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    Changing trends in the incidence of invasive melanoma in Victoria, 1985–2015

    David J Curchin, Victoria R Harris, Christopher J McCormack and Saxon D Smith
    Med J Aust 2018; 208 (6): . || doi: 10.5694/mja17.00725
    Published online: 2 April 2018

    Abstract

    Objectives: To estimate the incidence of cutaneous malignant melanoma in Victoria; to examine trends in its incidence over the past 30 years. Secondary objectives were to examine the anatomic location and thickness of invasive melanoma tumours during the same period.

    Design: Population-based, descriptive analysis of Victorian Cancer Registry data.

    Participants: Victorian residents diagnosed with melanoma, 1985–2015.

    Main outcome measures: Age-standardised incidence of invasive melanoma; estimated annual percentage changes in incidence.

    Results: In 2015, the incidence of invasive melanoma in Victoria was 52.9 cases per 100 000 men and 39.2 cases per 100 000 women. Since the mid-1990s, the incidence for men increased annually by 0.9% (95% CI, 0.3–1.5%), but for women there was no significant change (estimated annual percentage change, –0.1%; 95% CI, –0.8% to 0.5%). The incidence of invasive melanoma has been declining in age groups under 55 years of age since 1996 (overall annual change, –1.7%; 95% CI, –2.5% to –0.9%), but is still increasing in those over 55 (overall annual change, 1.6%; 95% CI, 1.0–2.2%). The most frequent site of tumours in men was the trunk (40%), on women the upper (32%) and lower limbs (31%).

    Conclusions: Melanoma remains a significant health problem, warranting continued prevention efforts. Awareness of differences in presentation by men and women and in different age groups would facilitate improved screening and risk identification.

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    • 1 Northern Clinical School, University of Sydney, Sydney, NSW
    • 2 Royal North Shore Hospital, Sydney, NSW
    • 3 Peter MacCallum Cancer Centre, Melbourne, VIC


    Correspondence: dcur0946@uni.sydney.edu.au
    Competing interests:

    No relevant disclosures.

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    • 5. Whiteman DC, Whiteman CA, Green AC. Childhood sun exposure as a risk factor for melanoma: a systematic review of epidemiologic studies. Cancer Causes Control 2001; 12: 69-82.
    • 6. Gandini S, Sera F, Cattaruzza MS, et al. Meta-analysis of risk factors for cutaneous melanoma: II. Sun exposure. Eur J Cancer 2005; 41: 45-60.
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    • 8. Erdmann F, Lortet-Tieulent J, Schuz J, et al. International trends in the incidence of malignant melanoma 1953–2008 — are recent generations at higher or lower risk? Int J Cancer 2013; 132: 385-400.
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    • 14. Youl PH, Youlden DR, Baade PD. Changes in the site distribution of common melanoma subtypes in Queensland, Australia over time: implications for public health campaigns. Br J Dermatol 2013; 168: 136-144.
    • 15. Holman DM, Freeman MB, Shoemaker ML. Trends in melanoma incidence among non-Hispanic whites in the United States, 2005 to 2014. JAMA Dermatol 2018; doi:10.1001/jamadermatol.2017.5541 [Epub ahead of print].
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    • 20. Meani RE, Pan Y, McLean C, et al. The Victorian Melanoma Service: a 20-year review of an Australian multidisciplinary cancer service. Australas J Dermatol 2016; 57: 235-237.
    • 21. Balch CM, Gershenwald JE, Soong SJ, et al. Final version of 2009 AJCC melanoma staging and classification. J Clin Oncol 2009; 27: 6199-6206.
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    • 23. Whiteman DC, Stickley M, Watt P, et al. Anatomic site, sun exposure, and risk of cutaneous melanoma. J Clin Oncol 2006; 249: 3172-3177.
    • 24. Anderson WF, Pfeiffer RM, Tucker MA, Rosenberg PS. Divergent cancer pathways for early-onset and late-onset cutaneous malignant melanoma. Cancer 2009; 115: 4176-4185.
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    • 27. van der Leest RJ, Flohil SC, Arends LR, et al. Risk of subsequent cutaneous malignancy in patients with prior melanoma: a systematic review and meta-analysis. J Eur Acad Dermatol Venereol 2015; 29: 1053-1062.
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    • 30. Watts CG, Cust AE, Menzies SW, et al. Cost-effectiveness of skin surveillance through a specialized clinic for patients at high risk of melanoma. J Clin Oncol 2017; 35: 63-71.

