Volume 195 Issue 4

Emergency contraception and medical abortion are options, but education about them is vital Prevention is better than cure — especially in the field of sexual and reproductive health. Australia’s teenage pregnancy rates (17.3 per 1000 women in 2003)1 and abortion rates (19.7 per 1000 women in 2008)2 are high compared with other Western countries. Such rates are not inevitable, and recent contraceptive strategies were developed to help in reducing them. One such strategy was the rescheduling in Australia of the emergency contraceptive pill (ECP) containing levonorgestrel to Schedule 3 (over-the-counter) status, making it available from pharmacists without a prescription. Improved access to the ECP is a crucial issue, given that the sooner it is taken after unprotected intercourse, the more effective it is. By rescheduling the ECP, it was hoped that women would be able to obtain it more easily within the narrow time frame recommended, especially after hours and on weekends, when it is more difficult to access a general practitioner. A second-generation antiprogestin ECP, ulipristal acetate (30 mg), has now been released and is thought to be a more effective option up to 120 hours after unprotected intercourse.3 Our recently published Australian population study of over 600 women aged 16 to 35 years found that although 95% had heard of the ECP and 26% had used it, just under half (48%) were aware that the ECP was available over the counter.4 In addition, under half (45%) thought it was safe for the health of women, most (61%) erroneously believed that it would damage a pre-existing pregnancy, and 32% that it was an abortifacient, similar to mifepristone — all findings consistent with overseas studies.5,6 Women’s attitudes towards the ECP revealed various views and beliefs influencing their use, including moral and religious reasons, fear of side effects, and unrealistically low perceptions of pregnancy risk.4 Unsurprisingly, women with good knowledge of the ECP were more likely to report having used it. Some women (12%) thought they were unlikely to become pregnant, even when having unprotected intercourse at the most fertile time of the menstrual cycle.4 Although our linked study found that pharmacists believe further information provision following ECP dispensing is their responsibility,7 most women (84%) prefer to receive information from a doctor rather than a pharmacist.4 This offers an important opportunity for GPs to help patients prevent unintended pregnancy and abortion. GPs could include discussion of the ECP in all general consultations with women of reproductive age regarding contraception or reproductive issues, such as cervical cancer screening. Ideally, GPs should seek opportunities to discuss the ECP within an overall contraceptive strategy and with all female adolescents during routine health care visits. GPs can play a critical role in informing and educating women about their risks of becoming pregnant, the use of contraceptives generally and how to use them correctly and consistently. They can also counsel about risky sexual behaviour and the higher risk of an unplanned pregnancy resulting from such behaviour. They could encourage women to keep an advance supply of the ECP at home, if appropriate. Access to such ECP options would be more widely available if it were to be subsidised or free for women who are socioeconomically disadvantaged (eg, health care card holders). As well as the prevention of unplanned pregnancy, assistance with pregnancy termination may be necessary and should always be available if women are unable to continue with a pregnancy. There are parts of Australia where sex education is inadequate, access to contraceptive advice or support is lacking, and hospitals do not provide pregnancy termination services. This can lead to problematically late presentations for abortion.8 In Australia, the removal of the requirement for ministerial approval for the importation and supply of mifepristone means that doctors can now apply to the Therapeutic Goods Administration for approval to provide this drug to their patients for medical termination of pregnancy. Mifepristone is widely used in many countries, including the United Kingdom, the United States, France, New Zealand, Sweden and China and has been shown to be a safe, effective and highly successful treatment for the termination of early pregnancy.9,10 Already, women are being offered greater options when making the decision about an unintended pregnancy — they can choose to continue with the pregnancy, to place the baby for adoption, or if they opt for termination, a limited number of clinics, such as Marie Stopes International Australia,11 are now able to provide medical termination with mifepristone as an alternative to referral for surgical abortion. This option could, and probably should, be more widely available, but a greater emphasis on prevention is clearly needed. At the very least, a sustained public information campaign should address the misconceptions we have uncovered, and publicise the availability of effective contraceptive options. At most, a more comprehensive national sexual and reproductive health strategy should be implemented.

Angela J Taft MPH, PhD · Melissa K Hobbs MPH, PhD · Safeera Y Hussainy BPharmSci, PhD · Lisa H Amir MB BS, PhD · Kay Stewart BPharmSci, PhD · Anthony M A Smith BA(Hons), PhD · Julia M Shelley MPH, PhD · Colin B Chapman BPharmSci, BVSci, PhD

Objectives: To compare the clinical diagnosis of chronic obstructive pulmonary disease (COPD) with results of post-bronchodilator spirometry in general practice, and examine practitioner, practice and patient characteristics associated with agreement between clinical and spirometric diagnoses.Design, setting and participants: General practitioners from practices in Sydney identified eligible patients aged 40–80 years seen in the past year and prescribed respiratory medications whom they regarded as having COPD. Between November 2006 and April 2008, we collected information on the GPs and their practices, and demographic information, smoking status, comorbidities, respiratory medicines use, vaccination status, quality of life and spirometry results for participating patients.Main outcome measures: Frequency of COPD diagnosis on spirometry; odds ratios for characteristics associated with agreement between clinical and spirometric diagnoses.Results: 56 GPs from 44 practices participated in the study. Of 1144 eligible patients, 445 were recruited (mean age, 65 years; 49% male). Of these, 257 (57.8%) had post-bronchodilator spirometry consistent with COPD ± asthma, 16 (3.6%) had asthma only, 82 (18.4%) had normal spirometry, and 90 (20.2%) had other spirometric diagnoses. Having a spirometer in the practice was not predictive of agreement between clinical and spirometric diagnoses. Older patient age was significantly associated with correct diagnosis, while higher numbers of comorbidities were associated with misdiagnosis.Conclusions: A substantial proportion of patients clinically identified as having COPD in general practice do not have the condition according to spirometric criteria, with inaccurate diagnosis more common in patients with comorbidities. Policy and practice change is needed to support the use of spirometry in primary care.

Nicholas A Zwar MB BS, PhD, FRACGP · Guy B Marks MB BS, PhD, FRACP · Oshana Hermiz MB BS · Sandy Middleton PhD · Elizabeth J Comino BVS, PhD · Iqbal Hasan MB BS · Sanjyot Vagholkar MB BS, MPH · Stephen F Wilson MB BS, PhD, FAFRM

Objective: To evaluate the prescribing practices of Australian dispensing doctors (DDs) and to explore their interpretations of the findings.Design, participants and setting: Sequential explanatory mixed methods. The quantitative phase comprised analysis of Pharmaceutical Benefits Scheme (PBS) claims data of DDs and non-DDs, 1 July 2005 – 30 June 2007. The qualitative phase involved semi-structured interviews with DDs in rural and remote general practice across Australian states, August 2009 – February 2010.Main outcome measures: The number of PBS prescriptions per 1000 patients and use of Regulation 24 of the National Health (Pharmaceutical Benefits) Regulations 1960 (r. 24); DDs’ interpretation of the findings.Results: 72 DDs’ and 1080 non-DDs’ PBS claims data were analysed quantitatively. DDs issued fewer prescriptions per 1000 patients (9452 v 15 057; P = 0.003), even with a similar proportion of concessional patients and patients aged > 65 years in their populations. DDs issued significantly more r. 24 prescriptions per 1000 prescriptions than non-DDs (314 v 67; P = 0.008). Interviews with 22 DDs explained that the fewer prescriptions were due to perceived expectation from their peers regarding prescribing norms and the need to generate less administrative paperwork in small practices.Conclusions: Contrary to overseas findings, we found no evidence that Australian DDs overprescribed because of their additional dispensing role.

