Surgery

Objective: To describe the quality of postoperative documentation of vital signs and of medical and nursing review and to identify the patient and hospital factors associated with incomplete documentation.Design, setting and participants: Retrospective audit of medical records of 211 adult patients following major surgery in five Australian hospitals, August 2003 – July 2005.Main outcome measures: Proportion of patients with complete documentation of medical review (each day) and nursing review and vital signs (heart rate, blood pressure, respiratory rate, temperature and oxygen saturation) (each nursing shift), and the proportion of available opportunities for medical and nursing review where documentation was incomplete. Univariate and multivariate odds ratios for the association between incomplete documentation and hospital and patient factors.Results: During the first 3 postoperative ward days, 17% of medical records had complete documentation of vital signs and medical and nursing review. During the first 7 postoperative ward days, nursing review was undocumented for 5.6% of available shifts and medical review for 14.9% of available days. Respiratory rate was the most commonly undocumented observation (15.4% undocumented). Certain hospitals were significantly associated with incomplete documentation. Vital signs were more commonly undocumented in patients without epidural or patient-controlled (PC) analgesia, during evening nursing shifts, and during successive postoperative ward days. Nursing review was more commonly undocumented in the evening and for patients without epidural or PC analgesia. Medical review was more commonly undocumented on weekends.Conclusion: Hospital and patient factors are associated with incomplete documentation of clinical review and vital signs after major surgery.

Forbes McGain FANZCA, FJFICM · Michelle A Cretikos MB BS, PhD, MPH · Daryl Jones FRACP, FJFICM · Susan Van Dyk RN · Michael D Buist FRACP, FJFICM, MD · Helen Opdam FRACP, FJFICM · Vincent Pellegrino FRACP, FJFICM · Megan S Robertson FRACP, FANZCA, FJFICM · Rinaldo Bellomo MD, FRACP, FJFICM

To the Editor: The recent article on the review of the University of Sydney Medical Program (USydMP)1 by Goulston and Oates included a lengthy list of “changes made or planned in accordance with key recommendations”.2 Regrettably, and to the despair of many, the most needed change will not take place. It is reported in the review that the average age of future USydMP graduates will be 29–30 years, as it has been for the past decade.1 From 2008, those who aspire to be surgeons will competitively enter the new Surgical Education and Training (SET) program of the Royal Australasian College of Surgeons (RACS) after completing “at least their second postgraduate year”.3 The SET program is for 5–6 years, depending on the specialty. Most trainees subsequently take a subspecialty fellowship for 1–2 years, either in Australia or overseas, by which time our hapless graduates will be 40 years old. A woman may have to have leave of absence for a pregnancy. A postgraduate degree is now a prerequisite for an academic career and this involves an additional 2–3 years of full-time research. Finally, it takes in the order of 5 years to establish a referral specialist practice in most branches of medicine. In the review document, Goulston and Oates nihilistically state “There is no opportunity for streaming within the USydMP”.1 There is no mention of undergraduate education in Australia, let alone the streaming of such education, in the article from the RACS outlining the SET program.4 However, strangely enough, it is noted therein: “North American students must make their long-term career choice in the final year of their medical school and are streamed accordingly”. One wonders if there is any purposeful communication between the RACS and our universities. There certainly should be. It is imperative in this day and age that undergraduate and postgraduate medical education be considered as a continuum so that we can begin to rid ourselves of the absurdly long and manifestly inefficient process outlined above. The historian and journalist Paul Johnson put his astute finger on the problem in writing a column about universities generally: “. . . a visitor from another planet, unfamiliar with the history of the institution, would think it odd that our ablest boys and girls, at a time when their mental and physical powers are at their highest, are withdrawn from the service of society and kept in comparative idleness . . .”5 One can but conclude that, at least for future surgeons, the wrong people are at the helm at the RACS and at the University of Sydney’s Faculty of Medicine.

Thomas K F Taylor

In reply: Taylor raises several issues that the Royal Australasian College of Surgeons (RACS) has carefully considered. The new Surgical Education and Training (SET) program commenced this year.1 The acronym SET could equally mean Shorter Efficient Training. In the previous program, 2–5 years of basic surgical training was followed by 4–6 years of advanced training, resulting in surgeons entering specialist practice an average of 10 years after graduating with their medical degrees. We responded to societal and regulatory factors, including the older age of medical (compared with other) graduates, sex, work–life balance, safe-hours requirements, workforce pressures and competition from other specialties. Our new system aims to streamline training by early selection directly into one of nine surgical specialties and completion of training by Postgraduate Year 7 or 8 in most cases. It is not only shorter, but more comprehensive than previously. It is much more than an apprenticeship, where training occurs by random clinical exposure. We are covering defined curriculum objectives for every trainee by offering training in metropolitan and regional hospitals, synthetic laboratories and the private sector. We are moving away from reliance on the number of years of training and numbers of operations as measures of experience. We are focusing on the development of a range of surgical competencies encompassing professionalism, communication, collaboration, clinical decision making, scholarship, leadership and health advocacy, as well as essential medical and technical expertise. These competencies are regularly monitored by performance assessment throughout training. At the completion of training and the RACS fellowship examination, a surgeon is competent to commence practice as a specialist. Additional formal training experience is optional. Of course, the RACS promotes the concept of lifelong learning. The RACS and universities are communicating. Common concerns are the compromised state of basic science education and the limited exposure of medical students to a range of surgical specialties. The College has had discussions with many universities and health authorities about the possibility of “streaming” in the later years of medical school and in Postgraduate Years 1 and 2. It is worth noting that the University of Sydney has plans for the final 2 years of its course to be integrated, with increased emphasis on critical care and surgery.2

Ian R Gough

In reply: We are in sympathy with Taylor’s concerns about the length of medical training and point out that a more careful reading of our review of the University of Sydney Medical Program1 contained the following comments (on page 203): Discussion with the Royal Australasian College of Physicians canvassed the possibility that students might master some educational modules during their medical degree which would be credited by the College. This could well apply to other Colleges. Such a process would be more easily achieved if the Colleges moved to an overall “point system” i.e. students (especially in nonclinical areas such as Ethics, Quality and Safety etc) could study postgraduate modules pari passu with the USydMP, gaining some points towards their chosen college specialty qualification. This is followed by three recommendations on page 204: Students with an early interest in a specialty could gain some speciality experience or credit towards their specialty by either working towards an MPhil and by making use of the electives, options and Honours research project. The future situation with regard to medical training in some of the specialties is fluid eg, the Royal Australasian College of Surgeons is introducing a method of streaming for surgical training (SET) and IMET [Institute of Medical Education and Training] is looking at criteria for competency in the residency years. In view of this the Dean should explore further opportunities for streaming when the options for future specialty training become clearer. Early streaming should be re-examined by Faculty when the curriculum and educational changes being considered by some of the Colleges become clearer.

