Issues
Volume 189 Issue 2
Editorials
General practice in 2008: a time of metamorphosis
Australia’s GPs are meeting the challenges of change, while maintaining some constancies A few short years ago, the death of general practice as we knew it was reported.1 However, as suggested by our cover image of the mythical phoenix (Box), with its reference to Ovid’s poem Metamorphoses — “what is called birth is change from what we were, and death the shape of being left behind” — there is another explanation. This perceived “death” may, in fact, have been the preface to a significant cycle of change now manifesting in general practice in many countries around the world, including Australia. These changes, reflected in the articles in this general practice theme issue of the Journal, are many. They include already evolving pandemics of chronic illnesses, including cancer (see Weller and Harris, "Cancer care: what role for the general practitioner?"; Jiwa et al, "Timely cancer diagnosis and management as a chronic condition: opportunities for primary care"), accompanied by the increasing realisation that patients with chronic illness often have multiple morbidities (see Knox et al, "Estimating prevalence of common chronic morbidities in Australia"; Britt et al, "Prevalence and patterns of multimorbidity in Australia"). Parallel with changes in the epidemiology of disease, there have also been changes in health care policy and funding, including a wide array of systems for remunerating practices for their services, all of which need to be acknowledged and some of which could do with a degree of rethinking (see Ashworth and Jones, "Pay for performance systems in general practice: experience in the United Kingdom"; Kirby et al, "Sharing or shuffling — realities of chronic disease care in general practice"). Much discussion and debate about the possibilities for further change have followed the election of the Rudd federal Labor government, particularly the proposed introduction of GP Super Clinics2 (see Kidd, "What impact will the change of federal government have on Australian general practice?"). The announcement that a National Primary Health Care Strategy is to be developed, with strong general practice input into the committee formed to steer the process, is a welcome indication of government interest.3 On the other hand, recent budget cuts to general practice programs such as after-hours services and e-health, and changes to the immunisation incentives program, send a contradictory message.4 Undoubtedly, major challenges surround the issues of general practice workforce and changing roles for general practitioners in clinical practice (see Thistlethwaite et al, Addressing general practice workforce shortages: policy options; Willcock, "Getting back into the emergency department: diversifying general practice while relieving emergency medicine workforce shortages"). Interesting and challenging questions are being asked about what sort of clinician might be best equipped to provide health care for patients with several complex, chronic illnesses. In a world of increasing specialisation and subspecialisation, including within general practice, it is paradoxical that the role of the generalist will become more important in providing comprehensive, coordinated and accessible care for all (see Gunn et al, "The promise and pitfalls of generalism in achieving the Alma-Ata vision of health for all"). This same need underpinned an earlier rebirth of general practice in the 1950s.5 Though much has changed in the world and in general practice, some constancies remain. As highlighted by Professor Trisha Greenhalgh in her keynote address at this year’s General Practice and Primary Health Care Research Conference in Hobart (http://www.phcris.org.au/conference/browse.php?confID=758), people in the community continue to want a knowledgeable, skilled and altruistic family doctor who understands evidence, but who also knows how to apply it with understanding and humanity. We believe this to be an apt description of a typical Australian GP. The phoenix — “and all things change” “The themes of rebirth and renewal of the phoenix legend are universal; the fire can represent illness, death of course, or perhaps another kind of adversity from which, with courage, we might emerge changed by the experience, perhaps stronger.” Dr Kate Hansford, General Practitioner, Hobart, Tasmania. Artworks by other GPs are also featured in this issue.
Ann T Gregory MB BS, GradDipPopHealth · Nicholas A Zwar MPH, PhD, FRACGP
Cancer care: what role for the general practitioner?
General practice is still somewhat adrift in the complex world of cancer services General practice has not traditionally had a central role in cancer care. Typically, general practitioners have had the task of identifying and referring patients to specialists in a timely manner, but have stayed on the periphery of cancer care until patients reach the palliative stage. But the climate is changing — driven partly by the growing burden of cancer and the need to expand and diversify the workforce. The prevalence of cancer has increased substantially in Western countries,1,2 largely due to the ageing of the population: in Australia, by the age of 75 years, the risk of cancer is 1 in 3 in men and 1 in 4 in women.1 There is now an explicit recognition that GPs should be involved in all stages of the cancer journey, from first presentation to palliative care, and that service reforms must incorporate more significant roles for primary care.3 This has found its way into policy and practice in the United Kingdom and Australia, where service guidance emphasises integration of services and urges all those involved in delivering cancer services to better connect the various stages of the cancer journey and to provide care that is accessible and convenient — all predicated upon significant primary care input.4,5 Management of cancer is complex. It requires specialised skills and knowledge, access to sophisticated diagnostic and treatment facilities, and often long-term management of symptoms and recurrences. Despite this complexity, when cancer patients are asked about how their care could be improved, their requests are often simple: they want to know who is in charge of their overall care, they want ready access to care that is convenient and non-threatening, and they want reassurance that they will have access to specialised services if needed.6 A diagnosis of cancer has a profound psychosocial impact, and those who care for cancer patients need to address a range of complex and often rapidly changing needs. Ideally, cancer care should be provided by teams, supported by a network of services. The concepts of multidisciplinary teams and managed clinical cancer networks have been widely advocated,7 but the place of primary care within these teams has remained poorly defined and highly variable.8 This variability is demonstrated by urban–rural differences: in Australia, rural GPs tend to play a more active role in treating cancer patients than their urban counterparts. General practice is still somewhat adrift in the complex world of cancer services. In this issue of the Journal, Jiwa and colleagues describe the many challenges faced by general practice in providing cancer care that is truly integrated with other parts of the health care sector.9 They emphasise that integrated care is required at all stages of the cancer journey. Just as cancer screening should link public health and clinical perspectives, post-diagnosis treatment needs a range of health care providers, including GPs, to be part of the team effort. Effective communication between specialist and primary care services is an essential component of this integration. There is growing emphasis on the concept of survivorship in cancer patients — rightly so, as cancer has taken on the characteristics of other chronic illnesses such as diabetes and coronary heart disease. Increasing numbers of patients have very prolonged periods of survival after cancer diagnosis, and die with their illness rather than of it. Survivorship is a very positive concept, and general practice, with its capacity for multidimensional care, is well placed to play a leading role in improving services for people living with cancer, providing follow-up that addresses patient priorities, and developing more personalised care for cancer survivors.10 This typically involves “survivorship care plans”, which include a range of tools for health care providers and users. It features heavily in the UK’s Cancer Reform Strategy.5 A challenge for primary care is to recognise its unrealised potential for promoting survivorship and to develop new models of care that allow it to do so.11 Primary care must be able to respond to rapidly changing health care needs of cancer patients in an appropriate and flexible manner. If we are to develop and test new models with enhanced roles for primary care, we need to better define and understand current patterns of care. Do GPs and primary care teams provide the kinds of services that cancer patients need? How well do they detect and manage recurrence of disease and toxicity from treatments? Do they provide the kinds of psychosocial support cancer patients need, and do they help or hinder truly integrated care? How well do they address issues of patient choice, and how good are they at providing education and support? The experiences and needs of cancer patients and their carers vary tremendously. We have perhaps been slow, in general practice, to respond to the needs expressed by our cancer patients. But if we take time to listen to our patients, from the time of diagnosis to death and bereavement, many ideas emerge about how the services we provide could be improved. Cancer patients have a range of illness and social trajectories, their patterns of wellbeing fluctuate, and they often perceive a lack of integration in the services they receive.12 GPs also need to maximise their contribution to primary prevention of cancer, especially in relation to smoking cessation and lifestyle risk factor management — despite the challenges of time constraints, practice systems and patients’ reluctance to change.13-15 To meet the challenges of the future and to adapt to changing health service environments, general practice must be prepared to evolve.16 A better understanding of the role of primary care in cancer management is vital if we are to improve outcomes and quality of life in our cancer patients.3,17 We need to know how primary care can contribute to new models of care. At present, there is little evidence on which to base service design and innovation. We need to develop new, genuinely integrated models of care that address important priorities for cancer patients, such as the availability of care close to home, timely management of symptoms, early detection of recurrences, and comprehensive psychosocial support. Until we have done so, GPs will remain at the periphery of cancer management, and there will be ongoing confusion over how we can make our most effective contribution.
David P Weller FRACGP, FAFPHM, PhD · Mark F Harris FRACGP, MD
Pay for performance systems in general practice: experience in the United Kingdom
P4P has raised the quality of primary care in the UK, but broader performance indicators are needed to accurately reflect the scope of general practice Pay for performance, or “P4P” as it is often known, is now centre-stage in primary care in the United Kingdom. P4P promotes change in clinical behaviour by offering financial rewards in return for achieving certain predefined targets. Both sides of the P4P “equation” are currently the subject of much debate: how generous should the financial reward be (the first “P”); and which performance indicators (the second “P”) should be used as the basis for calculating eligibility for the reward? From the foundation of the UK National Health Service (NHS) in 1948, general practitioners derived their income largely from capitation. Income was related more to the quantity than the quality of care. In 1990, and against much resistance from within the profession, the first performance targets were introduced into primary care. There were just two: rates of cervical smears and childhood vaccines. All this changed in 2004, when GPs accepted a new contract that radically promoted the role of P4P. This new contract tied about 25% of GP income to the achievement of a panoply of performance indicators. Large financial rewards were within reach for GPs able to achieve targets set for 147 performance indicators (subsequently revised to 135 indicators in 2006 and further revised to 128 in 2008). Details of the original 147 performance indicators and the mechanism for tying them to financial rewards have been well documented.1 The overall structure is known as the “Quality and Outcomes Framework” (QOF). In essence, the indicators are a mix of clinical indicators covering the management of 10 long-term conditions (eg, diabetes, coronary heart disease, hypothyroidism) and a series of indicators covering managerial, organisational, educational, prescribing and “patient experience” aspects (eg, undertaking an approved patient survey each year) of primary care. The clinical indicators are a mix of process indicators (such as creating a disease register or conducting a specific investigation), intermediate, or proxy, outcome measures (such as reduced cholesterol levels), and true outcome measures (such as improved epilepsy control). Achievement of an indicator is converted into “quality points”, which are weighted according to the perceived workload required to attain the target set for each indicator. Each quality point attracts a fee — currently set at £126 (A$260) for the average-sized general practice (5891 patients) — and the maximum attainable score is currently 1000 points. Since 2004, the components of the QOF have been revised twice. New indicators for an additional nine long-term conditions (eg, chronic kidney disease) were added in 2006, and in its latest 2008 incarnation, there are 80 clinical and 48 non-clinical indicators. What have been the positive consequences of P4P in UK primary care? The introduction of the QOF has demonstrated that GPs in the UK have achieved far higher quality standards than expected — at least, as budgeted for by government pay negotiators. In 2007, 5% of practices achieved the highest possible score, and the mean achievement of all practices in England was 95.5% of the available points.2 Such a demonstration of success has the potential to both affirm professional pride and to provide some evidence to the general public to justify the additional taxation that has been required to fund P4P. As with most systems of P4P, there is evidence that rewarded activity has increased. Substantial increases have been documented in some of the intermediate outcomes, such as blood pressure, cholesterol and glycosylated haemoglobin control, and also in the proportions of heart attack and stroke patients treated with aspirin.2 The overall rise in standards has been accompanied by a narrowing of the health inequality gap (as measured by the QOF) between least- and most-deprived neighbourhoods. Taken together, these achievements should translate into substantial national public health gains. What have been the unintended consequences of P4P in UK primary care? The success of P4P has been challenged from several perspectives. First, in the case of several QOF indicators, the achievement gains pre-dated the introduction of the QOF and, since then, the improvement rate has continued at a similar pace. For example, evidence has accumulated that overall cholesterol control was improving long before 2004.4 Second, high achievement may be interpreted as targets that were too easy to attain. For example, maximum QOF points are awarded for achieving target blood pressure control in just 60% of patients with diabetes, and the target blood pressure was set at 145/85 mmHg, which is above the value given in most guidelines. Third, GPs may indulge in “gaming” to boost their tally of QOF points — either by under-counting the number of patients on each disease register (only including those for whom target achievement is more readily accomplished) or by using the process of “exception reporting”, whereby GPs can decide whether it is “unsuitable” for a patient to be considered for a given clinical target on grounds such as “maximum tolerated therapy”, extreme frailty, or not responding to three letters inviting them to an appointment.5 More fundamentally, P4P has divided GPs on issues of professionalism. For some GPs, the electronic QOF prompts that accompany a consultation with a patient act as useful reminders and allow the GP to give more thought to deeper issues during the consultation. For others, these prompts represent the intrusion of a reductionist, points-driven approach to patient care that undermines professional autonomy.6 Furthermore, it is readily apparent that measures of patient satisfaction, patient enablement, listening skills, continuity of care, and many of the aspects of general practice that give GPs their greatest professional satisfaction lie outside the scope of any of the performance indicators. There are no measures of the psychosocial problems so common in primary care, nor of many medical conditions (such as any of the chronic gastrointestinal diseases). Indeed, even the advocates of the QOF would concede that probably only a quarter of all registered patients have any of the conditions for which QOF points are available. It is thus clear that P4P in its current form only rewards a small proportion of the overall work of a GP. Finally, the QOF has proven costly. Should such a large proportion of GP income be determined by these indicators, many of which lack a robust evidence base? Since its introduction, a vigorous debate has continued on balancing the “pay” component of P4P with the “performance” component. The higher than expected performance resulted in higher than expected costs, which contributed to NHS overspending in the early years of the new contract (although spending has now been reined in). What are the lessons for Australia? In the UK, the QOF was introduced as a “big bang” solution, without prior piloting. From our perspective as UK-based researchers and practising GPs, we think that perhaps the single greatest lesson from this experience is that piloting might have avoided many of the unintended consequences of P4P in primary care. Although P4P focuses attention on the quality of care, the definition of quality should be multifaceted and derived from evidence-based guidelines and the collective views of GPs, public health specialists and, importantly, patients. Performance indicators undoubtedly need to change over time, either because the evidence base has changed or because the original indicator has become redundant, and a transparent and robust system needs to be devised for regular updating of indicators and targets. An evolving QOF can act as a means to translate research evidence into practice. Simply put, the QOF has the capacity to “cut the implementation corner”. Although contentious, P4P represents a bold attempt to redefine the quality standards of primary care, such that best-practice targets quickly become the norm, expected by patients, health service planners and doctors alike. Beyond this, the next challenge is how P4P can evolve into rewarding a broader, more pluralist definition of quality and not merely the narrow focus of those things that are easy to measure.
