General medicine

To the Editor: Walters and Dawson1 correctly highlight access block (hospital overcrowding) as a whole-of-system problem. Acute medical assessment and admission units (AMAAUs), or other similar incarnations in Australia and New Zealand, are part of the solution, although the evidence presented is low-level non-Australasian data. The reduced length of stay achieved by these units and reported in papers cited by Walters and Dawson would, if replicated in Australasia, produce additional capacity, improving bed availability and patient flow. As has been repeatedly stated: it’s all about available beds!2 However, Walters and Dawson’s article stretches well beyond the evidence in its approach to emergency department (ED) roles and the interactions between AMAAUs and EDs. None of the cited studies suggested that AMAAUs provide better environments than EDs for sick undifferentiated patients. None studied effects that AMAAUs have on ED treatment and none proposed interventions specifically designed to alter ED management. They essentially examined improved patient journeys for front-loaded AMAAU versus standard (slower) general medical inpatient care. In addition, Walters and Dawson imply that these changes related to introduction of the United Kingdom’s 4-hour rule. However, many references were either non-UK or not specific to the 4-hour rule. Rigorous research in an Australasian context would be required before adopting models from a different system. The authors promote a view that undifferentiated acutely sick patients bypass the ED to be managed by “new” acute-care specialists. No evidence is presented to support this change, and it is difficult to see how this would be a sensible policy for Australia and NZ, which have mature ED systems. Emergency physicians are specialists specifically trained and skilled in early diagnosis, management and disposition of the undifferentiated, unwell patient. What is required is a system that builds on the excellent start made by the ED, removes the blocks to patient care caused by waiting for beds in the ED and then continues to emphasise rapid diagnosis, early management, disposition and flow. This is what AMAAUs can deliver and why they should be effective. Australasian EDs already provide an exemplary service in a difficult, access-blocked environment. What patients need is sufficient hospital capacity — hospitals that provide enough appropriate beds. We look forward to seeing AMAAU staff meet this need in partnership with their emergency physician colleagues. In summary, it’s all about available beds, about having enough overall capacity and optimising patient flow to maximise bed availability.2 The only revolution required is for governments to recognise this fundamental precept.

David Mountain · Daniel M Fatovich · Drew B Richardson · Sally M McCarthy

To the Editor: Although written from a United Kingdom perspective, the recent article by Walters and Dawson1 suggests a change in the clinical culture within hospitals, so that patient care and throughput can be improved. A critical factor in achieving change is the creation of an acute medical assessment and admission unit (AMAAU) within each district hospital. Characteristics of the AMAAU will “depend on local circumstances”: there is no one size that fits all.1 Because of Australia’s unique demography, and the number of communities beyond the reach of tertiary centres, many primary-care physicians (general practitioners and “rural generalists”) provide the continuum of care required by patients, both within the community and within their local hospitals (the acute admission, ongoing inpatient care and discharge planning). Twenty-first-century GPs deal daily with patients needing management of multiple comorbidities and the consequences of polypharmacy (the “sick general” and “complex elderly” clinical streams1). GP training prepares doctors for these responsibilities and could easily be expanded to include an AMAAU role for interested GPs, especially those in outer urban and major rural areas. The advent of AMAAUs is an opportunity to change the mindset in medicine: after 8 to 9 years of primarily hospital-based training, some GPs suddenly have no hospital access! This would seem to be a callous waste of talent and resources.

Frank R Jones

To the Editor: Walters and Dawson1 highlight growing interest in new models of care aimed at ameliorating hospital-bed pressures and access block. They advocate acute medical assessment and admission units (AMAAUs) as a potential solution, and claim, principally based on the United Kingdom’s experience, that these units can significantly improve clinical care and patient outcomes. A recent systematic review confirms that these units (which have attracted several different synonyms) have promise, although controlled trials have yet to be performed, and publication bias remains a potential confounder.2 Experience with such units in Australia and New Zealand is growing, with more than 30 units in operation, and up to another 15 due to open over the next few years. Several national workshops conducted during the past 12 months have allowed staff of the units to share lessons and insights, and to debate how to balance service needs with resource availability. Operating standards for AMAAUs have been developed by the Internal Medicine Society of Australia and New Zealand (IMSANZ),3 which represents consultant general physicians. A recent survey shows the operations of Australasian units concord, in the most part, with these standards.4 We caution against Walters and Dawson’s suggested separation of AMAAU physicians into two streams — acute physicians working shifts, and ward-based general physicians responsible for patients requiring transfer from the AMAAU. Given that at least half of AMAAU patients will require transfer to inpatient wards, and many may warrant ongoing outpatient care even if discharged from the AMAAU, the need for continuity of care is paramount at the interface between the AMAAU and ward or clinic. To minimise the number of handovers and their attendant hazards and inefficiency, the medical team assessing and managing the patient in the AMAAU should ideally be the same team that provides ongoing inpatient (and indeed subsequent outpatient) care. This practice also eliminates any confusion around who is ultimately responsible for decisions about individual patient care, particularly for patients who remain in the AMAAU for any length of time. General physicians can acquire and maintain skills in acute medicine by making use of professional development programs sponsored by the IMSANZ. Clinical directors are needed in AMAAUs to oversee unit operations, develop policies and procedures, and provide capacity for rapid consultant response if on-call consultants are temporarily unavailable. The real challenge, to which Walters and Dawson refer, is the need for health care professionals to recognise that whole-of-hospital redesign solutions — which include AMAAUs — are needed, if access block in emergency departments is to be successfully overcome.

