General medicine

Family medicine is undergoing dramatic transformation around the world. Its organisation, delivery, and funding are changing in profound ways. While the specifics of primary care reform vary, a common emerging strategy involves establishment of primary health care teams that provide improved access, use electronic records, are networked with other teams, and are paid using blended payment schemes. More family doctors are needed in all countries. New approaches beyond the traditional apprenticeships or residency programs will be required to meet global demand. Training of family doctors must change to prepare tomorrow’s family physician for a different practice reality. Curricula are more competency-oriented, rather than time-focused. Today’s trainees can anticipate a career that includes periodic reassessment of their knowledge base and competency. This article explores these trends and offers some strategies that have proved effective in various parts of the world for training increased numbers of qualified family doctors.

Richard G Roberts MD, JD · Vincent R Hunt MD · Teresa I Kulie MD · Wesley Schmidt MD · Julie M Schirmer MSW · Tiago Villanueva MD · C Ruth Wilson MD

Shortages in, and maldistribution of, the primary health care workforce will continue to limit access to health care. The current health reform proposals and policies recognise workforce development as a priority, but only partially address the barriers to improvement. In particular, there will need to be more systematic development of interdisciplinary education within primary health care services, and funding to support this.

Mark F Harris FRACGP, MD · Nicholas A Zwar PhD, FRACGP · Christine F Walker PhD · Sabina M Knight RN, MTH

Current proposals for significant primary health care reform in Australia create a timely opportunity to reflect on the education and training requirements of future general practitioners. Australian general practice will become increasingly team-based, with growing emphasis on coordinated care, chronic disease management, and disease prevention and self-management, while maintaining its focus on delivering high-quality, patient-centred care. This will require cost-effective application of new technologies and information management systems within new models of delivering health care. Future models of general practice training must respond to these new ways of working to ensure general practice remains an attractive career choice and training programs graduate doctors who are equipped to meet the health needs of Australians. This article discusses potential development of new general practice vocational training models in Australia. This includes hospital rotations that are more directly integrated with general practice placements and have greater emphasis on the needs of the future general practice workforce; and an extension of the training program to 4 years with a final year tailored to future career plans including development of expertise in practice management, specific clinical disciplines or academic skills.

Jon D Emery MB BCh, FRACGP, DPhil · Lesley P Skinner MB ChB, FRACGP · Simon Morgan FRACGP, DipRACOG, MPH · Belinda J Guest BMed, BMedSc(Hons), DCH · Alistair W Vickery MB BS, FRACGP

Medical Assessment Units (MAUs) provide an opportunity for multidisciplinary staff to manage recently admitted acutely unwell patients with complex medical illnesses. We propose concerted development of robust mechanisms for identifying and managing patients whose condition is unstable as they move through hospital departments. Track, trigger and response (TTR) systems (eg, medical emergency team calls and early warning scores) have been introduced to hospital practice, but evidence for their effectiveness is, so far, incomplete. The current variation in TTR systems within and between hospitals impairs intersite comparisons. A range of outcome measures, including risk of physiological deterioration, mortality and projected hospital length of stay, could be usefully investigated by future intersite collaborative research. More deliberate, systematic, evidence-based design of “response” in TTR systems may help in identifying patients who need early attention from skilled medical staff. We need more uniform TTR systems, more research on TTR systems and more multisite research; MAUs are ideally situated to address this important area.

Paul F Jenkins MB BChir, FRCPE, FRACP · Campbell H Thompson MD, DPhil, FRACP · Lorna L Barton MB BS, MRCP

The Australian Government is planning to pilot a model of prepaid funding for coordinated care of patients with diabetes in general practice. Patients will register with a practice that undertakes to coordinate their care, and practices will manage pre-allocated funds to provide services instead of billing Medicare. Systems to manage prepaid funds in Australian general practice have not yet been developed. In the model that has been proposed, practices with a small register of patients will be at risk of overspending, which may threaten practice viability and patient services. If the initiative is to have integrity, all patient services should be paid from the prepaid funds and patients should only attend the practice with which they have registered. Risks should be delineated and contingency plans made explicit before practices and patients commit to the initiative.

Douglas A Pritchard MB BS, FRACGP, PhD

This article explores various models and ideas for future sustainable general practice vocational training supervision in Australia. The general practitioner supervisor in the clinical practice setting is currently central to training the future general practice workforce. Finding ways to recruit, retain and motivate both new and experienced GP teachers is discussed, as is the creation of career paths for such teachers. Some of the newer methods of practice-based teaching are considered for further development, including vertically integrated teaching, e-learning, wave consulting and teaching on the run, teaching teams and remote teaching. Approaches to supporting and resourcing teaching and the required infrastructure are also considered. Further research into sustaining the practice-based general practice supervision model will be required.

Jennifer S Thomson MB BS, FRACGP, MBA · Katrina J Anderson BMed, MTh, FRACGP · Paul R Mara MB BS, FRACGP, FACRRM · Alexander D Stevenson MB BS, DCH, FRACGP

Objective: To determine the prevalence of patient-initiated aggression toward general practitioners in Australia.Design, setting and participants: A cross-sectional national survey, conducted during February – May 2010, of 3090 GPs in 19 Divisions of General Practice, purposively sampled to represent urban, rural and remote areas.Main outcome measure: Proportion of GPs experiencing patient-initiated aggression.Results: Eight-hundred and four GPs returned completed surveys (response rate, 26.3%). In the previous 12 months, 58% of GPs had experienced verbal abuse and 18% had experienced property damage or theft. Very few GPs had experienced physical abuse (6%), stalking (4%), sexual harassment (6%) or sexual assault (0.1%). After controlling for other demographic variables, GPs with fewer years of experience (P = 0.003), or who worked full-time or in larger practices (both P = 0.03) experienced significantly more verbal abuse than their counterparts, and GPs who worked full-time (P = 0.004) or in metropolitan areas (P = 0.01) experienced significantly more property damage or theft. Female GPs experienced significantly more sexual harassment than male GPs (P < 0.001).Conclusions: This is the first national evidence of the prevalence of patient aggression toward GPs in Australia, which could inform the development of policies and guidelines that aim to reduce the prevalence of patient aggression toward GPs.

