Issues
Volume 187 Issue 2
Editorials
Expanding primary care-based medical education: a renaissance of general practice?
The time to make it happen is long overdue There is a tide in the affairs of men, Which, taken at the flood, leads on to fortune; Omitted, all the voyage of their life Is bound in shallows and in miseries. William Shakespeare, Julius Caesar Australian medical education is facing a crisis of unforeseen proportions. This crisis will not only affect the quality of the education of future medical students but may also impact on their opportunities for vocational training. In essence, there is a mismatch between future demands for quality medical education and the capacity of the health care system to support this in both the undergraduate and postgraduate years. The immediate precipitant of this looming crisis is the recent undisciplined and poorly planned increase in medical school numbers. In response to projected medical workforce shortages (a predicament of the government’s own making), the Australian Government, in rapid succession, announced the establishment of seven new medical schools. The increase in medical school places was further augmented by a relaxation of the restrictions on local and international full-fee-paying students. From 2005 to 2012, the number of annual domestic graduates will increase by 81% (from 1348 to 2442), and the number of international graduates will nearly double (from 260 to almost 500).1 There will be at least 12 000 students in the system at any given time, and around 3000 will graduate each year. While the increase in medical school places is obviously welcomed, where are the educational resources to accommodate these student numbers? And, more importantly, will quality teaching and learning be sacrificed? The demand for an expansion of educational capacity comes at a time when teaching hospitals are losing their value and status as educational powerhouses.2 The reasons for this are diverse and complex, but include: the diminishing numbers of hospital beds; shorter lengths of stay for patients; a move to day-only admissions for surgical patients;3 and and the increasingly complex conditions of hospital patients, compared with those seen in primary care.2 Added to this litany of problems are the difficulties experienced by students in seeking access to patients in the hospital setting.4 As a consequence of these developments, there has been a reemphasis on involving general practice in medical education.5,6 This issue of the Journal features a number of articles exploring diverse issues related to this task. Thistlethwaite et al argue the case for general practice becoming a leading provider of medical education in the 21st century;7 Pearce et al expose the challenges involved in teaching in general practice;8 and Dick et al emphasise the importance of vertical integration in general practice-based medical education.9 Finally, Jackson and Marley present accounts of two established academic general practices, which may prove useful models for general practices involved in teaching.10 Other Australian models also exist, such as Lubims Inc, a not-for-profit Family Practice Network owned and operated through a trust by the University of Adelaide. However, whatever the model, we will need upwards of 500 new teaching general practices across Australia (Professor Justin Beilby, Executive Dean, Faculty of Health Sciences, University of Adelaide, personal communication). One intriguing outcome of all these developments is that this trend may well support a renaissance of general practice, which, sadly, has often been the target of negativism by both general practitioners and specialists alike.11,12 Furthermore, compared with general practitioners, doctors in teaching hospitals undoubtedly benefit from a profound professional advantage, which flows from the academic ambience and collegiality of their workplace; their ability to shape the learning and interests of young minds; and the institutional infrastructure that provides manifold opportunities for research. However, it can be argued that all these advantages and attributes can easily be replicated in general practice, if it is given appropriate infrastructure and funding. Importantly, the realisation of increased teaching in general practice should not depend on yet another series of temporising governmental inquiries. The time has come for a national taskforce to make it all happen — and happen soon! The Flexner Report of 1910, which provided the foundations of modern medical education, also arose from a crisis: community disquiet in the United States at the end of the 19th century over the quality of medical practice and practitioners. This crisis also had its origins in medical education — in the mediocre quality of many North American medical schools, with their inadequate curricula, atrocious facilities and their rapacious focus on profits.13 In response to this crisis, the American Medical Association (AMA) carried out an inspection of North American medical schools in 1906 and uncovered widespread deficiencies in teaching, and unacceptable profiteering. The report was not published, as it was deemed imprudent for a medical organisation such as the AMA to be critical of medical schools.13 However, the AMA invited The Carnegie Foundation for the Advancement of Teaching to look into the matter, and the outcome was the Flexner Report. Its recommendations for reform were widely accepted as principles for governing medical schools,13 and they are equally relevant for medical education in a community setting today. Firstly, Flexner urged that teaching should be equipped with appropriate infrastructure and funding; secondly, that the teachers must be adequately trained; and thirdly, that research should be a central activity, integral to and informing all medical practice. In practice, this means modern and appropriate facilities, good teachers, a university affiliation, and a commitment to excellence in research and care; in short, general practice with TLC — Time for teaching, Learnedness in the art and science of teaching, and a Commitment to teaching the next generation of young doctors the art and science of medicine. The national taskforce for implementing an expansion of teaching in general practice should not inadvertently “throw the baby out with the bathwater”. Obviously, there will continue to be a need for teaching hospitals, but these should be better configured, with closer ties to the general practice community, allowing students to follow patients on their journeys from the community to hospital.14 In keeping with a recommendation of the recent Productivity Commission report on Australia’s medical workforce, support for this taskforce should be provided by the Australian Government Department of Health and Ageing.15 Also in this issue of the Journal, Scott and Coote present their analysis of performance outcome measures pertaining to the Divisions of General Practice.16 The relevance of their findings is further developed by Sprogis.17 Both these contributions raise questions as to whether the Australian Government (and indirectly the community) obtains value for its not inconsiderable financial support of the Divisions. Could not all or a considerable proportion of this money be more profitably diverted to provide educational infrastructure in Australian general practices, using the models described by Jackson and Marley,10 or strategically located general practice teaching centres with a “hub and spoke” configuration linking with other local general practices and hospitals, as proposed by Douglas and his colleagues almost 15 years ago?18 Back then, the suggestion apparently fell on deaf ears, but maybe with the looming crisis in medical education, its time has come. At the very least, the teaching-in-general-practice movement should be able to capitalise on the developed infrastructure and facilities of the Divisions and of the General Practice Education and Training program. The fulfilment of general practice as a major provider of medical education remains an exciting and challenging task — and its realisation may well mean a continuing renaissance of Australian general practice.
Martin B Van Der Weyden MD, FRACP, FRCPA
Whither the Divisions of General Practice?