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      An update to the AIS–AMA position statement on concussion in sport

      Lisa J Elkington, Silvia Manzanero and David C Hughes
      Med J Aust 2018; 208 (6): . || doi: 10.5694/mja17.01180
      Published online: 2 April 2018

      The best approach is to take concussion seriously, treat each case carefully and be conservative with return to sport processes

      The Australian Institute of Sport (AIS) and Australian Medical Association (AMA) position statement on concussion in sport and its dedicated online platform (https://www.concussioninsport.gov.au) were launched in May 2016.1 The aims were to conduct a comprehensive assessment of the evidence and present it in a format that would be accessible to all stakeholders; and to develop a set of guidelines for concussion management that would suit Australians who sustained a concussion in any sport and any level of participation. However, concussion research and guideline development progresses at a very fast pace, and it has become clear that the project needs to be regularly revised and updated as knowledge of concussion in sport continues to evolve. The gold standard for concussion in sport guidelines is the proceedings of the consensus meeting of the Concussion in Sport Group (CISG), which meets every 4 years to compile and examine the most current evidence. The most recent meeting of the CISG took place in Berlin in October 2016 and the outcomes were released as a consensus statement in April 2017,2 accompanied by a series of systematic reviews covering many aspects of concussion research and management.3-7 It was therefore necessary to update the AIS–AMA position statement to incorporate several aspects of concussion detection tools and management guidelines arising from the Berlin consensus. We also incorporated our own analysis of the evidence8 and discussed the position statement with representatives from several contact and collision sports. The main changes are summarised in Box 1. The updated version of the AIS–AMA position statement in concussion in sport was launched in November 2017 as one of the most current and informed tools currently available in Australia.


      • 1 Australian Institute of Sport, Canberra, ACT
      • 2 Research Institute for Sport and Exercise, University of Canberra, Canberra, ACT


      Correspondence: david.hughes@ausport.gov.au
      Competing interests:

      No relevant disclosures.

      • 1. Elkington LJ, Hughes DC. Australian Institute of Sport and Australian Medical Association position statement on concussion in sport. Med J Aust 2017; 206: 46-50. <MJA full text>
      • 2. McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med 2017; 51: 838-847.
      • 3. Schneider KJ, Leddy JJ, Guskiewicz KM, et al. Rest and treatment/rehabilitation following sport-related concussion: a systematic review. Br J Sports Med 2017; 51: 930-934.
      • 4. Kamins J, Bigler E, Covassin T, et al. What is the physiological time to recovery after concussion? A systematic review. Br J Sports Med 2017; 51: 935-940.
      • 5. Davis GA, Purcell LK. The evaluation and management of acute concussion differs in young children. Br J Sports Med 2014; 48: 98-101.
      • 6. Feddermann-Demont N, Echemendia RJ, Schneider KJ, et al. What domains of clinical function should be assessed after sport-related concussion? A systematic review. Br J Sports Med 2017; 51: 903-918.
      • 7. Echemendia RJ, Broglio SP, Davis GA, et al. What tests and measures should be added to the SCAT3 and related tests to improve their reliability, sensitivity and/or specificity in sideline concussion diagnosis? A systematic review. Br J Sports Med 2017; 51: 895-901.
      • 8. Manzanero S, Elkington LJ, Praet SF, et al. Post-concussion recovery in children and adolescents: A narrative review. J Concussion 2017; 1: 1-8.
      • 9. Echemendia RJ, Meeuwisse W, McCrory P, et al. The Concussion Recognition Tool 5th Edition (CRT5): Background and rationale. Br J Sports Med 2017; 51: 870-871.
      • 10. Echemendia RJ, Meeuwisse W, McCrory P, et al. The Concussion Recognition Tool 5th Edition (CRT5). Br J Sports Med 2017; 51: 872.
      • 11. Echemendia RJ, Meeuwisse W, McCrory P, et al. The Sport Concussion Assessment Tool 5th Edition (SCAT5). Br J Sports Med 2017; 51: 851-858.
      • 12. Davis GA, Purcell L, Schneider KJ, et al. The Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5): background and rationale. Br J Sports Med 2017; 51: 859-861.
      • 13. Davis GA, Purcell L, Schneider KJ, et al. The Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5). Br J Sports Med 2017; 51: 862-869.
      • 14. Davis GA, Anderson V, Babl FE, et al. What is the difference in concussion management in children as compared with adults? A systematic review. Br J Sports Med 2017; 51: 949-957.
      • 15. McLeod TC, Lewis JH, Whelihan K, Bacon CE. Rest and return to activity after sport-related concussion: a systematic review of the literature. J Athl Train 2017; 52: 262-287.
      • 16. Mez J, Daneshvar DH, Kiernan PT, et al. Clinicopathological evaluation of chronic traumatic encephalopathy in players of American football. JAMA 2017; 318: 360-370.
      • 17. McKee AC, Cantu RC, Nowinski CJ, et al. Chronic traumatic encephalopathy in athletes: progressive tauopathy after repetitive head injury. J Neuropathol Exp Neurol 2009; 68: 709-735.

