Introduction

While analogous, there are many differences between the way in which community and individual health are practiced. In this short essay, I will outline some of these differences.

Definitions

The World Health Organisation in 1946 defined health as:

“A state of complete physical, mental and social well-being and not merely the absence of disease.”(World Health Organization, 1946)

This definition uses a biopsychosocial and inclusive model of health and can equally be applied to individuals as to communities, although the health of the individual is implied.

The NPHP in Australia defined public health in 1997 as:

 “the organised response by society to protect and promote health and prevent illness, injury and disability.”(National Public Health Partnership, 1997)

This encapsulates the modern, multidisciplinary approach to public health.

Ethical Differences

In treating patients, healthcare practitioners generally use “principles” and deontological frameworks such as beneficence, non-malfeasance, equity and fairness. One strives to improve a person’s health without harming them, in a fair and just manner. In particular we advocate for an individual patient when engaging with other stakeholders rather than necessarily making a decision that takes other individuals into account- responsibility for community health is usually handed over to public health agencies and administrative bodies. However in community health, measures such as disability-adjusted life years (DALY) are used to allocate resources & design interventions in a utilitarian manner as the aim is the greatest good for the greatest number.

This distinction however is not altogether clear-cut. While traditionally, utilitarianism is cited as the underlying ethical principle in community health and a deontological framework the underlying ethical principle for individual treatment, there is evidence that a mixture of models is what is used in practice.(Fortes & Zoboli, 2002; Hedner & Hansson, 1988)

In addition, sometimes these two methods clash. Surgical intervention for an individual with many complex medical problems may in fact be very expensive and improve community outcomes only slightly in comparison with inexpensive population measures such as vaccination programs. A 2001 study of American publicly-insured elderly patients estimated that the 5% of the population of elderly people who were in their last year of life contributed roughly 30% of the medical expenditure, 6 times the expenditure when compared with their surviving counterparts (Hogan, Lunney, Gabel, & Lynn, 2001).

Measuring Health

Health status of an individual can be assessed in several ways. Health practitioners assess symptoms, signs and the results of diagnostic tests. Medical and psychosocial wellbeing can be evaluated qualitatively during a consultation as well as using various quantitative tools designed to, for example, evaluate risk of depression, functional score or pain scores. Further investigations can also be used to measure health via methods such as blood tests, radiology, pathology, exercise tolerance and other physical components.

In comparison, analysis and measurement of community health is less straightforward and is conducted on a larger scale. Health surveys are analogous to using qualitative and quantitative tools applied to many representative individuals rather than a single individual. Incidence and prevalence of disease conditions may be collected via disease & death registers, hospital & general practitioner databases (eg coding discharge summaries after inpatient stays), surveillance systems where data is compulsorily submitted to a central authority such as for notifiable illnesses. Demographic data, economic and educational data that are continuously measured also give information as to social determinants of health.(Baum, 2003; Canadian Public Health Association, 1986; Lin, Chaplin, Robinson, Fawkes, & Smith, 2007)

Health Interventions

Health interventions for individuals are generally more focussed on secondary and tertiary prevention, ie treatment of risk factors & disease states that already exist rather than prevention in healthy individuals. An example would be that of someone who presents to their healthcare practitioner with ischaemic chest pain. While risk factor reduction such as diabetic control, cessation of smoking and initiation of an exercise regimen may all be appropriate, the initial response will be targeted to treatment of the underlying cause of chest pain and its psychosocial effects. The “history of presenting complaint” is the focus of what we often do.

In contrast, much of community intervention is primary prevention. Legislation and regulation, health promotion and education, screening, vaccination, treatment of risk factors, environmental management, socioeconomic and education policy are some of the many ways in which public health interventions are practiced. There is a “bigger picture” approach that emphasises prevention and often requires a co-ordinated and multidisciplinary approach to the health of the system.(Baum, 2003; Canadian Public Health Association, 1986; Lin et al., 2007)

Conclusion

Public health is not just individual health on a bigger scale. While the healthcare of individuals is increasingly holistic, public health necessarily has a “bigger system” perspective involving not just healthcare workers and departments but also legal, economic and educational systems.

The focus is on prevention, surveillance and maintenance of wellbeing rather than on treatment of ill-health.

