General medicine

Doctors and paintings. Insights and replenishment for health professionals. John Middleton, Erica Middleton. Oxford: Radcliffe Publishing, 2006 (x + 102 pp). ISBN 978 1 84619 052 0. I wanted to like this book. The idea of a husband British GP educator and wife artist/art historian coauthoring a book about the interface of painting and medicine intrigued me. The structure is also quite novel. It follows four fictional general practitioners starting up a group learning course about painting and medicine, listening in on their discussions in a play-like format. Superimposed on this are two more layers, the first being two other characters walking through an art museum, listening in on and commenting on the group of doctors. Secondly, there is a non-fictional analysis of various famous artists and their works, as well as the art-in-medicine movement. Strangely, the artist co-author includes her own works in the book for analysis, putting herself up against some of the most famous artists in history. All of this in a book under 100 pages long! It did come across as confusing to me; on many occasions, I found myself unaware of who was talking (author or character) or whether I was reading fiction or non-fiction. That said, both authors seem knowledgeable in their respective fields. Analysis of communication techniques, of empathy and listening, and of “patient-centredness” are well discussed and referenced. Philosophical points on the role of the doctor, of death and dying, and even faith suffuse both the fictional and non-fictional sections. Artists as diverse as traditionalists like Rembrandt and Rubens through to modern artists such as Francis Bacon and Mark Rothko are analysed both in terms of how their lives and personalities helped shape their works and in how their philosophy and its expression can influence us as doctors viewing their works. Rather than being printed in the book, the works discussed have web addresses for viewing (except for the coauthor’s work!), I suspect to reduce cost. While interesting in parts, Doctors and paintings may be trying to be too many things. Nevertheless, those with a passion for painting and/or medical philosophy might find it worth a read.

James A Best

To the Editor: The recent conference report by Knight and Taruscio highlights the need for a coordinated effort to fill knowledge gaps and improve service provision for Australians with rare diseases.1 Although, by definition, individual rare diseases occur infrequently, there are about 6000 rare diseases affecting 6%–10% of the population.2,3 This equates to 1.2 million Australians, 30 million people in Europe and 25 million in the United States. By comparison, diabetes affects 1.4 million Australians.4 It is increasingly acknowledged that low prevalence does not equate to low impact. Rare diseases often have their onset in childhood, continue throughout life, are difficult to diagnose, are disabling, and have significant impact on patients, their families, the community and health services.2,5 However, rare diseases receive such scant attention that they have been dubbed “orphan” diseases. Lack of epidemiological and scientific data has hindered development of evidence-based practice, policy and services. To tackle the problem of rare diseases, the European Union, the US, Canada and New Zealand have established policies and agencies to foster research, and develop resources for clinicians, community information services, and appropriate health facilities. The National Institutes of Health in the US established the Office of Rare Diseases because: . . . rare disease research requires the collaboration of scientists from multiple disciplines and the capacity to share access to geographically distributed national research resources and patient populations . . . knowledge about rare diseases may offer leads for scientific advancement in other rare diseases and in more common diseases.6 There is no coordinated national effort or policy in Australia. Currently, there are 14 national paediatric surveillance units, including the Australian Paediatric Surveillance Unit (APSU), to which paediatricians contribute epi-demiological, clinical and outcome data on rare conditions of childhood.7 These data inform development of health policy and improved diagnosis and clinical management, and result in the establishment of cohorts, thereby enabling further research.7 The APSU is developing information resources for clinicians and the community on rare infections, genetic disorders, mental health conditions and injuries in children. In Australia, the APSU is the only provider of prospective national data on up to 16 rare childhood diseases concurrently, but it receives no ongoing core funding. Sound evidence is needed to underpin development of policy and services. Sound evidence requires sound research into the causes, management and effects of rare diseases. Australian clinicians, researchers and, most importantly, patients and their families deserve the benefits of a coordinated national plan to address the common burden of rare diseases.