Kerry J Goulston · R Kim Oates

To the Editor: Gastric volvulus is rare but has been reported increasingly due to greater frequency of upper gastrointestinal tract investigations. Depending on the rotation axis, gastric volvulus can be classified as organoaxial, mesenteroaxial or mixed type. We report a case of laparoscopic mesh repair of a mesenteroaxial gastric volvulus secondary to a transverse colon diaphragmatic hernia. A 50-year-old woman presented with a 10-year history of intermittent epigastric pain and vomiting. Symptoms persisted despite multiple investigations over the years and treatment with proton-pump inhibitors and prokinetic agents. She described weight loss and intolerance to solid food, but her medical history was unremarkable. Gastroscopy revealed an unusual stomach configuration and difficulty was experienced in intubating the pylorus. A barium x-ray showed no gastric herniation, but the stomach had an unusual appearance (Box, A). Manometry studies showed normal gastric muscle activity. The patient underwent a laparoscopy, which revealed a mesenteroaxial intra-abdominal gastric volvulus secondary to the presence of a section of transverse colon caught in a diaphragmatic hernia adjacent to the oesophagus (Box, B). The colon was reduced and the hernia sac excised (Box, C). The defect in the diaphragm was subsequently closed, and a dual-layered prosthetic mesh was laid over the repaired area. The stomach was repositioned by anterior gastropexy. The patient’s recovery was uneventful and she was discharged on a fluid diet 3 days after surgery. At 4-month review, she was well and a follow-up abdominal computed tomography scan showed no abnormalities. Reports of isolated colonic hiatal hernia are rare.1,2 This case was interesting as it was associated with an intra-abdominal gastric volvulus that presented with chronic symptoms, despite most cases of mesenteroaxial volvulus presenting acutely. Barium studies from 19 patients with colonic herniation through the oesophageal hiatus showed that these hernias were invariably associated with herniation of the stomach, which was partially volvulated in many cases.3 These patients were mostly older women, and did not present in an emergency setting. With growing use of laparoscopic surgery, patients benefit from a minimally invasive approach, decreased pulmonary and wound complications, and faster postoperative recovery. Several authors have reported favourable outcomes after performing laparoscopic diaphragmatic hernia repairs and gastropexy.2,4,5 Our case demonstrates the feasibility of laparoscopic repair of a gastric volvulus secondary to a transverse colon diaphragmatic hernia. Diagnosis and repair of a gastric volvulus A: Barium x-ray of stomach, showing two air–fluid levels that give the impression of an “upside-down” stomach of mesenteroaxial rotation; pylorus (P) and diaphragm (D) are shown. B: Herniated transverse colon (TC) tracking under the liver (L) and into a hernia of the diaphragm. C: Diaphragmatic sac adjacent to the oesophagus, revealed by reducing the colon; oesophagus (O) and stomach (S) are shown.

Kevin Ooi · Christophe Berney

To the Editor: In his article on medical specialist education and training in Australia, Phelan1 raises two major issues: financial and educational. On the financial front, Phelan asks about the advantages and disadvantages of the new funding model for specialist (pre-Fellowship) training. One of the advantages of the model is that it makes the funding process more explicit. We believe that all who benefit from this educational exercise — trainees, supervisors, private hospitals and society — should contribute financially in some way. On the educational front, Phelan is disappointed that we did not provide evidence that university education will enhance the educational experience of trainees. However, undertaking educational studies that meet the standards required of reductionist experiments has proven to be difficult, and we have to make do with a more ecological approach. We have no doubt that our Macquarie University scholars will derive lasting benefit from working in an environment in which learning is one of the primary goals of their existence, rather than an add-on, after-hours, activity. Learning arises not from watching, but from doing. Modern concepts of neurobiology and learning suggest that learning results in structural changes in the brain, and these will be enhanced for the learner by full participation in all processes of care. We shall ensure that learning is maximised by an appropriate balance between scholars’ clinical experience and the educational opportunities that their clinical experience will provide. The Canadian contracting model, which Phelan mentions, is not dissimilar to the arrangement that will flow from the Memorandum of Understanding between Macquarie University and the Royal Australasian College of Surgeons and the Neurosurgical Society of Australasia, in that College trainees will substitute experience at Macquarie University for time spent in public hospitals in the College’s Surgical Education and Training Program. In Australia, we do not share the Canadians’ advantage of having only two postgraduate colleges. Given the current fragmented state of postgraduate medical education in Australia, we believe that it is better to experiment with and to evaluate new models than slavishly to copy what appears to work in a different setting. One of the flavours of the decade is competition, and we believe that competing models should be set up and should be rigorously evaluated from both educational and financial viewpoints. If history shows that the Macquarie lighthouse has illuminated the way to improved health for the Australian people, we shall be well satisfied.

Rufus M Clarke · Michael K Morgan

Failure to atone. The true story of a jungle surgeon in Vietnam. Allen Hassan. Sacramento: Failure to Atone Press, 2006 (272 pp). ISBN 978 0 9776049 0 6. Dr Hassan’s background is remarkable. He was a United States Marine Sergeant who qualified in veterinary medicine before becoming a doctor and serving two terms as a civilian in Vietnam, later completing a degree in law. From this unique perspective he presents disturbing insights and images of the Vietnam War. His clinical volunteer work was in the battered province of Quang Tri in mid 1968, and the experience completely altered Hassan’s life. The core of the book is a harrowing episode — the massacre of 40 infants, all shot in the head, apparently by his own Marine Corps — and his efforts to get to the truth behind this tragedy. Several of the 774 doctors despatched by the American Medical Association’s Volunteer Physicians for Vietnam have contributed stories from their own tours of duty. Also acknowledged is the work of civilian teams from other countries, including Australia and New Zealand, and there is praise for the US medical corpsmen who, of necessity, undertook major clinical responsibilities. Surgical triumphs and disasters, atrocities on both sides and the despair of embittered servicemen are all recounted, but it is the bigger picture that haunts Hassan’s conscience: the courage and dignity of the Vietnamese people; the death and destruction wrought by futile bombardment of innocent civilians; the failure of aid programs to concentrate more on preventive medicine, public health and training; and guilt that his country is making the same mistakes in Iraq. The book is well bound, with an arresting full-colour dust jacket. Within, unfortunately, the photographs are mediocre and the text poorly edited, uneven and repetitious. Nevertheless, it should be read, not least for such accounts as the mutilated soldiers kept in Vietnam to avoid lowering morale back home, and sinister activities by the CIA. Scarcely believable, but sadly convincing.

Marshall Barr

To the Editor: The recent editorial by Waxman1 implies that early streaming of students during medical school training is to become the norm for admission to the Royal Australasian College of Surgeons’ Surgical Education and Training (SET) program. We would like to draw attention to the disturbing nature of this development for medical students and junior doctors alike. Waxman described the imperative for students to now decide upon a career in surgery “usually as undergraduate medical students”.1 He stated that some universities have proposed early streaming of students into specific surgical modules in later years of their medical programs. While early streaming may appear to be the answer to the growing conflict between the time constraints of undergraduate medical programs and the expanding body of medical knowledge, there are a number of significant pitfalls to this approach that are yet to be explored. First, early streaming may jeopardise the quality of the generalist education offered at medical schools. International experience from McGill University in Canada, which implemented an early-streaming program in the late 1970s, supports this notion.2 The cohorts from McGill’s early-streaming program had poorer overall performance than their predecessors in the non-streamed program on the Medical Council of Canada’s national licensing examination, which was attributed in part to their reduced opportunity for generalist training. Second, the notion that well resourced university surgical departments could provide an early-streaming package for undergraduate students that “[gives] their students an advantage and an almost guaranteed pathway into SET”1 creates gross inequity in access to surgical training. This system would disproportionately disadvantage students from both graduate-entry programs, which have a shorter course duration, and newer universities, which lack the resources to provide advanced surgical training modules. Third, the program disadvantages students who have not formed firm career intentions by the later years of their medical program. With data from the United Kingdom showing that more than a quarter of junior doctors change their career intentions in the 3 years after graduation,3,4 a significant proportion of medical graduates will gain no appreciable benefit from early streaming, and may in fact be disadvantaged by it. We strongly discourage the introduction of early-streaming programs in medical schools. All schools should graduate “pluripotent” undifferentiated doctors with a strong generalist background.

