Volume 169 Issue 6

Staying in or leaving rural practice: 1996 outcomes of rural doctors' 1986 intentions Max Kamien MJA 1998; 169: 318-321 For editorial comment, see Cameron Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - ©MJA1998 Abstract Objective: To examine the 1996 outcomes of a sample of Western Australian rural doctors who in 1986 had indicated their intentions to stay in or leave rural practice. Design: Postal questionnaire survey in December 1996, semi-structured interview and feedback by doctors on a draft of this article. Participants: 91 respondents from the 101 doctors who in 1986 had filled in a questionnaire on their intentions to stay in or leave rural practice. Main outcome measures: Proportion of doctors whose actions by 1996 were at variance with their intentions in 1986, and the reasons for their change of direction. Results: 49% (22/45) of doctors who intended to leave had stayed ("stayers") and 24% (11/46) who intended to stay had left ("leavers"). Doctors' main concerns in 1986 were overwork, lack of locum relief, professional contact with colleagues, specialist backup in emergencies, downsizing of hospital facilities, continuing medical education, and income. By 1996 stayers had solved most of these professional problems and felt they were doing a special job which made a difference to their community. Conversely, more than half the leavers were unable to solve these problems and felt disempowered and dispirited. Their most potentially solvable problems were overwork, forced deskilling and conflict with other healthcare professionals. Conclusion: Professional satisfaction was the main reason for doctors staying in or leaving rural practice. Professionally dissatisfied rural doctors reach a critical phase which they have to surmount if they are going to stay. An examination of the positive experiences of the stayers points the way to retaining at least half the potential future leavers. Introduction Much is known about recruiting doctors to rural practice, but less on how to retain them.1-3 A difficulty in researching retention of doctors in rural practice is a lack of baseline data on the intentions of the doctors. In 1986, the Western Australian Minister for Health commissioned an inquiry into the recruitment and retention of rural doctors.1 Those doctors who did not make written or oral submissions to the 1986 inquiry were then sent a questionnaire which included an item on how long they intended to stay in rural practice. The focus of my study is on those doctors whose subsequent actions by the end of 1996 were at variance with their stated intentions in 1986. Methods In 1986, 121 doctors answered questions on their intention to leave or stay in rural practice and on factors which would influence their decision. At the end of 1996, various local and national databases were used to find these doctors. Twenty were either retired, overseas or not on any Australian medical register. The remaining 101 doctors were sent a questionnaire and 91 returned a completed reply. The 1986 responses of those doctors were used to classify these doctors in 1996. If, in 1986, the doctors stated they would stay another five years and were still there in 1996, they were classified as "stayers". If, on the other hand, they said they would still be in rural practice for 10 or more years but left before 1996, they were classified as "leavers" (Figure). The 1996 questionnaires to leavers and stayers contained similar questions but were worded according to the doctors' intentions in 1986 and their actions by 1996. For example, leavers were asked if a lack of locum relief had influenced their decision to leave, while stayers were asked if the availability of locum relief had influenced their decision to stay. Data were analysed with SAS for Windows,4 using Fisher's exact test. To improve depth of understanding of the questionnaire responses, five randomly chosen leavers and 10 stayers were interviewed by one research officer using a semi-structured questionnaire. A further random sample of 15 respondents were asked for comment on whether the findings of my study conformed with their experiences and those of their rural practice colleagues. Results Eleven (24%) of those who intended to stay in rural practice in 1986 had left by 1996 and 22 (49%) of those who intended to leave had stayed (Figure). Six of the stayers had moved from one rural area to another: two from one regional centre to another; one from one rural practice to another; one from one remote practice to another; one from a rural practice to a salaried position in a regional hospital; and one from a remote to a rural practice. This last doctor was the only one to mention medicolegal concern as a contributory reason for changing from a single-doctor practice to a rural group practice. The main reasons for relocating rural practices were to prevent deskilling, especially in anaesthetics, and to reduce workload. There was little difference in demographic characteristics between the leavers and the stayers (Box 1). The only statistically significant variable was the unexpected finding that the leavers were more likely to have completed a rural internship (P < 0.05). Other unexpected findings were that the leavers were more likely to be practising in the medical discipline of their first choice and stated, in 1986, that they would choose the same discipline given their life over again. Although both groups had equivalent postgraduate qualifications in 1986, all but two of the leavers had acquired further qualifications before leaving rural practice. The most commonly