Yvonne A Zurynski · Katie N Reeve · Elizabeth J Elliott

Withdrawal of government funding may force the closure of this invaluable resource General practice remains the cornerstone of Australia’s health services. About 85% of the population sees a general practitioner at least once in any year.1 Last financial year, that amounted to 103 million general practice services, at a cost to Medicare of $4 billion.2 Over the past decade, the Bettering the Evaluation and Care of Health (BEACH) program has provided a unique insight into these clinical encounters between GPs and their patients. BEACH tells us about the patients that GPs see, the problems that are encountered, and the treatment provided. The BEACH program is a continuous national study of general practice activity in Australia. Indeed, it is the only such study in the world. To date, it includes details of 900 000 encounters between GPs and patients. Every year another 100 000 encounters from a random, ever-changing sample of 1000 GPs are added. The strength of the BEACH data lies first in its sheer sample size, and second in that it provides a reliable, continuous measure of changes in general practice since 1998. Since that time, there have been a number of important changes to Medicare and a raft of new programs and initiatives to help GPs better manage their patients. These include financial incentives to boost bulk-billing, reimbursement for services provided by practice nurses, practice and service incentive payments for the management of patients with asthma and diabetes and for the provision of immunisations and cervical cancer screening tests, and new Medicare items to encourage GPs to work with allied health professionals to provide coordinated care for patients with complex and chronic health problems. Other factors have also intervened in the relationship between GPs and their patients. The GP workforce is increasingly older, has a higher proportion of women, and is looking to work fewer hours.3 At the same time there’s a growing shortage of GPs, especially outside metropolitan areas.4 Their patients are also ageing and beset by chronic illnesses such as heart disease, diabetes, arthritis, depression, and chronic obstructive airway disease. Many struggle to afford the out-of-pocket costs associated with their care, which have grown by 50% over the past decade.5 The push is on to get GPs to encourage their patients to exercise more and smoke less, to prescribe fewer diagnostic tests and medications, to talk to their patients for longer, to enquire about their use of alternative and complementary therapies, and to inform them about the use of generic medicines. This pressure is coming from government,6 professional bodies,7 the National Prescribing Service,8 and patients themselves.9 The BEACH data can be mined for information about all these issues and many more. It provides the only independent source of data about doctors’ prescribing practices, including how many prescriptions are for medicines not listed on the Pharmaceutical Benefits Scheme (PBS). The Pharmaceutical Benefits Pricing Authority uses calculations from the BEACH data to estimate the average monthly treatment cost of each PBS-listed medicine and then adjusts the price that the government pays the manufacturer. All this work is done by a small group of workers at the Australian General Practice Statistics and Classification Centre, a collaborating unit of the University of Sydney and the Australian Institute of Health and Welfare. It is done on a miniscule budget, which in the current financial year amounts to just $1.3 million. Now the Centre is under threat of closure because the Australian Government will not commit to ongoing financial support. The government’s contribution is just 23% of the BEACH budget (the remainder comes from a variety of public and private sources), but without the certainty of these funds for the 2008–09 financial year and beyond, the Centre must make the decision in November to close up shop. The amount involved is insignificant in the grand scheme of health expenditure — $300 000 a year — a sum so small that it is not itemised in the Australian Government Department of Health and Ageing budget, but is paid from the departmental expenses budget. Medical groups and academics have expressed concern that policy should be made and evaluated based on appropriate data, but the Department of Health and Ageing has signalled that it is no longer in the business of general practice research.10 Those who care about health policy and its impact understand the consequences if BEACH ceases to exist. Yet this rich and informative history of general practice activity is at risk because the Australian Government, in its short-sightedness, cannot make the 4-year commitment of $1.5 million that will ensure its future. The loss of BEACH will be a national shame.

