General medicine

To the Editor: Despite death being common in aged care, bereavement support for family and others is not part of care.1 In contrast, palliative care inherently extends to the patient’s family members, including after death.2 Coronavirus disease 2019 (COVID‐19)‐related deaths in aged care have left many families bereft. This is a consequence of forced separation in the final stage of life, the family member being transferred to an acute hospital, the question of whether the patient died alone, and limitations on traditional rituals and practices surrounding funerals.3,4 Like many community palliative care services, Melbourne City Mission’s Palliative Care (MCMPC) services have a well established aged care consultative team that provides advice on complex end‐of‐life issues. At the beginning of the COVID‐19 pandemic, MCMPC started to receive referrals for bereavement support — rapid referrals for residents in aged care facilities in the terminal phase of illness to speak with their families both before and after the patient’s death. Examples of catastrophic grief resulting from the COVID‐19‐related deaths in aged care facilities overseas prompted MCMPC’s preparation to respond to traumatised relatives.5 This work simply involved a phone call to families after the patient’s death. What was heard was sobering, summed up by one family member as “it was not meant to be this way”. Families expressed disappointment that the resident had contracted COVID‐19, stating they should have been safe in their home. The bereaved spoke of their enormous loss, having not been able to be with their loved one, in some cases, for a period of over 7 months. While most families were realistic about the frailty of their family member, they also said that “it was not their time,” that COVID‐19 unfairly changed the trajectory of how they expected their last days or months to go. Palliative care has much in common with aged care, notably the care of patients who are facing the final stage of their life. For staff it has been important to give each bereaved person a chance to capture their individual story, to give identity to the person who died, so they are not just another of the many deaths in aged care. In validating family members’ experiences, this simple phone intervention may mitigate poor bereavement outcomes5 by providing a space to honour their loss.

Margaret O’Connor · Bronwyn Wilson

To the Editor: Hereditary cancer predisposition syndromes (HCPS) account for at least 10% of paediatric cancers.1 Li‐Fraumeni syndrome (LFS) is a dominant HCPS caused by mutations in the TP53 gene and is associated with an 80–90% lifetime risk of cancer, commencing in infancy.2 Children of affected individuals are at 50% risk of inheriting the family mutation. Surveillance programs, involving clinical review and medical imaging, are being used in paediatric populations with HCPS, as significantly higher overall survival is reported with early tumour detection.3 In 2018, the Paediatric Surveillance Clinic was established at Perth Children’s Hospital to provide surveillance for asymptomatic children with, or at 50% risk of developing, LFS and with other HCPS, and to address the needs of their families. Families with at‐risk children can choose to attend the clinic, allowing them to receive information, support and sufficient time to make a decision regarding genetic testing. The quarterly clinic is in a general paediatric setting and offers surveillance for mutation‐positive children in line with eviQ guidelines — a free resource of evidence‐based, consensus‐driven cancer treatment and genetic testing protocols hosted by Cancer Institute NSW.4 Children at 50% risk of LFS, who have not had genetic testing, receive a six‐monthly clinical review and prompt assessment of any concerning symptoms during the interim period. Over an 18‐month period, the Paediatric Surveillance Clinic has seen 11 children from five families, aged from 3 months to 14 years. Most of these children are at risk of or have a TP53 mutation and one child has a VHL (Von‐Hippel‐Lindau) mutation. The Paediatric Surveillance Clinic offers a holistic service with a multidisciplinary team consisting of a general paediatrician, a paediatric nurse, a paediatric oncologist, a genetic counsellor and a clinical geneticist. The clinic has highlighted the specific and unmet needs of families dealing with HCPS and has allowed for essential integration of genetic, paediatric and oncology services for these families.5 As the number of identified HCPS grows, the Paediatric Surveillance Clinic will continue to offer a flexible service that supports families, assisting with decisions around genetic testing and surveillance for malignancy during childhood and adolescence.

Nicholas Leedman · Murray Princehorn · Nicholas Gottardo · Claire Franklin · Rebecca D'Souza · Catherine E Kiraly‐Borri

The large number of long term hydroxychloroquine users in Australia necessitates clear guidelines on hydroxychloroquine retinopathy screening Hydroxychloroquine retinopathy, which causes permanent visual loss, is a well documented adverse effect in long term users of both hydroxychloroquine and chloroquine. However, it can be difficult to detect as visual acuity is often well preserved until the disease is severe.1 Because of this, it was once thought to be a rare adverse effect, with only 0.5–2.0% of long term hydroxychloroquine users estimated to suffer from the condition.2 However, a 2014 epidemiological study of 2361 patients using hydroxychloroquine long term in the United States found that this was a large underestimation.2 The investigators found an overall prevalence of 7.5% in patients who had taken the drug for at least 5 years, but this risk increased with length of use and dosage.2 Owing to its efficacy in treating a variety of inflammatory and dermatological conditions (eg, systemic lupus erythematosus), cost‐effectiveness and relatively good safety profile, hydroxychloroquine is widely used by many Australians long term.3 In 2015, there were about 28 300 individuals (0.12% of all Australians) using the drug daily.4 Given this estimated number of users and the 7.5% prevalence rate,2 there could be more than 2000 potential cases of hydroxychloroquine retinopathy in Australia. However, there is no recommended consensus on screening for this condition in Australia, which may lead to inconsistent screening and missed cases.5 Existing screening guidelines Currently, two main guidelines on hydroxychloroquine retinopathy screening exist and are used by practitioners in Australia: the American Academy of Ophthalmology 2016 guidelines and the United Kingdom Royal College of Ophthalmologists 2020 guidelines.1,6 While both are very similar, small but significant differences exist between them. For example, both guidelines recommend that patients who fall within the high risk category should commence screening earlier than the general population, who are screened starting from 5 years of taking hydroxychloroquine.1,6 However, there is some disagreement on which risk factors warrant classification into the high risk category (Box 1). Recommendations also vary regarding the frequency of screening in high risk patients.1,6 There are also small differences in the investigations recommended by each set of guidelines. For example, the UK guidelines6 recommend fundus autofluorescence as an additional standard screening investigation (Box 2). The need for Australian guidelines There are currently no studies discussing the prevalence of hydroxychloroquine retinopathy in Australia, which makes it difficult to determine whether current screening practices are sufficient. However, the differences in the US and UK guidelines may have practical consequences for the consistency of hydroxychloroquine detection rates in the Australian population.5 As these guidelines were developed in non‐Australian settings, they may also need to be modified to better suit Australia’s unique context. For example, compared with the US and the UK, Australia has a significantly larger proportion of residents identifying as Asian in ancestry. In 2016, about 13% identified as having Asian ancestry,7 compared with 5.9% of Americans who identified as Asian in 2019.8 Due to the more peripheral pattern of damage from hydroxychloroquine sometimes seen in Asian populations, there are recommendations that a wider 24‐2 or 30‐2 visual field test should be performed for such patients, in addition to the recommended 10‐2 visual field test in the US and UK guidelines.9 Another factor to consider is whether Australia’s public health system can support ophthalmology screening at the frequency recommended by the US and UK guidelines. Already, waiting times for non‐urgent appointments for ophthalmologists in the public system can reach years. In South Australia, the median waiting time for an outpatient ophthalmologist appointment ranges from 4.8 to 17.6 months at metropolitan hospitals,10 which makes annual screening impossible for many patients without private care. The costs to the health system also warrant consideration. Under the current Medicare Benefits Schedule, a standard specialist consultation (item 104) and visual field test (item 11224) would cost $131.65, totalling more than $1.5 million to test 50% of the individuals taking hydroxychloroquine annually in the public setting.11 Australia‐specific screening guidelines could better account for these practical considerations, although further studies would be necessary to determine how successfully the system already supports hydroxychloroquine retinopathy screening based on existing guidelines. Conclusion Given its potential to cause permanent vision loss and the number of Australians taking hydroxychloroquine long term, developing Australian screening guidelines for hydroxychloroquine retinopathy would be beneficial in promoting consistent screening practices tailored to the Australian population. Before these can be established, however, more research needs to be conducted on the prevalence and current detection rates of hydroxychloroquine retinopathy in Australia. Box 1 – Risk factors and recommendations in the United States1 and United Kingdom6 hydroxychloroquine retinopathy screening guidelines Risk factor US UK Hydroxychloroquine dose > 5 mg/kg Yes Yes Renal disease Yes Yes Tamoxifen use Yes Yes Pre‐existing retinal and macular conditions Yes No Equivalent chloroquine dose > 2.3 mg/kg No Yes Box 2 – Screening investigations for hydroxychloroquine retinopathy recommended by the United States1 and United Kingdom6 guidelines Investigations US UK Baseline (for patients with no known pathology) Fundus evaluation of the macula Fundus evaluation of the macula Spectral domain optical coherence tomography Screening 10‐2 visual field test Spectral domain optical coherence tomography 10‐2 visual field test Spectral domain optical coherence tomography Fundus autofluorescence

Marisse T Sonido · Kristopher Rallah-Baker · Monisha Gupta

Objectives: To assess the efficacy of a pro‐active, absolute cardiovascular risk‐guided approach to opportunistically modifying cardiovascular risk factors in patients without coronary ischaemia attending a chest pain clinic. Design: Prospective, randomised, open label, blinded endpoint study. Setting: The rapid access chest pain clinic of Royal Hobart Hospital, a tertiary hospital. Participants: Patients who presented to the chest pain clinic between 1 July 2014 and 31 December 2017 who had intermediate to high absolute cardiovascular risk scores (5‐year risk ≥ 8%). Patients with known cardiac disease or from groups with clinically determined high risk of cardiovascular disease were excluded. Main outcome measures: The primary endpoint was change in 5‐year absolute risk score (Australian absolute risk calculator) at follow‐up (at least 12 months after baseline assessment). Secondary endpoints were changes in lipid profile, blood pressure, smoking status, and body mass index, and major adverse cardiovascular events. Results: The mean change in risk at follow‐up was +0.4 percentage points (95% CI, –0.8 to 1.5 percentage points) for the 98 control group patients and –2.4 percentage points (95% CI, –1.5 to –3.4 percentage points) for the 91 intervention group patients; the between‐group difference in change was 2.7 percentage points (95% CI, 1.2–4.1 percentage points). Mean changes in lipid profile, systolic blood pressure, and smoking status were larger for the intervention group, but not statistically different from those for the control group. Conclusions: An absolute cardiovascular risk‐guided, pro‐active risk factor management strategy employed opportunistically in a chest pain clinic significantly improved 5‐year absolute cardiovascular risk scores. Trial registration: Australia New Zealand Clinical Trial Registry, ACTRN12617000615381 (retrospective).

J Andrew Black · Julie A Campbell · Serena Parker · James E Sharman · Mark R Nelson · Petr Otahal · Garry Hamilton · Thomas H Marwick

Introduction: The 2001 Recommendations for clinical care guidelines on the management of otitis media in Aboriginal and Torres Islander populations were revised in 2010. This 2020 update by the Centre of Research Excellence in Ear and Hearing Health of Aboriginal and Torres Strait Islander Children used for the first time the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Main recommendations: We performed systematic reviews of evidence across prevention, diagnosis, prognosis and management. We report ten algorithms to guide diagnosis and clinical management of all forms of otitis media. The guidelines include 14 prevention and 37 treatment strategies addressing 191 questions. Changes in management as a result of the guidelines: A GRADE approach is used. Targeted recommendations for both high and low risk children. New tympanostomy tube otorrhoea section. New Priority 5 for health services: annual and catch‐up ear health checks for at‐risk children. Antibiotics are strongly recommended for persistent otitis media with effusion in high risk children. Azithromycin is strongly recommended for acute otitis media where adherence is difficult or there is no access to refrigeration. Concurrent audiology and surgical referrals are recommended where delays are likely. Surgical referral is recommended for chronic suppurative otitis media at the time of diagnosis. The use of autoinflation devices is recommended for some children with persistent otitis media with effusion. Definitions for mild (21–30 dB) and moderate (> 30 dB) hearing impairment have been updated. New “OMapp” enables free fast access to the guidelines, plus images, animations, and multiple Aboriginal and Torres Strait Islander language audio translations to aid communication with families.

