General medicine

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

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

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

A 62-year-old woman with an autoimmune disease presented with panuveitis and was treated with immune suppression. She subsequently developed herpetic acute retinal necrosis and later died of herpes simplex encephalitis. Acute retinal necrosis usually occurs months to years after herpes simplex encephalitis. In our case, the ocular findings were present for 5 weeks before the encephalitis presented. To our knowledge, this is the first Australian case of acute retinal necrosis preceding herpes simplex encephalitis. (MJA 2011; 195: 87-88) Clinical recordA 62-year-old woman was referred to our hospital after a left-sided uveitis failed to respond to both topical and systemic steroids. She was known to have systemic lupus erythematosus (SLE) with severe arthritic changes, but had not received immunosuppressive therapy. She had right temporal lobe surgery in 1995 for a benign brain tumour. In 2005, she had Legionella pneumonia that had resulted in an intensive care unit admission with multiorgan failure and acute respiratory distress syndrome. As part of the diagnostic work-up during her previous admission, she was diagnosed as having herpes simplex virus (HSV) type 1 and was treated with aciclovir. She had no known history of genital or oral herpetic lesions. She had no significant ophthalmic history. When she was first reviewed at our hospital, she had been symptomatic for 3 weeks. She had been diagnosed as having an SLE-related panuveitis and had been treated with topical, regional and systemic steroids for 2 weeks with no response; on presentation, she was taking oral prednisolone, 1 mg/kg/day. She described a loss of appetite for 6 weeks but had no headache, fever, rash, pleuritic chest pain or shortness of breath suggestive of a lupus flare. Her initial visual acuity was 6/9 in her right eye and “hand movements” in her left eye. There was a relative afferent pupil defect in her left eye. Her anterior chamber had large mutton-fat keratic precipitates, fibrin and posterior synechiae — all indicative of a granulomatous uveitis. There was no fundal view of the left eye. An ultrasound scan of the left eye showed vitreous debris and a retinal detachment. Fundal examination of the right eye showed one or two small scattered intraretinal haemorrhages (Box 1, A). Fluorescein angiography (Box 1, B) of the right eye showed mild leakage from the disc and vessels in keeping with an early vasculitis. There was no view of the left fundus. An anterior chamber tap and vitreous biopsy were taken from the left eye. Bacterial and fungal microscopy and culture were negative; results of cytological analysis were normal. There was insufficient specimen for viral polymerase chain reaction (PCR). (This is a common occurrence for aqueous and vitreous samples, in which the amount taken averages 0.4 mL.) Blood sampling showed an antinuclear antigen positive to a titre of 1 : 2560 (> 1 : 160 considered positive for probable autoimmune disease), an erythrocyte sedimentation rate of 38 mm/hour (reference range, < 20 mm/hour for women aged > 50 years), and anti-DNA antibodies > 100 IU/mL (reference range, < 6 IU/mL); a white cell count and serum angiotensin-converting enzyme levels were normal, and human leukocyte antigen (HLA)-B27 was not detected. Serological testing was negative for syphilis and HIV. Blood culture was negative. An echocardiogram and chest x-ray were non-contributory. At this stage, the differential diagnosis included a masquerade syndrome (intraocular lymphoma), active lupus, or an endogenous, infective endophthalmitis. The patient was referred for a surgical vitreous biopsy. She continued to take oral prednisolone 1 mg/kg/day. Two days later, there was a marked deterioration in the patient’s vision. Her visual acuity was recorded as “no perception of light” in both eyes. She had no headache, but she was febrile. Her right eye now had anterior chamber and vitreous cells and widespread retinal haemorrhages (Box 1, C). Magnetic resonance imaging (MRI) of the patient’s brain showed an area of encephalomalacia in keeping with her previous surgery. Inflammatory changes and a retinal detachment were noted in the left globe. The optic nerves appeared normal. No orbital masses were noted, and no cavernous sinus pathological features were observed (Box 2, A). A surgical vitreous biopsy was performed on her left eye. The next day, she was found to have a deteriorating neurological status. She was delirious and seemed unable to hear and follow commands. She remained febrile. A lumbar puncture was performed. PCR of cerebrospinal fluid and vitreous fluid samples were positive for HSV type 1. In addition, the cerebrospinal fluid had 75 lymphocytes/mm3 and normal cytological features. She was commenced on intravenous aciclovir. A repeat MRI scan 8 days after the initial scan showed increased signal on flair involving the thalamus, occipital, temporal lobes and brainstem in keeping with an encephalitis (Box 2, B). She failed to improve clinically and died 3 weeks later. An autopsy was refused by the family, but the cause of death was pressumed to be herpes simplex encephalitis (HSE). DiscussionAcute retinal necrosis (ARN) associated with HSE has been well described. Most published reports describe the ocular findings following the encephalitis with a variable time course; the mean interval is 6 months but it can range between 10 days and 20 years.1-6 To our knowledge, there has been only one report published of HSE following ARN.7 When ARN follows HSE, it is assumed that a reactivated latent virus is axonally transmitted from the brain to the retina. A retrospective study published in 2008 examined the causative virus among 52 patients with ARN.8 It found that 14% had a history of previous HSE. There were no cases in which ARN preceded the encephalitis. In one case report, the authors noted that there have been 20 cases of ARN following HSE published in the past 20 years, and only one case of HSE following 3 weeks after ARN.9 HSE remains a serious illness with significant risk of morbidity and death. A high index of suspicion is required to diagnose HSE. Neurons undergo lysis associated with haemorrhage — a process similar to that seen in the eye with ARN. The exact mechanism of cell death is postulated to be a combination of direct virus-mediated and indirect immune-mediated processes.8,10 Without treatment, the brain undergoes severe inflammation and necrosis. ARN typically causes panuveitis with a distinctive pattern of retinal involvement. Patients may develop painful, severe visual impairment over a few days, or experience an insidious onset with mild visual symptoms such as floaters. Ophthalmic examination shows evidence of a granulomatous uveitis, vitritis, peripheral retinal periarteritis, retinal infiltrates, retinal necrosis, and sometimes retinal detachment. The posterior pole (macula) is usually spared until late; thus vision may remain fairly good despite surrounding necrosis. Diagnosis is made using PCR-based assays of aqueous and vitreous fluid. Treatment of ARN is intravenous aciclovir for 14 days followed by oral valaciclovir for 3 months. Systemic steroids are started a few days after initiation of antivirals to lessen the immune-mediated retinal necrosis. Our patient had a history of HSV years before the current presentation. There was, however, no history of preceding encephalitis. We hypothesise that the unguarded use of steroids may have caused reactivation of the virus and subsequent spread to the brain via retrograde axonal transport from the eye or from a generalised viraemia. This case highlights the importance of considering a viral aetiology in cases of atypical uveitis. ARN may herald systemic or cortical disease. Viral PCR should be performed before commencing systemic steroids. Herpetic disease may remain latent for many years before presenting in a previously uninvolved tissue. Intraocular inflammation remains a diagnostic challenge frequently encountered in ophthalmic practice. It remains imperative that all patients presenting with a possible uveitis be referred to an ophthalmologist. 1 Photographs of the patient’s right fundus A. Initial presentation of the right eye with small intraretinal haemorrhages. B. Fluorescein angiogram of the right eye at initial presentation. C. Two days after initial presentation. 2 Magnetic resonance imaging of the patient’s brain and orbits A. Old area of encephalomalacia on the right, and inflammatory changes in the left globe. B. Repeat scan showing increased signal on flair settings.