Ian A Scott · John W Henley

To the Editor: The Journal took a significant step forward in publishing the three articles on access block in the 6 April 2009 issue.1-4 Walters and Dawson’s viewpoint article,4 in a later issue, touches on some ideas that will be useful in finding solutions to access block — ideas that some hospitals are implementing. However, I am not sure a microsolution aimed purely at acute medical patients can be called a whole-of-hospital revolution. The acute medical assessment and admission unit (AMAAU) is potentially a good idea. Fortunately, many hospitals all over Australia already have units that are highly efficient at the role that is proposed for it — they are called emergency departments (EDs). Most acute medical patients can be identified as needing admission after a few seconds in the ED by experienced emergency physicians. The remaining patients need some basic pathology or imaging service before a decision can be made, which should take an hour at the most. Having secondary inpatient units providing this role to the community via direct general practitioner referrals, as well as having some patients bypassing the ED by being cherry-picked by inpatient teams, may generate inefficient duplications of service. The AMAAU has merit, streaming patients to the right specialty and the right inpatient bed early in their presentation. Emergency physicians have largely known this for over a decade and these kinds of units have already been introduced in hospitals all over the country. Nepean Hospital, in western Sydney, has the PECC (Psychiatric Emergency Care Centre), AGS (Acute Gynaecological Service), MAU (Medical Assessment Unit), EDMAU (ED Medical Assessment Unit), EMU (Emergency Medical Unit) and ASU (Acute Surgical Unit), to name just a few acronyms. Unfortunately, this does not deal with the 20 patients in the ED, already admitted and sorted, waiting for an inpatient bed at 8 am on a Monday. Increased inpatient bed numbers to cope with the predicted acute ED admissions and the planned elective surgical workload must be the number-one priority. Once we have bed numbers to cope with demand, then we can plan how to use them. I propose my own revolution. We need to provide a true 7-day-a-week service to our hospital inpatients. Ward rounds should be conducted 7 days a week. All inpatient consults, including those of allied health practitioners, should be completed on the same day, including weekends. All complex imaging should be completed on the day it is ordered, not the next working day, with formal reports available the same day. Once we acknowledge that acute hospital medicine does not fit in with the 38-hour working week, then we can truly start acting as patient advocates.

James L Mallows

Objective: To examine the perception and management of cardiovascular disease (CVD) risk in Australian primary care.Design, setting and participants: The Australian Hypertension and Absolute Risk Study (AusHEART) was a nationally representative, cluster-stratified, cross-sectional survey of 322 general practitioners. Each GP was asked to collect data on CVD risk factors and their management in 15–20 consecutive patients aged ≥ 55 years who presented between April and June 2008, and to estimate each patient’s absolute risk of a cardiovascular event in the next 5 years.Main outcome measures: Estimated 5-year risk of a cardiovascular event, proportion of patients receiving appropriate treatment.Results: Among 5293 patients, 29% (1548) had established CVD. A further 22% (1145), when categorised according to the 2009 National Vascular Disease Prevention Alliance guideline, to 42% (2211), when categorised according to National Heart Foundation (NHF) 2004 guideline, had a high (≥ 15%) 5-year risk of a cardiovascular event. Of the 1548 patients with established CVD, 50% were prescribed a combination of a blood pressure (BP)-lowering medication, a statin and an antiplatelet agent, and 9% were prescribed a BP-lowering medication and a statin but not an antiplatelet agent. Among high-risk patients without established CVD, categorised using NHF 2004 adjustments, 34% were prescribed a combination of a BP-lowering medication and a statin. GPs estimated 60% of patients with established CVD as having a risk of less than 15%. The GPs’ estimates of risk among patients without established CVD agreed with the centrally calculated estimate (according to the NHF 2004 guideline) in 48% of instances (κ = 0.21).Conclusions: These data confirm substantial undertreatment of patients who are at high risk of a cardiovascular event. We recommend that GPs assess absolute risk for older patients and ensure that high-risk patients receive evidence-based pharmacotherapy.

Emma L Heeley BSc(Hons), MSc, PhD · David P Peiris MB BS, MIPH, FRACGP · Anushka A Patel MB BS, PhD, FRACP · Alan Cass MB BS, FRACP, PhD · Andrew Weekes BMedSci, BM BS · Claire Morgan BPhysio · Craig S Anderson MB BS, PhD, FRACP · John P Chalmers MD, PhD, FRACP

Objective: To assess whether the components of the Healthy Kids Check (HKC), a preschool screening check recently added to the Australian Government’s Enhanced Primary Care Program, are supported by evidence-based guidelines or reviews.Data sources: Guideline and MEDLINE databases were searched for guidelines and systematic reviews published between 2000 and 2008 that were relevant to screening, prevention or well-child care in primary health care, and including children of preschool age. Search subjects reflected the HKC components: growth, weight, obesity, vision, hearing, oral health, enuresis, encopresis, allergic disease and food allergies.Study selection: 34 relevant guidelines or reviews were retrieved.Data extraction: For each component of the HKC, guidelines addressing the presumed rationale for screening, or the test or tool required to implement it, were reviewed. Relevant evidence-based and consensus-based guideline recommendations were assessed as either supporting or opposing components of the HKC, or stating that the evidence was insufficient to recommend screening of preschool children.Data synthesis: Guidelines were often inconsistent in their recommendations. Most of the components of the HKC (eg, screening for chronic otitis media and questioning about toilet habits) are not supported by evidence-based guidelines relevant to the primary care setting, though a number of consensus-based guidelines are supportive.Conclusions: There is currently a dearth of evidence relevant to child health surveillance in primary care. The components of the HKC could be refined to better reflect evidence-based guidelines that target health monitoring of preschool children.

