Issues
Volume 185 Issue 2
Editorials
Uncertainty in general practice: a sure thing
The quest for certainty blocks the search for meaning. Uncertainty is the very condition to impel man to unfurl his powers — Erich Fromm General practitioners are many things but, as much as anything else, they are masters of uncertainty. From the problems behind the names on the appointment schedule, to whether the patients will actually show up, how much time they’ll need and what their expectations will be, GPs plunge daily into the great unknown. They take their patients with them. In the cold light of the consulting room, undifferentiated symptoms and a myriad of clinical dead ends can make a mockery of the clean lines of evidence-based medicine — which, after all, is merely a means of quantifying our uncertainty. GPs are called to stand in the breach between their own (justified) uncertainty and their patients’ wish for certainty. So the current uncertainties about the future of general practice, the need to adapt, and the directions for change are probably things most GPs take in their stride. This bumper General Practice issue of the MJA looks at some of the areas of uncertainty and concern. Workforce is a big issue. Many GPs are left wondering at the exodus from general practice and the tendency for existing GPs to subspecialise themselves out of the “general” part of their title. Joyce and McNeil confirm the prevailing impression that, at least among Monash University graduates, fewer new doctors are making the decision to enter general practice. Couple this with the projection for a flat growth in the GP workforce over the next 10 years,1 and the reason for all the uncertainty is obvious. The causes of the workforce shortage have been widely debated. More interesting is the debate surrounding how we should respond. How can we make general practice more efficient and effective? Smart use of information technology (IT) is an obvious avenue. As demonstrated by McInness et al and Henderson and colleagues, IT has been thoroughly pursued by the current cohort of GPs. More than 90% of general practices now use clinical software packages and about two-thirds keep at least some patient records electronically. But there are calls to make more use of computers. According to McInness et al, increasing the use of IT functions such as online decision support, registries of patients and progress notes will benefit patients, especially those with chronic conditions. Dowrick, a UK professor of primary care who has spent time considering strategies for dealing with chronic disease in Australia, echoes this sentiment: General practice will have a key role to play, especially in the early detection of disease and in providing integration and continuity of care. Registers and recall systems for patients with chronic diseases will need to be set up, preferably in electronic form. The Australian Government’s HealthConnect program, which enables health care providers to connect to business grade and advanced broadband arrangements, may provide a useful basis for efficient chronic disease care . . . Primary care teams will have to standardise medical procedures, provide information on local services and make links with patient self-management programs. These activities will need to be carefully coordinated for each patient. Tse and McAvoy and Bolton remind us that we are still far from this IT utopia, but the computers are on GPs’ desks, ready to be used for a variety of applications. Computers are only as good as the information available to them, and another problem in Australia is the evidence base for general practice. GPs publish far less research than their specialist colleagues, are less likely to obtain competitive research grants, and do not contribute extensively to the evidence base of their discipline.2 As noted by Yallop et al, “although improving patient care requires a sound evidence base, rigorously designed studies remain under-represented in primary care research”. This deficiency is at odds with the definition of general practice as “an academic and scientific discipline with its own educational and research base and clinical activity”.3 To its credit, in 2000 the Australian Government initiated a program to address this, with an injection of $50 million over 5 years through the Primary Health Care Research, Evaluation and Development (PHCRED) Strategy. Its purpose was to increase the research capacity of general practice through annual non-competitive grants to academic departments of general practice or rural health; to encourage the development of people with proficiency in primary health care evaluation and research through research development programs; and to establish a flagship — the Australian Primary Health Care Research Institute. The report of an independent evaluation of the PHCRED Strategy became available in April 2005,4 and in December 2005, the Australian Government committed a further $60.4 million to Phase 2 of the PHCRED Strategy, to run from 2006 to 2009.5 However, the evaluation of Phase 1 drew attention to a number of problems: involvement of practising GPs and GP registrars in PHCRED programs was minimal and not long term; an initial hesitancy to make decisions, implement components of the Strategy and elucidate appropriate outcome measures; a lack of depth and breadth in researcher training and development; a paucity of extensive research networks; and instances of suboptimal research relationships between universities and Divisions of General Practice. The need for extensive and effective research networks has long been recognised in the United Kingdom and the Netherlands. Zwar and colleagues argue compellingly for research networks in Australia, putting forward a hub-and-spoke model involving universities and Divisions of General Practice. Central to their plan are academic departments that already have a demonstrated strong role in capacity building; linkages to practice-based research networks through the Divisions of General Practice; and an adequately funded clinical research plan with appropriate remuneration of primary care practitioners for their participation in research. The key to the success of general practice research lies in the extensive involvement of GPs, including research involvement of GP registrars as a mandated part of their training, and the appropriateness of the research question. Indeed, the capacity of GPs’ involvement to make or break a clinical research project is poignantly recounted by Yallop et al. The time has come to test such a model in Australia. It should be open to competition, but restricted to a limited number of consortia so certainty of “proof of principle” is obtained by the end of Phase 2 of the PHCRED Strategy. Linkages between universities and Divisions of General Practice will be critical to this model — an issue explored by Kalucy and colleagues. Finally, if we are to ensure success at the end of the current PHCRED cycle, oversight by a national advisory committee composed of appropriate stakeholders will be imperative.4 Its absence in Phase 1 of the PHCRED Strategy is baffling. Strong general practice is “patient centred, consistently of high quality, safe and accountable”.6 In reality, this means using data to identify, learn from, and prevent error and system failure. In the interests of improving safety in Australian general practice, Makeham et al used data reported anonymously by GPs to surmise that about one error is reported for every 1000 Medicare-billed patient encounters, and about two for every 1000 individual patients seen. With similar intent, Hutchinson and Watts report on the acceptability of the complaints register component of the RACGP Standards for general practices. They found considerable variability in the use of complaints registers, but that GPs were not overwhelmingly adverse to their use. Both these studies indicate there is a healthy attitude to exploring indicators for safety in Australian general practice. There are many indications in this special issue of the Journal that general practice will move beyond the current uncertainty to emerge transformed but strong. We asked Jackson, and Harris and Harris to tell us what Australian general practice might be like in 2020. Both identified the need for a strategic approach to change, so that the GP’s role remains central in a society with changing needs, expectations and resources. In the future, what will make a good GP? In Dorothy H Cohen’s book The learning child,7 published in 1972, US educationalist Robert Havighurst is quoted as saying: The modern world needs people with a complex identity who are intellectually autonomous and prepared to cope with uncertainty; who are able to tolerate ambiguity and not be driven by fear into a rigid, single-solution approach to problems, who are rational, foresightful and who look for facts; who can draw inferences and can control their behavior in the light of foreseen consequences, who are altruistic and enjoy doing for others, and who understand social forces and trends. We are products of the modern world. The scenery has changed. But a good GP will be what a good GP has always been — a master of uncertainty.