K Nadia Wittles MB ChB, FCOPHTH(SA), FRANZCO · Lucy A Goold MB BS · Jagjit S Gilhotra MB BS, MMed (ClinEpid), FRANZCO

To the Editor: The number of vulvoplasty or labioplasty procedures rebated by Medicare Australia has more than doubled over the past 10 years;1 in the United Kingdom, a similar trend was observed in the National Health Service (NHS) (Box).2 Recent media debate in Australia highlights this as a concerning problem.3 The community assumes that surgical operations are clinically effective treatments performed for identifiable pathological features. In the context of female genital cosmetic surgery (FGCS), there is a blurring between disease and dissatisfaction, the latter being at least partly informed by cultural pressure about physical appearances. In addition, there is an absence of evidence on clinical effectiveness,4 and an apparent lack of commitment to monitor adverse events. This raises the question of how clinicians justify referring women for FGCS. A recent audit of referral letters for labioplasty in an NHS gynaecology clinic in the UK (University College London Hospitals project no. 03/0173) offers interesting insights. Of the 48 letters reviewed, the mean age of the women referred was 25 years (range, 9–50 years). Complaints about genital appearance were identified in 34/48 (71%) of letters (eg, embarrassment about undressing in public changing rooms). Physical discomfort was mentioned in 23/48 (48%) letters (eg, difficulty with activities such as cycling). Sexual problems were mentioned in 21/48 (44%) letters (eg, a reluctance to engage in sexual relationships). In two of the letters, the referrers mentioned disparaging comments by previous sexual partners, and one mentioned harassment by other girls at school. Alarmingly, a further seven letters (15%) alluded to concerns being flagged by the girls’ mothers. Only 77% of referrers reported examining the patient. A third of referrers judged the labia to be “normal”, yet nevertheless requested surgery for their patients. Pejorative language such as “leathery in appearance” or “pendulous and elongated” was used in 12 (25%) of the letters. Medical training may cover basic vulval anatomy, but detailed study of morphology is not included. This knowledge gap would have been less problematic in the past. However, in recent years, where intense marketing of FGCS5 is contributing to soaring demand, medical practitioners may not be sufficiently informed about female genital anatomy to assess and advise women about their concerns. Reasons for the increasing prevalence of female distress about genital appearance are likely to be complex and rooted in social and cultural changes. In the absence of identifiable diseases, referral for operations may not be the most appropriate way of managing women’s body insecurities. Labioplasty and vulvoplasty operations rebated by Medicare Australia1 and covered by the United Kingdom National Health Service2 over the past 10 years* INR = international normalised ratio. * Graph shows abbreviated, not daily, data. Intervals are weekly up to Week 9, then vary according to when INR was measured.

