From the MJA

This Special Issue of the Medical Journal of Australia is in partnership with the Lowitja Institute, Australia's only national Aboriginal Community Controlled Research Institute. This inaugural partnership publication has been timed to coincide with NAIDOC week — with the theme “Keep the fire burning! Blak, loud and proud” — and recognises and celebrates Aboriginal and Torres Strait Islander leadership and excellence in health and medical research. This article is a collaboration between the MJA Editorial Team and the Guest Editors, where we jointly reflect on the thinking and processes behind this Special Issue. Scholarly publishing sits at the core of issues of power, privilege, and the production of knowledge in health and medicine. As Australia's national medical journal, the MJA plays important roles not only in knowledge dissemination, but also in defining, legitimising and validating what types of knowledge matter in health and medical research, practice and policy making. To date, the Journal predominantly operated from a biomedical perspective that has embedded colonial practices, norms and assumptions that produce and sustain inequalities in health and unjust outcomes for Indigenous Australians. This inaugural collaboration between the Lowitja Institute and the MJA stems from the recognition that currently “Indigenous health research in Australia is largely informed by non‐Indigenous world views, led by non‐Indigenous people, and undertaken in non‐Indigenous organisations” (https://doi.org/10.5694/mja2.51757). In embarking on this Special Issue, then, the Journal accepted that the current model of publishing practices has not served Indigenous research and researchers well, and that in fact the Journal has, to some extent, become perceived as unwelcoming. In response to a letter to the editor, submitted by Lowitja CEO and a collective of Aboriginal and Torres Strait Islander researchers (https://doi.org/10.5694/mja2.51281), the MJA began discussions with the Lowitja Institute. This engagement affirmed that a meaningful approach to improve the ethical publishing practices at MJA required that the Journal relinquish control and hand over decision making for this issue to Aboriginal and Torres Strait Islander experts. The Lowitja Institute engaged a panel of Guest Editors who are recognised leaders in the fields of public health and clinical medicine. Guest editors were recently recognised in national awards both by the Lowitja Institute (https://www.lowitjaconference.org.au/awards) and the NAIDOC committee for their leadership and contribution to Aboriginal and Torres Strait Islander health. Guest Editors, along with Lowitja Institute executives, took on the collective care and responsibility of defining the scope and aims of the Special Issue, assessing and selecting its content, determining its editorial requirements, and nominating peer reviewers, with the support of the MJA editorial team. The editorial practices to develop this Special Issue draw on Aboriginal and Torres Strait Islander ways of knowing, being and doing. In this issue, the Guest Editors have held the sovereignty of our voices and experiences all the way, until you have opened and read this today. All care has been taken with the journey of researchers submitting articles to this issue, with collective caretaking of their knowledges. A call for papers was made in October 2023, with content eligible for consideration if it addressed an area of health and wellbeing that is a priority to Aboriginal and Torres Strait Islander communities, was led by Aboriginal and Torres Strait Islander authors (first or last authors), included an ethical research statement that addressed the Consolidated criteria for strengthening reporting of health research involving Indigenous peoples (CONSIDER) statement (https://doi.org/10.1186/s12874‐019‐0815‐8), and described the positionality of the author team. Authors were also given the opportunity in their articles to acknowledge the Indigenous knowledges that informed their work and to include their Language Groups in the authorship line. These practices uphold what Indigenous people have called for in ethical publishing practices (https://doi.org/10.5694/mja2.51281 and https://doi.org/10.1136/tc‐2022‐057702). Guest Editors were not involved in editorial decision making about submissions that they authored. The large number of high quality submissions received in response to the call for papers highlights the extraordinary breadth and depth of Aboriginal and Torres Strait Islander‐led research