Amanda J Leach · Peter S Morris · Harvey LC Coates · Sandra Nelson · Stephen J O'Leary · Peter C Richmond · Hasantha Gunasekera · Samantha Harkus · Kelvin Kong · Christopher G Brennan‐Jones · Sam Brophy‐Williams · Kathy Currie · Sumon K Das · David Isaacs · Katherine Jarosz · Deborah Lehmann · Jarod Pak · Hemi Patel · Chris Perry · Jennifer S Reath · Jessica Sommer · Paul J Torzillo

Objective: To investigate whether integrating pharmacists into general practices reduces the number of unplanned re‐admissions of patients recently discharged from hospital. Design, setting: Stepped wedge, cluster randomised trial in 14 general practices in southeast Queensland. Participants: Adults discharged from one of seven study hospitals during the seven days preceding recruitment (22 May 2017 ‒ 14 March 2018) and prescribed five or more long term medicines, or having a primary discharge diagnosis of congestive heart failure or exacerbation of chronic obstructive pulmonary disease. Intervention: Comprehensive face‐to‐face medicine management consultation with an integrated practice pharmacist within seven days of discharge, followed by a consultation with their general practitioner and further pharmacist consultations as needed. Major outcomes: Rates of unplanned, all‐cause hospital re‐admissions and emergency department (ED) presentations 12 months after hospital discharge; incremental net difference in overall costs. Results: By 12 months, there had been 282 re‐admissions among 177 control patients (incidence rate [IR], 1.65 per person‐year) and 136 among 129 intervention patients (IR, 1.09 per person‐year; fully adjusted IR ratio [IRR], 0.79; 95% CI, 0.52‒1.18). ED presentation incidence (fully adjusted IRR, 0.46; 95% CI, 0.22‒0.94) and combined re‐admission and ED presentation incidence (fully adjusted IRR, 0.69; 95% CI, 0.48‒0.99) were significantly lower for intervention patients. The estimated incremental net cost benefit of the intervention was $5072 per patient, with a benefit‒cost ratio of 31:1. Conclusion: A collaborative pharmacist‒GP model of post‐hospital discharge medicines management can reduce the incidence of hospital re‐admissions and ED presentations, achieving substantial cost savings to the health system. Trial registration: Australian New Zealand Clinical Trials Registry, ACTRN12616001627448 (prospective).

Christopher R Freeman · Ian A Scott · Karla Hemming · Luke B Connelly · Carl M Kirkpatrick · Ian Coombes · Jennifer Whitty · James Martin · Neil Cottrell · Nancy Sturman · Grant M Russell · Ian Williams · Caroline Nicholson · Sue Kirsa · Holly Foot

Posts can provide valuable feedback during public consultation for health guidelines

Benjamin C Riordan · Daniel T Winter · Paul S Haber · Carolyn A Day · Kirsten C Morley

Rapid advances in AI in ophthalmology are a harbinger of things to come for other fields of medicine The autonomous detection and triage of eye disease, or even accurate estimations of gender, age, and blood pressure from a simple retinal photo, may sound like the realms of science fiction, but advances in artificial intelligence (AI) have already made this a reality.1 Ophthalmology is at the vanguard of the development and clinical application of AI. Advances in the field may provide useful insights into the application of this technology in health care more broadly. Artificial intelligence Once described as the capacity of intelligent machines to imitate human intelligence and behaviour, AI now describes many theories and practices used to achieve computer intelligence (Box 1).2 Machine learning is an application of AI that uses algorithms or statistical models to make decisions or predictions. Complex patterns and relationships are learned from data to generate an outcome.2 Machine learning traditionally relies on the extraction of features from the data by human operators which then serve as input variables to optimise algorithm performance. The performance of these systems is constrained by the features that are recognised as important by humans. In contrast, artificial neural networks are an advanced method of machine learning able to extract features without explicit programming.2 Deep learning is the construction of multiple layers of artificial neural networks which can identify features in data that are not recognisable by humans. Although deep learning systems may be powerful, they lack human‐crafted inputs, meaning that large quantities of data are typically required to train algorithms. Artificial intelligence in ophthalmology As a discipline, ophthalmology is at the forefront of AI system development and translation in clinical practice. Leading uses of the technology include detecting, classifying and triaging a range of diseases, such as diabetic retinopathy, age‐related macular degeneration (AMD), glaucoma, retinopathy of prematurity, and retinal vein occlusion, from clinical images.3 The increasing global burden of eye diseases, coupled with the development of new therapies for previously untreatable conditions, has served as a major driver for AI innovation in ophthalmology. As a case in point, there are presently over 430 million people living with diabetes, most of whom require annual or biennial screening for retinopathy using retinal photography. This vast demand for diabetic eye screening services has stimulated the development of AI algorithms to identify sight‐threatening disease. Several algorithms have achieved performance that meets or exceeds that of human experts.4,5 Accordingly, in 2018, the United States Food and Drug Administration approved an AI system to detect referable diabetic retinopathy from retinal photographs, the first autonomous diagnostic system to be approved in any field of medicine.6 Advances in deep learning have extended to other imaging modalities that are commonly used in ophthalmology. Ocular coherence tomography is an imaging technology that produces highly detailed, depth‐resolved images of the retina. A recent collaboration between researchers and clinicians at Google DeepMind, Moorfields Eye Hospital and University College London culminated in the development of a deep learning system capable of detecting and triaging more than 50 different retinal conditions at levels equivalent to a panel of experienced ophthalmologists.7 AI systems with the capacity to detect a wide range of diseases, such as this, are likely to be most useful in clinical practice. A highly anticipated innovation is the development of AI systems capable of accurate disease prediction. Such tools could assist in managing patient expectations, improve the quality of care and reduce treatment costs.3 In ophthalmology, prediction models have been trained to personalise re‐treatment intervals for patients with neovascular AMD,8 predict progression from early to late AMD,9 estimate the extent of future visual field defects in patients with glaucoma,10 and predict diabetic retinopathy progression.11 Although these models presently achieve only moderate levels of accuracy, their performance has been shown to be superior to humans in several studies.3,8 Future advances in the accuracy of prediction models will likely come from the use of large longitudinal datasets drawing on multiple data sources, together with the development of more advanced AI systems.3 Despite these significant advances, AI systems are not in widespread clinical use and in some cases real‐world performance has been inferior compared with in silico validation.2,3 Training and validation of deep learning algorithms with large, representative data (eg, data from people of different ethnicities) acquired using multiple devices (eg, different retinal camera models) and data collection protocols (eg, retinal photographs acquired with and without pupil dilation) are key to achieving clinical applicability.4,5 This approach was used in the development of deep learning systems for retinal photographic screening for diabetic retinopathy, AMD and glaucoma which are now being used in large scale screening programs in Singapore and China.4,5 In these programs, AI is used to identify images without evidence of disease, so that human graders can focus their efforts on the images of those with disease, enabling improved efficiency and cost savings.12 Challenges to the clinical adoption of artificial intelligence Several obstacles to the adoption of AI in health care remain. The training of deep learning systems requires access to large amounts of medical data which has significant implications relating to privacy and data protection. In the context of ophthalmology, this is particularly pertinent, as the retinal vasculature may be considered biometric data, making it impossible to completely anonymise retinal photographs.3 Furthermore, characteristics that are not visible to human examiners, such as age and sex, can now be accurately predicted from a single retinal photograph using deep learning.1 Several recent major breaches of data protection laws relating to AI system development have already come to light.13 While individual patient data used to train an algorithm do not remain within the system, incorrect handling and sharing of data may lead to patients withdrawing consent to the use of their data under General Data Protection Regulation laws. It is not certain how data withdrawal requests will be dealt with when an individual’s data have been used in the process of training a deep learning system. Accordingly, developments in AI need to be accompanied by advanced data protection and security measures. Another challenge to the acceptance of deep learning algorithms in medicine is the difficulty in determining the basis for clinical decisions made by these systems, informally described as the “black box” problem. Visualisation tools have been developed to assist clinicians by highlighting the salient image features that contribute to the AI system classification (Box 2).12 This has the potential to create trust in system‐generated decisions, particularly if the features correspond with those used by experienced clinicians for clinical decision making.14 Interpretability is particularly important when considering legal liability in the event of patient harm arising from the use of AI in medicine. In traditional malpractice cases, a physician may be asked to justify the basis for a particular clinical decision and this is then considered in light of conventional medical practice.15 In comparison, challenges in identifying the basis for a given decision made by AI might pose problems for clinicians whose actions were based on that decision. The extent to which the clinician, as opposed to the technology manufacturer, should be held accountable for harm arising from AI use is a subject of intense debate.15 Factors such as the manner in which these AI systems are used and their classification as either products or software are likely to have important bearings on how cases are litigated.15 Further challenges for existing regulatory frameworks come from algorithms that continue to learn and evolve over time.15 Understanding how a given system is trained, its accuracy, and its operational limits is of great importance. Oversampling of a particular population or disease severity during training has the potential to introduce bias.4 Therefore, consideration of performance thresholds will help to inform appropriate use of AI systems. The Australian Government, through the CSIRO and Data61;16 the Australian Council of Learned Academies;17 the Australian Academy of Health and Medical Sciences;18 and specialty groups, such as the Royal Australian and New Zealand College of Radiologists,19 have made significant efforts to develop frameworks and policies for the effective and ethical development of AI. These consultative works have highlighted key priorities, including building a specialist AI workforce, ensuring effective data governance and enabling trust in AI through transparency and appropriate safety standards. Through targeted investment in research and development, Australia is aiming to advance its AI competitiveness. These framework documents provide guidance for developers, clinicians and health care consumers to navigate this rapidly evolving field. Broad dissemination of these documents should form part of a wider public engagement and education campaign to ensure that AI is developed and used in a considered and careful manner in health care. Rapid advances in AI in ophthalmology are a harbinger of things to come for other fields of medicine. While these technologies may eventually lead to more efficient, cost‐effective and safer health care, they are not a panacea in isolation. The successful integration of AI into health systems will need to first consider patient needs, ethical challenges and the performance limits of individual systems. Box 1 – Relationship between artificial intelligence and its subtypes Box 2 – Original retinal photograph of right eye with macular degeneration (A). Heat map of image A showing visualisation of traditional features associated with macular degeneration, such as central scarring (B). Original retinal photograph of left eye with referable diabetic retinopathy (C). Heat map of image C showing visualisation of traditional features, such as micro‐aneurysms and haemorrhages (D)

Jane Scheetz · Mingguang He · Peter Wijngaarden

To the Editor: We congratulate Hill and colleagues1 for their timely research on the performance of symptom assessment smartphone applications (apps) in Australia. The apps in the study were selected using structured criteria2 to identify those featuring most prominently in internet search engines and app stores. However, we note that this strategy is biased against an important class of symptom checkers. Because the app store search included “medical diagnosis” and “health symptom diagnosis”, the authors’ approach was less likely to identify many symptom checkers regulated in Europe under the CE (Conformité Européene) Marking system. Specifically, these apps must not describe themselves as “diagnostic tools”, as diagnosis is a function carried out by a doctor. We believe this to be the reason why the CE‐marked Ada health assessment app was not identified or selected by the authors.1 This represents a missed opportunity for analysis, as Ada has been freely available in Australia since 2016,3 and was downloaded at least 200 times more frequently in Australia between November 2018 and January 2019 than either Symptomate or Symcat, which were included in the study (App Annie [www.appannie.com] download data; viewed June 2020). Other studies have found that the Ada app performs well when compared with the other apps assessed, as recently published.4