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        Exercise: an essential evidence-based medicine

        Anita Green, Craig Engstrom and Peter Friis
        Med J Aust 2018; 208 (6): . || doi: 10.5694/mja18.00033
        Published online: 2 April 2018

        Despite all the evidence, doctors do not regularly prescribe physical activity and exercise

        The Gold Coast 2018 Commonwealth Games are a celebration of sporting excellence. Over 4000 elite athletes from 70 countries will compete in 18 sports and seven para-sports. The extraordinary performances of these athletes will be the culmination of long term dedicated training programs. Many of the next generation of elite Australian sportsmen and women will be inspired by these athletes and para-athletes and will passionately commit to specialised training and exercise regimes to pursue their sporting dreams. Sadly, there is no evidence, at a population level, that spectators enjoying the performances of highly trained athletes will increase their own physical activity and exercise patterns long term.1


        • University of Queensland, Brisbane, QLD


        Competing interests:

        Anita Green is Chief Medical Officer of the Gold Coast 2018 Commonwealth Games.

        • 1. Bauman A, Murphy NM, Matsudo V. Is a population-level physical activity legacy of the London 2012 Olympics likely? J Phys Act Health 2013; 10: 1-3.
        • 2. Lee IM, Shiroma EJ, Lobelo F, et al. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet 2012; 380: 219-229.
        • 3. Pedersen BK, Saltin B. Exercise as medicine - evidence for prescribing exercise as therapy in 26 different chronic diseases. Scand J Med Sci Sports 2015; 25: 1-72.
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        • 6. Short CE, Hayman M, Rebar AL, et al. Physical activity recommendations from general practitioners in Australia. Results from a national survey. Aust NZ J Public Health 2016; 40: 83-90.
        • 7. Fie S, Norman I, While A. The relationship between physicians’ and nurses’ personal physical activity habits and their health-promotion practice: a systematic review. Health Educ J 2011; 72: 102-119.
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        • 9. Gnanendran A, Pyne D, Fallon K, et al. Attitudes of medical students, clinicians and sports scientists towards exercise counselling. J Sports Sci Med 2011; 10: 426-443.
        • 10. Holtz K, Kokotilo K, Fitzgerald B, et al. Exercise behaviour and attitudes among fourth-year medical students at the University of British Columbia. Can Fam Physician 2013; 59: 26-32.
        • 11. Stanford F, Durkin M, Blair S, et al. Determining levels of physical activity in attending physicians, resident and fellow physicians and medical students in the USA. Br J Sports Med 2012; 46: 360-364.
        • 12. Weight CJ, Sellon JL, Lessard-Anderson CR, et al. Physical activity, quality of life, and burnout among physician trainees: the effect of a team-based, incentivized exercise program. Mayo Clin Proc 2013; 88: 1435-1442.
        • 13. Cooke P, Tully M, Cupples M, et al. A randomised control trial of experiential learning to promote physical activity. Educ Primary Care 2013; 24: 427-435.
        • 14. Dunlop M, Murray A. Major limitations in knowledge of physical activity guidelines among UK medical students revealed: implications for the undergraduate medical curriculum. Br J Sports Med 2013; 47: 718-720.
        • 15. Campbell D. Doctors ‘know too little about nutrition and exercise’. The Guardian 2016; 20 Oct. https://www.theguardian.com/society/2016/oct/19/doctors-know-too-little-about-effects-of-nutrition-and-exercise (viewed Dec 2017).
        • 16. Dacey M, Kennedy M, Polak R, et al. Physical activity counselling in medical school education: a systematic review. Med Educ Online 2014; 19: 24325.
        • 17. Thornton J, Fremont P, Khan K, et al. Physical activity prescription: a critical opportunity to address a modifiable risk factor for the prevention and management of chronic disease: a position statement by the Canadian Academy of Sport and Exercise Medicine. Br J Sports Med 2016; 50: 1109-1114.

