Trends in the specialist workforce in paediatrics in Australia, 1981-1997.

OBJECTIVE: The Royal Australasian College of Physicians has conducted periodic workforce censuses of Fellows practising paediatric medicine in Australia since 1981. The aim of this study was to document trends in the supply of paediatricians and to project these trends into the early 21st century. METHODOLOGY: Time series analysis using least squares regression. RESULTS: The paediatric consultant workforce in Australia increased in a linear manner from 374 in 1981 to 777 in 1997. If this trend persists, the number of paediatricians will grow by 62% to 1255 in 2016. The ratio of population aged 0-14 years per paediatrician fell from 9960:1 in 1981 to 5040:1 in 1997. The projected national decline in the child population will result in a ratio of 3050 children per paediatrician in the year 2016. The proportion of women in the paediatric workforce was 22.4% in 1997 and is projected to rise to at least 36% by 2016. The proportion aged 50 years and older rose from 22% in 1981 to 33.6% in 1997 and is projected to be 45% by the year 2016. The average total weekly working hours fell from 58.2 in 1984 to 53. 4 in 1997. The proportion practising in regional centres rose from 12 to 17.9%. CONCLUSIONS: The paediatric workforce in Australia has grown rapidly over the past 16 years. If this trend continues, the ratio of child population per paediatrician will continue to fall, acccentuated by the projected decline in the child population. The trends towards an ageing workforce with an increasing proportion of women, declining working hours and rising proportion practising in regional centres are expected to continue unless workforce intake or retirement change dramatically.

Trends in the specialist workforce in internal medicine in Australia, 1981-1995.

OBJECTIVE: To describe trends over the period 1981 to 1995 in the supply of consultant physicians in adult medicine in Australia, and to project these trends into the early part of the 21st century. DESIGN: Analysis of workforce data collected by the Royal Australasian College of Physicians in censuses of Fellows in 1981, 1984, 1986, 1988, 1990, 1993 and 1995. MAIN OUTCOME: Number of physicians and ratio of population aged 50 years and older per physician. RESULTS: The workforce increased linearly from 1641 in 1981 to 2701 in 1995, while the population/physician ratio fell from 2180:1 to 1720:1, with a decreasing rate of decline. The ratio is projected to rise after 1996 to 1780:1 in 2016. Among the State and Territories, the higher the population/physician ratio in 1981 the greater the rate of subsequent decline. The proportion of women physicians rose linearly from 4.8% in 1981 to 10.6% in 1995. The age structure changed from a youthful triangular profile in 1981 towards a rectangular profile characteristic of an aged population. All specialty fields displayed a decreasing rate of decline in the population/physician ratio. The proportion of physicians practising in regional centres increased steadily from 9.3% in 1981 to 12.9% in 1995. CONCLUSIONS: Although the number of physicians has risen markedly since 1981 and the ratio of population aged 50 years and older per physician has fallen, trends suggest that the ratio will rise again early in the 21st century. Any deliberate attempt to limit the growth of the physician workforce might result in a deficit in the future when the demand for physicians is growing rapidly due to population ageing.

Use of H2-receptor antagonists in patients with dyspepsia and heartburn: a cost comparison.

OBJECTIVE: Under the Pharmaceutical Benefits Scheme, the use of H2-receptor antagonists (H2A) in the treatment of dyspepsia and heartburn is only subsidised when there is a proven diagnosis of ulcer. This study compared the costs of this Australian practice with a simulation of British practice, which allows unrestricted prescribing of subsidised H2A. DESIGN: Patients with heartburn and/or dyspepsia were prospectively randomised to either a "British" group treated freely at the discretion of their general practitioner without necessarily being investigated or an "Australian" group where use of H2A was allowed only after gastroscopy or a barium meal had demonstrated a peptic ulcer or ulcerative oesophagitis. The patients were followed up for six months and all direct and indirect costs were recorded. SETTING: Forty-nine Sydney general practitioners recruited primary care patients for the study. PATIENTS: Any patient with heartburn or dyspepsia was considered for recruitment; 139 patients entered the study and 137 completed it. MAIN OUTCOME MEASURES: The outcome measures were the costs of general practitioner consultations, specialist consultations, radiology and gastroscopy, other tests, H2A, other medications, personal costs, and total cost per patient. RESULTS: The cumulative total cost per patient at the end of the study was equivalent in the "Australian" ($392) and "British" ($406) groups. A higher initial cost per patient of H2A in the "British" group was offset by a rapid decrease in the proportion that continued to use H2A and by the cost of specialist consultations and investigations in the "Australian" group. CONCLUSION: Over a six-month period the cost of early investigation of heartburn and dyspepsia was equivalent to the cost of a therapeutic trial of H2A.

