Perceived practice change in Australian doctors as a result of medicolegal concerns.

OBJECTIVES: To explore the perceived impact of medicolegal concerns on how Australian doctors practise medicine and to compare doctors who have experienced a medicolegal matter with those who have not. DESIGN AND SETTING: Cross-sectional survey (posted in September 2007, with reminder 4 weeks later) of Australian doctors from all major specialty groups, trainees and a sample of general practitioners who were insured with a medical insurance company. PARTICIPANTS: 2999 respondents of 8360 who were sent the survey. MAIN OUTCOME MEASURES: Perceived practice changes due to concerns about medicolegal issues, beliefs about medicolegal issues, and the influence of medicolegal issues on both career choices and how doctors relate to their patients. RESULTS: Respondents reported changes in practice behaviour due to medicolegal concerns, with 43% of doctors stating that they referred patients more than usual, 55% stating that they ordered tests more than usual, and 11% stating that they prescribed medications more than usual. Respondents also reported improved communication of risk (66%), increased disclosure of uncertainty (44%), developed better systems for tracking results (48%) and better methods for identifying non-attenders (39%) and for auditing clinical practice (35%). Concerns about medicolegal issues led to 33% considering giving up medicine, 32% considering reducing their working hours and 40% considering retiring early. These proportions were all significantly greater for doctors who had previously experienced a medicolegal matter compared with those who had not. CONCLUSIONS: This Australian study, like international studies, confirms that doctors' concerns about medicolegal issues impact on their practice in a variety of ways. There is a greater perceived impact on those doctors who have previously experienced a medicolegal matter.

Australian doctors' involvement in medicolegal matters: a cross-sectional self-report study.

OBJECTIVE: To investigate the frequency of, and factors associated with, Australian doctors' involvement in medicolegal matters. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional survey of Australian doctors (specialists, trainees and general practitioners) insured with the medical insurance company Avant. A self-report questionnaire was mailed to Avant members in September 2007 to gather data on their involvement in medicolegal matters. Information on psychiatric morbidity and alcohol consumption was also collected using the General Health Questionnaire and the Alcohol Use Disorders Identification Test. MAIN OUTCOME MEASURES: Occurrence and type of past and current medicolegal matters with which doctors have been involved. RESULTS: Of 8500 doctors invited to participate, 2999 returned completed surveys (36% response rate). Sixty-five per cent of respondents had been involved in a medicolegal matter at some time, and 14% were involved in a current matter. The two most common types of medicolegal matter were claims for compensation and complaints to a health care complaints body. Doctors were more likely to be involved in medicolegal matters if they were male, worked in high-intervention areas of medicine (surgery and obstretics/gynaecology), and worked longer hours. CONCLUSION: Our study concurs with other studies in finding an association between medicolegal matters and being male, working long hours and working in high-intervention areas of medicine. Unlike other studies, we found no association between age and involvement in a current medicolegal matter. Our findings also pose the question of whether psychiatric morbidity in doctors is a cause or effect of the medicolegal process.

The neuropsychology of cannabis and other substance use in schizophrenia: review of the literature and critical evaluation of methodological issues.

Research on the neuropsychology of substance use in schizophrenia has been steadily growing over the past decade. However, significant gaps remain in the knowledge of individual substances and their relationship to cognition in the schizophrenia spectrum disorders. Approximately 65 studies to date have directly examined this relationship. Of these, approximately 20 have focused on nicotine, 15 on alcohol, 10 on cocaine, three on stimulants/hallucinogens, one on benzodiazepines, 10 on polydrug abuse, and seven on cannabis. Research on cannabis is especially lacking, given that worldwide it is the most commonly used illicit drug in schizophrenia, is used at higher rates in schizophrenia than in the general population, and makes its own unique contribution to the onset and prognosis of schizophrenia. In the present paper an overview of the neuropsychology literature on substance use in schizophrenia is presented, with special emphasis on cannabis. This incorporates a discussion of the methodological limitations inherent in these studies, and range of potential confounding variables that were not considered or controlled, providing directions for future research into the cognitive correlates of cannabis and other substance use in schizophrenia.

The neuropsychological correlates of cannabis use in schizophrenia: lifetime abuse/dependence, frequency of use, and recency of use.

This study examined the relationship between neuropsychological performance and three different indices of cannabis use in schizophrenia. These indices were DSM-IV lifetime abuse/dependence, frequency of use, and recency of use. Sixty males with schizophrenia/schizoaffective disorder and 17 healthy males were recruited. The two groups were matched for age, years of education, and premorbid IQ. Medical history, substance use, and psychiatric symptoms were assessed. A neuropsychological battery was also administered to assess attention/processing speed, executive functions, memory, and perceptual organisation. Substance use within 24 hours of cognitive assessment was screened by urine analysis, and a range of confounds were controlled. In the schizophrenia group, 44 participants met DSM-IV criteria for lifetime cannabis abuse/dependence. In addition, there were three mutually exclusive frequency-of-cannabis-use subgroups comprising "high" frequency users (n=11), "medium" frequency users (n=7), and "low" frequency users (n=34) over the preceding year. There were also four mutually exclusive recency-of-cannabis-use categories comprising "cannabis abuse/dependence in the past week" (n=11 users), "non-dependent cannabis use in the past week" (n=7 users), "non-dependent cannabis use in the past month, but prior to the past week" (n=7 users), and "non-dependent cannabis use prior to the past month" (n=9 users). The control group performed better than the schizophrenia group in all cognitive domains. Within the schizophrenia group, a larger proportion of participants with lifetime cannabis abuse/dependence demonstrated better performance than those without lifetime abuse/dependence on a component of psychomotor speed. Frequency and recency of cannabis use were also associated with better neuropsychological performance, predominantly in the domains of attention/processing speed and executive functions. In conclusion, cannabis use is associated with enhanced cognitive functioning in schizophrenia. Implications of the results, limitations of the study, and directions for future research are discussed.

