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As doctors, we spend a lot of time learning facts but little time is formally dedicated to learning how to think. Ideally, this skill is learnt (“picked up”) during the years of clinical teaching at the bedside, in the clinic and in the operating theatre. Errors in clinical interpretation and reasoning can occur at any point during patient care. These are often due not to ...

Annette Katelaris MB BS, MPH, FRACGP

In this issue, we report a significant study by Runciman and colleagues that was designed to measure how well we deliver “appropriate care” to patients in Australia (doi: 10.5694/mja12.10510). The researchers were aiming to reproduce a landmark 2003 study that found that only 55% of patients in the United States received “recommended care”. While the methods used by the American and Australian studies were slightly different, ...

Annette Katelaris MB BS, MPH, FRACGP

For decades, there have been concerns about the extent to which the health system provides the right care to those who need it in a cost-effective, timely manner. In Australia, there has been much discussion and marked improvements in some areas, but the provision of highly ...

William B Runciman MB BCh, FANZCA, PhD · Enrico W Coiera MB BS, PhD, FACMI · Richard O Day MD, FRACP, MB BS · Natalie A Hannaford DipAppSc(Nursing), MPH · Peter D Hibbert BAppSc(Physio), GradDipComp, GradDipEcon · Tamara D Hunt BAppSc(Nursing), CritCareCert · Johanna I Westbrook PhD, GradDipAppEpid, MHA · Jeffrey Braithwaite PhD, MBA, FCHSM

Friends of Science in Medicine should avoid threatening their own valuesScience has always been — and should be — a battleground for contending views on what is true. Because of the close connection between knowledge and power, however, the risk is always present that those who command the dominant theories or ideologies will rely on their positions of influence to overcome those who oppose them. ...

Paul A Komesaroff MB BS, PhD, FRACP · Amber Moore BChineseMed(Hons), BA(Hons) · Ian H Kerridge MPhil, FRACP, FRCPA

To the Editor: A rising awareness of the prevalence of 25-hydroxyvitamin D (25OHD) deficiency over the past decade is likely to have led to a surge in the number of individuals who undergo 25OHD testing.1 United States data indicate that testing for 25OHD has increased by 80%–90% annually,2 yet there are no reports that investigate the cost of 25OHD testing in Australia. We analysed the ...

Kellie L Bilinski · Steven C Boyages

How appropriate is the health care delivered to Australians? A seminal study in the United States showed that American adults received “recommended care” only 55% of the time in the years 1999–2000. Estimates of “appropriate care” — defined here as care in line with evidence-based or consensus-based guidelines — are limited in most countries, including Australia, to small groups of conditions ...

William B Runciman MB BCh, FANZCA, PhD · Tamara D Hunt BAppSc(Nursing), CritCareCert · Natalie A Hannaford DipAppSc(Nursing), MPH · Peter D Hibbert BAppSc(Physio), GradDipComp, GradDipEcon · Johanna I Westbrook PhD, GradDipAppEpid, MHA · Enrico W Coiera MB BS, PhD, FACMI · Richard O Day MD, FRACP, MB BS · Diane M Hindmarsh MScAgr, MBiostats · Elizabeth A McGlynn PhD · Jeffrey Braithwaite PhD, MBA, FCHSM

Objectives: To investigate the acceptability and feasibility of using end-of-life (EOL) care pathways in residential aged care facilities (RACFs).Design, setting and participants: Multistage action research approach involving interviews, surveys and prospective audits of deaths and EOL care pathway use among residents and staff of RACFs and associated general practitioners from 14 RACFs in Victoria and South Australia between April 2009 and July 2010.Intervention: ...

Dell E Horey BAppSc, MMedSc(ClinEpi), PhD · Annette F Street BEd(Hons), PhD · Alison F Sands MB BS(Hons), FRACGP

Working with Indigenous communities towards research that is relevant, effective and culturally respectful. Writing in the Journal about Indigenous health in 2011, Sir Michael Marmot suggested that the challenge was to conduct research, and to ultimately apply findings from that research, to enable Indigenous Australians to lead more flourishing lives that they would have reason to value. As committed Indigenous health researchers in Australia, we reflect ...