Mark Ashworth DM, MRCP, MRCGP · Roger H Jones DM, FRCP, FRCGP
Promises to Policy
What impact will the change of federal government have on Australian general practice?
The new government is working hard to keep its promises, but it is too early to tell what long-term impact its new programs will have on health care delivered through general practice On 24 November 2007, the people of Australia elected a new Labor government. In the lead-up to the election, the Labor Party made many health care commitments. Here, I summarise and comment on the new government’s strategies and policies that can be expected to have an impact on general practice. What was promised, what has happened since the election, and what are we still waiting for? National Primary Health Care StrategyOn 17 November 2007, the then Shadow Health Minister, Nicola Roxon, advised that a Rudd Labor government would develop a National Primary Health Care Strategy. Primary care — like GPs [general practitioners] and allied health professionals — is crucial to keeping people healthy and out of hospital. The best way to equip our health system to deal with the challenges of the future is to boost primary care services.1 A promise of long-term planning was made through the development of a “long term strategy for delivering this care into the future”. Elements of the strategy would include: Examining providing incentives for GPs to practise quality preventative health care, including through longer consultations and evidence-based management of chronic disease; An increased focus on multi-disciplinary care from primary care teams; A review of the Medicare Schedule in an effort to alleviate the crippling red tape burden on GPs; $220 million investment in GP Super Clinics, which will be driven by local health professionals, and build upon the great work they are already doing in local communities; [and] Reforming the Rural Medical Infrastructure Fund to ensure funding gets to the communities that need it. The federal 2008–09 Budget papers state that a reference group of stakeholders and experts will be convened to develop the National Primary Health Care Strategy.2 Comment: While such a strategy is welcome, it needs a much wider scope. There is an urgent need to reduce the pressures on the nation’s general practice workforce and increase the number of GP registrars in training, while at the same time increasing the capacity of Australian general practice to train an increasing number of medical students, registrars and practice nurses. Further, the government has made few announcements to date about future roles for Australia’s network of Divisions of General Practice. The need for a more coherent approach to policy and service delivery was a major focus in the discussions of the health stream at the Australia 2020 Summit, held on 19–20 April 2008, which declared an ambition to have “one health system” with “single governance, management and funding” by 2020.3 GP Super ClinicsOn 26 August 2007, the Labor Party released a policy entitled New directions for Australia’s health — delivering GP Super Clinics to local communities.4 This promised to: provide infrastructure funding to establish a greater range of convenient and quality services in local communities — particularly in rural and regional areas and where Medicare has not been utilised to its fullest because of workforce shortages. Implementation of the GP Super Clinics Program is underway — GP Super Clinics have been announced for 31 localities across Australia,5 and “different processes” are being used to select the organisation that will “construct/refurbish and operate” each clinic. Comment: Any initiative to provide new centres of excellence in primary care service delivery and multidisciplinary health professional education and training in areas of need should be welcomed, but this funding only supports 31 such centres. An independent evaluation could be beneficial to determine whether the proposed GP Super Clinics are being planned for the 31 localities of greatest primary care need in Australia, to ensure the plans have the support of the local community and local GPs, and to ensure that there is no unnecessary duplication of existing services. Every primary care clinic in Australia needs the capacity to work within a framework that is relevant, timely and sustainable.6 Preventive health strategyOn 21 February 2007, the then Shadow Health Minister called “for consideration of a national preventative health taskforce ... to evaluate and make recommendations to Government on the basis of the safety, effectiveness and cost-effectiveness of prevention programs”.7 A focus on preventive health continued throughout Labor’s election campaign, including a commitment to an additional $15 million over 3 years for the National Tobacco Strategy.8 On 9 April 2008, the government announced the establishment of the National Preventative Health Taskforce, chaired by a Fellow of the Royal Australian College of General Practitioners. The taskforce, made up of health experts from around Australia, will develop strategies to tackle the health challenges caused by tobacco, alcohol and obesity, and develop a National Preventative Health Strategy by June 2009. The Government also announced that it would take immediate action to ensure preventive health measures become a key part of health funding agreements between the Commonwealth and state and territory governments.9 Prevention also received strong support from the members of the health stream at the Australia 2020 Summit.3 Comment: It remains unclear how the taskforce and the national strategy will involve general practice, in its long established role as a major site for providing preventive health care10 and health promotion advice.11 Given its seemingly strong commitment to prevention, it was surprising that the government announced reduced funding of general practice immunisation incentives in the federal 2008–09 Budget.2 National Health and Hospitals Reform CommissionOn 23 August 2007, the Labor Party made a promise to “establish a $2 billion National Health Reform Plan over four years to improve Australia’s health system and ensure better health services for patients in hospitals”.12 The plan would include: $2 billion in investments to deliver improved health outcomes for patients in Australia’s health care and hospital system [and a] commitment that a Rudd Labor Government [would] seek to take financial control of Australia’s 750 public hospitals if State and Territory Governments have not begun implementing an agreed National Health Reform Plan by mid-2009. [Further,] within the first 100 days of the election, a Rudd Labor Government — through COAG [Council of Australian Governments] — [would] establish a National Health and Hospitals Reform Commission to develop Federal Labor’s National Health Reform Plan.12 On 28 February 2008, federal Cabinet approved the establishment of the National Health and Hospitals Reform Commission.13 The Commission released its initial report, Beyond the blame game: accountability and performance benchmarks for the next Australian Health Care Agreements, on 8 May 2008, outlining 12 health care challenges and a series of proposed performance benchmarks.14 Comment: General practice perspectives are well represented on the National Health and Hospitals Reform Commission. With Labor in government not only nationally but also in each state and territory, there is an unparalleled opportunity to redress barriers and cost-shifting in our health care system that impact on health care delivery, access and equity. From a primary care perspective, the initial set of proposed benchmarks appear limited, but the Commission is welcoming comment and is engaging in an extensive process of consultation with the community and stakeholders. Aboriginal and Torres Strait Islander healthOn 13 February 2008, the Prime Minister, Kevin Rudd, apologised to the Stolen Generations. In his speech to federal parliament, he said: Let us resolve to ... provide proper primary and preventive health care for [Indigenous] children, to begin the task of rolling back the obscenity that we find today in infant mortality rates in remote Indigenous communities — up to four times higher than in other communities.15 This followed the commitment he made on 26 November 2007 to offering such an apology early in the new government’s term.16 Since the election, the Prime Minister has set a goal to halve the gap in infant mortality rates between Indigenous and non-Indigenous children within a decade, and to close the 17-year gap in life expectancy between Indigenous and non-Indigenous Australians within a generation,17 as well as making a commitment to provide an annual progress statement on closing the life-expectancy gap.18 As part of an earlier commitment “to improving Indigenous health, including through [a] $260 million Indigenous early childhood package”,19 an announcement was made on 23 April 2008 that the government would provide more health services for Indigenous families through funding to expand child and maternal health services and to boost primary health care service delivery in areas where health services are lacking.20 An announcement was made in the federal 2008–09 Budget of some funding increases for Indigenous health.2 Comment: Real action is now needed in Indigenous health, but what that action will be and what roles general practice will take are yet to be developed. As one solution, the health stream at the Australia 2020 Summit called for the establishment of a Health Equalities Commission for all Australians, with a focus on Indigenous health and other disadvantaged communities.3 Health care in rural AustraliaOn 12 September 2007, the Labor Party made a commitment to reform the Rural Medical Infrastructure Fund, to improve health infrastructure in rural communities.21 A further list of promises followed on 17 November 2007, including that “GP Super Clinics will be established in areas where there is under-utilisation of Medicare funded services, which will particularly include rural areas” and that the “National Health and Hospitals Reform Commission will be asked to explicitly identify a long-term plan for improving rural health services”.19 A promised audit of Australia’s rural and regional health workforce was released on 30 April 2008.22 Comment: Equity of access to health care services and equity of health care outcomes should be available to all people in Australia, regardless of where they live. Each of the reforms announced by the new government needs to have a specific focus on its impact on people living in rural and remote Australia. Dental healthOn 18 September 2007, the Labor Party made a promise to fund up to one million additional dental consultations for Australians needing dental treatment, by establishing a $290 million Commonwealth Dental Health Program.23 The Rudd government’s First 100 days report advised that negotiations had commenced with state and territory governments on the plan’s implementation.17 In a further development, the government announced on 2 March 2008 that it would “invest up to $360 million over three years in a Teen Dental Plan to make it more affordable for families to keep their kid’s teeth in good health”, and that this plan, assisting a million young Australians, would become operational on 1 July 2008.24 Comment: General practice organisations have long advocated for improvements in access to dental health services, especially for people on low incomes. Healthy Kids CheckOn 10 April 2007, the Labor Party made a commitment to develop a Healthy Kids Check, which would include an assessment of each child’s basic health such as teeth, hearing, balance and sight.25 This check would “ensure all children starting school receive a health and early skills assessment so they get off to the best start in life”. Comment: In the federal 2008–09 Budget, it was announced that new Medicare items would be developed to allow a “GP or a practice nurse [to assess] health indicators such as height, weight, eyesight and hearing”, and that this item would be claimable at the same time as the immunisation for 4-year-old children.2 Climate changeOn 30 May 2007, Kevin Rudd, then Leader of the Opposition, outlined Labor’s Framework for Climate Change. “We must immediately ratify the Kyoto Protocol to show we are serious and want to help forge a global solution”, he said.26 True to this commitment, the first official act of the new government was the ratification of the Kyoto Protocol on 3 December 2007.17 Comment: Global warming remains a concern for many Australian GPs, who have an important role in preparing for and responding to climate change-related threats to human health.27 In the words of one GP, responding to a conference presentation about health care reforms and innovations in general practice: “The rest of this is all very interesting, but if we don’t do something about climate change, it may all be irrelevant”. General practice is at the core of many of the health initiatives of the new government, and GPs need to be engaged in these developments, both as individuals having the opportunity to comment on each program, and through the viewpoints and advocacy of representative organisations. One of the national health initiatives currently under development that was not promised by the Labor Party is the new National E-Health Strategy, which is being developed through the Department of Human Services in Victoria on behalf of the Australian federal, state and territory health departments. E-health will be a crucial component of many of the government’s new health care initiatives. The new Australian Government is working hard to keep its pre-election health promises (see summary in the Box), and many of the programs announced have the potential to improve aspects of primary care. However, it is a shame that the National Primary Health Care Strategy is being developed after several of the initiatives that should be its core components have already been announced. General practice is accustomed to having to respond to piecemeal strategies from government, but it would be better if these programs were integrated in a way that supports the whole system in the delivery of high-quality primary care. Perhaps this is the intent of the new government, but it is too early to determine the likely long-term impact of these programs on the health care delivered to the people of Australia through general practice. Summary of the Rudd government’s health promises and actions to date Date Promise Action taken 21 Feb 2007 National Preventative Health Strategy Taskforce established 9 Apr 2008 30 Mar 2007 Ratify the Kyoto Protocol Protocol ratified 3 Dec 2007 10 Apr 2007 Healthy Kids Check Announced in Budget 13 May 2008 23 Aug 2007 National Health Reform Plan Commission established 28 Feb 2008 26 Aug 2007 GP Super Clinics Under development 18 Sep 2007 Commonwealth Dental Health Program Under development 17 Nov 2007 National Primary Health Care Strategy Under development 26 Nov 2007 Apology to the Stolen Generations Apology made 13 Feb 2008
Michael R Kidd MD, FRACGP
Chronic disease
Estimating prevalence of common chronic morbidities in Australia
Objectives: To estimate prevalence of selected diagnosed chronic diseases among patients attending general practice, in the general practice patient population, and in the Australian population, and to compare population estimates with those of the National Health Survey (NHS).Design, setting and participants: In late 2005, 305 general practitioners each provided data for about 30 consecutive patients (total, 9156) as part of the BEACH (Bettering the Evaluation And Care of Health) program, a continuous national study of general practice activity. GPs used their knowledge of the patient, patient self-report, and medical records as sources.Main outcome measures: Crude prevalence of each listed condition currently under management among surveyed patients, and adjusted prevalence for the general practice patient population, and the national population.Results: 39.6% of respondents had none of the listed conditions diagnosed; 30.0% had a cardiovascular problem (uncomplicated hypertension, 17.6%; ischaemic heart disease, 9.5%); 24.8% had a psychological problem (depression, 14.2%; anxiety, 10.7%); 22.8% had arthritis, mostly osteoarthritis (20.0%); 10.7% had asthma; and 8.3% had diabetes, mostly type 2 (7.2%). Adjustment to the population attending general practice resulted in lower estimates for cardiovascular disease, arthritis and diabetes but had little effect on prevalence of asthma and psychological problems. After adjusting for non-attenders, about one in five people in the population had a cardiovascular problem, a similar proportion had a psychological problem, 14.8% had arthritis, and about 10% had asthma, hyperlipidaemia and gastro-oesophageal reflux disease. Estimates were similar to NHS results for any arthritis, asthma, and malignant neoplasms; higher for any cardiovascular problem; far higher for specific cardiovascular diseases, cerebrovascular disease and hyperlipidaemia; and almost twice the NHS estimate for psychological problems (particularly depression and anxiety). Estimates for type 1 diabetes aligned with NHS results, but were far higher for “all diabetes” and type 2 diabetes.Conclusions: This study offers an alternative, perhaps more accurate, approach to measurement of disease prevalence than the NHS approach, which relies on respondent self-report alone. It provides valid prevalence estimates with the help of GPs at a fraction of the cost of the NHS. This study could be repeated annually to augment other data sources and better define existing health needs in the population.