incorporating our knowledges on all areas of our health and wellbeing. It also demonstrates the importance of relationships and relationship building in this space, including the roles of the Guest Editor team and others in disseminating the call for papers and encouraging submissions to a journal that many authors might not have considered a natural home for their work. The resulting Special Issue contains 12 articles that span a wide range of study designs and topics. The manuscripts have been ordered (while confining to a standard layout) as a narrative, privileging Aboriginal and Torres Strait Islander strengths and providing courageous conversations on system failures that impact the health and wellbeing of Indigenous peoples. The research within covers the life course and pays homage to the late patron Dr Lowitja O'Donoghue AC CBE DSG, who dedicated her life to fighting for human rights of Aboriginal and Torres Strait Islander peoples and worked across many of the fields of health covered in this Special Issue. Owing to time and space constraints, some articles submitted for consideration of the themed issue will be published by the MJA later in the year in a regular issue of the Journal. The first article, a perspective article by Carmen Parter and colleagues (https://doi.org/10.5694/mja2.52352), frames the Special Issue with a discussion of racism and the cultural determinants of health, and ends with a call for “all within the health care sector to take a purposeful journey of learning by walking alongside Aboriginal and Torres Strait Islander people and listening to their knowledges of cultural ways of being, knowing and doing, with open minds and hearts”. An Editorial by Jaquelyne Hughes and colleagues (https://doi.org/10.5694/mja2.52351) asserts sovereignty with the announcement of the Zenadh Health Science Research and Education Council to drive long overdue improvements for the Zenadh peoples. The Council brings together Zenadh experts in diverse knowledges, intellect and skills while drawing from the best of Eurocentric science epistemology. And a research article (https://doi.org/10.5694/mja2.52353) draws our attention to our older Aboriginal and Torres Strait Islander population. With Aboriginal and Torres Strait Islander governance, Odette Pearson and colleagues, provide quantitative evidence to support the multitude of stories told about the failure of the aged care system to care for our elders. They leave us with a determination that we must do better for all our elders, ensuring we do not leave anyone behind. This Special Issue was a deliberate attempt by the MJA to cede editorial decision‐making responsibility to a group of external expert Aboriginal and Torres Strait Islander Guest Editors. For the MJA team, this was a new experience and served as a lesson that ceding power is a prerequisite if progress is to be made in Indigenous health, and is a process that should feel uncomfortable and unfamiliar. For the MJA it was also a specific response to the outcome of the Voice referendum in 2024 (https://doi.org/10.5694/mja2.52074) — a recognition that meaningful change will only come when those in power are prepared to step aside and let Aboriginal and Torres Strait Islander peoples lead their own affairs while supporting where required. Editors are accustomed to being in the position of power, defining a journal's (and for a journal like the MJA, national) priorities, including concepts of research quality and likely impact. At the same time, being open to different perspectives on editorial priorities and practices and being willing to change is fundamental for the sustainability of any journal and its ability to effectively serve the communities that it represents — and wishes to represent. Working with the Guest Editor team to help enact their vision for the theme issue was a hugely rewarding experience for the MJA editors and a reminder that the Western norms the Journal has operated within can be far from the best way of working. The MJA team are deeply grateful for the generosity that the Guest Editors demonstrated in offering their time and expertise to producing this Special Issue. Many of the innovations introduced here will be taken forward by the MJA as we update our author requirements, including encouraging use of positionality statements when submitting work to the Journal. We extend a heartful thanks to all the authors and reviewers who contributed to producing this Special Issue, and look forward to feedback from readers. We hope this is the first of many future collaborations.

