General medicine

Containing hospital costs by limiting bed availability and reducing length of stay may no longer be a viable strategy

Natasha Reid · Thakeru Gamage · Stephen J Duckett · Leonard C Gray

The burden of asthma for patients and doctors can be reduced through simple evidence-based approaches to care and self-management

Christine R Jenkins · Philip G Bardin · John Blakey · Kerry L Hancock · Peter Gibson · Vanessa M McDonald

Blood donor screening laboratories use different testing algorithms to diagnostic laboratories and may yield results which do not conform to the usual patterns with which clinicians are familiar

Christopher D Swan · Clive R Seed · Claire E Styles · Iain B Gosbell

Opioid deprescribing is a complex and challenging practice, with continued prescribing the default behaviour

Aili V Langford · Christine CW Lin · Lisa Bero · Fiona M Blyth · Jason Doctor · Simon Holliday · Yun‐Hee Jeon · Joanna Moullin · Bridin Murnion · Suzanne Nielsen · Rawa Osman · Jonathan Penm · Emily Reeve · Sharon Reid · Janet Wale · Carl R Schneider* · Danijela Gnjidic*

Older women have been relatively neglected in discussions of reducing alcohol-related harm

Ann M Roche · Jacqueline Bowden

Debra J Rickwood · Jason Trethowan · Patrick D McGorry

Our stressed health system needs innovative solutions to care adequately for people with post- COVID-19 conditions

Tania C Sorrell · Martin Hensher · Lena A Sanci

To the Editor: The impact of the coronavirus disease 2019 (COVID‐19) pandemic continues to affect institutional care, both acute and aged care services. More hidden is the impact on community care, especially community palliative care. Community palliative care aims to enable people to die where they wish. About 70% of the population seek to die at home, but between 4% and 12% actually do.1 During the COVID‐19 pandemic, however, data from three Melbourne community palliative care services indicated a rise in deaths at home of between 30% and 50% (personal communication, John Doran, Manager, Melbourne City Mission Palliative Care; Janet Phillips, Chief Executive Officer, Peninsula Home Hospice; and Kelly Rogerson, Chief Executive Officer, Palliative Care South East; December 2022). This increase has not been recently reported in Australia. One factor may be family reticence to admit their family member for inpatient care because of continued visitor restrictions2 — also reflected in international literature.3,4 Consequentially, the client profile has changed as more people present with complex needs and a higher number need terminal care. This requires lengthier visits from clinical staff — one service employed a registrar to support general practitioners (personal communication, Janet Phillips, December 2022). More emphasis is placed on telehealth, now routine, often substituting every second scheduled visit; and many staff work from home (personal communication, John Doran, Janet Phillips, and Kelly Rogerson, December 2022). The use of in‐home overnight respite has markedly increased, providing additional support to family carers (personal communication, Janet Phillips, December 2022). Perhaps because of increased workload, locum doctors are less available, meaning that palliative care staff are increasingly called on to support terminal care, including complex symptom management, and to verify death (personal communication, John Doran, Janet Phillips, and Kelly Rogerson, December 2022). Staff are still required to do regular risk assessment, including COVID‐19 testing, and to wear personal protective equipment, aligned with Department of Health guidelines for health care workers.5 A significant number of inpatient bed‐days are saved when people are supported to die at home, which may reduce the burden of care in institutional settings.6 Further work is required to measure the impact of home‐based care on outcomes for terminally ill people and their families and to understand the value of that care to the health care system.

Margaret O'Connor

Prescribing of all psychotropic classes has risen since 2018, and increases were particularly marked during the COVID-19 pandemic

Rae‐Anne Hardie · Gorkem Sezgin · Lisa G Pont · Judith Thomas · Mirela Prgomet · Precious McGuire · Christopher Pearce · Andrew Georgiou

Smartwatches can count every step towards a predict–prevent health care system, but clinical regulation is the first leap

Graeme Mattison · Oliver J Canfell · Doug Forrester · Chelsea Dobbins · Daniel Smith · David Reid · Clair Sullivan

Australians should be confident that their generalist GP is trained to an acceptable level of competence in skin cancer diagnostics

Cliff Rosendahl · Simon Clark

Most incident melanomas are managed by primary care practitioners, underscoring the need for specific training

Nirmala Pandeya · Catherine M Olsen · Maja M Shalit · Jean Claude Dusingize · Rachel E Neale · David C Whiteman

