Volume 177 Issue 2

But let’s not forget that our main goal is improving our patients’ health Medical research, like football, can be played many different ways, and in general practice the code of choice is definitely the survey! A flick through the research papers published in the Medical Journal of Australia between 1997 and 2001 will reveal that nearly half of those with GPs as primary authors were based on questionnaire surveys, compared with nearly a fifth of papers authored by physicians and about a quarter of those by surgeons. This phenomenon is not resticted to this Journal — a review of the medical literature between 1980 and 1999 showed that 41% of Australian general practice research was purely descriptive, comprising mainly surveys of GPs' views.1 Why this preponderance of surveys? One of the reasons is historical. From 1990 to 1999, after the Commonwealth Government introduced structural changes to general practice, the government-funded General Practice Evaluation Program (GPEP) allocated over $13 million as the main source of funding for general practice research.2 The criteria for receiving and the short-term nature of the funding favoured descriptive studies such as surveys. Thus, 90% of all 248 GPEP projects funded between 1990 and 1999 were descriptive studies, while 13% were interventional studies.2 Other reasons relate to the nature of general practice itself. Research expertise and capacity are less evolved in general practice than in most other disciplines. Moreover, general practice does not lend itself easily to the methods of randomised controlled trials.3 Our patients often have problems that are multiple, multidimensional (with psychosocial as well as biological components), and undifferentiated, lacking set diagnostic criteria. Our interventions may be correspondingly complex, often involving non-drug therapies.3 A (very appropriate!) survey of British GPs supports the need for relevant research: at least 61% of GPs surveyed considered that clinical topics, such as dealing with chronic or acute illness, patient behaviour and treatment, should be priority areas for general practice research.4 In this issue of the Journal (page 74), Queensland GPs echo this belief.5 Yet, the research being performed does not reflect this "wish list". More than half of all GPEP-funded projects focused predominantly on service organisation and supply, education, training and research methods.6 While these are important issues to tackle, how immediately relevant are they to the nucleus of general practice activity, the doctor–patient encounter? Moving beyond surveysIn December 2001, general practice research funding appeared to join the big league. A new program of National Health and Medical Research Council Project Grants to support primary healthcare research arose as part of the Primary Health Care Research, Evaluation and Development (PHC-RED) Strategy funded by the Commonwealth Government (with $50 million over five years), replacing GPEP.7 However, it is still unclear how much of this will be spent on actual research projects. Results of the assessment of grant applications for the new funding (to start in 2003) are not yet available, and our attempts to determine the exact funding allocation from government sources have hit a bureaucratic wall. It seems GP researchers, like football teams, are at the mercy of the sponsors, who hold the purse strings. Also at question is the extent to which the new program will meet the research needs of general practice. Priorities have been set for the allocation of the grants (Box), but many of these appear to reflect existing government policy rather than the priorities of "bag-carrying" GPs. The PHC-RED standing committee of the ministerial advisory body, the General Practice Partnership Advisory Council, has recommended that the next stage of the priority-setting process for the PHC-RED Strategy should have more emphasis on clinical research (Professor Max Kamien, Department of General Practice, University of Western Australia, personal communication). We would argue that, if the ultimate purpose of medical research is to improve the health of the population, such research must: pose research questions relevant to daily practice; and use appropriate and rigorous study methods to answer these questions. How can general practice research meet these criteria? A day's consultation may bring three patients with vertigo, but different histories, social contexts, values and expectations, and not much by way of physical signs. Few data exist on the predictive value of particular clinical features in the general practice population, particularly those features which are "red flags" for serious conditions, warranting early intervention.9 We need research that documents the natural history of the undifferentiated presentations in general practice. This may be achieved, for instance, through cohort or case–control studies; the large samples required should be possible through collaborations involving Divisions and research networks, as espoused by Gunn10 (page 63) and van Weel11 (page 62) in this issue of the Journal. The process will be facilitated by the increased computerisation of general practice, allowing large-scale data collection. In assessing interventions, observational studies,12 cluster randomisation (where the unit of randomisation may be the practice, not the patient)13 and pragmatic trials (that measure the effectiveness of a treatment in routine practice rather than explanatory trials that measure treatment efficacy in ideal conditions)14 may also have a place. NHMRC assessors of applications for the new primary-care grants will need to avoid perpetuating poorer-quality research (as in many questionnaire surveys), yet appreciate that methods that are rigorous and appropriate to general practice are still evolving.15 The right moves: building research culture and capacityNot all GPs will want to be active researchers, but there should be funding and infrastructure to train and support those who do. This forms an integral part of the PHC-RED Strategy (for instance, through the new NHMRC fellowships and scholarships and the Researcher Development Program),7 and should build on the recommendations of the General Practice Strategy Review Group in 1998,16 including master's or doctoral programs, dedicated career pathways, research "mentors", and research networks. Practical issues, such as adequate remuneration and locum provision while GPs take time off from practice for research, also need to be managed.5 GPs need to be engaged in research throughout their careers, with fostering of critical appraisal and research skills from medical school onward. Clinical audits (now a requirement of the Royal Australian College of General Practitioners Quality Assurance and Continuing Medical Education Program17), coupled with the possibilities of information technology, will also encourage us to evaluate our practice and refine our craft, even if they do not constitute "true" research. The endgameGeneral practice research may have reached the big league, but let's not forget the endgame. The point of promoting the evidence base for general practice is to improve the health of our patients. Increasing general practice research culture and capacity is crucial to this process, but should not be an end in itself. The gap between evidence and practice is more likely to be bridged if the gap between researcher and clinician is bridged, with greater ownership of the research agenda by clinicians5,18 rather than government committees. Whether the stated priorities of the new Project Grants will be discordant with clinical priorities remains to be seen. GPs are, however, pragmatists at heart: we will be more likely to practise with reference to an evidence base if the research underlying it is directly relevant to our practice. Our patients expect no less and neither should we. National Health and Medical Research Council Project Grants in Primary Health Care (part of the Primary Health Care Research, Evaluation and Development [PHC-RED] strategy)8 Preference is given to: Applied research that will advise policymakers, planners and service providers on improvements to primary healthcare delivery Research operating within an integrated and multidisciplinary framework Thematic research areas for primary healthcare include: Evidence-based practice (including development and implementation of evidence for primary healthcare) Measurement and improvement of quality Evaluation and development of models of organisation and delivery Integration and multidisciplinary practice Optimal use of economic resources Health inequalities and the determinants of health (including access issues) Illness prevention and health promotion (including risk factors and early interventions for chronic disease) The eligibility criteria are the same as those for other NHMRC Project Grants.

Mabel Chew MB BS(Hons), FRACGP, FAChPM · Ruth Armstrong BMed

Research networks can change the culture of biomedical science When my predecessor Frans Huygen, the Founding Chair of General Practice of the University Medical Centre, Nijmegen, the Netherlands, stood to give his first lecture (on measles) in 1968, the head of paediatrics had tabled an official complaint before he reached the rostrum. Measles was part of the paediatric domain, and intrusion by a general practitioner was not acceptable. It would have been easy, even in the 1960s, to state that most cases of measles were treated in general practice and GPs were the best qualified to teach students about it. But such anecdotal information could not officially be acted upon. The experience triggered a project at the Nijmegen Department of General Practice for collecting morbidity data.1 This has since developed into a unique database for research,2 with an influence on general practice and undergraduate teaching that continues today. What was founded in Nijmegen in 1971 would now be called a "practice-based research network". In fact, the systematic exploration of the content of daily practice is the vital first step in the process of developing general practice.3 Founding practice-based research networks can enhance this process. But the role of research networks stretches beyond this initial development phase. General practice research networks in the United States, the United Kingdom and the Netherlands have, by tapping into patient care, made it possible to recruit large numbers of unselected patients from different practices for epidemiological and clinical research, to conduct effectiveness studies, and to study the process of care in general practice.2 To meet the local or regional needs of general practice, research networks have had to adapt. For instance, whereas networks in north-western Europe have focused on non-communicable chronic diseases,4 the South African practice-based research network, not surprisingly, concentrates on care of patients with HIV/AIDS.5 These different targets can lead to different organisational requirements, and should make us wary of standardised models. In this issue of the Journal, Gunn (page 63) reviews general practice research networks for Australian primary care, building from the UK and Dutch experience.6 Given the strong historic links, it is attractive to base Australian developments on the vast experience in the UK, but Gunn rightly emphasises that the important thing to consider is what networks produce, rather than how they are constructed. This is in line with European experience, where research networks have had to be flexible — not just in their clinical orientation but, more importantly, in how they fit the way biomedical research is organised, because research networks are part of the broader academic development of general practice. In the UK,7 the National Health Service is an important financial supporter of research and development, including research networks. More recently, the US has seen similar developments.8 In the Netherlands, where universities have traditionally played a key role in general practice research, research networks are linked to university departments of general practice.9 These organisational differences have implications: a university-based structure places practice networks in direct contact with academic research programs, suggesting a "top-down" approach, whereas stimulating practitioners to initiate research would enhance a more "bottom-up" generation of questions from actual patient care. Research networks need both links. A strong grassroots general practice link is vital to generate research questions to improve patient care. However, a connection to the overall organisation of biomedical research is essential to ensure scientific rigour. In the UK, Australia, the US and the Netherlands, practice networks are closely connected to centres for advanced education for research in primary care,10 and these centres of excellence, with their comprehensive research programs, can play a pivotal role in ensuring quality research. Research networks are a tool, not a means in themselves, so their organisational structure should be secondary to scientific and healthcare considerations. The complexity of general practice lies in the context of disease: the interaction between the disease and the patient's family and socioeconomic circumstances, the setting of the doctor–patient encounter, and values attached to illness and treatment.11 A major challenge for research networks is to include this context in their data. A successful example is the International Study of Errors in Family Practice, in which practice-based research networks in six countries — including Australia12 (page 68) — were able to collect data on errors in a way that allowed the contribution of medical and patient-related factors to be analysed. From this it will be possible to draw realistic recommendations to prevent errors in the general practice setting. The World Organization of Family Doctors (WONCA)13 has formed a group that brings together the research leaders and participating GPs from practice-based research networks in different countries.5 This group is open to any general practice research network in the world, and is particularly trying to include networks in developing countries. Meetings are organised to share experience and develop methods for data collection. In addition, an Internet mailing list provides an ongoing forum. This group is testimony to the coming of age of general practice, and its mission is likely to reach beyond general practice — scientists are increasingly aware of the need for community-based longitudinal data to evaluate innovative developments such as advances in genetics. Research networks can change the culture of biomedical science by shifting the focus of research from technology in the hospital to patients and their diseases in the community. Furthermore, networks can build general practice research capacity. The Dutch university-based research networks are a case in point, having made a substantial contribution to academic primary care research capacity and output, and the development of evidence-based general practice guidelines.9 General practice research networks can have substantial impacts on research, and their structure and financing require the attention of the scientific community. Ultimately, though, their future depends on the quality of their contribution to biomedical research.

Chris van Weel FRCGP

Primary care research networks have emerged in other countries over the past decade. Rigorous data to determine the level of their achievement are lacking. Research networks are a part of the current Australian primary healthcare research capacity building program, yet we have no systematic approach to their introduction. Australian networks should build upon international experience and should not duplicate the role of Divisions of General Practice. Each network should have clearly defined aims, strategies and key indicators against which to evaluate performance.