Stephen Gilbert · Paul Wicks · Claire Novorol

If we had a test that was both 100% sensitive and 100% specific for COVID-19, we would have no false-positive and no false-negative results

Katy JL Bell · Fiona F Stanaway · Les M Irwig · Andrea R Horvath · Armando Teixeira‐Pinto · Clement Loy

Peer support initiatives can help health professionals experiencing mental health and wellbeing challenges during the COVID-19 pandemic and beyond

Tahnee L Bridson · Kym Jenkins · Kieran G Allen · Brett M McDermott

Adequate capacity — beds, equipment, consumables, and, crucially, trained personnel — is needed to cope with a surge of critically ill patients

Mervyn Singer

Inappropriate behaviour harms health workers and patients, and evidence-based solutions are needed

Anthony Scott · Danny Hills

Controlling the exit from work and accumulating multiple resources early predict adjustment to retirement The traditional approach to leaving a career in medicine has been informal. The fact that about 10% of medical practitioners in Australia are aged 65 years or over1 — a seemingly natural consequence of increased life expectancy, improved quality of life and fluctuations in financial markets — highlights the need for a more methodical process for leaving medicine. The final transition in a medical career is one that the profession has largely ignored, thereby risking unplanned departures that affect succession planning for practices, continuity of care for patients, and the wellbeing of the practitioner. The eventual introduction of proposed mandatory health checks for practitioners aged 70 years and over in Australia2 may hasten the retirement of some, which only increases the urgency of retirement planning becoming a routine task for all practitioners. The aim of this article is to describe a framework that examines how this transition may be achieved, so that practitioner wellbeing and adjustment to retirement are enhanced. For all the changes in medical culture that must occur — and to which the colleges, employers and other professional organisations must contribute — the individual practitioner ultimately remains responsible for their own welfare across the career cycle. While this article is aimed mainly at clinicians, its principles remain pertinent to other medical practitioners. Understanding the process of retirement Retirement is not a lone event. It is better understood as a longitudinal process that comprises three phases that may overlap.3 In the “pre‐retirement” phase, the practitioner continues to work but may anticipate and prepare for retirement. In the “transition” phase, decisions are made about how and when the practitioner should approach stopping work. The final phase of “adaptation” may involve some paid work but the practitioner is principally retired. Each phase is considered a critical turning point, in which action or neglect can influence the outcome of subsequent phases. Some practitioners may chart a non‐linear transition, moving in and out of work. Any approach to determining the optimal time to transition out of a career in medicine must consider individual motivation as well as other competing factors. The first is the right of all and the desire of some older practitioners to continue working versus the extrinsic demands of family expectations or life events, such as illness in a loved one. The second is the continued provision of clinical services by senior medical practitioners, usually within well established patient relationships, versus the right of patients to receive the highest level of care possible. In this regard, older practitioners are at increased risk of physical and cognitive changes that may potentially affect practice, such as poorer patient outcomes,4 and may lead to being the subject of a complaint to a regulatory authority.5 Why retirement planning may be hard When the transition away from work should start is an individual decision. Yet a cross‐sectional survey found that more than one‐third of older practitioners working in Australia had failed to even reach the pre‐retirement phase, as they reported no intention of retiring or were unsure about doing so.6 Moreover, not intending to retire was an occupational factor that predicted practitioners’ perceptions of ageing successfully.7 This suggests that even considering leaving work may be viewed as a sign of personal weakness. Financial factors related to inadequate superannuation funds, continuing debt, or other commitments have been found to prevent retirement planning.8 Several other reasons for continued practice and delayed retirement, however, reflect more intrinsic difficulties in detaching from medicine. These include a feeling of responsibility for patients, a lack of interests outside of medicine, and a fear of potential changes in their relationship with a spouse.8 These factors may be the result of a lifetime of work centrality whereby medicine takes precedence over other life roles.6 For many doctors, self‐identity is bound up in their work and the drive to further their careers. A study of academics suggested that work–life balance was more nebulous because outside interests, including family, were considered an inconvenient distraction.9 Conversely, emotional connections towards a workplace or institution may strengthen. Prioritising work limits social connections and creative pursuits, thereby perpetuating a reluctance to retire. A structured transition to retirement plan The purpose of adequate retirement planning is to enhance wellbeing after ceasing work. Pre‐retirement planning is a long term goal‐oriented behaviour that has been associated with retirement satisfaction.10 In addition, retirement adjustment is predicted by the conditions of exit — namely, control over how and when one leaves work11 — and resource acquisition in multiple domains.12 While the elements of planning should occur throughout the career cycle, we recognise that it is not a compelling consideration for many practitioners. We would still propose that all practitioners formally write an initial transition to retirement plan by the age of 55 at the latest, review it regularly, and the intervals between reviews should become more frequent with time (Box). The proposed introduction of the mandatory health check for practitioners aged 70 years or over should be an important incentive for self‐care. Traditional pre‐retirement planning has tended to consist only of financial advice such as wealth creation, tax optimisation, and estate planning. This is an essential task as people tend to underestimate how much money will be required in retirement, but should not be used as the sole criterion of fitness for retirement. The more pertinent questions are how time in retirement will be spent and how much it will cost to support, rather than a pre‐determined goal of wealth accumulation. Resource accumulation While adequate financial resources do contribute to retirement adjustment, so do adequate physical health, social engagement and emotional resources.12 This means a much broader spectrum of planning that uses advice from multiple professionals is required. Methods for optimising financial, physical and leisure resources are relatively easily sourced. What may be more difficult to manage, however, are the emotional resources needed to navigate the transition to retirement. In particular, the inevitable loss of self‐identity may lead to anticipatory grief and bereavement.13 That intending to retire is viewed as a mark of ageing less well by practitioners not only poses a considerable challenge for their retirement planning, but highlights the importance of understanding successful ageing in any discussion of transitioning away from full‐time work in medicine. Successful ageing is a concept that has evolved from a biomedical model, requiring an absence of physical disease and good physical functioning, to a more subjective notion that emphasises adaptation and autonomy.14 A sense of engagement, a prominent feature of self‐rated successful ageing, is inherent in the work of medical practitioners and is reflected in the pursuit of continued stimulation and learning, a sense of purpose and utility to society.15 Successful occupational ageing is based on insight into personal strengths, a dynamic process of goal setting, generativity (guiding and mentoring the next generation), and self‐care.14 There are a number of areas that are important for self‐reflection, such as the original motivations for training in medicine, the reasons for continuing to work, the anticipatory grief of the loss of identity and role, and the fear of ageing.14 Not every practitioner will be capable of self‐reflection, so that professional help may be required via a career development counsellor or vocational psychologist. While many practitioners will set a pre‐determined age or personal milestone at which to retire, others may continue to work indefinitely, thereby increasing the risk of practising with an impairment. This may be prevented by incorporating a professional advance care plan16 that outlines a set of premorbid views about ongoing practice in the event that capacity to practise is impaired. Permission would be given to one or more people, such as a spouse, friend or colleague, to monitor fitness to practise and to provide regular feedback. “Red flags” to stop working may include physical illness or concern from a trusted source about deterioration in cognition or procedural or clinical skills. Developing an encore career Developing an encore career is the final aspect of the transition plan that allows the use of skills and experience developed over a career, and helps maintain meaning and engagement. Giving consideration to the encore career while still working enables the practitioner to better position themselves to access greater opportunities. Up until this point, the practitioner may have found integrating different life roles challenging and pursuing outside interests unnecessary. An encore career can lead to feeling purposeful, provide goals to strive towards, and opportunities for intellectual and social pursuits. For example, a general practitioner keen to maintain patient contact but reduce caseload may want to specialise in an area of medicine (eg, mental health). Some may investigate governance roles with accrediting bodies, sit on guardianship or mental health review tribunals, or take up committee membership. Others may wish to provide leadership through directorships or management roles in hospitals or medical services. Others may wish to apply their lifetime of insights to teaching or research pursuits. Examples include teaching medical students, mentoring trainees, writing research grants and articles. It might be worthwhile revisiting those businesses or volunteering opportunities that were set aside before a medical career became the sole focus. Conclusion Retirement should not be viewed as a single endpoint but as an anticipatory process that involves the accumulation of social, emotional, financial and other resources. Active participation in retirement planning is essential to ease the transition, gain a better sense of control and enhance emotional adaptation. Encore careers provide the opportunity to capitalise on a lifetime of accumulated wisdom by integrating training, experience, interests and strengths. Given medicine’s long‐standing neglect of retirement planning, there is also a need for professional bodies to provide education about the transition process and for practitioners themselves to share stories of encore careers and inspire peers to explore avenues for transition. Box – My plan for transitioning to retirement I will accumulate the following resources: Physical resources ► What am I doing to take care of my health (diet, exercise, adherence with medications)? ► How often am I seeking independent health care, including consulting my general practitioner? Financial resources ► How do I optimise my finances (reduce debt, maintain income)? ► Who is my professional adviser? How often do I consult with them? Emotional resources ► Who are the people I can connect with for emotional support? Who do I support in return? ► Who do I know who has aged well and transitioned well? What can they share? ► What types of professional assistance do I need to support the transition? Social resources ► How do I maintain healthy relationships (spouse, children, family and friends)? ► Who can provide professional support to help me manage these relationships now and when I am not working? ► What relationships have lapsed that I want to re‐initiate? ► What interests can I develop or revisit? Cognitive resources ► What intellectual pursuits outside medicine can I follow? ► How do l want to learn, develop and grow? ► What creative pursuits do I want to develop? ► What courses or training might help to reposition me for an encore career? My professional advance care plan I will discuss the timing of transition and retirement with my peers and loved ones I will engage my junior colleagues in a discussion about succession planning I will reduce my hours, stop procedural work etc, at age X or if the following health or practice problems occur … I will stop working at age X or if the following health or practice problems occur … I will set up a peer mentoring system with close colleagues so that we can provide each other with feedback on professional issues and review skill levels. Encore career What are some professional aspirations I can pursue given greater time availability? How do I convert my passions and interests into pursuits? Do I want to focus on areas of expertise, governance, leadership or teaching and research? Was there a business opportunity I considered before my medical career that I want to revisit? What other career options have people who have successfully transitioned considered?