It is a national disgrace how little is known about the impact of the Divisions after 15 years In this issue of the Journal, Scott and Coote provide an important contribution to a better understanding of one of the more significant Australian health policy changes of the past 20 years: the Divisions of General Practice (→ Wither Divisions of General Practice? An empirical and policy analysis of the impact of Divisions within the Australian health care system).1 Why this article is so significant in policy impact terms is that, according to the Australian Government: The Divisions network is Australia’s largest representative voice for [general practitioners] and provides local support to general practice. Divisions perform a range of activities to improve and address access, integration, chronic disease management, workforce issues and consumer needs.2 This makes the Divisions the third component of the Australian national organised health care system, the other two being the public health/hospital and private insurance sectors. It is therefore a national disgrace how little is known about the impact of the Divisions of General Practice after 15 years of operation. It is in this context that the article by Scott and Coote is so critical. A unique and key feature of the Divisions is that they are GP member owned and operated, regional health care organisations. This private ownership by a medical professional grouping is a unique approach to a national health structure, and is unlikely to be emulated by any other medical or allied health specialty group in the future. The Divisions have been allocated further core funding, as noted in the recent Australian Government budget papers: The Government will provide $243.3 million over three years from 2008–09 to continue funding the Divisions of General Practice network. The objective of the network is to promote the health and wellbeing of Australians by working with general practitioners and other health service providers to improve the quality and accessibility of health care at the local level. The programme also provides an important avenue for the support and delivery of Government programmes.3 Additional funding from various state governments and other sources is now growing more rapidly than the core Australian Government funding. My Division, the Hunter Urban, is a typical Division with more than 10% of local GPs having participated in a leadership role at board level over the 15 years. The Division serves a population of more than 400 000, with over 420 GP members; more than 90% of GPs participate in any divisional service or clinical activity and 80% of GPs were involved in more than five service or clinical activities in 2006. The range of activity is very broad, and encompasses funding from over 10 different sources (both public and private), a budget of more than $10 million (of which Australian Government core funding is about $1.5 million), and services across a significant spectrum of GP activity, including practice infrastructure support.4 However, the burning question for 15 years has been, and continues to be, what do Divisions do and, more importantly, what impact do they have? Are taxpayers receiving value for their investment? What should that value look like and how might it be quantified? The study by Scott and Coote involved “Regression analysis using longitudinal data across Australia”,1 and the first question it raises is why was such a complex tool necessary? A more conventional organisational analysis using targets and benchmarks set by the main funder (the Australian Government) should have been possible, particularly where a cumulative total of $2 billion or more of taxpayer funds have been expended over 15 years. Unfortunately, as the authors have noted, these data simply do not appear to exist — certainly not in readily analysable form. Despite a major review of the Divisions undertaken in 2002–2003,5,6 which made recommendations related to the need for clarity in measuring performance and for a rigorous evaluation process, in 2006–07, the Divisions’ goals for core funding from the Australian Government remain couched in vague terms. In 2006–07, the agreement between the Australian Government and the Divisions, known as the Multi Program Funding Agreement, has a set of overall goals (Australian Government, Agreement plan for the funding period annual plan 07/08). These include: Governance: organisational capability, financial accountability, and governance; Prevention and early intervention: focus on prevention and early intervention; Access: improve access; Integration: encourage integration and multidisciplinary care; Chronic disease: better manage chronic conditions; General practice support: support GPs and general practices within a changing primary care environment; Quality support: support quality and evidence base; Consumer focus: ensure a growing consumer focus; and Workforce: support the recruitment and retention of an appropriate primary care workforce. The only clearly specified funding-dependent target is organisational (organisational accreditation), with few other clearly targeted benchmarks for health or service outcomes. This lack of specificity in targeted outcomes is not unique to Divisions as, for example, an examination of the private health insurance sector (with an annual government subsidy expenditure in 1 year greater than Divisions over 15 years) also demonstrates how widespread the absence of service and health outcome data is. So what does the article by Scott and Coote reveal and, particularly, what does it not reveal? They report that Divisions have a positive effect at the infrastructure and organisational level and, in the absence of any other equivalently rigorous research, this now represents the best evidence we have for some aspects of the utility of Divisions of General Practice in 2002–2004. In an environment where workforce shortage and lack of patient access is a key issue, with improvements in infrastructure being seen as one of the main solutions, then the inference from the article is that Divisions should be increasingly funded to tackle the infrastructure and organisational deficits within general practice. Critical to the analysis of the Divisions, and acknowledged by Scott and Coote, is that “Only a relatively narrow range of Divisions’ outputs and primary care performance was examined, because of a lack of data”.1 This lack of outcome measures clearly is an indictment of the lack of responsibility the government and its agency, the Department of Health and Ageing (DHA), take in monitoring their own performance as administrators of community resources. It represents an accountability deficit at government level. What is puzzling is that, in other DHA-administered program areas, there are clear, simple and effective measures of performance. This does not seem to extend to the Divisions program. Service delivery forms a major part of the activity of many Divisions, particularly in rural areas. For example, under the More Allied Health Services program, rural Divisions are often the major or only suppliers of these services to their rural communities. As another example, in my region, the Hunter Urban Division is the default provider of ambulatory after-hours GP services, with more than 100 000 patient interactions each year delivered by more than 250 GPs and 60 nurses. Service delivery, as acknowledged by Scott and Coote, is the most rapidly growing part of divisional activity, and the relationship between Divisions and service provision needs something better than a “lack of data”, which implies a lack of performance indicators and targeted benchmarks to define its worth. My experience has been that individual Divisions and their peak bodies have been ready, willing and able to set and meet specific targets and it is the Australian Government and its bureaucracy that apparently is struggling with this facet of accountability. So, where to from here? The first step is not more studies using regression analysis or research involving experimental and control groups. Australia has had far too much policy by trials (a phenomenon internationally unique to Australian health policymakers and their bureaucracies). If, as I and many others believe, Divisions are the greatest single, positive, underutilised organisational health resource in our nation, and funding should match their potential for a much larger role in primary care health service delivery, then policymakers and governments need to put this to the test by establishing clear goals, with attached performance measures and targeted benchmarks that are open and transparent to all. We all have a right to see if what appears to be true is based on empirical evidence. It might well set an example for other health policy initiatives, which would have to meet the same challenge: transparent accountability to the Australian community. The article by Scott and Coote is a step in the right direction.
