111 skin grafts performed out of the 4825 cancers excised (2.3%). Thus, more than half of the skin cancers excised were closed with a flap repair! Moreover, more than half of the flaps used were “complicated” or “site-specific” flaps, with 24 flaps performed for every skin graft! Surely, no one can argue that these figures are reasonable or consistent with good clinical practice. In comparison, current Australian Medicare data indicate that dermatologists and specialist surgeons close large skin cancer excisions (lesions > 2 cm on the trunk [item number 31290]) with skin flaps at rates of 15% and 17%, respectively (Andrew Miller, Australian Medical Association Skin Representative Group, personal communication). Large lesions normally require a higher skin flap closure rate than smaller lesions. Hence, a flap repair rate of 55% — for lesions of all sizes and sites — reported by the skin cancer clinic doctors is all the more extraordinary. We believe that the above suggests that many skin cancer clinic practitioners are more concerned with maximising income than improving patient care.

Alvin L K Chia · Stephen Shumack

In reply: Our previous publications1,2 should calm Chia and Shumack’s “alarm”. We have urged for the development of education, standards, accreditation, research and audit for skin cancer clinics.1 Over the past 12 months, the Skin Cancer Society of Australia has been formed (http://www.skincancersociety.com.au), standards have been developed, a process of skin cancer practice accreditation has been established, and a masters-level degree in primary care skin cancer medicine has been created (http://www.som.uq.edu.au/skincancer/masters.htm). Our results described activities of a single network of skin cancer clinics.2 They should not be viewed as a benchmark, and caution must be exercised in making any generalisations from them. They are simply the first such data to be presented for public scrutiny. It will be important to see results from other skin cancer clinics. Regarding flap repairs, we were unable to confirm the findings alluded to by Chia and Shumack based on a personal communication. However, we are currently undertaking a detailed analysis of relevant Medicare Benefits Schedule data for general practitioners and specialists and we look forward to presenting this for rigorous peer review and publication shortly. Skin cancer medicine is an established component of primary care. Whether this occurs in mainstream general practice, “special interest services” or skin cancer clinics, the same standards apply to all.

David Wilkinson · Deborah A Askew

To the Editor: Food, medication or insect stings are the major causes of systemic allergic reactions.1 That topical agents can mimic such reactions is not commonly appreciated. I report here a systemic allergic reaction to a topical medication (initially attributed to food). A 7-year-old boy experienced generalised urticaria and facial swelling within an hour of eating a peanut-containing slice. His father recalled applying a topical antiseptic (Medi Creme [Pharmacare]) to a graze over the boy’s right elbow at about the same time. There were no respiratory or cardiovascular symptoms, and the urticaria settled within 2 hours of taking oral promethazine. Six months later, the same cream applied to a graze over the boy’s right chest resulted in a localised 15 cm urticarial welt. Intercurrent problems included atopic dermatitis but no known food or drug hypersensitivity. The active ingredients of Medi Creme are hexamidine isethionate, chlorhexidine acetate, cetrimide and lignocaine hydrochloride. With the assistance of the manufacturer, skin prick tests using a 10% weight/volume suspension of Medi Creme or a 10% suspension of hexamidine isethionate in normal saline produced 5 mm itchy weals at 15 minutes in the patient (but not controls). By contrast, skin prick tests to the other active ingredients, inert vehicles and relevant foods (including peanut, almond, brazil nut, cashew, hazelnut, pecan, walnut, sunflower seed and sesame seed) were negative. Avoidance of hexamidine was advised. The child has eaten peanut products before and since without any adverse reaction. Hexamidine is an aromatic diamidine antiseptic (other members of the group include pentamidine and dibrompropamidine). These drugs have broad antibacterial and antifungal properties and are also used topically to treat corneal infections and some skin infections.2 In Australia, hexamidine is an ingredient of one topical local anaesthetic/antiseptic cream (Medi Creme) and one nappy rash cream, as well as some tinea treatment creams, medicated shampoos, sunscreens and cosmetic facial wipes in other countries. Adverse reactions (such as contact allergic dermatitis and photodermatitis3) are rare — only four reports of localised dermatitis have been reported to Australia’s Adverse Drug Reactions Advisory Committee (ADRAC) in the past 6 years (Dr K Mackay, Acting Director, ADRAC, Adverse Drug Reactions Unit, Therapeutic Goods Administration, personal communication). There have been more reports of systemic allergic reactions (including anaphylaxis) triggered by chlorhexidine or cetrimide,4 with one description of anaphylaxis to hexamidine after patch testing, but none with clinical use.3 Underlying dermatitis is a risk factor for sensitisation to topical agents.5 This case emphasises the importance of documenting exposure to potential allergenic triggers in the setting of a short-lived episode of urticaria (where the search for an avoidable trigger is more likely to be productive) or anaphylaxis. Exposure to stinging insects is usually obvious, whereas exposure to particular foods or medications is often poorly recalled. That topical allergens can also trigger systemic reactions should be considered.