Chanaka Wijeratne · Joanne Earl

Hospitals in the Northern Territory often operate beyond capacity and serve a sparsely distributed population with rates of chronic disease and household overcrowding that are higher than in many other parts of Australia. The NT consequently adopted particularly strict public health measures to avert the potentially catastrophic consequences of community transmission of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), including supervised isolation until viral clearance of all people with confirmed SARS‐CoV‐2 infections (Supporting Information 1). This measure provided a unique opportunity to study the duration and trajectory of viral shedding in relation to clinical illness. In this article, we describe epidemiologic, clinical, and virological aspects of the first 28 cases of coronavirus disease 2019 (COVID‐19) in the NT. The Top End and Central Australian Human Research Ethics Committees approved the study (reference, 2020‐3737). Between 4 March and 4 April 2020, 28 cases of COVID‐19 were diagnosed in the NT, all linked to overseas or interstate travel. The median age of patients was 45.0 years (range, 1.5–75 years); 16 were women (Supporting Information 1, table). Two patients required supplemental oxygen, one of whom also required intubation. There were no deaths. Symptoms had been present for a median 3 days (range, 0–16 days) before oro‐nasopharyngeal swab collection and lasted a median 9.5 days (range, 4–18 days). Viral RNA could be detected by multiplex tandem real‐time polymerase chain reaction (PCR) assay (AusDiagnostics; Supporting Information 1) for a median 25 days after symptom onset (range, 14–41 days; interquartile range [IQR], 21–32 days), and in most patients for more than two weeks after symptom resolution (median, 17.5 days; range, 2–31 days; IQR, 14.5–22.5 days) (Box 1). Within‐patient variability in viral target cycle threshold values during follow‐up was considerable (Box 2; Supporting Information 1, figure), despite adequate and consistent amounts of human biologic material in test samples (data not shown). Prolonged compulsory isolation was distressing for several patients. The phylogeny of the 27 available NT viral genomes was consistent with acquisition in locations on all inhabited continents (Box 3). Five genetic clusters were evident (maximum of one single nucleotide polymorphism within each cluster) that were also epidemiologically linked by shared travel or household contact. The SARS‐CoV‐2 genomes from two independent travellers without epidemiologic connections were identical, but matched other publicly available genomes, highlighting the importance of interpreting genomic analyses in their epidemiologic context. The priority of the strict NT isolation requirements for patients with COVID‐19 was viral containment at a time when data on the duration of viral transmissibility were sparse. More recent evidence suggests that viable SARS‐CoV‐2 is rarely isolated more than 10 days after symptom onset,1,2,3 and requirements have consequently been eased, while maintaining supervised isolation with health management during the period of greatest infectivity. The high degree of temporal variability in viral shedding during follow‐up indicates that a single assay is not adequate for excluding infection in patients at epidemiologic risk of COVID‐19. The NT implemented particularly aggressive public health measures to contain SARS‐CoV‐2 transmission. Epidemiologic and genomic analyses suggest that this response has successfully prevented local community transmission of the virus. Box 1 – Time course of 28 cases of coronavirus disease 2019 (COVID‐19) diagnosed in the Northern Territory, 4 March – 4 April 2020 Each line represents a single patient. Day zero is the day of collection of the first SARS‐CoV‐2‐positive specimen; thickened sections indicate the period of COVID‐19 symptoms. Closed circles indicate positive SARS‐CoV‐2 assay results, hollow circles negative assay results. Patients 13 and 15 (lighter marking) required supplemental oxygen. The bottom line summarises the median duration of symptoms prior to diagnosis, the median duration of symptoms, and the median time to viral clearance. Box 2 – Multiplex tandem polymerase chain reaction cycle threshold values for detection of the SARS‐CoV‐2 open reading frame 1a gene (ORF1a) Box 3 – Maximum likelihood phylogenetic tree, depicting SARS‐CoV‐2 genomes from the Northern Territory and elsewhere SARS‐CoV‐2 = severe acute respiratory syndrome coronavirus 2. The phylogenetic tree shows that SARS‐CoV‐2 genomes in the Northern Territory (on the inner side of the outer ring) were drawn from across the range of genomes reported elsewhere (outer ring). NT travel‐related cases with epidemiologic links formed genomic clusters. Two cases without epidemiologic links also comprised a cluster, but the genomes were identical with overseas genomes. The context genomes were obtained from GISAID (https://www.gisaid.org), with region based on location of the submitting laboratory; the Wuhan‐Hu‐1 genome was used as an outgroup, and the scale bar indicates substitutions per site.

for the Northern Territory COVID‐19 Response Group

Introduction: Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) cause significant morbidity and premature mortality among Australian Aboriginal and Torres Strait Islander peoples. RHDAustralia has produced a fully updated clinical guideline in response to new knowledge gained since the 2012 edition. The guideline aligns with major international ARF and RHD practice guidelines from the American Heart Association and World Heart Federation to ensure best practice. The GRADE system was used to assess the quality and strength of evidence where appropriate.Main recommendations: The 2020 Australian guideline details best practice care for people with or at risk of ARF and RHD. It provides up‐to‐date guidance on primordial, primary and secondary prevention, diagnosis and management, preconception and perinatal management of women with RHD, culturally safe practice, provision of a trained and supported Aboriginal and Torres Strait Islander workforce, disease burden, RHD screening, control programs and new technologies.Changes in management as a result of the guideline: Key changes include updating of ARF and RHD diagnostic criteria; change in secondary prophylaxis duration; improved pain management for intramuscular injections; and changes to antibiotic regimens for primary prevention. Other changes include an emphasis on provision of culturally appropriate care; updated burden of disease data using linked register and hospitalisations data; primordial prevention strategies to reduce streptococcal infection addressing household overcrowding and personal hygiene; recommendations for population‐based echocardiographic screening for RHD in select populations; expanded management guidance for women with RHD or ARF to cover contraception, antenatal, delivery and postnatal care, and to stratify pregnancy risks according to RHD severity; and a priority classification system for presence and severity of RHD to align with appropriate timing of follow‐up.