Arn Sprogis MB BS, FRACGP, GradDipClinEpid
Primary care reform using a layered approach to the Medicare Benefits Scheme: unpredictable and unmeasured
The time has come to review and reflect on where these reforms are meant to be leading There is now a plethora of new Medicare Benefits Scheme (MBS) item numbers encompassing chronic disease management, diabetes annual cycle of care, asthma cycle of care, 45-year-old health check, health assessments for older people and refugees, general practitioner mental health care, pregnancy support counselling service, and domiciliary medication management reviews. The availability of these item numbers would appear to be logical, as they are linked to important national policy initiatives such as the National Chronic Disease Strategy,1 Australian Better Health Initiative,2 and the National Mental Health Strategy.3 However, of increasing concern is that, with each budget cycle, another layer of new MBS item numbers is added. There is little clarification of what the final end point of these reforms will be. If the goal is a strong, robust and integrated primary care system4 that will deliver improved outcomes for these patient groups, then using the rather crude tool of successive new MBS item numbers alone is unpredictable5 and is likely to provide only part of the solution. There is a paucity of published evidence that the new MBS item numbers have improved patient care. Some improvements in patients with diabetes have been noted,6,7 and smaller studies have found positive changes in referrals to allied health professionals due to the use of care plans.8 In a review of information technology and health, Georgeff cited evidence that “less than 14% of patients with chronic disease are placed on care plans” and less than 1% are followed to see if patients adhere to these plans.9 In this issue of the Journal, Hickie and McGorry query the geographical distribution of the uptake of the mental health items, the out-of-pocket expenses for patients referred, and the possible absence of focus on the highest risk groups (→ Increased access to evidence-based primary mental health care: will the implementation match the rhetoric?).10 They suggest that the uptake is in groups who were already accessing psychological support services.10 Another study found further evidence regarding the lack of equity in use of health assessments.11 It is an indictment of the health bureaucracy that no systematic evaluation has been established to formally assess the effect of these new MBS items. Earlier evaluations for the original enhanced primary care item numbers12 and asthma Service Incentive Payment (SIP) item number13 have resulted in constructive innovations. If the overall aim is an integrated general practice that can manage the burgeoning number of patients with these conditions, then it is important to gather evidence to support this hypothesis. Over the period from July 2005 to June 2006, the number of health assessments claimed for was 285 861; care plans and case conferences, 1 234 703; GP diabetes, asthma and mental health items, 249 620; and the use of psychological strategies, 30 261.14 This is about 2% of the 90 million patient consultations completed over this period. Yet we do not know the patient impact and cost-effectiveness of these activities. GPs are voting with their feet and continuing to focus on the core of general practice — the consultation. Red tape, GP workforce shortages and the paucity of trained allied health professionals have been regularly cited as causing the lack of uptake of these items.15 Jurisdictional differences between state, territory and federal governments also continue to surface as key barriers for evidence-based health policy. Also in this issue of the Journal, Harris and Zwar outline concerns with chronic illness (→ Care of patients with chronic disease: the challenge for general practice),16 arguing that these new chronic disease items are only part of a fully functional chronic disease model. The complete model would include:17 clinical information systems that measure quality of care; actively implemented decision support and guidelines; ongoing information management and data exchange; integrated chronic condition self-management programs; appropriate finance systems; practice-based teams; and community and consumer linkages. The only elements being fully supported by the new MBS items are the final two. The principal policy response seems to be to add new MBS item numbers and then hope that Australian general practice can adapt and deliver the required outcomes. There are no regular programs to consult on or support the development of the other elements. The way forwardThe time has come to halt this approach to the MBS and review and reflect on where these reforms are meant to be leading. We need a better system. Following are some of the elements this system should include. Developing an articulated vision for general practice and primary careThe reforms1-3 that underpin these new MBS items require more than item numbers. A vision that is accepted by all groups, with agreed goals, effective leadership and alignment across all governments and local non-government providers, is vital if these reforms are to deliver the desired outcomes. Methods of increased accountability that foster quality and accessibility for all groupsModels that “reward practices for delivering clinical and organisational quality”, such as in the United Kingdom,18 need exploring. Since 2004, general practices in the UK have been given the opportunity to receive extra funding for achieving a range of specific standards in clinical areas (eg, stroke, diabetes, and asthma), practice organisation (eg, information for patients), patient experience, and additional services.18 In a similar way, Australian general practices should be financially rewarded with extra payments for reaching agreed practice-based targets for health assessments, diabetes SIP, and GP chronic disease items. This model would need to be supported by ongoing practice-based audits, which could be implemented by the Divisions of General Practice. Supporting longer consultationsA debate is required about whether a financial model that rewards GPs for spending more time with the patients would achieve as much as the plethora of new item numbers.19 Improving the infrastructure to foster the use of shared e-health recordsIt has been calculated that $1.5 billion could be saved by “improved knowledge sharing and care plan management”.9 Providing financial incentives to all GPs and allied health providers to foster the use of shared records with the electronic delivery of referrals and discharge summaries is a logical initial first step.9 Improving the flexibility of delivery of chronic disease programsFunding self-management programs,20 and allowing other allied health groups to instigate multidisciplinary care plans and establish the primary care teams in partnership with general practice are other options. The health priorities that underpin the MBS item evolution will not disappear. They will only increase and we have a pressing need to find solutions that will provide sustainable and acceptable solutions. But the time to gather evidence for effectiveness and efficacy is long overdue.
Justin J Beilby FRACGP, DRCOG, DA
Will promoting general practitioners with special interests threaten access to primary care?
Increasing the number of “special interest” GPs may exacerbate the current GP shortage According to the Royal Australian College of General Practitioners (RACGP): In the provision of primary care, much undifferentiated illness is seen; the general practitioner often deals with problem complexes rather than with established diseases. The general practitioner must be able to make a total assessment of the person’s condition without subjecting a person to unnecessary investigations, procedures and other treatment.1 In this paradigm, a condition such as chest pain may have its roots in the physical, social and/or psychological domains, and a robust general practice system is crucial to managing these complex clinical interactions. A GP is well placed to determine the relative contributions of these causes and to effectively manage the interface between primary care and the hospital. Starfield and colleagues have long argued this case, and few have offered a cogent counterargument.2 However, in the United Kingdom, and now in Australia, a formal system of GPs with special interests (GPwSIs) — that is, GPs having a subspecialisation within general practice — is touted as the answer to the growing demand for specialist services in this issue of the Journal (page 111)3 and elsewhere.4 There is clear evidence of the value of subspecialisation in some areas of general practice — for instance, in Indigenous health, palliative care, drug and alcohol services, and HIV management.5 The case for expanding these roles to include yet more “special interests” is that the policy will “develop careers through offering additional interest, personal development and heightened self-esteem”.6 This may be a persuasive argument for increasing the attractiveness of general practice, where there is a growing manpower crisis and an urgent need for enthusiastic new recruits. However, this approach is also associated with a call for more “locums” to make up for manpower shortages in general practice and the deskilling of the GP pool in some clinical areas. Thus, diverting the GP workforce will compound shortages in “core general practice”. A key driving force behind the promotion of GPwSIs in the UK was the perceived need to reduce “inappropriate” referrals and hospital admissions, thereby improving the efficiency of health resource utilisation. However, referral processes in general practice are frequently complex and multifactorial, and are unlikely to respond to this approach.7,8 GPs may also be reluctant to refer to colleagues whom they perceive as generalists with much the same level of skill as their own.9 In other words, GPwSIs may offer an additional service rather than an alternative to specialist services. If GPwSIs were to reduce the workload for specialists, their impact on primary care could be unhelpful or even detrimental. In a recent UK patient survey, it emerged that patients foresaw difficulty making appointments with their chosen GP in circumstances where a special-interest GP was working at the practice.10 In the Australian context, it may be difficult to predict the likely impact, given that general practice is a privatised business. However, if such difficulties with access were mirrored here, the resulting loss of continuity of care could diminish the key value of the GP as defined by the RACGP. This is of special concern given the growing burden of chronic disease in an ageing population. Indeed, many patients are still receiving suboptimal care for chronic disease.11 Furthermore, with the increasing policy emphasis on prevention, screening and surveillance, many patients will need more access to GPs. To achieve the long-term benefits of these policy directions, we need to protect the principle of equal access for all. Patients in the UK, where the GPwSIs concept has been widely embraced, are impressed by the speed of access and personal aspects of the service, but not necessarily by its quality. In the UK, GPs-in-training have been reported to be naive about the potential complexities of accreditation and governance required for the roles of GPwSIs. If GPwSIs are to become a feature of the primary care landscape in Australia, appropriate training and accreditation will be critical to prevent them being regarded as a cheaper, second-class service. Another danger with facilitating growth in the number of GPwSIs is the possibility that it will interfere with the fabric of primary care — namely, an accessible, generalised, integrated and coordinated approach to patient management. Furthermore, we should not underestimate the financial incentive to dabble in lucrative specialist procedures in a largely unregulated health care system in which many GPs feel undervalued. Indeed, a more appropriate remunerative structure, especially for cognitive (as opposed to procedural) practice, may well serve to change perceptions of what is attractive and rewarding. Thus, promoting GPwSIs in Australia may serve only to redistribute scarce GP resources while running the risk of exacerbating GP workforce shortages. This, in turn, will require more GP training positions to be established, a decision that is not under the control of the profession. Balancing the increasing role of GPwSIs in Australian general practice will require careful workforce modelling and planning.