David Lim DrPH · Jon D Emery MB BCh, FRACGP, DPhil · Janice Lewis MBus, DBA, FACHSE · V Bruce Sunderland BPharm, DCC, PhD

There has been much written in the medical press about general practitioners subjected to violence. Prevention of such violence has been taken on board by medical defence organisations as part of “risk management”, and this is well and good, but it implies that the violence is the problem in and of itself, rather than simply a symptom of a deeper malaise. So, while it may well be in our best interests to place our chairs near an exit, train our staff to defuse tense situations and have our panic buttons at the ready, these all represent symptomatic approaches to the problem, and should not distract us from its root cause. Thirty-five years ago, when I began my medical career, physicians were considered god-like — lofty, infallible, unassailable. The patrician doctor (usually male) would stop at the foot of the bed (with underlings in tow), utter a diagnosis, pronounce sentence (otherwise known as treatment) and move on. Questions were not encouraged. Patients remained largely ignorant of the nature of their condition, the whys and wherefores of treatment and the risks involved. Few railed against this state of affairs, which reflected their expectations, based on the assumption that the doctor would invariably act in their best interests. Cruikshank’s “British beehive” (http://collections.vam.ac.uk/item/O155895/print-the-british-bee-hive/) prevailed — everything was in its place, and all was right with the world. No doctors were stabbed. There is something to be said for “benevolent despotism”, which mostly operates far more decisively and efficiently than its Westminster counterpart, a system that remains slow, cumbersome and hamstrung by competing interests. The assumption is that doctors are benevolent in their despotism, an assumption which generally holds as true today as it did then, despite the fact that honorary medical officers have given way to consultants. But slaves have been freed, the South has been desegregated, Indigenous populations have been enfranchised and the tyranny of paternalism has been replaced with the tyranny of information, a far more prickly and elusive master who, though ruling through fear, cannot be unseated through insurrection. The role of death as society’s greatest leveller has been largely usurped by the internet, and perhaps it is no coincidence that the rise in violence against medical practitioners has been most evident in the past decade, since its inception.1 For two generations now, society has been bombarded with a tsunami of media-generated headlines, slogans, myths, misinformation, disinformation, political correctitude and dumbed-down, vastly oversimplified, reader-digestible distillations of what passes for knowledge. This has resulted in a populace as pitifully under-equipped for medical decision making as it is convinced of its credentials to engage in it. Dumping the internet into the midst of this social foment is tantamount to placing a weapon in the hands of a murderer. And this is precisely what has happened. The mirage of patient empowerment — based though it is, on the illusion of knowledge — has, by extension, resulted in doctor disempowerment. We are now the natural victims. Were our patients happy with their new-age lot in life, all of this would probably come to nought. But the handmaiden of information is choice, whose tyranny is as vicious and unremitting as it is subtle. Paucity of choice meant that the patient of bygone days harboured few expectations. Hence, they were rarely disappointed. If a person had a job at 20, it was more than likely that they would still have one at 50, even if it was the same job. And it was equally likely that they would still have the knowledge and expertise to do that job, even with little ongoing training. Things didn’t change much. Life was predictable. But we now live in an age of rapid, accelerated change —something inherently anathema to human biology. Jet-lag has broadened to “life-lag”. When we arrive at work in the morning, we are never quite sure that we will still have a job that evening. And even if we do, we remain uncertain that we can cope with the ceaseless bar-raising that has become the lot of the accreditee. Along with the technology that has “freed” us has come a plague of choice — complex, often purposeless technical choice that we, as the butt of the IT joke, are not qualified to make. So we put our trust in the “experts”, whose interests remain more vested than altruistic. Choice, it seems, comes with a price tag redolent of coercion. And once you’re on the merry-go-round, there’s no getting off. Mobile phone contracts rival the theory of general relativity in their complexity. Computers consistently malfunction, requiring the intervention of a generation of pimply, postpubertal postliterate empiricists, and invariably demand frequent and overpriced upgrading. This is capitalism at its most razor-sharp, mercilessly herding the helpless consumer before the cow-catcher of its rapacity. The consumer is now the consumed; capitalism is perfected. And so society is now peopled with waves of anxious, uncertain, harried folk, constantly feeling put-upon and ripped off, operating on a hair-trigger fuse that only requires the slightest irritation (“I’m sorry, but there are no appointments available till this afternoon”) to throw the switch. Even the role of psychosis in several of the more notable violent incidents can be sheeted home, at least partly, to the wholesale levelling of society’s playing field. For, as an ill conceived token gesture in the direction of patient empowerment, many socially ill equipped, mentally ill patients who should still be in lock-up care have been released into the community. The world, it seems, is drunk with empowerment. Suckled on the teat of so-called “reality TV” (as if there could be anything further removed from reality than the highly fabricated environments of this pernicious medium), the present generation has been led to believe that Rome can be built in the time it takes to fry an egg. Ordinary citizens, devoid of training, can become opera stars overnight. Or master chefs. Or television show hosts. Or simply celebrities, famous for nothing more than being famous. All of this supports the perennial Hollywood myth that anyone can be or do anything their shiftless heart desires, regardless of intelligence, talent or the capacity for work. But there is a time when even the drunkard must sober up; when the illusion of empowerment, based as it is on a drive for the elimination of perceived elitism, is seen in the clear light of day for what it really is: the loss of respect for knowledge. Not cereal-box-coupon sloganry, nor shotgun-style prescribing information overload, nor Wikipediatric lowest common denominatricks, but good, old-fashioned, hard-won, rote-learned, experience-based, rigorously tested knowledge. What the political correctionists among us call elitism, I refer to as expertise. Expertise based on knowledge. The patient–doctor relationship does not represent a team, it represents an unequal pairing in which the doctor has the knowledge and the power and the patient does not. At the time I entered medicine, it was seen by most of my peers as more a calling than a service, a perspective shared by many of our patients. That is no longer the case. Until society relearns the centrality of these values, doctors will continue to be stabbed. But this is just the opinion of a mere medico.

Ron Elisha MB BS

To the Editor: Despite the availability of clinical guidelines,1 management of patients with colorectal cancer is variable.2 The lack of a clear referral pathway can delay this journey3 and result in patients not receiving optimal care.4 To increase our understanding of factors influencing the referral of patients with colorectal cancer from general practice to specialists, we examined the views of 19 general practitioners in four focus groups — held in rural and urban New South Wales, rural Queensland, and urban South Australia. The relationships of these GPs with specialists not only helped expedite referral but also improved quality of care and feedback. The GPs considered that direct personal contact enhanced their relationships with specialists. This was cultivated over time and was seen as a measure of the GPs’ commitment to getting the best care for their patients. This was especially important for the GPs in rural and remote areas who advocated for patient needs, including travel for diagnosis and treatment and completion of follow-up care. The GPs felt that influencing the referral process required overcoming barriers within the public health system and/or facilitating referral to private providers. GPs preferred referral to the private health services compared with referral to the public system because of perceived delays and communication difficulties in the public system. GPs described a system of referral that was ad hoc and not informed by best practice guidelines or outcomes. They were most influenced by the ease of access to appropriate and timely consultations and the quality of feedback from specialists. Although this works well much of the time, we need a system in the public and private health sectors that identifies patients who may have cancer, investigates and treats them in a timely fashion, and delivers care that meets optimal standards. As patients of surgeons with higher caseloads tend to have better outcomes,5 GPs need better information about surgeon caseload. Finally, as we increasingly move towards working in multidisciplinary teams, it would be useful for GPs to have information regarding other support staff linked to surgeons.