held qualifications were a Diploma of Obstetrics and Fellowship of the Royal Australian College of General Practitioners. In 1986, the two main professional satisfactions of both the leavers and stayers were providing full and continuous patient care and the ability to practise procedural medicine. A third professional satisfaction was the feeling of doing a special job for their community, and this was reported by 11 stayers but by only one leaver (P < 0.05). Seventeen stayers also reported the social enjoyment and esteem of being involved with the community, compared with only five of the leavers. This involvement was distinct from simply enjoying the quality of life from living in a rural area. In the words of one stayer: "I enjoy the feeling of being a big fish in a small pond." This was not a statement of arrogance but of self- efficacy. In 1996, five of the leavers reported their spouses' desire to move as a contributory factor, but only one as a definitive factor, in their decision to leave, while two stayers reported their spouse's view as a major influence in their decision to stay. However, there was little difference between the spouses (all were female) of the leavers and stayers with respect to rural background, work situation, attitudes to a rural lifestyle and 1986 intentions to stay in a rural area beyond 1996 (Box 2). Of those spouses with a professional qualification, all were nurses, except for two who were primary school teachers and who left before 1996. There was no statistical difference between families in which one or both partners were professionals with regard to staying or leaving rural practice. Box 3 shows the importance of various retention issues in doctors' decisions to leave or stay in rural practice. In 1986, the stayers were more concerned with being overworked, unable to find locums, the lack of specialist backup when managing emergencies, the adequacy of hospital facilities, and income. By 1996, the stayers had solved most of these problems, and this was important in their decision to stay. Conversely, the leavers had been influenced to leave because of these problems, and had left before 1994, by which time many of the problems were being addressed by the Western Australian Centre for Remote and Rural Medicine (WACRRM), the Rural Doctors' Association of Australia (RDAA), the Australian Medical Association (WA) Locum Services and the Federal Government's General Practice Rural Incentives Program. The leavers' mean age at leaving was 42 years and the mean time for leaving was 4.6 years from when they were surveyed in 1986 (range, 1-8 years). The final decision to leave rural practice was made after periods of deliberation ranging from two months to three years (mean, 10 months). The main reasons why leavers left rural practice were a desire to change professional direction through specialisation or to pursue a special interest (eg, medical education), burn-out, and disillusionment from the downgrading of hospital facilities resulting in an inability to fully use their skills (Box 4). The main social reasons for leaving were children's education and difficulties with marital relationships. Overwork, deskilling, conflict with other healthcare professionals, lack of privacy, poor income and inadequate housing (all potentially solvable) accounted for 60% of the problems and involved six of the leavers. Box 5 shows the main reasons why those who intended to leave stayed in rural practice. More than 60% of reasons for staying were related to job satisfaction, with the remaining reasons divided between social and financial issues. However, 12 stayers reported that interference with factors which contributed to their job satisfaction would make them seriously consider leaving rural practice. This included bureaucratic interference from State or Federal government (6 doctors), downgrading of local services (3), and overwork (3). The next-most-common reasons which could cause doctors to leave rural practice were personal and family difficulties (5). Discussion The number of doctors who were stayers was twice the number who were leavers. In agreement with a recent Queensland study, the main reasons for staying were the professional satisfaction of the variety of work, autonomy of practice and the social and personal satisfaction of rural life.5 Also important was the feeling of doing an important job. Conversely, some leavers felt disempowered and unable to regain control over their own life. Although both groups had comparable qualifications in 1986, the leavers had acquired more postgraduate qualifications by 1996. This gave them greater options and possibly greater confidence to change their professional direction. In 1986, the eventual stayers reported a much higher prevalence of problems than did the eventual leavers. By 1996, the stayers had solved most of these problems, including the provision of those hospital facilities which enabled the full use of their clinical and procedural skills. This indicates that professionally dissatisfied rural doctors have reached a critical phase which has to be negotiated if they are going to stay. The most common profile for such a doctor is a man aged 42 years, discouraged by deskilling from downgrading of hospital facilities or clinical privileges, with children aged 13 to 15 years (when the hard decisions about schooling and matriculation opportunities have to be made). Much effort is required to discover and assist these doctors; this is an important task for organisations such as WACRRM, RDAA and rural divisions of general practice. For Queensland rural