Health services administration

Australian services for people with dementia are fragmented, challenging to navigate and hard to access The coronavirus disease 2019 (COVID‐19) pandemic has led to reflections around reforming Australia’s health care system.1 In view of future reforms, this article is intended to provoke policy and clinical discussion regarding what an effective, efficient model of service delivery meeting the needs of people with dementia and their families may look like. The opinion presented here belongs to the members of the National Health and Medical Research Council (NHMRC) National Institute for Dementia Research Special Interest Group in Rehabilitation and Dementia. For the purposes of this article, we define a model of service delivery as the systemic framework through which services are organised, accessed, funded and delivered. Services in Australia for people with dementia are inadequate Dementia is the leading cause of disability, the second leading cause of death in Australians aged over 65 years, and the leading cause of death in women in Australia. In 2020, it is estimated that Australia will spend $8.1 billion on health care and $3.8 billion on social services for people with dementia, with a further $6.1 billion in lost productivity and earnings.2 Australian services for people with dementia are often fragmented, challenging to navigate and hard to access.3 It can be difficult for people with dementia to obtain a diagnosis, there are limited health and social services for early dementia, including post‐diagnostic support, and existing services are often poorly coordinated.3,4 Services face workforce shortages and gaps in worker knowledge and skills related to dementia.5 People with dementia and their care partners have called for support and information after diagnosis; flexibly delivered services that support their quality of life, including meaningful activity; and inclusion in decision making.6 A philosophical and societal shift in thinking is required: from provision of care to enablement, where people living with dementia are empowered to continue to direct their own lives.7 We are not meeting the human rights of people with dementia to health care Australia does not currently meet the human rights of people with dementia to timely and accessible health services of appropriate quality or to participation in health care decisions.4,6 The right to quality health care is affected by the variable delivery of best‐practice dementia care by memory clinics,8 acute hospitals,9 primary care,10 and community and residential aged care,11 perhaps because the role of each of these is unclear. Australia’s systems and context Australia has a long‐standing commitment to a universal health system and to long term care for older people. The health and aged care systems were developed largely in isolation from one another and have failed to resolve conflicts around medical and social models of care for older people. Health care systems are slowly adapting to this era of chronic disease and population ageing,12 but person‐centredness and integration within and across acute, primary, community and residential aged care systems remain a challenge.11 Principles underpinning models of service delivery for Australians with dementia Members of our group reviewed principles underpinning services such as the Department of Health Aged Care Sector and the Council of Australian Governments National Disability Insurance Scheme. 13,14 We reached a consensus that the following principles should apply to models of service delivery for dementia that: has an overarching objective to maintain positive health and wellbeing of people with dementia, their care partners and families; recognises dementia as a disability, consistent with the World Health Organization Convention on the Rights of Persons with Disabilities, and promotes autonomy, social participation and rehabilitation; takes into account the cognitive disability of people with dementia in accessing support and being a partner (along with their families) in planning care through supported decision making; is delivered by a multidisciplinary workforce who have knowledge and skills around dementia; is accessible for all people with dementia and care partners; is ongoing, cost‐effective and economically sustainable; is needs‐based, not capped according to central budgets; is integrated for seamless experience for people with dementia and care partners, within and across primary, acute and subacute health care, aged care and social services; and is evidence‐based. Review of possible models of service delivery for dementia We identified models of service delivery for dementia and other chronic conditions based on input from our broad authorship group and searching the peer‐reviewed and grey literature. These models are described in the and considered in terms of fit with the principles above. We included care pathways even though these are not a model because they are often used to improve service access and integration. In addition, we map the models of service delivery to our health and aged care funding systems, illustrating the limited integration across systems (Box). Learnings from these models: The self‐directed approach places the needs of the person with dementia centrally but may require processes to ensure supported decision making. Information is also needed regarding the risks and benefits of self‐management versus budget holding or service provider management, integration with health care, and consideration of costs. Case management improves outcomes for the person with dementia and could be flexible and needs‐based if sufficient workforce and integration across systems could be achieved. However, it would require a significant investment of resources. Strengths of the primary care chronic disease management model include equity and familiarity of access, and care coordination by a trusted health professional or practice team. Weaknesses include the limited amount of treatment (ie, current cap of five subsidised allied health consultations per year), limited dementia management skills in some general practitioners and practice nurses, and often poor integration with aged care. Shared and stepped care models may be able to be adapted to combine the strengths of the primary care chronic disease and specialist approaches, but integration of aged care services would be essential. Stepped care may not be the best fit for people diagnosed with dementia in other settings (eg, hospitals or residential care facilities). A specialist team approach with a skilled workforce is well equipped to provide evidence‐based care, although this is unlikely to be made universally accessible (eg, in regional areas) and may be cost‐prohibitive. Navigator and care pathway approaches may increase access to services, but do not improve the type or amount of supports or treatment available. None of the models of service delivery that we identified in Australia or overseas appear to sufficiently meet the principles above. There is no clear recognition that dementia is both a social and a medical issue. Australia has moved strongly in the direction of recognising the rights of people with disabilities including social participation but there is limited appreciation of this need in respect to most models for dementia. Recognition of dementia as a disability is only apparent in the self‐directed care model. The models also do not sufficiently consider the needs of the person with dementia and care partners together. Barriers to all the current models are the poor dementia knowledge and the tendency to stigmatise people with dementia by many health and aged care professionals.15 Next step: investment in model development We need to combine desirable elements in the primary care chronic disease management, case management, and specialist multidisciplinary care models. Having a system with a point of entry through primary care could maximise accessibility. Having a dementia and aged care specialist (eg, dementia nurse or case manager) working with GPs would bring the required skills and knowledge. A close partnership with a specialist multidisciplinary team (in person or using telehealth) would assist with diagnosis, ongoing support and management of complex cases, with possibly the most complex cases being managed by the specialist team. There needs to be investment to develop a model that is accessible, integrated and effective in meeting the needs of people with dementia. Our service delivery model needs to be co‐designed with people with dementia, their care partners, health, aged care, and state and federal government stakeholders, including treasury departments. Public health, social equity and human rights principles should underpin model design. Research is needed to explore proposed models and their elements with current recipients, service planners and providers. Methodologies may include service mapping; gap, risk and unintended consequence analysis; and economic modelling. Potential models will then need to be tested in a coordinated series of pilots and rigorous health system trials building towards national implementation. History has shown that piecemeal demonstration pilots and practice improvement projects will not bring about large‐scale change. Australia’s last National Framework for Action on Dementia 2015–2019 has just lapsed.16 Our new framework should include the development of a model of service delivery that considers accessible pathways to diagnosis and effective and seamless ongoing support of health and wellbeing throughout the course of dementia. Box – Current service funding structures and service models for Australians with dementia GPs = general practitioners; NDIS = National Disability Insurance Scheme; NGOs = non‐government organisations; PHNs = primary health networks.