Maternal attachment state of mind moderates the impact of postnatal depression on infant attachment.

BACKGROUND: Empirical studies have revealed a significant, but modest association between maternal depression and insecure mother-child attachment. Across studies, however, a substantial number of mothers with depression are able to provide a sensitive caretaking environment for their children. This paper aimed to explore whether a mother's own state of mind regarding attachment moderated the association between postpartum depression and insecure mother-child attachment. METHODS: Mothers (n = 111), mainly middle-class mothers, and their infants participated in a longitudinal study of postnatal depression, maternal attachment state of mind and child attachment. Depression was assessed using a diagnostic interview (at 4 and 12 months) and symptom checklists (at 4, 12 and 15 months). The Adult Attachment Interview was conducted at 12 months and the Strange Situation procedure at 15 months. RESULTS: Mothers diagnosed as depressed were more likely to have an insecure state of mind regarding attachment. Infants of chronically depressed mothers were more likely to be insecurely attached; however, the relationship between maternal depression and child attachment was moderated by maternal attachment state of mind. CONCLUSIONS: Results are discussed with reference to resiliency factors for women with postnatal depression and implications for intervention.

Burnout and psychiatric morbidity in new medical graduates.

OBJECTIVE: To determine the prevalence of psychiatric morbidity and burnout in final-year medical students, and changes in these measures during the intern year. DESIGN: Prospective longitudinal cohort study over 18 months, with assessment of psychiatric morbidity and burnout on six occasions. PARTICIPANTS: All 117 students in the first graduating cohort of the University of Sydney Graduate Medical Program were invited to participate in the study; 110 consented. OUTCOME MEASURES: Psychiatric morbidity assessed with the 28-item General Health Questionnaire and burnout assessed with the Maslach Burnout Inventory. RESULTS: The point prevalence of participants meeting criteria for psychiatric morbidity and burnout rose steadily throughout the study period. CONCLUSIONS: Internship remains a stressful time for medical graduates, despite initiatives to better support them during this period. The implications for the doctors themselves and for the communities they serve warrant further attention, including programs specifically aimed at reducing the rate of psychological morbidity and burnout during internship.

"Stress" and coronary heart disease: psychosocial risk factors.

An Expert Working Group of the National Heart Foundation of Australia undertook a review of systematic reviews of the evidence relating to major psychosocial risk factors to assess whether there are independent associations between any of the factors and the development and progression of coronary heart disease (CHD), or the occurrence of acute cardiac events. The expert group concluded that (i) there is strong and consistent evidence of an independent causal association between depression, social isolation and lack of quality social support and the causes and prognosis of CHD; and (ii) there is no strong or consistent evidence for a causal association between chronic life events, work-related stressors (job control, demands and strain), Type A behaviour patterns, hostility, anxiety disorders or panic disorders and CHD. The increased risk contributed by these psychosocial factors is of similar order to the more conventional CHD risk factors such as smoking, dyslipidaemia and hypertension. The identified psychosocial risk factors should be taken into account during individual CHD risk assessment and management, and have implications for public health policy and research.

Embryo donation for medical research: attitudes and concerns of potential donors.

BACKGROUND: The recent derivation of embryonic stem cell lines from human blastocysts and related implications for regenerative medicine has intensified a longstanding debate about the use of human embryos for research purposes. However, studies have shown that few couples with stored embryos opt to donate them for research. Herein, the attitudes and concerns of potential embryo donors to donation of surplus embryos for medical research were examined. METHODS: From a total of 509 couples who had stored frozen embryos and who had received a questionnaire about embryo donations for medical research, 152 women (30%) and 123 male partners (24%) responded. Embryos had been stored for a mean of 2.25 years (range 3 months to 12 years). RESULTS: Some 10% of respondents indicated it probable, and 34% possible, that they would donate their surplus embryos for research in the future. Women respondents whose embryos had been stored longer, and those committed to the practice of a religion, were more worried about their embryos. Respondents positively disposed to donation commented on their desire not to waste embryos, a desire to help infertile couples, and/or to advance scientific knowledge. Those with negative views commented on the embryo as a potential child and expressed concerns about a perceived lack of control over the type of research to be carried out. CONCLUSIONS: Findings indicate a need for tailored education and counselling about embryo donation for medical research.

Cocaine use and cardiovascular complications.

In Australia, the lifetime use of cocaine is rising, with 3% of the population aged over 14 using cocaine in 1991, increasing to 4.5% in 1998, and cocaine use accounting for 10% of all deaths secondary to illicit drug use in 1998. Cocaine is prepared from the leaves of the plant Erythroxylon coca, and is available as cocaine hydrochloride (a water-soluble powder or granule which can be taken orally, intravenously or intranasally) and as "freebase" or "crack" cocaine (heat stable, melting at high temperatures, thus allowing it to be smoked). Acute myocardial infarction (AMI) is the most commonly reported cardiac consequence of cocaine misuse, usually occurring in men who are young, fit and healthy and who have minimal, if any, risk factors for cardiovascular disease. The mechanism by which cocaine induces AMI is largely not understood. Cocaine effect should be seriously considered in any young patient with minimal risk factors for cardiac disease presenting with AMI, dilated cardiomyopathy, myocarditis or cardiac arrhythmias.