Timothy J Smith · Carly M Fox · Michael A Bonning

To the Editor: The editorial by Waxman1 on the Royal Australasian College of Surgeons’ new Surgical Education and Training (SET) program contains some factual errors that have led to anxiety among potential applicants. We wish to give the formal position of the College and to correct any misunderstandings. The SET program2 is evolutionary, builds on the strengths of the previously available program, and is based on an educationally sound framework and group of principles. Registering an interest in training with the College does not in itself confer an advantage but will enable those registered to receive up-to-date information and College publications. The College website also provides up-to-date, relevant information for potential applicants. Completion of the Australian and New Zealand Surgical Skills Education and Training (ASSET) course is not compulsory before selection into SET, but it must be completed by the end of the first 2 years of the SET program. The College and the specialist surgical associations and societies involved in the delivery of the SET program will rely on robust workplace-based assessment to monitor trainees’ progress and provide career advice. New in-training assessment tools are necessary to achieve this, and their implementation requires support, including courses for surgeons who undertake this vital work. Those contemplating a career in surgery will not have to decide on their career choices at an earlier stage than previously. In the previous program, graduates could apply during their internship but now must wait until their second year after graduation. The College is committed to a broad-based period of preparation for surgical training but does not wish to deny the opportunity to those in their second year after graduation who are certain of their career aspirations. Applications will also be accepted from those who delay their career decisions for whatever reason. Streaming medical students for vocational careers is an attractive educational philosophy, provided it does not interfere with the generalist experience required for all graduates. Furthermore, streaming is predicated on the medical colleges recognising this prior learning in their programs. Until this is resolved, the question of its implementation remains some way off. The current practice of undertaking electives in an area of interest is strongly supported. The College is committed to working with the universities for a more integrated approach across the continuum of learning and seeks to build on the meaningful and collaborative partnerships already established. The key interface is the practising surgeon in an academic position who understands the requirements of the College and the university, as well as the needs of the community. Selection into surgical training is through a national merit-based process. The curriculum vitae (CV) and its components of academic achievement, other accomplishments and clinical experience will each be scored and given appropriate weighting. The lower percentage overall for CVs (15%–25%) takes into account that many candidates will apply very early in their careers.2 While we laud the suggestion of university surgery departments providing a package for potential trainees, “giving their students an advantage and an almost guaranteed pathway into SET”1 does not necessarily follow, given the competitive nature of selection.

John P Collins · Ian D Civil

Donough O’Brien was born on 24 June 1911 in Dublin, Ireland. He was brought up on the family’s country estate in County Limerick and later won scholarships to Bromsgrove School in England and to Trinity College Dublin, where he began a medical course in 1929. He graduated top of his year, with first class honours, in 1934. In 1939, he gained Fellowship of the Royal College of Surgeons (Ireland) and was awarded the Surgical Travelling Prize. At the outbreak of war in the same year, he joined the British Army and spent 7 years as a surgeon in Scotland, Iraq, Egypt, Malta and Sicily. Early in the war, as a Duty Officer at Drymen in Scotland, he admitted and treated a “Captain Horn” for an injured ankle. It quickly transpired that the “captain”, who had flown a plane from Germany and landed in Glasgow, was in fact Rudolf Hess, who had come to the United Kingdom to try to negotiate a peace settlement with Winston Churchill. Donough had married his first wife Pamela in 1941, and his daughter Caroline was born in 1943, but the marriage did not survive his years away on active service. After the war, he undertook postgraduate study in orthopaedics, then spent 2 years in Tanganyika. He later married Lucy Stafford, and in 1951 they emigrated to Scottsdale in Tasmania, where he worked as Superintendent at the Soldiers’ Memorial Hospital. A few years later, with their two sons Bart and Ken, they moved to Burnie, where he worked as Superintendent at the North Western General Hospital. For some years, as the only surgeon on the north-west coast, he was constantly “on call”, but, as the staff and work at the hospital gradually expanded, he had more opportunity to develop his wide range of non-medical skills and interests. Donough and Lucy were allotted a derelict house belonging to the hospital, with an overgrown garden on a steep hillside. Together they restored the garden, which became a place of beauty and solace. As active members of the Burnie Arts Council and the Coastal Arts Group, they shared their garden with writers, artists and actors, and were constant and delightful hosts to their wide circle of devoted friends. Both he and Lucy were artists themselves, Lucy also being a poet. Donough was a skilled sailor, giving much time to the Burnie Yacht Club. There would always be a boat or two under repair in his shed. His passion for sailing was shared with his son Ken, who is now a sailmaker in Adelaide. Retiring from the hospital in Burnie at the age of 65, Donough practised rehabilitation medicine for a further 10 years. In 1976, he was awarded Membership of the General Division of the Order of Australia for services to the community. He and his wife later moved to Adelaide to be near their family, after Lucy had undergone a series of unsuccessful operations for a hip condition. Lucy died in 2005, and Donough died two years later, on 2 August 2007, of heart failure. He is survived by his three children. Donough will be remembered as a fine surgeon, an accomplished artist, writer, sportsman, a loving husband and father, and an inspiration to all whose lives were enriched by his skills and by the warmth of his care and friendship.

Mary L Kille

The new Australian surgical training program starts in 2008 The Council of the Royal Australasian College of Surgeons (RACS), with the support of the nine specialty boards and related specialist societies, has approved the new Surgical Education and Training (SET) program, to commence in 2008.1 The RACS has responded to drivers of change in medical education, the bottleneck of basic surgical trainees and a wish to move to a competency-based training program. There will be a single point of selection into one of the nine specialties for medical graduates who have completed at least their second postgraduate year. The training program will be 5 to 6 years, the duration depending on the specialty. The years of training will be called SET 1 to SET 6, with the Fellowship examination remaining the final exit assessment. Selection tools for all specialties include three components: a scored curriculum vitae, reports from mentors and referees, and a semistructured objective interview. The first round of selection was successfully completed in August 2007, with 1538 applications from 1000 applicants over the nine specialties. Applicants could nominate more than one specialty. Most reached the interview stage, and 472 offers were made (198 for SET 1 and 274 for SET 2); 80% of the positions were offered to current basic surgical trainees.2 Medical graduates and students can indicate their interest in surgical training by registering with the RACS in PreSET, an unstructured phase leading to selection into SET. Completion of the Australian and New Zealand Surgical Skills Education and Training (ASSET) course during PreSET will be compulsory. This course provides an educational package of required generic surgical skills.3 During the SET years, assessment will be largely formative and competency-based. It will test the RACS’s nine core competencies and will rely heavily on in-training assessment tools such as Mini-CEX (mini clinical examination) and DOPS (direct observation of procedural skills), with a structured performance management process, overseen by supervisors and trainers, who will have completed a prescribed course on assessment and management of trainees (SAT SET).4 A summative assessment involving a multiple-choice examination and an objective structured clinical examination will have to be completed in SET 1 or 2 before a trainee progresses. In addition, by the end of SET 2, trainees will need to have completed the skills courses: Care of the Critically Ill Surgical Patient (CCrISP), Early Management of Severe Trauma (EMST) and Critical Literature Evaluation and Research (CLEAR). Potential trainees contemplating a career in surgery will have to decide at a much earlier stage, usually as undergraduate medical students. To attract the brightest students, academic surgical departments will need to be innovative and raise the profile of surgery in the curriculum, a task that has proved difficult in the past. Some universities have met this challenge by proposing streaming students into programs with specific surgical modules in the later years of the course. Relationships with academic surgeons and universitiesFor the implementation of SET, the College is considering establishing its own university, and is evaluating other models, one of which is to form closer relationships with existing university surgery departments in curriculum development and infrastructure support and administration. Macquarie University has established a Master of Advanced Surgery program in neurosurgery and is negotiating with the RACS and the Neurosurgical Society of Australasia.5 Other ways that academic surgical departments can form closer relationships with the RACS is in the conduct of the courses, such as ASSET and SAT SET, by providing the venue, organisation, instructors and facilitators, with the added advantage of ease of access for trainees, supervisors and trainers in that institution. University surgical departments could consider providing a package for potential trainees from the undergraduate years through PreSET to selection into SET, giving their students an advantage and an almost guaranteed pathway into SET. The core business of academic surgical departments is research. SET provides a catalyst for undergraduates, graduates and trainees considering research projects, graduate diplomas and higher degrees. Because research and publications rate highly in scoring for SET selection, and the new policies and regulations require research as part of SET, clinical and laboratory-based research projects will be keenly sought after, and many will wish to undertake a Bachelor of Medical Science or higher degrees such as a Master of Surgery, Doctor of Medicine or the combined Fellowship (FRACS)–PhD program. Surgical departments in New Zealand have established a Master of Medical Science diploma, with 50% undertaken by dissertation and 50% by publication combined with research forums and surgical research networks.6 Training for academic surgeryThese initiatives by academic departments also provide trainees with the motivation to consider a career in academic surgery. Closer relationships among universities, the RACS and hospitals can also create the potential for young surgeons with an interest in an academic career to have infrastructure support, such as an administrative assistant or receptionist; acceptance into an existing clinical craft-group practice; operating theatre access; and an appropriate academic title. It is not surprising that when the Association of Surgeons of Great Britain and Ireland and the Society of Academic and Research Surgery met in a consensus conference in September 2005, the focus was on surgical training as the greatest opportunity for preparing young surgeons for an academic career.7 The private sector provides another opportunity. The Commonwealth Government has allocated significant funding and has established the Enhanced Medical Education Advisory Committee to explore opportunities for surgical training in the private sector, including surgical departments in private hospitals with university affiliation. SET is ready. Will academic surgeons and universities see this as an opportunity to go forward? Will they develop innovative programs for undergraduates, sponsor RACS courses, provide SET preparation packages, develop attractive research programs, form closer relationships with RACS and hospitals (public and private) to implement SET and serendipitously promote academic surgery as a career?

