General medicine

To the Editor: The letter by Johnson and Mitchell,1 responding to the two published papers of Rosenwax2 and Lowthian3 and their colleagues, about hospital, ambulance and emergency department use in the last year of life, concluded with the statement: Also essential is an ongoing dialogue with the patient and family to enable a clear understanding of the goals of treatment and to proactively plan for likely adverse events . . . [this] will potentially reduce the use of acute services and encourage the provision of care in more appropriate environments. The most significant factor in facilitating this latter objective is the timely preparation by the patient of the appropriate form of instructions to medical staff and designated family members about end-of-life management. Unfortunately, there is no common, state-recognised instrument for this in Australia. Many people appear to believe that conferring a “power of attorney” on a family member is all that is required, but this is not the case. In most situations, this allows the designated member or members to administer financial and property matters but not to make medical decisions about end-of-life care. The requirements for a valid medical decision-making authority differ from state to state. The instruments are variously known as: “enduring power of attorney” in the Australian Capital Territory; “enduring power of attorney (medical treatment)” in Victoria; “medical power of attorney” in South Australia; “enduring guardianship” in New South Wales and Tasmania; “enduring power of guardianship” in Western Australia; “advance health directive” in Queensland; and “medical enduring power of attorney” in the Northern Territory. It would be a major advance in the rational use of health resources, and towards ensuring compliance with the wishes of people who are terminally ill, while minimising the stress and distress of their family members, if general practitioners were to encourage their chronically and terminally ill patients to complete the appropriate form early in their illness.

John D Paull

Objective: To describe why, when and to whom general practitioners refer women with symptoms possibly attributable to cervical, endometrial or ovarian cancers, and to identify patient and GP factors that predict referral to either a gynaecologist or a gynaecological oncologist.Design and setting: A national survey of GPs between 1 April and 31 August 2009 using a randomised incomplete block design based on case vignettes, and using a self-completed postal or online questionnaire.Participants: A sample of GPs, stratified by location and randomly selected from a database of GPs maintained by the Australasian Medical Publishing Company.Main outcome measures: Proportion of vignettes that were deemed to reflect a high probability of cancer being referred; and the patient and clinician factors that were the strongest predictors of referral.Results: Of the 3082 GPs who were selected for participation, 1402 responded, giving a response rate of 45.5%. Overall, for vignettes identified as describing women with a high probability of cancer, 75% were referred by metropolitan GPs and 73% by rural practitioners. Metropolitan GPs were significantly more likely to refer women in scenarios indicative of endometrial cancer than rural GPs. For all three cancers, GPs were significantly more likely to refer a patient to a gynaecologist (between 70.8% and 95.4%) than a gynaecological oncologist. Metropolitan GPs had significantly greater access to both private and public gynaecological oncologists than their rural counterparts. Referral rates were higher for ovarian and cervical cancer (83% and 80%, respectively) and lower for endometrial cancer (68%). For all three cancers, patient factors were stronger predictors of referral than the demographic factors of participating GPs.Conclusion: There appears to be significant variation in referral practices among GPs and this variation is greater for endometrial cancer, for which there are currently no evidence-based clinical practice guidelines in Australia. There is a need for further research into understanding the basis of these differences, including a review of the existing guidelines for ovarian and cervical cancer and the development of guidelines for endometrial cancer.

Shanthi A Ramanathan BA, MHlthSci(Hons) · Genevieve Baratiny BSc(Hons), PhD · Nigel P Stocks MD, FRACGP, FAFPHM · Andrew M Searles BEc, MMedStats, PhD · Russell J Redford BSc, DipCompSc

Jim Macken was born in Sydney on 24 January 1924, the eldest child of Irish immigrants. He grew up in Greenwich, Sydney, and was educated at St Aloysius’ College, Milson’s Point. In his final year there he was a prefect and a member of the first XV (rugby) and first XI (cricket). After school, he joined the Commonwealth Bank, while successfully studying for his economics degree part-time. He switched careers in 1953, commencing his medical studies at the University of Sydney at the age of 29. At university, he was often referred to as “Senator” Macken, as he was a mature-aged undergraduate representative on the university senate. Jim was a medical student at Royal North Shore Hospital. After graduating in 1959, he undertook his residency at the Mater Hospital, Sydney, before entering general practice at North Bondi. This was a dedicated community practice, with the doctors doing house calls, nursing home visits and obstetrics. Jim remained there for almost 40 years. As a visiting GP Obstetrician at St Margaret’s Hospital, Darlinghurst, Jim delivered many babies over the years, and gained his Diploma of Obstetrics from the Royal College of Obstetricians and Gynaecologists in 1980. He became a Fellow of the Royal Australian College of General Practitioners in 1981 and was an examiner at the College exams for a number of years. His wide-ranging interest in history, politics, sport, cards and literature enabled him to discuss virtually any subject with his patients, whether young or old. Jim was always immaculately groomed and had a great sense of humour and charming bedside manner. He was a lifetime member of the Balmoral Beach Club and swam in the inaugural Jack Cox Memorial 1500 m swim in 1946. He enjoyed playing golf at the Royal Sydney Golf Club. For 50 years, Jim was married to Marie, who died from ovarian cancer 4 months before Jim died from cardiac and renal failure on 19 January 2010. Jim is survived by his children Philip, Peter, John, Marea, James and Rosie.

