General medicine

Objective: To identify sustainable governance arrangements for health care organisations undertaking integrated health service delivery based on best available evidence.Method: Systematic review of the literature (1990–2006), supported by key informant interviews as an integrative process.Results: 16 studies met our selection criteria. All described enablers of and barriers to delivering integrated health services. We identified three models for integrated health care governance with a demonstrated ability to be sustained in the medium term. Common themes that emerged as the logical starting point for more ambitious integrated governance arrangements regionally were: the need for a clear separation between governance and operational management; and the need for local communities with the vision, leadership and commitment to extend health service integration. These themes were reinforced by interviews with key informants. Careful measurement of the process, impact and outcomes of such activities was often overlooked.Conclusion: State governments are increasingly attempting to work with non-government organisations and the private sector to maximise scarce resources in the face of increasing health care demand. Ambitious integration agendas must be underpinned by effective governance mechanisms that are appropriate to the undertaking, the stakeholders involved and the scale of delivery.

Claire L Jackson MPH, GradCertMgmt, FRACGP · Caroline Nicholson GradDipPhysio, MBA, GAICD · Jenny Doust BM BS, PhD, FRACGP · Lily Cheung BA(Communications) · John O’Donnell MB BS, DipRACOG, MHP

Objective: To examine policy and implementation issues around multidisciplinary care planning (MDP) as a means of improving outcomes for patients with chronic disease and/or complex care needs.Methods: We conducted a series of five systematic reviews of the literature from 1990 to 2006, sampling a spectrum of issues associated with chronic disease and complex health care needs, with a focus on planning and provision of multidisciplinary care.Results: Our review showed that MDP does improve many functional outcomes in the areas studied. Analysis of MDP programs involves examination of two groups of variables — the multidisciplinary components (a range of clinical perspectives and specialist knowledge) and team components (eg, communication and support). Implementing MDP requires changing patterns of interaction between care providers, alignment of roles and work practices, and changes to organisational arrangements.Conclusion: While MDP improves many functional outcomes, widespread implementation of MDP in standard practice will require complex and targeted strategies. Devising and testing such strategies is a prerequisite for widespread, routine use of MPD in chronic disease management.

Geoffrey K Mitchell FRACGP, PhD · Jennifer J Tieman BSc, MBA · Tania M Shelby-James BAppSc, MPH

Objectives: To identify the types of strategy used to coordinate care within primary health care (PHC) and between PHC, health services and health-related services in Australia and other countries that have comparable health systems, and to describe what is known about their effectiveness; to review the implications for health policy and practice in Australia.Methods: We conducted a systematic review of the literature (January 1995 to March 2006) relating to care coordination in Australia, the United States, the United Kingdom, New Zealand, Canada and The Netherlands. Our review was supplemented by consultations with academic experts and policymakers.Results: Six types of strategy were identified at patient/provider level, falling into two groups: (i) communication and support for providers and patients, and (ii) structural arrangements to support coordination. These were broadly consistent with existing typologies. All were associated with improved health and/or patient satisfaction outcomes in more than 50% of studies, and interventions using multiple strategies were more successful than those using single strategies.Conclusions: The largely incremental approach to improving coordination of care in Australia has involved a broad range of strategy types but has also perpetuated existing structural problems. Reforms in governance, funding and patient registration in primary health care would provide a stronger base for effective care coordination.

Gawaine Powell Davies BA, MHP · Anna M Williams BSc, MPH · Karen Larsen BSc, GradDipPH · David Perkins PhD · Martin Roland DM, FMedSci · Mark F Harris MD

Objective: To review the implementation and impact of different funding initiatives across the health systems of three different countries — England, New Zealand and Australia — on the achievement of multidisciplinary primary health care (PHC) and to reflect on policy implications for Australia.Methods: A systematic review of the literature involving three stages: (i) identification and description of initiatives; (ii) a systematic review of their implementation and impact from 1995 to mid 2006; and (iii) an updated review of published literature from mid 2006 to mid 2007.Results: Few studies employed control groups, and the results should therefore be interpreted with caution. In all three countries, funding has supported general practitioner access to a broad range of providers. In Australia, financial incentives have been the main mechanism for bringing about change, whereas in both England and New Zealand, they are part of a broader range of funding reforms including the introduction of capitation and practice-based commissioning. The lack of patient data makes it difficult to assess the extent to which the Australian financial incentives have generally improved population access to a broader range of PHC providers.Conclusion: Individual, patient-level, financial incentives may present significant impediments for population subgroups with complex needs. Alternative funding arrangements, such as capitation and contracting, could be more widely adopted in Australia to enhance access to care for vulnerable population groups without fundamentally changing the overall fee-for-service financing arrangements.

Julie McDonald MPH · Mark F Harris DRACOG, FRACGP, MD · Jacqueline Cumming MA, DipHealthEcon, PhD · Gawaine Powell Davies BA, MHP · Pippa Burns BSc(Hons), MPH

Objective: To review innovative models of primary care in different countries in order to identify potential mechanisms for reforming primary care policy in Australia.Methods: We conducted a narrative review and synthesis of evidence about models of primary care from four English-speaking comparator countries (New Zealand, Canada, the United Kingdom and the United States) and one European country (The Netherlands), with a particular focus on the relevance and applicability of these models to Australia.Results: We identified four key mechanisms for bringing about reform in primary care: flexible funding, quality frameworks, regional-level primary care organisations, and primary care infrastructure. These mechanisms are interdependent.Conclusion: There are tensions and tradeoffs involved in balancing professional and bureaucratic control and in linking quality and accountability mechanisms. Enhanced linkage between researchers, policymakers and professional groups could assist in exploring options for effective primary care reform.

Lucio Naccarella BSc(Hons), PhD · Donna Southern BSc(Hons), GradDipEpiBiostat · John Furler MB BS, GradDipPubHealth, PhD · Anthony Scott PhD · Lauren Prosser BAppHealthSc(Hons) · Doris Young MB BS, MD, FRACGP · Hal Swerissen BAppSc(Psych), GradDipPsych, MAppPsych · Elizabeth Waters GDBIS, MPH, DPhil

Successful, “innovative” primary health care (PHC) models exist that have adapted to the specific circumstances of their rural and remote context. A typology of discrete, integrated, comprehensive and outreach rural and remote services exists rather than a “one coat fits all” PHC health service model. Successful models are characterised by macro-scale environmental enablers (supportive health policy, federal–state relations, and community readiness) and five essential service requirements (workforce organisation and supply; funding; governance, management and leadership; linkages; and infrastructure). Service sustainability depends on ensuring that key systemic service requirements are met at the local level in ways that accord with, and are supported by, the broader macro-scale environmental enablers. Based on these principles, these model types are amenable to generalisation and evaluation in other regions.

