Volume 179 Issue 1

Gains have been made, but many challenges remain In this issue of the Journal, Kamien, one of the foundation professors of general practice in Australia, adds an important contribution to the history of general practice as a discipline within Australian schools of medicine (page 10).1 He explores the views of his fellow foundation professors, appointed nearly 30 years ago, and the roles they played in the reform movements in Australian medical education. By their efforts, the foundation professors laid the groundwork for the continuous advancement of the academic discipline of general practice. Their work included the training of staff (some of whom are the present heads of general practice departments), and the establishment of research programs that continue to contribute to the evidence base, such as the Bettering the Evaluation and Care of Health (BEACH) study at the University of Sydney.2 Much of the initial opposition they encountered has dissipated. Academic general practitioners are now generally respected by their medical school peers, and innovative curriculum design in many schools (such as the programs at Newcastle, Monash and James Cook medical schools) has been spearheaded by GPs. They have achieved international reputations in their fields of expertise, and recently Australia has become an exporter to academia in the United Kingdom and Canada. Other influences have affected these developments. The general practice reforms in the early 1990s, introduced by the then federal health minister, Brian Howe, led to new avenues for research and research training through the General Practice Evaluation Program. This program spearheaded opportunities for individuals to pursue Master and Doctoral degrees, which were not always available within the founding departments of community practice. Since 1988, the Australian Medical Council (AMC) has insisted on a greater emphasis on general practice in the curriculum, and all medical schools now have chairs of general practice. In addition, they all have supporting infrastructure of teachers and researchers, funded by Commonwealth grants supporting teaching (eg, through the Rural Undergraduate Support and Coordination Programme)3 and research (eg, through the Primary Health Care Research Evaluation and Development Strategy).4 Kamien found that some foundation professors shared an ambivalent view of the Royal Australian College of General Practitioners (RACGP) and were "disappointed with the RACGP's failure to support . . . academic general practice". This has changed. In 2003, academic general practice is re-establishing its links with the RACGP. The current president of the RACGP is a professor of general practice. The chairperson and several members of the current RACGP council are general practice academics, as are the chairs of the college's national standing committees, such as the Research Committee and the Education Committee. If academic general practice has "arrived", what are the future challenges? Although the discipline has established itself in the medical schools, the problems outlined by Kamien and by others remain.5 Academic staff have impossible teaching loads and, consequently, little time for research or research training. Furthermore, the allocation of resources in medical schools tends to disadvantage general practice. In response to AMC requirements, the input of general practice across the whole medical curriculum has increased, but intramural funding has not kept pace with this increase. There are serious concerns about recruitment to the general practice workforce and poor morale among practising GPs.6,7 Reasons for these issues include a relative fall in remuneration for general practice compared with other medical disciplines, concerns about litigation in private practice, and the "red tape" demands of government with new programs (such as the Extended Primary Care Medicare items). Local solutions must be found. For a research culture to continue to expand, we will need to answer the criticism that "there is simply no rigorous evidence for many of the daily clinical decisions in general practice".8 Much of the research to date has been of a health services nature,9 and more clinical research, including robust randomised controlled trials located in general practices, needs to be pursued. The researchers themselves will need to be seen as relevant and helpful to the "bag-carrying practitioners"; there is a need to explore new ways to enable and promote research training among practising doctors who want to enhance their academic skills in practice. Those of us who are charged with the undergraduate education of medical students need to provide appropriate role models, who should emphasise professional competency and autonomy that is not undermined by the concerns of government. The discipline needs to be taught in a supportive environment, avoiding the impression of complexity and uncertainty sometimes gained by students, who are quick to compare it with the certainty of hospital-based teaching. The decentralised focus of medical education should enhance recruitment and retention of GPs. Mechanisms to achieve vertical integration include the sharing of staff and facilities, with joint appointments. Teaching programs and assessments need to be shared, and common processes used across regions to ensure uniformity of standards. The placement of students in practices requires careful management of complex databases and good personal communication with practices. The support of teachers at a distance is a constant challenge — innovative methods, such as videoconferencing and Web-based resources, are being trialled. Training opportunities for GPs in academic research and teaching are limited and difficult to achieve. The present scholarship arrangements, such as those of the National Health and Medical Research Council (NHMRC), are often inappropriate in terms of support and reimbursement. Links with postgraduate training consortia and the productive vertical integration of teachers, staff and curricula have the potential to enhance all involved. The same potential exists with departments of rural health and rural clinical schools, as shown in models already established (for example, in northern Queensland).10 Opportunities need to be developed for collaboration with the RACGP and training consortia for registrars to spend time in academic posts during fellowship training. The charter of the Divisions of General Practice is quite distinct from the functions of medical schools, and divisional roles in implementing programs of health improvement initiatives and practice support are well defined. However, the potential for collaboration with academic departments remains largely unfulfilled. General practice as a discipline is now represented on the Committee of Deans of Medical Schools and on the NHMRC assessment panels (although not on the council itself). Academic GPs will need to develop stronger leadership roles to consolidate our gains to date. The foundation professors had the courage and vision to begin the journey. Those with the responsibility of continuing leadership will need skill and flexibility to sustain the momentum in the changing and challenging environment of general practice.

Peter R Mudge FRACGP, FFAPHM

The 1973 inquiry into the "Expansion of Medical Education in Australia" resulted in the appointment of nine professors of "Community Practice". We (the foundation professors) have been leaders in a reform movement within medical schools and general practice and have had to fight hard for the right and resources to do the job for which we were appointed. Our most significant accomplishment has been to broaden the orientation of medical education beyond hospitals and laboratories to the community and those in the community who are underserved. Although small in numbers, our discipline fights above its weight and is essential for medical school accreditation by the Australian Medical Council.

Max Kamien MD, FRACGP

Medicopolitical objectives must be distinguished from the training of high quality GPs The high standard of registrar training for Australian general practice has long been recognised,1-6 and our training model has been replicated overseas. The training program of the Royal Australian College of General Practitioners (RACGP) provided vocational training for GP registrars in Australia for nearly 30 years. In January 2002, the Commonwealth Government established a new provider model for the delivery of GP registrar training. These changes were in response to government perceptions that aspects of the former training arrangements were not fulfilling some of the needs of the Australian population, especially in meeting workforce requirements in rural areas. General Practice Education and Training Ltd (GPET) was established as a Commonwealth-funded company to manage a new contestable regional model of vocational training. Twenty-two new regional training providers now carry out the actual delivery of vocational training programs. Funding for training is allocated on behalf of the Commonwealth by GPET to these providers under contract. The regional providers have representation from the appropriate colleges (RACGP and, in rural regions, Australian College of Rural and Remote Medicine), local Divisions of General Practice, local university departments of general practice and rural health, registrars, general practitioner trainers, and in some cases, local consumer representation. While the methods of delivery have changed, the new training arrangements still follow the curriculum for general practice training set by the RACGP, are based on the standards of education delivery set and monitored by the RACGP, and lead to a single training end point — the Fellowship of the RACGP. The diversity in the new training arrangements provides the opportunity to reinvigorate GP vocational training. However, there are also risks associated with these new arrangements. These relate to (i) their funding, (ii) the need for widespread professional support for them to succeed, and (iii) concerns among potential registrars about the future viability of a career in general practice. The workforce shortages which have led to these new arrangements for general practice training also pose risks for the independence of the vocational training provided for other medical specialties. Funding of the new training arrangements: This is currently being provided through short-term contracts. Quality education delivery requires funding stability. Without this stability, the education programs are at risk. These new arrangements need a fair go. The Commonwealth has made a decision to establish a more expensive system of training which requires independent governance and administration in 22 regions across the country. The Commonwealth now has a responsibility to continue to provide adequate funding, and long-term policy commitments and support for the new regional training providers and the profession, to ensure that educational standards are not only maintained but continue to be developed. Professional unity: The profession also has a responsibility to unite behind the new training arrangements. Without such cooperation, there is a risk that factional differences could hamper the delivery of high quality training and the Commonwealth's new model of alternative governance will not be able to deliver valid outcomes. GPET cannot meet its workforce outputs unless the training programs it purchases meet RACGP standards. The RACGP cannot approve training programs unless they are of an appropriate standard.7 GPET and its key stakeholders need to develop a collaborative model, which guarantees equity of training standards and opportunities for registrars no matter where they train in Australia. The model also needs to guarantee unified work between GPET and each regional training provider with the relevant professional colleges. And the model needs to meet the community need for access to well trained general practitioners and well supervised registrars. The current image of general practice and its training requirements among potential registrars: This probably poses the major risk to the new training arrangements. There is a strong need to maintain and enhance general practice as an attractive career choice for medical students and recent medical graduates. This change in the training program structure has taken place at a time when general practice is facing many challenges, including workforce shortages, uncertainty surrounding medical indemnity, and a failure of Medicare rebates to match the rising costs of providing a high quality general practice service. General practice training is also seen as less flexible and less able to accommodate the personal and professional needs of many potential registrars compared with training for some other specialties. It is clear that the Commonwealth will no longer separate GP training from other challenges facing general practice, especially workforce shortages. All stakeholders must ensure that medicopolitical objectives are clearly distinguished from the work of preparing high quality GPs for the Australian community. There also needs to be public recognition of the importance of a strong, stable system of general practice, and of a well-trained GP workforce to the health of the nation. We need long-term sustainable solutions to the serious challenges facing general practice to ensure that all people in Australia have equitable and affordable access to high quality primary care in the future. General practice is experiencing the conflicting demands of the government's requirements for medical workforce against the profession's need for continuing high standards of vocational training. This conflict could also lead to enforced changes in training for other medical specialties. It remains to be seen how other colleges respond to the risks posed by similar challenges in the development of their own 21st century registrar training programs. When facing risks there is some cold comfort in knowing that you are not alone.

Michael R Kidd MD, FRACGP

Despite explicit support of the federal and state health departments, most prevocational trainees do not experience general practice or rural medicine. We have been running a program of prevocational placements of trainees working as rural general practitioners under supervision. From our experience, we have identified various barriers to implementation of such programs. These barriers include: funding issues (trainees are providing federally funded Medicare-rebatable services, while receiving state-funded hospital salaries); conflicts between the placement of trainees outside the hospital when hospitals are undergoing staffing crises; difficulties in coordinating the many organisations (funding bodies, practices, hospitals) involved in providing the placement; and the isolation experienced by trainees when they arrive in rural practice. Funding from a single administration and coordination by a locally appointed rural Director of Clinical Training are essential to overcome these barriers.

