Letters

To the Editor: Recent reports have highlighted problems with our capacity to teach medical students.1,2 Others have described workforce problems, calling for innovative approaches.3 The Rural Internship program at the James Cook University (JCU) School of Medicine may contribute to such strategies. The first regionally based medical program in Australia, the School was founded in 2000 and has recently graduated its first cohort.4 All final-year students undertake an 8-week rural internship, having previously completed 12 weeks of structured rural placements in their 2nd and 4th years, and a core 2nd-year subject — Rural, Remote, Indigenous and Tropical Health. The rural internship allows students to develop and practise clinical skills in a rural context. All students in the first cohort completed the rotation in 2005 in hospitals across northern Queensland, usually in groups of two or three, providing full-time inpatient, outpatient and after-hours duties under supervision. Hospitals were in rural and remote communities (Rural, Remote and Metropolitan Area classifications 4–7; comprising rural areas with populations < 24 999 to remote areas with populations < 5000), with demonstrated capacity to supervise and teach. Most were 2–4-doctor hospitals, although one larger hospital (Mt Isa, 35 doctors) and one smaller hospital (Moranbah, one doctor) were used. Supervision was provided by experienced rural doctors (medical superintendents and senior medical officers) holding an FACRRM or equivalent. Evaluation in the first year included student questionnaires, site visits, interviews and follow-up teleconferences with instructors. Early evaluation suggests that the rural internship provides senior students with valuable experience in the health care team. Students accept limited responsibility and further their abilities and confidence to undertake the role of the intern. Importantly, specific feedback from medical superintendents indicated that the rural interns made a net contribution to the system when teaching time and supervision were considered. The rotation appears to meet educational objectives without burdening (indeed, possibly bolstering) the local workforce. This is consistent with other reports of students undertaking extended rural experiences.5 It also addresses a common conundrum: rural instructors and communities are keen to teach students and appreciate the long-term workforce implications, but are constrained by resources, particularly time. This model extends and enhances apprenticeship-style medical education through its rural focus, distributed delivery and involvement of the entire cohort of students. The contribution to patient care by senior students and junior doctors creates a consultant–registrar–resident model, in which experienced rural doctors function as consultants providing advice, support and tuition rather than predominantly face-to-face patient care. We feel that this innovative approach should be explored in other settings.

Tarun Sen Gupta · Richard B Murray

To the Editor: Three recent articles discuss Australia’s medical education arrangements,1-3 but do not propose a way forward. Dahlenburg notes “at least 10 different agencies are involved in postgraduate training”, leading to a “modern Tower of Babel”, but proposes eight more “independent” entities. McGrath et al comment timidly that a Productivity Commission suggestion for a national advisory council “has merit”, and Dowton et al simply comment: “It is time to comprehensively review the oversight and governance of postgraduate medical education and training.” None of these articles even mentions General Practice Education and Training (GPET), an innovative Australian initiative. GPET was established in 2001 as an incorporated entity with a board appointed by the federal Minister for Health. GPET has established regional training providers (RTPs) across Australia. GPET is required under its constitution and government funding arrangements to provide postgraduate training according to standards determined by medical colleges. For general practice, GPET provides features these authors find lacking in Australia’s medical education arrangements, such as “overarching governance and coordination”, “integrated mechanisms to draw together the interests of stakeholders”, “alignment between workforce planning, education and training needs” and “alternatives to teaching hospitals”.4 GPET manages the interaction between autonomous colleges and a funding agency, and conflict between the focused desires of young doctors and workforce policies, while organising training outside public hospitals. Change is difficult, perhaps more so in medicine than in other sectors. Michael Foot, once leader of the British Labour Party, reflecting on political differences with the British Medical Association, wrote: “Much the strongest bent in the medical mind was a non-political conservatism, a revulsion against all change, a habit of intellectual isolation which enabled them to magnify any proposals for reform into a totalitarian nightmare. Nothing good could ever come from the meddling of outsiders.”5 GPET was a political response to effective lobbying from rural doctors rather than imposition of some grand centralist plan. Nevertheless, the imagined threat to professional autonomy evoked gloomy foreboding about “training standards spiraling downwards”.6 Maybe Dahlenburg, McGrath and Dowton realise controversy would follow any proposal for a medical education system with attributes they see missing, such as overarching governance, more coordination, alignment of workforce needs with trainee numbers, and wider distribution of training resources. It might require some consolidation of organisations, common structures and processes across disciplines, and some direction in the distribution of training resources. Maybe these authors do enough by raising the issues and are wise to leave others to debate whether centralised control and coordination could solve the problems they describe. Maybe they took the advice of a well known Englishman and decided not to mention the war.7