Laura E Forrest BSc, GradDipGenCouns, PhD · Pushpani M Herath MB BS, MSc · Ian S McRae BSc(Hons), MSc, PhD · Rhian M Parker PhD

To the Editor: A recent study of adult bodyweights recorded in 199 countries showed an increase in mean body mass index (BMI) of 0.4 kg/m2 per decade between 1980 and 2008.1 The increase in Australia was even greater: 0.9 kg/m2 for men and 1.2 kg/m2 for women.1 This increase in BMI, sometimes referred to as an “obesity epidemic”, has also been reported in coronial cases in South Australia, with the percentage of morbidly obese individuals (BMI > 40 kg/m2) undergoing autopsy rising from 1.3% to 4.8% between 1986 and 2006.2 While attention is often focused on complications of obesity such as diabetes mellitus, hypertension and cardiac disease, there is also a link to pulmonary thromboembolism (PTE). A recent prospective forensic autopsy series found that 24 of 32 cases of fatal PTE were in individuals who were overweight or obese.3 To examine this association further, we performed two analyses. First, we recorded the numbers of sudden deaths subject to coronial autopsies in SA from 2000 to 2009 (inclusive) where the cause of death was PTE. These were divided into two periods (2000–2004 and 2005–2009) and expressed as the percentage of the total number of coronial autopsies. Second, we analysed all deaths due to PTE that were the subject of coronial autopsies in SA in 2008 (the most recent year for which complete autopsy data were available at the time that the study was initiated). Age, sex and BMI were recorded, and the group was compared with an age- and sex-matched control group taken from other coronial autopsy cases. Despite considerable yearly fluctuations, the death rate due to PTE showed a small increase over time (Box). The rate of deaths due to PTE per total number of autopsies increased from 3.59% (198/5521) in 2000–2004 to 3.71% (239/6442) in 2005–2009. In 2008, there were 44 individuals (21 men, 23 women) with PTE as cause of death. The age range of this group and the 44 matching controls was 27–93 years (mean, 67 years). The mean BMI for individuals dying of PTE (29.6 kg/m2; range, 19.0–51.8 kg/m2) was significantly higher than for the controls (25.9 kg/m2; range, 17.7–44.6 kg/m2) (Student t test, P < 0.05). If PTE is conclusively found to be associated with BMI, there may be significant effects on hospital diagnostic services, coronial forensic investigation units and public expenditure in the future. Coronial cases in South Australia where death was due to pulmonary thromboembolism, 2000–2009

Roger W Byard · Hannah Rosenfeld

Objective: To assess the number and characteristics of potentially harmful incidents occurring during placement of medical students in remote Aboriginal communities in the Northern Territory.Design, participants and setting: A retrospective audit of medical students’ files from Northern Territory General Practice Education placements in Central Australia for the period from January 2006 to December 2007.Main outcome measures: Number and type of potentially harmful incidents.Results: A total of 163 placements were undertaken. Of these, 98 (60%) had adequate documentation to determine whether an incident had occurred. There were 28 cases (17%) where potentially harmful incidents were judged to have occurred. Most incidents fell under several descriptive categories, but clinical supervision, professional practice and administrative issues were most common.Conclusions: One in six students experienced a potentially harmful incident during remote area placement in 2006–2007. While acknowledging the exploratory nature of this investigation and the major educational benefits that clearly arise from these placements, our findings indicate problems with clinical supervision and administration.

Ameeta Patel MB BS(Hons), FRACGP, DRANZCOG · Peter Underwood MD, FRACGP, MRCP · Hung The Nguyen MB BS, FRACGP, MPH · Margaret Vigants RN, BNBAS