Alistair W Vickery MB BS, FRACGP · Richard Tarala FRACP

Provision of "Focussed Psychological Strategies" by general practitioners is one component of the recent Better Outcomes in Mental Health Care (BOiMHC) initiative. The BOiMHC initiative requires GPs to undertake minimum training requirements before they may provide services under the new Medicare Benefits Schedule item number. We argue that GPs need further training and ongoing clinical interaction with mental health specialists (beyond the minimum training requirements) for refinement of psychological skills. Research focusing on GP training and how GPs interact with specialist services in the provision of psychological treatments is urgently required.

Grant Blashki MD, FRACGP · Ian B Hickie MD, FRANZCP · Tracey A Davenport BA(Hons)

General practice is suffering a crisis of status, as shown by financial, power and intellectual markers. This is serious as a strong general-practice workforce is important to deliver cost-effective, high-quality healthcare. We argue that strengthening the intellectual aspects of general practice (particularly critical thinking) is essential. Most strategies to achieve this centre on research, with many initiatives in Australia and overseas to enhance research by general practitioners; there is still insufficient clinical research in general practice. Other ways to improve critical thinking include promoting use of evidence-based medicine, provided it is not implemented only via "cook-book" guidelines. Other innovations are desperately needed.

Chris B Del Mar MD, FRACGP, FAFPHM · George K Freeman MD, FRCGP · Chris van Weel MD, FRCGP

Objectives: To explore general practitioners' views on chronic-disease care: the difficulties and rewards, the needs of patients, the impact of government incentive payments, and the changes needed to improve chronic-disease management.Design: Qualitative study, involving semi-structured questions administered to 10 focus groups of GPs, conducted from April to October 2002.Participants and setting: 54 GPs from both urban and rural practices in New South Wales and South Australia.Results: Consistent themes emerged about the complex nature of chronic-disease management, the tension between patients' and GPs' goals for care, the time-consuming aspects of care (exacerbated by federal government requirements), and the conflicting pressures that prevent GPs engaging in structured multidisciplinary care (ie, team-based care involving systems for patient monitoring, recall, and care planning).Conclusions: Structured multidisciplinary care for people with chronic conditions can be difficult to provide. Barriers include the lack of fit between systems oriented towards acute care and the requirements of chronic-disease care, and between bureaucratic, inflexible structures and the complex, dynamic nature of GP–patient relationships. These problems are exacerbated by administrative pressures associated with federal government initiatives to improve chronic-illness management. Changes are needed in both policies and attitudes to enable GPs to move from episodic care to providing structured long-term care as part of a multidisciplinary team.

John Oldroyd PhD · Judith Proudfoot PhD · Fernando A Infante MPH · Gawaine Powell Davies MHP · Mark F Harris MD · Tanya Bubner GDPH · Chris Holton BSocSc · Justin J Beilby MD

Objectives: To explore how Australian general practitioners use pharmaceutical decision-support (PDS) systems; to determine GPs' perceptions of the deficiencies and strengths of these systems; and how they believe they can be improved.Design and setting: Qualitative analysis of discussion from three focus groups of GPs (from one rural and two urban Divisions of General Practice) between April and May 2002.Participants: 22 GPs selected to include users of the five most popular prescribing/clinical practice software products available in Australia.Main outcome measures: Advantages and disadvantages of using PDS software; ideas for improving PDS systems; attitudes to electronic evidence-based guidelines.Results: GPs believed that important interactions may be missed because of desensitisation resulting from too many alerts (which also intrude on workflow); that interaction alerts need to be severity graded and only significant ones should appear; and that improved computer–user interface design could enhance the usefulness of PDS systems.Conclusions: Our results will provide useful feedback to government, software vendors and software developers on the needs and expectations of end users and on the development of agreed software standards.

Michael D Ahearn GradDipIT · Stephen J Kerr BPharm, PhD

Objective: To compare outcomes, costs and incremental cost-effectiveness of heroin detoxification performed in a specialist clinic and in general practice.Design and setting: Randomised controlled trial set in a specialist outpatient drug treatment centre and six office-based general practices in inner city Sydney, Australia.Participants: 115 people seeking treatment for heroin dependence, of whom 97 (84%) were reinterviewed at Day 8, and 78 (68%) at Day 91.Interventions: Participants were randomly allocated to primary care or a specialist clinic, and received buprenorphine for 5 days for detoxification, then were offered either maintenance therapy with methadone or buprenorphine, relapse prevention with naltrexone, or counselling alone.Main outcome measures: Completion of detoxification, engagement in post-detoxification treatment, and heroin use assessed at Days 8 and 91. Costs relevant to providing treatment, including staff time, medication use and diagnostic procedures, with abstinence from heroin use on Day 8 as the primary outcome measure.Results: There were no significant differences in the proportions completing detoxification (40/56 [71%] primary care v 46/59 [78%] clinic), participating in postwithdrawal treatment (28/56 [50%] primary care v 36/59 [61%] clinic), reporting no opiate use during the withdrawal period (13/56 [23%] primary care v 13/59 [22%] clinic), and in duration of postwithdrawal treatment by survival analysis. Most participants in both groups entered postwithdrawal buprenorphine maintenance. On an intention-to-treat basis, self-reported heroin use in the month before the Day 91 interview was significantly lower than at baseline (27 days/month at baseline, 14 days/month at Day 91; P < 0.001) and did not differ between groups. Buprenorphine detoxification in primary care was estimated to be $24 more expensive per patient than treatment at the clinic. The incremental cost-effectiveness ratio reveals that, in this context, it costs $20 to achieve a 1% improvement in outcome in primary care.Conclusions: Buprenorphine-assisted detoxification from heroin in specialist clinic and primary care settings had similar efficacy and cost-effectiveness. Buprenorphine treatment can be initiated safely in primary care settings by trained GPs.

Amy E Gibson BSc(Hons), BA · Christopher M Doran PhD · James R Bell FRACP, MD · Anni Ryan Grad Dip (AOD Studies) · Nicholas Lintzeris MB BS, PhD

Objectives: To examine the frequency of post-antibiotic vulvovaginitis (PAV); describe how women prevent and treat PAV; and determine whether concern about PAV affects their decisions about taking antibiotics.Design: Cross-sectional survey using a written questionnaire.Setting and participants: Five general practice waiting rooms in north-western Melbourne, in February 2000. 1298 women aged 18–70 years were surveyed.Main outcome measures: Self-reported symptoms and management of vulvovaginitis and PAV.Results: The response rate was 86%. Thirty-five per cent of women reported ever having PAV and 73% reported ever having symptoms suggestive of vulvovaginal candidiasis. Antifungal medications and lactobacillus products or yoghurt were most popular for both prevention (49%, 40%) and treatment (63%, 43%) of PAV. Other home remedies such as tea tree oil, vinegar, and dietary and clothing modification were infrequently used by the women surveyed. Twenty-three per cent of women who had taken antibiotics in the previous month had experienced symptoms of vulvovaginitis. Of women who had ever had vulvovaginitis, 35% were moderately to very concerned about developing PAV when prescribed antibiotics. Because of this concern, around a fifth of these women would not take prescribed antibiotics.Conclusions: Concern about PAV affects women's decision-making regarding antibiotic use. Many women use unproven complementary therapies to prevent or treat PAV. When prescribing antibiotics, doctors should discuss the risks of PAV and its management with patients.

Marie V Pirotta MMed, FRACGP, DRANZCOG, GradDipEpiBiostats · Jane M Gunn PhD, FRACGP, DRANZCOG · Patty Chondros BSc(Hons) GradDipEpiBiostat, MSc(Statistics)

We are all interested in the future, for that is where you and I are going to spend the rest of our lives. — Edward D Wood, Jr, director and screenwriter (from the movie Plan 9 From Outer Space) Nightmare in 2020: a day in the life of Dr Zen, FRACGP A tired-looking woman is sitting in the medical service bay at Corporation Enterprise (its motto: "Live long and prosper"). The electronic doors open to admit an overweight man. He faces her across a waist-high console. She scans his online medical record with her level 5 clearance. "Mr Unger, you have a five-minute consultation today. How can we help?" "I don't feel well —." "Chest pain?" "No, just not feeling myself. Since my wife died. My complementary practitioner can't help me. Can you?" "I'll try", Dr Zen replies. She selects the "Social stressor" option on screen. "Which of these symptoms do you have?" She reels off a list. He replies. They work their way through the appropriate algorithm pathway. "So, according to our evidence-based, Glerck-Pficham-sponsored guidelines, you have type III depression." A silent alert flashes on the screen: "Time's up!" "I'll prescribe you Ease, which [reading from the screen] has been effective in 360 hospital patients. You're also entitled to three telesessions with our cognitive behavioural therapist courtesy of Ease." The manufacturer of Ease has a Memorandum of Understanding with Corporation Enterprise. Dr Zen issues the script and patient education printout. Mr Unger walks out the door, triggering another screen message: "Consultation was two minutes over time — third infringement today. Action 1: repeat practice management module during your Quality and Education session." Dr Zen sighs. She had wanted to try the clinical research module instead. No wonder GP research in the Med e-J of Australasia is so dull: only non-clinicians and corporate administroids have time for it. But who wants to know about health service models and cost analyses? "Action 2: 5% deduction from today's pay for time infringements." Yeah, well what about patient care instead of the bottom line for a change? She makes an e-note to mention it again at the next corporation meeting with the Managers. Mustn't put them offside though. They may be heavy-handed but they're the ones doing the real work in general practice — administering new government health initiatives that appear monthly. Dr Zen is indentured to serve in this busy outer urban centre for another two years. Her husband is rural, but telemedicine clinics are making rural work easier these days. Like most doctors, he'd been put off becoming a GP by his compulsory term in "area-of-need" general practice. But beggars who miss out on other training schemes can't be choosers ... After her corporate session, Dr Zen drops in on the nurse-practitioner clinic in the slums to see medical referrals from the nurse. This government got in on the promise of "Primary care for the public". But the post-election reality: a teary 72-year-old whose Work-For-the-Aged benefits have been restricted as she can't afford a computer and missed the e-reminder for her Well-70s check. Dr Zen can't wait to do her taxi shift this evening. Thank goodness for time to talk to customers. It'll keep her going in more ways than one. Ann Gregory and Mabel Chew Deputy Editors, MJA This section of the MJA General Practice issue is pure fiction. That is to say, we created a futuristic general practice scenario and asked others to create more of their own. Why should a medical journal resort to science fiction, you ask? The answer: because the future is malleable. If you believe the popular fictions of time travel, you'll know that seemingly minor differences in our actions now can lead to destinies which are poles apart. To help us mould the future, we conceived a section which attempted to generate hypotheses and innovative solutions. We're not contending that the results represent accurate predictions, but neither are these idle speculations. By asking what forces currently drive general practice, we can imagine different futures that test the implications (good, bad and indifferent) of these forces, and advocate change that preserves the good, topples the bad and optimises the indifferent. Here are some driving forces we identified: The general practitioner Gatekeeper of medical care in Australia Desire to provide good care for the whole patient Health promotion and disease management Balancing work and personal interests Corporatisation Evidence–practice gap Information overload, information management Threat of litigation, indemnity woes Professional and financial under-recognition Autonomy versus structural straightjackets (regulation, red tape and time) Workforce shortages The patient More informed, with higher expectations of healthcare, its accessibility and affordability "Click-fix" mentality of instant gratification More likely to have (more than one) chronic illness More likely to require coordinated, continuous (not episodic) care Society Ageing and rise of grey power Mixing of diverse ethnicities, cultures and values More solo households and non-nuclear family groups Technological advances in everything Knowledge-based economy dictating labour market Widening gap between haves and have-nots: rich and poor, technologically literate and illiterate More government responsibility shifted to private enterprise Continued rise of political conservatism and the far right Globalisation of trade and thought Environmental concerns and hazards Ethical quandaries from technology and inequalities I don't try to describe the future. I try to prevent it. — Ray Bradbury, science fiction writer Next, we wrote a deliberately nightmarish scenario of general practice in the year 2020 (see the Box) showing the negative consequences of some of these forces. We sent the scenario to those involved in frontline and academic general practice, asking them to write short commentaries that identified values which had been lost in the nightmare suggested how to handle current trends to preserve these values offered a better future. Each commentator was asked to discuss a different facet of the general practice milieu: the consultation,1 practice management,2 training,3 workforce,4 society5 and research.6 We believe that the result is a rich vein of thought that shows us there are core values to hold fast and work for. The future need not be beyond us! → Go to the first commentary We must be the change we want to see — Gandhi

