General medicine

Many lower respiratory tract infections (LRTIs) are caused by organisms that do not require antibiotics or could be safely treated with narrow-spectrum antibiotics. Reducing the unnecessary use of antibiotics, particularly broad-spectrum agents, could reduce costs and side effects and delay the emergence of antibiotic-resistant organisms. Various point-of-care tests are becoming available to help clinicians identify the cause of LRTIs at the time of consultation. Point-of-care tests can be used to diagnose influenza, pneumococcal infections, Legionella and respiratory syncytial virus infections, thus allowing early decisions to be made on appropriate management.

Patrick G P Charles MB BS, FRACP · M Lindsay Grayson FRACP, MD, FAFPHM

To the Editor: Recent articles in the Journal referred to clinical characteristics of lesions caused by Mycobacterium ulcerans in Australia, and to recommendations and challenges in their management.1-3 Brazil may also be an endemic area of this devastating neglected but treatable disease. In developing countries, cases of Bairnsdale or Buruli ulcer (BU) can be misdiagnosed or underreported because neither the general public nor health care workers have sufficient knowledge about the disease, and because affected people usually have little contact with the health care system, or do not seek prompt treatment.4 Expensive tests like the polymerase chain reaction are not available to confirm all suspicious cases, and smears can give a low diagnostic yield; there are often minimal histopathological changes and absence of bacilli, particularly in patients with long-standing lesions previously treated with effective antimicrobial drugs.4 We report the case of a 65-year-old Brazilian woman with a 2-year history of BU in her extremities coexistent with osteomyelitis in the fourth cervical vertebra (Figure 1), and evidence of inadequate nutrition. Although she had received BCG vaccine as an infant, mycobacteria osteomyelitis developed in the site of an arthrodesis performed in 1998 to treat an accidental fracture.4,5 This patient had lived in a poor riverside rural area with a humid, hot climate. As in descriptions of Australian cases, our patient was much older than the age (5–15 years) at which most cases of M. ulcerans infection are reported in tropical and subtropical regions.1,2,4 Before her disease was characterised through positive cultures for M. ulcerans in samples from skin and bone lesions, the main differential diagnosis was ulcers resulting from fungal infection and leishmaniasis,4 conditions that are frequently seen in the region where she lived. The earlier skin lesions had appeared in May 2004 as papules and nodules, and evolved as painless, chronic, indolent ulcers with undermined edges.2,4 Despite treatment in another hospital that included surgery as well as medical therapy with rifamycin, aminoglycoside and quinolone antibiotics, the disease recurred. On admission to our hospital in August 2006, she had an extensive ulcer on her left arm in addition to scars on the right inner thigh (Figure 2). After nearly 2 months of hospitalisation, the patient was discharged to continue antimicrobial therapy with outpatient follow-up. Despite this, the lesions are healing very slowly. 1: X-ray image of osteomyelitis (arrows) affecting the body of the fourth cervical vertebra. 2: Extensive ulcer on the left arm (arrows; A) and brown pigmented scars on the inner right thigh (B).

Vitorino M dos Santos · Flávio L Noronha · Érica C Vicentina · Camila C Lima

Objective: To study the work satisfaction of general practice staff, the differences between types of staff, and the individual and organisational factors associated with work satisfaction.Design, setting and participants: Cross-sectional multipractice study based on a self-completed job satisfaction survey of 626 practice staff in 96 general practices in Australia between 16 December 2003 and 8 October 2004.Main outcome measures: Job satisfaction scores for all staff and for general practitioners alone; relationship between job satisfaction and the team climate, practice size, particular jobs within practices, demographic characteristics of participants, and geographical location of practices.Results: The response rate was 65%. Job satisfaction was high, with a mean score of 5.66 (95% CI, 5.60–5.72). Multilevel analysis showed that all general practice staff were highly satisfied if they worked in a practice with a good team climate. Practice managers reported the highest satisfaction with their work. Practice size and individual characteristics such as the sex of the participant were unrelated to job satisfaction. GPs tended to have lower satisfaction than other staff in relation to income, recognition for good work and hours of work. Rural GPs were more satisfied.Conclusions: Most general practice staff are satisfied with their work. Facilitating teamwork may be a key strategy for both recruitment and retention of the general practice workforce, especially staff who are not GPs.

Mark F Harris MD, FRACGP · Judy G Proudfoot BEd(Hons), PhD · Upali W Jayasinghe MSc, PhD · Christine H Holton BA(Acc), GDPH · Gawaine P Powell Davies BA, MHP · Cheryl L Amoroso BSc, MPH · Tanya K Bubner GDPH · Justin J Beilby MD, FRACGP

Recent publications on medical professionalism have created an impression of a medical profession under siege in several countries. These publications recommend a new approach to medical professionalism to assist the profession to respond to new challenges. I suggest that the issue is not one of failed professionalism, but a shift in the balance of the ethical responsibilities brought about by major changes in health care systems. This shift has not yet been accepted or responded to by the medical profession. Medical professionalism is not under threat in Australia. Stronger leadership is required to address this altered ethical balance in the responsibilities of doctors.