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          Traumatic cricket-related fatalities in Australia: a historical review of media reports

          Peter Brukner, Thomas J Gara and Lauren V Fortington
          Med J Aust 2018; 208 (6): . || doi: 10.5694/mja17.00908
          Published online: 26 March 2018

          Abstract

          Objective: To undertake a historical review of direct trauma-related deaths in Australian cricket, both organised and informal.

          Design, setting and participants: We conducted an extensive search of digitised print media (three databases) and traditional scientific literature (two databases) for on-field cricket incidents in Australia that resulted in deaths during the period 1858–2016.

          Main outcomes and measures: Numbers of cricket-related deaths by decade; type of cricket match (organised match or training, or informal play); site of fatal injury (eg, head, chest); activity at the time of the incident (eg, batting, fielding, watching).

          Results: 174 relevant deaths were identified. The number peaked in the 1930s (33 fatalities), with five deaths in the past 30 years. There were 83 deaths in organised settings, and 91 deaths in informal play (at school, 31; backyard, street or beach cricket, 60). Of the 72 deaths in organised settings for which the activity of the deceased was reported, 45 were batsmen, 11 were fielders, six were wicketkeepers, one a bowler, and three were umpires. Of the 45 batsmen, 26 died of injuries resulting from a blow by a ball to the head, 13 of blows to the chest, three of peritonitis, at least two of vertebral artery dissection, and one of tetanus. None of the five cricket-related deaths over the past 30 years were caused by head injuries.

          Conclusions: There appears to have been a substantial decline in the number of cricket-related deaths in recent years, probably linked with the widespread use of helmets by batsmen and close-in fielders.

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          • 1 La Trobe Sport and Exercise Medicine Research Centre (LASEM), La Trobe University, Melbourne, VIC
          • 2 South Australian Museum, Adelaide, SA
          • 3 Australian Centre for Research into Injury in Sport and its Prevention (ACRISP), Federation University Australia, Ballarat, VIC


          Correspondence: peterbrukner@gmail.com
          Acknowledgements: 

          We acknowledge the assistance of John Orchard with this study, and financial support from Cricket Australia. The Australian Centre for Research into Injury in Sport and its Prevention is one of the Research Centres for the Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee (IOC).

          Competing interests:

          Peter Brukner was employed as the Cricket Australia team doctor during 2012–2017. Thomas Gara received funding for this study from Cricket Australia.

          • 1. Bull A. Cricket has had too many “freak” deaths: players need better protection. The Guardian (Australian edition) 9 Dec 2014. https://www.theguardian.com/sport/2014/dec/09/cricket-freak-deaths-players-need-protection (viewed Dec 2017).
          • 2. Tripathi M, Shukla DP, Bhat DI, et al. Craniofacial injuries in professional cricket: no more a red herring. Neurosurg Focus 2016; 40: E11.
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            The management of epilepsy in children and adults

            Piero Perucca, Ingrid E Scheffer and Michelle Kiley
            Med J Aust 2018; 208 (5): . || doi: 10.5694/mja17.00951
            Published online: 19 March 2018

            Summary

             