Mabel Chew

Sociologists tell us that "Autonomy is the acid test of professional status ... all other characteristics of a profession flow from it".1 Poor Dr Zen* has no professional autonomy. Mr Unger's management is determined, not by her, but by an electronic decision system which then reduces her pay for taking too long and directs her continuing education. How did Dr Zen get into this thankless situation? Let me answer that with some more of her story. Dr Zen's dream is to become a Clinical Controller with Corporation Enterprise. Competition is intense as the status and salary are so much better than those of the general practitioners who labour in the corporation's clinics. To be considered she has to obtain an MBA from the Corporation Enterprise School of Business. One cold, wet night in 2020, Dr Zen is at a taxi rank waiting for a fare, correcting her first draft of an assignment for the subject HX101 "History of Corporation Enterprise". The assignment topic is a challenge: "Why did the GP leaders of 2003 call for policies to dramatically increase the number of general practitioners?" The course notes suggest that in 2003 the policies pursued by GP leaders undermined real opportunities for GPs. Dr Zen has undertaken extensive research. Her essay hypothesises that the key mistake in 2003 was not to pursue policy and structural changes so that general practice could adapt in a positive way to changing community expectations. GPs ignored opportunities flowing from technological developments and changes elsewhere in the health system. They concentrated on defending the status quo and, behind a smokescreen of rhetoric, lobbied government for higher pay for each consultation and for more doctors.2 This maintained short-term cash flow but further entrenched structural problems. The cash flow of most GPs depended on habits developed between 1984 and 2007 under a financing system called Medicare. Medicare rewarded "down-market" activities, not "up-market" skills. The highest incomes came from providing many short consultations and not providing services requiring the very skills that differentiated GPs from other "healthcare workers". The seriously ill and those requiring minor procedures or time-consuming care drained profits and, under Medicare, could be deflected to specialists or emergency departments. The network of corporate clinics already emerging across Australia before 2003 grew rapidly following the increase in GP numbers between 2003 and 2007. These clinics were based in the cities and absorbed most new GPs. In 2008, the government admitted that the policy of expanding numbers to get GPs into rural and outer urban areas had failed. A retired bureaucrat, Gletkin, was commissioned to review the situation. He concluded the government was simply underwriting the profits of a few large GP corporations: the GP workforce was less evenly distributed than in 2003; GPs were being paid for work that could be undertaken more cheaply by others; and the government's commitment of millions of dollars to educating GPs through six years of university and three years of vocational training was of doubtful value because GPs were not using the skills taught. The government of Mustapha Mond adopted radical measures recommended by Gletkin. Medicare was abolished and Corporation Enterprise established as a government-owned monopoly. This entity compulsorily acquired all GP clinics and rigorously implemented its charter of ensuring an even distribution of GPs across Australia and providing primary care at the lowest possible cost, using protocols designed to refer all serious cases to specialist polyclinics or hospitals. The company operated to a strict formula of one GP per 1750 people. With a population of 25 million, only 14 250 out of 30 000 GPs were contracted. Minimal incomes were offered. GPs had to agree to adhere strictly to the corporation's treatment protocols. The education of GPs was rationalised. School leavers, after five years administrative and assistant experience with the Corporation, could apply for entry to the GP course at the Corporation Enterprise School of Medicine, a three-year web-based course supported by "on-the-job" training. Dr Zen was in the first graduating class. Dr Zen now understands the sadness on the faces of the elderly couple in the next flat to hers in the Housing Commission complex. They commenced careers as GPs in the early 1980s, full of hope and expectation, but were bankrupted in 2007, when found personally liable for a medical indemnity claim. Since then they had been unemployed. Dr Zen hopes she can afford to buy them a hamper again next Christmas. Dr Zen is pleased it is a quiet night on the taxi rank. She can think about the conclusion of her essay. Students are asked to imagine a different scenario for general practice after 2003. She will argue that GPs, rather than squabbling with government over a few dollars, should have thought more deeply about what the community wanted from general practice and how GPs could "add value". They should have lobbied for policy and structural change so that simple tasks could be delegated to other staff, while the highly (and expensively) trained doctors used their skills managing acute medical conditions and common chronic conditions; coordinated the care of patients with complex conditions; enhanced the procedural aspects of their practices; and established arrangements of value to others, such as early hospital discharge. Such a role would have required fewer GPs, but those GPs would have had much more rewarding careers.

William Coote FRACGP, BEc

Those of us who wear spectacles consider "20/20 vision" utterly desirable. The "2020 vision" presented here,* however, is a nightmare that we must strive to avoid. The story of Dr Zen suggests that several important values have been lost to general practice. Having once been a positive career choice for many medical graduates, in 2020 the discipline is at the bottom of the heap — training in general practice is for "beggars" who miss out on other schemes. No longer valued by other members of the healthcare system, nor practising with any degree of independence, nor able to advocate for her patient, Dr Zen is just a binary drone, condemned to the restraints of protocol-driven diagnosis and algorithmic management. Such reductionism was rejected long before 2020 as a foundation for general practice1 and other branches of medicine.2 Can our elegant craft of hypothesis testing and revision survive alongside the brutishness of digital diagnosis? The primary focus of her attention is the third party paying for her time — what patient would appreciate that? Her clinical independence is severely compromised by the control the Ease manufacturer imposes on her therapeutic decision making. Dr Zen has no supportive collegiate contact, and her supervisors are the sort of managerial bureaucrats who thrive in environments from which general practitioners have been removed. What inspiration for medical students and vocational trainees would Dr Zen's role provide? Dr Zen's Fellowship of the Royal Australian College of General Practitioners still marks her as being competent to practise as an unsupervised GP anywhere in Australia, and she demonstrates this by moving easily between her outer urban push-button practice and the challenges of practice in an inner urban slum (presumably the future Toorak or Darling Point). At least her apparent comfort in working as part of a primary care team with a nurse practitioner makes it sound as though she has been trained in accord with the CanMEDS 2000 principles,3 which describe the GP as a collaborator among other things. The strength of GP training in Australia has long been its "enhanced apprenticeship" model, the only logical way to impart the values and skills of general practice. This combination of supervised training and needs-focused education allows registrars to practise in a real environment alongside carefully selected supervisors, while receiving relevant teaching from those supervisors and professional medical educators. Although vocational training for general practice has undergone major changes in the past two years, this model has continued. Our approach to training the doctors who will join us in general practice has a huge impact on the future of the profession. So where could we be in the year 2020, and how many of the positive values of the past will carry through to the future? Dr Zen's training, re-imaginedThe CanMEDS principles, updated, were incorporated by 2020 into a completely integrated curriculum for general practice that guides GP education from undergraduate study through to retirement. This curriculum has enough breadth to address all the disciplines that Dr Zen employs, ranging from population health, evidence-based practice and information management to business management, clinical governance and disaster medicine. Just as importantly, it has the depth to be relevant in any of the contexts in which GPs work, be that in Aboriginal health, a Muslim community, a rural area or the Antarctic. Information technology is a tool in the hands of the competent practitioner, but never a substitute for the practitioner's "presence". Nor does real time access to guidelines and algorithms substitute for the vast amount of knowledge about a patient that the GP acquires through careful communication. Dr Zen's Fellowship is not the endpoint of her formal learning. She will add a number of graduate certificates, a graduate diploma in preventive women's health, and a master's degree in cognitive behavioural therapy to her brass plate over the next decade. The Corporation values the role of the competent medical generalist, incrementally rewarding Dr Zen for the extra competencies she acquires, uses and maintains throughout her career. An exciting career path with the Corporation includes opportunities to contribute to its quality assurance, research and development program and to its education and training program. As part of its commitment to succession planning, continuing professional development activities form part of Dr Zen's paid contractual arrangements. Her work in the nurse-practitioner clinic is supported by a contract with the government. She enjoys this aspect of her life — different challenges, different demographics and a different team. But her commitment to quality patient care is just as strong. No taxi shifts for this alternative Dr Zen. Her income is sufficient, her work occupies four days each week by her choice and she has time for her children, friends and social activities.