doctors, the triggers to leaving were difficulties in coping with change, perceived problems with secondary education for children, poor housing, and personality clashes with colleagues. The ultimate pressures to leave were constancy of after-hours work, difficulty in obtaining locum relief, access to continuing medical education, bureaucratic requirements and family pressures.5 These factors also apply in Western Australia. But also important were professional isolation and the downgrading of hospital facilities, preventing the full use of the doctor's procedural skills. These two factors would also influence many stayers to leave rural practice. This is illustrated by the statements of a stayer who relocated in order to maintain his clinical skills, and by a leaver: "I am self-reliant, and have become disillusioned by interference from outside agencies like the Health Insurance Commission, Medicare, government, the Australian Medical Association, the Royal Australian College of General Practitioners, Divisions etc. I am waiting for the day when I will be asked to relinquish my duties in accident and emergency because I do not hold a fellowship in emergency medicine -- it just seems to be the way things are moving. I also wonder if the day will come when I can auction my provider number like a crayfisherman with a crayfish licence." "I would have stayed except that I was forced to be deskilled. Prior to commencing rural practice I spent three years training in emergency medicine, anaesthetics, surgery, caesarean sections etc. There were no medical mishaps, yet these procedures were stopped in the two country towns I worked in." It is therefore important not to create unnecessary problems and, where problems exist, to counter them. Health departments, in particular, need to be clear about their aims and should value rural doctors as a scarce resource and include them in deliberations about change. The ultimate criteria for decisions on rural workforce and hospital facilities should be the maintenance of essential services sufficient to provide safe medical care to rural and remote Australia and to use the full skills of doctors already resident in those areas. In turn, rural doctors need to be more innovative and flexible in devising methods to reduce their professional isolation, practise procedural medicine, and gain some relief from being constantly on call. Flexibility is also essential from medical organisations and statutory bodies. The doctor in this study who left for financial reasons had a recognisable qualification in psychiatry and wished to practise it on a 40% time basis. National Specialist Qualification Advisory Committee regulations did not allow him to be classified as a consultant psychiatrist, making his practice financially unviable and depriving 80 000 people of resident psychiatric expertise. He commented: "I had a specialist qualification and was happy to use it but got no cooperation from the Commonwealth Government to come to some accommodation to pay for consultant psychiatric services. So I could only charge the same fee as a dermatologist for prolonged consultations and this simply wasn't financially viable. I was sad to leave after 10 years, but the more of my speciality I did, the less I earned, and we were simply getting deeper into debt." The increasing accent on rural issues in undergraduate medical education, the rising proportion of women doctors and the decreasing migration of doctors trained outside Australia make it difficult to estimate the needs for the rural workforce in the next decade. A 1997 study of Australian rural doctors predicts that only 50% will be in their current practice in 2007 and, for Western Australia, only 20%.6 Western Australia will therefore have to recruit 250 doctors over the next decade simply to keep pace with anticipated loss. Attention to factors shown to be important in retaining doctors would have an appreciable effect on reducing this loss. In this study more than half the doctors who intended to stay left for professional and, to a lesser extent, for social reasons which were potentially preventable. Reducing this avoidable loss is therefore an important factor in maintaining the rural workforce. The other main factor in retention is to understand and facilitate the conditions which reinforce the autonomy, efficacy and self-esteem of rural doctors. Acknowledgements Thanks are due to Mrs Rosalind Woodcock, who was a Research Officer on this project, and to all the doctors whose participation and insights made the project possible. This project was funded by the Australian Rural Health Research Institute. References Western Australian Health Department (M Kamien, Chairman). Report of the Ministerial Inquiry into the Recruitment and Retention of Country Doctors in Western Australia. Perth: Western Australian Health Department, 1987. South Australian Health Commission, Royal Australian College of General Practitioners (SA), Australian Medical Association (SA). Review of general medical practice in South Australia. Third report: country general practice. Adelaide: South Australian Health Commission, 1992. Strasser R. Rural general practice in Victoria: the report from a study of the attitudes of Victorian rural general practitioners to country practice and training. Moe: Monash University Centre for Rural Health, 1992. SAS for Windows [computer program]. Version 6.11. Cary, North Carolina: SAS Institute, 1995. Hays RB, Veitch PC, Cheers B, Crossland L. Why doctors leave rural practice. Aust J Rural Health 1997; 5: 198-203. Strasser R, Hays R, Kamien M, Carson D. National rural general practice study. Draft report. Moe: Monash University Centre for Rural Health, 1997. (Received 16 Feb, accepted 1 Jun, 1998) Authors' details University of Western Australia, Perth, WA. Max Kamien, MD, FRACGP, Professor and Head of General Practice. Reprints: Professor M Kamien, Professor of General Practice, University of Western Australia, 328 Stirling Highway, Claremont, WA 6010. E-mail: mkamienATcyllene.uwa.edu.au - Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Max Kamien

