Letters

Henry Ekert Haematologist, Children's Cancer Centre and Department of Haematology, Royal Children's Hospital, PO Box 2096, Brighton North, Melbourne, VIC 3186; and Haematology Advisor, Australian Government Department of Health and Ageing. ekerthenryAToptushome.com.au To the Editor: The editorial on mandatory fortification of flour with folic acid by Maberly and Stanley is subtitled: “The scientific benefit is clear, but translating this into practice requires advocacy”.1 The only benefit that is scientifically clear is the reduction in the incidence of neural tube defects. All the other “benefits” listed by the authors are observational and have occurred in a setting where myriad environmental changes have occurred concurrent with folic acid fortification. To imply that the reduction in the rate of heart attacks and stroke is the result of folic acid fortification is, at best, anecdotal, because it is not supported by any randomised controlled studies, and is an extrapolation from the relationship between reduced homocysteine levels and the incidence of stroke and heart disease. The authors also did not mention the increased incidence of multiple pregnancies that has been observed with folate supplementation (relative risk, 1.02; 95% CI, 0.97–1.07).2 While this represents only a slight increase in the risks associated with the birth process, it should not be ignored when considering perceived risks. It is also possible that in a planned pregnancy where the mother is prescribed folic acid before conception, the additional folate intake from fortified flour may further increase the risk of multiple pregnancy. It seems to me that the editorial was in fact an item of advocacy rather than a dispassionate scientific assessment of the arguments for and against mandatory folic acid fortification. At the very least, if mandatory folic acid fortification is implemented, prospective mothers will have to be made aware of the increased risk of multiple pregnancy and the as yet unknown risk of combining the fortified diet with medically prescribed folic acid.

Henry Ekert

Fiona J Stanley,* Glen F Maberly† * Director, Telethon Institute for Child Health Research, PO Box 855, West Perth, WA 6872. † Professor of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA. fionaATichr.uwa.edu.au In reply: Ekert suggests that in our article advocating for mandatory fortification with folate to reduce neural tube defects,1 we omitted to mention the “increased risk of multiple pregnancies”. He then misquotes the Lumley meta-analysis “(relative risk, 1.02; 95% CI, 0.97–1.07)” — the real relative risk was 1.40 (95% CI, 0.93–2.11). This Cochrane systematic review shows that folate supplementation does not carry a statistically significant risk for multiple births, but confirms the dramatic reduction in neural tube defects.2 Another study, which did suggest an increased risk, did not control for the known increased risk of multiple births following infertility treatments, which could explain the increase observed.3 Ekert suggests that we inform women about this unsubstantiated risk and “the as yet unknown risk” which mandatory fortification might add to “medically prescribed folic acid”. Folic acid is found in leafy green vegetables and in many fruits, nuts and other components of a healthy diet. Tablets are available over the counter. What advice would he give to women about these “risks”? Our evidence is that we are not reaching many women in our society by education and voluntary fortification, and that countries that have fortified their flour have achieved much better reductions in these major defects than we have in Australia. Hence our advocacy. We acknowledge that the evidence for stroke and heart disease reduction is not as solid as that for neural tube defects. However, there is an increasing literature on the protective effects of folate on cardiovascular risk and possible mechanisms.4-8 Hence, with consideration of the proven benefits and the unsubstantiated risks, we will continue to advocate for the mandatory fortification of flour with folate.

Fiona J Stanley · Glen F Maberly

Paul D Fitzgerald General Practitioner, Suite 303, 83 Mount Street, North Sydney, NSW 2060. docfitzATihug.com.au To the Editor: It is heartening to see a positive professional response to clinical quality systems in the wake of Bundaberg. However, these are secondary responses, and overlook the primary, preventive solution. Clinical monitoring systems presuppose that some damage is done before a problem becomes apparent. Hospitals already have mechanisms to examine clinical competence, and their appointments credentialing and privileging procedures. The Queensland Health Systems Review Final Report (the Forster report)1 comments repeatedly on the apparent failure of these procedures in the Patel case at Bundaberg Hospital: It appears that the process of checking credentials did not involve the College of Surgeons and no written clinical privileges appeared to have been granted on appointment. (p 169) The report draws specific attention to special purpose registration for areas of need, pointing out the inherent conflict of interest: As an employer under pressure to fill medical vacancies, Queensland Health faces a conflict of interesting making . . . determinations of area of need to allow special purpose registration of overseas trained doctors. (p 175) It adds that these doctors are not subject to the same requirements as locally trained doctors, and recommends: No overseas trained doctor should commence employment in a senior position intended to be filled by a specialist before . . . [assessment via the established Australian Medical Council / Specialist College pathway]. (p 174) Furthermore, deemed specialists should participate in the usual clinical performance management processes applicable to all doctors. (p 175) And, finally: . . . local clinical leaders and managers have a conflict between credentialing someone about whom they are uncertain and having no one to deliver the service. It appears that these issues may have been relevant at Bundaberg. (p 176) More recently, the Queensland Public Hospitals Commission of Inquiry report (the Davies report)2 confirms a practice of appointing overseas trained doctors as senior medical officers in specialist roles in hospitals in designated areas of need. Such appointments in Bundaberg, Hervey Bay, Townsville and Charters Towers not only bypassed procedures for recognition as a “deemed specialist”, but were also not considered by hospital credentialing and privileging committees. The Davies report states that, in some hospitals, these committees did not exist. It may be premature for the proponents of clinical quality systems to dance on the ashes of Bundaberg. These recent reports outline a chain of existing systems problems including the Medical Board, the Department of Health, successive Health Ministers and Cabinets, and appointments, credentialing, privileging and complaints procedures in a sample of Queensland public hospitals. According to the Davies report (section 6.173), around half of the doctors in Queensland public hospitals were appointed under area-of-need arrangements by 2002. How are other states balancing the politically sensitive area of need registration with long-standing appointments, credentialing and privileging procedures?