William Coote

To the Editor: We surveyed current medical students and interns in Western Australia over the 5 weeks from 23 September to 30 October 2005 to determine their awareness of, and views on, the imminent increase in clinical student and intern numbers as a result of federal government plans to increase medical student numbers nationwide, and to seek opinion on proposed strategies to cope with the demand on health education resources. The study was in the form of a web-based survey. The questionnaire consisted of five sections: demographic information, awareness of changes, predicted impact of these, teaching strategies and a free-text section for comments and concerns. The predicted impact question focused on the medical profession, career prospects, teaching, training positions and programs, average income of medical practitioners and overall effect on the health care system. There were 561 responses to the questionnaire (of a possible 1083). Respondents comprised 27 interns (of 134; 20.1%) and 534 medical students (503 of 909 [55.3%] from the University of Western Australia and 31 of 40 [77.5%] from Notre Dame University). The medical students comprised 118/212 from 1st year (56%), 108/207 from 2nd year (52%), 103/151 from 3rd year (68%), 84/141 from 4th year (60%), 71/126 from 5th year (56%), and 50/112 from 6th year (45%). There were 323 women (57.6%); and 70 respondents (12.5%) were aged over 24 years and 10 (1.8%) were aged less than 18 years. Respondents’ perceptions of the impact of increased student numbers are shown in the Box. Of the 561 respondents, 501 (89.3%) believed more clinical teachers in teaching hospitals to be important in ensuring the increased number of medical students are taught effectively. Further, 246 (43.9%), 303 (54%) and 311 (55.8%), respectively, indicated that general practice, rural hospitals, and private hospitals are important additional or alternative strategies. Themes that emerged from the free-text section of the survey were dissatisfaction with problem-based learning, expanded roles for junior doctors as teachers, and concerns about high ratios of students to tutors. While it has been widely acknowledged that the current methods of teaching need revision and will not cope with the influx in medical student numbers,1-4 planning for expansion of educational roles in non-traditional settings will require input from medical students as they are the “consumers” of these resources. We therefore suggest increased student input to workforce planning be sought at all levels to ensure newer teaching strategies will be effective in educating the impending influx of medical students. Western Australian students’ perceptions of the impact of increased student numbers resulting from federal government plans to increase medical student numbers nationwide Perceived effect Positive Tending positive Neutral Tending negative Negative Overall effect on health system 28% 27% 16% 18% 12% On career prospects 3% 6% 31% 38% 22% On teaching provided 4% 4% 13% 32% 48% On training positions 4% 5% 14% 42% 35% On average practitioner income 1% 3% 53% 26% 17% On the medical profession 22% 31% 26% 13% 7% Percentages may not total 100% because of rounding.

Ruth E Blackham · Ian R Rogers · Ian G Jacobs

To the Editor: There has been much public discussion recently about comorbidity between substance misuse and psychiatric disorders.1,2 Drug and alcohol misuse can precipitate, exacerbate and prolong psychiatric disorders, and is often accompanied by a range of social problems. Here we report on the prevalence of substance misuse in an unselected group of patients admitted to the 20-bed acute psychiatric facility at Lyell McEwin Health Service, situated in an underprivileged region of northern Adelaide. The facility has five closed beds and 15 open beds. In October 2005, 45 patients (23 men, 22 women; mean age, 39 years) were admitted to the unit, of whom 28 (62%) were detained involuntarily. Semi-structured interviews, clinical history taking and collateral information gathering revealed that 27 patients (60%) had a comorbid substance misuse disorder. The most common substance misused was cannabis (20 patients [44%]), followed by alcohol (16 patients [36%]), amphetamines (15 patients [33%]), opiates (6 patients [13%]) and benzodiazepines (5 patients [11%]). Misuse of more than one substance was common — for example, all 15 patients diagnosed with amphetamine misuse also misused cannabis. Patients who misused cannabis were younger (mean age, 33 years) than those who did not (mean age, 44 years) (t43 = 0.23; P = 0.023) and were more likely to be male (61% of male patients misused cannabis compared with 27% of female patients; χ2 = 5.14; P = 0.036). Of 19 patients with psychotic disorders, 11 misused cannabis. These results indicate high rates of substance misuse in patients admitted to a psychiatric facility. Cannabis misuse by young men is a particular concern. It is apparent that more than half of inpatients with acute psychiatric conditions could benefit from interventions to address their substance misuse. The extent of cooperation between drug and alcohol services and mental health services varies between different localities and between the private and public sectors. In states such as South Australia, where there is a historical separation between drug and alcohol services and mental health services, the treatment of these disorders is regarded as outside the role of mental health services. Patients considered to have a primary problem with substance misuse are treated by specialised drug and alcohol services. This service divide does not reflect clinical reality. Patients with comorbidity can “fall through the cracks”, each service regarding them as someone else’s responsibility. Postgraduate training in psychiatry includes both academic input and the submission of case logs describing 10 patients with addiction disorders, but this aspect of training may need to be expanded in response to changes in the pattern of disorders in the patient population. Mental health clinicians, along with general practitioners and doctors working in settings such as emergency departments, will increasingly need to be highly skilled in diagnosing and managing comorbid drug and alcohol and psychiatric disorders.

Cherrie Ann Galletly DPM, FRANZCP, PhD · Darryl P Watson MB BS, FRANZCP

To the Editor: Much has been written to describe the best clinical protocols to improve patient outcome following a medical emergency in hospital.1-4 However, one simple step in the process has not been clearly articulated: what is the hospital internal emergency number to ring to summon the medical emergency or “code blue” team? Each hospital in Australia sets its own emergency phone number. Examples include 333, 444, 555, 666, 777 and 2333 — there are probably others. For the highly mobile workforce in our hospitals, it is often difficult to recall which number to ring when challenged by the immediacy of a situation. All hospitals should upgrade their phone systems to have a single standard phone number for internal emergencies. This solution has been successfully applied in the broader community. In the Australian community an emergency call is 000, in the United States it is 911, and in the United Kingdom it is 999. It ought to be possible for all Australian hospitals to use a standard emergency telephone number to initiate an internal emergency response. I have only been able to find one health service internationally that has attempted this solution — the UK National Health Service advises trusts to use the number 2222.5 Technical advice on what number would be most suitable in Australia would be required. Telecommunications experts should advise on the technical aspects, cost and a reasonable time frame for all hospitals. State and federal health services would need to direct all hospitals to move to the new number, either as able or by a date to be determined. I hope to raise the debate on what appears, at a superficial level, to be a very simple initiative that could save lives, or at least remove one more cause of error and delay in the internal emergency response of each hospital.5 I have written to various authorities asking that this concept be explored. Those that have responded agree in principle, but have not taken responsibility for its progression. If this is a good idea, who should or could take control of it? It would be helpful to find an authority to back this proposal. This is a call for help.