Mark F Harris · Shane W Pascoe · Lisa J Crossland · Justin J Beilby · Craig Veitch · Allan D Spigelman

Objective: To identify barriers to, and enablers of, the uptake of preventive care in general practice from the perspective of community members, and to explore their sense of the effectiveness of that care.Design, participants and setting: Qualitative study involving 18 focus groups comprising 85 community members aged over 25 years, from two areas of metropolitan Melbourne that were identified as being of high and low socioeconomic status (SES). The study was performed between 25 May and 9 December 2010. Groups were stratified by age, sex and location (high or low SES).Main outcome measures: Factors related to practitioners, patients and structure and organisation that may act as barriers to and/or enablers of preventive care in general practice.Results: Participants saw preventive care as legitimate in general practice when it was associated with concrete action or a test, but rated their general practitioners as poor at delivering prevention. Trust, rapport and continuity of care were viewed as enablers for participants to engage in prevention with their GP. Barriers to participants seeking preventive care through their GPs included lack of knowledge about what preventive care was relevant to them, consultations focused exclusively on acute-care concerns, time pressures and the cost of consultations.Conclusions: A disconnect exists between patient perceptions of prevention in general practice and government expectations of this sector at a time when general practice is being asked to increase its focus and effectiveness in this field.

Danielle Mazza MD, FRACGP · Lyndel K Shand BA(Hons) · Narelle Warren BA(Hons)/BSc, PhD · Helen Keleher PhD, FPHAA · Colette J Browning MSc, PhD, FAPS · Emma J Bruce BAppSc(Hons), PhD

Until now, services have been poorly coordinated and individual practitioners unsupported Each year Australia accepts around 14 000 refugees who have been forced to flee their homelands as a result of war and other traumatic events. The majority of these new arrivals have been assessed and granted permanent humanitarian visas offshore. Only a minority arrive by boat or aeroplane to seek asylum here.1 Among resettlement countries, Australia makes a significant contribution to the international effort, and our refugee settlement support services are laudable. However, we struggle at times to provide accessible and responsive health care services for refugees. Like other migrants destined for Australia, offshore refugees undergo a health assessment overseas to detect conditions of public health importance. Nevertheless, many refugees carry considerable health burdens that are not the focus of this medical assessment. They have had limited access to health care, and many suffer nutritional deficiency, are not immune to vaccine-preventable conditions and may suffer chronic illnesses such as hepatitis B.2-4 As a result of torture and other forms of trauma, many are psychologically vulnerable. Achieving good health care for refugees in Australia presents a number of challenges, both for the refugees who seek care and for the health care practitioners who seek to provide effective services. Our refugee population is too dispersed to have a single health assessment service such as New Zealand’s Mangere Refugee Reception Centre. Some states have specific services for short-term health assessment, while elsewhere, health care for newly arrived refugees is devolved to mainstream general practice, community health centres, or small non-government organisations.5 This patchwork of disconnected services is further strained by the trend for refugees to settle in outer metropolitan, regional and rural townships across Australia, where health services are already stressed.6 Lack of coordination and the isolation of those caring for refugees can lead to a number of problems. First, health care providers may be unaware of how best to manage unfamiliar disease profiles.7 Refugee health is a field that changes rapidly. About 5 years ago, 70% of newly arrived refugees were from Africa.8 In the financial year 2009–10, refugees from Burma or Iraq made up more than one-quarter of the humanitarian intake, and 15% were from Bhutan or Afghanistan.1 Doctors might need to focus on schistosomiasis and prevention of rickets in one cohort, then malaria and micronutrient deficiencies in another. Policies and practices for screening refugees for tuberculosis differ between states. Second, doctors may be unaware of specific provisions for and needs of refugees. For the 4 years that a specific refugee health assessment item (Item 714) existed on the Medicare Benefits Schedule (MBS), fewer than half of newly arrived refugees benefited from it (data retrieved as a Medicare Australia item report). Preventable deaths can occur when hospital referral mechanisms are not understood or interpreters not used.9 Third, emerging issues in refugee health care are rarely met with timely public policy solutions. Although populations known to be at high risk of vitamin D deficiency have formed a substantial part of the humanitarian intake for at least a decade, access to high-dose vitamin D treatment remains problematic. Schistosomiasis is highly prevalent in many African countries, but the standard treatment (praziquantel) was not subsidised under the Pharmaceutical Benefits Scheme (PBS) until more than 5 years after the first intakes of refugees from these countries. Since 2005, when changes to the funding of vaccinations were introduced, catch-up immunisation for refugees has become increasingly difficult, and long-term funding of free catch-up vaccines remains precarious in many states. Psychiatric services for asylum seekers and refugees remain underresourced. These problems reflect, in part, inadequate networks of communication between health care providers, and between health care providers and policymakers. The recently formed Refugee Health Network of Australia (RHeaNA) is helping to overcome these barriers. RHeaNA is a national collaboration of over 140 refugee health service providers (general practitioners, nurses, specialists, public health practitioners, academics and policymakers) across all states and territories. Its key purposes are summarised in the Box. RHeaNA supplements discipline-specific groups, such as the Royal Australian College of General Practitioners’ newly formed Special Interest Group in Refugee Health, and draws on state-level networks in Victoria and South Australia. Since its formation, the Network has collaborated in providing rapid feedback to the Australian Government Detention Health Advisory Group on health issues among asylum seekers exiting immigration detention centres. Through pooling data from refugee health services, the Network is uncovering an emerging problem of vitamin B12 deficiency among Bhutanese and Afghan refugees.10 RHeaNA has provided input at a national level on primary health care reforms, humanitarian settlement services, MBS item numbers, national hepatitis B policy, and the need for certain pharmaceuticals to be listed on the PBS. RHeaNA has engaged in a direct program of outreach to GPs and nurses about emerging health issues in each state, most recently in supporting GPs involved in providing quality health care to asylum seekers since the new policy of transferring asylum seekers from immigration detention centres to community detention took effect. In the new primary care landscape, where integrated care is an important focus, RHeaNA provides a much-needed forum for collaboration and communication between practitioners, policymakers and researchers, to support more effective health care for this vulnerable population. Refugee Health Network of Australia: key purposes To inform and support quality holistic health care for refugees in Australia. To provide advice to policymakers at Commonwealth and state and territory level on current and emerging issues in refugee health in Australia. To provide a forum for exchange of information between providers of refugee health care and other relevant stakeholders across Australia. To develop a research agenda and disseminate research findings. Contact details Refugee Health Network of Australia secretaryATrefugeehealthaustralia.org chairATrefugeehealthaustralia.org Special Interest Group in Refugee Health fsiATracgp.org.au

Christine B Phillips MB BS, MA, FRACGP · Mitchell M Smith MB BS, MPH, FAFPHM · Margaret Kay MB BS(Hons), FRACGP, DipRACOG · Sue Casey BAppSc(OccTherapy), BA, MA

Objectives: To determine whether community-based asylum seekers experience difficulty in gaining access to primary health care services, and to determine the impact of any difficulties described.Design, setting and participants: Qualitative study using semi-structured interviews between September and November 2010. Participants were community-based asylum seekers who attended the Asylum Seekers Centre of New South Wales, and health care practitioners and staff from the Asylum Seekers Centre and the NSW Refugee Health Service.Results: We interviewed 12 asylum seekers, three nurses, one general practitioner and one manager. Asylum seekers’ responses revealed that their access to primary health care was limited by a range of barriers including Medicare ineligibility, health care costs and the effects of social, financial and psychological stress. Limited access contributed to physical suffering and stress in affected asylum seekers. Participants providing care noted some improvement in access after recent government policy changes. However, they noted inadequate access to general practitioners, and dental, mental health and maternity care, and had difficulty negotiating pro-bono services. Both groups commented on the low availability of interpreters.Conclusions: Access to primary health care in Australia for community-based asylum seekers remains limited, and this has a negative effect on their physical and mental health. Further action is needed to improve the affordability of health care and to increase the provision of support services to community-based asylum seekers; extending Medicare eligibility would be one way of achieving this.