NHMRC National Institute for Dementia Research Special Interest Group in Rehabilitation and Dementia

To the Editor: Restrictions and concerns associated with coronavirus disease 2019 (COVID‐19) have led to decreased routine immunisation coverage in many countries, including the United Kingdom1 and the United States.2 Australian data showing the COVID‐19 pandemic’s impact on vaccination coverage are not yet available, but it has disrupted services provided by the National Immunisation Program, which funds vaccination for children, adolescents, adults and special risk groups. In the face of ongoing COVID‐19 risk and restrictions, maintaining a resilient routine vaccination program is crucial. The COVID‐19 pandemic has heightened barriers to vaccination. Lockdown restrictions have affected immunisation service accessibility. Specifically, some clinics reduced face‐to‐face appointments in favour of telehealth3 or closed due to insufficient space and increased staffing and other requirements.4 Patients may have rescheduled appointments to avoid COVID‐19 exposure in waiting rooms, while school‐based programs have been disrupted by closures. Reduced consultations limit not only opportunities to vaccinate but also opportunities for health care providers to address vaccine questions and concerns and reinforce trust. Employment changes related to COVID‐19 may also exacerbate cost barriers for people at risk of under‐immunisation, such as migrants, international students, asylum seekers and refugees.5 To improve access, some jurisdictions have successfully established drive‐through vaccine clinics, and pharmacists in some states have been granted expanded permission to vaccinate children against influenza. However, some families may have delayed vaccines due to the COVID‐19 pandemic, and governments may need to consider additional resources for catch‐up vaccination and extensions or grace periods for “No jab, no pay” and “No jab, no play” policies. School‐based vaccination programs should be re‐established as a priority when schools reopen. Publicly available vaccination coverage data will not reflect COVID‐19‐related impacts until as late as December 2020. We recommend early release of more timely data to ensure service providers gain feedback on program performance. We also recommend awareness campaigns promoting timely National Immunisation Program vaccination or catch‐up. Information should be culturally and linguistically appropriate and should be developed through consultation and engagement with diverse communities, including Aboriginal and Torres Strait Islander communities. Australia’s immunisation providers are dedicated and adaptable, but we must now respond quickly to the challenges of COVID‐19 and remain vigilant to maintain routine vaccination coverage across the lifespan.

the Collaboration on Social Science, Immunisation (COSSI) Working Group

Current calls for primary care‐based screening and brief interventions for alcohol use should be reviewed Alcohol continues to contribute to significant morbidity and mortality in the Australian community. It is responsible for 4.5% of total disease burden,1 and 4186 deaths in 20172 and over 144 000 hospitalisations per year.3 While levels of alcohol consumption are slowly declining, alcohol continues to be a major preventable contributor to disease and death among Australians. Currently, over 25% of Australians report consuming alcohol at moderate or high risk levels.4 Over the past 20 years, there has been considerable research into the value of alcohol screening, brief intervention and referral for treatment (SBIRT) in primary health care as a public health measure to reduce alcohol consumption and related harms. The Alcohol Use Disorder Identification Test (AUDIT)5 was developed to assist with widespread standardised implementation of screening, and brief intervention for alcohol use disorder and has been extensively researched. More recently, the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)6 was developed to address a broad range of substances. There is good evidence based on numerous randomised controlled trials that brief interventions for alcohol use result in reductions in drinking which are at least sustained for 12 months.7 However, the actual size of the reduction in drinking has been revised down from 2007 when it was estimated that SBIRT would result in a reduction of alcohol intake by 57 g (nearly six standard drinks) per week,8 to 20 g (two standard drinks) per week.7 This reduction in effect size will inevitably affect estimates in cost‐effectiveness models. While overall average consumption has reduced, at least based on self‐report, SBIRT has been found to have little effect on frequency of binge drinking, numbers of drinking days per week, and intensity of drinking.7 It is therefore likely to have little effect on adverse events from intoxication, the major cause of harm for younger people. Despite strong evidence that SBIRT will result in self‐reported reduced drinking (albeit less reduction than previously thought), there have been problems with real‐world translation into practice, both on a large scale multi‐practice level9,10 and a national basis as demonstrated in Scotland.11 In terms of demonstrated effects on alcohol consumption at a population level, the most extensive program implemented so far has been Scotland’s Alcohol Strategy.11 This program aimed to deliver SBIRT across the entire primary care, emergency department and antenatal populations and was part of a suite of measures to address alcohol‐related harms in Scotland. Other measures included prohibition of multi‐buy discounting (eg, “buy five, get one free”), minimum unit pricing (unsuccessfully challenged by the Scottish Whisky Association in the Scottish Supreme Court and now being implemented), tightening of liquor licencing processes, and a tripling of investment in treatment and support services. Subsequent measures of alcohol consumption across Scotland, Wales and England have not demonstrated any significant differences in the trajectories of alcohol consumption between these countries. Consumption has decreased in all three countries.11 Although 43% of hazardous and harmful drinkers were screened in Scotland and received brief interventions, data on exactly who was screened were difficult to collect, and screening among women attending antenatal care was only partially implemented.11 Young people were difficult to access, probably due to lower health service attendance rates. Furthermore, a 2018 Cochrane review7 found that research into the effects of SBIRT on alcohol‐related harms, the end point of most importance, has been very limited, and was unable to reach a conclusion regarding the effect of SBIRT on alcohol‐related harms. The studies that have looked at this important issue found that there was no effect.7 In addition, recent research has cast doubt on the effectiveness of referral to treatment among the higher risk (mostly dependent) drinkers. Frost and colleagues12 reviewed the effects of brief interventions on rates of referral. They found that patients at high risk who had received a brief intervention actually had less contact with specialist addiction services in the year following the brief intervention compared with those who had not received the brief intervention. Despite these concerns regarding effectiveness in real‐world settings, SBIRT has been recommended over the past decade in Australia by the 2009 National Preventative Health Strategy,13 and by the National Alcohol Strategy in 2019.14 Significant investment in structurally supporting SBIRT in primary care or other settings has not been forthcoming from Commonwealth or state governments. Currently in Australia, we have a situation where the Australian National Alcohol Strategy advocates for the adoption of SBIRT. This is despite a lack of evidence that it is effective in reducing harms even in research settings, as well as a lack of evidence for its effect on reducing population levels of drinking, and evidence that it does not result in increased engagement in specialist treatment even in well resourced health systems which have identified this as a target area. However, despite the current evidence that population‐based screening does not seem to have an effect on overall alcohol consumption, there is no denying the clinical value of addressing unhealthy alcohol consumption when identified in primary care. The AUDIT and the ASSIST both explore relevant key areas such as frequency of use, harms and dependence, which are important for the clinician and the patient to understand and address. They enable the clinician and patient to determine the risks associated with the patient’s current drinking patterns, and to start a conversation which then enables an agreed response. They should still be promoted as tools to use when a patient has been identified as drinking excessively through normal clinical processes. Despite current levels of alcohol‐related morbidity, the general practice environment does not support general practitioners responding to the problem. Longer consultations are insufficiently remunerated, skills development has been suboptimal, and secondary and tertiary services are not readily available when and where required. SBIRT alone will not address the current levels of alcohol use in Australia and associated harms. There should be increased emphasis on development of the skills base of the medical workforce at student, general practice and other specialty training levels so that clinicians can respond to hazardous and harmful alcohol and substance use effectively. Tools such as the AUDIT and the ASSIST may well have a role here. Use of current GP Medicare items such as mental health care plans, chronic disease management plans and team care arrangements should be encouraged and facilitated to better support complex care for patients with problems relating to alcohol and substance use. In addition, addiction services should work with general practice to streamline access to advice and referrals and improve communication channels. At the same time, policy changes to reduce alcohol‐related harms should continue to be pursued. Medical bodies including the Australian Medical Association and the Australian colleges representing physicians, GPs, surgeons, psychiatrists and emergency physicians have advocated strongly for such changes regarding alcohol, but despite this advocacy, most of the Australian community has not felt the need for major change. In general, policy change will only occur in response to community concern. The 2019 National Drug Strategy Household Survey indicated that the Australian community continues to identify methamphetamine as the drug of most concern, above alcohol. In addition, support continues to decline for reducing trading hours for pubs and clubs and increasing the minimum drinking age, as well as for all other evidence‐based measures aimed at reducing the harms nominated in the survey.4 It appears that the Australian community currently least supports the harm reduction strategies with the strongest evidence, but on the other hand supports the strategies with the least evidence. If there were more community support, other policy changes could include reviews of pricing of alcohol and packaged liquor outlet density, further regulation of advertising of alcohol, and further changes to drink driving laws. These might include requiring a zero blood alcohol level for broader groups of drivers such as all younger drivers (ie, under 25 years of age) and drivers with previous drink driving convictions. There should be a renewed emphasis on alcohol as a significant driver of morbidity and mortality at three levels: on the clinical level, renewed emphasis on education and training for medical practitioners to enable clinicians to better respond to people drinking harmfully; on the health care structural level, changing remuneration arrangements to better support primary care treatment for people with alcohol‐related problems should be advocated for; and in parallel with these changes, increased advocacy for changes to policies that reduce drinking and related harms on a population level, with particular emphasis on high risk populations. Health professionals are generally not trained as advocates. Bringing about change, even when supported by sound evidence, is difficult and takes time. Vested interests have sophisticated advocacy skills and are well resourced. Opportunities for the development of advocacy skills at medical student and postgraduate levels should be developed and promoted. Australia remains a world leader in tobacco control. The health professions should join forces, building on the lessons from tobacco control, to change the way the Australian community views alcohol, and then lead changes in clinical practice and policy which will reduce alcohol‐related harms.