Moyez Jiwa MD, FRACGP, MRCGP · Hooi C Ee MB BS, PhD, FRACP · Justin J Beilby MD, MPH, FRACGP
Conference report
International conferences on rare diseases: initiatives in commitment, patient care and connections
An Australian GP’s pilgrimage to Rome to sound the voice of primary care Rather than finishing paperwork after a busy Monday in a Katoomba general practice, I (A W K) found myself sitting (jet-lagged) in a marble auditorium in Rome within the Istituto Superiore di Sanità (Institute of Public Health; Box 1) with about 200 other conference participants from the United States, Australia, and more than 22 different European Union (EU) and non-EU member states. We were waiting for an announcement by the Honourable Livia Turco, the Italian Minister of Health. An article I co-authored, which was published in the Journal in July 2006,1 had led to an invitation to participate in the 2-day International Rare Disease Conference (IRDC) and the subsequent 3-and-a-half-day NEPHIRD (Network of Public Health Institutions on Rare Disease) conference organised by Dr Domenica Taruscio, Director of the Centro Nazionale Malattie Rare (National Centre for Rare Diseases) in Rome, together held from 18–23 September 2006. The Ministry of Health announcement confirmed the Italian Government’s commitment to rare diseases and to orphan drugs research and development. The IRDC proceeded with an overview of initiatives in rare diseases in Italy and some of the more than 22 countries represented. The NEPHIRD involved morning presentations and afternoon small-group work, with the first day devoted to prevention and epidemiology, and the second to diagnosis and treatment. The third day dealt with the social aspects of rare diseases and, on the final morning, we heard plenary sessions on specific rare diseases such neurofibromatosis, Prader–Willi syndrome, myasthenia gravis, Cornelia de Lange syndrome and Rett syndrome. Plenary presenters were significant people in the field of rare diseases from Europe and the US, including Dr Kerstin Westermark, Chair of the Committee for Orphan Medicinal Products of the European Medicines Agency, Dr Ségolène Aymé, the Chair of the European Rare Disease Task Force, and Dr Marlene Haffner, Director of the Office of Orphan Products Development, which is part of the US Food and Drug Administration. The patient voiceAs the week unfolded, a striking theme was the presence of patients. Patients and carers dealing with Ehlers–Danlos syndrome, cystic fibrosis, narcolepsy, multiple endocrine cancers, Sjögren syndrome, chronic fatigue syndrome, fibromyalgia, fibrodysplasia ossificans, muscular dystrophy, cyclical vomiting, neurofibromatosis, and many others disorders, participated in and presented sessions. Specific sessions were devoted to patient groups to allow them to present the problems they face. In one moving contribution, Claudio Buttarelli, President of the neurofibromatosis support group Ananas (Italian for pineapple — rough on the outside but sweet on the inside), described the impact of this rare and misunderstood disease on every aspect of his life from socialisation in his teenage years through to the limitations imposed by nerve palsies on playing soccer with his children. Such sessions kept presentations on genetic research, new compounds, and public health initiatives grounded in the everyday experience of patients. However, the presence of patients should have been no surprise, as patient voices were instrumental in bringing the problem of rare diseases to the attention of governments. In the 1980s in the US, a peak patient group, the National Organization for Rare Disorders (NORD),2 was established to lobby for funding and research that no single rare disease could attract (Box 2). Eurordis (the European Organisation for Rare Diseases) fulfils a similar function. Notably, there is no peak patient body for rare diseases in Australia. Different storiesThe USDr Stephen Groft, Director of the Office of Rare Diseases (ORD) of the US National Institutes of Health,4 spoke at both conferences, describing ORD and some of its activities. ORD was set up in 1993 to stimulate and coordinate research on rare diseases and to support research to respond to the needs of patients with rare diseases. ORD supports a grants program to establish a network for research on rare diseases; grants are provided for such activities as the training of rare diseases researchers and programs to stimulate clinical research on rare diseases. Of particular interest to Australians because of its online accessibility is an information centre aimed at the public, researchers, and health care providers (http://rarediseases.info.nih.gov/asp/resources/rardis_info.asp). ORD also supports a national scientific conferences program to stimulate research and regional workshops to help patient support groups obtain assistance through the National Institutes of Health. EuropeIn April 1999, the EU Parliament set forth Decision No. 1295/1999/EC, adopting a program of community action on rare diseases within the framework for action in the field of public health (1999–2003). Many projects were funded under this program, and important initiatives that continued in the 2003–2008 European public health program5 include ORPHANET, a database for the general public on rare diseases (http://www.orpha.net/consor/cgi-bin/home.php?Lng=GB), and EUROCAT (http://www.eurocat.ulster.ac.uk/), which surveys more than one million births per year in 19 countries to provide epidemiological information on congenital abnormalities. We heard about innovative Italian initiatives, including the national network for the prevention, surveillance, diagnosis and therapy of rare diseases made up of certified centres expressly identified by the regions (decentralised administrative units) and the National Registry of Rare Diseases. This registry is established at the Centro Nazionale Malattie Rare,6,7 led by Dr Domenica Taruscio. The centre carries out a wide range of activities including genetic research into rare diseases, quality assurance of genetic testing, primary prevention projects, maintenance of the rare disease registry, dissemination of information, development of guidelines, involvement and coordination of EU projects such as NEPHIRD, qualitative research on patients’ quality of life, narrative medicine, and training of health professionals. Lessons for an Australian GPA need for coordinated activityThe relative lack of coordinated activity in rare disease in Australia compared with the US and Europe is striking — we believe there is a need for a peak patient group (such as NORD or Eurordis) in Australia to lobby for patients with rare diseases. Australia’s small population (with consequent small numbers of patients with any given rare disease) and geographic dispersal presents particular challenges in connecting patients with rare diseases with each other and with expert care. Presentations at the rare diseases conference covered a number of potentially useful strategies for connecting and empowering patients. Of particular note is Ågrenska in Sweden,8 which organises week-long camps at which families and patients with similar problems receive intensive education and establish connections with each other, and hear about specialist services. Ågrenska has been able to demonstrate better outcomes and cost savings through its strategy.8 Europe is establishing networks of excellence in which researchers and institutions with expertise in particular diseases are linked. We wonder whether Australian patients and clinicians with interests in particular diseases could join these networks, perhaps even participating in e-medicine consultations. The role of primary careThe specialists and scientist researchers at the conferences expressed frustration about the supposedly “low” level of skills of their primary care colleagues in identifying the rare disease in which they were expert. One specialist exclaimed that some GPs had never even heard of neurofibromatosis type 1. Some sessions at the conference presented this as an equity issue — surely, a patient with Prader–Willi syndrome has as much right to prompt diagnosis and evidence-based treatment as a patient with type 2 diabetes? The natural reaction is to call for more education of primary care clinicians in individual rare diseases. However, we do not think it would be realistic or even wise for GPs to use their time learning all the details of the 6000 identified rare diseases.4 We do believe that primary care has a neglected but important role in rare diseases. To date, progress in rare diseases has been driven by patients through their specialist clinicians and