Raymond J Mullins PhD, FRACP, FRCPA

To the Editor: Extended-wear silicone hydrogel contact lenses allow the convenience of 24-hour correction of refractive error and freedom from cleaning solutions and storage containers. However, they are associated with an increase in the risk of microbial keratitis when worn overnight compared with daily wear.1-5 The following cases from a single ophthalmology practice illustrate the risk to contact lens wearers when they use silicone hydrogel contact lenses overnight. A 36-year-old woman presented 11 days after sleeping with her silicone hydrogel contact lenses in overnight. She had increasing right ocular pain and photophobia over the preceding 9 days, which had not resolved with chloramphenicol drops. On examination, visual acuity was 6/18 right and 6/6 left. Corneal cultures grew Acanthamoeba, which responded to polyhexamethylene biguanide and brolene drops hourly. Her final best corrected visual acuity was 6/9 right, 5 weeks later. A 24-year-old woman presented with 2 days of left ocular pain, conjunctival injection, and epiphora following continuous silicone hydrogel contact lens use over the preceding week. On examination, visual acuity was 6/6 right and 6/18 left. A central corneal ulcer with stromal infiltrate and significant anterior chamber activity was present in her left eye (Box). Corneal cultures grew Pseudomonas aeruginosa, which responded to topical gentamicin 1% drops hourly. Her final best corrected visual acuity was 6/5 left, 3 weeks after diagnosis. An 8-year-old girl was seen 2 months after commencing continuous wear of her silicone hydrogel contact lenses for uniocular myopia. She had worn the same lenses for 4 weeks continuously when she presented with a 2-day history of right ocular irritation, photophobia, and conjunctival injection. On examination, visual acuity was 6/36 right and 6/6 left. She was commenced empirically on cephalothin 5% and gentamicin 1% drops hourly. Corneal cultures did not grow any causative organism, and her clinical condition improved significantly over the following 7 days. Her final best corrected visual acuity was 6/9 right. Although microbial keratitis may only affect a small proportion of individuals1,2,5 and our patients did not experience significant reduction in vision following treatment, microbial keratitis is potentially blinding and should not be trivialised. Silicone hydrogel contact lenses have a lower risk of associated microbial keratitis than other lens types, but they do not remove it completely. In view of this, contact lenses should not be worn overnight or for an extended period. Furthermore, a painful red eye in a contact lens wearer should be considered microbial keratitis until proven otherwise, and needs a prompt ophthalmologist referral. Microbial keratitis in a 24-year-old woman

John A Landers · John L Crompton

To the Editor: Uveitis is an intraocular inflammation which potentially leads to permanent loss of vision.1,2 Tuberculosis is considered to be an infrequent infectious cause of uveitis in the developed world. However, its recurrence as a major public health problem raises the possibility that the incidence of tuberculosis-related uveitis in the developed world may rise.3,4 Uveitis in tuberculosis is presumed to result from either direct invasion or a hypersensitivity reaction. At the ophthalmology departments of the Erasmus Medical Center and the Eye Hospital in Rotterdam, The Netherlands, all patients presenting with refractory uveitis undergo investigation for a systemic cause, including tuberculin skin testing. When ocular findings are consistent with intraocular tuberculosis, and the tuberculin skin test is positive, while no other cause of uveitis is suggested by symptoms, signs or ancillary testing, then a diagnosis of presumed intraocular tuberculosis is made. Using these criteria, eight cases of presumed intraocular tuberculosis were identified among 89 people referred with refractory uveitis between January 2002 and January 2004. Characteristics of the eight patients are shown in the Box. One patient (F) withdrew from clinical care, and another (A) later had a positive culture result for tuberculosis on lymph node biopsy. This patient had complete remission of uveitis after tuberculostatic treatment, but was excluded from this study as the aim was to assess whether antituberculosis treatment is warranted based solely on a positive tuberculin skin test. We treated the patients with a complete tuberculostatic regimen (2 months of isoniazid, rifampicin, ethambutol and pyrazinamide, followed by 4 months of isoniazid, rifampicin and ethambutol). All had been previously treated for more than 3 years with immunosuppressive drugs (mainly corticosteroids), either local or systemic, or both, without adequate response. Main outcome measures were visual acuity and degree of intraocular inflammation seen on ophthalmological examination before and on completion of antituberculosis therapy. The predominant clinical finding was blurred vision. Five patients exhibited decreased intraocular inflammation and an increase in visual acuity after antituberculosis treatment, allowing tapering of the corticosteroid treatment. One patient had no response. Improvement as part of the natural history was regarded unlikely. As our department is a tertiary referral centre for patients with uveitis, our patient population is not a representative sample of all patients with uveitis in The Netherlands. Nevertheless, our findings suggest that intraocular tuberculosis should be considered in the differential diagnois of uveitis, even in developed countries. We believe that, given our results, antituberculosis therapy is justified in patients with uveitis even when a positive tuberculin skin test is the only argument for tuberculosis as the cause of the eye disease. An additional argument for antituberculosis treatment is that many patients with uveitis refractory to immunosuppressive therapy can be adequately treated with tumour necrosis factor-α (TNF-α) blocking drugs.5 However, as severe tuberculosis infection has been described after use of these agents, antituberculosis therapy is warranted in any patient with a positive tuberculin skin test who is a candidate for TNF-α blocking therapy. Details of eight patients with presumed intraocular tuberculosis Affected eye Place of birth Visual acuity Uveitis treatment Antituberculosis treatment Patient Sex Age Uveitis Before* After* Response A M 25 Left Anterior Congo NR† NR† NR† NR† NR† B F 40 Both Posterior Cape Verde 1.8/6 (R), 1.2/6 (L) 4.8/6 (both) Local steroids HRZE, HRE Partial response, local steroids continued C F 69 Left Posterior Netherlands‡ 4.8/6 4.8/6 Local steroids HRZE, HRE Complete response, local steroids stopped D M 49 Right Posterior Surinam 0.6/6 0.8/6 Vitrectomy, local steroids HRZE, HRE No response E F 36 Both Anterior Morocco 2.4/6 (R), 3/6 (L) 4.8/6 (R), 6/6 (L) Local steroids HRZE, HRE Complete response, local steroids stopped F F 62 Both Posterior Morocco 0.6/6 (R), 0.6/6 (L) Local steroids — Lost to follow up before treatment G M 54 Right Posterior Surinam 2.4/6 5.5/6 Local and systemic steroids HRZE, HRE Partial response, systemic steroids stopped H F 19 Both Intermediate Netherlands‡ 4.3/6 (R), 1.2/6 (L) 6/6 (R), 6/6 (L) Local steroids HRZE, HRE Complete response, local steroids stopped * Before and after antituberculosis therapy. † NR = no result as patient excluded from the study. ‡ Patient C’s parents were born in The Netherlands, but Patient H’s parents were from Morocco. M = male. F = female. H = isoniazid. R = rifampicin. Z = pyrazinamide. E = ethambutol.

