Information science

The pen & the stethoscope. Leah Kaminsky, editor. Melbourne: Scribe Publications, 2010 (x + 223 pp). ISBN 9781921640735. “Medicine is my lawful wife and literature my mistress; when I get tired of one, I spend the night with the other.” This quote from Anton Chekhov, perhaps the most famous doctor–writer, appears in the flyleaf of The pen & the stethoscope, a collection of stories by doctor–writers. Despite my misgivings about presenting fiction and non-fiction in the same volume, this is a seamless set of narratives by doctors, from varying specialties, who are also accomplished writers. It demonstrates that we, as doctors, have moved beyond the 19th century and Chekhov’s need to separate our scientific and humane selves in the clinical setting. Leah Kaminsky, herself an award-winning author and practising family physician in the United States, has assembled an international cast of doctor–writers who illuminate issues such as the challenge of ageing, suicide of a colleague, and guilt at failure but also success in medicine. We are treated to an insightful exploration of the thoughts and feelings of doctors in their daily work. The point of view of patients and their loved ones is also elaborated with great skill. Ethan Canin, in his exquisite tale, “We are nighttime travellers”, details the disintegration of a man and his marriage over many years, and his final very moving redemption. In “The checklist”, Atul Gawande details a doctor’s simple but ingenious idea that has saved lives. “Do not go gentle”, by Irvin Yalom, is an account of a psychiatrist who can identify with his patient who hoards the letters of a long-lost lover. Oliver Sacks, in “The lost mariner”, writes about a neurological conundrum with his usual fluidity and flair. Jacinta Halloran, in “Finding Joshua”, exposes every doctor–mother’s fear that a demanding job will not leave enough time for her children. I enjoyed reading The pen & the stethoscope. The stories are well written, thought provoking and appealing to both doctors and lay people. Medical students may find these narratives particularly enlightening. I recommend this collection as a good addition to the Christmas holiday reading list.

Sue Ogle

Voting in this year’s Christmas Competition was akin to picking the daily double, with two main categories emerging from the field — “humorous” and “true stories.” Apart from the need for clarification about the number of votes allowed per person (thwarting any attempts at race fixing) and comments about the much needed upgrade for a new voting “box” (the current one has survived three office moves since 2001), the voting proceeded quickly and without incident. Once again, all entries were of very high quality and reached the finish line unscathed — with two winners (by a nose). In the humorous category, “The hidden menace of non-equine horses” by John Craven and Jacquie Schutz won the day. The paper fills an important gap in the scientific literature and will no doubt have you recounting some of your own childhood encounters with this beast in its various guises. True stories are often sobering but some of them, such as Katie Moynihan’s heart-wrenching account of her experiences working in Uganda, need to be told. Along with the author, we hope that some of the human stories behind Uganda’s slow progress towards reducing maternal and child mortality will raise awareness of the country’s dire shortage of basic hospital facilities, and the very small amount of money that would be required to provide relief: much less than the average Australian spends on the Melbourne Cup! Our great thanks to all who entered this year’s competition. We know there are more stories and pictures out there and look forward to your future entries as you feel spurred on to take up the challenge and bolt to the finish line next year, for a chance to win not a cup but a basket (of goodies) for your Christmas table.

Alison Williams

To the Editor: “Student medical journals” are a very broad church, encompassing everything from pseudo-magazines to rigorously peer-reviewed publications. In April this year, a national journal of the latter variety was launched here in Australia: the Australian Medical Student Journal (AMSJ).1 The AMSJ accepts research, review and opinion articles from students of medicine or health sciences at Australian universities. The journal’s volunteer staff comprises only medical students, and peer-review is by academics associated with Australian medical schools, or clinicians at Australian teaching hospitals. The inaugural issue could hardly have been more national in its focus, with students from 14 Australian medical schools, covering every state, being represented among the authors. The issue was recently distributed free of charge to thousands of medical students around Australia in both print and electronic formats. After the success of the inaugural issue, we plan to begin biannual production from 2011, continuing in both formats. The AMSJ operates as a not-for-profit student organisation, and printing and other costs are provided for by sponsors, including the Australian Medical Association, Australian General Practice Training, and the Royal Australasian College of Physicians. While it is unique in a number of facets, the AMSJ is not the first publication of its kind. The Australian Medical Students’ Association magazine Panacea began life in 1968 as a journal, albeit not peer-reviewed.2 Several individual Australian medical schools have had their own academic publications for varying periods, such as the Sydney University Medical Journal, which was first published around 1905.3 More recently, our counterparts across the Tasman were well ahead of us, with the New Zealand Medical Student Journal releasing its first issue in 2004.4 Further afield, some of the better known student journals are the McGill Journal of Medicine (MJM) in Canada and the Student BMJ in the United Kingdom. Most student journals fall roughly into one of two categories: those whose focus is primarily instruction and entertainment, with shorter educational or blog-style articles (often written by non-students) having appeal to time-constrained students (eg, Student BMJ); and those that publish academically rigorous student work, perhaps at the expense of reader interest (eg, MJM). The AMSJ has a number of aims (Box), although central to our mission is to transcend this artificial tension and attract student-authored articles that are both thoroughly interesting and academically substantial. The rationale is that anything short of a proper peer-reviewed journal is patronising towards students, but, on the other hand, articles that are not appropriately pitched cause disenchantment. Medical students have played key roles in the history of medicine: notable discoveries made or shared in by medical students include heparin, insulin, the sinoatrial node, the pancreatobiliary sphincter, ether anaesthesia, islets of Langerhans, and spermatozoa.6 We hope that the AMSJ can continue to promote and foster this tradition of student achievement. Aims of the Australian Medical Student Journal5 To provide a medium for Australian medical students to publish their work and share ideas with their peers. To provide a suitable forum for students to make the transition between assignment writing and producing publishable academic work. To inform students about medical topics and issues not typically addressed in core curricula. To facilitate discussion of current issues relevant to medical students. To allow Australian medical schools to showcase the research aspects of their programs. To provide a further incentive for students to produce high-quality work in their studies. To foster the next generation of Australian medical researchers and physician–scientists. To provide an avenue for students interested in a career in medical editing or publishing to pursue this interest as a student staff member.

Matt D Schiller

In 2008, the Australian Government established three major health reform initiatives — the National Health and Hospitals Reform Commission, the first National Primary Health Care Strategy working group, and the Preventative Health Taskforce. We examined which journals were most frequently cited in the publicly available discussion papers, commissioned papers, submissions and final reports of these initiatives. Journal articles were cited most in discussion papers, commissioned papers and submissions, followed by reports and other publications from Australian organisations and governments. The Medical Journal of Australia was the most cited journal, with 392 references to its articles (11.8% of all journal articles cited) in discussion papers, commissioned papers, submissions and an interim report, and 58 references to its articles (13.7% of total journal articles) in the three final reports. Our findings demonstrate the importance of credible, local, accessible, peer-reviewed evidence in reforming the national health system, including hospitals, primary health care and preventive health care.

Elizabeth C Kalucy BSc, MSc, Dip Ed · Eleanor M Jackson Bowers BA(Soc Sci), MNurs, GradDipInfoStud

A simplified revision of the uniform conflict of interest disclosure form is now available The great variability in the processes that different journals use to ask about and report authors’ potential conflicts of interest creates confusion for authors, readers and the public. To help lessen this confusion, the International Committee of Medical Journal Editors (ICMJE) developed an electronic uniform disclosure form and placed it in the public domain in October 2009. The ICMJE member journals piloted the form, encouraged other journals to use it, and invited feedback. We recognised that the reporting of competing interests is complex and nuanced and sometimes contentious, and thus anticipated modifying the form based on feedback received. We are grateful to the many authors, editors and other interested parties who took the time to comment on the form and its implementation. The issues raised ranged from technical problems about the correct deployment of the form (it requires the user to download version 8.0 or higher of the free Adobe Reader software to function) to concerns about the ethics of inquiring about non-financial associations. The Committee considered these valuable comments and revised the form at our most recent meeting. We made several modifications. The major change in the reporting instrument is the removal of the queries about potential competing interests of authors’ spouses and minor children and about non-financial competing interests. We made this change based on the largely negative feedback that we received about these sections. People who commented about this issue made it clear that there is immense difficulty in defining competing interests beyond those that involve the direct exchange of money from an interested party to an individual author or the author’s institution. Because the Committee continues to believe that there are situations in which indirect or non-financial factors could influence (or appear to influence) the conduct or interpretation of work, we replaced the specific questions with a single open-ended query (new Section 4) that asks, “Are there other relationships or activities that readers could perceive to have influenced, or that give the appearance of potentially influencing, what you wrote in the submitted work?” This change places the onus on the person completing the form to identify and report appropriate non-financial competing interests. It has the advantage of being less intrusive than the previous queries, while providing a locus where authors can report non-financial relationships that may be perceived as potential conflicts of interest. In response to comments about the clarity of the form, each field in the form now has a numeric designation. We have modified the language in the instructions and in the individual queries. To make the form more useful to non-native English speakers, we are creating a glossary of terms used in the form and will be posting guidelines for translation of the form’s instructions into multiple languages. The translation of this form is particularly challenging because translations must capture the essence of the queries rather than their literal meaning. The glossary and guidelines will be available at the ICMJE website (http://www.icmje.org) in the next few months; translations will be posted on the ICMJE website as they become available. The new form, in English, is currently available on the ICMJE website and the websites of our member journals. Authors who have completed the older version of the form in conjunction with a journal submission need not complete the new form, but the new form will be the standard for new submissions. We welcome continued input from the user community. Comments can be sent via the “Contact ICMJE” link at the ICMJE website. The Committee will consider comments received before 1 May 2011 when we prepare the next iteration of the uniform conflict of interest disclosure form. The complexity, subjectivity and emotionality of conflict disclosure assures that some will consider this vehicle for reporting to be excessively burdensome, while others will think it falls short in one area or another. We cannot, however, let the perfect be the enemy of the good. We hope that the revised ICMJE form will be another step towards simplifying and standardising reporting of conflicts of interest. A more uniform reporting process will alleviate the confusion that prevails when multiple journals use different reporting formats, and will ease the reporting burden on members of the biomedical research community, so they can pursue the research that will improve the care that we deliver to our patients. With these thoughts in mind, we encourage all journals to adopt the new version of the uniform disclosure form.

Jeffrey M Drazen MD · Peter W de Leeuw MD, PhD · Christine Laine MD, MPH · Cynthia Mulrow MD, MSc · Catherine D DeAngelis MD, MPH · Frank A Frizelle MB ChB · Fiona Godlee MB BChir, BSc · Charlotte Haug MD, PhD, MSc · Paul C Hébert MS, MHSc · Astrid James MB · Sheldon Kotzin MLS · Ana Marusic MD, PhD · Humberto Reyes MD · Jacob Rosenberg MD, DSc · Peush Sahni MS, PhD · Martin B Van Der Weyden MD · Getu Zhaori MD

Mosby’s dictionary of medicine, nursing & health professions, 2nd Australian and New Zealand edition . Peter Harris, Sue Nagy, Nicholas Vardaxis, editors. Sydney: Elsevier Australia, 2009 (xvi + 2015 pp). ISBN 978 0 7295 3909 8. The first Australian and New Zealand edition of this popular American dictionary was published in 2006. It was a landmark achievement, with its Asia-Pacific orientation in both content and style. For instance, entries included the “bluebottle jellyfish”, common to Australasian waters. Local spelling and phonetic pronunciation guides were also provided. However, almost as soon as it was published, the need for a continuing process of review and revision was recognised. And so, editors-in-chief Peter Harris, Sue Nagy and Nicholas Vardaxis led a team of 60 specialists to produce further refinements, which resulted in this second edition. The language of medicine is constantly evolving to keep up with the latest developments in research and technology. Thus, some of the new terms in the second edition include Hendra virus, Nipah virus, swine flu and vancomycin-resistant enterococcus. There were some 40 000 entries and 2400 colour images in the first edition. More than 500 images, 300 drug entries and 73 tables have been added or updated in this edition. The many useful appendices cover areas such as nutrition guidelines, immunisation schedules, infection control and herb–drug interactions. Charts and graphs range in content from lung sounds and burn depths to contraceptive effectiveness and cardiac arrhythmias. Simple devices such as extensive cross-referencing and a thumb-style index make navigation easy. The bonus “Evolve” website access provides many free online resources, such as all the images from the book, directories of key health organisations and health promotion information. This strategy has enabled the dictionary to be confined to a single volume that is still kept current through the website. This dictionary can help health professionals and students become familiar with new medical terminology and techniques, and thus improve their communication and outcomes. Certainly, as a proofreader for the Journal, I’m sure to refer to it at least once a week.