Gerald F Williams

To the Editor: I am not a regular correspondent, as, with three children and a career, I rarely have the time. But, having read the recent personal perspective on missed conception1 and the accompanying commentary,2 I felt compelled to offer my own personal perspective on how, in medicine as a profession, we value (or don’t value) childbearing. Chapman and colleagues2 discuss the need for workplace reforms as a means of reducing barriers to earlier childbearing. If we, as doctors, are serious about this issue we need to lead by example and address workplace difficulties in promoting childbearing as a positive choice in our own profession. Despite women comprising at least half the medical students, they are still under-represented in most specialties, principally because training and childbearing are realistically seen by many women as “either/or” options. From my own experience, I can offer some illustrations of very real ways childbearing is devalued or discouraged in medicine. In my interview (around 1990) to gain admission to a physician training scheme, I was asked about my plans for a family, with the clear implication that, if I was considering having children, I should reconsider my options. Once a trainee, at the same hospital, I was advised by a senior (female) physician to delay pregnancy as long as possible, as it would mean death to any career aspirations. In my final year of advanced training, I was offered a job at one hospital, only to be un-offered the job days later when they heard, on the “grapevine”, that I was pregnant. When, as a National Health and Medical Research Council Research Scholar, I became pregnant with my second child and wanted to reduce my hours to part-time, I found the scholarship income became taxable — as it was assumed that part-timers were topping up income with private work. This significantly devalued the scholarship and went nowhere near covering childcare costs! After completing my PhD, in the course of applying for research funds while still working part-time, I discovered that granting bodies in Australia have no standard methodology for assessing curricula vitae of part-timers. With mothers comprising a large proportion of the medical part-time workforce, this effectively excludes us from competing for funds unless we wish to outsource our children. As recently as 2 years ago, when discussing these sources of inbuilt bias against medical mothers with a colleague, I was told my comments were inappropriate and offensive. If we, as a profession, can’t even discuss these stories, how can we set an example of positive family planning to the community at large? In listing the events described, I am not seeking sympathy or redress or claiming my path has been unusually difficult. Nor do I regret having my three lovely children! If one speaks to any working mother, similar stories emerge. As long as women feel the problems are their individual issues to grapple with in silence and embarrassment, rather than system failures, women embarking on any career will continue to be faced with a very real choice between children and a career (as opposed to a “job”). We may not be able to solve these issues on a community-wide basis, but let’s at least look in our own backyard.

Jane M Andrews

To the Editor: In an editorial in the 3 April 2006 issue of the Journal,1 Roughead and Lexchin estimated the annual incidence of adverse drug events (ADEs) in patients presenting to general practitioners, based on our data presented in the same issue.2 Calculating the incidence of ADEs from general practice encounter data is fraught with difficulties. Roughead and Lexchin’s calculation depends on all general practice patients having an equal chance of being in the sample. This would only hold true if all patients attended their GP an equal number of times. However, in our study, the age distribution of patients with ADEs shows that they are more likely to belong to older patient groups with a much higher than average general practice attendance rate. They thus represent a smaller proportion of all general practice patients, as their chance of being in the sample is much higher. Adjusting for the age and sex distribution results in an estimated incidence of about 1.6 million people. Further, these 1.6 million would, if asked, have reported an ADE in the previous 6 months. This cannot be extrapolated to an annual incidence of ADEs. The annual incidence figure could in fact be larger than that suggested by Roughead and Lexchin. We believe that recurrent monitoring of ADEs in patients attending general practice is a useful way of measuring the impact of the interventions suggested by Roughead and Lexchin, regardless of the difficulty of extrapolating to population incidence.

Graeme C Miller, Associate Professor and · Helena C Britt · Lisa Valenti · Stephanie Knox

To the Editor: We read with great interest the editorial by Gruen and colleagues on the recent developments in health services research and the establishment of an EPOC (Effective Practice and Organisation of Care) satellite at the National Institute of Clinical Studies in Australia.1 Before the social and political changes in Central and Eastern Europe in the 1990s, policymakers in Hungary (population 10 million) and many other former socialist countries had little interest in the effectiveness of health service interventions.2 Important tools of health policy decision making were missing from the health care system. Over the past 16 years, efforts have been made in Hungary to strengthen the institutional background and tools of health policy decision making. We would like to highlight some milestones of this process. During the 1990s, Hungarian researchers were sent to foreign universities to receive formal training in subjects related to health services research. Later, academic institutions and departments were established (Health Services Management Training Centre at Semmelweis University [Budapest], School of Public Health at the University of Debrecen [eastern Hungary], Unit of Health Economics and Health Technology Assessment at Corvinus University [Budapest], and Department of Health Insurance and Health Policy at the University of Pécs [southern Hungary]). In 2004, the National Institute for Strategic Health Research was established to guide governmental health policy decision making by undertaking activities in four main areas: health informatics and information policy; health economics; health services and health system research; and health technology assessment and coverage policy. A key issue of Hungarian health policy was the introduction of the “fourth hurdle” (cost-effectiveness) into the decision-making process.3 In a first step towards achieving this, methodology standards were published by the Ministry of Health, which regulates the guidelines for conducting economic evaluation.4,5 During the development of health services research in Hungary, we carefully studied many aspects of the Australian experience, published in the international literature or presented at scientific meetings, including: coverage policy, drug pricing and reimbursement, health technology assessment, price/volume agreements, diagnosis-related groups, evidence-based guidelines, the National Health and Medical Research Council, the Pharmaceutical Benefits Advisory Committee and the Pharmaceutical Benefits Scheme, and performance measurement. Several of these (coverage policy, drug pricing and reimbursement, and diagnosis-related groups) had a significant effect on Hungarian health policy decision making. We found the main advantages of the Australian system, compared with other countries, to be the strong scientific and professional background (evidence-based medicine) and the transparency of decision making. Although we did not make any formal ranking of countries, the Australian experiences were evaluated as worthwhile for local application, together with those of the Netherlands, Sweden and the United Kingdom. Notwithstanding the considerable distance between Australia and Hungary, we look forward to reading about further developments in health services research and the Australian EPOC satellite, and hope that we can also benefit from your experience with the appropriate implementation of research findings throughout health policy decision making and into everyday medical practice.