John S Humphreys BA, PhD, DipEd · John Wakerman MB BS, MTropHlth · Robert Wells BA · Pim Kuipers BA(Hons), MHumServ, PhD · Judith A Jones BA(Hons), GradDipAppSci(Comp), MSPD · Phil Entwistle BSc, MTropHlth, PhD

Objective: To consider the implications for mental health policy of a recent synthesis of the literature on the effectiveness of different service delivery models for depression in primary care.Methods: A discussion based on the results of several systematic reviews of primary care models for depression management. Primary care was defined broadly within a prevention, early-intervention, treatment and recovery/support framework, and incorporated both community and general practice settings.Results: There were promising effective models for depression interventions both in the broader community and in general practice settings.Conclusions: There is a need to support evidence-based models for depression care, including innovative new technologies for facilitating consumer self-management of depression. The ability of practitioner training and guideline implementation to improve consumer outcomes for depression is limited. Policies and incentives are required to facilitate the reorganisation of general practice and, in particular, the implementation of care management as well as enhanced care and guided self-help in these settings.

Kathleen M Griffiths BSc(Hons), PhD · Helen Christensen BA(Hons), MPsych, PhD

Objective: To review the literature on the effectiveness of competency-based education (CBE) as a means of equipping the Australian general practice workforce to deliver optimal chronic disease outcomes to articulate policy options for the Australian context.Methods: Systematic review of the literature (1991–2005) using a narrative approach followed by analysis of the findings using the actors/context/ processes/content framework of Buse et al.Results: Few high-quality studies were identified. National policy options include incorporating clear statements about education and training, research and evaluation in any policy document targeting chronic disease; and provision of funding to enhance general practice teaching facilities and/or facilitate the development of supportive coordinating and administrative structures for training practices. Designers of CBE should consider five key questions: Are the educational objectives of the CBE clearly aligned with the chronic disease or workforce-related outcomes of interest? Is the design of the CBE sound? Have similar educational programs targeting the same outcomes been identified and every attempt made to maximise synergies between programs? Are the educational designers fully aware of and working within the existing complexity of the training environment? Are all involved in the program actively managing the process of change?Conclusions: Policy options range from those relatively simple and achievable to more complex and difficult. The full report is available at http://www.anu.edu.au/aphcri/Domain/Workforce/final_25_glasgow.pdf.

Nicholas J Glasgow MD, FRACGP, FAChPM · Robert Wells · James Butler BEcon, MPolEcon, PhD · Anna Gear BMedSci

Transsexual and other disorders of gender identity: a practical guide to management. James Barrett, editor. Oxford: Radcliffe Publishing, 2007 (298 pp). ISBN 978 185775 719 4. This is an outstanding book, fulfilling a marked need. Barrett, principal author and editor, is a consultant psychiatrist and lead clinician at the Charing Cross Hospital Gender Identity Clinic in London. He draws on 20 years’ clinical experience; his writing and presentation are clear and most helpful. The book concentrates on the major aspects of the health care of transgender men and women, including the role of the psychiatrist and the contributions made by other medical specialists, speech therapists, and surgeons. That the general practitioner’s role in patient care was not given emphasis surprised me. GPs are often in the best position to provide continuity of patient care and coordination of the various specialist consultations. For the male-to-female transsexual, a masculine voice may be the major obstacle to the person being accepted in the desired sex role. Two chapters describe what can be achieved by speech training and laryngeal surgery. Feminisation of the male body or masculinisation of the female body is one of the most urgent requests that transgender patients have at their first consultation. Once their diagnosis of transsexualisation has been established, they will require lifelong hormone therapy. The chapter on this subject is essential reading. It is a masterly dissertation on all of the principles of hormonal treatment and the various regimes and modes of administration. Side effects of such therapy and their management are also discussed. Discussions of surgical treatments deal with breast augmentation or reduction, removal of penis and testicles, vaginoplasty, vulvoplasty, and phalloplasty. All are excellent chapters, but that on phalloplasty deserves special mention because it deals with a difficult and complex subject in an enlightening manner. In all of these chapters, postoperative care and complications are adequately discussed, along with limitations of the various surgical procedures. The legal issues of gender change are included in a chapter that addresses marriage, the family, employment, pensions and privacy. Even transsexuals in the military services, various religious traditions and their teachings about gender change, and fertility issues affecting transsexuals are considered in the concluding chapters of the book. The editor and authors have definitely produced a practical text on gender identity disorders for everyday clinical use. I strongly recommend it to all health care professionals involved in the care and management of patients with issues of gender identity. Educators in medicine and the health sciences should consider recommending this book for their undergraduate students. It can truly be said that this book is a clinical gem.

William A W Walters

Objectives: To investigate the relationship between admission glycaemic status and inpatient mortality in patients with and without pre-existing diabetes.Design: Prospective observational cohort study.Setting: A general medical ward in an Australian tertiary referral hospital.Participants: 903 patients admitted to the general medical ward between February 2003 and July 2004.Main outcome measure: Inpatient death.Results: The overall inpatient mortality was 5.4% (n = 49). In the total cohort, age > 75 years and admission fasting plasma glucose (FPG) levels ≥ 5.6 mmol/L were independent predictors of mortality. For patients without a known history of diabetes, each 1 mmol/L rise in admission FPG was associated with a 33% increase in mortality. In these patients, elevated (> 6.0%) and normal glycated haemoglobin (HbA1c) levels were associated with mortalities of 11.3% and 4.4%, respectively (odds ratio, 2.47; 95% CI, 1.16–5.26). In contrast, in patients with known diabetes, there was no association between admission FPG levels, HbA1c and mortality. Length of stay was not independently associated with FPG, HbA1c, or diabetes status.Conclusions: In patients without known diabetes, the risk of death was increased for admission FPG levels ≥ 5.6 mmol/L. However, pre-existing abnormal glucose metabolism, reflected by elevated HbA1c levels, appeared a more important predictor of inpatient mortality than glucose levels in patients without known diabetes.

