General medicine

To the Editor: A 60-year-old Hispanic woman, who had lived in the United States for 10 years, presented with a 1-day history of altered mental status. Physical examination revealed ascites and enlarged right axillary lymph nodes. Magnetic resonance imaging (MRI) of the brain showed multiple intracranial lesions (Box, A). Computed tomography of the chest and abdomen showed massive adenopathy in the right axilla, multiple nodules in upper lung fields, ascites and retroperitoneal adenopathy. Her cancer antigen (CA) 125 level was 1469 U/mL (reference range, 0–35 U/mL); CA27.29 and CA19-9 levels were within the upper limit of the normal ranges. She was initially thought to have metastatic cancer of unknown primary site. However, a right axillary node biopsy revealed necrotising granulomas and no malignancy; an acid-fast bacteria (AFB) stain was negative. Ultrasound-guided retroperitoneal lymph node biopsy showed necrotising granulomas and no malignancy; an AFB stain was positive. We began investigations for disseminated tuberculosis (TB). A QuantiFERON-TB Gold test (Cellestis, Valencia, Calif, USA) and sputum and right axillary node cultures were positive for Mycobacterium tuberculosis; peritoneal and cerebrospinal fluid cultures were negative. Polymerase chain reaction (PCR) of samples of peritoneal fluid and from bronchoalveolar lavage was negative for M. tuberculosis DNA, but a sample from the retroperitoneal lymph node tested positive. The patient was started on four-drug therapy for TB and her condition progressively improved. Follow-up MRI of the brain 5 months later showed a decreased size of all intracranial lesions (Box, B), and her CA125 level was 84 U/mL. Peritoneal TB can mimic advanced ovarian cancer because of similarities in clinical signs and symptoms, such as ascites, abdominal pain and elevated CA125 levels.1 The association of peritoneal TB with high CA125 levels was first described in 1987.2 The positive predictive value of CA125 levels to detect malignancy is estimated at 60%, rising to 98% in postmenopausal women.3-4 In most reported cases of peritoneal TB, CA125 levels were below 500 U/mL; rarely, levels up to 1200 U/mL have been seen.1-4 Culture is of limited clinical usefulness, as results take up to 6 weeks. Although microscopy is rapid, cheap and highly specific, its sensitivity has been shown to be as low as 31% for extrapulmonary TB.5 PCR is of limited value in diagnosing peritoneal TB. Detecting M. tuberculosis DNA by PCR in ascitic fluid poses many challenges — differences in technique, contamination with other bacteria, and the variable number of acid-fast bacilli in samples have been shown to influence its reliability.4-5 Negative results from microscopy, culture and PCR should not distract from a diagnosis of TB. In the face of a growing international incidence of TB, it is important to consider this transmissible and treatable disease in the context of abdominal symptomatology, ascites and raised serum CA125 levels — especially in ethnic groups in which TB prevalence is high. Misdiagnosis or delayed diagnosis can lead to infertility, premature menopause and death. Magnetic resonance (MR) imaging of the brain before and after treatment A: B rain MR image showing multiple intracranial lesions involving the left cerebellum, left occipital lobe, left parietal lobe and corpus callosum. B: MR image of the brain 5 months post-treatment, showing a decrease in the size of all intracranial lesions.

Riad O El Fakih · Bassem M Chehab · Rami A Mortada · Maha Assi

To the Editor: The article by Statham and colleagues raises important issues about the accuracy of diagnosis by primary eye care providers, with all professionals in the study recording a diagnostic accuracy rate of less than 50%.1 From the general practice perspective, the authors raise a number of important contributors — lack of equipment, ophthalmological expertise and time. Additional factors, such as undergraduate and postgraduate exposure, and targeted training in the diagnosis of sight-threatening acute eye conditions, are also crucial considerations. From a postgraduate point of view, the Royal Australian College of General Practitioners offers a comprehensive continuing professional development program to support broad-based GP training, including in eye disease.2 The Master of Medicine (GP) offered by the University of Queensland also includes a dedicated subject on primary eye care, with particular emphasis on sight-threatening presentations.3 The Division of General Practice in which one of the sites in the report by Statham and colleagues1 sits is currently working with that hospital’s Department of Ophthalmology to institute an education/continuing professional development reform program to better target hospital eye referrals from primary care (Shelley Kleinhans, Health Systems Improvement Program Manager, GPpartners [Brisbane North] Division of General Practice, personal communication). It is very important to describe accurately the dimension of missed diagnosis within primary care — the ensuing challenge is to address it by harnessing the significant momentum within the primary care community for quality improvement.