Ruth M Armstrong BMed · Martin B Van Der Weyden MD, FRACP
Accessing oral health care in Australia
Why try a doctor when you need a dentist? Oral conditions have some of the highest prevalence and incidence rates of all health problems in Australia.1 They are frequently associated with pain, functional limitations and interference with usual activities. Most people experiencing oral symptoms will visit, or at least contemplate visiting, a dentist. But why are some patients with oral conditions presenting to general practitioners? While signs and symptoms associated with dental caries and periodontal diseases are usually understood to be problems for dentists, sequelae of these conditions, such as abscesses, facial swelling, altered taste and halitosis, may sometimes be considered more of a medical than an oral problem. Furthermore, differences in the way dental and medical services are organised and delivered may provide a greater incentive for patients to present to GPs rather than dentists. This applies not only to conditions for which an ill-defined boundary exists, but also for management of acute symptoms of common oral conditions. Mansour and Cox outline some of these common oral conditions in this issue of the Journal (page 64).2 One result of the evolution of the medical and dental professions over the past century is a “separateness” that has diminished both professions’ understanding of the other’s discipline. While it is highly desirable to reduce this knowledge gap, it seems unlikely to be readily closed, given the existing curriculum pressures created by scientific and technological advances. A logical response to the inappropriate presentation of patients with oral conditions to GPs would be to both remove the incentives for this type of presentation and to provide more certain pathways for dental referral when they do occur. Indeed, Mansour and Cox recommended dental referral for most of the cases described and for all possible outcomes of their decision-making algorithm. But while the need for referral to dentists is generally well recognised, the ability to refer may be limited. Both the initial presentation to a GP and the difficulties in referral to a dentist are shaped by problems in accessing dental care in Australia. There are only about 9000 practising dentists in Australia (approximately 50 per 100 000 population),3 the vast majority of whom work in either the central business districts or middle-class residential suburbs of the major population centres, leading to significant maldistribution. Equally important is the fact that 86% of dentists work in the private sector, where they alone determine location, hours worked and fees charged. Outside normal business hours, the number of available dentists is very limited, and access is frequently restricted to existing patients of a practice. In some instances, major public hospitals and the limited number of dental hospitals do provide after-hours access to on-call dentists, but this is the exception rather than the rule. Publicly-funded dental care is usually restricted to holders of concession cards, which reduces those eligible to about 34% of the adult population. Further rationing of dental treatment occurs because of the limited facilities and shortage of dentists in the public sector. Only 19% of eligible dentate adults (ie, those with natural teeth) receive any dental care from public dental services in any year.4 An overall shortage of dentists makes access to dental treatment even more difficult. Within 4 years, Australia is predicted to be short of some 1500 dental care providers, mostly dentists.5 This shortage creates a bottleneck in the supply of dental treatment. It is most harshly felt by people already having difficulty obtaining dental treatment — low income Australians and those living in rural areas. However, the bottleneck also extends to dentistry in the “main street”; that is, private general dentists in middle-class residential areas. Increasing the number of positions in our universities for dental students may eventually overcome this problem — assuming there are academics to teach them and funding to competitively employ some of them in the public sector at the completion of their education. However, the current national output of less than 250 graduates a year does not begin to address the shortfall. Increased education of auxiliary dental personnel (hygienists and therapists) should lead to increased prevention programs, but is unlikely to address the problem of adults presenting with acute conditions. Cost is another significant barrier to accessing dental care. An estimated 25% of dental patients delay seeking treatment because of the expense.6 Public funding for dental treatment is dramatically less than for medical treatment. At present, public funding from the federal government is directed at the 30% private health insurance rebate, while state and territory government public funding is directed at low income adults and schoolchildren. The outcome is an inequitable pattern of public assistance in accessing dental treatment. Ironically, the average taxpayer may well pay the most and receive the least in terms of support in accessing dental treatment. The majority of patients will face the full cost of any dental treatment. The current average hourly rate for dental practices is $350 (of which overheads represent 73%).7 Thus it is likely that any substantial care (be it diagnostic or therapeutic) will represent a significant financial burden to the patient. The incentive for patients with oral conditions to present to a GP is obvious. GPs are more available, obtainable out of hours, and can be seen without the need to pay substantial out-of-pocket costs. The corollaries of these same issues are often the substantial barriers to dental referral for patients presenting to GPs. Recently, the federal government recognised the need for dental care among patients with a GP Management Plan and Team Care Arrangements or an Enhanced Primary Care multidisciplinary care plan. Essentially, approved patients may be referred to a dentist for an assessment and two other services within a 12-month period. In 2005, there were only 2055 referrals for dental assessment (Item 10975),8 and these resulted in 2500 items of treatment or referral to a dental specialist (Items 10976, 10977). The total cost of dental diagnostic and treatment procedures was just over $500 000 (or $250 per 100 000 population). These data indicate a negligible level of referral under these plans. Specific issues within these plans act as further barriers to referral for dental care. For GPs, the cost and time involved with administrative requirements far exceed the value of the remuneration. Referral cannot proceed until the original care plan has been completed and paid for, which largely negates treatment of acute conditions. The relatively small number of appointments permitted, dentists’ unfamiliarity with the Medicare remuneration system, and the level of remuneration make dentist participation professionally and financially unrewarding. The result is that current referral plans available under Medicare are unlikely to provide a simple or effective pathway for dental referral and treatment. Currently, patients with acute oral conditions should hope that the problem occurs during normal hours in a major population centre, that the condition is not part of a larger problem, and that they are wealthy enough to have a regular dentist who has the time to see them. For patients who are not so fortunate, presentation to a GP is likely to remain an option. As outlined by Mansour and Cox, on most occasions, little, if any, effective help can be offered beyond referral to a dentist. The short-term results are frequently only palliative, at best, and without appropriate follow-up care — resulting in increased costs to the public purse and ongoing suffering to the patient.