Stephen C Trumble MD, FRACGP · Nicholas J Glasgow MD, FRACGP

Recent attempts by several corporate entities to secure more of Australia's primary medical care profits have so far been unsuccessful, but it is probably not the last we will hear from them. The 2020 scenario,* far fetched though it may seem, depicts general practice succumbing to the dollar lures of the Corporates. It is a primary healthcare model characterised by heavy regulation, structural division, detachment and constant change. An interventionist government bureaucracy and a ruthless commercial administration have effectively removed all autonomy and personalised attention from the individual's practice. Adherence to strict administrative protocols protects the commercial interests of the company, and both take priority over providing quality primary care. "Practice management" has become "policy management", and the general practitioner's needs are second to those of business managers who have become slaves to legislative conformity. GPs no longer have support staff to help them provide quality care; rather, the tables have turned and the doctors assist the administration in toeing the company line. As a result, Dr Zen has been forced to compromise on almost every value and ethic crucial to best care. Today, the profession is witnessing unprecedented bureaucratic proliferation. Multiple regulatory bodies, including federal and state governments, make demands of increasing quantity and complexity. The cost of practice administration, insurance and government regulatory compliance is escalating at an alarming rate.1 The financial pressure presently being brought to bear on general practice may ultimately precipitate the collapse of bulk billing and "universally accessible healthcare for all Australians". To prop up a dying primary healthcare system, the federal government may continue to add legislative "patches" that succeed only in transforming a once simple primary healthcare model into one that will ultimately be too complex and financially unsustainable for the medical profession.2 At that point, frustrated, overworked and underpaid doctors, no longer able to cope with the administrative convolution and burdensome regulatory demands being forced upon them, will finally abandon their practices in search of an easier way. The attraction of the Corporates lies partly in the promise of inexpensive, efficient, centralised administration.3 Yet, as a profession, we should recognise that a corporation's loyalty necessarily lies with its shareholders and that there are inherent dangers in "selling our souls" to these groups. Dr Zen's passing self reminder to raise the issue of quality care again at the next managers' meeting is illustrative of the gap that has opened up between our future practitioners and administrators. An increased administrative complexity demands attention from managers and diverts valuable human resources away from the patient's comfort, confidentiality and care, and from work relationships. A centralised administration is, by its very nature, one that operates remotely and, in this case, one that uses technology to monitor and control the performance of its human resources. The digital revolution will continue to influence virtually every aspect of our professional lives, but only time will tell if that influence will be for the betterment of general practice. Given the sheer volume of information in which we presently trade, it is inevitable that clinical records will ultimately pass between practitioners exclusively in a digital format. In the nightmare scenario, patient records have become an "online resource", with potential compromise of privacy. Therefore, as we develop systems in which confidential information is exchanged, "secure" communication channels must be among the highest priorities for software developers, the profession and law makers. At Corporation Enterprise, technology primarily serves the administration by monitoring the activities of practitioners inside the consulting room. Time has become the single most valuable commodity. Quality care comes a distant second to the commercial interests of the firm. Can we imagine a better future? 2020: extract from television newsThe Federal Government and general practice representatives emerged from their latest series of goodwill talks on regulatory reform today to confirm that the future of independent private practice was guaranteed. The restructuring of general practice under the "Red Tape" reform package has seen the elimination of inefficiency over the last three years by removing administrative complexity in general practice structures and payment systems. Outmoded bureaucratic systems were scrapped virtually overnight, and new payments systems, linked to better patient outcomes, were introduced. Dr I M Spock, National President of the AMA, said that "simplified administrative systems combined with a better use of technology" meant that the costs associated with practice would be halved by 2022 and that "the funding crisis could be averted after all". It looks like government-funded universal healthcare is back, and community groups around the country have applauded the initiative. A union representative from the Australian Medical Borg, an army of half-human, half-microprocessor humanoids, said today that "assimilation into this new system is inevitable and resistance is futile".

Mark V Lipscombe

Dr Zen's first words* capture the context perfectly. She and Mr Unger have a fixed time of five minutes available for their consultation, with penalties for Dr Zen if they run over. Dr Zen inquires how "we", not "I", can help. Chillingly, it quickly becomes apparent that "we" includes not just Corporation Enterprise but also their industrial sponsor of clinical guidelines and the manufacturer of Ease. Of course, five minutes is never going to give Dr Zen the opportunity to explore the wealth of possible meanings behind Mr Unger's words "I don't feel well". Like many doctors under pressure, Dr Zen takes the patient's first complaint as the principal one, and limits her attention to that.1 Even using this strategy, it is unlikely that there will be time for much in the way of health promotion during this consultation. This is a pity, as Mr Unger probably consults a doctor rarely, and is at particular risk following his bereavement. And yet Dr Zen, who likes talking with her customers on her taxi shift, tries to encounter Mr Unger as a person. All good doctors struggle continually to reconcile what have been called the biomechanical and the interpretive aspects of medical practice.2 Who would not wish to be offered care based on the best available scientific evidence? Symptom checklists, diagnostic algorithms and evidence-based guidelines provide the basis for optimising health outcomes. Furthermore, we cannot ignore the pressures of time. Even in private practice, every extra minute spent with one particular patient is a minute lost for others in the waiting room. There is more to care, however, than the efficient optimisation of outcomes. As doctors, by listening to the patient's story we help to clarify and define their distress. By responding empathically we validate it. By exploring and discussing their symptoms we help elaborate their understanding of their bodies, and hence of themselves. Through diagnosis we provide the patient and their family with a vocabulary for their suffering, helping to integrate the illness story into their life narrative. And when we offer a prognosis and treatment, we provide elements of the plot for the patient's story of their future. Doctors who work in primary care, like Dr Zen, have an additional function, that of working with the patient to define what is to be classified as illness — and hence treated as a health problem — and what is to be regarded as one of the vicissitudes of life.3 Much mischief can arise when patients and their doctors get this distinction wrong. Although the scenario is fictional, it is an extrapolation, if extreme, of recognisable current trends. The influence of Corporation Enterprise and its industry partners on the process of the consultation is so pervasive that they seem personified in the room.4 Dr Zen's agenda is determined almost entirely by the technologies of biomechanical medicine, even though the evidence base she mentions for Ease is quite irrelevant to a bereaved person consulting in a primary care setting. Mr Unger's agenda is crowded out; he is a case to be managed rather than a person to be cared for. The human interaction is constrained and reduced to the minimum needed to define the problem in a form recognised by a third party, and then to provide the matching treatment. And Dr Zen has little opportunity to display the qualities of sensitivity, empathy and compassion that we all need from our carers when we feel anxious and perplexed by illness. With more time at their disposal, Mr Unger and Dr Zen would have the opportunity to discuss Mr Unger's story of illness in more depth and to consider other issues that might be troubling him. The shared understanding constructed in this conversation might still lead to the illness being labelled as depression, but other, more creative, possibilities might emerge. Perhaps Mr Unger just needs to be heard and reassured, or perhaps he is seeking a new story for his life following the death of his wife. Perhaps, too, Mr Unger has troubling physical symptoms that he is reluctant to disclose until he comes to trust Dr Zen. A richer conversation would provide Dr Zen with health promotion opportunities and a context in which to propose age- and sex-appropriate screening. And Corporation Enterprise might find that Dr Zen prescribes less, while Mr Unger reports greater satisfaction with his care.5 Medicine is fundamentally an ethical activity, concerned with right action towards others; doing the right things in addition to doing things right. While diseases can be classified, albeit imperfectly, illnesses cannot; every ill person has their own fears and concerns, hopes and needs, values and preferences. Bioscience provides the tools, but it is in the conversation between persons that the proper use of those tools is defined.

Tim Usherwood MD, FRACGP

Dr Zen's experience of life as a doctor seems much closer than 2020.* Many of her tribulations are already sapping the morale of clinicians in 2003. It is significant that Dr Zen is a woman. We continue to live in a sexist world, and as the medical workforce, particularly the general practice workforce, becomes more and more female, it is likely to become increasingly subject to exploitative working conditions. Those responsible for recruitment into medical school must ensure that all sectors of society are represented proportionately and that men and women are equally represented. It will then be important to try and ensure that women are given equal opportunities within every branch of medicine and that general practice remains equally rewarding and challenging for men and women. The working conditions within Corporation Enterprise seem unlikely to attract the brightest and best medical graduates of either sex. The clinical encounter between Dr Zen and her unfortunate patient is an emaciated shadow of a genuine, general practice consultation. The doctor is constrained by her management and financial context and by the technology that she is obliged to use. As medical science develops, clinical practice necessarily becomes more difficult.1 In the future, doctors will need to be more skilful, not less so. As people live longer, more will suffer multiple illnesses, both physical and mental, and will suffer them simultaneously and inseparably. The patient who is overweight, depressed and hypertensive does not have these conditions in separate compartments of his life. He has all three inseparably and he may also be lonely and frightened — all of this is a single condition. The permutations of comorbidity are complex and individual outcomes are always unpredictable.1 Practice based on algorithms pretends that none of this is true and that healthcare is simple. The reductive use of information technology ossifies the processes of care, stifles innovation and fails to realise the potential of computers to model complexity. Dr Zen works in a context within which the agendas of the pharmaceutical industry and of government leave no room for the needs of the patient or the professional aspirations of the doctor. The result, clearly seen in Dr Zen, is a loss of enthusiasm for education and the disappearance of original research that is inspired and directed by clinicians. Governments, dependent on systems of democratic voting, are driven by the utilitarian imperative of the greatest good for the greatest number. Within healthcare, we are seeing the rise of a new utilitarianism underpinned by modern epidemiology and imposed through systems of healthcare that are supported by information technology and sponsored by pharmaceutical companies. This new utilitarianism treats both doctors and patients as standardised and replaceable units, and would have us believe that a smoker is not an autonomous adult who has chosen to smoke but a patient who has been inadequately treated by their general practitioner. The waning of professional power has been regarded as promoting patient autonomy, but its replacement by corporate power compounded by centralised political control seems likely to be much more destructive of individual patient autonomy, dignity and, ultimately, health. Current health policy is driven by a view of health defined as the absence of disease and measured by the prolongation of life. This view works to the advantage of the pharmaceutical industry. The interests of corporate profit underpin the trends which are already shifting attention and investment within healthcare from the sick to the well and from the old to the young, and replacing care mediated by touch with a system driven by paper and computers. Only a minority of most populations is acutely ill at any one time, whereas the majority are healthy and can be persuaded of a need to take action to remain so by undergoing screening or taking preventive medication. There is more money to be made from selling healthcare interventions for the healthier, richer majority than for the sicker, poorer minority, both globally and nationally.2 Similar forces drive the widening of health inequalities seen by Dr Zen in a nurse-led service for the poor and a doctor-led service, however attenuated, for the more affluent. The events of 2025: people powerReturning to the not so distant future and confronted by the fear that is enduringly implicit in the human experience of illness, we find that the need for a trusting relationship between doctor and patient is so strong that, by 2025, Australia has witnessed the so-called Taxicab Revolt. More and more people realised that doctors like Dr Zen were being forced to supplement their incomes by driving taxis. Frustrated by the minimal and standardised healthcare offered by commercially sponsored organisations like Corporation Enterprise, worried patients began to seek out GP taxi drivers who gave them time to talk about the real extent of their fears and anxieties, and advice about how to begin to sort them out. An alliance was formed which eventually led to widespread civil unrest and demands for a health service free of commercial interference and offering personal and continuing care of named patients by named doctors.3 The alliance bridged social divides and produced a renewed social solidarity based on the recognition that the need for healthcare is fundamental to human thriving.4 Different services for rich and poor were no longer acceptable. The rest is history. Tyranny will always bring forth its opponents as the rain does grass.5

