General medicine

To the Editor: Primary care skin cancer clinics continue to receive negative publicity. We have previously reported on the workload profile of one network of clinics.1 We report here the profile of clinical activity of the four MoleScan skin cancer clinics situated on the Sunshine Coast, Queensland. Between them, these clinics have been open for a total of 22 years, ranging from 2 years to nearly 9 years of operation. MoleScan is a service company with clinics across Australia. Doctors are employed as subcontractors and are provided with digital dermascopes. The clinics do not have dedicated day surgery facilities, and surgical procedures are conducted in the consulting rooms (http://www.molescan.com.au). Using Medicare Benefits Schedule item number billing data (as previously reported1), we calculated the number of consultations, biopsies, excised lesions (benign, non-melanoma skin cancers [NMSCs] and melanoma), surgical repairs, non-surgical treatment of skin cancers, and non-surgical treatment of other skin lesions. We also estimated the number needed to treat (NNT), defined as the number of benign lesions removed per melanoma. There were 98 276 consultations at the four clinics during the 22 years of operation (Box). In all, 14 982 skin cancers were treated: 395 melanomas and 7468 NMSCs by surgical excision, and 7119 NMSCs by non-surgical methods. The estimated NNT was 22.5. Of the 16 962 lesions excised, 11% (1812) were repaired by a skin flap, 68% (1226) of which were simple flaps. Our previous report, on a different network of clinics,1 showed a different pattern of surgical repairs: 33% (2651) of the 8055 lesions excised were repaired by a skin flap, 45% (1187) of which were simple flaps. Clearly, the clinical practices of these two clinic networks vary. Another area of apparent difference between the two clinic groups is the NNT — 22.5 reported here, compared with 28.6 from the other network.1 The lower NNT in these MoleScan clinics may result from the use of digital dermoscopy, but this requires further study. These early findings from our analyses of MoleScan data highlight the dangers of generalising about the activities of primary care skin cancer clinics from one dataset. Workload profiles of different clinical services may vary markedly, and the widely expressed concern about large numbers of inappropriate surgical repairs may not be warranted. Activities billed at four MoleScan skin cancer clinics on the Sunshine Coast, Queensland, over a total of 22 years of operation * Eyelid, nose, ear, lip, neck, hand, digit or genitals.

Deborah A Askew · David Wilkinson · Gordon L Patrick

Chronic disease self-management education programs aim to empower patients through providing information and teaching skills and techniques to improve self-care and doctor–patient interaction, with the ultimate goal of improving quality of life. The recent 2006–07 federal budget allocated an unprecedented $515 million over 5 years for activation of patient self-management activities, commencing this financial year. Previous attempts in other countries to incorporate self-management education activities into the health care sector have faced setbacks because of inadequate integration into primary care. Engagement of health care professionals and their endorsement of self-management activities is critical to success.

Joanne E Jordan BSc, BA, MPH · Richard H Osborne DipApplBio, BSc, PhD

To the Editor: The article by Jordan and Osborne1 highlights some of the key issues to be addressed if chronic disease self-management programs are going to be effectively incorporated into the Australian health care system, particularly in primary care. Although the National Chronic Disease Strategy2 recommends that self-management programs be integrated and supported at all entry points into the health care system, many of the self-management strategies and programs have been developed with little engagement of general practitioners and have not been integral components of primary health care. Jordan and Osborne highlight that, without the support of GPs, programs such as the Expert Patients Programme3 may have limited success. We recently completed a systematic review for the Australian Primary Health Care Research Institute to explore the evidence for managing chronic disease in primary care, with specific reference to the Australian health care system.4 The self-management programs found to be most effective were those that developed self-efficacy in relation to specific behaviours, such as diet and exercise for diabetes, rather than those that were more general. The combination of self-management support with delivery system design changes (such as multidisciplinary team care and follow-up) was effective in improving patient health outcomes for a number of chronic diseases. This highlights an important and developing role for practice nurses in chronic disease management. Given the burden of chronic disease in Indigenous populations, it is important to conduct more research on the role of self-management education and support in Indigenous communities, as there were few relevant studies identified in our systematic review. The funding available through the Australian Better Health Initiative5 will enable primary health care professionals, such as GPs and practice nurses, to receive self-management education training. Furthermore, to ensure that self-management support is embedded in primary care, we suggest that self-management support be included in care plans or annual cycles of care for conditions such as diabetes. Self-management support could also be incorporated into allied health services that are provided as part of a care plan.