Karyn E Alexander MB ChB, FRACGP, MPH · Danielle Mazza MD, FRACGP, DRANZCOG

Clinical record An 88-year-old man presented to our emergency department with sudden loss of vision in his right eye. Past ocular history included amblyopia in his right eye and bilateral neovascular age-related macular degeneration (AMD). Previously recorded best corrected visual acuities were 6/120 and 6/18 in his right and left eye, respectively. The patient’s past medical history included acute myocardial infarction, atrial fibrillation, hypertension, hypercholesterolaemia and polymyalgia rheumatica. He had no history of diabetes, cerebrovascular accident or transient ischaemic attack. His medications included warfarin, aspirin, metoprolol, perindopril and simvastatin. His international normalised ratio (INR) had ranged between 1.3 and 2.3 over the preceding 12 months, with a target of 2.0. Visual acuity in the right eye was count fingers. Dilated slit lamp examination revealed a large submacular haemorrhage with associated vitreous haemorrhage (Figure A). An electrocardiogram showed atrial fibrillation with a heart rate of 72 beats/min. His blood pressure was 110/80 mmHg. His INR was 2.8. The eye was managed conservatively and, following resolution of the vitreous haemorrhage, vision remained at count fingers. Four months later, the patient reported sudden loss of vision in his left eye. Visual acuity was light perception, and dilated fundus examination revealed dense subretinal and associated vitreous haemorrhage (Figure B). The patient was still taking warfarin, and his INR at this time was 2.7. As this had been his better eye, he underwent pars plana vitrectomy and clearance of the vitreous haemorrhage. After surgery, his visual acuity was count fingers. After further discussion with the patient’s cardiologist, a decision was made to cease warfarin. A: Fundus photograph of the right eye at presentation, showing macular subretinal and intraretinal haemorrhage. The mild haziness of the photograph is indicative of vitreous haemorrhage. B: Fundus photograph of the left eye at the time of presentation of visual loss in this eye. Extensive subretinal haemorrhage is seen in the macula. Again, the haziness of the photograph is indicative of vitreous haemorrhage. This report highlights a potential interaction between a commonly used anticoagulant, warfarin, and an increasingly common ocular condition — AMD. The risk of AMD increases with age, with prevalence reaching 20% of people aged over 75 years in white populations.1 Neovascular (“wet”) AMD accounts for 10%–20% of cases,2 and for 80%–90% of patients who become legally blind from AMD.3 Peripheral vision is typically retained, and most patients are able to maintain a degree of functional independence. Development of large subretinal and vitreous haemorrhages in neovascular AMD is uncommon. Treatment options are limited and, even with surgical intervention, visual outcomes are in the range of light perception to counting fingers only, with significant loss of paracentral and peripheral vision.4 The functional effects are therefore profound. Previous studies have demonstrated an association between the use of anticoagulant medication, particularly warfarin, and large intraocular haemorrhages among patients with neovascular AMD.5,6 The largest of these, a retrospective case–control study comprising 100 patients, found that those with massive intraocular haemorrhage were 11.6 times more likely to be taking anticoagulant medication.6 Among these patients, INR ranged from 3.0 to 4.0. Patients with massive haemorrhage were twice as likely to be taking aspirin, although the significance of this finding is less certain, as the lower limit of the 95% confidence interval was less than 1. No patient was taking anticoagulants and aspirin concurrently.6 In our patient, the role of concurrent aspirin therapy is unclear, as there is no evidence in the literature to support or refute the hypothesis that concurrent antiplatelet therapy may have contributed to the development of haemorrhage. However, both instances of haemorrhage were noted to occur at times when his INR was high compared with those recorded over the previous 12 months. Our patient was taking aspirin at all times during this period. Although it is possible that intraocular haemorrhage may have occurred purely as a result of his underlying neovascular AMD, the temporal relationship between the development of the haemorrhages and the high INRs strengthens the case for the implication of warfarin therapy as a contributing factor. Application of the Naranjo probability scale7 indicates that this adverse drug event was probable (Naranjo score, + 5). The association between anticoagulant therapy and intraocular haemorrhage is of key importance for several reasons. Firstly, massive intraocular haemorrhage is an important diagnosis to consider in an anticoagulated patient who presents with loss of vision, and who has a background of neovascular AMD. Secondly, patients with neovascular AMD in one eye are at risk of developing neovascular AMD in the second eye,8 and therefore at risk of developing large intraocular haemorrhages in both eyes if long-term anticoagulation is continued. There are several clinical situations in which the indication for anticoagulation is relative. There are key roles for the ophthalmologist, cardiologist, and general practitioner to ensure that an appropriate risk–benefit evaluation is made before initiating anticoagulant therapy for patients with neovascular AMD. Patients taking anticoagulants who develop neovascular AMD, and in particular those with neovascular AMD who are taking anticoagulants and who develop intraocular haemorrhage in one eye, should have their therapy carefully re-evaluated. Importantly, awareness of the poor outcomes of intraocular haemorrhage in neovascular AMD, the role of anticoagulants as a risk factor, and effective communication between health professionals may help reduce the incidence of this devastating complication. Lessons from practice Patients with neovascular age-related macular degeneration (AMD) have a small but significant risk of intraocular haemorrhage, which may be increased in severity if patients are taking anticoagulant medication. The outcomes of intraocular haemorrhage are poor, with significant deterioration in paracentral and peripheral vision, and subsequent implications for ability to maintain functional independence. When considering anticoagulation therapy for patients with neovascular AMD, liaison between the general practitioner, cardiologist and ophthalmologist will ensure that an appropriate risk–benefit evaluation is made. If patients who take anticoagulant medication develop signs of neovascular AMD, it is essential that the ophthalmologist liaise with the GP and/or cardiologist to ensure that the need for anticoagulation, and the target international normalised ratio, are carefully reviewed.

Rajeev Chalasani MB BS · Salmaan Qureshi FRANZCO

To the Editor: Hellard and Wang1 are correct in emphasising the importance of the general practitioner in the management of hepatitis C virus (HCV) infection. As the authors note, HCV infection is a considerable source of morbidity and mortality in the community, and the infection may cause a substantial burden of illness in the future if it is not appropriately managed. The GP plays a pivotal role in managing HCV infection, being the first and most likely point of contact for patients. However, Hellard and Wang fail to note that the GP’s most useful role is to inform patients that “alcohol abstinence is strongly recommended before and during antiviral therapy”.2 The well recognised role of alcohol in disease progression is emphasised in the position papers of both the American Gastroenterological Association and the United States National Institutes of Health.2,3 From a public health perspective, it is difficult to think of a more cost-effective approach to the management of such a public health issue.

Anne E Duggan · John M Duggan

In reply: Duggan and Duggan are correct to highlight the well recognised role of alcohol consumption in progression of hepatitis C virus (HCV) infection. Alcohol consumption has been found to increase viral load and accelerate hepatic fibrosis in HCV infection.1,2 While studies have reported that a history of alcohol consumption adversely affects treatment outcomes (with some reporting a dose–response relationship),3,4 treatment success has also been reported among patients who continue to consume moderate amounts of alcohol during treatment.5 Although there are biologically plausible mechanisms through which alcohol consumption might negatively affect treatment, low rates of treatment success among drinkers may also be related to lack of adherence to treatment regimen in this population.1 To date, no study has specifically measured the effect of alcohol consumption during treatment while adequately controlling for the effects of compliance, disease progression and baseline viral load. Until studies are undertaken that measure the direct effect of alcohol consumption on treatment success, while adjusting for compliance, it seems reasonable to advise patients to decrease their level of alcohol consumption before and during HCV treatment. However, given that some patients have successfully completed treatment without abstaining from alcohol consumption, this should not be an automatic exclusion criterion.