Stephanie A Knox BA(Hons), MPH, BSc · Christopher M Harrison BPsych(Hons), MSocHealth · Helena C Britt BA, PhD · Joan V Henderson BAppSc(HIM)(Hons), PhD
Prevalence and patterns of multimorbidity in Australia
Objectives: To estimate the prevalence and patterns of multimorbidity in a sample of patients attending general practice, in the population who attended general practice in 2005, and in the Australian population.Design, setting and participants: Secondary analyses of data from a study of prevalence of selected conditions (a substudy of the BEACH [Bettering the Evaluation And Care of Health] program); data were provided by 305 general practitioners for 9156 patients seen in July–November 2005, based on knowledge of the patient, patient self-report, and medical records. Listed conditions were classified according to the Cumulative Illness Rating Scale morbidity domains.Main outcome measures: Prevalence of morbidity in each domain; prevalence of specific patterns of multimorbidity (defined as presence of morbidity in two or more domains).Results: Prevalence of multimorbidity was estimated as 37.1% of surveyed patients, 29.0% of people who attended a GP in 2005, and 25.5% of the Australian population. Prevalence and complexity (number of domains present) increased with age: 83.2% of surveyed patients aged 75 years or older had multimorbidity, 58.2% had morbidity in three or more domains, and 33.4% in four or more. Prevalence of multimorbidity did not differ between the sexes. The most common morbidity combinations were arthritis/chronic back pain + vascular disease (15.0% of sample), a psychological problem + vascular disease (10.6%) and arthritis/chronic back pain + a psychological problem (10.6%). We estimate that 10.6% of people attending a GP in 2005 and 9.3% of the population have arthritis/chronic back pain + vascular disease (± other morbidity types studied), and this group accounted for about 15.2 million Medicare-claimed general practice encounters in 2005.Conclusions: This study provides the first insight into prevalence and patterns of multimorbidity in Australia. Knowledge of the common combinations of multimorbidity may help in planning the health services needed in the future by an ageing population with an increasing burden of multimorbidity.
Helena C Britt BA, PhD · Christopher M Harrison BPsych(Hons), MSocHealth · Graeme C Miller PhD, FRACGP · Stephanie A Knox BA(Hons), MPH, BSc
Sharing or shuffling — realities of chronic disease care in general practice
To the Editor: We conducted a qualitative study to explore the perspectives of general practitioners and allied and other health professionals on their interactions in the care of patients with chronic disease, especially where Team Care Arrangements (TCAs) are involved. We interviewed 16 clinicians from urban and rural New South Wales who were involved in the care of patients with type 2 diabetes, ischaemic heart disease and hypertension — four GPs, two practice nurses, two medical specialists and eight allied health clinicians. Interviews took place from late 2006 to early 2007. While all those interviewed felt that a coordinated approach provided optimal management of chronic disease, this did not always seem to translate into smooth working relationships. Allied health clinicians and medical specialists described two types of attitudes of GPs to team care. They perceived some GPs as accepting of the involvement of others in patient care, leading to mutually respectful and highly satisfying working relationships. However, they felt other GPs did not value the opinions of allied health professionals and referred patients to them to fulfil a process (either for TCAs or at the patient’s request), or saw them as competitors. As one urban allied health clinician said, “I think they’ve got to realise that we’re not there to compete, we are there to assist”. TCAs provide financial incentives for GPs to coordinate care.1 We have previously reported that multidisciplinary care plans are associated with improved attendance at allied health services and improved metabolic control for patients with diabetes.2 However, in the present study some respondents felt that TCAs were little more than “paper shuffling” — predominantly a mechanism to attract reimbursement, rather than to facilitate two-way communication. Although TCAs provide an opportunity for communication between health care professionals, they have not overcome all the barriers to communication, especially in cases where an interprofessional relationship based on clear understanding of each other’s roles has not already been established. Our findings suggest that relationship-building and discussions about roles in shared care, including the power differentials between professionals, would improve the functioning of TCAs. Other recent studies have also reported on the lack of effective collaboration between GPs and other health professionals in managing chronic conditions.2,3 Respondents felt that it was uncommon for clinicians to discuss and agree on a plan of care. Optimal management of chronic disease requires a team approach and, consistent with other studies,4,5 we found that all the professional groups interviewed acknowledge the desirability of team care and its potential to improve patient outcomes. With increasing emphasis on team care, it is imperative that policies fund and facilitate a real team approach that is in the best interests of patients — one that places greater emphasis on two-way communication rather than paper shuffling or gatekeeping. This requires working with allied health professionals, medical specialists and GPs to improve communication and trust between clinicians. The Divisions of General Practice must surely be well placed to facilitate this process.
Sue E Kirby · Joyce L Chong · Maureen Frances · Gawaine Powell Davies · David A Perkins · Nicholas A Zwar · Mark F Harris
Timely cancer diagnosis and management as a chronic condition: opportunities for primary care
One in three men and one in four women in Australia will be diagnosed with cancer in the first 75 years of life. The majority will survive the cancer and ultimately die from unrelated causes. Many cancer patients and their families will experience some physical, social, economic and psychological sequelae, regardless of the prognosis. A recurring theme is that patients are disadvantaged by the lack of coordination of care and their needs are not being adequately met. We argue that greater integration of care through a multidisciplinary team of professionals, peer support groups and primary health practitioners functioning within a care hub could offer better practical and psychosocial supportive care for patients and their families.
Moyez Jiwa MD, MRCGP, FRACGP · Christobel M Saunders FRCS, FRACS · Sandra C Thompson FAFPHM, PhD · Lorna K Rosenwax BAppSc(OT), MSc, PhD · Scott Sargant BPharm, MPS · Eric L Khong MB BS, PGradDipPrimHlthCare, FRACGP · Georgia K B Halkett BMedRad(Hons), FIR, PhD · Gloria Sutherland BAppSc, PGradDipHlthEd · Hooi C Ee MB BS, FRACP, PhD · Tanya L Packer BSc(OT), MSc, PhD · Gareth Merriman BAppSc(Psych) MPsych, PhD · Hayley R Arnet BHSc(Pod), PGradDipHlthInform
In Clinical Practice
Information overload: what’s behind it, what’s beyond it?
Literature alert services, good evidence-based resources and real-time decision support can all help to reduce information overload If all disease was caused by the four humours; if our only treatments were blood-letting, purging or cold baths; and if all research was forbidden, medicine would be much easier. But medicine has changed, and is changing, more than most practitioners recognise. While no organisation keeps a precise count of the number of diseases, the expert system DiagnosisPro (http://www.diagnosispro.com) claims to assist with the diagnosis of over 11 000 diseases. Thus, diligent generalists such as general practitioners and physicians who updated their learning on one disease every day would take over 30 years to examine current knowledge just once. But medical knowledge is not static: MEDLINE now adds over 12 000 articles to its database per week, including more than 300 reports of randomised trials. For generalists, and those who help with continuing medical education of generalists, there is a clear need to make good use of what we know and to develop parsimonious strategies to cope with the growth of medical knowledge, with a clear focus on what will improve patient care. So what can the GP do? Addressing our information overload involves balancing two processes: information “pull” (seeking information to answer specific questions) and “push” (receiving information unsolicited).1 Both modes are important. Information “pushed” to us should focus on the clinical conditions we commonly see in practice, and particularly on important new research on those topics. For the GP, this might be the 50 conditions most commonly seen in a month. For example, one study suggested that roughly half of new complaints could be attributed to 36 presenting problems.2 GPs should consciously restrict their paper and electronic browsing to essential literature alerts about new research likely to improve clinical decision making. Several alert services, such as the In other journals section of the Medical Journal of Australia and Journal Watch (http://www.jwatch.org), attempt to alert clinicians to important breakthroughs and new developments. Among the most rigorous processes is that carried out by staff of the journal Evidence-Based Medicine, who hand-search about 60 000 articles from 140 journals annually, including the five highest-rating general medical journals and a variety of other specialty journals.3 Each year, around 3400 of the 60 000 articles (about 1 in 18) pass the basic validity checks (eg, a treatment article requires a randomised trial with at least 80% follow-up, whereas a prognosis study requires an inception cohort). Hence the “number needed to read” to find one valid study is about 18 articles.4 The clinical relevance of valid articles is rated by 4–12 clinicians from various disciplines. Each bimonthly issue of 20 articles is a distillation of roughly 10 000 articles from 140 journals — a 500-fold “noise” reduction. But no matter how well we “browse”, there will still be a long tail of uncommon clinical problems for which we will need to hunt for specific information. Such information “pull” requires reference sources based on good evidence that give us rapid and valid answers to clinical questions, preferably within the time frame of the consultation or ward round. Ideally, these would be readily digestible resources covering all possible clinical topics and giving up-to-date summaries of the best available research. This is a desirable but near impossible task. Two complementary approaches to the problem have been the attempts by the Cochrane Collaboration to synthesise all available randomised trials (and recently other types of study as well) and the efforts of a network of guideline developers to produce best-practice guidance. In the 15 years since the founding of the Collaboration, great strides have been made, but less than half the treatment questions that might require a systematic review have been completed,5 and more trials are added to MEDLINE each day than are incorporated into systematic reviews. While no single resource is likely to solve the problem, several systems, such as TRIP (Turning Research into Practice) (http://www.tripdatabase.com/index.html) and QuickClinical (http://www.chi.unsw.edu.au/CHIweb.nsf/page/QuickClinical), are designed to search several sources simultaneously. But, no matter how well designed a system may be, its value ultimately depends on how frequently it is used. A study of QuickClinical in general practice over a 12-month period6 showed an initial high usage (9–10 searches per GP per month), but this dropped to 1–2 searches per month by the end of the study — a level well below the one question per five patients observed to arise in a recent study of 3500 GP consultations.7 Literature alert services, reference sources based on good evidence, and real-time decision support are all important parts of our personal “solution” to information overload. In workshops run by the Centre for Evidence-Based Medicine in Oxford, United Kingdom, we ask clinicians to audit their current push–pull processes and balance, and to work out the best way to use their precious learning time. Medical curricula, both undergraduate and postgraduate, must recognise that such learning management skills are at least as important as skills in other areas of medical practice.8 Professional development in evidence-based medicine and reflective learning need a clear place in the curriculum alongside skills in physical examination and communication. In addition, the “basic sciences”, such as information management and clinical epidemiology, need a place alongside anatomy and physiology. Furthermore, managing the information flood requires not just basic skills, but also regular practice. As the Red Queen said to Alice: “it takes all the running you can do, to keep in the same place. If you want to get somewhere else, you must run at least twice as fast as that!”9 But keeping up with the flood of information doesn’t mean working twice as hard. It can at least become manageable if we develop information skills, share the work within the team, and have ready access to reference sources based on good evidence. Alice with the Red Queen Illustration by John Tenniel from the 1871 edition of Through the looking glass.9
Paul P Glasziou FRACGP, PhD
The effect of advertising in clinical software on general practitioners’ prescribing behaviour
To the Editor: The observational study by Henderson and colleagues1 is important, as it is the first to look at the effect of advertising in clinical software on prescribing behaviour in Australia. However, the stated conclusion — that “exposure to advertisements in clinical software has little influence on the prescribing behaviour of [general practitioners]” — requires qualification, as there were potentially important confounders including the effects of other forms of pharmaceutical promotion that were not evaluated. Evaluating the effect of a single advertising medium in isolation from concurrent activities (eg, print advertising, pharmaceutical detailing, provision of sample packs) is problematic. Pharmaceutical promotion relies on a range of activities to influence prescribing — multiple activities are synergistic, even if a single strategy shows little or no effect.2 Similarly, from a quality prescribing perspective, numerous studies show that changing prescriber behaviour is most effective when multiple strategies are used.3 There is evidence to suggest that providing information in clinical software at the point of decision making influences prescribing behaviour; for example, prompts are effective in reminding clinicians about preventive interventions such as Pap smears and immunisations.4,5 Since the study was done, another form of promotion by pharmaceutical companies has been introduced in the “advertising software” — “drug support” prompts. These prompts are linked to specific drugs and contain sponsored information from a pharmaceutical company. Users of the software may find it difficult to identify these prompts as a form of advertising, because their format and design are similar to clinical decision support prompts such as drug interaction alerts. Clinical software has become an essential tool, with a potentially powerful influence on prescribing. If promotional messages are to be permitted in clinical software, at the very least they should be clearly labelled as such, so that the user can distinguish them from genuine decision support. Prescribing should be based on the clinician’s sound knowledge of a drug’s indications and its relative benefits and harms, and patient treatment preferences and value for money. Advertising of medicines in any form may not be in the patient’s best interest.