Rectal bleeding. Patient delay in presentation.

Patient delay in presentation of rectal bleeding has been identified as a factor in delayed diagnosis among patients with colorectal cancer. The aim of this study was to identify demographic or psychological factors, or beliefs or behaviors related to delay in presentation of rectal bleeding. In 93 patients presenting with this symptom to their general practitioner, delay ranged from 0 to 249 days with a median of 7 days; 27 (29 percent) delayed more than 14 days. Delay was unrelated to age, sex, ethnic origin, competence in English, length of schooling, social status, availability of social support, measured psychologic traits, and to the belief that the cause might be cancer. The proportions delaying more than 14 days were statistically significantly elevated among those who were not worried by the bleeding (47 percent delayed); those who did not regularly look at their feces or the toilet paper after use (37 percent); and those who took some other action before presenting to their general practitioner (43 percent).

Postwar mortality among Australian World War II prisoners of the Japanese.

The impact of detention as a prisoner of war on postwar survival and disease-specific mortality was examined in Australian veterans of World War II. A random sample of 908 ex-prisoners and 797 other veterans of the same theatre of war, all of whom had returned to Australia alive, was traced over the 40 years since the war. The date and cause of death were recorded for those who were found to have died. By means of the subject-years method, the mortality of the prisoners of war was compared with that of the non-prisoners of war while the analysis controlled for the length of follow-up and the subject's age at the close of the war. The prisoners of war showed a higher over-all mortality rate than did the non-prisoners of war. This difference was pronounced in the period from five to 14 years after the war but diminished subsequently. There also was an indication that this effect varied with the subject's age at the end of the war: prisoners of war who were aged 25-29 years at that time had the highest mortality differential from non-prisoners of war, followed by prisoners of war who were aged 30-34 years. However, log-linear modelling, which controlled for age and the follow-up period, did not suggest that these mortality differences could be attributed to particular causes of death.

Rectal bleeding. Do other symptoms aid in diagnosis?

It has been shown previously that it is difficult for a general practitioner to predict anal vs. colorectal sources of bleeding in patients presenting with rectal bleeding. The aim of the present study was to determine whether there are any aspects of such a patient's history or clinical features that strongly indicate bleeding from a colorectal cancer or polyp. One hundred forty-five consecutive patients, aged 40 years and older, who had complained of rectal bleeding to a general practitioner, were referred to a specialist for full colonic investigation. Among 15 symptoms and clinical features examined, few had any statistically significant association with the source of bleeding. There was an elevated probability of colorectal cancer (21 percent) in patients who had seen blood mixed with feces. Most bowel symptoms and clinical features are not helpful in deciding whether to proceed with full colorectal assessment in patients aged 40 and older who have rectal bleeding of recent onset.

Evidence of hepatitis virus infection among Australian prisoners of war during World War II.

A sample of Australian male veterans of World War II was surveyed after 40 years. One hundred and seventy veterans had been held by the Japanese as prisoners of war and 172 veterans had served in southeast Asia but had not been taken captive (non-prisoners of war). A medical history was obtained and a physical examination undertaken. Blood was drawn and analysed for standard liver biochemistry and serological markers of hepatitis A and B virus (HAV, HBV) infections. The prevalence of immunoglobulin (Ig)G class antibodies to HAV was 95.2% in non-prisoners of war and 93.3% in prisoners of war. Only three cases of hepatitis B surface antigen (HBsAg) seropositivity were identified (two cases from the prisoner-of-war group). Thirty-six (21.8%) prisoners of war were seropositive for the presence of antibodies to HBsAg (anti-HBs) and 34 (20.0%) prisoners of war for that of antibodies to hepatitis B core antigen (anti-HBc), compared with 16 (9.8%) and eight (4.7%) of the non-prisoners of war, respectively (P = 0.002 and P = 0.0001, respectively). Those veterans who reported jaundice during World War II had a higher prevalence of antibodies to HBV. Among prisoners of war who were forced to work on the Burma-Thailand railway, 24.1% were seropositive for anti-HBc compared with 11.1% of the remaining prisoners of war (P = 0.048). It would appear that hepatitis B was common in prisoners of war but that those who survived 40 years were able to clear the virus and do not appear to have significant liver disease.

Precursors of depression in World War II veterans 40 years after the war.