Claire L Jackson

To the Editor: The recent article by Penington, highlighting the apparent neglect by Australian hospitals of actively participating in research over the past two decades,1 is both timely and concerning. During this time, many of our hospitals have seen themselves increasingly as clinical service providers, with teaching and research perceived as additional costs rather than contributions to their status, to the quality of patient care and to clinical and scientific discovery. My point is not simply to add weight to Penington’s eloquent historical, contemporary and strategic analysis of the nexus between hospitals and universities, but to explore areas that he touched on that need more detailed examination. I refer to the potential link between hospitals and community-based primary care. As Penington points out, “health care is increasingly provided outside hospitals”, yet this vital link between hospitals and primary care is often defunct, particularly when it comes to general practice. When Penington refers to hospitals working with “general practice networks” to meet the demands of an ageing population and chronic disease, we need to ask: which hospitals and which networks? In Melbourne, we have health networks that include groups of hospitals with extended primary care and community facilities and responsibilities. Driven by casemix funding, the hospitals or health networks have a vested interest in primary care to ensure short patient stays. However, not all states are the same and not all hospitals have similar links with the community. The other issue of concern is that general practice networks are often politicised and factionalised. Divisions of General Practice do not speak with a single voice, and their state-based organisations and national body do not always represent the views of regional Divisions. Added to the mix of 120 Divisions, we have 22 regional general practice training providers, the colleges (Royal Australian College of General Practitioners, Australian College of Rural and Remote Medicine), the Rural Doctors Association, the Australian Association for Academic General Practice, the Australian Medical Association, etc. Integration of the research, teaching and training activities of general practice or primary health care with hospital networks can only be achieved at a regional level. We need to think globally, but act regionally. This calls for the formation of new regional consortia including universities, health networks (hospitals), Divisions and regional training providers (responsible for general practice registrar training) to work together on national clinical and health service research agendas in large and well defined geographic regions. If the National Health and Hospitals Reform Commission is to take its role seriously, it will need to move beyond the confines of traditional hospital settings and explore opportunities in the community.

Leon Piterman

To the Editor: Penington identifies the appointment of a National Health and Hospitals Reform Commission (NHHRC) and the suspension of 5-year Australian Health Care Agreements as a “once in a generation” opportunity to rediscover university teaching hospitals for Australia.1 He identifies changes to health funding in Australia since 1975, the growth of “cost shifting” between federal and state governments, and reduced funding for university functions in hospitals as important contributors to the decline of university teaching hospitals in Australia.1 We agree with this analysis, but propose that the privatisation of many outpatient clinics as a result of cost shifting has had a disastrous effect on the clinical training of medical students, residents and registrars. Moreover, the reduced funding of university functions in hospitals has been replaced in “teaching” and community hospitals by industry funding, and the perception that industry has “bought” patients for their “research” agenda by providing data management services through per capita payments and gifts or perks for clinicians. The infrastructure sustaining clinical research should not be so reliant on industry. Funding from the federal government (in partnership with state governments) is needed to nurture independent research in university teaching hospitals. Penington highlights the fact that the key element of the university teaching hospital model was leadership of all units by academic clinicians with questioning minds. Since 1975, we believe leadership of units in “teaching” hospitals has changed such that very few are now led by academic clinicians. We recently experienced a lack of interest by medical specialists in supporting clinical research that had been approved and funded by the National Health and Medical Research Council (NHMRC). The project will evaluate doctor–patient communication about treatment options in oncology, including clinical trials. Participating doctors were required to post letters of invitation to patients and audio-record one consultation per patient recruited (20 per doctor). Specialists in all major teaching hospitals in New South Wales and Victoria were contacted; 17 of 41 specialists contacted in NSW (41%) and 15 of 52 contacted in Victoria (29%) have agreed to participate. The most common reasons doctors gave for not participating was that they were too busy or that there was no reward for participation. It is notable that no specialist from two major teaching hospitals — one in Sydney (3 contacted) and one in Melbourne (6 contacted) — agreed to participate. A concerning theme is that the motivation to participate in trials is driven by financial incentives rather than the importance of the question being addressed or interest in supporting novel investigator-initiated clinical research. A starting point for improving the quantum and calibre of “independent” clinical research in university teaching hospitals would be to support clinical research infrastructure by providing per capita payments for recruited patients — a model used by industry. Rebuilding independent research capacity in university hospitals will improve the standard of research in this country, and foster clinical research training. We believe reviving the university teaching hospital model in Australia is an important task for the NHHRC.

Rachel F Dear · Martin H N Tattersall

To the Editor: The randomised controlled trial recently reported by Blashki and colleagues does not support their hypothesis.1 The drop-out rates in both arms of the trial were very high — only 62% of general practitioners in the intervention group and 54% in the control group completed the trial. One cannot have any confidence in their conclusion that a short training course can improve GP skills in the provision of cognitive behavioural strategies (CBS). For example, what if the 38% of GPs in the intervention group who dropped out actually deteriorated in their CBS skills and therefore declined to be videotaped? Furthermore, only 56 of 1021 GPs in Victoria were willing to enrol in the trial. The authors concluded that their findings could only be applied to GPs who have a special interest in mental health. Perhaps the low participation rate indicates another more relevant idea — that GPs have had enough of “training models” being imposed on their lives. A recent systematic review has confirmed the low impact that educational training programs have on GPs for the management of mental health problems.2