Anna P Ralph · Sara Noonan · Vicki Wade · Bart J Currie

There are legal considerations for both clinicians and patients when recording health care consultations Studies show that patients often have inaccurate recall of health care events and diagnoses.1 Concentration during a medical consultation may be “hampered by unspoken anxieties or pain, making it difficult to recall detail”.2 Audio recordings of consultations can be useful for patients and clinicians to assist memory and understanding. They have mainly been evaluated in oncology and paediatrics.3,4 Patients report that listening to their consultation recording increases knowledge and understanding of their illness, and recordings can assist with treatment decision making, increasing a sense of empowerment.5 Sharing recordings with family can facilitate support and understanding. Clinicians likewise recognise recordings’ benefits for patients and for improving the quality and efficiency of their care.6 Research in the United Kingdom found that 69% of patients wish to record consultations.7 Increasingly, patients are using smartphones to record consultations, either with permission or covertly.7,8 Recording systems have been developed by health services themselves, transformed by the ubiquitous use of smartphones and other flexible technologies.9,10,11 Examples include the Open Recording Automated Logging System (ORALS) software in the United States9 and telephone‐based digital recording in Denmark.11 In Australia, the Second Ears smartphone app, developed at the Victorian Comprehensive Cancer Centre in 2018, is designed to make recordings available to both the patient and the hospital health information management service.6,10 Patients can choose whether to download and use the app (either before their appointment or in the clinic), access the recordings on their smartphone, and share them with family and friends.6,10 Common design features of such health service‐led recordings address data security, file storage and patient consent. Whether the clinician or the patient controls the recording process may differ across technology platforms; for instance, in the Danish example above, the clinician initiated the recordings, whereas with Second Ears the patient would do so. The use of consultation recordings often raises legal questions.5,7,10,12 In this article, we compare the legal implications of overt and covert recordings of health care consultations and address key concerns identified by clinicians, notably the requirement for consent to record and share the recording, and the use of recordings in negligence claims.8,13,14,15 We distinguish between three recording types: Overt patient‐led recordings: for example, a patient recording a consultation with the clinician's consent. These recordings are akin to a patient's handwritten notes. Overt health service‐led recordings: for example, the Second Ears app, where both clinician and patient consent (actively or impliedly) to the recording; the app is facilitated by the health service and the primary version of the recording stored on their system. Covert patient‐led recordings: for example, a patient recording without the clinician's knowledge or consent. As each legal question is identified, we consider the law in the context of the Second Ears app. This article is general in nature and does not constitute legal advice. References to legislation are current at 13 October 2020. References to state or territory laws relate to the location of the recording or the place at which the sharing of the recording originated. We do not address the issue of intentional recording of private conversations by third parties, either overtly or covertly. Consent to record a consultation Clinician consent to patient‐led recordings Clinicians consider that their consent to be recorded is a key issue. Perhaps surprisingly, at law in many Australian jurisdictions, the patient need not obtain explicit consent from the clinician. In Victoria, Queensland and the Northern Territory, the law does not consider a recording of a conversation that is made by one of the parties (as opposed to a third party). In New South Wales, Tasmania and the Australian Capital Territory, patients can record their consultation without the clinician's consent (or, by extension, their knowledge) if the recording is only for the patient's own use (ie, to listen back to the recording later), or to protect their lawful interests (such as in a negligence claim). In South Australia and Western Australia, clinician consent is required (ie, two‐party consent) for recording a consultation for later listening‐back by the patient (Box 1). Patient consent to health service‐led recordings Where the recording is made on an app like Second Ears with data stored by the health service, this is an act of health information collection about an individual that requires the patient's express or implied consent. The patient's decision to download and install the app can act as implied consent; the app's terms and conditions could also include a clear statement about patient consent. Consent of other people captured incidentally in any overt recording A consultation recording — whether patient‐led or health service‐led — might accidentally capture another conversation, for instance from the clinic's reception desk. No consent of the third party is needed in this case, because they are not a party to the recorded conversation. Typically, Australian surveillance device laws do not regulate recordings of conversations occurring in circumstances in which the parties ought reasonably to expect to be overheard, such as in public or an open hospital ward. This means that if a patient is overtly recording their own consultation while in a curtained cubicle, their inadvertent capture of another clearly heard conversation in the next cubicle would not require the consent of those having that conversation. Consent when someone else joins any overt recording If another person, such as the patient's relative or another clinician, enters a room where a consultation is being recorded, but does not join in the conversation, the new person is not a party to it and that person's consent is therefore not needed. However, if the new person does join the conversation, they become a party to it. Box 1 indicates when that new party's consent to be recorded is required. In SA and WA it is usually required. In NSW, the ACT and Tasmania it is required if the patient makes the recording intending to share it with anyone else, but not if the recording is intended only for the patient to listen to. Consent, when required, can be either express or implied. An example of how this situation might be addressed could be a health service policy to have a door sign stating prominently that a recording is in progress and that by entering the room the new participant consents to be recorded. A person entering the room could then signal their non‐consent by verbally requesting the recording be stopped. This applies to health service‐led and patient‐led recordings. Covert recordings by patients Covert recording by patients is not uncommon; a survey conducted in the UK found that 15% of respondents self‐reported recording clinical encounters without permission. A further 35% of respondents would consider covert recordings in the future.7 In the US, a similar survey found that far fewer respondents recorded covertly (2.7%);8 possibly because some health services routinely provided permission for recording. Currently, the proportion of Australian patients who record covertly is unknown; anecdotally, however, clinicians report that it is occurring.16 Covert recording has been described as a topic of “significant legal ambiguity”.17 In Australia, as noted above, the law varies significantly by jurisdiction. Only SA and WA require two‐party consent and thus prohibit patients covertly recording for their own use (Box 1). Covert recordings: legal penalties Not all consultation recordings require consent. In SA and WA, where two‐party consent is required, a person making a covert recording for their own use is subject to legal penalties; for example, in SA, fines of up to $15 000 or imprisonment for up to 3 years. In Toth v DPP (NSW) [2014] NSWCA 133, a case concerning a patient's illegal covert recording, the magistrate imposed an 18‐month good behaviour bond. Dealing with unwanted recording If their consent is legally required but the clinician does not want to be recorded, they can simply ask the patient to discontinue the recording. Regardless of whether the act of recording legally requires their consent, a clinician's refusal to be recorded, or the exposure of covert recording by a patient, may lead to breakdown of the therapeutic relationship,14 necessitating transfer of care to another clinician as per the Medical Board of Australia's code of conduct (https://www.medicalboard.gov.au/codes-guidelines-policies/code-of-conduct.aspx). While discontinuing a relationship may be appropriate in the context of misuse of an audio recording or its use with malicious intent, it would be a drastic response to a simple request by the patient to record, given the benefits of doing so. Health service‐led systems such as Second Ears may overcome this problem by incorporating clear frameworks around participation, consent and sharing. Sharing recordings with others Health care organisations sharing recordings Recordings made by the health service with the patient's consent (eg, via the Second Ears app) form part of the medical record and the organisation can lawfully share the recording in various ways, which are broadly similar across Australian states and territories. These include: with the person's consent; without the person's consent for a directly related purpose as long as the person would “reasonably expect” the disclosure (eg, in transferring care to another provider at the same service: F v Medical Specialist [2009] PrivCmrA 8); to defend a legal claim; for research in the public interest (if certain privacy guidelines are met, such as those set out by the National Health and Medical Research Council18); and with an immediate family member of the patient for compassionate reasons or to provide the patient with care when the patient is incapable of providing consent. This mirrors other parts of the medical record such as written notes and scans. If the recording is de‐identified (which may be difficult because voice patterns are distinctive and health information discussed during consultations is often reasonably identifiable), it can usually be used without patient consent for communication training within the health service. Consent may provide a more appropriate legal basis for such use. Patients sharing recordings Apps such as Second Ears facilitate patients’ sharing of recordings with family and others for treatment decision making and care. The law relating to such sharing of recordings with third parties varies between jurisdictions and also turns upon the question of whether the original recording was overt or covert. Separate legislative provisions address the act of recording compared with the recordings’ subsequent use. Two‐party consent is generally, but not always, required for patients to lawfully share recordings with third parties (Box 2). In Queensland, Tasmania and the ACT, there is a distinction between patients sharing a recording with immediate family (which can be done without the clinician's consent to share) and sharing with the wider world (which requires the clinician's consent). In NSW, unusually, a recording that is originally lawfully made with only one party's consent but with no intention to share can be subsequently shared without restriction (eg, on social media) (Surveillance Devices Act 2007 (NSW), section 11). Clear communication and consent remain the most desirable mechanisms to frame patients’ expectations and choices around the sharing of recordings with others, even where consent is not legally required. For the avoidance of doubt, an agreement to create a recording — whether a clinician's oral agreement for a patient to record on their smartphone, or the terms and conditions built into an app — should explicitly address the extent to which a patient can share the recording with others. Such an agreement might, for instance, permit the patient to share the recording with family but not publish it at large, for example, on public social media. This could override any legislative entitlement to share a recording openly. If a patient distributed the recording in violation of the terms and conditions, the health service could pursue a legal claim for breach of contract. We are not aware of previous such claims. Health services would need to weigh up the financial and reputational costs of pursuing such a claim. The use of recordings in legal proceedings Recording the consultation does not change clinicians’ medico‐legal obligations to patients. Such recordings provide transparency of the discussion and could be used as evidence of appropriate information sharing with patients, thus meeting the clinician's required standard of care. Clinicians have a duty to provide sufficient information on inherent risks of treatment and alternative treatments, to enable patients to exercise a meaningful choice. A claim may lie in negligence if the patient can demonstrate a “failure to warn”, where the clinician did not meet the appropriate standard of care and the patient consequently made an uninformed choice about treatment which resulted in harm. The importance of patient‐centred communication was highlighted in the UK decision of Montgomery v Lanarkshire [2015] UKSC 11 and the Australian case Rogers v Whitaker [1992] HCA 58. In a claim for negligent non‐disclosure, where the patient states that the clinician did not provide information concerning material risks about the proposed procedure, the recording could be used to provide evidence of the consultation. In most states and territories, whether the recording itself was taken with both parties’ consent or by one party covertly does not affect its admissibility in court. In jurisdictions where covert recording is not lawful (Box 1), an exception typically exists permitting a person to covertly record a private conversation to protect their lawful interests. An example is where there is a serious dispute between two parties regarding different versions of an arrangement (Georgiou Building v Perrinepod [2012] WASC 72). The relevant lawful interest must exist at the time of the recording (Marsden v Amalgamated Television Services [2000] NSWSC 465). The recording's lawfulness is a separate issue to its admissibility. It has been established that tape recordings are admissible to provide primary evidence of the conversation or sounds recorded on the tape. In the case of Butera v Director of Public Prosecutions (Vic) [1987] HCA 58, it was held that the tape is “a part of the machinery by which the evidence is produced”. It would follow that the recording on an app such as Second Ears provides evidence of the conversation that took place between the clinician and patient. Such a recording is admissible in court if the content is relevant and otherwise admissible, the voices are properly identified, and the recording has provenance — it is authentic, accurate and has not been tampered with. In this instance, the voices recorded would fall within the category of hearsay evidence — that is, representations made out of court that are led as evidence of the truth of the fact. As audio recordings fall within the definition of “document” in the Evidence Act 1995 (Cth) (which is uniform with most state and territory Acts), they may be admissible if they conform to the statutory requirements. As an example, in Victoria courts have the discretion to admit recordings as evidence if the evidence is relevant (Evidence Act 2008 (Vic), sections 55 and 56) and if the desirability of admitting the evidence outweighs the undesirability of doing so (Evidence Act, section 138). The recording will form only part of the record of information flow between clinician and patient. Contemporaneous notes and other non‐recorded conversations will also be relevant to determine if the standard of care has been met. There is no evidence that audio or video recordings of consultations increase litigation.19,20 A study evaluating the provision of consultation video recordings to patients found that in the high risk specialty of neurosurgery, none of the 2807 patients recorded used the video in a legal action.19 Recordings might actually reduce conflict and litigation because they overcome differences in recollection between two parties.21 Ownership of recordings Traditionally, the law has not conceived of information as property (Boardman v Phipps [1967] 2 AC 46). In Australia, patients have no proprietary interest in a doctor's medical notes (Breen v Williams [1996] HCA 57) (although legislation provides a right to access them). Nor do doctors have any proprietary interest in a patient's handwritten notes, or by extension, an overt patient‐led recording. However, a health service‐led recording such as one made using the Second Ears app could be said to be jointly created. As there are two copies of it, one held by the patient and one by the health service, it could be argued that each has some proprietary interest. A recent exploration of this position posited that there may be multiple rights holders of health data.22 This view has yet to be tested in the courts. It is appropriate to focus instead on the obligations of the different parties to protect and store the recording data. Data security and storage of overt recordings A recording made on a system such as Second Ears forms part of the medical record and the organisation must take reasonable steps to protect it from misuse, loss and unauthorised access or disclosure. Any contract with a third‐party organisation (eg, a cloud storage provider) should also reflect these requirements and address issues of security and access. Health records must be retained for a specified period; in Victoria, NSW and the ACT, this is 7 years after the patient last received care from the organisation, after which the records should be destroyed if they are no longer needed. By comparison, patients need neither keep nor protect their own copy of a recording. If the recording is made using a third‐party app, the terms and conditions of that app are relevant, adding further complexity in relation to custodianship and data protection. Conclusion Health service‐led recording technologies, of which Second Ears is an example, can draw on a framework that makes explicit all parties’ rights and responsibilities, and ensure that an authenticated version of the recording is maintained securely. Such an approach promotes shared expectations between patients and clinicians and is likely to reduce miscommunication. Our analysis found surprising diversity in Australian legislation pertaining to consultation recording, leading us to conclude that, to avoid confusion, expressly articulated permissions around the act of recording and the extent of sharing recordings are desirable. While covert recording is not uniformly unlawful in Australia, transparency promotes trust and enhances the clinician–patient relationship. There is some evidence that concerns about a heightened litigation risk as a consequence of recording are unfounded; rather, the existence of a recording should minimise conflicting recollections and enhance a sense of collaboration. While the act of recording does not alter a clinician's duty to disclose relevant information to a patient, communication skills training may be a way to alleviate concerns about being recorded.10 Box 1 – Patient‐led recordings: when is consent from the other party required for the act of recording? Jurisdiction Patient makes recording for unspecified purpose Patient makes recording intending it for personal use only Patient makes recording that is reasonably necessary for the protection of their own lawful interests Legislation Victoria, Queensland, Northern Territory Consent not required Consent not required Consent not required Surveillance Devices Act 1999 (Vic): no relevant provision Invasion of Privacy Act 1971 (Qld), s 43(2)(a) Surveillance Devices Act 2007 (NT): no relevant provision New South Wales, Australian Capital Territory, Tasmania Consent required Consent not required Consent not required Surveillance Devices Act 2007 (NSW), s 7(3) Listening Devices Act 1992 (ACT), s 4(1)(b), (3) Listening Devices Act 1991 (Tas), s 5(1)(b), (3)(b) South Australia, Western Australia Consent required Consent required Consent not required Surveillance Devices Act 2016 (SA), s 4 Surveillance Devices Act 1998 (WA), s 5 Box 2 – Can a patient share their lawfully made recording with third parties for general purposes* without the clinician's consent for the sharing? Jurisdiction Sharing with immediate family and friends† Sharing with public at large Legislation Victoria, Northern Territory No (clinician consent for sharing required) No (clinician consent for sharing required) Surveillance Devices Act 1999 (Vic), s 11(2)(a) Surveillance Devices Act 2007 (NT), s 15(2)(a) Western Australia No (clinician consent for sharing required) No (not even with clinician consent) Surveillance Devices Act 1998 (WA), s 9(2)(a)(ii), (3) Queensland, Tasmania, Australian Capital Territory Yes‡ No (clinician consent for sharing required) Invasion of Privacy Act 1971 (Qld), s 45(2)(a), (d) Listening Devices Act 1991 (Tas), s 10(2)(a), (d) Listening Devices Act 1992 (ACT), s 5(2)(b), (e) New South Wales, South Australia Yes§ Yes§ Surveillance Devices Act 2007 (NSW), ss 7(3)(b), 11(1). Surveillance Devices Act 2016 (SA), ss 4(2)(a)(i), 12(1). * Legislation usually deals separately with the sharing of recordings for different purposes, such as “in the public interest”, for protecting the “lawful interests” of the person who is sharing the recording, “in the course of legal proceedings”, “in the performance of a duty”, or as authorised by law. This table solely addresses when clinician consent is required for the sharing of a recording with a family member or with the public at large when the purpose of the sharing is not specified. This may include for the patient's health and wellbeing. It does not address sharing for other purposes. † This is typically expressed in legislation as: persons who have, or are believed on reasonable grounds by the person who is communicating or publishing the recording to have, such an interest in the private conversation (ie, the health care consultation) as to make the sharing reasonable under the circumstances. ‡ In these jurisdictions, the original recording may be lawfully made covertly by the patient for their own use, and then shared with family, without the clinician's consent. § Section 11 of the Surveillance Devices Act 2007 (NSW) is silent about the sharing (publication or communication) of recordings that were made lawfully. A recording that is made by one party without an original intention that the recording be published or otherwise disseminated is lawful in NSW: section 7(3)(b)(ii). Section 12 of the Surveillance Devices Act 2016 (SA) is silent about the sharing of recordings that were made lawfully, such as a recording made with the consent of both parties under section 4(2)(a)(i).