Jane M Gunn PhD, FRACGP

Objectives: To develop an international taxonomy describing errors reported by general practitioners in Australia and five other countries.Design and setting: GPs in Australia, Canada, the Netherlands, New Zealand, the United Kingdom and the United States reported errors in an observational pilot study. Anonymous reports were electronically transferred to a central database. Data were analysed by Australian and international investigators.Participants: Non-randomly selected GPs: 23 in Australia, and between 8 and 20 in the other participating countries.Main outcome measures: Error categories, and consequences.Results: In Australia, 17 doctors reported 134 errors, compared with 301 reports by 63 doctors in the other five countries. The final taxonomy was a five-level system encompassing 171 error types. The first-level classification was "process errors" and "knowledge and skills errors". The proportion of errors in each of these primary groups was similar in Australia (79% process; 21% knowledge and skills) and the other countries (80% process; 20% knowledge and skills). Patient harm was reported in 32% of reports from Australia and 30% from other countries. Participants considered the harm "very serious" in 9% of Australian reports and 3% of other countries' reports.Conclusions: This pilot study indicates that errors are likely to affect primary care patients in similar ways in countries with similar primary healthcare systems. Further comparative studies are required to improve our understanding of general practice error differences between Australia and other countries.

Meredith A B Makeham BMed(Hons), FRACGP · Mary County LLB(Hons) · Michael R Kidd MD, FRACGP · Susan M Dovey MPH, PhD

Objectives: To determine general practitioners' (GPs') attitudes towards and involvement in general practice research.Design: Postal survey and semi-structured interviews conducted from May to September 2001.Participants and setting: 467 of 631 GPs in four Queensland Divisions of General Practice responded to the survey (74% response rate); 18 selected GPs were interviewed.Main outcome measures: Survey — attitudes to research; access to information resources; and involvement in research. Interviews — the need for general practice research; barriers against and factors enabling greater participation in research.Results: 389/463 (84%) GPs, especially younger and more recent graduates, had positive attitudes to research, but only 29% wanted more involvement. 223/462 (48%) were aware they had access to MEDLINE, although presumably all those with Internet access (89%) would have free access via PubMed. Barriers included the general practice environment (especially fee-for-service funding), and the culture of general practice. Enabling factors included academic mentors; opportunities to participate in reputable, established research activities relevant to general practice; and access to information resources.Conclusions: Although Australian general practice has a weak research culture, about a third of GPs would like to increase their involvement in research. However, the research must be perceived as relevant, and structured to minimise the inherent barriers in the environment and culture of general practice.

Deborah A Askew GradDipNutr · Alexandra M Clavarino BA, PhD · Paul P Glasziou MB BS, PhD · Christopher B Del Mar MD, FRACGP, FAFPHM

Widespread availability of quality general practice services is the key to the Australian healthcare system.1 The general practitioner is the gatekeeper. Lack of access to general practitioners flows on to lack of access to specialist and tertiary healthcare, thereby challenging key principles of Medicare such as universality and equity. In the past, adequacy of the general practice workforce was assessed by comparing crude doctor-to-population ratios through time and against other countries, and by assessing utilisation (the number of GP visits per capita per year) against some arbitrarily chosen standard. Neither approach took adequate account of issues such as the differing roles of the GP, availability of alternative primary care services, population demographics or health status of the population. Nor did it take into account maldistributions. This approach was very crude, and it soon became apparent that better methods of assessment were needed. In the 1970s and 1980s, opinion swung between the notion that we had too few medical practitioners,2 and then too many.3 By the mid-1990s, government favoured a restriction on provider numbers and on the entry of overseas-trained doctors. Also, it was no longer assumed that distributional issues could be left to resolve themselves. In the 1992–93 financial year, the Federal Government started spending money on the rural medical workforce problem, introducing the Rural Incentives Program (later constituted as the Rural and Remote General Practice Program, or RRGPP). More recently, in the second half of the 1990s — reinforced by successive Australian Medical Workforce Advisory Committee (AMWAC) reports4,5 — it was the orthodox view that Australia had too many GPs overall, but too few in rural and remote areas, and too few medical specialists. By 1998, AMWAC had undertaken studies covering 50% of the specialist workforce, had reported shortages in most of them, and had recommended increases in training numbers.6 This was despite increasing anecdotal evidence of shortages across the board in the availability of general practice locums and the availability of GPs in outer metropolitan areas. The adequacy (or otherwise) of the medical workforce is not solely a function of the demand for services. There are important supply-side issues, such as lifestyle choices, the feminisation of the medical workforce, and the length of specialist training. As female GPs work fewer lifetime hours, feminisation of the workforce means more doctors are needed for the same total hours of work. These factors affect the required number of medical graduates in order to "produce" the necessary hours of work. However, decisions to increase or decrease medical school intakes do not influence practising doctor numbers for at least a decade. A model developed by Access Economics uses econometric tools to analyse both the supply and demand for GPs.7 With this model, demand for general practice services is shown to be well explained by patient demographics (age and sex both influence demand for general practice services) and socioeconomic factors, together with rurality and remoteness and the price of general practice services. The model also found, as detailed in the Access report, that Australia has a current overall shortage of GPs, and that the shortage is no longer confined to rural and remote regions, but is also increasingly apparent in outer urban areas, often areas of significant socioeconomic disadvantage.7 The report foreshadows that Australia is heading toward GP shortages that would be socially and politically unacceptable. In the early 1970s, Julian Hart, a United Kingdom general practitioner, described the "inverse care law", which essentially states "the availability of good medical care tends to vary inversely with the need for it in the population served".8 Some 30 years later the report by Furler and colleagues in this issue of the Journal (page 80) shows that the inverse care law is still alive and well in general practice consultations in Australia.9 They showed that there is an inverse relationship between the need for longer consultations and the provision of them, thus adding a further dimension — a quality-of-care issue — that was not quantified in the Access model.7 Workforce planning is one of the most difficult areas of public policy. There is no proud record of achievement. As a nation, we have got it wrong more often than we've got it right. Currently, there are skill shortages in many areas of healthcare — nursing, medical technology and radiation therapy, to name just a few. One policy option is to increase public spending on medical education, but there's not much evidence this will be embraced in the near future. The Federal Government is emphasising skilled workers in immigration programs, but many other First World countries are competing with us. We are seeing the emergence of "world markets" for skilled workers, stimulated by the growth of transnational companies and trade in services.10,11 Trade barriers are falling, along with barriers to the international movement of skilled workers. This adds an extra burden to public policy, because actions taken on the other side of the globe will influence the effectiveness of what is done here. If we trained more doctors, would we simply lose them to other countries that can and will pay more? The Federal Government has a very strong influence over doctor numbers. It determines and controls undergraduate places, GP vocational training positions and overseas-trained doctor and temporary-resident doctor intakes. It also shares control with the States over the availability of specialist postgraduate training places through public hospital funding decisions. The government will struggle to solve the problems. To get the "right" number of doctors is hard. To solve the distributional problems is harder still. But get it right we must, especially in light of our ageing population with its burden of chronic illnesses. The equity, access and health-outcome implications of getting it wrong are significant. The profession must also grapple more visibly with the issues and enter the dialogue with a preparedness to engage on a wide range of sometimes controversial issues, including greater use of nurses within practices, differential rebates, and greater use of patient copayments to dampen demand.

John F O'Dea BA · Roger J Kilham BEc

Objective: To compare the rate of provision of longer consultations per head of population across practice locations categorised by socioeconomic status.Design: Retrospective analysis of Medicare data for all consultations for all general practitioners in Australia for the 1998–99 and 1999–2000 financial years, grouped by postcode of practice location. Postcodes were categorised by the Socio-Economic Indexes for Areas, Index of Relative Socio-Economic Disadvantage score.Main outcome measures: Number of consultations and number of brief, standard, long and prolonged consultations per capita in each postcode grouping.Results: The absolute number of long plus prolonged consultations showed no trend across postcode groups, but the rate ratio per person was significantly higher in more advantaged postcode areas. This represents an example of care provision in inverse relationship to need.Discussion: Despite higher rates of chronic disease and lower rates of preventive care uptake, patients in low socioeconomic status areas receive longer GP consultations at a lower rate than patients in more advantaged areas. Possible strategies to overcome this inverse care provision include increased numbers of GPs in disadvantaged communities, removal of financial disincentives to longer consultations, and strengthening health promotion and community health services in disadvantaged areas.

John S Furler MB BS, MRCGP, GDipPubHlth · Patty Chondros BSc(Hons), GDipEpi · Doris Y L Young MB BS, MD, FRACGP · Elizabeth Harris BA, MPH · P Gawaine Powell Davies BA, MHA · Mark F Harris MB BS, DRCOG, FRACGP, MD

Objective: To examine the demographic changes in the cohort of general practitioners servicing residential aged-care facilities (RACFs) from 1984 to 2000.Design: Quantitative analysis of Medicare datasets from 1984 to 2000.Participants and setting: All GPs who provided Medicare-claimed RACF services from 1984 to 2000.Main outcome measures: Aggregate data on RACF GPs by age group and sex; total and average number of RACF services by GP age group and sex.Results: The proportion of RACF GPs younger than 35 years has declined from a peak of 30.2% in 1986 to 11.5% in 2000. GPs aged 45 years and older made up 58.1% of all RACF GPs in 2000, compared with 41.4% in 1984. In 2000, 28.4% of RACF GPs were female, compared with 13.5% in 1984. The proportion of RACF services provided by GPs younger than 35 years fell from 19.2% in 1984 to 4.5% in 2000, and the proportion provided by GPs aged 45 years and older increased from 54.7% to 72.4%. Female GPs' RACF services as a proportion of all RACF services increased from 8.9% to 15.9% between 1984 and 2000, but the average number of RACF services per female GP declined by 15.6 services per year. In contrast, the average number of RACF services per male GP increased by 11.2 per year. The increasing rate of RACF servicing by older GPs is independent of female GPs' declining involvement.Conclusion: Our results suggest an increasing reliance on older, male GPs in the supply of RACF services. Although the proportion of female RACF GPs has increased, average services by these GPs, who are generally younger, has declined. The personal and work preferences of female GPs may have implications for future RACF services supply as older, generally male, GPs retire.

Gregory A Lewis MPubAd, MA(Psychoanalytic studies) · Robert W Pegram MB BS, MHSM

Objective: To identify key issues affecting women general practitioners in their professional and non-professional lives.Design: A qualitative study using the Delphi technique, with three rounds of data provision circulated to each participant. Coding was used to ensure anonymity.Setting and participants: The participants were a purposive sample of 40 women GPs drawn from all Australian States and Territories. The study was conducted between October 1996 and January 1997.Outcome measures: Key issues affecting the professional and non-professional lives of women GPs.Results: Some of the key professional issues for women GPs were job satisfaction, balancing work and personal life, autonomy, availability of flexible and part-time work and training, affordability of professional expenses, fair remuneration, and having a voice in decision-making. Key non-professional issues included self-care; time for relationships with a partner, children, family and friends; and time management to allow pursuit of non-medical interests.Conclusions: The conflicting demands made on women GPs diminish their job satisfaction and lead to stress and imbalance in their lives. Recommendations to ameliorate the problems for women GPs include appropriate training, policy formation, financial and other support, and a change in cultural expectations of women GPs by the community, the profession and governments.