Chris B Holmwood

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has raised multiple health challenges for Australian society. In addition to the direct impacts of infection, there will be broader health impacts caused by physical and social distancing and the collapse in economic activity leading to the loss of employment and income. Interventions by the federal government, including JobKeeper, increased JobSeeker payments, the introduction of telehealth, and increased mental health spending, have made an important initial contribution to addressing the health impacts for individuals, families, and communities.1,2 A by‐product of these interventions, however, has been a rapid increase in government debt.3 We are now seeing increased calls to enact austerity policies. Such policies prioritise rapid reductions in government debt usually through cuts to health and social services. These calls should cause concern. Economic crises can damage mental health, increase the misuse of alcohol and other drugs, and increase suicidal behaviour.4 Austerity policies are likely to worsen these effects.4 Such concerns are illustrated by the effects of austerity policies in Europe and the United Kingdom made in response to the global financial crisis, which had serious health‐related consequences.5 For example, a study on the impact of austerity measures on health reported that austerity policies were implicated in worsening mental health, increased suicide rates, heightened mortality in older age groups, and greater unmet health care needs.6 Indeed, despite relatively progressive government interventions during the global financial crisis in Australia, we still had a rise in suicide rates among employed and unemployed Australians.7 If enacted in Australia, austerity policies have the potential to lead to health‐damaging effects. It is important not to compound the health impacts of the pandemic with austerity programs focused on short term reductions in government debt. Health and social services are critical buffers against economic shocks,8 and austerity is likely to undermine these buffers. Policies that prioritise economic and social supports as well as increasing access to care are likely to reduce the health impacts of economic crises.4 In particular, European countries that invested most in social protections during the global financial crisis suffered the least harms to their populations’ wellbeing.5,6 It is also crucial to recognise that austerity policies are a choice. There are alternatives for managing high levels of government debt to cutting public spending on services,6 and austerity policies are not widely endorsed by economists.9 Government spending on health, education, and social supports has the potential to increase economic growth.10 Taking a longer term view and avoiding austerity measures will better serve the health of Australia’s population, and indeed the health of the nation.