Roderick I Marshall BDSc, MDSc, FRACDS(Perio) · A John Spencer MDSc, PhD, MPH
The Chronic Disease Strategy for Australia
There is a considerable mismatch between evidence and policy The Australian National Chronic Disease Strategy The National Chronic Disease Strategy is a nationally agreed agenda to encourage coordinated action in response to the growing impact of chronic disease on the health of Australians and the health care system. It has five health priority areas: asthma cancer diabetes heart, stroke and vascular disease osteoarthritis, rheumatoid arthritis and osteoporosis. It is structured to reflect the phases of illness: reducing risk finding disease early managing acute conditions long-term care care in the advanced stages of disease. Implementation of the strategy will be the responsibility of individual jurisdictions. Chronic diseases now have a major impact on Australian society, accounting for about two-thirds of health care expenditure (more than $35 billion) in 2000–01. Last November, the Australian Health Ministers’ Conference endorsed a national strategic policy approach to manage and improve chronic disease prevention and care in the Australian population. The approach has three elements: a national chronic disease strategy; a set of five national service improvement frameworks; and a blueprint for nationwide surveillance of chronic diseases and associated determinants.1 The policy focuses attention on five chronic disease groups: asthma, cancer, diabetes, cardiovascular diseases and musculoskeletal conditions. These have been identified because they are common and lead to substantial levels of disability among Australians. The authors propose a multilayered strategy aimed at preventing or delaying the onset of chronic diseases, intervening early in disease processes to minimise harm and improve quality of life, ensuring integration and continuity of care, and encouraging the active participation of people in their own health care. People living with chronic medical conditions are clear about the elements they require from a modern health care system. They need access to high quality information about their condition, care which is continuous and well coordinated, effective management of their symptoms and — perhaps most importantly — help in managing the social, economic and psychological consequences of their symptoms.2 This ambitious Australian strategy is timely and well considered. If successfully implemented, it will go a long way towards meeting these requirements. The key question is, what must be done to translate it from a worthy set of words to an effective set of deeds? What steps must be taken to give it the best chance of success? First, there is a need to promote chronic illness on the agendas of policymakers so that the necessary political and economic changes can be made to the Australian health care system.3 Structures must be put in place to reduce health care inequalities and to maximise efficient resource allocation. It is not yet clear whether such structures are best situated at federal or at state level, nor what role the private sector should play. Assuming a degree of competition is both inevitable and healthy, it may be best to base such decisions not (as historically) on answers to the question “who pays?”, but rather on answers to the question “who provides best value?”.4 Second, primary health care must change. General practice will have a key role to play, especially in the early detection of disease and in providing integration and continuity of care. Registers and recall systems for patients with chronic diseases will need to be set up, preferably in electronic form. The Australian Government’s HealthConnect program, which enables health care providers to connect to business grade and advanced broadband arrangements, may provide a useful basis for efficient chronic disease care, insofar as it enhances the ability of health providers to share information about patients.5 Primary care teams will have to standardise medical procedures, provide information on local services and make links with patient self-management programs. These activities will need to be carefully coordinated for each patient. Australian general practice is not currently configured to deliver this strategy to maximum effect. Models of good practice, such as the South Australian HealthPlus experiment,6 show what can be done with the injection of energy and imagination, and the provision of adequate resources (particularly at the care coordination level), but there remains a substantial mismatch between evidence and policy.7 It will be necessary for managers and practitioners to resolve the complex structural problems inherent in realigning a fee-for-service system that is designed to provide acute medical care towards a managed care system which must inter alia provide adequate financial support for high-quality electronic information systems, and generate funding models which enhance multi-disciplinary care rather than encouraging individualistic approaches to health care delivery. Recent policy developments in the United Kingdom offer useful guidance, and provide evidence for their success.8 Third, new programs of education will have to be put in place for patients and carers, and also for health professionals. Education for patients and carers can be provided to an extent through the mass media or via the Internet,9 but the main focus is likely to be through the expansion of facilitated self-management or “expert patient” programs.10 It is important to ensure that such programs enable patients with chronic diseases to actively engage in promoting their own health, and to make effective links with relevant health professionals. They must also avoid the tendency of becoming the preserve of a motivated minority, as this increases the risk of health inequalities.11 The focus of health care education has already begun to change, with a gradual shift of location from hospital to community, and increased recognition of the value of scientific perspectives drawn from psychology and sociology. Learning outcomes also need to be reviewed, as symptom control and quality-of-life issues become the priority in effective management of chronic medical conditions. The next generation of health care professionals will have to become more experienced in pain management and in understanding the psychosocial aspects of long-term conditions, the needs of carers, best practices for coordinating care, and how to work well in partnership with patients.12 Finally, there will be a need for new research. Care coordinators are likely to be central to new models, but we do not yet know enough about their best role definitions, nor their economic costs and benefits. Do self-management programs work best when run by and for patients, or when they habitually involve health professionals? What are the principal barriers to a reorientation of general practice to meet the needs of patients with chronic diseases, and how can they be overcome? Questions about the cost-effectiveness of new models of chronic care also need to be asked. To address these questions, researchers must better understand the context in which they are operating: how health care functions as a complex adaptive system,13 and the processes which enable (or hinder) the implementation of new technologies into routine clinical practice.14
Christopher Dowrick BA, MD, FRCGP
Clinical practice
Patients presenting to the general practitioner with pain of dental origin
Dentofacial pain is a common presentation in general practice, and more than 50% of cases arise from dentally related pathology. In a carious tooth, pain that is site-specific, severe and spontaneous usually denotes extension of caries into the tooth pulp. Caries does not always appear as a cavity in the tooth, but may lie beneath intact enamel or on surfaces between teeth. Examination of tooth pain should include firm percussion (eg, with a tongue depressor). Tenderness on percussion denotes progression of infection into the subdental tissue. Pain occurring 24–48 hours after a tooth extraction is commonly caused by superficial osteitis in the exposed alveolar bone. Examination will reveal the absence of a blood clot in the extraction socket and severe tenderness on local palpation. Severe pain related to impacted wisdom teeth is frequently caused by pericoronitis, an infection in the gingival tissues surrounding the tooth. The surrounding gingiva is erythematous and tender to palpation. Localised facial swellings of dental origin require immediate referral to a dentist. Progressive facial swelling requires aggressive antibiotic therapy and referral to hospital for definitive management.
Mohammed H Mansour MSc, MD · Stephen C Cox OAM, MSc, FRACDS
An audit of structured diabetes care in a rural general practice
Objective: To assess the impact of structured diabetes care in a rural general practice.Design and setting: A cohort study of structured diabetes care (care plans, multidisciplinary involvement and regular patient recall) in a large general practice in a medium-sized Australian rural town. Medical care followed each doctor’s usual practice.Participants: The first 404 consecutive patients with type 2 diabetes who consented to take part in the program were evaluated 24 months after enrolment in July 2002 to December 2003.Main outcome measures: Change in cardiovascular disease risk factors (waist circumference, body mass index, serum lipid levels, blood pressure); change in indicators of risks associated with poorly controlled diabetes (glycated haemoglobin [HbA1c] concentration, foot lesions, clinically significant hypoglycaemia); change in 5-year cardiovascular disease risk.Results: Women had a lower 5-year risk of a cardiovascular event at enrolment than men. Structured care was associated with statistically significant reductions in mean cardiovascular disease risk factors (waist circumference, − 2.6 cm; blood pressure [systolic, − 3 mmHg; diastolic − 7 mmHg]; and serum lipid levels [total cholesterol, − 0.5 mmol/L; HDL cholesterol, 0.02 mmol/L; LDL cholesterol, − 0.4 mmol/L; triglycerides, − 0.3 mmol/L]); and improvements in indicators of diabetic control (proportion with severe hypoglycaemic events, − 2.2%; proportion with foot lesions, − 14%). The greatest improvements in risk factors occurred in patients with the highest calculated cardiovascular risk. There was a statistically significant increase in the proportion of patients with “ideal” blood pressure (systolic, < 130 mmHg; diastolic, < 80 mmHg) and LDL cholesterol level (< 2.5 mmol/L) of 6.4% and 20.5%, respectively.Conclusions: Implementing structured care in this rural general practice coincided with improved risk factor management, and may have contributed to the improvement. The greatest benefits were in patients with high cardiovascular risk.