Peter L Macken · V John Roche

To the Editor: We agree with Smith and colleagues1 that it is important to raise awareness among health professionals — and consumers — about recently revised dosing recommendations for colchicine. Software decision-support tools have an important role in ensuring safe prescribing of such drugs. However, we have questions about whether this software uses information that is up-to-date with current evidence, particularly in relation to colchicine. We believe that the clinical software systems used by clinicians and pharmacists could better support them in relation to medicines safety issues like this one. First, they could provide up-to-date, evidence-based dosing information. Second, they could warn the user when potentially harmful drug doses are being prescribed or dispensed, or when there are new recommendations about drug therapy. In this case, the situation is not straightforward because there are inconsistencies in the dosing recommendations for colchicine. In 2010, an article in NPS RADAR highlighted new evidence to support the use of low-dose colchicine in acute gout.2 This new dosage regimen was also recommended in the Australian medicines handbook in 2010.3 Nevertheless, higher doses are currently recommended in the Australian approved product information (PI), the consumer medicines information leaflet, and other commonly used medicine reference sources (this raises other issues, including the fact that there is currently no process to ensure that the PI is regularly reviewed, and the role of the Therapeutic Goods Administration4; however, these are beyond the scope of this letter). There is no guidance for clinical software vendors regarding which information to provide, and, at present, drug dosage information in these systems is frequently based on the PI as provided by the manufacturer or sponsor. We examined colchicine dosing information provided at (or accessible from) the point of prescribing or dispensing in a number of commonly used systems, and none showed the recent low-dose recommendations. Nor were any alerts or warnings displayed about potential toxicity specifically related to the dosage regimen for colchicine. Our previous research has shown that, in general, there is little of this type of decision support available in general practice software.5 Guidance for software vendors and high-quality, up-to-date knowledge bases are required to support this functionality. Currently, there is no overarching governance mechanism in Australia to guide the development of decision support, or to ensure that the inclusion of clinical information in software is up-to-date or based on the latest evidence. A coordinated approach to ensure that these systems support safety and quality is long overdue.6

Michelle Sweidan · James F Reeve · Kitty Yu

To the Editor: The letter from Smith and colleagues in the 6 June 2011 issue of the Journal1 highlights the potential toxicity of colchicine, even when used in the therapeutic doses recommended in the current product information (PI).2 This in turn highlights how important it is that all medicines have PI that continues to be maintained with the most clinically accurate and up-to-date information. The current system for maintaining PI seems to break down most significantly with out-of-patent, “grandfathered” and “orphan” medicines.3 During 2009, we identified an important change in the recommended dose in the American PI for colchicine through our usual processes of scanning the medical literature (including the websites of drug regulatory agencies). Colchicine is an out-of-patent medicine. The American study underpinning the American PI changes was sponsored by a different company and used a strength of colchicine tablet (600 μg) not available in Australia.4 The local sponsor companies were contacted at the time, but did not plan to update their Australian PI. Amending a PI is a costly and lengthy process, and the expense is hard to justify for an inexpensive and relatively low-use product. We updated the Australian medicines handbook dosing information5 and then wrote to the Therapeutic Goods Administration (TGA) suggesting the PI change could be initiated by them in the public interest. As yet, we have not received a response from the TGA and the dose in the PI remains unchanged. Despite its limitations in cases such as these,3 the PI forms the backbone of default dosing and drug interaction data in electronic prescribing software in Australia.6 We hope that Smith and colleagues’ letter might not only help prompt a change to the Australian PI for colchicine, but also a reconsideration of whether a more proactive approach is warranted for updating PI dosing and safety information for orphan drugs.