Shane A Kavanagh · Anthony D LaMontagne · Sharon Brennan‐Olsen

Recommendations to guide residential aged care facilities in preparing for and managing infectious disease outbreaks

Georgia E Aitken · Alice L Holmes · Joseph E Ibrahim

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

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

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

Anthony Scott · Danny Hills

Our findings may help remove the stigma attached to pyjama wearing

David G Chapman · Cindy Thamrin

Researchers who live and work in community can respond to local clinical questions and provide feedback to community on their findings Australians enjoy some of the best health outcomes in the world1 and those benefits are concentrated in our urban centres. Australians who live in rural and remote Australia have poorer health than their urban peers. The more remote your residence, the shorter your life span and the greater the burden of disease carried by your community.2 Australians living in remote areas are admitted to hospital at 1.3 times the rate of those living in urban and regional areas. For Australians living in very remote areas, the rate is nearly double the urban rate.2 Potentially preventable hospitalisations also increase steeply with remoteness. The difference is most marked for acute conditions where remote rates are almost 2.5 times those of urban areas.2 The median age at death in major cities in Australia is 82 years; in outer regional, remote and very remote areas it is 3, 9 and 18 years younger, respectively, and the statistics are much worse for First Nations Australians.3 Social determinants such as lifestyle factors, poor housing conditions, and lower average levels of educational attainment and employment in rural and remote communities predispose members to increased rates of disease and illness. Rural and remote residents experience increased difficulty in accessing timely care, which is a key factor in effective prevention and management of chronic disease and in improving population health outcomes. For example, 20% of people who live in remote and very remote areas report not having a general practitioner nearby as a barrier to seeing one, compared with 3% of those living in major cities, and 58% report not having a specialist nearby as a barrier to seeing one, compared with 6% in major cities.4 These factors contribute to the higher burden of chronic disease and shorter life expectancy in remote locations.2 Given this high burden of disease, an overload of social determinants of poor health and increased barriers to care, one might expect to see greater expenditure on health research and services in rural and remote Australia. This is not the case.5 Non‐community controlled health expenditure decreases with remoteness, but the detail here is telling. Medicare services and Pharmaceutical Benefit Services decline with remoteness but expenditure per patient admitted to hospital increases.6 The investment is in people after they become ill rather than on preventing illness. I have seen many examples of innovative models of care in rural Australia. I have seen health services, training providers, health professionals and communities co‐designing solutions that work for them, making a difference to the lives of rural people. To improve rural health we need to better understand it. We need to understand the why of health outcomes and evaluate which interventions are acceptable and effective. Evidence to inform such answers is scarce. Gaps in the Australian rural health research evidence base threaten to leave holes in Australian health policy. Ongoing engagement with rural communities that deepen understandings of local context and experience enrich research outcomes. In the Torres Strait, people talk of “seagull” research. They are not referring to studies of marine birdlife. They are referring to researchers who fly in, rapidly collect data and fly off with it, leaving only guano behind. Researchers who live and work in community can respond to local clinical questions and provide feedback to community on their findings. The Supplement published with this issue of the MJA7 comes from the Spinifex Network, which comprises such community‐based researchers. Within this network, researchers are able to find collegiate support and collaboration and conduct research that will lead to improved rural and remote health outcomes. The Supplement presents a number of review articles relating to people living in rural and remote Australian communities, covering issues such as food security, the impact of natural disasters, recruitment and retention of health workforce, and global crises. Australians living outside urban centres will benefit from such community‐based research.

Ruth Stewart

The MJA–Lancet Countdown on health and climate change was established in 2017, and produced its first Australian national assessment in 2018 and its first annual update in 2019. It examines indicators across five broad domains: climate change impacts, exposures and vulnerability; adaptation, planning and resilience for health; mitigation actions and health co‐benefits; economics and finance; and public and political engagement. In the wake of the unprecedented and catastrophic 2019–20 Australian bushfire season, in this special report we present the 2020 update, with a focus on the relationship between health, climate change and bushfires, highlighting indicators that explore these linkages. In an environment of continuing increases in summer maximum temperatures and heatwave intensity, substantial increases in both fire risk and population exposure to bushfires are having an impact on Australia’s health and economy. As a result of the “Black Summer” bushfires, the monthly airborne particulate matter less than 2.5 μm in diameter (PM2.5) concentrations in New South Wales and the Australian Capital Territory in December 2019 were the highest of any month in any state or territory over the period 2000–2019 at 26.0 μg/m3 and 71.6 μg/m3 respectively, and insured economic losses were $2.2 billion. We also found growing awareness of and engagement with the links between health and climate change, with a 50% increase in scientific publications and a doubling of newspaper articles on the topic in Australia in 2019 compared with 2018. However, despite clear and present need, Australia still lacks a nationwide adaptation plan for health. As Australia recovers from the compounded effects of the bushfires and the coronavirus disease 2019 (COVID‐19) pandemic, the health profession has a pivotal role to play. It is uniquely suited to integrate the response to these short term threats with the longer term public health implications of climate change, and to argue for the economic recovery from COVID‐19 to align with and strengthen Australia’s commitments under the Paris Agreement.

Ying Zhang · Paul J Beggs · Alice McGushin · Hilary Bambrick · Stefan Trueck · Ivan C Hanigan · Geoffrey G Morgan · Helen L Berry · Martina K Linnenluecke · Fay H Johnston · Anthony G Capon · Nick Watts

Objective: To assess the demographic, social, and clinical characteristics of young Australians who die by suicide. Design: Retrospective analysis of National Coronial Information System (NCIS) data. Setting, participants: People aged 10–24 years who died by suicide in Australia during 2006–2015. Main outcome measures: Demographic, social, and clinical characteristics of young people who died by suicide; circumstances of death recorded in the NCIS. Results: 3365 young people died of suicide during 2006–2015 (including 2473 boys and men, 73.5%); 1292 people (38.4%) lived in areas of greater socio‐economic disadvantage. Free text reports were included in the NCIS for 3027 people (90%), of whom 1237 (40.9%) had diagnosed mental health disorders and 475 (15.7%) had possible mental health disorders. Alcohol consumption near the time of death was detected in 1015 of 3027 cases (33.5%); histories of self‐harm were recorded in 940 cases (31.1%) and of illicit substance misuse in 852 (28.1%). Adverse life events included history of abuse or neglect (223, 7.4%), suicide of relatives, friends, or acquaintances (202, 6.7%), and financial difficulties (174, 5.8%). Conclusions: Three‐quarters of the young people who died by suicide were boys or young men, and 57% had diagnosed or possible mental health disorders, suggesting that the mental health and wellbeing of young Australians should be a key target for youth suicide prevention. To reduce the number of youth suicides, it is imperative that prevention strategies target the mental health and psychosocial stressors that lead to suicidal crises in young people.