A profile of rural surgeons in Australia Martin H Bruening and Guy J Maddern MJA 1998; 169: 324-326 For editorial comment, see Cameron Abstract - Introduction - Method - Results - Discussion - Conclusion - References - Authors' details - - ©MJA1998 Abstract Objectives: To develop a profile of rural surgeons for comparison with profiles of rural general practitioners in the light of shortages in the rural medical workforce. Design: Rural surgeons were surveyed by a postal questionnaire in November 1997. Participants: Members of the Provincial Surgeons of Australia residing in towns with fewer than 50 000 inhabitants. Results: 239 questionnaires were sent and 137 surgeons replied, a response rate of 59%. Our survey showed that rural surgeons are predominantly male, middle-aged and married. They work long hours, and nominate as their major concerns difficulty in finding locum cover, continual on-call work, peer isolation, children's schooling, and lack of privacy. Conclusion: Rural surgeons and general practitioners share similar characteristics and concerns. Introduction There is a shortage of doctors in rural areas of Australia. For general practitioners this situation has been well documented,1 and now the focus has shifted to surgeons. The Australian Medical Workforce Advisory Committee has recently published comprehensive information on the general surgery workforce in Australia,2 with important demographic information about Australia's general surgeons, both urban and rural. A considerable proportion (estimated at up to 23.3%) of all general surgeons reside in rural or remote areas.2,3Despite the current interest by government and College groups, few published reports deal specifically with Australia's rural general surgeons. However, the Royal Australasian College of Surgeons (RACS) undertook a survey in 1997 of about 500 non-metropolitan general surgeons to build a database of surgeon demographics. Our study attempts to profile rural surgeons in Australia to compare with profiles of rural general practitioners. Method Our study was performed in November 1997. We used the 1997 mailing list of members of the Provincial Surgeons of Australia (PSA), an organisation that holds an annual conference at which rural surgeons can meet and discuss issues of relevance. Currently, 350 surgeons are members of the PSA. The term rural can be subdivided into rural major, rural other, remote major and remote other.2 For our study, we identified surgeons residing in towns with fewer than 50 000 inhabitants (ie, encompassing predominantly the categories rural major and remote major). Anonymous questionnaires were sent to these surgeons. From the original postal list, it was not possible to differentiate surgical subspecialties. Non-respondents were not followed up. Questions asked included specialty, qualifications, sex, age, marital status, number of children, length of time in current practice location, spouse employment and hours worked per week. Surgeons were also asked about the negative and positive aspects of their rural surgical practice. Discussion The low response rate of our survey may be attributed to several factors. Given the large number of hours worked by most of the study group, it may be that those who did not respond were simply too busy, or too fatigued or distracted, to do so. The rural workforce, now the subject of increased national attention, may also be suffering from "questionnaire burnout". Demographics The profile of rural surgeons developed from the respondents to our survey is that they are predominantly male, middle-aged and married. They work long hours, and most are well established in their current location and will remain there until retirement. Rural general practitioners and surgeons appear to have similar age distributions. In the early 1990s it was predicted that by 1998, 20% of rural general practitioners would be over the age of 60,4 and our proportion of 15% is not far behind. Without adequate input into the more junior ranks, the average age of rural surgeons will increase proportionately over the next few years.5 The Australian Institute of Health and Welfare medical workforce survey from 1994 found the average age of all specialists to be 48.8 years.6 Practice profile Frequent on-call work was identified as a major negative aspect of rural surgical practice. This is also often cited as a major disincentive to rural general practice, both in Australia7 and other countries.8,9 The rural divisional group of the RACS is establishing a national locum service and aiming to recruit surgeons nationwide to participate in the service. If successful, the service will relieve the burden of many rural surgeons, especially those in solo or two-person practices. The problem of lack of locum cover is also experienced by rural general practitioners and has long been a major cause for disenchantment and increasing the drift of practitioners back to urban areas.10,11 Another way of alleviating the pressure on a solo surgeon would be to provide a second resident surgeon in the same location. Some government reports have argued