Scott T Baker MB BS, BMedSc, FRACP · Cherie Y Chiang MB BS · Jeffrey D Zajac MB BS, PhD, FRACP · Leon A Bach MB BS, PhD, FRACP · George Jerums MB BS, MD, FRACP · Richard J MacIsaac MB BS, PhD, FRACP

Objective: To investigate primary health care service utilisation and health presentations among asylum seekers living in Melbourne.Design and setting: Retrospective audit of files of people who attended three Melbourne asylum-seeker health clinics between 1 July 2005 and 30 June 2006.Main outcome measures: Rates of reasons for the encounter, diagnostic tests or investigations required, treatments prescribed and referrals.Results: Data were collected from 998 consultations corresponding to 341 people. Eighty-eight per cent of visits involved people with no Medicare access, owing to their visa status. The most common reasons for the encounter were general and unspecified symptoms or problems (rate, 59.9 per 100 encounters; 95% CI, 55–65), followed by musculoskeletal conditions (27.1; 95% CI, 24–30), and psychological problems (26.5; 95% CI, 23–30). The rate of referrals was 18.3 per 100 encounters (95% CI, 16–21).Conclusions: The three clinics providing services to asylum seekers in Melbourne are delivering care to a considerable number of people with complex health needs. A substantial number of asylum seekers present to clinics with psychological and social problems. Most cannot access government-subsidised health care. This must be addressed urgently by policy change at the federal and state and territory levels.

Ignacio Correa-Velez MB BS, PhD · Vanessa Johnston MB BS, MPH · Joanne Kirk RN · Angeline Ferdinand BA

Clinical records Patient 1 In March 2005, a 58-year-old man was referred by his general practitioner for evaluation of a central scotoma with macular sparing in his right eye of 6 weeks’ duration, noticed during reading as a sort of shadow following his point of fixation. He had had no previous ophthalmic complaints and had worn spectacles to correct moderate myopia since the age of 12 years. His health was excellent; he was on no medication and had never had a surgical procedure. Both parents had lost vision from glaucoma. For this reason, his intraocular pressure (IOP) was monitored by his brother, an optician. Over 4 years, repeated IOP measurements of under 22 mmHg had been obtained by non-contact tonometry in both eyes. On examination, visual acuity was 6/6 in both eyes. IOPs of 38 mmHg in the right eye and 30 mmHg in the left eye were obtained by applanation tonometry. A non-contact method yielded pressures of 28 mmHg in the right eye and 22 mmHg in the left eye. Further examination showed open anterior chamber angles and a myopic optic nerve head which was pathologically cupped on the right side and “suspicious looking”, with elongated vertical cupping on the left (Figure A). Later, automated visual field testing showed a large central defect in the right eye, almost reaching the point of fixation (Figure B). The left eye was normal. Therapy with eye drops (timolol/dorzolamide fixed combination, twice daily) was started, which stabilised the pressure at around 10 mmHg in both eyes. The patient’s brother, who had never consulted an ophthalmologist, was advised to do so. He showed no signs of glaucoma. Patient 2 A 69-year-old man presented in June 2005 with slowly deteriorating vision over several years. For the previous 2 months, he complained of bumping into objects in his path. He had never experienced eye pain and had been healthy all his life. His mother, whom he had accompanied to the GP and ophthalmologist for many years, had eventually become blind from glaucoma when very elderly. His sister went blind from glaucoma at the age of 65 years. Twenty-five years earlier, the patient had been seen by an ophthalmologist who saw no signs of glaucoma during a routine examination. The patient claimed that he had never been told to have regular eye checks for glaucoma, and had not done so. On examination, visual acuity was light perception in the right eye and hand movements at 2 m in the left eye. IOPs by applanation tonometry were 53 mmHg for the right eye and 49 mmHg for the left eye. Gonioscopy showed open anterior chamber angles. Both optic nerve heads were completely cupped (Figure C). Visual field examination showed no vision in the right eye and a temporal island of vision in the left eye (Figure D). In an attempt to preserve his remaining vision, medical therapy (timolol/dorzolamide fixed combination, twice daily and latanoprost, daily) was instituted, which stabilised pressures at below 18 mmHg in both eyes. He has noticed no further decline in vision since presentation. The two cases we present here are good examples of how the diagnosis of glaucoma is often missed because of lack of history-taking and/or insufficient clinical examination. Glaucoma is the second leading cause of blindness worldwide;1 nevertheless, knowledge of this disease is poor among the general population as well as among health professionals.2 Primary open-angle glaucoma (POAG) is a chronic and progressive optic neuropathy that causes visual field loss, eventually leading to complete blindness. It can be present for a long time before patients have symptoms. About half of those affected with glaucoma are not aware they have the disease.3 While the most important risk factor for POAG is elevated intraocular pressure (IOP), pressure is only one component of a constellation of findings that define POAG. Glaucoma is a specific optic neuropathy, characterised by optic nerve head cupping and usually associated with (arcuate) visual field loss. Glaucoma may be associated with elevated IOP, but can be diagnosed irrespective of the IOP, so IOP is no longer considered part of the diagnosis. Established risk factors for POAG (besides elevated IOP) are higher age, African ethnicity, a positive family history, thinner corneal thickness, and myopia.1 Diagnostic clues include gonioscopy (visualisation of the drainage angle), characteristic changes in the optic nerve head (cupping — elongation of the optic cup in a vertical direction, as result of, typically inferior, notching of the neuroretinal rim that will be the first sign of POAG), and characteristic (mostly midperipheral) defects on visual field testing. To date, the only effective evidence-based treatment for glaucoma is decreasing IOP;4 any local or systemic risk factors should also be addressed. Lessons from practice All primary care doctors should ask their patients about a family history of primary open-angle glaucoma (POAG), which is an important risk factor for this disease. Patients with POAG should be told to alert their first-degree relatives to the need for an adequate glaucoma screening. “No visual symptoms” does not equal “no POAG”, as visual field defects occur mainly at advanced stages of the disease. Pain is seldom a symptom in POAG (it is associated with acute angle closure glaucoma). About a third of patients with POAG have so-called “normal tension glaucoma”; this will not be detected by measuring intraocular pressure alone. Examining the optic disc is much more important for a correct diagnosis of POAG than measuring intraocular pressure. It is critical to note that symptoms occur late in POAG. If a diagnosis is based only on symptoms, advanced irreversible vision loss is likely. Patients with POAG need to be identified early, which requires a high level of suspicion, adequate screening and prompt referral. In many countries, primary eye care is provided by general practitioners and eye specialists. In others, this role is fulfilled by optometrists. Unfortunately, many health care workers, including (in our experience) even some ophthalmologists, only look at IOP when considering glaucoma as a diagnosis, as in our Patient 1. Over a third of patients with glaucoma have an IOP within the average range (10–21 mmHg).5 They have “normal tension glaucoma” in which, despite an IOP that is not elevated beyond the arbitrary upper limit of 21 mmHg, the optic nerve can show pathological cupping, and the visual field examination can show characteristic defects. These patients will easily be missed if diagnosis is based on IOP. Moreover, some health care workers tend to use non-contact tonometry to measure IOP. Such tonometry tends to underestimate the true pressure, which is more accurately measured with a Goldmann applanation tonometer (Haag–Streit International, Koeniz, Switzerland).6 We emphasise that examination of the optic disc is much more important for a correct diagnosis of POAG than IOP. However, measuring IOP remains important, as our Patient 2 would have been diagnosed by screening IOP alone. We also emphasise that pain is seldom a symptom of POAG. Pain is a feature of acute angle closure glaucoma, in which the IOP reaches very high levels in a very short time because of acute blockage of the drainage angle; this is not a feature of POAG. Family history played an important role in both our patients and should have been investigated during history-taking. First-degree relatives of patients with POAG have a risk about 10 times greater than for people with no family history of glaucoma.7 However, relatives are often unaware of their risk, sometimes even decades after treatment is initiated in their family.8 Patients with primary glaucoma should be advised to alert relatives to the need for adequate glaucoma screening and follow-up. We believe awareness of POAG among the general population (as well as among health care professionals) is poor at best. To increase awareness in the general population, primary care health professionals in particular need a better understanding of this disease. We believe that asking about a family history of glaucoma as a part of an ophthalmic history, or as part of a general medical history, should be routine in all new patients. First-degree relatives of patients with POAG should be advised to be screened by an ophthalmologist or optometrist. Depending on ophthalmic findings, age and other risk factors, first-degree relatives should have a full ocular evaluation on a regular basis (eg, every 2 or 3 years, or more frequently if findings are equivocal). This simple step, and a timely referral can prevent much disability and associated cost for individual patients and the community.