on behalf of the MJA Editorial Team

Earlier this year, Australia for the first time hosted the Regional Meeting of the World Health Summit. Among the key themes on the packed three‐day agenda were the geopolitical environment for global health, improving health in an increasingly divided world, the impacts of misinformation and technology on the health of populations, health equity, and pandemic preparedness. Speaking at the meeting, Helen Clark distilled the major challenges facing global health today as the “three Cs” — conflict, climate, and COVID‐19. Indeed, over four years on from the World Health Organization declaring COVID‐19 a global pandemic, although the world has moved on from the acute phase of the response, it is clear that the so‐called long tail of COVID‐19 continues to affect health directly and through its effects on our social and political systems. Three articles in this issue of the MJA remind us that Australia is not immune from these ongoing impacts. The act of care, on individual and communal levels, has the power to foster a sense of shared humanity. Many health and medical practitioners, experts and advocates thus envisage the health system as an important driver of social cohesion. But during the COVID‐19 pandemic, health arguably became something that divided us instead of something that brought us together. Jessica Kaufman and colleagues (https://doi.org/10.5694/mja2.52304) explore how this dynamic has played out in terms of parental misconceptions about routine childhood vaccinations. Surveys of a nationally representative sample of Australian parents of children done in 2017 and 2023 showed that after the onset of the pandemic, there were increases in the proportion of respondents who believed children receive too many vaccines (17% v 25%), that vaccine ingredients cause harm (15% v 19%), and that vaccines cause autism (9% v 14%). Such misconceptions might help explain the documented increases in vaccine hesitancy and decreases in childhood vaccination coverage that occurred during the pandemic, and point to the need for health institutions to re‐establish trust with the communities that they serve. A major way that COVID‐19 transformed Australia's health system was by prompting the widespread adoption of telehealth services. In a perspective article, Sagda Osman and colleagues (https://doi.org/10.5694/mja2.52294) argue that whereas the many benefits of telehealth have been widely explored — including improved health care access, reduced costs, increased clinician learning opportunities, and gains in productivity, satisfaction and convenience — less recognised are the unintended negative consequences of this transformation, especially in rural and remote areas of Australia. In particular, the authors highlight how “dependency on telehealth can mask the need to invest long term to improve rural health, such as direct investment in infrastructure and the rural health workforce. By relying on metropolitan centres to provide care to rural Australians, telehealth essentially redirects rural resources to these centres, reducing future rural health care funding”. If telehealth is to help reduce geographic‐based health inequities, they contend, “studies relying on complexity science and systems thinking” are needed. Finally, despite a markedly decreased sense of political urgency about COVID‐19 in recent years, the disease continues to cause substantial morbidity and mortality among Australians. Using data from the Australian Cardiovascular COVID‐19 Registry (AUS‐COVID), Hari Sritharan and colleagues (https://doi.org/10.5694/mja2.52307) investigated the cardiovascular outcomes among 1714 people admitted to hospital with COVID‐19. Among the participants, 11% died, 17% required intensive care, pre‐existing cardiomyopathy or heart failure was exacerbated in 19%, and around 1–3% developed new atrial fibrillation or flutter, had pulmonary embolisms, or experienced new heart failure or cardiomyopathy. Having received at least one dose of a COVID‐19 vaccine was associated with lower risk of in‐hospital mortality (adjusted odds ratio [aOR], 0.38; 95% CI, 0.18–0.79) and intubation (aOR, 0.30; 95% CI, 0.15–0.61). Notably, of the study participants with known vaccination status, around 40% had not received a COVID‐19 vaccine dose. Given the well documented protective effects of vaccination against severe disease, hospitalisation and death from COVID‐19, the study findings point to the ongoing need to support uptake of COVID‐19 vaccination in the Australian community.