Evan W Ackermann FRACGP, DRACOG · Geoffrey K Mitchell FRACGP, PhD
Weight management in general practice: what do patients want?
Objective: To explore patients’ views of the role of general practitioners in weight management.Design: Waiting-room questionnaire survey, including measurement of height, weight and waist circumference, May–August 2005.Participants and setting: 227 patients from five general practices located in metropolitan and rural New South Wales.Main outcome measures: Patients’ views on: the role of GPs in weight management; the usefulness of weight-loss strategies; and the likelihood of following the GP’s advice about weight loss.Results: Most patients (78%) felt that GPs had a role in weight management, but only 46% thought that GPs would be able to spend enough time to provide effective weight loss advice. Over 80% of patients perceived advice on healthy eating and physical activity to be useful or very useful, and were likely to follow weight-loss recommendations; 78% were in favour of regular review. Patients indicated they would be less likely to see a dietitian or to attend information sessions, and unlikely to take weight-loss medication. Views of overweight and obese patients were generally similar to those of normal weight patients, but there were significant differences in perceptions of the usefulness of information on weight and weight-related medical conditions, as well as willingness to change lifestyle, possibly reflecting resistance to change among obese or overweight patients.Conclusion: These findings have implications for the design of primary care interventions for managing obesity.
Daisy Tan MB BS, DCH, FRACGP · Nicholas A Zwar MB BS, PhD, FRACGP · Sarah M Dennis MSc, PhD · Sanjyot Vagholkar MB BS(Hons), MPH, FRACGP
Muscle pain as an indicator of vitamin D deficiency in an urban Australian Aboriginal population
The prevalence of vitamin D deficiency among Aboriginal people in Australia is unknown. One of the possible sequelae of vitamin D deficiency, muscle pain, appears to have a higher prevalence in Aboriginal people. A deficiency of vitamin D can cause osteoporosis,1 rickets in children, muscle pain and weakness.2-4 It is one of the main causes of undiagnosed muscle pain in adults.2,3 Such pain resolves rapidly with adequate doses of vitamin D.3-5 Risk factors for vitamin D deficiency include darker skin pigmentation, urban lifestyle, veiling of women for cultural reasons, and intestinal malabsorption or a diet deficient in vitamin D.1,6-10 Refugees from Africa and the Middle East are known to have a high risk of rickets and muscle pain caused by vitamin D deficiency.2-4,8-11 There is also research showing a deficiency in asymptomatic patients, both those at high risk as well as those with no obvious risk factors.12 This is important for the infants of women who are deficient in vitamin D during their pregnancy, as their children will also be deficient in vitamin D,13,14 and hence at increased risk of both short- and long-term sequelae.8,13 A study of a rural Aboriginal community found that 95% of the population had chronic non-specific musculoskeletal pain, compared with 30% in the general population.15 Traditional Aboriginal people spent much of their day outdoors, but most now have an urban lifestyle.16 They are less likely to spend enough hours in the sun1 or have a diet rich in vitamin D.1,6 After noting a high prevalence of muscular pain among patients at our health service (Nunkuwarrin Yunti, an Aboriginal Community Controlled Health Service, at Elizabeth Downs in the northern suburbs of Adelaide), we conducted a case–control study to determine if muscle pain was associated with low vitamin D levels. MethodsDiscussions about the study’s relevance with Elder Aboriginal Women in the community, and with the staff and Chief Executive Officer of Nunkuwarrin Yunti acknowledged its importance to individuals, families and the community. Ethics approval was obtained from the University of Adelaide and the Aboriginal Health Research Ethics Committee. Results from Indigenous patients seen in our clinical practice before the study showed a serum vitamin D (25-hydroxyvitamin D) range of 35–55 nmol/L (standard deviation, 5 nmol/L). Anticipating a difference between cases (with muscle pain) and controls (without muscle pain) of 10 nmol/L, we calculated that a sample of six cases and six controls would be required, assuming a power of 0.8 and a significance level of 0.05. Data were collected from eight patients in each group in October and November 2005, at the end of the Australian winter. Blood samples were collected from patients aged 18 years and older with muscle pain and from a sex- and age-matched control group without muscle pain. People with renal failure or who had recently taken vitamin D supplements were excluded. All patients had what would be classed as medium skin pigmentation.17 The blood samples were sent to the local pathology service, where 25-hydroxyvitamin D was measured. Serum levels were tabulated and analysed using SPSS version 13.0 (SPSS Inc, Chicago, Ill, USA). ResultsOur results are summarised in the Box. All patients with muscle pain had a vitamin D level below the normal value of 50 nmol/L.1,18 The mean vitamin D level was 40.88 nmol/L (SD, 3.52 nmol/L) for patients with muscle pain, and 58.25 nmol/L (SD, 15.90 nmol/L) for controls. Data were normally distributed and equal variances could not be assumed. A t test showed a mean difference between cases and controls of − 17.38 nmol/L (P = 0.017). DiscussionThe eight Aboriginal patients with muscle pain had lower vitamin D levels than those without muscle pain. Vitamin D deficiency was not observed in asymptomatic patients except for one with mild deficiency. Despite being at a lower risk of osteoporosis,19 Aboriginal people may have an increased risk of muscular symptoms of vitamin D deficiency. We did not assess intercurrent illness, severity of symptoms, skin pigmentation, diet, time spent outdoors and success of treatment, and this limitation may affect the generalisability of our findings. We found that muscle pain is an indicator of vitamin D deficiency in urban Aboriginal patients. General practitioners are well placed to screen those at high risk and may be able to improve the lifestyle and level of function of many previously undiagnosed patients with chronic muscle pain by having a high index of suspicion for vitamin D deficiency. As more research reveals the sequelae of vitamin D deficiency, its importance to general health is likely to increase. A larger study looking at the prevalence of muscle pain in the urban Aboriginal population, its effect on lifestyle, how that pain relates to vitamin D deficiency, and whether pain is reduced with treatment would clarify some of the issues. The potential for better quality of life resulting from successful treatment of muscle symptoms caused by vitamin D deficiency makes the clarification of this association a priority for Aboriginal health. Sex, age, vitamin D level and vitamin D class* for patients with muscle pain and controls with no muscle pain With muscle pain Without muscle pain Sex Age (years) Vitamin D level (nmol/L) Vitamin D class Sex Age (years) Vitamin D level (nmol/L) Vitamin D class F 50 37 3 F 50 50 4 F 38 40 3 F 35 70 4 F 39 38 3 F 40 78 4 F 72 37 3 F 55 28 3 F 19 41 3 F 20 50 4 F 48 46 3 F 47 56 4 F 62 45 3 F 55 63 4 M 53 43 3 M 53 71 4 * Vitamin D class: class 4, ≥ 50 nmol/L, normal; class 3, 26–49 nmol/L, mild deficiency; class 2, 12.5–25 nmol/L, moderate deficiency; class 1, < 12.5 nmol/L, severe deficiency.1,18
Jill Benson MB BS, DCH, FACPsychMed · Anne Wilson PhD, RN, MN · Nigel Stocks MD, FRACGP, FAFPHM · Nicole Moulding BSW, GradDipPublicHealth, PhD
General practitioners' experiences of managing patients with chronic leg ulceration
Objective: To understand general practitioners' experiences of managing patients with chronic leg ulceration, thus informing future strategies to improve leg ulcer care in general practice.Design: Qualitative study using phenomenology and in-depth interviewing.Participants and setting: Maximum variation sample of 12 GPs working in the Perth and Hills Division of General Practice between September and December 2004.Main outcome measure: Themes in participants' experiences of leg ulcer care.Findings: Participants regarded leg ulcer management as an integral part of general practice. They expressed a desire to maintain their involvement, yet relied on nursing assistance. They perceived that ulcer care was usually straightforward and successful. Approaches to management appeared to differ significantly from that outlined in current guidelines. Instead, participants valued accessibility of care for the patient, awareness of patient context and regular review. Occasional problems with non-healing ulcers were experienced, and, in these situations, specialist opinion was appreciated.Conclusion: This study highlights fundamental differences between GP and specialist conceptualisation of leg ulcer care. For GPs, it identifies key areas of ulcer management that could be improved. For specialists, it suggests that widespread implementation of traditional guidelines may not be appropriate or acceptable. New approaches to leg ulcer management in general practice are likely to need a combination of education, human resources and practical support.