Kerry J Breen MB BS, MD, FRACP

Studies demonstrating health benefits of religion are many and growing in number, and some claim the results are ripe for application in clinical settings.1,2 However, others argue that the research is not nearly as good or consistent as portrayed, and caution against acting rashly on inconclusive evidence.3,4 The goal of this supplement is to determine what this growing body of research means for Australian practitioners and patients. Religion involves beliefs and practices related to the sacred, where the sacred is defined as God, the numinous (mystical or supernatural) or ultimate truth. Religion is a unique construct, different from other psychological and social phenomena. Spirituality, on the other hand, is more difficult to define, as its definition today has changed — from one based in religion to a more diffuse concept, self-defined by each individual. The result is that there is no widespread agreement on what spirituality means, producing a real challenge when trying to measure it. Attempts to measure spirituality have taken two approaches: Asking questions about religious involvement; Asking questions about positive psychological characteristics, such as meaning and purpose in life, connectedness to others, peacefulness and high personal values. There are two problems with the latter way of defining and measuring spirituality. The first is that atheists might claim that they are neither religious nor spiritual — yet argue, rightly, that their lives have purpose and meaning, that they experience connection with others, and that they maintain high personal values. The second problem with defining spirituality in terms of positive psychological characteristics is that doing so produces a construct that is really a quasi-indicator of mental health. This makes it difficult or impossible to interpret research on the relationship between spirituality and health, especially mental health. Correlating a construct defined by indicators of mental health (spirituality) with another mental health construct (eg, wellbeing, life satisfaction, depression or anxiety) will always lead to an association between the two. Such an approach could also lead to false relationships between spirituality and physical health, given the strong links between mental and physical health. The word spirituality, when used in research, should be restricted to those things that have something to do with the sacred (as defined above). If there is no connection with the sacred, then it should not be referred to as spiritual or spirituality. We already have psychological and social terms to deal with concepts that all humans have in common, regardless of belief, and I think we should keep these concepts distinct from religious terms. I realise that many others in both the United States and Australia will not share this opinion, including a number of authors who have contributed to this supplement. From a purely scientific standpoint, if we are to study the relationships between religion, spirituality and health, it is essential to have constructs that are clear and non-overlapping. For these reasons, I refer mainly to religion when discussing relationships with mental and physical health. My definition of religion, however, is quite broad and means a lot more than just institutional religion or religious affiliation. Another reason for using religious language when discussing the research is that most published research has really been examining religion, even if it is presented and discussed in terms of spirituality. However, when talking with patients in clinical practice, there are good reasons for using the word spirituality, rather than religion. Research shows that, while many patients do not distinguish between being religious or spiritual,5 others feel alienated from institutional religion and see themselves more as spiritual than as religious. This may be particularly true for patients in Australia. The term spirituality is vague enough to allow patients themselves to define the playing field. Why should religion and health be connected? The argument is a rational one. If religious people have a world view that gives hope and meaning in the face of stress and loss, if they have social support from other members of the religious community, and if they live healthier lifestyles by smoking less, drinking less, and making more conservative, less risky decisions in marriage, the workplace, and recreational activities, there is good reason to expect that they will have better physical health as well. All of these factors influence health in ways that are increasingly being understood through the field of psychosomatic medicine.6 It should not be surprising, then, that in 2006 more than 70 published research studies examined the relationships between religion, spirituality and health, many finding positive relationships.7 The articles in this supplement review research on religion, spirituality and health relevant to Australian patients and practitioners and discuss the application of that research to clinical practice. Although not all of the research comes from Australia, the articles provide an important summary and background that will assist Australian researchers in designing and implementing future research. While most of the articles do not contain original research, they begin to address some of the research gaps identified by Peach in 2003.8 Williams and Sternthal9 assess the importance of religion and spirituality to Australians and discuss the evidence for both positive and negative effects of religion on health (→ Spirituality, religion and health: evidence and research directions). Eckersley10 looks at the relationship between spirituality, religion and health in a broad cultural context (→ Culture, spirituality, religion and health: looking at the big picture), while Wilding11 presents a case study to illustrate the meaning of spirituality at a personal level (→ Spirituality as a sustenance for mental health and meaningful doing: a case illustration). The different approaches to spiritual assessment in health care practice are summarised by Rumbold12 (→ A review of spiritual assessment in health care practice), and Winslow and Wehtje-Winslow13 raise a number of ethical issues relating to the provision of spiritual care (→ Ethical boundaries of spiritual care). Jantos and Kiat14 present evidence on the health benefits of prayer (→ Prayer as medicine: how much have we learned?), and D’Souza15 suggests ways in which clinicians can approach the subject of spirituality with their patients (→ The importance of spirituality in medicine and its application to clinical practice). Hopkins and colleagues16 focus on evidence-based strategies that could be implemented by church-associated organisations to reduce high-risk behaviours in young people (→ Developing healthy kids in healthy communities: eight evidence-based strategies for preventing high-risk behaviour), and, at the other end of the age spectrum, MacKinlay and Trevitt17 provide a model of spiritual tasks in later life (→ Spiritual care and ageing in a secular society). The contributions presented here suggest that spirituality and religion are important to many Australian patients, and that the spiritual needs arising from religious beliefs should be identified and addressed as part of whole person health care. They also suggest that much more research in this area is needed in Australia. While some of the findings of US research may be applicable to Australian patients, there are important cultural differences between the two countries that may influence the relationship of religion to health and the needs of patients in this regard.

Harold G Koenig MD

Many people use prayer, and some studies have shown a positive association between prayer and improved health outcomes. This article explores four possible mechanisms by which prayer may lead to improved health. While acknowledging the efficacy of prayer and recognising the needs of patients, prayer, being a personal spiritual practice, cannot be prescribed, nor should it be used in place of medical care.