Marjan Kljakovic

In reply: Our words in conclusion to our article were carefully chosen as: “Competency in CBS [cognitive behavioural strategies] in highly motivated GPs [general practitioners] can be improved by a brief training intervention”1 (italics added) — not that all such interventions will lead to improvements for all GPs, but that well designed and conducted training for selected GPs can do so. Research so far leaves open the possibility of large enough effect sizes for GP mental health training to be relevant to policy.2 The review cited by Kljakovic was limited in scope and noted the poor quality of studies included.3 A drop-out bias in our study, as proposed, seems most unlikely to us. Rather than being imposed, this training model was developed with GPs, by GPs and for GPs, and so might achieve better results than previous interventions studied. Funding for GP participation such as that more commonly available in drug studies might have increased participation. It is true that a great deal of training has been offered to GPs, and we hold that our study shows that such training can lead to GPs significantly improving their skills in this area. GP training should be considered within multifaceted interventions to improve primary mental health care.4

Grant A Blashki · Leon Piterman · Graham N Meadows · David M Clarke · Vasuki Prabaharan · Jane M Gunn · Fiona K Judd

To the Editor: The incidence of type 1 diabetes mellitus (T1DM) is increasing in Australia.1,2 There is also general consensus that the incidence of diabetic ketoacidosis (DKA) is increasing in children, as noted in an Australian study.3 We conducted a retrospective audit of the referral pattern of patients with newly diagnosed T1DM presenting to the Children’s Hospital at Westmead, a tertiary referral centre serving the population of western Sydney. Referral data were available for 191 of 204 patients with newly diagnosed T1DM admitted to the hospital between January 2003 and December 2004. Most patients (150; 79%) had presented to their general practitioner before admission to hospital, and the remainder had initially presented to an emergency department. In the former group, the diagnosis of diabetes was indicated in referral letters or admission notes for 128 patients (85%), while a diagnosis other than diabetes (eg, gastroenteritis, urinary tract infection, sepsis) was made for 22 patients (15%). DKA was less common among patients whose referral letter indicated a diagnosis of diabetes compared with those with an alternative or no diagnosis or without a referral letter (27% v 47%; P < 0.001). Most patients (105; 70%) were referred to an emergency department within 24 hours of presentation to the GP, and their rate of DKA was lower than in those referred after 24 hours (31% v 51%; P = 0.03). These data suggest that better understanding by primary carers of the symptoms of new-onset T1DM and earlier referral are significantly associated with reduced risk of DKA. Most patients who first saw a GP (125; 83%) had initial investigations arranged; bedside urinalysis and/or measurement of fingerprick blood glucose levels were performed in 66%, while 31% were sent for formal blood tests. Patients who had bedside investigations performed had a significantly lower rate of DKA than those who had only formal blood tests or no investigations performed (26% v 52%; P = 0.002). It is noteworthy that, among patients who first saw a GP, 23 (15%) were diagnosed with diabetes but were not referred to an emergency department within 24 hours. The reasons for this are unclear but may be due to the GP waiting for confirmatory blood test results. The Australasian Paediatric Endocrine Group and International Society for Pediatric and Adolescent Diabetes guidelines recommend immediate referral for suspected new-onset T1DM, as DKA is fatal if left untreated.4 A public awareness campaign conducted in Italy in the 1990s was successful in reducing the incidence of DKA in children with newly diagnosed T1DM.5 Australian communities might benefit from a similar campaign to encourage prompt identification of symptoms of diabetes in childhood, prompt bedside investigations, and immediate referral to hospital for definitive care.

Maria E Craig · Catherine H Wong · Joanna Alexander · Ann M Maguire · Martin Silink

To the Editor: Wilhelm and colleagues falsely concluded in their recent study that general practitioners in metropolitan Sydney and rural New South Wales had a low rate of recognition of psychological problems overall.1 Furthermore, Wilhelm et al took GPs’ judgements of the presence of psychological problems as the benchmark for “caseness” because of the difference between GP practice and psychiatric practice in the process of assessing psychological problems in consultation. My disagreement lies with what the researchers meant by “overall” and by “caseness”. The rate of recognition of caseness of psychological problems by GPs will vary according to the nature of the cases under consideration. In their study, Wilhelm et al found that they had complete data on 76% of their patients. Our work in New Zealand found that a major variable that influenced diagnostic behaviour within consultations was the frequency with which patients had previously consulted their GP.2 The more frequently the patient had been seen in the previous year, the more likely the GP was to diagnose a mental disorder. A second variable found in our research was the presence or absence of disability in the patient.3 GPs were less sensitive to the presence of mental disorders if there was little concomitant disability, and in sub-threshold cases, the presence of disability increased the chance of GPs identifying clinically significant symptoms. In general practice, the “new patient” is a different kind of case than the frequent attendee. Similarly, a patient diagnosed with depression who is seriously disabled is a different kind of case to the more common kind found in general practice — namely, a patient diagnosed with depression but with little or no disability. It would not be surprising if Wilhelm et al were to find that among the 20% of patients overall in whom GPs identified psychological problems, many were “typical cases” seen by GPs — namely, frequent attendees and those with disability.