To the Editor: The Medicare item for annual child health checks (CHCs) for Aboriginal and Torres Strait Islanders involves taking a comprehensive health-related history from the antenatal period onwards, recording growth parameters, performing a medical examination, identifying new diagnoses and commencing management, which may include advice, referral, vaccinations and treatment. The CHC has had little evaluation as a primary health care tool in the urban setting; indeed, outside remote regions, it has barely been taken out of the toolbox. Although 76% of Aboriginal and Torres Strait Islander people live in urban or regional areas,1 we are unaware of any published research on CHCs outside remote areas. We therefore aimed to evaluate the role of the CHC for 0–14-year-olds at Inala Indigenous Health Service, an urban primary care service in a suburb of Brisbane. Ethics approval was obtained from the University of Queensland’s Behavioural and Social Sciences Ethical Review Committee and Metro South Health Service District Human Research Ethics Committee at the Princess Alexandra Hospital. The local Inala Elders Aboriginal and Torres Strait Islander Corporation supported the project. Descriptive statistical analysis was conducted using Stata, version 10 (StataCorp, College Station, Tex, USA). Of 867 eligible children, we completed 786 CHCs from May 2007 to December 2009. We excluded 245 “subsequent” CHCs (31%) in children who had already had a CHC in the study period, and 109 of the remaining 541 (20%) that were not accompanied by a research consent form, leaving 432 CHCs available for analysis. The children (234 male [54%]) were Aboriginal (394, 91%), Torres Strait Islander (9, 2%) or both (29, 7%). Reported health risk factors included living in households with a smoker (75%), parental unemployment (67%), exposure to domestic violence (29%), never having been breastfed (32%) and not having teeth brushed twice daily (46%), although more than half the children (57%) exercised at least 30 minutes every day. New diagnoses made at the CHC (40%) were primarily dental caries (36%) or conditions involving the skin (18%) or ears (10%). During the CHC, 63% of parents were given health advice, 24% of children were referred for follow-up and 22% were vaccinated (Box). From May 2006 (when CHCs were introduced) to June 2009, 4610 Indigenous CHCs were reported by Australia’s 54 metropolitan Divisions of General Practice, comprising just 4.3% of the eligible population.2 This contrasts with the 14 500 CHCs (89% coverage) completed in prescribed remote areas by the Northern Territory Emergency Response (NTER).3 A recent report highlights the low number of CHCs performed outside the NTER and the lack of timely follow-up within the NTER to address detected health problems. The report concluded: “It’s clearly time to reconsider this failed health policy”.4 However, a distinction should be drawn between the NTER CHCs — usually performed by “fly-in, fly-out” teams who are not in a position to provide ongoing care — and a CHC program embedded in a local clinic as a cornerstone of usual health care. In the wake of the NTER, the then National Aboriginal Community Controlled Health Organisation chairperson, Dr Mick Adams, said, “This is not to say that we do not want more child health checks [but we reject] the present way of doing them”.5 Strengths of our study include the high proportion of our clinic’s eligible population who had CHCs (541/867, 62%). Although our practice comprises only 0.8% of Australia’s urban Indigenous children, our service completed 10% of the CHCs done in Australian metropolitan areas to June 2009.2 Because the study was limited to the day of the CHC, we were unable to evaluate whether referrals resulted in attendances. Further research is required to document the success of follow-up resulting from CHCs, including referral attendance rates. We have found that the Indigenous CHC, performed within the patient’s usual primary care service, provides an important opportunity to make new diagnoses and to identify and initiate management of health risk factors. The CHC is an underused tool worth dusting off in primary care. Health risk factors (reported by parent or carer), new diagnoses and interventions from child health checks of 432 Aboriginal and Torres Strait Islander participants attending Inala Indigenous Health Service, May 2007 – December 2009* Variable No. (%) Variable No. (%) Maternal substance use during pregnancy Adolescent (12–14-year-olds) behaviour (n = 65) Tobacco (n = 432) 156 (36%) Consumes alcohol (n = 54) 5 (9%) Alcohol (n = 432) 70 (16%) Current smoker (n = 54) 4 (7%) Cannabis (n = 431) 36 (8%) Sexually active (n = 51) 3 (6%) Intravenous drugs (n = 431) 16 (4%) New diagnosis resulting from health check Household characteristics Any new diagnosis (n = 432) 174 (40%) Household with a smoker (n = 416) 312 (75%) Dental caries (n = 345) 124 (36%) Unemployed parent (n = 432) 288 (67%) Skin condition, all causes (n = 432) 77 (18%) Single parent caring for child (n = 432) 194 (45%) Ear condition‡ (n = 432) 43 (10%) Stressful event impacting on household (n = 432) 180 (42%) Overweight (n = 332) 83 (25%) Households with six or more residents (range, 6–12) (n = 408) 149 (37%) Obese (n = 332) 36 (11%) History of domestic violence exposure (past or current) (n = 432) 124 (29%) Interventions (n = 432) Perinatal characteristics Any health/lifestyle advice 270 (63%) Premature birth (gestation < 37 weeks) (n = 336) 45 (13%) Nutrition advice 119 (28%) Perinatal complication (n = 432) 170 (39%) Learning/behavioural advice 54 (13%) Never breastfed (n = 339) 110 (32%) Physical activity advice 54 (13%) Childhood health behaviour Smoking cessation advice 42 (10%) Watch electronic media ≥ 60 min/day (n = 237) 183 (77%) Alcohol consumption advice 33 (8%) Teeth not brushed twice daily (n = 360) 165 (46%) Any referral (n = 432) 103 (24%) Suboptimal physical activity† (n = 215) 92 (43%) Paediatrician referral 31 (7%) Parental/carer concerns about child’s behaviour (n = 264) 81 (31%) Dental referral 26 (6%) Parental/carer concerns about child’s learning (n = 276) 82 (30%) Audiology referral 17 (4%) Dietitian referral 13 (3%) Vaccinations given on the day of the check (n = 432) 96 (22%) * Denominators vary because of missing data. † ≤ 30 min/day for < 7 days a week. ‡ Defined as having signs (eg, perforation, bulging) or a diagnosis (eg, otitis media, otitis externa) of ear disease in at least one ear.

Justin J Coleman · Geoffrey K Spurling · Deborah A Askew · Noel E Hayman

Gwen Fleming was born in Taree, New South Wales, on 9 June 1916, the third of John and Caroline Lusby’s six children. She graduated in medicine from the University of Sydney in 1939, just in time to answer the call to military service. Appointed to the rank of Captain, Gwen worked at Yaralla Military Hospital at Concord (“They called me ‘Sir’, during the war”). In 1945, she became the first woman major in the Royal Australian Army Medical Corps and was subsequently appointed Officer Commanding Medical Company. In 1945, Gwen was one of the first women admitted as a Member of the Royal Australasian College of Physicians and, in 1973, she was admitted as a Fellow. She married the brilliant young surgeon Justin Fleming, a Flight Lieutenant in the Royal Australian Air Force, in 1946. Justin was awarded an Oxford Nuffield Medical Fellowship to the University of Oxford, and they took up residence at the Radcliffe Infirmary. In 1950, they returned to Sydney to raise what became a family of six children. The children flourished in an environment where a love of cricket, theatre, art, music and literature was encouraged. Gwen and Justin wanted happiness for their children, not duty from them. The family motto was animo toto laborate (“no half jobs”). After Justin’s death in 1974, Gwen became the family breadwinner. She joined Dr Brian McEwen in his Macquarie Street practice and took a teaching position at St Vincent’s Hospital in Sydney, a demanding regime that she continued until she was 77 years of age. Her patients and students were struck by her calm, clear approach which elucidated both the detail and the big picture. Gwen was innately altruistic and held a firm Christian belief that God travelled through human action. Among the gifts that she brought to medicine were clarity of judgement, patience of manner and accuracy of diagnosis. To her, gaining the trust of the patient was part of the healing. In her last weeks, Gwen suffered from severe angina and a subsequent heart attack, and passed away on 18 January 2011. She is survived by her sister, Sr Elizabeth Lusby OP, and children Margaret, Paul, Justin, Judith and Peter — another son, James, died in 1999.