Marek Jantos MA · Hosen Kiat MB BS

People need to feel like themselves and believe that the health care is connected to their lives As a medical student in 1989, I did my final year elective in Alice Springs and at an Indigenous community on the Pitjantjatjara Lands. In the depressed and squalid town camps of Alice Springs I came to understand that, even if a swab from a discharging ear grew Haemophilus, the patient didn’t have middle ear disease because of a bacterium. It triggered an ongoing interest in the determinants of health and disease — socioeconomic, personal and political. I discovered that Indigenous Australia is like Europe. There are different ethnic and language groups. Many people speak several languages and may speak English as their second, third, or fourth language. I understood that Australia’s interior is inhabited, not empty. I started to understand the magnitude of insult embedded in terra nullius. I had my first adult glimpse into Indigenous cultures and came away fascinated and respectful, knowing that we — me and my culture and they and their cultures — had fundamentally different ways of experiencing the world. I finished my degree, did the early years, travelled overseas, worked in general practice in community health settings, did a couple of brief stints in urban Aboriginal health services and a 4-month locum in the Pilbara, had two children, and quietly waited until I could get back to Central Australia. The time came, and I accepted a job-share position with my partner Niall in a remote Indigenous community about 300 km north-east of Alice Springs in Alyawarr country. Between 250 and 400 people live in the community, but we tracked the health business of around 700 people from the area. Life as a doctor in a remote Indigenous community is rich and fraught. People are so sick and die so young. It is deeply shocking. As I grew to understand more powerfully that these are real lives, and to grasp the amount of grief that people live with, and to comprehend how much time is lost to sickness and death, I was able to better appreciate the context in which I was providing medical care. In this setting you must be medically meticulous but also, to access the population, you need to offer services in a way that people recognise and want. People need to feel like themselves and believe that the health care is connected to their lives, that they are involved and have choices, that it’s not primarily someone else’s agenda. It’s often not so much about empowering people as not disempowering. This is what I think of as cultural safety. The clinic had a nurse and an administrator, but we knew that we also needed health and cultural liaison workers from the community. We needed language support and translation and a way to find out who and where people were, but also a way of checking understandings and beliefs about health and disease. People slowly began to feel comfortable and trust us, and within 6 months we had several health and cultural liaison workers. Only then could we start providing effective primary health care, including effective acute health care. Under guidance from the community-based Health Council and with other community members, we steadily built the clinic as a culturally safe place. We discussed, listened, made suggestions, checked and tried always to do things in a transparent and inclusive way. The look of the clinic transformed. The women chose the colour for the outside of the clinic and all the clinic doors were painted with bush tucker and local stories. We employed community members to collect and prepare a topical bush medicine that was given out as liniment and for various skin conditions. As well as being particularly effective for burns, this bush medicine gave the whole clinic a smell that was deeply familiar to the community and strongly associated with health care. I was struck at some stage by the fact that the local people never or rarely saw themselves reflected in positive ways on television or in books. I wondered how you can value and acquire literacy if you cannot relate to anything you read, and so had the idea of building a mini-library in the clinic. People loved it. We obtained a book depicting local artists and their batik work, and other books about snakes, spiders, bush foods, and plants. We got maps of the surrounding areas and an aerial photograph of the community, allowing many — some of them for the first time — the experience of seeing their world and their lives depicted in books. It was very powerful. At some point I expanded on the usual letter of referral and made a much fuller letter of introduction. This had so much impact on staff in Alice Springs and in Adelaide hospitals that I wondered that I hadn’t thought of it earlier. I really understood this as part of building safety in how Indigenous people accessed health services outside culturally familiar territory. People came to the clinic in droves. It became easier and easier to establish robust primary health care programs: We increased and maintained vaccination rates to more than 95% cover. We provided antenatal care for all women from the first trimester. Most of the 12 or so women per year had their babies in Alice Springs by choice — ours and theirs. Children younger than 5 years were all mapped on a wall chart, recording when they were due for vaccination, weights, haemoglobin, developmental checks and so on. The community accepted this degree of visibility for the children’s health business. More than that, I would say this was consistent with the sense of collective responsibility for the welfare of the kids. By the time we left, most of the women had had a Pap smear. Most adults had had chronic disease screening and a large proportion came to the clinic for regular checkups and monitoring. (Our audits showed that around 30% of adults had diabetes and around 25% had impaired renal function.) Regular screening for and treatment of sexually transmitted infections was in place. A healthy dogs program included an annual visit from a vet backed up by Niall and health workers who would spay dogs, put down sick dogs, etc. We conducted annual school screening. The community had access to the industrial washing machine that had been installed in the clinic for washing blankets. Our predecessor had initiated this — a simple, powerful public health measure that resulted in a dramatic and sustained fall in scabies infestation and related skin infections. We provided palliative care for several people, including extensive family consultation and support. As well as these programs, we tried to visit the elderly people in their camps each week. Many of them never came to the clinic, so this was the only way they accessed health care. We were also providing acute care day to day in the clinic, which was busy in itself. We were on-call all the time, second on call to the nurse half the time. We did a weekly 150 km round-trip visit to three satellite communities. And lurking in the background were the could-happen-at-any-moment medical emergencies, which of course did happen. Together with the nurse we treated a gunshot wound to the chest (and I put in my second-ever chest tube), a ruptured ectopic pregnancy, births, cardiac emergencies, and road and various other traumas. Although work was full-on, there was also a simplicity about our lives. I got enough sleep for the first time in years. We were absorbed by life within the community. I felt like I had time to think. I read and thought and reflected a lot. Niall and I had time to talk and didn’t have to have conversations about shopping, who’d pick up the kids, babysitting and other domestic arrangements. It was sparse and refreshing. Under the vast sky in that uncluttered country, I connected to seasons, phases of the moon, movement of the stars. I got the kids up one night to see the Leonids, which is a meteor shower that happens to a greater or lesser extent every year in November. By luck, that year was the greatest shower in years. We lay on the trampoline and saw maybe 200 shooting stars in half an hour. It was exhilarating. I went hunting many times with the women. As well as the time with people and experience of culture, my way of seeing the country transformed. I saw it was fecund, fertile, providing. I saw and learned how to find and collect seasonal foods — beans, potatoes, all sorts of fruits, wild honey. I ate kangaroo, turkey, echidna, witchetty grubs, the honey sac of honey ants, and goanna. I also understood that the land was knowable. That people were at home in their country, the land was steeped in the events and stories of their lives. That nomad didn’t mean moving willy-nilly around, but was actually travelling within country that was all home. That, in comparison, non-Indigenous Australians move to places we have no connection to — country, city, suburb. I learned to see things, but not everything. A close friend and I went out one day tracking goanna and I couldn’t see the tracks. I asked her to show me and she laughed and pointed. We squatted down on the ground and she pointed exactly to the tracks. I still couldn’t see anything. We just both ended up laughing and laughing — she truly disbelieving that I couldn’t see anything . . . and I thinking about how you can never really know what you’re not seeing. I know we can’t change history. We can change our knowledge and understanding of it. My understanding is that many Indigenous people are sick because of the accumulated losses and trauma and now the burden of sickness and early death and the grief that comes with that. They are sick because of not having access to or not being able to or not knowing how to or not believing in the value of making life-affirming choices. I don’t believe there has yet been real political will to change the health of Indigenous people, despite there being substantial knowledge about what makes a difference. People (we) need to have a sense of power in their (our) lives, and the principle of cultural safety is fundamental to the design of services that support this. I think we understood this well enough to have been able to go to this community and provide medical and health care in a way that people found useful. It was certainly a most enriching experience for me and my family.