            • The International League Against Epilepsy has recently published a new classification of epileptic seizures and epilepsies to reflect the major scientific advances in our understanding of the epilepsies since the last formal classification 28 years ago. The classification emphasises the importance of aetiology, which allows the optimisation of management.
            • Antiepileptic drugs (AEDs) are the main approach to epilepsy treatment and achieve seizure freedom in about two-thirds of patients.
            • More than 15 second generation AEDs have been introduced since the 1990s, expanding opportunities to tailor treatment for each patient. However, they have not substantially altered the overall seizure-free outcomes.
            • Epilepsy surgery is the most effective treatment for drug-resistant focal epilepsy and should be considered as soon as appropriate trials of two AEDs have failed. The success of epilepsy surgery is influenced by different factors, including epilepsy syndrome, presence and type of epileptogenic lesion, and duration of post-operative follow-up.
            • For patients who are not eligible for epilepsy surgery or for whom surgery has failed, trials of alternative AEDs or other non-pharmacological therapies, such as the ketogenic diet and neurostimulation, may improve seizure control.
            • Ongoing research into novel antiepileptic agents, improved techniques to optimise epilepsy surgery, and other non-pharmacological therapies fuel hope to reduce the proportion of individuals with uncontrolled seizures. With the plethora of gene discoveries in the epilepsies, “precision therapies” specifically targeting the molecular underpinnings are beginning to emerge and hold great promise for future therapeutic approaches.

             


            • 1 Royal Melbourne Hospital, Melbourne, VIC
            • 2 Monash University, Melbourne, VIC
            • 3 Epilepsy Research Centre, Austin Health, University of Melbourne, Melbourne, VIC
            • 4 Florey Institute of Neuroscience and Mental Health, Melbourne, VIC
            • 5 Royal Adelaide Hospital, Adelaide, SA


            Correspondence: piero.perucca@mh.org.au
            Acknowledgements: 

            This work was supported by the Melbourne International Research Scholarship and the Melbourne International Fee Remission Scholarship from the University of Melbourne and the Warren Haynes Neuroscience Research Fellowship from the Royal Melbourne Hospital Neuroscience Foundation (P Perucca); and by a National Health and Medical Research Council (NHMRC) Program Grant (1091593, 2016–2020) and an NHMRC Senior Practitioner Fellowship (1104831, 2016–2020) (IE Scheffer).

            Competing interests:

            P Perucca has received honoraria from Eisai. IE Scheffer serves on the editorial boards of and ; may accrue future revenue on a pending patent on a therapeutic compound; has received speaker honoraria from Athena Diagnostics, UCB, GlaxoSmithKline, Eisai, and Transgenomic; has received scientific advisory board honoraria from Nutricia, UCB and GlaxoSmithKline; has received funding for travel from Athena Diagnostics, UCB and GlaxoSmithKline; and receives research support from the NHMRC, the Australian Research Council, the National Institutes of Health, the Health Research Council of New Zealand, March of Dimes, the Weizmann Institute of Science, Citizens United for Research in Epilepsy (CURE), the United States Department of Defense and the Perpetual Charitable Trustees.

            • 1. Fisher RS, van Emde Boas W, Blume W, et al. Epileptic seizures and epilepsy: definitions proposed by the International League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE). Epilepsia 2005; 46: 470-472.
            • 2. Beghi E, Hesdorffer D. Prevalence of epilepsy — an unknown quantity. Epilepsia 2014; 55: 963-967.
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              Obstructive airway disease in 46–65-year-old people in Busselton, Western Australia, 1966–2015

              Arthur (Bill) Musk, Michael Hunter, Jennie Hui, Matthew W Knuiman, Mark Divitini, John P Beilby and Alan James
              Med J Aust 2018; 208 (5): . || doi: 10.5694/mja17.00867
              Published online: 19 March 2018

              Abstract

              Objective: To document the changing levels of tobacco smoking, respiratory symptoms, doctor-diagnosed asthma, and lung function in Busselton adults aged 46–65 years over the past 50 years.

              Design, setting, participants: Repeated cross-sectional population surveys (1966 to 2010–2015) of adults registered to vote in the Busselton shire, Western Australia, including a modified version of the British Medical Research Council questionnaire on respiratory symptoms.

              Main outcome measures: History of doctor-diagnosed asthma and chronic obstructive pulmonary disease (COPD), tobacco smoking history, respiratory medications used, spirometry parameters (forced expiratory volume in one second [FEV1], forced vital capacity [FVC]).