Margaret R Kilmartin MB BS, FRACGP · Christopher J Newell MA, PhD · Martin A Line MSc, PhD

Since 1998, listed public corporations have actively sought to capture a significant proportion of the Australian general practice market. They have paid generously for the "goodwill" of existing practices, entered limited contracts with the doctors in those practices, and relocated some of these doctors to large centres where general practice is linked directly with other diagnostic, imaging and treatment services owned by the corporation. The benefits of these changes for the corporations include assuring referrals to their diagnostic and imaging services (in a competition for market share for these high-cost services), access to private insurance rebates through licensed day-procedure centres, and possible economies of scale. General practice corporatisation and the issues involved have been described elsewhere.1-3 However, the process of general practice corporatisation is maturing, and I would like to discuss some emerging trends and their implications. Emerging trendsThe initial enthusiasm for shares in general practice corporations is waning. Shareholders, institutions and analysts now focus on earnings rather than projections. A collapse in the price of shares in listed general practice corporations in August 2001, followed by a partial recovery, led to a more realistic focus on earnings as a determinant of share price. In addition, the collapse contributed to decisions to terminate practice purchases and to delay public listing by at least one corporation.4 General practice corporations have not shown the same earnings performance as other sectors of the health market, such as private hospital operators. Those owning their own pathology, imaging and specialist services are more profitable than those without vertical integration of referrals. These changes, coupled with recent amendments to the Privacy Act — Privacy Amendment (Private Sector) Act 2000 (Cwlth) — which now require a patient's consent for the transfer of medical records, have caused most general practice corporations to limit new practice purchases, making their initial targets of 50% of the general practice market overly optimistic. Although corporations have a large share of the Perth market (around 40%), it is unlikely they will achieve more than 20% of other metropolitan markets, such as Sydney or Melbourne. Future trends include corporatised practices moving away from bulk-billing of all GPs' services (this has already commenced in some areas of Sydney). Mergers between general practice corporations should further concentrate the market. Other models of general practice integration are emerging, such as general practice market-based cooperatives, where GPs share ownership of diagnostic and therapeutic services and benefit from the profits of those services; Division-based cooperatives;5 and serviced-office arrangements, where GPs collocate, but retain ownership of their own practice (for example, Health Connectiv Pty Ltd). General practice corporatisation and medical ethicsIn the past, some Australian doctors have been induced to act as agents of corporations, not of their patients.6,7 I have previously argued that an informed health consumer relies on the advice and assistance of his or her GP. For the health system to operate as a free market, GPs must act as their patients' agent, not as agents of third parties.3 As there is considerable information asymmetry between health consumers and providers, access to an informed agent or broker, who is free to act solely as a patient's agent in the health system, is a consumer protection issue, not just an issue of professional freedom. This is also the primary principle of medical ethics, which for over 3000 years has required doctors to put their patient's health needs before all other considerations.8 On the other hand, directors of corporations are required to put the needs of shareholders first.9 Meeting the needs of shareholders through customer service is good business practice, but the needs of patients and shareholders will not always coincide. In such a situation, if GPs are not able to put their patient's needs before the needs of the corporation their patients lose. Governments, health consumer representatives, health professionals and managers of health corporations must clearly understand that GPs have a role as honest brokers for their patients in the healthcare system, and must ensure GPs are free to stand up to third parties such as insurers or corporations in the event of competing interests. Governments and general practice corporatisationThe New South Wales Government was the first in Australia to respond to the potential for doctors to experience competing interests. After ministerial inquiries into the provision of male impotency services and the cosmetic surgery industry,6,7 the NSW Government introduced amendments to the Medical Practice Act 1987 (Medical Practice Amendment Act 2000). The Act can now exclude an employer, manager or director from involvement in any company providing medical services if he or she is found to have incited doctors to unsatisfactory professional conduct, or is party to either payment of pecuniary benefits for unnecessary services or directing referrals. Although some States are prepared to act to the extent of their powers to ensure corporations do not influence clinical practice, the Commonwealth Government has encouraged corporatisation of medical practice through its own inertia. It is responsible, through the payment of Medicare rebates by the Health Insurance Commission, for most of the expenditure in this market, where listed corporations are making shareholder profits largely from the public purse. As an example, the Commonwealth Government permits vertically integrated corporations to share profits from internal referrals while continuing to enforce regulations that prohibit the sharing of profits from referrals between traditional practices. The Australian Medical Association and some corporations, with the later involvement of the Royal Australian College of General Practitioners (RACGP) and the federal Minister for Health, developed a Code of Conduct, which was released in October 2001.10 The code was criticised as ineffective at that time.11,12 At 3 June 2002, the code had three signatories. Corporatised practice and health policyThe balance of powerThe prime policy problem is imbalance in the relationship between GPs and their contracting corporation, and the subsequent vulnerability of their patients to exploitation by third parties. As a result of the Australian Competition and Consumer Commission's (ACCC) interpretation of the Trade Practices Act 1974 (Cwlth), the AMA is able to provide professional and legal advice about contract issues to its members, but is prevented from representing individuals or groups of GPs in a contract dispute with a corporation. Leaving aside the possibility that corporate doctors could be deemed to be employees by the Australian Taxation Office, and so become eligible for group representation through a union, GPs under contract are currently sole agents in their relationship with a corporation. Regardless of the details of the contract or the merits of their position, all remedies involve possible civil action. It is unlikely that many individual GPs would take action against a corporation able to defend its position with hundreds of millions of dollars. It would also be difficult for a GP to win a contested case in a civil court against a well funded opponent. An additional inhibiting factor for corporatised GPs is the need to renegotiate a contract with the corporation every four to five years. It is a simple matter for the corporation to refuse to renew a contract, or to make a contract so onerous that a GP would not renew. The doctor is then without a practice or an income source, facing ongoing geographic exclusions from the area of the previous contract, as well as the costs and difficulties of establishing a new practice in another area. Far more subtle, however, is the use of recontracting by corporations to reward profitable or compliant doctors. As more contracts come up for renewal, this is likely to be the most pervasive form of influence corporations exert on GPs. There is an overwhelming argument that it is in the public interest to support organised representation for GPs in contracts with general practice corporations. If the Commonwealth Government, the ACCC and the AMA are unable to provide this, GPs' class actions in civil courts could provide some relief and alter the balance between individual GPs and large corporations. GPs of the future: agents or honest brokers?A policy initiative within the medical profession's grasp is ensuring that GPs clearly understand their ethical responsibilities to their patients, and remain alert to the ways corporations, governments, drug companies and insurers seek to influence them, and so influence the decisions they make on behalf of their patients. This is not a simple matter. The medical profession must also recognise that its actions as a group determine the services and resources available at a population level, while at the same time encouraging doctors to deliver the best possible care for each individual patient. As Australia moves further along the path to "for profit" healthcare, there is a need for greater emphasis on teaching professional ethics in undergraduate, postgraduate and continuing education for general practice. The economics of medical practiceEconomists and governments, under the mistaken belief that primary medical care is not delivered in a competitive market, attempt to apply free-market principles without understanding their effects on the operation of the market and the vulnerability of uninformed consumers in the market. The response to corporatisation of general practice is only one example of government confusion about the components of competition in healthcare, and their need to ensure public protection.3 Other examples include advertising of medical services, the application of the Trade Practices Act to rostering arrangements by medical practitioners, and recent attempts by the Commonwealth Government and insurers to influence the way GPs prescribe or refer their patients. A better-informed economic analysis of the operation of the Australian health system, which includes the opinions of consumers and providers, could assist policymakers to design a health system which follows function, rather than the current design which promotes dysfunction. LegislationFinally, legislation to cover competing interests when doctors refer should not be seen as a remedy for this problem. Attempts in the United States to codify relationships between referring doctors and third parties (the Stark Laws)13 have, for little benefit, increased the clinical and legal complexity of medical practice. These laws were passed in response to widespread public and legislative dissatisfaction about the perceived divided loyalties of US doctors, and the consequent effects on patient care, resulting from longstanding interference by insurers, governments and corporations in the relationship of trust between doctors and their patients. Enforcing the existing prohibition of commercial arrangements between referring doctors, and between doctors and third parties, is preferable to legislating to ensure propriety in arrangements which result from corruption of normal ethical practices. Australians are still in a position to prevent a similar outcome, but the market is operating and time is short.

Paul D Fitzgerald FRACGP, FAFPHM, FAIM

To the Editor: In 1997 an analysis of the medical workforce in North Queensland showed that Townsville's 125 000 people were served by about 180 GPs providing about 120 full-time-equivalent (FTE) GP workloads. A doctor–population ratio (DPR) of about 1: 1000 was evidence of some sort that the community was reasonably well served, at least according to benchmarks of the time. As a result, the "area of need" status was removed from many North Queensland centres, a decision reinforced by similar findings from the Australian Medical Workforce Advisory Committee (AMWAC) report released soon after.1 Further, the AMWAC report was the basis of a decision not to increase the number of GP vocational training places in the region, even though there is spare capacity and the program is one of the more successful in terms of retention of rural GPs.2 Despite persistent claims to the present time that there is no shortage of GPs in regional centres, in 2002 the number of FTE GPs in this community appears to have fallen to about 95, despite strong population growth to about 150 000 people, resulting in a DPR of around 1: 1500. The city's two extended-hours clinics have closed, very few practices direct bill, new residents have trouble getting an appointment in any general practice, and fewer GPs are providing after-hours care. The recent Access Economics report, commissioned by the AMA, indicates that this trend is evident elsewhere. Anecdotal evidence suggests that it is not necessarily the total number of GPs that is changing, but rather their work patterns. The increasing proportion of female graduates probably reduces the available FTE workforce, and more male graduates are now opting for a lifestyle that better balances clinical work with family responsibilities and interests outside of medicine. Medical workforce research is an interesting, yet risky, academic business, beset by many complex issues relating to definitions, data sources and the measurement and interpretation of DPRs.2 Despite our best endeavours and close proximity, the report conducted by me and my colleagues in 1997 was almost certainly incorrect within a very short time. I am inclined to think that GPs have a better sense of what is happening on the ground than do the sifters of data. The biggest challenge to workforce analyses, and therefore to patient access to GP care, may be the societal changes in work patterns, not in raw numbers, and these issues need to be better understood if we are to make progress in managing workforce issues.