Bibliography

Baum, F. (2003). The new public health. Oxford University Press. Retrieved from http://www.cabdirect.org/abstracts/20043034459.html

Canadian Public Health Association, W. (1986). Ottawa charter for health promotion. Ottawa: Canada.

Fortes, P. a. C., & Zoboli, E. L. C. P. (2002). A study on the ethics of microallocation of scarce resources in health care. Journal of Medical Ethics, 28(4), 266–269. doi:10.1136/jme.28.4.266

Hedner, T., & Hansson, L. (1988). A Utilitarian or Deontological Approach Toward Primary Prevention of Cardiovascular Disease? Acta Medica Scandinavica, 224(4), 293–302. doi:10.1111/j.0954-6820.1988.tb19587.x

Hogan, C., Lunney, J., Gabel, J., & Lynn, J. (2001). Medicare Beneficiaries’ Costs Of Care In The Last Year Of Life. Health Affairs, 20(4), 188–195. doi:10.1377/hlthaff.20.4.188

Lin, V., Chaplin, S., Robinson, P. M., Fawkes, S. A., & Smith, J. (2007). Public health practice in Australia: the organised effort. Retrieved from http://arrow.latrobe.edu.au:8080/vital/access/manager/Repository/latrobe:24280

National Public Health Partnership. (1997). Memorandum of Understanding. National Public Health Partnership.

World Health Organization. (1946). www. who. int/bulletin/archives/80 (12) 981. pdf WHO definition of Health. In Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York (pp. 19–22).

Introduction

I am a doctor who has worked in hospital settings of varying sizes including the Western Sydney Local Health District which is home to the largest urban Aboriginal population. However, I have not worked in a community setting or in a dedicated Aboriginal or Torres Strait Islander medical service. Prior to my medical training I completed my education in New Zealand, where welfare of the indigenous people of New Zealand was compulsory in our curriculum, which informs some of my pre-existing beliefs surrounding Indigenous Health in Australia.

My previous exposure in the area of indigenous health in Australia- as a medical student, doctor and member of the general community- had led me to the belief that there were very large disparities between the health of Aboriginal and Torres Strait Islander Peoples and the health of the general population. Statistical measures of health and wellbeing such as life expectancy, maternal and infant mortality and death rates to my understanding were comparable to developing world conditions, as were morbidity and mortality from chronic health conditions such as diabetes, cardiovascular disease, renal disease, infectious diseases and liver disease.

Similarly, from both reading and through my observations as a medical practitioner, my views and beliefs of the underlying reasons for the gross health inequalities came from both a biomedical as well as a biopsychosocial model of health incorporating social determinants of health. Socioeconomic inequality, mental health issues, dietary, overcrowding and environmental factors, streptococcal and staphylococcal colonisation, high smoking rates were some of the many risks that stood out to me as relevant to the poor outcomes in comparison with the general population.

This I viewed in the context of historical segregation, dehumanisation (via the Flora and Fauna & Aborigines Acts) and assimilation policies, political, institutional and media racism as well as the ongoing racism and discrimination that I had seen both in the workplace by colleagues and in the wider community.

However, although I felt that I had a some ideas and knowledge about why a large health disparity exists, I did not feel that my understanding was particularly complex or equipped to answer questions of how best to address this disparity. I also felt that without either formal education or direct experience of the complexities of the situation, I was unlikely to be able to interpret statistics such as why a large disparity existed in mortality from liver disease despite a similar chronic alcohol abuse rate to the general population.

Having now consumed subject readings and participated in the intensive workshops, have a more nuanced, evidence based and complex perspective on indigenous health issues.

Defining Health

Understanding of health requires adequate definitions and evidence.

A concept I have become familiar with is the WHO definition of Health:

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (World Health Organization, 1946)

This is a holistic concept which encompasses biopsychosocial understandings of wellbeing rather than just a biomedical understanding of disease.

The definition of Aboriginal Health in the National Aboriginal Health Strategy (1989) shares similar concepts but also includes community and cultural understandings of wellbeing:

“’Aboriginal health’ means not just the physical well-being of an individual but refers to the social, emotional and cultural well-being of the whole Community in which each individual is able to achieve their full potential as a human being, thereby bringing about the total well-being of their Community. It is a whole-of-life view and includes the cyclical concept of life-death-life.