Lisa M Jamieson PhD · Yin C Paradies PhD · Sandra Eades PhD · Alwin Chong MPH · Louise Maple-Brown PhD · Peter Morris PhD · Ross Bailie PhD · Alan Cass PhD · Kaye Roberts-Thomson MPH · Alex Brown PhD

Information from clinical trials informs our treatment of breast cancer, as it does that of many other common diseases. The trials establish “ideal” management, but the relevance of this information to any individual patient varies because the strict inclusion criteria used for trials exclude many important groups in the community. In breast cancer trials, the old, the poor and the rural-dwelling are often underrepresented. So, ...

Annette Katelaris MB BS, MPH, FRACGP

Objectives: To estimate the incidence of metastatic breast cancer (MBC) in Australian women with an initial diagnosis of non-metastatic breast cancer.Design, setting and participants: A population-based cohort study of all women with non-metastatic breast cancer registered on the New South Wales Central Cancer Register (CCR) in 2001 and 2002 who received care in a NSW hospital.Main outcome measures: 5-year cumulative incidence ...

Sarah J Lord MB BS, MS, FRACGP · M Luke Marinovich BA, MPH · Jillian A Patterson BSc, MBiostats · Nicholas Wilcken MB BS, PhD, FRACP · Belinda E Kiely MB BS, FRACP · Val Gebski BA, MStats, FRANZCR(Hons) · Sally Crossing AM, BEc · David M Roder AM, MPH, DDSc · Melina Gattellari PhD, MPH, BSc(Psychol) · Nehmat Houssami MB BS, PhD, FAFPHM

In this issue, Handelsman (doi: 10.5694/mja11.11277) describes changes in the patterns of testosterone prescribing in Australia from 1992 to 2010. He reports that there has been at least a twofold increase in total expenditure on prescriptions, taking into account inflation and population growth, and the increase in expenditure is greater than the increase in prescribing. Yet, ...

Annette Katelaris MB BS, MPH, FRACGP

To the Editor: The report by Scott and colleagues on the “demographic characteristics, diagnostic category, stage of illness, as well as psychosocial and vocational impairment” of 1260 patients presenting to two Sydney headspace centres1 is problematic for several reasons. No convincing data were presented to support the authors’ conclusion that the research demonstrated that “well designed youth ...

Jon N Jureidini

To the Editor: The study of headspace attendees by Scott and colleagues1 illustrates problems common in articles being used for lobbying purposes in the Australian mental health policy arena. These include misrepresentation of evidence, inappropriate medicalisation, and undeclared competing interests. The authors refer to un(der)employment, lack of engagement in study, and receipt of income support as ...

Melissa Raven

In reply: The detailed demographic, diagnostic and disability data we presented1 responds directly to the critics of headspace clinics. Following the initial establishment phase,1 our two centres now provide services to 390 and 411 young people per month, respectively (data from July to September 2011). Each of the 30 established headspace services now assesses an average of 265 clients ...

Ian B Hickie · Daniel F Hermens · Elizabeth M Scott

Objective: To determine hepatitis C (HCV) treatment effectiveness and predictors of response in the “real-world” Australian clinic setting. Design, setting and participants: Patients with chronic HCV, who were HCV-treatment-naive at enrolment, and were then treated with standard therapy (pegylated interferon-α plus ribavirin), were recruited prospectively through a national network of 24 HCV clinics ...

Heather F Gidding MAppEpid, PhD · Matthew G Law PhD · Janaki Amin PhD · George Ostapowicz BMed, MD, FRACP · Martin Weltman PhD, FAChAM, FRACP · Graeme A Macdonald MB BS, PhD, FRACP · Joe J Sasadeusz MB BS, PhD, FRACP · Paul AW Haber MD, FRACP, FAChAM · Jacob George MB BS, PhD, FRACP · Gregory J Dore MPH, PhD, FRACP

Objectives: To develop a mathematical model to project the potential impact of hepatitis C virus (HCV) treatment on HCV infection prevalence among people who inject drugs (PWID). Design and setting: An existing model of HCV transmission among PWID was parameterised using data from Victoria, Australia, including specific parameter estimates of the number ...

