Issues
Volume 218 Issue 9
Editor’s choice
Focusing on the challenges facing primary care
This issue of the MJA focuses on primary health care in Australia. General practice is one of the most enigmatic specialities in medicine in Australia, as in its very nature of generalist medicine, the boundaries and limitations of care are very hard to define. Most general practitioners are absolute generalists and will see patients for an initial consultation on a variety of issues. The “cradle to grave” care that GPs provide covers acute and urgent presentations, chronic disease management, population screening, immunisations and child developmental reviews, procedures, disaster management, and special interests. Most GPs, depending on their qualifications and geographic area of practice, also handle specific areas in medicine such as women's health, mental health, and skin cancer management. In this issue of the MJA, Pandeya and colleagues examine the rates and outcomes of melanoma diagnoses in a sample from Queensland, finding that “More than 75% of melanomas were initially managed in primary care” (doi: 10.5694/mja2.51919). In terms of management of melanomas, despite current Australian guidelines recommending excisional biopsy with 2mm margins as the initial management of lesions, only half were initially diagnosed on excisional biopsy within the analysis. Dermatologists were more likely than other specialists to use shave biopsies for initial diagnosis. GPs continue to be at the frontline for the management of skin cancer in Australia, yet the support offered to them for this is often lacking, as pointed out in the linked editorial by Rosendahl and Clark (doi: 10.5694/mja2.51928). Although dermatoscope use is considered the gold standard in melanoma diagnosis, especially for early lesions, GP trainees do not currently have any standardised method of training available to them in the use of dermatoscopes and diagnosis of skin cancers. In their research letter, Anderson and colleagues analyse the performance of general practice trainees in their first year of training across two formative assessments: a multiple choice questionnaire as well as an external clinical teaching visit (doi: 10.5694/mja2.51928). Scores for trainees from James Cook University did not differ between regional, rural and remote areas, showing that the quality of training appears to be equivalent in this region across the board. Although outcomes for the Fellowship exam are not known, this article highlights the value of a standardised teaching program for general practice trainees to help manage the broad nature of the specialty. With the Royal Australian College of General Practitioners recently taking over training, this will be a space to watch. In managing the undifferentiated patient, patients with multiple chronic diseases and patients with complex socio‐economic backgrounds, GPs are more likely than other specialties to manage uncertainty in clinical practice, as pointed out in the narrative review by Scott and colleagues (doi: 10.5694/mja2.51925). The authors note that “Clinicians with higher intolerance of uncertainty may be more likely to avoid certain kinds of patients with complex needs, such as substance users, the poor, older patients and the underserved, contributing to health inequities”. Furthermore, “Intolerance of uncertainty is also associated with more psychological distress and burnout, loss of self‐compassion, career dissatisfaction and disengagement at work, more discomfort dealing with death and grief, more concerns about malpractice risk, less propensity to adopt new and effective clinical interventions, and more limited leadership abilities”. The review offers several helpful methodologies for managing uncertainties in clinical practice, depending on the scenario. Despite having been at the frontline during the pandemic, general practice continues to be an underappreciated and underfunded specialty in Australia. There has been little change in the Medicare rebate offered to GPs for their consultations over several years, and they continue to manage an increasing burden of patients with complex care needs as costs across the health system escalate (https://insightplus.mja.com.au/2023/9/mental‐health‐generalism‐invisible‐workhorse). The poor remuneration combined with a significant prevalence of burnout in the profession has led to a decline in doctors signing up to train in general practice. A significant proportion of practices in remote and rural areas have either closed due to the declining workforce or switched to a private billing model to stay afloat (https://insightplus.mja.com.au/2023/14/doctors‐need‐more‐say‐in‐fixing‐gp‐crisis). These issues do not seem to be addressed by government in any meaningful way. General practice is the pillar of the health care system in Australia; everyone sees their GP. The declining numbers of GPs will have a significant ripple effect on health care expenditure and acute care service use by patients across Australia unless this problem is addressed adequately. The MJA will continue to focus on these challenges and remains committed to supporting GPs through publishing research and commentary in this area.