Margaret E Hellard · Yung-Hsuan J Wang · Rachel Sacks-Davis

To the Editor: The Australian Medical Council recognises the importance of clinical experience in general practice for all medical students.1 In their recent article in the Journal, Vickery and colleagues identify three significant barriers to clinical teaching by Australian general practitioners: time, space and opportunity costs.2 They suggest that General Practice Super Clinics will be well placed to address the issue of space and, with additional funding, could also overcome the barriers of opportunity cost and lack of time. The latter claim may be true, but we need to invest in all teaching practices, not just in Super Clinics. The Australian Government is currently committed to establishing 35 Super Clinics. Even if more are set up in the future, it is difficult to see how they will ever make a major contribution to providing general practice placements for the 3000-plus students entering medical training each year. There are many high-quality general practices across Australia that have been committed to teaching for years. For this, they receive a $200 Practice Incentives Program payment per student per day. This amount has not increased since 2004, and is widely seen as insufficient to meet practice teaching costs. There is an urgent need to increase the sessional payment for teaching to an amount that realistically reflects the time and opportunity costs to practices. In addition, a national fund for capital investment in teaching practices would help address the third barrier that Vickery et al identify: many excellent practices are unable to provide student placements due to lack of space.

Timothy P Usherwood

Two phenomena are shaping physician assistants and their futures: change in human societies and change in health care delivery The physician assistant (PA) is a global phenomenon: a product of medicine that enjoys unparalleled success within the health profession in many societies. Born in the 1960s, nurtured in the 1970s, and grown in the 1980s, the PA proved to be a capable player in American health policy in the 1990s. By 2000, the PA had emerged in a handful of countries, and by 2015, PAs will surpass 100 000 worldwide.1 Various explanations regarding why this profession is growing have been advanced. Clearly, PAs fit well in the entrepreneurial American health care system; economic advantages, clinical flexibility and dependence on doctors are factors that contribute to their success. But it is other countries that are building on the original model. With a worldwide shortage of 4.5 million doctors and an inadequate number of medical schools, the sheer weight of population growth demands more medical personnel and resources.2 In addition, improvements in childhood survival and the control of archaic diseases (eg, malaria, tuberculosis, dengue fever, smallpox, polio) have resulted in people living longer and more comfortably than their parents. Technological advancements are limited only by the logistics of delivery to populations, both urban and remote.3 The increasing years of productivity of individuals indicates the need for an unprecedented cadre of health workers. Without more doctors and nurses, the next group of providers to look to is PAs. Canada, the United Kingdom, South Africa and the Netherlands are examining not only their present workforces, but also what will be needed in decades to come. The alternative to not growing their own workforces is recruiting overseas-trained doctors — a strategy with its own ethical considerations.4,5 A sociological explanation for the emergence of PAs is an evolution in the division of medical labour, not a loss of autonomy for doctors. Medicine has become infinitely more complex over the past several decades and the information base required to practise medicine is enormous, leading to greater levels of team-based care. Health care knowledge was once a vaunted supremacy of doctors, but now diagnostic and therapeutic tasks are shared with other health care professionals (in part because modern-day doctors cannot know and do everything in so vast a field). Throughout the 20th century, analytical technologies and therapeutic approaches produced new specialties, and today we have genetics, interventional radiology, robotic surgery and the resurgence of midwifery. Further expansion of medical activities and capabilities will necessitate the inclusion of additional trained personnel who share the domains of doctors but remain dependent on doctors for directing care. Other social forces have had a major influence on the PA movement. Changing lifestyles — doctors’ preferences for greater work–life balance grew during the 1970s. Today, most are eager to work (though not as hard as their predecessors) and desire help. Gender shifting — women have entered the workforce in a major way. They have tried out careers that are traditionally dominated by men, and have found them to their liking. For PAs, the education path is shorter than for medicine but has similar rewards. The opportunity to be engaged in a well respected career and successfully raise a family ranks high with many female applicants. Doctor dependency — the unwavering commitment of the PA profession to remain dependent on doctors bolsters widespread acceptance of PAs by medical professional bodies. National competency — the establishment of program accreditation and an independent national board overseeing the specific skills and competencies of PAs allows states to focus on licensure, roles and supervision. Primary care — for PAs, the emphasis on training in general medical care and obtaining core competencies creates a known entity. Such a model permits more role flexibility and mobility (beneficial characteristics in a changing health care environment) than exists for doctors and nurse practitioners. The PA succeeds, in part, because of the attributes of individuals. Early entrants saw themselves as change agents who wanted to prove that allied health individuals trained in this PA model could benefit society safely and effectively. The PA profession continues to attract those who feel dead-ended in their current health care roles but do not want the burden of a protracted medical school experience or investment. For example, an experienced military medic may seek to use his or her skills in civilian life or an indigenous health care worker who is isolated without options for career progression may wish to upgrade his or her role to enable a return to cultural roots. Looking forward, key questions emerge. What does the future hold for the PA profession? How will the changing faces of various health care systems affect the PA profession? Will a PA trained and certified in Utrecht, the Netherlands, be able to work in Mt Isa, Australia, and be effective? Two phenomena are shaping PAs and their futures: change in human societies and change in health care delivery. These are on convergent paths that predict the growth of PAs for many years to come — at least in many countries. How Australia will fit this new provider into its health care system is contentious for some. For those who want to expand the capacity of its highly skilled workforce, the pace of change leaves few options.6

Roderick S Hooker PhD, PA

Objective: Community-based medical education is growing to meet the increased demand for quality clinical education in expanded settings, and its sustainability relies on patient participation. This study investigated patients’ views on being used as an educational resource for teaching medical students.Design: Questionnaire-based survey.Setting and participants: Patients attending six rural and 11 regional general practices in New South Wales over 18 teaching sessions in November 2008, who consented to student involvement in their consultation.Main outcome measures: Patient perceptions, expectations and acceptance of medical student involvement in consultations, assessed by surveys before and after their consultations.Results: 118 of 122 patients consented to medical student involvement; of these, 117 (99%) completed a survey before the consultation, and 100 (85%) after the consultation. Patients were overwhelmingly positive about their doctor and practice being involved in student teaching and felt they themselves played an important role. Pre-consultation, patients expressed reluctance to allow students to conduct some or all aspects of the consultation independently. However, after the consultation, they reported they would have accepted higher levels of involvement than actually occurred.Conclusions: Patients in regional and rural settings were willing partners in developing skills of junior medical students, who had greater involvement in patient consultations than previously reported for urban students. Our study extends the findings from urban general practice that patients are underutilised partners in community-based medical training. The support of patients from regional and rural settings could facilitate the expansion of primary care-based medical education in these areas of workforce need.