Rebecca Deans · Lih-Mei Liao · Naomi S Crouch · Sarah M Creighton

General medicine is being challenged by increasing numbers of patients who are presenting with multiple comorbidities and a decline in numbers of suitably trained personnel to manage these patients. A resurgence in generalist care, with collaboration between generalists and specialists, is the key to successfully managing patients who present with acute medical conditions. Better funded collaborative training programs for general physicians, which promote a diversity of skills and address clinical demand in a proscriptive manner, are needed. Research aimed at designing acute services to match local clinical demand is also required.

Paul F Jenkins MA, MB BChir, FRCP · Campbell H Thompson MD, DPhil, FRACP · Alasdair B MacDonald BMedSc, MB BS, FRACP

Use of social media by doctors and medical students is common and growing. Although professional standards and codes of ethics that govern the behaviour of medical practitioners in Australia and New Zealand do not currently encompass social media, these codes need to evolve, because professional standards continue to apply in this setting. Inappropriate use of social media can result in harm to patients and the profession, including breaches of confidentiality, defamation of colleagues or employers, and violation of doctor–patient boundaries. The professional integrity of doctors and medical students can also be damaged through problematic interprofessional online relationships, and unintended exposure of personal information to the public, employers or universities. Doctors need to exercise extreme care in their use of social media to ensure they maintain professional standards.

Sarah J Mansfield MB BS(Hons), BMedSci · Stewart G Morrison MB BS · Hugh O Stephens · Michael A Bonning MB BS, BAppSci(Hons) · Sheng-Hui Wang · Aaron H J Withers MB ChB · Rob C Olver · Andrew W Perry MB BS

Silent burden, unseen weight Companion of years, my partner in fate Of lonely dinners long gone cold Together we age, together grow old. Missed fairytales and goodnight kisses Headlight’s flicker disturbing “the missus”. Heart attack asthma caesarean born Trauma OD bloody red dawn Weary of night, the yoke near lifted Cresting sun, you’re happily gifted. Starlight’s tarnish is tired and grumpy Cups of coffee, sugar that’s lumpy. Dreams cleft and left unclaimed Mindless drifting readily explained. Prematurely pulled warm from bed Thoughts can be fragile, movements like lead. Perchance at home, if need is slight Family television, lounge at night The rest is tainted, not quite as sweet As those untroubled by calls from sleep. Veterans know it’s a waiting game; Fortune’s spin, career’s disdain And so I wake at nocte’s fall Delighted clocks strike — “You’re now off call!”

Robert F Grace MMed, FRACP, FANZCA

To the Editor: Weight fluctuations may lead to significant changes in a patient’s treatment, so it is vital that hospital scales are accurate. A literature review revealed that calibration,1 accuracy2 and centralised hospital quality control3 of hospital scales were issues that are being recognised and addressed around the world. We audited all scales at the Royal Melbourne Hospital, city campus, to assess their accuracy and identify the types of scales that are likely to be most accurate. A preliminary survey identified all scales on the wards and in outpatient departments. On a single survey day, each scale was categorised and photographed. Scales were “zeroed” and standard weights of 5 kg, 10 kg, 15 kg and 20 kg, and a person whose weight had been established elsewhere as 106 kg, were then weighed on each scale. Our primary measure of accuracy was the difference between 106 kg and the recorded weight of the person, as this most closely approximated the weight of an average patient (rather than using the 5, 10, 15 and 20 kg weights). Forty-three of 50 scales identified in the hospital were tested. Scales that were excluded were either not working or not able to be tested with the weights we used. All scales in the outpatients department were digital (22). On the wards, there was a mix of sit-on (6) and stand-on (15), and digital (9) and analogue (12) scales. The digital scales had an accuracy (range around the standard weight) of − 1 kg to +1.5 kg, compared with an accuracy of − 3.5 kg to +1 kg for the analogue scales (P = 0.006; Wilcoxon signed rank test). Interquartile ranges were − 0.45 kg to +0.07 kg for digital scales and − 2 kg to +0.5 kg for analogue scales. The mean deviation from the correct weight was 0.06 kg for digital scales and 0.55 kg for analog scales. The most accurate scales were in the renal wards, used by dialysis outpatients and inpatients. Some areas had scales that were unusable by patients, such as sit-on scales in the geriatric ward (Box 1) that were difficult to mount. A haematology ward, where decisions are often made on the basis of changes in weight, had five sets of scales, with significant inaccuracies and differences between them. In one ward, no scales could be located, and five out of 23 outpatient rooms had no scales. The digital scales were more accurate than the analogue scales (Box 2). In areas where treatment decisions are made on the basis of changes in weight, scales should regularly be checked for accuracy, and patients should be weighed on the same scales each time they are weighed. For greater accuracy and consistency in measuring patient weights, we recommend that all scales be upgraded to digital scales throughout the hospital. 1 Sit-on analogue scale at Royal Melbourne Hospital, unusable for some patients 2 Weight variations in 43 digital and analogue scales at Royal Melbourne Hospital * As measured using standard weights of 5 kg, 10 kg, 15 kg, 20 kg and a 106 kg person.