Gita Sankaran

The most notable event at the MJA this year for readers was the change in online access. In 1996, the MJA was made partially accessible online, and fully accessible in 2002, when our resources became sufficient to support this. Readers then enjoyed full open access to all MJA content until this year, when the company’s Board felt that it was not financially viable to continue this model and restricted full access to subscribers. Non-subscribers can, however, still access much of the Journal for free — research articles for the first 2 weeks following publication, selected articles free permanently and all articles free 12 months after their initial publication date. All online articles published before 2009 remain freely available. We will analyse the effect this restriction has had on our readership once we have more data, but interim indications are that our hit rates have not changed significantly. Many of our readers can access the Journal online via their institution’s subscription, and published contributors and reviewers receive a year’s free subscription. The next big event for the MJA was the mid-year departure of Deputy Editor Dr Ruth Armstrong. Ruth had worked at the Journal since 1998. She was a tireless supporter of the ideals of scholarly publishing and the greater good, with never-ending enthusiasm and dedication well above and beyond the call of duty. Ruth enjoyed the challenge of being a catalyst for change in the health system and championed many causes, but perhaps her most enduring legacy is the MJA’s annual Indigenous Health issue. Ruth developed relationships with Indigenous stakeholders and expanded what was once a small Indigenous health section to become a full issue, complete with a $5000 prize for an essay by an Indigenous person who works or studies in a health-related field. Fortunately, she has agreed to return as Guest Editor for the 2010 Indigenous Health issue. Ruth is heading back to the wilds of clinical practice — we wish her well (but really we wish she’d come back!). By the time this issue is published, another from our team of Deputy Editors, Dr Tanya Grassi, will also have left to return to clinical practice. Tanya has worked at the Journal for 5 years (with some time out in the middle to obtain a degree in veterinary science), bringing with her an enormous capacity to keep the endless incoming manuscripts moving, and a particular sensitivity to help authors, especially the less experienced ones, get over the many hurdles leading to publication. Her return to specialist pathology training proves that she certainly is a woman who can turn her hand to anything! To complete the hat-trick, Dr Martin Van Der Weyden, MJA Editor since 1995, has announced his intention to retire in the near future. We have thus embarked on a search to find a very special person to lead the Journal in to bat for its second century (see the notice on our website calling for “expressions of interest”). Before taking over as Editor of the Journal, Dr Van Der Weyden was Professor and Head of Haematology and Chief of Investigative Medicine at the Alfred Hospital, Melbourne. He had a strong research background, with over 100 articles published in peer-reviewed journals, was a renowned and sought-after speaker at medical meetings, had a special interest in administration and management (fuelled by a short stint at Harvard Business School) and had a passion to bring the important issues affecting the organisation of health systems and the equitable provision of health care to the attention of all Australian doctors. Over nearly 15 years, he has certainly done this while maintaining the MJA’s position as Australia’s premier general medical journal, and significantly improving the academic calibre of its content. His success is reflected in the Journal’s rising impact factor (Box). This year he was elected a Director of the Executive Board of the World Association of Medical Editors. The MJA has also managed to do a few things other than turn over staff. The MJA participated in the world’s largest gathering of journal editors, the Sixth International Congress on Peer Review and Biomedical Publication (yes, there is such a thing as research into peer review and scholarly publishing!). The Congress is a quadrennial event, this year held in Vancouver. We published a new book, Enhancing patient care: a practical guide to improving quality and safety in hospitals (available from the eMJA shop). We awarded two prizes (see our 3 August 2009 issue) — the MJA/Wyeth prize of $10 000 for the best published clinical research, to Dr Lindsay Grayson and colleagues from Melbourne (who reported their successful statewide rollout of a multifaceted hand hygiene program), and the Dr Ross Ingram Memorial Essay Prize of $5000 to Beverley Spiers, a Justice Health Aboriginal Health Worker, for her essay about efforts in screening Aboriginal prison inmates. We also dealt with 1522 new manuscripts (Box) and expanded our capacity for rapid online publications with breaking news on swine flu. As always, the high quality of MJA articles is maintained by the high quality of our volunteer reviewers and our Content Review Committee (listed below), who share their expertise with us. We are extremely grateful for your assistance and hope you will continue to provide your invaluable insights. In this double Christmas issue, we offer you some lighter and more eclectic holiday reading on a diverse range of topics, from tragic and uplifting personal stories to the humorous anecdotes of our Christmas competition. We hope you enjoy it, and we look forward to seeing you back again next year. Bronwyn Gaut Deputy Editor, Medical Journal of Australia, Sydney, NSW Manuscripts received 2008–2009 Manuscripts accepted/received (%) Total 605/1522 (40%) Research articles 103/450 (23%) Cases 25/149 (17%) Reviews 12/50 (24%) Letters 227/358 (63%) Mean days to decision To reject 36 (research articles, 31) To accept 84 (research articles, 135) Reviewers used (invited) 1654 (2783) Impact factor 3.32 Reviewers Content Review Committee Craig S Anderson Leon Bach Flavia Cicuttini Jennifer J Conn Marie-Louise B Dick Mark F Harris A Thomas C Kotsimbos Campbell H Thompson Timothy P Usherwood Elmer V S Villanueva E Haydn Walters Bruce P Waxman Owen D Williamson Jane M Young Jeffrey D Zajac Reviewers (reviews submitted 01/11/2008 – 31/10/2009) Penelope A Abbott Peter J Abbott Amr Abou Elnour Stephen P Ackland Caroline H C Acton Karen Adams Barbara-Ann Adelstein Stephen Adelstein Michael A Adena Rebecca M Albury Rosemary Aldrich Frank P Alford Jean-Pierre Allain Margaret N Allars Katrina J Allen Geoffrey Ambler Craig S Anderson Ian P S Anderson Jonathan S Anderson Robert P Anderson Warwick P Anderson Rachel A Ankeny Nicolas M Anstey Gregory E Antonio D Barry Appleton Simon C Apte Bruce K Armstrong Ruth M Armstrong Peter C Arnold Constantine N Aroney Michael A Ashby Deborah A Askew William (Bill) Atkin David N Atkinson Tony J Attwood Mark S Awerbuch Philip E G Aylward Peter D Baade Christopher J Baggoley Ian J Baguley Ross S Bailie Mark S Baker Philip R Baker Robert A Baker John I Balla Hilary J Bambrick Lilon G Bandler Paul R Barach Michael Barakate Michael P Barbato Ruth A Barker Peter L J Barnett Ian G Barr Bruce H Barraclough Alexandra L Barratt Andrew Bartholomaeus Christopher A Barton Anne E Bartu Ivan B Bastian Robert G Batey Diana Battistutta Adrian E Bauman Peter E Baume Louise A Baur Robert W Beal Renae B Beaumont Penny E Bee James G Beeson Justin J Beilby Cameron J Bell James R Bell Sally J Bell Richard A V Benn Belinda Bennett Derrick A Bennett Jill Benson Vasili Berdoukas Michael Berk James Donovan Best J H Nicholas Bett Barbara E Biggins Robert Birrell Deborah A Black Robert J Black David J Blacker Tim Blackmore Tony Blakely Jane Bleasel R Warwick Blood John D Boffa Nikolai Bogduk Terry D Bolin Michael D Bollen Stephen N C Bolsin Patrick G M Bolton Catriona M F Bonfiglioli Michael A Bonning Heather S Boon Ron M Borland Mari Botti Louis-Philippe N A Boulet Christopher J Bourke Craig S Boutlis Francis J Bowden Scott Bowden Simon D Bowler John Boyages Ian W Boyd David L Bradford Clare Bradley Pamela J Bradshaw Maggie Brady George Braitberg Jeffrey Braithwaite Caroline A Brand Jennie C Brand-Miller Graeme A Brazenor Kerry J Breen Joan M Brewster Charles Bridges-Webb David Brieger Jo-anne E Brien Esther M Briganti Timothy A Brighton Peter J Bristow Helena C Britt Kaye E Brock David Brockman Henry Brodaty Peter M Brooks Anthony M Brown Peter D Brukner Ingrid Bucens David Buckley Michael F Buckley Anne E Buist Michael D Buist Fiona C L Bull Max K Bulsara Mary Burbidge Jonathan G W Burdon John R Burgess David Burgner John R Burnett Colin D Butler Tony G Butler Jim P Buttery Brian Buxton Julie E Byles Paul M Byleveld Edward Byrne John F Cade Peter I Cairney Ian D Cameron Peter A Cameron Emily M Campbell Lesley V Campbell Terence J Campbell Susan M Carden Magnolia Cardona John B Carlin Philippe Carrière Phillip J Carson Armand Casolin Alan Cass Erin Cassell Donald R C Chalmers Ian M Chalmers Alex J Chamberlain Albert K F Chan Annabelle C Chan Raymond C Chan Anne B Chang Jeremy R Chapman Simon Chapman Patrick G P Charles Barry E Chatterton Allen C Cheng Ian R Cheong David A Cherry Winston Cheung Derek P B Chew Marcia Day Childress Donald J Chisholm Beng H Chong Christopher Y P Choong Peter F M Choong MacDonald J Christie Christopher Christophi Flavia M Cicuttini Ian A Clark Stephen L Clark Caroline F Clarke David M Clarke Rufus M Clarke Stephen J Clarke Moira A Clay Josephine M Clayton Mark Clements Peter M Clifton Alan R Clough Harvey L C Coates Catherine H Cole Stephen A Cole James G Colebatch Jacinta M Coleman Peter J Collignon John J Collins John P Collins Nicholas P Collins Brian T Collopy Mark E Colson Elizabeth J Comino Christopher A Commens John R Condon Jennifer J Conn Julie Considine Pedro Conthe W Graham E Cooksley Nicholas B Cooling Alan J Cooper David (Gus) M Cooper Michael D Coory William Coote Stephen J Corbett Yvonne E Cossart Anthony J Costello Douglas J Coster Jennifer J Couper Richard T L Couper Sophie Couzos Benjamin C Cowie Benjamin J Cowling Brian Cox Helen M Creasey Patrick C Cregan Allan W Cripps Ashley M Croft John L Crompton David B Cross Jisheng (James) Cui Graham L Cullingford Robert G Cumming Adrian G Cummins David Cunliffe Frances C Cunningham Russell C Dale Andrew Dalton Craig B Dalton Seamus E Dalton Kim M Dalziel Diona L Damian John Daniels Anthony M Dart Mike M Daube Sandra K Davidson Andrew M Davis Stephen M Davis Timothy M E Davis Wendy A Davis Elizabeth M Dax Lesley M Day Richard O Day David J de Carle Caroline M de Costa Nicholas H de Klerk Diego De Leo Loretta R de Plevitz Stephen A Deane Christopher B Del Mar Martin B Delatycki Leigh W Delbridge Michael C d'Emden Charles P Denaro Sarah M Dennis Greg Denomme Catherine A D'Este Helen M Dewey Terrence H Diamond Marie-Louise B Dick James A Dickinson Jan E Dickinson Hans Peter Dietz Paul M Dietze Andrew E Dix Helen G Dixon Jane Dixon John B Dixon Geoffrey J Dobb Annette J Dobson Hilary M Dobson Stephen L Doggett Dorota A Doherty Basil J Donovan John S Dowden Marlene M Drysdale Stephen J Duckett Patricia Dudgeon Maureen Duffy Johan A Duflou James A Dunbar David N Durrheim Seeta Durvasula Dominic E Dwyer John M Dwyer John R Dyer Sandra J Eades Kathy Eagar Creswell J Eastman Peter R Ebeling Paula Edgill Hooi C Ee Paul V Effler John W Eikelboom Robert H Eikelboom John A Eisman Peter Eizenberg Henry Ekert Mohsen S El-Alfy Diann S Eley Jaklin A Eliott John H T Ellard David A Ellwood Adam G Elshaug Jesus Esquivel Adrian J Esterman Wendell Evans Daniel P Ewald Douglas M Ezzy Paul P Fahey Kathleen M Fahy Christopher K Fairley Anthony D Falconer Gregory L Falk Mark W Faragher H John Fardy Elizabeth A Farmer Alan E Farnsworth Cynthia M Farquhar Robert G Fassett Daniel M Fatovich Thomas A Faunce Michael R Fearnside Michael Fenech John K Ferguson Mark J Ferson Suzanne A Fidler Simon R Finfer David W Firman David G Fish Colleen M Fisher John Fisher Dominic A Fitzgerald Gerard J FitzGerald Michael P Fitzharris M Andrew Fitzpatrick Louisa Flander Vicki Flenady David R Fletcher Susan L Fletcher Leon A Flicker Joanna M Flynn Romano A Fois Therese (Terri) M Foran David A Forbes Brett H R Forge Kevin D Forsyth F Gerry R Fowkes Richard M Fox Brad Frankum David R Fraser Robert D Fraser Craig J French Frank A Frizelle Mark Frydenberg Gordian W O Fulde John S Furler Eli Gabbay Alexander S Gallus Robert (Frank) A Gardiner Paul A Gatenby Peter C Gates Paul H Gavel Paul Gerber Richard P Gerraty Robert W Gibberd Kay L Gibbons Karen Gibson Peter G Gibson Peter R Gibson Alan J Gijsbers Gwendolyn L Gilbert Peter N Gilchrist Graham G Giles Marisa T Gilles Elizabeth E Gillespie James Gillespie Amanda K Gilligan Christopher M Gilpin Allan R Glanville Ian N Glaspole Richard J Glassock Paul P Glasziou Martyn S Goddard Robert D Goldney John M Goldsmid Paul N Goldwater Jonathan Golledge David Golovsky Julie E Goodman J Jill Gordon Des F Gorman C Roger Goucke Kerry J Goulston Stephen R Graves Dennis Gray Nigel J Gray M Lindsay Grayson Sally Green Peter B Greenberg Ann T Gregory Robert D Grenfell Michael C Grimm David W Gronow Scott D Grosse Sonia R Grover Michele A Groves Charles S Guest John A Gullotta Brian Gulson Leena Gupta Ian D Gust Geoffrey A Gutteridge Paul S Haber Ruth M Hadfield Mary M Haines George Halasz Robert G Hall Wayne D Hall P Shane Hamblin Ian R Hamilton-Craig Alan W Hampson Heather Hancock Graeme J Hankey C Alex Harper Richard W Harper Elizabeth Harris Ian A Harris Mark F Harris Bernie T Harrison Michelle S Harrison John A L Hart Ken J Harvey Richard B Hays Colleen P Hayward Philip L Hazell David L Healy Robert N S Heard Robert J Heddle William F Heddle Kelsey L Hegarty Robert D Helme A Scott Henderson Michael A Henderson David A Henry Sue Henry-Edwards Geoffrey K Herkes Peter Hersey Ian B Hickie Kim N Hill Lybus C Hillman Richard Hillman Christopher D Hogan Stephen R Holdsworth John D Horowitz Elizabeth D Hotham Warwick Hough Anthony K House Nehmat Houssami Laurie G Howes Rae-Lin Huang Nicky J N Hudson Helen Hughes Michael A Hull John S Humphreys Alexander P Hunyor Joseph E Ibrahim Rick A M Iedema Francesco L Ierino Timothy J J Inglis Paul Ireland Steven M Irons Donald H Irvine David Isaacs Terri J Jackson Peter A Jacoby Bin B Jalaludin Judith B James W Philip T James Konrad Jamrozik Edward D Janus Tania (Tatiana) Janusic Michael H Jefford Grant A Jenkin Chris Jensen George Jerums Moyez Jiwa Paul D R Johnson William R Johnson Ian R Johnston Damien J Jolley Dorothy A Jones Graham R D Jones Mike P Jones Sandra C Jones Timothy W Jones Anthony F Jorm Christine M Jorm Anthony P Joseph Catherine M Joyce Fiona K Judd Rodney T Judson Stephen M Jurd Jon N Jureidini Rezan Kadir Jayashree Kalpathy-Cramer Dinesh K Kalra Ross S Kalucy Max Kamien Joey M Kaye Megan A Keaney Marc J N C Keirse Nicholas A Keks Anne-Maree Kelly Heath A Kelly N Patrick Kelly David J Kennaway Peter J Kennedy Stephen J Kent Ian H Kerridge Ross K Kerridge Alison M Kesson Mohamed H Khadra Soo Keat Khoo Michael R Kidd Warren J Kidson James F King Richard King Scott Kinlay Julia C Kirchheiner Scott J Kitchener Simon C Kitto Britt Klein Andrew W Knight Ann P Koehler Paul A Komesaroff Tony M Korman Michael A Kortt Robert J Kosky Steven Kossard Joe M Kosterich Mark A Kotowicz Vicki Kotsirilos Gabor T Kovacs Emma E Kowal Henry Krum Dennis L Kuchar Susan E Kurrle Jennelle M Kyd Kypros Kypri Justin T La Brooy Leon Lack William Y Y Lai Fiona R Lake Stephen B Lambert Cecilie M Lander Iain A Lang Helen M Lapsley Richard G Larkins Sarah L Larkins Kevin B Laupland Gillian A Laven Malcolm R Law Matthew G Law Ian C Lawrance Christopher H Lawrence Richard T Le Mesurier Julie Leask Karin S Leder Amanda J Lee Richard P Lee Stephen R Leeder Peter A Leggat Barbara A Leggett Nat P Lenzo Christopher R Levi Florence Levy Michael H Levy George T Lewith Joel Lexchin Qiang Li Lynette L-Y Lim Steven J Lindstrom Wendy L Lipworth Andrew F Little Bebe Loff Robert F Loneragan David F M Looke Ruth Lopert Julie A V Lord Charles W Lott Jeanne Louw David Lowe Julia M Lowe Raymond M Lowenthal Dan I Lubman Judith M Lumley Kristine K Macartney Sarah A MacDermott Graeme A Macdonald Graham J Macdonald Peter S MacDonald Andrew I MacIsaac Alastair A J MacKendrick Dorothy E M Mackerras Alastair H MacLennan Finlay A Macrae Richard Madden Guy J Maddern Parker J Magin Roger S Magnusson Donna B Mak Laurence A Malcolm Elizabeth Manias Linda Mann Paul R Mara Lynette M March Peter G Markey Tania P Markovic John E Marley Caroline Marshall Roderick I Marshall Roger J Marshall Wendy E Marshman Andrew J Martin Frank Martin Isobel R Martin Jose M Martin-Moreno R John Massie Francis L Mastaglia Timothy H Mathew John D Mathews Ross G Maxwell Brian R McAvoy W John H McBride James S McCarthy Sally M McCarthy Catherine A McCarty Kieran A McCaul Philip I McCloud Peter J McCluskey Joseph G McCormack Lesley McCowan Peter McCrorie Liane McDermott Christine F McDonald Susan J McDonald Joseph McDonnell Patrick McElduff Heather J McElroy Suzanne P McEvoy John McEwen Patrick D McGorry Katherine M McGrath Del McGuiness Fran McInerney H David McIntyre Peter B McIntyre Dean McKenzie Moira McKinnon Rick McLean Catherine A McMahon I Chris McManus Ian B McPhee Jean V McPherson Graham N Meadows Alan P Meagher Muhammed A Memon Désirée Mészáros Lynn B Meuleners Antonina A Mikocka-Walus J Alasdair Millar Anne M Miller Graeme C Miller I Harry Minas Adrian Mindel Gary Misan Christopher D Mitchell David H Mitchell Gillian Mitchell Paul R Mitchell Philip B Mitchell Ramon Mocellin Paula J Mohacsi Mohammed Mohsin Michael Montalto Scott C Montgomery Gavin H Mooney Kate H Moore Helen J Moriarty Belinda Morley Peter S Morris Philip L P Morris Robert G Moses David Mountain Raymond J Mullins Howard R Munro John F Murray Richard B Murray Kenneth A Myers Ludomyr J Mykyta Sydney M L Nade Louise M Nash Bruce C Neal Rachel E Neale Mark R Nelson Jonathan W Newbury Harvey H Newnham Phillip Newton Kathleen M Nicholls James H Nichols Geoffrey C Nicholson Olav B Nielssen Paul Nisselle Terence M Nolan B E Christopher Nordin Robert J Norman Nicola North Robyn N Norton Len Notaras Caryl Nowson Don Nutbeam R Kim Oates Jeremy J N Oats Paul E O'Brien Beverly O'Connell Dianne L O'Connell Liam F O'Connor Christopher J O'Donnell Susanne P O'Malley Michael F O'Rourke Nicholas Osborne Richard H Osborne Jeyaraj D Pandian Francesco Paolucci Gordon B Parker Malcolm H Parker Neil R Parker Robert M Parker Richard Pascal Megan E Passey Amit Patel Anushka A Patel Mahomed S Patel Sanjay Patel George C Patton Hedley G Peach Louis G Peachey Bronwyn J Peirce Brita A Pekarsky Stella Pendle David G Penington Andrew G Penman Paul L Pers Andrew F Pesce Madelyn M Peterson Peter E Petros Peter D Phelan Christine B Phillips Paddy A Phillips Peter I Pillans S Praga Pillay Carole B Pinnock Jane E Pirkis Marie V Pirotta Leon Piterman Gerd J Pluschke Jennifer R Powers David A Powis Vicki Poxon Paul Prociv Anthony M Proietto Joseph Proietto Judith Proudfoot Ramon P Pujol Carolyn Quadrio Michael A Quinn Shantha M W Rajaratnam Ron M Rapee Simon Raymond Christine M Read T John Redhead Alison M Reid Christopher M Reid Joseph M Rey Drew B Richardson Malcolm D Riley Ian T Ring Maria Magdalena Riper David C Rivett Glenn B Robert Chris Roberts Mick G Roberts Sally A Roberts Jane Robertson Jeffrey S Robinson Maxine Robinson Stephen J Robson Ann M Roche Alan Rodger Stephen J Rodrigues Wendy A Rogers Robin Room Pauline V Rosenau Glynis P Ross Elizabeth E Roughead Dominic B Rowe Kevin G Rowley Robert J Ruben Richard E Ruffin William B Runciman Darren B Russell Lesley M Russell Richard C Russell Peter F J Ryan Jonathan M Samet Sally J Sandover (nee Reagan) Christobel M Saunders Peter L Schattner Carlos D Scheinkestel Peter Schiff Deborah J Schofield Ian A Scott David J Scrimgeour Holly Seale J Paul Seale Sanjaya N Senanayake Jamie E Seymour Anthony Shakeshaft Sepher Shakib Norman Sharpe Jonathan E Shaw Dale Catherine Sheehan Julia M Shelley Sam Shemie Juanita M Sherwood Timothy D Shortus Stephen P Shumack Damin M Si Rebecca K Simmons Leon A Simons Rodney D Sinclair Sonal Singh John Skelton Loane L C Skene Clare A Skinner Steven J Skov Richard A Smallwood Anthony C Smith David E Smith David P Smith David W Smith J Anne S Smith Julian A Smith Mitchell M Smith Richard S W Smith Simon Smith Mary J Sneyd Michael J Solomon Daya Somasundaram Helen Somerville Andrew Somogyi Khee Chee Soo Denis W Spelman A John Spencer Allan D Spigelman Andrew Spillane Arn Sprogis Geoffrey K Spurling D James B St John Carolyn Staines Rosemary A Stanton Margaret P Staples Richard A Stein Ian D Steven Matthew Stevens Christopher E Stevenson Mark R Stevenson Graeme J Stewart Janelle Stirling Russell W Stitz Jim R Stockigt Martin R Stockler Timothy R Stockwell Johannes U Stoelwinder Elsdon Storey Roger P Strasser Simone I Strasser Alison M Street Annette F Street John E Stuart Rhonda L Stuart Robin C Stuart-Harris David M Studdert Allan D Sturgess Joachim P Sturmberg Nabil D Sulaiman David R Sullivan Melissa A Sweet Rand S Swenson Hal Swerissen Boyd A Swinburn George A Tallis Martin H N Tattersall Hugh R Taylor Glyn Teale Helena J Teede Maree Teesson David E Theile Francis C K Thien David P Thomas Campbell H Thompson John F Thompson Peter L Thompson Sandra C Thompson Colin J H Thomson Dominic S Thyagarajan James Tibballs Mark L H Tie David J Tiller John W G Tiller Joseph Y S Ting Nickolai Titov Ronald P Tomlins Shilu Tong Andrew M Tonkin Anne L Tonkin Les J Toop Duncan J Topliss Adrienne J Torda Paul J Torzillo Douglas G Travis Ronald J A Trent Stephen C Trumble Stephanie K Trust David R Turner Gillian M Turner Dimitra Tzioumi Timothy P Usherwood David Vaile David van der Poorten Helen J Van Gessel Annemieke van Straten Chris van Weel Alasdair Vance Janette Vardy Erkki Vartiainen Samuel D Vasikaran Antony J Veale Phillip C Vecchio Shyan Vijayasekaran Elmer V S Villanueva Graham V Vimpani John M Violanti Kumar Visvanathan Agnes I Vitry Jitu K Vohra Victoria (Tori) Wade Elizabeth Wager Todd H Wagner Gerard V Wain Paul Walker John P Walsh Garry J Walter Barry N J Walters Darren L Walters E Haydn Walters Tamara Walters Merrilyn Walton Han Wang Zhiqiang Wang Jeanette E Ward John A Ward Michael R Ward Robert S Ware Emma Warnecke Grant W Waterer Lyndsey F Watson Edward D Watt David A K Watters Bruce P Waxman Andy Wearn Susan M Wearne Karen L Webb Lynn M Weekes Philip Weinstein Timothy A Welborn David P Weller Beres C A Wenck Steven L Wesselingh Johanna I Westbrook Andrew V White Harvey A Whiteford David Whiteman Judith A Whitworth Alison Wicks Nicholas R Wilcken Kay A Wilhelm Chris S Wilkinson David Wilkinson Simon M Willcock Nicholas J Williams Ian G Williamson Owen D Williamson Rachael-Anne Wills Amanda J Wilson David H Wilson Ian G Wilson Jeremy S Wilson Tania M Winzenberg Frances M Wise John H Wlodarczyk Alex D Wodak Fiona M Wood Marion Lester Woods Alistair J Woodward Michael C Woodward Ian J Woolley Barry G Wren Elizabeth J Wylie Kwang C Yee Ben J Youdan Danny Youlden Iven H Young Jane M Young Jeffrey D Zajac Bernard A Zicat John B Ziegler Paul Z Zimmet Stephen R Zubrick Nicholas A Zwar