Lesley Russell BSc(Hons), BA, PhD · Stephen R Leeder MB BS, MD, PhD

To the Editor: The Journal’s unbalanced supplement on spirituality and health fails to satisfy your policy on sponsored supplements, cites at least one fraudulent study, and contains much poor science and non-science. I discuss here only a fraction of the supplement’s flaws. Firstly, dissenting voices were not cited or discussed in the supplement. An objective appraisal of the field would have included sceptical viewpoints such as those of Paul,1 who demonstrated lower levels of societal dysfunction in highly secular democracies than in more religious societies such as that of the United States. It is remarkable that the supplement article by Williams and Sternthal2 ignored Paul’s study. Secondly, Jantos and Kiat3 cite Cha and Wirth’s debunked Columbia University study into the relationship between intercessory prayer and fertility rates for in-vitro fertilisation treatment. Flamm, a Californian professor of obstetrics and gynaecology, demolished this article,4,5 and his rebuttal was reported widely.6 That this citation survived the peer review process suggests either that the reviewers did not know their field well enough, or that they deliberately allowed unqualified citation of a fraudulent study. Either way, they failed in their role as reviewers. Thirdly, Jantos and Kiat state that scientific investigation of prayer may not be possible, adding that scientists “must” accept that “some aspects of prayer . . . may go beyond the reach of science”. (Yet prayer’s putative physical effects must be measurable!) They also regard bible stories of Jesus’ healings as scientifically valid observations, stating that “All were examples of healing by supernatural means” — an unsupported, unscientific statement of belief that has no place in a peer-reviewed scientific journal. Similarly, Eckersley7 states that “we are spiritual beings, psychically connected to our world”. It is extraordinary and lamentable that statements such as these survived the editorial process. Finally, potential authorial conflict of interest is not disclosed. Koenig8 is the Co-Director of the Center for Spirituality, Theology and Health at Duke University Medical Center, a significant role that is not noted in his author details. Despite Jantos and Kiat’s assertions about the limitations of science, Koenig’s Center supports many studies of prayer. The well funded, US-based push to research the interface between religion and science, especially medical science, jeopardises scientific integrity. Its apotheosis, the Templeton Prize, is — at $US1.5 million — the world’s richest academic prize.9 The Journal’s supplement is best perceived as being a part of this agenda. It is an indictment on the MJA as a scientific journal that it was published.

Chris O Jackson

To the Editor: I take issue with the presentation of evidence by Jantos and Kiat1 — firstly, on the effect of intercessory prayer on health, and secondly, on prayer as a supernatural intervention. The minor positive findings of the Byrd study2 on prayer for coronary care patients, given so much column space, have proved non-reproducible.3 When meta-analysis is applied to the review by Astin et al4 of randomised trials of “distant healing”, the quoted “inconsistent” results of prayer become most definitely non-significant.5 The largest and most robust trial of prayer, by Benson et al (involving 1802 subjects),6 showing no positive effect of prayer on recovery after heart surgery, is mentioned but somewhat dismissed by Jantos and Kiat. As for the Cha and Wirth study on prayer and in-vitro fertilisation7 cited by the authors, simple investigation reveals it to have been an embarrassing fraud. The article was subsequently removed from the journal that published it, and one of the authors went to jail. In the section entitled “Plausible mechanisms by which prayer delivers health benefits”, the paragraph on “supernatural intervention” includes bible quotations on healing miracles presented as “evidence”. This may constitute sectarian theological material, but it is not medical science. Analogous to the financial interests of authors, religious groups have their own vested interest in the outcome and interpretation of medical studies involving religious issues. This is due to the intrinsic nature of religious faith, whereby a point of belief constitutes an absolute truth to the believer, irrespective of any other data, but seems implausible to non-believers. I would suggest that, for the benefit of a secular readership, in articles concerning religion and medicine in the Journal, the Editor should require the authors’ religious position to be stated under “competing interests”.

Jon Clarke

To the Editor: In your recent supplement on spirituality and health, I note that none of the authors cited competing interests. However, several authors gave their affiliations as Loma Linda University, an institution owned and operated by the Seventh-day Adventist Church, a fundamentalist Christian sect with strong evangelical and millenarian beliefs. I also note the financial support given to the publication by the same church. Does the above not constitute “competing interests”?