Mary Belfrage MB BS

Objective: To determine whether primary care management of chronic heart failure (CHF) differed between rural and urban areas in Australia.Design: A cross-sectional survey stratified by Rural, Remote and Metropolitan Areas (RRMA) classification. The primary source of data was the Cardiac Awareness Survey and Evaluation (CASE) study.Setting: Secondary analysis of data obtained from 341 Australian general practitioners and 23 845 adults aged 60 years or more in 1998.Main outcome measures: CHF determined by criteria recommended by the World Health Organization, diagnostic practices, use of pharmacotherapy, and CHF-related hospital admissions in the 12 months before the study.Results: There was a significantly higher prevalence of CHF among general practice patients in large and small rural towns (16.1%) compared with capital city and metropolitan areas (12.4%) (P < 0.001). Echocardiography was used less often for diagnosis in rural towns compared with metropolitan areas (52.0% v 67.3%, P < 0.001). Rates of specialist referral were also significantly lower in rural towns than in metropolitan areas (59.1% v 69.6%, P < 0.001), as were prescribing rates of angiotensin-converting enzyme inhibitors (51.4% v 60.1%, P < 0.001). There was no geographical variation in prescribing rates of β-blockers (12.6% [rural] v 11.8% [metropolitan], P = 0.32). Overall, few survey participants received recommended “evidence-based practice” diagnosis and management for CHF (metropolitan, 4.6%; rural, 3.9%; and remote areas, 3.7%).Conclusions: This study found a higher prevalence of CHF, and significantly lower use of recommended diagnostic methods and pharmacological treatment among patients in rural areas.

Robyn A Clark MEd, FRCNA · Kerena A Eckert MPH · Simon Stewart PhD, FCSA · Susan M Phillips DPhil · Julie J Yallop NZRN · Andrew M Tonkin MD, MRACP, FRACP · Henry Krum PhD, FRACP

Cyril Evans was born on 27 April 1921 in Sydney and attended Fort Street Boys’ High School. He graduated in medicine with credit from the University of Sydney in 1943, despite having had to work during the course to support his mother and sister and pay his university fees. He obtained a Diploma in Tropical Medicine in 1946. After doing his residency at Royal Prince Alfred Hospital, Sydney, Cyril joined the Australian Army in 1945. When the War ended, he worked for several years as a missionary doctor in the Solomon Islands. Between 1950 and 1954, he completed specialty training in internal medicine in the United Kingdom, working first at Hammersmith Hospital, London, and later in Cornwall and Wales. He became a Member of the Royal College of Physicians (London) in 1953. Cyril spent the next 21 years specialising in chest diseases, particularly tuberculosis, first in North Carolina, USA (1954–1955), then as Deputy Director of Tuberculosis Services in Queensland (1956–1968). During this time, he was seconded to the World Health Organization for 2 years (1964–1965) to work at the Tuberculosis Chemotherapy Centre in Madras, India. From 1969 to 1973, he served as Director of Tuberculosis Services for South Australia and then as Commonwealth Director of Tuberculosis Services in Canberra (1974–1975). In 1975, Cyril was appointed Deputy Director-General of the Commonwealth Department of Health. Over the next few years, he became a Fellow of the Royal Australasian College of Physicians (1975), the Royal College of Physicians (London) (1978) and the Royal Australian College of Medical Administrators (1979). He was highly regarded by his colleagues — respected not only for his expertise in public health, but also for his patience and consideration towards others. He was made an Officer of the Order of the British Empire in 1978. After retiring from government service in 1982, Cyril spent a year as Adviser in Chronic Diseases at the Western Pacific Regional Office of the WHO in Manila, The Philippines, and then over 10 years as Medical Director of the Australian Kidney Foundation (1986–1997). Cyril was passionate about the welfare of his fellow human beings. He decided against continuing to work in the USA in 1956 because of the racism he saw in the hospital and the community. From the 1960s, he volunteered his time to various programs to help people stop smoking and, more recently, was a keen supporter of Canberra ASH (Action on Smoking and Health) Inc. He was also a supporter of the Medical Association for Prevention of War and a long-time member of the Board of the Richmond Fellowship, a charity providing mental health care and accommodation to adolescents with behavioural problems. Cyril and his wife, Beryl, also provided a home-away-from-home for scores of people, particularly international students in Canberra, for more than 30 years. Cyril died on 1 February 2007 after a period of failing health associated with Parkinson’s disease and Alzheimer’s disease. He is survived by Beryl and children Bronwyn, David, Susan and Annette.

David B Evans · David de Souza

To the Editor: We welcome your recent focus on rural and remote health. Kamien and Cameron’s editorial addressed medical workforce supply issues,1 and the accompanying article ranged across not only workforce supply issues, but also broader systemic issues, including the roles of different levels of government.2 Coincidentally, the Australian Institute of Health and Welfare released its latest medical workforce report, which reported a rise in the number of doctors per head of population overall, particularly specialists, and particularly in urban areas, but decreased numbers of doctors in the bush, particularly in remote areas.3 Most of the media response ignored the contemporaneous nursing workforce report,4 which described a much more even geographical distribution of the nursing workforce — the largest health professional group. We agree that access to health care is more than a workforce supply issue.2 While we acknowledge the critical importance of general practice, perhaps part of the problem in improving access has been an almost exclusive policy focus on medical workforce supply issues, and not the broader consideration of a range of factors that will improve access to effective primary health care services for the 30% of Australians living in rural and remote areas. Our recent systematic review of models of rural and remote primary health care service delivery in Australia identified a number of essential requirements of successful primary health care models.5 These inter-related requirements are adequate workforce supply; appropriate workforce organisation; adequate funding and appropriate financing; leadership, good management and governance; adequate infrastructure; and strong linkages — both internal and external. Successful models also exhibited an appropriate level of community participation. There are a number of demonstrably successful rural and remote models, such as the Katherine West Health Board, an exemplary remote comprehensive primary health care service.5 To generalise these successful models and improve access, we need a rural and remote primary health care policy framework for Australia that coordinates national, state and territory resources to ensure that all of these essential requirements are systematically addressed. We agree with Kamien and Cameron1 that a solution will not be forthcoming until governments take a courageous stance in overcoming the implementation gap associated with translating research evidence into policies and programs. The time has never been riper for Commonwealth, state and territory governments to assume leadership and agree on an evidence-informed implementation strategy to assure rural and remote communities of accessible, high quality health care. Our systematic review5 provides a solid base to underpin such a response.