General practice training in remote areas provides equivalent opportunities for learning and progression toward the fellowship

Emily Anderson · Matthew R McGrail · Aaron Hollins · Louise Young · Lawrie McArthur · Belinda O'Sullivan · Tiana Gurney

A new clinical care standard provides evidence-based guidance to help clinicians deliver best care for people with low back pain

Christopher G Maher · Aline Archambeau · Rachelle Buchbinder · Simon D French · Julie Morphet · Michael K Nicholas · Peter O'Sullivan · Marie Pirotta · Michael J Yelland · Leo Zeller · Nivene Saad · Elizabeth Marles · Alice L Bhasale · Christina Lane

The ever-increasing novelty and complexity of modern medicine brings decisional uncertainty for clinicians; various strategies can be used to minimise and manage this uncertainty without compromising the clinician–patient relationship or clinician credibility

Ian A Scott · Jenny A Doust · Gerben B Keijzers · Katharine A Wallis

A 78-year-old man with hypertension, dyslipidaemia, hypothyroidism and gout presented with two weeks of migratory polyarthritis and fever

Hannah Poole · Amy Crowe · John Daffy

A 40-year-old man was referred to the neuromuscular clinic with generalised fasciculations

Dhayalen Krishnan · Matthew C Kiernan

More effective, coordinated approaches are needed to improve and secure the universality of public health care

Mary Rose Angeles · Paul Crosland · Martin Hensher

To the Editor: The article by Williams and colleagues1 is a narrative review of prostate cancer care from a urological perspective. However, developing recommendations for prostate cancer screening requires complementary perspectives, including population health, general practice, and the wider community. Population‐based prostate‐specific antigen (PSA) testing to screen asymptomatic men for prostate cancer is not supported by the references cited by Williams and colleagues or by systematic reviews, which identify and account for bias.2 The Royal Australian College of General Practitioners (RACGP) has assessed the current evidence and has advised against prostate cancer screening.3 The RACGP guidelines specifically state that GPs have no obligation to offer prostate cancer screening, and advise against adding PSA to a battery of pathology tests. The RACGP and the National Health and Medical Research Council have developed information sheets drawing attention to the numbers of men with screen‐detected prostate cancers who would never know they had cancer if they had not undergone screening, as well as to the impotence, incontinence and bowel problems that prostate cancer diagnosis and treatment can cause, whether necessary or not.3,4 Between 42% and 66% of screen‐detected prostate cancers would not have been diagnosed without screening. Prostate cancer is discovered at autopsy in 36% of men of European ancestry and in 21% of Asian men aged 70–79 years.5 As Williams and colleagues note, prostate cancer screening can lead to earlier diagnosis of aggressive cancers, and modern techniques enable individualised patient‐centred treatment.1 However, for the men whose cancers would never have been detected without screening, any treatment is unnecessary and potentially harmful.5 Prostate cancer screening does not meet the aim of reducing overall mortality.2 After 11 years of annual screening, four of 1000 screened men compared with five of 1000 unscreened men have died of prostate cancer. Among the screened men are 87 cases with a false positive PSA test result, of whom 28 have complications of biopsy, including 0.5 extra heart attacks. Both groups have lost 190 men from all causes.3 Australia's GPs manage a growing demand for evidence‐based primary health care, and the RACGP supports them by developing standards and guidelines. These are based on unbiased approaches and, with the current evidence, they cannot recommend prostate cancer screening.3