through public health institutions. Primary care clinicians provide a key link between patients in our community and the very specialised services those with rare diseases require. The Australian proposal of a generic model of general practice care1 was presented and discussed at the IRDC. One important and simple strategy identified during the week was careful monitoring of infant development as a generic strategy to screen for many rare congenital diseases. A voice from the perspective of primary care seemed to be quite strange to this very specialised community. In the main, they welcomed the general practice contribution and were excited by the possibilities of adding a primary care perspective to the rare disease agenda. Patients at the conference in particular confirmed the need to continue to develop the role of primary care clinicians in rare disease. Future connectionsThe pursuit of an idea (the common problem of rare disease in general practice) through to publication in the Medical Journal of Australia has led to a number of connections which have been professionally stimulating, satisfying and helpful. One of them was the IRDC in Rome 2006, which highlighted the international agenda on rare diseases. This conference has stimulated one Australian GP (A W K) to think further about and conduct more research into the role of GPs in rare disease. Policymakers, other clinicians, and patient groups in Australia also have the opportunity to reflect on the way forward. In particular, a funded initiative to establish a peak patient body for rare diseases seems long overdue. 1 The Istituto Superiore di Sanità (Institute of Public Health), conference venue, Rome 2 Rare disease facts Rare diseases are life-threatening or chronically debilitating diseases that have such a low prevalence (not more than 5 per 10 000) that specially combined efforts are needed to prevent morbidity and perinatal or early mortality, and to address quality-of-life and equity issues. There are approximately 6000 defined rare diseases. It is estimated that up to 6%–10% of the community have a rare disease.2 Patients with rare diseases have common experiences — including delayed diagnosis, wrong diagnosis, inappropriate surgery, lack of access to evidence-based care, and social consequences — because their diseases are rare.3 Orphan drugs are pharmaceuticals developed to treat diseases that affect relatively few people.
Andrew W Knight FRACGP, MMedSci(Clin Epid) · Domenica Taruscio MD
General Practice In Action
Multidisciplinary care plans for diabetes: how are they used?
Objective: To understand how multidisciplinary care plans are being used in the management of patients with diabetes, and to explore the role of collaboration in care planning.Design: Grounded theory interview study.Setting: Primary care, June 2005 to October 2006.Participants: Thirty-eight people from three New South Wales Divisions of General Practice: 19 general practitioners, eight diabetes-related allied health providers, two endocrinologists, and nine adults with type 2 diabetes. Sampling was purposeful then theoretical.Results: GPs use care plans to organise clinical care and help patients access allied health providers. Written plans are used to educate patients about their care and to motivate change. GPs rarely discuss care plans with other providers, and providers are unlikely to change their approach to patients on the basis of care plans. Patients do not expect to participate in care planning.Conclusions: Care planning may increase evidence-based multidisciplinary care for patients with diabetes, but it rarely results in genuine collaboration between providers and patients. This suggests a difference may exist between Australian policymakers’ and providers’ definitions of patients with complex needs. Care plans could facilitate patient self-management by including more personalised information. Further research is needed to clarify which patients would benefit from a truly collaborative approach to their care.
Timothy D Shortus MB BS, MPH, FRACGP · Suzanne H McKenzie MMSc(ClinEpid), GradCertULT, FRACGP · Lynn A Kemp BHSc, PhD · Judith G Proudfoot BEd, MA, PhD · Mark F Harris MD, DRACOG, FRACGP
Gold Coast general practitioners’ recommendations of health websites to their patients
Objective: To identify trends associated with health website recommendations by selected general practitioners to their patients.Design and setting: Quantitative data collection using a prepaid postal survey, consisting of 17 questions, mailed to 250 of 410 GPs (61%) on the Gold Coast, Queensland. The survey was conducted between 9 October and 11 December 2006.Main outcome measures: GPs’ website recommendations to patients; associated GP demographic variables (age, sex and years of practice).Results: 59% (64/108) of participating GPs recommend health websites to their patients during consultations. Male GPs (63%, 45/72), those aged 41–50 years (55%, 35/64), and those practising for < 10 years (60%, 12/20) are more inclined to recommend a health website to a patient. The majority of GPs (69%, 44/64) reported that they most often recommended websites to patients 26–45 years old. 53% of GPs (34/64) recommended websites to 1%–20% of their male patients, while 47% (30/64) recommended websites to 21%–40% of their female patients. A greater proportion of participating female GPs (47%, 17/36) do not recommend health websites, compared with male GPs (38%, 27/72).Conclusions: More than half the surveyed GPs actively recommend websites to their patients, with a GP’s sex, age and years of experience influencing his or her recommendation decisions. Web-based continuing medical education courses or programs in medical schools may help doctors develop the skills necessary for the delivery of effective e-health care.
Wayne T Usher MHealthSci
A tale of two cities: academic service, research, teaching and community practice partnerships delivering for disadvantaged Australian communities
An innovative team approach and integration of care across sectors, including general practices, community health services, allied health professionals and hospitals, can deliver high-quality comprehensive care in disadvantaged areas while providing teaching and research opportunities and community service. Academic general practice departments are committed to supporting and evaluating such models. A governance infrastructure that encourages strong partnerships across health care sectors is essential. With broad health partnership support, bulk-billing is viable in an Australian general practice team model providing health care to the disadvantaged.
Claire L Jackson MPH, GradCMt, FRACGP · John E Marley MD, MB ChB, FRACGP
General practice and aged care
General practitioner consultations at residential aged-care facilities
Objectives: To describe the patients seen and the clinical activity undertaken by general practitioners during encounters at residential aged-care facilities (RACFs), and to ascertain how these differ from all GP encounters in Australia as a whole.Design and participants: A secondary analysis of encounter data from the Bettering the Evaluation and Care of Health (BEACH) study, April 2004 to March 2006, comparing RACF consultations (identified by Medicare item numbers) with all BEACH study encounters in Australia. Participants were a random sample of GPs who had claimed at least 375 general practice Medicare items in the 3 months prior to the study.Main outcome measures: Differences in the characteristics of GPs and patients at RACF consultations, morbidities managed, and treatments provided to patients.Results: Over the study period there were 2310 RACF encounters out of a total of 197 000 BEACH encounters; 360/1970 GPs (18.4%) recorded at least one RACF consultation. GPs aged ≥ 45 years were more likely to record at least one RACF consultation than those aged < 45 years. Patients were predominantly women (70.7%), and 83.4% were aged ≥ 75 years. At RACF consultations, problems managed significantly more often included chronic problems, as well as psychological, neurological, urological, circulatory, eye and musculoskeletal problems. Dementia was the most common problem managed, at 33 times the usual management rate in everyday practice. Significantly fewer medications, non-pharmacological treatments, referrals, pathology and imaging tests were recorded at RACF consultations.Conclusion: GP encounters at RACFs involve the management of chronic and complex conditions, including some not frequently seen in everyday general practice. The provision of additional education and resources where required may assist with workforce shortages in this setting.