Paul D Fitzgerald

David van Gend Queensland Secretary, World Federation of Doctors who Respect Human Life, Mackenzie House Medical Centre, 116 Russell Street, Toowoomba, QLD 4350. vangendATmachousemedical.com.au To the Editor: As politicians prepare to debate the Therapeutic Goods Amendment (Repeal of Ministerial responsibility for approval of RU486) Bill 2005,1 one question is central: why should mifepristone require special approval from the Minister of Health and Ageing, when all other drugs are simply assessed by the Therapeutic Goods Administration (TGA)? The answer is that abortifacients such as mifepristone are unique in that they are the only drugs designed to end a human life, and therefore their use demands a unique level of ethical assessment and accountability, beyond the scope of the TGA. The TGA has the vital but limited role “to ensure the quality, safety and efficacy of medicines”. These criteria are adequate for assessing most medications, but inadequate for a drug designed to extinguish life. The TGA in its approval process does not consider ethical criteria.2 However, without broader ethical considerations, such as what medical conditions might justify the use of mifepristone, or the moral status of the life to be extinguished, no meaningful assessment of an abortifacient can be made. Abortion “on demand” (ie, without medical justification) is readily available in Australia, even where, as Judge Fred McGuire stated in a Queensland case: “There is no legal justification for abortion on demand”.3 Evidence for the predominantly non-medical justification for abortion was documented in a 1995 survey of women seeking termination of pregnancy in New South Wales.4 The most frequently listed contributing factor, given by 60% of the 2249 respondents, was “financial concerns”. Younger women were more likely to cite youth, career, single parenthood and changes to lifestyle, while women aged over 30 were more likely to cite completed family and problems in their relationship with their partner. Because abortion law is under state jurisdiction, the federal government has no stated position on abortion “on demand”. Now that it is being asked to authorise a drug for abortion, the government has the opportunity and responsibility to defend basic standards of law and ethics by limiting mifepristone use to medically essential terminations of pregnancy, excluding abortion for non-medical reasons. The government should establish, in consultation with medical authorities, valid medical indications for mifepristone, including certain cancers, hormonal diseases, and medically essential termination of pregnancy, and approve the drug for those uses. The criteria could be specified using the existing authority prescription mechanism. This would exclude abortions for which there is no medical indication; for this category, the compelling task for government and the profession is to address the underlying social stresses for which abortion is seen as a solution, reconstructing social supports for women distressed by unplanned pregnancy. Certainly, setting ethical parameters for the use of mifepristone will not affect the availability “on demand” of surgical abortion, which operates without effective ethical or legal restraint. Yet, even largely symbolic acts can be important. If it is right ethically and medically to set limits on the use of abortifacients such as mifepristone, these limits should be set. The medical profession should use the debate on mifepristone to reaffirm ethical limits on abortion, upholding our duty of care to both mother and unborn baby. Disappointingly, in the debate so far, leaders of organised medicine have limited discussion of mifepristone to sterile technical matters of safety and efficacy, as if ethical concerns have no bearing on public policy or medical practice.5 Much expert advice would be needed concerning authentic medical grounds for the use of mifepristone, and even then the authority prescription system could still be abused. But at least the attempt will have been made to establish valid medical indications for this gravest of medical acts, and the profession will be seen to distance itself from abortion “on demand”.

David van Gend

Philip L P Morris Psychiatrist, 16 Riverbank Court, Ashmore, QLD 4214. pmorrisATiprimus.com.au To the Editor: In their letter on “GP Psych Opinion”, Wong and Tiller highlighted the poor uptake by general practitioners of a psychiatric consultation service based in a private psychiatric hospital in Melbourne.1 They compared the results of their service to the similar poor uptake by GPs of the public hospital-based psychiatric consultation service in Brisbane.2 One explanation for this disappointing result may be that most psychiatric illness is chronic, and continuity of care and advice from a consistently available psychiatric colleague is of great importance to GPs — over and above having the patient assessed. This does not seem to have been a strong characteristic of the Melbourne service, given that the assessing psychiatrist was a psychiatric trainee registrar, who is usually either rotating between clinical placements as part of training, or waiting to move on to a more senior position. GPs’ referral practices to specialists are based on a multitude of influences, of which availability is only one. Personal contact, quality of service and continuity of assistance are highly relevant. Perhaps if the Melbourne and Brisbane consultation services can push on and attend to these issues, then utilisation by GPs will increase over time — as this is what happens in more conventional private practice referrals.

Philip L P Morris

Dorothy L Robinson Senior Statistician, Armidale Air Quality Group, Building W46, University of New England, Armidale, NSW 2351. drobinsoATmendel.une.edu.au To the Editor: There should be no contradiction in recommending that people enjoy recreational exercise when air pollution is low but nonetheless walk/cycle for transport.1 I cycle home after 5 pm, when pollution increases to health-hazardous levels (Box), but it is astounding to see people out jogging in such unhealthy air. Cycling for transport is undoubtedly better than driving. Despite dangers from pollution and busy roads, commuter-cyclists have 40% lower mortality than drivers.2 Nonetheless, cycling in diesel fumes at concentrations typically present on busy roads causes significant damage to blood vessels,3 and should be avoided if there is a choice. This concept is no harder to understand than the concept that moderate intake of mono- and polyunsaturated fats is beneficial but excessive saturated fat intake is bad. Regrettably, this distinction was once considered so complicated that people were told simply to reduce all fat consumption. Until people understand the hazards of air pollution, controls will remain inadequate. In Sydney, Melbourne, Brisbane and Perth, air pollution causes an estimated 1611 premature deaths every year, with more than 3000 estimated for Australia as a whole. The most serious health problems relate to fine particles (PM2.5), emitted predominantly by diesel-powered vehicles and woodheaters.4 Winter measurements in Liverpool, Sydney, follow a similar temporal distribution to those in Armidale, in regional New South Wales (Box), suggesting that both regional and metropolitan residents should jog at lunchtime in winter, rather than after work. A recent review estimated that health costs of PM2.5 emissions in urban Australia range from $100 to $300 per kilogram of particles. A typical woodheater (emitting 20 kg of these particles every winter) therefore generates $2000–$6000 in health costs — considerably more than switching to non-polluting heating.4 Older (pre-1990) diesel cars and utilities emit about 0.75 g PM2.5 particles per kilometre (13.8 kg per 20 000 km), generating estimated annual health costs of $1380–$4140. This exceeds the cost of converting to liquid petroleum gas or retrofitting a particle trap/oxidation catalyst. When PM2.5 pollution was reduced in Dublin by banning non-smokeless coal in 1990, there were 2154 fewer deaths in the first 6 years of the ban than the previous 6 years (15.5% fewer respiratory and 10.3% fewer cardiovascular deaths/year).1 Euro II emission limits for new diesel-powered vehicles became mandatory in 1996/97 in Europe (and in 2002/03 in Australia). Simple, cost-effective measures for reducing the major sources of urban PM2.5 pollution — including converting or retrofitting diesel-powered vehicles that exceed Euro II limits, phasing out woodheaters and strongly discouraging stubble-burning in areas where it increases smoke pollution in rural towns1 — would significantly reduce pollution-related illness. It would also allow cyclists, pedestrians and joggers to exercise whenever desired, with fewer worries about air quality. Hourly concentrations of fine particle pollution (PM2.5 measured by nephelometer scattering coefficient) in Armidale (regional NSW) and Liverpool (Sydney) on the first occasion (11 June 1997) that Sydney residents were asked to reduce pollution by not using woodheaters. (Data sources: Sydney, NSW EPA; East Armidale, Armidale Air Quality Group, with assistance from CSIRO Department of Atmospheric Resources.)