Iona Heath

What's wrong in this scenario* is that Dr Zen's practice has been hijacked by guidelines, economic imperatives and intrusive technologies. Evidence-based medicine may be a comfort to Zen in the five minutes she has and may improve the look of the annual report of Corporation Enterprise, but the value of her skilled interpretation of the patient's narrative has been ignored. She remains a world away from her patient, with little time to weigh and integrate the research evidence on her screen. Algorithms and hospital-based trials cannot care compassionately for a man grieving for his lost wife, but narrative-based research may provide guidance. In Corporation Enterprise, the role of team care and the balance between managers and clinicians have been lost. Managers have implemented research-based reforms focused on efficiency, with little regard for the clinical needs of patients.1 In this context, the relationship between Ease and Corporation Enterprise is dangerously ill-directed and reduces the credibility of Ease's research. General practitioners are naturalists by training, spending many hours each day observing and summarising the multiple encounters they have with patients. Research that is not patient focused will simply entrench the cultural divide between researchers and practitioners. Dr Zen needs to reintegrate clinical research using observational data into her practice, and this can only happen if Corporation Enterprise revalues such research. To balance her own experience, Zen needs evidence on the natural history of the diverse presentations she encounters and on the use of diagnostic tests, therapies, and screening and prevention activities.2 For this evidence to be relevant to Zen, it has to be generated by networks of GP researchers using appropriate information technology.3 Narrative research is also needed, where the patient's story, including where they live and work, their family, culture, and past health experiences, can form the subject of enquiry.4 By its very nature, such research requires the active involvement of GPs like Zen, and it must value their story as part of the final result, just as it values evidence of patient empowerment and preferences,5 as well as the more conventional morbidity and mortality measures. We see that GPs will embrace the world of relevant research, given time, support and leadership. Establishing networks of research practices across Australia with strong and positive relationships with key academic centres and GP divisions is a priority. These research groups need to be cross-disciplinary and embrace multiple methods to answer the complex everyday problems that present in general practice. They must train their members to ask focused and answerable questions. Protected (funded) time is vital for those GPs who want to spend time answering these questions. Three- to five-year career paths for new researchers and passionate visionary mentors are other important elements. Above all, we need GPs to constantly question what they do in everyday practice and feed these queries into these research networks. Clinically important studies will follow. How to manage tiredness in a 55-year-old man, night sweats in a 17-year-old teenager and headache in a 10-year-old girl are some of the everyday priorities facing Zen and all practising GPs for which there is no evidence. What will the future look like? We hope — with some justification — for something better than Dr Zen's nightmare. 2020: Better findings for GP research2020 is a good year for general practice research. All 20 established GP research groups, in collaboration with other primary care organisations and consumer groups scattered across Australia, have secured large National Health and Medical Research Council grants, many being cross-disciplinary. Five of the projects from these groups have just won awards for "excellence in societal impact". These new awards were established in 2010 for projects judged most likely to improve the quality of care provided to the community. Twenty new GP and primary care fellowships of five years' duration have been secured. Corporation Enterprise has just announced the extension of a Professorial General Practice position in Primary Care Leadership and Practice-Based Research. Dr Zen has just logged on to the Professor's website and found new information from research programs on back pain in young men, headache in teenagers and the role of exercise in patients with rheumatoid arthritis. She downloads a new decision support algorithm for the management of tiredness. She emails the professor's personal assistant about a new question she has concerning the palliative care management for her patient in heart failure, and receives a return invitation to apply for funding for protected time to explore the research potential of this question. She takes a taxi home with a smile on her face as she contemplates how to fit this new opportunity into her working life.