Paul L A van Daele · Marleen Bakker · P Martin van Hagen · G Seerp Baarsma · Robert W A M Kuijpers

To the Editor: Mycobacterium ulcerans is an environmental pathogen with a global geographic distribution and focal disease clusters. The World Health Organization considers M. ulcerans infection to be of increasing global importance, particularly in West Africa. In Australia, the clinical and pathological features were fully described in 1948, when the disease was named Bairnsdale ulcer.1 Since then, the number of cases has increased, and new focal areas continue to emerge around southern coastal Victoria.2 In Queensland, the disease is most frequently reported in the Mossman area (north of Cairns in north Queensland), where it is known as Daintree ulcer.3 However, the organism is probably more widely distributed. We describe four patients recently diagnosed with proven M. ulcerans infection in the Capricorn coast region of central Queensland (Box). The suspected epicentre of infection is around Yeppoon, approximately 1000 km south of Mossman. None of the patients had significant contact with recognised endemic areas in north Queensland or Victoria. Patient 1 had visited Townsville in July 2000, but had minimal contact with the natural environment. She undertook extensive gardening at her home in North Rockhampton, using sugar cane bagasse mulch from north Queensland. The previous occupants of her house had lived in north Queensland and left behind at her home numerous potted plants originally from that area. However, investigation of soil from potted plants, gardens and roses at the home using polymerase chain reaction (PCR) failed to detect any evidence of M. ulcerans. Patient 2 lived near a coffee plantation originally planted with seeds transported from north Queensland. Sampling of plants and soil in the area by PCR revealed no atypical mycobacteria. M. ulcerans is an environmental organism associated with bodies of water, but its specific ecological niche is unknown.4 The organism is difficult to culture from the environment but has been identified by PCR in water, biofilms, aquatic insects, snails and fish. The mode of transmission to humans remains unknown. It has shown a marked propensity for causing intense focal outbreaks in Victoria (Phillip Island and Point Lonsdale) and Queensland (Daintree region). The recognition that M. ulcerans occurs in coastal central Queensland is important, as early diagnosis of M. ulcerans infection minimises the extent of tissue debridement necessary and improves outcomes. The patients we describe had complicated disease requiring multiple debridements and, in one case, amputation. Awareness of the possibility of M. ulcerans infection is critical, as diagnosis by PCR is straightforward once the infection is considered in the differential diagnosis. In 1942, Cilento described possible M. ulcerans infections from around Rockhampton.5 Four other culture-confirmed cases were reported between 1957 and 1962 from the Glass House Mountains (Sunshine Coast)3 and Maryborough (Fraser Coast)6-8 regions in Queensland. Our four cases occurred within a small geographic area centred on Yeppoon and the suburbs of Rockhampton. If the cases previously described by Cilento were truly related to M. ulcerans, then there appears to have been a five-decade gap in identification of M. ulcerans infection in the Capricorn Coast region of central Queensland. Possible explanations for this include low organism numbers resulting in sporadic infection, focal concentrations of the organism with environmental changes, such as development, land clearing and cultivation modifying human contact, or failure to diagnose the condition. Patients who acquired the infection in central Queensland may also have been diagnosed outside the area. The increase in cases in Victoria raises the possibility of a potentially similar dramatic increase in cases in central Queensland. Consideration should be given to making M. ulcerans infection a reportable disease to enable monitoring. Four patients with Mycobacterium ulcerans infection in central Queensland Age/sex Location Presentation Site Clinical features Diagnosis Treatment 47 F North Rockhampton Sep 2000 Fifth finger (left hand) Nodule Histology, PCR Debridement, antimycobacterial antibiotics, amputation 33 F Yeppoon Jun 2003 Left knee Ulcer Histology, culture Debridement 64 M Bungundarra Aug 2004 Right elbow Ulcer Histology, PCR Multiple debridements 18 M Keppel Sands Nov 2004 Right knee Ulcer Histology, culture Multiple debridements, antimycobacterial antibiotics PCR = polymerase chain reaction. F= female. M = male.

Glenn D Francis · Michael Whitby · Marion Woods

To the Editor: “... what a difference can be made and how bureaucracies can stuff things up”. “... systematic testing and treatment of people with high blood pressure and kidney disease dramatically improved blood pressure and resulted in a 50% reduction of deaths”. “... excellent results were achieved by good management and they were lost when intensity of management was relaxed”. The above quotes are from an episode of The health report broadcast late last year on Radio National.1 The episode, which described a deterioration in the health of an Indigenous community after a chronic disease treatment program was handed over to a community health board, caused me to take a closer look at the articles in the Journal by Hoy and colleagues on which the claims were based.2,3 I found several issues of concern. The small numbers of deaths each year in the study community and the analysis and presentation of the death data mean that the conclusions about trends in mortality over time are tenuous. This is highlighted by the discrepancies between the two articles in the terminology used to classify deaths, in the numbers of deaths reported, and in the trends over time. Discrepancies in terminology or numbers of reported deaths are not explained. The declining trend in the number of “natural” deaths described in the 2000 article is not apparent in the “non-renal” deaths in the 2005 article. The rate of “non-renal” death for the period 1996–97 to 1998–99 reported in the 2005 article appears to be increasing rather than declining, as described in the 2000 article (rates for earlier years are not presented in either article). It is clear that, with these small numbers, the reclassification or misclassification of a single death can affect the trends in “renal death” or end-stage renal disease over time, and that the use of “rolling averages” hides the year-to-year variability that would be expected in these data. The trend over time in the key intermediate outcome indicator of blood pressure control does not support the conclusion regarding impact of the “handover” on the program. The data presented in the 2005 article show a decline in control commencing in the third year. An earlier analysis of the same data showed the decline in blood pressure control began as early as the second year after entry into the program.4 Neither analysis shows any clear change in the declining trend in blood pressure control around the time of “handover” of the program. While the discussion of the findings of the 2005 article is circumspect, at the time of interview, Hoy conspicuously did not deny the statement of The health report host that the primary cause of the apparent loss of the early impact of the program was the bureaucracy “stuffing up”. The article makes some important points about the operation of chronic disease programs, but makes no mention of the commonly experienced difficulties of sustaining health programs,5,6 or the research requirements for understanding sustainability.7 These issues raise serious questions about the validity of the conclusions and the simplistic claims arising from the articles.