Bruce P Waxman FRACS, FACS, MRACMA

To the Editor: A recent MJA Supplement discusses prognostic and end-of-life communication for health professionals on the basis of a systematic literature review and an expert advisory panel.1 It is usually the case that malignant disease is diagnosed after biopsy, and this is usually undertaken by a surgeon. In a consecutive series of 100 patients presenting with a lesion in a bone with no past history of malignancy, the lesion was the presenting feature of systemic malignancy in 44 of those patients.2 Hence, it is usually the surgeon’s role to advise the patient (and caregivers) that the patient has a terminal disease and, in some cases, the prognosis can only be measured in weeks. It will be obvious that this can be a significant shock to all, particularly when there was no prior indication that malignancy was a possibility. I note that not one of the 35 experts was a surgeon. I also note that surgery as palliation is given virtually no role other than a brief mention in Box 11, despite the well documented role of surgery.3 It has been my experience that the most common question asked by patients with the diagnosis of a terminal malignancy is about the role of surgery; the question “Why can’t you just cut it out?” is a universal feature. This has not been addressed. It is my sincere hope that further expert advisory panels addressing this area become truly multidisciplinary and include perhaps the most relevant discipline — surgery.

Mark T Clayer

In reply: We agree that the content area of these guidelines is very relevant for surgeons, as for all health professionals involved in the care of adult patients with advanced life-limiting illnesses and their caregivers. Surgical representation on our expert panel would have been very useful. We agree that surgery has an important role in terms of palliative treatment options that may be available for certain clinical circumstances. The issue of how to respond to the question “Why can’t you just cut it out?” is an important one. We believe that the principles outlined in these guidelines would be relevant when responding to this question, but would welcome specific suggestions from Clayer and other surgeons about how they respond to such patients. We would hope to include these suggestions along with other input from surgeons in any future update of these guidelines.

Josephine M Clayton · Karen M Hancock · Phyllis N Butow · Martin H N Tattersall · David C Currow

An 80-year-old woman presented with abdominal pain, nausea and diarrhoea. She had undergone a laparoscopic cholecystectomy 10 years previously. The surgery was complicated by an umbilical hernia at the umbilical port site, which was repaired surgically 5 years later. The patient reported intermittent drainage of clear fluid from the umbilicus after the hernia repair. She had right lower quadrant tenderness without guarding or a palpable mass. Laboratory investigations showed a serum lipase concentration of 393 U/L (reference range, 114–286 U/L) with normal white blood cell count. Abdominal computed tomography revealed a 2.8 × 2.4 cm mass in the right lower quadrant, with a calcific rim and foci of calcium within the lesion (Figure, A). The mass appeared to be outside the small bowel, suggesting a mucocele or mucoid tumour. Laparoscopy revealed a 2.5 cm solid mass containing a gallstone (Figure, B and C). The drainage from the umbilicus continued after surgery and was apparently unrelated to the spilled gallstone. Gallstone spillage is more common during laparoscopic than open cholecystectomy. It occurs in 5%–40% of laparoscopic cholecystectomies, but complications are very rare,1 with a reported incidence of 0.08%–0.3% of cases.2 The reason that only a fraction of patients develop complications is uncertain.1 Figure A: Computed tomography scan of the abdomen showing a 2.8 × 2.4 cm mass (arrow) external to the small bowel. B, C: The gallstone recovered during exploratory laparoscopy.

Edgard Wehbe · Reggie J Voboril · Elisha J Brumfield

Objective: To describe the results of lung transplantation (LTx) in adolescents at a hospital for adults.Design and setting: Prospective cohort study set in an LTx unit at an adult tertiary referral hospital from 1991 to 2006.Patients: 37 consecutive adolescent lung transplant recipients including 13 males and 24 females (mean age, 16.7 ± 2.0 [SD] years; range 12–19 years) who received heart–lung (six patients) or bilateral LTx (31 patients) for cystic fibrosis (29), congenital heart disease (four), acute respiratory failure (two), or another disorder (two). Two patients were transplanted after invasive ventilation, five after non-invasive ventilation and two after extracorporeal membrane oxygenation.Main outcome measures: Overall survival compared with an adult cohort; survival free of bronchiolitis obliterans syndrome (BOS); overall and BOS-free survival in those transplanted before and after January 2000.Results: Mean waiting time was 273 days (range, 5–964 days; median, 163 days), mean donor age was 28 years (range, 9–53 years). Median inpatient stay was 11 days (range, 7–94 days). Mean follow-up was 1540 ± 1357 days (range, 35–5163 days). The 5-year survival rate for the 16 patients transplanted before January 2000 was 38%, versus 74% for the 21 transplanted since January 2000 (P = 0.05; Mantel–Cox). Overall, 18 of 35 evaluable patients developed BOS. Only BOS was associated with an increased mortality risk (P < 0.01).Conclusion: LTx may be performed successfully in adolescents at a hospital for adults.