The impact of wartime stress and other psychosocial and health variables on depressive illness in the 40 years since the Second World War is examined in this study of Australian male prisoners of the Japanese and other veterans. A random sample of 170 surviving members of the captured Eighth Division of the Australian Army residing in Sydney in 1983 (POWs) was compared with a similar sample of 172 veterans who fought in Southeast Asia during the war but were not imprisoned (non-POWs). Multiple regression analysis involving nine predictor variables revealed that self-reported nervous illness during the war and depressive illness since the war had pronounced independent effects on current depression as measured by the Zung Scale. Being married and better educated had significant protective effects against depression for the non-POWs while being employed and having higher socioeconomic status were protective for POWs. A clear linkage was shown from wartime nervous illness to postwar depressive illness to present-day depression.

How important is rectal bleeding in the diagnosis of bowel cancer and polyps?

Overt bleeding from the anus is a common symptom of colorectal cancer but most frequently arises from a benign anal source. The aim of this study was to determine how successfully general practitioners and gastroenterologists could differentiate anal from colorectal sources of bleeding before full colonic investigation. 145 consecutive patients aged 40 years and over who had presented to a GP with rectal bleeding of less than 6 months' duration were referred to a specialist for total colonic investigation. The source of bleeding was diagnosed as colorectal cancer in 15 patients (7 stage A, 3 stage B) and polyps in 11. Of 63 patients in whom GPs predicted an anal source of bleeding only, 11 were ultimately found to be bleeding from a colonic or rectal source. The gastroenterologists (after rigid sigmoidoscopy) predicted an anal source of bleeding in 97, in 5 of whom the source was ultimately found to be colorectal. All patients aged over 40 who present with recent rectal bleeding should be referred for full colonic investigation.

The psychological effects of being a prisoner of war: forty years after release.

Forty years after the end of World War II, the authors compared a random sample of former Japanese-held Australian prisoners of war (POWs) with a group of non-POW combatants of the same era. The POWs were significantly more depressed than were the control subjects, but the two groups did not differ in prevalence of anxiety symptoms or alcohol problems. Apart from a higher rate of postwar duodenal ulcer in the POWs, the two groups had similar degrees of medical morbidity.

Bowel symptoms in an apparently well population.

The aim of this study was to determine the prevalence of various kinds of bowel behavior and symptoms thought to be indicative of colorectal cancer in people randomly selected from the community. A probability sample of 330 dwellings in the inner western suburbs of Sydney yielded 202 completed interviews with occupants aged 30 years and older. Eight percent reported annoying abdominal pain that had lasted for two weeks or more in the preceding six months, while 19 percent reported a feeling of incomplete evacuation at least once every two weeks. Blood on the toilet paper was reported by 14 percent and blood in the toilet bowl by 2 percent. Twenty-one percent said they always looked at their stool in the toilet bowl and 34 percent always looked at the toilet paper after using it, but 43 percent seldom or never looked at either their stool or the paper. Of the 75 who said they looked at their stool about half the time or more, two (3.1 percent) reported seeing blood during the preceding six months. Symptoms that may be associated with colorectal cancer are common in apparently well adults. Whilst this includes bleeding from the rectum in toto, it may not be true for blood seen specifically in the toilet bowl. Because this latter symptom has potential discriminating value, it may be worthwhile to promote public education encouraging people to inspect their stools regularly, and to visit their doctor if blood is seen.

Recent changes in gastrointestinal investigation in a university hospital.

There have been major advances over recent years in the endoscopic investigation of the gastrointestinal tract. The annual number of radiological and endoscopic procedures in a 700-bed university hospital over seven years has been reviewed. The average annual number of barium meal examinations decreased by 67%, while the number of gastroscopies increased by 36% over the same period. Similarly, colonoscopy rates increased and fewer barium enema examinations were performed. The procedural work-load of the Gastroenterology Unit has more than trebled over the seven years. These changes, together with other diagnostic and therapeutic procedures, should decrease the need for surgery and reduce the length of stay in hospital.

Gastrointestinal morbidity among World War II prisoners of war: 40 years on.

A study of Australian male World War II veterans was conducted to assess clinically the gastrointestinal ill-effects which were present 40 years after the stress of internment as prisoners of war of the Japanese. A random sample of 170 surviving members of the captured Eighth Army Division resident in Sydney in 1983 (ex-POW) was compared with a similar sample of veterans who fought in Southeast Asia during the War, but were not imprisoned (non-POW). Duodenal ulcers and strongyloidiasis were more prevalent in the ex-POW group than in the non-POW group. The increased rate of duodenal ulcer (24.7%, compared with 10.5%; P = 0.0005) was confirmed by a higher proportion of ex-POWs currently taking cimetidine (9.0%, compared with 2.3%; P = 0.008). Strongyloidiasis had been found in 9.7% of all veterans, but in 15% of ex-POWs and in 19% of those who had worked on the Burma-Thailand railway. No other significant differences in gastrointestinal disease were found.