Erin A Spike · Mitchell M Smith MB BS, MPH, FAFPHM · Mark F Harris FRACGP, MD

Objective: Previous research with the Australian Morbidity and Treatment Survey (1990–1991) showed significant differences in general practitioner characteristics and patient mix of male and female GPs. Even after adjusting for these, it was seen that male and female GPs managed different types of medical conditions. The proportion of female GPs increased from 19.6% in 1990–1991 to 37.1% in 2009–2010. This study investigates whether differences remain two decades later.Design and setting: Analysis of 2009–2010 Bettering the Evaluation and Care of Health (BEACH) data examining GP characteristics, patient encounter characteristics, patient reasons for encounter (RFE), problem types managed and management methods used, by GP sex. Whether GP sex was an independent predictor of problem types being managed, or management methods used, was tested using multiple logistic regressions and Poisson regression.Participants: 988 GPs recorded 98 800 GP–patient encounters.Main outcome measure: Adjusted differences in clinical activity of male and female GPs.Results: After adjustment, compared with male GPs, females recorded more RFEs about general and unspecified issues and endocrine, female genital, pregnancy and family planning problems; and fewer concerning the musculoskeletal, respiratory, skin and male genital systems. Female GPs managed more general and unspecified, digestive, circulatory, psychological, endocrine, female genital and social problems; recorded nearly 20% more clinical treatments and referrals; recorded nearly 10% more imaging and pathology tests; and 4.3% fewer medications.Conclusions: After two decades, even with increased numbers of female GPs, the differences in problems managed by male and female GPs remain, and will probably continue. Female GPs use more resources per encounter, but may not use more resources in terms of annual patient care.

Christopher M Harrison BPsych(Hons), MSocHealth · Helena C Britt BA, PhD · Janice Charles BA, MSc(Med)

Objective: To describe how Medical Benefits Schedule (MBS) chronic disease (CD) item claims vary by sociodemographic and health characteristics in people with heart disease, asthma or diabetes.Design, setting and participants: A cross-sectional analysis of linked unit-level MBS and survey data from the first 102 934 participants enrolled in the 45 and Up Study, a large-scale cohort study in New South Wales, who completed the baseline survey between January 2006 and July 2008.Main outcome measure: Claim for any general practitioner CD item within 18 months before enrolment, ascertained from MBS records.Results: The proportion of individuals making claims for MBS CD items was 18.5% for asthma, 22.3% for heart disease, and 44.9% for diabetes. Associations between participant characteristics and a claim for a CD item showed similar patterns across the three diseases. For heart disease and asthma, people most likely to claim a CD item were women, older, of low income and education levels, with multiple chronic conditions, fair or poor self-rated health, obesity and low physical activity levels. The pattern of claims was slightly different for participants with diabetes in that there was no significant association with number of chronic conditions, smoking or physical activity.Conclusions: Many individuals with self-reported CD do not claim CD items. People with diabetes and individuals with greatest need based on health, socioeconomic and lifestyle risk factors are the most likely to claim CD items.

Kirsty A Douglas DipRACOG, MD, FRACGP · Laurann E Yen BSc, MPsych · Rosemary J Korda BAppSci, MAppSci, PhD · Marjan Kljakovic MB ChB, FRNZCGP, PhD · Nicholas J Glasgow BHB, MB ChB, MD

A 60-year-old woman with a history of severe depression presented with erysipelas of the lower limbs. Her feet were malodorous, with thickened skin, a leathery texture, hyperkeratosis and fissuring. Severe onychogryphosis was also observed (Box). She lived in a country house with her son, who was developmentally delayed, in conditions of poor hygiene, and refused any outside assistance. Onychogryphosis (also known as “ram’s horn nails”) may be associated with several factors, including peripheral vascular disorders, infection, injury, diabetes, or the inadequate intake of nutrients, but most often, as in this case, it occurs as a result of long-term neglect. Severe onychogryphosis, with thickened, curved, discoloured toenails penetrating adjacent toes