Nicholas A Buckley · Simone O P Rossi

Patricia Brennan was born in Hurstville, Sydney, on 15 April 1944. She attended St George Girls High School and graduated in medicine from the University of Sydney in 1968. After residency at Sydney Hospital, she worked at the Sudan Interior Mission hospitals in Jos, Nigeria, and Galmi, Niger. Patricia became aware of the poverty and powerlessness of many African women and the vulnerability of the powerless to hidden sexual and domestic abuse. Patricia returned to Australia in 1973 to become Haematology Registrar at Prince of Wales Hospital, Randwick, while also holding the position of general practice consultant for the Sudan Interior Mission. In 1977, she established a solo general practice at Summer Hill, which she maintained until 1986. During this time, Patricia also became Assistant Medical Director of the Sydney Square Breast Clinic. Throughout her life, Patricia accepted and sought opportunities to work against oppression and injustice. Each phase of her life was characterised by questioning, passion and intellectual rigour. In the 1980s and early 1990s, her defining work was a voluntary commitment outside of medicine to reform the position of women in the church, especially in her own Anglican church. As founding President of the Movement for the Ordination of Women from 1985 to 1989, she was a charismatic and inspirational leader with a ready wit and great presence, who galvanised support and sometimes opposition to the cause. She believed ordination would achieve a transformational change in the role of all women in the church and have a symbolic power in the wider fight against abuse and coercion. In 1995, she worked with World Vision, assessing funded health programs, including programs to combat sexual assault and to manage post-traumatic stress in children in refugee camps in Gaza and the West Bank, Israel. In 1996, while undertaking her doctorate in medical anthropology, Patricia commenced as a medical officer with the Liverpool/Fairfield Sexual Assault Service and, in 2001, she became its Medical Director. This resulted in the next stage of her vocation: calling on the medical and wider community to recognise the widespread and long-lasting trauma caused by sexual assault and family violence. She completed a Masters in Forensic Medicine from Monash University, developed specialist pathways for training and, at the Royal Prince Alfred Hospital, became the first Staff Specialist in Clinical Forensic Medicine specialising in sexual assault appointed to an emergency department in New South Wales. She was a Fellow of the Australasian College of Legal Medicine, a member of the Forensic and Medical Sexual Assault Clinicians Australia, and a founding committee member of the Australasian Association of Forensic Physicians. In 2009, she became acting Medical Director of the Clinical Forensic Medical Unit of the NSW Police Force, and was appointed a Visiting Fellow in Law at the University of NSW in 2010. She pushed for medical rigour in a field of medicine where there was a history of ill founded medical opinion contributing to grave injustices: the return of children to situations of abuse, failed prosecutions due to inadequate medical evidence and, occasionally, false convictions. Patricia’s achievements were recognised with a Bicentennial Woman of Achievement Award in 1988 and, in 1993, she was made a Member of the Order of Australia for services to the community, particularly as founding President of the Movement for the Ordination of Women. Patricia was a doctor of ready wit and apt speech who exercised leadership on big picture issues with passionate intelligence. She could be discouraged by frustration at the slowness of change, but she always returned with energy and creativity to the cause. All her struggles were motivated by a bold vision and a sense of calling. She died on 6 March 2011, 4 months after being diagnosed with pancreatic cancer. She is survived by her husband Robert, children Kate, Peter and James, and grandson Gabriel.

Rosemary A Isaacs

It is hard to imagine that clinical guidelines, in their current incarnation, will survive. Undoubtedly, doctors need high-quality information to guide clinical decisions, but the development and implementation of clinical guidelines is fraught with difficulty. We have seen heated debate on this subject in the MJA, and two more articles in this issue add fuel to the fire. Williams and colleagues make a strong demand for the “Comprehensive disclosure of conflicts [of interest] . . . to safeguard the integrity of clinical guidelines and the medical profession”. As they observe, and we know, compliance with guidelines is equated to delivery of high-quality care, and can affect doctors’ remuneration. Guidelines themselves, then, must be beyond reproach. Yet, according to Williams et al, only 15% of the 470-plus guidelines on the National Health and Medical Research Council portal contain a conflict of interest statement — a longstanding requirement for research papers. This is surprising, as guidelines have much more influence on clinical practice than a single research paper. A 2009 Institute of Medicine report (Conflict of interest in medical research, education and practice) outlined several examples of inappropriate industry influence on clinical guidelines development in the United States. Pharma ties to individuals and organisations still loom large as an important issue. And there are many other concerns. Subtle influences from personal opinion, cultural mores and vested interests can influence the translation of evidence into clinical care — a step for which the methodology is less well defined than it is for the finding and grading of evidence (BMJ 2010; 340: c306). The role of the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system in separating the strength of a recommendation from the strength of the evidence is hotly contested (MJA 2011; 195: 324-325). Because of the protracted process of development, guidelines are often out of date before publication, and so lose credibility and currency. Grol and Buchan (MJA 2006; 185: 301-302) lamented the high cost of development in time, labour and money and implored guideline developers to provide useful tools for practitioners and patients. Also in this issue of the MJA, as an example of the discordance between guidelines and actual practice, Inam and colleagues report that disease-modifying antirheumatic drugs are underused in managing early rheumatoid arthritis compared with guideline recommendations. Instead of the usual explanations for such failure — “habit, lack of motivation, and external barriers such as lack of time, resources and organisational support” — they suggest it may reflect awareness by clinicians of the difficulties of translating a deficient evidence base into practice and practitioners’ sensitivity to individual patient issues, such as treatment cost. Patient comorbidity is a real-life issue that makes guideline translation difficult. Generally, guidelines, as a result of development by specialist experts, focus on managing the disease, but not necessarily managing the whole patient, and commonly exclude non-drug treatments. Perhaps new collaborative technologies may soon help to overcome many of the issues that currently plague this essential clinical tool. We intend that the MJA will continue in its role as a repository of clinical guidelines. We already insist on a full conflict of interest statement for each contributor, and all guidelines published in the MJA are peer reviewed.