Bronwyn Gaut

New forms of journalism offer opportunities and pitfalls for health Newspapers and other forms of “old” media face an uncertain future because of withering traditional revenue streams, rising new media technologies, and changing audience expectations. Comparisons have been drawn between the demise of the Roman Empire and that of modern media empires.1 To date, the collapse has been most evident in the United States, where, between 1 January 2008 and 15 September 2009, 46 599 jobs in the journalism industry were lost and 201 media outlets closed.2 The journalism industry lost jobs at almost three times the rate of other industries.2 The number of full-time journalism positions in Australia fell from 8500 to 7500 between 2001 and 2007,3 and more losses are expected (Jonathan Este, Director, Communications, Media Entertainment and Arts Alliance, 20 October 2009, personal communication). The changing nature of the media landscape brings dangers and opportunities for those concerned with the health of societies and populations. The mass media, for all their flaws, have been a powerful force that have influenced and informed policy, practice and attitudes in the health sector and other spheres. The “fourth estate” has also had an important role in scrutinising society’s powerful institutions, and holding them accountable. Media coverage has contributed to significant advances in public health policy. Notably, according to the Advocacy Institute in the US: “News coverage has been the lifeblood of the tobacco control movement”.4 The demise of the traditional media, therefore, has serious implications if it means fewer resources for investigating important health and medical issues or related matters, such as social determinants of health. The traditional media are losing their monopoly on news gathering and dissemination as the Internet and related technologies enable a proliferation of new media outlets and applications. These include blogs, wikis and online social media tools such as Facebook and Twitter. The definition of a blog is a fluid one. Originally coined to mean an online journal in which the entries appeared in reverse chronological order, the term is now used to encompass a wide range of Internet publishing, including journalism.5 A wiki is a website that can be freely edited by participants, who can be either the public at large or a defined group working on a project or from within an organisation. The best-known wiki is the online encyclopaedia Wikipedia. Online social networking tools are evolving fast. One of the first was MySpace, where individuals could post information and send other members messages. Facebook has largely overtaken it as the most popular social networking site, whereas Twitter is a newer social networking tool that is possibly the most relevant for journalism, relying as it does on short, real-time 140-character “headline messages”. The transition from mass media to “masses of media” creates new opportunities. Never before has there been so much media choice or so many adept media users. Anyone with access to the Internet can publish news and views for the world to see. This is a first in human history, and has contributed to the rise of “citizen journalism”. The technology also enables news to reach larger audiences in more ways, and creates new ways of telling stories and engaging audiences. As Mark Scott, managing director of the ABC, stated: “The opportunities to connect and engage have never been more exciting”.1 At the same time, new media have undermined the business models of media institutions. Commercial free-to-air broadcasting remains the main way Australians get their news and information.6 It makes money by aggregating audiences and selling their attention to advertisers, but the audience is fragmenting as more choices become available. Once Australia’s National Broadband Network is complete, and more audiovisual material is delivered via the Internet, the audience will be everywhere at once. Meanwhile, newspapers, which have been the largest employers of journalists, have seen classified advertising decline as advertisers find the Internet is a cheaper and more efficient way of reaching buyers. Although all newspapers have an Internet presence, so far none of their websites make money in their own right once the costs of providing editorial content are factored in. Companies cannot charge as much for an online advertisement as they have been able to charge for a printed advertisement because there are so many online options. If the price is too high, there is always the possibility that industry groups — for example, real estate agents — might start their own online publication. Indeed, this has happened in the case of car dealers. Hence, over the past few years, Australian newspapers have radically decreased their editorial staff. Industry analysts anticipate that, within the next decade, major Australian mastheads will cease to exist, at least as print products and as major employers of journalists.7 However, there is no evidence to suggest that there is a crisis in terms of the public’s appetite for news and information. The health sector is exploiting the opportunities offered by new media. Organisations such as the Cancer Council Australia use social media tools to communicate health information and build communities of engaged supporters. Members of the public also use these tools for patient advocacy, to raise funds for medical research and to mount public health campaigns.8 Social media have also helped disseminate critical information during bushfires and other disasters. US academics who analysed the role of new media in President Barack Obama’s election campaign concluded that there were many lessons relevant to public health advocates, including the potential for increasing audience engagement.9 These lessons appear to have been absorbed by those responsible for the Australian Government’s health reform website (http://www.yourhealth.gov.au/), which encourages interaction from members of the public and health professionals. Health-related blogs compiled by media outlets, organisations, governments, commercial interests and individuals are also proliferating. They open up new avenues to communicate information and disseminate research, and they enable “bottom up” as well as “top down” exchanges. A survey of medical bloggers found that they wanted to share practical knowledge and skills, and their blog ideas were often reported by mainstream media.10 The authors of the survey concluded that blogs are an important vehicle for influencing medical and health policy. At the BlogWorld & New Media Expo held in the US in October 2009, the implications of new media for the health sector were widely discussed. The quality of bloggers’ information is enormously variable, but some, such as Effect Measure (http://scienceblogs.com/effectmeasure/), authored anonymously by senior public health experts in the US, enable more open and incisive discussion about health issues. The Pump Handle (http://thepumphandle.wordpress.com/) is another public health blog with an interest in issues that are “not getting the treatment we think they deserve in the mainstream media”. In Australia, staff at Katoomba Hospital have also harnessed the anonymity available to bloggers to raise matters of interest to their local community (http://whowillspeakforus.blogspot.com/). On the other hand, anti-health interests such as tobacco companies have been quick to seize online opportunities for marketing campaigns, often covertly.11 Meanwhile, media practitioners concerned with the public interest are attempting to develop new journalism models. In the US, several not-for-profit organisations, often funded by philanthropists or universities, commission investigative journalism projects, and some have covered important health issues. The Center for Public Integrity (http://www.publicintegrity.org/) has published investigations into illicit tobacco trafficking and the political influence of the pharmaceutical industry in US politics, for example. Another not-for-profit organisation, ProPublica (http://www.propublica.org/), commissioned an investigation into how hospital staff responded in the aftermath of Hurricane Katrina. A number of health stories are commissioned through an innovative project called Spot. Us (http://www.spot.us/) that experiments with different journalism methods, including the use of community funding and community-sourced news. Australia has been relatively slow to develop new journalism models, perhaps because the traditional media here have not been as hard hit as elsewhere. However, there are some notable examples, including online publications newmatilda.com, funded by a single philanthropist, and Inside Story, based at the Institute for Social Research at Swinburne University of Technology, which has run lengthy pieces on health issues.12 Both of us helped found and are on the board of the recently established Foundation for Public Interest Journalism (also based at the Institute for Social Research), which will develop and test new journalism models. The Foundation will give priority to issues that are under-reported by the traditional media, providing an opportunity to improve coverage of currently neglected health issues. New media ventures are not only expanding the range and type of outlets, but are also changing the nature of the relationship between media and their audiences. According to a US journalism academic, the audience has become “the people formerly known as the audience”.13 They are now also collaborators, antagonists and participants. This changes the relationships between professional news gatherers and their audiences in ways that can make them more interactive, open and transparent than they have been in the past. We believe this can lead to healthier public debate than existed in the era when only a few people had privileged access to the means of publication. However, the new media era involves many challenges and uncertainties, including the need to develop viable and sustainable business models to support journalism that is in the public interest. The proliferation of new media outlets may have some advantages, but it also risks fragmenting public debate — with all the attendant risks that this brings for policy processes and society more broadly. It also raises legitimate anxieties about the quality and reliability of information. Editors have a critical role in new media; in fact, curating masses of material and sifting for quality and importance may be one of the main roles of journalists in the future. There are also concerns about the impact of proliferating digital media on the development of children and young people; there is a need for research to help guide policy in this area.14,15 The new media revolution is underway, but it will be some time until its impact upon the health of our societies and populations is fully understood.

Melissa A Sweet BA, MA(SciTechStud) · Margaret J Simons BA, DCA

Objective: To describe the content and structure of health and medical news and current affairs reportage on free-to-air television in Sydney, New South Wales.Design and setting: Review of content of all health-related evening news and current affairs items recorded over 47 months (May 2005 – March 2009).Main outcome measures: Number and length of health-related items on news and current affairs programs, and topics covered in these (21 broad content areas and the leading 50/237 specific content areas); use of news actors, soundbite duration and apparent news triggers.Results: 11 393 news items and 2309 current affairs items were analysed. Health news items lasted a median of 97 seconds. In a randomly selected sample of 251 items, items featured a mean of 2.2 news actors (3.9 in longer current affairs items). Median soundbite duration was 7.2 seconds for news items and 8.9 seconds for current affairs items. People affected by disease or injury were the most commonly featured news actors (84% of items), followed by experts and health professionals (56%). Many items (42%) appeared to be trigged by incidents, but a further 42% could have been triggered by press releases and other forms of publicity.Conclusions: Health workers wishing to participate in news coverage should be aware that complex issues are reduced to fit the time constraints and presentational formulae of the news media. Advocates should plan their communication strategies to accommodate these constraints.

Simon Chapman PhD, FASSA · Simon J Holding BA · Jessica Ellerm BSc · Rachel C Heenan · Andrea S Fogarty MIPH · Michelle Imison MIPH · Ross Mackenzie MA · Kevin McGeechan BSc

Stimulate: To animate, excite, arouse. — Concise Oxford dictionary, 8th ed It’s been a tough year. To survive the economic downturn (not technically a recession, but it feels like one), we have been forced to tighten our belts, hire DVDs and stay home for cheese on toast. Here at the MJA, we have decided this is a time to keep smiling, even as property prices plummet (or skyrocket, depending on which paper you read), the mercury rises, and the promise of health reform languishes. As the prospect of the annual beachside holiday recedes and you attempt to convince morose and monosyllabic teens that playing under the sprinkler in the garden really is as much fun as the Gold Coast, we are delighted to entertain you. Thus, we offer you an alternative to turkey sandwiches and reruns of Bush Christmas by announcing our own stimulus package — the MJA Christmas Competition. As usual, the calibre of the entries this year was very high and, once again, the number of submissions record-breaking — supporting the premise that the health care industry really may be recession-proof. In keeping with our theme, and proving finally that men are wimps, Furyk and colleagues show that when it comes to stimulating pain, it is preferable to pull a bandaid off fast rather than slow, especially if your patient happens to be hirsute. So when you find yourself in the position of removing a sticky dressing after one of the aforementioned teens has done a skid on the concrete under the sprinkler, you can reassure him that you are a health professional and you have the evidence. Then just rip it off (→ Fast versus slow bandaid removal: a randomised trial). Another humour-stimulating offering comes from Mullins, who, while working in East Timor, found that dancing about an operating suite clutching a newborn baby and repeatedly whacking oneself over the head does not translate into any language. But he certainly learned one way to communicate — by stimulating a smile, both from his bemused colleagues and MJA staff members (→ Out of my depth in East Timor). If exciting your guests’ jaded appetites causes you to consider a seafood alternative to turkey this year, perhaps you should take note of Davies and Bate, who suggest that the bones of Dory are the least visible on x-ray of the common fish species they examined (→ Relative radio-opacity of commonly consumed fish species in South East Queensland on lateral neck x-ray: an ovine model). To avoid a trip to the emergency department, maybe have prawns instead — if you can afford them, of course. In a more poignant vein, offerings from Livermore (→ Christmas celebrates birth: new life, new love, new hope), Hodgkinson (→ The pressure of time) and O’Callaghan and colleagues (→ ”The moment is all we have“: patients and visitors reflect on a staff Christmas choir) remind us of the spirit of the season, and Johnson remembers with a smile how a slip of a patient’s tongue can make even the most exhausted medical team fall about the ward in fits of restorative laughter (→ A prescription for a smile). While digesting our erudite Christmas offerings this year along with the turkey, Dory, or prawns, you might like to peruse Parry’s take on the DSM-IV — while concurring with an “‘ah, yes’ and ‘hmmm’ (shorter, higher pitched subtype, usually indicative of agreement)” Parry (→ Cough disorder: an allegory on DSM-IV). But there must be a winner, even among a selection as strong as this. Our ballot, conducted with the utmost secrecy, akin to inviting a peer review, showed that the True Story with the most votes was Geoffrey Mullins’ account of obstetrics in a developing country. In the Christmas Offerings category, the winner was Francis Bowden’s thought-provoking musings on the great divide between physicians and surgeons, “When two tribes go to war”. Both winners will receive a fantastic hamper courtesy of the MJA as an extra stimulus to further creativity. Finally, remember that we appreciate and enjoy your every contribution throughout the year, and wish you all the peace and goodwill of the season. It may be that you are not yourself luminous, but you are a conductor of light. Some people without possessing genius have a remarkable power of stimulating it. — Arthur Conan Doyle

Tanya Grassi

All established researchers are well aware of the challenges involved in getting their unique and vital contributions published. The frustration of multiple journal rejections and resubmissions, and the ensuing revisions, would be known to almost all published researchers. This contrasts with the joy and satisfaction that authors derive from having their publications appear in print. The manner in which authors celebrate their successes will vary from person to person. I propose a formula to guide authors on the extent of celebration that their success warrants: C = J × R where C = number of celebratory drinks, J = number of different journals submitted to, and R = number of revisions. Of course, responsible, moderate and safe alcohol consumption must be encouraged. Therefore, the total number of drinks does not need to be taken in one session and the drinks need not be alcoholic. Alternatively, “C” can be substituted for any other form of celebratory activity or treat, such as massages or dinners at nice restaurants.