James F Reeve · Judith M Mackson · Michelle Sweidan · Margaret Williamson
Investigation of cardiovascular risk factors in type 2 diabetes in a rural Australian Division of General Practice
Objective: To examine the changes in cardiovascular disease (CVD) risk factors for a cohort of patients with type 2 diabetes in general practice.Design and setting: A 4-year retrospective cohort study using extracted data from an active Division of General Practice diabetes register in Australia.Participants: 628 patients (297 female; 331 male) with type 2 diabetes who participated in the diabetes program of the Southern Highlands Division of General Practice and for whom evaluation data were recorded each year from 2002 to 2005.Main outcome measures: Changes in the following CVD risk factors over time: body mass index (BMI), serum lipid levels (total cholesterol [TC], low-density lipoprotein cholesterol [LDL-C], high-density lipoprotein cholesterol [HDL-C], total triglycerides [TG]), systolic and diastolic blood pressure (BP), and glycated haemoglobin (HbA1c) level.Results: After adjusting for age, sex, duration and clustering, there was significant improvement in serum lipid levels (TC and LDL-C; P < 0.05) over time; and there was no significant change in BP, HbA1c level or BMI. Older patients had significantly worse systolic BP, but significantly better BMI and lipid levels than younger patients. Longer duration of diabetes was associated with worse systolic BP and HbA1c level, but better HDL-C level. People with higher BMI were likely to have worse systolic BP, and HDL-C and HbA1c levels, but better TC level than those with lower BMI.Conclusions: Improving BP, HbA1c level and BMI may be more difficult than improving lipid levels. There is a need for more intensive and comprehensive interventions to reduce the total risk of CVD.
Qing Wan MB BS, MPH, MMed · Jane Taggart BEd, DipPE, MPH · Mark F Harris FRACGP, MD · Upali W Jayasinghe MSc, PhD · Warwick Ruscoe MB BS, RACGP · Jill Snow RN · Gawaine Powell Davies BA, MHP
Health care for people with intellectual disability
To the Editor: General practitioners play an influential role in the improved health care of people with intellectual disability (ID) through assessment, diagnosis, and development and maintenance of health plans. GPs also help patients access specialist health care and community-based services.1 Recent initiatives by the International Association for the Scientific Study of Intellectual Disabilities (IASSID) and Medicare Australia have been introduced to develop a national strategy for GPs and other health practitioners in their contribution to the promotion of health care for people with ID. With the support of the World Health Organization, the IASSID set health targets for people with ID. These in turn contributed to a national strategy for improved health care for people with ID.2,3 Medicare Australia introduced Medicare rebates for people with ID on 1 July 2007 (Medicare Benefits Schedule Items 718 [“Attendance by a medical practitioner . . . at consulting rooms for a patient with an intellectual disability”] and 719 [“Attendance by a medical practitioner . . . not being an attendance at consulting rooms, a hospital or residential aged care facility for a patient with an intellectual disability”]).4 These rebates aim to provide a structured clinical framework, allowing more time for GPs to spend with patients with ID to assess their overall health and plan for their long-term care, thus improving the quality of service through improved decision making in the context of prescribed medication, specialist referrals and hospital admissions.1 GPs can implement a health assessment program aimed at enhancing interactions between the adult with ID, his or her carer and the GP through the systematic gathering of a health history and review and, subsequently, development of a health action plan.2 To assist GPs in their assessment of patients with ID, Lennox and colleagues have developed the Comprehensive Health Assessment Program (CHAP).2 The CHAP is a 21-page booklet, split into two parts. The first part covers the medical history of the patient with ID and is filled out by the patient’s carer and brought to the GP. The second part is the CHAP assessment, completed by the GP. The CHAP assessment involves a review of the medical history, a targeted examination, and assistance for the carer in completing a health action plan. A 1-year post-intervention review has shown a substantial increase in GPs’ attention to the health needs of adults with ID, with concomitantly more disease detection.2 Thus, these initiatives have demonstrated positive clinical outcomes for this group of patients. Comment: The research is clear that people with intellectual disability have been receiving inadequate health care. A seminal population study clearly demonstrated that they experience high levels of unmet health need, with 42% of health conditions persistently undiagnosed and half of the conditions that are diagnosed inadequately managed.1 Their life expectancy is much lower than the general population — about 20 years lower for people with severe disabilities.2 These unmet health needs are partially addressed by the Comprehensive Health Assessment Program (CHAP) one-off health review. In the only randomised controlled trial of the health assessment process, we found a significant increase in health promotion and disease prevention, and greater case finding.3 We believe the CHAP enhances communication between adults with intellectual disability, their carers and their general practitioners. The widespread use of an annual health review now afforded by Medicare Australia provides an example of best practice in the health of this neglected group of Australians. This change was achieved after sustained collaborative lobbying driven by the Australian Association of Developmental Disability Medicine and the National Council on Intellectual Disability (New South Wales branch) — an advocacy organisation — and supported by other national medical organisations. While these changes are welcome, they are not enough, as half a million Australians4 (a population at least as large as the Indigenous population) with intellectual disability continue to experience poor health care while being excluded from most generic research. We call upon the Australian Government to act to regularly monitor and assist in the development of strategies to improve the health of this population. Would any other population of this size and health status receive such scant attention in the national discourse?
Kathryn A Vanny · Michael H Levy · Susan C Hayes · Nicholas G Lennox · Miriam T Taylor
I went to work with a “cold” ...
A cold never killed anyone ... did it? I went to work with a cold. My nasty sore throat woke me early, so I spent the time emailing our incoming clinical students: Get your influenza vaccinations before you start your clinical rotations — influenza kills people, vaccinating health care workers decreases mortality in nursing homes, and vaccination reduces other viral infections and days off work or school, and meets duty of care for oneself and others!1,2 Sincerely, your (vaccinated) Clinical Dean Sneezing and miserable, I considered staying home, abandoning the 20 complex, high-admission risk (general medicine) patients scheduled at the Aboriginal Health Centre and the hospital, many of whom had waited 2–3 months for an appointment. I thought of my mother — “Go to school, you’re not dying, you only have a cold!” Memories of my only previous sick day resurfaced: as an on-call intensive care unit senior registrar — feverish, achy, sneezing, nose running like a faucet, I had decided this wasn’t good for anyone. Caving at the prospect of working all night sick, I settled for guiltily calling in a fellow registrar. My “chief” had then rung — “How are you?” — Oh no, they think I’m skiving off! Peer pressure is strong stuff. So, this time, with patients waiting and my past lurking, I took some paracetamol, packed some tissues, and went to work. My first patient, recovering from a lung resection for bronchiectasis after last winter’s viruses almost killed him, is now surviving his first postoperative virus — not a drama. After warning him to stay far away and not shake my hand, I got through the rest of the day constantly apologising to my patients and colleagues, suppressing sneezes, washing my hands, and touching as few things as possible. After clinic, an email explained the coincidental absence of my medical students — “Sick with cough, unable to attend”. A colleague’s voice from the doorway wryly observed, “You’re sending the students mixed messages about getting vaccinated and duty of care while working with a cold yourself, potentially infecting everyone in sight”. I responded blithely, “I’m more dedicated to my work than the students are (different generation), and besides, a cold never killed anyone” ... but then, a moment of evidence-based-medicine horror hit me — That’s true, right? Although my work-despite-a-cold ethic hasn’t done me any harm (misery aside), I salved my skiving-off guilt with my greater desire to “do no harm”, collected kilos of paperwork and my laptop, and retreated home for a day in isolation. A hasty MEDLINE search for “common cold AND mortality” from 1997 to 2007 revealed 68 papers. Of these, the 13 highly relevant papers (gulp) fell into three categories: chronic obstructive pulmonary disease (COPD) or asthma complications (eight); childhood morbidity and deaths, largely related to cold medications (four); and HIV-related deaths (one). I quickly discovered that over 50% of COPD exacerbations are attributed to respiratory viruses — no big surprise.3 More concerningly, rhinoviruses are now well established culprits causing significant morbidity and even mortality.4-6 Indeed, only miniscule amounts of rhinovirus are needed to infect patients who then develop lung function changes typical of COPD exacerbations.7 If COPD causes 4% of all deaths per year in the United States (Australia should be similar)8 and viruses cause half of COPD exacerbations, then about 2% of mortality is potentially attributable to respiratory viruses. I began to worry about my patient with bronchiectasis. On the other hand, at least I hadn’t done any harm by prescribing over-the-counter cold medications with worrying potential for harm for any of my adult patients, let alone any children.9 Hmm ... non-steroidal anti-inflammatory medications seem to have evidence for relief (as long as I don’t have hypertension, stomach ulcer, heart failure, or kidney disease),6 so I think I’ll take some. What about vaccination? Reassuringly, at least for my reputation among my students and staff, several reviews supported influenza vaccination,10,11 especially since influenza viruses account for up to 10% of “common colds”.6 Distressingly, however, vaccination rates among health care workers are less than optimal — 82% of doctors and 40% of nurses had been vaccinated in one emergency department study (the best rates I could find).11 One dilemma remains. I, like 80% of doctors, worked with an illness for which I would have “sick-listed” my patients,12 but given that I care for under-served patients in a rural area with a shortage of doctors, is it worse to stay home and reschedule patients for appointments weeks to months later or to risk exposing them to my virus-laden self? Mortality rates for residents of rural and regional areas in Australia are 10% higher than for city-dwellers13 — largely due to health care access issues. My personal vaccination campaign should decrease the frequency of my own (and my students’ and staffs’) “colds” and, if I’m sick less often, this should increase access to me, thus decreasing my patients’ morbidity and mortality. Sadly, the evidence suggests that if I were working in an intensive care unit or a medical ward with high-risk COPD patients, I could justify staying home, but in my general medicine role and doctor-shortage situation, the mortality trade-offs suggest that I should probably go to work with a cold next time too (sigh). But as for you, dear health care providers: first, do what I say and what I do (get vaccinated against influenza); and second, do what I say and not what I did, and consider staying home with your own cold — because, you never know, it just might kill someone ...