Sarah M Dennis · Nicholas A Zwar · Iqbal Hasan · Mark F Harris

Objective: To provide a contemporary picture of the general practitioner and specialist obstetric workforce in Victoria.Design, participants and setting: Postal census by questionnaire of all 317 Fellows and 961 Diplomates on the Victorian database of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists in September 2003.Main outcome measures: Sex, age and geographical distributions and patterns of retirement from and recruitment to the GP and specialist obstetric workforce in Victoria.Results: 244 Fellows (77.0%) and 652 Diplomates (67.8%) participated. The average age of Diplomates was 42 years; only 20% were involved in procedural obstetrics. Of GPs practising procedural obstetrics, 56% intended to cease within 7 years. Two-thirds of specialist obstetricians continued to practise obstetrics. Among those ceasing obstetrics, almost half had done so since 2000. Among Fellows ceasing obstetric practice, there is a peak in the 50–60-years age group, but cessation of obstetric practice occurred across all age groups.Conclusion: The proportion of GPs involved in procedural obstetrics has fallen markedly over the past decade, with half of those ceasing practice in the 40–50-years age group. New GPs entering the workforce with the Diploma and overseas doctors are unlikely to meet the procedural workforce shortfall. Attracting the large cohort of doctors aged 40–50 years back to obstetric practice must be a priority. Given the pattern of retirements from obstetrics, there will be insufficient numbers of specialists to maintain current levels of service. The reasons include non-participation in obstetrics by new graduates and international medical graduates, the inadequate number of new graduates, and the predominance of women among specialists aged under 40 years, whose work output tends to be affected by family commitments.

Cameron S Loy FRACGP, DCH, DRANZCOG · R Bruce Warton FRCOG, FRANZCOG, FRACMA · James A Dunbar MD, FRCPEdin, FRACGP

To the Editor: No one denies the right of insurers, or law firms acting for an interested party, to obtain information relating to a claim with due authority from the patient. After all, it’s fair enough for insurers to check the details of a claim. This system has worked well for decades and allows the insurance industry to operate reasonably and fairly. But a recent development gives cause for great concern. There is a trend among both insurers and lawyers to demand copies of a patient’s entire medical file. Not just details relevant to the claim, but the entire medical file, often extending for years before the relevant event. A cynic has suggested this is financially motivated, as a reasonable fee for copying and forwarding a file is likely to be less than the fee for reviewing the file and preparing a report. Another equally uncharitable explanation is that insurers are embarking on “fishing trips”, hoping to find grounds to mitigate a claim. I’m sure the industry could produce examples in which fishing trips have identified dishonest claims that might not otherwise have been detected. But I cannot justify sacrificing the privacy of many patients to expose the occasional fraudulent claim. In one case, one of my patients suffered a work-related injury that prevented her working as a private contractor for some months. The case was clear-cut, simple and straightforward. Yet the insurer refused to process her claim without receiving a copy of her entire file — including very personal details of a sexual assault nearly 20 years earlier, together with confirmation that she had contracted a sexually transmitted infection and details of her subsequent breakdown. For a vulnerable and very private person, it was a terrible ordeal to have this brought up and to have to sanction its disclosure to a claims officer. My financially strapped patient was held to ransom when the insurer advised that the claim would not be processed until the disclosure was authorised. How can the individual claimant ever stand up to a multinational insurer? And, in this case, appeals to the industry regulatory body were peremptorily dismissed. I support any stand by our profession against this unjustifiable invasion of privacy.

Bernard S Pearn-Rowe

Comment: Agents for a workers compensation authority commonly assert they have the right to see the patient’s entire medical history to assess whether the injury arose from work or from another past or current illness or injury. Two points need to be underscored. Firstly, patients have a right to waive their right to privacy. A consent for total disclosure, given when initiating a claim for compensation, could be invalid, as it is a consent given under (economic) duress — that is, payments will not commence unless the patient consents to full disclosure. A doctor may feel a duty to point out to the patient that full disclosure will reveal distressing matters from the patient’s past that the doctor believes are not relevant to the claim. The doctor may recommend that the patient seek legal advice on how to object to full disclosure. Whether the patient objects or agrees to total disclosure is a decision for the patient, not the doctor, with the help of legal advice. Doctors should not give that advice. Secondly, the legislation governing statutory compensation schemes in Australia gives extraordinarily broad powers to the relevant authority to demand information. For example, section 239 of Victoria’s Accident Compensation Act 1985 states that the Victorian WorkCover Authority (and its agents) may “require any person – to furnish the Authority with such information as the Authority requires . . . and may require the person to produce all books in the custody or under the control of the person relating thereto.” Doctors and medical records are not excluded from the broad sweep of section 239. Notwithstanding such clauses, a claimant can object directly to WorkCover about a request or demand to supply his or her entire medical history if the claimant believes there are matters not relevant to the claim that he or she does not wish to be disclosed. If that process fails, the claimant then has a number of legal avenues that can be pursued. Pearn-Rowe may be concerned at the David–Goliath imbalance of power between patient and insurer, but that does not justify omission of information because the doctor thinks it is not relevant. The Medical Defence Association of Victoria recently settled a case in which a member, asked to provide a “Personal medical attendant’s report” for a patient applying for a new disability insurance policy, omitted information about the patient’s history that would have affected the insurer’s assessment of the application. The patient had signed a consent for full disclosure. The insurer issued the policy, and a short time later the patient was diagnosed as suffering a major illness, the premonitory symptoms of which were described in the omitted information. Whether or not it was a deliberate omission was not the point — it was a negligent omission. In summary, the patient has a right to object to disclosure. If the patient chooses not to, the doctor has a legal obligation to comply with the literality of the patient’s signed consent for disclosure.