Nicola Mumoli

To the Editor: Equitable access to health care in Australia is facilitated by bulk-billing so that patients incur no out-of-pocket costs for medical services. From 1995 to 2001, there was a steady decline in bulk-billing of general practice consultations and rates of bulk-billing were lower for women living in rural areas than for those from urban areas.1 In 2004, Medicare incentives for bulk-billing were introduced — additional rebates for bulk-billed services provided to concession card holders or children under 16 years, and a higher rebate for services provided to eligible patients in rural and remote areas, selected metropolitan areas with a shortage of general practitioners or low bulk-billing rates, or anywhere in Tasmania.2,3 We assessed the bulk-billing rates for participants in the Australian Longitudinal Study on Women’s Health4,5 following the introduction of these items. We analysed 2002–2008 data on out-of-pocket costs for general practice consultations (services with item numbers 1–98, 601, 602, 697 or 698 in the Medicare Benefits Schedule). Cohorts of older, mid-aged and younger woman (born 1921–1926, 1945–1951 and 1973–1978, respectively) who had consented to the release of Medicare data were included in the analysis. They were classified according to area of residence recorded at Survey 5 (conducted in 2007–2009), using the Accessibility/Remoteness Index of Australia Plus (ARIA+).6 Claims for services, including items charged to the Department of Veterans’ Affairs, were identified from linked Medicare data.7 The study was approved by the Human Research Ethics Committees of the University of Newcastle and University of Queensland. Medicare data were available for 3631 older women, 6697 mid-aged women and 3546 younger women (Box). In 2002, 61% of older women in major cities had no out-of-pocket costs, and this proportion was lower for older women in regional and remote areas. From 2005, there was a marked increase in the proportion of older women with no out-of-pocket costs across all areas, especially in remote and very remote areas (where 87% had no out-of-pocket costs in 2008). Older women from inner regional areas were most disadvantaged in terms of bulk-billing, even after the introduction of bulk-billing incentives. Mid-aged and younger women were less likely to have no out-of-pocket costs than older women but showed similar, albeit less dramatic, increases in bulk-billing. Our data show an overall improvement in access to bulk-billing, although some inequity remains for women in inner regional areas. This contrasts with earlier findings of declining rates of bulk-billing and increasing out-of-pocket costs, particularly in rural areas and for older women.1 The large increases in bulk-billing that we observed for older women are likely to be due to increased use of general practice services overall8 and a higher likelihood of having a concession card. The impact of the concession card holder incentive may have been greater than the geographical targeting. A strength of this study is that the results are based on a large national random sample. A limitation is that women who consented to the release of Medicare data had higher levels of education than non-consenters,9 which may have resulted in underestimation of the proportions of women who had all their consultations bulk-billed. Also, while bulk-billing incentives are aimed at areas defined by Rural, Remote and Metropolitan Areas classification, our data were analysed according to the ARIA+ classification (which is now the standard classification for accessibility and remoteness and is stable over time). The Medicare incentives scheme for bulk-billing should be evaluated further to assess the potential for reducing inequity for people in inner regional areas and for disadvantaged groups who may have a greater need for services but less access. Women who had at least one claim but incurred no out-of-pocket costs for general practice consultations, 2002–2008* 2002 2003 2004 2005 2006 2007 2008 1921–1926 birth cohort Major city (n = 1598) 971 (61%) 875 (55%) 935 (59%) 1131 (71%) 1148 (73%) 1181 (75%) 1183 (75%) Inner regional (n = 1351) 635 (48%) 565 (42%) 634 (47%) 855 (64%) 879 (66%) 922 (69%) 909 (68%) Outer regional (n = 551) 269 (49%) 266 (49%) 309 (57%) 391 (72%) 414 (76%) 403 (74%) 410 (75%) Remote or very remote (n = 62) 35 (57%) 28 (48%) 35 (59%) 46 (78%) 51 (84%) 52 (85%) 54 (87%) 1946–1951 birth cohort Major city (n = 2495) 720 (31%) 624 (27%) 595 (26%) 670 (29%) 711 (30%) 794 (34%) 803 (34%) Inner regional (n = 2711) 429 (17%) 367 (15%) 434 (17%) 579 (23%) 645 (26%) 680 (27%) 743 (29%) Outer regional (n = 1264) 237 (21%) 225 (19%) 254 (22%) 334 (29%) 364 (32%) 409 (35%) 432 (37%) Remote or very remote (n = 213) 59 (31%) 58 (30%) 54 (28%) 63 (33%) 77 (40%) 84 (45%) 86 (44%) 1973–1978 birth cohort Major city (n = 1944) 599 (33%) 457 (26%) 445 (25%) 455 (26%) 475 (28%) 514 (29%) 523 (30%) Inner regional (n = 903) 161 (20%) 135 (16%) 140 (17%) 173 (21%) 176 (21%) 208 (25%) 193 (23%) Outer regional (n = 494) 92 (21%) 83 (19%) 91(21%) 93 (21%) 103 (24%) 107 (25%) 116 (26%) Remote or very remote (n = 115) 30 (30%) 30 (30%) 30 (29%) 31 (31%) 34 (35%) 41 (43%) 36 (38%) * Sixty-nine women from the 1921–1926 cohort, 14 women from the 1946–1951 cohort, and 90 women from the 1973–1978 cohort had no claims for these items during 2002-2008, and n values vary slightly for each year depending on the number of women with a claim for that year.

Xenia Dolja-Gore · Julie E Byles · Deborah J Loxton · Richard L Hockey · Annette J Dobson

Objectives: To compare the findings of the 1997 and 2007 Australian national surveys of mental health and wellbeing (NSMHWBs) with respect to the role of general practitioners in providing mental health services.Design, setting and participants: There were 10 641 participants Australia-wide in the 1997 survey and 8841 in the 2007 survey. Data were gathered through face-to-face interviews using a written questionnaire.Main outcome measures: Rates of use of GPs and other health care providers for treatment of mental health problems; levels of met and unmet need for mental health services reported by those accessing GP services.Results: Between 1997 and 2007, the proportion of people accessing any mental health care service within the previous 12 months increased significantly, from 12.4% to 21.4% (P < 0.01), although the proportion accessing GP care for mental health problems did not increase. In both surveys, nearly 60% of individuals with self-assessed mental health problems sought no professional help for their problems, although about 80% of these non-users had seen GPs about other matters. The proportions of participants who reported receiving sufficient information, medication and/or therapy for their mental health problem increased significantly over the 10-year period. However, unmet need for information also increased. In both surveys, over 90% of participants aged 60 years or over with self-assessed mental health problems reported obtaining no help for their mental health problem despite seeing a GP for other reasons.Conclusion: Despite a significant rise in the use of mental health services, the role of GPs in providing such services has not increased.

Ruth A Parslow MPH, PhD · Virginia Lewis PhD · Geraldine Marsh BEd, GradDipHlth AdminEduc

Objective: To compare the demographics of general practitioners in two practice-based research networks (PBRNs) and to explore the generalisability of research findings from these PBRNs.Design, setting and participants: Cross-sectional questionnaire-based study of two geographically-based PBRNs — Hunter New England Central Coast Network of Research General Practices (NRGP) and Primary Healthcare Research Network-General Practice (PHReNet-GP) — during August–September 2010. All 183 GP members of both PBRNs were invited to participate; of these, 140 (77%) participated.Main outcome measures: GPs’ demographics, use of languages other than English in consultations, and previous participation in research. Practices’ use of practice nurses. Socioeconomic status and rurality or urbanicity of practice location.Results: Compared with PHReNet-GP GPs, NRGP GPs were more likely to work in a practice employing a practice nurse (100% v 53.8%; 95% CI for difference, 30.5%–61.8%; P < 0.001), worked in larger practices (2.9 more full-time-equivalent GPs per practice; 95% CI, 2.1–3.6; P < 0.001), and were less likely to work in a major city (33.7% v 89.7%; 95% CI for difference, 42.8%–69.3%; P < 0.001). NRGP GPs also worked in practices with a different spectrum of socioeconomic disadvantage, and were less likely to have been involved in research as a researcher (35.4% v 76.9%; 95% CI for difference, 25.3%–57.8%; P < 0.001). Fewer NRGP GPs consulted in languages other than English (8.9% v 64.1%; 95% CI for difference, 39.1%–71.2%; P < 0.001). There were also differences between these and national general practice statistics.Conclusions: These results suggest possible lack of generalisability of findings from some types of studies conducted in single PBRNs. In such circumstances, collaboration of PBRNs may produce more generalisable results.

Parker J Magin PhD, FRACGP · Melanie J Marshall BSc(Hons), GradCertMath, PhD · Susan M Goode BSc · Georgina L Cotter BA, GradCertApplSci(SocialStats) · C Dimity Pond PhD, FRACGP · Nicholas A Zwar MPH, PhD, FRACGP