Richard H C Zegers MD · Erik F Reinders MD · Marc D de Smet MD, PhD

To the Editor: I congratulate Haslam on his excellent overview of the role of empathy in medicine.1 He rightly reminds us that empathy is not vague or ill defined; rather, its presence improves clinical outcomes, and it can be both learned and lost. I would go further and argue that empathy is not an optional extra but a clinical competence essential for sound medical practice, no matter what our specialty. All clinical practice requires a doctor–patient relationship, the core skill of which is empathy. I wish to draw readers’ attention to a time-honoured but, in Australia, somewhat neglected educational activity where empathy is the major focus — that of Balint groups. In London in the 1950s, Hungarian-born psychiatrist Michael Balint and his wife Enid developed a unique method for studying the doctor–patient relationship.2 A Balint group is an experiential, small-group educational activity in which practising clinicians meet regularly to discuss their own doctor–patient interactions. The focus is on the emotional content of the doctor–patient relationship; the group’s primary task is to describe and empathise with both the doctor’s and the patient’s experience. Participants’ learning, therefore, is based on real-life situations they have encountered in their practices. A rationale for this kind of training is that all doctors tend to have habitual responses to certain clinical situations. Although these responses can be strengths which doctors bring to the care of some patients, they can also limit their capacity to help other patients. In certain situations, limits to doctors’ capacities for empathy may be unhelpful or even harmful to patients. A growing body of research suggests Balint-group training increases: practitioner sensitivity to hidden patient cues;3 the proportion of the consultation spent listening to the patient;4 practitioners’ experience of wellbeing during the consultation;3,5 practitioners’ sense of control in their work situation;5 and practitioners’ work satisfaction.6 At the same time it decreases: practitioner burnout;3,5 and unnecessary prescriptions,3 referrals5 and tests.5,6 In many countries today, Balint-group training is used in undergraduate and postgraduate education, most often in general practice training, but also in psychiatry, paediatrics, obstetrics and gynaecology, and internal medicine. At an international level, the vibrancy and energy of Balint-group work is reflected in the 26-year-old International Balint Federation (http://www.balintinternational.com). The Balint Society of Australia (http://www.balintaustralia.org), formed in 2005, joined the Federation in 2007.

Marion Lustig

More than three-quarters of Australia is classified as geographically remote. Remote areas are characterised by geographic isolation, cultural diversity, socioeconomic inequality, resource inequity, Indigenous health inequality, and a full range of extreme climatic conditions. Although several descriptive definitions have been developed for “remote health” and “remote practice”, definitions of “remote medical practice” or “remote medicine” have not been previously published. In 2007, a working group of doctors and academics with experience in remote medicine was formed to develop the first advanced specialised remote medicine curriculum for remote doctors undertaking training with the Australian College of Rural and Remote Medicine. The first step was to define remote medical practice. Remote medical practice has eight key features: employment rather than private practice, isolation, use of telehealth, increased clinical acumen, extended practice, cross-cultural setting, multidisciplinary practice, and an emphasis on public health and personal security. From these eight features, we developed the first working definition of remote medical practice in the Australian context. Our definition will assist policymakers, medical colleges, standard setters, and educators to develop programs and resources for the future remote medical workforce.

Janie D Smith MPHC, EdD · Stephen A Margolis DRANZCOG, FRACGP, FACRRM · Jeff Ayton AFFTM, DRANZCOG, DA · Victoria Ross MB BS, FRACGP, MPHTM · Elizabeth Chalmers FACRRM, ACRRM, AFPHM · Patrick Giddings FACRRM, FRACGP, DRANZCOG · Louise Baker FRACGP, DRANZOC, DCH · Martin Kelly MB BS, PhD · Catherine Love MB, FACRRM, FRACGP

Learning to consult. Rodger Charlton, editor. Oxford: Radcliffe Publishing, 2007 (xiii + 282 pp). ISBN 978 1 85775 852 8. Consulting is something that every doctor does. For most, it is performed without reflection and for many with only the patient (or a relative) observing. This is a pity because consulting has a rich theoretical framework, and every skill should be practised and refined to ensure it achieves the best outcomes for patients. It should also be an activity, when done well, which provides us with some intrinsic satisfaction. This book is edited and written by general practitioners but it is aimed at all students, trainees and medical educators, both undergraduate and postgraduate. The authors have extensive clinical and teaching experience, and while all are from the United Kingdom the lessons are universal. While the book does focus on consulting skills, particularly communication, it also touches upon the themes of partnership and understanding that are central to a modern comprehension of the consultation process. The summaries and practical points throughout the book are well written and useful. The chapter on consultation models, incorporating biomedical and psychosocial approaches, was particularly helpful and enabled me to better understand my own evolution and interrelationships. The book also incorporates chapters on the physical examination, aids to learning, and prescribing for common conditions. This is a little ambitious as there are many more comprehensive textbooks available covering these areas, yet it doesn’t detract from the overall aim of the book to provide the reader with tools to develop or improve their consultation style. Finally, the referencing, although not extensive, was more than adequate for an educational text. Overall, this textbook provides a good starting point for medical students to learn about consulting skills and could be used as a text or revision aid for postgraduate trainees, particularly in general practice. It also offers experienced doctors a chance to consider their own consulting style and perhaps incrementally improve a fundamental part of their clinical practice.