              Results: The prevalence of tobacco smoking among men declined from 53% in 1966 to 12% in 2010–2015, and from 26% to 9% among women. The prevalence of ever-smoking (ie, smokers and ex-smokers) decreased from 80% to 57% for men but increased from 33% to 50% for women. The prevalence of doctor-diagnosed asthma increased, as did the use of long-acting bronchodilator aerosol medications by people with asthma and COPD. There have been no consistent changes in the prevalence of specific respiratory symptoms, but measures of lung function have significantly improved.

              Conclusions: Smoking rates declined as a result of changes in pricing, prohibitions on smoking and the feedback of survey results to Busselton participants. Significant improvements in lung function were measured, and it can be anticipated that the prevalence of other smoking-related diseases will also decline.

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              • 1 Sir Charles Gairdner Hospital, Perth, WA
              • 2 University of Western Australia, Perth, WA
              • 3 Busselton Health Study Centre, Busselton Population Medical Research Institute, Busselton, WA
              • 4 Busselton Population Medical Research Institute, Perth, WA
              • 5 PathWest, Queen Elizabeth II Medical Centre, Perth, WA


              Correspondence: jennie.hui@uwa.edu.au
              Acknowledgements: 

              We acknowledge the participation and support of the Busselton community. This investigation was funded by the National Health and Medical Research Council (grant 353532), Healthway WA, the Department of Health (Western Australia), and the Western Australian Office of Science.

              Competing interests:

              No relevant disclosures.

              • 1. Peat JK, Woolcock AJ, Leeder SR, et al Asthma and bronchitis in Sydney schoolchildren. II. The effect of social factors and smoking on prevalence. Am J Epidemiol 1980; 111: 728-735.
              • 2. Peat JK, Keena V, Harakeh Z, et al. Parental smoking and respiratory tract infections in children. Paediatr Respir Rev 2001; 2: 207-213.
              • 3. James AL, Palmer LJ, Kicic E, et al. Decline in lung function in the Busselton Health Study: the effects of asthma and cigarette smoking. Am J Respir Crit Care Med 2005; 171: 109-114.
              • 4. Melén E, Granell R, Kogevinas M, et al. Genome-wide association study of body mass index in 23000 individuals with and without asthma. Clin Exp Allergy 2013; 43: 463-474.
              • 5. Cotes JE, Chinn DJ, Miller MR. Respiratory surveys. In: Lung function: physiology measurement and application in medicine. 6th edition. Oxford: Blackwell Publishing, 2006; pp 82-96.
              • 6. Renzetti AD. Standardization of spirometry. Am Rev Respir Dis 1979; 119: 831-838.
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              • 10. Jamrozik E, Knuiman MW, James A, et al. Risk factors for adult-onset asthma: a 14-year longitudinal study. Respirology 2009; 14: 814-821.
              • 11. James AL, Knuiman MW, Divitini ML, et al. Changes in the prevalence of asthma in adults since 1966: the Busselton health study. Eur Respir J 2010; 35: 273-278.
              • 12. Gregory AT, Armstrong RM, Grassi TD, et al. On our selection: Australian longitudinal research studies. Med J Aust 2008; 189: 650-657. <MJA full text>
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              • 14. Knuiman MW, Clarkson JP, Bulsara M, Bartholomew HC. Evaluating the impact of repeated community-wide health surveys on cardiovascular morbidity and mortality in the Busselton population. Aust N Z J Pub Health 2004; 28: 267-272.

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                Bedside cognitive assessment

                Lorenzo Norris and Elizabeth L Cobbs
                Med J Aust 2018; 208 (5): . || doi: 10.5694/mja17.00660
                Published online: 19 March 2018

                Screening for cognitive impairment may lead to diagnostic and treatment plans that improve patients’ safety

                Mild memory changes and reduced speed of processing information are normal cognitive changes in older adults, but between 35% and 50% of adults over the age of 85 years have moderate to severe cognitive impairment. Cognitive impairment includes a range of conditions, such as mild cognitive impairment, delirium and the various dementia syndromes. It is an independent predictor of excess mortality1 and increases the risk of adverse medication effects from benzodiazepines and anticholinergics.