Health care services should strive to achieve the state where every individual is able to achieve their full potential as a human being and this bring about the total well-being of their community.”(National Aboriginal Health Strategy Working Group, 1989)

The concept of cultural loss as a risk factor in mental health is also mentioned in Hunter (2002) and the health of the environment in Kingsley, Townsend, Phillips, & Aldous (2009).

Thus, my view of Indigenous Health and health in general has expanded to include not just the biomedical and biopsychosocial concepts of health but also cultural and community concepts and the life-cycle as important for wellbeing.

Historical Context

Pre-Colonial Era

Franklin & White (1991) note that prior to the colonisation of Australia by European settlers in 1788, that “the average Aborigine, in fact, enjoyed better health than the average Englishman” . The Aboriginal population and semi-nomadic hunter-gatherer culture was certainly ancient, settlement having occurred at least 50,000 years prior to colonisation (Franklin & White, 1991 p. 1). Life expectancy was estimated at roughly 40 (Abbie, 1969), significantly greater than the corresponding life expectancy of the mid-30s in England at the same time (Mokyr, 1993) and comparable to life expectancy in England in 1900 (Kinsella, 1992).

Even allowing for the health problems and epidemiology of crowded urban living, this longevity surprised me. Unfortunately, although both Abbie (1969) is widely cited, I was unable to find many other objective estimates of Aboriginal life expectancy prior to colonisation.

Colonisation

Franklin & White (1991) and Saggers & Gray (1991) both outline the history of post-colonial Indigenous Affairs in various major stages.

Firstly, the early contact & colonisation era, in which European settlers indulged in brutal treatment of local people- as competitors for land, or as employees- despite Indigenous Australians having rights as British subjects, and despite official government statements regarding their welfare. Australia was not considered to be inhabited or owned prior to colonisation despite its inhabitants. Infectious diseases, some still major contributors to Indigenous burden of disease were introduced, either accidentally or intentionally. The result was a significant decline in health. (Franklin & White, 1991)

Following this, a period of “segregation” and “protection”, initiated by missionaries and the British colonial government with the stated aim of improving the health and welfare of Indigenous Australians via forced resettlement, with the expectation that eventually they would either be “assimilated” into lower echelons of European-Australian society or die out as a race. “Assimilation” also encompassed the removal of “half-caste” children from their families during the Stolen Generation. These policies were economically beneficial due to minimisation of clashes between settlers and Indigenous peoples, employment of otherwise unemployable people to “look after” Indigenous people, reduced social welfare and infrastructure costs and generation of a compliant, dependent, underpaid workforce of Indigenous people (Franklin & White, 1991; Saggers & Gray, 1991).

Within this context, it struck me that several familiar themes emerged which are still evident in the political discourse surrounding Indigenous health and affairs:

• Discordance between official government policy and actual behaviour
• Indigenous dispossession, maltreatment and disempowerment at the expense of economic profit
• Persistent stereotypes dating back to the early colonial era
• Assumptions of European cultural norms as “superior” and “healthier”
• Dissent with discriminatory policy & behaviour from Indigenous and non-Indigenous Australians leading progressive change
• If one is to believe that government actions are benign and follow the official policy, then one (incorrect) line of reasoning is to disbelieve the reality of mistreatment and instead to state that Indigenous people are responsible for their own ill-health as they have failed despite benign government intervention.

While I did know that there was historical context, I was surprised and shocked to find how eerily similar the arguments of past generations were to beliefs I hear expressed by some politicians, healthcare workers and educated people now.

Post World War Two Australia & the Modern Era

Following greater community exposure to the plight of Indigenous Australians and greater empowerment of Indigenous Australians during World War Two, more progressive policies and changes were implemented. In 1967 was the referendum which recognised Indigenous Australians as citizens with equal rights.

“Self Determination” was the next broad policy direction, with community-run Aboriginal and Torres Strait Islander Peoples organisations receiving funding and autonomy for provision of Aboriginal health services to run in parallel with “mainstream” services.

Unfortunately, partially due to the structure of federal and state governments in healthcare in Australia as well as changes of government, there was frequent restructuring of government and community organisations with dilution of responsibility and funding and erosion of community autonomy.(I. Anderson & Sanders, 1996; I. Anderson, 1997)

The Howard Federal Government in 2004 abolished the Aboriginal and Torres Strait Islander Commission (ATSIC) and took control of Indigenous health funding,  a process labelled “mainstreaming” due to diversion from community organisations to “mainstream” organisations.