that, to provide a specialist service in a rural area, there should be a workload to justify a minimum of two specialists.12 This recommendation, although sound in theory, ignores the current shortage of rural surgeons.1,5 Moreover, the introduction of a second surgeon may disrupt long-established referral patterns, and any proceduralist general practitioners may be reluctant to give up one of the major incentives for pursuing rural general practice, as well as the extra income they receive for procedures.13 The issue of peer isolation has been raised in previous studies and continues to be a major concern for rural surgeons.14,15 A strategy such as the proposed RACS rural locum service, whereby metropolitan surgeons can appreciate the unique demands of rural practice, will not only achieve the immediate aim of providing locum cover, but may also change long-held city attitudes regarding rural medicine in general.16Increasing links and support from tertiary institutions as a result of the locum service will give a higher profile to rural hospitals. A separate initiative, which depends on the correct infrastructure being in place, is the introduction of rural surgical attachments for undergraduate medical students. This could provide many long term benefits: exposure of students to rural surgery may encourage more of them to take up the challenge of country practice,17-19 and an appreciation of the skills of rural surgeons could lead to a change in attitude regarding the overall standard of rural medicine. On the other hand, the rural surgeon may enjoy teaching and fostering university links. Family issues Schooling opportunities for children of surgeons were identified by our survey as a major negative aspect of rural practice. Many respondents were apparently dissatisfied with the available local schooling, as over 50% were sending or had sent their children to boarding school, no doubt at significant cost. General practitioners nominate the education of their children as one of the major reasons for not practising in the country.20 Given the shortage of education funding, it appears that, in the short term at least, the problem of establishing high quality schooling in all rural areas is insoluble. The importance of an understanding partner when deciding on country practice has been stressed recently.21 The high proportion of married surgeons among the respondent group would seem to support this theory. Moreover, a large number of the surgeons' partners were in some way employed within the practice. From the Results of our study it would seem that, with 41% of surgeons having spent some time as children in a rural area, a rural upbringing does significantly influence the decision to practise in the country. This concurs with numerous studies.17,22 Conclusion The Results of our study indicate that rural general practitioners and rural general surgeons share similar concerns and characteristics. Major efforts will be needed to arrest the ageing of the rural surgical workforce and improve the working conditions of current rural surgeons. References Australian Medical Workforce Advisory Committee. The medical workforce in rural and remote Australia. Sydney: AMWAC, September 1996. (AMWA Report 1996.8.) Australian Medical Workforce Advisory Committee. The general surgery workforce in Australia. Sydney: AMWAC, May 1997. (AMWA Report 1997.2.) Australian Institute of Health and Welfare. Medical Labour Force Survey 1994, Canberra: AIHW, 1996. Davies PG. Problems with training for general practice in South Australia. Med J Aust 1992, 155: 459-462. Royle JP. Rural surgery initiatives. RACS Bull 1996; 16(1): 42. Australian Medical Workforce Advisory Committee. Annual Report 1995-96. Sydney: AMWAC, 1996.5. Wise AL, Hays BRB, Adkins PB, et al. Training for rural general practice. Med J Aust 1994; 161: 314-318. Forti EM, Martin KE, Jones RL, et al. Factors influencing retention of rural Pennsylvania family physicians. J Am Board Fam Pract 1995; 8: 469-474. Anderson E, Beryeron D, Crouse BJ. Recruitment of family physicians in rural practice. Minn Med 1994; 77: 29-32. Kamien M, Buttfield IH. Some solutions to the shortage of general practitioners in rural Australia. Part 4. Professional, social and economic satisfaction. Med J Aust 1990; 153: 168-171. Hamilton IJ, Gillies J, Ross S, et al. Attitudes of general practitioners who practice in remote island communities. Health Bull 1997; 55(2): 103-108. Gadiel D, Ridoutt L. The specialist medical workforce and specialist service provision in rural areas. Canberra: AGPS, 1994. (MWDRC Consultancies No. 1.) Sax S, Andrews G, Brand I, et al. Enquiry into hospital services in South Australia. Adelaide: SA Health Commission, 1983. Nelson PG. General surgical manpower, Victoria, Australia. Aust N Z J Surg 1991; 61: 576-588. Faris I. The making of a rural surgeon. Aust N Z J Surg 1997; 67: 153-156. Chesterfield-Evans H. A mantle of care. 1991: 105-106 (available from Provincial Surgeons of Australia, PO Box 30, Kingaroy, QLD 4610). Rolfe IE, Pearson SA, O'Connell DL, et al. Finding solutions to the rural doctor shortage: the roles of selection versus undergraduate medical education of Newcastle. Aust N Z J Med 1995; 25: 512-517. American College of Physicians Position Paper on rural primary care. Ann Intern Med 1995; 122: 380-390. Kamien M. Undergraduate rural incentives programme. Med J Aust 1995; 162: 228-229. Kamien M, Buttfield IH. Some solutions to the shortage of general practitioners in rural Australia. Part 4. Professional, social and economic satisfaction. Med J Aust 1990; 153: 168-171. Adamthwaite DN. The making of a rural surgeon: comment. Aust N Z J Surg 1997; 67: 813. Fryer GE Jr, Stine C, Vojir C, et al. Predictors and profiles of rural versus urban family practice. Fam Med 1997; 29: 115-118. (Received 22 May, accepted 28 Jul, 1998) Authors' details Martin H Bruening, BM BS, FRCS(Edin), Lecturer in Rural Surgery. Guy J Maddern, MD, FRACS, R P Jepson Professor of Surgery. Reprints will not be available from the authors. Correspondence: Professor G J Maddern, Department of Surgery, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville, SA 5011. E-mail: sirelandATmedicine.adelaide.edu.au - Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Martin H Bruening · Guy J Maddern