Julie O’Halloran BAppSc(HIM)(Hons) · Helena Britt BA, PhD · Lisa Valenti BEc
Medical services provided by general practitioners in residential aged-care facilities in Australia
We conducted a literature review to assess the current status of general practitioner services in residential aged-care facilities (RACFs) in Australia and the impact of recent initiatives to enhance access by RACF residents to these services. Of 400 publications identified, 22 were selected as relevant to our study. We also analysed publicly available statistical data on GP services in RACFs. Recent initiatives to improve quality of care and facilitate access to GP services for RACF residents include the Aged Care GP Panels Initiative, the Enhanced Primary Care program, and an expanded role of palliative care. Despite these initiatives, many GPs still find RACF services unappealing due to a perceived poor level of remuneration for the effort involved. Further improvements in access to and quality of GP services to RACFs may require new models of care delivery and financing.
Svetla Gadzhanova PhD · Richard Reed MD, MPH
General Practice and Policy
Whither Divisions of General Practice? An empirical and policy analysis of the impact of Divisions within the Australian health care system
Objective: To examine the effect of Divisions of General Practice on various measures of primary care performance.Design and setting: Regression analysis using longitudinal data across Australia.Participants: All Divisions of General Practice between 2002 and 2004.Main outcome measures: Fourteen indicators of primary care performance in the areas of general practice infrastructure, access, multidisciplinary working, chronic disease, and measurable aspects of quality of care.Results: Between 2002 and 2004, Divisions and the activities they performed were associated with a number of measures of primary care performance, particularly measures of general practice infrastructure. Of the total variation in each performance indicator, between 19% and 64% can be attributed to the influence of Divisions while controlling for remoteness, health needs, and general practitioner characteristics. In all regression models, these effects were significant (P < 0.05). Divisions that provided support in electronic communication and electronic transfer of data were associated with: a 0.56 (95% CI, 2 0.04 to 1.2; P = 0.07) percentage point increase in the proportion of Practice Incentives Program (PIP) practices; a 0.73 (95% CI, 2 0.09 to 1.5; P = 0.08) percentage point increase in the proportion of PIP practices with electronic prescribing software; and a 0.66 (95% CI, 0.05 to 1.3; P = 0.03) percentage point increase in the proportion of PIP practices with a modem. Divisions providing activities with an asthma focus were associated with a 0.84 (95% CI, 0.02 to 1.5; P = 0.01) percentage point increase in the proportion of PIP practices receiving the asthma sign-on payment. There were no significant effects of Division activities on clinical aspects of care, such as GP claims for Service Incentive Payments for asthma, diabetes or cervical screening.Conclusions: Divisions of General Practice had an effect on primary care performance in a difficult health system context.
Anthony Scott BA(Hons), MSc, PhD · William Coote MB BS, BA(Econ), FRACGP
Increased access to evidence-based primary mental health care: will the implementation match the rhetoric?
There is clear evidence that coordinated systems of medical and psychological care (“collaborative care”) are superior to single-provider-based treatment regimens. Although other general practice-based mental health schemes promoted collaborative care, the new Medicare Benefits Schedule payments revert largely to individual-provider service systems and fee-for-service rebates. Such systems have previously resulted in high out-of-pocket expenses, poor geographical and socioeconomic distribution of specialist services, and proliferation of individual-provider-based treatments rather than collaborative care. The new arrangements for broad access to psychological therapies should provide the financial basis for major structural reform. Unless this reform is closely monitored for equity of access, degree of out-of-pocket expenses, extent of development of evidence-based collaborative care structures, and impact on young people in the early phases of mental illness, we may waste this opportunity. The responsibility for achieving the best outcome does not lie only with governments. To date, the professions have not placed enough emphasis on systematically adopting evidence-based forms of collaborative care.
Ian B Hickie MD, FRANZCP · Patrick D McGorry MD BS, PhD, FRANZCP
Care of patients with chronic disease: the challenge for general practice
General practice can provide good quality care for a range of high-prevalence chronic diseases, at the same time providing continuity of care and management of comorbidity. Although the quality of care for patients with chronic disease is improving in general practice, about half of patient care does not meet optimal standards. Factors contributing to the gap between optimal and current practice include the method of financing, the availability of other disciplines to participate in team care, limited engagement with self-management education, and lack of information and decision support systems. National initiatives and incentives have enhanced planned and systematic care in general practice, and some programs have been introduced to improve access to allied health care. The number and complexity of programs, and lack of integration between them are a significant administrative burden for general practice, and the financial incentives are small compared to overseas programs. A better integrated and more comprehensive strategy is required to achieve widespread and sustained improvements in the quality of care for people with chronic disease in general practice.
Mark F Harris FRACGP, MD · Nicholas A Zwar FRACGP, PhD
Practice nurses in Australia: current issues and future directions
Almost 60% of general practices now employ at least one practice nurse. Australian Government initiatives to support the expansion of practice nursing are not consistently based on strong evidence about effectiveness, outcomes or efficiencies. Reviews from other countries suggest that practice nurses can achieve good health outcomes, but there is little information about the Australian practice-nurse workforce, funding models to support their work, scope of their practice, or its outcomes. Australian practice nursing lacks a career structure and an education framework to advance nurses’ skills and knowledge. To maximise the contribution of nurses in primary care, a more systematic approach is needed, with a stronger evidence base for policy to support effective outcomes.
Helen Keleher PhD · Catherine M Joyce BA(Hons), MPsych, PhD · Rhian Parker BScEcon(Hons), MSc, PhD · Leon Piterman MRCP, FRACGP, MAFOM
General Practice Special Interests
The breast physician: an example of specialisation in general practice
General practitioners face the challenge of developing a career path and credentialling pathway for doctors working in special interest areas to ensure safe practice and to develop a professional profile for these groups. Breast physicians are one example. They care for women with benign and malignant breast disease and work in multidisciplinary teams in hospitals, clinics, private practice, and the breast screening program. The training and credentialling of breast physicians has recently been formalised by the Australasian Society of Breast Physicians with the introduction of a training program and fellowship in breast medicine.
Meagan E Brennan FRACGP, FASBP · Andrew J Spillane MD, FRACS
General practitioners and cancer control
Cancer is the leading cause of death among Australians, causing 28% of all deaths. The average general practitioner will only encounter about four new patients each year with a potentially fatal cancer. A GP’s cancer-related workload mostly involves prevention, and dealing with patients with suspicious symptoms or concerns about possible cancer, or who may be at increased risk due to family history or lifestyle factors. GPs cover the full spectrum of cancer care from prevention to palliation, including providing psychosocial support to patients and their families and carers. GPs have a key role in early diagnosis and referral, follow-up and detection of recurrence, and survivorship. There is a developing role for GPs in cancer policy and research.