I was unaware of the context of complex bureaucratic restructuring, waste and gradual erosion of self-determination in the recent history of Indigenous health provision. Certainly in the light of the historical context of cultural loss, assimilationist policies, racist stereotypes and the cultural and community definitions of Aboriginal health, I now perceive a significant set of barriers and an additional risk factor.

Evidence Base

Data & Measures of Healthcare

Quality statistical data on health outcomes and interventions for Indigenous Australians is limited. Multiple reasons have been identified including but not limited to:

• Incomplete or incorrect identification of Indigenous status in research
• Lack of studies into Indigenous health and health outcomes
• Reduced participation in studies

(I. Anderson et al., 2007; Madden & Pulver, 2009)

Demographics show that Indigenous Australians are younger overall, have higher birth rates and tend to live in much more remote settings, have lower education and birth weight and much lower health funding.  The statistical evidence that exists paints a picture of gross health disparity with poor outcomes on many key measures including life expectancy and maternal & child mortality. Chronic illness represents the biggest contributor to morbidity and mortality. Most alarmingly given the high rate of diabetes, the rate of smoking is double that of the general population at 45%. (Nettleton, Napolitano, & Stephens, 2007; Ring & Brown, 2002)

Interventions and Future Directions

The approach that has been devised by multiple working groups and endorsed by Indigenous health organisations is that of partnership, shared responsibility, greater funding and research and collaboration.(I. P. Anderson, 2006; I. Anderson, 1997; Australia, 2007; Chapman, 2010; National Aboriginal Health Strategy Working Group, 1989; Thomson, 2003; “Time To Remove the Barriers Preventing Indigenous Australians Getting Equal Access To Quality Health Care,” n.d.)

This holistic and inclusive and culturally appropriate model of intervention is compatible with the Aborignal definition of health and I was very encouraged to find a concrete set of possible interventions which were possible at multiple levels of government and health.

Bibliography

Abbie, A. A. (1969). The Original Australians. Muller. Retrieved from http://www.aiatsis.gov.au/library/documents/Arrente_Aranda_Published_Apr2011.pdf

Anderson, I. (1997). The National Aboriginal Health Strategy. Health Policy in Australia, 119–135.

Anderson, I., Crengle, S., Kamaka, M. L., Chen, T.-H., Palafox, N., & Jackson-Pulver, L. (2007). Indigenous health 1: indigenous health in Australia, New Zealand, and the Pacific. The Lancet, 367, 1775–85.

Anderson, I. P. (2006). Mutual obligation, shared responsibility agreements & indigenous health strategy. Australia and New Zealand Health Policy, 3(1), 10. doi:10.1186/1743-8462-3-10

Anderson, I., & Sanders, W. (1996). Aboriginal health and institutional reform within Australian federalism. Australian National University, Centre for Aboriginal Ecomonic Policy Research. Retrieved from http://caepr.anu.edu.au/sites/default/files/Publications/DP/1996_DP117.pdf

Australia, O. (2007). Close the gap: Solutions to the Indigenous health crisis facing Australia. Oxfam Australia.

Chapman, N. (2010). Partnership Position Paper. Close the Gap Steering Committee for Indigenous Health Equality.

Franklin, M.-A., & White, I. (1991). Chapter 1: The History and Politics of Aboriginal Health. In J. Reid & P. Trompf (Eds.), The health of aboriginal Australia (pp. 1–33). Houghton Mifflin Harcourt P.

Hunter, E. (2002). “Best intentions” lives on: untoward health outcomes of some contemporary initiatives in Indigenous affairs. The Australian and New Zealand journal of psychiatry, 36(5), 575–584.

Kinsella, K. G. (1992). Changes in life expectancy 1900-1990. The American Journal of Clinical Nutrition, 55(6), 1196S–1202S.

Madden, R. C., & Pulver, L. R. (2009). Aboriginal and Torres Strait Islander population: more than reported. Australian Actuarial Journal, 15(2), 181.

Mokyr, J. (1993). Technological Progress and the Decline of European Mortality. The American Economic Review, 83(2), 324–330. doi:10.2307/2117685

National Aboriginal Health Strategy Working Group. (1989). A national Aboriginal health strategy. Canberra: AGPS.