Elizabeth Zuccala

Recently, my partner and I have been trying to relate some of the disciplining that we do as a family with our almost 3‐year‐old child back to respect: for boundaries, for feelings and for our elders. The two of us have also been reflecting on what respect means to us currently within our profession between various specialties. In this issue of the MJA focusing on general practice, Suetani and colleagues (https://doi.org/10.5694/mja2.52281) make a compelling case for a drastic change in the way mental health care is organised in Australia which requires a respectful collaboration between specialties. They write that increased funding will not necessarily improve mental health care provision, nor will it be particularly efficient without a greater inclusion of the biopsychosocial model in the way mental health is managed. Most general practitioners are currently shouldering the cost of complex mental health care, especially in socially and economically disadvantaged groups without adequate support or funding. Care is often fragmented and lacks a more holistic approach. They argue that a comprehensive approach with adequate inclusion of non‐mental health care workers to help manage some of the socio‐economic inequities that underscore mental health conditions and improve cohesion between the providers of mental health care is likely to yield better value. Primary care is an integral part of health care provision in Australia. Despite recent fragmentation of care with an increasing scope for pharmacists to prescribe antibiotics for urinary tract infections and the advent of urgent care centres, GPs continue to be important in the diagnosis and management of acute conditions in undifferentiated patients as well as screening for and managing a comprehensive list of chronic conditions. In their perspective article, Venning and colleagues (https://doi.org/10.5694/mja2.52287) acknowledge the difficult work that GPs do in trying to diagnose cancer in an undifferentiated patient. In highlighting the Australian Cancer Plan, unveiled in November 2023, which emphasised a strategic commitment to “maximising cancer prevention and early detection,” they acknowledge that currently “no cancer risk assessment tools are in mainstream use in Australian general practice”. They discuss various prediction tools in use and being trialled in Australia as an exciting addition to assist GPs in their day‐to‐day workflow. In a research article, Cameron and colleagues (https://doi.org/10.5694/mja2.52288) examine dysmenorrhea in adolescents, an oft encountered issue in primary care. Using data collected from 1600 adolescents in the Longitudinal Study of Australian Children (LSAC), they have shown an incredibly high prevalence of dysmenorrhea in young Australian adolescents that directly correlates to missed days of school and sports or extracurricular activities. An accompanying editorial by Grover and colleagues (https://doi.org/10.5694/mja2.52290) highlights the need for primary care physicians to recognise and ask about pelvic pain in young female adolescents while also discussing some management strategies. The most important take‐home message seems to be that too many health professionals normalise dysmenorrhea without considering its impact on daily activities. It has become rare as an editor of the MJA who also works as a GP to see research that focuses on the good that GPs do. Most research manuscripts conclude that primary care physicians need better training in or need better funding to perform an intervention. In this issue, a research letter by Albarqouni and colleagues (https://doi.org/10.5694/mja2.52285) illustrates the positive effect of GP intervention. They examined data collected by the 2020–21 National Health Survey and specifically looked at questions around consumption of alcohol, smoking and dietary habits. The team found that although a small proportion of respondents received advice regarding unhealthy levels of drinking alcohol, smoking and poor intake of fruits and vegetables, the proportion who changed their behaviours over time were more likely to have received advice from a GP regarding their habits compared with those who did not. It was heartening to see the power that general practice potentially has in changing behaviours that have a direct impact on the development of chronic disease. As a GP, respect that GPs get from the government feels lacking. The waning respect and renumeration across the profession are reflected in a significant decrease in training numbers of medical graduates choosing primary care as a career. In their research article, Sturman and colleagues (https://doi.org/10.5694/mja2.52291) perform a qualitative analysis with various stakeholders at different levels of general practice training to provide insight into this complex problem. They provide four recommendations: increasing medical student and junior doctor placements in general practice, increasing exposure to inspiring GP clinicians and educators, improving trainee pay and entitlements, and improving integration care and interprofessional relationships between hospitals and general practice clinics. Although intuitively these suggestions should go far to address the burnout and exhaustion evident in the primary care workforce, it feels like none of this would work unless primary care in Australia receives the respect it deserves from governing bodies. The participants in this study, most of them GPs, express their ongoing passion for the profession despite the challenges involved. One quote that was particularly poignant was of a participant talking about “saving the profession we love”. Current workforce projections already talk about a shortfall of GPs with regards to our rapidly ageing population. The problem is that without adequate funding, that comes from respecting the role GPs play in managing chronic disease, most of the solutions for primary care provision seem to focus on fragmenting care to other professionals rather than the resource we have at hand: a group of dedicated, incredibly well educated, and professional doctors that see anyone and everyone walking through their clinic doors.