Dorothy L Robinson

Katina Kardamanidis,* Bruce Armstrong† * Research Fellow, Injury Prevention and Trauma Care, The George Institute for International Health, PO Box M201, Camperdown, NSW 2050; † Head, School of Public Health, University of Sydney, NSW. kkardATdoh.health.nsw.gov.au To the Editor: Not all asylum seekers in Australia are confined to detention centres. Those who arrive with a valid visa live in the community. If they apply for refugee status within 45 days of arrival, they are entitled to work and to Medicare while their refugee claims are processed;1 if they apply too late, they are denied these benefits. In New South Wales in 2003 about 1500 men, women and children were in this situation, which may last from 3 months to 3 years. Asylum seekers who appeal a refusal of their application, or are released from mandatory detention with an application outstanding, are in the same situation.2 Some are eligible for the federally funded Red Cross Asylum Seeker Assistance Scheme, but, for most, access to health care is jeopardised because they are unable to pay full fees for medical services.3,4 We asked health professionals working with asylum seekers about the costs of asylum seekers’ difficulties in accessing health care. Their responses, with illustrative quotes, are divided into “tangible costs” and “intangible costs” (Box). Some individuals and institutions sympathetic to the plight of asylum seekers give their professional time or donate money to pay for health care, but are not able to address the full range of health care needs. Obtaining access to secondary care, particularly admission to hospital, is very difficult. There is no uniform approach to charges, either between hospitals or within any one hospital on different occasions. The approach seems to depend on the decision-maker present. Such difficulties in accessing care may lead to uncomplicated health problems developing into chronic and more serious ones. The attempt to save costs is likely to lead to higher costs in the future. The effect on asylum seekers is increased physical, psychological and social disadvantage and diminished opportunities for a healthy life. Health professionals are faced with the dilemma of turning these people away, or aiding them without financial compensation. In either case, they cannot provide the necessary standard of care. Although many Australians are conscious of the hardship of these people, the society as a whole seems unaware of it or of the impact that its unfairness may have on the social fabric of their communities. If all Medicare-ineligible asylum seekers in NSW were to have the same access to health services as other Australians, we estimate that the total annual cost would be about $3.4 million.5 This is about 0.015% of the total annual recurrent health expenditure in NSW in 2000–01.6 This economic cost, some if not most of which will be spent regardless, does not justify the disadvantage created by the Australian Government’s immigration rules. We suggest that state governments consider giving this small group of asylum seekers free access to public hospital services. Costs of asylum seekers’ difficulties accessing health care and who bears the costs: responses of health professionals working with asylum seekers Theme Illustrative quote Tangible costs Insufficient voluntary aid to address all health needs “We have one patient . . . with a urinary infection, and it was decided that . . . he needed a TURP [transurethral resection of the prostate], and then they realised he didn’t have any funds and they discharged him . . .” Inconsistent attitudes of hospitals “There’s quite a difference between different hospitals. For example, the X hospital at Y is very tough. . . . much tougher than the hospital here, on refugees. . . . They are different Area Health Services . . . it may not even be the Area Health Service directors, but the hospital manager’s idea that these people should pay.” More costs in the long term “I have a lot of patients with diabetes and high blood pressure . . . Now if their diabetes or their blood pressure or their cholesterol is not managed properly, then they get heart disease or strokes. So, I have a patient who has had a stroke . . . high blood pressure and so on . . . if he had [had] better access to health care, would he have had the stroke? . . . So [now], the government has had to pay . . . it doesn’t make any sense really.” Intangible costs To the asylum seeker (recounted by a health professional) “If you say to someone, I really think you need to have this test, but, if I refer you, you have to pay a lot of money, so I’m not going to refer you, how does that make you feel? It makes you feel worried and powerless.” To health professionals “. . . if someone came in complaining about it [diarrhoea, losing weight], you would do a whole lot of checks, and with that particular lady . . . we were able to negotiate to get a couple of tests done free, and the family and she paid a certain amount of money to get some others [done] . . . if the person had Medicare, you’d take it that step further and do extra just to be 101% sure. So, there is that real ethical dilemma . . .” To the Australian society “. . . if people actually knew on a face-to-face level . . . what it meant to deny a newborn baby the right to health care, [or] . . . turn away someone who is extremely depressed . . . [Would they] actually be able to say ‘No, they don’t [have a right to health care]’.”

Katina Kardamanidis · Bruce Armstrong

To the Editor: British authors Wilson and Parker in their editorial on hospital in the home1 acknowledge the outdated Cochrane review of 20012 in relation to costs of hospital in the home. More recent research in New South Wales provides compelling evidence of cost saving in excess of 50% when community costs are compared with inpatient costs for certain diagnosis related groups.3,4 Patient selection for these services is based on safety, functional ability, carer support, and consent. The treatment regimens are based on evidence and governed by strict quality assurance. These elements form the foundations of successful acute and post-acute care programs. Amendments to the National Health Act 1953 (Cwlth) in 2001 endorsed the provision of acute care in places other than hospital beds.5 The Macarthur Health Service in south-western Sydney received Commonwealth acute outreach accreditation in 2004 and currently supplies at least 13% of total bed-days in the specialties of medicine, surgery and paediatrics. An added benefit is a system that allows people to choose a private outreach service instead of a hospital bed and have expenses covered by their health fund, which pays a bed-day rate for this care in the community. Patient quality of care, choice and satisfaction have been the drivers for hospital in the home. Demonstrated savings for ambulatory sensitive diagnoses and the opportunity for revenue from private patients should be appealing to hospital administrators in an environment of chronic bed shortages. Editor’s note: The Cochrane review was updated after Wilson and Parker submitted their editorial: Shepperd S, Iliffe S. Hospital at home versus in-patient hospital care. Cochrane Database Syst Rev 2005; (3): CD000356. Available at: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000356/frame.html (accessed Dec 2005).

Stephen F Wilson · Nicholas Collins

Allen C Cheng,* Andrew J Hughes,* Julian B Stella,† Eugene Athan* * Infectious Diseases Physician, Hospital in the Home Programme, Department of Infectious Diseases, † Emergency Department Physician, Geelong Hospital, Geelong, VIC 3220. allencATmenzies.edu.au To the Editor: We note with interest the studies published in the Journal by Richards et al and Ong et al.1,2 The authors conclude that treating pneumonia and pulmonary emboli in an ambulatory setting is safe for selected patients. However, this represents a large change in the conditions traditionally treated on this basis, from conditions that are associated with a very low mortality (such as cellulitis) to a subgroup of patients with potentially serious infections that are identified as being of low risk. We feel that safety is of prime importance in hospital-in-the-home programs because of limited or delayed access to acute medical care, and that both studies were underpowered to define this endpoint. Both studies incorrectly quote previous work that suggests that the groups they have identified have mortality rates of up to 5% (for pulmonary emboli) and up to 9.2% (for mild to moderate pneumonia). Published data suggest that the mortality of mild pneumonia (with CURB-65 scores ≤ 2) is in the range 1.7%–3%,3,4 and that mortality from treated sub-massive pulmonary emboli is in the range 1.0%–1.3% within the first week.5 These rates, although seemingly small, are still much higher than that associated with the treatment of soft tissue infections on ambulatory care programs. Recurrent pulmonary embolus, in particular, may be sudden and unexpected. Although admission to hospital may not necessarily prevent these deaths, the additional trauma of a death at home, particularly soon after transfer to ambulatory care, may carry a higher significance in the minds of patients, their families and the public than a death in hospital. We acknowledge that benefits for patients in ambulatory treatment programs need to be balanced against potential adverse outcomes. However, if these conditions are to be treated where access to medical attention may be delayed, it is imperative that informed consent be obtained from patients (including an awareness of the possibility of death), a mechanism be available for patients to summon urgent attention at any time, and patients and health care providers be aware that readmission to the hospital may be necessary in the event of clinical deterioration.