Marjan Kljakovic

In reply: I must apologise for the inclusion of a comma in the first sentence of the conclusion in our article’s abstract, which changes the sense of the sentence.1 That was my oversight. It should read “Low rates of recognition of psychological problems by GPs [general practitioners] and infrequent treatment for those presenting with somatic symptoms ...”, meaning that there are low rates of recognition and treatment in patients with somatic symptoms rather than in patients overall. We were reflecting the need for more recognition of how to deal with depression and anxiety in the presence of somatisation. We think the 12-item Somatic and Psychological HEalth REport (SPHERE-12) is a useful instrument, but that it has an intentionally low “caseness” threshold and needs to have some other tool to increase clinical relevance. Kljakovic also comments on our use of GP judgement as a benchmark for caseness. The thrust of our article was to see how GPs make judgements and which of three different types of screening tool may assist them. This is not to say that GP judgement is an overall “gold standard” for caseness in an epidemiological sense. It is certainly true that new patients are very different from those who are frequent attendees and/or well known to the GP. The screening tools are probably more useful in the first instance or when there is a change in the patient’s mood. However, we wished to test these measures across the range of people seen by each GP, and the individual GPs were given the results from their own practices. The feedback from GPs was that these tools did prove helpful in drawing their attention to people they already knew about and also in identifying some that they did not. Such screens can also save time by ensuring that certain questions are routinely asked and responses are tracked, so the GP can see the results, reflect on them, and go on to ask other questions that build on this information, helping to make better use of the “face to face” time rather than having to run through them in the interview.

Kay A Wilhelm

Aboriginal primary health care. An evidence-based approach. 3rd ed. Sophia Couzos, Richard Murray. Melbourne: Oxford University Press, 2007 (i + 862 pp). ISBN 978 0 19 555138 9. Let me tell you a secret. I admired this book for a long time before I actually read it. Like Dickens and Dostoyevsky, it’s a great achievement, and I knew I should read it, but the sheer size put me off. Fortunately, it’s worthy of the trust I had invested in it. The authors, all experts in their fields, have done an incredible job of collating the evidence behind their recommendations. Just as important is the backing of the National Aboriginal Community Controlled Health Organisation (NACCHO). To close the gap in health outcomes, Aboriginal communities must be able to make decisions for themselves. NACCHO’s involvement means these guidelines don’t start off as outside impositions. It’s a dry read at times. The most memorable parts are quotations from other authors. The chapters start with quotes from Puggy Hunter — if you read only these, you will understand more of Aboriginal health than when you started. The opening chapters are essential reading for linking together history, policy and health (or if you want to argue with someone who believes Aboriginal health is overfunded). The heart of the book devotes chapters to important clinical topics. Each chapter sets out the goals to be achieved, goes through interventions on individual, service and community levels, and supplies performance indicators as measures of how well you are doing. Most practices would find useful ideas here, whatever their population. This book should be used alongside good-quality clinical guidelines for more practical detail for individual patients. The references will direct you to the appropriate places, although a bibliography would have been more helpful. In some instances the evidence has moved on since publication, but in many remote clinics a book is still the best way to access information. This one is more than good enough to work from.

Timothy P M Senior

Objective: To explore use of bone densitometry in Australia and to identify any sex and geographic differences, as a marker of osteoporosis diagnosis and care.Design and setting: Analysis of claims data from Medicare Australia in patients aged over 45 years during the period 2001–2005.Main outcome measures: Age-standardised rates of bone densitometry use, by sex and by metropolitan, rural or remote classification.Results: Bone densitometry use increased by 26% over the 5 years. Rates were lower for rural and remote populations, with people in capital cities about three times as likely to undergo the investigation as those in remote areas. The sex ratio for the rate of bone densitometry use (women to men) decreased from more than 6 : 1 in 2001 to 4 : 1 in 2005.Conclusion: Although the sex ratio for osteoporotic fracture is close to 2 : 1 (women to men), the sex ratio for testing is much higher, suggesting underuse of bone densitometry in men. Sex and rural inequities in use of the investigation need to be addressed as part of a national approach to reducing minimal trauma fracture.

Dan P Ewald FRACGP, MAppEpid, FAFPHM · John A Eisman FRACP, PhD, AO · Ben D Ewald BMed, MClinEpid, PhD · Tania M Winzenberg FRACGP, MMedSci(ClinEpid), PhD · Markus J Seibel MD, PhD, FRACP · Peter R Ebeling MB BS, MD, FRACP · Leon A Flicker MB BS, FRACP, PhD · Peter T Nash MB BS(Hons), FRACP