Ross S Bailie MD, FAFPHM

In reply: I appreciate the feedback on the 2000 and 2005 articles describing the dynamics and outcomes of the “Tiwi treatment program”.1,2 Thorough and timely identification and enumeration of deaths is a problem, especially for people not enrolled in the treatment program. Without a register of such people, systematic checking of their fate was not possible. The additional “non-renal” deaths in the community-at-large presented in our 2005 article, compared with previous articles, seem to have been captured largely by the broad net spread by the Tiwi Health Board when it assumed responsibility for its primary care services, in an attempt to identify all its potential clients. This process identified several hundred more people than expected and captured additional deaths, several dating back years. The precise definition of a community member is also a problem, especially for people living permanently or intermittently elsewhere (eg, in Darwin or other communities). The broadened definition of “renal deaths” in the 2005 article,2 which accommodates people who died with renal failure but did not begin dialysis, more fully represents the impact of renal disease. Conversely, recording only those who began dialysis allows estimates of the impact on health services and potential savings from better management.3 Both approaches have their place. Rolling averages, which indeed have limits, were used in view of the overall small and erratically spaced number of terminal events in any year. The figures we reported in our 2005 article did not show a deterioration in blood pressure at Year 2, either in the treatment group as a whole, or in the smaller cohort followed for a full 6 years.2 An earlier analysis, which largely embraced the active years of the program, also showed that blood pressure at Year 3 was not significantly different from that at Year 2 (systolic blood pressure, P = 0.68) (Box). With time, the number of people who had moved through 3 years of treatment increased, and the timing of their 3-year blood pressure measurements moved from a mix of 1998–1999 to 1999–2002, when, as program dynamics suggest, intensity of management was relaxed, and mean values deteriorated, as we reported in 2005. The blood pressure measurements in the report by Bailie’s group5 were compiled from a review of paper-based medical records, the clinic’s newly implemented Coordinated Care Trial Information System, and the Territory’s Information System (Systematic Health Information Logically Organised), as well our from our treatment program database. Those blood pressures were allocated time definitions in a different way, and the summary data were derived from adjusted predictions from cross-sectional time series modelling, rather than from factual recordings at the stated intervals.5 I did not solicit the interview for The health report, nor determine its directions nor the resulting headlines. However, the under-resourcing of primary care relative to needs in remote Aboriginal settings, and the lack of stability in the organisations in which it is delivered, are very detrimental. I regret that, once the Tiwi Health Board was constituted, it was not mentored and supported through its difficulties. More recently, the fledgling community-controlled Gulf Health Service in the Borroloola region of the Northern Territory met a similar fate. Chronic disease remains underserviced in both these regions, where the people are among the sickest in Australia. Blood pressure measurements (mm Hg) over 3 years of follow-up after enrolment in 123 people who had observations at every interval4 Baseline 6 months 1 year 2 years 3 years Mean systolic BP (SD) 136.2 (21.6) 125.4 (21.6) 123.6 (20.3) 120.6 (21.6) 121.7 (21.5) Mean diastolic BP (SD) 81.9 (13.2) 75.5 (13.7) 76.3 (12.9) 74.5 (13.7) 74.0 (11.0)

Wendy E Hoy

To the Editor: As I have said elsewhere, “The last thing the majority wants is that the tyranny of the majority be applied to it. It is much easier to apply the tyranny of the majority to a minority. In a properly functioning democratic society minorities are not subjected to, but are protected against, the tyranny of the majority. Is the tyranny of the majority being applied through the medium of the Howard government onto the Aboriginal communities of Australia in this matter of ‘shared responsibility agreements’?”1 I note with interest recent articles by Collard and colleagues2 and by Kowal,3 debating “shared responsibility agreements”. The expressions “shared responsibility agreement”3 and “mutual obligation” are variations of the expression “social contract”. The concept of “social contract” underlies the concept of democracy originating in the writings of Thomas Hobbes, John Locke and Jean-Jacques Rousseau. Present-day political scientists discuss social-contract theory in their writings about democracy, and may mention “mutual obligation” or “shared responsibility”. While it is commonplace for aspects of the social contract to apply to subgroups in the population, it is discriminatory to make arrangements that apply only to a particular racial or ethnic group. Even though the agreements are declared to be voluntary, it is likely that Aboriginal communities are under pressure to do as they are told to achieve social contracts with the Australian Government. If Indigenous people must comply with certain conditions before they can achieve social contracts, how might similar conditions be applied to the rest of the Australian population? The “ticking time bombs” of Australian public health are smoking and obesity. If non-Indigenous Australians refuse to stop smoking and refuse to eat less and take more exercise, should access to public hospitals and pharmaceutical benefits be denied them? Should they be denied petrol to force them to walk and to use public transport? Obviously not. These services are not subject to social-contract agreements as thiswould be a clear violation of Australian law. Australian members of parliament in particular, and Australians in general, for the sake of themselves, their families and of Australian health care costs, would benefit from negotiating “shared responsibility agreements” with themselves to stop smoking and to lose weight. In current circumstances, “shared responsibility agreements” with Aboriginal communities represent inequality of sharing the responsibility for health.