Clinical practice guidelines before the law: sword or shield? Janet E Pelly, Liza Newby, Fiona Tito, Sally Redman and Amanda M Adrian Clinical practice guidelines are designed to improve patient care by promoting best practice. But what is the status of clinical practice guidelines in law? MJA 1998; 169: 330-333 For editorial comment, see Dwyer Subsequently cited in Maddern, Surgery and evidence-based medicine, MJA 1998; 169: 348-349. Introduction - Questions and answers - Where to next? - Acknowledgements - References - Authors' details - - ©MJA1998 Introduction The purpose of clinical practice guidelines (CPGs) is to achieve better health outcomes by improving the practice of health professionals and by better informing consumers about management options.1There is good evidence that CPGs can improve patient management. A review of 59 studies2 which evaluated the effect of CPGs on clinical care detected significant improvement in the process of care in all but four of the studies. Nine of 11 trials that assessed the outcome of care reported significant improvements.2 Despite the widespread recognition of CPGs' potential value in improving care, their legal status has been unclear and of growing concern to some health professionals. For example, the National Health and Medical Research Council National Breast Cancer Centre (NBCC) surveyed a representative sample of 150 surgeons to determine their views on the NHMRC Clinical Practice Guidelines for the Management of Early Breast Cancer;3 37% felt that the guidelines would increase their exposure to medicolegal problems, while 41% felt that CPGs would protect clinicians from legal problems.4 It is perhaps not surprising that there is a lack of clarity about how CPGs may be used in a legal arena. In particular, there is confusion about whether doctors will be more, or less, vulnerable to a successful lawsuit if they follow guidelines or depart from guidelines for sound clinical reasons. Will the guidelines be a shield, enabling doctors to show that they were not negligent because they followed the CPGs? Or will they be a sword, enabling a plaintiff's lawyers to establish negligence in court when they show that the doctor's treatment of the patient departed from the CPGs? How will the courts deal with the fact that proper clinical management of individual patients cannot always be achieved by strict adherence to guidelines? Because of the time lag before malpractice cases come to court, litigation currently before court often relates to incidents which occurred several years before CPG use became widespread. To date, CPGs have rarely, if ever, been used as evidence in medical litigation, and there is virtually no judicial comment on their legal status. There is little information available, even from the United States. In one of the few studies that looked at how guidelines are used in the US legal system,5 259 randomly selected insurance company malpractice claims were reviewed and 960 medical malpractice attorneys were surveyed. Clinical guidelines were important or used as evidence in only 6% of surveyed cases and, significantly, were used by both plaintiff and defendant. However, this study related to claims which were opened in 1990-1991, a period when rigorously developed, evidence-based guidelines were not common.5 Interestingly, CPGs did appear to play a role in the decision to settle; 27% of attorneys reported that the existence of guidelines in respect of a particular disease or condition had influenced their decision to settle, and 26% of plaintiffs' attorneys reported that guidelines were influential at least once in the previous year in a decision not to take a case.5 Against this background, and because of concerns by some clinicians about the adoption of the NHMRC's early breast cancer guidelines, the NBCC commissioned a research paper in June 1997 on the medicolegal implications of CPGs. A forum was then convened to address several issues relating to the law and CPGs (Box 1). Where do guidelines fit in the legal process? The commissioned research paper6 explored the Australian and international experience and concluded that: Clinical practice guidelines neither hinder nor encourage litigation directly -- they are simply likely to be considered another form of expert evidence; or evidence of practice in a court case. In considering CPGs as "just another form of expert evidence", the authors of the paper noted that the evidentiary value of guidelines depends on their purpose, development, ratification, dissemination, use, and whether they are current. For example, in the United Kingdom, judges do not automatically equate established guidelines with reasonable and proper medical practice. Questioning (in court) may address the scope of the guideline, how it was developed and adopted, the mandatory force of its recommendations, the existence of known exceptions to its application, and