Genevieve M Sadler MB BS · Grant M Russell FRACGP, MFM · Duncan P Boldy MSc, PhD · Michael C Stacey FRACS, DS
The common problem of rare disease in general practice
Rare diseases affect 6%–10% of the population, which equates to about 1.2 million people in Australia having a rare disease. The United States, the European Union and many other nations have coordinated policies and patient advocacy groups for rare diseases as a group. Australia has enacted orphan drug legislation, but there is no coordinated approach either from government or from patient groups. General practitioners see rare diseases commonly, but their role for this group has not been adequately described. People with rare diseases and their families have similar experiences despite their different diagnoses. GPs are well placed to help with these problems. The development of a generic general practice strategy for these patients may improve their overall care.
Andrew W Knight MB BS, FRACGP, MMedSci(ClinEpid) · Timothy P Senior BM BCh, FRACGP
Information Technology
Extent and utilisation of computerisation in Australian general practice
Objective: To assess the availability of computers to general practitioners and individual GPs’ use of computers for clinical functions.Design, setting and participants: A secondary analysis of data from a random sample of 1319 Australian GPs who participated in the Bettering the Evaluation and Care of Health (BEACH) survey, a continuous cross-sectional survey of general practice activity, between November 2003 and March 2005. Participants reported the availability of computers at their major practice address and the clinical functions for which they used the computers.Main outcome measures: Proportion of practices with computers available; proportion of individual GPs who used computers for clinical purposes.Results: The proportion of GPs not using a computer was 11.2% (6% did not have a computer at their major practice address and a further 5.2% chose not to use an available computer). The majority of GPs using a computer at work used it for electronic prescribing (94.7%), ordering tests (82.2%) and keeping some patient data in an electronic medical record (79.5%). Of those with clinical software available (n = 1114), 6.6% chose not to use it. A third of GPs (32.8%) kept all patient information in an electronic format. The proportion of GPs keeping all data electronically and using all clinical functions available in their computer was 21.7%.Conclusion: While the physical presence of computers has increased significantly over the past decade, GPs are still reluctant to fully embrace the technology.
Joan Henderson BAppSc(HIM)(Hons) · Helena Britt BA(Psych), PhD · Graeme Miller MB BS, PhD
General practitioners’ use of computers for prescribing and electronic health records: results from a national survey
Objective: To describe how general practitioners use computers for clinical purposes.Design: Mail survey of a cross-sectional national stratified random sample of 3000 GPs in primary care settings between 10 October and 31 December 2005.Main outcome measures: Use of computers, and use of computerised clinical functions such as prescribing, medication checking, generating health summaries, running recall systems, and writing progress notes.Results: Of 1186 GPs responding (39.5% response rate), 90% used a clinical software package. GPs used clinical packages for prescribing (98%), checking for drug–drug interactions (88%), recording a reason for prescribing (65%), to order laboratory tests (85%), run recall systems (78%), and record progress notes (64%). Less frequently used functions included generating lists of patients needing vaccines (43%) and taking the same medication (39%). Less than 20% of GPs who used a clinical package accessed computerised information during the consultation.Conclusions: Australian general practice has achieved near-universal clinical computerisation. Electronic prescribing alone has probably improved efficiency and quality of care, and reduced medication errors. Increasing the use of other functions, such as accessing online decision support and maintaining registries of patients, is likely to lead to further health gains, especially in managing chronic conditions.
D Keith McInnes MS · Deborah C Saltman AM, MD, FRACGP, FAFPHM · Michael R Kidd MD, FRACGP
Information mastery and the 21st century doctor: change management for general practitioners
The Internet and computers have brought immense change in how society deals with information. Uptake of these technologies has been disjointed and has occurred in a non-uniform way among general practitioners, compared with other professionals. Information mastery is a key 21st century skill that GPs should acquire. Applying “change management” concepts may help improve uptake of information mastery skills in general practice.
Justin Tse MB BS, MMed, FRACGP · Brian R McAvoy MD, FRACGP, FRCP
Information mastery and 21st century general practice
A solution in search of a problem? At first glance, the modish and engaging concept of “information mastery” is a reasonable one to apply to general practice, but on closer inspection, it may be a misdirected application of current information technology (IT). There are four reasons for this. First, computerised information systems have some way to go before they can usefully contribute to a general practice consultation in the manner proposed. The process of searching for and retrieving information from a clinical database currently takes several minutes at best. The search engine, Google, gives hope that improved search algorithms and computer interfaces will reduce this, but even if relevant information were provided instantly, time is still required by humans to read and understand it. The process of retrieving and digesting information distracts doctors from relating to patients, which is the primary task in a consultation. So, while there is an essential requirement for evidence to inform practice, it is difficult to see IT offering a major improvement on how this can be done during the consultation. Second, the application of IT to “information mastery” overlooks a simpler, currently more useful, aspect of computing which can be integrated into current GP work practice. Computers are good at simple, repetitive tasks; humans are not. There is abundant evidence of the value that computers can bring to quality assurance processes, such as checking drug doses and drug–drug interactions.1 A number of Divisions of General Practice have developed computerised systems which ensure that patients with chronic diseases receive interventions proven to improve their outcomes. These applications are simple things done consistently, and do not require the more abstract objective of “information mastery”. Third, the application of IT in health care is high risk: it is infrequently and inadequately assessed, and when it is assessed, it is often found not to be cost-effective.2 It follows that there is no advantage in being an early adopter of IT. A more effective strategy is to let others test whether a particular application works and wait for the costs to fall — they always have in IT! Finally, and not uncommonly in IT, “information mastery” seems to be a solution in search of a problem: even if it were to deliver the benefit it promises, it offers more of the same, not an improvement. Throughput may increase, but quality need not. If our objective is to improve health care, then we need to start with health care problems. This may lead us to IT as a tool to provide relevant and timely information, but it needs to do so in a manner that supports patient care, rather than dictating it.