Peter W New

Introducing a new disclosure form for member journals of the International Committee of Medical Journal Editors Disclosure of financial associations of authors of articles published in biomedical journals has become common practice. The information provided in these disclosures helps readers understand the relationships between the authors and various commercial entities that may have an interest in the information reported in the published article. At present, many journals ask authors to report such relationships by completing a form with information about their financial associations. The journals then either post the complete information online or create a summary of the information and publish it with the article in question. Although efforts are underway to establish uniform reporting systems, there is currently no uniform vehicle for the disclosure of financial associations. Thus, authors may provide similar information to different journals in multiple formats. In addition, slight differences between journals in requirements for reporting can lead to confusion, as the same individual may report different information to different journals. With this editorial, which is being published simultaneously in all International Committee of Medical Journal Editors (ICMJE) journals, we introduce a new disclosure form that has been adopted by all journals that are members of the ICMJE. We encourage other journals to adopt this reporting format, and we are placing the form in the public domain. We ask authors to disclose four types of information: their associations with commercial entities that provided support for the work reported in the submitted manuscript (the time frame for disclosure in this section of the form is the life span of the work being reported); their associations with commercial entities that could be viewed as having an interest in the general area of the submitted manuscript (the time frame for disclosure in this section is the 36 months before submission of the manuscript); any similar financial associations involving their spouses or their children under 18 years of age; and non-financial associations that may be relevant to the submitted manuscript. The form now posted on the ICMJE website (http://www.icmje.org/coi_disclosure.pdf) includes instructions and examples to help authors provide the required information. A sample completed form is also available (http://www.icmje.org/sample_disclosure.pdf). Authors can download the form from the Internet, add the information, and save the completed form on their computers. The completed form can then be uploaded to the website of the journal that has requested the information. As all ICMJE journals now use the same reporting format, authors may save a partially completed form on their computers; when a manuscript is ready for submission to a journal that accepts this reporting format, authors can simply complete the form by adding information specific to the manuscript and then upload the completed form to the journal’s website. Our goal is to make the process of disclosure uniform and easy; the new form should eliminate the need to reformat disclosure information for specific journals. We realise this disclosure form requires authors to report a great deal of information about their relationships with entities that could be viewed as having interests that compete with the research being reported. With this in mind, some journals may ask for all these details at the time of initial manuscript submission, whereas other journals may ask for much less information at submission and require the detailed form to be completed later in the editorial process. These decisions will be left to the discretion of each journal. We also realise that to be useful, the reporting format must be responsive to community needs. Although ICMJE member journals have “use tested” the form, there may be situations that are not covered by the form, aspects of the instructions that are unclear, or bugs in the programming that we have not yet discovered. Therefore, we regard the period from publication of this editorial until 10 April 2010 as a period of beta testing. We encourage you to let us know about problems that arise with the form and to send us your comments by using the comments feature at the home page of the ICMJE website (http://www.icmje.org). The ICMJE will meet in late April 2010 and will adapt the form to address concerns identified by users. In the future, we will revisit the form’s usefulness and modify it as needed. We are grateful to the authors who take the time to provide complete disclosure information and thus help to ensure the transparency of the publication process. By adopting a uniform format, we hope to make the process of disclosing competing interests easier for authors and less confusing for readers.

Jeffrey M Drazen MD · Martin B Van Der Weyden MD, FRACP, FRCPA · Peush Sahni MS, PhD · Jacob Rosenberg MD, DSc · Ana Marusic MD, PhD · Christine Laine MD, MPH · Sheldon Kotzin MLS · Richard Horton FMedSci · Paul C Hébert MD, MHSc · Charlotte Haug MD, PhD, MSc · Fiona Godlee MB BChir, BSc · Frank A Frizelle MB ChB · Peter W de Leeuw MD, PhD · Catherine D DeAngelis MD, MPH

Everybody thinks that if everybody used common sense, the problems in health care would go away — but common sense isn’t that common, and health care is more complex than it seems. However, MJA Books’ latest publication provides a simple, clear guide to effective clinical risk management. So said Professor Bruce Barraclough, President of the International Society for Quality in Health Care, at the official launch of Enhancing patient care: a practical guide to improving quality and safety in hospitals, authored by Alan Wolff and Sally Taylor. The Hon Daniel Andrews, Victorian Minister for Health, officially launched the book on 31 August 2009 at the Victorian Department of Human Services. The book summarises extensive, confusing literature and shows results that can reasonably be expected to be achieved. It provides a logical, simple and effective model, along with summaries and checklists to help put the model in place; and outlines what does and does not work in the real world. Associate Professor Alan Wolff is Director of Medical Services for the Wimmera Health Care Group. He credits the success of the Group’s risk management program (on which the book is based) to five factors: the hospital’s intermediate size; its dedicated, long-serving staff; commitment from those at the top of the organisation; an innovative, flexible and cooperative hospital culture that does not “blame and shame”; and using simple improvement strategies. “We open high-risk medical records on a daily basis, run checklist programs, and have the clinical risk management team located in the wards, not as a separate function”, he said. Mr Andrews praised the book’s authors for taking their own successful project and providing it for others to use. “We can never eliminate errors, but we can have a shared commitment to learn from each error. This is a roadmap of a framework to always make sure health care is about care”, he said. Enhancing patient care is published by MJA Books and is available from the MJA BookShop at <http://shop.mja.com.au> Above Left to right: Sally Taylor, Associate Professor Alan Wolff, the Hon Daniel Andrews and Professor Bruce Barraclough. Below Left to right: Sally Taylor, Alan Wolff and Rivqa Berger.

Rivqa Berger

Crikey is a daily electronic bulletin aimed at providing independent news. It was established in 2000. In 2007, journalists and public health advocates collaborated with Crikey to initiate an innovative health reporting project, the Crikey Health and Medical Panel (CHAMP). CHAMP members contribute articles and news tips to Crikey, broadening Crikey’s scope of public health coverage. CHAMP continues to evolve, and has expanded to include a freely accessible online health forum, Croakey. CHAMP was established to enhance public debate about health, to encourage public health advocates to engage in debate, and to help the media to identify public health advocates and issues as sources for articles.

Melissa A Sweet BA, MA(SciTechStud) · Simon Chapman PhD, FASSA · Ray N Moynihan BA · Jonathan H Green

Objective: To review television and print media coverage of the campaign to regulate solaria that was initiated by Clare Oliver before her death from melanoma in late 2007, and to investigate how the media constructed the aetiology of her disease.Design and setting: Frame analysis of all direct and attributed statements about the causes of, and responsibility for, Oliver’s melanoma, and about the legacy of her campaign, in reportage on five free-to-air Sydney television stations and in Australian capital city newspapers, 21 August 2007 to 20 February 2008.Results: 26 television and 83 print media reports were identified, containing 279 statements on Oliver: 146 (52%) dealt with the responsibility of >solaria or their need for regulation, 23 (8%) were on issues of self-responsibility, and 110 (40%) were on her legacy. Oliver stated she had visited solaria 10 times, but had spent years acquiring a tan outdoors. However, less than one in 10 statements about the aetiology of her melanoma referred to her outdoor tanning history, with most explaining the cause as solarium ultraviolet radiation. Oliver’s campaign was credited with precipitating rapid regulation of solaria in Australia. However, the new regulations will not prevent a person of her age or skin type visiting solaria and fall well short of the ban she hoped for.Conclusion: Unlike sun exposure, solaria are an entirely tractable factor contributing to melanoma. Failure to ban solaria has been a disappointment in a high-profile window of opportunity to change public health law.

Ross MacKenzie MA · Michelle Imison MIPH · Simon Chapman PhD · Simon Holding BA

The effects of “appearance medicine” programs need closer scrutiny Recent data released by the British Association of Aesthetic Plastic Surgeons show that more people are having cosmetic and weight reduction surgery than ever before: the number of surgical procedures performed by members of the Association in 2007 was 12% greater than in the previous year.1 The increased demand for cosmetic surgery was not limited to women — 18% more procedures were performed on men compared with the previous year. The greatest increases were in anti-ageing procedures, such as facelifts and eyelid surgery, which both increased by over 36%. Data recently reported by the American Society of Plastic Surgeons show that almost 12 million cosmetic surgery procedures were performed in the United States during 2007, representing a 59% increase from the number performed in 2000.2 Current Australian figures are difficult to establish but seem to be rising.3 An important driving factor behind the increase in cosmetic and weight reduction surgery may well be the large number of “reality” television programs that focus on weight loss and appearance change. Recent data from patients seeking first-time cosmetic surgery reveal that many were regular viewers of “appearance medicine” programs, and that four out of five reported that plastic surgery reality television influenced their decision to undergo cosmetic surgery.4 Dentists also report that “extreme makeover” programs have recently increased the demand for cosmetic dental procedures.5 Two categories of programs are particularly relevant. In the first category are programs with a focus on weight reduction through drastic diet and lifestyle changes. Recent examples in Australia include The biggest loser Australia and Overhaul; in the United Kingdom, they include Supersize vs superskinny and Superslim me. Contestants in such programs compete to make the fastest or most dramatic changes in weight. In 2007, The biggest loser Australia averaged over a million viewers per episode, and the finale drew nearly two million viewers.6 The winner of this series lost 70 kg, which represented 47% of his starting weight. In the second category of programs, participants undergo extensive surgical and cosmetic procedures to improve their lives. In the UK, this category includes Supersize surgery and Make me perfect. In the US, popular examples are The swan and I want a famous face, where participants compete to make the most drastic changes in appearance through strict diet and exercise regimens, and cosmetic surgery procedures.7 The winner of the 2004 series of The swan underwent 13 cosmetic face, dental and body procedures, including brow, eye and mid-face lifts, liposuction, fat transfer to the lips, and abdominoplasty. The portrayal of cosmetic and weight loss procedures on television typically distorts the speed and difficulty of these changes. Most programs focus on the few individuals who have the most dramatic changes in appearance, thus exaggerating the likelihood of positive outcomes. Condensation of time, to fit a television program format, also makes the rate of weight loss and other appearance changes seem extremely rapid. Complications, infections and failed procedures are barely mentioned, giving the impression that negative outcomes are rare. Moreover, the environments in which appearance medicine programs are filmed are often highly artificial, as they provide time and resources (such as equipment, personal trainers and chefs) that are not readily available to the public at large. The recent increase in numbers and popularity of appearance medicine programs has heightened the potential for harm to both participants and viewers. Given the dissatisfaction that participants typically express about themselves and their lives at the programs’ commencement, the extreme psychological pressure that is created during filming, and the difficulty of maintaining rapid weight loss, it would be surprising if all participants and their families walked away unscathed. However, we have been unable to find any follow-up studies of program participants. Another concern is that viewers may be negatively affected by appearance medicine programs. A recent study demonstrated that women who felt societal pressure to be thin had significantly lower self-esteem scores after viewing an episode of The swan, compared with a home improvement program.8 Viewers may find it easier to identify with participants of reality shows than with actors in scripted television programs. This process may contribute to inflating viewers’ expectations of the transformations they themselves could achieve through surgical procedures, and the ease and speed with which these changes occur.9 The issue of the negative effects of appearance medicine television highlights the differences between public concern for the welfare of participants in medical research and television program participants. While researchers need to convince ethics committees that their participants will not be harmed, or induced by money to participate in risky experimental procedures, similar well developed constraints do not exist for television programs. Ethical safeguards for those who choose to participate in such programs are needed, as is research into the effects of these programs on both viewers and participants. Both would help improve participant selection procedures and ensure that vulnerable individuals are not placed in potentially damaging situations.

Keith J Petrie PhD · Kate E Faasse BSc · Sarah A I Fuhrmann BSc

Sick to death. Hedley Thomas. Sydney: Allen & Unwin, 2007 (ix + 427 pp). ISBN 978 1 74114 881 7. Typically, journalists write readable books; even journalism textbooks are easy to follow. So it is with Hedley Thomas’ story of Bundaberg Hospital’s saga with Dr Jayant Patel. The journalist credited with publicly exposing the discredited surgeon (and more importantly, the terrible deficiencies of the Queensland public health system) leads us on a trail of discovery, ineptitude, political chicanery and tragedy. The tragedy lies with the patients who put their trust in both their local hospital and Patel, then Director of Surgery, a trust that was shattered and will take a generation to repair. There is a terrible poignancy in the level of personal harm suffered and documented in the book. The ineptitude is staggering: from the local hospital administration up to the highest levels of Queensland Health. In retrospect, how easy it would have been to avoid much of the scandal by conducting a proper investigation into Patel rather than trying to cover up the truth. Instead, here is a tale which harmed almost everyone who came in contact with it. Thomas chronicles rather than analyses as he exposes how a thriving department of surgery was destroyed by an appalling administrative culture and turned into Patel’s fiefdom. Thomas is mostly, but not always, accurate. He relies a little too much on National Party gossip instead of checking facts. Gastroenterologists would no doubt be astonished to learn that they are the most qualified practitioners to perform oesophagectomies, Patel’s signature procedure. At the end of 427 pages, one has to reflect on whether there are any winners. Many Bundaberg patients are still waiting for compensation, surgical waiting lists are no better, and institutional reform of Queensland Health is still required. Burdensome legislation makes medical registration and quality assurance in Queensland inefficient and insidious. There were no political winners, except, perhaps, the incumbent state government. Plus ça change, plus c’est la même chose...