Allen C Cheng · Andrew J Hughes · Julian B Stella · Eugene Athan

Dee A Mangin (née Richards),* Les J Toop,† Michael J Epton,‡ Graham R B McGeoch,§ G Ian Town,¶ Simon M H Wynn-Thomas,** Robin D Dawson,†† Michael C Hlavac,‡‡ Anja M Werno,§§ Paul D Abernethy¶¶ * Senior Lecturer, † Head, †† Research Fellow, Department of Public Health and General Practice, ‡ Senior Lecturer, ¶ Dean, ‡‡ Research Fellow, Department of Medicine, Christchurch School of Medicine and Health Services, Otago University, PO Box 4345, Christchurch, New Zealand; § Director, Community Care, ** Medical Director, Extended Care @ Home, ¶¶ Manager, Health Services, Pegasus Health Independent Practitioners Association, Christchurch, NZ; §§ Community Patholgist, Canterbury Health Laboratories, Christchurch, NZ. derelie.manginATchmeds.ac.nz In reply: Thank you for the opportunity to reply to the letter from Cheng et al. The mortality figures we cited are correct.1 The cited article by Lim et al supports our statement that “Patients with a CURB-65 score of 0–2 have a low mortality (0.7%–9.2%)” (Table 4 shows mortality for CURB-65 score 0 is 0.7% and for score 2 is 9.2%).2 The 3% figure in the abstract is a summary measure obscuring the difference across the CURB 0–2 range — important information for anyone considering community management of community-acquired pneumonia where, we agree, safety is paramount. The rate of 1.7% cited by Cheng et al is for a modified CURB-65 score, which adds a further point, and thus is for the equivalent of CURB-65 scores of < 1.3 Cheng et al correctly observe our study was not powered to detect mortality differences. As explained in our discussion, mortality was not a primary outcome measure. With low mortality, large numbers are required to detect a statistically significant difference — the base rate of 3% in the validation study would require 10 602 patients in a randomised controlled trial to detect a 33% relative (1% absolute) increase in mortality. The study did provide for informed consent (including the possibility of readmission) and the ability to summon urgent attention. Careful patient selection, routine twice-daily nurse and daily doctor visits, along with a highly trained nurse available by telephone 24 hours a day who can dispatch a doctor or nurse immediately, provides a structure that should match hospital care. Careful patient monitoring will detect failure to respond as expected. It is important to treat in hospital those who will benefit, but not feasible to admit all with potential mortality risk (nor is there evidence of benefit). Hospitalisation also has risks. With this tool for predicting accurately who will suffer worse outcomes, it could be argued there has to be good evidence that better outcomes will result from continuing inpatient treatment of mild to moderate community-acquired pneumonia. These wider issues are worthy of debate. There is an assumption by some professionals and consumers that hospital-sanctioned death is more acceptable, that everything possible has been done, and that community-based death implies unsatisfactory management. As a counterpoint to this, there is a clear patient preference for treatment in the home where possible. Avian influenza may, of course, drastically redefine our expectations about locus of care and of death.

Les J Toop · Michael J Epton · Graham R B McGeoch · G Ian Town · Simon M H Wynn-Thomas · Robin D Dawson · Michael C Hlavac · Anja M Werno · Paul D Abernethy

Bin Soo Ong,* Margaret A Karr,† Daniel K Y Chan,‡ Anthony Frankel,§ Qing Shen¶ * Director, Department of Ambulatory Care, † Research Manager, ‡ Director, ¶ Research Assistant, Department of Aged Care and Rehabilitation, § Respiratory Physician, Bankstown-Lidcombe Hospital, Locked Mail Bag 1600, Bankstown, NSW 2200. bin.ongATswahs.nsw.gov.au In reply: We acknowledge the concerns of Cheng and colleagues regarding the safety of patients with pulmonary embolism (PE) treated in an ambulatory care setting. Caution is important as this is a relatively new area of treatment in ambulatory care compared with the management of deep venous thrombosis. The main objective of our study was to describe our experience in the management of PE in ambulatory care; it was not a randomised controlled study to conclusively define safety as such. As stated in our paper, there have been reports of the management of PE in the ambulatory care setting.1,2 We now know that more than 90% of patients with sub-massive PE will have a good response to treatment. The challenge is to accurately define this group. The mortality rate we quoted of less than 5% was derived from a review article on prognosis of patients with PE.3 This article quoted three studies on sub-massive PE, one of which was referenced by Cheng and colleagues in their letter.4 We note also that the specific study that was referenced4 included patients with cyanosis and shock; these patients would have been excluded by our selection criteria. We do not advocate management of all patients with sub-massive PE in the ambulatory care setting. It is also important to be conservative initially in the selection of these patients. There have been various studies examining prognostic indicators for PE, which we have referenced in our paper. There is evidence now that, for patients with specific prognostic indicators, the risk of death and adverse outcomes is significant and such patients should always be admitted. The practice of managing patients with sub-massive PE should only occur in ambulatory care units which are appropriately resourced, have strict admission criteria and well defined protocols and specialist medical input, consistent with the recommendation of the British Thoracic Society.5 In the meantime, further studies are required before this becomes standard practice in ambulatory care or hospital-in-the-home units.

Bin Soo Ong · Margaret A Karr · Daniel K Y Chan · Anthony Frankel · Qing Shen

Stephen F Wilson,* Peter McGeorge† * Program Director, Population Health, Sacred Heart Rehabilitation Centre, † Director of Mental Health Service, St Vincent's Hospital, Darlinghurst, NSW 2010. stwilsonATstvincents.com.au To the Editor: Corbett’s recent proposal to create a “Ministry for the Public’s Health” has merit. However, this Ministry may not achieve its intended purpose in relation to disadvantaged people, chronic and complex health care, or the mental health problems confronting acute services in today’s urban communities. The current situation may be the result of long neglect of population health. However, a new Ministry runs the risk of becoming yet another compartment within an existing non-integrated health care system. The efficiencies of an integrated service for acute health care of older people are well known.2 This integration requires a reinvestment in community care and changes in roles and relationships of health workers. There is currently a gap between services maintained by state funding for acute care in and around hospitals, and services which are federally funded for the community sector via general practice, preventive and maintenance services. The gap created between these two workforces results in suboptimal “management” of chronic and complex disease and mental health, and care of disadvantaged groups. The lack of a strong focus on management drives patients to rely on the acute health care system, particularly emergency departments. This situation is aggravated by the poor coordination with general practice, non-government organisations and community services. The current challenge is to develop a health environment which simultaneously addresses the present and future needs for prevention, management and response. Another approach is to construct a health “sandwich”, with a foundation layer of population health, a “filling” of illness management services, and a top layer of acute response and hospital services. A model guided by the mission of St Vincent’s Hospital, and implemented in 2005, has created a partnership for emergency department, community health, aged care, rehabilitation and palliative care within an administrative division called Population Health. A Psychiatric Emergency Care Centre within the emergency department has established a shared approach to acute patient care along with the mental health services. In the future, a patient entering the emergency department for an acute response to physical, mental or combined illness should also be “consuming” a health program of management and disease prevention, which is lacking in current health service provision. This healthy sandwich may prove easier to digest than the dry biscuits of policy.