Patrick G M Bolton PhD, FRACGP
Quality and Safety
The Threats to Australian Patient Safety (TAPS) study: incidence of reported errors in general practice
Objective: To determine the incidence of errors anonymously reported by general practitioners in NSW.Design: The Threats to Australian Patient Safety (TAPS) study used anonymous reporting of errors by GPs via a secure web-based questionnaire for 12 months from October 2003.Setting: General practices in NSW from three groupings: major urban centres (RRMA 1), large regional areas (RRMA 2–3), and rural and remote areas (RRMA 4–7).Participants: 84 GPs from a stratified random sample of the population of 4666 NSW GPs — 41 (49%) from RRMA 1, 22 (26%) from RRMA 2–3, and 21 (25%) from RRMA 4–7. Participants were representative of the GP source population of 4666 doctors in NSW (Medicare items billed, participant age and sex).Main outcome measures: Total number of error reports and incidence of reported errors per Medicare patient encounter item and per patient seen per year.Results: 84 GPs submitted 418 error reports, claimed 490 864 Medicare patient encounter items, and saw 166 569 individual patients over 12 months. The incidence of reported error per Medicare patient encounter item per year was 0.078% (95% CI, 0.076%–0.080%). The incidence of reported errors per patient seen per year was 0.240% (95% CI, 0.235%–0.245%). No significant difference was seen in error reporting frequency between RRMA groupings.Conclusions: This is the first study describing the incidence of GP-reported errors in a representative sample. When an anonymous reporting system is provided, about one error is reported for every 1000 Medicare items related to patient encounters billed, and about two errors are reported for every 1000 individual patients seen by a GP.
Meredith A B Makeham MPH(Hons), FRACGP · Michael R Kidd MD, FRACGP · Deborah C Saltman AM, FRACGP, FAFPHM · Michael Mira MD, SS, PhD · Charles Bridges-Webb AO, MD, FRACGP · Chris Cooper MRCGP, MPH · Simone Stromer FRACGP
Field testing a complaints register proposal as a requirement of Australian general practice
Objective: To investigate the feasibility, achievement and acceptance of indicators of quality general practice in the RACGP Standards for general practices (third edition), using complaints registers as a case study.Design, setting and participants: A purposive sample of convenience of 200 general practices (stratified according to location and size) participated in a field test of quality and safety proposals during an accreditation survey visit between October 2004 and February 2005. Included was a test of the proposal for a complaints register (a document where complaints made to the practice are recorded).Main outcome measures: Achievement of the complaints register proposal, assessed by accreditation surveyors; questionnaire rating of the feasibility and acceptance of the proposal.Results: Few practices used a formal complaints register (79/200; 39.5%), with large practices more likely (12/20; 60.0%) and very remote practices less likely (1/11; 9.1%) to use one. The proposal for complaints registers was rated feasible by 123 general practices (61.5%) and rated acceptable by 121 general practices (60.5%).Conclusions: The proposal for complaints registers in general practice, while popular with policymakers, gained limited support when tested in Australian general practice. This shows the need for a balance between the expectations of policymakers, the need to increase performance by setting standards, and the practicalities of every-day general practice.
Ronelle L Hutchinson BA(Hons), PhD · Ian T Watts BSW, DipSocPlan, MBA(Exec)
Workforce
Fewer medical graduates are choosing general practice: a comparison of four cohorts, 1980–1995
Objective: To compare general practice career choices of four cohorts of medical graduates.Design and setting: Retrospective longitudinal study of medical graduates. Data on employment since graduation, nature of current employment, and postgraduate qualifications were collected by postal survey in 2003.Participants: Four cohorts of Monash University Medical School graduates who completed their degrees in 1980, 1985, 1990 and 1995 (n = 386).Main outcome measure: Proportion of each cohort pursuing a general practice career.Results: At 8 years after graduation, half of the graduates in the 1980 and 1985 cohorts were working in general practice, compared with 38% of 1990 graduates and 33% of 1995 graduates. Differences were mainly attributable to fewer female graduates working as GPs: female GPs comprised 62% of the 1980 cohort compared with 31% of the 1995 cohort. Graduates in more recent cohorts also entered the general practice workforce at a later stage than those in earlier cohorts.Conclusion: A rapidly declining proportion of new graduates from Monash University Medical School, particularly female graduates, are choosing general practice as a career. This will exacerbate future shortages in the general practice workforce.
Catherine M Joyce BA(Hons), MPsych, PhD · John J McNeil PhD, FRACP, FAFPHM
The independent effect of age of general practitioner on clinical practice
Objective: To establish the extent to which general practitioner age alone explains variations in patient morbidity and treatment patterns.Setting: An on-going, national survey of general practice activity in Australia.Participants: A random sample of 5013 GPs with a minimum of 375 general practice Medicare items claimed in the previous 3 months. Each GP contributed details of 100 consecutive encounters, with about 1000 GPs sampled each year between 1998 and 2003.Main outcome measures: Effect of practitioner age on GP activity after removing the influence of measured confounding factors: doctor, patient and practice characteristics; number of problems; and morbidity managed at encounters.Results: GP age played a significant role in practice style. In comparison with young GPs (< 35 years), older GPs provided more home visits (P < 0.001) and attendances at residential aged-care facilities (P = 0.044); were more likely to manage chronic problems (P < 0.001); had higher prescribing rates (P < 0.001), and lower rates of pathology ordering (P < 0.001) and non-pharmacological treatments (P < 0.001). Individual body system management rates also differed significantly between younger and older GPs.Conclusion: A GP’s age plays a significant role in determining practice style. Our results have implications in terms of the ageing GP population and in the wider context of the ageing medical labour force.
Janice Charles BA, MSc(Med) · Helena Britt BA, PhD · Lisa Valenti BEc
Research
Supporting research in primary care: are practice-based research networks the missing link?