Annette Katelaris

Peter Schmidt was born on 29 December 1922 in Beaudesert, Queensland, where his father managed a sawmill. He was the youngest of three children. Peter attended St Joseph’s Nudgee College in Brisbane and studied medicine at the University of Queensland. After graduating in 1945, he took up residency at the Mater Hospital in Brisbane. In 1948, he established a general practice in Greenslopes, Brisbane, which he maintained until he fully retired in 1996. Peter had a long association with the Queensland Faculty of the Royal Australian College of General Practitioners (RACGP). In 1967, he became a member of its Board, where he served for over 20 years. In 1970, Peter gained Fellowship of the RACGP. He served on the medical education committee, was Chairman of the courses committee for several years before the formation of the Family Medicine Programme in 1974, and was elected Chairman of the accreditation committee, a position he held with distinction until 1997. From 1975 to 1996, Peter was Director of the postgraduate medical education committee of the University of Queensland. The Australian Medical Association acknowledged his services to medicine when he was elected to Fellowship in 1984. In 1993, Peter was awarded a Medal of the Order of Australia, in recognition of his services to postgraduate medical training and to his local community. Peter died on 18 June 2011. He was predeceased by his wife Fay and is survived by his children Peter and Mary.

John A Comerford

Objective: To evaluate the effectiveness of the Practitioner Asthma Communication and Education (PACE) Australia program, an innovative communication and paediatric asthma management program for general practitioners.Design: Randomised controlled trial.Setting: General practices from two regions in metropolitan Sydney.Participants: 150 GPs, who were recruited between 2006 and 2008, and 221 children with asthma in their care.Intervention: GPs in the intervention group participated in two 3-hour workshops, focusing on communication and education strategies to facilitate quality asthma care.Main outcome measures: Patient outcomes included receipt of a written asthma action plan (WAAP), appropriate medication use, parent days away from work, and child days away from school or child care. GP outcomes included frequency of providing a WAAP and patient education, communication and teaching behaviour, and adherence to national asthma guidelines regarding medication use.Results: More patients of GPs in the intervention group reported receipt of a WAAP (difference, 15%; 95% CI, 2% to 28%; adjusted P = 0.046). In the intervention group, children with infrequent intermittent asthma symptoms had lower use of inhaled corticosteroids (difference, 24%; 95% CI, − 43% to − 5%; P = 0.03) and long-acting bronchodilators (difference, 19%; 95% CI, − 34% to − 5%; P = 0.02). GPs in the intervention group were more confident when communicating with patients (difference 22%; 95% CI, 3% to 40%; P = 0.03). A higher proportion of GPs in the intervention group reported providing a WAAP more than 70% of the time (difference, 23%; 95% CI, 11% to 36%; adjusted P = 0.002) and prescribing spacer devices more than 90% of the time (difference, 29%; 95% CI, 16% to 42%; adjusted P = 0.02).Conclusions: The PACE Australia program improved GPs’ asthma management practices and led to improvements in some important patient outcomes.Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12607000067471.

Smita Shah MB ChB, MCH · Susan M Sawyer MB BS, MD, FRACP · Brett G Toelle DipAppSc(Nursing), BA(Psychology), PhD · Craig M Mellis MPH, MD, FRACP · Jennifer K Peat PhD · Marivic Lagleva BSc(Hons) · Timothy P Usherwood MD, FRACGP, FRCP · Christine R Jenkins MB BS, MD