Imre Boncz · Andor Sebestyén

To the Editor: Shewan and Coats1 are right to draw attention to the shortcomings of the Research Assessment Exercise (RAE) in the United Kingdom in relation to the formulation of the Research Quality Framework in Australia. The impact of the RAE on clinical academic medicine in the UK has been disastrous, and it will take years to recover. Driven by the imperatives of the RAE, gross distortions of the role of medical schools have occurred. Many major departments, particularly in the surgical disciplines, have been closed, irrespective of the service and teaching implications. Over the past 6 years, some 20% of clinical lecturer posts have been abolished.2 These are training-grade posts that inevitably make only a limited contribution to the RAE returns. However, these posts provide the seed corn for future academic staffing in clinical medicine. In academic pathology, 40% of all academic posts have been lost and there are now only 12 remaining lecturer posts in England and Wales. All these changes have occurred in the midst of a substantial increase in medical student numbers, when academic staff numbers should have been increased. Those responsible for funding tertiary education in the UK have consistently failed to understand that the role of clinical academic staff is to integrate the practice of medicine with research and teaching. This means that at least a third of their working hours will be taken up with clinical practice; therein lies the strength of clinical academic medicine. The RAE has effectively engendered a split in the roles of clinical academics and, by so doing, has seriously jeopardised the future existence of clinical academic medicine.3 The damage that this exercise in academic self-interest has caused has now been recognised at the highest political level, with a recommendation that the RAE be discontinued as from 2008.

E Malcolm Symonds

To the Editor: Now that Calver and colleagues have unequivocally established that “High costs appear to be needs-driven”,1 can we dispense with the Orwellian language used in this article? “High-cost users” can now become “high-needs patients”. The language in the article subtly reflects a view that is often adopted by senior non-clinical health service administrators, who are themselves usually in robust good health. This view is that people with high levels of health service need are merely rapacious consumers of rare health dollars, of which the administrators are guardians. For those of us providing services in primary (mostly ambulatory) care, life is complicated enough choosing between “patient”, “person with”, “client”, “consumer” or “punter”. Can we please avoid adding “user” to the already overcrowded lexicon of nominals used for patients? I am sure if we changed the terminology then those “high-cost users” would feel a bit more valued when they read this article.

Chris Holmwood

To the Editor: Boerhaave’s syndrome is a rare condition in which increased intra-oesophageal pressure associated with forceful vomiting leads to spontaneous oesophageal rupture. Although the condition mostly affects middle-aged men,1 we present here a case arising as a complication of appendicitis in a child. A 10-year-old boy presented with a 4-day history of abdominal pain, diarrhoea and bloodstained vomiting. He was febrile and tachycardic, with a mildly distended abdomen but no peritonism. Chest and abdominal x-rays were normal. Over the next 6 hours, despite being given 4 litres of normal saline intravenously, the patient became hypotensive, oliguric and hypoxic, with increased abdominal guarding. A perforated appendix was suspected and an urgent laparotomy was planned. A preoperative chest x-ray revealed a large left-sided hydropneumothorax causing tracheal deviation. Insertion of an intercostal catheter immediately returned 600 mL of haemoserous fluid. At laparotomy, amid gross purulent contamination, a perforated appendix was removed. A subsequent computed tomography (CT) scan of the thorax showed contained mediastinal contrast extravasation with an associated air/fluid level from the lower oesophagus on the left side (Box), suggesting oesophageal rupture and establishing Boerhaave’s syndrome. Intravenous antibiotics and nasogastric and pleural drainage were instituted. A repeat CT scan of the thorax 3 days later showed no further mediastinal contrast extravasation. The child improved clinically until spiking high temperatures on the seventh day postoperatively. A chest x-ray showed a left-sided pleural effusion. Thoracoscopy revealed a loculated empyema. This was managed by a formal decortication via a left lateral thoracotomy. The patient was discharged after 2 weeks. Vomiting is a common presenting symptom in acute appendicitis. Yet there is only one previously reported case of Boerhaave’s syndrome secondary to acute appendicitis.1 Therefore, this unusual complication of acute appendicitis may be missed. Without treatment, 100% mortality is expected.2 In retrospect, it was evident that our patient showed the classical clinical symptoms of Boerhaave’s syndrome: a history of prolonged haematemesis, systemic compromise and a left-sided tension hydropneumothorax.2,3 As an initial chest x-ray may be normal, a repeat x-ray is worthwhile in any patient with prolonged vomiting. If clinical suspicion persists, a CT scan of the thorax, which is a more sensitive and specific test for detecting oesophageal rupture, is advisable.2,3 The management of Boerhaave’s syndrome involves initial resuscitation with broad-spectrum antibiotics, nasogastric intubation and pleural drainage.2-5 In recent literature, urgent operative intervention has been recommended to control communication between the oesophagus and mediastinum.2,3,5 In our case, we pursued non-operative management based on radiological evidence of a small, contained mediastinal collection and clinical improvement after pleural drainage. The present case highlights a rare complication of a common surgical condition and suggests that careful non-operative management may be successful. Computed tomography scan of thorax