Margaret E Hellard PhD, FRACP, FAFPHM · Rebecca Jenkinson BEng(Geol), MEpid, PhD · Peter Higgs BSW, MA, PhD · Mark A Stoové BaAppSci(Hons), GradDip(Ed), PhD · Rachel Sacks-Davis BA BSc(Hons[Arts]) · Judy Gold BBiomedSci(Hons), PhD · Matthew Hickman MSc, PhD, FFPH · Peter Vickerman DPhil, BSc · Natasha K Martin PhD

A very public slanging match has arisen between The Lancet and one of Australia’s most high-profile medical opinion leaders in psychiatry. The Lancet’s editor, Dr Richard Horton, has queried whether or not Professor Ian Hickie, of ...

Annette Katelaris MB BS, MPH, FRACGP

To the Editor: From 2007 to 2009 in Australia, a three-dose course of quadrivalent human papillomavirus (HPV) vaccine was offered to all females aged 12–26 years through school and primary health care settings, with coverage recorded on the ...

Bianca Barbaro · Julia M L Brotherton · Dorota M Gertig

Objective: To determine the incidence of and factors associated with vitamin D deficiency rickets in Australian children.Design: 18-month questionnaire-based prospective observational study, using Australian Paediatric Surveillance Unit (APSU) data.Setting: ...

on behalf of the APSU Vitamin D Study Group

Pain, and, in particular, chronic pain, is older than medicine itself, and a major reason why people see doctors. It is central to human experience, and pervasive in clinical practice. However, pain — and patients in pain — are not well understood or managed. Our lack of understanding of pain mechanisms ...

Annette Katelaris MB BS, MPH, FRACGP

Objectives: To document and describe outpatient persistent pain management services in Australia.Design, participants and setting: Systematic survey conducted between 1 December 2008 and 31 January 2010 of 57 services providing outpatient care to adult clients with persistent pain, plus five specialised paediatric services throughout Australia.Main outcome measures: Service structure, including funding processes; activity, including client numbers, access to specialised services (inpatient care, pain relief interventions); waiting times; and use of allied-health-professional-based pain management programs.Results: Of 68 services identified, 57 participated in the study. The median waiting time from referral receipt to initial clinical assessment for a publicly funded outpatient adult pain management service was 150 days, compared with 38.5 days for a privately funded service (P < 0.05). There was substantial variability among providers in range of services offered, including provision and duration of allied-health pain management programs. The level of service provision for children and rural patients is notably lower than that reported for urban adult constituents.Conclusions: Persistent pain management services are currently unable to meet service requirements adequately, and waiting times are more prolonged for publicly funded than privately funded services. Greater service provision is required in rural areas and for children.

Malcolm N Hogg MB BS, GrDip(PM), FFPANZCA · Stephen Gibson BBSc, PhD · Amal Helou BHlthSc(Nursing), MM(PM) · Jacklyn DeGabriele BHlthSc(Nursing), GrDip(Midwifery) · Michael J Farrell BAppSc(Phty), MSc(Gerontology), PhD

Incidence rates of cancer vary over time;1 this is called a “period effect”. Incidence rates of cancer also tend to increase with age;1 this is called an “age effect”. Another time variable that is associated with the incidence of cancer is year of birth of the patient — the “cohort effect”. Many authors have used real data to emphasise the importance of cohort effects for assessing trends in incidence.2,3 Here, I present a simple, hypothetical example to illustrate the cohort effect. Consider the data shown in the Box. In this hypothetical population, the age groups are 0–29, 30–59 and 60–89 years and everyone dies on their 90th birthday. The Box contains data for three years (1940, 1970 and 2000). For each year and age group, n denotes the size of the population, P denotes the probability of being diagnosed with cancer in the year, and EI denotes the expected incidence (the expected number of new cases of cancer), which is calculated with the formula: EI = n × P In 1940, in the 0–29-year age group, there were 600 people, the probability of being diagnosed with cancer was 0.01, and the EI was thus 600 × 0.01 = 6. In the whole population, 41 of 1000 people are expected to be diagnosed with cancer. In this scenario, a wonder drug that prevents cancer was discovered in 1941. However, it must be administered in utero, so only people born since 1941 can benefit. In 1970, assume there were 100 people aged 0–29 years. In this group, the probability of being diagnosed with cancer was 0, because they were born since 1941, and the EI was 0. The 600 people, who were aged 0–29 years in 1940, were aged 30–59 years in 1970; the probability of being diagnosed with cancer in that age group was 0.05, as in 1940; so the EI was 30. In the whole population, 90 of 1000 people are expected to be diagnosed with cancer in 1970. In 2000, only those aged 60–89 years were born before 1941. Overall, 120 of 1000 people are expected to be diagnosed with cancer. Thus, in 1940 there would be 41 new cases in a population of 1000, in 1970 there would be 90 new cases in a population of 1000, and in 2000 there would be 120 new cases in a population of 1000. This trend suggests that things will be worse in 2030. In fact, the disease will disappear in 2030. A hypothetical population that illustrates the cohort effect 1940 1970 2000 Age (years) n P EI n P EI n P EI 0–29 600 0.01 6 100 0 0 300 0 0 30–59 300 0.05 15 600 0.05 30 100 0 0 60–89 100 0.20 20 300 0.20 60 600 0.20 120 0–89 1000 41 1000 90 1000 120 In this scenario, n denotes the population size, P denotes the probability of being diagnosed with cancer in the year and EI denotes the expected incidence of cancer, and a drug that prevents cancer when administered in utero was discovered in 1941.