Nigel P Stocks

To the Editor: In a recent article, Youl and colleagues provided information about the ability of doctors to accurately diagnose skin lesions that they excise or biopsy.1 We wish to offer some comments about their comparison between general practitioners and skin cancer clinic doctors. First, in the study by Youl et al the behaviour of GPs and patients in mainstream practice was different from that of doctors and patients in skin cancer clinics, as indicated by the comparative frequency of whole body skin examinations performed (GPs, 30.4%; skin cancer clinic doctors, 73.2%).1 The study did not indicate the circumstances under which each decision to excise took place. Did patients become aware of a new or changing skin lesion and bring it to the attention of the doctor, or did the diagnosis result from a whole body skin check that might have revealed an earlier, previously unnoticed and more subtle lesion? It may be useful to separate basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) into histological subtypes, as early superficial BCC and intraepidermal SCC may be more difficult to diagnose than other subtypes.2 Second, the casemix of non-melanotic skin cancers in the two groups of doctors was quite different, with a BCC : SCC ratio of 1.1 : 1 for GPs and 2.1 : 1 for skin cancer clinic doctors. The difference in casemix was reflected in a study of our own3 in which we described the histology of 1247 lesions excised by doctors, including 76 lesions removed by one doctor in a designated skin cancer clinic. In an unpublished sub-analysis, we divided the results into two settings for comparison (Box). Like Youl et al, we found that the casemix of non-melanotic skin cancers was significantly different for the two groups of doctors (P < 0.001), but in our study the BCC : SCC ratio was much higher for skin cancer clinic doctors (4 : 1) than for GPs (0.6 : 1). We believe this most likely reflects an increased pick-up of BCC in skin cancer clinics, owing to the higher frequency of full body skin examinations and the consequent detection of lesions of which the patient is unaware. Third, the reported sensitivity and specificity in the study by Youl et al refers only to excised lesions. There is no information given about the lesions that practitioners decided not to excise. The sensitivity and specificity of skin examinations can only be determined if all relevant skin lesions are assessed, thereby giving an accurate representation of the number of true- and false-negative diagnoses. However, this would require multiple excisions, which would be clinically unacceptable. An important limitation of the study is that it does not assess or compare how many skin cancers each group of doctors missed. In conclusion, although the study by Youl et al provides comprehensive information about diagnostic accuracy, we do not feel — based on the information available — that a meaningful comparison between the two groups of doctors can be made. Comparison of lesion excisions in skin cancer clinic and general practice settings Mean patient age (years) Proportion of excised lesions that were malignant* BCC : SCC ratio Number needed to treat† Skin cancer clinic 56.5 76% (58/76) 4 : 1 (44/11) 4.7 (14/3) General practice 56.9 45% (512/1145)‡ 0.6 : 1 (190/305) 9.0 (154/17) BCC = basal cell carcinoma. SCC = squamous cell carcinoma. * BCC, SCC or melanoma. † Benign or dysplastic naevi excised per melanoma. ‡ There were 26 cases in which histology results were missing. All were in the general practice setting.

Clare Heal · Beverly Raasch

To the Editor: Youl and colleagues are to be commended for their research into the performance of special-interest skin cancer clinicians.1 However, the conclusion that the performance of general practitioners and skin cancer doctors in the diagnosis of skin cancer is similar is highly questionable. To truly compare the two groups and their diagnostic accuracy, it must be established that the participants were representative of the groups they are supposed to represent. The fact that the participating GPs were largely self-selected, perhaps on the basis of their personal interest in the subject, was a potential flaw that the authors acknowledge. Further, an examination of diagnostic accuracy should also take into account whether the lesions found were of similar type, size and stage. There was no determination of any qualitative differences (eg, in size or thickness) between the tumours seen and diagnosed by the two groups. When a patient presents, specifically, with a large, tender, hyperkeratotic squamous cell carcinoma (SCC), there is no real test of diagnostic skills. On the other hand, detecting a small early posterior-thigh melanoma or a superficial BCC on a whole body examination is a challenge. Overall, one would expect at least two to three BCCs to be diagnosed for each SCC found2 — however, in the study by Youl et al, GPs found a similar proportion of each type of lesion, suggesting that perhaps a large number of BCCs were not being detected at all in the GP group. The lower incidence of whole body examinations in the GP group suggests that a higher proportion of asymptomatic lesions may have been missed by the GP group and thus not included in their sensitivity/specificity data. This possibility could have been examined by noting the site of lesions found: identification and diagnosis of lesions in areas covered by clothing or footwear may be more likely on whole body examination. Although Youl et al reported that the diagnostic sensitivity for melanoma among skin cancer clinic doctors was twice that of GPs, a re-examination of the data with all of the above in mind may well reveal that skin cancer clinic practitioners are performing even better than suggested. That being said, the number of melanomas found per week by the skin cancer group (0.25 melanomas/doctor/week) in the study by Youl et al is much lower than in our own dedicated primary care skin cancer clinic (1.47 melanomas/doctor/week, based on audit data gathered between February and September 2007). Good medical care relies on accurate diagnosis and appropriate treatment, and the earlier the diagnosis is made, the less costly and less invasive the treatment and the greater likelihood of a cure. Surely we should all be working together — skin cancer clinic practitioners and GPs, alike — towards achieving optimum outcomes for our patients. To that end, a wider range of higher education in skin cancer medicine is being encouraged by the University of Queensland’s Master of Medicine program3 and the Skin Cancer College of Australia’s fellowship program,4 and bodies such as the Skin Cancer Society of Australia and the Royal Australian College of General Practitioners have been working together to introduce an accreditation process for those practising primary care skin cancer medicine.5,6