Justin Fleming

To the Editor: Nash and colleagues have produced another report on medicolegal matters and Australian doctors.1 This report, and one that preceded it in 2009,2 are derived from responses to a questionnaire from nearly 3000 doctors. The survey showed that 65% of respondents had been involved in “medicolegal matters”. From a mass of data, the authors conclude that medicolegal concerns impact on doctors’ practice of medicine. As potential benefits of medicolegal matters, they list improved communication of risk to patients, disclosure of diagnostic uncertainty, and better methods to track test results and non-attenders. Negative impacts included increased referral to specialists, ordering more tests, and seeing fewer patients. The authors recommend targeted training in patient safety and medicolegal aspects of practice to help doctors to be “better informed”. However, as 65% of the group had been involved in medicolegal matters, it seems unlikely they need to be better informed about them. In the title and throughout the article, there is much emphasis on the word “perceived”. With this heavy emphasis on perception, it might be thought that the key finding was that fear of a medicolegal matter was greater than the reality. In fact, the reverse was found. Of those who had experienced medicolegal matters, 46% had considered retiring early, 39% considered giving up medicine and 38% considered reducing hours of work. The respective figures for those who had not experienced medicolegal matters were 29%, 22% and 21%. The difference was highly significant. An inescapable conclusion is that medicolegal matters result in large numbers of demoralised doctors. The reality is worse than the perception. Unfortunately, the obvious question — What was the outcome of the medicolegal matter? — was not included in the survey. Given the numbers involved, it seems likely that for many doctors, although the outcome was favourable, the process had a profoundly negative effect on their work. Forty-one per cent now regard every patient as a potential litigant. A logical response to these data might have been to ask: (1) Could there be a problem with the way medicolegal matters are conducted? and (2) Is the demoralisation of a large percentage of the medical workforce good for society? Neither question was asked here. This is perhaps not surprising as, in their previous article, the authors questioned, without embarrassment and on the basis of a questionnaire, whether “psychiatric morbidity in doctors is a cause or effect of the medicolegal process”.2 This study is “one of the largest [of its kind] in the world”. Sadly, the authors’ negativity towards doctors and their unquestioning allegiance to current medicolegal practice have greatly diminished its value.

Padraic J Grattan-Smith

In reply: I agree with Grattan-Smith that current medicolegal processes have profoundly negative effects on doctors. I do not agree that my coauthors and I have “negativity” towards doctors and an allegiance to current medicolegal practice. Our aim was to investigate the impact of medicolegal matters on Australian doctors — their emotional response and their practice changes.1,2 We have shown that doctors who have a current medicolegal matter have higher levels of psychiatric morbidity,2 and that most doctors believe they change how they practise due to medicolegal concerns — more so in the case of doctors who have experienced a medicolegal matter.1 Justice Ipp and colleagues,3 when reviewing the law of negligence for the Commonwealth of Australia in 2002 with the objective of limiting liability and damages arising from personal injury or death, made note of the lack of empirical evidence in the submissions they received. We have now provided some empirical evidence of medicolegal matters from the doctors’ perspective. If such a review were conducted now, I would suggest the current medicolegal systems are not good for patients, for doctors, or for the health system in general. The evidence from our studies1,2 now allows a more informed conversation on this issue to take place.

Louise M Nash

To the Editor: I found Van Der Weyden’s editorial “Whither medicine? The expansion of non-doctor practice”1 to be an unduly negative view of the emerging new clinical roles, such as nurse practitioners, in our health system. To imply, for example, that the access to prescribing rights for nurse practitioners is a significant challenge (rather than a help) to doctors is contrary to the experience of many such implementations of these roles. I have a clear view of the role of doctors. They should: be in charge and lead the decision-making process of multidisciplinary teams; be responsible for the cognitive and integrative aspects of clinical care, including the initial assessment and planning of management for undifferentiated patient presentations in all care settings; and provide high-level complex care, including procedural and diagnostic services that require their level of expertise. Doctors should not continue to provide clinical services that are not a good use of their considerable training and experience. These services, that could be provided by nurse practitioners, include routine monitoring and prescribing (under protocol and medical leadership) of maintenance treatments (such as haemodialysis treatment or routine diabetes review), and simple repetitive diagnostic or therapeutic procedures. In my experience, many doctors are bored with these intellectually limited aspects of their practice and find the quality of their clinical life substantially enhanced when given the opportunity to work in partnership with nurse practitioners. Again, in my experience, some tertiary-educated nurses are also bored with their limited clinical roles (still dominated by personal care) and can offer much more to the clinical team by focusing on the higher end of their skill base. There are clear differences between doctors and nurses in terms of selection process, education and training. However, this does not preclude both professional groups from looking at their scope of practice and focusing on the tasks that best use their expertise, rather than retaining roles based on custom and practice that are no longer relevant. If doctors embrace and lead the role redesign program, they can ensure that sensible delegations of their clinical tasks to other health practitioners can occur with benefit to all. Resistance and disengagement of doctors will not stop role redesign, as we clearly cannot sustain a health workforce in the future with a staffing model that has not changed materially for 100 years. Resistance and disengagement are more likely to lead to dysfunctional new roles being produced, without the necessary strong relationship with the medical profession required for the best patient care.

Brendan F Murphy

To the Editor: In his recent editorial,1 Van Der Weyden laments the “displacement” of doctors in modern health care by nurse practitioners and physician assistants, and bemoans the fact that discussion and debate about these matters is largely confined to medical tabloids such as Australian Doctor. In this context, the editorial cites unsubstantiated and inflammatory comments from Australian Doctor correspondents claiming that nurse practitioners place patients at risk.2,3 Remarks that nurse practitioners are “a disaster unfolding” and “people will die”3 are not only inflammatory but also inaccurate. Medical and nursing insiders have made these claims with self-appointed legitimacy and without evidence. They demonstrate a surprising level of ignorance about the role of nurse practitioners and the evidence base that supports their practice, particularly in emergency care.4 In an era where the drum of quality and safety in health care and evidence-based practice beats the loudest, where is the evidence to support such claims? Perhaps the lack of evidence is the reason why such claims implying that nurse practitioners present a risk to patients are housed in medical tabloids, where they escape the rigorous scrutiny of peer review that would otherwise expose this deficit. Van Der Weyden bewails that nurse practitioners are the only health professionals “whose skills and talents are extolled”.1 We doubt whether such trivialities are at the forefront of the minds of emergency nurse practitioners, who comprise a large proportion of nurse practitioners in Australia. As part of the broader health care team, their focus — and the focus of their physician, nurse and allied health colleagues — would be on the immediate and ongoing needs of their patients. Van Der Weyden asserts that an assumption of the equivalence of nurses and physicians underpins the political and industrial agenda for “doctor displacement” in general practice in Australia. Such an assertion is entirely moot. High-quality and safe health care cannot be realised by a monopoly of nurses, or physicians, or any other health profession. Nurses and physicians are only two of the many threads in the tapestry of high-quality, safe and evidence-based health care. Their success lies in symbiotic mutualism, not commensalism, amensalism, or parasitism. And, just like in tapestry, pulling any one thread from the fabric renders the picture incomplete.5 Unless there is substantial evidence to the contrary, bringing the safety of nurse practitioners into question is senseless, particularly given the well deserved support they have from their peers in the wider health community and their patients, both in Australia and overseas.