Dawn E DeWitt MD, MSc, FRACP
Inspiration for life and love
Love has no limits. Tania Hayes. Sydney: Mira Books, 2008 (ix + 291 pp). ISBN 978 1 74116 621 7. As the cover says, this book is “an inspirational true story” and “much more than a tale of medical drama”, though it is that as well. It is an unimaginable story of the strength of love between Tania and her fiancé Warren, who developed a brain tumour and nearly died several times after his operations, and was left with some severe disabilities. Yet he came through years of medical treatment to marriage, fatherhood, and continued life. It is told in a simple, direct and very moving way. Tania wrote, “deep inside I knew I had to trust the hand that life had dealt me, even if the road was uncertain . . . I trusted to love” and “You never know where life will take you . . . But by holding on to love, you can emerge”. As one doctor said to Tania, “Your journey has been nothing short of amazing . . . your love brought Warren through”. There was also the loving support of family and friends. There is much evidence of the importance of human interaction between medical staff and patient and family alongside medical care. When a nurse displayed “much love and tenderness” to Tania and let her help care for Warren, she felt like she was contributing “instead of sitting there agonizing”. Later, she felt included when “The rehabilitation specialist was very open to my ideas”. There were, of course, also a few hiccups. While there is too much medical and health care detail, its seeming endlessness was undoubtedly what Tania and Warren experienced. It is so moving, one would like to know more about their family and social relationships, the context of the story, and the personal feelings and spiritual background of Tania and Warren and the extent of the love that was so important to them. The final chapter, Through Warren’s eyes, makes one wish that more from him could have been woven into the narrative. This is a story about life and love to inspire and move us all to share our journeys. Read it.
Charles Bridges-Webb
From the patient’s perspective
Measuring patient-reported outcomes: moving from clinical trials into clinical practice
Patient-reported outcomes (PROs) are reports coming directly from patients about how they function or feel in relation to a health condition and its therapy, without interpretation of the patient’s responses by a physician or anyone else1 (Box 1). PROs are increasingly used in clinical research, and their usefulness to inform clinicians’ and patients’ decisions about treatment alternatives is beginning to be understood.3 But results of empirical testing of using PROs in clinical practice have been inconsistent, and ascertaining the circumstances under which PROs are truly helpful beyond research settings remains a challenge. What benefits and harms can we expect from using PRO measures in clinical practice?The potential benefits of using PRO assessments in daily clinical practice include facilitating patient–clinician communication about issues that are important to patients, thereby promoting shared decision making; monitoring disease progression and response to treatment; identifying vulnerable patients; and enabling continuous assessment of quality of care.1,3 These benefits could lead to improvement in outcomes that are important to patients. On the other hand, the use of PROs may interfere with doctor–patient communication and patients may be concerned about who will review or use the information. Even in the absence of harm, the use of PROs would carry an opportunity cost, which is an important consideration given that administering some of the currently available measures is already burdensome, and scarce resources would be consumed in computing and reviewing PRO scores. What is the evidence for using PRO measures in clinical practice?A number of systematic reviews have assessed the impact of measuring PROs in clinical practice. The most recent included 28 randomised controlled trials and the results were consistent with previous reviews: in most trials, the impact of PROs was limited.1 Feedback of PROs to health professionals has, in some studies, had an impact on the process of care, with a less evident impact on health outcomes. In cancer clinics, feedback of PROs to health professionals has been shown to increase the frequency with which doctors discuss issues such as quality of life and symptoms with their patients, without an increase in the visit duration.4,5 In one of these studies, physicians informed by PROs had greater agreement with their patients about how well the patient was functioning.5 A meta-analysis showed that PRO reports of mental health status in a variety of settings resulted in a higher likelihood of diagnostic notations recorded in patients’ medical records.6 There are a number of additional steps that must be taken before changes in the process of care can be translated into changes in outcome (Box 2). For instance, routine provision of feedback to health professionals may not necessarily translate into routine use of the information for all patients. Thus, those who demand evidence of improved patient-important outcomes will not be impressed simply by improvements in process. Moreover, randomised controlled trials on PROs have been highly heterogeneous in setting (primary care; specialised outpatient and inpatient clinics), participants (new and known patients; experienced and more junior clinicians), the intensity and content of the PRO intervention implemented, and diversity of outcomes reported.1 This heterogeneity poses a major challenge in interpreting the evidence and in identifying the clinical contexts and strategies for measuring and reporting PRO results to clinicians that will result in improved patient outcomes. Some additional methodological weaknesses affect these trials. Often, the investigators analysed the data as if they had randomised patients, when in fact they had randomised clinicians or groups of clinicians.1 This error would bias results in favour of the intervention. Some interventions were suboptimal in the degree of training clinicians received in interpreting the results, and in the manner of presentation of results to the clinicians.8 Methodologically stronger trials successfully implementing feasible interventions with clear positive effects are required to provide clear direction for clinicians. What are the challenges for implementing PRO measures in clinical practice?The systematic use of PRO instruments in clinical practice has the potential to bring about significant improvements in a number of relevant areas of health care. But possible barriers to implementation would need to be overcome, including scepticism about the validity and potential utility of PRO data; unfamiliarity with the interpretation of PRO information; a paucity of direct face-to-face instrument comparisons; costs of data collection; and the need for rapid data manipulation and processing. Significant progress has been made in some of these areas. A recent review comparing common medical measurements and their associated error with PRO measurements concluded that the latter were comparable with commonly used outcome data.9 The next step is to convince clinicians that this is the case and that they may reliably benefit from information derived from PROs. Researchers are also finding new, imaginative ways to help clinicians understand the magnitude of treatment impact on quality of life. One useful measure in this regard is the Minimal Important Difference (MID) — the smallest change in instrument score that patients perceive as important.10 For instance, the MID for the Chronic Respiratory Questionnaire is 0.5 on a scale that ranges from 1 to 7. This means that changes smaller than 0.5 should not be considered relevant, regardless of the statistical significance of the comparison. Some authors propose linking PRO scores with expected performance profiles to facilitate interpretation of results.7 The development of standardised tools relying on sound criteria11 is making direct comparison between instruments and their devised purposes easier. These evaluative approaches should facilitate the selection of the most appropriate PRO for each occasion. Also, efforts are being made to develop very brief questionnaires by either shortening existing ones or applying computer-based methods to tailor the content of the instrument to each patient based on the responses provided to each previous item. This approach should reduce the burden of collecting PRO data. Finally, the development of new PROs specifically devised for use in the clinical setting might also help to overcome barriers to successful implementation. Where to from here?PRO instruments used in clinical research can theoretically provide important information to guide decisions about alternative treatments. There are some grounds for optimism that the use of PROs could have a positive impact on clinical practice (specifically in improving diagnosis and recognition of problems and in patient–physician communication), but considerable work is still required before clinicians can invest resources in the process and confidently anticipate benefits for their patients. 1 Examples of patient-reported outcome (PRO) instruments Medical Outcomes Study short-form health surveys (SF-36, SF-12, SF-6D): the most used family of PRO measures EuroQol (EQ-5D): a well known econometric preference-based measure, and one of the shortest instruments available McGill Pain Questionnaire: the most widely cited PRO instrument for measuring pain KIDSCREEN: a specific tool for PRO measurement in children and adolescents Patient Health Questionnaire (PHQ-9): a tool for assessing severity of depression; currently part of the “pay-for-performance” incentives scheme for primary care practitioners in the United Kingdom2 Schedule for the Evaluation of Individual Quality of Life (SEIQoL): an individualised measure, eliciting both the content of the items and the ratings from the respondent 2 Assessing the impact of patient-reported outcomes in clinical practice: a model for feedback on functional assessment* in clinical practice7 * The assessment of a patient’s ability to perform tasks.
Jose M Valderas MD, PhD, MPH · Jordi Alonso MD, PhD · Gordon H Guyatt MD, FRCPC
Access to general practitioners in South Australia: a population survey
Objective: To determine the timeliness of access to general practitioner appointments in South Australia.Design and setting: Face-to-face interviews with a random and representative sample of South Australians living in metropolitan Adelaide and country towns with a population of 1000 or more in 2007.Participants: 2507 people aged 15 years and over who had seen a GP in the previous 12 months.Main outcome measures: Waiting times for obtaining an appointment with a GP, patients’ perceptions about appointment waiting times, and waiting times at the GP’s surgery.Results: Most respondents reported that for their last visit with a GP, they were able to be seen on the same day (39%) or within 1 or 2 working days (33%); 20% waited more than 2 working days for their appointment. Nine per cent of respondents (159/1764) reported waiting more than 2 working days because an earlier appointment was not available. Respondents reporting lower levels of household income were more likely to report longer waits for GP appointments. Most respondents (78%) felt that they were able to make a GP appointment as soon as they thought necessary. At the surgery, 46% of respondents were seen within 15 minutes, but 13% waited 45 minutes or longer.Conclusions: In general, access to GPs is timely, and most South Australians reported that for their last GP visit they were able to make an appointment as soon as they thought was necessary.
Richard L Reed MD, MPH · Leigh S Roeger BA(Hons), PhD · Nova Reinfeld-Kirkman BBSc(Hons) · Sara L Howard BHlthSc(Hons), PhD
Research enterprise
The Brisbane International Initiative: fostering leadership and international collaboration in primary care research
Australian-based researchers are participating in an international collaboration to improve general practice research Primary care is where most patients receive most of their health care. It makes a greater contribution to the community’s health than specialty practice.1,2 Yet research in primary care lags far behind that in the specialties; it is a “Cinderella”, criticised for its comparatively small output and its lack of relevance and methodological rigour.3-6 This discordance has focused attention on the need to strengthen primary care research infrastructure and capacity.7,8 In Australia, the federal government responded with the Primary Health Care Research, Evaluation and Development program.9 The Brisbane International Initiative (BII) is another approach with similar — but international — objectives. Wide-ranging and ambitious, it was founded at a Brisbane meeting of leaders in primary care research from eight countries in 2002.10 Its aim is to develop expertise in primary care through promoting capacity and fostering excellence in primary care research. It now operates within the World Organization of Family Doctors (WONCA). Originally a collaboration of 14 university departments of general practice (in North America, the United Kingdom, Europe and Australia), the BII has since expanded and promotes primary care research capacity-building through a range of activities (Box 1). One of these activities is the convening of postdoctoral peer-learning cohorts in a 2-year program of development for research leadership administered at the University of Oxford in the UK. We were among the second (2007) cohort of 12 researchers (Box 2): two of us are Australian (P J M and J S F), and the third (M L v D), originally from the University of Ghent, has since taken up an academic position in Australia. The 2-year program has a flexible overall structure but begins and concludes with meetings at the host institution. The initial meeting for our cohort was held on 3–6 September 2007 at St Hugh’s College, Oxford (Box 3). The meeting had a conventional structure — seminars, talks and workshops — but stood out for the quality of its content. It was designed and seamlessly facilitated by Alison Ward (Research Support Director, Department of Primary Health Care, University of Oxford). Box 4 outlines the material covered and the impressive range of presenters. However, the meeting had a further agenda: the smallness of the group, the cloistered surroundings, and the privileged access to distinguished and influential people in the field of primary care research instilled in us a sense of responsibility; the meeting also introduced us to international peers at a similar career stage and, specifically, gave us an opportunity to plan collaborations. Key lessons from the meetingOur role as research leaders Critically, we explored the difference between leadership and management. Sue Dopson showed us how being a leader is about inspiring and motivating others, exploring new frontiers and crossing boundaries. To influence policy, we need links with policymakers. As primary care research deals with the realities of implementing policies in daily patient care, it should automatically feed back to the settings where policy is designed. Martin Roland outlined the importance of primary care leaders sitting on decision-making committees. He also suggested that we should not ignore links with the media and the wider community. Career paths and the pursuit of researchTrisha Greenhalgh and Paul Glasziou gave us insights into their own careers. Each engaged and intrigued us with stories of careers that were rarely linear, and were most often guided by intuition and an open mind. Greenhalgh spoke of diverging into political advocacy and a triathlon career, all pursued with the energy and passion she continues to bring to primary care research. Glasziou spoke of how a “feeling” for a research idea could drop into the mind over tea or at the photocopy machine, and then evolve into a research question that contributes to the knowledge base of primary care. He keeps a record of many such research ideas in development at any time, refining the questions and ideas through discussions with others and small-scale pilot work. The insights of these speakers suggested that we should be open to students and early-career researchers choosing less-than-conventional options in our efforts to build a creative and thriving primary care culture in the future. Publication — an insider’s viewFiona