whether any school of medical thought rejects it and adopts a different approach to treatment.7 The same rules would apply in Australia and the United States. In Australia, the NHMRC has established a nationally credible and effective process for the development, ratification and endorsement of CPGs, and in October 1995 published Guidelines for the development and implementation of clinical practice guidelines,1 which is currently being updated. Endorsement by a recognised expert body such as the NHMRC may add weight to the evidentiary value of guidelines, as can formal evaluations which establish the clinical efficacy of the guideline. Where CPGs are accepted as good evidence of appropriate practice, it can be more difficult for a doctor whose actions and decisions are not consistent with the CPG's recommendation to defend a case simply on the basis of customary local practice.6 Recommendation of the forum: see points 1, 2, and 3 (Box 2). How will guidelines be considered as evidence? Some clinicians are concerned that courts will treat CPGs as inflexible rules of conduct, and thus reduce the scope for individual clinical judgement in particular cases. However, the result of any litigation will depend on the evidence brought before a court. The patient who is suing a doctor must prove negligence on the part of the doctor. Where a clinician has not followed a CPG, there is no automatic assumption of negligence. A clinician could show that the guideline was not relevant in a particular case. Alternatively, he or she could show that the treatment actually provided was supported by other good evidence, or that the guideline was sufficiently flexible to include the chosen treatment. Equally, following a guideline may not automatically prevent a doctor from being sued successfully for negligence. It will depend on all the evidence before the court. The authors of the research paper argue that, were CPGs not available, similar information could be adduced from the scientific information used to develop guidelines. However, there is little doubt that the meta-analysis and distillation of this often enormous volume of scientific evidence, as achieved in a rigorous guideline development process, make the research and clinical practice more understandable to a court, just as it does to an individual consumer or clinician. Therefore, guidelines can aid the legal process by presenting a clear summary of available evidence, rather than leaving the courts with the responsibility of distilling this information from expert testimony. Recommendation of the forum: see point 4 (Box 2). Will a doctor be medicolegally protected if he or she practises within the guidelines? CPGs are not designed to be prescriptive rules, but, rather, to provide guidance. They provide leeway for clinical judgement concerning the circumstances of the patient, the preferences of the patient and a range of other factors. This flexibility is explicitly stated in the introduction to the NHMRC's early breast cancer guidelines. Following them to the letter would not be possible or desirable; as such, words like "must" or "should" are not appropriate, and are not used in these guidelines. With appropriate ratification and credible standing in the health community, guidelines may well represent the agreed professional "standard of care", but the courts are the final arbiters of this standard, and retain the right to base judgments on information other than that in the guidelines. What will happen if a doctor practises outside of the guidelines? The content of CPGs pertain to the "usual" case, as CPGs are based primarily on evidence from randomised trials, which, because of inclusion and exclusion criteria and controlled clinical environments, produce an average result for the conditions studied. However, there may be many reasons for a clinician to provide care to an individual that departs from the guidelines' recommendations. The clinician may be aware of evidence other than that included in the guidelines, appraise the evidence differently to the guideline developers, be managing a person whose situation is different from that within the guidelines, or be treating a person who selects management outside of the guidelines. For example, the NHMRC's early breast cancer guidelines recommend that radiation therapy be offered after breast-conserving surgery. However, women who are carriers of a mutant ataxia telangiectasia (AT) gene have an extreme sensitivity to ionising radiation and can sustain severe normal tissue damage.8 In the rare case where a woman's AT status is known, radiation therapy would be best avoided. The paper concludes that:5 It is likely that departure from the practices advised in a guideline would be subject to the same test as any other departure from a generally accepted standard of care. Departure from practices recommended in guidelines because of ignorance of the guidelines would seem more likely to expose a doctor to risk of litigation, if a patient is damaged by a breach of the guidelines. Conscious departure from guidelines because of specific circumstances in a particular patient may be much easier to defend as consistent with an appropriate standard of care. If a clinician practises outside the guidelines, it is important to ensure that this is well documented and that appropriate strategies have been implemented. Recommendation of the forum: see point 5 (Box 2). Do consumer guides satisfy the criteria of informed consent? Australian law recognises the individual's fundamental right of self-determination,9 unless there is an overriding public policy