Predictive value of rectal bleeding in screening for rectal and sigmoid polyps.

Overt rectal bleeding is a common symptom of colorectal cancer and polyps but also occurs in apparently healthy people. It is not known how often this represents bleeding from an undiagnosed rectal or sigmoid polyp or cancer. Three hundred and nineteen apparently healthy men aged over 50, selected by random sampling, were interviewed and underwent flexible sigmoidoscopy to at least 30 cm. Polyps of 10 mm or more in diameter were diagnosed in 12, one of whom also had an adenocarcinoma. Rectal bleeding during the previous six months was reported by 48, four of whom were found to have polyps; seven polyps and one cancer were diagnosed among the 271 who reported no rectal bleeding. Rectal bleeding had a specificity of 86%, a sensitivity of 33%, and a positive predictive value of 8% for rectal or sigmoid polyps or cancer. Restricting the analysis to those subjects who regularly inspected their stools did not improve the predictive value. Sigmoidoscopy in apparently healthy subjects with rectal bleeding will not result in the diagnosis of appreciable numbers of rectal and sigmoid polyps or cancers.

Immunochemical detection of fecal occult blood.

An immunochemical test for fecal occult blood has been evaluated. It has been found to be specific for human hemoglobin and to be reproducible, accurate and four times more sensitive than chemical occult blood tests. Storage of prepared slides at -20 degrees C prevented reduction in sensitivity. To determine the effect of blood from the upper gastrointestinal tract, six volunteers ingested 100 ml of their own blood. Positive chemical, but no positive immunochemical tests were produced. In 20 healthy subjects, challenge with red meat and vegetables with high peroxidase content increased the positivity rate of chemical tests but had no effect on the positivity rate of the immunochemical test. The immunochemical method for fecal occult blood has advantages over chemical testing in that it is specific for human blood and for lower gut bleeding. Its increased sensitivity should result in a high detection rate of colorectal neoplastic lesions. However, this same increased sensitivity may also reduce its effectiveness in bowel cancer screening because of positive results in patients with trivial blood loss from non-neoplastic colonic sources.

Immunodiagnosis of colorectal cancer: clinical evaluation of Tennessee antigen (Tenagen).

Blood samples from 172 consecutive patients undergoing complete colon investigations to exclude colorectal cancer (CC) were examined for levels of Tennessee antigen, i.e., Tenagen (Tg), and carcinoembryonic antigen. Patients included 48 with CC, 34 with adenomatous polyps, 14 with colitis, and 76 with no organic mucosal disease. All patients were investigated by the one clinical and histopathology department. Laboratory estimations were performed blindly. Although there were some statistically significant differences among average values, the degree of overlap among the groups of patients precludes the practical application of Tg in the diagnosis of CC.

Relationship of survival to stage of the tumour and duration of symptoms in colorectal cancer.

It has been suggested that reduction of diagnostic delay in symptomatic colorectal cancer will not improve survival. Published reports show varying effects of duration of symptoms both on stage of cancer and on survival. However, tumour stage can be measured only at the end of the symptomatic period and, therefore, conclusions cannot be drawn about early diagnosis of symptomatic colorectal cancer and its effect on survival. On current evidence, early diagnosis and treatment may improve survival and should be encouraged.

Participation in faecal occult blood screening for colorectal cancer.

Chemical faecal occult blood testing has been proposed as a means of screening for colorectal cancer (C.C.) in populations or in identified high-risk groups. The level of public participation is a critical factor in the effectiveness of screening programmes. This study was conducted as a methodological pretest for an intended investigation of factors influencing screening participation. Faecal occult blood screening was offered to 728 employees of a teaching hospital in Sydney, New South Wales and 41% participation was obtained. Both participants and non-participants were questioned on demographic and social background factors, on their experience of C.C. in others, and on their reasons for participating or not participating. Major reasons for participation were: a general feeling of the importance of health checks and screening tests; a belief that it is important to diagnose C.C. early; and the fact that the test was simple and easy to do. Prominent self-acknowledged reasons for non-participation were indifference, procrastination, absence of previous bowel complaints, preference for one's own doctor to do such tests and inconvenience or lack of time. Those more likely to participate were: females; those of Australian or British origin; single, separated or divorced persons; those having two or more dependents and those with personal knowledge of a C.C. patient.