J Nicky Hudson BM BS, MSc, PhD · Kathryn M Weston PhD · Elizabeth E Farmer FRACGP, BSc, PhD · Rowena G Ivers FRACGP, MPH, PhD · Russell W Pearson FRACGP, FACRRM

Paying incentives above the baseline Medicare Benefits Schedule to health services for the additional work required to meet the health needs of Aboriginal people or Torres Strait Islanders might mitigate inequalities of care, but evidence supporting this is lacking. The proposed “Indigenous health” incentive payment to reduce Aboriginal health disadvantage, which is largely aimed at increasing the responsiveness of mainstream general practices, provides an opportunity to examine the assumptions behind this and other recent health reform bids. Contentious implementation issues include: the ineligibility of several Aboriginal community controlled health services (ACCHSs) to receive this payment; determining Aboriginality and the potential for misappropriation of payments; the difficulty accounting for practice population diversity and patient mobility; and concerns about the benefits or otherwise to the Aboriginal community. Evaluation of the measure will present problems: to attribute outcomes, an evaluation must disaggregate outcomes by type of service provider (general practice or ACCHS). If these challenges are not addressed, this initiative may end up merely funding coordination of care for those Aboriginal people and Torres Strait Islanders who are already regular users of the health system.

Sophie Couzos FRACGP, FACRRM, FAFPHM · Dea Delaney Thiele PGDipHlthMgt

Living with bipolar. A guide to understanding and managing the disorder. Lesley Berk, Michael Berk, David Castle, Sue Lauder. Sydney: Allen and Unwin, 2008 (xiv + 298 pp). ISBN 978 1 74175 425 4. Over the past decade there has been a palpable surge of fascination with bipolar disorder in this country, generated at least in part by the moving testimonies of high-profile patients, and a resurgence of academic and pharmaceutical interest in the condition. This increasingly transparent public discourse has been a boon to those who have suffered in silence for so many years, and who now demand and expect quality information and guidance on understanding and living with the highly disabling illness. Consequently, there is now a healthy, growing market for well written, informative self-help books targeting bipolar disorder, for sufferers, their families and the lay community. Living with bipolar, written by an impressive team of Australian researchers and psychologists, is an excellent addition to the genre, complementing an Australian canon of quality books. Others include Sarah Russell’s A lifelong journey: staying well with manic depression/bipolar disorder (a self-help manual written by a researcher who has experienced bipolar disorder), Penelope and Jessica Rowe’s The best of times, the worst of times (a frank account of a family’s struggles dealing with bipolar), and Mastering bipolar disorder, a compilation of individuals’ accounts of managing their mood swings, edited by Kerrie Eyers and Gordon Parker. Living with bipolar, unlike the others, is both a highly palatable mini-monograph on bipolar disorder for the layperson, and rich, common-sense advice for managing the condition. I particularly enjoyed the chapters on modern psychological strategies that patients can use to manage symptoms, including specific guidance on “catching symptoms early” and “managing your triggers”. This is no anti-medical treatise, finishing rather with advice encouraging patients to establish a collaborative relationship with their medical practitioner. A highly recommended book for your bipolar patients.

Philip B Mitchell

To the Editor: The general practitioners’ dilemma is acute. Women asking for mammography and/or testing for ovarian cancer; men asking for prostate-specific antigen (PSA) testing for prostate cancer. The debate, fuelled by uncertain knowledge, rages in the general medical journals,1,2 including contributions in the 17 August 2009 issue of the MJA.3,4 The PSA test is, of course, intimately associated with the name of its inventor, Thomas A Stamey. I am, therefore, somewhat surprised that neither of these recent MJA articles mentioned Stamey’s 2004 “recanting” of his proposed value of the test back in 1987: “current evidence from the last 10 years is convincing that the relationship between prostate cancer and serum PSA is tenuous at best, especially with serum PSA less than 10 ng/mL and perhaps even less than 22 ng/mL. This time is not the first we have had second thoughts regarding the usefulness of serum PSA in preoperatively reflecting prostate cancer”. He concludes: “any excuse to biopsy the prostate has an excellent, age dependent chance of being positive”.5 Perhaps the authors could tell your readers why they did not think that Stamey’s 20-year experience of PSA testing and his 2004 conclusions warranted a mention?

Peter C Arnold

In reply: The letter by Arnold highlights the practical dilemma facing busy doctors when communicating with patients about whether to screen for various cancers, prostate cancer in particular. There are no easy answers at present, although presentation of both sides of the argument regarding prostate cancer testing helps doctors and patients make a shared decision.1 We believe the following decision-aid show card, written in plain English, is an excellent resource to assist with this: <http://www.cancer.org.au/File/HealthProfessionals/GPprostateshowcard.pdf >.

David P Smith · Emily Banks · Mark S Clements · Robert A Gardiner · Bruce K Armstrong

Objective: To assess the extent to which general practitioners in Australia are engaged in identifying age-related hearing loss and facilitating its management.Design, setting and participants: Cross-sectional analysis of data collected between 1998 and 2000 from the Blue Mountains Hearing Study (BMHS), a representative population-based cohort of people aged ≥ 50 years in two postcode areas west of Sydney. Also analysed were data collected between 2003 and 2008 from random samples of Australian GPs who participated in the Bettering the Evaluation and Care of Health (BEACH) study, a national continuous cross-sectional survey of GP activity.Main outcome measures: Rate of facilitating management and identification of hearing loss in older patients; content of GP–patient encounters with hearing-impaired people; characteristics of participants seeking help from their GP.Results: Of older people in the BMHS with measured (objective) bilateral hearing loss, about a third reported seeking help frovm their GP. BEACH survey data showed that only about 3 per 1000 GP consultations with patients aged ≥ 50 years involved management of age-related hearing loss. For every 100 age-related hearing problems managed, GPs undertook 12 procedural treatments, provided 20 referrals to specialists, and made 29 referrals to allied health professionals.Conclusion: In their routine consultations with patients, GPs have opportunities to identify hearing loss and appropriately refer patients to specialists or allied health professionals. Although GPs are responding to patient presentations for hearing loss, referring around 50% of cases, there appear to be relatively few cases in which hearing loss is identified opportunistically. Levels of identification and management of hearing loss by GPs in Australia are relatively low.