Judith M Morton MB BS, FRACP · Monique A Malouf MB BS, FRACP · Marshall L Plit MB, FRACP, PhD · Phillip M Spratt MB BS, FRACS · Allan R Glanville MB BS, FRACP, MD

Until recently, liver transplantation was contraindicated in Jehovah’s Witness patients because of recipient-imposed restrictions on use of blood products. However, recent improvements in surgical and anaesthetic techniques and new procoagulant agents challenge this practice. We describe two Jehovah’s Witness patients who had successful liver transplantation without blood transfusion. To our knowledge, these are the first such cases in Australasia. The techniques used to minimise blood loss and transfusion requirements could potentially benefit all patients undergoing major surgery. Clinical recordsPatient 1A 48-year-old farmer with end-stage cirrhosis due to α-1 antitrypsin deficiency had evidence of moderate portal hypertension with splenomegaly and ascites (Child–Pugh score B), but no significant lung disease. He met minimum recipient suitability criteria for liver transplantation, according to the Transplantation Society of Australia and New Zealand (TSANZ) liver standing committee.1 As a Jehovah’s Witness, he would not accept transfusion of red blood cells, fresh frozen plasma or platelets. However, he indicated that he would accept blood fractions and recirculated autologous blood and cell-saved blood. A relative, also a Jehovah’s Witness with similar restrictions on use of blood products, offered to be a live liver donor, but this offer was rejected by the treating team on the basis of unacceptable donor risk. The patient was placed on the transplantation waiting list, and was treated with erythropoietin. Over 6 months, this increased the haemoglobin concentration from 112 g/L to 151 g/L (reference range [RR], 135–180 g/L). Results of other preoperative blood tests included: platelet count, 74 × 109/L (RR, 150–400 × 109/L); international normalised ratio (INR), 1.2 (RR, 0.9–1.3); serum concentration of bilirubin, 60 μmol/L (RR, < 20 μmol/L); albumin, 26 g/L (RR, 35–50 g/L); alanine aminotransferase (ALT), 102 U/L (RR, < 40 U/L); and creatinine, 143 μmol/L (60–110 μmol/L). Liver transplantation was performed using an organ from a 54-year-old deceased donor. The piggyback implantation technique, without venovenous bypass, was used. Coagulation was monitored intraoperatively using routine coagulation tests and thromboelastography (Haemoscope, Skopie, Ill, USA). The latter technique measures the kinetics and tensile strength of clot formation. Prophylactic aprotinin was administered as a bolus followed by a constant infusion. The patient also received cryoprecipitate, albumin, haemodilution, and autotransfusion of cell-saved and recirculated blood. On arrival in the intensive care unit, haemoglobin concentration was 118 g/L. The patient received recombinant factor VIIa to treat an INR of 3.4, and erythropoietin was continued. There was significant primary graft dysfunction, and ascites was slow to resolve. Three months after transplantation, the patient developed a pulmonary embolism and required anticoagulation. Currently, at 4 years after transplantation, the patient is well and works full time. Patient 2A 43-year-old woman with chronic hepatitis B infection was found to have an unresectable multifocal hepatocellular carcinoma at laparotomy. She had well compensated cirrhosis (Child–Pugh score A) with no evidence of portal hypertension, and met listing criteria for transplantation. A Jehovah’s Witness, she would not accept transfusion of red blood cells, fresh frozen plasma or platelets, but determined that she would accept blood fractions and recirculated autologous blood and cell-saved blood. Pretransplant laboratory results were: haemoglobin concentration, 129 g/L; platelets, 203 × 109/L; INR, 0.9; bilirubin, 7 μmol/L; albumin, 38 g/L; ALT, 58 U/L; and creatinine, 70 μmol/L. Liver transplantation was performed using an organ from a 42-year-old deceased donor. An inferior vena cava interposition technique was used without venovenous bypass because of the proximity of the tumour to this vessel. The central venous pressure was maintained below 5 cmH2O to minimise blood loss. The patient received cryoprecipitate, haemodilution, autotransfusion, and cell-saved and recirculated blood. Unfortunately, she had an allergic reaction to the colloidal plasma-volume substitute, gelofusine; coagulation studies and thromboelastography showed fibrinolysis, which was treated with aprotinin and recombinant factor VIIa. On arrival in the intensive care unit, haemoglobin concentration was 75 g/L, and INR was 1.3. Erythropoietin and iron supplements were started. Postoperative recovery was uncomplicated, and the patient remains well 3 years after the operation. DiscussionTo our knowledge, these are the first reported cases of liver transplantation in Jehovah’s Witness patients in Australasia. While the two patients filled accepted criteria for recipient suitability for liver transplantation,1 the likely need for blood transfusion would until recently have precluded this procedure. Liver transplantation is a well established and successful intervention for liver failure that results in long-term survival (70% at 10 years) in individuals who otherwise have minimal 1-year survival.2 The shortage of deceased donor livers remains the major factor limiting the number of liver transplantation operations in Australia and New Zealand. In 2000, the death rate while waiting for a donor liver in Australia and New Zealand was 40% for acute liver failure and 5%–8% for chronic liver disease.3 This donor shortfall creates an ethical dilemma in which the potential benefit to individual patients has to be balanced against the need to maximise the benefits of this scarce resource. Following a well publicised case in Edinburgh of a death due to acute liver failure, a recommendation was made for a colloquium to address the question of patient selection for liver transplantation and the need for a uniform code of practice in the United Kingdom. The colloquium, held in 1999, recommended that liver transplantation should be performed in patients when their expected survival is less than 12 months and the expected post-transplant survival is over 50% at 5 years.4 These recommendations have been incorporated into the minimum recipient listing criteria used by the TSANZ liver standing committee,1 and were met by both the reported patients. Over the past decade, improvements in surgical and anaesthetic techniques, combined with new procoagulant agents, have resulted in a dramatic reduction in the requirement for transfusion of blood and blood products during liver transplantation. In selected patients, the need for blood transfusions can be avoided completely.5,6 These advances have resulted in reassessment of the use of liver transplantation in Jehovah’s Witness patients. The first-ever reported liver transplantation in a Jehovah’s Witness patient was in 1994.7 Since then, transplantation has been successfully performed in selected individuals for acute and chronic liver failure without the need for blood products.8,9 Outcomes of liver transplantation in adult Jehovah’s Witness patients have been reported as 92% survival with a mean follow-up of 2.2 years (range, 0.3–5.6 years).10 Live-donor liver transplantation using Jehovah’s Witness donor/recipient pairs has more recently been reported.10 However, the risk to the potential live donor in the case of our first patient through refusing blood products, added to the known 0.5% mortality associated with donation of the right lobe of the liver, was thought to be excessive, and this option was rejected.11 As always, careful selection of the recipient is required. Two other Jehovah’s Witness patients referred to us for liver transplant assessment rejected, or were rejected for, transplantation: one, after lengthy consideration, refused to accept a donor liver; while the other had multiple hepatocellular cancer tumours which fell outside the minimal listing criteria. By way of comparison, in a previously reported series, only nine of 29 Jehovah’s Witness patients were found to be suitable for liver transplantation.9 The Jehovah’s Witness church teaches that blood transfusion (whole blood, red blood cells, white blood cells, platelets and plasma) should not be accepted, but individuals themselves are to decide whether to accept organ transplantation and blood fractions. Both our patients accepted the use of cryoprecipitate, albumin, recombinant factor VIIa, recirculated autologous blood and cell-saved blood, and signed a preoperative agreement to this effect. Consent to the use of these factors and techniques were minimum listing criteria required by the treating teams to proceed with liver transplantation. In selected Jehovah’s Witness patients with hypersplenism (not present in our patients), the use of partial splenic artery embolism increased platelet count, allowing transplantation to proceed.9,10 Transjugular intrahepatic portosystemic shunt formation has been less successful in reversing hypersplenism, and should not be used for this indication.12 Jehovah’s Witness patients with severe decompensated liver disease and coagulopathy (Child–Pugh score C), severe portal hypertension and renal failure are at high risk for perioperative mortality and should not receive liver transplantation. Preoperative use of erythropoietin to increase haemoglobin levels has a number of potential benefits. The most obvious is that the patient begins the procedure with a higher blood haemoglobin level. This also enables use of haemodilution to minimise red cell loss during the explant procedure, and autotransfusion to raise the haematocrit after haemostasis is secure. Maintaining a low central venous pressure also decreases blood transfusion requirements during liver transplantation.13 Although recombinant factor VIIa is expensive (average $6000 per patient), it reduces coagulopathy and transfusion requirements.14 Overall, use of these blood conservation techniques may result in a cost benefit, compared with use of large volumes of blood product.7,10 Successful liver transplantation is possible in selected Jehovah’s Witness patients, but early referral before the development of severe, decompensated liver disease is mandatory. Also, we believe that techniques that minimise blood loss and transfusion requirements for liver transplantation should be more widely practised to benefit all those undergoing major surgery.