Rosalie Schultz

Objective: To review and synthesise the global evidence regarding the health effects of electronic cigarettes (e‐cigarettes, vapes). Study design: Umbrella review (based on major independent reviews, including the 2018 United States National Academies of Sciences, Engineering, and Medicine [NASEM] report) and top‐up systematic review of published, peer‐reviewed studies in humans examining the relationship of e‐cigarette use to health outcomes published since the NASEM report. Data sources: Umbrella review: eight major independent reviews published 2017–2021. Systematic review: PubMed, MEDLINE, Scopus, Web of Science, the Cochrane Library, and PsycINFO (articles published July 2017 – July 2020 and not included in NASEM review). Data synthesis: Four hundred eligible publications were included in our synthesis: 112 from the NASEM review, 189 from our top‐up review search, and 99 further publications cited by other reviews. There is conclusive evidence linking e‐cigarette use with poisoning, immediate inhalation toxicity (including seizures), and e‐cigarette or vaping product use‐associated lung injury (EVALI; largely but not exclusively for e‐liquids containing tetrahydrocannabinol and vitamin E acetate), as well as for malfunctioning devices causing injuries and burns. Environmental effects include waste, fires, and generation of indoor airborne particulate matter (substantial to conclusive evidence). There is substantial evidence that nicotine e‐cigarettes can cause dependence or addiction in non‐smokers, and strong evidence that young non‐smokers who use e‐cigarettes are more likely than non‐users to initiate smoking and to become regular smokers. There is limited evidence that freebase nicotine e‐cigarettes used with clinical support are efficacious aids for smoking cessation. Evidence regarding effects on other clinical outcomes, including cardiovascular disease, cancer, development, and mental and reproductive health, is insufficient or unavailable. Conclusion: E‐cigarettes can be harmful to health, particularly for non‐smokers and children, adolescents, and young adults. Their effects on many important health outcomes are uncertain. E‐cigarettes may be beneficial for smokers who use them to completely and promptly quit smoking, but they are not currently approved smoking cessation aids. Better quality evidence is needed regarding the health impact of e‐cigarette use, their safety and efficacy for smoking cessation, and effective regulation. Registration: Systematic review: PROSPERO, CRD42020200673 (prospective).

Emily Banks · Amelia Yazidjoglou · Sinan Brown · Mai Nguyen · Melonie Martin · Katie Beckwith · Amanda Daluwatta · Sai Campbell · Grace Joshy

We must complement simplistic responses to urgent problems with strategic, considered, long term redesign across the whole health system

Kirsty A Douglas · Sally Hall Dykgraaf · Danielle C Butler

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has changed the doctor–patient relationship. The technological revolution that is telehealth has brought undeniable benefits to patients, including greater access and convenience, and more control and empowerment through self‐care.1 There are high satisfaction ratings for patients utilising digital health care technologies.2 Unsurprisingly, there has been an increased uptake in the use of online prescription, referral and medical certificate services where a pre‐existing doctor–patient relationship is not always present.3 In our experience, there is an increasing digital incursion on the traditional general practice consultation. General practitioners are being pressured by their patients to issue prescriptions4 and referrals outside of scheduled consultations. Presumably to preserve the doctor–patient relationship and potentially business interests, we have seen GPs acquiesce to these patient requests, often with little to no consultation. This is occurring despite previous research showing that consumer demand is a driver of unnecessary tests and treatments.5 This non‐contemporaneous doctor–patient interaction exacerbates the demand for fast, convenient health care delivered how and when patients dictate. In this instance, ensuring consumer satisfaction is potentially at odds with ensuring good and safe patient outcomes. There are risks of engaging with this type of instant medicine. Increased accessibility to, and demands made of, GPs increases their workload burden2 and precipitates cognitive overload. This emerging expectation of doctors to engage in asynchronous interactions with patients, outside of consultations, creates what we term a “digital fourth wall”. Patients can access their GP in an inherently one‐sided encounter, with doctors given little time and opportunity to reciprocate. Our concern is that the impersonal nature of this doctor–patient interaction may beget a diminution of professional responsibility towards the patient and suboptimal treatment and diagnosis. Striving for a mutually acceptable outcome through shared decision‐making processes will ensure that duty of care to the patient, based on GPs’ best clinical judgment, is not compromised. This may mean saying “no” to a patient, despite what we observe to be the natural inclination of many GP colleagues to acquiesce to increasing digital demands. The medico‐legal risk, and responsibility for patient care, ultimately rests with the GP. Despite appearances, novel innovations in technology do not always lead to health improvements.

Michael Tran · Katrina Anderson

Action to incorporate evidence- based nutrition concepts in medical education is essential

Eleanor J Beck · Lauren Ball · Breanna M Lepre · Rachael McLean · Clare Wall · Melissa Adamski · Helen McCarthy · Jennifer Crowley

Health care professionals caring for men with prostate cancer starting ADT should ensure that their bone health is routinely assessed

Mariya F Hamid · Amy Hayden · Tania Moujaber · Sandra Turner · Howard Gurney · Mathis Grossmann · Peter Wong

Until we have strategies to reduce the barriers of video consultations, Australia needs long telephone consultations

Feby Savira · Eva Yuen · Anna Ugalde · Katherine Graham · Anna Peeters