Aajuli Shukla

This issue of the MJA includes several articles that raise what it looks like to meaningfully involve consumers in health care discussions. The first is a research article (https://doi.org/10.5694/mja2.52283) that brings together two fascinating and topical issues in health care: artificial intelligence (AI) in health care and the involvement of the community in health care, in this case via a citizens’ jury. In their article, Carter and colleagues describe the process and the outcome of citizen jury recommendations after being asked to consider this question “Under which circumstances, if any, should [AI] be used in Australian health systems to detect or diagnose disease?” As the authors note, “The aim of deliberative democratic methods, developed in political science and government, is to enhance democracy by involving communities in developing the laws or policies that affect them”. The approach, however, is not without challenge — notably the inevitability of selection bias to the jury despite the best efforts of the researchers in recruiting jurors. The jury was larger than court juries, with 28 jurors participating in the process and final deliberations. Their deliberations produced a set of recommendations that included processes of evaluation, fairness, patients’ rights, and technical requirements for AI in health care. These recommendations have relevance to a diverse group of people across the health system, from individual clinicians to health care organisations and service providers and patient representatives. As the authors note, the article shows it is possible to get meaningful public engagement: “Our study illustrates the feasibility of robust public engagement and deliberation for guiding AI development and implementation”. In their editorial on this research article (https://doi.org/10.5694/mja2.52282), Sullivan and Pointon note that this article provides evidence that the “public understand that doing nothing with regard to AI in health care is not an option and that we should proceed to accept it with important caveats regarding governance and privacy”. They conclude that next steps “require the timely and systematic implementation of [the jury's] recommendations, which in turn will require ongoing, systematised input by the public” and that “the engagement of human beings must be genuine”. This is a good reminder for everyone involved in health care innovation; we must be “guided by the principle: nothing about me without me”. In their ethics and law article (https://doi.org/10.5694/mja2.52254), Cormack and colleagues discuss the individual ramifications that can arise if consumer experiences and understanding are not at the forefront of patient care and counselling — specifically, how genomic testing is used and the need for counselling associated with it. They describe the challenges for a family in receiving information about, and then managing, the potential wide implications of the genetic cause of their child's seizures. In their perspective article (https://doi.org/10.5694/mja2.52261), Rogers and colleagues ask if we are ready for Medicare‐funded reproductive genetic carrier screening in Australia, noting that there are “no provisions in the Medicare rebate for pre‐ or post‐test counselling”. They highlight the importance of pre‐test counselling, as in Cormack and colleagues’ article, so that “Individuals should be given the opportunity to prepare for a clinically significant result, which may lead to complex decision making in a current or future pregnancy”. As genomic medicine becomes more widespread and complex innovations such as AI spread, these issues will become more common. All these articles reinforce that there are no shortcuts, nor should there be, to meaningful engagement of both individuals and whole communities in health care decisions.

Virginia Barbour

This issue of the MJA has two pieces that reflect on medical leadership, the role of professional organisations, and the challenges that remain for women in leadership. In their perspective, Proimos and colleagues (doi: 10.5694/mja2.52244) discuss specifically the role of medical colleges and other member‐based medical organisations. This is not a problem that is unique to Australia: as the authors say, a recent report from the World Health Organization “showed women make up 70% of the global health workforce but only 25% of the leadership”. It is even worse for women from minority groups. And, as they note, although getting women into leadership is important for equity and social justice, more diversity, including having more women in leadership, also improves outcomes. So, who should take responsibility around barriers to women's leadership? As the authors argue, “The burden of addressing barriers on a woman's path to leadership should not sit with individuals but rather with changing the culture, organisations and systems where women work”. They go onto describe the Advancing Women in Healthcare Leadership (AWHL) initiative, which focuses on system‐level change. What happens next will be important in determining how the evidence‐based interventions they identified can be translated into outcomes. A second perspective in this issue by Wheeler and Govindasamy (doi: 10.5694/mja2.52242) looks at the flip side of women's leadership: that there is not just a glass ceiling for women in leadership, including medical leadership, but also a “glass cliff”. They define this concept as follows: “The glass cliff phenomenon, drawn from the glass ceiling concept, refers to the tendency for women and other minoritised people to be appointed to leadership positions in times of crisis, compared with periods of stability”. Such appointments are, as the authors say, “a poisoned chalice” since “when circumstances are bad … women and other minoritised people are often pushed forward as visible signals of change … these appointed leaders are expected to perform a miracle to turn the crisis around”. As in the previous article, the authors note that solutions must lie with organisations, not individuals. There must be “renewed focus on institutional changes that facilitate work–life integration and organisational inclusivity … [to] deliver the benefits of diverse leadership back to our health system”. First published online to coincide with International Women's Day 2024, these two articles are a stark reminder of how far we have to go. The stakes are high not just for gender equity: if we are serious about putting in place leadership that will improve health outcomes, more diverse and more female leaders are not just nice to have, they are essential.