Rimma Goldberg · Geoffrey Hebbard

Reflection on past achievements and future challenges 10 years after the establishment of the Australian General Practice Training program On 5 March 2001, the Australian Government established General Practice Education and Training (GPET).1 The main role of this new company was to establish the Australian General Practice Training (AGPT) program. Ten years later, the AGPT is strong, dynamic and continuing to evolve. This supplement was commissioned by GPET to review the activity of the past decade, to examine contemporary issues in general practice education and training, and to explore some of the future directions for the training of Australia’s general practitioner workforce. Capturing past experienceAustralian general practice vocational training has come a long way since 1973, when the Whitlam Labor Government provided funding to the Royal Australian College of General Practitioners (RACGP) to set up the original Family Medicine Programme, (later renamed the RACGP Training Program). In the first section of this supplement, two prominent Australian general practice educators, Willcock and Coote (→ The Australian General Practice Training program — reflections on the past decade)2 and Trumble (→ The evolution of general practice training in Australia),3 look back and provide their perspectives on the evolution of general practice vocational training in Australia, the legacy of the previous RACGP program, the events leading to the establishment of GPET and the AGPT program, and progress made over the past decade. Hays and Morgan examine the general practice training programs in New Zealand, Europe (including the United Kingdom and Ireland), Asia and North America and compare these with the developments in Australia (→ Australian and overseas models of general practice training).4 Contemporary issuesThe AGPT was created with a set of expectations — to establish a regionalised model of training, to improve vertical integration of general practice education, and to foster innovation.5 The second section of this supplement addresses these contemporary issues affecting general practice training. Campbell and colleagues examine whether the regionalisation focus of GPET has succeeded in meeting the needs of rural Australia and addressing maldistribution of the medical workforce (→ Regionalisation of general practice training — are we meeting the needs of rural Australia?).6 Stocks and colleagues describe the scope of vertical integration in Australian general practice through the establishment of regional training providers, and assess the linkages that have developed with universities and their rural clinical schools to improve integration in medical student training with the training of recent medical graduates and general practice registrars (Vertical integration of teaching in Australian general practice — a survey of regional training providers).7 Martin and Reath provide an assessment of innovations in general practice training in Aboriginal and Torres Strait Islander health (→ General practice training in Aboriginal and Torres Strait Islander health),8 while Kitchener and colleagues examine innovations in linking military medicine to general practice education and training (Training Australian Defence Force Medical Officers to civilian general practice training standards — reflections on military medicine and its links to general practice education and training).9 Finally, the current president of the World Organization of Family Doctors (Wonca), Professor Richard Roberts, and colleagues provide a global perspective on the challenges of primary health care delivery to the people of all nations, and the education and training needs of each country’s future GPs (→ Family medicine training — the international experience).10 Future directionsAt the start of the second decade of the AGPT program, Australia is moving through a process of health system reform that promises to shake up the delivery of primary medical care through the transformation of Divisions of General Practice into broader primary health care organisations called “Medicare Locals”,11 through the Australian Government’s investment in a network of “GP super clinics” and expanded general practices for primary care delivery, and through plans to better integrate both community-based health care and hospital care. The establishment of Health Workforce Australia12 has also created an urgent need for clarity around how we educate and identify supervisors for all medical and other health profession graduates. The supplement’s third section looks at the opportunities ahead and how all those involved in general practice training can seize them. Harris and colleagues discuss the trends that are putting pressure on Australia’s primary health care workforce and the implications for future training (→ Strategic approaches to the development of Australia’s future primary care workforce).13 Laurence and colleagues examine the strengths and weaknesses of the current regionalised training model and look at opportunities for expanded roles (→ Getting governance right for a sustainable regionalised business model).14 Emery and colleagues propose a series of training reforms to better meet future professional needs of GPs (→ Future models of general practice training in Australia),15 and Thomson and colleagues examine ways to ensure future sustainability by ensuring adequate support of this nation’s GP teachers (→ Supervision — growing and building a sustainable general practice supervisor system).16 What lies ahead?Reading through the supplement demonstrates many commonalities, with several observers reporting the same events from slightly different perspectives. However, it also reveals some of the challenges for general practice training over the years ahead. It is clear that the enhanced apprenticeship model of general practice training has served Australia well, but by its very nature the apprentice ends up cast in the mould of the master. It is a confronting reality that tomorrow’s GP will look very different to yesterday’s, and even today’s. GP supervisors need the flexibility to train registrars for quite a different role to what their own has been. General practice training must allow registrars to develop into what they need to be to best meet the future health care needs of their patients and their communities. It also appears that a focus on competency-based training is inevitable if we are to produce a sufficient number of GPs with the right skills to meet Australia’s evolving health needs. Clearly defining the outcomes of training by competencies, rather than by time served in a specific location, may be a way to provide future GPs with a myriad flexible, yet integrated, pathways offered by a range of providers that lead to the same professional standard. It could also allow for more contemporary competencies to be added to the GP’s traditional skill set, for example in management, teaching, research, quality and safety, teamwork, e-health and leadership.* At the same time as the vertical integration model needs to be reinforced across undergraduate and postgraduate medical training, better horizontal links must be established with other craft groups. This will strengthen interprofessional learning as general practice moves more to team-based care, to better meet the complex needs of many of our patients and our communities. Perhaps the future lies not in a single, rigid pipeline that delivers a fully trained — yet somewhat startled — new GP to an area of medical workforce need, but in acknowledging that there are multiple ways in which each new doctor can acquire, to established end points, the competencies required for safe, independent and appropriate general practice. * The RACGP will be addressing each of these areas in the development of its curriculum program in 2011.