Kenneth Wong · Gerard Roy

To the Editor: The arrest and imprisonment of 17 Australian-based suspected terrorists on 8 November 2005 underscores a need for Australian prison medical workers to implement strategies for either preventing or following up prison torture incidents. The definition of prison torture is problematic, not least because modern prisons evolved to sequester torture practices from public view.1 I define prison torture as custodial practices that: increase the likelihood of extreme deprivation in prison settings; facilitate traumatic stress on prisoners, resulting from beatings or excessive force used more as punishment than as restraint; result in inadequate or unaffordable health care; and/or expose prisoners to heightened risk of interpersonal violence and sexual assault. Advocates of prison torture regard it as a means of quickly extracting information, humiliating prisoners to the extent of weakening their resolve, and sending a “tough on crime” message to potential terrorists. However, as the well publicised Abu Ghraib prison incidents in Iraq demonstrate, torture practices diminish the moral clout of implicated military physicians and governments.2 Physical and psychological scars from torture commonly lead to depression, major disconnection of victims from friends and family, and occasionally suicide. Confessions obtained under torture conditions are inadmissible in modern legal systems. Moreover, graphic torture incidents may be framed by terrorist organisations as recruitment tools. The 1975 World Medical Association Declaration prohibits doctors’ involvement in torture.3 Unfortunately, active medical complicity in prison torture did not end with the Nazi era.4 While Australian doctors have so far not been directly implicated in prison torture practices,5 the inability (or unwillingness) of Australian prison doctors to recognise and promptly speak out on such incidents in the past has been unfortunate. Prison torture practices in which doctors are actively or passively involved diminish the standing of the medical profession, whose members are expected to be advocates for people at risk of torture. With a likely increase in the number of people imprisoned for terrorist activities in Australian prisons, medical workers need to be trained in the proper application of the Istanbul Protocol6 — a 1999 international guideline for the investigation and documentation of torture and its consequences — to enhance their skills in suspecting, documenting, and reporting prison torture incidents. It is also important that prison doctors are not placed in a “dual loyalty conflict” with regard to the treatment of terrorist suspects.4 Such risks may be minimised by administering prison health care through mainstream health departments, as well as by regular anti-torture training programs for frontline prison workers.

Niyi Awofeso

To the Editor: I note with interest the findings of Diamond et al.1 However, I would like to make some comments about the validity of the results presented. The authors state that an intention-to-treat analysis was used. However, this was unusual as the intention was to treat everybody, with the control group being made up of patients who were offered the intervention but refused it because of the lack of published data on the safety of the procedure. There was a marked decrease in the pain scores at 24 hours in the intervention group. The methods state that all patients were offered similar analgesia titrated to individual need. However, there was no mention of how many of the intervention group (if any), compared with the control group, received parenteral analgesia. The intervention group may have tended to receive more parenteral analgesia than the control group, but this was not mentioned. Indeed, Predey et al2 specifically mention this possibility in their review. Diamond et al state that lower pain scores persisted in the vertebroplasty-treated group at 6 weeks. However, from the results given in Box 3, it seems that there was no clinically significant difference between the intervention and control groups at 6 weeks. I would have liked the report to have included pain scores at 1 week. The decision to use means ± 1 SD instead of 95% CIs in the results is interesting. One SD will only include 66% of a normal population whereas a 95% CI would refer to the mean ± 2 SDs. More importantly, the size of the SD introduces the possibility of an enormous spread in the pain scores for both groups, which was not commented on in the Results or the Discussion. Finally, it was unclear whether the patients were treated in the private or public hospital system. Regardless of my comments above, I applaud any attempt to treat back pain in elderly people (especially that caused by osteoporotic crush fractures) in a time-expedient fashion. I look forward to the day when this therapy is first-line treatment for this disease and not something to consider 2 weeks down the track. The cost savings in reduced length of stay and the decreased morbidity associated with this treatment, as well as the reduced geriatric workload with the more rapid improvement in function, must outweigh the initial up-front costs.

James L Mallows

In reply: We thank Mallows for his constructive comments, and would like to reply as follows. 1. Intention-to-treat analysis is normally associated with randomised controlled trials (RCTs). Our study was not an RCT, as patients who refused vertebroplasty formed the comparison group.1 We used intention-to-treat analysis to indicate that all patients who were assessed as eligible for our study at the outset were enrolled and were all included in the results presented, irrespective of subsequent events (ie, whether they were completely compliant, had died or were lost to follow-up). We thought it was important to make clear that the study was prospective, that all patients entered into the study were represented in the outcomes, and that patients had not been selected on the basis of later events or results. 2. A description of the analgesic requirements of a subgroup of the patients in our study has been published.2 More than 90% of the vertebroplasty-treated cohort were either able to cease or reduce their analgesia dose by at least 50% within 24 hours after the procedure. Before the procedure, an intravenous injection of pethidine (50–100 mg) was the only parenteral analgesia given routinely and would not have affected the pain scores at 24 hours. 3. Pain scores at 6 weeks were statistically lower in the vertebroplasty-treated group compared with the control group. The clinical significance was not apparent, as measured by the changes in the Barthel indices. This indicator is only a crude assessment of patients’ wellbeing, and a more detailed questionnaire of activities of daily living may have shown a difference. Pain scores recorded at 24, 48, 72 and 96 hours after the procedure would have been more sensitive, so that the additional pain, without vertebroplasty, could have been calculated from the area under the pain curve; the more data points, the more accurate the curve. 4. We elected to report the results as means ± 1 SD instead of 95% CIs. We used SDs to be consistent with our previous publications and other reports in this field. We agree that we could have used 95% CIs. 5. Patients were referred to Sydney Imaging Group from the inpatients and outpatients departments of St George public and private hospitals. All patients were treated without any out-of-pocket patient expenses. Private hospital inpatients were billed according to standard Medicare fees and outpatients were bulk-billed, which was revenue neutral for the radiology practice.