Nettleton, C., Napolitano, D. A., & Stephens, C. (2007). An overview of current knowledge of the social determinants of Indigenous health. In Symposium on the social determinants of Indigenous health, Adelaide. Retrieved from http://new.paho.org/hq./index.php?gid=12421&option=com_docman&task=doc_view

Ring, I. T., & Brown, N. (2002). Indigenous health: chronically inadequate responses to damning statistics. Medical Journal of Australia, 177(11/12), 629–632.

Saggers, S., & Gray, D. (1991). Chapter 9: Policy and Practice in Aboriginal Health. In J. Reid & P. Trompf (Eds.), The health of aboriginal Australia (pp. 381–394). Houghton Mifflin Harcourt P.

Thomson, N. (2003). Responding to our’spectacular failure’. Retrieved from http://ro.ecu.edu.au/ecuworks/3437/

Time To Remove the Barriers Preventing Indigenous Australians Getting Equal Access To Quality Health Care. (n.d.). Australian Medical Association. Retrieved March 24, 2013, from https://ama.com.au/node/2699

World Health Organization. (1946). www. who. int/bulletin/archives/80 (12) 981. pdf WHO definition of Health. In Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York (pp. 19–22).

“Yotti” Kingsley, J., Townsend, M., Phillips, R., & Aldous, D. (2009). “If the land is healthy … it makes the people healthy”: The relationship between caring for Country and health for the Yorta Yorta Nation, Boonwurrung and Bangerang Tribes. Health & Place, 15(1), 291–299. doi:10.1016/j.healthplace.2008.05.009

Since the former Australian government introduced a tax incentive for private health insurance (or should I say, a tax disincentive for not having it), a lot of people now have some degree of private health insurance.

Most people are, however, somewhat confused at what this actually entitles to them- which is understandable given that it's actually quite confusing.

The bottom line is that although there are now private hospitals that have ICU facilities and emergency departments, they really are set up for low-risk elective admissions, while public hospitals are much, much better at handling sick, complex emergency patients. Public hospitals are geared towards prioritising the sickest patients first (thus why waiting lists for non-urgent things are long). Private hospitals are businesses and are geared towards servicing things that are low-risk and high-gain, such as elective surgery or people who aren't that sick.

There are also often costs that are not obvious to those who aren't familiar with the healthcare system and how it works. The public health system is free. The private health system is not. If you are having an operation or procedure, you will have to pay whoever is doing the procedure (surgeon, dentist, gastroenterologist, cardiologist etc) as well as the anaesthetist and the hospital.

What private health insurance entitles you to:

• Usually some or all of your money back if you have an admission or procedure or consultation at a private hospital (as long as it's been long enough since diagnosis, etc). The amount varies considerably from plan to plan and is often capped at a certain amount. There is also often an excess payment for making a claim.
• "Private in Public" status at a public hospital which usually includes the ability to choose your own specialist, have procedures done by your choice of specialist (if they agree) and extra funding is given to the hospital by your insurer.
• If you have at least "Basic Plus" cover or similar, you can usually get covered 2/3 of the cost of dental care, physiotherapy, other allied health services, massage, acupuncture, other alternative healthcare practitioners. This is of course based on reasonable costs- if your practitioner overcharges you or the "reasonable cost" is actually unrealistic then you may not have the whole 2/3 covered.
• Elective (non-urgent, non-emergency) procedures will usually be performed much faster in the private sector. Good examples include varicose vein surgery, tonsillectomy, tendon repair, carpal tunnel release and arthroscopy.
• Transfer to the public system if you cannot afford the private service or run out of money (depending on resources available)

What private health insurance does not entitle you to:

• A single room. Single rooms are usually reserved for infectious, dying or delirious patients.
• Coverage of costs beyond what your plan covers or beyond what the insurance company deems a reasonable cost- there may be a price gap which you would have to pay out of your own pocket.
• Shorter waiting times for emergency procedures in a public hospital. Emergency procedures are prioritised according to urgency of the case. If you have an abscess on your thigh or a cut on your finger, your operation will be delayed if someone comes in from a car crash or is about to die of dead bowel or a woman in the middle of childbirth has a threat to the safety of the baby.
• Automatic transfer to a private hospital if you are unhappy with your treatment in the public hospital. Being admitted to a private hospital requires that your medical condition suitable for the private hospital, that a specialist is willing to look after you there and that there is a bed available for you.
• Inappropriate medical treatment, procedures or tests just because you think they are a good idea. Ultimately all doctors have to adhere to ethical conduct and the Hippocratic Oath, which forbids doing things that are harmful or unnecessary. Being in the private sector does not mean that you are only a customer. You are still a patient, and your doctor is obliged to act in your best interests.