Ramon Z Shaban · Julie M Finucane · Dianne J Crellin

In reply: I welcome the comments of Murphy and of Shaban and colleagues on my recent editorial,1 which explored, as Shaban et al say, the “displacement of doctors in modern health care by nurse practitioners and physician assistants”. The main focus of the editorial was on the current philosophical relativism muddying the definition of what a doctor is and the academic qualifications underpinning all professional training. It calls for equally rigorous criteria to be applied to non-doctor practitioners and their scope for independent practice. Undoubtedly, the potential utility of non-doctor practice is dependent on bilateral mutualism, with a clearly defined scope of practice. However, the push for independent practice remains problematic. Whether there is a genuine commitment for bilateral mutualism to occur, beyond the usual rhetoric, is of concern — witness the recent difficult negotiations on defining the framework for cooperative practice, and the reticent views of doctors on the suitability of nurse practitioners and their scope for independent practice, as reported in Australian Doctor.2-4 The fundamental question, which must be addressed, is whether the granting of Pharmaceutical Benefits Schedule and Medicare Benefits Schedule privileges to non-doctors is simply a political strategy to create a two-tiered health system under the illusion of cost containment.

Martin B Van Der Weyden

Objective: To explore factors associated with the frequency of multidisciplinary Team Care Arrangements (TCAs) and the impact of TCAs on patient-assessed quality of care in Australian general practice.Design and setting: Data were collected as part of a cluster randomised controlled trial conducted in 60 general practices in New South Wales, the Australian Capital Territory and Victoria between July 2006 and June 2008. Multilevel logistic regression analysis evaluated factors associated with the frequency of TCAs recorded in the 12 months after baseline, and multilevel multivariable analysis examined the association between TCAs and patient-assessed quality of chronic illness care, adjusted for patient and practice characteristics.Main outcome measures: Frequency of TCAs; Patient Assessment of Chronic Illness Care (PACIC) scores.Results: Of 1752 patients with clinical audit data available at 12-month follow-up, 398 (22.7%) had a TCA put in place since baseline. Women, patients with two or more chronic conditions, and patients from metropolitan areas had an increased probability of having a TCA. There was an association between TCAs and practices with solo general practitioners and those with greater levels of teamwork involving non-GP staff for the control group but not the intervention group. Patients who had a TCA self-assessed their quality of care (measured by PACIC scores) to be higher than those who did not.Conclusions: Findings were consistent with the purpose of TCAs — to provide multidisciplinary care for patients with longer-term complex conditions. Significant barriers to TCA use remain, especially in rural areas and for men, and these may be more challenging to overcome in larger practices.

Mark F Harris MD, FRACGP · Upali W Jayasinghe MSc(Maths), GradDipStats, PhD · Jane R Taggart MPH, BEd, DipEd(PE) · Bettina Christl DipPsych, MIPH · Judith G Proudfoot BEd(Hons), MA(Psych), PhD · Patrick A Crookes PhD, BSc(Nursing), RN(NSW) · Justin J Beilby MB BS, MD, FRACGP · Gawaine Powell Davies BA, MHA

Objective: To describe the proportion of 16–29-year-olds tested for chlamydia by Australian general practitioners in a 12-month period.Design and setting: Between October 2007 and September 2008, the national chlamydia testing rate in 16–29-year-olds was calculated by dividing the number of Medicare-reimbursed chlamydia tests by two denominators: (i) Medicare-reimbursed GP consultations; and (ii) estimated resident populations adjusted for the proportion who were sexually active.Main outcome measures: GP chlamydia testing rates in 16–29-year-olds per 100 patients attending a GP consultation and per 100 sexually active population, by patient age and sex, state/territory of residence, and remoteness area.Results: Among the estimated Australian population of 16–29-year-olds, 85.6% of females and 64.4% of males had at least one GP consultation in the 12-month period. The national GP chlamydia testing rate per 100 patients was 8.9% (95% CI, 8.88%–8.94%). The national GP chlamydia testing rate per 100 sexually active population was 8.0% (95% CI, 7.92%–7.98%). The rate per 100 sexually active population was higher in females (12.5%) compared with males (3.7%) (P < 0.01); higher in 20–24-year-olds (9.0%) compared with 16–19-year-olds (8.7%) and 25–29-year-olds (6.6%) (P < 0.01); higher in those living in non-metropolitan areas (11.0%) compared with metropolitan areas (8.4%) (P < 0.01); and highest in those living in the Northern Territory (21.4%) compared with other jurisdictions (P < 0.01).Conclusions: Despite clinical guidelines recommending annual chlamydia testing for sexually active 15–29-year-olds, our analysis showed that a high proportion of young people aged 16–29 years attend a GP each year, but few of the sexually active population in this age group were tested for chlamydia in general practice. Strategies are needed to support GPs to enhance chlamydia testing in young people.

Fabian Y S Kong BPharm, MEpi · Rebecca J Guy BAppSc, MAppEpid, PhD · Jane S Hocking MPH, MHthSc(PHP), PhD · Tony Merritt MB BS, MPH · Marie Pirotta MB BS, FRACGP, PhD · Clare Heal MB ChB, FRACGP, PhD · Isabel Bergeri PharmD, MSc, DTMPH · Basil Donovan MD, FRCPI, FAChSHM · Margaret E Hellard MB BS, FRACP, PhD