John Wakerman · John S Humphreys · Robert W Wells · Pim Kuipers · Philip Entwistle · Judith Jones

Objective: To examine pre-registration junior doctors’ perceptions of the value of a general practice term in their training program.Design, setting and participants: Semi-structured interviews, in five teaching hospitals in South Australia in 2005, with 20 pre-registration junior doctors (interns) who had completed a general practice term and at least one core term of intern training.Main outcome measure: Comparisons between general practice and teaching hospital core training terms with respect to the domains of junior doctor education.Results: Interns perceived general practice and teaching hospital terms to be complementary in their overall training program. The general practice term provided them with knowledge and skills they would not have acquired in the teaching hospital terms alone. One-on-one consulting, initiating patient management, and the opportunity to practise a range of practical and procedural skills were seen to be of particular value.Conclusions: The general practice and teaching hospital terms both contribute to the training of interns, offering contrasting environments and experiences which enhance interns’ professional and personal growth. General practice terms should be considered for inclusion in intern training programs across Australia.

Anne A Martin BSc(Hons), PhD · Caroline O Laurence BA(Hons), MHlthServMt · Linda E Black BA(Psych), DipApplPsych, MAPS · Bruce V Mugford BM BS, FRACGP, FACRRM

To minimise the health impact of pandemic influenza, general practice will need to provide influenza-related and non-influenza primary health care, as well as contribute to the public health goal of disease control. Through interviews and workshops with general practitioners, nurses and policy leaders between March and July 2006, and literature analysis, we identified potential models of general practice in an established pandemic, and assessed their strengths and weaknesses. Three possible clinical models were identified: a default model of no change to service delivery; a streamed services model, where general practices reorganise themselves to take on either influenza-specific care or other clinical services; and a staff-determined mixed model, where staff move between different types of services. No single model or set of strategies meets the needs of all general practices to deliver and sustain the essential functions of primary health care during an established pandemic. Governments, general practice and the relevant peak professional bodies should decide before a pandemic on the suite of measures needed to support the models most suitable in their regions. Effective participation by general practice in a pandemic requires supplementary infrastructure support, changes to financial and staffing patterns, a review of legislation on medicolegal implications during an emergency, and intensive collaboration between general practices.

Christine B Phillips MPH, MA, FRACGP · Mahomed S Patel MB BCh, FRACP, FAFPHM · Nicholas Glasgow FRNZGP, FRACGP, FAChPM · Christopher Pearce MFM, FRACGP, FACRRM · Paul Dugdale MPH, PhD, FAFPHM · Alison Davies MPubPol, BPhty · Sally Hall RN, GradCertClinMan · Marjan Kljakovic FRNZCGP, FRACGP, PhD

To the Editor: I was surprised by Wong’s letter on the role of history-taking and examination in the diagnostic process.1 I would suggest that Wong, as a surgical registrar, receives the majority of his abdominal pain referrals from the medical staff of the emergency department. Although he advocates the liberal use of abdominal computed tomography (CT) scanning, I believe he ignores the fact that another medical practitioner has already taken a history and performed an examination that has suggested a surgical cause of pain for which a surgical opinion is then requested. Wong would thus remain unaware of other cases in which patients present with abdominal pain but the case is ruled non-surgical on the basis of history, examination and limited investigation not involving abdominal CT scanning. History, examination and even appropriately targeted investigations remain imperfect diagnostic tools, but I agree with Schattner2 that history-taking and examination are very important adjuncts in the diagnostic process.

Andrew P Wright

To the Editor: Like Schattner, I am appalled by the attitude to diagnosis displayed by Wong regarding the use of computed tomography (CT) scanning in preference to initial history-taking and physical examination in abdominal pain.1 Unfortunately, this approach is becoming increasingly more prevalent among junior staff (and even among some senior staff). Wong poses the question, “[W]hy do some clinicians continue to routinely promulgate the sacred and arcane ritual of taking a history and doing an examination, which, as diagnostic tools, are clearly second-rate?” There are several reasons why I continue to promulgate the classical paradigm. Firstly, I would remind him of Bayes’ theorem: post-test probability equals pre-test probability multiplied by the likelihood ratio of the test. Put simply, this means that, for a test that is not 100% accurate (ie, effectively, all imaging tests), you cannot interpret the meaning of the result without having some idea of the pre-test probability of a diagnosis. And how can you satisfactorily arrive at a pre-test probability without having clinically assessed the patient? In addition, the radiologist is able to interpret the images more accurately when there are clinical details provided.2 Secondly, is Wong seriously suggesting that all patients with abdominal pain, including young adults and children, undergo CT scanning without any kind of clinical filtering or assessment? This is wrong and potentially negligent. The radiation dose received by the patient from an abdominal CT scan is a serious consideration. Assuming a total effective body dose of 10 mSv, there is an excess risk of a radiation-induced fatal cancer of about 1 in 2000.3 Apart from the risk to the individual, the number of iatrogenic cancers potentially induced in the community by indiscriminate use of CT would be a major concern.4 Thirdly, the implication of Wong’s letter is that clinical assessment and imaging are somehow in competition with each other, whereas nothing could be further from the truth. Of course, modern imaging has contributed to making diagnosis far more accurate than in the time of Hippocrates, but a complementary approach is far more rewarding for patients and doctors. Lastly, in patients with abdominal pain, there are many occasions when no imaging is required and others when ultrasonography is more appropriate than CT, because it avoids ionising radiation in young patients and is more accurate for diagnosing gynaecological causes of pain.5