Richard B Hays

In 1999, the Commonwealth Government introduced the Enhanced Primary Care (EPC) package, aimed at improving preventive healthcare and coordination of care, particularly for elderly people.1 This package comprised a number of elements, including the introduction of new items on the Medical Benefits Schedule (MBS) to enable general practitioners to conduct health assessments (annual assessments of medical health and physical, psychological and social function in elderly patients), care plans (plans to coordinate the care of patients with chronic disease requiring care from multiple providers) and case conferences (see Box 1). Case conferencing was designed to enable GPs to shift from episodic care to providing longer-term care in collaboration with a wider healthcare team. It involves GPs organising or participating in a conference with two or more other healthcare providers. It may be conducted in person or by telephone or videoconferencing. The patient's consent must be obtained, and patients and carers may also be involved. The case conference is a tool for coordinating care across a multidisciplinary team.2 It is used by team members to identify and discuss the care needs and goals of patients with chronic or complex conditions and to assign interventions to particular members of the team.3 Although there is little evidence as yet of their impact on health outcomes, the value of case conferences is that they help ensure that problems are properly identified, care is not duplicated, and errors in communication (which all too often result in adverse events4) are minimised. Case conferences can also serve as a vehicle for education and an opportunity for healthcare providers to get to know each other, thereby building up capacity and strengthening the team approach.5 Those who stand to benefit most from the case-conference approach include patients who have complex problems for which the GP has difficulty finding solutions (eg, patients with stroke or other physical or intellectual disabilities);6 are coping with complex psychosocial problems, such as child abuse;7 have cognitive problems that make them unable to coordinate their own care among providers; require case management across multiple services (eg, those with mental health problems); are managed by telemedicine or by visiting teams in rural areas;8,9 and need coordination of care after being discharged from hospital. There has now been considerable uptake of the health assessments and care-planning items by GPs. However, uptake of the case-conferencing items has been particularly slow, representing less than 3% of total EPC items claimed (see Box 2). In February 2002, there were 577 case conferences in the whole of Australia, compared with 25 787 care plans for the same period. What are the reasons for this? Mitchell et al (page 95)10 detail some of the difficulties GPs experience in fulfilling the requirements for case conferencing. The main problems are logistical ones. The procedures to be followed (including prior patient consent) when initiating case conferences are complex. Even when teleconferencing is used, it is difficult to synchronise times when all participants are available. A single case conference is not enough to build the knowledge and trust required among participants with differing agendas and service orientations, making commitment to participation and joint decision-making difficult. Healthcare workers other than GPs may initiate case conferences. However, the EPC has been a somewhat one-sided development. GPs and private physicians are remunerated for their roles (new physician MBS items were introduced in May 2002), but community and allied health professionals are not. Nor are non-government organisations such as Home and Community Care services or community-controlled Aboriginal health services. Many State-funded health services (such as those for aged or palliative care) are understaffed and find it difficult to engage GPs in their existing case conferences because of conflicting demands on their time. In contrast to case conferences, health assessments require action only by the GP, and much of the work can be done by other healthcare professionals, such as a practice nurse working with the GP. Thus, GPs have been quick to make use of health assessments. The uptake of care-planning items has been slower, but started to take off in the first half of 2001. This was due to various factors: the establishment of education and training programs, the provision of practice support from Divisions of General Practice, and the offer of extra incentives through the Practice Incentives Program. Given the extra organisational complexity of case conferences and the lack of specific support systems to date, it is hardly surprising that uptake by GPs has been low. Continuing with the existing items, using a targeted approach to identify patients who will benefit most (eg, patients with complex psychological or social problems), may be appropriate. However, we should also consider whether the current case-conferencing items are what is really needed. Consultation–liaison (in which a specialist provider provides consultation support to the GP) and case management approaches have been shown to be effective in primary care.11,12 Two separate phone discussions to develop a care plan with two other providers may achieve many of the same objectives as a single case conference. While this may not represent a full "multidisciplinary" approach as envisaged in the EPC package, it does at least work. Such a model should be considered for an EPC rebate as an alternative to the current requirements, which are clearly too difficult. On a more fundamental level, perhaps we first need to devote more time to developing primary care teams within practices and between GPs and local community-based and allied health services.13 Case conferencing not only facilitates integration between health service providers, it depends upon it.14 The difficulties in implementing case conferencing may simply be a demonstration of the lack of effective multidisciplinary education and team building within much of Australian primary care. 1: Requirements for case conferences under the Enhanced Primary Care program* Which patients are eligible? Patients with one or more chronic conditions and multidisciplinary care needs How often can a case conference be held? No more than five times a year, or once for each hospital admission Participants General practitioner and at least two other formal care providers What is involved? Provision of relevant patient history and identification of problems and management issues Setting (or review) of goals and management strategy Evaluation of progress Allocation of tasks to team members Paperwork required List of participants and times the conference commenced and concluded Documentation of problems, goals, and strategies discussed Summary of outcomes (provided to all participants) Obligations to patient Patient must provide informed consent and receive a copy of the summary. *Medical Benefits Schedule book. 1 Nov 1999. Sections A.20, A.21, A.22 (Items 700–773). Canberra: Commonwealth Department of Health and Aged Care, 1999: 32-35. Available at: <http://www.health.gov.au/pubs/mbs>. Accessed 13 June 2002. 2: Claims for enhanced primary care items, by month* *Australian Health Insurance Commission. MBS item statistics reports. Available at <http://www.hic.gov.au/statistics/dyn_mbs/forms/mbs_tab4.shtml>. MBS = Medical Benefits Schedule.

Mark F Harris FRACGP MD

Objectives: To identify general practitioners' views on the barriers to using case conferencing (as outlined in the Medical Benefits Schedule (MBS) Enhanced Primary Care package) and to develop a set of principles to encourage greater GP participation in case conferences.Design: Qualitative study, involving semistructured questions administered to focus groups of GPs, conducted between April and July 2001 as part of a broader study of case coordination in palliative care.Participants: 29 GPs from urban, regional, and rural areas of Queensland.Principal findings: Many of the GPs' work practices militated against participation in traditionally structured case conferences. GPs thought the range of MBS item numbers should be expanded to cover alternative methods of liaison (eg, phone consultations with other service providers). The onerous bureaucratic processes required to claim reimbursement were an additional disincentive.Conclusions: GPs would probably be more likely to participate in case conferences if they were initiated by specialist services and arranged more flexibly to suit GP work schedules.

Geoffrey K Mitchell MB BS, FRACGP · Christopher B Del Mar MD, FRACGP · Alexandra M Clavarino BA, PhD · Inge C de Jong MPsychEd, BSc · Rosemary Kennedy PhD, BA, GradDipSocSc, GradDipTESOL

Objective: To determine whether doctor–patient encounters in general practice with patients from a non-English-speaking background (NESB) differ from encounters with patients of English-speaking background (ESB) in terms of the type of practice where the encounters occur and the type of problems managed.Design and setting: A national cross-sectional survey of GP–patient encounters from a sample of all active registered GPs in Australia.Participants: A random sample of 1047 GPs recruited in the 12 months from April 1999 to March 2000, each providing details of 100 consecutive patient encounters.Main outcome measures: GP demographics, practice characteristics, patient demographics (including whether the patient mainly spoke a language other than English at home), and problems managed at the encounter.Results: After adjusting for significant predictors, encounters with NESB patients were significantly more likely to occur at solo practices than practices of five or more GPs (odds ratio [OR], 2.15; 95% CI, 1.49–3.09), in metropolitan practices (OR, 6.34; 95% CI, 4.04–9.96), and with GPs who mostly consulted in a language other than English (OR, 5.44; 95% CI, 3.78–7.83). NESB encounters were relatively more likely to involve a respiratory problem (OR, 1.14; 95% CI, 1.04–1.26), endocrine/metabolic problem (OR, 1.41; 95% CI, 1.22–1.63) or digestive problem (OR, 1.14; 95% CI, 1.02–1.27), and relatively less likely to involve a psychological problem (OR, 0.73; 95% CI, 0.61–0.88) or social problem (OR, 0.67; 95% CI, 0.49–0.92).Conclusion: Differences in morbidity management rates between encounters with NESB patients and ESB patients may reflect both differences in underlying prevalences of some disorders in the population of general practice patients, as well as different reasons among the two groups for attending general practice.

Stephanie A Knox BSc, BA (Hons) · Helena Britt BA, PhD

Alcohol is probably one of humanity's oldest drugs, and is the most widely used drug in the Australian community.1 In this issue of the Journal (page 103), the article by Graham and colleagues, on newer pharmacotherapies to help people with alcohol dependence,2 highlights specific interventions that general practitioners can use to help their patients with more severe alcohol-related problems. It is worth noting that most of the morbidity associated with alcohol use does not occur in people with dependence, but rather in those who have hazardous or harmful drinking patterns. The National Mental Health and Wellbeing Survey indicated that, among young men aged 18–24 years, the prevalence of harmful use of, or dependence on, alcohol was over 20%.3 The 1998 National Household Drug Survey found that 18% of people surveyed admitted to driving, 30% admitted to verbally abusing another person, and 2% admitted to physically assaulting another person while under the influence of alcohol.1 The acute health and social effects of alcohol intoxication are just as devastating as the long-term effects of chronically excessive alcohol consumption. Many GPs have negative perceptions of dealing with people who have alcohol and other drug-related problems.4 However, GPs can be very effective at altering the consumption habits of non-dependent drinkers.5 If the matter is raised, most Australians who drink too much will respond to a structured discussion with their GP about their alcohol consumption patterns. This may be where the general practice "main game" ought to be. The first step in managing people with alcohol-related problems is to identify them, and currently the AUDIT questionnaire is accepted as the most appropriate screening tool in the general practice setting.6 A copy can be found in the recent Guidelines for preventive activities in general practice.7 Screening of all Australians over the age of 15 is recommended. Brief intervention — the steps Identify individuals in whom alcohol consumption is hazardous or harmful Determine the person's readiness for change If contemplating change, discuss the benefits of reducing drinking Suggest strategies for reducing consumption Negotiate goals Arrange follow-up Brief intervention (see the Box) involves GPs raising the question of alcohol intake, and determining whether patients might consider changing their levels of consumption. If so, then risks and benefits of drinking are explored, strategies for reducing alcohol intake to safer levels are presented, goals are set, and follow-up is arranged. If patients do not wish to discuss their drinking, they can be given some printed information and the door left open for them to return if they change their minds. The intervention is quick and easily learnt. Many Divisions of General Practice across Australia offer training in brief intervention and motivational interviewing. GPs can also help their patients overcome alcohol dependence, but interventions for this require more time. Detoxification in the community, supervised by GPs, can be a safe option,8 and rural GPs supervise hospital-based detoxification on a regular basis. The use of anti-relapse medications such as acamprosate or naltrexone can help alcohol-dependent patients remain abstinent once they have undergone detoxification. However, as such patients ideally require counselling and support from professionals specifically trained in addiction, the GP's role is as a member of a team. The medication is only part of the assistance package. It should also be remembered that screening and therapeutic interventions for alcohol problems are just one of many competing demands on GPs. High blood pressure; diabetes; smoking; screening for breast, cervical and colorectal cancer; depression; domestic violence; falls — the list of competing preventive priorities seems endless. Where should alcohol fit into all of this? What are the opportunity costs? What are the workforce ramifications of these types of preventive activities? Is there spare capacity within general practice to address these tasks? Clinical practice guidelines and recommendations about preventive activities are positive developments in themselves, but are rarely accompanied by any consideration of whether they are possible to implement on a broad and equitable basis. Despite significant philosophical shifts within general practice and a growing acceptance of the value of prevention, the dominant medical model remains diagnosis and treatment. This pervades the way that general practice functions, the way it is structured and the way it is remunerated. In a recent survey of general practice in 2000–2001,9 alcohol-related activities did not rate in the "top 30" most frequently managed problems. This reflects a reality that most health bureaucrats are reluctant to acknowledge — what is being asked of general practice is often beyond its capacity to provide. The GP is stuck in the middle, trying to respond to the community demand for diagnosis and treatment, while at the same time being asked to do more and more on a preventive level. The pertinent question as to whether the (usually population health) problem is best tackled through the medical model is almost never asked. There are often other approaches to these issues that are more effective, but might be politically unpalatable. In the case of alcohol misuse, reducing access though higher levels of taxation (resulting in a higher price), targeting public education campaigns, restricting advertising, random breath testing and increasing penalties for drink driving are all effective methods of reducing alcohol-related morbidity and mortality. In short, alcohol consumption is best addressed by public policy. General practice needs to focus on what it does best: diagnose and treat. There will be some circumscribed areas of prevention where the medical model fits well or where it is an important part of the whole picture. If we decide that alcohol consumption is one such area, then general practice needs to be adequately resourced to undertake this new task. However, there will be opportunity costs. There is good evidence that we can have a positive impact on alcohol consumption patterns, but we currently do not focus on this area in a substantial way because of real competing priorities that our community has placed before us.