Brian R McAvoy MD, FRCP, FRACGP
General practice and occupational health
Increasing violence in Australian general practice is a public health issue
Violence is a serious public health issue and the medical profession has a role to play in tackling this issue. Occupational violence is a significant problem in Australian general practice. Doctors need training to recognise and manage patients at risk of becoming perpetrators or victims of violent behaviour, both to protect themselves and to reduce violence in the wider community. A national taskforce on violence in medical practice should be established to monitor, evaluate, prevent, and reduce medical workplace violence. A national summit of all medical groups should be held to examine the increasing violence in Australian society as a public health issue. Australia’s medical practitioners are in a strong position to advocate for better mental health, drug and alcohol, and family support services to manage patients at risk of violent behaviour.
Leanne Rowe AM, MB BS, MD, FRACGP · Michael R Kidd MB BS, MD, FRACGP
Clinical update
Treating adults with acute stress disorder and post-traumatic stress disorder in general practice: a clinical update
General practitioners have an important role to play in helping patients after exposure to severe psychological trauma. In the immediate aftermath of trauma, GPs should offer “psychological first aid”, which includes monitoring of the patient’s mental state, providing general emotional support and information, and encouraging the active use of social support networks, and self-care strategies. Drug treatments should be avoided as a preventive intervention after traumatic exposure; they may be used cautiously in cases of extreme distress that persists. Adults with acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) should be provided with trauma-focused cognitive behaviour therapy (CBT). Eye movement desensitisation and reprocessing (EMDR) in addition to in-vivo exposure (confronting avoided situations, people or places in a graded and systematic manner) may also be provided for PTSD. Drug treatments should not normally replace trauma-focused psychological therapy as a first-line treatment for adults with PTSD. If medication is considered for treating PTSD in adults, selective serotonin reuptake inhibitor antidepressants are the first choice. Other new generation antidepressants and older tricyclic antidepressants should be considered as second-line pharmacological options. Monoamine oxidase inhibitors may be considered by mental health specialists for use in people with treatment-resistant symptoms.
David Forbes MClinPsychol, PhD · Mark C Creamer PhD · Andrea J Phelps MPsych · Anne-Laure Couineau MA · John A Cooper MPM · Richard A Bryant PhD · Alexander C McFarlane MD · Grant J Devilly PhD · Lynda R Matthews PhD · Beverley Raphael MD
General practice and medical education
General practice: a leading provider of medical student education in the 21st century?
General practice is well placed to become a major setting for medical student education over the next decade. New models of clinical education are required, to take account of changes in the patient population, disease profile and management strategies. While there has been an increase in general practice-based and other community-based education, there is the potential for further expansion. Evidence for the positive role of general practitioners and general practice in medical education is growing, including the benefits of prevocational training in general practice. If GPs are to assume a major role in community-based education of medical students, there will need to be changes in funding structures and supporting resources, particularly at this time of increasing medical student numbers and workforce shortage and maldistribution.
Jill E Thistlethwaite MB BS, PhD · Michael R Kidd MD, FRACGP · Judith N Hudson MB BS, PhD
The challenges of teaching in a general practice setting
An attractive strategy to meet the increasing need for medical education is teaching in community general practice. General practice will be in a position to meet and sustain this need only if various conditions are met, including: Teaching is undertaken in general practice at all levels of medical education (medical student, postgraduate years 1–3 and GP vocational training); Standards and quality of teaching are maintained while the number of sites involved increases; Further Australian research is conducted into innovative models of general practice teaching and their cost-effectiveness; and Appropriate remuneration and infrastructure is available to support practices and general practitioners involved in teaching.
Rod Pearce MB BS, FAMA · Caroline O Laurence BA(Hons), MHSM · Linda E Black BA(Psych), DipApplPsych, MAPS · Nigel Stocks MD, FRACGP, FAFPHM
Vertical Integration in Teaching And Learning (VITAL): an approach to medical education in general practice
There is increasing demand to provide clinical and teaching experiences in the general practice setting. Vertical integration in teaching and learning, whereby teaching and learning roles are shared across all learner stages, has the potential to decrease time demands and stress on general practitioners, to provide teaching skills and experience to GP registrars, and to improve the learning experience for medical students, and may also help meet the increased demand for teaching in general practice. We consider potential advantages and barriers to vertical integration of teaching in general practice, and provide results of focus group discussions with general practice principals and registrars about vertical integration. We recommend further research into the feasibility of using vertical integration to enhance the capacity to teach medical students in general practice.
Marie-Louise B Dick MPH, FRACGP · David B King FRACGP, MPH · Geoffrey K Mitchell FRACGP, FAChPM, PhD · Glynn D Kelly FACPsychMed, FRACGP, GradCertHigherEd · John F Buckley FRACGP, DipRACOG · Susan J Garside BEd(Hons), GradCertEd
Obituary
Norma Clyde (“Babette”) Stephens MB BS
Babette Stephens was the adored daughter of Clyde and Norma Yeomans. Born in Adelaide on 9 October 1922, Babette and her family moved to New Zealand in 1926 and lived there until 1935. She returned to Sydney to complete her schooling at Ascham School and commenced her undergraduate medical course in 1941 at the University of Sydney. Graduating in 1946 with first class honours, Babette won the Dagmar Berne Prize for proficiency among women graduates. She was also awarded the Norton Manning Memorial Prize for psychiatry. Babette married Dick Stephens in 1945 and began her residency at the Royal Prince Alfred Hospital in the following year. In 1948, the Stephens family moved to Newcastle for 2 years before returning to Sydney, where Babette worked with Dick’s father in general practice in Vaucluse. In 1951, the family moved to Northbridge, where Babette and Dick practised until her retirement in 1987. In addition to her role as a general practitioner, Babette frequently assisted patients by helping them with meals and laundry within their own homes. She provided a shining example to fellow GPs and specialist colleagues of exceptional dedication to patient care. Her own practice provided a 24-hour service with assistance from her husband Dick, who also practised as an anaesthetist. Babette’s contribution to society included a remarkably dedicated involvement with the Women’s Medical Society of New South Wales from the early 1960s, including Presidency of the Society in 1967. She was Medical Convenor of the National Council for Women and a member of the Ascham School Company, as well as a member of the Council of the Medical Benevolent Association from 1982. She remained a Member of this Council until her recent death. Her extraordinary contribution is recalled by fellow councillors, David Pope and Mary Doherty, who confirmed Babette’s regular attendance at every meeting and her generous contribution to annual general meetings — her asparagus rolls were particularly appreciated! Until the time of her death, she remained an invaluable member of this charitable organisation, which contributes so significantly to assisting doctors and their families. Babette died on 4 March 2007 of metastatic cancer. She is survived by her husband and their children Allan, Rosemary and Tony.