Julie M Schneider BAppSc(Hons), PhD · Bamini Gopinath BTech(Hons), PhD · Catherine M McMahon PhD · Helena C Britt BA, PhD · Christopher M Harrison BPsych(Hons), MSocHlth · Tim Usherwood MD, BS · Stephen R Leeder MD, PhD · Paul Mitchell MD, PhD, FRANZCO

To the Editor: My compliments on the issue of the Journal on the survival of general practice (20 July 2009). But something was missing — a patient’s perspective. I hear from fellow Sydneysiders that they cannot find a general practitioner offering continuity of care. They tell me that: All recommended GPs have “closed books”. They can’t get an appointment on the day and have to wait until a few days later, unless it’s a “real emergency”. At big, “commercial” practices, they seldom see the same GP again — and must tell their story each time. Their GP (preferably female) is there some weekdays only. They can’t find a GP who does home visits. Neither “their” GP, nor any of the others in the practice, is available after hours — they must ring an emergency doctor with no access to their records. GPs want them out quickly with a prescription or referral. GPs say that, although it’s a simple procedure, it’s better done by a specialist. GPs want to start a “care plan”, even if there’s nothing much wrong. They’re not happy with attention from the nurse — they want to see the doctor. And so it goes. Back in 2006, the Australian Consumers Association, together with advice on choosing a GP, commented: The relationship you have with your doctor can be one of the most crucial in your life ... A positive ongoing relationship with your GP is extremely valuable, making it all the more important to choose the right one.1 Shouldn’t the MJA open its pages — on an issue which matters so much to them — to patients, to air their concerns? As it would be anecdotal, we would need evidence. A recent article in the BMJ surveyed British attempts at harnessing the views of patients.2 The authors’ opening comments were: “There is now a widespread realisation that patients’ views are not optional but essential to achieving high quality care.” Similarly, Australian patients’ expectations about weight management in general practice were discussed in the Journal in 2006.3 Is general practice’s survival not about adapting to meet patients’ requirements for high quality of service? In special issues devoted to the adaptation of general practice to future change, should not bodies like the Australian Consumers Association and some of the patient support groups, such as Arthritis Australia, be asked to contribute? Perhaps the MJA’s discussion is missing the wood for the trees?

Peter C Arnold

I have always dreaded that moment at funerals when you see the coffin for the first time. Perhaps it’s the finality of death or the sadness of the loss, but that moment seemed an inevitable consequence of the dying process, until I was faced with the impending death of my father. My father was 75 years old when he died of cholangiocarcinoma. He was a man with many friends. He was curious and loved to chat, he loved a beer, he made people laugh, he worked hard and was well loved. He was cared for at home, mostly by my mother. Friends and family came to pay their respects, and some came again for another “last time”. We sat with him, tended to his needs and contemplated life without him. The palliative care team visited often and waited for the cue to arrange hospice care because we could no longer cope; to us, this meant dad leaving and being cared for by someone else. The cue never came. The family rallied and dad stayed at home. This raised another issue I had with dying — the moment of separation when the body is taken away from the family. I had witnessed it often in my working life and wondered how families determined the right time to go and how they felt about leaving their loved one behind. Would they want to take the body with them? A few days before dad died, the funeral director came to the house. We leafed through folders of coffins and flowers, and discussed the service. She said to call them at any time when he died and they would come to the house (to take him away). I took a breath. “Can’t we keep him here?” My mother looked at me. “Are you sure you’re allowed to?” We hadn’t discussed this option so I had no idea what she thought about it. In fact, I didn’t think I would raise it. I hadn’t thought it through completely but felt intuitively it was the right thing to do, for me and possibly for her. Between us we had attended many funerals but had no knowledge of anyone who had kept the body at home. Ultimately, the decision would be hers; he was her husband, and she would continue to live in the house. Maybe it would be too much for her to bear, but she didn’t seem opposed to the idea, and it was possible. In the warmer months a cold table can be provided, but we were in the middle of winter and the garage under the house was particularly cold, so a body could rest down there. After some discussion, we decided that dad would go to the garage and not leave us until the last. That decision would have a profound effect on my view of death and grieving. Dad died early one Sunday morning at home, with my mother by his side. The rest of the family slowly arrived. Dad stayed in his bed, where we washed him and dressed him as if ready for golf. The children came in and out of the bedroom. They tied up his shoes and added things to his pockets. We ate lunch. The civil celebrant conducting the funeral came over and we talked about dad. Someone would disappear into the bedroom for a while and come out with red eyes. In the afternoon, the funeral directors arrived. We carried dad downstairs and placed him in the coffin, next to the caravan my parents used as their second home on travels. His golf clubs were beside him and his work bench just behind. Mum moved into the caravan for two nights. Dad was now in the garage. Mum’s sister arrived after a long journey. After cups of tea, they went downstairs to see dad. The garage became a sanctuary where people came and went and the children ran and danced around the coffin. Being close by allowed many quiet moments to sit next to the coffin, talking, weeping and taking time. Mum sat beside him in the early hours of the morning. On the day of the funeral, the family gathered for more food, more cups of tea and last-minute writing of speeches. We went down to the garage and lifted the lid of the coffin. Dad was still the same, looking pale and peaceful. We cried, laughed and added extra things that we thought he might want, or that we wanted him to have. The hearse arrived and we carried dad out and drove slowly to the church in this small country town. The family carried the coffin into the church that was filled with dad’s family and friends, and the friends of his children and friends of friends. Many burst into tears at the sight of us and the coffin. It was a good ceremony, and then we carried him out again. We arrived at the cemetery and carried the coffin to the graveside. The children wondered whether we would also have to dig the hole. The coffin was lowered and we all went for more cups of tea, and sherry and cake. The death of my father was an experience I had not expected. I imagined being inconsolable with grief and unable to make decisions. However, it was a gentle time that brought the family together and created a wonderful memory. He had a good death at home and a good after-death. Keeping his body at home was an unusual decision in the eyes of many. For the family, it represented an opportunity to do something special for someone we loved, but it also facilitated the grieving process. It seemed to slow down the period from the death to the funeral. There was no pressure to have the body removed or to pay visits to the funeral home for a “viewing”. He was in the garage and we could see him whenever we wanted; we grew accustomed to looking at the coffin and began to come to terms with his death. There was also comfort in continuing to offer care until the end, rather than his body being in the care of someone else. There are cultures where it is the norm to keep the body at home. I had witnessed it in Tonga on my student elective, where I equally appreciated the symbolism of coming together and sharing a meal (or cups of tea!) at these times. In contrast, the ritual of keeping the body at home is uncommon in Australian culture. It certainly seemed uncommon to the funeral director and others I have spoken to. Maybe people think about it but don’t ask. Perhaps we should ask for them.