John N Burry

To the Editor: Where is the evidence for the claim by Joyce, McNeil and Stoelwinder1 that there was a boom in medical workforce supply in the 1970s? They are perpetuating the accepted macroeconomic myth of there having been a surplus at that time. The microeconomic, marketplace truth was that there was a shortage of general practitioners throughout the 1970s.2 This was so severe that, after battling for some years after 1974 to find a partner for my suburban Sydney practice, I resorted to advertising overseas, finally importing an overseas-trained graduate. It is time for this myth to be laid to rest. There has been a marketplace shortage of GPs since the early 1970s. The truth is that federal governments have baulked at the expansion of payments through Medibank/Medicare. Rather than apply any controls on demand, they have obstinately rationed supply, repeatedly citing dubious statistics and invalid international comparisons to justify a diminution in the supply of GPs.

Peter C Arnold

In reply: Our reference to a boom in medical workforce supply during the 1970s was based on the marked increase in medical workforce entries in that decade. The number of Australian medical graduates rose from 851 in 1970 to 1278 in 1980.1,2 In contrast — and as a result of a shift to a policy of constraint — graduate numbers remained quite static during the 1980s and 1990s, at around 1200–1300 per year (Commonwealth Department of Education, Science and Training custom datasets RFI 03-312, RFI 04-360, 2004). Although the policy shift in the 1980s was based on a perception of surplus, judgements about workforce adequacy were contentious at that time and remain so. We did not intend to imply necessarily that there was a surplus in the medical workforce (or the general practice workforce specifically) during the 1970s. Rather, our historical reference was intended to show the parallels with the large influx that will result from current expansion in medical school intakes, and to highlight the cyclic nature of both medical workforce policy and perceptions of adequacy. We agree with Arnold’s implication that policies which attempt simply to adjust gross supply (up or down) are insufficient to ensure an adequate medical workforce.

Catherine M Joyce · John J McNeil · Johannes U Stoelwinder

To the Editor: We read with interest the letter by Breeze et al on management of abnormalities detected on cervical screening.1 Their study identifies a universal and fundamental feature of the Pap smear — namely, that it is an imperfect predictor of underlying abnormalities in the cervical epithelium. For smears reported as a low-grade squamous intraepithelial lesion (LSIL) (atypical squamous cells of uncertain significance) or possible LSIL, Breeze and colleagues have shown that underestimation of the extent of the underlying abnormality is greater in infrequently screened women than in frequently screened women. They claim that following the latest National Health and Medical Research Council (NHMRC) guidelines for cervical screening2 will put women in rural and remote areas with cytologically detected low-grade lesions at risk of developing high-grade lesions that go undetected through lack of timely follow-up. I contend that following the new NHMRC guidelines presents a significant risk to all women with LSIL or possible LSIL reported on smears, regardless of ethnicity, locality or social class. The risk is merely greater for women living in rural and remote areas. In addition to delays in diagnosis of high-grade lesions, data from cervical cytology registries indicate that there will be delays in diagnosis for the 30–50 women each year whose smears show changes only of LSIL or possible LSIL but who are shown on biopsy to have cervical cancer.3 The problem of women defaulting on clinic appointments or being lost to follow-up is a phenomenon commonly encountered in cervical screening programs in general, but in Far North Queensland the risks of inadequate follow-up are magnified. For these and other reasons, the Royal College of Pathologists of Australasia, other learned societies and individuals have consistently and strenuously opposed the latest NHMRC guidelines during the period of their development and during the consultation period of many months. Rather than advocate a separate set of guidelines for women in rural and remote areas, it would be better to have a universally accepted safe set of guidelines that conforms to international best practice and applies to all Australian women. Using the guidelines that were in use until 20054 and that have served us so well in the past is one option. Another option, which is backed by first class scientific evidence,5 is to use human papillomavirus DNA testing for triage of women with smears reported as possible LSIL.

Stewart Bryant

In reply: In June 2005, the National Health and Medical Research Council (NHMRC) endorsed new guidelines for managing asymptomatic women with screen-detected abnormalities because they were safe for Australian women and were based on the best available Australian and international evidence.1 The NHMRC accepted that new information about the natural history of human papillomavirus (HPV) infection of the cervix and cervical neoplasia demanded a reassessment of our traditional approach to this disease. HPV infection of the cervix and associated, potentially neoplastic precursor lesions are very common, but not all of these have malignant potential. Optimal prevention of cervical cancer will depend on timely diagnosis and treatment of lesions that are most likely to progress. Overdiagnosis and treatment of all incident lesions is unnecessary and potentially results in avoidable morbidity. The approach recommended in the latest guidelines moves away from probabilistic prediction and intensive investigation based on a single cytological specimen to an evidence-based program of intermittent cytological surveillance of this chronic viral infection. Intervention is timed to coincide with evidence of persistent and potentially dangerous infection. Contrary to Bryant’s claim about Australian registry data, there is no evidence that the new guidelines will mean any increase in the diagnosis of cancer, a view that is supported by independent epidemiological expert review (M Clements, Research Fellow, National Centre for Epidemiology and Population Health, Australian National University, personal communication). The experience of Breeze and colleagues in Far North Queensland suggests that the greatest risk factor for any woman to develop cervical cancer is infrequent screening.2 Furthermore, in the unlikely event that the latest guidelines do result in increased cancer incidence, such an increase will immediately be detected by the monitoring program that is integral to the new approach. Bryant advocates increased pathology testing using HPV DNA tests. We are not aware of any population data demonstrating that such an approach would result in improved cancer prevention, nor that such an approach would be cost-effective. Consequently, the Guidelines Review Group did not recommend the use of HPV DNA testing as part of triage of women with abnormal smears. The approach recommended in the guidelines is also consistent with contemporary international experience3 — namely, that the clinical significance of a single incident measurement of HPV status is not established. We believe that the latest NHMRC guidelines1 are safe and acceptable for all Australian women and that all women deserve appropriate investigation and treatment of cervical abnormalities in a manner that will protect them from both cervical cancer and unnecessary, potentially harmful interventions. Finally, to address the concerns of Breeze and colleagues, the guidelines specifically advise that clinical management be tailored to the patient’s individual circumstances.

