Desperately seeking . . .
At the end of a long day in general practice a new patient turns up, acting agitated but overfriendly. With a sinking feeling you realise that an inappropriate request for drugs will end in a confrontation ... No GP relishes this situation, but, like most behaviours, "doctor shopping" can mean many things. According to Martyres et al (→ Seeking drugs or seeking help? Escalating "doctor shopping" by young heroin users before fatal overdose), escalating doctor shopping may be a cry for help in young heroin users. Kamien (→ "Doctor shoppers": at risk by any other name) says the study’s findings underscore the importance of providing GPs with a rapid means of "diagnosing" doctor shoppers — for their own good!
Starving for choice
Recently, asylum seekers in Nauru sustained a hunger strike for almost a month. In Australia, the Department of Immigration and Multicultural and Indigenous Affairs can instruct (but not compel) doctors to force-feed such protestors. Would you comply? Kenny et al’s thoughtful exposition of the ethics and legalities (→ Legal and ethical implications of medically enforced feeding of detained asylum seekers on hunger strike) might help you make up your mind.
The dynamics of statins
More Australians than ever before are on lipid-lowering medications — statins alone cost the Pharmaceutical Benefits Scheme over $800 million last year. But cardiovascular risk is not distributed evenly throughout the population; nor is statin prescribing. Stocks et al (→ Statin prescribing in Australia: socioeconomic and sex differences) used prescription and demographic data to determine whether statins are getting to the people who need them most.
Your patient attends with the culprit in a jar — a big black (squashed) spider that looks a bit like a funnel web. How dangerous are mouse spiders? Isbister used all known sources to find out (→ Mouse spider bites (Missulena spp.) and their medical importance).
During the outbreak of severe acute respiratory syndrome last year, Australia was among a handful of countries to screen incoming passengers for signs of the disease. Was it worth our while? Yes and no, say Samaan et al (→ Border screening for SARS in Australia: what has been learnt?).
Seeing it through
In the same way that death is one of life’s certainties, care of dying patients will remain a part of general practice. Yet Mitchell et al believe that the pressures of practice and the advent of palliative care as a specialty have caused some GPs to step back from this aspect of care. They provide some role definition and advice on overcoming the barriers to GPs' participation in palliative care (→ Palliative care: promoting general practice participation).
The study by Charles et al (→ Trends in childhood illness and treatment in Australian general practice, 1971-2001) provides more evidence that general practice is changing. Using three national datasets, they compared childhood illness and management patterns in three time periods, spanning 1971-2001.
The change experts
Much has been said about getting research evidence into practice, with doctors often in the firing line for their seeming intransigence. A forthcoming supplement from the National Institute of Clinical Studies will examine this issue but, for a start, say Sanson-Fisher et al (→ The science of changing providers' behaviour: the missing link in evidence-based practice), if you want to know how to change behaviour, ask a behavioural scientist.
Osteoarthritis (OA) makes it onto the list of the top 10 problems managed in general practice — and we all know that many of our patients are quietly living with OA-related pain and disability. Forget the hype surrounding some of the current therapies. Grainger and Cicuttini provide a balanced and sane approach to hip and knee OA (→ Medical management of osteoarthritis of the knee and hip joints).
Thyroid lumps and bumps
What should you do when a patient presents with a "lump in the neck" or, as increasingly happens these days, a thyroid nodule is discovered fortuitously on ultrasound? Mackenzie and Mortimer tackle these and other questions (→ 6: Thyroid nodules and thyroid cancer) in our Practice Essentials: Endocrinology series.
We're well into the Decade of Bone and Joint Disease, and moves are afoot in Australia to ensure that the Decade lives up to the rhetoric. The supplement with this issue details some important new initiatives, including a registry of all joint replacements, which will be invaluable in guiding future practice.
Another time ... another place...
Imperative drugging — the ordering of medicine in any and every malady — is no longer regarded as the chief function of the doctor.
Aequanimitas, with Other Addresses, "Medicine in the Nineteenth Century" Sir William Osler, 1849-1919
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