To the Editor: While clinicians often communicate with patients and families, documentation of these conversations is inconsistent. Documentation is critical for continuity of patient care, medicolegal reasons and research,1 and is particularly important in the intensive care unit (ICU), where discussions regarding prognosis and withdrawal of care occur frequently. There are scant published data on documentation of conversations with patients in ICUs and their families. We conducted a retrospective audit of patients admitted to the ICU of Wesley Hospital (a 500-bed private teaching hospital in Brisbane) between 1 January and 31 August 2009 to: determine levels of documentation of communication with patients and their families by the ICU medical staff; and compare this with documentation of communication by the primary physician before and after admission to the ICU. After obtaining Wesley Hospital ethics committee approval, all patients who were cared for in the general ICU for more than 5 days were studied. During the study period, there were 862 ICU admissions, 100 of which met our inclusion criteria. The charts of only 82 patients could be successfully retrieved and these were used for final analysis. These patients had a mean age of 64 years (SD, 14 years), and a mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 17 (SD, 7). Sixty patients (73.1%) survived to hospital discharge. In the ICU, there were 39 family conferences at any stage between an ICU clinician and the families documented for 24 patients (29% of patients; 1.6 conferences per patient). Eleven of these conferences took place in the first 48 hours, eight between 2 and 4 days, and 20 beyond 96 hours of ICU admission. The Box shows that there was a greater proportion of documented family conferences for patients who died compared with those who survived at both 2–4 days (27% v 3%; P < 0.01) and beyond 96 hours (86% v 1.5%; P < 0.001). Of note, there was no documented communication between the hospital’s admitting physician and patients or families before ICU admission or after discharge from the ICU. Intensivists use any prior discussions to make decisions about continuing or withdrawing care.2 The absence of documentation before ICU admission is clinically relevant in this context. Potential reasons for inadequate documentation include (i) discussions occurring informally at the bedside or outside of the ICU (corridor conversations) and (ii) nurses providing updates in the clinician’s absence. Better documentation in the charts of dying patients may reflect their longer ICU stays, which provide more opportunity for communication. Moreover, discussions on treatment withdrawal are more likely to be documented as they are often a shared decision-making process. Globally, levels of documentation vary (10%–90%).3,4 Potential strategies to improve documentation include: bedside reminders (such as “have you documented family conferences?”); availability of a communications officer; an internal appointments system for formal discussions; and the use of communication kits.5 Despite being a retrospective study, our findings suggest a need to improve levels of documentation, and may prompt clinicians to examine their documentation practices and develop protocols to improve record keeping. Comparison of the documented communication rates for intensive care unit (ICU) patients who died and those who survived

Riad L Silcock · Bala Venkatesh · Ranald L Pascoe · Dianne K Fisher

The Journal has a new Editor and big plans for the future With this issue, Dr Martin Van Der Weyden retires after 16 years as Editor of the Journal. A tribute to Martin and his many achievements will appear in the next issue. Martin has been a generous and wise teacher, and his columns have set the benchmark in editorial writing. Under his guidance, the Medical Journal of Australia has become the leading publisher of general medical research in Australia. It makes a vital contribution to the debate on local and global medical issues including Indigenous health, patient safety, the honesty and integrity of scientific publishing and peer review, and Australian health policy. The Journal he bequeaths is robust and central to medical communication in this country. As the Journal of the Australian Medical Association, the MJA has a freedom that is unavailable to most other general medical publications in the country: to publish and report free of commercial interests. You can be confident that studies published in the MJA are subject to strict rules requiring disclosure of conflicts of interest, and that they have been expertly peer reviewed. The MJA is uniquely placed to inform and facilitate discussion and education across our profession, and to anchor it within the context of the broader Australian health system. To keep abreast of changes in clinical medicine and professional issues, and to meet the challenge of maintaining the Journal’s relevance for all doctors in the face of these changes, there are plans for the continued evolution of our print publication and an enhanced presence on the web. The MJA will continue to publish major Australian research studies and remain the natural place for publication of data that are important to all Australian clinicians. I want to foster this role for the Journal. My dilemma, however, is that of the editor of any general medical journal: it is difficult to produce an article that meets the needs of both researchers who are interested in the minutiae of their topic and readers who may prefer a brief overview.1 While many Australian studies are appropriately published in specialty and international journals, general medical journals such as the MJA have a crucial role in building and disseminating a strong, usable base of medical knowledge. All doctors have specialised educational requirements and have to be selective in their reading — 75 trials and 11 systematic reviews are published daily2 — thus there is a greater need than ever for relevant interpretation and commentary. I will be inviting the authors of these “specialty” or “international” papers to write editorials for the MJA, which interpret their data. This will feed into an increased emphasis on articles, written by leaders in their field, that synthesise new information for our readership. I want to develop the MJA ’ s natural role as a forum for the presentation of news relevant to doctors and for debate that develops around these issues. Currently, too many medical issues play out in the public media before the profession has a chance to consider or respond. A prime example has been the coverage of prescribing rights for non-doctors.3 Other important issues include the delivery of effective and efficient health care, the planning for, and training of, our medical workforce, and the improvement of Indigenous health outcomes. Our engagement in this process will determine the degree to which we remain an independent and vital profession and will also help to improve health outcomes for the community. One crucial issue is health funding. Currently, Australia spends over 9% of its gross domestic product on health,4 increasing at up to 0.5% per annum.5 The population is ageing and demands on the health system are increasing, necessitating hard choices with respect to the way a limited health budget is spent. As doctors, we need to understand the opportunity costs of ordering a test or admitting an elderly patient to intensive care. In this way, we can participate in decisions involving the allocation of funds within the health budget. The MJA is the appropriate forum for this informed conversation. Discussion about the practice of medicine needs to continue. Good medical practice: a code of conduct for doctors in Australia, adopted by the new Medical Board of Australia, was developed with little discussion within the profession.6 How this code is implemented is yet to be defined, and we should take this opportunity to explore and, perhaps, refine the way we practise. This debate should include doctors’ contributions to the public health care system, the organisation of medical practices, billing practices and time spent with patients, and the complexities of patient education and obtaining informed consent. Our future doctors also need to be included. I plan to engage more with our readers via electronic media. Inevitably our website, planned to be relaunched, will become increasingly important in the life of the Journal. It will embrace new technologies and media, allow for the publication of more research and medical content and facilitate timely discussion around issues. Soon, I hope you will enjoy easy access to the Journal from mobile electronic devices and that you will use this resource to have your say in these conversations. The MJA is your forum. Already, our recently launched email newsletter, MJA InSight, boasts the highest audited email circulation of any medical newsletter in the country.7 My background is as a general practitioner and medical editor, and I will be seeking to both broaden and strengthen the MJA community so that many voices (not just the loudest or best-positioned) are heard. I will be expanding our base of peer reviewers and plan to introduce a rotating position of “Guest Medical Editor”. This person will commission work in his or her field of expertise and refresh and inform our editorial team about advances in his or her area of interest. Already, I have been overwhelmed by the passion and generosity of the MJA community, who, without favour, payment or (much) recognition, contribute to this publication. Peer reviewers are indeed our “unsung heroes”.1 Thank you to all who already contribute to the MJA and to those who will help in the future. I envisage that an enhanced MJA will play an even more important role in the discussion of issues that affect medicine in Australia. With an expanded range of content and new technologies, we have the potential to engage the entire profession. As the new Editor of the MJA, I look forward to guiding its evolution and to working with you.