Godlee gave us a view inside the editorial workings of the BMJ as it struggles with the tensions between publishing high-quality research reports and publishing articles reflecting the world in which clinicians work, and between the needs of multiple audiences (general practitioners and specialists, UK and international). Godlee acknowledged feedback that the BMJ’s balance needs to tip more towards research articles, including primary-care research articles, to support its overarching purpose of helping doctors make better decisions. Outcomes of the meetingThe BII has high aims. A major objective of the week in Oxford was to bring the cohort together and foster collaborations. But was it just a talk fest for a privileged few? The proof is in the pudding. What matters is what we achieve as a group from coming together. Already there are good signs. The 2007 cohort will organise a workshop at the Society for Academic Primary Care conference in Galway, Ireland, in 2008, focusing on developing measures of research output for departments of general practice. The group (led by J S F) has written an article on future directions in primary-care research and submitted it to a peer-reviewed journal. The Australian BII participants are developing other collaborations. These include an article on journal impact factors and their influence on research and researchers (lead author, M L v D).11 P J M has developed a collaboration to study GP referral patterns for transient ischaemic attack and is exchanging ideas with another group member on parallel projects on inappropriate prescribing in older people. Undergraduate students from the University of Aberdeen, Scotland, may be offered the opportunity to complete an elective research term in a collaborating department at the University of Newcastle, Australia. P J M will also make short visits, facilitated by colleagues at Keele University, the University of Sheffield, the University of East Anglia and University College London, to study the organisation and functioning of British research networks of general practices. In addition, the Australian-based BII participants hosted a breakfast meeting at the national General Practice and Primary Health Care Research Conference in Hobart in June to explore the possibility of local Australian postdoctoral peer-learning groups. These may be modelled on the experience of Andrew Farmer (Lecturer in General Practice, University of Oxford) who spoke at the BII meeting of his experience as a member of a Medical Research Council peer-learning group of postdoctoral primary care researchers. Opportunities for othersIt is still quite early in the 2007 cohort’s BII program, but it is proving to be an exciting and potentially productive exercise. We urge Australian postdoctoral (or near to doctoral submission) primary care researchers to consider applying for subsequent cohorts. Applicants must be nominated by their department. If they are selected, the department agrees to become a partner institution of the BII. This involves providing financial support for their participants to complete their BII obligations (except for accommodation and expenses at the Oxford meetings, which are funded by the University of Oxford), and agreeing to host BII participants from partner institutions. We feel strongly that this would prove a sound investment in research capacity-building for the departments involved. 1 Activities of the Brisbane International Initiative Cooperative development of research educational resources Convening of expert groups and think tanks Fellowships and visiting traineeships Support of small, international peer-learning cohorts aimed at postdoctoral primary care researchers 2 Some of the participants at the 2007 meeting Left to right: Chris Del Mar (Visiting Professor of General Practice, University of Oxford), Parker Magin (Senior Lecturer, University of Newcastle), Mieke van Driel (Senior Lecturer and Research Fellow, University of Ghent), Caroline Mitchell (Senior Lecturer, University of Sheffield), John Furler (Senior Research Fellow, University of Melbourne), Umesh Kadam (GP Epidemiologist, Keele University), Barbara Hanratty (Senior Lecturer in Population and Community Health, University of Liverpool), Greta Rait (Senior Clinical Lecturer, Royal Free and University College Medical School), Jennifer Cleland (Clinical Senior Lecturer in Primary Care and Medical Education, University of Aberdeen), and Colin McCowen (MRC Training Fellow, University of Dundee). 3 St Hugh’s College, Oxford, venue of the meeting 4 Program of the 2007 meeting Scene setting. A presentation on the current state of primary care research and the challenges and opportunities facing the group (Chris Del Mar, Dean of Health Sciences and Medicine, Bond University, and Visiting Professor of General Practice, University of Oxford). Skill development for leadership. Seminars on: leadership theory (Sue Dopson, Reader in Organisational Behaviour, University of Oxford); the research–policy nexus (Martin Roland, Director, National Primary Care Research and Development Centre, University of Manchester); and scenario planning for anticipating future strategy and policy in primary care (Sara Ward, Executive Director, James Martin Institute for Science and Civilization, University of Oxford). Skill development for research. Presentations on developing research questions (Paul Glasziou, Professor of Evidence-Based Medicine, University of Oxford) and successfully collaborating in large-scale trials and meta-analyses (Mike Clarke, Director, UK Cochrane Centre). Inspiration. Before- and after-dinner presentations on the career paths of eminent primary care researchers (Paul Glasziou, and Trisha Greenhalgh, Professor of Primary Health Care, University College, London). Inside knowledge. A seminar on the strategic editorial issues facing the British Medical Journal (Fiona Godlee, Editor, BMJ). Networking and bonding. Each participant spoke about their personal research and that of their department. Ample opportunities were provided for discussion and exploring potential collaborations, in organised small groups, in free time and also at nightly in-house dinners.
Parker J Magin PhD, FRACGP · John S Furler PhD, FRACGP · Mieke L van Driel MD, PhD
Research productivity in Australian general practice: what has changed since the 1990s?
The Primary Health Care Research, Evaluation and Development (PHCRED) Strategy aims to improve Australia’s output of high-quality research from primary care. We compared publication rates from general practice, medicine and surgery for the period 2000–2007, and found that general practice publications increased since 1990–1999 from 1.0 to 3.0 publications per 1000 general practitioners per year. However, general practice publication rates have plateaued since 2000, and represent only 2%–5% of the equivalent rates for medicine and surgery. This finding suggests that more time and sustained investment in PHCRED are essential to see tangible outputs from funded research in general practice. Since 2000, the Australian Government has invested $110 million in the Primary Health Care Research, Evaluation and Development (PHCRED) Strategy to “improve Australia’s capacity to produce high quality primary health care research”. An evaluation of the PHCRED Strategy in the 2004–05 financial year reported significant progress in achieving this aim.1 Published research is one measure of research capacity. As evaluation of Phase 2 of the Strategy has commenced,1 we considered it timely to measure the publication rate from general practice research, and to compare this with rates of published research from other medical disciplines and with an earlier stocktake of published research from the 1990s.2 MethodsWe repeated the search strategy used in the previous stocktake.2 The United States National Library of Medicine’s PubMed database details the institutional affiliation of the first author in the address field of indexed publications. We used this information to identify publications from three Australian disciplines — general practice, medicine and surgery — published between 1 January 1990 and 31 December 2007. Publications with the terms “comment”, “editorial”, “letter” or “review” in the publication type field were excluded. Average annual publication rates from 2000 to 2007 for each discipline were calculated as the number of publications per 1000 practitioners per year. Poisson regression was used to compare these rates with those in the previous stocktake, to model the raw numbers of general practice publications (using discipline workforce size as the exposure), and to adjust general practice publication rates relative to medicine and surgery publication rates (referenced to 1990). For all models, goodness-of-fit and residual checks were undertaken. All analyses were performed using Stata, version 10.0 (StataCorp, College Station, Tex, USA), and a level of α = 5% was used to define statistical significance. ResultsFrom 2000 to 2007, there were 545 publications from Australian general practice, published in 130 different journals, including eight specific primary care journals. These eight journals together published 223 (41%) of the publications from general practice. For the period 2000–2007, there were 3.0 (95% CI, 2.8–3.3) publications per 1000 general practitioners per year — a significant increase from the previously reported level of one publication per 1000 GPs per year for the period 1990–1999,2 but still less than 5% of the rate for surgeons during 2000–2007, and about 2% of that of physicians (Box). From 1990 to 2007, the number of publications from each discipline increased. After adjusting for changes in publication rates for medicine and surgery, general practice publication rates increased significantly between 1990 and 2000, but plateaued between 2000 and 2007. No evidence was found to doubt the adequacy of any of the Poisson regression models. DiscussionThe annual general practice research publication rate has trebled since the PHCRED Strategy was introduced, but remains very low compared with medicine and surgery, and is incommensurate with the level of clinical activity in general practice. Despite considerable investment in building research capacity in general practice, its level of research output continues to be much lower than that of other disciplines. This can be partly explained by the very small number of GPs on government salaries (2%) compared with physicians and surgeons (56% and 26%, respectively).3 GPs working in a fee-for-service environment lose revenue if they take time away from direct patient care, which is a disincentive for conducting research. This is not the case for their salaried colleagues, for whom research is often an expected component of their work. Could this be replicated in general practice? Two components of the PHCRED Strategy (the Research Capacity Building Initiative and the Researcher Development Program) have largely focused on training novice researchers (from all fields within the extensive primary care workforce) and funding small, short-term projects that are unlikely to produce many publications. In contrast, the PHCRED Fellowships, Scholarships, and investigator- and priority-driven clinical research project grants are long-term investments with lengthy timelines for completion and publication of outcomes. Our inability to identify any real increase in the number of general practice publications suggests the level of investment is insufficient and more time is needed to see funded activity translate into tangible research output. As with the earlier stocktake,2 our approach has important limitations. The search strategy was not specific to research articles, it did not identify publications by general practice researchers whose institutional affiliation does not include the words “general practice”, and it identified only first authors, ignoring general practice researchers collaborating with other disciplines and those outside Australia. Additionally, current and accurate workforce data are not available, requiring us to use different sources to estimate workforce sizes. Nevertheless, our approach is quick, easily replicable and produces an indicative comparison of general practice research productivity over time and with other disciplines. The large disparity we found in relative publication rates is unlikely to disappear with a more rigorous assessment. Importantly, although research productivity is an indicator of research capacity, it is not the only indicator, and it does not provide information on the quality of research. The PHCRED Strategy should not be assessed solely on the number of publications produced, but also on other indicators of research capacity, including the number of research grants applied for and funded, evidence of research participation, and involvement in research training. Sustained and targeted investment is needed to develop a sustainable primary care research workforce, if general practice is to provide high-quality, evidence-based care to fulfil its role as the cornerstone of the Australian health care system. Relative publication rates of Australian general practitioners, physicians and surgeons, identified in PubMed search, 2000–2007 Number (%) of publications Approximate size of workforce Proportion of total medical workforce (N = 60 252)* Publications per 1000 practitioners per year (95% CI)† GPs 545 (3%) 22 600* 38% 3.0 (2.8–3.3) Physicians 11 487 (72%) 9 000‡ 15% 159.5 (156.6–162.5) Surgeons 3 849 (24%) 7 100§ 12% 67.8 (65.6–69.9) * Source: Australian Institute of Health and Welfare, http://www.aihw.gov.au/publications/hwl/mlf05/mlf05-xx-all-employed-practitioners.xls (accessed Feb 2008). † 95% confidence intervals calculated using exact Poisson distribution. ‡ Source: Royal Australasian College of Physicians (total of all Fellows of the RACP, including those from New Zealand), http://www.racp.edu.au/index.cfm?objectid=3F6EF93E-2A57-5487-D7CE8B12AD671563 (accessed Apr 2008). § Source: Royal Australasian College of Surgeons (total of all Fellows and trainees of the RACS, including those from New Zealand), http://www.surgeons.org/AM/Template.cfm?Section=Who_We_Are (accessed Apr 2008).
Deborah A Askew PhD · Philip J Schluter BSc(Hons), MSc, PhD · Jane M Gunn MB BS, FRACGP, PhD
Feasibility of conducting a primary prevention trial of low-dose aspirin for major adverse cardiovascular events in older people in Australia: results from the ASPirin in Reducing Events in the Elderly (ASPREE) pilot study
Aim: To determine the feasibility of performing a large clinical trial of the use of aspirin for the primary prevention of cardiovascular disease in older participants — the ASPirin in Reducing Events in the Elderly (ASPREE) trial.Design and participants: A randomised double-blind placebo-controlled pilot trial of 100 mg of enteric-coated aspirin tablets daily, in men and women aged 70 years and over who did not have overt cardiovascular disease, and who were followed for 12 months. Participants were identified from the computer databases of general practitioners who were co-investigators in a previous trial.Setting: The Melbourne metropolitan area between March 2003 and June 2005.Main outcome measures: The level of response to participation by GPs; the level of response from potential trial participants; the screening-to-randomisation rate to ensure the recruitment target could be achieved; and the retention of participants in the trial after 12 months.Results: Forty-two GPs (23% of 180 mailed) expressed interest in participating in the pilot trial. Nineteen became co-investigators, of whom six were not required to meet recruitment targets. Letters were sent to 2614 patients, of whom 243 were screened and 209 (86%) were randomly allocated to receive aspirin or placebo. At 12 months,192 (92%) returned for follow-up, and 153 of these (80%) were still taking trial medication. There was a significant reduction in mean haemoglobin level in those taking aspirin.Conclusions: The recruitment strategy for ASPREE, based on methods developed for the conduct of a previous large-scale trial conducted in general practice, was successfully redeployed in this pilot study, with improved efficiency resulting from computerised database searching, telephone pre-screening, a simpler run-in phase and participant familiarity with the trial drug. We conclude that conducting ASPREE in Australian general practice with 18 000 participants is feasible.Trial registration: International Standard Randomised Controlled Trial Number Register ISRCTN83772183.