Mastering bipolar disorder. An insider’s guide to managing mood swings and finding balance. Kerrie Eyers, Gordon Parker, editors. Sydney: Allen & Unwin, 2008 (xiv + 272 pp). ISBN 978 1 74175 546 6. Bipolar disorder has seen an expansion of clinical, media and research interest, driven largely by the availability of new treatments. Although there are many quality books on bipolar disorder aimed at consumers, they generally share a theoretical derivation (psychoeducation, cognitive therapy, family therapy), tailored to a general readership. Almost all are written by health professionals. Mastering bipolar disorder differs from the herd because it is an edited collection of extracts from essays submitted to the Black Dog Institute essay competition, tasked with describing “The getting of wisdom — managing the ‘highs’ of bipolar disorder”. This collection of anecdotes, experiences and hints from people who have learned from their experiences, successes and difficulties provides a unique perspective. It has the credibility of being the learned experience of survivors, and is a useful counterpoint to evidence and theoretically based books. It is highly readable, creatively using metaphor and image. Its focus on mania captures a range of issues, including dealing with mania, acceptance of illness, medication, detecting and managing early warning signs, and the impact on the family, but does not attempt to cover all areas, lacking sections on key issues such as depression. As a collage of edits, Mastering bipolar disorder does not aim to be comprehensive or definitive, and is likely to be used in conjunction with more systematic books.

Michael Berk

Objective: To explore the experiences of patients with acne, psoriasis or atopic eczema in their relationships with their treating doctors.Design: Qualitative study, using semi-structured interviews conducted between January 2004 and April 2005, thematic analysis and modified grounded theory methodology.Setting and participants: Participants were patients with acne, psoriasis or atopic eczema recruited from urban general practices and urban dermatology practices.Results: 62 semi-structured interviews were conducted. Reports of negative experiences with doctors treating participants’ skin conditions were common. Both general practitioners and dermatologists were reported as having poor comprehension of the psychological implications of skin diseases, being insensitive to their patients’ emotional suffering, and trivialising participants’ disease. Participants acknowledged that time considerations and other pressures may explain these apparent deficiencies. Some participants perceived their doctors as medical technicians and sought treatment for their physical skin disease, not for its emotional or social aspects.Conclusion: We recommend education for GPs about the psychological effects of skin diseases, and education for dermatologists and GPs on how to elicit and manage, or appropriately refer, these problems.

Parker J Magin PhD, DPD, FRACGP · Jon Adams MA, PhD · Gaynor S Heading BA, GradDipHSS(MSS), PhD · C Dimity Pond MB BS, PhD, FRACGP

To the Editor: I read with interest the article by Hardie and Critchley, in which the authors attempted to measure attitudes towards both Australia’s current health care system, and shifts to greater public or private funding of health care.1 The article’s finding that pro-public funding attitudes were greatly favoured over pro-private funding attitudes may in fact be more of a reflection of the leading nature of the authors’ pro-private statements than of the true attitudes of the 800 study participants. Most Australians, regardless of their views on public versus private funding of health care, would be unlikely to support the statements “Australia should adopt a private, user-pays system like they have in the [United States]” and “The very best health care should be available only to those who can afford it”.1 The results are certainly not consistent with the findings from the 2007 Ipsos Health Care and Insurance study2 — a survey with more than 5300 participants and a solid 20-year history, which is supported by governments (Commonwealth and state/territory), private providers and industry associations. This study found that just over half of respondents (52%) supported full government funding of Australia’s health care system, while 42% opposed such a funding approach. In fact, more than 20% of respondents “disagreed a lot” with the proposal that “All hospital and medical costs should be met out of government revenue — the taxes we all pay — people should not have to pay anything directly”.2 The Ipsos results suggest there is still significant diversity of views on how Australia’s health care system should be funded and, importantly, these results do not support the conclusion of Hardie and Critchley that Australians “overwhelmingly favour a more socially responsive public health system, funded by the public purse”.

Michael H Armitage

In reply: We are intrigued by the discrepancy between our findings1 and the 2007 Ipsos study results2 noted by Armitage. We took a psychometrically rigorous approach to measuring the public’s preference for health care systems. If our pro-private statements seem “leading”, then the pro-public statements (“Australia should adopt a collective social health system supported by higher taxes as is done in some Scandinavian countries”, “I would be willing to pay higher taxes to improve Australia’s health care services”) could be similarly construed. Armitage reports that 52% of the Ipsos sample supported (and 42% opposed) full public funding of health care. If we apply this support–oppose dichotomy (ie, per cent above and below the scale mid-point) to our own data, a striking 70% of our sample support (and 30% oppose) greater public funding, while just 7% support (and 93% oppose) more private funding. This is consistent with other Australian studies showing a preference for health and medical research being conducted in public, as opposed to private, settings.3-5 We cannot directly compare our methods and results with the Ipsos survey because, ironically, when we tried to access this research supported by “governments ... private providers and industry associations”, we were advised by Ipsos that the report is not publicly available.

Elizabeth A Hardie · Christine R Critchley

Objective: To determine the core qualities that men value when communicating with general practitioners in primary care settings.Design, setting and participants: In a qualitative study using semi-structured interviews in non-clinical environments, 36 white Australian men drawn from the Florey Adelaide Male Ageing Study, stratified by age and marital status, discussed their help-seeking behaviour and health service use. Participants were from the North West Adelaide region. Interviews were conducted between January and November 2005.Results: The core qualities men value when communicating with GPs in primary care settings include the adoption of a “frank approach”, demonstrable competence, thoughtful use of humour, empathy, and prompt resolution of health issues.Conclusions: The core qualities men value when communicating with GPs are concordant with most key dimensions of a patient-centred approach, but not necessarily all. Adopting these qualities has the potential to enhance communication with and care of men in primary care settings.