Stephen F Wilson · Peter McGeorge

Frank H Beard,* Jeremy M McAnulty,† John W Tapsall,‡ Angelo M Zaia§ * Senior Medical Officer, Communicable Diseases Unit, Queensland Health, 147-163 Charlotte Street, Brisbane, QLD 4001; † Director, Communicable Diseases Branch, NSW Health, Sydney, NSW; ‡ Senior Specialist in Microbiology, SEALS, Prince of Wales Hospital, Sydney, NSW; § Molecular Biologist, University of Melbourne, VIC. Frank_BeardAThealth.qld.gov.au To the Editor: We report two cases of serogroup B meningococcal disease, caused by genotypically indistinguishable organisms, where transmission is likely to have occurred on a school bus. To our knowledge, transmission of meningococcal disease on a bus has been reported only once before.1 In June 2005, two cases of serogroup B meningococcal disease in teenagers from the same school were reported to the Northern Sydney Public Health Unit. Patient 1 had symptoms of fever, headache, vomiting, and an erythematous rash. Two days after onset of this patient’s symptoms, Patient 2 also developed fever, headache and vomiting. In both cases, diagnosis of meningococcal disease was confirmed by polymerase chain reaction (PCR) testing of cerebrospinal fluid (CSF). CSF cell counts were consistent with bacterial meningitis, but blood and CSF culture were negative, despite lack of prior antibiotic administration. The patients were in different school years. No obvious links, such as common classes, sporting teams, or mutual friends, could be found. However, they reported travelling on the same buses to and from school each day. These buses carry up to 78 students (53 seated and 25 standing) from the patients’ school and other nearby schools. The patients reported that the buses were usually crowded. Chemoprophylaxis was provided 8–9 days after symptom onset in Patient 2 to 132 students who claimed to have travelled on these buses during the exposure period. The two patients recovered fully and returned to school. No subsequent cases of meningococcal disease have occurred at the school. In the absence of meningococcal isolates, porA/porB genotyping2,3 was conducted on the meningococcal DNA contained in the CSF samples, and yielded identical sequences. While genotyping is not routinely conducted, porA/porB sequence nomenclature can be equated with serotype/subserotype (phenotypic expression of porA/porB). All 38 serogroup B isolates to date in NSW in 2005 have had serotyping/subserotyping performed, with no other cases having a serotype/subserotype equivalent to that of the two cases reported here. This supports the school bus as the most likely setting of transmission, given the lack of mutual friends and activities identified between the two cases. Asymptomatic nasopharyngeal carriage of meningococci is common, with about 10% of individuals being carriers at any one time.4 While crowding and close contact increase transmission of meningococci, factors leading to invasive disease are poorly understood.5 Antibiotic chemoprophylaxis is given to close contacts to eradicate nasopharyngeal carriage and limit disease spread.5 However, the absence of further cases among the 132 fellow travellers in this setting does not provide evidence of effectiveness of the chemoprophylaxis, given that the secondary attack rate, even in close household contacts, has been estimated at 2–4 per 1000 people.6 Current Australian guidelines recommend that, in school-based outbreaks, chemoprophylaxis be considered for a wider group than solely close contacts of a household nature.7 This report provides evidence to support chemoprophylaxis in similar circumstances, where linked cases are identified in school bus co-travellers, and no other, more specific natural grouping makes epidemiological sense.

Frank H Beard · Jeremy M McAnulty · John W Tapsall · Angelo M Zaia

David B Preen,* Belinda E S Bailey,† Alan Wright‡ * Research Associate, School of Population Health, University of Western Australia, 35 Stirling Highway, Crawley, WA 6009; † State Manager, Royal Australian College of General Practitioners — Western Australian Faculty, Perth, WA; ‡ Hospital Liaison General Practitioner, Department of General Medicine, Fremantle Hospital and Health Services, Perth, WA. davidpATsph.uwa.edu.au To the Editor: The care of patients at the time of hospital discharge and on returning home is often neglected, and has implications for those needing multidisciplinary care. Research has shown that discharge planning can produce better health outcomes, facilitate the patient’s and the general practitioner’s involvement with discharge care, and improve communication between hospital and general practice services.1-3 To encourage GPs to be involved in discharge care planning for patients with chronic diseases, there are Enhanced Primary Care (EPC)-specific Medicare Benefits Schedule (MBS) Items for contributing as a team member to EPC discharge care planning (Item 728), and for review at 3 months post-discharge (Item 724).4 However, the fact that < 1% of claims for EPC care plans are for discharge-related items has been attributed to barriers to GPs’ involvement in discharge planning, or their unwillingness or inability to initiate such a process rather than simply participate.5 Further, little evidence exists that, given the opportunity, GPs are willing to be involved as a team member in this process. In a recent study of ours investigating EPC discharge care planning for chronically ill patients,3 we required GPs to comprehensively review and comment (in writing) on discharge plans developed by the hospital. GPs also performed a follow-up consultation within 7 days of discharge and completed a questionnaire. We found that 90.1% of 91 GPs in the intervention arm of the study willingly contributed to discharge care planning for their patients, indicating that, when offered input into planning discharge and post-discharge care, GPs are willing to fulfil such a role. Further, this finding, in addition to the high questionnaire response rate of trial GPs (80.6%), indicates the importance of this issue to GPs and the belief that GPs are not sufficiently included in discharge processes. Additional results from a follow-up survey, at 28 days post-discharge, of those GPs who participated in discharge planning (n = 91, 70.3% response) showed that only 42% of GPs claimed the MBS Item 728 ($39.80 in 2002, at the time of the study). Results from a subsequent survey (n = 91, 45.1% response) suggested that even fewer (about 15% of respondents) claimed reimbursement for a 3-month care plan review (Item 724, $98.20), although we do not have data on the number of 3-month reviews performed. The reasons given for not claiming these Items included poor understanding of the Item and claiming procedures, and a belief that excessive administration was required to claim the increasing number of MBS items. In the light of sanctions for administrative claiming errors, this may explain the low claim counts for these Items. However, the most common response was that input into the discharge care plan was, in their opinion, not sufficient to justify reimbursement, even with the extra time required for care plan review and post-discharge follow-up. This suggests that GPs do not simply view EPC discharge care planning as a revenue raising exercise, but rather as quality patient care. Further, it may indicate an undervaluation by some GPs of their role in hospital-driven processes. Considering the evidence in support of discharge care planning for improving quality of care, focus should be directed towards ways of encouraging this process, other than simply providing a financial incentive.