Ross B Holland

To the Editor: It is an embarrassment to your Journal that an article such as Jantos and Kiat’s “Prayer as medicine: how much have we learned?”1 should have been allowed publication. The article neglects to apply scientific rigour to the topic of prayer research in failing to effectively review the most significant and largest studies on the efficacy of prayer.2-5 The results of the largest study of third-party prayer, which suggested such prayer was ineffective in reducing complications following heart surgery, were noticeably absent.2 The article by Jantos and Kiat1 begins by suggesting that a spiritual search for meaning and hope is integral to human existence. This may be true for some, but certainly not all — which means that it can not be “integral” to human existence. Their abstract asserts the efficacy of prayer, without showing a causal relationship between prayer and improved outcomes anywhere in the article. Articles discussing the efficacy of prayer should include, if not an original study, a meta-analysis and interpretation of existing studies. The article also outlines “plausible mechanisms by which prayer delivers health benefits”, one of which includes the claim that it could in fact involve “supernatural intervention”. In a scientific publication, such a suggestion deserves thorough scientific evidence. Instead, all the authors provide is an anecdotal story and a bible passage. The article also uses the phrase “critics of prayer research”, presumably to describe people who are critical of the efficacy of prayer. A distinction is important, because critics of the efficacy of prayer are not necessarily critical of the research. In fact, critics would most likely encourage research so that they can, if evidence warrants, show how ineffective prayer is. Furthermore, the statement “prayer may not be transparent to scientific investigation and may go beyond the reach of science” begs the question: what, if prayer is beyond the realms of science, is this article doing in a scientific journal? Your publication has lent undue credibility to a gratuitous article without scientific substance.

Lahn D Straney

To the Editor: I am seeking some clarification on the recent MJA supplement article by Jantos and Kiat.1 One of the mechanisms suggested by the authors for the alleged beneficial effect of prayer is that it is “a channel for supernatural intervention”. Can I just clarify with you, given the vagueness of the statement and the religious overtone of the paragraphs that followed it, whether the authors were implying that there is a personal, caring God who performs supernatural interventions for people who pray — ie, that the beneficial effects are a direct result of such interventions. Or are they saying that the belief in the existence of such a being is itself the plausible mechanism — in which case, it should be more appropriately classified as a “placebo” effect (ie, the second mechanism listed in their article).

Tom Huang

To the Editor: I read with interest the recent MJA supplement on spirituality and health. It is interesting to observe the relationship between religious affiliation and life expectancy at birth over the past 100 years using population data supplied by the Australian Bureau of Statistics (Box).1,2 The life expectancy data shown here is for males, but the graph is almost identical for females. While there are many variables in this relationship, they are akin to those chiefly neglected in most of the articles in the supplement. It is easy to see from the graph that, as religious affiliation within the community has declined, life expectancy (a gross surrogate measure of health) has increased. The correlation is very good. Religious affiliation versus life expectancy at birth in Australia1,2* R2 = correlation coefficient. * Lines on graph are lines of best fit.