Jeffrey Keir

In reply: We thank Heal and Raasch, and Keir for their comments and suggestions. First, as acknowledged in our article, it is possible that general practitioners with an interest in skin cancer may have been over-represented in our sample. It is also the case that the comparison between GPs and skin cancer clinic doctors may have been affected by characteristics of patients attending each type of practice. Patients attending skin cancer clinics are self-selected (often worried about a specific skin lesion), while for those attending GPs in mainstream practice, skin lesions are more likely mentioned during a consultation for something else.1 Case selection, which helps increase diagnostic ability by Bayesian principles (improving pretest probability of malignant lesions), may thus be more likely for skin cancer clinic doctors than GPs.2 Our study represented a broad cross-section of skin cancer clinics, and the number of melanomas excised per doctor per week ranged from 0 to 1.7. The ratio of basal cell carcinomas to squamous cell carcinomas excised ranged from 0.1 to 6.0 for mainstream GPs and 0.8 to 8.0 for skin cancer clinic doctors. Whether clinical and histological features of skin lesions or the type of skin examination undertaken influence diagnostic accuracy was beyond the scope of our initial study. This question will be the subject of future analyses. It has been suggested that a limitation of our study was that it did not assess or compare the number of skin cancers each group missed. However, as specifically stated in our article, the aim of our study was to examine diagnostic accuracy of excised or biopsied lesions. To examine the sensitivity and specificity of all lesions (excised and non-excised) and of screening examinations would require a different study design. We disagree that meaningful comparisons between the two groups cannot be made from the data collected in our study. Our prospective study included over 11 000 skin excisions or biopsies from a large group of mainstream GPs and from doctors working in a variety of skin cancer clinics. One of the most important outcome measures of our study was the degree of accuracy of skin cancer diagnoses within the primary care setting. We have demonstrated that primary care practitioners, whether mainstream GPs or skin cancer clinic doctors, diagnose skin cancer with similar, high levels of accuracy. This is a reassuring result, particularly in a country with the world’s highest incidence of skin cancer.

Philippa H Youl · Peter D Baade · Monika Janda · Christopher B Del Mar · David C Whiteman · Joanne F Aitken

Pharmaceutical companies must believe there are benefits from advertising, but just what these benefits are, and how they are measured, is not clear Pharmaceutical company executives must believe that advertising is effective. Otherwise, pharmaceutical advertising would be illegal under the Australian Corporations Act 2001 (Cwlth), which requires that company staff rationally believe their business judgements to be in the best interests of their corporation.1 However, Henderson and colleagues’ study in this issue of the Journal may have found an advertising delivery channel that does not work (→ The effect of advertising in clinical software on general practitioners' prescribing behaviour).2 They compared prescribing by general practitioners exposed to advertisements in clinical software with prescribing by unexposed GPs during 2003–2005. Despite a large sample size and carefully controlling for many possible confounders, they did not detect any significant difference in prescribing for six of the seven drugs studied. Interestingly, there was significantly less prescribing of one drug by exposed GPs — possibly a false-positive finding arising by chance, but this is the first ever published evidence that pharmaceutical advertising may sometimes unintentionally reduce sales. Opinions about the effectiveness of advertisements (one-way persuasive messages from an identified sponsor) have varied over the past 100 years. Founder of one of the first department stores in the United States, John Wanamaker, may have lamented that “half the money I spend on advertising is wasted; the trouble is I don’t know which half”.3 A pharmaceutical marketing textbook asserts that advertising alone does not increase sales, but is cost-effective for increasing awareness of new drugs.4 According to this text, advertising has a small but useful role, because it synergistically boosts the effectiveness of other promotional methods, including drug representatives. By contrast, advertising executive Pierre Garai asserted that “advertising which does not work does not continue to run. If experience did not show beyond doubt that the great majority of doctors are splendidly responsive to current [prescription drug] advertising, new techniques would be devised in short order.”5 This suggests that advertising becomes more effective over the years by a trial-and-error process akin to evolution by natural selection. Recently, marketing academic Dick Wittink concluded that medical journal advertising produced competitive returns on investment in many situations.6 In 2007, it is not clear how effective advertising is, or how accurate companies have become at measuring its effectiveness. The findings of Henderson and colleagues2 are consistent with many hypotheses. It is possible that advertising has an effect that their study failed to detect. There may have been an unknown confounder, or an effect that was too small to be detected but still large enough to provide adequate return on investment. The study focused on drugs that had been available for more than a year but advertising is more effective for introducing new drugs.4 The study measured market share, but advertising may increase market size. Competitors who did not advertise in clinical software may have promoted their drugs with other equally effective methods. Advertising to GPs in the exposed group may have saved promotional resources that were used to target GPs in the control group in other ways. Perhaps advertising in clinical software really is ineffective. This is plausible because these advertisements impinge on the doctor–patient relationship in a way many find annoying, and some find repugnant.7 Doctors are habituated to medical journal advertisements, but may give advertisements delivered through a new channel more attention and thus more scrutiny, rendering them less effective.8,9 Perhaps any additional advertising that targets doctors will have little impact because expenditure on pharmaceutical promotion may now be high enough to run into the law of diminishing returns.10 Maybe advertising is sometimes counterproductive. For example, some doctors may react against advertisements they dislike. During a consultation, when patients also see an advertisement on the computer screen, the doctor may choose an unadvertised drug to avoid having it appear that the decision was biased. However, there would still be a bias (but in the opposite direction) that would be problematic if the advertised drug was the best treatment. If any type of drug promotion is ineffective, then it wastes money earned from the high prices paid by patients and taxpayers that are supposed to provide incentives for research. If pharmaceutical executives come to believe that advertising in clinical software is ineffective, they will be required to cease investing in it. This would have major repercussions for the clinical software industry where, currently, the software maker who accepts advertising revenue dominates the market. However, the pharmaceutical industry may want to persist with this very new advertising channel. Companies might decide to allow time for more effective techniques to evolve. They may pay for ineffective advertising just to keep the channel open in case it works during new drug launches. Advertisements in clinical software could become more effective in a few years when doctors have become habituated to them, and so give them less attention.8,9 Perhaps the companies’ real aim is not short-term sales, but to gain influence over future decision-support functions within clinical software that could have considerable impact on prescribing in the long term. Like Wanamaker, we may never really know if advertisements in clinical software in 2003–2005 were just a waste of money or not. If pharmaceutical executives are motivated and able to determine the true effectiveness of advertisements in clinical software, then these advertisements will either become extinct or evolve to become more influential, for good or ill for all concerned.