Despite the size and importance of primary health care (including general practice) within the health system, traditional research output has been relatively low, both here and overseas. General-practice and primary-care research in Australia has been criticised for the preponderance of small-scale, descriptive and survey-based studies. If we are to conduct larger-scale clinical, epidemiological and health-services research, new structures and processes are needed. The research networks set up under the first phase of the Australian Government’s Primary Health Care Research, Evaluation and Development (PHCRED) Strategy have tended to focus on up-skilling, research literacy and dissemination. This is important, but for general-practice research to evolve, a new type of practice-based research network is needed. These new practice-based networks require commitment and funding from policymakers, a base in academic departments, plus active involvement from Divisions of General Practice and the practitioners themselves.
Nicholas A Zwar MPH, PhD, FRACGP · David P Weller PhD, FRACGP, FAFPHM · Lucy McCloughan BSc(Hons), PhD · Vanessa J Traynor BA
What supports effective research links between Divisions of General Practice and universities?
Objective: To find out what supports effective links between Divisions of General Practice and universities.Design: Qualitative study based on semi-structured interviews during October 2004, from which a framework for effective linking was constructed and its validity assessed by discussion with researchers and Division staff and members at four interactive workshops held between 9 November 2004 and 5 November 2005 .Participants: 21 participants from Divisions of General Practice and universities in Australia.Results: Qualities conceptualised as “opportunity” and “fair relationships” were critical factors in establishing successful links between the two sectors. The relationship between these two factors describes the types of interactions that currently occur.Conclusions: To develop effective links requires an environment that promotes adequate opportunities, and in which mutual trust can grow. This will require commitment and system change from all parties.
Elizabeth C Kalucy BSc, MSc, DipEd · Christopher M Pearce FRACGP, FACRRM, MFM · Barbara Beacham BSocSc · Belinda L Lowcay BBehavSc · Rachel E Yates BTec(UK), BSci(Hons)
Primary health care research — essential but disadvantaged
Primary health care is the foundation of effective, sustainable population health and is associated with higher patient satisfaction and reduced aggregate health spending. Although improving patient care requires a sound evidence base, rigorously designed studies remain under-represented in primary care research. The pace of research activity in general practice and the rate and quality of publications do not match the pace of structural change or the level of funding provided. Recruitment difficulties are a major impediment, fuelled by general practitioners’ time constraints, lack of remuneration, non-recognition, and workforce shortages. Radical reform is required to redress imbalances in funding allocation, including: funding of GP Research Network infrastructure costs; formalising relationships between primary care researchers and academic departments of general practice and rural health; and mandating that research funding bodies consider only proposals that include in the budget nominal payments for GP participation and salaries for dedicated research nurses.
on behalf of the CHAT Study Group
Future
Facing the challenges: general practice in 2020
A strong primary medical care system is essential to the equity, efficiency and effectiveness of the health system as a whole. General practice in Australia faces significant challenges to its capacity to fulfil its role and function: in its financing, recognition, capacity to provide comprehensive care, and integration with the rest of the health system. Addressing these challenges requires a better system of remuneration for quality in general practice care, strengthening of the role of the generalist within the health system, involvement of Divisions of General Practice in service development, and establishment of collaborative networks and integrated primary health care services.
Mark F Harris DRACOG, FRACGP, MD · Elizabeth Harris DipEd, DipSW, MPH
General practice in Australia 2020: “robust and ready” or “rudderless and reeling”?
The future role and structure of Australian general practice remains uncertain, despite a decade of seemingly constant change following the release of the National Health Strategy papers. Some of the suggested change strategies (such as rural Practice Incentive Payments and practice accreditation) have been implemented; others (such as general practitioner involvement with area health authorities in delivering national goals and targets for communities) still await attention. An overarching vision for our health care system in 2020 and general practice’s role within it are still to be clearly enunciated. Australia is at variance with other Western countries, such as the United Kingdom, Canada and New Zealand, which have spent significant time refocusing their health systems to deal with an ageing population with an increased burden of chronic disease. Health bureaucrats and governments need to invest strategically in operational primary care now. This will require the active commitment of general practice’s national bodies to articulate and actively promote a shared vision for Australian general practice.
Claire L Jackson MPH, GradCertMt, FRACGP
Letter
Research is needed before GPs can engage in "positive" family planning
To the Editor: Bachrach’s article1 “Missed conceptions” and the accompanying commentary by Chapman et al2 made compelling reading. The plea of these authors coincides with calls from the Fertility Society of Australia and the South Australian branch of the Australian Federation of Business and Professional Women for campaigns to better inform women about the biological limits of their fertility. Personal stories can alert us to social problems sliding under the radar. But before we heed the call for “positive family planning”, we need to know more. Firstly, whether intervention by a general practitioner (as Bachrach, in her forties and wanting children, would have wished) would be appreciated by younger women who may not yet, or may never, be interested in motherhood. We also need to know how GPs would view this sort of intervention, and whether they feel equipped with the knowledge and tools to ensure an effective engagement that is appropriately respectful of their patient’s autonomy. There is a long history of women being valued by society only as mothers. It is important that any GP-based fertility intervention be sensitive to a woman’s fertility values and plans, be they for motherhood or freely chosen childlessness. Bachrach’s article is a call for action, but we need to ensure that action is well grounded in research-based knowledge about current practice and the barriers both GPs and women perceive to discussing fertility plans in the consulting room. Such knowledge would be useful for the development of a tool to assist GPs in helping women make timely, well informed fertility decisions that are consistent with their parenting plans.