Robert F Grace

In reply: The spirituality and health supplement was a compendium on religion and spirituality in clinical practice, based on recent presentations at the National Spirituality and Health Conference. The authors sought to highlight clinically relevant research exploring associations between religiosity and health. Clarke and Jackson express concerns about the quality of the literature on intercessory prayer. Yet all the studies on intercessory prayer cited in our article on prayer and medicine1 belong to references included in the 2007 Cochrane database systematic review on the subject.2 As stated by Clarke, the pioneering work of Byrd was given prominent mention, by being the first of several studies on intercessory prayer employing a prospective, randomised, double-blind protocol. Clarke and Jackson question the ethics of not declaring authors’ religious affiliations. This factor (along with other personal factors not listed as “competing interests”, such as race, sex and age) should not influence the clarity, objectivity, and validity of peer-reviewed scientific publications, nor impair the authors’ objectivity, integrity and performance as clinicians. Their concern about the legitimacy of citing biblical verse is also unfounded. The medical literature is replete with biblical citations. A recent publication on the topic of biblical origins of placebo3 is just one example from the MEDLINE database. Straney expresses concern regarding the clinical relevance of prayer. More than 88% of the world’s populations believe in the supernatural,4 and prayer, being one of the oldest and most widely practised spiritual rituals, is frequently practised by patients when they have health problems.1 Knowing that patients commonly resort to prayer as a means of coping and finding meaning in life obliges clinicians to have some insight into how this practice affects patients’ health. Courses in spirituality and medicine are now offered in medical schools in the United States.5 In examining the relationship between belief in supernatural agents and mortality, Norenzayan and Hansen6 concluded: “our findings support the idea that belief in the supernatural agency is a core response to the human awareness of mortality” (original authors’ emphasis). Their conclusion supports the view that the spiritual search for meaning and hope in life is integral to human existence. Such exploration is virtually universal, albeit to varying degrees of depth, length and frequency. The study by Benson et al that Straney alludes to as being absent from our article on prayer as medicine1 was in fact cited (reference 12) and discussed in the body of the text. Our article reviewed the plausible mechanisms by which prayer may benefit individuals who engage in the practice. The postulation of a mechanism of action does not imply an explanation of aetiology. For example, a postulation that the resolution of an infection occurs through bacterial mitotic inhibition would neither prove nor disprove that a particular antibiotic is the agent of healing. Thus, Huang’s contention that “belief in the existence of such a being [(God)] is itself the plausible mechanism . . . [and] should be . . . classified as a ‘placebo’ effect” is a naturalistic fallacy. Grace cited data on religious affiliation and life expectancy among Australians. However, these data have not been subject to systematic and appropriate analysis for possible association. In contrast, religiosity was positively correlated with longevity among 10 000 Israelis over a 23-year period.7 Similar results were obtained in a 28-year follow-up of 5000 Californians.8 Religiosity was also shown to be an independent risk factor in a prospective study of over 300 elderly patients having cardiac surgery:9 compared with patients who reported preoperatively that they derived strength and comfort from their religious beliefs, those who didn’t were found to have a threefold greater risk of perioperative and 6-month mortality. Furthermore, a study of 34 000 Seventh-day Adventists in California10 revealed that they outlived other white male and female Californians by 7.3 and 4.4 years, respectively, giving them probably the highest life expectancy of any formally described population. Improved health practices and social connection are probably factors that provide a causal link between religious affiliation and health or longevity. In an era of spiralling health care costs, the big picture is the potential public health implications of religiosity as a low-cost health measure. Individuals or bodies responsible for health care policy, budgeting and delivery should welcome further exploratory research into the preventive and therapeutic effects and cost-effectiveness of religious practice in health promotion within appropriate community settings.

Hosen Kiat · Marek Jantos

In reply: The MJA’s spirituality and health supplement has reawakened the long-standing tension between supporters of science and supporters of spirituality, and I welcome their conflicting and unaccommodating views. The barrage of letters received reflects a perceived incongruity between spirituality and evidence-based medicine, with its requirement for evidence that is controlled, measured, counted and analysed by statistical methods.1 But the task of physicians has always been to understand not only the disease but also the patient. And for some patients, religion and spirituality are important — or, indeed, central — to their lives and health. The purpose of the supplement was to explore this area. Jackson is perturbed that, in publishing the supplement, the Journal has sold its scientific soul. However, one of the goals of the Journal is to provide a scholarly forum for continuing education and informed debate on standards of clinical practice, ethics, and social, legal and other issues related to health care in Australia.2 While it must be acknowledged that religion and spirituality involve areas of knowledge not governed by the scientific method, it would be intellectually dishonest to refuse to consider any role for spirituality in health care. Jackson also alleges that the supplement fails to satisfy the Journal’s policy on sponsored supplements, but proffers no evidence. In fact, the supplement complies completely with our policy for such publications.3 Despite the ongoing conflict between science and spirituality, exploration of the latter is increasingly considered for inclusion in modern medical curricula.

Martin B Van Der Weyden MD, FRACP, FRCPA

To the Editor: The Guidelines for the management of acute coronary syndromes 20061 state: “Enoxaparin may be used in conjunction with fibrin-specific fibrinolytic agents in patients under the age of 75 years, provided they do not have significant renal dysfunction. An intravenous bolus dose of 30 mg followed by a 1 mg/kg subcutaneous injection every 12 hours in combination with tenecteplase is the most comprehensively studied therapy.”1 In Australia, enoxaparin is not licensed for intravenous use (Tony Hall, Team Leader, High Risk Medications and Systems, and Christine Maclean, Associate Director, Safe Medication Practice Unit, Queensland Health, personal communication) and there is no recommendation for the intravenous use of enoxaparin in the drug product information.2 Are the authors recommending “off-label” use of intravenous enoxaparin, or do they wish to modify the guidelines to reflect what the management should be if clinicians are unable to use intravenous enoxaparin?