David B Preen · Belinda E S Bailey · Alan Wright

Alan R Clough,* Bart J Currie,† Maymuna W Yunupingu,‡ Katherine M Conigrave§ * Postdoctoral Fellow, Institute of Advanced Studies, Menzies School of Health Research, Charles Darwin University, PO Box 1479, Nhulunbuy, NT 0881; † Professor, and Head, Tropical and Emerging Infectious Diseases Division, Menzies School of Health Research, Charles Darwin University, and Northern Territory Clinical School, Flinders University, Royal Darwin Hospital, Darwin, NT; ‡ Senior Aboriginal Health Worker, NT Department of Health and Community Services, Yirrkala, NT; § Specialist in Drug Health Services, Royal Prince Alfred Hospital and University of Sydney, Sydney, NSW. Alan. CloughATbigpond.com To the Editor: We are concerned that the Northern Territory’s regulations on kava have not succeeded in controlling its availability in Arnhem Land (the north-eastern region of the NT). Under the Kava Management Act 1998 (NT), one wholesaler is licensed to supply kava (Piper methysticum Forst. f.) to four licensed retailers in Arnhem Land Aboriginal communities.1 “Kava Management Plans” in “Kava Licence Areas” permit retailers to supply 600–800 g per week of kava powder to each purchaser1 — more than double the known harmful consumption levels (240–440 g per week).2 Legal kava supplied will reach 26 tonnes in 2005 (worth $3.6 million), with a persistent illegal trade adding 8 tonnes, worth perhaps $2 million (Box). Two proposed additional retail licences1 will increase kava’s availability. Kava’s social and economic effects remain an ongoing concern. The region’s community-controlled health service attributes to kava abuse an accelerated decline in participation in traditional ceremonies and mortuary rites in some localities. Kava is the psychoactive substance with greatest impact on the financial resources of communities and individuals in Arnhem Land.2 Kava’s health effects include seizures and extreme weight loss in heavy users (up to 20% of body mass), similar to that seen in anorexia nervosa.4 Extreme weight loss, evident during the 1980s, has re-emerged in the region’s kava users (M W Yunupingu, unpublished observations). Raised total and low-density lipoprotein (LDL) cholesterol levels4 add to unresolved concerns that heavy kava use may be a risk factor for cardiovascular disease and sudden cardiac deaths. Potential immunosuppressive effects are suggested by relative lymphocytopenia in heavy kava users4 and by increased risk of melioidosis.5 Raised levels of liver enzymes (alkaline phosphatase and γ-glutamyltransferase), which reverse after ceasing moderate kava use, should be monitored because of fatal hepatotoxicity documented in users of manufactured kava products available as natural therapies.6 Given the scarcity of substance misuse treatment services in the region, with no effective treatments for kava misuse, controlling supply is the only practical measure to reduce kava-related harms. Tighter controls on kava supply are urgently required while licensees implement promised demand-reduction and harm-minimisation strategies.1 We recommend that: no further retail licences be granted until kava supply is reduced; retail licensees supply no more than 440 g per week to individual kava consumers; quantities permitted to be imported by the wholesaler and supplied to retailers be limited; kava selling prices be reviewed in the light of trade-offs between higher prices to reduce demand and minimal financial drains on communities; rigorous enforcement be continued to eliminate illegal kava dealing; and the Kava Management Act be reviewed to facilitate these changes. History of kava use and retail value ($ million) on the legal and black markets in Arnhem Land, Northern Territory, since 1982, extrapolated to the end of 2005* * Data on kava supplied were obtained from d'Abbs (for 1982–1993);3 were estimated from population surveys of kava use (for 1994–1997); were estimated from kava seized by Police and Licensing Inspectors (for illegal use, 1998–2005) (seizures were estimated to account for 14% of the illegal kava supplied, based on correlation with population surveys in 1999 and 2000); and were based on the licensed wholesaler’s monthly figures, extrapolated to the end of 2005 (for legal use from May 2002). Retail value was calculated from data on kava supplied and regulated values of $100 per kg (1990–1993), $140 per kg (2002–2004) and $150 per kg (2005), or a black market value of $250 per kg.2 † Approval required from Minister for communities to supply kava. pa = per annum.

Alan R Clough · Bart J Currie · Maymuna W Yunupingu · Katherine M Conigrave

John W Orchard Visiting Fellow, South Sydney Sports Medicine, University of New South Wales, 111 Anzac Parade, Kensington, NSW 2033. johnorchardATmsn.com.au To the Editor: I congratulate Harris et al1 on conducting a survey that identified aspects of specialty training that are difficult for female doctors and doctors with partners and/or children. However, there are some omissions in their article, which, although small, illustrate further ways in which “specialty” training is unfriendly to the aforementioned groups. The authors purported to survey all medical graduates registered in 2002 “with a clinical college training program”. It appears that registrars on the Australasian College of Sports Physicians (ACSP) training program were not included. This training program has been in place since 1992, has been recognised by the Health Insurance Commission since 1999, and is most definitely a “clinical college training program”. Although similar in structure, there are two major differences between the sports physician training program and most other “specialty” training programs; namely, that the training is almost entirely non-hospital based and that the resulting qualification (the FACSP) is not recognised as a “specialty” in Australia. In 2002, I believe that the Australasian College of Sexual Health Physicians was in a similar position to the ACSP, administering a “non-specialty” clinical college training program (which is now under the auspices of the Royal Australasian College of Physicians). The recognised specialties in Australia, with the major exception of general practice, almost all conduct most of their training in hospitals. Not only are these hospital-based positions relatively “female-unfriendly” and “parent-unfriendly”, they don’t adequately train specialists for the majority of doctor–patient interactions, which do not actually take place in hospitals. They also contribute to the reality that our “health” system is focused on treatment of disease rather than prevention.2 Areas such as women’s and men’s health, travel medicine and dietary medicine also exist within our health system.3 Ideally, if we want a health system that is better at actually promoting health, these areas should also have formally recognised training programs. The conservatism of both the Australian Government and the medical profession is reflected in the process for recognising new specialties, which has severely discouraged community-based specialties from being developed. The “choice” of specialty training that Harris et al examined in their study was limited by what was officially sanctioned in 2002. If it were accepted that there should be more recognised specialty postgraduate training positions in community-based fields of medicine, then not only would our medical system start to address its deficiencies in health promotion, but there would be far more attractive training opportunities for doctors who don’t wish to pursue full-time hospital-based positions.