Peter R Mansfield BM BS

Objective: To assess the effect of pharmaceutical advertising embedded in clinical software on the prescribing behaviour of general practitioners.Design, participants and setting: Secondary analysis of data from a random sample of 1336 Australian GPs who participated in Bettering the Evaluation and Care of Health, a national continuous cross-sectional survey of general practice activity, between November 2003 and March 2005. The prescribing behaviour of participants who used the advertising software was compared with that of participants who did not, for seven pharmaceutical products advertised continually throughout the study period.Main outcome measures: Prescription for advertised product as a proportion (%) of prescriptions for all pharmaceutical products in the same generic class or group.Results: GP age, practice location, accreditation status, patient bulk-billing status and hours worked were significantly associated (P < 0.05) with use of advertising software. We found no significant differences, either before or after adjustment for these confounders, in the prescribing rate of Lipitor (adjusted odds ratio [AOR], 0.90; P = 0.26); Micardis (AOR, 0.98; P = 0.91); Mobic (AOR, 1.02; P = 0.89); Norvasc (AOR, 1.02; P = 0.91); Natrilix (AOR, 0.80; P = 0.32); or Zanidip (AOR, 0.88; P = 0.47). GPs using advertising software prescribed Nexium significantly less often than those not using advertising software (AOR, 0.78; P = 0.02). When all advertised products were combined and compared with products that were not advertised, no difference in the overall prescribing behaviour was demonstrated (AOR, 0.96; P = 0.42).Conclusion: Exposure to advertisements in clinical software has little influence on the prescribing behaviour of GPs.

Joan Henderson BAppSc(HIM)(Hons) · Graeme Miller MB BS, PhD, FRACGP · Ying Pan BMed, MCH · Helena Britt BA, PhD

One aim of Medicare’s Enhanced Primary Care (EPC) initiative is to encourage multidisciplinary care of patients with chronic disease by funding five allied health treatment sessions per patient per year. In many cases, the number of funded treatments is far less than standard clinical practice indicates, particularly when the five visits are shared between service providers. We believe clinical outcomes may be compromised by adhering to the funded hours, and inequity of outcome may arise based on socioeconomic status and the ability of patients to pay. Research that determines how patients and allied health practitioners are responding to this initiative is required. Research is also required to evaluate whether EPC enhances clinical outcomes compared with no allied health intervention and standard allied health practice.

Michele M Foster PhD · Geoffrey Mitchell FRACGP, PhD · Terry Haines BPhysiother(Hons), GCertHealthEcon, PhD · Sean Tweedy BHMS, MHMS, PhD · Petrea Cornwell BSpPath, PhD · Jennifer Fleming BOccThy(Hons), PhD

The patient from hell: how I worked with my doctors to get the best of modern medicine and how you can too. Stephen H Schneider, with Janica Lane. Cambridge, Mass: Da Capo Press, 2006 (xix + 300 pp). ISBN 978 0 7382 1078 0. When Doug, the father of a patient of mine, handed me this book, I should not have been so worried. I am a paediatrician and practitioner of evidence-based medicine; reading this has triggered me to reflect on my own thought processes and practice. The book is written by world-renowned climate expert, Professor Stephen Schneider. He was diagnosed with a rare lymphoma in 2002 and chronicles his course, making astute observations on the processes surrounding his tests and treatments. He questions everything, suggesting changes to just about anyone who will listen. Schneider and his wife, both intelligent academics, gather information but also take responsibility for his disease and make health care professionals part of their team, rather than the other way around. When the data are absent, they challenge doctors to make decisions using decision analysis and Bayesian thinking tools (prompting me to re-examine notes from a course I took on decision analysis and to read more about Bayes’ theorem). There is much we can learn about the health care conveyor belt by taking the patient’s perspective. Paediatricians know that children with good advocates generally get the best out of health professionals, and other patients would probably benefit from good advocacy too. Schneider overstates it by calling himself a “patient from hell” — he is simply doing what he can to get the best out of the health care team. Every patient should attempt to do so, but not many could use Schneider’s approach. I wonder what the health consumer may feel reading it — perhaps intimidated if they can’t be as dogmatic and thorough as he is. Hence, this book is perhaps more valuable for health professionals than patients. I still don’t know what Doug was trying to say by lending me this book, but I’m glad he did. I commend this book to every doctor.