Karen L Dunn MB BS, FRACP, PhD

Charles Darwin visited New Zealand in December 1835, and Australia from January until March 1836, on the return portion of his voyage around the world in HMS Beagle. Despite the shortness of these visits, he retained an interest in these countries throughout his life, maintaining correspondence and receiving many biological specimens. His experiences in these places influenced his thinking on evolution, particularly on the evolution of man. Aspects of his health recorded during this part of the voyage support a new hypothesis for the diagnosis of the illness that Darwin endured for most of his life.

John A Hayman MB BS, MD, FRCPA

Waiting room. A memoir. Gabrielle Carey. Melbourne: Scribe, 2009 (217 pp). ISBN 9781921372629. I’ve got mixed feelings about memoirs. Having cringed my way through the insipid or vitriolic ramblings of a number of previously admired politicians, actors and journalists, I’ve come to the conclusion that some people’s inner worlds are best kept that way. Nonetheless, I had high hopes as I read the blurb for well known Australian writer Gabrielle Carey’s Waiting room, and plucked it from the review pile to read over a long weekend. All doctors should read patient stories and Carey is an accomplished Australian writer of my generation — surely there would be much in the book to learn from and relate to. I was not disappointed. Waiting room details the diagnosis and management of Carey’s elderly mother’s meningioma. As a medical story, it appears accurate and straightforward and its portrayal of the clinical encounters, surgery and hospital stay is surprisingly undramatic. Without labouring the point, and with a very Australian sense of acceptance and ultimate trust in the medical system’s competence, Carey documents long hours spent waiting for life-changing medical appointments and the all-too-common experience of having planned surgery delayed by a lack of hospital beds. The medical characters are in the book for their functionality rather than their personalities. In fact, the medical story is really a backdrop to the main business of the book; Carey’s relationship with her enigmatic mother. When you reach a certain age, you realise that life is filled with unanswered questions, incomplete understandings, ambiguous meanings and relational loose ends. The beauty of a memoir is that it can unapologetically reflect this chaos without the need for momentous conversations, dramatic revelations and eventual resolution. As a doctor, writer, daughter, wife and mother, I found much to learn from and relate to in Carey’s Waiting room. Sometimes the truth may be stranger than fiction, but generally it is just much more real.

Ruth M Armstrong

General practitioners hold the key to expanding access to treatment Hepatitis C virus (HCV) is an important cause of morbidity and mortality in Australia. More than 200 000 people are estimated to be living with chronic HCV infection, with over 80% of these infections resulting from unsafe injecting drug use. About 10 000 new infections occur annually, although incidence is thought to be declining.1 Following primary HCV infection, persistent viraemia and chronic hepatitis occurs in 50%–80% of patients; after 20 years approximately 7% develop cirrhosis, and a small proportion of these patients develop hepatocellular carcinoma.1 Treatment of HCV infection has advanced over the past 10 years, leading to improved outcomes; the most effective current treatment is pegylated interferon combined with ribavirin. The aim of treatment is viral eradication, and treatment is deemed successful if a patient has a sustained virological response (SVR).2 The subsequent reduction in liver disease progression in patients who obtain an SVR3 suggests that the burden of advanced liver disease could be reduced if more patients received treatment. Treatment uptake has increased over the past 10 years, but has remained low. The removal of restrictions to prescribing for treatment — including the requirement for patients to have abnormal alanine aminotransferase levels or liver biopsy results (restrictions that were removed in 2005 and 2006, respectively) — has increased access,4 but the total number of individuals being treated for HCV infection in Australia remains low, at around 3500 individuals per year.5 Estimates vary, but recent modelling suggests that at least 6000, and closer to 10 000, people with chronic HCV infection need to be treated annually to reduce the burden of advanced liver disease in the future.1 While we acknowledge that not all people want or can have treatment for HCV infection, the number could be increased. HCV treatment can only be prescribed by certain medical practitioners or specialists, or at liver clinics, and cannot be prescribed by most general practitioners. Opportunities for treatment in tertiary hospitals and opioid pharmacotherapy clinic settings need to be expanded,6 but equally important is increasing GPs’ capacity to manage and treat patients living with HCV. GPs are usually the initial point of contact for patients with or at risk of HCV. It is imperative that GPs provide clear, accurate and up-to-date advice on HCV risk, prognosis and management. Several surveys in the past 10 years have reported that most GPs want further education about treatment, interpretation of test results, pre- and post-test counselling, and referral information.7,8 Many GPs’ knowledge of HCV is limited. A study undertaken in the period 2005–2006 found that, although GPs were aware of which patients are at risk of HCV (injecting drug users in particular), many underestimated the large number of Australians infected with HCV.9 A 2002 study reported that 39% of surveyed GPs mistakenly believed that positive results from HCV serological testing, as opposed to positive results from HCV RNA testing, differentiated current and resolved infection.7 An anti-HCV antibody test only provides information on whether a patient has ever been exposed to HCV — a positive result does not necessarily indicate an ongoing infection. An HCV RNA test is required to determine whether a patient has an ongoing infection or has spontaneously cleared their infection. GPs’ awareness of HCV treatment was also limited. The 2005–2006 study showed that only 42% of surveyed GPs were aware of the effectiveness of current HCV treatment, and only 28% were aware of the eligibility criteria for access to subsidised treatment.9 The 2002 study showed that 52% of GPs were not aware that pegylated interferon–ribavirin combination therapy was the most effective HCV treatment.7 Other studies have shown that fewer than 52% of people living with HCV in Australia had ever been referred to a specialist liver clinic10,11 despite the general acceptance that this should occur for the vast majority of patients with HCV. In addition, many GPs have reported being uncertain about when to refer patients to hepatitis specialists.9 Ongoing education is vital if GPs are to remain up to date on the management of HCV infection. A range of options are required to meet the needs of different GPs and their patients. One option is training GPs to fully manage their own patients, including training to become accredited prescribers of pegylated interferon and ribavirin under the federal government’s Section 100 (s100) Highly Specialised Drugs Program. Currently, the availability of such training is limited and varies between states and territories. A shared care model is a second option. Some GPs could be actively involved in the management and follow-up of patients without being an s100 prescriber. This model could suit GPs who manage only a few patients with HCV infection, as well as nurse practitioners and GPs in rural and regional areas. A specific training program could be developed to provide GPs and nurse practitioners with the necessary knowledge and skills, particularly for managing the side effects of HCV treatment. A third option should be provided to potentially the largest group of GPs — those who have patients at risk of or infected with HCV, but who do not want to be directly involved in HCV management. Through ongoing and regularly updated training programs, these GPs need to stay up to date on who is at risk of HCV infection, what tests should be ordered to diagnose and monitor HCV infection, and when patients should be referred to a specialist. In addition, all GPs need to have a broad understanding of what HCV treatments are available, that current and recent injecting drug users are eligible for HCV treatment, and that a liver biopsy is no longer required for a patient to have access to treatment (Box). Encouraging GPs to undertake HCV training in a setting of competing education priorities is a major challenge. Perhaps the first step should be to highlight that HCV occurs in about 1% of the population and that treatment options and outcomes for their patients have improved considerably during the past 5 years and are likely to continue to do so. Hepatitis C virus (HCV): what general practitioners should know HCV is common — more than 200 000 Australians have ongoing infection. Approximately 25% of people infected with HCV spontaneously clear their infection.12 An anti-HCV antibody test only detects whether a patient has ever been exposed to HCV — it does not detect ongoing infection. An HCV RNA test is required to determine whether a patient has an ongoing infection or has spontaneously cleared their infection. HCV can be successfully treated with pegylated interferon combined with ribavirin. The most common HCV genotypes in Australia are genotype 1 and genotype 3.1 Genotype 1 HCV infection usually requires 48 weeks of treatment, and genotype 3 usually requires 24 weeks of treatment; the chance of successfully clearing the virus with such treatment is approximately 45% and 75%, respectively.13 Treatment is deemed successful if a patient has a sustained virological response — defined as having a negative HCV RNA test result 24 weeks after completion of treatment. After successful treatment, patients will be HCV RNA negative but will remain anti-HCV antibody-positive in the vast majority of cases. Subsidised treatment is available to people older than 18 years who are anti-HCV antibody-positive, have detectable serum HCV RNA levels, have compensated liver disease, and have not had prior treatment with pegylated interferon or interferon alfa.