Mark R Nelson FRACGP, PhD, FAFPHM · Christopher M Reid BA, MSc, PhD · David Ames MD, FRCPsych, FRANZCP · Lawrence J Beilin MD, FRACP, FRCP · Geoffrey A Donnan MD, FRACP · Peter Gibbs MB BS, FRACP · Colin I Johnston MB BS, FRACP · Henry Krum FRACP, PhD · Elsdon Storey DPhil, FRACP · Andrew Tonkin MB BS, FRACP · Rory Wolfe BSc, PhD · Robyn Woods BSc(Hons), PhD · John J McNeil PhD, FRACP
Redefining Roles
The promise and pitfalls of generalism in achieving the Alma-Ata vision of health for all
Defining the ideal generalist medical practitioner is essential to effective primary care It is 30 years since 3000 delegates from 134 governments, 67 international organisations and many non-government organisations gathered in Alma-Ata, Kazakhstan, to agree upon a declaration about how primary health care could achieve “health for all by 2000”.1 The conference was convened by the World Health Organization and the United Nations Children’s Fund (UNICEF) in response to the growing inequality among large sections of the world’s population. The conference was influenced by global political and social change in the preceding decades and a strong desire to move away from medical dominance and elitism,2 to focus on developing countries rather than dominant Western nations, and to propose a model of health as a tool for economic development.1 The leadership of WHO Director-General Halfdan Mahler (1973–1988) was crucial to the direction of the declaration, as he had been impressed by developments in China, India, Africa and Latin America that provided health care via local community-controlled services using lay participation, and he envisioned such programs addressing health inequalities across the world.3 The resulting Declaration of Alma-Ata consisted of 10 sections (Box 1). Anniversaries often prompt reflection, and as the Alma-Ata Declaration reaches its 30th birthday, it is clear that implementing the Declaration has been more difficult than creating the vision.4-7 Many commentators argue that the Alma-Ata experiment failed;5 others say it has never been tried.8 Some highlight the influence of the Declaration on policy agendas in developing countries (eg, Mozambique, Nicaragua) and on the development of community health workers.4 However, many programs that evolved were disease-focused, and critics would say that the community health workers, rather than being agents of change, became civil servants.8 So what is the relevance of a WHO declaration made 30 years ago to the Australian health care system? Some may see the Declaration as applying mainly to developing countries, but on reflection there is much we can gain from considering it in our own context. As a population, we desire health for all, and yet we continue to see health inequities. The rise in chronic disease and the ageing population means that multiple morbidities are the most common reasons for presentation to primary care,9-12 yet Australia, like many countries, continues to focus on single-disease-led health care linked to relative disease burden, often via treatment guidelines.13 This approach encourages specialisation, leads to fragmentation of health care, and affects our ability to deliver the goal of “health for all”. The fragmentation in so many health initiatives goes against the spirit of the Declaration. Perhaps governments, the health professions and wider society did not fully understand or truly value the kind of health care proposed. The Declaration called for a dramatically different approach to health and health care, but it failed to articulate the attributes required of the health care workers. The essential role and inclusion of primary medical care in the conceptualisation of primary health care was poorly articulated. Perhaps the desire to reject medical dominance, combined with a poor understanding of primary care,14-17 explains why there was no definition of what a “suitably trained physician”1,18 would need to be like to deliver the ambitious goals. Even though there was increasing focus on the need for a team of professionals to provide primary health care,19,20 there was little systematic gathering of evidence to inform the roles and values of various team members. What kind of physician could contribute to achieving the Alma-Ata vision?We propose that a generalist primary care medical practitioner is a vital component of primary health care. Australia has a well trained general practitioner workforce, yet most GPs continue to practise mostly reactive, consultation-based medicine with little time for planning, monitoring, teamwork, community involvement, and networking or integration activities. As a nation, we face a medical workforce crisis in that general practice struggles to attract and maintain high-quality graduates. The policy response is to shift the work of GPs to non-medically qualified practitioners and assistants. Interestingly, there has been little public involvement in debate of this issue. Our recent review, commissioned in 2007 by the Australian Primary Health Care Research Institute (APHCRI), provides, for the first time, a conceptual model of a primary care generalist based on a systematic narrative review of the literature (Box 2). A full description of the review methods and findings is available from the APHCRI website.21 The generalist ideal encapsulated in our model can bridge the inclusive vision of who should be involved in promoting health for all, with the much more narrowly and often specialty-focused health care found in many countries, such as the United States. The type of generalist role proposed is sophisticated and requires interpretive skills, a broad approach, excellent networks and supports. We conceptualise generalists as exhibiting compassion, tolerance, trust, empathy and respect (virtues). They reflect carefully on each clinical interaction, recognise its complexity, and acknowledge their prejudices (eg, towards obesity, unsafe sex practices, single parenthood, substance misuse, poverty, violence, religion). By acknowledging and dealing with their feelings (being reflexive), generalists can begin to fully engage with each patient. The generalists spend time gathering information from the biopsychosocial and cultural domains, rather than focusing solely on physical symptoms and signs. Each interaction requires biotechnical expertise, and the generalist needs to use the best available evidence to manage health. This is likely to be facilitated by access to independent evidence-based guidelines and reliable information systems. The generalist knows how to access appropriate technology to achieve health (this will range from familiarity with accessing online evidence to knowing how to access a magnetic resonance imaging scan to being aware of how to get patients from a remote area to a district hospital during the rainy season). In addition, the generalist will exhibit a high index of suspicion for medical, psychological and social “complications” and awareness of the complex interaction of morbidities and social factors. A fundamental role of the generalist is to balance the biotechnical with the biographical. The generalist must know and understand how each life story and social context are constantly influencing and being influenced by physical and emotional health. To achieve the balance between the biotechnical and biographical aspects of each interaction, the generalist must have the skills to reach a mutual understanding of the priorities and challenges that individual patients face when managing their health. The ideal generalist would be easily accessible and knowledgeable about other services to arrange appropriate and timely referral. The generalist would balance individual needs against those of the population, and consider the whole person and what they know about each to provide comprehensive care, dealing with areas such as sexual health with as much knowledge, interest and respect as diabetes. They will be comfortable working with both mental and physical health problems (flexible), and able to negotiate a plan for health care that suits each person (patient centred). This might be as simple as ensuring that single parents can get appointments that suit their work schedule and childcare requirements. The generalists would work in a system that allows them to ensure that each person receives all the health care they need regardless of their ability to pay for it, and the generalists would have the potential to guard against fragmentation in the delivery of care. Such a generalist embodies the medical practitioner role for primary health care that has the potential to deliver health for all. Like the Declaration, it is an ideal, but striving towards this goal is likely to have far-reaching health benefits. Generalism and the Alma-Ata DeclarationThe generalists’ character, reflexive and interpretive ways of being, biographical ways of knowing, and accessible, longitudinal, contextual approach place them at the crux of the social, economic and community sectors that are the focus of the Alma-Ata Declaration. The generalists’ biotechnical focus is the link to medicine, but also a way of bridging the gap between medicine and the personal, social and cultural circumstances of individual patients. This vision of generalism responds to the Alma-Ata Declaration and can inform primary care practice in developed or developing countries. There is a strong synergy between the Declaration and the conceptual model of generalism, especially around the importance of incorporating biopsychosocial aspects in the delivery of health care and the focus on first contact, locally accessible health promotion, prevention, cure and rehabilitation (section VII of the Declaration). The virtuous character in our model is in keeping with the spirit of social justice required in the Declaration (section V). The community focus of the generalist is critical to integrating the social and economic sectors into the promotion of health (section I), to bringing health care as close as possible to where people live and work (section VI), and to getting the kind of work done that the Declaration called for (section VII). The promise of generalismWe have identified a conceptual model of generalism that could underpin a new primary health care approach, building on the bold vision of the Alma-Ata Declaration. We have argued that a major limitation of the Declaration was its failure to consider the kind of physician and the health care relationships needed to deliver health for all. Having control over resources, participating in health care and ensuring communities are equipped and empowered to deal with their health needs are important ideals. But someone must integrate health care within a relationship context, continue that care, and support promotion of health, prevention, diagnosis and treatment. Health for individuals, let alone health for all, cannot happen without access to health care practitioners able to promote health, prevent disease, diagnose, treat, and follow up. This will require more than one health professional, but acknowledgement of the important central role of the generalist is missing from the Declaration. Few studies have explored whether generalist approaches to primary care are cost-effective. No randomised trial of generalism has ever been conducted, nor is it ever likely to be undertaken. But there is observational evidence that generalist primary health care contributes to achieving the goals of Alma-Ata.22 The potential pitfalls in achieving generalismGeneralism alone is not the answer. The issues of sustainability, war, terrorism, well planned cities, public transport, affordable housing, secure employment, quality childcare and education are just as important to health as the common physical and emotional health problems that consume most of the health dollars. The generalist offers a bridge between the biomedical and the social, but within limits. To truly realise the potential that generalism offers will require that generalists work closely with others with an expanded view of health and health care. In Australia, this would require us to reconsider the way GPs work and the infrastructure support required to enable them to undertake preventive, curative and rehabilitative health care as a core component of the primary care team. If this is made possible, generalists may find themselves not only providing physical and mental health care, but playing a role in a team that focuses on keeping individuals in their community safe from harm, finding them work for a living wage, advocating for a child-friendly environment, changing the gaming laws, or introducing a cervical cancer vaccination program. The generalist is a part of the wider health care and social system and the generalist role is inherently adaptable to local needs and grounded in local relationships. To avoid the pitfalls of fragmentation in health care and interprofessional rivalry that may stand in the way of achieving generalism and the ideals of Alma-Ata, this role will increasingly need to pay attention to the broad partnerships called for in the Declaration. ConclusionCritics may argue that our literature-based model encompasses an ideal that is impossible to achieve. But, much like the Declaration, if it is not an aspiration, it will never be achieved. One major challenge remains — whether the community as a whole will value the concepts of generalism and the Declaration made at Alma-Ata 30 years ago over the more seductive promise of specialism and high-tech, high-cost intervention. If health for all is the goal, governments, health care professions and individuals need to carefully consider the central role of generalism and the components set down at Alma-Ata, and will need to invest in making sure that they can happen. 1 Summary of the Declaration of Alma-Ata1 The 1978 Declaration of Alma-Ata formally adopted primary health care as the means for providing a comprehensive, universal, equitable and affordable health care service for all countries. Consisting of 10 sections, in summary it declares: I: health as the state of complete physical, mental and social wellbeing; II: the unacceptability of health inequalities, especially between developed and developing countries; III: the necessity of economic and social development for health; IV: the right and duty for lay participation in planning and implementing health care; V: the responsibility of governments for providing primary health care and for measuring health and social wellbeing; VI: the role of primary health care as the local, universally available, essential, first point of contact with the health system, based on practical, scientifically sound and socially acceptable methods and technology at a cost the community and country can afford; VII: the essential elements of primary health care (culturally relevant; addresses the main health problems; provides preventive, curative and rehabilitative care; provides health education; includes a multisectoral approach; community participation; integrated functional referral systems; consists of physicians, nurses, midwives, auxiliaries, and community workers trained to work as a health team); VIII: the need for government policies on primary health care; IX: the need for international cooperation for health; and X: the need for better use of the world’s resources and a policy for peace and disarmament. 2 A conceptual model: essential dimensions of a primary care generalist medical practitioner Ways of being (ontological frame) Virtuous character: holds ethical character traits of compassion, tolerance, trust, empathy and respect. Reflexive: interdependent; reflects on judgements and biases; lifelong learner. Interpretive: uses processes of interpretation to understand patients, with an emphasis on the contextual factors; use of multiple health systems languages; active listener; autonomous decisionmaker; has good communication skills. Ways of knowing (epistemological frame) Biotechnical: uses scientific and rational evidence; high index of suspicion; biomedically driven; technically focused; uses advanced information systems. Biographical: concentrates on lived experience and life story; family, carers, community and social knowledge all provide evidence. Ways of doing (theoretical frame) Access: accessible; first-contact point; gatekeeper; provides referral. Approach: balances individual versus population needs; consultation-based; holistic; comprehensive; flexible; adaptable; acts across clinical boundaries; provides early diagnosis; interdisciplinary team approach; negotiates and coordinates services; integrates knowledge; promotes health through education; prevents disease; is culturally sensitive; provides patient-centred care; minimises service inequities; reduces service fragmentation. Time: provides continuity of care over whole of life cycle. Context: community-based; uncertain; complex; deals with undifferentiated multiple problems of patients; acute and chronic care.