                • George Washington University, Washington, DC, USA


                Correspondence: ecobbs@mfa.gwu.edu

                Series editors

                Balakrishnan (Kichu) Nair

                Simon O’Connor

                Competing interests:

                No relevant disclosures.

                • 1. Sachs GA, Carter R, Holtz LR, et al. Cognitive impairment: an independent predictor of excess mortality: a cohort study. Ann Intern Med 2011; 155: 300-308.
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                • 4. Borson S, Scanlan JM, Watanabe J, et al. Improving identification of cognitive impairment in primary care. Int J Geriatr Psychiatry 2006; 21: 349-355.
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                • 6. Wong CL, Holroyd-Leduc, Simel DL, Straus SE. Does this patient have delirium?: value of bedside instruments. JAMA 2010; 304: 779-786.
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                • 8. Tariq SH, Tumosa N, Chibnall JT, et al. Comparison of the Saint Louis University Mental Status Examination and the Mini-Mental State Examination for detecting dementia and mild neurocognitive disorder: a pilot study. Am J Geriatr Psychiatry 2006; 14: 900-910.
                • 9. Jorm AF. A short form of the informant questionnaire on cognitive decline in the elderly (IQCODE): development and cross-validation. Psychol Med 1994; 24: 145-153.

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                  Will Australia have a fit-for-purpose medical workforce in 2025?

                  Roger P Strasser
                  Med J Aust 2018; 208 (5): . || doi: 10.5694/mja17.01169
                  Published online: 19 March 2018

                  To produce a fit-for-purpose medical workforce, Australia needs streamlined training pathways in all medical disciplines

                  Around the world, there has been a developing focus over the past decade on the importance of a fit-for-purpose medical workforce1 with the right skills, providing the right care, in the right place, at the right time, and with skill sets which include leadership skills, communication expertise and the ability to work within teams.2 Coupled with this is the perspective that health care should address the needs of patients and the public as its central purpose.3 The underlying assumption is that the provision of medical and other health care should be designed and delivered to meet the health needs of the population being served.


                  • Northern Ontario School of Medicine, Laurentian and Lakehead Universities, Sudbury, ON, Canada


                  Correspondence: Roger.Strasser@nosm.ca
                  Competing interests:

                  No relevant disclosures.

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                    The gaps in specialists’ diagnoses

                    Ian A Scott and Donald A Campbell
                    Med J Aust 2018; 208 (5): . || doi: 10.5694/mja17.00905
                    Published online: 19 March 2018

                    Specialists need broad expertise in diagnosing clinical problems arising from diseases involving different organ systems

                    On average, about 10% of primary care visits result in a referral to a specialist,1 and of these, up to half relate to diagnostic uncertainty.2 Diagnostic error is estimated to occur in between 10% and 15% of clinical encounters.3 Medicolegal concerns loom large around missed or delayed diagnosis of potentially serious conditions such as heart disease or cancer. Patients often present with non-specific symptoms and signs, especially in the early stages of emerging illness, which can be accentuated in the complex context of multiple comorbidities, frailty or other disabilities. Accordingly, a broad differential diagnosis that includes diseases of more than one organ system has to be considered, followed by a recursive refinement of diagnostic probability in the face of uncertainty.


                    • 1 Princess Alexandra Hospital, Brisbane, QLD
                    • 2 University of Queensland, Brisbane, QLD
                    • 3 Monash Health, Melbourne, VIC


                    Correspondence: ian.scott@health.qld.gov.au
                    Competing interests:

                    No relevant disclosures.