David Molloy

Have you ever wondered what makes a good research paper? Since 1995, the best original research paper published each year in the Medical Journal of Australia (MJA), as judged by the Journal’s Content Review Committee, has been awarded the MJA/Wyeth Research Award. To date, 12 papers have won the award ($10 000 and a commemorative trophy), representing a diverse range of research methodologies, practice settings, professional disciplines, and subsequent citation rates (Box 1). We recently interviewed key researchers associated with this distinguished dozen, inviting them to tell us the behind-the-scenes stories of their papers and the impact their work has had since publication. In the course of our discussions, we heard 12 very different but often strikingly similar stories — stories of curiosity, innovation, purpose, determination and teamwork, as well as some significant concerns about the future of medical research in Australia. 1995: Gastric emptying is not needed after acute oral overdose in adultsAs you administered a particularly unpleasant medical intervention, have you ever wondered whether it was really necessary? Susan Pond, an Australian medical graduate, found herself working in the United States as a Fellow in Clinical Pharmacology at San Francisco General Hospital in the 1970s. Following on from the Haight-Ashbury hippie days of the previous decade, drug overdose was a major problem in the city. At that time, the treatment of overdose was quite empirical, and Pond set about collecting evidence for the ways in which charcoal could be used to remove poisons. Adapting the well known tradition of self-experimentation, Pond co-opted a couple of her six children to test out “easy” formulations of activated charcoal (Box 2). “One of them was game enough to swallow this awful black stuff, and he threw up within minutes ... the mess was just terrible”, Pond said. Referring to standard treatment, she added: “Not only were we making overdose patients vomit with ipecac, but we were also giving them activated charcoal, after which they promptly vomited again. It seemed to me to be very pointless”. Pond returned to Australia in the 1980s, where the opportunity arose, at Princess Alexandra Hospital in Brisbane, to challenge the long-established routine care for poisoning through a prospective, randomised controlled trial, comparing activated charcoal with a combination regimen of gastric emptying plus charcoal. In designing the study, Pond spent a long time talking with an American toxicologist, Ken Kulig, who had reported that acutely poisoned patients could be effectively treated without gastric emptying. Pond wanted to build on Kulig’s earlier research but without running into the same pitfalls: insufficient patient numbers and allocation bias.1 The Australian trial involved 876 eligible patients who presented to the emergency department at Princess Alexandra Hospital between January 1988 and June 1990. No significant differences were detected between the two treatment arms, and Pond and colleagues concluded that gastric emptying could be omitted from the treatment regimen for adults after acute oral overdose. Published in the MJA in October 1995, it did not take long for the study results to filter through to clinical practice — in 1997, the American Academy of Clinical Toxicology issued a position statement on ipecac syrup, which concluded that gastric emptying by ipecac should not be administered routinely in the management of poisoned patients.2 “The field was ready for a big study and it [our study] served to crystallise the thinking”, Pond said. “Very rapidly, the issue became whether or not charcoal needed to be administered, and the field moved on quite rapidly to suggest that even that’s not necessary in many cases of poisoning.” In 1997, Pond joined Johnson & Johnson Research Pty Ltd in Sydney to pursue the application of the genomics revolution to therapeutics. Her current research involves discovery and development of RNA and DNA molecules that regulate gene function and expression. The most advanced product, currently in clinical trial, is an anti-HIV RNA molecule inserted into bone marrow stem cells of patients infected with HIV. 1996: A public health investigation detects Japanese encephalitis virus in AustraliaHow would you go about investigating the mysterious deaths of two members of a small island community? When such a tragedy occurred on the outer Torres Strait island of Badu in March–April 1995, the residents welcomed a wide range of investigators from the Australian mainland, led by public health physician Jeffrey Hanna. Scott Ritchie, medical entomologist on the project, told us that Murray Valley encephalitis was initially thought to be the most likely culprit but, before long, virological studies on samples from the encephalitis cases, and serological surveys of other asymptomatic residents revealed evidence of Japanese encephalitis (JE) virus infection. The researchers found themselves investigating an outbreak of a virus that had never been found in Australia before — a classic, emerging, infectious disease. Ritchie said the various teams — medical, public health, entomological, veterinary, and laboratory — worked away for days at a time, applying known “shoe-leather” epidemiological methods to get the information they needed. When not working, they watched late-night test cricket and slept on mattresses at the health centre. The whole investigation took about a month. In addition to infection in the residents, the investigators also identified recent JE virus infection among domestic pigs (one of the viral hosts) on the outer islands of the Torres Strait. Virus isolations and mosquito surveys on Badu Island implicated the mosquito Culex annulirostris as the major vector in the outbreak. The researchers speculated that migratory birds and/or windblown mosquitoes had imported the virus into the Torres Strait, possibly from Papua New Guinea, and that a combination of environmental factors — including large numbers of domestic pigs kept in “wet” pigpens close to human dwellings and mosquito-breeding sites (Box 3) — had facilitated the outbreak. “It fit the pattern of JE virus overseas. In South-East Asia, you have rice paddies and people with pigpens in the backyard. In the Torres Strait, it’s quite low and swampy, and pigs are abundant”, Ritchie said. Ritchie is certain that lives were saved as a result of the public health response to this research. After the Badu Island outbreak, an inactivated JE vaccine was offered to the inhabitants of the outer Torres Strait islands. On Badu Island, pigs were moved from backyards to a piggery out of town, and swamps were drained. “JE virus is now detected nearly every summer in sentinel pigs on Badu Island, but there haven’t been any other human cases since a second outbreak in 1998. If we hadn’t vaccinated, I think we would have definitely seen more human cases”, Ritchie said. Hanna and colleagues have continued to publish papers on disease outbreaks, including the 1998 JE outbreak and the Noah Beach malaria outbreak in Far North Queensland;3,4 the cross-agency collaboration continues to this day. 1997: Photographic surveillance can effectively detect melanoma in patients with multiple dysplastic naeviHow you would respond if you were questioned about your everyday clinical practice because it was different from that of your peers? In the 1980s, when Melbourne dermatologist John Kelly was asked why he was using total body photographic surveillance to follow a group of melanoma-prone patients with multiple dysplastic naevi (MDN), instead of undertaking the then widely used practice of prophylactic excision, he decided to conduct a study to determine the value, including cost-effectiveness, of his approach. Several years earlier, while working in a melanoma clinic in San Francisco, Kelly had been involved in a case–control study that found that MDN were a strong and independent risk factor for the development of melanoma.5 “It seemed logical that if these people were most at risk for melanoma, then they were the people to put into a follow-up program to find the melanoma in the future”, Kelly said. But what if the case–control study had been flawed? He wanted to reassure himself as well as others. Kelly enlisted the assistance of several colleagues and his sister-in-law (a clinical photographer) and followed a high-risk cohort of 278 patients with MDN, using photographic surveillance, for an average of 42 months. All the patients had presented at his private dermatological practice between March 1985 and November 1992. Over the course of the study, 20 new melanomas were detected in 16 patients, corresponding to an age-adjusted incidence of melanoma in these patients that was 46 times that of the general population. “The use of the photographs enabled earlier diagnosis because we were able to detect new and changed lesions that were early melanomas but that were not yet showing typical clinical features. The median tumour thickness was much lower than for tumours reported to the State Cancer Registry at the time”, Kelly said. Further, more than 60% of the melanomas were de-novo, rather than arising from dysplastic naevi, suggesting that prophylactic excision of dysplastic naevi was not a satisfactory alternative to follow-up. This study, along with others, helped to confirm the very high rates of melanoma in patients with dysplastic naevi and to “guide guidelines” for the use of total body photography, said Kelly. With others, Kelly has conducted further research along similar lines with a new cohort of patients, confirming the previous findings and showing that a new or changed pigmented lesion is more likely to be a melanoma in patients older, rather than younger, than 50 years of age.6 Internationally, photographic surveillance is now the standard practice in managing people with MDN. 1998: Outdoor air pollution is linked to night-time cough and chest colds in childrenHow would you go about assessing the effects of the environment on child health in an industrial city? Ongoing community concern about a possible link between childhood asthma and air pollution in the steel cities of New South Wales — Newcastle and Wollongong — helped Peter Lewis and Michael Hensley and their colleagues achieve high participation rates in their 1993 cross-sectional survey of children’s respiratory symptoms and home environment. The existing body of work had been done primarily in the US and Europe, but there were some significant differences in aspects of air quality and air-quality basins in Australia. “We had some lower levels of pollution, in particular, particulate pollution”, said Hensley. The researchers consulted widely and often with the community. They surveyed primary school children living in suburbs close to the steelworks, as well as children from surrounding suburbs further away, who acted as “normals” exposed to “background” levels of pollution. The study found that particulate pollution was associated with respiratory symptoms such as head cold and coughs but not with asthma. They also found that the effects on health were seen at lower levels of particulate pollution than had previously been thought. In 1999, the Newcastle steelworks closed, principally for economic reasons, said Lewis. “However, this paper was one of several studies that contributed to how air quality guidelines should be set in Australia”, he said. “It certainly strengthened the case that the levels of air pollution we were experiencing are not without their potential side effects.” Hensley, with co-researchers, has gone on to publish related papers about indoor air quality, including the effects of environmental tobacco smoke and bronchial reactivity among children,7,8 and is now Dean of Medicine at the University of Newcastle. Lewis has taken his environmental epidemiological research approach to public health work on the Central Coast of NSW and is now involved with measuring the impact on health of such diverse entities as bushfires, fluoridation of the water supply, and retirement village living. 1999: Comprehensive screening and treatment program reduces prevalence of STIs in remote Aboriginal communitiesWho do you think has made a contribution to the control of sexually transmitted infections (STIs) in Aboriginal Australia that is greater than the sum of everyone else’s? For this accolade, Paul Torzillo would not hesitate to pick Penny Miller, a primary care doctor who created a program in the mid 1990s that aimed to improve access to and delivery of STI services in remote Aboriginal communities on the expansive Anangu Pitjantjatjara (AP) Lands in the far north-west of South Australia, with a view to reducing transmission not only of STIs but also HIV. “At the time, it was widely touted that community-wide STI screening would be virtually impossible, let alone unethical, because the Aboriginal communities would not want it; and, if it did occur, it would be ineffective”, Torzillo said. But the Aboriginal communities did want it. Nganampa Health Council is the independent, Aboriginal-controlled health service that provides primary health care to nearly 3000 Aboriginal people living on the AP Lands. The Council’s Aboriginal board of management, which is also the ethics committee, approved Miller’s project. Annual community-wide screening for syphilis was already well established in the AP Lands, and community participation in the new program was voluntary and high. Miller’s community-based program took full advantage of technological advances in screening for gonorrhoea and chlamydial infections, with urine polymerase chain reaction tests replacing diagnosis by urethral swab in men and by vaginal and cervical swabs in women. The urine testing made mass screening both more acceptable and more feasible. The program also involved more than a dozen further interventions, including presumptive treatment (before diagnosis was confirmed by pathology results), single-dose rather than multidose therapy, and reporting back to the community. The program was effective. Coauthored with Torzillo and Wayne Hateley, an Aboriginal health worker who until recently lived and worked in the communities, Miller’s paper reported that, in the short period of 2 years, the prevalence of gonorrhoea in people aged 12–40 years was significantly reduced — in fact, almost halved — from 14.3% in 1996 to 7.7% in 1998. The service also achieved reductions in chlamydia and syphilis. The paper weakened a general resistance at the time to applying public health principles to Aboriginal health. “In retrospect, the resistance was clearly because inadequate screening and treatment isn’t effective, but comprehensive screening and treatment can be”, Torzillo said. Miller now works in the field of international HIV research. Torzillo continues to work for the Nganampa Health Council, as he has done since it was first established in 1983. He also maintains an appointment as a respiratory and intensive care consultant at Sydney’s Royal Prince Alfred Hospital. Today, aggressive public health approaches to STIs are considered the “norm” in Aboriginal communities. On the AP Lands, this program and others, like women’s health and child immunisation programs, continue to operate. New STI program initiatives continue to emerge, like Ushma Scales’ song about condom use, Take your shield to town, with lyrics in Pitjantjatjara.9 2000: Systematic chronic disease treatment program reduces rates of renal failure and death in Aboriginal communitiesWhat would you do if your research revealed a whole community with untreated early disease whose progression could be slowed by a simple intervention? When working in New Mexico in the US, Wendy Hoy, with co-researchers, demonstrated that end-stage renal disease was a significant problem in Native American tribes. On her return to Australia, she investigated a burgeoning epidemic of renal failure in Aboriginal people in the Northern Territory and found probably the world’s highest recorded rates of renal failure in the communities of the Tiwi Islands, north of Darwin. There was also a great reservoir of early disease, including hypertension and albuminuria. Hoy said: “I knew from existing literature that the progression of renal disease could be reduced by treatment with angiotensin-converting enzyme inhibitors. This treatment needed to be widely applied in the Tiwi community, but the health services were very scantily resourced at that time and couldn’t do it”. Another barrier was a prevailing attitude that if you gave Aboriginal people a pill, they wouldn’t take it; and that if they did take it, it wouldn’t have an effect because their biology was different. “You’ve got people with a deadly disease for which treatment guidelines are out there in the international literature, with known very beneficial outcomes. It would have been wrong to allow it to go unattended”, Hoy said. So the research team delivered a service offshoot that was embraced by the community — a systematic chronic disease treatment program to modify renal and cardiovascular disease, involving antihypertensive agents to achieve blood pressure goals and attempts to improve the control of blood glucose and lipid levels. After 2 years of treatment, Hoy and colleagues were able to report a rapid, dramatic improvement in clinical profiles and a fall in death rates. Their paper declared: “These results show that Aboriginal people are interested in health issues and receptive to health messages, and will take medications over the long term to protect against future health risk, with excellent response”. Over the past decade, there has been increasing acceptance and practice of the principles of chronic disease surveillance and rigorous management in Aboriginal communities. “Endorsement, intellectually, of chronic preventable disease strategies is no longer the issue; now, it’s resources and staffing to execute them in remote areas where the people have disastrous disease profiles”, said Hoy. After handover of the treatment program to the local health board in the Tiwi Islands, the intensity of the program declined and compliance with medicines use fell for a time, due to inadequate resources.10 However, Hoy is optimistic about the future of Indigenous health. “The spotlight on Aboriginal health here is becoming brighter, and dialogue encouraging government to be, one, more receptive; and, two, more accountable in terms of delivering good services is only going to intensify.” 