Danielle Mazza · Leslie Cannold · Cate Nagle
Book reviews
GPs: acting the part
BARD in the practice. A guide for family doctors to consult efficiently, effectively and happily. Ed Warren. Oxford: Radcliffe Publishing, 2006 (xi + 136 pp). ISBN 1 85775 665 7. Dr Ed Warren is an obviously learned and wise middle-aged general practitioner who practises in Sheffield, in the United Kingdom. His thesis is that doctors have much to learn from actors, whose skill is to understand human motivation and communicate to their audience how it influences behaviour. So he has come up with the BARD approach to improve performance in a consultation. B is for behaviour, with an emphasis on the non-verbal kind through which over 50 per cent of interpersonal communication occurs. A is for aims the broad direction in which a GP wishes to progress the patient and other stakeholders in the achievement of said aims. Here Warren introduces the concept of the good enough consultation. The essential components are securing the patients safety and ensuring that both patient and doctor are proceeding in the direction of their aims. The doctor/actor doesnt have to compress the whole play into one 12-minute scene. There will be more scenes and acts to follow. R is for room and is equivalent to the theatre in which the action takes place. This includes the approaches to the building, the interior layout and the costume of reception, nursing and medical staff. D is for dialogue the process by which doctor and patient try to adjust their transmitters and receivers to the same frequency. A novel suggestion is the use of voice lessons. The last two chapters in this book are on training for, and the ethics of, becoming a BARD GP. But this is not a syrupy How to win friends and influence people book. At no stage does the author suggest readers adopt behaviour incongruent with their beliefs and personality. Rather, the author wishes to transpose elements of Stanislavskis be yourself method acting to the medical consultation. This book is an innovative addition to the literature on improving ones consultation skills. Actors and sportspeople train to optimise their performances, as do spokespeople for the Australian Medical Association. So why not GPs? Reading this book is guaranteed to improve the consultation skills of even the most accomplished GPs. It has particular relevance for registrars and their mentors. Max KamienEmeritus Professor of General Practice, University of Western Australia, Perth, WA
Max Kamien
Beyond the machismo
What men dont talk about. Maggie Hamilton. Melbourne: Penguin Australia, 2006 (x + 364 pp). ISBN 0 670 02879 7. What makes a man a man? Once this might have been a simple question. Since feminism and sociobiology, however, things have got a lot more complicated. Firstly, there is the distinction between sex and gender. Sex is a matter of being biologically male or female. Gender is a broader concept, incorporating social roles, norms and psychological traits, and is a key determinant of personal identity. Spaces and objects, as well as people, may be gendered: a Hummer is masculine, while a Ford Focus, even without a chihuahua accidentally left on the roof, is more feminine. Much of the argument has been about whether gender differences are intrinsic or constructed (by biology or society), and how society has developed in the face of these differences. There are a number of opinions about this. Philosophers like Luce Iragaray believe gender differences are intrinsic, but historically the feminine has been overlooked; evolutionary psychologists like Helena Cronin view them as largely biological and the result of natural selection; and those second wave feminists see sex as biological but gender as an artificial, political construct. Maggie Hamilton is not a philosopher; she is an Australian writer and publisher with an interest in personal development. Perhaps sensibly, she does not buy into the contentious issue of whence gender arises, though her book might have been more interesting if she did. Growing up with feminism, she assumed that, although women had suffered under patriarchy, life for men must be pretty good. Prompted by a range of personal experiences and the alarming increase in male suicides, she came to realise that men experience their share of gender-related suffering too, and that she had little understanding of men beyond anecdote and stereotype. This book, drawing on a range of interviews with men and psychologists and other therapists who deal with them, is an attempt to overcome that deficit. It examines the ways in which stereotyped expectations of masculinity affect men at all stages of their life cycles, from infancy to old age. If there is one key message, it would be dont be fooled by appearances. Men have feelings, men need affection, men are vulnerable, men need to communicate even though they are not always very good at it. In short, men are nowhere near as tough or self-sufficient as they look. It seems to me that how useful this book will be to a doctor or a patient will depend on how uncritically they have previously accepted male stereotypes. Someone who has been taking the conventional image of masculinity at face value will find its many encounters with real men and their manifold vulnerabilities very illuminating. Those who have already critically engaged with the male psyche as subjects, partners, family members, friends or clinicians may want something a little more scholarly. Simon CowapGeneral Practitioner, Sydney, NSW
Simon Cowap
Communicating electronically
e-Communication skills. A guide for primary care. Louise Simpson, Paul Robinson, Mark Fletcher, Rob Wilson, editors. Oxford: Radcliffe Publishing, 2005 (x + 132 pp). ISBN 1 85775 868 4. This short guide to the world of e-communication for United Kingdom general practitioners is a departure from the plethora of books on health informatics for primary care services, which tend to focus on detailed descriptions or evaluations of information systems and management. This book attempts something quite different and novel to provide guidance to health practitioners on how they should use the information tools at their disposal to access information and to communicate with patients and other providers. The editors are from the north-east of England and are known for their contribution to health informatics in British general practice. Their book is designed for a UK audience, but is mostly still of relevance in Australia (although it does not deal with some important tools for e-communication in Australian general practice, such as registers and care plans). e-Communication skills comprises a series of brief chapters which can be read in 15 to 20 minutes each, providing clear take-home messages that are understandable to any clinician. The second chapter notes three key issues identified in a Scottish report on patients views: enabling shared decision making, patient and clinician access to evidence-based guidance, and interdisciplinary teamwork. However, the book does not follow this thematic structure. Thus, while many chapters contain very useful ideas or suggestions (such as how to prevent use of the computer from disrupting rapport in the consultation and how to send and receive better emails), it is difficult to identify the key messages from the book as a whole. This is an accessible book which will be of interest to all those involved in facilitating information management and communication within general practice. Despite some limitations, it is worth the read. Mark F HarrisProfessor of General Practice, University of New South Wales, Sydney, NSW
Mark F Harris
Meaningful curiosity
To travel hopefully. An autobiography. Charles Bridges-Webb. Melbourne: Sid Harta Publishers, 2005 (v + 470 pp). ISBN 1 921030 26 7. Charles Bridges-Webb (CB-W) had two professional lives. He was a country GP in Traralgon from 1960 to 1975 and then Foundation Professor of Community Medicine at Sydney University from 1975 to 1994. Active in the research and disease classification committees of the RACGP and the World Organization of Colleges of General Practice, he has had a major influence on Australian general practice research and education. His autobiography traces the influences through which his natural curiosity became organised. A family tradition of keeping a personal journal began with his paternal great-grandfather, the architect of the Windsor Hotel in Melbourne. His maternal grandfather, a farmer dependent on rural finance and weather conditions, impressed upon him the importance of keeping meticulous records. As a medical student and young doctor, his original questions aroused the nurturing instinct of teachers, such as professors Sydney Rubbo and Basil Hetzel and the physician, John Bolton. His descriptions of the development of his research interests, projects and collaborations should be of interest to budding GP researchers. CB-W describes his simple philosophy of life based on travelling quietly but hopefully towards ideals that he knows he will probably never reach. So his disappointments are understated and he ignores the contemporaneous political controversies of Sydney University and the Royal Australian College of General Practitioners. He considers that the important parts of life are dependent on the little matters. There is much in this book on family, children, travel, churches, acting, cricket and gardening. All is shared with his can do wife and soulmate Anne. They are a package where their friends and acquaintances always get two for the price of one. Like most doctors, CB-W tells some good medical tales. My favourite is when he was asked to do a house call to an elderly lady whose son reported that she had had a bit of a shock. On arriving at her house he discovered that it had been hit by lightning. This is an honest autobiography. It avoids the pitfalls of self-aggrandisement and self-pity. CB-W has many friends. His autobiography enables us to know him better. Max KamienEmeritus Professor of General Practice, University of Western Australian, Perth, WA
Max Kamien
Increased medical school places: a crisis in the making?
Martin B Van Der Weyden
Conundrums in community-acquired pneumonia
Patrick G P Charles MB BS, FRACP · Paul D R Johnson MB BS, FRACP, PhD · M Lindsay Grayson FRACP, MD, FAFPHM
Epidemic Clostridium difficile
Thomas V Riley PhD, FRCPath, FASM
Quality among a diversity of health care providers
Richard A Cooper MD
Physician assistants and nurse practitioners: the United States experience
Roderick S Hooker PhD
Workforce substitution and primary care
David P Weller PhD, FRACGP, FAFPHM
Advanced nurse roles in UK primary care
Bonnie Sibbald PhD, FRCGP(Hon) · Miranda G Laurant MSc · David Reeves PhD