Chris Holmwood MB BS(Hons), MClinEd, FRACGP, DipRACOG

Alcohol accounted for an estimated 3668 deaths and 95 917 hospital separations in Australia in the 1996–97 financial year.1 Alcohol-related deaths in Australia declined from 460 per million population in 1990 to 369 per million in 1997.2 The net economic cost of alcohol to the economy in 1992 was estimated to be $4.5 billion (this estimate includes increased healthcare expenditure and costs to industry from impaired productivity, increased accidents and absenteeism).3 Prevention and treatment of alcohol-related problems has been improving in recent decades. In the 1980s, brief interventions4 were developed for problem drinkers who reject abstinence or are unsuitable for this treatment goal. Brief interventions involve a combination of techniques, including motivational interviewing, feedback to patients of likely adverse consequences of current drinking, self-monitoring of drinking, developing a contract for future drinking, providing strategies to cut down drinking, and regular follow-up. Most clinicians try to discourage patients with life-threatening complications from alcohol from pursuing brief interventions. Recently, more effective pharmacological treatments have been developed for alcohol dependence. The aetiology, natural history, compliance with and response to treatment of alcohol dependence are similar to those for other common, chronic, relapsing–remitting conditions readily accepted by the medical profession as worthy of treatment.5 Treatment of alcohol dependence has been shown to substantially reduce healthcare costs in the period after compared with the period before treatment.6 PharmacologyThe main drugs used to treat alcohol dependence are acamprosate and naltrexone. Their profiles are shown in Box 1. EfficacyThis review is restricted to major studies providing the highest-quality evidence. Studies were preferred if they were larger, had a longer study duration and were more recent. Studies or reviews with a more rigorous design were preferred. Only one study directly compared acamprosate and naltrexone.10 AcamprosateThere have been 16 randomised controlled trials (RCTs) comparing acamprosate and placebo, two systematic reviews of acamprosate only (by the same principal author),11,12 and one cost-effectiveness study of acamprosate compared with placebo13 (E1) (for an explanation of level-of-evidence codes, see Box 2). The efficacy of acamprosate has been evaluated in a large number of well-designed studies involving large numbers of participants with six to 12 months of treatment or follow-up. These reports have drawn very consistent conclusions. Fourteen showed a statistically significant beneficial effect for acamprosate on several measures of alcohol consumption, including time to first drink, total abstinence rate and duration of cumulative abstinence (the proportion of drinking days per unit time). Many studies have also found a satisfactory retention in treatment and reduction in laboratory indices of alcohol consumption (γ-glutamyltransferase, carbohydrate-deficient transferrin). However, one randomised controlled trial of acamprosate versus placebo showed only a modest treatment effect and poor compliance.15 Unlike the other studies, patients in this study began treatment an average of 25 days after the last drink; 32% had relapsed before starting drug therapy. The cost-effectiveness study estimated that treatment with acamprosate resulted in net savings of 528 euros (equivalent to approximately A$880) per patient over 24 months compared with no pharmaceutical treatment.13 NaltrexoneThere have been 11 randomised controlled studies comparing naltrexone with placebo, one meta-analysis16 and one systematic review17 of the use of opioid antagonists for alcohol dependence (E1). Naltrexone has been assessed in fewer studies overall, with smaller numbers of participants, and only one study18 extended beyond three months' duration. Naltrexone has been shown to have a statistically significant beneficial effect on several measures of alcohol consumption, including time to first drink, time to first episode of heavy drinking, duration of cumulative abstinence and number of standard drinks consumed. The Cochrane review17 also noted that such benefits were lost six months after completion of treatment. The meta-analysis concluded that in the seven existing studies of naltrexone versus placebo, involving 804 patients, naltrexone produced a modest benefit: a reduction in relapse rates of 14% and an improvement in abstinence rates of 10%. All seven studies were of three months' duration. The incidence of at least one adverse event or discontinuation of treatment because of adverse events was comparable. However, nausea, somnolence, abdominal pain, anorexia and vomiting were significantly more common in patients treated with naltrexone. The systematic review concluded that the short-term benefits of naltrexone included an increase in total abstinence, and a reduction in the percentage of drinking days and the number of standard drinks of alcohol consumed. However, six months after the completion of treatment, the benefits of treatment were generally lost. Overall, the observed effects have been modest, and there is no evidence that these benefits extend beyond the duration of treatment. Intention-to-treat analyses of two recent studies comparing naltrexone and placebo resulted in largely unimpressive findings.18,19 However, in one of these studies,19 the overall completion rate was much lower than other studies. In a recent study of older, predominantly male, patients, 12-step facilitation counselling was used in conjunction with naltrexone,18 whereas other studies tended to use coping-skills therapy or relapse-prevention training. Two recent Australian studies showed a reduction in relapse rate for naltrexone compared with placebo;20,21 one of these was conducted in a standard clinical setting without extensive psychosocial intervention.21 Acamprosate and naltrexoneIn the only direct comparison of both drugs, there was no difference between treatments in time to first drink10 (E2). However, patients treated with naltrexone had a significant benefit in several measures of alcohol consumption compared with the acamprosate group. At the end of the first year, 41% receiving naltrexone and 17% receiving acamprosate had not relapsed, defined as having five or more drinks in a day. However, in this study patients and the doctors were aware of the treatment received. A meta-analysis for both drugs found that both drugs exerted significant, but modest, effects on drinking outcomes, with sizeable variability in results between studies22 (E1). More recent and more rigorous studies of naltrexone have found less favourable outcomes than earlier research. One systematic review concluded that both drugs achieved similar results, but naltrexone was not as well tolerated.23 Another systematic review of a similar selection of the literature concluded that both drugs reduced the frequency and severity of drinking over most of the aforementioned end-points.24 A multi-centre, placebo-controlled trial of naltrexone and acamprosate, alone or in combination, is in progress and may resolve some of these differences.25 Specific indicationsFormulating guidelines for pharmacotherapy of alcohol dependence is difficult because of the paucity of data from direct comparison of acamprosate and naltrexone. However, acamprosate should probably be considered the first-line treatment for patients with moderate to severe alcohol dependence, because of the larger body of supporting evidence and the benefits extending after treatment. Naltrexone is indicated for alcohol-dependent patients in whom acamprosate has not proved effective or has not been well tolerated, or for individuals whose lifestyle or past history indicates that compliance with taking medication is poor. The use of naltrexone for managing heroin dependence is controversial. However, there may be a place for prescribing naltrexone to alcohol-dependent patients who are also dependent on heroin. DiscussionDefining clear guidelines for use of the two main pharmacotherapies (acamprosate and naltrexone) is difficult in the present state of knowledge. This difficulty stems from the fact that the various studies have examined the use of these drugs over varying groups of outcome measures and study durations. Studies of acamprosate have generally used absolute-abstinence-based measures as the primary outcomes, while naltrexone studies have also measured more relative "harm-reduction" measures, such as relapse to heavy drinking or total amount of alcohol consumed. Acamprosate appears to have a prolonged action for up to a year after therapy has ceased, but compliance with a medication requiring thrice-daily administration is often difficult. On the other hand, naltrexone has well documented efficacy, at least in the initial three months of treatment, and is easier to take on a once-daily basis. Consideration of the outcomes desired by the patient, compliance history, other drug therapy and medical conditions may all influence the choice made by the prescriber. In patients with alcohol dependence who also suffer from chronic pain, naltrexone will cause some not insurmountable problems. In this situation, or in acute pain, analgesia can be provided by non-opioid drugs such as non-steroidal anti-inflammatory drugs (including parenteral ketorolac). Other approaches could include local or regional anaesthesia. Attempting to overcome blockade with high doses of opioids is dangerous and not recommended outside an intensive care unit. Opioid withdrawal may be precipitated in alcohol-dependent patients treated with naltrexone if they have also been taking heroin recently. Naltrexone has been used (with uncertain benefit) for treating heroin dependence, but to avoid the problem of precipitating heroin withdrawal naltrexone should only be introduced in patients who have abstained from opioids for seven to 10 days. The optimal duration of acamprosate or naltrexone treatment has not been established, but six months should be considered a minimum, and 12 months a more desirable duration of treatment. It is generally recommended that naltrexone should be avoided in patients with advanced liver disease or elevated results on liver function tests. Higher than recommended doses of naltrexone may elevate liver function test results, but these dangers may be overstated. It is not clear how severe liver damage has to be before naltrexone administration becomes dangerous. Avoiding naltrexone in patients with decompensated liver disease is prudent; naltrexone should also be used with caution in patients with less severe forms of hepatic impairment. Some authors recommend that naltrexone be avoided in patients with aspartate transaminase levels three times greater than normal, while others set the limit at five-times normal. Few studies have included many patients with the combination of severe alcohol dependence and mental illness. It is therefore unclear what effect mental illness has on the efficacy of acamprosate or naltrexone. However, one study included patients with stable mental illness and showed that they could be treated safely.20 There are no existing studies on the effectiveness and safety of the combination of acamprosate and naltrexone, but there is no theoretical reason preventing the combined use of these drugs. Acamprosate and naltrexone have been approved under the Pharmaceutical Benefits Scheme (PBS) for use in treating alcohol dependence, provided that the patient is in a comprehensive treatment program for alcohol dependence with the goal of maintaining abstinence. Each authority prescription lasts for two months. There is no stated limit to the duration of treatment, but further extension of PBS authority requires an additional application each time. The PBS subsidy reduces the price (30 days' supply) from $170.10 (acamprosate) or $167.28 (naltrexone) to $22.40 (both drugs). Product information for naltrexone states that treatment duration is up to 12 weeks. However, the length of treatment is at the discretion of the prescriber. Other drugsDisulfiram inhibits acetaldehyde dehydrogenase, so that alcohol consumption results in a build up of acetaldehyde, causing extremely distressing symptoms, including flushing, syncope, nausea, vomiting and diarrhoea. It is available in 200-mg tablets; the usual starting dose is 100 mg daily increasing to 300 mg maximum, with 200 mg being the usual dose. It has been available for many years for treating alcohol dependence, but is prescribed rarely as compliance is often poor. Evidence of efficacy is limited, although this may be partly due to difficulties in trial design24 (E1). Nalmefene has similar properties and a proposed similar mechanism of action to naltrexone26 (E2). It is not currently used to treat alcohol dependence other than in research settings. Ondansetron, a selective 5-HT3-receptor antagonist, has been shown in one study to have a beneficial effect on early-onset alcohol dependence27 (E2), presumably by modulating dopamine release in mesocorticolimbic dopamine pathways. There is insufficient evidence to justify its routine use at present. Other psychoactive drugs, such as lithium and some selective serotonin-reuptake inhibitor antidepressants, have been suggested, but no positive effect on alcohol dependence has been demonstrated in addition to the documented benefits in treating depression and other psychiatric conditions24 (E1). General managementWhen pharmacotherapy is included in the management of alcohol dependence, doctors should ensure that patients are also followed up closely and regularly, and should draw up a comprehensive treatment plan with each patient. This should include attempts to resolve any psychosocial issues. Prescribers are required to obtain a Health Insurance Commission (HIC) authority before prescribing acamprosate. The comprehensive plan can be provided by general practitioners using, where required, Expanded Primary Care (EPC) items. Engaging allied health professionals, such as alcohol and drug counsellors, may help patient management and also helps fulfil HIC requirements. A comprehensive treatment plan should be tailored to the needs of the individual patient and may need to involve combinations of modalities, including detoxification, counselling, referral to self-help groups or group therapy. The diagram in Box 3 may help guide doctors through the stages of managing patients who drink hazardous or harmful quantities of alcohol. Box 4 provides advice for patients, as well as telephone numbers for help-lines throughout Australia. 1: Profiles of acamprosate and naltrexone Acamprosate Action: Chronic exposure to alcohol causes a decrease in the inhibitory γ-aminobutyric acid (GABA)-ergic system and a corresponding increase in activity of the excitatory glutamate system in the central nervous system.7 Acamprosate, which has a similar structure to GABA, enhances GABA transmission by increasing the number of sites for GABA uptake. Acamprosate also interferes with the action of glutamate at various sites, such as n-methyl-d-aspartate (NMDA) receptors, and has also been shown to affect calcium channels, which increase in number as alcohol dependence develops.8 Dose: Acamprosate comes as 333 mg tablets, with the recommended daily dose for adults weighing over 60 kg being six tablets (1998 mg) orally in three divided doses, with meals. Adults weighing under 60 kg should take four tablets (1332 mg) per day. Usual practice is to start at half these doses and increase by one tablet a week. Metabolism: Only 10% of acamprosate is absorbed, of which 90% is excreted unchanged into urine. Adverse effects: Acamprosate is well tolerated, and its predominantly gastrointestinal adverse effects (commonly diarrhoea) usually resolve spontaneously. Side effects are minimised by gradual dose increases. Other low-grade side effects, including mild abdominal pain, are reported by some patients. Rash or isolated pruritus, paraesthesiae, decreased libido and confusion have all been reported at low frequencies. Drug interactions: Tetracyclines may be inactivated by the calcium component in acamprosate during concurrent administration. Contraindications: Acamprosate is contraindicated in patients with known hypersensitivity to the drug, renal insufficiency or cirrhosis with severe hepatic decompensation. The safety of acamprosate in pregnancy or lactation has not been established. Naltrexone Action: Naltrexone, a potent opioid-receptor antagonist, blocks the effects of endogenous opioids, which increase after alcohol consumption.9 Dose: Naltrexone is administered orally at 25 mg for 1–2 days, and then increased to the standard dose of 50 mg daily. Metabolism: Naltrexone undergoes extensive first-pass metabolism in the liver to β-naltrexol. Although a much weaker antagonist than naltrexone, the half-life of β-naltrexol is longer, and plasma concentrations of the metabolite are always higher than those of the parent drug. The mean elimination half-life values for naltrexone and 6-β-naltrexol are four hours and 13 hours, respectively. Adverse effects: Naltrexone is generally well tolerated. A number of studies indicate that non-specific and systemic symptoms, including headache, back-pain, flu-like symptoms, nausea and anorexia, have been more commonly reported by patients receiving naltrexone than those receiving placebo. However, there are also reports that side effects are no more common in patients taking naltrexone than in those taking placebo. Drug interactions: Naltrexone blocks the action of opioid analgesics, which can be problematic in clinical practice. Contraindications: Naltrexone is contraindicated in patients receiving long-term opioid therapy for chronic pain or heroin dependence. 2: NHMRC level-of-evidence codes Evidence for the statements made in this article is graded according to the National Health and Medical Research Council system14 for assessing the level of evidence. E1 Level I: Evidence obtained from a systematic review of all relevant randomised controlled trials. E2 Level II: Evidence obtained from at least one properly designed randomised controlled trial. E31 Level III-1: Evidence obtained from well-designed pseudo-randomised controlled trials (alternate allocation or some other method). E32 Level III-2: Evidence obtained from comparative studies with concurrent controls and allocation not randomised, cohort studies, case–control studies, or interrupted time series with a parallel control group. E33 Level III-3: Evidence obtained from comparative studies with historical control, two or more single-arm studies, or interrupted time series without a parallel control group. E4 Level IV: Evidence obtained from case-series, either post-test, or pre-test and post-test. 3: Managing patients who drink hazardous or harmful quantities of alcohol 4: Advice for patients Alcohol dependence is a chronic, relapsing–remitting condition. Treatment is moderately effective and comparable with that for many other chronic medical conditions. Inducing remission is usually less difficult than preventing relapse. It may help to attend self-help groups such as Alcoholics Anonymous <http://www.alcoholicsanonymous.org.au/> or the less well established Rational Recovery <http://www.rationalrecovery.net/>, although these interventions are difficult to evaluate and do not appeal to all. Self-help groups are also available for family members and children <http://www.al-anon.alateen.org/meetings/international.html>. As the risk of relapse is high, it is important to try to identify high risk factors and then to develop strategies to avoid these. Relapse should be dealt with by undergoing detoxification when required. It is helpful to attend follow-up with a doctor with whom you can establish a strong therapeutic relationship. Telephone counselling services are available 24 hours a day, seven days a week: Alcohol and drug telephone help-lines in Australia ACT: "Alcohol & Drug Programs" (02) 6205 4545 NSW: "Alcohol and Drug Information Service (ADIS)" 9361 8000 in Sydney, 1800 422 599 elsewhere in the State NT: "Alcohol & other Drug Service" (08) 8922 8399; Central Australia (08) 8951 7580 QLD: "ADIS" (07) 3236 2414; 1800 177 833 SA: "ADIS" (08) 8274 3333; 1300 13 13 40 TAS: "ADIS" 1800 811 994 (from interstate call 03 9416 1818) VIC: "Directline" (03) 9416 1818; 1800 136 385 WA: "ADIS" (08) 9442 5000; 1800 198 024