Mark Little · Chris Johnstone

In reply: The guidelines were published to provide clinicians with the most contemporary information on the management of acute coronary syndromes based on the international literature, and may include treatments which are not currently available, officially licensed or available through the Pharmaceutical Benefits Scheme in Australia. In the context of adjuvant therapy for patients with ST-segment-elevation myocardial infarction (STEMI), the guidelines recommend that antithrombin therapy should be used with fibrin-specific fibrinolytic agents.1 Based on the best evidence available at the time, the guidelines mention two antithrombins, unfractionated heparin and enoxaparin, to be considered for use in this setting. The recommendation for enoxaparin is based on comprehensive evidence of clinical benefit with the regimen of an initial intravenous (IV) bolus dose followed by subcutaneous injections every 12 hours. It is up to individual practitioners to determine whether the IV dose should be provided “off-label” or omitted, based on the evidence and the circumstances of the individual patient and setting. The issue of superiority of enoxaparin over unfractionated heparin as adjuvant therapy for patients with STEMI is currently being evaluated in light of recent evidence,2 and will be included in a future update of the guidelines.

Constantine N Aroney · Philip Aylward

To the Editor: Two recent articles in the Journal touch on the current plight of medical academics. Hays emphasises the need to reassert the role of teaching in academic medicine — otherwise, “our aim to produce safer, more efficient doctors will be under threat”.1 Joyce and colleagues outline the projected increase in the number of graduates from Australian medical schools, although their concern is more for the post-graduate careers of these young doctors than for their initial clinical training.2 In 2006, Van Der Weyden warned that not only do new ways of teaching medical students need to be rapidly explored but also that more skilled teachers must be found and trained.3 Medical students themselves believe that more clinical teachers are required to ensure that the increasing numbers of students are taught effectively.4 From personal experience we know that, while many full-time clinicians are both willing and inspiring teachers at undergraduate level, a core of permanent academics is needed to direct teaching during these clinical years. But why would anyone choose to be a medical academic today? Certainly not for the money — a recently qualified obstetrician/gynaecologist, starting at senior lecturer level after about 15 years of training, is looking at an income of less than half that of a staff specialist at the same level, and a quarter of that possible in private practice. One day of private practice per week does not help — obstetrics is a full-time commitment, and even in gynaecology the need to pay practice and indemnity costs outweighs any financial benefits. Is it the kudos? Adjunct academic titles are easily gained by non-academics: hospitals are awash with adjunct associate professors and lecturers. The adjunct appointment system often lacks regular and critical appraisal, and in some cases titles are used to the professional or financial gain of the recipient, with little reciprocal input into teaching at the institution concerned. (However, there are indications of attempts to crack down on such practices.)5 The lifestyle then? Academics may have a less frenetic clinical schedule, but the continuing pressure to produce quality research and to jump increasingly higher hurdles to obtain grants can mean that the limits of the working week are much less defined than for our staff specialist colleagues. We have seen many colleagues depart academia in the past few years for the more verdant pastures of full-time clinical practice. While we are in agreement with Hays about the need for more research into how best to design medical education, we believe that, unless there are urgent improvements in the remuneration, career structure and professional regard for clinical academics, the core workforce of skilled teachers so clearly needed for incoming students will just not be there to deliver that education.

Ajay Rane · Caroline de Costa

People with traumatic brain injury (TBI) have an increased risk of suicide, suicide attempts and suicide ideation compared with the general population. Most suicide deaths and attempts involve self-poisoning. General practitioners are strategically placed to make a significant contribution to preventing suicide in this group. Assessment approaches need to take into account the chronic nature of suicide risk in people with TBI. The assessment of post-TBI depression is complicated by the confounding effect of post-TBI motor–sensory and cognitive impairments, but psychological symptoms (feelings of hopelessness, worthlessness, and anhedonia, in particular) suggest the diagnosis of depression after TBI. Management includes close attention to how medications are prescribed, dispensed and administered. Family and community brain injury agencies can be enlisted to provide emotional support and monitoring of people with TBI. GPs can facilitate access to needed mental health services for people with TBI during times of suicidal crisis. Clinical practice guidelines for the care of people living with traumatic brain injury in the community, recently published for general practice, may be of use in managing people with TBI (http://www.maa.nsw.gov.au/default.aspx?MenuID=188).