What private hospitals & insurance are good for:

• Elective, low-risk surgery and procedures
• Simple problems and short admissions
• Covering dental care and allied healthcare
• Rehab- physical & otherwise

What private hospitals are not good for:

• Emergencies, critically unwell and complex patients- in the public system there is always a doctor on site and transfer to intensive care or theatre is prioritised for sick patients. Not always the case in a private hospital where there may not be a doctor on site at night time. Additionally, if your stay is complicated in any way, you may end up with large out of pocket costs.
• Trauma. For exactly the same reason. If you fall off a roof, are in a car accident or get stabbed, you are much, much better off in a public hospital where they routinely deal with trauma, sick patients and have the staff to take you for emergency procedures if required.
• Heart attacks, strokes, liver failure, cancer, hepatitis, cyanide poisoning, etc... I think you get the point.

If you choose to go ahead with doing something in the private hospital setting, I'd advise the following:

• Make sure that you know exactly what you are covered for. The insurance company should be able to advise you in advance if you're contemplating an admission under the private system.
• If it comes to having an operation, make sure you get a quote from 1) the person doing the procedure 2) the anaesthetist and 3) the hospital and then go to your insurer to find out what you are actually covered for. A lot of people get stung by the cost of the anaesthetic for the reason that they assume that it's part of the cost or that there will be no gap. In reality a lot of insurers do not pay a lot of money to the anaesthetist, while the anaesthetist actually pays a lot in indemnity insurance due to risk. The gap can be in the hundreds of dollars if not more.
• Discuss the cost of the procedure, the anaesthetic and the hospital with the person doing the procedure if you can't afford it. They may negotiate a different set up or doing it via the public system. Certainly they can't help you if they don't know that you are going to have financial problems.
• Public hospitals have a liaison person assigned to deal with "private in public" admissions. They can usually tell you a fair bit about what you are and are not covered for and entitled to. At the very least they can tell you who to talk to.

Whew. Hope this helps!

Not a particularly controversial post as the evidence is quite clear.

First: here is a review article from the American Journal of Obstetrics & Gynaecology 2009 going through the various studies on flu vaccine safety in pregnancy.

The conclusion is that influenza is pretty dangerous in pregnancy, while the influenza vaccine is pretty safe. Additionally, no long term side effects from the small dose of thimerosal which is a mercury based preservative.

Thimerosal free vaccines are available.

Second: here is an earlier review article from The Lancet Infectious Diseases 2008

Once again, conclusion is that benefit outweighs risk. As this was prior to the large prospective double blind randomised controlled trial in 2008, there was not enough data at the writing of that article regarding the flu vaccine and safety in pregnancy.

Finally here is the New England Journal of Medicine 2008 prospective double blind RCT that seals the deal with enough evidence- 340 patients.

House of God by Samuel Shem is full of many sorry truths of hospital medicine, of General Medicine in particular. One of those is the art of the "buff" and "turf". No-one wants extra work. It is an eternal rule of human nature (unless you are a workaholic such as myself and find work somehow interesting, exciting or, heaven forbid - fun). And it is true that being in hospital for too long is bad for patients. The "buff" is the polishing up of the patient so that they are as healthy as you can get them from your point of view. The "turf" is the act of sending them to another medical team, to rehab or home or to a nursing home. And you want to do this in such a way that they don't "bounce" - otherwise known as a failed discharge. On the whole this can be an effective system. Certainly it is the kind of system that everyone seems to like - administrators, consultants, registrars, residents and the patients themselves. Less work, less costs, less time in hospital- you can see the advantages right there. Sadly though this leads to the very predictable problem wherein no-one wants patients unless somehow the rules state they can't be discharged or turfed. Usually the "buff" is very incomplete at this stage. Because we are all just focussed on the turf. So we have some 75 year old patient with an uncomplicated heart attack being admitted under general medicine rather than cardiology because she has a urinary tract infection as well. Or no-one has bothered to check liver function tests and someone with ascending cholangitis ends up on general surgery instead of gastroenterology. Or neurosurgery takes a patient who "definitely has an acute disc prolapse" because overnight no-one wants to argue with the emergency registrar who wants to get patients out of a full emergency department and they turn out to have septic arthritis. It is well documented that admitting patients under the appropriate speciality unit leads to significantly improved outcomes - in particular coronary care units and acute stroke units are cited as examples. It leads to shorter hospital stay, lower complication rates and marked improvements in morbidity and mortality. This is relevant to both speciality and general units, I feel. Often general medicine is better for complex or geriatric patients because rehabilitation and multiple referrals are streamlined, while speciality units can be very focussed- and can miss multisystem disorders. Perhaps what will happen in the futures is that we will have speciality multisystem units- those dealing with "metabolic syndrome and smoking diseases", those dealing with disorders of immunity and infections and such-like. Either way, appropriate unit protocols can be a way of reducing fighting over rejecting patients. It certainly simplifies the process of admission. Another thing that must be done is reducing bed pressures and simplifying routine task management for junior doctors. It is high (and unnecessary) workloads and often very unfair bed concerns that mean the "buff" is not complete. And so they bounce.