issue to the contrary. Part of this is the right to have access to proper information on which to base decisions. Consumer versions of guidelines assist people by providing them with information about the choices available in their treatment. Just as a signed consent form is only considered to be one piece of evidence of consent, simply handing a patient a booklet about a particular condition or procedure is unlikely to be accepted as sufficient evidence of disclosure of risk by a doctor. There would also need to be evidence that the patient had had an opportunity to ask the doctor questions, as well as adequate opportunity to read and understand the material contained in the booklet. Recommendation of the forum: see point 6 (Box 2). Are guideline developers liable? Concerns have been raised that CPG developers such as the Australian Cancer Network, NBCC and NHMRC could be held liable if patient harm occurs as a result of a doctor following the guidelines. The NHMRC's Guidelines for the development and implementation of clinical practice guidelines addresses this issue:1 Normally a general publication, even where negligently collated, does not give rise to liability because the author does not owe a duty of care to the general public at large, although the guideline issuer could be held liable if a relevant close relationship can be established between them and the person who suffers a loss. If guidelines purport to be a definitive statement of the correct or appropriate procedure there would be a greater risk of liability than where the guidelines are expressly stated to be provided as a general guide subject to the medical practitioner's expert judgement in each case. As already outlined, guideline developers need to be able to demonstrate that the information in the guidelines has been properly developed and ratified. Additionally, the guidelines should clearly state that they are not a definitive statement, and note the date of development to make clear that the information is correct only to that date. Recommendation of the forum: see point 7 (Box 2). Where to next? The commissioned research paper and the forum agreed that changes should not be sought to the current legal status of guidelines. Rather, attention should be given to satisfying the criteria relating to appropriate development, ratification, evaluation and updating. If this is done, the likelihood of their acceptance within the current legal framework is enhanced. The general view at the forum was against legislating to define the status of guidelines within the legal framework. Rather, evidence-based guidelines should be used to inform the standard of care in courts of law. The forum recommended that a continuing legal education program be established to promote a better understanding in the legal profession of the role, development and use of CPGs among the legal profession. Recommendation of the forum: see point 8 (Box 2). Acknowledgements The authors would like to acknowledge the valuable contribution of The Hon. Justice Margaret Beazley of the NSW Court of Appeal to this paper. References 1. National Health and Medical Research Council. Guidelines for the development and implementation of clinical practice guidelines. Canberra: NHMRC, 1995. 2. Grimshaw J, Russell I. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993; 342: 1317-1321. 3. National Health and Medical Research Council. Clinical practice guidelines for the management of early breast cancer. Canberra: NHMRC, 1995. 4. Carrick SE, Bonevski B, Redman S, et al. Surgeons' opinions about the NHMRC clinical practice guidelines for the management of early breast cancer. Med J Aust 1998; 169: 300-305. 5. Hyams A, Brandenburg B, Lipsitz S, et al. Practice guidelines and malpractice legislation: a two way street. Ann Intern Med 1995; 122: 450-455. 6. Tito F, Newby L. Medico-legal implications of clinical practice guidelines. Sydney: NHMRC National Breast Cancer Centre, 1998. 7. Hurwitz B. Clinical guidelines and the law. BMJ 1995; 311: 1517-1518. 8. Appleby JM, Barber JB, Levine E, et al. Absence of mutations in the ATM gene in breast cancer patients with severe responses to radiotherapy. Br J Cancer 1997; 76: 1546-1549. 9. Review of professional indemnity arrangements for health care professionals [Tito F, chairman], Final Report. Compensation and professional indemnity in health care. Canberra: Commonwealth Department of Human Services and Health, 1995. Authors' details NHMRC National Breast Cancer Centre, Sydney, NSW Janet E Pelly, MA, Communications Manager. Liza Newby, LLB, MA, FAIM, former Health Services Commissioner, Victoria. Sally Redman, BA(Hons), PhD, Director. Enduring Solutions Pty Ltd, Waniassa, ACT. Fiona Tito, BA(Hons), LLB, Executive Director. NSW Department of Health, Sydney, NSW. Amanda M Adrian, RN, LLB, BA, Director, Private Health Care Branch.

Janet E Pelly · Liza Newby · Fiona Tito · Sally Redman · Amanda M Adrian

Matters Arising Doctors' working hours Three articles (and a controversial cover photo) in our 15 June issue, highlighting the perennial problem of excessive working hours for doctors, have inspired comment from junior and senior doctors, and even doctors' family. MJA 1998; 169: 339-341 Shorter hours reduces training - William B Molloy Family concern - Annie Lee The forgotten generation - Terry G Coupland Treat the cause, not the symptoms - Michaela J Farrall In reply: Long hours are a financial reality - Leslie G Olson Smoking among doctors - Mark C J Craddock In reply: Recollections of smoking among doctors - Martin B Van Der Weyden ª 1999 Medical Journal of Australia.