Gary P Jeffrey FRACP, MD, MRCP · John McCall FRACS · Edward Gane MD, FRACP · Andrew W Mitchell FRACS · Neville M Gibbs MD, FANZCA · Vanessa Beavis FANZCA · Kerry Gunn FANZCA · Stephen Munn FRACS · Anthony K House MS, FRACS

Clinical record A 44-year-old man underwent coronary artery bypass surgery in 2004. He had been in satisfactory health as an adult apart from hypertension, for which he was receiving treatment. He ate a normal diet, including dairy products, meat and other high protein food. At age 44 years, he developed acute central chest pain while exercising at a gymnasium. An angiogram showed coronary artery occlusions. Forty-eight hours after successful coronary artery bypass surgery, during which time he received intravenous sodium but not glucose, he felt unwell, and the following day he became delirious. Computed tomography of the brain, initially reported as appearing normal, was later thought to show cerebral oedema. Plasma ammonium level was 110 μmol/L (reference range [RR], 10–50 μmol/L), but the timing of this sample was unclear. Wilson’s disease was initially considered because of elevated liver enzyme levels, but serum copper and ceruloplasmin levels were not measured. Eight days after the bypass surgery, a urine sample was sent to the NSW Biochemical Genetics Service, for metabolic screening. This showed gross elevations in glutamine and orotic acid (orotic acid, 14.8 μmol/mmol creatinine; RR, 1.23 μmol/mmol creatinine), indicating a likely diagnosis of ornithine transcarbamylase (OTC) deficiency. Plasma glutamine level was 3527 μmol/L (RR, 385–862 μmol/L). Plasma tyrosine and methionine levels were also moderately elevated, which was consistent with liver dysfunction. Plasma citrulline level was mildly elevated at 57 μmol/L (RR, 10–45 μmol/L), but this finding was difficult to interpret in the light of the other elevated amino acid levels. (Citrulline level is very low in neonatal OTC deficiency, but not necessarily low in late-onset phenotypes.) The patient was by then gravely ill, requiring maximum life support, and under consideration for liver transplantation. His condition progressively deteriorated despite introduction of intravenous sodium benzoate and l-arginine, and life support was withdrawn. He died 8 days after surgery. The diagnosis of OTC deficiency was subsequently confirmed by mutation analysis which showed hemizygosity for the c.622G>A (p. A208T) mutation in exon 6 of the OTC gene (as males have only one X chromosome, they are said to be hemizygous with respect to X-linked genes). Cascade testing of family members (Figure) showed that the patient’s mother (person II-2) was a carrier, heterozygous for the c.622G>A (p. A208T) mutation, while his asymptomatic brother (III-2) was hemizygous for the same mutation. Random biochemical testing of the brother showed normal levels of plasma glutamine, citrulline, arginine and urinary orotic acid. No information was available on causes of death of first-generation relatives. Past history revealed that, at age 7 years, the patient had an episode of acute encephalopathy following a 2-month history of intermittent nausea, vomiting and frontal headache. There was no preceding febrile illness, intercurrent infection or history of trauma. The symptoms reappeared after a 2-week period of apparent recovery. On admission to hospital, he was drowsy, disorientated and restless, but quickly settled and made a satisfactory recovery. No haematological or biochemical results were evident in his medical records. He was discharged with a diagnosis of viral meningitis/encephalitis. We report a 44-year-old man who presented with fatal hyperammonaemia after coronary artery bypass surgery. He had previously been asymptomatic, apart from a possible episode of unrecognised hyperammonaemia in childhood. The diagnosis of ornithine transcarbamylase (OTC) deficiency was made too late for successful intervention. Inborn errors of metabolism are frequently unrecognised or diagnosed late in adults. OTC deficiency is the most common disorder affecting the urea cycle. In New South Wales, the incidence is of the order of one in 70 000 births.1 It is an X-linked disorder leading to potentially lethal hyperammonaemia. The clinical severity ranges from acute neonatal hyperammonaemic coma to symptom onset at any time from infancy to adulthood, depending on environmental triggers and residual enzyme activity.2 The timing of episodes in late-onset OTC is dictated by environmental factors that increase nitrogen turnover, including dramatic increase in protein intake, medications affecting protein catabolism, viral illness or other generalised stress, rapid weight loss, and poor nutritional intake.3 Lessons from practice Inborn errors of metabolism are frequently unrecognised or diagnosed late in adults. Postoperative catabolism with insufficient calorie intake may unmask previously asymptomatic, but potentially lethal, inborn metabolic errors. Patients with acute onset of unexplained neurological or psychiatric symptoms need urgent metabolic investigation, including measurement of plasma ammonia level, to exclude metabolic causes. The first step in ureagenesis is the production of carbamyl phosphate from ammonium and bicarbonate. OTC then catalyses the biosynthesis of citrulline from ornithine and carbamyl phosphate. Thus, a deficiency of OTC leads to accumulation of ammonia and glutamine (the major extrahepatic source of ammonia for ureagenesis), and a reduction in citrulline. The accumulating carbamyl phosphate enters the pyrimidine synthetic pathway, resulting in increased excretion of orotic acid. The missense mutation p. A208T, replacing alanine with threonine at codon 208 of exon 6 in the OTC gene, has been previously reported in a late-onset OTC patient we investigated,4 and in others.5-7 This group showed an extremely wide phenotype, ranging from encephalopathy at age 4 months7 to no symptoms at age 97 years.5 Our patient developed hyperammonaemia following postoperative catabolism, caused by surgical stress and fasting with inadequate calorie supply from intravenous fluids pre- and postoperatively. In addition, a high nitrogen load from bleeding sites, tissue trauma or tissue protein breakdown could have overwhelmed urea synthesis and promoted the excessive ammonia production. OTC deficiency is not the only inborn error of metabolism that can result in fatal postoperative decompensation. Another example is medium-chain acyl-CoA dehydrogenase deficiency, which appears more prevalent, with several recorded cases (eg, Raymond et al8). Other mild fatty-acid oxidation defects and, perhaps, intermittent maple syrup urine disease could behave similarly. Death during an initial episode seems frequent in patients with late-onset OTC deficiency, as lack of familiarity with the disorder in the adult setting delays diagnosis and appropriate treatment.9-11 Treatment of hyperammonaemia is well established, and includes aggressive calorie support to counteract catabolism, early use of intravenous sodium benzoate as an ammonia sink, and intravenous arginine.2 It was unfortunate that no objective evidence was gathered on the cause of the patient’s episode of encephalopathy during childhood. While the cause could have been viral encephalitis, the clinical course, and appearance of the cerebrospinal fluid on microscopy and the brain on computed tomography did not strongly support this diagnosis. Assessment of plasma ammonia level would most likely have led to the diagnosis of OTC deficiency. Establishment of the correct diagnosis in the patient led to the finding that his mother and brother were also affected, enabling them to be advised about precautions. The genetic implications for the family’s younger generation were not critical, as the proband had no children, and his brother’s children were both male and could not have inherited their father’s X chromosome (Figure). This case illustrates the difficulty of diagnosing late-onset OTC. The X-linked inheritance may be obscured, even when more than one family member is affected, as some patients remain asymptomatic. Patients with acute onset of unexplained neurological or psychiatric symptoms need urgent metabolic investigation, including measurement of plasma ammonia level, to exclude metabolic causes. Cascade testing of family members The G-to-A base change in exon 6, which results in an amino acid substitution from alanine to threonine at position 208 (p. A208T), was identified in DNA from the blood of the patient with late-onset ornithine transcarbamylase deficiency (person III-1) and his brother (III-2). Their mother (II-2) was found to be heterozygous for the p. A208T mutation.

