Letters

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

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