Robert Graham MB BS · Alex D Wodak FRACP · Greg Whelan FRACP

"Hey doc, whaddaya reckon? Is this sore infected? Do I need antibiotics? Mind if I walk with you?" So starts my clinical day as I walk from my parked car and potential patients fall in for street therapy. An informal consultation frequently ensues. Street drug users are in a hurry. Appointments and time management have no place in their chaotic lives. Setting aside time to see a doctor is well down the list of priorities. Most are in an endless rotating door — scamming at least a hundred dollars a day for heroin is the main game. Informal street consults are the way I dispense medical advice to this marginalised group. Most have no GP and have never sat in a waiting room; nor are they likely to. Time is precious as they push the limits of endurance to survive on the streets. Tolerating this exotic clinical behaviour has given me access to an unusual underclass of patients who rarely see doctors at all. I treat drug dependence within general practice in Kings Cross in Sydney. It is a magnet to drug users and is the epicentre of street drug culture in Australia — users flock here from all over the country. But first let me tell you what it is that makes the Cross different from anywhere else in Australia. Demographically, Kings Cross is a village perched on a hill between Rushcutters Bay and Woolloomooloo with the highest population density in Australia. Few of its denizens travel by car, and so the streets are always full of people at all hours of the day and night. From its halcyon days as a place where actors, artists and writers lived to now, when drug users rub shoulders with yuppie designers, journalists and movie makers, the Cross has seen more than its share of eccentric and odd behaviour, holding, as it does, an edgy juxtaposition of the marginalised with the mainstream. If nothing else, the Cross and its habitués are tolerant of extreme diversity. My practice is unique in that around half of my patients are injecting drug users. By the time they make it into treatment, a large proportion have depleted their finances and their health. Wasted, demoralised, often with criminal charges for break-and-enter or stealing hovering over their heads and the prospect of a jail sentence awaiting them, they attend my rooms. Their recent history is littered with failed attempts at home detoxification or geographical relocation to beat the heroin habit. Desperate family members will drag them in, trying to coerce them into treatment. This is rarely successful. Untreated serious infections are commonplace. Hepatitis C, chronic airways limitation, psychiatric comorbidity and serious injuries complicate their initial presentation. For them, I facilitate treatment with pharmacotherapies like methadone, buprenorphine and naltrexone. These treatments fit well into a primary care setting, allowing users a window of sobriety, a chance to "chill out" and reassess their lives. However, none of these treatments is a panacea. Many will start treatment only to fall out and resume again at another time. Others manage to stick it out, putting up with the rigour of attending treatment centres to requalify as functioning members of society. There is a clear correlation between staying in treatment and improved outcomes in this population. But, for me, the most important thing is to establish a therapeutic alliance with these once-feral individuals — no matter how tenuous this may appear — and slowly, over time, to observe the re-integration of personality and lost talent. For many have rare gifts and capacities that have fallen into disuse over years of addiction. This process is among the most gratifying experiences in medicine that I can think of. A psychiatrist once told me that treating addiction was the most difficult area of medicine to work in. I should adjust my expectations down from what I had been used to. In treating drug dependence, "there is no such thing as failure, just varying degrees of success", he said. This adage has stuck with me over the years. It really means that any engagement with a drug user is a success of sorts, and that to keep them in treatment, even for a few weeks, may give them that glimmer of hope to revisit treatment options in the future. In the past year I have had referrals from the nearby Medically Supervised Injection Centre. Some of these clients had never considered treatment as an option, but have had some gentle counselling in the "chill out room" after they have used their drug of choice. If they have experienced overdoses, there is some urgency in commencing treatment and I try to minimise the bureaucracy involved in providing them with a substitution treatment. My guess is that my street consultations while I walk to coffee, lunch or back to my car in the evening will continue. Sometimes I will examine an abscess under a street light, listen to a wheeze on Darlinghurst Road and maybe get asked if I want to buy some marijuana by the 15-year-old kids who sell the stuff on the streets every night. "Sorry doc, I didn't recognise you for a moment."