Annette G Katelaris MB BS, MPH, FRACGP

Australia should lead in the effort to reduce the huge burden of non-communicable diseases When it comes to global health, the international aid effort is almost entirely focused on the immense burden that communicable diseases inflict on the world’s low- and middle-income nations. But the world is also facing what United Nations (UN) Secretary-General Ban Ki-moon describes as “a public health emergency in slow motion”.1 Across the globe, non-communicable diseases (NCDs) — principally heart disease, cancer, diabetes, kidney disease and chronic lung disorders — are imposing ever greater burdens on individuals, families, health systems and economies. The World Health Organization believes that NCDs now account for some eight million premature deaths (before the age of 60 years) each year in low- and middle-income countries. Altogether, there are an estimated 35 million NCD deaths each year, with around 80% occurring in low- and middle-income countries.2 Deaths from NCDs are projected to increase by 17% worldwide in the coming decade, with the largest increase (27%) occurring in Africa. The highest absolute number of deaths will be in Australia’s local regions: the Western Pacific and South-East Asia.2 And yet, much of this burden is avoidable, with around 80% of heart disease, stroke and type 2 diabetes and over a third of cancers deemed preventable by eliminating shared risk factors, including tobacco use, poor nutrition, physical inactivity and alcohol misuse. Despite the growing burden that NCDs inflict on the developing world, a pittance — just 2.3% — of overall development assistance for health was dedicated to NCDs in 2007.3 This is even more surprising given the impact that NCDs have on productivity. The World Economic Forum, an organisation of private, mostly multinational companies, already considers chronic disease in both developed and developing nations to be a major risk to the global economy.4 While prevention and treatment of NCDs make sound economic sense, calls for help from developing nations have met with little response. The UN said in a report on NCDs last year that “requests for technical support to scale up efforts, through aid and expertise, remain largely unanswered”.5 There is, however, some light at the end of the tunnel. Things are starting to change. After a concerted campaign by international chronic disease organisations and collective action by Commonwealth and Caribbean countries, the UN has agreed to hold a special summit on NCDs, the first health summit since the landmark HIV/AIDS gathering a decade ago. To be held in New York on 19–20 September 2011, the summit will consider what action might be taken to help all countries, but especially those of low and middle incomes, to meet the NCD challenge. It is clear that NCDs must become a key part of the global health and development agenda. This is the goal of the NCD Alliance,6 a coalition convened by the World Heart Federation, Union for International Cancer Control, International Diabetes Federation and the International Union Against Tuberculosis and Lung Disease. While the global campaign is being waged, an Australian group — Australians for Global Action on NCDs — has formed to encourage the Australian Government to help lead global change, by seeking tangible outcomes from the UN summit and playing a strong role beyond it, particularly in the Western Pacific region. Although much remains to be done at home, particularly for Aboriginal and Torres Strait Islander peoples and those from lower socioeconomic backgrounds, Australia should also boost efforts to assist developing nations in our region escalate their NCD-prevention efforts and improve screening, early detection, treatment and palliation. A gathering organised by our group at Parliament House on 2 March 2011 will help sell the message to federal politicians, many of whom are already sympathetic to the cause. Over the coming 7 months, the world will be looking to countries with strong records in prevention and management of chronic disease to help set the agenda for the UN summit on NCDs. While this includes nations across the income spectrum, Australia should be thrusting its hand in the air. We have much to offer. For example, Australia has been a leader in tobacco control. Robust action, including price hikes, comprehensive advertising bans and investment in social marketing, has seen smoking rates plummet in Australia, from 34% of the adult population in 1980 to less than 20% today.7 So, what do we want from the UN summit? Work is underway to define the best possible outcomes, but there is growing international consensus among NCD Alliance members around six primary objectives: Governments must have NCD plans and be accountable for progress. The existing WHO Framework Convention on Tobacco Control should be fully implemented. There must be a global commitment to prevention of NCDs. Globally agreed approaches to treatment and care must be forged. Resources must be available to deliver effective interventions and enhance the capacity of developing nations to meet the NCD challenge. NCDs must be prominently included in the targets that will follow the current Millennium Development Goals. Reducing the burden of NCDs will take dollars. It will take courage. And it will take long-term commitment. But it will pay for itself many times over by helping countless millions of people to lead longer, healthier, happier and more productive lives.

Australians for Global Action on NCDs*

The move to national registration of doctors presents both threats and opportunities for the manner in which doctors seek health care and for providing assistance to doctors who may be impaired by illness. The most striking threat is the regressive nature of the provisions for mandatory reporting of ill doctors. The new system should be grasped as an opportunity to achieve national agreement on resourcing adequate services to help distressed doctors and to foster education and research into the health of doctors and medical students. The new system also provides opportunities to explore ways of encouraging doctors to improve their poor record of not attending to their own health, such as denying Medicare rebates for most doctors who self-refer.

Kerry J Breen MB BS, MD, FRACP

To the Editor: In their paper, Campbell and colleagues list the potential pitfalls of introducing pay-for-performance into Australian primary care.1 They emphasise that, in Australia, the electronic medical records used in general practice would not support the introduction of a scheme such as the Quality and Outcomes Framework (QOF) that is in place in the United Kingdom. In 2009, we demonstrated that it was quite possible to apply a QOF in a large Australian general practice by adapting the in-built search facility of a commonly used medical records program.2 We concluded that the introduction of a QOF in Australia would drive up the quality of our care. The non-clinical standards of a QOF are already similar to those set by the Royal Australian College of General Practitioners for accreditation and could be readily achieved. Campbell and colleagues suggest that the QOF is expensive and without proven benefits.1 This is incorrect. As predicted, the QOF has not only led to a reduction in cardiovascular disease events, but the benefit is greatest in the lowest socioeconomic groups.3 It is now possible to measure the cost effectiveness of a QOF, which is likely to show that it pays for itself by way of reduced morbidity and health service costs.4 Rather than argue for general practitioner remuneration based on pay-for-performance to be less than 20%, one should err on the side of caution, which recognises that 20% has ensured a massive public health gain for the British population. Now that 95% of GPs use computers, at least for prescribing,5 it is plausible that an Australian QOF could be developed, but pay-for-performance may need to include some pay-for-data incentives.