To the Editor: Scott and Guyatt are absolutely correct that as much transparency as possible is required in the process by which any clinical guidelines are formulated.1 I also agree that this must include careful management of conflicts of interest, particularly in the selection of the members of the expert panels required to formulate guidelines and in the functioning of those panels.1 However, transparency does not necessarily require adopting the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system or any other hierarchical system for formulating guidelines, nor does it necessarily require seeking formal feedback from external stakeholders. The GRADE system, like most hierarchical systems, assumes there is at least some evidence in the literature that addresses the relevant clinical problem — thus, it gives its lowest grade to observational studies with a very uncertain estimate of effect. But, often, practitioners most want help with the complex and multifaceted clinical problems on which there are not even formal observational studies. The GRADE system would presumably put these problems in the category of “You’re on your own, chaps, and don’t expect us to help you”. Recommendations on the problems that are most vexing to practitioners will be mainly (and inevitably) based on clinical experience and circumstantial evidence — in other words, expert opinion. Most practitioners looking for guidance will be well aware that such recommendations are likely to be based on expert opinion rather than excellent formal evidence. When deciding whether or not to trust the recommendations, they will be much more concerned that any conflicts of interest for the experts making the recommendations have been recognised and appropriately redressed, rather than that the level of evidence has been rigorously graded. Seeking formal feedback from stakeholders is also a separate issue from transparency. Potential users should be well represented on any writing panel, and their feedback is obviously essential — there is no point in producing guidelines that don’t address the problems that the potential users are facing. However, many stakeholders — for example, the pharmaceutical industry — will have much more serious conflicts of interest than do the members of the expert panel, and these can be impossible to deal with. Of course, feedback should be sought where appropriate, but to make it an absolute requirement under the guise of transparency seems nonsensical. It is clearly essential that users of clinical guidelines must be able to have confidence that they have been developed as rigorously as possible, but an excessively doctrinaire approach to their development will almost certainly lead to a decline in usefulness without a counterbalancing increase in trustworthiness.

Robert F W Moulds

To the Editor: Bismark, Spittal and Studdert observed that complaints clustered around certain doctors.1 They state that, in Victoria, extrapolations from their findings indicate that 1% of the medical workforce in private practice accounts for nearly 20% of complaints, and that male surgeons who have practised for more than 30 years are the doctors who are most complained about.1 Bismark and colleagues established that complaint-prone doctors are more likely to be male, surgeons or psychiatrists, to have trained in Australia and to have been in practice for at least 30 years. They agree with previous studies that suggest that the inherent risks of surgical procedures and the relative visibility of poor surgical outcomes are likely to play a role, and also note that the potential for power imbalances between doctor and patient is high in both surgery and psychiatry. That training outside of Australia was found to have a “protective effect” may seem surprising, but this fits my view about what most often motivates a patient to complain about a doctor when something goes a little astray. My belief, based on a long period of surgical practice and of observing other doctors, largely surgeons, is that a common stimulus to make a complaint when there is a degree of dissatisfaction is a perception that the doctor was overconfident, perhaps to the point of arrogance, and had little personal interest in the patient’s welfare. The lower self-confidence of some overseas-trained surgeons could therefore lessen the likelihood of complaints being made about them, whereas the supreme confidence of some highly experienced Australian-trained surgeons may go against them when something goes wrong. Good manners, kindness, demonstrations of personal interest and concern, and a degree of humility all discourage complaints! In an article subtitled “Arrogance: the biggest sin of all”,2 in the United Kingdom Telegraph, in 2009, Dr James LeFanu appropriately commented, “The virtues of generosity, cheerfulness and discretion should be the hallmark not just of medicine, but of all the liberal professions. How many doctors live up to these ideals is, of course, impossible to quantify, but certainly some readers of this column take a rather jaundiced view”.2

John A Buntine

Subacute unilateral visual impairment accompanied by pain on eye movement is characteristic of optic neuritis. Most cases of optic neuritis resolve spontaneously, and acute treatment with intravenous steroids hastens recovery but does not alter the ultimate visual outcome. Brain magnetic resonance imaging (MRI) may permit a diagnosis of multiple sclerosis (MS) to be made after a single clinical demyelinating event such as optic neuritis. Current evidence supports the introduction of disease-modifying therapy in patients with a single clinical event such as optic neuritis and brain MRI compatible with MS. The diagnosis of MS is a confronting life event associated with significant personal, social and financial burdens. The diagnosing neurologist should provide a detailed explanation of the disease and its clinical spectrum and introduce the patient to the wide range of support services, educational material and MS clinics.

Michael H Barnett MB BS, PhD, FRACP · Gurjit Chohan MB ChB · Leo Davies MB BS, MD, FRACP