Gerard V Wain · Ian G Hammond · Penelope I Blomfield · Marion A Saville · Margaret Davy

To the Editor: The National Cancer Control Initiative (NCCI) was established in 1997 jointly by the Department of Health and Ageing and The Cancer Council Australia to “provide timely advice, identify appropriate initiatives, and make specific recommendations to the Commonwealth Government and other key groups regarding the prevention, detection, treatment and palliation of cancer for all Australians”. It has been the only independent group dealing with all aspects of cancer nationally, and incorporating government, non-government, consumer and professional input. On 31 May 2006, it ceased operation due to lack of funding support, and no arrangements have been made to allow continuity between its work and that of a proposed new body, Cancer Australia, which at the time of writing was still not functioning. The NCCI’s contributions include national surveys of colorectal cancer management and of skin cancer incidence and treatment; clinical trials assessing the management of skin lesions in primary care; the first protocols for pilot programs for bowel cancer screening; national programs to promote the implementation of National Health and Medical Research Council guidelines on psychosocial aspects of cancer and on lung and other cancers; programs to improve decision making in prostate cancer screening; a nationally agreed core clinical dataset for cancers; support for cancer registries to include staging and survival information; new methods to establish evidence-based requirements for radiotherapy services; and support for cancer research, for strengthening clinical trials and for consumers’ activities. Since 2000, the small group of NCCI staff has produced seven national workshops, over 30 published reports, and over 60 peer-reviewed articles. These are available online at <http://www.ncci.org.au/> along with current contact details of NCCI staff, and the final report of the NCCI is at <http://www.ncci.org.au/pdf/Final%20 report/NCCI_final_report.pdf>. An independent review in 2004 reported that NCCI’s work was of high quality, well researched, insightful, and cost-efficient, and recommended a considerable increase in funding. A major contribution of NCCI was producing, jointly with The Cancer Council Australia and the Clinical Oncology Society of Australia, the report Optimising cancer care in Australia. The government’s 2004 election policy on cancer (http://www.health.gov.au/internet/budget/publishing.nsf/Content/health-budget2005-hbudget-hfact1.htm) was based partly on this report, and included setting up Cancer Australia, with terms of reference overlapping those of NCCI. The assumption of many policymakers, consumer representatives and cancer experts was that NCCI would become a component of Cancer Australia. This has not happened. Indeed, from 2005, proposals from NCCI for the planned next stages of work on topics including psychosocial aspects of cancer, lung cancer, and primary care in cancer, received no response from the Department of Health and Ageing. With the closure of NCCI, the Director and Deputy Director are relocating overseas, and the highly productive staff members, specifically praised in the independent review, are moving to other roles. The premature demise of the NCCI, before Cancer Australia has started to function, is short-sighted, inefficient, and wastes the experience, resources and staff that NCCI has developed. This finishes a decade-long unique partnership between the Australian Government and non-government national cancer organisations. Cancer Australia will need to develop anew the expertise to identify and address issues in cancer control in Australia, and to link the government and non-government sectors.

J Mark Elwood · Robert C Burton · Michael A Quinn

To the Editor: Bachrach’s article1 “Missed conceptions” and the accompanying commentary by Chapman et al2 made compelling reading. The plea of these authors coincides with calls from the Fertility Society of Australia and the South Australian branch of the Australian Federation of Business and Professional Women for campaigns to better inform women about the biological limits of their fertility. Personal stories can alert us to social problems sliding under the radar. But before we heed the call for “positive family planning”, we need to know more. Firstly, whether intervention by a general practitioner (as Bachrach, in her forties and wanting children, would have wished) would be appreciated by younger women who may not yet, or may never, be interested in motherhood. We also need to know how GPs would view this sort of intervention, and whether they feel equipped with the knowledge and tools to ensure an effective engagement that is appropriately respectful of their patient’s autonomy. There is a long history of women being valued by society only as mothers. It is important that any GP-based fertility intervention be sensitive to a woman’s fertility values and plans, be they for motherhood or freely chosen childlessness. Bachrach’s article is a call for action, but we need to ensure that action is well grounded in research-based knowledge about current practice and the barriers both GPs and women perceive to discussing fertility plans in the consulting room. Such knowledge would be useful for the development of a tool to assist GPs in helping women make timely, well informed fertility decisions that are consistent with their parenting plans.

Danielle Mazza · Leslie Cannold · Cate Nagle

To the Editor: We believe the study by Kirkwood et al,1 investigating the use of nurse-led perioperative cataract clinics, contains flaws, and their conclusions are premature. The authors do not explain the reduction in elective surgery waiting times. Use of a nurse-led clinic should not affect surgical throughput, which is dictated by surgeon and theatre availability. The rate of postoperative complications with cataract surgery is very low.2,3 An assessment of the concordance in management between the nurse practitioner and ophthalmologist would therefore only be possible if a large number of patients were compared, not just the 18 used in the study. The authors do not justify the statements “a nurse practitioner might be more . . . experienced in managing patients with ophthalmic conditions” [than a junior registrar] and “the experienced nurse practitioner might be more efficient in use of consumables and investigations” by reference to their own clinic or the literature. In our opinion, a medical practitioner is best placed to understand and make these decisions. In Queensland, registrars perform or observe most cataract operations done in public hospitals. It is important for their training to see these patients both before and after surgery,4 making the presence of a nurse practitioner unnecessary. If the authors are interested in increasing the efficiency of the process, they could reduce unnecessary clinic visits, which is very relevant here in Australia given that patients may have to travel great distances for operations. The two preoperative visits proposed in the authors’ model could be replaced by one. Standardised referral forms can be used for screening, and facilities can be put into place so that all necessary tests can be performed on the same visit for eligible patients. The 4-week visit can be eliminated if the patient’s dispensing optometrist is aware of the expected postoperative visual acuity and can readily refer back if there are any concerns. Although the model outlined by Kirkwood et al has merits, the conclusions are misleading. Health care providers and governments must find ways to deliver high quality care during this period of workforce shortages. This should be achieved by increasing efficiency, while preserving doctor training opportunities, rather than through role substitution.