Terrence H Diamond · Carl Bryant · Lois Browne · William A Clark

To the Editor: We now know the outcome of the parliamentary vote on mifepristone (RU-486), which restored responsibility for its use to the Therapeutic Goods Association (TGA). Politicians from both houses used their conscience votes to support the scientific scrutiny of medical abortion. van Gend will now be worried about Australian women “demanding” abortions.1 However, abortion on demand in Australia does not exist. I refer van Gend to state laws which specify under what circumstances termination of pregnancy can take place. In no state can women “demand” an abortion whenever, wherever or however they wish. Regulations exist in all states and territories and, as a family doctor, van Gend must be aware of the multiple requirements. While there remains a lack of clarity about various state laws,2 the current position in Australia is that termination of pregnancy is available under certain conditions and in particular cases. The attempt by the Minister for Health Tony Abbott to influence women’s decisions about abortion by providing Medicare-funded, church-affiliated counselling for pregnant women3 has only further entrenched the view that the Minister is not able to speak for the majority of Australians. The previous situation whereby any Minister for Health, rather than the TGA, had the power to decide on the safety and efficacy of new medications before their entry into the pharmaceutical market place was ludicrous. Despite the endorsement of science over theology in health, and potential access to medical abortion, we still have the freedom of our own conscience. No one can force medical practitioners to prescribe mifepristone and no one can force women to accept medical (or surgical) abortions. Morals in Australia are a private matter and these decisions should be left to individuals and their families. Who would decide the authenticity of the medical grounds for abortion, mentioned by van Gend — doctors or priests, or academic ethicists, or feminists? van Gend is clearly not in favour of women deciding. I agree that more attention should be paid to the reasons for women stating they do not want to continue with a pregnancy, and, yes, we could do more to assist them. But I do not agree that excluding non-medical reasons is the answer — which, as van Gend points out, are financial hardship, relationship problems, single motherhood, and a completed family. To many, these appear convincing reasons to choose abortion. While this may not sit comfortably with van Gend’s medical paradigm, the “non-medical” reasons include the mental health of the woman (see the Menhennitt ruling which stipulates that an abortion is lawful if a doctor believes that the abortion is necessary to preserve her physical or mental health).4

Suzanne Belton

In reply: Belton is correct that “safety and efficacy of medications” is a matter for the Therapeutic Goods Association. The dispute was whether such limited criteria can meaningfully assess a drug designed to take life. The government needed to consider higher criteria for RU-486 — its ethical and medical justifiability. Doctors needed to advise the government on justifiable indications for RU-486, in contrast to the corrupt practice of abortion for non-medical reasons. That advice was withheld. The Australian Medical Association advised only on the ethically neutral question of “. . . who is best qualified to scientifically assess the safety and efficacy of a drug”.1 Such marginalisation of ethical concerns is consistent with the AMA’s earlier response in the context of late-term abortion: “There is no place for third parties — governments, over-zealous politicians and lawyers, hospital committees, or even the spectre of legal action”.2 This assertion of unchallengeable medical power over an unborn life is wrong. Belton’s notion that the morality of abortion is “a private matter” is wrong; neither parents nor doctors are above the moral and legal prohibition on intentional killing. “The law in this state has not abdicated its responsibility as guardian of the silent innocence of the unborn”,3 even if medical leaders have.

David van Gend

To the Editor: The report by Brooks and Ellis on the Health Workforce Innovation Conference held in November 2005 was, in my opinion, very misleading.1 I was one of about five doctors who attended this conference; the other 200 attendees were non-medical health care workers. It was fortuitous I attended — no invitation was extended to the Australian Society of Anaesthetists. Not only was the audience nearly exclusively composed of people dedicated to the introduction of non-doctors to replace doctors, but the presentations themselves included nobody expressing a contrary view. Such an unbalanced 2-day meeting therefore failed to truly examine medical task substitution. It failed to explore whether there truly is an inadequate number of doctors in Australia and whether the introduction of non-doctors to do medical work would actually save any money at all. In fact, the presentation by Sibbald indicated that nurse practitioners in the United Kingdom are no more cost effective: although they cost half as much, they take twice as long, so the overall cost is the same. The issue of the quality of Australian health care and how that quality would be affected by the introduction of non-doctors to do the doctoring was not addressed at all. There was also no examination of the consequences on the workforce of the rather illogical proposal to greatly expand the nurses’ scope of practice into medical work when there are already too few nurses in Australia. Such a proposal would surely only worsen the nursing workforce problem. Overall, the meeting was very disappointing, as it failed to approach the topic of medical task substitution in a balanced fashion, failed to justify why the proposal should be contemplated to begin with, failed to address whether there would be any improvement in health care delivery, failed to address whether there would be any reduction in health care costs, and absolutely failed to address how the proposed medical task substitution would not lead to an inevitable reduction in the quality of health care in Australia.