2001: Quality improvement project reduces inhospital deaths in patients with acute myocardial infarctionHow would you respond to the suggestion that patients hospitalised with acute myocardial infarction (AMI) at your hospital might have a higher mortality rate than similar patients at peer hospitals? In the mid 1990s, Ian Scott, then Director of Medicine at Queensland’s Ipswich Hospital, responded by initiating a quality improvement project that aimed to achieve, among other things, a reduced time to thrombolysis and an increased number of patients who were taking lipid-lowering agents when they left the hospital. He wrote local guidelines for coronary care practice, started an echocardiography service, and got together with the local Division of General Practice to set up a cardiac rehabilitation program, as well as providing sequential feedback to health care providers. A before–after time-series study suggested that quality of care at the hospital did improve as a result of the project.11 This evidence was soon bolstered when hard outcomes data on inhospital deaths, from the Queensland Hospitals Admitted Patient Data Collection, came to Scott’s attention. Using this state-based data, Scott and colleagues were able to demonstrate a significant reduction in the mortality rate for AMI at Ipswich Hospital, from 12.5% in 1994–1995 (pre-intervention) to 8.8% in 1996–1999 (post-intervention). The rates at a group of control hospitals in Queensland showed no significant change (remaining at about 12.8%) over the same period of time. “The study has given a higher profile to quality improvement science by showing that we can improve and evaluate practice on a reasonable scientific footing, with real data to support what we are saying”, said Scott. The quality improvement interventions have now been rolled out, with beneficial effects, across more Queensland hospitals.12 “I think it’s been a real success story. We’ve gone from a small community hospital to a collaborative of about 21 hospitals across the state, accounting for close to 80% of all AMI admissions.” Now based at Brisbane’s Princess Alexandra Hospital, Scott has continued to pursue further quality improvements in relation to the management of AMI and heart failure. Recently, together with colleagues, he reported on “risk–treatment mismatching”, where much more treatment goes to lower- or moderate-risk patients than high-risk patients.13 2002: Serious doctor–patient and health care worker–patient miscommunication may be compromising Indigenous health outcomesHave you ever struggled to communicate with a patient? What if the patient didn’t speak much English — what would you do? Working in Darwin with Indigenous patients who had kidney disease, Alan Cass and colleagues found themselves operating across what seemed to be a significant cultural and, often, linguistic divide. At the same time, people working as linguists and community researchers in Arnhem Land were also becoming aware that, despite everyone’s best intentions, there were communication problems they didn’t understand. “It was a somewhat fortuitous coming together of people from very different backgrounds, including some of the patients themselves, who wanted to think about how we could work together in undertaking some cross-cultural research to try to understand the issues”, Cass said. The group considered various possible methodologies before settling on the qualitative approach of participatory action research — using video to capture interactions, then analysing them to identify issues. They also conducted post-interaction interviews in the health care workers’ and patients’ first language to clarify what each person had understood to be communicated. In the setting of a satellite dialysis unit, where many of the carers were fairly well known to the patients and vice versa, the researchers videotaped five clinical interactions concerning diagnosis, treatment and management in diverse individual patients from the Yolngu language group of north-east Arnhem Land. In their “Sharing the true stories” study, the researchers found that miscommunication was pervasive, even when both the health care worker and the patient perceived the communication to be effective. Multiple issues were identified — beyond the limited use of interpreters — including “gratuitous concurrence” (when patients tell the health care worker what they think the worker wants to hear); problems with culturally specific understanding and ways of explaining health and illness (eg, health professionals would frequently describe health states using quantification such as percentages of kidney function, which had little meaning for most Yolngu people); and a lack of staff training in cross-cultural communication. Cass said the paper has engendered a powerful response from people working in all kinds of cross-cultural health settings. “So, I think communication — or miscommunication — issues talk very broadly”, he said. The study has been presented and cited not only nationally but internationally, leading to ongoing relationships with doctors and educational videomakers in the US. A “Sharing the true stories” website has been developed, with links to further education resources (Box 4). There is also now greater systematic use of interpreters in Indigenous health settings. Cass is currently involved in several research programs related to Indigenous health. He remains committed to developing and fostering universally available, high-quality education and training in cross-cultural care. 2003: Non-toxic treatment is effective for chronic suppurative otitis mediaWhat would you do if the only treatment your community could access for a particular condition was a product that was potentially toxic in your circumstances? Until recently, Aboriginal health services were faced with treating chronic suppurative otitis media (CSOM) in patients who had a perforated tympanic membrane with aminoglycoside ear drops, which are potentially ototoxic. In 2001–2002, Sophie Couzos, a public health physician with the National Aboriginal Community Controlled Health Organisation (NACCHO), led the NACCHO Ear Trial, which set out to assess the effectiveness of non-toxic fluoroquinolone ear drops compared with the usual treatment. Couzos said Dr Puggy Hunter, then NACCHO Chair, had wanted the organisation to instigate and undertake a research project to benefit the Aboriginal community. “Hearing issues were a big priority, and particularly runny ears due to chronic otitis media. The community needed a non-toxic alternative for treating the condition”, she said. The methodology was to be that of a double-blind randomised controlled trial, so that it would be scientifically meaningful. But the study also had to be community-based, designed in such a way that the Aboriginal organisations had leadership. At the time, Hunter coined the phrase, “We are not just participants, we are in charge”. As well as providing “real-world” results, the trial was designed to build capacity in the communities so that the intervention would be sustainable and transferable. Thus, the researchers opted for a challenging multicentre approach rather than putting all their investment into only one or two sites. Aboriginal health workers, rather than research assistants, were trained to undertake the trial protocol as part of core primary health care. Far from resisting the research project, health services were eager to be part of it. “Some services had to be turned away, because of the limited study budget or because they could not meet explicit criteria, such as having a doctor employed within the service”, Couzos said. Hunter died soon after the NACCHO Ear Trial was underway, but the trial went on to show that non-ototoxic fluoroquinolone drops were more effective than aminoglycoside drops in achieving cure for CSOM. The paper has had an impact in several key areas. Firstly, thanks to NACCHO’s advocacy role, said Couzos, remote area Aboriginal health services can now provide non-ototoxic ear drops to their clients for free, under Section 100 of the National Health Act 1953 (Cwlth). Secondly, the trial was pivotal to the listing of ototopical fluoroquinolone drops on the Pharmaceutical Benefits Schedule, which means that health care providers in non-remote areas can also provide subsidised medicine. Australian prescribing recommendations have also endorsed the use of fluoroquinolone ear drops in the presence of tympanic membrane perforation.14,15 Finally, in terms of research policy, the NACCHO Ear Trial has provided a real-world example of successful, community-based participatory research.16 2004: The Australian Medical Sheepskin halves incidence of pressure ulcers in lower-risk patientsIf you had a product you thought would benefit patients in hospital, how would you get the attention of hospital managers and clinicians? Having developed a sheepskin that they were confident would reduce the incidence of pressure ulcers in low- to moderate-risk patients, staff of the Commonwealth Scientific and Industrial Research Organisation (CSIRO) Leather Research Centre approached Don Campbell at the Royal Melbourne Hospital (RMH) about generating some clinical evidence of efficacy. “Here was an Australian industry initiative; here was a large public health problem and an opportunity to collaborate. It was a very attractive proposition”, said Campbell. After gaining some initial data from a small trial conducted in a high-risk group setting in Western Australia,17 the research partnership was granted National Health and Medical Research Council (NHMRC) funding for an open-label randomised controlled trial, conducted at the RMH in 2000. The Australian Medical Sheepskin was designed with a fibre length and density sufficient to perform a pressure distribution function, to minimise shear and friction, and to withstand high-temperature cleansing. In the trial, the sheepskins were used without covering as a partial mattress overlay, in accordance with their design. Sheepskin elbow and heel protectors were also used, as necessary. Of the 441 patients enrolled in the trial, 58 developed pressure ulcers. However, patients randomly assigned to the sheepskin group were less than half as likely to develop pressure ulcers as those in the usual care group. “Our evidence showed that we had a piece of technology that was clearly of demonstrable benefit. But the sheepskin hasn’t been widely taken up into practice. The real tragedy is that it hasn’t been capitalised on from an Australian perspective”, Campbell said. Sales of the sheepskin have mostly been incidental, for use in non-clinical environments and for people who are bed-bound or in wheelchairs. In retrospect, Campbell and the study’s first author, medical statistician Damien Jolley, would have liked the trial to have had sufficient funding to incorporate two further features: a third treatment arm, comparing the sheepskin “head to head” with pressure mattresses; and a proper cost-effectiveness analysis, including effects on hospital length of stay. However, what was missing and is still needed for real translation of their study findings into clinical hospital practice, they said, is an industry partner of sufficient size to manage advertising, sales and distribution requirements. But there is good news too. Recognising that pressure ulcers are a clinical indicator of quality of care, the Victorian Quality Council identified their reduction as a key objective for health care services in Victoria. Since state-wide surveys of the prevalence of pressure ulcers within Victoria’s acute and subacute health services began in 2003, progress has been made in implementing elements of a comprehensive program of pressure ulcer prevention and management. There has been a 33% reduction in the proportion of patients with pressure ulcers, from 26.5% in 2003 to 17.6% in 2006.18 2005: Hand hygiene program reduces nosocomial MRSA ratesHave you ever said you’d like to embark on an ambitious project, not really expecting to be given the opportunity? After an unexpected change in Victorian state government, the infection control team at a Melbourne hospital, Austin Health, suddenly found themselves the recipients of new infection control staff and an opportunity to apply for a state government Quality Improvement Fund grant. Their plan was to try to cut nosocomial methicillin-resistant Staphylococcus aureus infection (MRSA) at Austin Health by 30% over a 3-year period. The only hitch was that they had no real idea how to achieve their grand goal. “It was kind of exciting and scary at the same time”, said Paul Johnson, one of the study authors. Around the same time, while in Geneva at a World Health Organization meeting, Johnson arranged to meet Didier Pittet, who had recently published a landmark Swiss study in the Lancet showing that when staff regularly used a hand hygiene solution before and after every patient, contact rates of hospital infections, including MRSA, could be substantially cut.19 The “secret” of encouraging staff to use the solution was to include, along with the antibacterial alcohol and chlorhexidine, an emollient to protect the skin. “The other insight they had, partly I think because of their French culture, was that you have to engage people at an emotional level as well as cognitive, and one of the ways they set out to do this was by using art — they had these posters that were created as works of art by the staff of each ward to introduce the program ... they called them ‘talking walls’ in Geneva”, said Johnson. Pittet encouraged the Austin Health group to develop a similar program, and so they did — the multifaceted Operation Clean Start (OCS) program — developing their own hand hygiene solution (DeBugTM) and even adapting the concept of the “talking walls” (Box 5). The hospital staff and, in particular, nurses in infection control were incredibly supportive of OCS. “After we’d introduced it [the program] in one area, there was a real demand to introduce it into the next area, and so on. It just took off like wildfire”, said Johnson. Run over 3 years, OCS showed that staff’s compliance with hand hygiene improved. The Australian researchers also added an innovation of their own to the project design: by analysing large datasets in the hospital using interrupted time-series analysis, they were able to show a significant reduction in hospital rates of MRSA infections. After their paper was published, the OCS researchers were approached by the Victorian Quality Council, who were keen to replicate the reduction in MRSA infections state-wide. An alcohol-chlorhexidine hand hygiene program was rolled out initially in six major hospitals and then across the whole of Victoria. At the time of our interview with Johnson, coauthor Lindsay Grayson was in Geneva with Pittet, working with the WHO on aspects of hygiene policy for the world. 2006: Hot water immersion for 20 minutes can relieve the pain of a bluebottle stingHave you ever imagined conducting your research on a beach in summer? More importantly, what if that research were to turn a time-honoured treatment on its head? It might sound ideal, but Geoff Isbister and colleagues in the coastal NSW city of Newcastle weathered several difficulties in conducting their randomised controlled trial comparing hot water immersion with ice packs for relieving the pain of bluebottle stings. For example, in addition to the usual ethics committee approval, there was the not-so-small matter of local council approval, particularly in an era when public liability has become a major issue. Then there was the sporadic nature of bluebottle stings — 35 subjects were recruited in a day; 4 weeks went by with no one stung. And what about beach user behaviour — once a sting had eased with treatment, why sit around for the full 20 minutes required by the study protocol? Although it was organisationally challenging, the actual study was very simple and successfully challenged the existing belief that ice was the best way to relieve pain in this situation. The researchers suggested that the mechanism of reducing pain with heat treatment was the inactivation of venom. It is still early days since publication. Although local practice has changed on the beaches where the study was conducted, national changes in clinical practice as a result of this study are yet to be fully implemented. However, Isbister hopes that the Australian Resuscitation Council’s recent adoption of the new evidence in their treatment recommendations will mean hot water immersion becomes more widely available, and that cost and safety issues related to installing hot-water plumbing at surf lifesaving clubs around Australia can be resolved. And, after all, people can control the way they choose to treat their own jellyfish stings.20 Isbister is actively involved in much more “bites and stings” research. He said, “Within medicine, there are so many myths and, particularly in my area of research, so little research, that for just about anything you do in clinical practice, you can ask the research question and do it [the research]”. Twelve winners, one voiceEach year in the MJA we publish over a hundred research papers. Each one has a story: a reason for being, a unique setting, colourful protagonists, a narrative, a resolution and, in many cases, the possibility of development and continuation. As we spoke to the authors of each of the MJA/Wyeth Research Award-winning papers, however, it often seemed as though they were speaking with one voice — the engaged, thoughtful tones of a focused, committed, intelligent and passionate individual, working in the interests of both science and humanity. None had set out to win an award in doing their work; they had all simply wanted to answer a real question in a real area of need. So what did we learn about what makes a good research paper? Having a question whose answer will have a real impact on public health or clinical practice would seem to be a good start, as would using appropriate, pragmatic methodology. Our MJA/Wyeth winners’ research was also well planned, and each came to embrace the power of collaborative teamwork in conducting their research, not only across medical disciplines but across a diverse range of fields, and often, critically, with study participants. Accessing funding for good clinical research was not easy for many of our winners, several of whom suggested that Australia needs a formal mechanism within the health and medical research environment to specifically fund applied clinical research. Publication was also often a thorny issue — when the time came to submit their papers, many award winners reported pressure from their institutions or funding bodies to publish in “high impact” journals, preferably overseas. In the long run, however, they had considered that the MJA was the right journal with the right readership for communicating messages of relevance to Australian clinicians, particularly when local or national health policy needed to be “influenced”. Several interviewees said, in almost precisely the same definite way, that the intent of their research had been to benefit people and patients rather than to further their careers. Nearly all the award winners were gratified with the impact their work has made since publication. Several were concerned that the long-term sustainability of successful programs was at risk due to funding inadequacies or health service management restructuring beyond their control. Can a single piece of research change the world? There are a few spectacular examples where this may have been the case but, in the end, as many of our winners acknowledged, most research papers contribute only a fragment to the “big picture” of health and health care. As a powerful example, we leave you with Sophie Couzos’ perspective after completing the NACCHO Ear Trial, the first double-blind randomised controlled trial conducted in, and controlled by, Aboriginal communities: While healing the tympanic membrane will improve hearing, if you have recurrent infections because your living circumstances aren’t right, then using ear drops will not totally solve the problem. It will create an environment where healing can occur, but the solution to Aboriginal health problems is not just medicines. Although improved access to medicines is vital, the solutions are holistic. 1 The Medical Journal of Australia/Wyeth Research Award-winning articles, 1995–2006, with ISI citations to date* Year Article and authors Citations 1995 Gastric emptying in acute overdose: a prospective randomised controlled trial. Susan M Pond, David J Lewis-Driver, Gail M Williams, Adèle C Green, Noel W Stevenson. Med J Aust 1995; 163: 345-349. 89 1996 An outbreak of Japanese encephalitis in the Torres Strait, Australia, 1995. Jeffrey N Hanna, Scott A Ritchie, Debra A Phillips, Jack Shield, M Clare Bailey, John S Mackenzie, Michael Poidinger, Bradley J McCall, Phillip J Mills. Med J Aust 1996; 165: 256-260. <eMJA full text> 86 1997 A high incidence of melanoma found in patients with multiple dysplastic naevi by photographic surveillance. John W Kelly, Josephine M Yeatman, Cheryl Regalia, Grahame Mason, Amanda P Henham. Med J Aust 1997; 167: 191-194. <eMJA full text> 53 1998 Outdoor air pollution and children’s respiratory symptoms in the steel cities of New South Wales. Peter R Lewis, Michael J Hensley, John Wlodarczyk, Ruth C Toneguzzi, Victoria J Westley-Wise, Trevor Dunn, Dennis Calvert. Med J Aust 1998; 169: 459-463. <eMJA full text> 13 1999 Impact of improved diagnosis and treatment on prevalence of gonorrhoea and chlamydial infection in remote Aboriginal communities on Anangu Pitjantjatjara Lands. Penny J Miller, Paul J Torzillo, Wayne Hateley. Med J Aust 1999; 170: 429-432. 19 2000 Reducing premature death and renal failure in Australian Aboriginals: a community-based cardiovascular and renal protective program. Wendy E Hoy, Philip R Baker, Angela M Kelly, Zhiqiang Wang. Med J Aust 2000; 172: 473-478. <eMJA full text> 40 2001 The effects of quality improvement interventions on inhospital mortality after acute myocardial infarction. Ian A Scott, Michael D Coory, Catherine M Harper. Med J Aust 2001; 175: 465-470. 10 2002 Sharing the true stories: improving communication between Aboriginal patients and healthcare workers. Alan Cass, Anne Lowell, Michael Christie, Paul L Snelling, Melinda Flack, Betty Marrnganyin, Isaac Brown. Med J Aust 2002; 176: 466-470. <eMJA full text> 17 2003 Effectiveness of ototopical antibiotics for chronic suppurative otitis media in Aboriginal children: a community-based, multicentre, double-blind randomised controlled trial. Sophie Couzos, Traven Lea, Reinhold Mueller, Richard Murray, Margaret Culbong. Med J Aust 2003; 179: 185-190. <eMJA full text> 13 2004 Preventing pressure ulcers with the Australian Medical Sheepskin: an open-label randomised controlled trial. Damien J Jolley, Robyn Wright, Sunita McGowan, Mark B Hickey, Don A Campbell, Rodney D Sinclair, Kenneth C Montgomery. Med J Aust 2004; 180: 324-327. <eMJA full text> 2 2005 Efficacy of an alcohol/chlorhexidine hand hygiene program in a hospital with high rates of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection. Paul D R Johnson, Rhea Martin, Laurelle J Burrell, Elizabeth A Grabsch, Susan W Kirsa, Jason O’Keeffe, Barrie C Mayall, Deidre Edmonds, Wendy Barr, Christopher Bolger, Humsha Naidoo, M Lindsay Grayson. Med J Aust 2005; 183: 509-514. <eMJA full text> 18 2006 A randomised controlled trial of hot water (45°C) immersion versus ice packs for pain relief in bluebottle stings. Conrad Loten, Barrie Stokes, David Worsley, Jamie E Seymour, Simon Jiang, Geoffrey K Isbister. Med J Aust 2006; 184: 329-333. <eMJA full text> 3 * As of August 2007. ISI = Institute for Scientific Information (now Thomson Scientific). 2 A little black mouth A “volunteer” tests samples of activated charcoal. 3 Backyard pigpens on the outer Torres Strait islands Pigpens (A) adjacent to swampy conditions or (B) situated over standing water were found to breed Culex annulirostris mosquitoes. 4 Artwork from the “Sharing the true stories” website Courtesy: Phyllis Batumbil, Matamata, Northern Territory. http://www.sharingtruestories.com. 5 Hand hygiene poster DeBugTM — an alcohol/chlorhexidine hand hygiene solution — was featured on a “talking walls” poster as part of Operation Clean Start at Austin Health, Melbourne.