Nicole TM Hill · Katrina Witt · Gowri Rajaram · Patrick D McGorry · Jo Robinson

Objective: To identify individual and organisational factors associated with the prevalence, type and impact of unprofessional behaviours among hospital employees. Design, setting, participants: Staff in seven metropolitan tertiary hospitals operated by one health care provider in three states were surveyed (Dec 2017 – Nov 2018) about their experience of unprofessional behaviours — 21 classified as incivility or bullying and five as extreme unprofessional behaviour (eg, sexual or physical assault) — and their perceived impact on personal wellbeing, teamwork and care quality, as well as about their speaking‐up skills. Main outcome measures: Frequency of experiencing 26 unprofessional behaviours during the preceding 12 months; factors associated with experiencing unprofessional behaviour and its impact, including self‐reported speaking‐up skills. Results: Valid surveys (more than 60% of questions answered) were submitted by 5178 of an estimated 15 213 staff members (response rate, 34.0%). 4846 respondents (93.6%; 95% CI, 92.9–94.2%) reported experiencing at least one unprofessional behaviour during the preceding year, including 2009 (38.8%; 95% CI, 37.5–40.1%) who reported weekly or more frequent incivility or bullying; 753 (14.5%; 95% CI, 13.6–15.5%) reported extreme unprofessional behaviour. Nurses and non‐clinical staff members aged 25–34 years reported incivility/bullying and extreme behaviour more often than other staff and age groups respectively. Staff with self‐reported speaking‐up skills experienced less incivility/bullying (odds ratio [OR], 0.53; 95% CI, 0.46–0.61) and extreme behaviour (OR, 0.80; 95% CI, 0.67–0.97), and also less frequently an impact on their personal wellbeing (OR, 0.44; 95% CI, 0.38–0.51). Conclusions: Unprofessional behaviour is common among hospital workers. Tolerance for low level poor behaviour may be an enabler for more serious misbehaviour that endangers staff wellbeing and patient safety. Training staff about speaking up is required, together with organisational processes for effectively eliminating unprofessional behaviour.

Johanna Westbrook · Neroli Sunderland · Ling Li · Alain Koyama · Ryan McMullan · Rachel Urwin · Kate Churruca · Melissa T Baysari · Catherine Jones · Erwin Loh · Elizabeth C McInnes · Sandy Middleton · Jeffrey Braithwaite

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has highlighted the need for accessible information for people with disability during public health crises. Accessible information — including Easy Read, Auslan, large print, Braille and audiovisual formats — is a human right.1 Such information is critical for people with disability to understand public health crises and know how to remain safe and access support. These needs are important, particularly given that people with disability commonly have underlying health conditions that may make them vulnerable to public health risks,2 are subject to service systems that may enhance their exposure to infection,3 and often face entrenched system‐driven inequalities, such as being excluded from health prevention and response actions.4 In Australia, accessible information is provided by governments, specialist information access agencies, disability advocacy groups, and service providers. As these groups have provided information about COVID‐19, lessons have emerged for informing better practice during future crises.5 To be appropriate for a public health crisis, accessible information must be: Accurate and of high quality — the information needs to be correct and sufficiently accessible. This requires collaboration between medical professionals and information specialists. Timely — delays in producing accessible information are common, but dangerous. Kept up‐to-date — producing accessible information that is never revised is inappropriate when the details of a crisis are constantly changing. Provided in sufficient detail and breadth — just as the rest of the population needs to know about many different aspects of a crisis, so do people with disability. Resources with a range of subtopics are required. Produced with people with disability — including people with disability in producing the information will ensure it is useful to and accepted by them. Disseminated appropriately — people with disability need to be able to access information through agencies they trust, as well as news media and governments. Where applicable, hard copies should be available, not only online.

Ariella Meltzer

The pandemic is a vast, expanding disaster with no end in sight, producing chronic stress, disruption, and multiple losses The coronavirus disease 2019 (COVID‐19) pandemic has been a once‐in‐100‐years event. The scale of the disaster overshadows all others in living memory. Most disasters are focal and time‐limited. This one will span a considerable period of time and the economic impact will last years. This means the mental health effects will be deeper and more sustained than in other disasters. A survey during the first month of the pandemic in Australia assessed the nation's “temperature” early, as reported in this issue of the Journal.1 This survey and other information2,3 confirm that the initial mental health impact has been severe, and worse may be coming. Scientific models predicted that Australia would face a second curve of mental ill health and suicide,4,5 and this has now clearly arrived. We have been willing to turn our society and lives upside down to flatten the COVID‐19 curve. The same commitment is now required to flatten the mental health curve. After acute disasters, most people experience a transitory wave of distress that is considered normal and they do not generally require professional care. COVID‐19 is fundamentally different. It is not a single shock, but a vast, expanding disaster with no end in sight, producing chronic stress, disruption, and multiple losses, and many of the usual mitigation strategies are banned or unavailable. Modelling and earlier recessions show that it is the economic consequences, especially financial stress, unemployment, and educational failure, that fuel mental ill health and suicide risk.4,6 This impact is anything but short lived, and will produce a long, deep second wave of mental ill health and suicide. The impact is not uniform and there are groups at especial risk: notably, the already marginalised and disadvantaged, young people, women, those living alone and those already unemployed. Young people are especially disproportionately affected, and face a generation‐defining disruption that will have a multifaceted, long term impact on their lives. Socio‐economic inequality is a major risk factor for an array of negative health and social outcomes, including mental illness,7 and the potency of this risk factor will be magnified by a pandemic followed by a recession. We may all be in this together, but some are further in than others. The response so far has been based upon thinking from earlier crises and disasters. The focus is on the general public and aims to stress the normative aspect, that “it is OK to not be OK”, that simple coping mechanisms will get people through the crisis, and wishful thinking that professional help is available if needed. Crisis lines have been bolstered, but there has been no major effort to increase the capacity of the system, although the pivot to telehealth has sought to maintain access. These steps are welcome, but they will be inadequate on their own. The scale and sustained nature of the stress, the undermining effect of the containment measures, especially second lockdowns, and economic collapse mean that a much larger proportion of the population may need mental health care and be at risk for suicide than in more focal disasters. The capacity of the mental health system, even before COVID‐19, had been inadequate for responding to the demand.8,9 The system is now expected to respond to the surge in need for mental health care. It has been admirable how single‐mindedly governments and the health system have responded with public health measures and a boost to intensive care capacity10 in order to flatten the infection curve and to treat infected patients. At the time of writing, 886 people have died of COVID‐19 in Australia. During the same time period (February to October), more than 2000 Australians will have died from suicide,11 let down by an inadequate health and social system response. Most suffered from clear‐cut mental ill health, although only a minority had accessed mental health care.12 It is predicted that the number of suicides will rise in parallel with the COVID‐19 crisis and associated recession.4 These lives are surely just as precious as the ones directly lost to and threatened by COVID‐19. They have not yet been lost, and many, if not all, can be saved. What can be done? Firstly, policymakers must accept that this is not a routine disaster and that the times call for a very different approach. I believe the Prime Minister and some premiers are engaged with resolving this problem. Economic measures to soften the impact of the recession are the paramount preventive strategy, and the federal government has acted promptly with the JobKeeper and JobSeeker schemes, which have been partially extended while being reduced in stages. The global financial crisis showed how destructive austerity policies are, increasing inequality and social determinants of mental ill health, as well as weakening the social fabric and democracy itself. Secondly, the crisis provides a unique opportunity to create the “new mental health care” by dramatically reforming and strengthening the current system. An international position paper13 has been published, but Australia is ahead of the curve with key innovations, such as home‐based care and hospital in the home, assertive outreach models, and a national youth mental health platform (headspace), supported by digital and telehealth, which not only suit the times but are evidence‐based and strongly preferred by patients and families to emergency and inpatient care. Shifting the centre of gravity of mental health care to local communities via integrated care hubs linked closely with primary care is an innovation strongly supported by the federal government and Health Minister Hunt, not only through headspace, but also through the adult mental health hub model announced in 2019.14 Integrated care hubs with deeper capacity and expertise in helping people (young and older) with more complex needs could easily be fast tracked in the shadow of COVID‐19, initially as pop‐ups boosted by digital technology and outreach. State governments should consider releasing the governance of community mental health care from large hospital‐centric health networks so that it is embraced and can be accessed by local communities. And federal commissioning of community mental health care should be more coherent, guided by national evidence‐based standards, with the goal of regional integration of services, reversing the fragmentation produced by the competitive tendering policies of the excessively devolved primary health network model. The coming months will reveal whether we are really all in this together or whether the 5 million15 Australians (and rapidly growing) who confront mental ill health each year will continue to be treated as second class citizens.