Richard M Mendelson

To the Editor: It is clear Dr Wong1 has a practice rather different from mine. He is not used to the truly undifferentiated patients that present in their thousands to emergency departments and general practices every day. There, the art of history and examination is truly alive. No one questions the value of complex imaging. It has its place after a detailed history has been taken and focused examination and relevant investigations have been carried out, leading to a risk assessment and management plan. One does not order computed tomography (CT) scans willy-nilly. For example, the Canadian CT Head Rule2 for patients with minor head injury sets out which patients should have a head CT scan, based on a simple set of historical and examination findings. Moreover, CT scans are wasted on conditions for which CT imaging is inappropriate — it is rare that I order a CT scan for a child with abdominal pain. When I ask surgical registrars for their opinion, I am actually asking for their consultant’s opinion. Nothing guides like an experienced hand, whether it be feeling a belly or writing a CT request form. On many occasions, I have concluded that all the imaging performed on a patient with abdominal pain did not contribute to the diagnosis and the patient simply needed a laparotomy. At my insistence, the consultant is called, appropriate treatment commences, and the patient boards the experience express on the track to recovery. As Shem quips, in his satirical book on medical training and hospital life — nothing heals like cold steel.3 CT is not the be-all and end-all of medicine. Hopefully, by the end of his training, Wong will have developed the hand of experience and be able to continue the art of medicine through the ages. In the words of William Osler: The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with potions and powders, but with the exercise of an influence of the strong upon the weak, of the righteous upon the wicked, of the wise upon the foolish.4

James L Mallows

To the Editor: Apropos the letter by Wong entitled “Clinical paradigms revisited” in the Christmas issue,1 declaring fossilisation of the very pillars on which medicine stands, we would like to express a contrary opinion. To be adept physicians, clinicians must hone their skills at taking a lucid and informative history and conducting a thorough physical examination. It would be a crying shame if young doctors, having slaved for 5 or more years to obtain a medical degree, had to rely solely on expensive investigations when they have the God-given tools of the five senses. To confirm a clinical diagnosis and assess the extent of disease, doctors should order specific and appropriate investigations, rather than ordering tests that may be irrelevant and financially bleeding the patient. The issues of cost, radiation hazard, availability of trained personnel, and need for expensive equipment have been trivialised. In a country like India, where the majority of the population cannot afford even minimal hospital fees, to even contemplate using a computed tomography scan as a first-line diagnostic tool for something as basic as abdominal pain is absurd. Moreover, the use of advanced technology does not guarantee a correct diagnosis. A recent case of aortic dissection was misdiagnosed as acute coronary syndrome on the basis of electrocardiography.2 If due emphasis had been given to pulse and blood pressures in both limbs, this mistake could have been avoided. In another case, involving recurrent loss of consciousness, investigations were non-contributory, but a history of substance misuse at home pointed to the correct diagnosis.3 In another study, clinical judgement regarding the severity of pneumonia was found to be a more reliable predictor than a standardised scoring system based on clinical signs and laboratory findings.4 Doctors ought to be able to make a clinical judgement in the first instance, rather than resorting blindly to expensive investigatory tools. We do not deny the usefulness of modern technological devices for confirming or ruling out clinical possibilities, but they must be used judiciously. Such investigations cannot take precedence over physicians’ reliance on their clinical skills, lest we become helpless without technology.

Sandeep Chauhan · Ruth D’Cruz · Sanjay D’Cruz · Ram Singh · Atul Sachdev

To the Editor: Schattner1,2 and Wong3 raise issues that examine what has been the core of medical practice since antiquity. Grasping antiquity for its own sake is problematic, at best, and possibly heralds the extinction of long held practices, at worst. As technology improves, we are witnesses to improved imaging modalities that provide higher diagnostic yields, with improved sensitivity and specificity, at increasingly reduced costs. Refusal to even acknowledge the possibility that the history and examination may be terminal is not prudent. Instead, we need to examine carefully our mantra(s) with respect for the temporal nature of medicine. History and examination evolved in their current form because previous generations could not see inside the body, or examine physiological and pathological processes in real time. Our predecessors amassed a series of verbal cues and physical rules that generally conformed to the presentation of a particular disease. The future of medicine heralds dramatic departure from the world view that preceded computed tomography and magnetic resonance imaging. Wong raises an important issue with regard to diagnosing emergency abdominal conditions in busy hospital practice. He does not discount a role for the history or physical examination. He does, however, challenge their pre-eminence in “conditions that require emergency surgical treatment”. Is it really in the best interests of patients and the health care system for the emergency department intern/resident, then the registrar/consultant, then the surgical fellow, to all take the history and perform a physical examination? In essence, doesn’t Wong’s “scan first approach” reflect a prudent reliance on, and respect for, the information already gathered? Schattner4 states that “all imaging studies combined (computed tomography, magnetic resonance imaging, ultrasound, and echocardiography) were decisive in only 10.5% of cases” whereas “the patient’s history and the evolution of the condition proved to be the decisive diagnostic method in 23% of cases”. Doesn’t this show that Wong’s approach provides a heuristic that increases the diagnostic yield, reduces delays and guesswork, and streamlines the processing of patients presenting with acute abdominal pain — or is it acceptable to miss the significant percentage of diagnoses that are decided by imaging alone?!

Stuart Kostalas

To the Editor: Refugees are a particularly marginalised group, often originating from countries where immunisation coverage is low.1 As vaccine-preventable diseases such as hepatitis B and measles are endemic in both their countries of origin and the countries in which they spend time in displaced persons camps, the potential burden of disease for refugees is greater than for Australians.2 It is important to determine whether our health systems provide refugees with access to optimal health care, including vaccines. From May 2004, refugee families arriving in Newcastle, New South Wales, have attended the Newcastle Refugee Clinic, where, with the assistance of interpreters, health screening is provided and catch-up vaccination regimens are commenced according to the Australian Standard Vaccination Schedule.3 Vaccines administered are documented in an appropriate personal health record. All age-appropriate vaccines are registered with the Australian Childhood Immunisation Register (ACIR). Families are provided with a copy of the catch-up schedule and, through interpreters, are advised to complete their vaccination schedule through a general practitioner. In NSW, general practices can obtain free vaccines for refugees through public health units. In March and April 2006, there was an outbreak of measles in NSW. A review of ACIR records of refugee children seen over the previous 12 months (May 2005 to April 2006) at our clinic showed that, of the 35 children aged under 7 years, all were overdue for subsequent vaccinations, and only two children had received any additional vaccines after their Refugee Clinic visit. By contrast, vaccination coverage for all children in the Greater Newcastle area is high, and exceeds 90% for scheduled vaccines. Older members of refugee families also required additional vaccines, highlighting concerns that refugee families are not attending general practices for this basic preventive health care measure. While the reasons for this are unclear and need further research, it is likely that multiple factors, including lack of knowledge of the health system, lack of transport, no local government or community vaccination services, and lack of bulk billing by general practices, all play a role. Further, a number of local general practices have closed their books and do not accept new patients. Consequently, catch-up vaccination sessions were conducted at the Refugee Clinic, and transport was provided. Home visits were conducted for families unable to attend these clinics. Seventy-seven people were vaccinated and 209 vaccine doses administered. A thorough assessment of refugees for important medical and psychological conditions is merited soon after they arrive in Australia.4 It is also essential that early access to general practice is secured for continuity of care and completion of vaccination. It is the responsibility of all — the Department of Immigration and Citizenship, contracted resettlement organisations, proposers, public health services and general practitioners — to ensure that vaccinations are accessible to newly arrived refugees. We believe they deserve the same protection against vaccine-preventable diseases as other Australians.