Megan Prictor · Carolyn Johnston · Amelia Hyatt

The involvement of patient advocates should ensure that guidelines are rigorously patient‐focused The fundamental objective of clinical management guidelines for any disease entity is to ensure that the information required to provide evidence‐based management recommendations to patients is readily available to their treating clinicians. It is well established that familiarity with guidelines by clinicians and adherence to them increases the number of patients receiving best‐practice care and improves outcomes.1 However, although management guidelines are intended primarily for clinicians, they must also reflect the patient perspective.2 Patient representation on the Melanoma Guidelines Working Party After identifying the need to produce new Australian guidelines on the management of melanoma, a multidisciplinary working party — under the auspices of Cancer Council Australia and the Melanoma Institute Australia — was established in 2014 to critically assess new evidence and update the previous national guidelines. In addition to clinicians and researchers, two patient advocates (consumer representatives), representing patients with melanoma from around Australia through their affiliations with patient advocacy and support networks, were invited to join the working party. These patient advocates had personal experience of melanoma diagnosis and treatment and extensive prior involvement in melanoma advocacy. This meant that they were able to make important contributions based on their experience as well as providing feedback from the patient networks they represented. Electronic publication Whereas the two previous editions of Australian melanoma guidelines, published in 1999 and 2008 respectively, were printed documents, each taking more than 4 years to compile,3,4 the new guidelines were electronic and were made available on Cancer Council Australia's Wiki platform.5 This publication format allowed individual sections to be published as they were completed and permitted selective updating as new evidence became available. Electronic publication has also meant that the guidelines are more readily accessible to both doctors and patients. They can simply search on their computer, tablet or smartphone for “Australian melanoma guidelines” or go directly to the guidelines website (https://wiki.cancer.org.au/australia/Guidelines:Melanoma).5 The level of evidence supporting each guideline recommendation is clearly documented, informing doctors and assisting patients in their decision‐making process. Patients’ expectations from their treating clinician When patients who are concerned about the possibility of having a primary melanoma consult a general practitioner, dermatologist or surgeon, they are entitled to expect that evidence‐based guidelines will be followed and therefore that the steps below will take place: if there are any suspicious skin lesions, they will be carefully examined; if the doctor suspects that a lesion may be a melanoma, the recommended form of biopsy will be carried out (usually complete excision biopsy with a 2–3 mm margin); if melanoma is diagnosed, the recommended treatment and likely outcome will be clearly explained; the melanoma will be staged correctly, appropriately wide surgical excision will be recommended, and the option of sentinel node biopsy will be discussed for melanomas 1 mm or greater in Breslow thickness or 0.8–1.0 mm in thickness with higher risk pathological features, so that prognosis can be estimated accurately and the eligibility for adjuvant post‐operative systemic therapy can be determined;6,7 and the potential benefits and possible side effects of adjuvant therapy will be discussed. When patients are given a diagnosis of metastatic melanoma in regional lymph nodes, or at a systemic site and are referred to a surgeon, medical oncologist or radiation oncologist, again, they should be able to expect that the following will happen: appropriate surgery will be recommended, and surgery that may be unnecessary (eg, completion lymph node dissection for sentinel node positivity8,9) will not be undertaken without a full discussion of the advantages and disadvantages; and if surgery is not considered appropriate, therapeutic systemic therapy options will be discussed, again with a realistic description of the likely benefits and possible side effects.10 Use of the guidelines While different stakeholders will use guidelines in different ways, they are intended to be useful to both clinicians and patients: to GPs, particularly those who work in skin cancer clinics; to dermatologists, who see many patients when they first present with a primary melanoma but who rarely manage patients with metastatic melanoma; to surgeons who treat patients with both primary and metastatic melanoma; to medical and radiation oncologists who are involved in the care of patients with metastatic disease; and importantly, to patients by providing a reliable source of information. It is hoped that by having access to guidelines based on the best available evidence, both treating clinicians and patients will be better informed, treatment options will be better understood, and patients will receive the most appropriate care. The ongoing involvement of patient advocates in the process of developing and updating the Australian melanoma guidelines should ensure that they are useful and relevant to patients and that the health care outcomes most valued by them are considered, resulting in guidelines that are rigorously patient‐focused, as they should be.

Alison E Button‐Sloan · John F Thompson

Name badges are a simple additional method of communicating doctors’ names to patients and their families, but uptake remains poor Most new relationships begin with an exchange of names and most existing relationships are reinforced using names. Except in health care. Despite campaigns such as #hellomynameis (https://www.hellomynameis.org.uk/), clinicians’ names remain absent from many health care experiences and environments. Patients meet many people during an illness journey, particularly when that takes place in a public hospital. There are nurses rotating through different shifts, the specialist under whom the patient is admitted, a registrar, resident or intern, plus maybe a medical student or two. There are also teams of allied health providers. One study found that 75% of inpatients were unable to name anyone when asked to recall the name of the physician in charge of their care.1 Limited recall of doctors’ names is part of a broader pattern. Only 42% of patients can name their diagnosis at discharge,2 and in a study of older patients, only 18% of patients could recall a single message one hour after the ward round, falling to 9% four hours after the ward round.3 The very basic components of effective health care communication, particularly in hospitals, are lagging. Barriers to effective communication are complex and structural.4 Let's for a moment focus on the most fundamental information transfer in any patient–doctor encounter: names. Patients’ names are documented from the moment of admission, printed on sticky labels, placed on wrist bands, attached to meal trays, printed on patient lists, and displayed and discussed in ward and team meetings. In contrast, doctors’ names usually appear only on faded ID swipe cards attached at the hip, or on crowded lanyards around the neck. This asymmetry in identification is just one symptom of the enormous information gulf separating patients and their doctors. Studies consistently show that the majority of patients believe doctors should wear name badges,5 with a preferred site being the breast pocket.6 In 2019, our hospital introduced voluntary name badges for all interns and residents. Something as simple as a name badge, which nearly every other service‐oriented industry employs without question, required careful navigation in the hospital. What name should appear on the badge? Should surnames be included? Should “Intern” or “Resident” or just “Doctor” appear on the badge? Badges were rolled out to interns and residents at the start of the clinical year with a mixed response. Anecdotally, senior doctors commented favourably on the badges, and nurses and allied health workers found it helpful for learning and remembering the names of doctors rotating through their wards. Mid‐year, we collected data on how many interns and residents were wearing badges. During two compulsory teaching sessions, we quietly counted the number of interns and residents wearing name badges: adherence was a lowly 25%. To determine why three‐quarters of interns and residents were not wearing badges, we circulated a voluntary, anonymous and electronic survey to all 108 interns and residents. Our aim was to identify levers or incentives that we could incorporate into a series of behavioural nudges to improve name badge adherence. Around one‐third (34%) of the cohort took part in the survey, 80% of whom did not wear their name badge. Half of respondents reported that their ID swipe card contained their name and was sufficient. About one‐fifth (22%) did not see a need to wear a name badge and a similar number mentioned that senior doctors not wearing badges discouraged them from wearing one. Not wanting members of the public or patients to know their name was a reason indicated by 16% of respondents. Free text responses mainly centred on forgetting to, or being annoyed by, attaching it each day. In response, we have developed new strategies to increase name badge adherence. For example, a brief lecture will be given on the evidence‐base underpinning good communication, coffee vouchers will be provided to doctors seen wearing their badges, badges will be provided to new interns during orientation, and name badges will soon be rolled out across the hospital for all medical staff. Making name badges available to senior doctors is important as they can influence the cultures within units and teams, and our cohort identified a lack of badges among seniors as a barrier to adherence. An informal poll of intern and resident representatives across New South Wales suggests a similar pattern of poor name badge adherence. Five networks with name badges reported that adoption by junior doctors was low. Four networks did not provide name badges. Only three networks provided name badges and have good adherence among junior doctors. As pressure on hospitals, and our clinical interactions, continues to grow, we must look for ways to support effective communication. Alongside a clear introduction, easy‐to‐read name badges reinforce familiarity and contribute to rapport between patients and our (increasingly) busy workforce.

Benjamin D Bravery · Jovana Stojkov · Jeremy Brown

Overcoming patient, GP, and health system barriers to changes in care delivery are critical to progress

Charlotte M Hespe · Anna Campain · Ruth Webster · Anushka Patel · Lucie Rychetnik · Mark F Harris · David P Peiris