Michael R Kidd AM, MD, FRACGP · Justin J Beilby MB BS, MD, FRACGP · Elizabeth A Farmer MB BS, PhD, FRACGP · Claire L Jackson MB BS, MPH, FRACGP · Stephen C Trumble MD, FRACGP

How has general practice vocational training progressed towards the original goals established by the federal government and General Practice Education and Training 10 years ago? Over the past two decades, the federal government has used various financial and regulatory levers to influence the organisation and activities of Australian general practitioners.1 A contentious initiative was the 2001 decision to cease funding the Royal Australian College of General Practitioners (RACGP) Training Program and to create a government-owned company, General Practice Education and Training (GPET) to implement a national vocational training program for general practice.2 GPET was created to establish a system of regional training providers (RTPs) and to oversee the implementation of a new system of general practice vocational training, the Australian General Practice Training (AGPT) program. Disentangling and weighting the many influences that led to this decision is best left to other historians. Hayden White, a central figure in academic debate about the nature of history, suggests it is difficult to get an objective history of a scholarly discipline, because if the historian is himself a practitioner of it, he is likely to be a devotee of one or another of its sects and hence biased; and if he is not a practitioner, he is unlikely to have the expertise necessary to distinguish between the significant and the insignificant events of the field’s development.3 However, three broad themes dominated academic, political and policy debate on general practice education in the years leading to the establishment of GPET and the AGPT program. First, reference to fragmentation of the general practice education “continuum” was common. In 1988, the “Doherty Report” recommended that “stronger links . . . be developed between university general practice units and the institutions providing vocational training for general practitioners”.4 In 1991, Kamien and MacAdam listed “cooperation with the RACGP-Family Medicine Program (FMP)” as a priority for general practice undergraduate departments.5 The future of general practice, a 1992 government report, noted the “artificial separation between undergraduate and continuing education” and the “guarded relationship between academic general practice and the FMP” resulting in “little scope for ensuring continuity in what is taught”.6 Second, establishment of the Australian College of Rural and Remote Medicine (ACRRM) challenged the hegemony of the RACGP over general practice vocational education. The ACRRM was incorporated in 1997 by the Rural Doctors Association of Australia as an acknowledgement of: · the importance of rural and remote medicine as a broad but discrete form of general practice · the need for well-designed vocational training and continuing medical education for rural doctors, and · the need to address the shortage of rural and remote doctors in Australia, by providing them with a separate and distinctive professional body.7 Third, the federal government wished to leverage the arrangements through which it funded general practice vocational education and training, to pursue medical workforce policies to manage overall numbers of GPs (and general practice Medicare outlays) and the distribution of general practice trainees. The 1998 report of the Ministerial Review of General Practice Training considered these influences in the context of broader changes in the way medical care was being provided, referring to all these forces as: “environmental barriers and constraints leading to calls for overhaul of the GP vocational training environment”. The report concluded that “the RACGP [training program] is now confronted with myriad conflicting demands brought about by influences that it cannot fully control”.8 It recommended fundamental changes, most significantly “development of local collaborative arrangements, or consortia, in education-service delivery” with a national body to promote “better coordination at all levels of the general practice education continuum”.8 From a political perspective, the establishment of GPET in 2001 was a government response to an astute, coordinated and persistent political campaign by rural doctors’ organisations. Rural doctor advocates wanted more rural influence and control over public funds that support general practice training, arguing that the RACGP Training Program had become “metrocentric”. From a workforce policy perspective, the government instituted measures through GPET to boost the supply of doctors in rural areas. These included an unequivocal requirement that all registrars undertake a minimum 6 months’ training in rural areas, and financial incentives for trainees who undertook additional rural-based training. A key educational aim underpinning the establishment of GPET and the AGPT program was regionalisation to facilitate vertical integration of training, thereby fostering an environment that would encourage innovation and competition between RTPs (over, for example, quality and cost of training and the nature and length of the educational experience). Other outcomes included a well trained, appropriately distributed workforce in sufficient numbers to meet the health needs of a growing and ageing population, and those of Indigenous Australians. Ten years onThe establishment and subsequent history of GPET and the AGPT program between 2001 and 2011 raise many interesting questions. To what extent has vertical integration of general practice training and education actually occurred across medical school, prevocational and vocational training entities in terms of measurable outcomes? To what extent have RTPs been able to innovate, caught as they are between contractual obligations to GPET and the need to deliver training according to, at times, prescriptive college requirements? Has the overall supply of GPs (particularly in rural regions) been boosted by the new arrangements? Regionalisation outcomes — vertical integration, competition and innovationInitial hopes, at least by the federal government, for competition between RTPs did not eventuate in any substantial sense for two main reasons. First, GPET was required to ensure training met existing “college standards”. This was a late addition to the GPET constitution following lobbying by general practice organisations, and significantly defined the