Kylee J Parsons · Maggi Osbourn · David N Durrheim · Murray T Webber

To the Editor: The enormous influence of the news media on health issues is widely acknowledged,1 and health and medicine rank among the most frequent topics covered.2,3 This influence extends from the setting of personal health agendas to shaping public health policy. Health and medical agencies have an obvious interest in how their areas of concern are depicted, and health interest groups can use the news media as a means of influencing government policy and legislation. Much of the existing research into the portrayal of health topics in the news has been based on newspapers and other print media, yet television is the most popular mass communication medium for Australians.4 A study underway at the School of Public Health, University of Sydney, is investigating how television frames health stories, and how this influences personal, institutional and political priorities. Since May 2005, all news, current affairs and “infotainment” programs concerned with health or medicine on five free-to-air Sydney television channels have been digitally recorded. Recordings are then indexed by category (date, program, broad topic, specific issue, and sources quoted) and stored in a large digital archive that will be used by researchers to undertake critical studies of media content, audience response and deconstruction, and studies of the journalistic framing process. Early returns of the project include a study of media narratives in coverage of Kylie Minogue’s recent breast cancer diagnosis, and an assessment of the impact of this reporting on bookings for breast cancer screenings by mammography in four states.5 Other studies include media depiction of obesity and notions of personal responsibility and a recently commenced analysis of news discourse on prostate cancer screening. Currently, the nearly 9000 news items collected address a broad range of topics including cancer, cardiovascular disease, environmental health, mental health, nutrition, obesity and medical technology. We are keen to collaborate with agencies and researchers who wish to draw on this unique resource for research purposes.

Simon Chapman · Ross MacKenzie

To the Editor: Improving clinical efficiency helps sexual health services deal with the demands of increasing rates of sexually transmitted infections.1,2 Many Australian sexual health centres require all clients to return in person to obtain their HIV test results; legislation only requires those who test positive to return in person.3 Giving HIV test results by phone to low-risk clients may improve efficiency. We determined the proportion of women testing positive for HIV infection at Melbourne Sexual Health Centre (MSHC) between 1 January 1996 and 1 January 2006, and reviewed the files of those who tested positive to determine their risk factors for HIV acquisition. In this period, 16 655 women were tested for HIV and 48 (0.29%) tested positive. For 11 of these 48 women (0.07%; 95% CI, 0.027%–0.10%), this was their first positive test. Six had been born in a high-prevalence country4 and had had sexual contact in those countries (two in South Africa, one in Ethiopia, one in Zimbabwe, one in Kenya, and one in Thailand); two had a sexual partner with HIV; one had had sex with a resident of a high-prevalence country (Thailand); one had had sexual contact in Australia with a man from a high-prevalence country (South Africa); and one had had sex with a bisexual man. All these risk factors were recorded in the patient’s history at the time of initial testing. Of the 37 women who tested positive and whose initial HIV test was performed elsewhere, risk factors were documented for 34. Thirty-one women (91%) had similar risk factors to the 11 who had first tested positive at MSHC. All three women without identified risk factors at the time of testing subsequently discovered their male partners were known to have HIV. We found that fewer than one in 1000 women attending MSHC tested positive for the first time, and all who did had clear risk factors. The upper 95% CI for testing positive among those without risk factors (ie, none in 16 655) was also extremely low and in the order of 1 in 1000. In the light of these findings, it is difficult to justify providing all results in person. MSHC now provides HIV test results by telephone to women without risk factors. Women with unexpected, indeterminate or positive results are recalled. This requires sensitive management to minimise stress and anxiety.

Carol A Hopkins · Rosey A Cummings · Tim R H Read · Christopher K Fairley

To the Editor: My father, a retired general practitioner now 86 years old, continues to lament the fact that Latin terms have fallen out of use in medical practice. Even today, he can still recite the conjugation of Latin verbs without a mistake, and he likes to tell the story of how Latin helped a young teacher in the 1950s. Although World War II had made it acceptable for single and widowed women to work (but not for equal pay with men!), women who continued to work after getting married were considered to be “stealing jobs” from men who needed to support their families. Today, a pregnancy without a marriage certificate does not even cause a raised eyebrow, but, back then, it condemned a girl to a lifetime of discrimination and gossip. Single pregnant girls went to stay with distant relatives or went to religious homes for “wayward girls”. One day, a GP colleague of my father telephoned seeking advice. He had a young, single, very distressed teacher in his surgery and he had just confirmed her pregnancy. She had told an all too common story about being “unofficially engaged” to her university-student boyfriend and not having the money to get married. Apparently, on finding out about the suspected pregnancy, the boyfriend had decided that this was the time to end their unofficial engagement. The young teacher was still unsure whether to have the baby adopted, try to find a supportive relative, or bring up the child herself. The patient, being a full-time teacher with the Department of Education, was one of the few “lucky women” for whom society considered it acceptable to work and earn a living while married or with children. It was therefore very important that she keep her job. The medical certificate for her employer was to be a very important piece of paper. My father advised his colleague to put the following words on the patient’s medical certificate: “The patient is suffering from non-pseudocyesis and will be unfit for work for 3 months”. The colleague was delighted with this diagnosis. The teacher came to see her GP a short time later and reported that departmental leave had been approved and that her teaching colleagues had wished her well in her recovery. My father’s colleague continued to chuckle about the diagnosis and enjoyed providing the additional leave certificates until full-term delivery, when the non-pseudocyesis miraculously disappeared.