John W Orchard

Ami Schattner,* Noa Ben-Baruch† * Associate Professor of Medicine, † Head, Breast Cancer Unit, Hebrew University Hadassah Medical School, Kaplan Medical Centre, Bilu Junction, Rehovot, 76100, Israel. amiMDATclalit.org.il To the Editor: We describe a patient with malignant ascites and bacterial peritonitis, with no apparent intra-abdominal source of infection. A 56-year-old woman with advanced breast cancer was admitted to hospital with a 10-day history of diffuse abdominal pain, umbilical tenderness, and increasing abdominal girth. Breast cancer had been diagnosed 13 years before admission (T2 N0 M0) and treated with radical mastectomy and adjuvant chemotherapy. Five years before admission, disease had recurred at the chest wall, and 2 years before, liver metastases were found. Chemotherapy had failed, and her only current treatment comprised capecitabine and analgesics. On admission, the patient had tachycardia (110 beats per min), tachypnoea (26 breaths per min), blood pressure of 115/80 mmHg, and no fever or signs of sepsis. Examination showed evidence of local recurrence around the left mastectomy scar, and marked ascites with discoloration, warmth, tenderness and a diffuse infiltration over the umbilicus. There were no signs of peritoneal irritation, nor leg oedema. Blood test results were in the normal range, except for mild leukocytosis (10.6 × 109 cells/L; reference range [RR], 3.8–9.8 × 109 cells/L), with left shift (86% neutrophils, and 6% lymphocytes; RR, up to 67% neutrophils, and at least 32% lymphocytes). X-ray did not show abdominal free air. Abdominal computed tomography revealed ascites, retroperitoneal lymph nodes, omental and umbilical infiltration, and the known liver metastases without signs of portal hypertension. Peritoneal tap removed 2800 mL of fluid. Examination of the fluid revealed a white blood cell count of 2 × 109 cells/L (80% neutrophils), glucose concentration of 790 g/L, and albumin concentration of 22 g/L (serum–ascites albumin gradient, 0.7; a gradient < 1.1 indicates that the patient does not have portal hypertension). Gram stain of the ascitic fluid revealed gram-positive cocci, and culture identified Staphylococcus aureus. Cytological examination showed sheets of atypical enlarged epithelial cells highly suggestive of malignancy. Therapy was begun with parenteral cloxacillin and ciprofloxacin, but the patient died shortly after. This patient’s condition is unlikely to have been spontaneous (“primary”) bacterial peritonitis, which usually occurs in patients with liver cirrhosis, portal hypertension and ascites with high serum–ascites albumin gradient,1 and occasionally in patients with malignant ascites.2 However, in our patient, infection may have originated from the umbilical metastasis. The umbilicus has a direct connection with the intra-abdominal cavity and is also connected to a number of intra-abdominal organs via embryological remnants, such as the umbilical vein and the urachus. Both routes may be involved in the spread of malignant tumour to the umbilicus,3 but spread may also be in the opposite direction, causing peritonitis. This diagnosis may be missed by physicians who may not notice anything new in a patient with longstanding malignant ascites, and may fail to consider bacterial peritonitis, a treatable condition.

Ami Schattner · Noa Ben-Baruch

John C Bridgman,* William F Heddle† * Cardiology Registrar, † Cardiologist, Flinders Medical Centre, Flinders Drive, Bedford Park, SA 5042. cameronbridgmanAThotmail.com To the Editor: A 50-year-old morbidly obese woman (weight, 183 kg; body mass index, 70 kg/m2) presented after 1 month of worsening dyspnoea. Risk factors for cardiovascular disease included hypertension, smoking and previous heavy alcohol consumption. She had left ventricular failure (thought to be due to diastolic dysfunction) and atrial fibrillation with rapid ventricular response. There was no evidence of infection or pulmonary embolism. A transthoracic echocardiogram showed normal systolic function, although the images were poor. Measurement of arterial blood gases showed a compensated respiratory acidosis (Paco2, 58 mmHg; Pao2, 76 mmHg; pH, 7.39; bicarbonate, 34 mmol/L; base excess, 8 mmol/L). Administration of intravenous digoxin, frusemide and heparin led to some symptomatic improvement. Cardiac monitoring showed atrial fibrillation, with ventricular rates of 120–170 beats/minute despite the digoxin treatment. Overnight, 70 pauses in heartbeat of up to 7 seconds were recorded (Box). The constellation of the nocturnal rhythm disturbance, hypercapnia and obesity suggested sleep disordered breathing as a unifying diagnosis. Further questioning revealed symptoms indicative of obstructive sleep apnoea. Polysomnography, performed that night, showed a respiratory disturbance index (number of apnoeic or hypopnoeic episodes per hour) of 130 (normal value, < 15). The longest apnoeic episode was recorded at 34 seconds. The average minimum oxygen saturation was 84% during non-REM (rapid eye movement) sleep and 64% during REM sleep. The lowest saturations reached during non-REM and REM sleep were 64% and 61%, respectively. These results suggested severe obstructive sleep apnoea.1 The following night, her condition improved with application via mask of continuous positive airway pressure (CPAP) at a level of 12 cm H2O using room air. Cardiac monitoring continued to show atrial fibrillation with high ventricular rates, but no pauses in heartbeat occurred. This allowed treatment with atenolol and digoxin to control the ventricular rate. At 6-week review, the patient was complying with home CPAP therapy and felt well. An electrocardiogram confirmed spontaneous reversion to sinus rhythm at 70 beats/minute. There is increasing evidence to suggest a link between obstructive sleep apnoea and atrial fibrillation.2 Obstructive sleep apnoea is also a risk factor for hypertension, coronary artery disease and heart failure, all of which are known to precipitate atrial fibrillation.3,4 Transient heartblock has been found in 10% of patients with obstructive sleep apnoea. Pauses of up to 2 seconds are a predictable physiological response to inspiratory airflow obstruction and hypoxia. These pauses are exacerbated by negative chronotropes. Studies have shown that bradycardia can be effectively abolished with mask CPAP therapy.5 The dramatic response to CPAP therapy in this patient suggests that sleep apnoea caused the significant nocturnal ventricular pauses and had a role in the aetiology of the atrial fibrillation. Overnight cardiac monitor trace, showing atrial fibrillation and a 7-second pause

John C Bridgman · William F Heddle

John D Paull Anaesthestist, Launceston General Hospital, PO Box 200, Exeter, TAS 7275. jdpaullATintas.net.au To the Editor: A black day for the MJA, I thought, on seeing the title of the article by Crotty, “More students and less patients: the squeeze on medical teaching resources”.1 I hesitate, but only briefly, to wave the Fowler brothers’ classic work at you. The revised 3rd edition, by the brothers’ proxy, R W Burchfield, notes that “Regrettable, but prevalent among some standard as well as many non-standard speakers, is the use of less with an unprotected plural noun”.2 He goes on to give examples, among which your article title could well appear, and concludes, “The incorrect use is very widespread and seems likely to be ineradicable, however regrettable that may be”. The author of the Editorial is not discussing an amorphous pile of patients. He is writing about a countable number of people, of which, regrettably, fewer are willing to participate in the education of those they expect to look after them in later life.