Raymond C Seidler MB BS

For both human and systemic reasons, there is a chronic shortage of general surgical and obstetric–gynaecological specialists in some parts of rural and remote Australia. There is also a shortage of other specialists (eg, ENT, urology, and plastic surgery) in some regional centres. Additionally, many rural towns with one surgeon have a workload that would support two, and some two-surgeon towns could sustain more. The Royal Australasian College of Surgeons (RACS) and most State health departments have a policy of, or preference for, at least two surgeons in appropriate towns with populations and resources to warrant these services.1 This allows manageable "on call" hours, safe-hours work practice and professional support. Most of the major remote centres in Australia have two resident general surgeons or one surgeon with backup and support (or relief) from an appropriate regional or metropolitan centre. These surgeons may not always be Australian-trained, but they play an important role in "areas of need". These days, for mainly social and family reasons, surgeons may not spend their entire professional life in these towns, so an ongoing supply of trained replacement surgeons is needed.2 The RACS Rural Surgical Training Programme, which has now been functioning for four years, is starting to fulfil this need, providing up to 10 appropriately trained surgeons to go into rural practice each year. Logistically, or for geographic reasons, some remote and rural towns will continue to rely on GPs for "on the ground" initial assessment and management of patients with surgical problems. Optimally, this occurs not in isolation, but with professional support from the regional surgeons to whom these GPs refer, and with the backup of regularly provided outreach specialist services.3 As a generation of broadly trained older and experienced GPs approach retirement, there is an obvious need for suitably trained replacement GPs. The Advanced Surgical Skills Training Programme for Rural GPs is a joint initiative of RACS, the Royal Australian College of General Practitioners (RACGP) and the Australian College of Rural and Remote Medicine (ACRRM). Unfortunately, this program has foundered because of the tardiness of implementing more decentralised training schemes under the auspices of the RACGP and the ACRRM, but it is hoped that it will be re-introduced soon. Intensive training courses provided by various State Rural Medical Support Agencies into all aspects of emergency medicine (including surgery, obstetrics and ophthalmology) provide some level of appropriate training and capability for GPs going to rural and remote areas (and those already there) (for example, the Queensland Rural Medical Support Agency).4 These courses are important and not universally known about. But does the chronic under-resourcing of rural surgeons and the geographic location of GPs influence surgical referral patterns? This interesting question is addressed in this issue of the Journal by Gruen and colleagues (page 111).5 Their findings, based on data accrued by the Bettering the Evaluation and Care of Health (BEACH) program, suggest that rural and remote GPs without resident surgical services refer patients at about the same rate as their regional and metropolitan colleagues. However, these GPs manage more obstetric and ophthalmological patients locally. This probably reflects their training and expertise made necessary by their geographic isolation. However, many rural and remote towns in Australia have regular surgical services (from weekly to quarterly) provided by outreach services from regional and metropolitan centres, and these services may not be reflected in the BEACH data. Many Australian rural and remote hospitals now have tele-conferencing, telemedicine and satellite communication facilities. These are used particularly for educational purposes, but also increasingly for clinical applications. They are not usually available at short notice or for 24 hours a day, which limits their use for acute surgery and obstetrics. The telephone remains the communication medium of choice. Telephone support is particularly valuable for GPs if the specialist at the other end has an ongoing relationship with and a knowledge of the capabilities of the facility, and the expertise available in the rural or remote town. A variety of models and methods will continue to be needed to provide specialist surgeons to all the centres that need them: The Flying Surgical Service in Queensland (based in Roma and Mt Isa) provides outreach services to many Queensland country towns; The University of Adelaide Department of Surgery provides a rotating specialist surgeon to Port Augusta; The University of Western Australia outreach program provides a cost-effective service to many small rural towns;3 and The New South Wales Department of Health is trialling a "mobile surgical bus" fully equipped to provide specialist surgical services (particularly elective services in ENT, urology and ophthalmology) to rural centres in New South Wales where these surgeons or the facilities required are not otherwise available. It is vital that any outreach service does not lead to de-skilling of rural GPs (or general surgeons), but rather is an enhancing, educational experience. Despite advances and improvements in the availability of aeromedical evacuation services, many rural and remote parts of Australia will continue to need appropriately trained and supported rural GPs to provide acute surgical care. These GPs will know when it is best to refer on to larger centres. These larger centres will continue to need professional onsite specialist services, staffed by local surgeons, with appropriate financial resources to provide their rural or remote general practice colleagues with ongoing support and advice.

Anthony J Green

Objective: To determine the effect of proximity of surgical specialists on general practitioners' (GPs') rates of referral of surgical problems to specialist care (ie, are surgical referral rates of GPs in rural or remote areas similar to those of GPs in urban centres?).Design: A cross-sectional survey of GP–patient encounters.Setting: The Bettering the Evaluation and Care of Health (BEACH) program, which involves all active registered GPs in Australia.Participants: A random sample of 3030 GPs, each providing details of 100 consecutive patient encounters.Main outcome measures: Proportion of surgical problems (including ophthalmological and obstetric and gynaecological) referred to surgical specialists (surgeons' rooms, hospital outpatient departments or hospital emergency departments).Results: Absence of a local specialist did not significantly influence the proportion of surgical problems referred by GPs overall, but the proportion referred was significantly lower for obstetric (odds ratio [OR], 0.56; 95% CI, 0.44–0.70) and ophthalmological (OR, 0.60; 95% CI, 0.49–0.73) problems. Other factors independently associated with referral of a lower proportion of problems included male GPs, female and younger patients, holders of a Health Care Card, injury-related and non-cancer-related problems, follow-up presentations, and more than one problem managed at an encounter.Conclusions: Our findings confirm that rural and remote GPs undertake much of their patients' antenatal care, and are less likely to use specialists when managing ophthalmological problems. Absence of local specialists in other surgical specialties is not a barrier to referral of patients with surgical disorders.

Russell L Gruen MB BS, DipEpidBiostat · Ross S Bailie MB ChB, MD(Community Health), FAFPHM · Stephanie Knox BSc, BA(Hons) · Helena Britt BA, PhD

South Bank Medical Centre York, UK I needed a change and I got one — more than one, in fact. In July 2000, I resigned as a general practitioner in York, England, to become GP Educator at the Centre for Remote Health in Alice Springs. My remit includes training medical students and GP registrars, and providing professional development for GPs and other health professionals. I do a clinical session at the Aboriginal Medical Service and another in private practice. Squirrels and oak trees have been exchanged for parrots in the pawpaw tree outside my kitchen window. What has it been like? What changes have I encountered, and what cultural adjustments were required? With more "foreigners" being enticed to the bush, my experience may be of interest to those who follow and to those who work with them. The most obvious change is the interaction with Aboriginal culture. It was also a change I expected, as did colleagues, who helped me along, recommending books1 and arranging cultural awareness courses. But to this was added the cultural shift from city to remote area, from clinical service to academic medicine, from England to Australia, and from a National Health Service to private practice. Each change has had its own challenges and rewards. Centre for Remote Health, Alice Springs Remote practiceThe prospect of medical practice in a remote area was frightening. I observed the debate between the Royal Australian College of General Practitioners and the Australian College of Rural and Remote Medicine about the nature of rural and remote practice and wondered how I would cope. In reality, Alice is a regional centre, and I have better access to help than I did in urban York, where patients sometimes waited a year to see specialists. Relationships with patients and communication skills remain the cornerstone of practice. Where I have needed skills retraining has been in aspects of practice that, in England, are performed by practice nurses, such as Pap smears and ear syringing. Although the principles of medicine are similar, some of the practice is inevitably different. Service delivery in private practice is less cohesive than in England, where the registered list system encourages continuity of care and work within multidisciplinary teams. Conversely, the absence of the responsibility brought by the list system means that "extra" patients at the end of the day are seen by choice rather than contractual obligation. Indigenous healthThe high morbidity and mortality among Indigenous Australians is well documented, but the suffering behind those statistics jolts into reality when patients younger than myself shuffle in with the after-effects of a stroke or are semi-incarcerated by renal dialysis. Because of the high incidence of rheumatic fever, practising evidence-based medicine requires that sore throats are treated with penicillin, not just analgesics. Without a first language or health beliefs shared between patients and staff, achieving a common understanding of a problem and its appropriate management takes time. Teamwork between staff of different professions and cultures is essential to reduce "non-compliance" caused by misunderstandings and unallayed fear.2 Academic practiceI often wondered about a career in academic general practice. It would capitalise on my love of books and teaching, as well as my experience of different practices acquired during my husband's ophthalmology rotations. In addition, coursework on organisational change and medical sociology for a Master's degree in primary healthcare was invaluable preparation, revealing that values, behaviours and ideologies are culturally transmitted and relative.3 The good side of academic life is the flexibility and ability to work at home if children are ill; the downside is the halving of income. It took time to escape from the habit of 10-minute consultations and the expectation that colleagues "book with my receptionist". Just as the pressures of academic life are less visible, so are the rewards — the results of teaching may never be seen, while research projects take an age. As a clinician, I believe a patient's story unless compelling contrary evidence forces me not to. The world of medical politics, into which academics are unwittingly propelled, requires a more circumspect approach. Grant applications, teaching schedules and research reports have replaced insurance forms and prescription requests as the bottomless pit of paperwork in my life. Life in AliceMy neighbour on a flight to Sydney asked what it was like living in a remote place. Despite my previous concerns, I struggled to understand the question. I could think only of the privilege of working and living in a friendly community. It takes no more than five minutes to get anywhere, the tourism industry supports a wide range of facilities, and the weather is fantastic. In cities, I now find it stressful working out how to cross the road — it is much easier just to wander over when no "utes" or four-wheel-drives can be heard. BureaucracyThe hardest struggle has been to navigate the path to obtaining registration and visas. Is it a deliberate ploy to enlist human psychology — to inspire doctors to want what they cannot have? The declared need for doctors in rural and remote areas is not matched by Commonwealth action or policy towards overseas doctors. Our visas arrived three weeks before our departure — six months after the application was submitted. As "temporary residents", we had difficulty getting a mortgage, yet buying a house seemed a logical way of ensuring a commitment to the area. While I appreciate the need to maintain standards, I have only just gained conditional registration to work as a GP in the Northern Territory. A letter from the medical board previously advised me either to pass the Australian Medical Council examination or to enter a recognised training program, despite my having an FRACGP. I replied that it was difficult to enter a training program that I had been appointed to assist in running! Surviving and thrivingHow have I survived? Flights, family, friends, faith, keeping fit and the phone, plus knowing my limits and previous experience of work in a cross-cultural environment. We miss friends and extended family, but this also happened in England, as the hours of work and commuting reduced life to a subsistence sandwich of work, shop, eat, sleep and more work. Email, videos and a family website of our latest camping exploits help us keep in touch. The community in Alice has been welcoming and supportive, and the fundamentals of my life have not altered. I am still married with two children and regularly attend church. The children have had their ups and downs but hope that we will be allowed to stay. Knowing one's personal limits seems important for survival. My limit was a desk of my own, and when space became short I offered to bring my tent to work. In the end, it was not needed, but a place to work was an essential anchor. Others will have different needs, which may sound equally odd or difficult. Try to provide the luxury that will keep your colleagues sane. So, if you need a change, it can be done, and life can be richer for it. If not, enjoy your situation, and ensure that you perceive that life is greener on your own side of the fence.