Patrick McGorry

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

Megan Prictor · Carolyn Johnston · Amelia Hyatt

The associated risks, particularly that of long term use, are underestimated, and appropriate measures are needed

Stephan A Schug

Objective: To compare treatments for localised prostate cancer for men diagnosed in private and public health services in Victoria. Design: Retrospective analysis of Victorian Cancer Registry data linked to population‐based administrative health datasets. Setting, participants: 29 325 Victorian men diagnosed with prostate cancer during 2011–2017. Main outcome measures: Proportions of men in private and public health services receiving radical prostatectomy (with or without curative radiation therapy) or curative external beam radiation therapy alone within 12 months of diagnosis. Results: After adjusting for age, tumour classification and comorbidity, men diagnosed in private health services received radical treatment more frequently than men diagnosed in public health services (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.31–1.49). The proportion of private patients who underwent radical prostatectomy was larger than that for public patients (44% v 28%; OR, 2.28; 95% CI, 2.13–2.44) and the proportion of private patients who received curative external beam radiation therapy alone (excluding brachytherapy) was smaller (9% v 19%; OR, 0.45; 95% CI, 0.42–0.49). These differences were apparent for all International Society of Urological Pathology (ISUP) tumour grades. The magnitude of the difference for prostatectomy was greater for men aged 70 years or more; for radiation therapy alone, it was larger for those diagnosed before age 70. The differences between private and public services narrowed during 2011–2017 for men with ISUP grade 1 disease, but not ISUP grade 2–5 tumours. Conclusion: Prostate cancer treatment choices differ substantially between men diagnosed in private and public health services in Victoria. These differences are not explained by disease severity or comorbidity.

Luc te Marvelde · Roger L Milne · Colin J Hornby · Adam B Chapman · Graham G Giles · Ian E Haines

Fit testing of respirators is recommended to ensure proper fit for individual health care workers and is required to comply with respirator standards