Mary Anne Chiong MD · Bruce H Bennetts PhD · Simone I Strasser MD, FRACP · Bridget Wilcken FRACP, FHGSA

To the Editor: I was surprised by Wong’s letter on the role of history-taking and examination in the diagnostic process.1 I would suggest that Wong, as a surgical registrar, receives the majority of his abdominal pain referrals from the medical staff of the emergency department. Although he advocates the liberal use of abdominal computed tomography (CT) scanning, I believe he ignores the fact that another medical practitioner has already taken a history and performed an examination that has suggested a surgical cause of pain for which a surgical opinion is then requested. Wong would thus remain unaware of other cases in which patients present with abdominal pain but the case is ruled non-surgical on the basis of history, examination and limited investigation not involving abdominal CT scanning. History, examination and even appropriately targeted investigations remain imperfect diagnostic tools, but I agree with Schattner2 that history-taking and examination are very important adjuncts in the diagnostic process.

Andrew P Wright

To the Editor: Like Schattner, I am appalled by the attitude to diagnosis displayed by Wong regarding the use of computed tomography (CT) scanning in preference to initial history-taking and physical examination in abdominal pain.1 Unfortunately, this approach is becoming increasingly more prevalent among junior staff (and even among some senior staff). Wong poses the question, “[W]hy do some clinicians continue to routinely promulgate the sacred and arcane ritual of taking a history and doing an examination, which, as diagnostic tools, are clearly second-rate?” There are several reasons why I continue to promulgate the classical paradigm. Firstly, I would remind him of Bayes’ theorem: post-test probability equals pre-test probability multiplied by the likelihood ratio of the test. Put simply, this means that, for a test that is not 100% accurate (ie, effectively, all imaging tests), you cannot interpret the meaning of the result without having some idea of the pre-test probability of a diagnosis. And how can you satisfactorily arrive at a pre-test probability without having clinically assessed the patient? In addition, the radiologist is able to interpret the images more accurately when there are clinical details provided.2 Secondly, is Wong seriously suggesting that all patients with abdominal pain, including young adults and children, undergo CT scanning without any kind of clinical filtering or assessment? This is wrong and potentially negligent. The radiation dose received by the patient from an abdominal CT scan is a serious consideration. Assuming a total effective body dose of 10 mSv, there is an excess risk of a radiation-induced fatal cancer of about 1 in 2000.3 Apart from the risk to the individual, the number of iatrogenic cancers potentially induced in the community by indiscriminate use of CT would be a major concern.4 Thirdly, the implication of Wong’s letter is that clinical assessment and imaging are somehow in competition with each other, whereas nothing could be further from the truth. Of course, modern imaging has contributed to making diagnosis far more accurate than in the time of Hippocrates, but a complementary approach is far more rewarding for patients and doctors. Lastly, in patients with abdominal pain, there are many occasions when no imaging is required and others when ultrasonography is more appropriate than CT, because it avoids ionising radiation in young patients and is more accurate for diagnosing gynaecological causes of pain.5

Richard M Mendelson

To the Editor: It is clear Dr Wong1 has a practice rather different from mine. He is not used to the truly undifferentiated patients that present in their thousands to emergency departments and general practices every day. There, the art of history and examination is truly alive. No one questions the value of complex imaging. It has its place after a detailed history has been taken and focused examination and relevant investigations have been carried out, leading to a risk assessment and management plan. One does not order computed tomography (CT) scans willy-nilly. For example, the Canadian CT Head Rule2 for patients with minor head injury sets out which patients should have a head CT scan, based on a simple set of historical and examination findings. Moreover, CT scans are wasted on conditions for which CT imaging is inappropriate — it is rare that I order a CT scan for a child with abdominal pain. When I ask surgical registrars for their opinion, I am actually asking for their consultant’s opinion. Nothing guides like an experienced hand, whether it be feeling a belly or writing a CT request form. On many occasions, I have concluded that all the imaging performed on a patient with abdominal pain did not contribute to the diagnosis and the patient simply needed a laparotomy. At my insistence, the consultant is called, appropriate treatment commences, and the patient boards the experience express on the track to recovery. As Shem quips, in his satirical book on medical training and hospital life — nothing heals like cold steel.3 CT is not the be-all and end-all of medicine. Hopefully, by the end of his training, Wong will have developed the hand of experience and be able to continue the art of medicine through the ages. In the words of William Osler: The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with potions and powders, but with the exercise of an influence of the strong upon the weak, of the righteous upon the wicked, of the wise upon the foolish.4

James L Mallows

To the Editor: Apropos the letter by Wong entitled “Clinical paradigms revisited” in the Christmas issue,1 declaring fossilisation of the very pillars on which medicine stands, we would like to express a contrary opinion. To be adept physicians, clinicians must hone their skills at taking a lucid and informative history and conducting a thorough physical examination. It would be a crying shame if young doctors, having slaved for 5 or more years to obtain a medical degree, had to rely solely on expensive investigations when they have the God-given tools of the five senses. To confirm a clinical diagnosis and assess the extent of disease, doctors should order specific and appropriate investigations, rather than ordering tests that may be irrelevant and financially bleeding the patient. The issues of cost, radiation hazard, availability of trained personnel, and need for expensive equipment have been trivialised. In a country like India, where the majority of the population cannot afford even minimal hospital fees, to even contemplate using a computed tomography scan as a first-line diagnostic tool for something as basic as abdominal pain is absurd. Moreover, the use of advanced technology does not guarantee a correct diagnosis. A recent case of aortic dissection was misdiagnosed as acute coronary syndrome on the basis of electrocardiography.2 If due emphasis had been given to pulse and blood pressures in both limbs, this mistake could have been avoided. In another case, involving recurrent loss of consciousness, investigations were non-contributory, but a history of substance misuse at home pointed to the correct diagnosis.3 In another study, clinical judgement regarding the severity of pneumonia was found to be a more reliable predictor than a standardised scoring system based on clinical signs and laboratory findings.4 Doctors ought to be able to make a clinical judgement in the first instance, rather than resorting blindly to expensive investigatory tools. We do not deny the usefulness of modern technological devices for confirming or ruling out clinical possibilities, but they must be used judiciously. Such investigations cannot take precedence over physicians’ reliance on their clinical skills, lest we become helpless without technology.

Sandeep Chauhan · Ruth D’Cruz · Sanjay D’Cruz · Ram Singh · Atul Sachdev

To the Editor: Schattner1,2 and Wong3 raise issues that examine what has been the core of medical practice since antiquity. Grasping antiquity for its own sake is problematic, at best, and possibly heralds the extinction of long held practices, at worst. As technology improves, we are witnesses to improved imaging modalities that provide higher diagnostic yields, with improved sensitivity and specificity, at increasingly reduced costs. Refusal to even acknowledge the possibility that the history and examination may be terminal is not prudent. Instead, we need to examine carefully our mantra(s) with respect for the temporal nature of medicine. History and examination evolved in their current form because previous generations could not see inside the body, or examine physiological and pathological processes in real time. Our predecessors amassed a series of verbal cues and physical rules that generally conformed to the presentation of a particular disease. The future of medicine heralds dramatic departure from the world view that preceded computed tomography and magnetic resonance imaging. Wong raises an important issue with regard to diagnosing emergency abdominal conditions in busy hospital practice. He does not discount a role for the history or physical examination. He does, however, challenge their pre-eminence in “conditions that require emergency surgical treatment”. Is it really in the best interests of patients and the health care system for the emergency department intern/resident, then the registrar/consultant, then the surgical fellow, to all take the history and perform a physical examination? In essence, doesn’t Wong’s “scan first approach” reflect a prudent reliance on, and respect for, the information already gathered? Schattner4 states that “all imaging studies combined (computed tomography, magnetic resonance imaging, ultrasound, and echocardiography) were decisive in only 10.5% of cases” whereas “the patient’s history and the evolution of the condition proved to be the decisive diagnostic method in 23% of cases”. Doesn’t this show that Wong’s approach provides a heuristic that increases the diagnostic yield, reduces delays and guesswork, and streamlines the processing of patients presenting with acute abdominal pain — or is it acceptable to miss the significant percentage of diagnoses that are decided by imaging alone?!