Jane M Gunn PhD, FRACGP, DRANZCOG · Victoria J Palmer PhD, BA(Hons) · Lucio Naccarella PhD · Renata Kokanovic PhD, BSociol · Catherine J Pope PhD, BA(Hons) · Judith Lathlean DPhil, MA, BSc(Econ) · Kurt C Stange MD, PhD
Getting back into the emergency department: diversifying general practice while relieving emergency medicine workforce shortages
New medical graduates expect to work in an environment that allows scope for flexibility and change across a career in medicine. Recruitment to general practice is adversely affected by its perceived limited scope of practice. Training in procedural and hospital skills is not difficult to access for general practice trainees, but complex and inconsistent credentialling criteria and protectionist attitudes among some specialist colleges mean that many skilled general practitioners are unable to utilise the full range of their skills in clinical practice. The discipline of emergency medicine is also experiencing difficulty in recruiting trainees. The employment of skilled GPs in emergency departments (including metropolitan departments) could improve vocational satisfaction for GPs and emergency physicians, and possibly also improve patient outcomes and flow through the emergency department.
Simon M Willcock PhD, FRACGP, DipRACOG
Addiction and addiction medicine: exploring opportunities for the general practitioner
Addiction medicine deals with problems arising from the use of psychoactive substances, and encompasses the disciplines of general practice and primary care, psychiatry, psychology, internal medicine, public health, pharmacology and sociology. Addiction is a chronic, relapsing illness that is difficult to cure. There are now effective, evidence-based interventions for the prevention and treatment of substance misuse disorders. Harm minimisation and treatment are more cost-effective than policing and supply-reduction methods of responding to substance misuse.
Brian R McAvoy MD, FAChAM, FRNZCGP
General Practice Workforce
Addressing general practice workforce shortages: policy options
There is an ongoing shortage of general practitioners in Australia, accompanied by a decline in the popularity of general practice as a career choice. Many factors influence the career choice of junior doctors and medical students, including role models, the quality of clinical attachments during training, remuneration, and flexibility of training and working hours. Evidence-based strategies that could increase the number of doctors choosing general practice as a career include longer and higher-quality general practice attachments during medical school and the early postgraduate years, and emphasising the positive aspects of general practice, such as flexibility. General practice would become a more attractive choice if remuneration was in line with hospital specialties.
Jill E Thistlethwaite MB BS, PhD, FRACGP · Stephen R Leeder MD, PhD, FRACP · Michael R Kidd MD, FRACGP · Tim Shaw PhD
Women’s contribution to general practice: Medusa or Mother Teresa?
If the female perspective is missing, how can true feminisation of the medical workforce occur? Much has been written about the feminisation of the medical workforce. However, this usually refers to the increasing numbers of women entering medicine, rather than to an adaptation of medical theories and practices to incorporate a female perspective. Women and men work differently, and these behavioural differences are attracting attention as the workforce debate brings women’s contribution to medicine, and their place in general practice,1 under an intense spotlight. A number of studies have demonstrated the gendered nature of communication and practice styles,2-6 health care delivery7 and patient care.8 Some have raised the question of whether female work styles contribute to the workforce problem9 — work styles that are often assumed to represent inherent female behavioural attributes.10 The tension generated by increasing numbers of women within a predominantly male-driven medical ethos can be examined using two conceptual models — the “Medusa effect” and the “Mother Teresa effect”. These are used to demonstrate how gender-based stereotyping, plus entrenched assumptions and concepts about gendered behaviour, may be affecting the interpretation of practice styles11 and underpinning the workforce debate. We argue that there is an urgent need to re-think the gendered nature of medicine in order to allow us to explore innovative solutions to the problem of the current workforce shortage in general practice. Exploring female attributes: what is acceptable behaviour? The Mother Teresa effect exemplifies the virtuous in female behaviour. It is based on the famous Roman Catholic nun who worked in the slums of Calcutta, India, for much of the 20th century. Her universally admired behavioural qualities included selflessness; a commitment to vocation above ambition or a personal life; chastity; a willingness to care for the bereft and the destitute; and subservience to a greater authority. Although these behavioural traits are not exclusively female, they do embody socially accepted female behavioural attributes. Medusa, on the other hand, is a mythical goddess whose fate is emblematic of transgressing the boundaries of acceptable female behaviour and highlights the complexities of gender relationships. Medusa emerges in the dawn of history, in many guises and in many civilisations. Her name means sovereign female wisdom, and she possessed powers of foresight, but Medusa paid a gruesome price for her wisdom and her power. Mythology has it that Medusa, a beautiful maiden, so enraged Athena after coupling with Poseidon in Athena’s temple that Athena turned Medusa into a hideous sight, and then assisted the hero Perseus to pursue the pregnant Medusa and behead her. The symbolism of Medusa hints at retribution if female knowledge, wisdom, sexuality and independence overpower the more acceptable female virtues of nurturing and caring. Female behaviour, women doctors and general practiceAn interplay between the Mother Teresa effect and the Medusa effect echoes the complexity of the female presence in medicine across several professional domains, including the doctor–patient relationship (and local care), the societal delivery of health care, and the medical profession itself.12 The doctor–patient relationshipWomen’s presence in medicine has been good for patient care. Studies from Western countries about gender differences in the consultation have produced similar findings — women have an inclusive and democratic style of communication13 that helps foster “collaborative relationships” with patients.12 Women tend to be “information giving”, use a more participatory decision-making model14 and appear less motivated by financial rewards.15 They deal with more complaints, are more patient-centred in their approach, and provide more preventive health care.2,16 These attributes, which could be grouped or labelled as consistent with the Mother Teresa effect, are valued by patients, appear to produce good patient outcomes,17 and have helped shift medical teaching away from a doctor-centred agenda to a patient-centred one.18 On the other hand, in relation to health care delivery, women’s work patterns are seen by some to limit patients’ access to medical services as well as being a contributory cause of workforce shortages. Although acknowledging that “empathy and communication are important”,1 quantitative studies also demonstrate that women work about 13.8 hours less per week than men, tend to work part-time, have longer consultations, and provide less institutional care, emergency services or procedural services.10 However, simply assuming that quantitative studies are evidence of female doctors’ inefficiency or “inability to live with risk”,1 or are a consequence of female doctors preferred working styles7 may confuse cause and effect. Numbers merely describe gendered work patterns — they do not and cannot explain them. Seeking such an explanation may help clarify solutions for some of our workforce problems. Attributing the cause to “women’s behaviour” and in doing so ignoring any other possible factors could reflect an underlying attitude related to the Medusa effect. The importance of these other factors, such as the patient’s gender, the sex match of the doctor–patient duo or the patient’s prior health status,5,19 was highlighted in an Australian study by Britt and colleagues, who established that some of the associations attributed to gendered work styles disappeared after controlling for the influence of age, experience, other practitioners’ characteristics, and patient mix.20 Similarly, a cross-sectional European study into consultation length found that 55% of the variance was due to factors at the patient level and that “the age and sex of the doctor had no impact on the duration of the consultation”.21 Societal delivery of health careThe missing ingredient in contemporary discussions of the effect of women in medicine is the role of sex socialisation, a powerful force for both women and men. The traditions of Western medicine have been forged in a male-centric work model. In this model, vocational commitment is demonstrated by long hours of work and dedication to the profession.18 This could be seen as the male version of the Mother Teresa effect, except that it is predicated on a personal life that is provided by a full-time “invisible” other. That invisible other is traditionally female. It would seem that little has changed. Many female medical students still see their gender as a disadvantage for their careers and expect that they will be required to sacrifice their professional lives to have a personal life, even if they are in a dual career relationship.22 This persistence of “gendered schemas” within the medical profession means that “men are consistently over-rated and women under-rated” in relation to competence and performance.23 Invisible barriers such as the classic glass ceiling24,25 — or other hidden forms of the Medusa effect — may often stymie women’s attempts at assertiveness or leadership. Overcoming the constraints of such a “discriminatory environment”18 may be having an adverse effect on female doctors’ health and wellbeing,26 especially if the effects of gendered behavioural expectations are not given a place at the “workforce patterns” discussion table. In any debate that draws on quantitative data, women are likely to “fall foul” for biological reasons. In a male-centric environment, periods of peak career building coincide with the time of establishing a family. Both are time hungry, and gendered socialising still sees women expected to take the prime responsibility for both children and domestic requirements.27 Gjerberg, from the Norway Work Research Institute, has pointed out that any discussion of medical workforce patterns that does not factor this expectation in ignores the fact that, while women work shorter hours in paid work, compared with their male colleagues, they work longer hours in total.28 The medical profession Women are here to stay, and we believe that trying to dance to the Henry Higgins refrain of “why can’t a woman be more like a man?” will not help us find workable and practical solutions to help shape the profession’s future. Women now account for about 37% of the Australian general practice workforce overall and half the workforce among general practitioners younger than 45 years. These trends appear set to continue, as two-thirds of all GP registrars younger than 35 years are female.29 As the medical workforce races toward a gender balance, to what extent is the female perspective influencing major decision making within the profession? Evidence suggests this is limited, as gender still appears to have a filtering effect in terms of leadership roles, choice of specialty, and academic advancement for women within the profession.30 Embracing gendered health careIf the female perspective is absent from medical decision making, how is it possible for true feminisation of the medical workforce to occur? Real feminisation implies an adaptation of medicine’s epistemology to include a female perspective and female ways of knowing, which are then expressed ontologically through its workforce. If the female voice is missing, so is the female perspective. As the number of female doctors continues to grow, their perspective is vital for finding workable and realistic solutions that meet society’s needs and expectations for adequate health care. An obsessive focus on women’s behaviour, whether it be on the Mother Teresa or the Medusa traits, in a gender “blame game” is unlikely to accomplish this perspective. As Australian researchers Joyce and colleagues have said, it is indeed “time for a new approach to workforce planning”.31 Are we mature enough then, as a profession, to explore assumptions about gendered social and professional roles and responsibilities? In laying these bare, are we ready to truly “feminise” the medical workforce and embrace new possibilities in workplace patterns that do not sacrifice ourselves, our children, our personal relationships or our responsibilities to our community to provide medical care? The implications for medical education, clinical practice and health care policy will be considerable (for some examples, see Box). A tall order certainly, but in the spirit of the recent Australia 2020 Summit, a think tank is urgently needed that has the gendered basis of medicine firmly at its centre, with a vision focused on the need for medical theory and practice to be inclusive of all the factors that are currently moulding medical workforce styles and health care delivery. Placing gendered workplace solutions on the agenda — some suggestions Medical education All students applying for medicine should be able to attend information sessions about the personal and social expectations of being a doctor. Medical students need to understand how sex socialisation and sexual stereotyping can affect self-expectations, patient expectations and society’s expectations of being a doctor. Vocational educational perspectives could address how the gender of the doctor (and the gender of the patient) can sculpt clinical practice. Clinical practice Alternative models of health care delivery could be explored, such as including childcare subsidies in practice incentive payments. This could, for example, help support practices to provide childcare facilities on site to enable doctors to have access to their children, while their patients have access to the doctors. Job-sharing rosters could address peak times for both practice and families; split (rather than continuous) shifts may help to better match supply and demand. Enhanced electronic communication could ensure appropriate patient handover and follow up. Health care policy There should be a decreased reliance on “proxy” workforce measures such as consultation times (if not controlled for patient gender, conditions managed, and health promotion). Patient health outcomes should be included in workforce modelling. The new opportunity provided by the GP Super Clinics could be used to trial gender-friendly workplace models of health care.
Lyn E Clearihan MB BS, MD, FRACGP, GradDipFM, MFM(Clin) · Jan Y Coles MB BS, PhD, MMed(Women’s Health), DCH, GCHPE
Medical teaching in rural Australia: should we be concerned about the international medical graduate connection?
The two rural workforce strategies of rural clinical schools and deployment of international medical graduates (IMGs) geographically overlap in Australia’s large expanse of under-served rural and remote areas. We used the Rural Clinical School of Western Australia (RCSWA) as a model to examine the relative numbers of IMG clinical academics, and the contribution of IMGs to rural clinical school development and education. IMGs have established six of 10 rural clinical school sites, maintained an academic presence, and continue to staff the RCSWA in high proportions. In a fragile rural work ecology, WA’s IMGs are contributing to both meeting current workforce needs and the education of future rural doctors. The “double debt” Australia owes to IMGs, stemming from the rich cross-fertilisation of these two workforce strategies, should be acknowledged.
Denese E Playford PhD · Moira A L Maley PhD, PGCertMedEd
Medical workforce expansion — uncertain times
Martin B Van Der Weyden
In This Issue
Bronwyn Gaut
Pelvic pain in women: common and challenging
Cynthia M Farquhar MB ChB, MD, FRANZCOG
Mandatory reporting of professional incompetence
Peter C Arnold BSc, MB, BA
Good manners and doctors
Martin B Van Der Weyden
In This Issue
Ruth Armstrong
Sustaining health reform
Martin B Van Der Weyden MD, FRACP, FRCPA
Clinical stroke guidelines: where to now?
Craig S Anderson FRACP, PhD