James A Smith BAppSc(HumMovt)(Hons), BEd · Annette J Braunack-Mayer PhD · Gary A Wittert MB BCh, MD, FRACP · Megan J Warin PhD

To the Editor: Attending, as a “junior” outpatient rather than a Senior Physician, the hospital where I once worked has been a quantum change that has been both fascinating and instructive. There is a strict hierarchy among us out-patients. Having only my second intraocular injection makes me junior to the stout, slightly dyspnoeic man opposite, who is having his sixth. His status is increased by his wife’s attendance at the Cardiology Clinic. The elderly married couple nearby gain much prestige by having to leave their farm at 6:00 am and drive more than 150 km to the hospital. The rising cost of petrol is a worry, but while here they will take the opportunity to visit their married daughter who lives in the city near the hospital. Pride of place goes to the man who proved the doctors wrong — “They said I’d die two years ago and look at me now!” The staff do not escape scrutiny. Dr A is good but doesn’t talk much. Dr B is a lovely lady and her new hairdo is a big improvement, although the green dress is not quite right for her. Dr C is elderly and worried about his wife’s illness. Dr D is extremely good but is always running late. It’s best to get him, even if you have to wait. The appointment clerk on the left is more willing than the other clerk to give you the time and date you prefer for your next appointment. It is a new insight into the social dynamics of the hospital, even if it comes some years after I have retired from active duty. But clearly, all hospital administrators would gain much by spending six months as an anonymous outpatient.

Richard A Joske

During the Middle Ages, uroscopy was an important tool for evaluating health, and medical practitioners often carried Johannes de Ketham’s urine wheel as a diagnostic aid. In honour of de Ketham, a modern urine wheel is presented, which may be a useful diagnostic tool for present-day physicians. Hippocrates, Aristotle and the ancient Egyptians inferred diagnoses from urine evaluation, but it was not until the Middle Ages that uroscopy reached diagnostic dominance. A major reason for its rise to prominence was the publication of Johannes de Ketham’s Fasciculus medicinae in 1491.1 This was the first illustrated medical book printed and is also among the most beautiful of such texts. The importance it places on urine evaluation is evident on page 1b, which depicts a urine wheel: a large circle surrounded by 21 thin-necked, urine-filled flasks (matulae) (Box 1). This wheel shows how the colour and consistency of urine could be matched to a diagnosis. Disease was thought to result from the imbalance of humours, reflected by urine colour. In the corners of the urine wheel, four small circles contain descriptions of the four temperaments: sanguineous, choleric, phlegmatic and melancholic. In an era nearly four centuries earlier than Laënnec’s stethoscope, three centuries before the first investigations into blood pressure and two centuries earlier than Hooke’s microscope, uroscopy became the most important tool in evaluating internal health of the human body — more highly valued than the pulse. Its use is depicted by a woodcut from the first Italian edition of de Ketham’s Fasciculus medicinae, showing a professor teaching diagnosis by uroscopy as different matulae are presented to him (Box 2). Although modern technology allows greater insight into the hidden clues of bodily functions, visual observation of urine is still useful. A contemporary urine wheel with diagnoses that might be associated with visually abnormal urine is presented in Box 3. 1 Urine wheel from the first edition of Fasciculus medicinae* * An English translation of de Ketham’s urine wheel is available at www.mhm.ku.dk/upload/urinposter.pdf.2 2 Professor teaching diagnosis by uroscopy 3 A modern-day urine wheel that contrasts de Ketham’s diagnoses (italics) with modern interpretations of urine appearance

Charles J Diskin MD

Round the red lamp. Arthur Conan Doyle. Robert J L Darby, editor. Chicago: Valancourt Books, 2007 (xxiv + 320 pp). ISBN 0 9792332 7 5. Certainly not in the 1890s, or at least, not with any sense of realism. Better known for his Sherlock Holmes series, Conan Doyle shocked Victorian England with his collection of short stories about medical matters, with its graphic descriptions of diseases and medical disasters, and a somewhat jaundiced view of his own medical profession. This was a view that did not sit well with the romanticised image of doctors at the time. From a modern physician’s perspective, this collection offers some intriguing insights: a wide range of physician and surgeon capabilities and personalities remain unchanged. Further, our view of our colleagues of 110 years ago may well be close to Conan Doyle’s. I found fascinating their knowledge, or lack thereof, of aetiology, diagnosis and management of diseases. Medicine practised day to day was notable, such as the preponderance of home visit-based practice, surgery as a spectator sport, and the lack of regulation or accountability (yes, quackery was even more widespread then than it is now!). The stories themselves vary quite a deal in subject, length and quality. The better of them draw complex characters (both doctors and patients), discuss difficult social and medical issues, and do not pull punches. Others are overly sentimental and simplistic, venturing back to the more traditional territory of medical fiction of that century. This patchiness would draw me to conclude this collection is more fascinating as a piece of medical history than as a work of great fiction. Yet there are some very entertaining stories that will resonate long after they are read, and may well cause a medical reader to reflect on what is the true role of the doctor. Who knows, I might start doing more home visits!