Justin J Beilby MD, FRACGP · John S Furler MB BS, MRCGP

Roger W Hunt Palliative Care Specialist, 700 Goodwood Road, Daws Park, SA 2041. roger.huntATrgh.sa.gov.au To the Editor: Somerville argues that Resolution 3 passed at the 2002 Australian Medical Association (AMA) Annual General Meeting "might inadvertently go well beyond" a position consistent with current ethics and law and might open a door to euthanasia.1 Resolution 3 states: . . . that the AMA support doctors whose primary intent is to relieve the suffering and distress of terminally ill patients in accordance with patients' wishes and interests, even though a foreseen secondary consequence is the hastening of death. As the mover of this resolution, I wish to comment on Somerville's arguments. Pain versus suffering: Somerville claims the phrase "to relieve their pain" does not open up the possibility of legitimating euthanasia, whereas "to relieve their suffering" does. She suggests better language would be "the relief of pain and other symptoms of serious physical distress of terminally ill patients". This argument is weakened by the fact that powerful analgesics and adjuvant pain medications can be used for euthanasia, but the methods of palliating other suffering cannot so readily be used for this purpose. Furthermore, the concept of purely physical pain has long been discredited. The dimensions of suffering cannot be neatly separated. Existential suffering can be just as agonising as physical discomfort, and there are moral and clinical imperatives to relieve all kinds of suffering. Current law: Resolution 3 is based on the "Care of the Dying" clause in the South Australian Consent to Medical Treatment and Palliative Care Act 1995. This clause codified the common law position. It was overwhelmingly supported in parliament — politicians believed terminally ill patients should not have to suffer pain and distress because clinicians feared prosecution for hastening death. The Act and Resolution 3 are fundamentally similar: both involve the principle of double effect, and both stipulate the need for patient-centred decision-making. Patients' wishes and interests: Somerville is critical of the phrase "in accordance with patients' wishes and interests". She says it justifies rather than excuses life-shortening treatment: "an excuse carries the message that life-shortening is wrong . . . The message of a justification . . . is that the conduct of shortening life is right." I believe it is better for a doctor to provide a valid justification than offer an excuse for a treatment that contributes to a patient's death. An excuse equates with an unsatisfactory attempt at explanation, whereas a valid justification implies ethical and appropriate care. If a doctor aims to act in the patient's interests, and with the patient's informed consent, then the life-shortening consequences of an action may be accepted. The treatment, rather than the outcome, may be seen as "justified". Ethical care involves negotiation with the patient (or representative) to select the treatment that best suits the patient's wishes and interests. Somerville apparently undervalues the principles of patient autonomy and informed consent, but these have a crucial role in medical decision-making. Decision-making about treatments that affect the time of death must be balanced between being doctor-centred and patient-centred. Conclusion: Resolution 3 is consistent with current ethics and law, and with relevant clinical concepts. If a medical treatment results in a patient's death then a valid justification, rather than an excuse, is required. This justification involves the careful consideration of, and respect for, the patient's wishes and interests. Malcolm Parker Senior Lecturer in Ethics and Professional Development, School of Medicine, University of Queensland, Herston, QLD 4006 m.parkerATuq.edu.au To the Editor: Somerville's analysis of the Australian Medical Association's (AMA's) confusion in its recent resolutions concerning death and dying is helpful, but her subsequent anti-euthanasia arguments are inadequate.1 Somerville suggests that the AMA has moved closer to supporting euthanasia by adopting a neutral stance, because being neutral means the AMA has no principled reasons to oppose it. This is incorrect. Taking a neutral stance is to recognise that there are both good reasons to oppose an issue and good reasons to support it. In fact, a neutral stance remains more felicitous to the status quo, because it suggests that the AMA does not contemplate action in regard to the issue, but action is clearly required to legalise euthanasia. Somerville distinguishes the right to have treatment withdrawn from the right to be killed, on the basis of the difference between death caused by the underlying illness, and death caused by a lethal injection. She states that there are "long-established, well understood, profound and important differences between allowing people to die, when it is ethically and legally justified, and making them die", and "respecting people's refusals of life-saving treatment belongs in the former category, euthanasia in the latter". It is difficult to assess what force Somerville thinks these assertions have. They do not constitute arguments for her position. The only reason Somerville appears to offer is that acting with the primary intention of killing another person is inherently wrong, except in justified self-defence or defence of others, and this is a cornerstone of our law and relationships. However, anything that is inherently wrong but admits exceptions is at least open to further argued exceptions. If there are cases in which assisting someone to die would be better than letting nature take its course (and many people believe there are such cases), then there is clearly a case for seriously questioning our "deep moral intuitions", rather than issuing infallible moral proclamations based on tradition. Finally, while Somerville is correct in stating that doctors' secret involvement in euthanasia does not mean that it is right, she makes the stronger empirical suggestion that if doctors are presently ignoring the law against murder, we should expect them to disobey guidelines for voluntary euthanasia. This suggestion is no more than a rhetorical mischief, as doctors who ignore the current law are those who support euthanasia, and they would have no reason to disobey legal guidelines. Rodney A Syme Surgeon, 20 Woodside Crescent, Toorak, VIC 3142 To the Editor: Somerville1 says that language matters, which is why she selects the definition of euthanasia as "a deliberate act that causes death undertaken by one person with the primary intention of ending the life of another person, in order to relieve that person's suffering". This obviously produces a different response compared with the realistic definition (based on the classical understanding of the word) as "an act to cause a peaceful and dignified death on request", or the practical definition (that of the Voluntary Euthanasia Society of Victoria) as "an act, taken by, or at the request of, a rational informed person, whose intention is to relieve their intolerable suffering, by hastening their death in a dignified manner", which incorporates all the components of euthanasia in a medical context. Somerville provides a legal definition, which ignores the simple fact that the primary intention of an act of euthanasia is to relieve suffering — it is an act of palliation. The doctor involved has no desire to end life — that is the intention of the patient. Somerville seems to choke on the word "voluntary", dismissing it in one sentence, despite the Australian Med-ical Association accepting, rightly, that doctors should respect "the patient's wishes and interests". She also, not surprisingly for a lawyer, recognises no suffering other than physical pain, ignoring dyspnoea, paralysis, cachexia, or psychological and existential suffering. She claims, without any evidence, that allowing euthanasia would cause profound damage to society. The Netherlands have openly practised voluntary euthanasia for nearly 20 years, and the Swiss have allowed assisted suicide for 50 years2 without any evidence of societal damage. Medically assisted suicide in Oregon (US) has been closely and officially documented over the past 5 years with positive effects on the use of hospice care, opioid use, and deaths at home rather than in hospital.3 Finally, how long must it take for this debate to focus more intently on physician-assisted suicide? Most patients who wish to relieve their suffering can do this for themselves, with the assistance of a physician for advice, support and prescription. This then places the responsibility for this fundamental decision and action where it should be, with the patient. It also minimises the small possibility of non-voluntary euthanasia. Just because the Dutch adopted direct lethal injection as their principal method of voluntary euthanasia does not mean that we in Australia should allow that method to dominate the debate. Julia M Anaf C/- PO Box 2151, Kent Town, SA 5070 turanaATozemail.com.au To the Editor: In endorsing the Australian Medical Association's (AMA's) reiteration of a negative policy on voluntary euthanasia, Somerville claims that "language is not neutral".1 In discussing the wording of the resolutions, she argues for the term "suffering" to be subsumed within "pain and physical distress", even though "suffering" better reflects the complex physical and psychosocial dimensions of the human condition. This suggested white-out is troubling, but to be anticipated. Defending an unequivocal negative stance on euthanasia inevitably results in conditional compassion, for it must assume the right to control patients, instead of respecting their autonomy. A negative policy has no more credence than a positive one. Neither represents the diversity of opinion that exists within the profession, or the broader community.2 A negative stance takes refuge in, instead of challenging, the problems imposed by the doctrine of double effect as public policy. Although this doctrine offers a (compromised) level of legal and emotional surety for the doctor, it takes no real account of other relevant moral considerations, or the views of the patient. A policy stance which mirrors Somerville's view that "euthanasia is simplistic, wrong and a dangerous response to the complex reality of death" cannot respect the complexities arising from each person's very personal meanings and values attaching to life, death and dying. Its adherents must defend against acknowledging the true extent of suffering that some patients are forced to endure. A negative policy also fails to acknowledge that all end-of-life decision-making attracts moral evaluation, including "doing nothing", withdrawing futile treatment, or shortening life by symptom control. Rightly or wrongly, the AMA's policy stance can also be interpreted as a way of absolving itself of any responsibility to face, let alone challenge, the legal and social circumstances under which medicine is practised — circumstances that inevitably lead to the "euthanasia underground" and the horrors of self-deliverance.3 Somerville's implication is that a negative policy stance based upon moral absolutism will resolve difficult moral dilemmas. It will not. Clem F Nommensen Retired General Surgeon, 9 Moorabinda Street, Buderim, QLD 4556 nommensAThotkey.net.au To the Editor: Somerville discussed her perspectives on the debate concerning voluntary euthanasia which took place at the 2002 Australian Medical Association Annual General Meeting.1 This debate arose because of submissions which sought the adoption of a neutral stance on this issue, similar to that taken on abortion.2 The voluntary euthanasia debate (including physician-assisted suicide) has intensified over the past 10 years, fuelled by enabling legislation in Switzerland, the Netherlands, Oregon (US), Belgium, and briefly in the Northern Territory, and by a groundswell of favourable public opinion. The arguments have been rehearsed countless times. Somerville's article adds nothing, but underlines the total failure of consensus. Her initial discussion on definitions and voting patterns seems pointless in the real world. Public opinion polls have shown that more than 70% of Australians support the idea that terminally ill and severely suffering people should be free to make a choice,3 and that palliative care is not always the answer. Some surveys of medical opinions, such as one within the Royal Australian College of Surgeons,4 suggest most doctors probably agree, although many do not approve legalisation. These findings accord with my practice experiences, and contacts with colleagues, throughout a long surgical lifetime. This indicates that voting at the conference did not reflect the opinion of most Australians, or a possible majority of our profession. Unfortunately, much of Somerville's article reads like a homily urging the negative view. Like her opponents, she claims the high moral ground, but opinions have clearly consolidated on the basis of previously accepted philosophical positions. In spite of the published studies, there is no clear and convincing knowledge of what percentage of Australian doctors approves voluntary euthanasia, whether legalised or not. We need a well-conducted poll to determine an appropriate medical community stance on this issue, bearing in mind that community standards are now broadly accepted as the appropriate basis for legal sanctions on behaviour and practice. Frances J Coombe President, South Australian Voluntary Euthanasia Society, 11 Boord Court, Dernancourt, SA 5075 fcoombeATadam.com.au To the Editor: I agree wholeheartedly with Somerville's closing statement "How a society treats its weakest, most in need, most vulnerable members best tests its moral and ethical tone".1 Unfortunately, by preceding this with an argument against choice for euthanasia, Somerville effectively condemns those weakest and most vulnerable people who are suffering intolerably from a hopeless or terminal illness to a horrendous existence. A position statement by Palliative Care Australia acknowledges that, although pain and other symptoms can be alleviated, complete relief is not always possible, even with optimal palliative care.2 The only relief from intractable pain and symptoms comes through death, and the present law perpetuates suffering by denying this release. The moral and ethical tone of our society in this regard is shamefully weak. For too long, end-of-life decisions have centred on a doctor's stated intentions — "double effect". Somerville gives a lengthy justification of this doctrine and tells us that language and doctors' decisions about euthanasia are most important. Where do the needs of suffering people fit here? The moral and legal validity of a doctor's action would be best determined by factors such as: the patient's right to self-determination and bodily integrity; the provision of informed consent; the absence of less harmful alternatives acceptable to the patient; the severity of the patient's suffering; and the requirement that a doctor should work always in the best interests of the patient. Such a patient-focused approach will meet the needs of and protect all vulnerable people, thereby strengthening our society's moral and ethical tone with rationality and unconditional compassion. Margaret A Somerville Samuel Gale Professor of Law, McGill Centre for Medicine, Ethics and Law, McGill University, 3690 Peel Street, Montreal, Quebec H3A 1W9, Canada margaret.somervilleATmcgill.ca In reply: Hunt seems not to understand the reason for distinguishing between life-shortening treatment to relieve pain and physical distress, and that to relieve suffering in general. Whether either type of treatment is likely to be used for euthanasia is beside the point. The doctrine of "double effect" can be used to justify life-shortening treatment to relieve pain, but not to relieve suffering in general. More-over, if an intention of relieving suffering in general became a justification for giving life-shortening treatment, there would be no limits on using such treatment, that is, euthanasia would be legitimised. I disagree that "there are moral and clinical imperatives to relieve all kinds of suffering" (emphasis added). Doctors, like the rest of us, should respond humanely to suffering people. But it is beyond the role of doctors and the mandate of medicine to assume an authority to kill people in the name of relief of suffering in general. I agree with the position taken in the South Australian Consent to Medical Treatment and Palliative Care Act 1995, that patients should not have to suffer "pain or distress", but that is a narrower category than "suffering". Depending upon how the Act and Resolution 3 are interpreted, they might or might not be "fundamentally similar". However, if interpreted to allow life-shortening treatment for the relief of suffering in general, then they go well beyond the accepted common law position on double effect. Parker is wrong in stating that the Australian Medical Association (AMA) adopted a neutral stance; it expressly rejected doing so. However, his misunderstanding makes my point that the resolutions are inconsistent and confusing. He is also wrong to write that a neutral stance on euthanasia is morally neutral. It is not — it means that euthanasia is not morally wrong, which would contradict the AMA's current position. One strategy for legalising euthanasia is to move incrementally towards its acceptance by using ambiguous or confusing language. Whatever Hunt's intention in drafting Resolution 3, it reflects those characteristics. Doctors need to be aware of that strategy. Hunt appears to misunderstand the legal difference between justifications and excuses. These terms apply to the consequences of justified acts. Shortening life as a consequence of a justified treatment should only be excused. Similarly, both Hunt and Syme do not seem to understand how informed consent functions in law and ethics. Consent is necessary but not sufficient to justify potentially life-shortening treatment. That treatment must also be not contrary to public policy. It meets this condition only if needed for pain or symptoms of physical distress. Parker is dissatisfied with my statements on the distinction between killing and letting die. This distinction hinges on ethical and legal doctrines of causation and intention that are too complex to discuss here. There is a further distinction between intention and desire, which Syme confuses. Anaf says I argue for "the term 'suffering' to be subsumed within 'pain and physical distress'". The fundamental point of my article is the absolute opposite. She appears equally confused on other points. One can only be for or against euthanasia, so "diversity of opinion" does not make sense here. Of course, all end-of-life decision-making attracts moral evaluation, but my article was not about all such decision-making. Nommensen implies that "community standards" and "an appropriate medical community stance" necessarily equate to an ethically acceptable one. This is incorrect — majorities can decide to act unethically. Contrary to Parker's final claim, there is evidence that many doctors in the Netherlands who support euthanasia do not follow the guidelines for carrying it out.1 Similarly, experience in the Netherlands contradicts Coombe's assertion that legalising euthanasia will "protect all vulnerable people".1 Some of the most vulnerable — mentally incompetent — people have been subject to euthanasia. The same source challenges Syme's statements on the Netherlands and Oregon (US). Finally, Syme confuses the definition of euthanasia with the justification put forward by advocates of its legalisation. Creating such confusion can be a deliberate advocacy strategy.