Hamish D R McKee · Glen A Gole

In reply: The points made by McKee and Gole are valid. However, the demand for eye-care services is outstripping the ophthalmological workforce. Some task substitution is necessary. The effect of the nurse-led cataract clinic has been largely to increase patient access to outpatient appointments — it helps deal with a large hidden waiting list (time to first clinic appointment), and frees up ophthalmologists to spend more time in the operating room. Registrars in training are not likely to cope with an increasing demand for services. The number of trainees is determined by the Royal Australian and New Zealand College of Ophthalmologists. Flinders Medical Centre sees 15 000 eye outpatients a year and does 1500 elective procedures — and has been allocated one first-year trainee. The nurse practitioner is more experienced and does not rotate to another hospital every few months. Nurse practitioners may not be the preferred substitute for ophthalmologists. The employment conditions of nurses can be restrictive, and senior nurses are expensive to employ compared with other professionals, such as orthoptists and optometrists. Perhaps McKee and Gole are more comfortable with the use of professionals other than nurses, as they advocate the involvement of optometrists to decrease the load on outpatient clinics.

Bradley J Kirkwood · Konrad Pesudovs · Paul Latimer · Douglas J Coster

To the Editor: We read with interest two recent articles and an editorial on the state of medical education in Australia.1-3 As cancer clinicians and academics, and members of the Oncology Education Committee of the Cancer Council Australia, we have been following medical student education about cancer in Australia for almost 20 years and have learned first hand what is not sufficient to achieve change. Highlighting the need: Cancer claims more lives than any other disease4 and is set to increase in incidence by 31% over the next decade,5 yet medical curricula devote little time to cancer education because of competition with other disciplines, historical precedent, personal preferences or just lack of teachers. Developing a national curriculum: An ideal oncology curriculum,6 developed in Australia in 1999, has been endorsed by the International Union Against Cancer, yet has been taken up by a minority of medical schools in Australia. This is largely because of the lack of a national medical curriculum and the absence of a compliance mechanism through national credentialling. Demonstrating deteriorating standards: A comparative study published in 2003 highlighted the fact that recent medical graduates had less exposure to cancer patients than those who graduated 11 years earlier, and that their knowledge was inferior.7 Evidently, community awareness, recommended curricula and evidence of system failure do not effect change. Why? Perhaps because, in the present system, curriculum content is divorced from medical outcomes. There is little or no feedback linking curricula to their consumers: medical students, postgraduate training programs and patients. The Australian Medical Council, the main accrediting body for medical curricula, is more concerned with process than content or outcomes. There is no national outcomes monitoring, nor an exit exam.8 No one knows whether students achieve desired outcomes. We do not even agree on what these are. Outcomes of medical education must feed back to content and process. To do this, we must monitor outcomes nationally, provide feedback to medical schools and have mechanisms to effect change based on such feedback. Without closing the loop, medical education seems to have some features of cancer: vigorous but uncontrolled growth, and uncertain outcome.

Bogda Koczwara · Michael B Barton · Martin H Tattersall · David R Turner · Ian N Olver · Darren L Starmer

To the Editor: McGrath and colleagues raise important questions about medical training in Australia.1 Their solutions take an admirable overall approach to policy, but fail to fully acknowledge the current reality of training and service delivery in the health sector. The Productivity Commission is certainly taking a broad approach to these matters,2 but I wonder if more lateral thinking and a reference to the past might help provide a solution? In 1910, the landmark Flexner report recommended that universities take over undergraduate training so that a uniform standard could be achieved.3 Previously, many hospitals trained their own doctors, hence the term “teaching hospital”. I am increasingly of the opinion that the pendulum has swung too far since Flexner, and that universities now are ill-equipped to train the doctors of the 21st century. Doctors in hospitals and communities are largely responsible for the clinical training of students anyway, and it is also in these arenas that prevocational and vocational training occur. It appears that the universities are the odd ones out when the full spectrum of medical education is considered. Very little “higher education” takes place during a basic medical degree — it is hard to argue against the notion that a basic medical degree has more in common with “further education” and the training of a trade. With this in mind, might it not be sensible for hospitals to take over the training of doctors again? There have been similar recent calls for nursing and school-teacher training to return to workforce-based training, and they moved to universities far more recently than doctors. Such a move could have a number of tangible benefits. All levels of training would be in alignment, thereby achieving the educational Holy Grail of “vertical integration”. Medical students would be immersed in a clinical environment from the start, thereby experiencing a true integrated curriculum. They would also be exposed to workforce requirements and this could address a number of current concerns surrounding graduates’ readiness for work.4 It would return public hospitals to being eminent training institutions, and would give true meaning to the term “teaching hospital”. Other health professionals could be trained within a similar model, introducing an interdisciplinary approach to training from an early stage. Basic sciences could be taught by scientists and clinicians alike throughout all stages of the course, all employed by the one institution and providing many educational benefits. Community-based education would be incorporated in a “hub and spoke” model, and clinical linkages would be significantly improved. Such an innovative move could bring medical education and service delivery back into alignment. Any impediments would be purely technical and, of course, political — and easily overcome.