James A Best

Although there is evidence for the effectiveness of self-management support, there has been limited engagement of Australian general practice staff with self-management support provided by other services. Efforts to integrate self-management support into general practice have also been challenging, largely because of capacity constraints and the difficulties of incorporating it into existing work practices. A broader systemic approach is needed, including a collaborative approach between providers, a range of self-management support options, training of general practice staff, and changes to the organisation of services and the way in which they relate to each other. The expanding role of practice nurses, new models of integrated primary health care and changes to the role of the Divisions of General Practice present an opportunity for this to be incorporated “from the ground up”.

Mark F Harris FRACGP, MD · Anna M Williams BHlthSc, MPH · Sarah M Dennis MSc, PhD · Nicholas A Zwar MB BS, PhD · Gawaine Powell Davies BA(Hons), MHA

Objective: To measure the prevalence of somatisation (multiple somatic symptoms and hypochondriasis) among Australian general practice attendees, its recognition by general practitioners, and its relationship with symptoms of depression and anxiety.Design, setting and participants: Self-reported questionnaires completed by 10 507 consecutive patients aged ≥18 years attending 340 GPs enrolled in a 6-hour national mental health program of continuing professional development who accepted invitations to participate; audit form completed by GPs for each patient during the period March 2004 to December 2006.Main outcome measures: Somatic symptom severity (measured with the 15-item Patient Health Questionnaire [PHQ-15]); hypochondriasis (measured with the Whiteley Index [Whiteley-7]; depression and anxiety (measured by the Kessler Psychological Distress scale [K10]); prevalence of “somatisers” (defined by medium to severe somatic symptom severity and hypochondriasis); GP recognition of somatisation (determined by their responses on audit forms to questions on whether patient’s complaints were most likely to have a physical or psychological explanation).Results: 18.5% of patients were classified as somatisers and 9.5% as probable cases of depression or anxiety. While 29.6% of somatisers had high anxiety or depression scores, 57.9% of people with anxiety or depression were also somatisers. Sex and age asserted significant but weak effects on psychometric scores. GPs identified somatic complaints as “mostly explained by a psychological disturbance” in 25.1% of somatisers.Conclusions: Somatisation is common in general practice, and more prevalent than depression or anxiety. While a minority of somatisers have significant anxiety and depression, most patients with depression and anxiety have a significant degree of somatisation. Recognition of depression and anxiety can be hindered by a somatic presentation and attribution. On the other hand, managing somatisation does not just involve recognising depression and anxiety, but also dealing with the health anxieties that underpin hypochondriasis.

David M Clarke PhD, FRACGP, FRANZCP · Leon Piterman MMed, FRACGP, FRCP · Claire J Byrne BSc(Behav)(Hons) · David W Austin PhD

Incorrect drug dose: In the Clinical Update “Avoiding common problems associated with intravenous fluid therapy”, in the 3 November 2008 issue of the Journal (Med J Aust 2008; 189: 509-513), an incorrect drug dose was printed. On page 512, at the base of the first column, the intravenous dose of desmopressin to control urinary free water loss in central diabetes insipidus was given as 2–4g. It should have been 2–4µg. Both the HTML and PDF versions of the article have been corrected.

Andrew K Hilton · Vincent A Pellegrino · Carlos D Scheinkestel

To the Editor: I have read every issue of the Journal since graduating in 1953. In my opinion, one of the best articles I’ve seen is Dawn DeWitt’s story, “I went to work with a ‘cold’ ...”.1 Dr DeWitt’s dilemma mirrors that of the average doctor precisely. Her “solution” gives us a good dose of commonsense that we seldom hear. In my time as a general practitioner, I have given thousands of doses of influenza vaccine; but I have never had the flu or pneumonia shot myself (nor has my wife — a registered nurse). I took 2 weeks off duty in 1971 with a “cold”, when I simply flaked out on the floor. A corneal transplant and transurethral resection of the prostate were done while “on vacation”. Luckily, I no longer have the dilemma of whether or not to go to work when I am sicker than my patients, but I will have the flu shot this week anyway. Thanks Dawn.