John D Yeo
Book reviews
Better care for respiratory infections
There’s a lot of it about: acute respiratory infections in primary care Graham Worrall. Oxford: Radcliffe Publishing, 2006 (136 pp). ISBN 1 84619 084 3. Although there appears to have been a decline in attendance to general practitioners in Australia for acute respiratory infections (ARIs), they still account for close to 10% of the GP’s workload. The evidence base for their management has never been better defined and yet, given recent research and prescribing patterns, many GPs either find it difficult to, or do not, apply this evidence in practice. Worrall does not waste any time on trying to distinguish between upper and lower respiratory tract infections but discusses each condition in a separate chapter, starting with “The common cold” and ending with “Bronchiolitis”. Each chapter is a concise summary of the available literature and, despite now being an academic in Canada after many years as a GP in the United Kingdom, he limits the number of references he uses. However, as succinct as he may be in conveying the evidence in the text, it will be the summary boxes “Epidemiology and aetiology”, “Clinical course and diagnosis” and “Treatment” that many readers will be drawn to. This is a pity because a real understanding of the topic can only be drawn from the studies themselves and a discussion of their strengths and weaknesses; something the author does very well. The chapter on croup demonstrates this; summary boxes provide simple treatment details, but the text highlights the need for primary care-based randomised controlled trials to determine the best form of management for mild and moderate croup in the community. The final three chapters highlight the importance of clinical assessment and the lack of decision rules for the majority of ARIs, the relentless battle between bacteria and antibiotics and the potential role inappropriate prescribing of antibiotics in the community has had on emerging bacterial resistance, and finally, evidence-based strategies that GPs can use to change their own and their patients’ behaviour for the better (eg, delayed prescribing to reduce antibiotic use being one of the simplest and best). This textbook offers established GPs an opportunity to revisit and improve their current management of ARIs, and general practice registrars a chance to get it right from the start.
Nigel P Stocks
Psychiatry in practice
General practice psychiatry Grant Blashki, Fiona Judd, Leon Piterman, editors. Sydney: McGraw-Hill, 2006 (xii + 388 pp). ISBN 007471351 5. Who might have anticipated that a book dealing with psychiatry in general practice has, as its second chapter, “GP self-care”? Or that the first third of the text includes chapters on cross-cultural and Indigenous issues, consumers’ and carers’ views of general practice psychiatry, and mental health and the law, among others? What I like about this book is that it challenges conventional priorities and paradigms and offers new, unforeseen material, while retaining obligatory examination of the various psychiatric illnesses — depression, anxiety, substance misuse, psychoses, and others — encountered in general practice. The need for general practitioners to be skilled in the assessment and management of mental health problems is unarguable. Among other reasons, these problems are very common in the community (and far too common to be seen exclusively by mental health professionals), and many sufferers choose to seek help from a GP, certainly in the first instance. In this book’s pages, the reader will find much practical advice: there is information about assessment techniques, useful rating scales, psychological treatments and pharmacotherapy (in some detail), and strategies for difficult behaviours (eg, for the persistently angry patient or for when a staff member is a target of anger). The style is engaging, with regular use of case studies (often revisited later in a chapter), “key facts”, other lists (oddly, referred to as figures) and tables. The editors and assembled authors have a strong reputation in this field. It is noteworthy that each chapter was co-developed by a GP, so the utility for general practice was always in the contributors’ minds. General practice psychiatry is an ambitious book — at once attempting to be thought-provoking and to provide the “good oil” — but the editors and authors appear to have pulled it off. It is very good value for money.
Garry J Walter
Every illness is a story
What seems to be the trouble? Stories in illness and healthcare Trisha Greenhalgh. Oxford: Radcliffe Publishing, 2006 (viii + 112 pp). ISBN 1 84619 122 X. In What seems to be the trouble? Trisha Greenhalgh, Professor of Primary Care at University College London, takes a narrative approach to narrative. A story, she says, can explain an illness, help to diagnose an illness, illuminate the dark corners of a complex illness and generate new meaning, or help to shape an illness. Her book is not just about individuals. There are stories about systems, too. A chapter on “Stories and organisations” begins with a comment in a hospital visitors’ book. After describing the delays in treatment for his dying father, the writer said, “I am shocked and amazed that you consider the management of my father’s case and the administration of his treatment to be of a good standard”. In the same chapter, a consultant obstetrician tells the story of a teenage girl who froze to death in the grounds of a hospital after being discharged late in the afternoon, following a miscarriage, “Apparently no one — or at least no one on duty at the time — had known that this unfortunate young woman did not have a home to go back to”. The obstetrician was one of a group of health professionals who were opposing an attempt by the National Institute for Clinical Excellence to delete such stories and adopt a more evidence-based approach in their report writing. Facts and figures, the group agreed, are not enough — stories have emotional traction, and emotions drive change. A chapter on “Stories and research” provides a small dose of narrative theory and some narrative research methods. It’s a bit unnerving to see J K Rowling (author of the Harry Potter childrens’ books) on the same page as Martha Nussbaum (the American philosopher), or to skip from Aristotle to Derrida and Foucault in a book of fewer than 100 pages, but the author has the deft touch of a skilled raconteur. In these and the other chapters on illness, healing, learning and ethics, medical readers will gain practical insights and a better understanding of the narrative approach.
J Jill Gordon
Menopause — it’s not just hormones
Is it me or my hormones? Understanding midlife change. 2nd ed. Margaret Smith, Patricia Michalka. Sydney: Finch Publishing, 2006 (278 pp). ISBN 187645174 2. We’ve all seen them in our practices: anxious women, bewildered or even frightened by the signs of the menopause transition. Perhaps they’re carrying the burden of family folklore; perhaps they’ve somehow managed to insulate themselves — even through pregnancy and childbirth — from a proper understanding of their own bodies; perhaps they’re shocked by these intimations of mortality. Hot flushes, night sweats and mood swings may have taken them by surprise. The loss of sexual desire or the experience of discomfort during intercourse may be evoking confused responses, ranging from self-doubt (“Am I still an attractive woman?”), to worry about the state of the relationship with their partner. For some women, patient listening and an assessment of their physical state (including, in appropriate cases, hormone therapy) may provide all the reassurance they need. For others, though, something more comprehensive is called for. For women who need detailed information — physical, emotional, sexual, social and even spiritual — about the menopause transition, this book is a godsend. Margaret Smith, a gynaecologist specialising in the menopause, and Patricia Michalka, a psychotherapist, have distilled their combined wisdom into a book that addresses one of the most fundamental questions raised by menopausal women: “Is it me or my hormones?” In a genuinely holistic approach, the authors explore the many symptoms and issues that sometimes confuse menopausal women to the point of despair. The case-study approach is handled warmly and with compassion: worried women will find it easy to identify with the stories in this book. We all know that the “one size fits all” approach flies in the face of common sense and our experience of the uniqueness of each patient’s situation. Is it me or my hormones? emphasises the need to take an individual approach, and to recognise that symptoms are rarely a sign of only one thing.
Sheila O’Neill
Australians deserve better than this
Martin B Van Der Weyden
In This Issue
Ann Gregory
Human embryonic stem cells leap the barrier
David G Penington AC · Graham F Mitchell AO
How should stable coronary artery disease be managed in the modern era?
Keith V Woollard MRCP, FRACP · Mark A J Newman DS, FRACS
Centralising the blame game
Martin B Van Der Weyden
In This Issue
Ruth Armstrong
Methicillin-resistant Staphylococcus aureus in hospitals: time for a culture change
Peter J Collignon FASM, FRCPA, FRACP · M Lindsay Grayson MD, FRACP, FAFPHM · Paul D R Johnson MB BS, PhD, FRACP
Towards the appropriate use of diagnostic imaging
Richard M Mendelson MRCP, FRCR, FRANZCR · Conor P J Murray MB BS, DCH, FRANZCR