                    • 1. Barnett ML, Song Z, Landon BE. Trends in physician referrals in the United States, 1999-2009. Arch Intern Med 2012; 172: 163-170.
                    • 2. Donohoe MT, Kravitz RL, Wheeler DB, et al. Reasons for outpatient referrals from generalists to specialists. J Gen Intern Med 1999; 14: 281-286.
                    • 3. Graber ML. The incidence of diagnostic error in medicine. BMJ Qual Saf 2013; 22 Suppl 2: ii21-ii27.
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                    • 18. Jha S. Uncertainty and the diagnostic leviathan. JAMA Intern Med 2015; 175: 1085-1086.
                    • 19. Scott IA, Mitchell CA, Logan E. Audit of consultant physicians’ reply letters for referrals to clinics in a tertiary teaching hospital. Intern Med J 2004; 34: 31-37.
                    • 20. Rosenblatt RA, Hart LG, Baldwin LM, et al. The generalist role of specialty physicians. Is there a hidden system of primary care? JAMA 1998; 279: 1364-1370.
                    • 21. Simpkin AL, Vyas JM, Armstrong KA. Diagnostic reasoning: an endangered competency in internal medicine training. Ann Intern Med 2017; 167: 507-508.
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                    • 23. Arkes HR, Christensen C, Lai C, Blumer C. Two methods of reducing overconfidence. Organ Behav Hum Dec 1987; 39: 133-144.
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                    • 26. Meyer AN, Singh H, Graber ML. Evaluation of outcomes from a national patient-initiated second-opinion program. Am J Med 2015; 128: 1138.e25-1138.e33.

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                      Selecting medical students: we need to assess more than academic excellence

                      Paul Garrud
                      Med J Aust 2018; 208 (5): . || doi: 10.5694/mja17.01224
                      Published online: 12 March 2018

                      Medical schools require selection processes that reflect the type of doctor they aim to produce

                      Selection for medical school is based on the applicant’s academic record, aptitude testing, and assessment of their personal attributes. The indicator of subsequent performance best supported by evidence is prior academic attainment,1,2 with the evidence coming mostly from exam performance at medical school and in postgraduate specialties. Rationales for employing further selection criteria have included alignment with professional body guidance,3 better discrimination between equally qualified applicants, and recognition that becoming a good doctor requires qualities beyond academic excellence.4 In light of current practice, which selection criteria are necessary (ie, provide a minimum required threshold) and which may be sufficient, singly or in combination, for selecting medical students?


                      • University of Nottingham, Derby, United Kingdom


                      Competing interests:

                      Paul Garrud chairs the Medical Schools Council Selection Alliance (United Kingdom). The views expressed in this editorial are personal and do not represent any formal position or policy of Medical Schools Council.

                      • 1. McManus IC, Woolf K, Dacre J, et al. The academic backbone: longitudinal continuities in educational achievement from secondary school and medical school to MRCP (UK) and the specialist register in UK medical students and doctors. BMC Med 2013; 11: 242.
                      • 2. Sladek RM, Bond MJ, Frost LK, et al. Predicting success in medical school: a longitudinal study of common Australian student selection tools. BMC Med Ed 2016; 16: 187.
                      • 3. Australian Medical Council. Standards for assessment and accreditation of primary medical programs by the Australian Medical Council. 2012. https://www.amc.org.au/files/d0ffcecda9608cf49c66c93a79a4ad549638bea0_original.pdf (viewed Jan 2018).
                      • 4. Medical Council of New Zealand. Good medical practice. Dec 2016. www.mcnz.org.nz/assets/News-and-Publications/good-medical-practice.pdf (viewed Dec 2017).
                      • 5. Shulruf B, Bagg W, Begun M, et al. The efficacy of medical student selection tools in Australia and New Zealand. Med J Aust 2018; 208: 214-218.
                      • 6. Papadakis M, Teherani A, Banach M, et al. Disciplinary action by medical boards and prior behaviour in medical school. N Engl J Med 2005; 353: 2673-2682.
                      • 7. Powis D. Selecting medical students: an unresolved challenge. Med Teach 2015; 37: 252-260.
                      • 8. Medical Deans Australia and New Zealand. Medical schools outcomes database: national data report 2017. http://www.medicaldeans.org.au/wp-content/uploads/Medical-Students-Workforce-Survey-report-2017-FINAL.pdf (viewed Jan 2018).
                      • 9. Yates J. Development of a “toolkit” to identify medical students at risk of failure to thrive on the course: an exploratory retrospective case study. BMC Med Ed 2011; 11: 95.
                      • 10. Patel RS, Tarrant C, Bonas S, et al. Medical students’ personal experience of high-stakes failure: case studies using interpretative phenomenological analysis. BMC Med Ed 2015; 15: 86.

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