John F Knight AM

The draft Good Medical Practice code of professional conduct is now available for public comment and consultation Over the past few years, all medical boards in Australia have issued guidance to doctors about expected standards of medical practice. Most of these documents were adapted from Good Medical Practice, a code of conduct first issued by the General Medical Council of the United Kingdom in 1995.1 Given their shared origin, the various medical board guidelines have much in common, but they are not identical. On behalf of state and territory medical boards, the Australian Medical Council (AMC), through an expert working group, is developing good practice guidelines for the entire nation. This project is now well developed, and a draft Australian Good Medical Practice code2 is currently the subject of a consultation process with the medical profession and the community. The project deserves the attention of the medical profession. Indeed, the profession’s input is critical, principally to ensure that the proposed standards are realistic and consistent with current good practice. In addition, experience tells us that codes of practice are more likely to be followed when those affected have contributed to their development. A number of questions are likely to cross the minds of doctors. Why do we need a code of practice? Doesn’t the Australian Medical Association (AMA) issue a Code of Ethics?3 Who is drafting the new Code? Why is the community involved? Is this project related to the Council of Australian Governments (COAG) decision to introduce uniform national registration for all health professionals? Is the new Code to be enforceable, and by whom? The project began before the COAG decision, but the timing now makes it highly likely that the Australian Good Medical Practice code will be adopted as a starting point by the proposed national medical board. A national registration system will need national standards. These standards must reflect the considered views of both the medical profession and the community served by the profession. In effect, the national Code will amount to a declaration to the new national board from the profession and the community about the standards of medical practice expected in Australia. It is not intended to supplant the AMA Code of Ethics. Rather, it extends the principle-based AMA Code into an explicit statement to the community and the profession about standards of practice. The draft Code covers issues in detail, including providing good care, working with patients, working with other health professionals, minimising patient risk, ensuring the health of doctors, and doctors’ performance in teaching, supervising and conducting research (Box). The Code aims to define clear, nationally consistent standards of practice. To develop these, the AMC established an expert working group with strong clinical representation, and including the perspectives of junior doctors and medical students, medical regulators and educators, medical and health administrators, consumers and community groups, medical profession advocates, rural and Indigenous practitioners, and international medical graduates. This working group reviewed the codes of each of the state and territory medical boards, comparable initiatives in the UK, New Zealand, Canada and the United States, the professional standards documents of the specialist colleges, guidelines from the National Health and Medical Research Council (NHMRC) and the AMA Code of Ethics. How will the Australian Good Medical Practice code be used? Firstly, it will give all doctors and the broader community a clear understanding of what is expected of medical practitioners in Australia. Secondly, it is expected to be used in the assessment of complaints about doctors and allegations of unprofessional conduct. Currently, the legislation establishing state medical boards and defining their powers gives the existing codes slightly different status in different states, but in all cases the boards use their codes in assessing practitioners’ conduct. Practitioners who depart from the standards set out in these codes may need to justify their conduct. Serious or persistent failures to meet the standards may have consequences for a doctor’s registration. The legislation governing the new national medical board has not yet been written. However, as a number of boards currently have the power to regulate standards of medical practice and issue codes of practice to guide practitioners, it is likely that the national board will have these powers, and that the national Code will be applied in the same way. This Code is important for all practitioners, so please have your say. The Australian Government Department of Health and Ageing has funded a comprehensive national process, seeking involvement and feedback from the profession and the community across Australia through face-to-face meetings, an online survey and written submissions. The consultation process is open until 28 November. More information is available at <http://goodmedicalpractice.org.au>. Outline of the draft Australian Good Medical Practice code of professional conduct, August 2008 Providing good patient care is the core of good medical practice requires doctors to maintain high levels of competence and professional conduct includes assessment, planning of management and ensuring effective care involves shared decision making between patient and doctor Working with patients requires relationships based on openness, trust and good communication Working with other health care professionals requires respect for colleagues, teamwork and willingness to share information and resources Working within the health care system doctors have a responsibility to contribute to the effectiveness and efficiency of the health care system Minimising patient risk requires doctors to understand what to do if patient care is compromised and the importance of reporting and responding to adverse events Maintaining good standards of medical practice requires doctors to participate in relevant continuing professional development and credentialling, and to practise within their accepted scope of practice Professional behaviour doctors’ standard of behaviour must justify the respect and trust of the community Ensuring doctors’ health maintain own health and wellbeing and look after the health of colleagues Teaching, supervising and assessing important to the care of patients now and in the future Undertaking research vital in improving health of individuals and the population researchers carry particular responsibilities.

on behalf of the Australian Medical Council Code of Professional Conduct Working Group

Objective: To describe the steps taken by health professionals to diagnose dementia and the timeframes for these steps, as reported by carers.Design, setting and participants: A cross-sectional, anonymous survey was mailed or distributed by Alzheimer’s Australia New South Wales, six Sydney residential aged care facilities and 13 Sydney general practitioners to 415 carers or family members of patients with dementia between May and August 2007.Main outcome measures: First symptoms noticed and actions taken; time to first health professional consultation and diagnosis; reported actions of first health professional; satisfaction with first consultation; and use of dementia and chronic illness resources.Results: 209 surveys were returned. Family members noticed the first symptoms of dementia at a mean of 1.9 years before the first health professional consultation about dementia, and 3.1 years before a firm diagnosis. Resource use first occurred 2.8 years after the first symptoms. Most carers (72%) were satisfied with the first consultation, which was usually with a GP (84%). Two-thirds of carers (64%) reported that the first health professional had performed a memory test.Conclusions: Delays in presentation, diagnosis and resource use may have clinical and social implications for people with dementia and their families, in addition to the challenges of the process of obtaining a firm diagnosis.

Catherine M Speechly BMedSc, FRACGP · Charles Bridges-Webb MD, FRACGP · Erin Passmore BA(Hons)