Roger W Hunt · Malcolm Parker · Rodney A Syme · Julia M Anaf · Clem F Nommensen · Frances J Coombe · Margaret A Somerville

William Lancashire*, Craig Hore† and Jennifer A Law‡ *Conjoint Senior Lecturer, †Senior Lecturer, ‡Lecturer, School of Rural Health, University of New South Wales, PO Box 2466, Port Macquarie, NSW 2444. Bill.lancashireATmaynegroup.com To the Editor: We read with interest Hillman's editorial on the hospitalist movement.1 As our group includes a couple of recent expatriates from the Canadian healthcare system,* we can give some historical perspective on the evolution of the hospitalist in Canada, some of which parallels what is happening in Australia. Traditionally, family physicians (general practitioners) in Canada were able to manage their patients in hospital, either as the primary care doctor or in consultation with a specialist. Not infrequently, the specialist would assume primary care and consult with the family doctor. Continuity of care was assured, and both the family doctor and the specialist benefited socially and professionally from the interaction. The "corridor consultation" thrived and the doctor's lounge was a source of medical education and social interaction as GPs and specialists met over a morning coffee before rounds. Around 10 years ago, the family doctor became increasingly unwelcome in the hospital, particularly in teaching centres. As there was never a financial incentive to be involved in hospital practice, this atmosphere persuaded most family doctors to resign their hospital privileges. However, it soon became apparent that a visiting-consultant-based service could not cope with the numbers of patients being admitted to hospitals. Patients with no apparent "teaching value" were becoming difficult to admit into teaching units. Consequently, those few GPs who had retained hospital privileges were increasingly being asked to accept patients primarily under their care. As the system became more stressed, they found that they were managing more and more acutely ill patients. These experienced GPs evolved to become hospitalists — essentially, primary care doctors who were prepared to look after acutely ill inpatients, often in consultation with a specialist. Unfortunately, attempts to encourage GPs back into the hospital system have generally proved unsuccessful. The College of Family Physicians of Canada, recognising that there may no longer be ready access to specialist services or hospital beds, is starting to train its residents accordingly. We agree with Hillman that the complexities of acute medicine require specialists (such as emergency physicians, intensive care specialists and general physicians) with training and skills in acute medicine, resuscitation and multisystem problems. Indeed, our experience in rural Australia suggests that hospital-based multidisciplinary critical care physicians are already undertaking some of the hospitalist roles that Hillman describes. Perhaps we are witnessing the emergence of hospitalists in Australia.

William Lancashire · Craig Hore · Jennifer A Law

F Frank Pyefinch Director of MD Development, Health Communication Network, 2 Santa Fe Drive, Bundaberg, QLD 4670 frank.pyefinchAThcn.com.au To the Editor: I would like to comment on the recent article by Newby et al.1 They conclude that the default settings in computerised prescription packages result in a significant increase in the use of antibiotics. I do not believe this is a valid conclusion. As the authors state that 85% of general practitioners generating computerised prescriptions are using Medical Director (MD), it is reasonable to assume that the default settings in MD would contribute significantly to this effect if their conclusion is correct. I have installed and tested MD v.2.3 from February 2000, MDW v.1.85 from February 2000 and MD v.2.4 from May 2000. These were the versions that would have been in use at the time of this study. All versions default to printing "once-only" prescriptions without repeats. In fact, when a "once-only" prescription has been selected, MD's default behaviour is to display a prompt for the quantity and repeats with the default repeats field set to "0". This is very easy to verify simply by installing a copy of MD onto a "clean" computer and printing some scripts. As this was evidently not done, it casts doubt on the quality of the whole study. How can the authors reach a conclusion about the effect of the default settings in computerised prescription packages without first ascertaining what those default settings are? They appear to have assumed that the default behaviour of all computer prescription packages is to print the maximum number of repeats allowed by the Pharmaceutical Benefits Scheme. No attempt appears to have been made to verify whether this is the case. Whatever the reason for the observed increase in repeat antibiotic prescriptions, it is incorrect to conclude that it is due to the default settings in computerised prescribing packages. No discussion of other possible explanations for the observed increase is presented and it appears as though the data have been used to support a conclusion that had been decided before the study was commenced.

F Frank Pyefinch

Colleen T Bruce,* Margaret M Sanger,† Paul S Thomas,‡ Jonathon R Petkus,§ Deborah H Yates¶ * Research Assistant, ‡ Senior Lecturer, Faculty of Medicine, University of New South Wales, Randwick, NSW; † Deputy Medical Director, Concord Repatriation General Hospital, Concord, NSW; § Medical Student, ¶ Senior Lecturer, Faculty of Medicine, University of Sydney. Correspondence: Dr Deborah H Yates, Department of Respiratory Medicine, St Vincent’s Hospital, Darlinghurst, NSW 2010. deborahy88AThotmail.com To the Editor: The demands of practising medicine can have significant effects on general health, work satisfaction, professional and non-professional life.1 We conducted a survey among senior medical staff in a metropolitan teaching hospital. The survey explored the pressures of work, social and family demands on consultants, and whether there was a difference between sexes. Participants completed a self-reported questionnaire on quality of life, levels of stress and feelings of work satisfaction, using previously validated questions and scoring from the General Health Questionnaire (GHQ-28, a 28-question subset of the GHQ)2 and Specialist Doctors Stress Inventory (SDSI).3 (Questionnaire available from authors on request.) Respondents answered anonymously and gave informed consent. Fifty-seven per cent of consultants (54/94) returned surveys, of whom a third (18/54) were women. The response rates were comparable to those of other physician surveys.4 On average, consultants had been employed at the hospital for 10.8 (SD, 8.0) years, had been qualified for 22.2 (SD, 9.6) years, and were working 47.7 (SD, 14.0) hours per week. Eighty-one per cent (44/54) were married, 74% (40/54) had children and 54% (29/54) lived in a double-income household. Half (27/54) reported an unreasonable ratio between work hours and leisure time, and 50% (27/54) reported feeling stressed. Despite this, 65% (35/54) believed they had or would achieve their ideal medical career. Female consultants worked fewer professional hours, but more hours in unpaid domestic work, than male consultants. Furthermore, female doctors were more likely to have had their career modified by family or social factors; more likely to use paid support to cope with their domestic workload; and, if they had children, more likely than men to have modified their careers to look after dependants (see Box). Consultants who reported feeling stressed were more likely than other consultants to report an unreasonable ratio between work hours and leisure time (74.1% [20/27] v 48.1% [13/27]; P = 0.05). Forty-one per cent (22/54) scored above 4 on the GHQ-28, indicating that a high level of stress and psychiatric “caseness” (ie, clinically significant levels of psychiatric disturbance) is experienced by senior doctors. This result is similar to that of a UK study in which 46% (30/65) of senior doctors reported experiencing high levels of stress.5 From our data there appears to be a significant relationship between stress, psychiatric “caseness” and hours worked (P < 0.001). Our study and others have identified potential reasons why women work fewer hours in medical work and have a shorter working life. These include having and caring for children, stress, dual-career marriages, personality and social expectations.6 Our survey highlights the fact that female consultants in Australia face undue pressure in balancing their medical and domestic roles compared with male consultants. There is a continuing need for flexibility in workplace and training environments for women in medicine to ensure equal career choice, balance between work and domestic commitments, and professional satisfaction. Comparison of self-reported factors between female and male consultants (n = 54) Female consultants (n = 18) Male consultants (n = 36) P value Mean age in years (SD) 45.3 (10.5) 47.7 (8.1) 0.43 Mean hours in medical work per week (95% CI) 33.4 (28.5–38.4) 54.7 (51.5–58.0) < 0.001* Mean hours in unpaid domestic work per week (95% CI) 22.9 (8.0–37.8) 10.6 (7.6–13.5) 0.02* Uses paid domestic support 14/18 (78%) 18/36 (50%) 0.05* Has children 11/18 (61%) 29/36 (81%) 0.12 Expects to achieve future medical goals 12/18 (67%) 24/36 (67%) 0.78 Has had career expectations modified by: Workplace 8/18 (44%) 22/36 (61%) 0.25 College/training 4/18 (22%) 7/36 (19%) 0.81 Family/social factors 12/18 (67%) 14/36 (39%) 0.05* Illness 1/18 (6%) 4/36 (11%) 0.51 Has had career opportunities modified by care for dependants 9/11 (82%) 10/29 (34%) 0.02* Reports partner is inconvenienced by respondent’s career goals 10/18 (56%) 9/36 (25%) 0.03* Mean score on GHQ-28 (95% CI)† 2.24 (1.81–2.68) 2.10 (1.95–2.26) 0.45 Psychiatric “caseness”‡ 8/18 (44%) 14/36 (39%) 0.30 Median job satisfaction score§ 3 (range, 3–4) 3 (range, 1–4) 0.15 Median life stress score§ 2 (range, 1–2) 1 (range, 1–3) 0.13 GHQ-28 = 28-item General Health Questionnaire. * Difference between men and women significant. † Minimum score = 0; maximum score = 28. ‡ ie, Clinically significant psychiatric disturbance (GHQ-28 score > 4). § Minimum score = 1; maximum score = 4. Data were analysed by Pearson’s χ2 test, Student’s t-test or the Mann–Whitney test and stratified by sex.

Colleen T Bruce · Margaret M Sanger · Paul S Thomas · Jonathon R Petkus · Deborah H Yates

David A Newby,* Jayne L Fryer,† David A Henry‡ * Lecturer, † Statistical Analyst, ‡ Professor, Department of Clinical Pharmacology, University of Newcastle, Newcastle Mater Misericordiae Hospital, Newcastle, NSW 2298 mddanATalinga.newcastle.edu.au In reply: As Pyefinch notes, if the "once only" option in Medical Director (MD) is chosen during prescribing, the doctor must enter the quantity and number of repeats that he or she wishes to order. However, if the doctor chooses the "regular" medicine option (both options are offered during prescribing), then the maximum Pharmaceutical Benefits Schedule quantities and repeats are inserted. There are various reasons why doctors may be using the "regular" option rather than the "once only" option when prescribing antibiotics using MD. Some of these have been discussed on the General Practice Computing Group Listserv,1 and include factors such as confusion regarding the terms "regular" and "once only" and difficulties recalling patient medication histories if the "once only" option is used. Another explanation is that doctors commonly prescribe chronic medications, and therefore use of the "regular" option may become a habit. Whatever the cause, there is no obvious explanation for the differences observed, except for the use of prescribing software. Our recommendation that prescribing software be altered to avoid these shortcuts was made because it represents the most immediate way of resolving the problem.