Gregory J Deacon

In reply: Deacon has unfortunately missed the whole point of the Health Workforce Innovation Conference. It was about innovation — new ways of doing things. It was also about health, not medicine — a concept that some doctors might find difficult to accept, but is actually the reality. Deacon seems to suggest that we still need to debate whether there is an “inadequate number of doctors in Australia” — surely most of us have moved on from there. One of the consequences of the “rather illogical proposal to greatly expand the nurses’ scope of practice” might be to retain nurses in the workforce. This, as most of us know, is a major issue. The Health Workforce Innovation Conference was not necessarily about saving costs; it was about producing a more effective health system and trying to provide for those who cannot access services because they are not available or there are long waiting lists for procedures that could well be done by other health professionals. A number of papers presented at the conference demonstrated that care could be provided by groups such as nurse practitioners or physician assistants without any reduction in quality, and it behoves Deacon (whom I assume is a believer in evidence-based practice) to present data to the contrary if he wishes to make those assertions. Deacon commented from the floor on a number of occasions, making the assertions that we would expect from an organisation which is dedicated to maintaining the status quo. I really think the time has come to move on.

Peter M Brooks

To the Editor: I would like to clarify several issues relating to the competing interests statement for my editorial in the 16 January issue of the Journal.1 In my statement, I declared that I have used several meal replacement products in clinical settings and that I am not employed by, and do not receive benefit from, any companies producing these products. By way of further information, I have used Optifast (Novartis) and Dr MacLeod’s (Orfam) products in clinical work in the past. These were always sold at cost to patients, or patients were referred to a chemist, so there was no direct financial benefit to me. I currently use KicStart (Pharmacy Health Solutions) as part of the kit for “Professor Trim’s weight loss program for men”. I purchase these in bulk at wholesale prices from the manufacturer and include them as part of the total program (which is much more than just meal replacement).

Garry J Egger

To the Editor: Reading the excellent Christmas edition of the Journal, I was struck by the symmetry of the computed tomography scans of rectus sheath haematomas in a husband and wife, reported by James and colleagues1 (Box). I was wondering if the couple had not been involved in a minor car accident or incident of heavy braking several days earlier, where the lap–sash or buckle of a seatbelt might explain the mirror injuries?

Mark R Nelson

In reply: The rare and spontaneous nature of rectus sheath haematoma leaves its origins open to such interesting questions. Neither of our patients was able to recall a history of motor vehicle trauma, but minor braking trauma certainly remains a possibility, as does respiratory infection leading to protracted cough. Computed tomography scans of matching rectus sheath haematomas in a 62-year-old woman (A) and her husband (B).

David James

To the Editor: I found the recent letter to the Editor from Riley1 fascinating, and the comment from Teo2 depressing in the extreme. Of the many factors that drove me from anaesthetic practice and into the houseboat business 4 years ago, the selfish attitude of many surgeons towards our communal working environment was high on the list. If all parties in an operating theatre wish to be “entertained” with music while operating on their fellow man, then I suppose it might be permissible (but one wonders what many patients would say if they knew). However, it seems quite beyond the autocratic mindset of many surgeons to understand that auditory input is important to anaesthetists for monitoring the patient and for communication between the anaesthetist, surgeon and nursing staff. To impose music as background noise is unacceptable to many of us, especially as auditory discrimination decreases with age. Riley’s description of video as well as audio to distract from the primary function of surgery beggars belief. I note that Teo agrees with me here. When are surgeons going to realise that surgery is only one part of the professional work that goes on in an operating theatre?

Douglas N Gow

To the Editor: The Ear, Nose and Throat Department at the Royal Darwin Hospital services an area of about 550 000 km in the Northern Territory. As part of our remit involves dealing with conditions affecting the organs of speech and hearing, a proportion of our patients have communication handicaps. We have frequently encountered the use of “Hand Talk” among Indigenous patients with communication handicaps, and we feel this merits highlighting to your readership. Hand Talk is an established sign language within and between Aboriginal groups in the NT. Although various groups have different signing systems, there are enough similarities between them to enable inter-group communication. Its existence is thought to date as far back as other spoken Aboriginal languages that have now been lost. Theories about its conception include a means of overcoming language barriers between different language groups, a silent form of communication during hunting expeditions, a means of conversation for women during long periods of mourning when speech is prohibited, and a means of communication for deaf or aphonic individuals.1 While completely separate from established Western sign languages, Hand Talk is a sophisticated and intricate means of communication that allows complex interactions to take place and proficient individuals to integrate into their society.2 In the course of our service delivery in Darwin and to outlying districts, we have been struck by both the frequency with which Hand Talk is used in an impromptu manner and the proficiency users exhibit in communicating with it. The significance of this requires an appreciation of the difficulties of applying Western-type communication rehabilitation to Indigenous Australians in remote regions. For example, providing hearing aids, a basic and standard form of communication rehabilitation in urban areas of Australia, can face numerous obstacles in a remote setting. These include lack of a service provider and technical and maintenance support, poor compliance, and logistical problems (something as simple as running out of hearing aid batteries can be a major problem for those in remote areas). While no data are available on the ubiquity of Hand Talk, it clearly represents a valuable part of Aboriginal culture with an important practical function in a situation where Western models of communication rehabilitation are difficult to apply. While attempts to improve conventional communication rehabilitation should continue, these should be combined with efforts to foster Hand Talk through education and facilitating its dissemination by existing users so it does not suffer the fate of other lost Indigenous languages.3