Ann T Gregory MB BS, GradDipPopHealth · Ruth M Armstrong BMed · Tanya D Grassi MB BS(Hons), BSc(Vet)(Hons) · Martin B Van Der Weyden MD, FRACP, FRCPA

A brief taxonomy of reviewers, and how to deal with them Progress, we are told, can be helped by differences in opinion. If we always agreed on every issue, advance would be slower or perhaps even non-existent. This applies to all walks of life, and medical publishing is no exception. But differences in opinion can involve criticism, and criticism can be difficult to take. Today most journals rightly insist on peer review, which essentially means you receive written criticism on your submission. Having had my fair share of it, I would like to assist the novice by describing the archetypical critics and by suggesting strategies for dealing with them. The nitpickerThe nitpicker is obsessed with detail. Acting as peer reviewers is where nitpickers have their heyday! They might dislike anything — from your approach to statistics to the way you use semicolons. The best way of dealing with nitpickers is, I am ashamed to admit, to give in. It is, of course, tempting to justify this or that semicolon, but my advice is, don’t. Life is too short! Unless you are a nitpicker yourself, try to rise above nitpicking criticism. The aggressorFor those of us who are not born masochists, criticism is rarely an enjoyable experience. The aggressor makes sure it is thoroughly unpleasant. Whatever the arguments, they articulate them so forcefully that the opponent is likely to get hurt — regardless of the validity of the argument itself. I once received a review of a paper I had submitted for publication which started with the statement “This article is staggering in its incompetence”. What followed was hardly a qualification of this opinion, more a mindless enforcement of it. Aggressors do not normally assist you in your efforts to enhance anything; constructive criticism is not their cup of tea — they only aggress. There are several ways of dealing with the aggressor. Avoid an escalation of aggression, but insist on discussing the real issues openly. You might just win the day because the quality of the aggressor’s arguments is often inversely correlated to the force with which they are produced. The evangelistEvangelists are so utterly convinced of being correct that they view any deviation from their truth as heresy. If your data fail to support their beliefs, your data must be wrong. Evangelists read medical publications upside down — they first study the conclusions. If these are in accordance with the evangelists’ convictions, you have little to worry about. Even if your method is fatally flawed, they will praise you and your work. But if your conclusions contradict their beliefs, they will find plenty of fatal flaws in your work and condemn you forever — even if the research is flawless. After having been confronted by evangelists all too often, my advice is to ignore them. There’s no other choice. Only another evangelist can change an evangelist. The wind-bagIf a written criticism extends to more than five pages, or if a verbal comment goes on until you feel hypoglycaemic, it is, in my experience, likely to be worthless. Wind-bags love to hide the presumptuousness of their arguments behind large quantities of pseudoscientific waffle. They use tedious pseudoscientific jargon to indulge in apparently complex thoughts or theories. Unfortunately, this tends to impress a surprising number of people. But, once one manages to look behind the smokescreen, one is usually struck by the hollowness of the arguments. Subsequently, it is easy to deal with wind-bags; simply expose their elaborations for what they are: hot air. The inventorIf your opponent cannot find anything wrong with your work or arguments (or cannot even be bothered to study them), he or she may decide to become inventive. This strategy works best in published debates. Once the invention is out there in black and white, it is difficult, perhaps even impossible, to re-establish the truth. Whenever I publish research suggesting that a given “alternative” therapy does not work, you can be sure that someone counters by claiming I was bribed by “big pharma” to do so. There is nothing more efficient for tarnishing somebody’s work than a good old-fashioned lie. If the lie is important enough, you obviously have to deal with it. You then need to expose it and clarify who is inventing things and why. This process can be nerve-racking. Therefore, it might be wise to just ignore inventors, particularly if their lies are inconsequential. Criticism is meant to be helpful. It can and should be a good and constructive contribution to progress. Every now and then we do receive thoughtful criticism that is highly profitable. It enables us to reconsider certain issues and perhaps correct or prevent mistakes. This is the sort of criticism that does indeed further progress. I only wish we had more of it!

Edzard Ernst MD, PhD, FRCP, FRCPEd

Riding on the tail of the coauthorship explosion Once upon a time, well-bred scientists sucked on the end of a quill and produced magnum opuses with single-author bylines, such as Charles Darwin’s The origin of species. Following the model of other creative domains (eg, Rodgers and Hammerstein for musicals, Gilbert and Sullivan for operettas, and Galton and Simpson for television series), scientists moved to byline couplings (eg, the double-helix twist of Crick and Watson). But now, the contemporary “explosion” in scientific publications has been outstripped by an explosion in coauthors, presumably reflecting publication counts that allow an academic career to slouch towards Bethlehem. This report provides some quantification of the proliferation in prolix and profuse bylines, notes their climate-change impact and argues for a climacteric solution. MethodsWe (et al, et moi) sought to examine the average number of authors of research reports (ie, excluding editorials, reviews, correspondence, book reviews and corrigenda) appearing in the July issues of two leading general medical journals (BMJ and JAMA) and, as a reflection of this author’s discipline, two psychiatry journals (the American Journal of Psychiatry and the British Journal of Psychiatry), at 5-yearly intervals (2007, 2002, 1997, 1992 and 1987) over a 20-year period. ResultsByline creep was established. In the BMJ there was a modest increase (of 36%) from 1987 to 2007, with the 2007 issue averaging 6.3 authors per paper. In JAMA, a differentiation of the article types from “articles” to multiple classifications in more recent years allowed comparison only of “original contributions” across relevant 2002 and 2007 issues. The average number of authors per paper increased by 73% (from 6.8 to 11.8) over that brief period. The number increased by 58% in the American Journal of Psychiatry (rising from 3.9 authors per paper in 1987 to 6.2 in 2007), and 130% in the British Journal of Psychiatry (from 3.2 in 1987 to 7.3 authors per paper in 2007). During the quantification process, this author became distracted by the byline gallop in published letters. A “letter” is surely a brief personal communication from one person to another. Letters (other than belles-lettres) should not be expected to have great status or (other than petitions to the Queen) require multiple authors. But again, authorship of letters is breeding to such a profligate extent that the list of authors can take up more space than the letter itself. And letters breed letters. A representative example is a letter published in Nature, in which Nusbaum, the principal author, was joined by 53 coauthors.1 However, as one author’s name “was accidentally omitted”, a new letter pointing out this grave anomaly was subsequently authored by 55 authors,2 with the byline requiring eight lines of text, as against the one line occupied by the actual 23-word correction “letter”. DiscussionThe current study — like much of science — merely quantifies what is widely known. It is perhaps more important to recognise the causes and the consequences. Unless otherwise explained, we must assume that the coauthorship explosion is a virus designed to advance the academic and research careers of individuals and their institutions. As competitive grant funding is like rain on a salt flat, coauthors will breed like Sea Monkeys in such a climate. While medicine is viewed as a particularly “collaborative” discipline,3 and doctors are expected to be caring and generative, gift authorship — defined in the Lancet as “polyauthoritis giftosa”4 — comes with a price. The question must be asked: is byline creep good breeding, or overpopulation? While acknowledging all those who have contributed to the research endeavour seems a model of responsibility, responsibility so diffused risks irresponsibility writ large. The equivalent of verbal filibustering, such unsightly frilly cluttering of articles signals more style than substance. The recent corrective strategy, whereby many journals now require authors’ individual responsibilities to be stated, is merely a challenge inviting creative writing. The Biblical story of “Ruth amid the alien corn” has contemporary relevance, and journals need to review their current chaff-to-wheat ratio. In some arenas, such as medicine (eg, genomics, clinical trials) and other scientific disciplines (eg, physics), we also see a blitzkrieg phenomenon, in which it appears that overwhelming numbers of authors and affiliated institutes (rather than the science itself) are being deployed to allow a particular field to be captured or dominated, as described in Nature.5 Hypercollaborative sciences, such as high-energy physics, have led to so-called “mega-authored” publications arising out of international collaborations, like CERN (European Organization for Nuclear Research) in Geneva, where the OPAL and ALEPH collaborations had 209 and 277 coauthors, respectively, appearing on two articles.6,7 Particularly high-mega-authorship collaborations have arisen out of the DESY (German Electron Synchrotron) research group, with the ZEUS and H1 efforts publishing reports with close to, or more than, 300 authors.8,9 A species of gravitational interaction has emerged. The impact? Could I suggest reference to an H1 collaboration article.9 This nine-page article has two-and-a-quarter pages taken up with the 296 authors, their 40 affiliative institutions and their 11 funding bodies. Next, as in cinematography, the assorted associates are likely also to be listed at the article’s end as “data wranglers”. The future? Well the future is already here, as just noted and illustrated earlier by the Nature letter–corrigendum scenario. All of us who aspire to having a letter published by Nature will be teamed up by “Google Coauthor” and coalesced into a consortium. The multiplicity of authors should ensure sufficient errors for the average letter published in Nature to generate at least one correction “letter”. This might draw attention to authors who were initially missed, perhaps because they were late in bedding down with the original letter writers (spontaneous co-respondents become formal correspondents). A few more “letters” to Nature might draw attention to a missing umlaut or some other critical byline error. Everyone will be able to fight for his or her contribution to a letter to Nature (risking Nature being read in tooth and claw?) and soon — as Nature abhors a vacuum — it will be unnatural for a scientist not to be published in Nature. The ceiling will have become the floor. Solutions? Perhaps the once-condemnatory journalistic term “hack” needs to be redefined and a hacksaw brought into play. I propose that scientific journals publish only single-author papers or, if multiple authors are involved, the non-principal authors be grouped as “et al” in the byline and in the reference section. By rough calculations, this would reduce the contents of the average scientific journal by 12.6745%, which, multiplied by the current number of scientific journals, would save 250 000 hectares of South American rainforests and numerous butterflies from putting chaos theory into practice. We need ecoauthorship rather than having coauthorship put our climate at further risk. Clearly, we need to ensure that “et al” receives its rightful place in the sun, replacing all coauthors in any article byline. At first pass, some might reject the possibility, perhaps judging that “et al” sounds like “also ran”. But the term “et al” has majesty and status. In traditional Hawaiian society, the hereditary “ali’i” or “alii” occupied the highest societal class, even ranking above priests (and editors). Possessed of divine powers, they were able to place curses on others, including, presumably, first authors who traduced their byline status and any editor who did not view their manuscript as Nobel Prize-winning material. A more contemporary argument can be offered. Presuming that the name “Alfonso Joseph D’Abruzzo” means nothing to you, I can reveal that this man’s acting career was launched by his changing his name to “Alan Alda”, merely one step before the even more alliterative “Al Al”. The logical next step, a paper published by “Al et al”, has already occurred in a British journal,10 demonstrating respect for, and gravitas surrounding, “Al”. “Al” clearly implies “A 1” status. Instead of the disquiet experienced by authors who quibble with the order of authorship, the proposed system would give comparable status to both the first author and those high-class members of the et al set; thus, it is a non-hierarchical parity model. We could go further and delete the titles of many research papers, and merely add a subject to the et al predicate. For example, a paper by “Bloggs et alalia” would be immediately recognised as discussing speech impediments; “Bloggs et al-Qaeda” would be considering the impact of terrorism; “Bloggs et alimentary” would be a gastrointestinal review; “Bloggs et algolagnia” would cover painful sexual experiences; and “Bloggs et al-anon” would report on alcoholism support systems; while a paper on climate change would be sufficiently explained by the byline of “Bloggs et al Gore”. The last suggestion even encourages the convenient truth that et al could run for President.

Gordon B Parker DSc, MD, FRANZCP

Satirical prints and drawings have been popular for centuries, and politicians and prominent people have been fair game for the barbed pen of the artist. The medical profession has come in for its share of satire, usually in relation to the treatment available and the fees charged In newspapers and periodicals, artistic expressions of political and social events are presented to us daily in various forms, from caricatures of prominent people to line drawings and thumbnail sketches that depict a particular situation. In 18th and 19th century London, such satirical prints were very much in vogue. Satire was the language of the day, and no level of society was spared. Prints were the only pictorial records of life at that time, and the print shops were extremely popular. They provided amusement, but also powerful social and political criticism. In those times, society, politics, and economics were changing rapidly, and scientific knowledge was emerging. Managerial and professional classes were rising in power and status. Tall poppies were there to be cut down, and the caricaturists were always willing to do this with their pens. The first publication in the United Kingdom of Punch, in 1841, and the British version of Vanity Fair, in 1868, saw the emergence of illustrated journalism. Medical treatment in the 18th and 19th centuriesIn the 18th and 19th centuries, medical treatment was harsh and violent, and the cartoonists treated it and its practitioners in the same way.1-5 The aetiology of diseases was unknown, and conditions such as fever, ague (malaria-like acute fever) and gout were personified as monsters or devils. The doctors were depicted as pompous pretenders to fashion, with their wigs, cocked hats and gold-headed canes (Box 1). Physicians prescribed medicines — many ineffective and unpalatable — including emetics, cathartics and clysters (enemas). Being ill was bad enough, but being “physicked” could be even worse. Surgeons lanced, cut, bled and amputated, their skill being judged by their speed. Anaesthetic agents were non-existent until the mid 1800s, and the only relief would have been from opium or alcohol. Therefore, disease and doctors were to be feared. The standing of those practising medicine, in the eyes of the artists and the public, was not high, and disease and death were considered to be the doctor’s constant companions. The humour of the time was “black”. The misfortune of the patients and the attitude of the doctors were material for satire by the artists. William Hogarth (1697–1764) is regarded as the founder of the English form of satirical art. He was not a caricaturist, but is better described as a graphic satirist and moralist. His works are a perfect representation of life in London in the first half of the 18th century, and examples would be such works as The March to Finchley, Southwark Fair and Gin Lane (Box 2). After Hogarth, other British satirists who applied themselves to recording life and events were Thomas Rowlandson (1756–1827), James Gillray (1757–1815) and George Cruikshank (1792–1878), and the period in which they worked has been referred to as the “Golden Age of English caricature”. The social stratification at the time was reflected in the medical profession. The pecking order of those practising medicine would have been: The physicians with degrees from Oxford or Cambridge, who considered themselves to be learned men and above all others. The licentiates who had a qualification from some other university in England or abroad. The surgeons. The apothecaries. The quacks. However, success in the practice of medicine did not always depend on qualifications, but often on patronage and, in the case of the quacks, advertising. Hogarth’s work, A consultation of physicians or The company of undertakers (which he presents as a coat of arms), satirises the standing of the physicians (Box 3). It shows 12 members of the College of Physicians examining a flask of urine. In the escutcheon, he presents three famous quacks of the time, (“Chevalier”) John Taylor the oculist, Sally Mapp the bone setter and Joshua (“Spot”) Ward of “drop and pill” fame. In Hogarth’s opinion, there was little difference, if any, between them. Another Hogarth print, published in 1726, Cunicularii, or the wise men of Godliman in consultation, depicted the story of Mary Tofts. In 1725, Mary Tofts of Godalming had been reported in a Guildford newspaper as having given birth to rabbits, and the doctors believed it! The event even came to the attention of the king, who sent his anatomist–surgeon to investigate and report. Eventually, the situation was found to be a complete fraud, and Mary Tofts confessed. In the drawing, three “surgeons” are pilloried for their gullibility — Mr Howard, the midwife, who first reported the event; Nathaniel St Andre, the royal anatomist–surgeon; and Cyriacus Ahlers, a royal surgeon. It has been suggested that the accoucheur, labelled as the philosopher searching into the depths of things, was Sir Richard Manningham (Box 4). Jealousies and enmity existed among the strata of the medical profession — physicians, surgeons, apothecaries and quacks. These reached the press, and even the law courts, providing more material for the print shops, who would represent them as battles. The cartoon, Siege of Warwick Castle (1767), illustrates a fight between the licentiates and the Fellows of the College of Surgeons (Box 5). The licentiates had invaded the College after having been denied access to a College meeting and dinner at an establishment in Warwick Lane. The president is depicted as a skeleton and the weapons are urinals, clyster pipes and syringes, as well as canes and fists. The licentiates were finally dismissed with the aid of the College fire engine. The physicians also battled with the apothecaries over whether the latter could treat patients. Eventually, this was settled by the court, which found in favour of the apothecaries. All levels despised the quacks. Cruikshank satirised the board of examiners at Surgeons’ Hall in his drawing, The examination of a young surgeon (1811). A fierce-looking examiner asks the candidate to describe the organs of hearing. Of the motley collection of examiners around the table, two are deaf, others are bored or uninterested, another takes snuff, and a skinflint counts his money (Box 6). Patients then, as today, sought cures to their ailments and improvements to their wellbeing in clinics and health centres. Bath was a popular place for the gentry and wealthy to visit to bathe in the hot springs, and to take the air and the waters. There was also a very important social side to the Bath visit, which involved afternoon teas, dinners and balls. Doctors were in abundance and available for consultation. Rowlandson satirised the situation in his series, The comforts of Bath, published in 1798.6 One of the main figures in the series is an elderly obese gentleman with a gouty leg. Cartoons show him being examined by a group of doctors; attending the pump room in his Bath chair; and visiting the marketplace where he appears to critically examine a large fish as well as the lady assistant’s attributes. In another scene titled The gourmets, two gentlemen indulge themselves in the good food and drink that would suggest a contributory factor in the aetiology of their gouty legs and other medical conditions. Another satirical view of the Bath visit was the Bath races. Here, the decrepit visitors race down the slope below the Royal Crescent. Death was also in attendance, and in a couple of cartoons was shown driving a coach drawn by some of the visitors. Lecherous doctors did not escape the artist’s pen. A Rowlandson drawing, Medical dispatch or Doctor Doubledose killing two birds with one stone, shows a portly doctor taking the pulse of a dying crone and at the same time putting an arm around the shoulders of a nubile maid (Box 7). Innovations in medical treatment also provided material for the satirists. One of Gillray’s prints shows Jenner inoculating patients with cowpox exudate. As a consequence of the procedure, the patients have begun to sprout miniature animals from their arms and faces, etc. A drawing by Gillray titled Scientific researches! New discoveries in pneumatics! satirises the effects of air or nitrous oxide treatment in a lecture–demonstration. The subject’s trousers are blown off, while members of the audience show shock and disgust. Death was considered to be the doctor’s constant companion, and the skeleton was used as a symbol. One cartoon (artist unknown) illustrates a doctor carrying a bag of gold, with a skeleton riding on his back (Box 8). The doctor has pointed ears, which might suggest an association with the devil, and in the background, a funeral procession can be seen. Metallic tractors were invented by Elisha Perkins in 1795. These instruments were supposed to produce galvanic electricity and were available (at 5 guineas a set) to cure all conditions. A Gillray cartoon of 1801 shows them being used to treat a brandy-loving patient’s large inflamed nose, with resulting discomfort (Box 9). Boards of public health were established during the 1831–1832 outbreak of cholera in England; the Central Board was in London, and its members were employed on high salaries. (The present-day analogy would be “jobs for the boys”.) Although the board issued statistics, it had no effective measures to deal with the problem, and The Times stated that “Choleraphobia was profitable to the medical profession”. The members of the Central Board of Health were lampooned by the cartoonists, and in one drawing by Cruikshank, four distinguished members, indulging themselves with a sumptuous dinner, drink a toast: “May we preserve our health by bleeding the country” (Box 10). The relationship between contaminated drinking water and cholera had not been appreciated at that time. In London, 130 sewers emptied into the Thames near the site where the Southwark Water Company drew its drinking water. A cartoon by Cruikshank depicted John Edwards, the owner of the company, sitting on a buoy in the filthy Thames while people on the bank called for pure water. It was not until 1854 that John Snow confirmed that the cholera infection was related to the quality of the water. Later 19th centuryIn the latter half of the 19th century, the satire became more sedate and the humour more subtle, a change from the black humour of the earlier years. Because of the advances in medicine, violent treatment such as amputation and other painful procedures were no longer a target. Doctors and patients became the main subjects, the former because of their pretensions to upper-class status and the latter, their gullibility. The doctors’ attire changed to the top hat, morning coat and striped trousers. A cartoon in Punch shows the fashionable patient protesting at the medication prescribed (cod-liver oil) and the fashionable doctor’s solution to the problem (cream and curaçao). In another drawing, the specialist writes a prescription, which the patient can have filled or not — for it would make no difference.7 Diagnostic problems were illustrated, as shown by a few examples from Punch: The specialist physician searching for a diagnosis asks the patient, “What do you drink?” The reply, “Oh, Sir! — thank you Sir . . . I’ll leave it to you, Sir!” The beneficial effect of taking the patient’s temperature and the patient’s comment, “That done me a lot o’ good, Sir!” The doctor makes a diagnosis on the patient’s symptoms of “feeling wretched . . . no interest in anything, have no appetite, can’t sleep”, and his advice is “Why don’t you marry the girl?” Another cartoon (1882) shows an American physician and an English physician in discussion (Box 11). Modern timesBetween the 1940s and the 1990s, Giles in the British Daily Express used members of the “Giles family” to put a humorous aspect on events of the day, medical and otherwise. The foils were usually Grandma and sickly, snivelling Aunty Vera, who always had her handkerchief to her nose and carried her bottle of pills. In Australia in the 1970s, Larry Pickering drew a series of sketches on the activities of the medical profession,8 which included a doctor operating on his hobby antique car assisted by his son in the role of theatre sister, and another rather cynical set published in The Weekend Australian newspaper in 1979 lampooning doctors and their fees (Box 12). Handwriting and fees are perennial subjectsThe handwriting of doctors has always been criticised. A cartoon in Punch shows the annual pharmacists’ competition, in which they are adopting many bizarre positions in their attempts to interpret the writings of members of the British Medical Association. In the 1970s, the Australian cartoonist Larry Pickering produced a drawing on this subject in which a lady, leaving the pharmacy carrying a large purchased teddy-bear, complains to her companion that her doctor’s writing is not getting any better. Fees have been a subject for satire throughout the years. An 18th century drawing shows Dr Gallipot weighing the guinea (at the time a precaution against “light guineas”). Punch had its own examples, such as the specialist surgeon being asked by his colleague, “What did you operate on old Jones for?” “100 pounds.” “But what had he got?” “100 pounds”. Another cartoon, in the 1920s, shows the patient expressing surprise on receiving the bill: “Good Lord, doctor, have I been as near death as that?” Disease and doctors both fair targets for humourHumour and jokes have often been used as a way to deal with adversity, and satirical humour could be described as a form of benign aggression. Disease and death have been mankind’s greatest enemies. Anything that interferes with life and makes it uncomfortable (which could include the doctors and their medicines) falls into a similar category. Being physicked, 250 years ago, was unpleasant, and going to the surgeon a painful and horrible experience. Those unpleasantries have passed but are now replaced by other inconveniences and irritations, such as waiting times for appointments and operations, and complicated and invasive tests and the fees they generate, all of which can act as grist to the mill for the satirist. 1 A Going! A Going! Reproduced with permission of the Museum of the Royal Pharmaceutical Society of Great Britain. 2 Gin Lane Hogarth, 1751 (engraving). 3 A consultation of physicians or The company of undertakers Hogarth, 1736 (engraving). 4 Cunicularii, or the wise men of Godliman in consultation Hogarth, 1726 (engraving). 5 Siege of Warwick Castle Source: George MD. Hogarth to Cruikshank.1 6 The examination of a young surgeon From a print in the library of the Royal College of Surgeons of England. 7 Medical dispatch or Doctor Doubledose killing two birds with one stone Rowlandson, circa 1800. 8 The doctor’s constant companion Anon. From the Stephen Don Print Collection, Royal College of Obstetricians and Gynaecologists 9 Treatment by metallic tractors Gillray, 1801. From the Boston Medical Library. 10 “May we preserve our health” Cruikshank, 1832. From the Manfred Kraemer Collection, Harvard Medical School. 11 An American physician and an English physician in discussion “Now, in Vienna, they’re first-rate at diagnosis; but then, you see, they always make a point of confirming it by a post-mortem!” From Mr. Punch among the doctors.7 12 The Australian medical profession, by Larry Pickering From The Weekend Australian.8