Some form of diagnostic error occurs in up to one in seven clinical encounters, and most are preventable Diagnosis consists of eliciting information from history and examination, formulating a differential diagnosis, and selecting a final diagnosis based on the predictive value of specific clinical features and laboratory investigations. A timely and accurate diagnosis is every patient’s expectation. Prevalence, impacts and causes of diagnostic error Diagnostic error comprising missed, wrong or delayed diagnoses (Box 1) affects between 8% and 15% of all hospital admissions in the United States,1,2 with similar rates among patients with common diseases attending outpatient clinics.1 As many as 1.1% of adult hospital admissions will involve diagnostic error that causes harm to patients.3 Nearly a third of all preventable deaths in acute hospitals in the United Kingdom are attributed to diagnostic error.4 In Australia, an estimated 140 000 cases of diagnostic error occur each year, with 21 000 cases of serious harm and 2000–4000 deaths.5 Almost one in two malpractice claims against general practitioners involves diagnostic error.6 More than 80% of diagnostic errors are deemed preventable.7 Cognitive factors in clinician decision making are primary or contributory causes of more than 75% of diagnostic errors, with system errors (eg, missed communication or follow‐up of a laboratory test result) being less frequent.1 Failure to formulate an adequate differential diagnosis8 and overconfidence in incorrect diagnoses9 are major contributors. Clinical culture discourages disclosure of diagnostic errors and they are largely neglected within professional training curricula10 and organisational quality and safety programs.11 Identifying the cognitive causes of diagnostic error which can inform preventive strategies requires an understanding of clinical reasoning (Box 2).12,13,14,15 Intuitive thinking is the preferred reasoning mode, using heuristics (ie, mental shortcuts or rules of thumb) to accelerate the process by limiting the load on short term working memory to no more than seven ideas at a time. While efficient and accurate in many situations, heuristics can be misapplied due to cognitive bias (Box 3). Emotions, fatigue, distractions, peer opinions, and cultural norms can also further impair cognitive fidelity. Strategies to prevent diagnostic error Various preventive strategies have been proposed, the choice of which may vary according to clinician experience, types of clinical scenarios encountered, and the clinical environment. Optimise the clinical interview Taking a good history, including collateral information from relatives and other health professionals, and performing an adequate physical examination are fundamental. In combination, these will yield the correct diagnosis in more than 80% of cases,16 while failure to enact them contributes to 40% of missed diagnoses.5,17 Target education to specific scenarios commonly associated with diagnostic error Knowledge deficits are infrequent (< 5%) causes of diagnostic error among practising clinicians.18 It is not that clinicians are unfamiliar with a diagnosis, they simply fail to consider it when appropriate. Educational interventions to increase overall knowledge do not necessarily improve diagnostic performance.19 More useful is tuition focused on scenarios involving frequently missed or wrongly diagnosed conditions, including vascular events, infections, cancer, and neurological disorders (eg, multiple sclerosis).20 Targeted training, such as how to recognise subarachnoid haemorrhage,21 has prevented some condition‐specific diagnostic errors. Verify past diagnostic labels Between 11% and 40% of listed diagnoses in older patients with Parkinson disease, dementia, heart failure and chronic obstructive pulmonary disease do not satisfy accepted diagnostic criteria.22 Verification of past diagnoses, especially those based solely on subjective judgements and lacking specific diagnostic tests, is needed when clinical trajectories are atypical or appropriate therapies yield no response. Implement strategies for reducing cognitive errors Recent reviews describe various strategies for reducing cognitive errors23,24,25 with varying levels of evidence of efficacy. Lectures, seminars, group discussions, and interactive videos can all improve knowledge of cognitive biases and debiasing strategies, broaden differential diagnosis, and enhance reasoning processes. However, evidence of improved diagnostic accuracy is lacking, suggesting that, despite such educational interventions, clinicians may still not reliably identify when biases are influencing diagnostic decisions. Diagnostic checklists can take various forms: a generic checklist prompting clinicians to optimise their cognitive approach; a differential diagnosis checklist prompting clinicians to consider the correct diagnosis as a possibility; and Only the differential diagnosis checklists show improvements in the completeness of differential diagnosis in simulated or actual cases.27 In one study, a differential diagnosis checklist led to fewer errors overall;28 another similar tool combined with a debiasing checklist increased diagnostic accuracy compared with intuitive reasoning.29 Cognitive forcing strategies, defined loosely as any form of disciplined thinking, require clinicians to consciously slow their thinking and systematically evaluate all potential alternatives and mimics before finalising a diagnosis.30 In some studies,31 but not others,32 this approach improves diagnostic accuracy compared with first impression diagnoses or reasoning without any specific instruction. In one study, instructing participants to reconsider their diagnosis after removing a distracting detail from the case outline greatly improved diagnostic accuracy.33 Similar to cognitive forcing strategies, analytical reasoning involves instructing participants to use a guided, analytical approach (System 2) rather than rapid intuition (System 1). Diagnostic accuracy improves,34,35 more so when dealing with complex cases,36 and in a randomised trial,35 this approach overcame deliberate attempts within test cases to induce cognitive biases. Deliberate practice actively engages clinicians in solving diagnostic conundrums (real or vignette) and verbalising their reasoning (“thinking out loud”) as the case unfolds.37 By comparing participants’ reasoning with those of an expert who has worked through the same case, cognitive errors and knowledge deficits can be identified. Simply seeing more cases, without any attempt at calibration, does not guarantee diagnostic expertise,12 although whether deliberate practice improves diagnostic accuracy remains uncertain. Metacognition involves clinicians thinking about their thinking and reflecting on past diagnoses and appropriate use of heuristics. In some studies, cued and modelled reflection improves diagnostic accuracy compared with a more generic, free‐floating reflection38 or leaving participants to reflect in whatever way they choose.39 Seeking second opinions on one’s diagnoses from one’s clinical peers can increase diagnostic accuracy by as much as a third.40 Seeking the diagnostic opinion of patients, families and other members of the health care team, even if expressed in general terms, can also help detect and prevent errors.41 Following up patients over time, asking patients and colleagues to report errors, and implementing protocols for identifying errors (eg, trigger tools within electronic medical records for identifying unexpected adverse events or unplanned readmissions, or systematic identification of errors within mortality and morbidity meetings) all provide information on final outcomes, thus checking the accuracy of initial diagnoses. Such strategies, combined with reflection on identified errors (“cognitive autopsies”), improve diagnostic performance.42,43 Such feedback is important as clinicians’ self‐assessment of their diagnostic accuracy is unreliable and their level of diagnostic confidence can be insensitive to both accuracy and case difficulty.9 Feedback also tempers over‐reliance on the results of diagnostic tests that are at odds with the overall clinical picture and likelihood of a specific disease.44 High risk clinical environments, in which diagnostic error is more likely to occur, require clinicians to be more vigilant about their reasoning in such circumstances.45 Rushed clinical handovers, heavy caseloads, distractions and interruptions, caring for critically ill or complex multimorbid patients, interactions with uncooperative or non‐communicative patients, and clinician fatigue or personal stressors are some examples.46 Computer‐assisted diagnosis in various forms can improve diagnostic performance. Computed decision support systems that generate differential diagnoses using inputted clinical data yield small improvements in diagnostic accuracy when clinicians revisit their diagnoses following a differential diagnosis generator consultation.47 A digital image library of skin eruptions increased diagnostic accuracy of dermatology residents by 19% in a randomised trial.48 An interactive computed decision support system achieved up to 75% reduction in diagnostic errors relating to vignettes of neurological disorders.49 A web‐based system that facilitated internet crowdsourcing of multiple opinions improved diagnostic accuracy among junior physicians.50 Acknowledging, explaining and sharing diagnostic uncertainty with patients helps to protect clinicians from rushing to ill‐considered diagnoses. Up to 40% of first‐contact primary care consultations involving a diagnostic question do not yield a definite answer.51 In such situations, clinicians may feel pressured to prematurely commit to a diagnosis in order to activate management plans and demonstrate competence. In contrast, patients welcome an open discussion of possible differential diagnoses and a plan and timeline for ongoing review.52 Injudicious ordering of multiple diagnostic tests to reduce uncertainty does not reduce patient anxiety and may cause harm from false positive results.53 Need for more research into diagnostic reasoning While we have sought to shed light on the causes and prevention of diagnostic error, we concede current research has several limitations: enrolment of predominantly novice rather than experienced clinicians; non‐randomised or before and after designs; relatively small samples; short term follow‐up; variable methodological rigour; missing data; and multiple, often unvalidated, measures of error and reasoning style. Primary outcome measures are restricted to improvements in knowledge or skills in vignette studies, although these are deemed reliable proxy measures of real‐world decision making.54 Strengthening the evidence base for error mitigation is one objective of the recently established Australian and New Zealand Affiliate of the US Society to Improve Diagnosis in Medicine. This group aims to improve clinical diagnosis in this country with planned initiatives in practice improvement, research, education, and patient engagement (Supporting information). Conclusion Despite limitations in current research, the scale and harm of diagnostic error obliges clinicians to consider adopting preventive strategies that have reasonable face validity, are easily implementable in workplaces, and target individual decision making. Box 1 – Typology of diagnostic error Diagnostic errors can be of three types: missed diagnosis — the correct diagnosis was never considered; wrong diagnosis — the provisional or working diagnosis is incorrect; delayed diagnosis — sufficient information was available to enable the correct diagnosis, which was eventually made, to be made at an earlier time. The term “overdiagnosis” refers to a separate concept where a diagnosis is correct (eg, a patient has prostate cancer) but the diagnosed condition is not causing symptoms, is of low grade of malignancy, and will not prematurely kill the patient before they die of other diseases. In this scenario, the very act of diagnosing this disease may actually cause harm by invoking needless clinical intervention. It is different to when a diagnosis is actually incorrect, which is the focus of this article. Box 2 – Theories of diagnostic reasoning Proponents of organised (or structured) knowledge emphasise content specificity whereby reasoning proficiency varies from case to case, depending on levels of knowledge of particular clinical scenarios. Clinicians construct multiple illness scripts as mental representations of diagnostic, therapeutic and prognostic attributes of specific conditions.12 These scripts store and, with increasing experience, elaborate knowledge in a readily accessible format for application to new clinical scenarios. This emerging expertise is further developed by deliberate practice under supervision coupled with regular feedback.13 Proponents of cognitive processing (or dual processing theory) describe a rapid, intuitive form of pattern recognition (fast [System 1]) and a more deliberate, analytical approach (slow [System 2]).14 When considering different or even single cases, clinicians oscillate between the two systems according to their level of experience and store of memorised patterns. Expert clinicians spend more time in System 1, novice clinicians more in System 2. Central to System 2 is the hypothetico‐deductive model whereby the initial problem representation, gained from history and containing key clinical features (or cues), triggers a number of possible diagnostic hypotheses. These are ranked in decreasing likelihood and, based on further information from hypothesis‐driven, focused physical examination and selected laboratory investigations, gradually eliminated in arriving at a provisional diagnosis. The two schools of thought are not mutually exclusive and are in fact interdependent. Clearly, more hypotheses may be generated, or more patterns recognised, if the clinician can draw on a larger store of illness scripts that share cues with the problem at hand. Similarly, knowledge becomes more organised more quickly if clinicians consistently and systematically apply analytical thinking to obscure or atypical cases. Approaches to improving diagnostic reasoning vary in their emphasis on expanding organised knowledge, mitigating cognitive bias, or optimising system of care factors according to how much each, in different circumstances, is considered the prime determinant of diagnostic error.15 Box 3 – Common cognitive biases in diagnostic reasoning Bias Definition Example Premature closure Narrow rapid focus on single or a few clinical features in the clinical presentation to support a diagnostic hypothesis without considering other alternatives Patient with rheumatoid arthritis who is receiving immunosuppressive medication presents with shortness of breath, inspiratory crackles on chest auscultation and diffuse fine infiltrates on chest x‐ray. Congestive heart failure is quickly accepted as the diagnosis but subsequent bronchoscopy reveals Pneumocystis pneumonia Anchoring bias Tendency for clinicians to cling to their initial diagnostic hypotheses even as contradictory evidence accumulates Patient with end‐stage renal disease presents with altered mental status and myoclonus of the left arm, which is attributed to uraemia (the anchor). Failure of this syndrome to improve with dialysis (contradictory evidence) is underweighted until clinicians finally accept the eventual diagnosis of status epilepticus Confirmation bias Tendency to selectively search for features that support the initial or favoured diagnostic hypotheses rather than take deliberate note of features that challenge these hypotheses Patient with past history of coeliac disease presents with symptomatic anaemia and low reticulocyte count, which is diagnosed as iron deficiency anaemia. Iron studies showing borderline low serum ferritin are interpreted as confirmatory evidence, while the finding of a widened mediastinum on chest x‐ray is ignored. The patient is later diagnosed as having a thymoma associated with aplastic anaemia Availability bias Tendency to overestimate the probability of a diagnosis based on how easily it is recalled, which is often skewed by recent and memorable, or emotionally laden cases A clinician who has recently seen a patient with myosarcoma who presented with left calf pain then begins to evaluate all subsequent similar presentations for the possibility of the same diagnosis Representativeness bias/base rate neglect Tendency to greatly overestimate the likelihood of a rare diagnosis on the basis of some prototypical features of that disease Patient presenting with pulsatile headache, palpitations, diaphoresis and elevated blood pressure is diagnosed as having a pheochromocytoma (rare disease) whereas anxiety syndrome complicated by severe migraine (common disease) is later verified Framing bias Tendency for a presentation to be framed in a certain way according to past diagnostic labels (diagnostic momentum) or clinical setting (eg, medical v a surgical ward) Patient with long‐standing anorexia nervosa and post‐traumatic stress disorder presents with weight loss, abdominal pain and diarrhoea. Her past history causes the clinician to frame the problem as one related to her mental health, leading to a diagnosis of irritable colon and laxative misuse associated with restrictive feeding. The presence of intermittent rectal bleeding and an elevated erythrocyte sedimentation rate (ESR) are underemphasised. The patient is eventually diagnosed as having Crohn’s disease

Ian A Scott · Carmel Crock

To the Editor: We read with interest the article by Koff and Lyons1 and agree that there is a need to develop, implement and evaluate health systems around patient needs and wishes. Implementing value‐based health care is an excellent initiative to address sustainability and patient‐centred care.2 Genuine reform requires a transition away from volume‐based service contracting towards a multidisciplinary approach focused on evidence of improved outcomes.1,2 This would reward doctors and the system for keeping patients healthy and independent in their own homes, with community support, for as long as possible.2 The Leading Better Value Care initiative (2016–2020)1 may be misinterpreted as another set of top‐down policies. It may also have unintended consequences such as reinforcing the silo approach to disease states, diverting finite hospital and local health district resources, such as staff and expertise, to these 13 policy‐driven priority projects. In our work in perioperative health care, we have identified some concerns. First, the sustainability of our health systems is tested by patients who are frailer, who have chronic diseases, and who present for high risk surgery.1,3,4 Second, these patients have a higher incidence of post‐operative complications3,4 and are more likely to be discharged to a higher care facility, rather than back to their home.4 Third, performing surgery on these patients is associated with higher costs and hospital readmissions.4 Fourth, our research has found that past policy for surgical patients5 has led to today's “wicked problem”; that is, frontline perioperative clinicians and managers are dealing with lack of time, increased demand for precision, fragmentation of care, lack of coordination across an episode of care, bed block, complexity of care, and unclear patient outcome measures. In this context, work is required to empower patients and staff in shared decision making to understand the true complexity of risks and outcomes associated with high risk surgery. In conclusion, implementing statewide value‐based care is timely and can be transformational. The high risk surgical patient cohort and the staff providing their care are likely to benefit from, and should be included in, this important reform agenda.