Terence M Mills

Objectives: To determine incidence and trends in antibiotic resistance in Australian Salmonella enterica subspecies enterica serovars Typhi (S. Typhi) and Paratyphi (S. Paratyphi) isolates over the past 26 years.Design: A retrospective analysis of consecutive microbiologically confirmed enteric fever isolates.Participants and setting: All S. Typhi and S. Paratyphi isolates from patients diagnosed with enteric fever in Australia between 1985 and 2010.Main outcome measures: Incidence and variation in antibiotic resistance over time and according to country of origin.Results: We analysed 2551 isolates, which originated from 74 countries or regions, mainly India (33%) and Indonesia (22%). The incidence among Australian residents increased from four to five before 2003 to seven cases per million person-years after 2003. Multidrug resistance (chloramphenicol, ampicillin, trimethoprim) and nalidixic acid resistance emerged rapidly from the early 1990s, with nalidixic acid resistance increasing to 70% in 2009–2010, while multidrug resistance was relatively stable at between 4% and 11%. Nalidixic acid and multidrug resistance rates are highest in isolates from the Indian subcontinent. Some countries in South-East Asia, such as Indonesia, had very low rates of resistance; however, this varied across the region.Conclusions: Nalidixic acid resistance has become widespread in enteric fever isolates from the Indian subcontinent and some parts of South-East Asia, justifying the use of ceftriaxone or azithromycin rather than ciprofloxacin as first-line treatment. However, resistance in some countries remains rare, potentially allowing treatment to be adjusted according to country of origin.

Robert J Commons MB BS, BMedSci, DipObsGyn · Emma McBryde MB BS, FRACP, PhD · Mary Valcanis BSc, MPH · Joan Powling BAgrSc · Alan Street MB BS, FRACP · Geoff Hogg BM, BS, FRACP

Objective: To estimate the number of cancers to be diagnosed in 2025 that could be prevented solely due to changes in diet and physical activity.Design and setting: We used an Australian population-based cancer database to estimate the total number of cancers to be diagnosed in 2025, by applying published age- and sex-specific population projections to current cancer incidence rates, and multiplying the projected numbers of cancers by estimates of population-attributable fractions.Main outcome measures: Projected number of preventable cancers that would be diagnosed in 2025.Results: Our projections suggest that there will be about 170 000 Australians diagnosed with cancer in 2025. This represents an increase of about 60% on the 2007 incidence. Almost 43 000 of these cancers (low estimate, 42 295; middle, 42 657; high, 43 990) could be prevented through improvements to diet and physical activity levels, including through their impact on obesity. It is likely that this is an underestimate of the true figure. The most preventable cancer types in 2025 were estimated to be bowel cancer and female breast cancer (10 049 and 7273 preventable cases, respectively).Conclusions: About 25% of cancers, or about 43 000 cancers in 2025, can potentially be prevented through improvements in diet and physical activity. It is imperative that governments, clinicians and researchers act now if we are to reduce the significant future human and financial burden of cancer.

Peter D Baade PhD · Xingqiong Meng PhD, MD · Craig Sinclair MPPM, BEd · Philippa Youl MPH

Viewing germs through biological and sociological lenses. In 1922, Simon Flexner, the director of the Rockefeller Institute in New York City, observed that “each generation receives its particular impression of epidemic diseases”. After the influenza pandemic of 1918, the postwar medical generation was trying to ...

Warwick H Anderson MD, PhD