Aajuli Shukla
Perspectives
A step in the right direction: the potential role of smartwatches in supporting chronic disease prevention in health care
Smartwatches can count every step towards a predict–prevent health care system, but clinical regulation is the first leap
Graeme Mattison · Oliver J Canfell · Doug Forrester · Chelsea Dobbins · Daniel Smith · David Reid · Clair Sullivan
The impact of climate change on skin health
Climate change affects skin health and skin diseases; mitigation and adaptation strategies are required and are time-critical
Austen Anderson · Fiona Bruce · H Peter Soyer · Crystal Williams · Rebecca B Saunderson
Medical education
Hypertensive retinopathy in the paediatric setting
A 12-year-old girl presented to a general practitioner with a two-day history of progressively worsening blurry vision
Nandini Singh · Kanika Chaudhri · Caroline Catt
Scombroid poisoning: a traveller's tale
A 23-year-old previously well Australian woman with no known allergies developed an erythematous, non- pruritic and non- tender rash while in Bali
Natalie SY Lee · Susan C Chu
Editorials
General practice and melanoma management in Australia: controversies and implications for generalist GP training
Australians should be confident that their generalist GP is trained to an acceptable level of competence in skin cancer diagnostics
Cliff Rosendahl · Simon Clark
Preventing overdoses with over‐the‐counter medicines
Engagement and education of the general public, together with regulatory reforms, are needed to prevent overdoses with non- prescription medicines
Elizabeth E Roughead · Renly Lim
Research
The diagnosis and initial management of melanoma in Australia: findings from the prospective, population‐based QSkin study
Most incident melanomas are managed by primary care practitioners, underscoring the need for specific training
Nirmala Pandeya · Catherine M Olsen · Maja M Shalit · Jean Claude Dusingize · Rachel E Neale · David C Whiteman
Research letters
Comparison of performance outcomes after general practice training in remote and rural or regional locations in Australia
General practice training in remote areas provides equivalent opportunities for learning and progression toward the fellowship
Emily Anderson · Matthew R McGrail · Aaron Hollins · Louise Young · Lawrie McArthur · Belinda O'Sullivan · Tiana Gurney
Over‐the‐counter cough and cold medicines: reported poisonings of children before and after the 2012 and 2020 labelling changes in Australia
Off-label use in young children suggests that health care professionals and the public underappreciate their risks
Abrar Arbaeen · Nial J Wheate · Jared A Brown · Rose Cairns
The impact on poisonings of up‐scheduling of modified release paracetamol to Schedule 3 (pharmacist only medicine)
Further up-scheduling would probably reduce casual use and consequently the number of overdoses
Rose Cairns · Firouzeh Noghrehchi · Nicholas A Buckley
Bloodstream infection rates in Aboriginal and non‐Aboriginal people in Central Australia, 2014–2018
Bloodstream infection rates in Aboriginal residents of Central Australia remain extremely high, and risk factors must be remediated
Alice Coe · Richard J Woodman · Rob Baird · Lloyd Einsiedel
Narrative reviews
Coping with uncertainty in clinical practice: a narrative review
The ever-increasing novelty and complexity of modern medicine brings decisional uncertainty for clinicians; various strategies can be used to minimise and manage this uncertainty without compromising the clinician–patient relationship or clinician credibility
Ian A Scott · Jenny A Doust · Gerben B Keijzers · Katharine A Wallis
Management of cutaneous melanoma in Australia: a narrative review
The management of cutaneous melanoma has been revolutionised in the past decade, with ongoing efforts to improve patient outcomes centred on rich translational research endeavours and robust clinical trials
Prachi Bhave · Jessica Wong · Aideen McInerney‐Leo · Anne E Cust · Craig Lawn · Monika Janda · Victoria J Mar
Letter
Access to voluntary assisted dying in Australia requires fair remuneration for medical practitioners
To the Editor: Haining and colleagues discuss compensation for medical practitioners in supporting patients through the voluntary assisted dying process, which requires much time and effort.1 We want to inform you how the Netherlands, where euthanasia has been performed since 2002, has dealt with this challenge. A Dutch physician who performs euthanasia must evaluate whether a patient is suffering hopelessly and unbearably, is adequately informed, has no reasonable alternatives available, and is making a voluntary and well considered request. A second independent physician also needs to evaluate the patient, which often requires multiple house visits. Six weeks after the procedure, a review committee establishes whether all due diligence requirements were fulfilled. In 2021, 7666 people underwent euthanasia in the Netherlands, mostly performed by general practitioners for patients suffering from a malignancy.2 Everyone who lives or works in the Netherlands is legally required to have health insurance. Insurance companies finance the health costs through premiums and an income‐related contribution, collected through the government's tax on wages. On a side note: for religious reasons, it is possible to choose an insurance company that does not reimburse the costs of euthanasia or abortion. Every patient needs to be registered with a specific GP, who receives a registration payment every three months from the health insurer of between €18.76 and €51.86 (AU$30.37 and AU$83.96 at 3 April 2023), depending on age. When the patient visits the physician, an additional €11.51 (AU$18.63) is paid.3 However, as euthanasia is a time and effort consuming trajectory, the physician is entitled to additional compensation. Several home visits are required to investigate and explore the euthanasia request, for which the physician receives €88.85 (AU$143.84) per visit. On the day euthanasia is performed, the GP receives €269.99 (AU$437.09) from the health insurer. The second, independent physician receives €602.27 (AU$975.01) for their efforts. The pharmacist who prepares and processes the return delivery of the euthanasia drugs can invoice €274.00 (AU$443.58). Here, we have provided some insight into the compensations for physicians and pharmacists who facilitate euthanasia in the Netherlands, and we hope this can contribute to the discussion on the remuneration of this important work in Australia.
Stefan Leus · Jan Bollen
Access to oral COVID‐19 antivirals in the community: are eligibility criteria and systems ensuring equity?
Nicole L Allard · Jose Canevari · Nick Haslett · Benjamin C Cowie
Avoiding severe drug hypersensitivity reactions: a case for HLA genotyping for at‐risk patients
Jana Stojanova · Richard O Day · Graeme Suthers
Locally acquired respiratory diphtheria in Australia
Simon Smith · James Stewart · Joshua Hanson · Julian Harris · Fred JJ Chuang · Gavin Quail · Bryan Hawarden · Roshni Lad · Shannon McNee · Benjamin McCartney · Tonia Marquardt · Ian Wilson · Catherine Tacon · Bernard CS Whitfield
Why losing Australia's biodiversity matters for human health: insights from the latest State of the Environment assessment
Katherine A Barraclough · Marion Carey · Kenneth D Winkel · Emily Humphries · Brooke Ah Shay · Yi Chao Foong
Centring equity in data‐driven public health: a call for guiding principles to support the equitable design and outcomes of Australia's data integration systems
Catherine Smith · Claire M Vajdic · Niamh Stephenson
Japanese encephalitis virus: changing the clinical landscape of encephalitis in Australia
Sarah Allen · Celia M Cooper · Ajay Taranath · Allen C Cheng · Philip N Britton