The nuff-nuff is the bane of our existence. That person who comes in complaining of tummy pain or feeling weak or some vague and inconsistent symptomatology completely without medical explanation and almost certainly psychological in nature. They have some tawdry and dreary sort of social background and probably reside in a slumlike place (oh boo-hoo). They have all sorts of medications for somatic relief. The endones and pethidines and maxolons and valiums. Not to mention the psychiatric pharmacopoeia of zolofts and efexors and zyprexas. Some of them drink and smoke too much (but not enough, sadly). We do all the tests (or just enough to satisfy ourselves) and find nothing while they abuse us for "not caring". So we send them home, kicking and screaming while they threaten "if you send me home I will be back here tomorrow" (which we know is true). And sit back exhausted but relieved that they've finally left. They are the bane of our existence, the nuff-nuffs. The bane. But would you know that:

• Schizophrenia and other psychotic illnesses
• Depression, anxiety
• Personality disorders
• Substance abuse

are all associated with greater rates of illness and mortality? Multiple presentations to hospital are a bad sign that there is something going wrong- whether it be physical or psychiatric. Or both for that matter. Even worse, as they say "you can't prove a negative"; in other words there are many for whom we do not find the real answer (even though it exists). Additionally, chronic diseases lead to significant psychiatric burden- people become depressed, anxious, sometimes even epileptics have psychological "pseudo-seizures". And the mentally ill just do not look after themselves properly. So what do you do when faced with the nuff-nuff? There is I suppose only one thing you can do - exclude organic pathology while treating the psychiatric disorder.

• Approach things with an open mind each time. Ask yourself "why" and be prepared for a complex answer. Sometimes people with worsening disease become anxious and depressed and present to hospital even without a need to. Sometimes it is a cry for help. Sometimes despite mostly being psychiatrically unwell or having a pathological personality there is genuinely a medical cause for the symptoms.
• Involve a psychiatric team early. Sometimes the diagnosis is psychiatric and this in itself is the main thing.
• Keep a high index of suspicion for both organic and psychiatric disease- nuff-nuffs get sick too (and sometimes die)
• Have a sympathetic but professional attitude; be caring but consistent and do not get too wound up in the transferred anxiety.
• Do not get angry, violent or abusive. Additionally do not take on their stresses as your own.
• Be as prepared for gratitude as for the potential to be verbally abused for your approach (and don't take it too personally)
• Exclude dangerous things
• Do what your duty of care towards your patient behoves you to do; do not discriminate on the basis of psychiatric illness.

Doctors are angered by these patients for more than one reason. We are educated to believe that only organic disease is "real" or "significant". But even more than that, being (often unconsciously) manipulated and having large amounts of angst and anxiety offloaded onto us - and then finding that the underlying cause is not what it seems- makes people feel betrayed or lied to (even if that is not the conscious aim of the patient). But why should we feel betrayed? A psychiatric diagnosis (even that of a somatoform or personality disorder) is still a medical - and pathological- condition that causes harm. Often the best thing we can do for these people is to acknowledge their underlying issues and refer appropriately. Sometimes that is all they have been hoping for.