educational content of the new program. RTPs were free to explore innovative delivery models, but the curriculum prescribed for all RTPs to achieve these standards was essentially constant. Second, there was an effective exclusion of completely new prime providers by criteria defining governance of RTPs that restricted participation to entities controlled by collaborations of local general practice interests such as medical colleges and Divisions of General Practice. At least two universities sought to become prime providers, but these proposals were unsuccessful. Despite GPET’s development of a vertical integration framework,9 integration of education and training across the undergraduate, postgraduate and vocational spectrum struggled to evolve in the early years of the AGPT program, with the focus on more urgent training imperatives such as registrar selection and recruitment for an increased number of training places per year (rising from 450 to 600 in 2004). Some university-based departments of general practice have been contracted by RTPs to deliver components of registrar training, and many RTP medical educators have university appointments. In recent years, vertical integration has gained further momentum with: the transition to GPET of the Prevocational General Practice Placements Program — an experiential program in community-based general practice for junior hospital doctors;10 and GPET-funded initiatives to foster general practice exposure within medical schools, including support for the General Practice Students Network and GP Compass programs. GPET continues to seek collaborative opportunities with medical schools to foster integration of student placements with prevocational and vocational training. However, this has been hampered by funding mechanisms and incentive schemes for undergraduate student placements that are not sufficiently aligned with prevocational and vocational training supervisor and practice support initiatives. The regionalised model has facilitated local decision making by identifying local health needs, local opportunities for training of registrars by resident supervisors, and more local career development opportunities for supervisors and educators. Many large RTPs have recognised the need to develop regional nodes that address the unique needs of the local population while operating within an overarching governance structure. One outstanding example has been the Kimberley Aboriginal Medical Services Council’s medical education project, which has improved general practice access for area-of-need populations and has provided an effective model for engaging a diverse spectrum of stakeholders.11 Some RTPs, for example, Coast City Country General Practice Training (covering Wollongong, Canberra, the Riverina and the New South Wales South Coast) and Western Australia General Practitioner Education and Training, have developed “nodal” operational models, servicing multiple regional communities while achieving administrative efficiencies. The perennial problem of efficiency versus local representation has continued, however — some smaller RTPs proved unsustainable and the original 22 RTPs (from 32 valid applicants) were reduced to 17 through a series of mergers. Workforce training — capacity, resources and distributionFrom the outset, RTPs across Australia were encouraged by GPET to develop registrar training capacity in areas of medical workforce need. Box 1 highlights significant growth in training service delivery from the initial 2003 AGPT training year — registrars have increased by 88% in metropolitan locations and 102% in Rural, Remote and Metropolitan Areas (RRMA) 3–5. RRMA 6 and 7 also experienced a significant 64% increase. However, the absolute number completing training does not yet meet the demand for additional GPs. Box 2 shows the growth in the number of GP registrars who completed terms in Indigenous health posts by RRMA between 2003 and 2009. The growth in these numbers is broadly in line with the growth in total registrar numbers over that time. The number of Aboriginal and Torres Strait Islander registrars has risen from two to 34 over the same period. In March 2010, the Australian Government Department of Health and Ageing announced that AGPT program places would be doubled to 1200 a year by 2014 to meet anticipated need for 3000 extra GPs by 2020.12 While this is welcome news, it presents a challenge in recruiting additional GP medical educators and supervisors at a time when the general practice workforce is already stressed by service delivery requirements as well as demands for clinical placements in general practice from the undergraduate medical, nursing and allied health sectors. There is, therefore, a need for a comprehensive assessment of training demand in general practice to identify the additional resources required to meet the projected need, particularly in physical infrastructure for clinical training, supervisor support and development, and the establishment of a robust and sustainable workforce of skilled medical educators. Increased demand can potentially be offset by exploring new training models, including integrated, interprofessional models in large community-based clinical facilities with a primary care focus. These larger community-based centres of care would be suitable for group activities, including education programs for patients, students and clinicians. There is also scope to expand the historical model of general practice training from a general practice “consultation apprenticeship” model to include significant time in other domains of practice such as emergency medicine, aged care, palliative care and routine procedural work. The rural generalist training approach, introduced by the Queensland Government in 200513 and implemented in Western Australia in 2009,14 is likely to provide a good model for enhanced diversity in GP vocational training. Indigenous health trainingIn 2003, some 2 years after its establishment, GPET developed its Framework for General Practice Training in Aboriginal and Torres Strait Islander Health.15 Since then, a range of issues and challenges have emerged, with important lessons learned. GPET has recognised the benefit of improved collaboration with Aboriginal and Torres Strait Islander organisations, and these partnerships will continue to inform AGPT’s Aboriginal and Torres Strait Islander health training initiatives. Evaluation of the Framework suggested that the comprehensive, multilevel approach to Aboriginal and Torres Strait Islander health