Mark A J Morgan · James Dunbar

In reply: Our article, which related to clinical care, not non-clinical standards, was intended to generate debate, and the points raised by Morgan and Dunbar are important ones. We address the central issue, which relates to the intended purpose of introducing a pay-for-performance scheme, similar to the Quality and Outcomes Framework (QOF) in the United Kingdom, into Australian general practice. Morgan and Dunbar state in their letter, “Now that 95% of GPs use computers for prescribing”; this emphasises that it would not be a level playing field. Even if all indicators only related to prescribing, at least 5% of practices would be disenfranchised. That statement also appears to presume that 95% of practices use compatible and comparable clinical codes. The UK witnessed years of computerisation and clinical code usage across a wide range of clinical issues before the introduction of the QOF. Elliot-Smith and Morgan adapted “the in-built search facility of a commonly used medical records program”, and introducing a QOF-like scheme in Australia would involve this investment in all practices. The percentage of income attributed to pay-for-performance is a political decision, and most people who are involved in the QOF in the UK strongly believe that it is too high. Whatever level is set, it must result in a level playing field for practices.

Stephen M Campbell · Anthony Scott · Rhian M Parker

To respond to changing population and workforce needs and expectations, evidence must inform policy investment, implementation and evaluation We all understand evidence-based practice, but what about evidence-based reform? The Australian Government emphasises the need to strengthen the primary health care (PHC) system1 and has undertaken to boost Australia’s health workforce by funding Health Workforce Australia (HWA)2 and committing policy investments in three areas in its National Health and Hospitals Network report:3 Providing additional general practitioner, medical specialist and PHC training places. Improving PHC service delivery through GP Super Clinics. Improving planning and coordination of PHC services through Primary Health Care Organisations (PHCOs, also known as Medicare Locals). Does the government have an evidence base for its primary health care workforce reforms? The need for evidence-informed policy making and implementation has been emphasised4 — rightly so, as the government needs to be transparent and accountable for its decisions and actions. Because policy implementation is complex and context-dependent, reflection is required on the evidence that informs policy implementation, and the likely success of such reforms. We acknowledge that multiple “policy vectors” (eg, practitioner and patient realities) also need to be considered. Although we focus on the Australian context here, similar issues and debates exist internationally.5,6 This editorial does not summarise evidence underpinning the PHC workforce,7,8 but draws on it to consider important strategic, evaluative and contextual research questions relating to the government’s three policy investment areas. Providing additional GP, medical specialist and PHC training places. To ensure that the additional investments are targeted, research questions should include: Strategic questions. Where could training capacity be increased? What additional resources are required to maximise the effectiveness of these training places? How do additional training places address existing areas of workforce shortages? Evaluative questions. Do medical schools and training programs improve consumer access to services and meet the needs of communities over time? Contextual questions. Are these the most appropriate health professional groups to expand? Are there different models of care that might be more relevant to contemporary practice or, more importantly, practice in 2020? Data from the Medicine in Australia: Balancing Employment and Life (MABEL) longitudinal survey, the Medical Schools Outcomes Database, Medicare, HWA surveys, and national registration may help to address these questions. For example, as part of the first wave of MABEL, a discrete-choice experiment was completed by 532 junior doctors in 2008 before they chose a specialty training program.9 In a policy simulation, researchers found that increasing GPs’ annual earnings by $50 000 and increasing opportunities for procedural or academic work could increase the number of junior doctors choosing general practice by between 8 and 16 percentage points (representing 212–376 junior doctors per year). These results can help policymakers to address the unbalanced supply of doctors across specialties. Improving PHC service delivery through GP Super Clinics. Twenty-three new GP Super Clinics will be funded and 425 existing PHC facilities will be upgraded to improve team-based care. To efficiently plan the locations and roles of the new GP Super Clinics, research questions should include: Strategic questions. Are GP Super Clinics located in areas of workforce shortage and hence eligible for additional support? Do GP Super Clinic workforce skill mixes and skill sets match population health needs? Evaluative questions. What impacts are GP Super Clinics having over time on patient care and on workforce models of care and skill sets? Contextual questions. Given the importance of team-based care, what role can interprofessional learning have in GP Super Clinics? Improving planning and coordination of PHC services through PHCOs. PHCOs will be established to improve the planning and coordination of PHC services at the local level.10 To efficiently plan the locations and roles of PHCOs, research questions should include: Strategic questions. How does the profile of the local PHC workforce need to be expanded, retrained or shifted in relation to population health profiles? Evaluative questions. Can PHCOs measure and predict access problems (eg, for refugees and Indigenous people) and hence inform the extent to which PHC services need to be tailored to these groups? Contextual questions. How can different models of care that focus on patients’ needs, and learning programs that inform patient choice, be developed to improve health literacy and reduce the demand on health services? The above policies should also be considered from an equity perspective: What are the equity implications of each reform (especially GP Super Clinics and PHCOs) from a workforce point of view? Will these policies exacerbate imbalance in the workforce, which is already unequally distributed on the basis of socioeconomic need? HWA and the National Primary Health Care Strategy provide the opportunity for these questions to be addressed. However, a national PHC workforce policy is needed to guide key policy reform investment, development, implementation and evaluation. To respond to changing population and workforce needs and expectations, evidence must inform policy investment, implementation and evaluation. Until we have a better understanding of how evidence is being used, there will be limited knowledge about what makes policy implementation work, for whom and in what circumstances.

Lucio Naccarella BSc(Hons), GradDipMHS, PhD · Peter M Brooks AM, MD, FRACP · Bill Newton BA · Danielle Butler MD