Team care is replacing individual GP care, but is this good for patients and for general practice? Dr James Best is a GP from Sydney who won the Royal Australian College of General Practitioners General Practice Supervisor of the Year Award 2010. As a young fella, graduating from medicine and then going through general practitioner training, I was drip-fed a culture of fierce independence. This independence extended to the notion that a “good GP” was one who was intricately connected with his or her patients, and barriers to this connection, including computer screen distraction, outsourcing of patient contact to others, or anything that stopped you looking your patients in the eye and spending time with them, were to be avoided. My colleagues and I learnt — and believed — that if we were spending one-on-one time with our patients, observing their body language, picking up social cues, and finding out about how they were connected with their families and communities, these would all enhance our ability to develop rapport and maximise clinical success. We wanted to know — really know — our patients, and didn’t really want anyone else in the room with us. How things have changed. We are now in a period of flux regarding the best way to manage patients in Australian primary care. Other factors besides the “connection” to our patients have entered the equation. The looming wave of chronic disease management — the one we are looking anxiously over our shoulders at as it heads our way — is one of them. A gradual but steady increase in the understanding and (at times) acceptance of the value of team care is another. We are slowly coming around to the idea of letting other professionals help us in our connection and, conversely, helping other professionals connect with our patients and each other. Yet, 20 000 professionals do not represent a homogeneous group. An individual GP in Australia may have been trained any time in the past 50 years, may be rural or urban, young or old, motivated or disenchanted, innovative or conservative. Governments and their advisers chip away at GP independence with both carrot and stick. They want change and they want team care management, but, as many of us know, not always for the right reasons. So, do we dare disturb the GP universe? Yes and no. We need to take the best of the old and the best of the new. We should never lose sight of the fact that connecting with our patients, establishing rapport over time and developing a relationship between patient and doctor founded on trust is clinically invaluable. This will require one-on-one time, and quite a lot of it, and will still be built on all the same time-honoured principles of communication. There are some things that patients will only reveal to someone they know and trust, and there are some things that will only be picked up by a doctor who knows an individual patient and his or her particular idiosyncrasies well. However, a changing world requires nimble thinking. We and our governments and funders cannot ignore what is happening to the population we seek to serve and the increasingly rationed resources — financial, workforce and otherwise — available to do so. We should also be cognisant of the benefits of letting others into our party. Other professionals such as practice nurses, allied health workers and specialists connect with our patients in their own ways, and differing viewpoints can provide a clearer picture of the problems at hand. It should not be about replacement, but enhancement. If we can incorporate the differing viewpoints of all professionals, outcomes for patients are only likely to improve, just so long as that cornerstone — the family doctor knowing and connecting with his or her patients — is never allowed to be trumped by competing interests.

James A Best MB BS, FRACGP, DipPaed

Will Medicare Locals represent a new layer of potentially ineffectual bureaucracy? The Australian federal government is seeking to boost the role and organisation of primary care as part of a suite of health system reforms.1,2 Yet much of the all-important detail on what the primary care sector will look like, the shape new Medicare Locals (primary health care organisations that have the aims of supporting health professionals, improving primary care service delivery at a local level and improving access to after-hours primary care)3 will take, and how these new organisations will function remains to be worked through. New Zealand has a wealth of experience in primary care reform over the past two decades that Australian policymakers could usefully consider for lessons. There have been two main reform eras in New Zealand (Box), with different lessons. The first, through the 1990s, saw general practitioners grouping into Independent Practitioner Associations (IPAs). Stimulated by the introduction of contracting for health services in New Zealand’s public health system, IPAs were organised and driven by doctors. Key to IPA development were a number of visionary GP leaders who saw benefits to organisation, as well as government funders willing to provide support. By the end of the 1990s over 80% of GPs belonged to an IPA and numerous innovations had emerged, including budget holding for referred services, capitation for some groups, delivery of services by allied practitioners, and commencement of research initiatives into comparative effectiveness.4 IPAs facilitated one of the highest rates of primary care computerisation among Organisation for Economic Co-operation and Development countries in the period, and developed a working model of “clinical governance”.5 Some IPAs had produced plans to purchase and integrate all health services for their patients. GPs showed that, with leadership and will, “organised primary care” focused on improved service delivery and professional development, with strong buy-in and commitment from the GP community, was possible. The second era, in the 2000s, saw the introduction of Primary Health Organisations (PHOs) by a government opposed to the medically dominated private delivery model of the IPAs. PHOs were instead modelled on World Health Organization Alma-Ata principles of free or low-cost comprehensive primary care, delivered by multidisciplinary teams with community governance. Hastened by an additional 6%–7% in the total health budget, with the new money specifically designated for primary care, around 80 PHOs of varying sizes developed from 2002 to 2008. A PHO required an enrolled population, GPs were all moved to capitation for the government portion of their incomes (around 50%), including additional funding to reduce patient charges, and special funding was provided for “Services to Improve Access”, “Care Plus” programs for people with chronic disease, and health promotion. Perhaps expectedly, there was resistance to PHOs within the IPA movement, as the government failed to consult with GPs in the policy development process. The government thought IPAs would be subsumed under PHOs. They weren’t, and several IPAs strengthened, with PHOs requiring their management services. Furthermore, PHO implementation was poorly managed, with many GPs failing to see the relevance of a new admininstrative layer that appeared only to be a vehicle to receive funding. The result has been a complex and confusing primary care landscape of multiple organisational layers and silos, and a failure to achieve many government goals.6 It is difficult to say how well PHOs have performed. Almost all New Zealanders are now enrolled with one, the range and scope of primary care services has broadened, many nurse-led programs have emerged, and there is a stronger focus on population-based programs in primary care settings. Patient charges have come down, although financial barriers remain for a quarter of the population with a disproportionate impact on lower socioeconomic groups and Maori.7 Very importantly, PHOs largely failed to coordinate with one another or integrate with hospital services. They have not provided a coherent structural format for comprehensive primary care.8 While some PHOs have been well run and proactive, many would not be noticed by patients or GPs. For many GPs, the IPA — which provides considerable “back-office” support — remains the most important organisational player. What was extraordinary about the PHO era was government failure to engage with the IPAs to build on already strong foundations. Instead, a lost opportunity may be an apt description of the period. By the late 2000s, a series of questions about the shape and expectations of the primary care sector remained unanswered, with the government failing to provide clear policy.8,9 The present National Party-led coalition government (elected in 2008), while committing to PHOs, has downplayed their role. Mergers in several regions have been ordered for 40 or so PHOs. Meanwhile, the government is promoting new Integrated Family Health Centres, larger groups intended to straddle the traditional divide between community and hospital care, offer round-the-clock access to a range of primary care services, diagnostics and some specialist services. Nine pilot centres are currently being developed with IPAs and PHOs variously involved. Gazing into the crystal ball, one could see integrated centres providing the infrastructure for much of the purchasing work that is presently the role of New Zealand’s 20 District Health Boards, diminishing the need for these. New Zealand could follow the path of current GP commissioning policy in the United Kingdom National Health Service.10 Back to Australia. What is to be learned from New Zealand? First, ask whether the Medicare Locals represent a new layer of potentially ineffectual bureaucracy, as many of New Zealand’s PHOs have proved to be. Second, engage health professionals, especially GPs, unless you want the mediocrity and complexity of our PHO era. Identify GP leaders, involve them in refining policy and provide the necessary support for them to champion new directions. Third, ask how the new structures facilitate service integration, as separate funding sources for primary and hospital care could create barriers.9 Finally, consider how new policy directions might be pursued within existing structures. Ideas for new structures often appear promising, but, as with New Zealand’s PHOs, they routinely falter in implementation without careful attention to the institutions that matter to key players.11 New Zealand’s primary care reforms From 1993 General practitioner-led Independent Practitioner Associations (IPAs) developed. Several remain in place today. From 2002 to 2008 Government policy and funding stimulated Primary Health Organisations (PHOs). Many required IPA management services. There are currently around 50 PHOs. Since 2010 Integrated Family Health Centres in development.

Robin Gauld PhD

United Kingdom primary care trusts resembled the primary health care organisations (PHCOs) that have been proposed for Australia — for example, Medicare Locals. They resulted in a loss of innovation, creativity, motivation and morale among general practitioners and other front-line staff. English primary care trusts are being abolished and £80 billion will be handed over to GP commissioners. Management theory and practical experience shows repeatedly the dangers of reorganising into larger units. Lessons for Australia are to defer deciding on the size of PHCOs until their purposes are clear, to enshrine the principle of subsidiarity, and to opt for networking of the current Divisions of General Practice over mergers. So far, debate on the functions and structures of PHCOs has been muted. It is now time for vigorous debate.