Su‐Jen Yap · Roberto Forero · David Greenfield · Kenneth M Hillman

A live‐streamed teaching strategy that can be applied to all areas of medicine and many clinical scenarios The emergence of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) has resulted in unprecedented challenges to hospitals, the community and society. Although the necessary focus has been to care for patients and communities, the profound effects of coronavirus disease 2019 (COVID‐19) have disrupted medical education and required intense and prompt attention from medical educators. COVID‐19 poses unique challenges to the clinical clerkship model that is fundamental to medical students’ education and has the potential to change forever how future physicians are educated.1 For more than a decade, medical schools have been working to transform pedagogy by reducing live face‐to‐face didactic lectures; using technology and simulation; implementing team‐facilitated, active and self‐directed learning; and promoting individualised and interprofessional education.2,3 However, as described by Sir William Osler, clinical teaching of medical students at the bedside remains vitally important: “to study the phenomena of disease without books is to sail an uncharted sea, while to study without patients is not to go to sea at all”.4 Medical graduates must function in a team‐based, collaborative work environment, have sound knowledge and clinical skills, and have a capacity for lifelong learning.5 In response to COVID‐19, there has been rapid development of the “boot camp” model of accelerated learning for final year medical students to support their swift transition to assistants in medicine. However, it is unclear how medical schools will manage students from the middle years of medical school, where clinical exposure is a vital part of clinical education. Typically, during years 3 and 4 of the Doctor of Medicine degree at the University of Newcastle, students spend about 50% of their time attached to wards, clinics, operating theatres and other clinical exposure opportunities. How can this clinical education continue while medical students are omitted from the clinical environment due to the COVID‐19 pandemic? Further, given that social distancing is anticipated to last many months, clinical teaching rounds with multiple medical students are unlikely to be able to recommence soon. The clinical teaching team from the University of Newcastle at John Hunter Hospital have developed the concept of “live‐streamed ward rounds”. The initiative addresses the challenge of maintaining the clinical clerkship model of education while students are excluded from the hospital for several months during the vital early years of clerkship training. This model of education has three phases (Box 1), which broadly align to advanced cognitive levels of learning expected of medical students. The Hunter New England Local Health District Ethics Committee confirmed that ethics approval was not required for this project. Phase 1: student remote observation (assess and analyse) Clinicians undertake routine ward rounds with medical students in attendance as part of routine inpatient care. During live‐streamed ward rounds, a medical student is engaged securely (password‐protected) via mobile phone to participate in the ward round, including discussion before and after a patient visit. In addition to participating in discussions, similar to face‐to‐face teaching, the student can be shown clinical records (eg, pathology results, observation charts, medical imaging, intraoperative photographs) on video via platform‐agnostic streaming software (eg, Skype for Business, Pexip, Zoom) to broaden engagement with the clinical interaction. When the patient is visited, the patient provides verbal consent for student involvement in the live‐streamed round before the consultation. This is documented in the clinical record of each patient. After obtaining verbal consent, student introduction occurs by turning the phone around so the patient can see the student and vice versa. After the introduction, the phone is turned back to the clinician so the student can see the clinician holding the phone to observe non‐verbal cues. No streaming of the clinical examination occurs during the patient encounter. When the consultation is complete, the phone is turned briefly to the patient to facilitate eye contact when the student thanks them for permission to participate in the encounter. This process is repeated with each patient on the ward round, after which the student is involved in the post‐round clinical discussion that occurs routinely as part of multidisciplinary patient care. The phone is muted or disconnected during the patient encounter if the patient declines student involvement. Phase 2: student preparation (evaluate and synthesise) During the live‐streamed ward round, the student is directed to take detailed notes so they can formulate a series of case presentations for the subsequent student case‐based ward round. The medical student obtains any missing medical information from the junior medical officer at the completion of Phase 1. Clinical records are not available electronically for the students. The aim is to prepare the student for the role of a junior medical officer in the ward environment. Phase 3: student remote case‐based ward round presentation (construct and justify) This element of the learning cycle is typically held later in the week of the live‐streamed clinical round at a time when three to 40 students can be engaged simultaneously for 60–90 minutes through videoconferencing software. The student who attended the live‐streamed clinical round presents each patient to the group as if they were a junior medical officer performing clinical handover. A clinician educator is present to facilitate case‐based discussion. After each patient is discussed, the student presents what actually occurred on the clinical round and presents the plan for ongoing care with justification. This element of the interaction is designed to emphasise patient‐centred care. We have conducted live‐streamed rounds at John Hunter Hospital in obstetrics, gynaecology and birth suite handover rounds. Approval was provided by the hospital executive after review by the local health district privacy team — student involvement by phone using a secure application (Skype for Business) was thought to be similar to student involvement with telehealth consultations in outpatient clinics. The benefits and challenges experienced with live‐streamed ward rounds are summarised in Box 2. After completion of 50 live‐streamed rounds, an informal evaluation was conducted via an anonymous voluntary Qualtrics online survey. Most of the 25 student respondents and clinicians provided positive feedback. Key findings from this survey are presented in the Supporting information. Clinical teaching is a fundamental component of medical education, particularly for developing tangible and intangible skills of medical students.6 Bedside teaching is a key opportunity for medical students, with the presence of the medical teacher, to develop medical knowledge, history taking and physical examination skills, clinical data gathering and clinical decision making.7 While students cannot participate in the clinical examination component of the patient interaction during live‐streamed ward rounds, they can hear the relevant history taking. Evidence indicates that physicians can collect 60–80% of the information relevant for a diagnosis just by taking a medical history, leading to a final diagnosis in more than 70% of cases.8 Previous studies investigating factors that are most important in creating an effective learning environment for medical students found that the level of participation students are afforded in the workplace is vital in clinical practice learning.9 Greater participation in the workplace facilitates greater confidence and competency, especially in clinical practice.9,10 A recent Australian study11 of final year medical students found the top six responses as to why students found clinical venues the most educationally useful include: the amount of patient contact; various patient presentations; being part of the clinical team; the opportunity to ask questions and receive useful information; the high level of supervision in training; and the amount of formal bedside teaching. Tutorials in a clinical setting also allow for professional development to be taught, such as communication, teamwork and ethics.12 Students require teaching in real clinical settings to develop skills for success in the real clinical environment. The structured live‐streamed ward round stimulates student participation and effectively develops clinical knowledge, enhances depth and permanency of learning, and enriches the stability and dependability of the knowledge attained. Being able to follow up patients to discharge is the ideal ending to these scenarios, where the student can see how effective the management plan was, as well as its implementation and results.11 We identified quality supervision as a key factor for maximising the educational value of clinical learning in live‐streamed ward rounds. Supervisors who are experienced and engaging make students more motivated to critically analyse patients’ clinical conditions, encourage their learning about these presentations, and formulate management plans.13,14 Live‐streamed clinical encounters should inspire us to revisit and prioritise the development of virtual clinical encounters, involving detailed scenarios that can be delivered flexibly, are always accessible and adaptive, and prioritise individualised learning. There are many advantages to live‐streamed clinical encounters, including their cost‐effectiveness in both set‐up and maintenance, the possibility of increasing access and usability of streaming technology, and allowing for the nuance of expertise and immediate feedback. As demonstrated by the COVID‐19 pandemic, they can be rapidly implemented and use principles of adult learning. The live‐streamed teaching strategy can be applied to all areas of medicine and many clinical scenarios, including ward rounds and clinical handover rounds. Recommendations on how to introduce this innovative teaching method are summarised in Box 3. This strategy is one of the many that the University of Newcastle plans to use to provide ongoing clinical teaching during the COVID‐19 pandemic. Being adaptable and flexible, cognisant of costs and driven by evidence are critical features of delivering medical education and contemporary medical practice.15 Box 1 – The three phases of the live‐streamed ward round Box 2 – Benefits and challenges of live‐streamed ward rounds Benefits The program is able to continue while students are not allowed in hospital The program is able to run while social distancing rules severely limit the number of students physically able to attend face‐to-face ward rounds The program facilitated discussions in Phase 3 which can go into greater depth than is possible in a ward environment The program provided the ability to engage larger number of students than possible in physical ward rounds The program creates more opportunity to simulate the role of a junior medical officer The program moderates clinical team variability for capacity to provide equivalent learning focus each week Challenges The program may potentially slow down ward round There is risk of technological limitations (eg, dependent on mobile phone signal and teleconferencing software) There are timetabling challenges in an unpredictable clinical environment There is inability to observe or participate in physical examination There is a loss of some of the valuable elements of the informal curriculum on ward round (eg, exemplary professional values, behaviour and collegiality via positive role modelling) Box 3 – Recommendations for introducing live‐streamed ward rounds into teaching Step 1 Design a live‐streamed round and a follow‐up reflective simulation round. This should include addressing the process for privacy, consent and technology (ie, preferred mobile videoconference platform) Step 2 Include discipline and departmental consultants running the live‐streamed round and follow‐up round in reviewing the design Step 3 Include technology support officers in reviewing the design Step 4 Seek written approval from relevant senior local health district and hospital staff (eg, medical and clinical directors) Step 5 Pilot, refine, implement

Craig E Pennell · Hannah Kluckow · Shirley Q Chen · Kerrie M Wisely · Ben LD Walker

To the Editor: A recent article highlighted a case where self‐collection enabled detection of an early cervical adenocarcinoma and curative treatment in a previously underscreened woman.1 This case underlines the important benefits from self‐collection making cervical screening more accessible and acceptable to women who have previously declined or delayed screening. Unfortunately, self‐collection is currently very underutilised in Australia. Although it is currently restricted to women aged 30 years and over who are 2 or more years overdue for cervical screening, potentially around a million women are eligible.2 In contrast, data from Medicare, VCS Pathology, and the National Cancer Screening Register suggest that fewer than 6000 self‐collected tests were processed over 2018 and 2019, indicating that less than 1% of eligible women have had a self‐collected test. What drives this discrepancy? Self‐collection is highly acceptable to underscreened Australian women, and very high uptake can be achieved with appropriate clinical support.3 A recent survey reported that many practitioners, especially outside Victoria, do not yet feel comfortable discussing or recommending self‐collection, and lack confidence that self‐collection is a reliable test.4 Potentially, this is due to an initial delay in self‐collection being available, confusion about eligibility, and current restrictions giving the false impression that self‐collection is less sensitive. Self‐collection is now available to eligible women nationally (provided samples are sent to one of two accredited laboratories, which accept samples from anywhere in Australia), and updated evidence demonstrates that polymerase chain reaction‐based human papillomavirus (HPV) testing is equally sensitive for detecting pre‐cancer in self‐collected and clinician‐collected samples.5 Another barrier may be difficulties for providers in checking whether women are eligible. The rollout of the provider portal into the National Cancer Screening Register, allowing providers to view a woman's screening history at the point of care, will be important in addressing this issue. Many screening‐eligible women who have not had their first HPV test are now overdue and could be eligible for self‐collection. Self‐collection is a reliable test now available nationally to eligible women, which can have a transformative effect in the lives of underscreened women, as shown in the recent case study.

Megan Smith · Marion Saville · Karen Canfell