Virginia Barbour

This issue of the MJA returns to the topic of climate and health, with the publication of the 2023 report of the MJA–Lancet Countdown on health and climate change, focusing on the need for sustainability in Australia's health care sector (doi: 10.5694/mja2.52245). This is the sixth report in this series. The Countdown on health and climate change in Australia was established in 2017, producing its first national assessment in 2018. The report comes after yet another catastrophic year for the climate with 2023 having been the hottest year on record (https://www.climate.gov/news‐features/understanding‐climate/climate‐change‐global‐temperature) and following extreme floods in Australia in 2022. The early reports appeared in the context of the severe 2017–2019 droughts; this year's report “thus [completes] a picture of Australia's drought‐to‐flood cycle”. As in previous years, the report tracks progress on five broad domains: health hazards, exposures and impacts; adaptation, planning and resilience for health; mitigation actions and health co‐benefits; economics and finance; and public and political engagement. In the run‐up to 2030, the next phase of the countdown is even more critical. Although they observe signs of progress, including the release of Australia's first National Health and Climate Strategy, the authors note that their “results highlight the health and economic costs of inaction on health and climate change”. The MJA will continue to publish on health and climate change, and we encourage submissions in this area. Elsewhere in the issue, Pemberton and colleagues highlight the growing challenge of care of older people within the prison population, especially at the end of life (doi: 10.5694/mja2.52240). Reports regularly emerge of patients being subject to restraints, even when very frail and in palliative care, despite doctors calling for restraints to be removed. As the authors conclude, it seems clear that when prisoners enter hospital or palliative care, the justice and health care systems are directly challenging each other. The authors note that this is an important reminder that international standards require “prisoners should be entitled to the same level of health care as the wider community”. Finally, an editorial and research article explore how Aboriginal and Torres Strait Islander caregivers are involved in parenting programs. In their scoping review of randomised controlled trials (RCTs) (doi: 10.5694/mja2.52198), MacDonald and colleagues assess the extent to which Aboriginal and Torres Strait Islander parents, particularly fathers, are included in trials of parenting programs in Australia and whether these programs are culturally appropriate. The answer is unfortunately that Aboriginal and Torres Strait Islander families have been engaged in such studies to only a very limited degree. The authors' conclusions are sobering: “We could not identify any RCTs in which the participation of Aboriginal and Torres Strait Islander fathers was reported, and few interventions were tailored to the cultural needs of Indigenous people.” In their editorial, Sherriff and Gwynn reinforce this concern (doi: 10.5694/mja2.52238), although they note that “RCTs are generally not the preferred method of assessment for Aboriginal communities because direct benefits are not evident and they do not conform with cultural views on reciprocity and community‐centred approaches”. As they conclude, “Aboriginal ways of knowing, being, and doing must be privileged across all aspects of research in their communities”.

Virginia Barbour

While representing less than 5% (6513 out of 138127) of the registered Australian medical practitioners (https://www.medicalboard.gov.au/news/statistics.aspx), surgeons are involved in the care of 2.8 million (out of approximately 11.6 million) hospitalisations yearly (https://www.aihw.gov.au/reports‐data/myhospitals/intersection/activity/apc). Surgeons and surgical care teams are intimately involved in how our health care system operates, from what type of care we receive, to how the public and private sectors interact (or are at odds at times) (doi: 10.5694/mja2.51844). Additionally, they are often at the forefront of innovations. Their cautiously optimistic approach to the introduction of new devices, techniques, and of late, artificial technology enabled tools, is important to ensure safety in care. The critical roles of surgeons and surgical teams in our health systems and technological development and assessment have meant that surgical research has expanded outside traditional laboratories and small scale clinical studies. Their wheelhouse now includes research areas with broad population level clinical and policy implications, including health services, comparative effectiveness, and health technology evaluation. In this issue of the MJA, we have curated high quality national surgical research, focusing on topics of critical national (eg, surgery in rural areas, national health technology assessment) and international (eg, artificial intelligence, evidence‐based care) significance. The issue was developed to highlight surgery research that can influence our health system and discuss challenges encountered by the discipline today. The contemporary narrative review by Paynter and colleagues discusses the role of surgeons in rural Australia where 29% of the general population, but only 20% of general surgeons, live (doi: 10.5694/mja2.52232). The authors expertly describe the rural surgical workforce, heterogeneity in care models, and workforce and training challenges. They argue that despite these challenges, several Australian studies have found rural general surgery outcomes are comparable to metropolitan centres. Another unique challenge nationally is raised in Ryan's thought‐provoking piece on TAVI procedures and their access (doi: 10.5694/mja2.52226). This article looks at the evidence base for technology implementation and recommends a coordinated national approach rather than the current federal v state (or public v private) approach, which can lead to inequity of service access. Research articles in this issue call attention to the increasing utilisation of implantable cardiac defibrillators (ICDs) in New South Wales, and the potential impact of upscaling a program that could prevent hip fractures, and therefore reducing emergency surgeries. In their study on ICDs, Zhu and colleagues suggest that the increases in ICD use seen in our most populous state are likely due to primary prevention (people at high risk of sudden cardiac death) and call for better guidance regarding their use (doi: 10.5694/mja2.52246). Discussing hip fractures, Jones and colleagues describe the potential fracture reduction benefits of scaling up the 29 fracture liaison services in place nationally since 2018 using a novel system dynamics modelling approach (doi: 10.5694/mja2.52241). With promising but modest results, the authors call for alternatives for secondary fracture prevention to continue to be explored. Finally, a perspective on the use of artificial intelligence in surgery and an invited editorial are evidence of surgeons’ balanced approach to the adoption of new technology. Kovoor and colleagues support the ethical introduction of artificial intelligence in practice, and optimistically suggest Australia can be a leader in its safe introduction (doi: 10.5694/mja2.52225). However, introduction of these tools in practice also requires an infrastructure for their ongoing monitoring and evaluation. This point is confirmed by the editorial by Darval and Richards (doi: 10.5694/mja2.52239), which while calling for more evidence‐driven surgery to address national waiting lists, also reminds us that rigorous studies and frameworks for ongoing evaluations can change the course of surgery, including demand, adoption, and outcomes.