H Reginald Magee FRCS, FRACS, FACS

Quotes from MJA contributors in 2007 Peer review is a critical component of quality control in scientific medical journals. However, given the competitive nature of publishing, it is not surprising that the process of peer review has been described as a turf battle — the writers and originators of ideas aligned against the editors and critics — with the ultimate prize of the knowledge or doctrine being published.1 Peer review of medical care was first documented in a book called Ethics of the physician by Ishap bin Ali Al Rahawi (854–931 ce) of Al Raha, in northern Syria.2 However, its presence in scientific medical publishing is more a part of modern than ancient history. Beginning in the mid 18th century and flourishing after World War II, particularly with the development of the photocopier in the 1950s,1 journal peer review is now often Internet-based, as at the MJA. The “Cyperspace Wars” are here. Participants on the “critics” side of the battle may receive briefings from recent articles like Ten simple rules for reviewers,3 freely available on the Internet. But, war is war in any time and place. This year, we share with you quotes from MJA reviewers who may well have studied a definitive work on military strategies and tactics: The art of war, a Chinese military treatise written during the sixth century bce by Sun Tzu.4 Consider, in particular, this from the chapter on “laying plans”: Attack him where he is unprepared, appear where you are not expected. And this, from the chapter on “energy”: The quality of decision is like the well-timed swoop of a falcon which enables it to strike and destroy its victim. Therefore the good fighter will be terrible in his onset, and prompt in his decision. No part of the main IMRAD (Introduction, Methods, Results, and Discussion) structure is impenetrable to such an attack. Introduction: why did they do it? On analysing “aged” data: It is a romantic notion to think that we’d uncover stunning new insight into the past, by rummaging through attics and basements filled with relics of a bygone age. We’re more likely to find dust bunnies and Nan’s collection of vaudeville programmes than to uncover Macfarlane Burnet’s long-lost personal diaries. Methods: what did they do? On study design: The authors continually refer to their sample as a cohort. It is not. A cohort is a sample of people followed over time. The Romans established and maintained their empire by building roads, straight roads, enabling them to deploy their army in any corner of the empire. The basic unit of the Roman legion was the cohort and these cohorts marched forward along these roads. In epidemiology, a cohort marches forward in time. Results: what did they find? On outcome measures: “Mild toxicity” could be considered to be an etymological oxymoron. The word toxic comes from the Greek word meaning a bow (as in bow and arrow) and is inextricably linked with the word poison. This is, of course, because of the early use of poisoned arrows by the Greeks. This idea endures in the phrase “a poisoned arrow”. Discussion: what does it mean? On possible researcher bias: It looks as if there is a political agenda at work here and the complexity of the truth is hidden behind broad generalisations made through the obscuring power of the P value. Implications: what happens next? On style of writing: The authors write as if they have discovered Third World poverty and a partial mechanism for its solution ... I recommend that the article be reworked so that it is more realistic, humble, and less enthusiastically gushing. The authors’ prediction is for future medical leaders, not spin doctors. Of course, at the MJA, we prefer to see things as though innovators, authors, editors and reviewers are all on the same side — working together to advance science against disparate, unproven hypotheses. As Sun Tzu put it: We can form a single united body, while the enemy must split up into fractions. Hence there will be a whole pitted against separate parts of a whole, which means that we shall be many to the enemy’s few.

Ann T Gregory MB BS, GradDipPopHealth

Provision of incorrect information or incorrect data interpretation does not serve anyone well In this issue of the Journal, MacKenzie and colleagues present data to show that, over an 18-month period, media reports about prostate cancer were dominated by statements emphasising Australian men’s risk of prostate cancer, encouraging screening for early detection, and providing reassurance about side effects for treatments that emphasise emerging technologies (→ "The news is [not] all good": misrepresentations and inaccuracies in Australian news media reports on prostate cancer screening).1 In particular, they draw attention to rhetoric that unequivocally supports screening, which would seem to be irresponsible, given the lack of definitive data to show that population-based screening will reduce mortality. Although this is a fair comment to make, the enthusiasm with which the media has responded to the call to promote screening should not take anyone by surprise. Prostate cancer is the most common internal male malignancy in Australia and the second most common cause of cancer deaths in men.2 In 2003, there were 13 526 new cases of prostate cancer and 2837 deaths. By contrast, in that same year, 11 788 women were diagnosed with breast cancer and 2710 died of this disease. Although the biology of these cancers may differ, from the lay public point of view it is a “line ball” call. Little wonder then that, in the face of seeming inaction by government, consumer advocacy groups and some clinicians find a willing media to enter into a discourse that promotes action. In the context of a disease with a high community and individual burden, uncertainty about effective management plans and with no clearly articulated national public health strategy in place, advocacy such as this may be inevitable. A particular characteristic of this debate has been the polarisation of views for and against screening to the point where, at times, constructive debate has been constrained. However, it is important to differentiate between prostate-specific antigen (PSA) screening, with indiscriminate testing of all men (between prescribed ages), and testing after informed consent, as recommended by peak Australian cancer control and health agencies.3-6 Apart from the fact that PSA is not a test for prostate cancer and has no threshold level providing a high sensitivity and specificity, but rather has a continuum of prostate cancer risk at all values,7 a raised PSA level often commits men to the invasive procedure of transrectal ultrasound (TRUS) guided biopsies. Most men presenting for TRUS biopsies have serum PSA levels of 4–10 ng/mL and do not have prostate cancer detected with extended numbers of biopsy cores. If the diagnostic process were non-invasive and treatments with curative intent were not associated with significant unwanted effects, few would quibble about whether it is appropriate to be tested. Although estimates vary, there is no doubt that many men having treatment with curative intent are unlikely to benefit in terms of survival.8-10 Problematically though, such men are at risk of physical and psychosocial adverse effects from treatment that will affect both them and their partners.11,12 As a consequence, there is increasing support for stratifying patients, with an active surveillance protocol advocated for men identified as having low-risk prostate cancer.13 One expert advocates an intense monitoring protocol to identify the minority of low-risk patients (about 30%) with unappreciated aggressive disease for whom definitive therapy should be considered.13 However, this strategy can be undertaken only after biopsy diagnosis. There is no doubt that timely intervention does save lives. However, at the outset, men need to be fully informed of the possible adverse effects of potentially curative treatments and then consider whether, in the event of an abnormal PSA result and subsequent prostate cancer diagnosis, they would wish to proceed to treatment. Only then should they have a PSA test. Nomograms indicating cardiovascular life expectancy accurately may have a role in the future to allow a more tailored approach to overall management, including whether to proceed with prostate cancer testing. MacKenzie et al call for health authorities to commission and promote decision aids to assist men in making an informed decision about PSA testing for the early detection of cancer.1 Such decision aids already exist in a wide range of formats and have been shown to improve men’s understanding and knowledge about prostate cancer and to reduce decision-related conflict, although they have little effect on actual testing behaviour.14 The current need is not to develop more decision aids, but to translate shared and informed decision making about prostate cancer testing into primary care, the place where the decision to test is enacted.15 Barriers to translation include time constraints in busy general practices, general practitioner concerns about medicolegal risks, and GPs’ own knowledge and attitudes to prostate cancer testing. To address these barriers, a consortium, led by The Cancer Council Queensland and including The Cancer Council Australia, Australian Prostate Cancer Collaboration, Urological Society of Australia and New Zealand, and the National Cancer Control Initiative, developed an educational program and decision-aid showcard to support shared decision making about the early detection of prostate cancer in primary care.15 With funding from Andrology Australia, these materials are now available online, and uptake from general practice has been steady, with positive review by users.6 Importantly, the Prostate Cancer Foundation of Australia, as the leading prostate cancer consumer group in Australia, has been included in this initiative. This has been an important step in moving towards a constructive dialogue about this contentious issue. Whatever strategies emerge in terms of diagnosis and treatment in the future, provision of incorrect information, incorrect data interpretation or adverse consequences of the editing process itself do not serve anyone well, least of all patients and their relatives. Moreover, the task of supporting informed patient decision making is made more difficult when having to address misconceptions that may be derived from such reports. Articles such as that by MacKenzie et al highlight the need for media spokespeople to ensure that public discussion of prostate cancer is directed towards a realistic representation of the current status and limitations in relation to PSA testing and prostate cancer management in this country.

Suzanne K Steginga PhD · Robert (aka Frank) A Gardiner MD, FRCS, FRACS

Objective: To list and critically review recent inaccurate statements made by advocates of prostate cancer screening in Australian news media.Design: Accuracy audit of all news on prostate cancer broadcast on Sydney footprint free-to-air television stations between 2 May 2005 and 18 December 2006 (42 items), and published in print media from 6 February 2003 to 31 December 2006 in Australian capital cities (388 items). These contained 436 direct or attributed statements.Results: Of the 436 statements analysed, 44 (10%) were factually inaccurate or made claims not supported by the scientific literature or most cancer control agencies. Misleading statements about prostate screening and its sequelae were found in five categories: mortality from prostate cancer; expert agency support for screening; the efficacy of screening in preventing death from prostate cancer and the importance of early detection; the accuracy of the prostate-specific antigen test; and prevalence and severity of adverse effects from treatment.Conclusions: Despite near universal lack of support for prostate cancer screening of asymptomatic men by leading international and Australian cancer control agencies, Australians are exposed to an unbalanced stream of encouragement to seek testing. This coverage includes inaccurate information which ignores scientific evidence and the general lack of expert agency support.

Ross MacKenzie MA · Simon Chapman PhD · Alexandra Barratt PhD · Simon Holding BA

Objective: To examine whether television news and current affairs coverage of overweight and obesity frames obesity in ways that support or oppose efforts to combat obesity.Design and setting: A content and framing analysis of a structured sample of 50 television news and current affairs items about overweight and obesity broadcast by five free-to-air television channels in New South Wales between 2 May and 31 October 2005.Main outcome measures: Dominant discourses about causes of overweight and obesity; proposed solutions and location of responsibility for the problem; the age-group focus of television items; the relative prominence of stakeholders; and the aspects of obesity which attract news attention.Results: Most television items (72%) framed obesity as a problem of poor nutrition. Obesity was largely seen as the responsibility of individuals (66% of items). Just over half of news items (52%) focused only on adults while 26% focused only on children. Obesity was framed largely as a problem to be solved by individual nutritional changes, exercise and surgical and medical interventions.Conclusions: While individual lifestyle is crucial to controlling weight, the research community now recognises the importance of sociocultural and environmental factors as drivers of the obesity epidemic. However, television news portrays obesity largely as an individual problem with individual solutions centred mostly on nutrition. Media emphasis on personal responsibility and diet may detract attention from the sociopolitical and structural changes needed to tackle overweight and obesity at a population level.

Catriona M F Bonfiglioli BA(Hons), PhD · Ben J Smith BSW(Hons), MPH, PhD · Lesley A King BScPsych(Hons), MPsych · Simon F Chapman BA(Hons), PhD · Simon J Holding BA