Grahame K Simpson PhD · Robyn L Tate PhD

To the Editor: We are concerned about aspects of the study of selection predictors of medical school performance in Australian medical schools by Groves et al,1 and how they may be interpreted. A “voluntary” response rate of 13.6% is very small and unlikely to be representative, and selection or response bias is likely. Although noted by the authors, this fundamental flaw may be overlooked in interpreting the results. This aside, of what value is the outcome measure of clinical reasoning skills among students, some of whom are only in second year, and whom we would not expect to have developed substantial expertise in clinical reasoning at this early stage? More significantly, we consider that the research question itself may be flawed, as we are not at all convinced that selection scores are intended to predict relative performance in programs. Groves et al, of course, show that, in fact, they do not. Selection serves two purposes, one obvious and the other questionable. The first is to reduce the large pool of well qualified students to the available number of places. The second is the Holy Grail of selection: attempting to select those best suited to success in medicine. The key problem is that nobody can fully define, let alone measure, such success, other than in the negative terms of professional misconduct after graduation.2 Moreover, medicine offers a wide range of careers requiring different attributes, making a broad range of entry characteristics beneficial to the profession and the community at large, and putting in question the pursuit of a profile of critical criteria. Further research is needed, involving large, representative samples to confirm or discount putative outcome measures, but most medical students succeed in medical school and do not create problems as doctors, indicating that we are currently getting more of this right than wrong. If the predictive value of entry attributes for (often questionable) outcomes is modest at best, and if we teach and assess communication skills, clinical reasoning and professionalism during the programs, does it not make sense to focus our energies and resources more effectively there, and relinquish our continuing anxiety over selection? We should remember what motivated the flurry of activity towards more complex selection processes in the first place: concern over communication by doctors, failure in aspects of professionalism, and to a much lesser extent, clinical competence.

Malcolm H Parker · David Wilkinson · Ray G Peterson · Ieva Z Ozolins · Haida Luke · Jenny Zhang · Gerard J A Byrne

In reply: The limitations of our study have been acknowledged, and we agree with Parker and colleagues that further research is needed. However, their proposition that selection scores may not be intended to predict relative performance in programs seems at odds with their recommendation to select principally on the basis of academic performance. If selection scores do not provide predictability, why bother establishing any criteria at all? Why not simply use a lottery system, as they have been claimed to be equally effective?1 Although our study did not set out to evaluate the relative merits of cognitive versus non-cognitive criteria for selecting medical students, surely the first question to be decided is whether non-cognitive characteristics, including interpersonal skills, attitudes and behaviour, are important in medical practice and should be considered in selecting future doctors. If so, then the next question is how best to select students with these characteristics or, at least, the capacity to develop them during their medical training. The selection processes of most medical schools indicate that the answer to the first question is “yes”. In answering the second question, not only the validity of the chosen method, but its feasibility in terms of cost and effectiveness need to be considered.

Michele A Groves · Jill Gordon · Greg Ryan

To the Editor: Could I use a tiny fragment of a recent article as springboard to a plea for a change in terminology? Wilcken et al refer to two observations on the use of tamoxifen changing clinical practice, “and thousands of lives were potentially saved”.1 Are we fooling ourselves? Surely it is more accurate to say, in the situation of breast cancer in lives already well advanced, that thousands of deaths were postponed? “Humankind cannot bear very much reality.”2 Could we leave “lives saved” to the populist sensationalist media, and only use it in medicine for interventions in trauma, and possibly infection, in young people whose life expectancy is otherwise so good that their life has been truly “saved”? “. . . speech impelled us to purify the dialogue of the tribe and urge the mind to aftersight and foresight . . .”3