James A Dunbar MD, FRCPEdin, FRACGP

In April this year, the Federal Minister for Health and Ageing, Nicola Roxon, stated that by July 2012 all Australians will be able to “sign up for a personally controlled e-health record . . . [that] will enable better access to important health information currently held in dispersed records around the country”.1 Laudable aims, but can patients and clinicians trust the reliability and confidentiality of this personally controlled e-health record (PCEHR)? The National eHealth Transition Authority’s draft concept of operations document proposes that individuals will be able to access a data repository (“My PCEHR”) and tools (“My Access Controls”) to make this dispersed information available to their chosen health care providers.1 The authors failed to give essential details on how the PCEHR will work, but showed insight in their assessment that the scope and extent of information to be shared in the PCEHR is dependent on the readiness of the health care sector to participate. The concept of democratisation of personal health information is central to the PCEHR, reflecting the populist philosophy of the present Web 2.0 and social networking environment where information is freely published and shared.2 This increases the potential for leakage of information, albeit often unintended, from clinician-held electronic health records (EHRs) via the disparate members of the PCEHR network (Box). Information that, if leaked, might have potential adverse impacts includes family history of disease, and information that may reflect negatively on other health professionals, friends or family members.2 Information leakage, along with complex access and provenance arrangements and individuals “hiding” rather than “denying access” to PCEHR information, will discourage clinicians from participating in a system where they are uncertain about the completeness of the information. Personal health information should stay within a confidential patient–clinician therapeutic relationship, a concept promoted by the patient-centered medical home movement3 and endorsed by the National Health and Hospitals Reform Commission.4 Information exchange within a multidisciplinary care network, no matter who controls it, should be facilitated within the patient–clinician relationship. Ensuring consistency of shared terminology and a method to address misrepresentations will improve the quality of personal health information. Such alignment of patients’ and clinicians’ perceptions and understandings of health concepts and processes will improve health literacy, and this will encourage consumer empowerment, not consumer populism.5 The creation of shared information resources to support collaborative team care must take into account the business, architectural, workflow, provenance and governance requirements from both patients’ and clinicians’ perspectives. However, the success and sustainability of this system also requires careful alignment of the patient’s and the clinician’s EHRs (Box) within a health care home that provides a safe, effective continuum of care within a trusting patient–clinician relationship. This will minimise risks and engender the required confidence to make the PCEHR program work. Pathways for the collecting, sharing, and possible leakage of information in an individual personally controlled electronic health record Reproduced with permission from: Hannan T. What the hell is a PCEHR and what does it have to do with me anyway? The InformaticsInsider [internet] 2011; Jun (1). http://www.austemrs.com.au/page/informatics_insider.html

Siaw-Teng Liaw · Terry Hannan

Increasing numbers of medical students and junior doctors learn and work in general practice. Increased supervisory responsibilities for general practitioners threaten the quality of care provided to patients and the income thus derived. Incremental changes to infrastructure and funding are welcome, but insufficient. Alternative models must be funded, trialled and evaluated. One such model, involving consultant on-call GP supervisors, is proposed.

Susan M Wearne MMedSc, FRACGP, FACRRM

To the Editor: Primary health care is the part of the health care system used by most people and contributes substantially to the health of the population. Research conducted in primary health care ensures quality care provided in this sector is underpinned by the best evidence.1 To build the primary health care research evidence base, the Australian Government has invested around $135 million in the Primary Health Care Research, Evaluation and Development (PHCRED) Strategy since 2000.2 The Strategy has supported primary health care research capacity building through Australian university Departments of General Practice and Rural Health. From 2011, this funding will be replaced by competitively funded centres of research excellence in primary health care.2 From 2000 to 2008, the National Health and Medical Research Council (NHMRC) administered research funding of over $3.5 billion.3 Using NHMRC data, we found that 1.9% (183/9409) of the total number of grants awarded by the NHMRC were primary health care related (Box).3 Of these, 28% (51) were funded through the PHCRED Strategy, with total funding of $18.5 million.2 About 80% (146) of primary health care grants were awarded to the university sector and 19% (34) to medical research institutes. There were no apparent trends over this period, reflecting a persistent lack of maturity of primary health care research funding within the NHMRC. Our findings are similar to those for Canada’s premier health research agency. The Canadian Institutes of Health Research has, since its inception in 2000, distributed CA$20.4 million to primary health care projects. In 2004–2005, less than 1% ($3.52 million) of the $516 million spent by the agency on research funding was devoted to primary health care research.4 The discipline of primary health care is still evolving and will continue to need infrastructure support to ensure it develops the capacity to provide the best evidence for quality primary health care in Australia. Because of the greater emphasis on primary health care in current health reforms, and with significant changes being implemented in this sector, the need for research in this area at all levels is greater than ever before. We strongly urge the NHMRC to increase their support for primary health care research to provide best evidence for significant improvement in primary health care in Australia. Australian Government funding sources for primary health care research, 2000–2008*2,3 NHMRC = National Health and Medical Research Council. PHCRED = Primary Health Care Research, Evaluation and Development. PHCRED grants are administered by the NHMRC. * Identified by code and title. Includes all categories of grants and support for personnel.

Ellen L McIntyre · Danielle Mazza · Naomi P Harris

To the Editor: A recent interview-based study of the experience of 60 general practitioner teachers in Brisbane1 found that private, fee-paying patients were perceived by a number of participants as being less accepting of active student involvement in teaching consultations than those in bulk-billing practices. Some examples of a perceived relationship between patient payment and patient attitudes — and perhaps obligations (although no participants explicitly related non-payment for health care with an increased patient obligation to assist with doctor training) — in relation to teaching are provided in the Box. Arguably, there is an implication that private fee-paying patients may be more inclined to be litigious in the event of an adverse outcome associated with teaching, and that these patients may choose to obtain their general practice care elsewhere if they are imposed on. These perceptions are likely to influence GPs’ decisions to seek patient consent for active student learning. The literature does not explore whether fee-paying GP patients have more or less positive views about teaching than those who are bulk billed or treated in public hospitals, although a United States emergency department study2 found no significant difference between patient income and patient consent rates. However, an “uncomfortable sense of obligation” to, and boundary blurring with, patients who assist with teaching has been reported by GPs in the United Kingdom,3 and it is interesting to hypothesise that this sense may be sharpened by patient payment, and relieved somewhat by reducing fees. In relation to any perceived obligation for (bulk-billed) patients to assist with teaching, for the “greater good” of securing ongoing health care for society, Waterbury4 argues against sacrificing patient autonomy and refutes several arguments for a patient’s obligation to assist. He also argues powerfully against placing any teaching burden disproportionately on community members who are both ill and impoverished. The extent of the “teaching burden” on patients is difficult to assess in the absence of evidence about patient health outcomes in relation to teaching, but both patients5 and doctors1 report that student presence in consultations may be inhibiting. An element of “marginalisation of the patient in the (teaching) doctor’s duties”4 is arguably inevitable. Further Australian general practice research into private patient attitudes might challenge these GP perceptions. If many of these patients are in fact willing for greater involvement than that anticipated by the GP, both patients and students may be frustrated by the loss of teaching opportunities. Quotes: patient payment and teaching “It’s not my job to teach Pap smears or procedures on private patients. That’s the role of the public health system.” “Rural practices may be able to offer students a different experience operating almost as a practice nurse, but patient expectations are different in a professional practice with patients paying top dollar.” “I’ll often bulk bill a patient if a student has taken a major role in the consultation.” “The majority of my patients accept students; I have a high-end professional practice, mostly lawyers, but they make it clear they don’t want students taking histories or doing examinations — they want me to do it.” “It’s much easier to give students a greater role in a bulk-billing practice with a high turnover — the patients don’t really have a choice — but I can’t offer this.”