Stuart Kostalas

Objective: To determine whether treatment in a private versus public hospital was an independent predictor of survival outcomes in patients with colorectal cancer.Design: Retrospective, population-based study.Setting: Tertiary care hospitals.Participants: All patients diagnosed with colorectal cancer in Western Australia between 1993 and 2003.Interventions: Management in private versus public hospitals.Main outcome measures: Overall survival and cancer-specific survival rates.Results: 5809 patients were treated for colorectal cancer. Of these, 1523 (26%) were managed in private hospitals. The 5-year overall survival rates for private and public hospital patients were 59.4% (95% CI, 56.9%–61.9%) and 48.6% (95% CI, 47.0%–50.2%), respectively. Significant independent predictors of overall survival were: treatment in a private hospital (P = 0.0001; relative risk [RR], 0.764; 95% CI, 0.696–0.839); younger age (P = 0.0001; RR, 1.032; 95% CI, 1.029–1.036); male sex (P = 0.001; RR, 1.148; 95% CI, 1.068–1.234); and cancer stage (eg, Stage II: P = 0.0001; RR, 1.508; 95% CI, 1.316–1.729).Conclusions: Treatment in a private hospital was a significant independent predictor of survival outcomes. Further validation of these results would have a significant bearing on how we approach health care delivery for patients with colorectal cancer.

Melinda Morris MB BS · Barry Iacopetta PhD · Cameron Platell MB BS, PhD, FRACS

Surgeons and government must work together to evaluate new surgical technologies Robot-assisted surgery has been evolving over the past decade, from simple adjustable arms to support cameras in laparoscopic surgery, through to the more sophisticated four-armed machines now being installed in a number of hospitals in Australia.1 The name “robot” is somewhat misleading, as these devices do not perform autonomous tasks, but are under the direct control of a surgeon who usually works from a remote console to insert robot-controlled instruments into a patient. This technology has certainly made a number of surgical procedures, such as total prostatectomy and cardiac anastomosis (coronary artery bypass grafting), somewhat easier to perform; however, the true benefit of these interventions is yet to be clearly demonstrated.2 Over the past 150 years, surgery has been driven by technological advances. The introduction of anaesthesia; the development of imaging, from x-rays through to ultrasound, computed tomo-graphy scanning, and magnetic resonance imaging; and the availability in the operating theatre of heart/lung machines, stereotactic-guided imaging systems, and an array of extraord-inary prosthetic inserts for the heart, joints and the vascular system have all meant that surgeons are constantly being challenged by new technologies. The benefits gained from the introduction of laparoscopic surgery into general surgical pro-cedures over the past 15 years have also been possible only through the advances of technology. With these developments has been the need to adapt practice, as new technologies are demonstrated to be of value to patients. Not all new technologies have survived the test of time, however, and some fail on long-term review to deliver on their early promise.3,4 While hundreds of robotic systems have been sold worldwide, there are presently four commissioned robots in practice in Australia. One is located in a public hospital; the other three are in private hospitals. This has caused some concern within segments of the surgical community, as the motives for installing these robotic machines appear to be more commercial and marketing-oriented than based on well established science and surgical benefit. However, since more than half of the surgical procedures in our health system are performed in the private sector, it is hardly surprising that aggressive marketing and commercial interests should be factors in the availability of robotic surgery. Is this in the best interests of the Australian community, the patients treated and the associated cost for the health care system? The purchase price of robotic machines varies but is in the range of $1.5–$2 million.5,6 The costs of disposable items required for a procedure are also substantial, adding a large premium to each surgery performed. If clear and measurable benefits result from robotic surgery, then these costs may be easy to defend and should be supported. But a fundamental issue is why, if the benefits are so tangible, does robotic surgery occur predominantly in private facilities? It may be that the funding is only available within the private sector, or it may be due to a lack of current clear evidence that there is true benefit associated with this technology.7 Indeed, if all the robots were removed from surgical practice tomorrow, the impact on the health care system would not be significant; the overall cost may, in fact, drop. The introduction of robotic surgery has many potential advantages. It makes difficult and previously inaccessible body areas easier for surgeons to access and may lead to decreased morbidity for patients.7 There are exciting prospects for using robotic systems remotely — where the surgeon operates on a patient who is heading to Mars, remotely located in Antarctica, or close to the frontline of a battlefield — none of which are beyond the realms of possibility with the level of technology currently available.8,9 Furthermore, the possibility for surgeons to perform simulated surgery based on a patient’s imaging information and to prepare a range of operative strategies for difficult and complex cases will be greatly facilitated by the availability of robotic systems that are interfaced with computed tomography and magnetic resonance imaging scans and ultrasound information, all brought together in a virtual surgical environment.7,8 We need health professionals who are excited by new developments and new opportunities. Without them we would still be practising surgery as it had been done for hundreds of years. It is unfortunate that our health care system spends much of its energy trying to hold back innovation and development on the basis that funding is unavailable or evidence of benefit is yet to appear. Evidence demonstrating the value of new surgical interventions takes time; its acquisition needs to be properly funded and supported and it needs to be honestly collected and evaluated. Since the Australian Government is the major funder of health care in Australia, and even in the private sector contributes 75% of the scheduled fee for surgical procedures, it has a vital interest in setting up systems where all new surgical technologies (the robot being no exception) are monitored, evaluated and reported on. Most such systems are currently somewhat ad hoc. One exception is the Australian Safety and Efficacy Register of New Interventional Procedures – Surgical (ASERNIP-S), an organisation run by the Royal Australasian College of Surgeons with funding from the Australian Government to evaluate new surgical technologies (http://www.surgeons.org/asernip-s/). If we are to have cost-effective surgical care that is innovative and relevant, we need the Australian Government to recognise that for all important new technologies, trials are established, data collected and the information fed back to hospitals, doctors and patients. There is clearly a cost involved in such activities, but introducing a poor technology without clear patient outcomes in the long term is a much more expensive activity. The challenge for surgeons and government is to work together as a team, with the surgeons agreeing to appropriate protocols and careful evaluation, and the Australian Government recognising that this innovation needs to be funded from the public purse. “Toys for boys” implies a somewhat frivolous approach to new technologies. This is probably not the case. Rather, surgeons — male or female — are excited by new technologies and the possibilities they offer for the care of their patients. Robotic surgery will become commonplace over the next 10 years. These machines will not replace surgeons, but will provide added precision and enable surgeons to work on difficult cases, regardless of location. The robots will become cheaper, smaller and easier to use. There will be tactile feedback mechanisms and instrumentation integrated into the robot’s arms to enable imaging and sampling to occur at the same time as the procedure is being performed. Just as artificial hips, heart valves and heart/lung machines seemed far-fetched 50 years ago, so too we will look back on this first decade of robotic surgery as the beginning of a major change in the way in which surgery is evaluated and delivered, and care is managed for patients.

Guy J Maddern PhD, FRACS, MS