Margaret E Hellard FRACP, PhD, FAFPHM · Yung-Hsuan J Wang MB BS, FRACGP, MAppEpid

To the Editor: We commend the Indigenous Health issue of the Journal (18 May 2009). Its editorial emphasis — that partnerships with and continued leadership by Aboriginal and Torres Strait Islander peoples will be key to closing the gap between Indigenous and non-Indigenous Australians1 — is supported by preliminary, unpublished findings from our research into improving mainstream general practice care of Indigenous patients. Couzos and Thiele emphasised that closing the gap in health and life expectancy between Indigenous and non-Indigenous Australians depends on Aboriginal community controlled health services (ACCHSs).2 By virtue of their governance structure and focus, these services deliver culturally safe and appropriate primary health care to Indigenous Australians, while addressing issues of Indigenous autonomy and other social determinants of health.2 However, although not all general practices see Indigenous patients, 0.9% of general practice encounters (range, 0.7%–1.6%) are with Indigenous patients, equating to about one million consultations a year. Indigenous Australians present to general practitioners with essentially the same range of clinical conditions as do non-Indigenous Australians, although consultation rates for diabetes and circulatory conditions are higher for Indigenous patients.3 Most Indigenous Australians (76%) live in urban and regional areas, and are widely spread through the general population. They are likely to need mainstream services including general practice and primary care services, at least some of the time and for the foreseeable future. There is clearly a need for initiatives beyond support for ACCHSs, Indigenous workers and communities, to improve mainstream services for Indigenous Australians in a culturally sensitive and appropriate manner.4 Better sociocultural education for health care providers, trainees and students is required to close the gap that exists in mainstream understanding and acceptance of Indigenous cultures and aspirations. The Inala Indigenous Health Service in Brisbane is an example of a mainstream practice successfully developing into an accessible service.5 Our research aims to improve mainstream general practice care for Indigenous Australians with diabetes who live in urban areas of Victoria. As the following statement made by Indigenous participants in focus groups for our research indicated, health services must be patient-centred: We need to hold the health system — and that includes GPs — accountable for delivering help to Aboriginal people. The best one to do that is the consumer. Focus group participants also highlighted the importance of working together: I think we need to take some responsibility ourselves as (Indigenous) workers in organisations and go to these mainstream services. Whether it’s diabetes or drugs and alcohol, we need to say look, you get funded to look after everybody, and we want to come here and tell you how to look after our people when they come to your centres.

Siaw-Teng Liaw

In reply: It is unclear how many mainstream general practice consultations involve Aboriginal and Torres Strait Islander patients. Of 485 300 patient encounters attributed to general practices in the BEACH study (2003–2008), 7292 were with Indigenous patients, but 2906 of these encounters took place in Aboriginal community controlled health services (ACCHSs) rather than in general practices.1 If funding to close the gap in Aboriginal disadvantage is being channelled to general practice and the Divisions of General Practice (through recent measures of the Council of Australian Governments), then the Indigenous health outcomes of mainstream services must be carefully attributed.2 The ACCHS sector agrees there is a need to make general practices culturally secure for Indigenous Australians. For example, the Aboriginal Health Council of Western Australia has developed modules for cultural safety training, which are accredited by the Royal Australian College of General Practitioners for GPs’ professional development.3 The National Health and Hospitals Reform Commission report recommends that health services be required, by accreditation processes, to meet specific standards of cultural safety for Indigenous patients to ensure high-quality care.4 Within a quality assurance framework, systematic reforms such as these can potentially improve mainstream services, while supporting Indigenous workers who face unrealistic pressures to improve their local services. As Liaw points out, these initiatives are in addition to the vital role of ACCHSs in closing the health disparity gap.

Sophie Couzos · Dea D Thiele

Incorrect author affiliation: In the article “General Practice Super Clinics — how will they meet their educational objectives?” in the 5 October 2009 issue of the Journal (Med J Aust 2009; 191: 393-395), an incorrect author affiliation was printed. The correct author affiliations are included here.

Alistair W Vickery MB BS, FRACGP · Jennifer Dodd PhD, BASocSci(Hons) · Jon D Emery MB BCh, FRACGP, DPhil