Patrick Jassar · Garrett F Hunter

To the Editor: On 1 November 2005, the Australian states and territories introduced quadrivalent, pentavalent or hexavalent vaccines for childhood immunisations. This simplifies vaccination for young children, but may impair the ability of health services to provide primary immunisation for refugees over the age of 8 years. The Australian refugee and humanitarian program targets refugees from many countries that have poor primary health infrastructure. In the 2004–05 financial year intake, at least 75% of the 12 096 entrants under the offshore resettlement program came from countries that had immunisation coverage rates below 50% in the 1990s.1,2 Adolescents and adults from these countries generally have patchy vaccination histories and no records. According to Australian guidelines, they warrant full catch-up vaccination, often involving a primary vaccination course.3 Primary vaccination against tetanus, diphtheria and pertussis requires three doses of vaccine. The dose of diphtheria toxoid in vaccines for children or adults over 8 years of age is significantly lower than in early childhood preparations because of potential adverse effects. In 2004, the conjugated pertussis–adult diphtheria–tetanus vaccine for adolescents (Boostrix, GlaxoSmithKline) was introduced to the immunisation schedule to provide boosters against pertussis, diphtheria and tetanus. However, Boostrix has no proven efficacy for primary vaccination against pertussis and is not recommended for adolescents and adults who have no primary cover against pertussis.3,4 As monovalent pertussis vaccine is not available, refugees over the age of 8 years cannot be provided with a primary vaccination course against pertussis. Adult diphtheria–tetanus vaccination (ADT) is the most-used primary vaccine for refugees over the age of 8 years. After the introduction of Boostrix, many state and territory health departments reduced their supply of ADT to immunisation providers. Some refugee health services have attempted to meet demand for ADT by collating individual doctors’ stocks provided under the Emergency Drug (Doctors Bag) supplies section of the federally-funded Pharmaceutical Benefits Scheme, which provides for up to 15 doses of ADT per month. But this is a cumbersome and unsustainable strategy. Some jurisdictions, such as the Australian Capital Territory, supply ADT directly to refugee health service providers. All the new polyvalent childhood vaccines include inactivated polio vaccine. Unless states and territories procure monovalent polio vaccine, primary vaccination against polio for people over 8 years will remain inadequate. People from refugee backgrounds warrant the same level of protection against vaccine-preventable diseases as other Australians. The level of protection may be reduced by failure to provide suitable vaccines. We encourage state and territory health departments to stock sufficient vaccines for adult and adolescent refugees, including ADT and monovalent inactivated polio vaccine. We also recommend that the Australian Technical Advisory Group on Immunisation provide detailed advice on the needs of refugees when crafting immunisation guidelines.

Christine B Phillips MPH, MA, FRACGP · Mahomed Patel FRACCP, FFAPHM

To the Editor: Leprosy rates in Australia are low (less than one case per million population)1 and predominantly occur in Indigenous Australians and immigrants from leprosy-endemic areas.2 A 21-year-old pregnant Burundian woman had migrated to Australia in 2005 from a refugee camp in Tanzania. In the year before her arrival, she had received intermittent courses of steroids for an undefined illness characterised by fever, nightsweats and painful symmetrical peripheral polyarthritis. Three months after arriving in Australia, the patient presented to a rural hospital with a recurrence of the previous symptoms. The symptoms improved on recommencement of prednisolone treatment. The patient was transferred to the Royal North Shore Hospital, where examination revealed bilateral peripheral sensory neuropathy (confirmed by nerve conduction studies); bilateral, enlarged, tender ulnar nerves; and tender hyperpigmented 2–3 cm nodules on the upper arms, but no other skin lesions or infiltrations. Skin biopsy revealed features consistent with erythema nodosum leprosum (ENL), but no acid-fast bacilli (AFB) were detected. Slit-skin smears were also negative for AFB. Leprosy was confirmed by histopathological examination of a sural nerve biopsy, which showed AFB and granulomatous changes of leprosy. The patient commenced multidrug therapy for multibacillary leprosy, with prednisolone for ENL. Leprosy is a chronic granulomatous infection of skin and peripheral nerves with Mycobacterium leprae. Host immune responses determine the spectrum of clinical presentations. Leprosy is classified into either multibacillary disease (≥ 6 skin lesions and/or skin smears positive for AFB) or paucibacillary disease (< 6 skin lesions, with no bacilli on skin smears).3 Type 1 (reversal) reactions are delayed-type hypersensitivity reactions and manifest as neuritis and increased inflammation of pre-existing skin lesions. Type 2 reactions (ENL) are a systemic response to immune complex deposition and manifest with multiple tender nodules, fevers, neuritis, arthritis and iritis.4,5 ENL occurs exclusively in multibacillary disease in 10%–20% of patients, and negative slit-skin smears (as in our patient) are unusual. Possible explanations include undisclosed diagnosis and treatment of leprosy in Tanzania or the combination of steroid therapy and immune changes that occur during pregnancy.6 Multidrug therapy is well established and regarded as safe for pregnant women. Diagnosis of infections that are uncommon in Western countries, especially leprosy, is often delayed.7 For refugees living in remote areas, access to expertise and support may be limited. Therefore, doctors, especially those involved in refugee health, should be aware of “exotic” infections and their varied presentations. Furthermore, effective referral networks should be encouraged, as this resulted in a swift positive outcome in our case.

Sebastiaan J van Hal MB ChB · Bernard J Hudson FRACP, FRCPA