Two children in far northern Western Australia tattooed their arms with maangga berries (Grevillea pyramidalis ssp. leucadendron), which resulted in unintentional, caustic, partial thickness skin burns requiring specialist burn care. An understanding of the chemistry of the burn agent (5-n-alkyl resorcinol), appropriate first aid management and referral, and possible physiological sequelae are essential for optimal medical management and preventive community education. Clinical recordsPatient 1A 10-year-old Aboriginal girl with burns was referred to the Princess Margaret Hospital burns unit by a local general practitioner in far northern Western Australia. Relatively little was known about the nature of her burns or the potential toxic chemical sequelae and, because of the distances involved, it was decided to bring her to Perth. The patient had used local berries to “tattoo” both her forearms, causing bilateral caustic burns to 1% of her body surface area (Box 1, A). After consultation with the burns unit, the area was washed thoroughly with water to remove any remaining traces of caustic substance and the pH of the area was repeatedly tested. The berries had induced a partial thickness burn with blistering of the skin. The blisters were deroofed and washed and the pH checked again. The child was observed overnight for systemic and metabolic effects. The burns were initially treated with nanocrystalline silver dressing and hydrocolloid dressing, which were changed every 2 days (Box 1, B and C). These were later replaced with calcium alginate dressing and hypoallergenic polyacrylate adhesive, which were changed every 2 days until complete resolution 3 weeks later. The patient was advised to massage and moisturise the area and to use sunscreen protection. Patient 2Almost exactly 1 year later, a 14-year-old Aboriginal girl with burns was referred to the burns unit from the same area as Patient 1. The maangga berry was confirmed as the seed pod she had used. She had burns on her right forearm, cubital fossa and distal arm. The area was washed with soap and water and irrigated while determining the pH of the wound area. She was admitted for wound dressing, observation and treatment for metabolic derangement. She sustained partial thickness burns to 3% of her body surface area. Her forearm was treated with nanocrystalline silver dressing and hydrocolloid dressing, which were changed every 2 days, then replaced with calcium alginate dressing and hypoallergenic polyacrylate adhesive, which were changed every 3 days until complete resolution after 3 weeks. She was advised to massage and moisturise the affected area and protect it from direct sunlight. DiscussionMost caustic burns are secondary to accidental ingestion of a corrosive substance, causing significant oesophageal stricture or perforation, or from topical exposure to agricultural or building chemicals.1,2 According to some studies, almost half the burns described are in children (despite them comprising less than 3% of all burns), and burns have significant cultural and psychological sequelae.3,4 Excluding a few case series of self-inflicted garlic burns and fruit juice mouthwash gingivitis, as far as we are aware, no described cases exist of caustic burns from plant matter, especially plants that have cultural significance for the Aboriginal people of Australia.5 Of further interest is that the topical chemical burn also may have significant systemic consequences related to the burn chemical. Regional and national poisons centres were contacted for advice, but staff were unable to advise on the management of the patients because little is known about this berry internationally. The patients were from an area that is a natural habitat for Grevillea pyramidalis ssp. leucadendron. The tree is also known as the konkerberry, maangga berry or caustic tree, which are generic terms for many different species of berry shrubs. These berries have traditionally been used by local Aboriginal people for tattooing; the berry is used to puncture the skin, and the fluid released from the berry causes a greenish discoloration of the skin followed by permanent black tattooing. The elders of the various tribes within the relevant region have been made aware (after liaising with the burns unit) of the potential harmful effects of the berries when used incorrectly by inexperienced users. High-performance liquid chromatography has been used to isolate the corrosive substance, identified as 5-n-alkyl resorcinol, a phenol derivative, which is also a precursor for tetrahydrocannabinoid (the psychoactive chemical in marijuana). There has been a resurgence of interest in 5-n-alkyl resorcinol because of its antioxidant, antigenotoxic and cytostatic characteristics. It is a phenolic lipid metabolite of plants, animals, fungi and bacteria during normal development, as well as during times of stress, such as when infection or wounds are present or when the organism is affected by ultraviolet radiation. It has also been found to inhibit bacterial, fungal, parasitic and protozoal growth, and to reduce the efficacy of viral transfection.6 Chemical burning seems to occur when 5-n-alkyl resorcinol binds with proteins to form esters that irreversibly bind calcium. This interferes with cellular mitochondrial performance, leading to cellular anoxia and energy deprivation, causing protoplasmic poisoning and necrosis. This organic compound also binds and dissolves the lipid membrane of the skin cells, leading to proteinaceous structural disruption. In a medical setting, naturally derived 5-n-alkyl resorcinol could be used as a potent heat shock protein-90 (Hsp-90) inhibitor. Hsp-90 is instrumental in the regulation of oncoproteins Her2, Akt, Bcr-Abl, c-Kit, EGFR and mutant BRAF, and when these oncoproteins are dysregulated, they lead to solid and haematological cancers.7 Clinically, Hsp-90 is the active compound in endodontic fillings and vascular glue and has been used extensively as a peeling agent.8 5-n-alkyl resorcinol has many side effects, including theoretical goitrogenic consequences, and G. pyramidalis is listed as poisonous in the United States Food and Drug Administration Poisonous Plant Database (http://www.accessdata.fda.gov/scripts/plantox/index.cfm). The fact that G. pyramidalis berry juice causes haemolysis is of concern, but the cardiac glycosides it contains may be of more concern, even though ingestion (not skin penetration) is required for a lethal dose. Other effects of cardiac glycosides include blurred vision, nausea, vomiting, bradycardia, confusion and lethargy, and people showing these signs after contact with G. pyramidalis should be referred to an emergency department immediately. We hope this article may be educational for doctors in far northern Western Australia and anyone coming into contact with the Grevillea species, some of which (eg, G. banksii and G. robusta) contain trace cyanide and grow in residential Australian gardens. We believe these two cases offer a unique insight into a region-specific phenomenon. 1 Partial thickness burns to the left arm of a 10-year-old Aboriginal girl (Patient 1), secondary to self-tattoo with berries from Grevillea pyramidalis ssp. leucadendron A. Day 1. B. Day 3 (after 2 days’ dressings). C. Day 6 (after 5 days’ dressings). 2 Grevillea pyramidalis ssp. leucadendron Photography by Lynley Wallis. Used with permission (http://florabase.dec.wa.gov.au/help/copyright). 3 Geographic distribution of Grevillea pyramidalis ssp. leucodendron Map data by Paul Gioia and the Western Australian Herbarium. Used with permission (http://florabase.dec.wa.gov.au/help/copyright).