Geoffrey A Couser

To the Editor: The article by Sanson-Fisher and Lynagh criticising problem-based learning (PBL)1 has elicited surprisingly little response, especially in light of the fact that these authors are from the University of Newcastle, the institution that first introduced PBL in Australia. The authors cite evidence that PBL students have inferior overall knowledge and competence than students taught by traditional curricula. Most medical faculties now have in-house education centres which are involved increasingly in learning process rather than content. The education centre in the Faculty of Medicine, Dentistry and Health Sciences at the University of Western Australia, for example, incorporates personal and professional development “as one of the four themes” in the curriculum2 — this includes such topics as ethical behaviour, diversity (what the patient brings to the relationship), self-evaluation (what the doctor brings to the relationship), teamwork, self-care and stress management. The old adage: “Those who can, do. Those who can’t, teach. Those who can’t teach, teach teachers” applies so appropriately to these new education centres. I support Lawson-Smith in calling on the Minister for Health, the Australian Medical Council, the Australian Doctors’ Fund, the learned Colleges, all interested colleagues and medical students to support the proposal for a national exit exam based on the most important function of a medical school: core knowledge.3 Medical students and medical schools should compete nationally in an examination to assess core knowledge. “Competition promotes the pursuit of excellence” should surely be the mantra of every medical school.

Ian N Bernadt

To the Editor: The recent article by Olson et al1 and the accompanying editorial by Crotty2 confirm the impressions of anyone who has graduated from an Australian medical school within the past 30 years. The paucity of clinical cases has probably been more significant in teaching hospitals in cities larger than Newcastle (where Olson and colleagues are based), as there has traditionally been a preponderance of student teaching in such institutions. This is something that seems to be slowly fading as new medical schools emerge in smaller cities, such as Canberra. What is harder to measure is the time and angst associated with the process of determining which patients are accessible for medical students. Students can be frustrated not only by the concerns of the nursing staff, but also by paramedics, technicians, clerks, relatives, other students and, perhaps most discouraging of all, patients themselves. Once this minefield of obstacles is negotiated, interaction with the patients is highly variable in terms of the learning opportunities afforded. Perversely, the most “valuable” patients in this sense can sometimes be the least accessible as they spend so much of their time away from the ward undergoing investigations. Crotty’s call to expand clinical teaching into the private sector has some merit, particularly as supervising consultants would be keen to make the student–patient interaction relatively efficient. I believe a more concerted effort to tap into the clinical resources in the expanded ambulatory sector is also required. Whatever “solutions” are found, it is hard to imagine that the clinical exposure of senior medical students to patients will be adequate any time soon.

Andrew Thomson

To the Editor: The article by McGrath and colleagues summarised neatly the challenges facing medical education in Australia.1 One solution suggested by Crotty for meeting the training needs of medical students at a time of increasing student numbers and decreasing numbers of hospital inpatients is to move a greater proportion of medical education into the community.2 Internationally, many medical schools are adopting a more community-based curriculum,3 while in Australia, students are spending a greater proportion of their time in general practices and other community settings. However, community-based education should not come cheaply. Many general practitioners have been hosting students in their practices for years, and are motivated to do so because of an interest in education and the stimulus provided by students in keeping up-to-date.4 Rarely are they solely involved because of remuneration. While there are payments for teaching, these do not reflect the time and loss of earnings that GPs incur in providing attachments. If GPs are to be asked to be more involved in the undergraduate curriculum, there should be a true costing of the process. GPs who teach students are often involved in vocational training of GP registrars and, from this year, in supervising interns in general practice through the PGPPP (prevocational GP placement program). I am concerned that we are approaching full capacity, and that finding quality GP placements for all these students and junior doctors will become very difficult. One solution for practices that provide a substantial amount of training would be to pay them enough to employ an extra doctor either to carry the teaching load or free up others to do so. However, even if there was the funding for this, at present, there is a shortage of GPs to provide patient care, let alone education. There certainly needs to be a rethink in relation to the prestige given to clinicians who teach, adequate training in education for clinical tutors, and the necessary resources to provide good learning experiences. Not only do I believe that all medical students should have the opportunity to work and learn within general practice, but that all junior doctors should have at least one attachment in the community. GPs will need support, training and space to offer this, and we should not continue to rely on their altruism to support medical training.

Jill E Thistlethwaite

To the Editor: I was recently amazed to learn that the solution to the educational needs of prevocational doctors was more teaching from registrars.1 My understanding was that registrars were themselves in a predominantly learning position, desperately hoping to glean some scraps of wisdom from consultant doctors. Often, the registrar, this supposed demi-god of all knowledge, is only 1 or 2 years ahead of the prevocational doctor and permanently juggling yet another postgraduate examination and the rigours of clinical duties. Then, with Australian medical schools springing up here and there, there are the inevitable hordes of medical students. So, registrars have an inherent and significant conflict of interest, namely, self-education to be able to continue climbing the slippery slope of postgraduate vocational education versus the altruistic provision of education for others. Perhaps graduating medical students need to take personal responsibility for their own education. Continuing medical education (CME) is a lifelong process that requires individual initiative. Support from the various specialist Colleges is welcome but not essential. Weaning prevocational doctors from their dependency on “formal education” is an essential first step towards independent clinical practice. This is not to say that CME for prevocational doctors should not be supported, but rather that it is unrealistic to demand that it should all be spoon-fed from registrars. An informal verbal survey of my registrar colleagues unanimously showed that we would all like to expand our teaching load, but not at the expense of clinical care. So what can the system do to support the beginners? Nurses have clinical nurse educators, and soldiers have drill sergeants. The nursing education system and the army have both recognised the value of employing personnel purely for educational purposes. The medical profession could do likewise. The pretence that service is educational for prevocational doctors should be denounced. Routine tasks performed by prevocational doctors that do not require medical expertise, but consume much time, could perhaps be delegated to non-medical professionals. This would free up time for medical education on the job. However, protected time for teaching by adequately remunerated clinical teachers requires workforce expansion and, ultimately, public funding and political will. Finally, from within a profession that often subscribes to the view that good resident staff are seen but not heard (that is, work hard and don’t complain), recognition by consultants that they too were once beginners may lead to positive cultural changes.

Kenneth Wong