Katherine A Haley

To the Editor: In From the Editor’s Desk in the 20 November 2006 issue of the Journal, Van Der Weyden acknowledged the 100th anniversary of the first performance of George Bernard Shaw’s play The doctor’s dilemma, and the fact that both society and medical practice have since changed dramatically in the ensuing century. He then asked: “. . . what is the modern doctor’s dilemma?”1 Contemporary Australian medical practice faces challenges posed by changes in community and government expectations, free market policies, workforce shortages and infrastructure changes, so this question should not be regarded as rhetorical. Answers to it will depend to some degree on the type of medical practice under consideration and where it is situated geographically, but to get the ball rolling, I suggest that in respect of general practice anywhere in Australia, a significant set of dilemmas surround notions of responsibility. Traditionally, general practitioners have held responsibilities primarily to individual patients. With increasing emphasis being placed, appropriately, on preventive and screening activities, to what extent should GPs’ responsibilities be extended to the community as a whole, and how should any such extension be resourced? Given that the interests of individuals and communities will not always be in accord, how might the resulting conflicts of interests best be managed? And, to increase the complexity of such considerations, to what extent ought responsibility to patients extend to responsibility for patients? Another dilemma for doctors in respect of responsibility relates to identifying the boundaries between altruism and martyrdom. To what extent should health care professionals be expected to put the interests of their patients or of the community before those of themselves and their families? To extend the notion of responsibility further, and with the GP’s role as patient advocate particularly in mind, to what degree should health care professionals be active against social injustices which impinge on their patients’ health? I know that in responding to the Editor’s question I have posed another set of questions, none of which are easily answered — if they could be, they would not be dilemmas. However, acknowledging and clarifying these questions is the first step towards answering them, and also towards preventing much community misunderstanding.

David E Smith

To the Editor: I am one of the septuagenarians described by Arnold in his cri de coeur over the demise of professional courtesies.1 In my medical student days, my teachers extended the courtesy of free medical treatment to my parents. I have continued this tradition, in the certain knowledge that this will be the only situation in which medical students save their parents money. Such professional courtesies are still the norm in Western Australia. But, with the exception of medical colleagues, I have only once, in the 30 years of operation of Medibank/Medicare, had a bulk-billed patient realise that he has received a discount. I recently asked a picture framer/patient for a 40% discount and he laughed. When I explained that by bulk-billing I was effectively giving him a 40% discount, he was incredulous, but he did reciprocate. In the 1970s, Australian Medical Association spokesmen and medical educators often confused etiquette (a code of desirable behaviour between doctors) with ethics (a more important set of moral principles underlying a person’s general behaviour). This is no longer the case, and etiquette has disappeared from undergraduate and postgraduate medical curricula. I think it is time to reintroduce the topic into the education of both our future doctors and our patients.

Max Kamien

To the Editor: There would be few medical students who have not had drummed into them the tautological aphorism, “Common things occur commonly!” And few practising clinicians who have not come across or read about a serious adverse event arising from the actions of a colleague or nurse who thought, “It was only X, which is so common at this time of the year/around these parts/among these people. I didn’t think it was anything serious.” The patient might have been a child with meningitis sent home with a diagnosis of a winter upper respiratory tract infection or a very anxious young woman with an intracranial haemorrhage discharged with a diagnosis of tension headache. Guided by this aphorism, we doctors will almost always make the correct diagnosis, and nurses an accurate assessment of a patient’s complaints, and we will glow with professional satisfaction. But how does this boost to our professional confidence measure up against what should be our paramount concern — the safety of each patient in our care? When assessing junior colleagues, we must, above all else, be seeking reassurance that patients will be safe in their hands. We do not want to hear a junior doctor brushing aside a commonly occurring symptom or clinical sign as of little importance merely because it is common. But we do want to know that he or she has considered, “What is the most serious condition that this could be?”, followed by relevant enquiries into the patient’s history, appropriate clinical examination and warranted laboratory or other investigations. Knowing that the doctor has checked that there is no suggestion of a serious illness, we can be reasonably assured that the patient will be safe. An excellent candidate would make the correct diagnosis sooner and perhaps with less pain, discomfort and inconvenience for the patient, and at less cost to the health care system, than a less able colleague. But the patient will be safe with either doctor, as a dangerous, perhaps life-threatening, illness has been excluded. All that remains is for the correct diagnosis to be made and appropriate treatment administered — a burden for the patient perhaps, but not a disaster. I suggest that readers of the Journal, in their role as teachers, advise their students to abandon that inane and dangerous “commonness” tautology, and replace it with: “Exclude the worst possibility and then assist Nature in its healing processes”.

Peter C Arnold

Objective: To examine the frequency of dyslipidaemia and treatment with lipid-lowering drugs in patients with type 2 diabetes managed in Australian primary care.Design, setting and participants: The NEFRON study (National Evaluation of the Frequency of Renal Impairment cO-existing with NIDDM [Non-Insulin Dependent Diabetes Mellitus]) was an incident-driven, cluster-stratified survey of 3893 patients with type 2 diabetes from across Australian primary care between April and September 2005.Main outcome measures: The most recent fasting lipid levels were compared with therapeutic targets for lipid control and current prescribing guidelines.Results: 64% of patients with type 2 diabetes presenting in primary care received lipid-lowering medication. Despite the widespread use of statins (61%), 75% of patients had a total cholesterol level ≥ 4.0 mmol/L, and 47% had a low-density lipoprotein (LDL) cholesterol level ≥ 2.5 mmol/L. Few untreated patients met the Australian Pharmaceutical Benefits Scheme (PBS) criteria current at the time for subsidised primary prevention with lipid-lowering agents (4%). However, new PBS subsidy criteria will potentially include 93% of all diabetic patients seeing their general practitioner in primary care.Conclusion: Changes in the provision of subsidised therapy for high-risk diabetic patients are long overdue. However, more needs to be done to optimise management strategies, which still fail to achieve treatment targets in many treated patients.

Merlin C Thomas PhD, FRACP · Paul J Nestel MD, PhD