Maria C Inacio · Francis Geronimo · Virginia Barbour

One of the challenges for health care practitioners is to keep up to date with key developments in their field, which is not trivial at a time of huge information excess. Medical journals have a critical role in this by the very processes that we use for peer reviewing and selecting papers for publication. You can read about our processes at https://www.mja.com.au/journal/instructions‐authors‐reviewers. At the MJA, we specifically focus on what matters for Australian health care with a clear remit to publish high quality research and commentary to inform health policy and influence medical practice in Australia. This dates back to the very beginning of the Journal in 1914 where the first editorial states its role as “to record the progress of scientific medicine, and to assist in rendering the practice of medicine in all its branches of the greatest benefit to the people of Australia” (https://doi.org/10.5694/j.1326‐5377.1914.tb78499.x). This may mean publishing articles that highlight the local application of a more global challenge, or at the other extreme, publishing articles on topics that are of unique importance to Australia. Several articles in this issue highlight this range. In a guideline summary, Biswadev Mitra and colleagues synthesise the 2023 update of the patient blood management guideline for adults with critical bleeding published by the Australian National Blood Authority (doi: 10.5694/mja2.52212). The authors highlight several changes in management as a result of the guideline, including that “[major haemorrhage protocols] be established as standard of care in all institutions managing patients with critical bleeding” and that “temperature, biochemistry and coagulation profiles be measured early and frequently”. The development of the guideline was based around nine research questions, and systematic reviews were done for each question. While aiming to provide evidence to inform standardised management, the authors conclude that “There exists geographical and institutional variability in composition and delivery of [major haemorrhage protocols] throughout Australia” and that “Implementation of this guideline requires adaptation to the local context”. In their research article, Claire Gibbs and colleagues assess the prevalence of bronchiectasis among adult Aboriginal and Torres Strait Islander people in the Top End of the Northern Territory, and the associated mortality of these individuals (doi: 10.5694/mja2.52204). It was already known that chronic respiratory diseases are common in Aboriginal and Torres Strait Islander people, but the high prevalence of bronchiectasis that the authors found in the Top End is alarming — they estimate it as 19.4 per 1000 residents. This article is an important starting point for understanding the prevalence of this disease, but as the authors note, there is a need for future prospective studies to further characterise the epidemiology and disease burden. Finally, a perspective by Rebecca Goodall and colleagues reflects on the role that medical students in Victoria came to play in the COVID‐19 pandemic as clinical assistants (doi: 10.5694/mja2.52200). It was a voluntary, paid role and feedback on the program was positive from the medical students and those they worked with. The authors discuss the need for clear guidelines and evaluations for these roles but conclude that these students “form a dynamic workforce that is available and adaptable to meet the health care system's specific needs at any given time”.

Virginia Barbour