Robert J Knight MB BCh, MRCS · Tania McWilliams BScNurs · Dawn Reeler MB ChB, DA · Liz Whan FRACS · Fiona Wood FRACS, AM

To the Editor: I endorse the viewpoint expressed by Jenkins and colleagues.1 They refer to the dearth of hospital medical generalists, at a time of increasing numbers of elderly patients with multiple comorbidities. Nowhere is this lack of appropriate clinical skill to match demand so apparent as in our regional centres. More often than not, junior doctors are responsible for older patients, and are required to manage disparate inputs from several medical and/or surgical subspecialists. Particularly for surgical patients with medical comorbidities, the junior resident medical officer (generally supervised by a visiting surgeon) is an inappropriate medical “case manager”. There is a desperate need in our regional centres to train and employ hospital-based generalists. At the same time, there is a need to move away from the visiting medical officer (VMO) fee-for-service model, designed around the needs of private practitioners, and move towards a hospital-based specialist model, in which specialists are available, accessible and part of the fabric of our hospitals. While the VMO model has been useful, it is no longer appropriate as a basis for default clinical care arrangements. Only by moving towards a hospital-based generalist model, as suggested by Jenkins et al, will we see an improvement in hospital culture, junior doctor supervision and training, and, most importantly, medical governance for best patient care in our regional hospitals.

Joanna R Sutherland

To the Editor: I commend Jenkins and colleagues for an engaging article on the future of general medicine in Australia.1 It mirrors a debate that is occurring in many acute-care hospitals, particularly in the context of a nationwide shortage of acute-care beds and increasing numbers of older patients presenting with chronic and multisystem disease.2 Currently, emergency physicians see the majority of acutely unwell patients who present to Australasian hospitals, particularly large urban centres, which is of great benefit to these patients.3-5 Thus, creating a new specialty of acute-care physicians to look after these undifferentiated patients seems like unnecessary duplication of service. Indeed, this duplication is one of the main issues in the journey of patients through the acute-care hospital system, particularly in tertiary institutions. After presentation to an acute-care hospital, patients often experience multiple consultations in multiple venues before admission to a home medical ward. They are often seen by a junior emergency doctor, then a senior emergency doctor, then a registrar from a subspecialty, and finally by the general medical registrar — and only then are they “admitted” and the often lengthy wait for a hospital bed commences. This journey could be dramatically improved by a single emergency department consultation with a senior emergency doctor (registrar or above), with stabilisation and immediately necessary investigations being done at that stage. After this, the patient could be either discharged to the community or admitted directly to a home medical ward where they can be seen by the home inpatient team. This would abolish much of the duplication that currently occurs and ultimately make the hospital visit safer for the patient and more cost-effective for the hospital.

Alan E O’Connor

To the Editor: The research by Rosenwax and colleagues1 and Lowthian and colleagues2 published in the Journal highlights the need for increased capacity in end-of-life care within primary care to reduce the inappropriate use of acute health care services at the end of life. Providing high-quality care for people diagnosed with advanced chronic conditions is among the most complex challenges for general practitioners.3 GPs and other primary care providers are able to provide appropriate palliative and end-of-life care when they are well supported by relevant specialists.3 For patients to be well cared for in the community, it is also necessary for informal carers to have the strength, the will and the skill to provide such care, as well as timely access to support and medical care. The recent National Health and Hospitals Reform Commission’s report4 and the Australian Government’s National Primary Health Care Strategy5 both recognise the need to build “the capacity and competence of primary health care services”4 to support their dying patients. These documents make recommendations that begin to address the current difficulties of caring for these patients in the community. Of significance are recommendations for increased support for carers; improved shared-care arrangements; and better access to specialist palliative care, support and funding for advance care planning and improved access to primary health care professionals.4 This includes a commitment to address workforce shortages and improving out-of-hours access to medical care.5 Such recommendations are positive and will be helpful when they are fully realised. However, issues within primary care — both at the community and individual general practice levels — also need to be addressed. People for whom a palliative approach is appropriate need to be systematically and proactively identified in a timely way. Needs assessment and care planning should be undertaken to ensure that problems and preferences for care are identified and mechanisms are put in place to support such care. To promote optimal end-of-life care, a coordinated, multidisciplinary approach is as important in the community as it is in the hospital setting. Good communication and collaboration between primary care providers, the patient’s specialists and specialist palliative care providers are imperative. Also essential is an ongoing dialogue with the patient and family to enable a clear understanding of the goals of treatment and to proactively plan for likely adverse events. Routinely planning for likely scenarios will potentially reduce the use of acute services and encourage the provision of care in more appropriate environments.