training has been one of the program’s strengths.16 GPET, along with the RTPs, is playing a national leadership role in responding to the specific regional circumstances and needs of Aboriginal and Torres Strait Islander communities in collaboration with the relevant state- and territory-affiliated organisations. While the regionalised training program model has worked well generally, one of the immediate issues that emerged was the uneven capacity to host general practice training in Aboriginal Community Controlled Health Services (ACCHSs) throughout Australia, with a resultant uneven distribution of registrars undertaking the training. Since 2003, the three RTPs with geographical footprints in northern Australia have consistently recorded the highest proportion of their registrars undertaking training in an Aboriginal and Torres Strait Islander health training post. Today, 66% of all general practice training in Aboriginal and Torres Strait Islander health occurs in northern Australia. Some of the challenges to expanding training capacity in ACCHSs in southern Australia include long-term supervisory vacancies and inadequate infrastructure. Solutions may require a review of the scope of current AGPT programs, and will certainly need close collaboration with other agencies involved with health service provision to Indigenous communities. ConclusionsThe AGPT program and its regionalised delivery system are now well established in Australia. It is generally acknowledged as a successful program, and is now broadly accepted by the profession and government. The system continues to be future-focused, and is cohesive, responsive to changing community needs and well positioned for future challenges and opportunities. In retrospect, the fundamental aims and outcomes for GPET and the AGPT program remain relevant today. The decline in general practice workforce numbers in rural and remote Australia has been halted, but an ageing workforce and an underrepresentation in the 35–50-year age demographic due to past restrictions on training numbers mean that we will need to significantly increase our entrants into vocationally registered general practice over the next decade to maintain an adequate general practice workforce in both rural and metropolitan Australia. There remains a need for a well trained and appropriately distributed workforce in sufficient numbers to meet the requirements of a growing and ageing population. While contestability of general practice vocational training has not been achieved to any major extent, there is significant progress towards vertically integrated training. The current cohesion between various general practice organisations is likely to facilitate further integration within undergraduate and continuing professional development sectors. Others aims, including regionalisation, workforce distribution, enhanced training capacity, resource development and Indigenous health training, show pleasing progress but require ongoing review, expansion and further development over time, based on experience to date and the evolving needs and demands of our health care system. Since their establishment in 2001, GPET and the AGPT program have achieved many of the “outcomes for regionalisation” set by the federal government and the GPET Board, particularly in relation to delivery of vocational training and provision of medical education services by GP registrars in areas of greatest need — rural and remote areas, outer metropolitan regions and Indigenous communities. Underpinning these outcomes is the economic question: Have the policy outcomes of GPET and the AGPT program justified the resources required to maintain GPET and 17 regional RTP offices? Finally, the experiences of GPET and the AGPT program should be of interest to the wider profession as components of training in many specialist disciplines move outside the traditional public hospital setting into private practices and private hospitals; and as the health system places increasing emphasis on preventive and primary care. Pressure for a formal process for recognising, meeting and administering the costs incurred by both practitioners and facilities is likely to emerge within other health professions and disciplines. It is reasonable to state that the AGPT program experience provides a useful template for change within the broader professional education and training environment. 1 Numbers of general practice registrars-in-training by RRMA, 2003 and 2009*†‡ 2003 2009 RRMA 1–2 RRMA 3–5 RRMA 6, 7 Total in state/territory RRMA 1–2 RRMA 3–5 RRMA 6, 7 Total in state/territory New South Wales/ Australian Capital Territory 257 167 4 359 502 348 5 756 Victoria 179 165 1 304 285 292 5 512 Queensland 123 121 22 218 248 260 41 474 South Australia 64 37 1 86 141 107 5 210 Western Australia 73 34 17 100 144 61 26 196 Tasmania 13 22 0 33 39 41 0 76 Northern Territory 29 8 31 55 33 17 44 78 Total Australia 733 551 76 1126 1377 1112 125 2237 RRMA = Rural, Remote and Metropolitan Areas. * Source: General Practice Education and Training, unpublished data. † Where registrars trained in more than one RRMA category during the year, they are counted once in each. The totals for RRMA columns and state rows include each registrar only once. ‡ In 2010, the system for categorising remoteness changed from RRMA to the Australian Standard Geographic Classification — Remoteness Area (ASGC-RA). These systems are not comparable and 2010 data are not available in RRMA format. 2 Numbers of general practice registrars training in Indigenous health posts by RRMA, 2003 and 2009*†‡ 2003 2009 RRMA 1–2 RRMA 3–5 RRMA 6, 7 Total in state/territory RRMA 1–2 RRMA 3–5 RRMA 6, 7 Total in state/territory New South Wales/ Australian Capital Territory 5 6 2 13 18 22 2 42 Victoria 4 3 — 7 2 6 — 8 Queensland 7 6 4 17 3 12 16 27 South Australia — 1 — 1 7 7 — 7 Western Australia 2 1 5 7 — 3 19 22 Northern Territory — 6 14 19 — 9 25 34 Tasmania 1 — — 1 1 — — 1 Total Australia 19 23 25 65 31 59 62 140 RRMA = Rural, Remote and Metropolitan Areas. — = Data not available. * Source: General Practice Education and Training, unpublished data. † Where registrars trained in more than one RRMA category during the year, they are counted once in each. The totals for RRMA columns and state rows include each registrar only once. ‡ In 2010, the system for categorising remoteness changed from RRMA to the Australian Standard Geographic Classification — Remoteness Areas (ASGC-RA). These systems are not comparable and 2010 data are not available in RRMA format.