David A Newby · Jayne L Fryer · David A Henry

Jennifer A O'Dea Senior Lecturer, Faculty of Education, University of Sydney, Building A35, Sydney, NSW 2006. j.o'deaATedfac.usyd.edu.au To the Editor: As part of a large, national nutrition study, height and weight were measured among 4441 students from 38 schools randomly selected from lists of all state and territory schools in Australia in 2000. Public, private and Catholic schools, in both rural and urban areas, were represented. Schools were categorised as being of low or middle/high socioeconomic status (SES),1 based on direct measurement of parental income. Parental consent was obtained, and the study was approved by the University of Sydney Ethics Committee and all state departments of education. Overweight and obesity, as defined by an international standard definition,2 were identified in 17.3% and 6.4% of participants, respectively. These characteristics showed a trend towards greater prevalence among students from low-SES backgrounds compared with those from middle/high-SES backgrounds for the total group (19% v 16.8% overweight [P = 0.09]; 8.9% v 5.8% obese [P = 0.02]), females (19.7% v 17.2% overweight [P = 0.2]; 6.9% v 6.2% obese [P = 0.56]), and males (18.5% v 16.3% overweight [P = 0.23]; 9% v 5.5% obese [P = 0.003]), although not all differences were statistically significant. After controlling for SES differences in age and height, mean body mass index (BMI) was significantly higher among low-SES than middle/high-SES participants for the total group (20.3 kg/m2 [95% CI, 20.1–20.5 kg/m2] v 19.7 kg/m2 [95% CI, 19.6–19.9 kg/m2]; P < 0.001), females (20.4 kg/m2 [95% CI, 20.1–20.7 kg/m2] v 19.8 kg/m2 [95% CI, 19.6–19.9 kg/m2]; P < 0.001), and males (20.2 kg/m2 [95% CI, 20.0–20.5 kg/m2] v 19.6 kg/m2 [95% CI, 19.5–19.8 kg/m2]; P < 0.001). A breakdown of results by SES, sex and school level is shown in the Box. Low-SES primary school children were also 1–2 cm shorter, on average, than middle/high-SES primary school children (boys: mean 141.5 cm [95% CI, 140.6–142.5 cm] v 143.5 cm [95% CI, 143.0–144.0], P < 0.001; girls: mean 141.0 cm [95% CI, 140.8–142.6 cm] v 143.3 cm [95% CI, 142.5–143.6 cm], P = 0.01). The average proportions of overweight and obese children and adolescents in the study were similar to those found in other Australian studies.3-5 The results suggest that SES is a factor in the development of overweight and obesity among Australian school children. This may be a relatively recent trend, as these data were obtained in late 2000. Low SES in children may also be associated with nutritional deprivation and height retardation. Further research should clarify these relationships among children from low, middle and high SES backgrounds, as well as examining the combined impact of both SES and ethnicity. School students classified as overweight or obese* according to socioeconomic status (SES), school level and sex Males (n = 2232) Females (n = 2209) Low SES (n = 574) Middle/high SES (n = 1658) Low SES (n = 508) Middle/high SES (n = 1701) Primary school students (grades 1–6; ages 6–13 years) Overweight students 19.4% (42/216) 16.2% (110/680) 23.2% (51/220) 17.8% (136/766) Obese students 6.9% (15/216) 5.3% (36/680) 6.4% (14/220) 5.7% (44/766) High school students (grades 7–12; ages 13–18 years) Overweight students 17.6% (63/358) 16.4% (160/978) 17.0% (49/288) 16.8% (157/935) Obese students 10.1% (36/358) 5.6% (55/978) 7.3% (21/288) 6.5% (61/935) * Overweight and obesity are classified according to the international standard definition.2

Jennifer A O'Dea

Re: "Asthma symptoms associated with depression and lower quality of life: a population survey?", the Research article by Robert D Goldney, Richard Ruffin, Laura J Fisher and David H Wilson in the 5 May issue of the Journal (Med J Aust 2003; 178: 437-441), in which variables in Box 1 were incorrectly labelled. "Male sex" should have been "Female sex", and "Overseas born" should have been "Australian born". The corrected table is shown. The html and pdf versions of the article were corrected online on 30 June 2003. Predictors of asthma determined by logistic regression Variable Odds ratio (95% CI) P Female sex 1.55 (1.22–1.99) 0.003 Depression 1.40 (1.04–1.88) 0.026 Australian born 1.60 (1.18–2.18) 0.003

Robert D Goldney MD, FRANZCP · Richard Ruffin MD, FRACP · David H Wilson MPH, PhD · Laura J Fisher BA(Hons)

The Federal Committee of the British Medical Association in Australia has recently dealt with the question of the abuse of the name plate which medical practitioners usually display outside their professional chambers or residences. The proposal was made that the Committee should express the opinion that it was undesirable for a medical practitioner to display a name plate on which the specialty practised was announced. The Committee, after careful review of the history of name plates in Australian cities and of the practice that has grown up during the course of many years, came to the conclusion that there was no objection to the announcement on the plate of a specialty, provided that the practitioner confined his activities exclusively to that specialty... Medical practitioners find it convenient to indicate the place where they may be consulted by affixing a name plate outside their premises. The object is not to attract practice, not to invite a chance patient to enter, but to guide the patient wishing to consult a particular practitioner to the proper address. In an emergency a doctor's name plate is used by the messenger for the purpose of obtaining medical aid as speedily as possible. Under ordinary circumstances the indication should not have the object of arresting the attention of a wandering patient seeking medical aid. On the other hand, there would be no real objection to the reception by a medical practitioner of a patient who elected to consult a stranger merely because the name plate was encountered. Many valuable practices have been built up by young practitioners putting up a plate and waiting. Someone is sure to come sooner or later, although the early callers not infrequently are those who avoid the doctors of longer standing because of unpaid accounts. The plate, however, should be of modest dimensions and it is usually held that there is no need for any indication other than the practitioner's name... In some towns and cities in Great Britain even the affix "Dr." is by common consent replaced by a plain "Mr.," even when the practitioner is a graduate in medicine and practises as a physician. More often practitioners either affix "Dr." to their names, or employ other words to indicate that they are medical practitioners. A few years ago the Royal Colleges of Physicians and Surgeons in England granted their diplomates the right to use the courtesy title "Doctor," provided that they did not convey the impression that they possessed a degree of any university... ... The majority of medical practitioners will, no doubt, adopt a dignified attitude in regard to their name plates and avoid the display of anything which might be regarded as unusual. Med J Aust 1922; 1: 302-303 [editorial]

In the short space of a mere eighteen months, doctors in Australia have come to understand the meaning of medical politics and how these problems affect every aspect of their professional existence. In this short time, the medical profession in Australia has come to face the harsh realities of medical economics when the Government is meeting the major part of the cost of providing medical care in the community. ...the profession has been jolted into the realisation that many of its previously-held attitudes either were myths, or were at best quite unsuited to assist them in their new-found situation. As might well be expected with such a conservative group as the medical profession, these changes have resulted in enormous internal pressures to the fabric of organised medicine in Australia, which have produced, in their turn, obvious cracks in the façade of unity which the profession strives to maintain. ... The majority of medical practitioners will, no doubt, adopt a dignified attitude in regard to their name plates and avoid the display of anything which might be regarded as unusual. Splinter groups have sprung up particularly in general practitioner ranks, all having essentially the same purpose, but all speaking with discordant voices... For some years now, the student of health-care delivery has realised that, in common with most of the Western world, the pattern of delivering health care to the Australian community has been undergoing considerable changes. In particular, the role of the general practitioner in Australian urban communities has been changing. While the profession's leaders have been aware of these changes, a largely uninterested rank-and-file has been no stimulus for them to experiment or initiate remedies. It was not until the economic pressures mentioned above provided the necessary stimulus that general practitioners in Australia began to take stock of what was happening. The future role of the general practitioner (and in particular his place in the hospital environment), the place, if any, for the "health centre" in the delivery of health care to the Australian community, and even the role of the general practitioner in the provision of obstetrics services are some of the issues which, only two years ago...would have seemed unreal, but are now matters of common debate. Lionel L Wilson, Med J Aust 1972; 1: 30

The city The newly qualified man may be contemplating starting as a general practitioner in the City of Sydney and after thirty-two years' experience in [the city], I may be able to give some advice as to his taking such a step... My advice to any young graduate thinking of general practice in the city is that of Punch to those about to take a step in another serious direction — "Don't!" If he still persists, he must try to get some friendly society lodge work and even if successful in that he must be prepared for a long waiting period. I would say to any young medical practitioner, do your resident hospital appointments, then see something of the outside world, get into general practice in the suburbs or country... A Maitland Gledden, Sydney, NSW The suburbs ... A few years' practice in the country is an excellent preliminary to suburban work. The experience gained by the practitioner...stands him in good stead when he settles down in the suburbs... In choosing a suitable locality the medical man should try to find one of the newer suburbs which is not too thickly populated, where there is plenty of spare ground and where buildings are constantly going up. In this type of suburb population will grow rapidly and the doctor's practice will grow with it. If he chooses one of the older suburbs, where nearly every foot of ground is built on and consequently where there is little room for increase of population, the growth of his practice will depend on the number of patients he can get away from his colleagues. This is often a long job and usually an unpleasant one. The question is often asked: "How long should a squatter be prepared to last?" The answer... Personally, I think if the squatter has not made good in three years, it would be advisable for him to "seek fresh fields and pastures new"... The suburban practitioner has the great advantage over the country one of having specialists always available to come to his assistance either privately or at hospital... Even if the specialist is not able to do much in the way of a cure, the attendant's position is much strengthened by the specialist's opinion and advice... I would urge the suburban practitioner in cases when a pathological examination has to be made, to try to educate his patient to go to a private practitioner. Far too many patients are sent to the Board of Health or the public hospital. It will often surprise the practitioner to find how many of his lodge patients can afford one or two guineas for a special pathological report... C H E Lawes, Petersham, NSW The country ... There are two types of country practitioners, those who belong to the community and become part and parcel of it; the other especially the younger men who commence because it is cheaper and there is less opposition and they can learn their work and perhaps earn enough money to commence in a bigger centre... The first thing we have to decide is whether we will serve God or Mammon... If we serve God, we shall serve the community faithfully. Our work will go on and on improving and our reputation with it. If we serve Mammon, life will be more or less easy. We may make money and become the popular doctor... We shall become past masters in the art of saying and doing the right thing. We shall know exactly what the patients themselves want to do and shall advise them to do it... The universal use of cars, good roads and the telephone have quite altered the country doctor's life. Trips which took you all day, you do now in a few hours. Patients come in much more often to see you, so that travelling is much less... Life is much easier, yet it has lost much of its charm. One misses a good pair of horses or a hack for which you have more than a kindly feeling, especially on moonlight nights, in big timber and places where the fairies dwell... ... You have to be doctor, nurse and everything that entails. The great difficulty is to teach people that orders are orders. Orders should be given in plain words and they should be quite simple ones and if the case is urgent, they should always be written down... The question of fees is a difficult one. The main duty of us country practitioners is to serve the community. In most country districts our patients are chiefly strugglers or fighting an uphill game... It is just that we receive reward for our labour, yet it is impossible to charge for labour done. You alter a patient's whole outlook, alter the whole course of his life and perhaps charge half a guinea, you operate and save him from certain death and only charge a small fee, which is all out of proportion... ... We receive little honour as men call honour; we can earn an income, we can never get riches; we can understand and live to the meaning of Kipling's lines: Not as a ladder from earth to heaven, Not as a witness to any creed, But simple service simply given to his own kind In their common need. Horace Pern, Leongatha, VIC Med J Aust 1929; 2: 276-282