Adrian Regli · Britta S Ungern‐Sternberg

Australia has relied, for most of its history, on international medical graduates (IMGs) to supplement its workforce. Since 1978, IMGs applying for general registration to practise in Australia have usually needed to pass the examinations of the Australian Medical Examining Council, or since 1986, its successor, the Australian Medical Council (AMC). The AMC provides several pathways to registration by the Australian Health Practitioner Regulation Agency (AHPRA). The route now termed “the standard pathway” consists of a two‐part assessment including a multiple choice question (MCQ) examination followed by a clinical examination. While most IMGs are required to pass both examinations, since 2007, IMGs who qualified in the so‐called competent authority countries (the United Kingdom, Ireland, the United States and Canada) have usually not been required to sit these examinations.1 The examinations have sometimes provoked controversy and political responses in various forms.2,3,4 Partly in reaction to these, but mainly through an internal process of continuous improvement, their formats have been adapted considerably over the 42‐year period. The MCQ examination assesses “basic and applied medical knowledge across a wide range of topics,” and since 2000, its pass mark has been set using item response theory.5,6 The original clinical examination used short cases and viva voces; in 2004, this was replaced by a 16‐station objective structured clinical examination (OSCE). The standard of both examinations is set at that “of newly qualified graduates of Australian medical schools who are about to commence intern training”.6 The last account of the demographic features of candidates attempting the examinations and their performance was provided in 2010.5 Now, a decade later, there have been striking changes in both these parameters, which we document and evaluate in this article. A further aim was to identify some demographic or candidate factors that might influence examination success. Source of data De‐identified information about candidates who took the MCQ and clinical examinations of the Australian Medical Examining Council and AMC, from their inception in 1978 until October 2019, were provided by the Council. It included the country and year of primary medical qualification, gender, year of birth, years of first attempt and success, and number of attempts for each candidate. From this information, we calculated the numbers of candidates, numbers of attempts, the success rate per attempt, and the proportion eventually achieving success each year. To examine the contributions of individual countries, results were aggregated into decades. Countries of training were also consolidated into regions, according to the United Nations geographical regions report, last updated in 1999 (Supporting information, table 1).7 Ethics approval was obtained from the University of Melbourne Human Research Ethics Committee (ID: 1750338.3). Demographic features of candidates Over the 42‐year period, a total of 35 699 candidates from 153 countries sat the MCQ examination, 16 588 (46.7%) of whom were female (Box 1). The median age of all candidates at their first MCQ attempt was 32 years (interquartile range [IQR], 28–37 years; range, 20–73 years). The clinical examination was attempted by 20 494 candidates. Their demographic features were similar to that of the candidates for the MCQ. Box 1 shows the number of candidates for the MCQ and clinical examination for the top ten countries of primary medical qualification at each examination. The data for countries grouped by UN region are provided in the online Supporting information, table 1, and data for candidates from all individual countries (except those with very few candidates) are provided in the online Supporting information, table 2. South Asia was the region contributing most candidates, with just under half the total — predominantly graduates from India, Pakistan and Sri Lanka. Next in order were those from South‐East Asia and North Africa. Candidate performance From a low base until about the year 2000, there was a marked increase in candidates attempting each examination, reaching a peak in 2009 for the MCQ and 4 years later for the clinical examination (Box 2 and Box 3). Although the candidate numbers declined slightly after these peaks, they remained almost fourfold higher than in 2000. The pass rate at each attempt in the MCQ examination fluctuated, with most year‐to‐year variations not reaching statistical significance. However, overall pass rates per attempt increased over time, from a low of 28% in 1987 to a high of 66% in 2018. Some candidates showed great persistence: 86 attempted the examination ten or more times. As with the MCQ examination, the pass rate in the clinical examination increased between the 1980s and the 2000s, reaching a peak of 64% in 2007. However, between 2011 and 2012 it fell by more than 10%, followed by a further decline; and for the past 5 years (excepting 2019 when data were incomplete), it has remained just above 30%. Nevertheless, most candidates who persevered managed to pass after one or two further attempts. As with the MCQ, there were a few who found it much more difficult. Five or more attempts were made by 621 candidates (3.0%), 144 of whom have not yet succeeded. Pass rates by individual country are provided in the Supporting information, table 3. In the MCQ, during the past three decades, women had a higher pass rate per attempt and overall, although the magnitude of the difference (about 3%) was small (Box 4). In the clinical examination since 1990, women had both a higher pass rate and fewer attempts. In the most recent decade, the difference in pass rates was substantial (+12%). Box 5 and Box 6 show the pass rates in the MCQ and clinical examinations, respectively, graphed against candidates’ age and the interval (recency) since their medical graduation. There was a marked decline in success with both increasing age and interval since graduation; this was more marked in the clinical examination. While the number of candidates who were 55 years or older was small (245; 1.2% of total), their pass rate was one‐third that of candidates aged 20–29 years, and only 45% of the older group eventually passed. Commentary Before 2000, the number of IMGs attempting AMC examinations annually was usually less than 300 and never exceeded 600. However, between 2000 and 2018, candidate numbers increased more than threefold to an annual mean of 1003 during a period when the number of all Australians born overseas increased only from 4.5 to 7.3 million.8 Some factors likely to have contributed to the increase in candidates were removal in 1998 of the requirement to be an Australian citizen, and offering the computer‐delivered MCQ examination from 2005 in several centres outside Australia. A further increase in candidates for the MCQ examination resulted from the 2006 decision by the Council of Australian Governments that all IMGs with limited or temporary registration with the individual state medical boards should pass that examination. The peak in attempts at the clinical examination in 2013 followed the establishment of the National Registration and Accreditation Scheme in July 2010 and the requirement that limited registrants (non‐specialists) demonstrate progress towards full registration (including passing the AMC clinical examination where applicable). It is important to note that these data are specific to those sitting the AMC examinations. They give only a partial picture of medical immigration over this period. Firstly, they do not include IMGs who were registered as specialists by the various states, and subsequently by AHPRA on advice from specialist colleges. Secondly, until 1992 the Medical Acts in all Australian states allowed graduates from the UK (and usually Ireland) exemption from the need for further examination. For the next 15 years, generalists from those countries usually had to take the AMC examinations, but from 2007 they were again exempted (along with IMGs from Canada and the US) when the AMC introduced the competent authority pathway. The overall success rate in the MCQ examination increased significantly from the 1980s. The AMC made several changes over that time to increase reliability and fairness. One was altering question types to formats less dependent on English language skill; another was publication of annotated question banks to assist candidates in their preparation.5,6,9 From 2000, the pass mark has been set by criterion‐referenced methodology. A further refinement from 2011 was administering the MCQ examination in computer‐adaptive format, where the difficulty of items is adjusted in real time according to a candidate's performance, considered to increase fairness and precision.10 A factor likely to have contributed to the recent lower pass rate in the clinical examination (Box 3) is the removal of nearly all candidates from the competent authority countries. Up till 2009, UK graduates had the highest pass rate in this examination (Supporting information, table 3), and their removal from the pool would inevitably lower the overall rate. However, the decline since 2010 cannot be fully accounted for by this since competent authority candidates comprised less than 10% of the 2000–2009 total. Thus, other factors affecting the most recent cohorts of candidates (eg, the changing mix of parent countries) are likely to have contributed. Many IMGs must often overcome hurdles less likely to be faced by those from competent authority countries. These include adapting to an unfamiliar health system, developing fluency in English, preparing for the examinations while under time pressure from short‐stay visas, and needing to support themselves with sometimes long hours of work outside the health system.11 It is possible, though, that changes in the format or content of the OSCE have also contributed. The differences between the results for women and men in the MCQ should not be overplayed, since the magnitude was small. Others have found little gender effect in postgraduate written examinations in the UK and the US.12,13 However, the outperformance by women in the clinical examination, particularly in the past decade, is more striking. Those findings have been seen elsewhere. Women perform better than men in Step 2 of the United States Medical Licensing Examination.14 Female overseas‐trained doctors were twice as likely as males to pass the UK Federation of Royal Colleges of Physicians’ Practical Assessment of Clinical Examination Skills (PACES) at their first attempt.15 The PACES examination has many similarities to the AMC OSCE, with communication skills important for both. Female superiority in patient–doctor communication has been documented previously,16 and may partly explain the present findings. That performance in the MCQ deteriorated with both age and time since graduation is not entirely surprising: the examination tests knowledge in all domains of medicine, including some of the basic sciences. The longer since these were studied, the more difficult it might be to pass questions based on them, especially for IMGs who had practised as specialists in their original country. More unexpected was the much lower performance in the clinical examination by older candidates. Clinical experience might have been expected to give them an advantage, but this does not appear to have been generally so. We have been unable to find exactly comparable data from medical licensing examinations in other countries. A UK retrospective analysis observed that international graduates aged more than 37 years actually performed better in a postgraduate paediatric examination.17 However, a US analysis noted a negative correlation between age when first certified by the American Board of Internal Medicine and the American Board of Surgery and subsequent success in maintenance of certification examinations.18 Since 1978, these examinations have played an important role in informing the credentialing of generalist IMGs by state medical boards and now the national board. This article has documented substantial changes over the four decades in the demography of candidates, and some factors that were associated with their success in the examinations. The information will be of interest to health planners, but more particularly to those IMGs who have passed through the process and others who are contemplating it. Many rural health services still struggle to meet their workforce needs and rely heavily on doctors who have migrated to practise medicine here.19 Australia continues to owe a debt to its immigrant doctors. Box 1 – Multiple choice question (MCQ) and clinical examinations: numbers of candidates, top ten countries* Country of training 1978–1989 1990–1999 2000–2009 2010–2019 Total MCQ examination India 351 496 2619 2483 5949 Pakistan 32 113 1007 1838 2990 Sri Lanka 159 246 1005 1394 2804 Egypt 179 356 375 1171 2081 Bangladesh 16 99 777 1107 1999 Iran 32 34 664 1197 1927 Philippines 83 182 646 714 1625 China 4 219 641 745 1609 Myanmar 21 66 485 772 1344 Iraq 8 160 420 602 1190 Total all countries 1864 3859 12 722 17 254 35 699 Clinical examination India 190 392 1059 2074 3715 Sri Lanka 101 194 399 960 1654 Pakistan 13 59 342 1168 1582 Bangladesh 7 53 483 831 1374 Iran 8 27 263 688 986 China 0 109 398 475 982 Egypt 78 296 195 375 944 Myanmar 5 45 175 661 886 Philippines 11 104 198 507 820 Iraq 2 85 303 358 748 Total all countries 897 2588 5806 11 203 20 494 * By total number of candidates. Data are listed by the year each candidate first attempted the examination. Many candidates made multiple attempts. International medical graduates trained in the United Kingdom and Ireland were exempted from the Australian Medical Council examinations by most states until 1992. Since 1997, few candidates from the competent authority countries (UK, Ireland, Canada and the United States) were required to take the examinations. Box 2 – Number of candidates and success rate per attempt in the multiple choice question examinations since 1978, and total number of attempts by candidates each year* * Data for 2019 truncated at October. Box 3 – Number of candidates, success rate per attempt and total attempts in the clinical examinations since 1978, and total number of attempts by candidates each year* * Data for 2019 truncated at October. Box 4 – Influence of gender on examination success* Period Gender N Total attempts Total passes Mean (SD) attempts Pass total (%) Pass/attempt (%) MCQ examination 1978–1989 Female 568 1299 412 2.29 ± 1.84 72.5% 31.7% Male 1142 2431 817 2.13 ± 1.68 71.5% 33.6% 1990–1999 Female 1691 3279 1434 1.95 ± 1.57 84.8% 43.7% Male 2164 4275 1729 1.98 ± 1.71 79.9% 40.4% 2000–2009 Female 5438 8666 4813 1.59 ± 1.14 88.5% 55.5% Male 7287 11846 6192 1.63 ± 1.32 85.0% 52.3% 2010–2019 Female 8891 12238 7378 1.38 ± 0.86 83.0% 60.3% Male 8365 12041 6845 1.35 ± 0.85 81.8% 56.8% Clinical examination 1978–1989 Female 257 503 233 1.96 ± 1.58 90.7% 46.3% Male 543 1085 471 2.00 ± 1.47 86.7% 43.4% 1990–1999 Female 1156 2037 1084 1.76 ± 1.07 93.8% 53.2% Male 1432 2917 1243 2.04 ± 1.35 86.8% 42.6% 2000–2009 Female 2636 3662 2428 1.39 ± 0.82 92.1% 66.3% Male 3170 5036 2772 1.59 ± 1.08 87.4% 55.0% 2010–2019 Female 6150 9802 4535 1.59 ± 1.03 73.7% 46.3% Male 5053 9184 3132 1.82 ± 1.30 62.0% 34.1% * MCQ = multiple choice question; SD = standard deviation. * The Australian Medical Examining Council did not list candidates’ gender in a few instances during the first decade. Box 5 – Australian Medical Council multiple choice question (MCQ) examination, 1978–2019: pass rates versus (A) age and (B) recency (interval since graduation) in the year when candidates first attempted the MCQ (all countries combined)* Spearman rank order correlation: (A) r = −0.964, P < 0.001; (B) r = −0.983, P < 0.001. Box 6 – Australian Medical Council clinical examination, 1978–2019: pass rates versus (A) age and (B) recency in year when the examination was first attempted* * Spearman rank order correlation: (A) r = −0.950, P < 0.001; (B) r = −0.950, P < 0.001.