Claire E Johnson · Geoffrey K Mitchell

To the Editor: The finding of Wilkinson and colleagues1 that the Undergraduate Medicine and Health Sciences Admission Test (UMAT) score and medical school performance are only weakly correlated came as no surprise. Another shortcoming of the UMAT process has been its inability to recognise the effects that failure in the test can have upon applicants. The Selection Committee for the School of Medicine at the University of Notre Dame in Fremantle rejected the UMAT from the outset. We considered its content to be arbitrary, and that there was no evidence to suggest that it could predict a medical student’s performance, let alone a medical practitioner’s sensitivity and empathy. My concern with the need for fairness and sensitivity in the selection process evolved from my experience of being approached by applicants to other medical schools who were distressed by their failure to pass the UMAT hurdle. What upset them most was that the UMAT literature claimed that one could not study for the test as it tested “aptitude”. Rejected applicants therefore felt that they intrinsically lacked the necessary personal characteristics to be a good doctor. The truth was that they had not performed as well as others in an idiosyncratic test, which included tests of “spatial orientation” and other arcane matters. At the University of Notre Dame, we recognise the great disappointment that unsuccessful applicants feel and counsel those who contact us. We reassure them that they can try again the next year, and are likely to have a better chance of success then. We never imply that they are not suitable to be a doctor. Medical educators can only expect students to possess fairness, empathy and understanding of the suffering of others if we demonstrate the same qualities to them. In the case of the UMAT — an experiment that has dominated medical student selection in Australia for more than a decade — those qualities have been lacking. I believe that the UMAT has left a scar on many unsuccessful applicants and on the perception of the Australian selection process that was used in many universities over those years. Let us remember that doctors’ responsibility to be caring, sensitive and humane extends beyond the consulting room.

Barry N J Walters

To the Editor: The Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study, a large, blinded, multinational study, showed an increased risk of adverse maternal and neonatal outcomes in relation to maternal glycaemia, at glucose levels below the current Australian criteria for diagnosing gestational diabetes mellitus (GDM).1 The International Association of Diabetes and Pregnancy Study Groups (IADPSG), an international consensus group, has proposed new criteria for the diagnosis of GDM.2 As a result, these new criteria have been adopted by the American Diabetes Association, which predicts a significant increase in the prevalence of GDM.3 The new criteria were discussed at the Australasian Diabetes in Pregnancy Society annual scientific meeting in 2010. Moses and colleagues accurately outline the increased prevalence of GDM if IADPSG criteria are adopted in Australia.4 An increased prevalence has implications for resource allocation, and the anticipated increase in workload can be managed by appropriate planning and exploration of alternative models of care. We surveyed attitudes to the management of GDM among general practitioners already involved in antenatal shared care programs in the Liverpool and Fairfield areas of Sydney (GDM is not currently part of the shared care program in this urban area, which has a high prevalence of diabetes). Around 120 GPs are enrolled in the antenatal shared care program in the Liverpool and Fairfield areas. Forty-six of these GPs attended an educational meeting at which the survey was distributed, and of the 46 (who all completed the survey), only seven believed that GDM can always be managed in the antenatal shared care program. Seventeen felt that, due to lack of time or lack of access to appropriate resources, GDM cannot be managed at all by GPs as part of shared antenatal care; eight of these 17 indicated that they never initiated insulin for patients with type 2 diabetes. Only two indicated that no up-skilling was required for them to manage GDM. These attitudes may be limited to GPs in urban practices. Whether the involvement of GPs in the management of GDM is appropriate is unclear, and the provision of supporting resources requires further review. Additionally, as determined by Moses and colleagues,4 the predicted increase would come from older women who are possibly more likely to have other comorbidities that make them less suitable for shared care.

Barbara Depczynski · Vincent W Wong · Hamish D Russell · Nicole Opie

A 35-year-old man sent us this self-portrait, taken with a digital camera, showing significant asymmetric flushing on the left side of his face after jogging. The episode resolved spontaneously after 30 minutes of rest. Harlequin syndrome consists of flushing limited to one side of the face due to sympathetic disturbance on the contralateral side.1 Although most cases are benign, imaging and neurological examination should be performed in patients with this condition to rule out serious structural lesions of the sympathetic pathway, such as mediastinal neurinoma, spinal invasion by lung cancer and brainstem infarction.

Agustín Toll · Alberto Gálvez-Ruiz

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