Every speciality has its bugbear. Emergency departments have D-dimers (always positive if you spend more than 2 mins in a hospital, seemingly). Gastroenterologists have "melaena" (often just dark brown stool or even frank PR bleeding). Rheumatologists, chronic back pain (the worst thing you can do is admit them to hospital). And cardiologists have troponins. Good ol' troponin. Touted as "the" test for myocardial infarction (heart attacks to the layman), troponin has gone from being the wunderkind of cardiology to a much maligned villain due to its (sometimes) excessive sensitivity. "Why did they order a troponin?" I hear you cry. "Don't bother with it, it's just troponinitis." What is troponinitis? What is this entity which like "acopia" appears to have entered the everyday parlance of the hospitalist? It is, quite simply, a troponin higher than the 3 times the reference range which for whatever reason is not felt to be due to a myocardial infarct. Troponin is an enzyme that only occurs in cardiac muscle, and thus is only released during death or damage to cardiac myocytes. There is obviously a small baseline amount of damage that is normal wear and tear. The main worry with a very high troponin, then, is a large amount of cell death secondary to a clot or stenosis completely obliterating arterial supply to cardiac muscle - an acute myocardial infarction. Rises in troponin can also occur secondary to sepsis, uncontrolled tachycardia, pulmonary embolus, cardiomyopathy and other causes for cardiac strain. Additionally a troponin can be mildly elevated when it isn't been excreted by the kidneys- in renal impairment. So should we worry about a high troponin in the setting of sepsis, tachycardia or other causes? The key issues here are as follows. Is this:

1. A real myocardial infarction, and if so:
   1. Is this caused by thrombus (clot) post plaque rupture (type I MI)?
   2. Is this caused by cardiac failure/hypotension in the setting of fixed coronary artery disease (type II MI)?
2. Is this another condition causing a raised troponin, and if so:
   1. Does the raised troponin mean there is cardiac damage?
   2. If not, does the raised troponin have any significance?
3. Is there coexisting cardiac as well as other pathology?

Obviously the above must be evaluated in every patient. Additionally any test - including a troponin - should be ordered at an appropriate time when you have a high pre-test probability of an acute coronary syndrome. Thus, underlying risk factors (especially diabetes), clinical features- history and examination, an appropriate acute deterioration, etc. Now, for the controversial bits:

• It is possible to have a watershed infarct in the setting of fixed coronary artery disease where hypotension, tachycardia or cardiac failure is present (eg sepsis or arrhythmia)
• It is also possible to have clinically significant cardiac damage in those settings even without true infarction secondary to strain
• Raised troponin has been shown to be associated with a significantly worse prognosis in acutely unwell patients where another pathology is shown to be the cause

Which leads to my next conclusion:

A raised troponin in an acutely unwell patient, especially one with risk factors and evidence of haemodynamic compromise and/or heart failure should never be ignored.

"But what are you going to do about it?!" you say, incredulously. Watershed infarct without a thrombus? "Troponinitis" due to sepsis? What the heck are you going to do about that? Shouldn't we just stop checking the damned thing? Given that these patients have in fact had the possibility of thrombosis, fixed coronary atherosclerosis, severe cardiac strain/hypoxia or just very bad underlying disease the following should be done:

1. Follow up troponins to monitor trend - MI less likely if troponin persistently raised
2. Aspirin (if not contraindicated) and prn anginine
3. Optimisation of fluid status, strict fluid balance and daily urea, electrolytes and creatinine
4. A transthoracic echocardiogram to assess heart function and see if there is in fact evidence of either infarction or heart failure
5. Cardiologist review in all patients
6. Referral for percutaneous coronary intervention/angiogram:
   1. In patients with ST elevation and likely infarction and who are well enough for the procedure and do not have sepsis (risk of septicaemia and endocarditis)
   2. In patients who will benefit and are well enough for the procedure in whom there is high pre-test probability- as an elective procedure when well.
7. Therapeutic anticoagulation for 48-72 hours in patients with high pre-test probability of infarct with no ST elevation and no contraindication to anticoagulation
8. Addition of cardiac risk factor modifying agents and optimisation of cardiac failure medications
9. Treatment of acute illness, underlying problems and optimisation of chronic conditions
10. Discussion with the patient and family regarding diagnosis and prognosis

Of course, unfortunately the one thing that everyone will groan about is the fact that I have listed 10 things that need to be done for sick patients with "troponinitis". It is much easier to ignore it and do nothing- but that is a grave disservice to our patients and very contradictory to the actual evidence on the matter.