Neville D Yeomans · Jillian R Sewell · Philip Pigou · Stuart Macintyre

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

Benjamin D Bravery · Jovana Stojkov · Jeremy Brown

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

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

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

Ian A Scott · Carmel Crock

To the Editor: The incidence of bushfires, forest fires and wildfires, is increasing globally. Epidemiology shows that individuals with chronic respiratory diseases are most affected with increased hospitalisations. However, the impacts or safe exposure levels of bushfire smoke are not well known.1 We were recently awarded the Medical Research Future Fund's Bushfire Impact Research grant 2020 and in this project we will address the following questions: How does bushfire smoke exposure affect respiratory health? How does it exacerbate chronic respiratory diseases and affect different age groups? What are the impacts on cells, tissues and molecular pathways? How can we target the effects therapeutically? Bushfire smoke is a complex mix of inspirable particles, volatile organics, aldehydes, carbon monoxide, and particulate matter (PM).2 Although extensive research evaluating the effects of bushfire smoke has not been carried out, studies utilising cigarette smoke or vehicular PM10−2.5 show that exposure to these insults induces lung inflammation and oxidative stress, and promotes the progression of chronic respiratory diseases.3,4,5 Further, in vitro studies with healthy human fibroblasts and bronchoepithelial cells show that bushfire smoke affects pathways including oxidative stress, barrier function, innate defence, and autophagy.6 Accordingly, we plan to expose mice to the different PM particles from bushfire smoke and will elucidate the acute and prolonged effects on lung inflammation, airway remodelling and lung function. In addition, by using our mouse model of chronic respiratory diseases (chronic obstructive pulmonary disease, asthma) and mice at different ages (pregnant, infant, aged), we will assess the impact of bushfire smoke on predisposition, pathogenesis and progression of chronic respiratory diseases. We will use advanced molecular and multi‐omics (single cell/tissue sequencing, proteomics, epigenetics) technology to elucidate cell and tissue responses. Furthermore, we will define therapeutic avenues for prevention and treatment (antioxidants, metabolic modulators) (Box). The outcomes of this project will inform the development of safe exposure guidelines and define preventive/treatment measures. Moreover, we will address evidence gaps related to harmful health effects of hazardous bushfire smoke exposure which we hope will aid government and health agencies to design appropriate policies, prevention measures, and treatment strategies to deal with future bushfire smoke events. Box – Methodology for evaluating the impact of bushfire smoke COPD = chronic obstructive pulmonary disease; PM = particulate matter.

Vivek Dharwal · Keshav R Paudel · Philip M Hansbro