Nancy J Sturman

Fast facts: Parkinson’s disease. 3rd ed. K Ray Chaudhuri, Christopher G Clough, Kapil D Sethi. Oxford: Health Press, 2011 (144 pp, $25.00). ISBN 9781905832880. Since the first description of Parkinson disease in 1817 as the “shaking palsy”, it has become increasingly known that this common condition is not simply a motor disorder but a complex neurodegenerative process that requires a holistic approach to management. This book aims to provide an easy guide for doctors who are not necessarily specialists in neurology for managing the motor and non-motor symptoms of the disease. All three authors are leaders in the field — Chaudhuri is professor of neurology and movement disorders at King’s College Hospital, London; Clough is medical director of King’s College Hospital; and Sethi is Director of the Movement Disorders Program at Georgia Health Sciences University in the United States. The book presents information on the diagnosis, pathogenesis, genetics and treatment of the condition in a concise and readable form, as well as on the psychosocial aspects of the disease and palliative care. This third edition has a chapter on new developments and gene therapy. It includes an excellent table on drugs currently undergoing trials to treat the non-motor symptoms of the disease. Recent advances in neuroprotection are reviewed, such as the findings of the ADAGIO study (N Engl J Med; 361: 1268-1278) that suggest that early treatment with the monoamine oxidase inhibitor rasagiline confers benefits not seen with delayed treatment with the same agent. The book lists some useful resources for those managing the disease, and contact details of Parkinson disease associations in several countries including Australia. The only shortcoming is that it would benefit from more detail about the management of the gastrointestinal and autonomic symptoms of Parkinson disease. This book is certainly good value. In a world of limited time, it can be read quickly and carried in your pocket to read when you have a spare moment.

Rebekah M Ahmed · Simon Lewis

A medical-legal companion to the AMA Guides Fifth. Guides to the evaluation of permanent impairment. Kenneth Kingdon, JD, LLM. California: American Medical Association, 2011 (xxi + 410 pp, $120.00). ISBN 9781603591980. This publication by the American Medical Association (AMA) provides a detailed review of the AMA guides to the evaluation of permanent impairment, 5th ed. (AMA5). These guides, which provide a systematic and highly descriptive methodology for rating impairment arising from illness or injury, have been adopted not only in many American states and other countries but also in many Australian compensation jurisdictions as a standard reference upon which state-specific guidelines have been designed. Medical practitioners are increasingly being requested to evaluate impairment for lawyers and insurance claims managers. This companion to the AMA guides is helpful to doctors as well as lawyers and claims managers in bridging the gap between medicine and the law. The text analyses each chapter of AMA5, and includes an overview of the salient points regarding the impairment-rating procedure. This is particularly useful as it picks the eyes out of the expansive AMA5 and highlights areas that need to be understood to ensure correct impairment-evaluating methodology. Included in the text are comments regarding contentious or ambiguous rating issues, with explanations and definitions of medical terms that make the information more comprehensible to the non-medical reader. Each chapter has numerous worked examples to help the reader understand the points being made and the correct application of methodology. This is followed by review questions that allow the reader to test whether he or she has completely understood the impairment evaluation principles being discussed. This book accurately and authoritatively interprets impairment-evaluating methodology (strictly according to AMA5) and addresses various issues in interpretation that are relevant to any user of AMA5 in Australia. For medical assessors who are already trained in using AMA5 (as modified regionally in Australia), this publication provides a useful review of definitions, procedures and methodology. For non-medical readers (eg, lawyers and claims managers), it is a relatively inexpensive and helpful tool for clarifying the sometimes overwhelming content of AMA5.

Dwight K Dowda

A unique migration: South African doctors fleeing to Australia. Peter C Arnold. USA: CreateSpace, 2010 (252 pp, $35.00). ISBN 9781452830780. As signalled by its title, Peter Arnold’s treatise is an analysis of South African doctors who migrated to Australia during the latter half of the 20th century. Arnold himself was part of this exodus, soon after graduating in medicine from the University of Witwatersrand in Johannesburg in 1961. He subsequently crafted an illustrious career in Australian medicine, moving between his roles as general practitioner in Sydney’s eastern suburbs, President of the General Practitioners’ Society in Australia, Chairman of the Federal Council of the Australian Medical Association and Deputy President of the New South Wales Medical Board. In fact, Arnold is but one of more than 2000 South African medical graduates who have adopted Australia as their home, and South Africa now joins the United Kingdom, India and New Zealand as a major contributor to Australia’s medical workforce. The book follows a logical order, with chapters on “Why did they leave?”, “Why did they choose Australia?”, “The Australian experience” and “Bringing the kids, but leaving Granny behind”. It also includes a review of the various theories on what made this migration distinctive. Above all, A unique migration is an accessible thesis, in which the wealth of data never overwhelms the narrative. At the same time, it is underpinned by admirable scholarship and an almost encyclopaedic attention to detail, neatly reduced to a series of informative diagrams. It reveals Australia’s debt to this unique migration, which now accounts for one in 30 of the country’s doctors, including luminaries such as Priscilla Kincaid-Smith, Sidney Sax and Michael Denborough. Perhaps the most controversial aspect of the book is whether this great trek was the result of “push factors” such as the social upheaval following the end of apartheid, or “pull incentives” such as Australia’s comparable geographic features. A unique migration is an intriguing journey into a previously undocumented aspect of Australian immigration, and a rewarding book for interested readers. It is compulsory reading for those dealing with the medical workforce. Conflict of interest statement: I know Peter Arnold from when I was editor of the MJA and he was a director of AMPCo, the publisher of the Journal.

Martin B Van Der Weyden

CorrectionsIncorrect percentage: In “Prevalence and predictors of anxiety and depression in women with invasive ovarian cancer and their carergivers” in the Anxiety, depression and cancer supplement to the 6 September 2010 issue of the Journal (Med J Aust 2010; 193: S52-S57), the percentage given in Box 2 (page S54) for participants categorised as having a normal score for anxiety on the Hospital Anxiety and Depression Scale was 60.8%. The correct percentage is 66.8%. This error has no impact on any of the analyses, results or conclusions of the article; it has been corrected in the online version (http://www.mja.com.au/public/issues/193_05_060910/pri11382_fm.html).

Melanie A Price · Phyllis N Butow · Daniel S J Costa · Madeleine T King · Lynley J Aldridge · Joanna E Fardell · Anna DeFazio · Penelope M Webb

CorrectionTypographical error in base number for calculation of estimates: In “Counting the cost: estimating the number of deaths among recently released prisoners in Australia” in the 18 July 2011 issue of the Journal (Med J Aust 2011; 195: 64-68), the incorrect number 50 504 was used as a basis for calculating some estimates instead of the correct number, 50 405. This has resulted in small errors in some numbers in two tables and one paragraph of the Results in the article. These errors are not substantive and do not alter the conclusions of the study. The numbers have been corrected in the online version of this report (http://www.mja.com.au/public/issues/195_02_180711/kin10879_fm.html).

Stuart A Kinner · David B Preen · Azar Kariminia · Tony Butler · Jessica Y Andrews · Mark Stoové · Matthew Law