Warwick H Ruse

In reply: We agree that attention to terminology is important, and that claims about potential medical advances are often exaggerated. On the other hand, on the rare occasions when things go really well, we should not hide our light under a bushel. In the overview cited in our article, the risk of death 15 years after diagnosis was about 35% for the controls and about 25% for those who were given tamoxifen for 5 years1 — a reduction in the death rate of about a third. Another example is the finding from the earliest chemotherapy trials that significantly more women in the treatment arms were alive nearly 30 years later,2 showing that postoperative systemic therapy can have very long-lasting effects on the chances of being alive or dead. Over the years, this adds up to a lot of women not dead from breast cancer. However, whether these are really “lives saved” may be more a philosophical than a medical question. It is true that, despite decades of research and billions of dollars spent, the mortality rate remains at 1.0 per person, and death still consumes much of our thoughts.3 Rather than “lives were potentially saved”, perhaps a compromise could have been the less poetic “breast cancer deaths were avoided”.

Nicholas R Wilcken · Val J Gebski · Anthony C Keech · Rhana Pike

Religions, culture and healthcare Susan Hollins. Oxford: Radcliffe Publishing, 2006 (ix + 115 pp). ISBN 1 85775 755 6 Written by the lead chaplain of the UK National Health Service’s National Chaplaincy Strategy, this handbook is designed to serve as an accessible reference for health care professionals seeking to understand various practices and beliefs associated with a range of faiths. As the book was produced in the United Kingdom, it focuses on faiths which are most widely practised there (Christianity, Judaism, Hinduism, Sikhism, and Islam), but also includes less familiar traditions such as Jainism, Zoroastrianism, Mormonism, Baha’i, and even paganism. The bulk of the book is devoted to detailed examinations of each religious tradition, presented in an easy-to-use format. Sections provide basic information on the history of the faith and core tenets, and outline beliefs associated with key areas related to care, including attitudes toward illness; gender and privacy; naming, diet, and hygiene; birth, dying, and death; contraception and assisted reproductive technologies; and organ/tissue donation. The author is careful to note the diversity of beliefs within faiths where relevant (for instance, within Islam, Judaism, and Zoroastrianism there are debates over the permissibility of organ donation). The book includes a thoughtful set of introductory chapters that explore cultural and religious diversity in health care, as well as spiritual care for patients. They promote the idea that health care professionals must maintain open minds with regard to patients, and to avoid stereotyping on the basis of religion or culture, in order to provide sensitive and appropriate care. Hollins notes in her preface that this book should be placed at nursing stations and other places where it can be easily accessed for quick answers. It must be noted that there are some local differences in belief systems between the UK and Australia, but as a preliminary guide to religious beliefs in health care, this is an excellent resource.

Rachel A Ankeny

Why am I so tired? How to put the fuel back in your tank Ginni Mansberg, Anne Thomson. Melbourne: Michelle Anderson Publishing, 2006 (vi + 151 pp). ISBN 085572 369 6 This book is written for patients who experience tiredness. Most general practitioners appreciate this is a common complaint they see and agree it can be quite challenging to treat, especially within consultation time constraints. There are a number of aspects of this book that I love. It is easy to read. It is written as though the authors are having a friendly, chatty conversation with the reader. The authors encourage patients to attend their GP by making a longer consultation time with them. They also discuss what diseases need to be excluded and why certain tests (such as iron levels and thyroid function) are performed by the GP. The role of depression in fatigue is also given due respect. Mansberg and Thomson focus on lifestyle factors that are known to impact on health and energy. These include improving diet, exercise, sleep, stress management, and avoidance of smoking and alcohol. They also cover the possible role of nutritional supplements and herbs for the treatment of fatigue, but do quite rightly emphasise the lack of research in this area. Tiredness can be a difficult condition to treat and is often confused with chronic fatigue syndrome. The book provides some nice, easy practical lifestyle solutions. It motivates the patient to take control of and responsibility for their health; to be more proactive, taking simple steps to help restore their energy and vitality. So when a GP is next confronted with a tired patient, this would be a useful book to suggest, to reinforce their advice on the importance of lifestyle changes. I have already started recommending this book to my patients. At $19.95, the book is great value for money.

Vicki Kotsirilos