Susan M Wearne MMedSc, FRACGP

It is February 2005. A bus crawls down the hill into Teepokana (a small fictional town on the west coast of Tasmania) and grinds to a halt near the harbour. Arash stares out of the window. On one side, all he can see is the great Southern Ocean. On the other is a colourful row of shops, cafes and houses nestling under the steep hillside. As a final-year medical student, Arash is just starting his three-week rural general practice placement, at a rather unusual practice. The old blue four-wheel-drive is waiting, just as Fiona, his preceptor, had told him it would be. Fiona is sitting on the tailgate tapping away on her laptop and intermittently sipping a cappuccino. After a friendly welcome, Arash is soon bouncing along the gravel road that leads out of town. He has never driven a "cruiser" before. Meanwhile, Fiona is catching up on a few review consultations, juggling her laptop and mobile phone with admirable dexterity. "Here they are," she says, pointing at the screen, "Mrs Mansell's TFT results. She'll need to up her thyroxine a bit, I reckon". Arash looks puzzled. "All our pathology results come direct to the Multipurpose Centre's secure server. I can access new results remotely and then transfer them to her records. They're also web-based." A quick phone call to Mrs Mansell, and the plan is made. "See. I can do a script from my laptop that'll go direct to the pharmacy by email, and her medication will be dropped off by the postman first thing tomorrow. And here's the appointments page. I've got her booked in to recheck her TFTs." Arash slows down as he pulls into a small settlement some 30 minutes' drive south of Teepokana. Fiona is just finishing her sixth review over the phone. "It's made a big difference now that rural doctors can claim through the MBS [Medical Benefits Schedule] for telephone consultations," she says. "Now, this is Spero Bay. Only 400 or so people live here permanently. It's mostly the copper mine and a bit of tourism that keeps this place alive. One of us comes down once a fortnight and we hold a surgery in the community hall." Half an hour later and Arash is stuck. He has 40-year-old Bill Hodgson to see. Bill is worried about heart disease, because his workmate has just had a heart attack, and he thinks he should have his cholesterol checked and get some treatment. It is all very well knowing risk factors for heart disease, but Arash is struggling to answer some of Bill's questions. He turns to Fiona. "Don't worry, you can't carry this stuff in your head. Now here's the practice home page," she says, turning the laptop's screen so that Bill can look as well. "Click on 'consultation tools' . . . there it is . . . 'New Zealand Risk Tables'.1" Arash is soon able to help Bill understand things more clearly. "So, your overall risk of having heart trouble in the next five years is between 2.5% and 5%. That's pretty low, isn't it? But if you could stop smoking then you'd halve your chances of getting heart disease." Guided by Fiona, Arash "clicks" a few more times and prints out some information for Bill from the Quit campaign2 and National Heart Foundation3 websites. Fiona suggests that Bill contact Aaron, the nurse practitioner, if he wants to give up smoking. "Aaron's great", says Fiona as they drive back later that morning. "He does some sessions to relieve Linda, our regular community nurse, and also runs our respiratory and diabetes clinics. He's really good at the educational side of things. It makes a real difference to managing chronic disease. He works from sets of guidelines that we developed. In fact, our income through the Practice Incentive Program has meant we can pay for an endocrinologist and optometrist to visit annually." Arash looks puzzled again. "But how can Aaron work in the surgery and in the community, and why would you use your own income to pay for visiting services?" Fiona smiles. "We solved quite a few problems like that when we took the plunge 18 months ago. Our municipality became the first fundholding demonstration site. Essentially, we set up a service company that takes an annual lump sum from State Health and all our Medicare and PIP [Practice Incentive Program] income. In fact, every dollar we can grab from grants, university teaching appointments or whatever goes into one pot. The service company is overseen by a local board of directors, with both professional and consumer representation. So both Aaron and I are employed locally. We do quite nicely out of this arrangement, so we can just get on with planning and delivering services as best fits our skills without worrying about income or bureaucracy or traditional professional roles. "It's certainly not an easy way to go. The local community has had a hard time deciding priorities out of the limited bucket of money. But the important thing is that it is their decisions and their priorities, not some bureaucrat's. They really own their health service." Arash is feeling a bit numb as he walks into the Multi-purpose Centre. It seems he is going to need a heap of skills to be a doctor that he is not learning at medical school. Still pensive, he follows Fiona into the videoconferencing room next to the office. "This should be a good session for you to join", she says, as a group of eight students appears on the large screen in front of them. "These students are all in final year and come from Medicine, Nursing and Pharmacy. We have integrated skills teaching with all three schools early on in their courses and then a series of integrated sessions throughout the course. Today, we're doing some problem-based stuff on chronic disease. We'll focus on multidisciplinary team work. We're using the videoconferencing equipment much more for clinical applications as well, particularly for psychiatry. We've got so few psychiatrists in this State — most of our referrals go to Brisbane now. It works very well." After lunch, Fiona flicks through her emails. There is one from Oliver, an exploration geologist who spends a good deal of time overseas. His asthma often worsens in hot humid climates and today, in Brazil, it is doing so again. Fiona opens his web-based record and finds the page with his asthma management plan to jog her memory. Oliver has entered a few peak flow readings over the past few days for Fiona to look at and informed her that he has doubled his inhaled steroids. He is really wanting some reassurance. Fiona enters a few comments in his notes and then emails him back. She also has an email from Marjory. "Marjory's a poor soul really, but much better than she was a year or so ago. For the last few years, she's had a worsening combination of agoraphobia and panic disorder. She was taking up a lot of our time in house calls as she wouldn't leave home. And, worse, we weren't even helping her. Last summer, her grandchildren visited, got her hooked up to the Internet and bought her a small webcam for her computer. She had a few sessions of CBT [cognitive–behavioural therapy] with a psychologist using videoconferencing and has been using some Internet-based self-guided CBT. She's even had exposure therapy for her agoraphobia using virtual reality. Linda and I started taking turns to see her face-to-face once a month and would hook up with the videoconferencing in between. It was quite amazing — she actually started doing her hair and make-up for these sessions. She came to the surgery to see me last week for the first time in three years." Fiona points to another email. "I'll sort this one out tonight", she says. "I do some charity work with some doctors in Nepal. I get one or two referrals a week for second opinions. They'll email me the history and any x-rays or things and any questions. If I don't know something, I can more easily find out than they can." Arash has his thinking cap on by now. "How do you manage to keep up to date with everything?" Fiona smiles. "You can't, so I don't really try. Look, it's a question of redefining education and what it means and how we use it. And that's where all our fancy IT [information technology] really helps. I can't predict who is going to walk through the door tomorrow, so how do I know what to learn about? And what I learnt at the last evening meeting might be old hat by the time I need it anyway. We use 'just in time' education, and it's revolutionised the way I manage my patients. Our practice homepage links to websites like the BMJ's "Clinical Evidence" site4 and the National Electronic Library of Health in the UK.5 I usually get the answers I want quite quickly. Sometimes, we'll look for things during the consultation. If I can't get what I want in 30 seconds, I'll chase it up later. Sometimes, my patients will find the answers for me. It's sort of healthcare homework, I suppose. The practice provides an up-to-date list of reliable websites, and I just help patients work through it all. This way we get the answers to the questions we've got, as and when we need them." Fiona clicks again on her laptop. "What's all that about?" asks Arash. "Up the top is the height of the ocean swell, and at the bottom are the local tide tables. Which means we've done enough work for one day. It's time to go surfing."

Edi Albert MSc FRACGP

General practice provides a vantage point for gathering data and observing the natural history of disease. . . . Problems of a family, a social, or emotional nature can be studied directly in cross-sections of the community, and study of some epidemiological problems is facilitated by the long, continuing contact between doctor and patient.. There are certain areas which are special features of general practice, and which present exceptional opportunities for research. These are the promotion of health and the prevention of disease (by advising on methods such as weight control, adequate diet, and the rational use of drugs and alcohol); the recognition of the early manifestations of diseases (such as hypertension, anaemia, and diabetes mellitus); and the management of patients with chronic illnesses such as arthritis, diabetes mellitus and hypertension. . . . Many features of illness seen in the community are different from those seen in hospitals and by specialists, so that the findings of institutional research are often not directly applicable to general practice. General practice questions need to be solved in the setting of primary care, and caution should be exercised in applying answers derived from other sources. . . . Despite considerable enthusiasm and effort, progress in general practice research is very slow. Now is the time to define the needs, priorities and goals of such research, and to consider the difficulties that prevent us from reaching these goals. The output of research from general practice has been low by comparison with that from hospital and specialist practice, although larger numbers of doctors and patient contacts are involved. Among the many reasons for this are three main obstacles — lack of training, lack of sufficient power base in hospitals and universities, and lack of funding. These three are inter-related, and reflect the history of general practice in Australia. . . . Today, as it was when the College of General Practitioners commenced its activities in 1954, doctors entering general practice are seldom trained to conduct or be critical of research, and few perceive their practice as a place in which organized curiosity can exist alongside patient care. When such doctors participate in research projects, it is usually in a passive role to assist a pharmaceutical company, a university department, a hospital or a health authority. Usually, the essential contribution is to provide patients for study, or as controls, in the testing of a newly marketed drug or other new treatment. . . . The other common request to general practitioners is to fill in a questionnaire. This generally arrives by mail with a host of material of varying relevance. The questions may be about his patients, himself, or his use of drugs, and will often be couched in a way that makes an accurate response difficult. For example “What percentage of your patients . . . ?”, “How many . . . do you see in an average week?” or “What percentage of your time is spent doing . . . ?”. Faced with such questionnaires, many doctors demonstrate passive non-cooperation by way of the wastepaper basket. They have, one imagines, scant regard for imprecise information, have insufficient time to spare, and their records, being designed for other purposes, cannot provide accurate answers to such questions. No wonder general practice research gets a bad name! . . . The need for resources to promote general practice research and the education of general practitioners in research is urgent — perhaps more urgent now that when it was recommended by the Australian Medical Association Study Group on Medical Planning in 1971. Alan Chancellor Chairman, Research Committee The Royal Australian College of General Practitioners, Sydney MJA 1984; I: 6-7 [editorial]

. . . The general practitioner of 50 years ago sat in his street corner surgery in secluded dignity and charged his fees according to his judgement, his conscience, or his patient’s ability to pay. His successor today is presented with a book of charges which divides the practice of medicine into more than 8,000 “items”, with references and cross references and definitions of charges according to length in centimetres, depth, anatomical regions and boundaries. Medical historians of the future will have an easy time to prove the decadent barbarism of this humanistic profession in the second half of the 20th century. Medical practice in general, and the traditional general practice in particular, is doomed unless it decides to accept the challenge and adapts itself to changing demands of the present and the foreseeable changes of the future. . . . The average Australian looks at the medical profession with a hesitant reserved blink, and accepts the fact that every time the doctors hit the headlines there is an increase in fees. General practitioners should at least take the initiative to give the oncoming generation of doctors an adequate training which they so sadly missed themselves, and mobilize public opinion in support of their plan for a better, more up-to-date medical and health service. It is up to the Australian general practitioner to accept this responsibility, and to prove that he is committed to provide such a service before his patronizing peers manipulate him into a state of professional sterility or extinction. Present failure and future commitments of general practice A Deery, MJA 1971; I:1191-1195 Sir: Re your leader of January 5, the general practitioner is heartily sick of the many platitudes uttered about his glory. Gradually, with the establishment of baby, pre-maternity, T. B., venereal, asthma, diabetic, rheumatism, and other clinics, his work has been filched from him and gradually his income has fallen. The very hospitals which train him are his leading competitors; and where will it end and what use all this extensive training? Why should we keep up to date in diseases we never see? It can lead to only one way: the degeneration of the general practitioner. His income will ultimately fall so much that he will be obliged to take a government job and many will lose interest in their profession. It behoves the powers that be to seriously consider these things before it is too late. Yours, etc., Leslie Larbalestier MJA 1935; I:192 [letter]

To be effective, medical reading should be regular and systematic. This is not always easy. The general practitioner has an exacting life and, apart from his work, many demands are made on him. However, if he wishes to read, he will find the time to devote to it. He may read from text-books or from journals. Members of the British Medical Association in Australia receive both The Medical Journal of Australia and The British Medical Journal. In the pages of these journals most of the newer aspects of medical science are discussed and abstracts from journals of other countries are published. In urging medical practitioners, . . . to look to their journals for their reading matter, we would suggest that each practitioner should subscribe to at least one extra journal. He would then be in a position to help his neighbour as well as himself, and he might initiate a seminar or study circle for the exchange and discussion of journals. From time to time the statement is made that the day of the general practitioner is done, that so much is being filched from him by the major and the minor specialist on the one hand and by the governmental octopus on the other that little will remain or even now remains for him. It will be a sorry day for medicine and for the public if this should ever happen. . . . There will always be need for the man who takes the whole of medicine for his province, and he will always be the most honoured and honourable of its servants. The general practitioner can best preserve his status by remaining a student all his days. MJA 1936; II: 501-502 [editorial]