Rob Roseby

The first 100 days after an election are full of enthusiasm, energy and chaos, and they are crucial to establishing the shape, style and content of the new government’s tenure. The electorate is eager for plans, changes and new ideas, and for election promises to become reality. Early action that is visible and accepted will secure the credibility of longer-term plans. Here, in an open letter to the new Health Minister, we state our hopes for Australian health and health care in that 100-day period Dear Minister, You have come to this task with a raft of policies and initiatives that you and your party have promised to implement, and you probably have a long list of ideas and issues that you want to address, or that others have lobbied for. In a previous issue of this Journal, we put forward eight challenges that we think you will face,1 and you have outlined your own list. Your first 100 days will be crucial, but please don’t rush into action. Take time to consider three fundamental things. First, what health system will be best for Australia in the 21st century, taking into account the health needs of all Australians and how the electorate wants its tax dollars spent? Second, what distinctive role can you, as the federal health minister, play to achieve that system and leave the nation healthier as a consequence of your term as minister? After all, you are accountable to all Australians for precisely such an achievement. Third, you need a strategy, so that your reforms and policies are not just isolated initiatives, but form a coherent plan that will ensure that current problems are addressed and health benefits are maximised. A carefully formulated plan is the difference between just replacing the cracked tiles on an old leaking roof and rebuilding the roof with a better design, updated technology and new tiles. The challenges you face are of two orders: issues that are now causing a huge increase in costs as their incidence grows (examples are chronic disease, childhood obesity, the uptake of new technologies and the workforce crisis), and others that are polity issues (such as the current dual — or should we say duel? — Commonwealth and state–territory funding streams, the public–private mix, and the focus on treatment at the expense of prevention, affordability and equity). It is the polity issues that demand that the “roof”, the protection that our nation’s health care system offers, is redesigned and brought up to date. Without such attention, there will be no sustainable solutions to the other issues that threaten to inundate us; a few new or recycled tiles just won’t do. We urge you to spend your first 100 days, first, planning several high-priority, national concerted actions in the three broad health service policy areas — prevention, community-based care and hospital services — and, second, developing national consensual mechanisms that will address the polity issues robustly and drive the concerted actions. Both these approaches, tackled simultaneously, are essential. United States Government Accountability Office The US Government Accountability Office (GAO) is known as “the investigative arm of Congress” and “the congressional watchdog”. GAO supports Congress in meeting its constitutional responsibilities, and helps improve the performance and ensure the accountability of the federal government for the benefit of the American people. GAO’s work includes oversight of federal programs; insight into ways to make government more efficient, effective, ethical and equitable; and foresight of long-term trends and challenges. GAO’s reports, testimonies, legal decisions and opinions make a difference, for Congress and the nation.2 You have promised a national health and hospitals reform commission, which will meet in the first 100 days of government. While requiring a broader focus than so far described, this commission could give you the expert support and consultative mechanisms needed for comprehensive and robust planning. Your initial success will be measured by the key performance indicators — cooperation and buy-in from the states and territories, non-government organisations, the private sector, health professionals and the public. At the end of 100 days, there must be evidence of a strong developing consensus and growing public confidence that you will stop the blame and cost-shifting of the past and create a new health system to meet national needs. But the gloss of these early glory days will last only if there are long-term commitments of resources to planning, infrastructure (including more effective e-health systems), the workforce, and research and development; to making patients’ experiences and outcomes central to health care decision making; and to monitoring and evaluating the effects of health-policy changes on health, so we know what is working and what is not. This last point is crucial to your long-term success. So we also propose that you establish an office of accountability for health to ensure that you and your partners in health planning and reform can know that agreed outcomes are being achieved, and the public can know that their tax dollars are wisely invested. The United States Government Accountability Office is a good model (Box).2 We offer here two of many reasons why we need the equivalent of the US Government Accountability Office. The cost of medical errors in Australia is over $1 billion annually and could be as high as $2 billion.3 About half of all medical mistakes are preventable.4 The current failure to collect comprehensive national data means that our progress towards better quality and safety remains anecdotal. The Editor of this Journal has spoken out on the failure to clearly enunciate and implement a comprehensive range of relevant safety indicators, mandatory incident reporting and learning systems for mishaps, and an outcome measurement system, stating that “Australians deserve better than this”.5 We agree. The cost of obesity in Australia last year was $21 billion in ill health and disability, premature death and productivity losses.6 Over 3 million Australians are obese, and this could rise to over 7 million people within 20 years if current trends persist unabated and unaddressed.6 The last Australian Schools Health and Fitness Survey was conducted in 1985, and the last National Nutrition Survey in 1995. This means that policymakers are hindered by the lack of current data to inform the development of new policies. Without ongoing measurements and feedback there is no way to evaluate the effect of implemented policies. It is only through repeated surveys, done by the same people using the same survey instrument, that we are able to assess progress and evaluate the success of individual initiatives. The overwhelming impression left from the election campaign is of 6 weeks of piecemeal policies, and local funding commitments that add to the multitude of health programs but do not strengthen or reform the health system. Your task now is to build a better health system that can deliver better health programs more effectively and efficiently. The multiple challenges must be tackled, with a focus on better health outcomes and better value for money. They can only be resolved by a shared national vision, national leadership and national action across a period that may encompass decades, but your actions in the first 100 days and investments in the first 3 years will be critical. This surely is where the Australian Government must play its main role and where a committed Health Minister can make a real difference and leave a lasting legacy. Since 1933, when Franklin Delano Roosevelt tackled the worst effects of the Great Depression in a rush of breathless reform,7 the first 100 days of a new government have provided the test of its leadership and reformist credentials. Australian state government leaders, from Jeff Kennett in Victoria to Geoff Gallop in Western Australia, have adopted this benchmark for achievement. We strongly advise you to embrace this benchmark, and we wish you well in the 100 days ahead.

Lesley Russell BSc(Hons), BA, PhD · Stephen R Leeder AO, MD, PhD · Bruce K Armstrong AM, DPhil, FRACP · James A Gillespie BA, PhD · George L Rubin FRACP, FAFPHM

Objectives: To assess changes in emergency department (ED) activity and visits to EDs that could have been managed by general practitioners (GP-type visits) in the Christmas and New Year holiday period compared with the rest of the year.Design and setting: Retrospective descriptive and analytical comparison of New South Wales ED visits in the holiday period and the rest of the year; data were obtained from the NSW Emergency Department Data Collection database for the period 2001 to early 2006. More detailed information in 2005–2006 allowed GP-type visits to be assessed in this period only.Main outcome measures: The change in the number and percentage of weekly ED visits during the holiday period.Results: Between 2001 and 2006, average weekly counts of ED visits increased by 9% (95% CI, 7%–11%) during the holiday period. The holiday increase was largely accounted for by visits that were less urgent, and for patients who were not admitted, did not arrive by ambulance, had a shorter treatment time and arrived between 08:00 and midnight. In 2005–2006, average weekly counts of GP-type visits increased by 21% (95% CI, 15%–28%) compared with 8% (95% CI, 4%–12%) for ED visits overall. However, GP-type visits accounted for only 39% of the additional holiday visits. GP-type visits increased mainly for adults and more in urban than rural areas.Conclusions: The Christmas and New Year period is the busiest time of year for NSW EDs. However, only some of the additional holiday visits can be attributed to GP-type visits. Improving access to GPs, but also to broader hospital and community-based health care services over the holiday period, should be considered for managing the excess demand.

Wei Zheng MPH · David J Muscatello MPH · Adam C Chan MB BS(Hons), FACEM

A 39-year-old man with a lifelong history of asthma reported recurrent productive cough and wheeze over the previous 2 years. Antibiotics and specific asthma treatment produced only temporary decreases in symptoms. Chest examination revealed monophonic wheeze in the right mid and lower zones. The appearance on computed tomography was unremarkable. On flexible bronchoscopy, the blue end-cap of a ballpoint pen was seen within the apical right lower-lobe bronchus (Figure, A and B). It was removed by rigid bronchoscopy (Figure, C). Subsequent questioning of the patient revealed no history of aspiration, although he habitually chewed his pen while working. Airway foreign bodies are more common in childhood1 and are often not considered in adults. This case underscores the clinical significance of a monophonic wheeze,2 which may arise from abnormalities not detectable by imaging.

Celia M Zubrinich · Christine F McDonald · Simon R Knight · Fergal J O’Donoghue