John D Paull

Helen Randall Senior Assistant Editor The Medical Journal of Australia In reply: We plead guilty, but knowingly so. When this article was being proofread, there was much discussion about this “regrettable” use of less, but in this instance a catchy title was preferred to following Burchfield’s prescription.1 We take comfort from The Cambridge Australian English style guide, which notes that “using fewer rather than less is . . . a stylistic matter rather than one of correct grammar”.2

Helen Randall

Richard B Hays,* Ian Wronski,† Jan Veitch,‡ Tamara McCloskey§ * Foundation Dean, † Pro-Vice-Chancellor, ‡ Lecturer in Medical Education, § Project Officer, Faculty of Medicine, Health and Molecular Sciences, James Cook University, Townsville, QLD 4811. richard.haysATjcu.edu.au To the Editor: The School of Medicine at James Cook University (JCU) was established in 1999, based on a case that the workforce needs of northern Australia needed to be addressed.1 The model was based in part on other regional medical schools in the United States, Canada and Europe, which had demonstrated that local student recruitment and training could produce graduates who prefer to work in either local or similar regional and rural areas.2 The 6-year undergraduate curriculum at JCU has achieved considerable success in recruiting students from rural backgrounds3 and in developing and delivering a rural curriculum.4 The first cohort of students graduated at the end of 2005, and the intended locations of their internship are now known. JCU students were treated like graduates of other schools by the intern allocation systems within each state. Of 58 graduating students, 51 (88%) have chosen to remain within Queensland, with 29 (50%) in the three North Queensland intern training hospitals, occupying a majority of available intern places in the region. Twelve (21%) will work in other regional hospitals in Queensland and 10 (17%) in a hospital in Brisbane. Seven will work interstate. Furthermore, most of the 37 students of North Queensland origin are staying in North Queensland or adjacent regional centres (only two are leaving Queensland); and about half of the Brisbane-origin and interstate-origin students are staying in Queensland. Hence, while some local students have chosen to move away, some from other states have chosen to stay close to where they moved to study. Forty-two students (72%) responded to a brief survey exploring their decisions. The most popular reasons for choosing the location of their internship were proximity to family and friends, and trying somewhere different from where they had received their training. All but five respondents indicated that they were “likely” or “very likely” to work somewhere in North Queensland in the future, depending on the availability of postgraduate training opportunities. This outcome suggests that the intended workforce mission of the school may be achievable through a combination of selection and curriculum strategies. A longitudinal cohort study is in progress to address longer-term graduate career choice outcomes.

Richard B Hays · Ian Wronski · Jan Veitch · Tamara McCloskey

Robert G Batey Professor of Medicine, Faculty of Health, University of Newcastle, Locked Bag 119, Wallsend, NSW 2287. Robert. BateyAThnehealth.nsw.gov.au To the Editor: The article by Sanson-Fisher and Lynagh on problem-based learning (PBL)1 is very timely, raising important questions about the popularity and efficacy of this method. My “traditional” education included lectures involving 600 students, as well as small-group sessions on the wards and in tutorial rooms. The sessions focused on real patients. Problem-based sessions often deal with videos, at best, and, at worst, paper case histories and laboratory data. I believe the differences between PBL and the standard “curriculum” have been overstated. The quality of the teacher is a critical factor that is understated by proponents of PBL. An excellent teacher can captivate large groups with highly relevant and exciting deliveries, and there is nothing to suggest that such teaching is less effective, stimulating or encouraging than PBL-based teaching. The authors challenge the proponents of PBL to provide evidence that their methodology works. It is also time for those who teach PBL curricula to ask whether this approach is cost-effective. With the knowledge base of medical science increasing exponentially, it is hard to understand how students, without some guidance, can be expected to take on board the complexities of some of the problems that they are faced with. Taking a humane approach and communicating well with patients are commendable goals, but not if they are pursued to the point where patients fail to receive a correct diagnosis and appropriate treatment. Good teaching is provided by good teachers rather than by a particular teaching approach. The PBL system is just as fallible as any other system. I applaud the authors for raising this matter and for asking the questions they asked. I look forward to seeing answers provided in the months to years ahead.

Robert G Batey

Graham D Tracy Emeritus Professor of Surgery, University of New South Wales, PO Box 720, Port Macquarie, NSW 2444. gtracyATbigpond.net.au To the Editor: The two excellent articles in the MJA on an issue important for medical education provided too few strategies for improvement.1,2 First, there is a need for a fundamental attitude change concerning the role of student “doctors”. As long as they are viewed as inexperienced novices, intruding on hapless “guinea pigs”, barriers will always be found to reduce access. Patients should be informed that interview and examination by a student doctor adds much to the discussion of their problem, with real clinical advantage for their care program. Student doctors are usually grateful for the privilege, and should be encouraged to be part of the team, and assured of the value of discussion with nurses, residents and other team members. No additional funding should be needed for such activity. Secondly, as surgical patients are admitted on the day of operation, students should attend the preadmission clinics to help with fuller evaluation. Most teachers would welcome student doctors in their rooms, but this requires planning. It works best when there is a separate examining room for students and patients seeking the added benefit of re-examination. Thirdly, although it is difficult to conduct symptom analysis for someone without symptoms, much value can be obtained from rehearsing specific interrogation and physical examination of all systems in normal people; for example, family and friends. It is not surprising that a few students in exams cannot feel pulses, when they have never tried to feel their own! Fourthly, with modest financial compensation, an army of people with abnormal signs, not in need of treatment, could be recruited for clinical teaching. This task could be assigned to a teaching coordinator, with skills in social interaction, and would need the cooperation of clinical staff.

Graham D Tracy

To the Editor: Goldney and Fisher recently reported data on medication use in an Australian community sample and estimated the financial savings that could be made if the number of prescribed medications was reduced.1 However, the assumption that the average number of medications per patient could be reduced ignores the large body of evidence that has accumulated over recent years demonstrating under-use of beneficial medicines. Under-prescribing has been identified in the management of a broad range of chronic conditions, including heart failure, ischaemic heart disease, hypertension, atrial fibrillation, asthma, osteoporosis, pain, and depression.2,3 It has been suggested that under-use of beneficial therapies may be an even bigger problem than over-prescribing, especially in older patients.4,5 As Goldney and Fisher did not collect any clinical information about their study subjects, no conclusions can be drawn about whether medications were more frequently over-prescribed or under-prescribed. Focusing solely on reducing the number of medications prescribed may be misguided and may result in poorer health outcomes. A broader view of prescribing is required, recognising that problems result from both over- and under-prescribing, as well as inappropriate dose selection and monitoring.5

Rohan A Elliott

Robert D Goldney,* Laura J Fisher† * Professor of Psychiatry, † Research Officer, The Adelaide Clinic, Suite 13, 33 Park Terrace, Gilberton, SA 5081. robert.goldneyATadelaide.edu.au In reply: We agree that, because of our research methodology, we could not necessarily assume that any medication prescription was inappropriate, and we noted that on two occasions. However, our economic analysis addressed only those people using six or more prescribed medications (mean, 7.8), and we reported multiple use of same-class medications, and, at times, use of two different preparations of the same medication. Therefore, we believe our estimate of potential cost savings to be conservative. Nevertheless, we accept that our hypothesis needs more formal testing using clinical data.

Robert D Goldney · Laura J Fisher