Simon M Willcock PhD, MB BS, FRACGP · William Coote MB BS, FRACGP, BEc

Training for general practice in Australia has undergone a 60-year evolutionary process punctuated by revolutionary events. The discipline of general practice has also evolved significantly over this period. Today’s Australian general practice training program strongly resembles its ancestors, with adaptations that better suit its regionalised environment. General practice training has been affected frequently by political and professional forces. Many of these forces were powered by the government’s need for general practice training to deliver immediate workforce solutions, and the profession’s struggle to respond. Pressure on general practitioners to train increasing numbers of clinical learners is challenging traditional apprenticeship models. The Australian general practice training program needs to continue to evolve if it is to remain successful within its volatile environment.

Stephen C Trumble MB BS, MD, FRACGP

General practice training in Australia continues to evolve. It is now the responsibility of an independent organisation, is delivered by regional training providers, and comprises a structured training program. Overseas, general practice varies in its importance to health care systems, and training models differ considerably. In some cases training is mandatory, in others voluntary, but the aim is always similar — to improve the quality of care delivered to the large majority of populations that access health care through primary care. We review the current status of vocational general practice training in Australia, compare it with selected training programs in international contexts, and describe how the local model is well placed to address future challenges. Challenges include changes in population demographics, increasing comorbidity, increasing costs of technology-based health care, increasing globalisation of health, and workforce shortages. Although general practice training in Australia is strong, it can improve further by learning from other training programs to meet these challengers.

Richard B Hays PhD, MD, FRACGP · Simon Morgan MB BS, FRACGP

This article reviews the history of general practice vocational training in Aboriginal and Torres Strait Islander health, identifies current initiatives and recommends future approaches based on recent evidence. General practice vocational training in Aboriginal and Torres Strait Islander health requires ongoing support and investment from governments and training and general practice organisations if the gains made to date are to be consolidated and health outcomes are to improve. In particular, investment in sustained and respectful partnerships with Aboriginal and Torres Strait Islander peoples and organisations will continue to provide the groundwork for effective training of general practitioners in this critical health area, and will also play an important role in capacity-building in Aboriginal and Torres Strait Islander communities.

Mary E Martin · Jennifer S Reath MB BS, FRACGP, MMed

The concept of “social accountability” has underpinned the development of many medical education programs over the past decade. Success of the regionalisation of the general practice training program in Australia will ultimately be measured by the ability of the program to deliver a sufficient rural general practice workforce to meet the health needs of rural communities. Regionalisation of general practice training in Australia arose from the 1998 recommendations of the Ministerial Review of General Practice Training. The resultant competitive structure adopted by government was not the preferred option of the Review Committee, and may be a negative influence on rural workforce, as the competitive corporate structure of regional training providers has created barriers to meaningful vertical integration. Available data suggest that the regionalised training program is not yet providing a sustainable general practice workforce to rural Australia. The current increase in medical student and general practice training places provides an opportunity to address some of these issues. In particular, it is recommended that changes be made to registrar selection processes, the rural pipeline and vertical integration of training, and training for procedural rural practice. To achieve these goals, perhaps it is time for another comprehensive ministerial review of general practice training in Australia.

David G Campbell MB BS, FRACGP, FACRRM · Jane H Greacen MB BS, FAFOM, FACRRM · Patrick H Giddings MB BS, FRACGP, FACRRM · Lesley P Skinner MB ChB, FRCGP, FRACGP

Objective: To examine vertical integration of teaching and clinical training in general practice and describe practical examples being undertaken by Australian general practice regional training providers (RTPs).Design, setting and participants: A qualitative study of all RTPs in Australia, mid 2010.Results: All 17 RTPs in Australia responded. Eleven had developed some vertical integration initiatives. Several encouraged registrars to teach junior doctors and medical students, others encouraged general practitioner supervisors to run multilevel educational sessions, a few coordinated placements, linkages and support across their region. Three RTPs provided case studies of vertical integration.Conclusions: Many RTPs in Australia use vertical integration of teaching in their training programs. RTPs with close associations with universities and rural clinical schools seem to be leading these initiatives.

Nigel P Stocks MD, FRACGP, FAFPHM · Oliver Frank MB BS, FRACGP, PhD · Andrew M Linn MB BS, GradDipChildHealth · Katrina Anderson BMed, FRACGP, MTh · Sarah Meertens MB BS(Hons), FRACGP