Paul Nisselle

The more things change, the more they stay the same Nearly 100 years ago, George Bernard Shaw, in the preface to his play The doctor’s dilemma, savagely attacked the medical profession for its direct personal and pecuniary interest in the treatment of patients and argued that doctors could not be trusted to act in their patients’ best interests.1 He observed that medicine was not driven by science but rather by patient demand and service. Nor was Shaw particularly impressed with medical science, noting that “medical science is as yet very imperfectly differentiated from common curemongering witchcraft”. In short, he argued that the medical practice of his time was mostly ineffectual and that doctors should advise patients that wellness is not attained through a bottle of medicine but through decent housing, clothes, food and clean air. The doctor’s dilemma was that providing this advice would jeopardise his already meagre income. Despite Shaw’s vitriolic criticism, doctors of that era enjoyed the respect of society because of their care and compassion — attributes poignantly captured by Sir Luke Fildes’ famous painting “The doctor” (1891), which portrays a pensive doctor sitting by lamplight at the bedside of a sick child, with her anxious father hovering in the dark background. It is tempting to speculate what Shaw would make of the medical profession in Australia if he were sitting in judgement today. He would note that health care has become an economic giant, consuming large chunks of our gross domestic product (GDP) each year. In the financial year 2004–05, this amounted to 9.8% of GDP, or $4319 for each Australian.2 And this will only increase with the ageing of our population, the increase in chronic disorders, and the public demand for new drugs, biotechnology, medical devices and sophisticated surgery. As a prominent Fabian, Shaw would enthusiastically endorse Australia’s Medicare scheme, with its ideals of universal and unfettered access to medical care and provisions for meeting its costs. But public health insurance comes with a price — the overwhelming bureaucratisation of medical care with regulations, red tape and incessant reviews of activities.3 It also means the dominance of politicians and public servants in health decisions, with the medical profession relegated to myriad special interest and lobby groups. Considering Shaw’s scepticism about medical science, he would welcome evidence-based medicine and marvel at medical research and the role it has played in reducing infectious diseases, in widening the scope of surgery and in providing sophisticated tools for diagnosis. And with stem cell technology and medical genomics on the horizon, the sky’s the limit. He would note that medical research has become entangled with industry. In 2003, biomedical research funding in the United States reached the astronomical figure of US$94.3 billion. Industry accounted for 57% of the funding, the three major contributors being pharmaceutical, biotechnology and medical device firms.4 With this level of involvement, the purpose of biomedical research has passed from being purely for the public good to being for the good of researchers, institutions and corporations.5 Critical to this process is the promotion of products to doctors through incentives such as “taking meals, gifts, trips and . . . joining company advisory boards and speaker bureaus . . .”.6 Shaw might also be taken aback by the complexity of the organisation of medicine. From a simple structure of general practitioners supported by physician and surgeon consultants, it has evolved into numerous silos of medical subspecialties, each with their own technical territory and professional and political purposes. Doctors now work as members of health care teams, and the doctor–patient relationship has shifted from paternalism to partnerships in which doctors are health and social advisors. The ready availability of information via the Internet has given patients more knowledge and control of their own health. Patients’ expectations have also changed. The success of medical research and medicine’s capacity to cure many illnesses have led to unrealistic expectations of what doctors can achieve. Furthermore, Shaw would be amazed at how health concerns have mesmerised modern society, fuelled mainly by hyped reports of cancer “breakthroughs”7 and the shroud-waving of epidemiologists about yet another lifestyle danger to health.8 Finally, Shaw would congratulate the medical profession for being consistently endorsed by the public as an ethical and honest profession9 and be comforted by doctors’ prosperity.10 In his day, doctors were “hideously poor” and were “offered disgraceful prices for advice and medicines”.1 However, Shaw would also detect undercurrents of discontent, and debate and dilemmas for doctors in several domains: Medical practice. The burden of bureaucracy has had an insidious impact on medical practice and the independence of doctors. Conforming to evidence-based and protocol-driven practice continually erodes the capacity for discretionary practice and dampens its intellectual challenge. These sources of discontent, along with pressure from patients and the need to keep up with rapid changes in knowledge, have eroded professional satisfaction.11 The dilemma for some doctors is whether to continue in clinical medicine, to retire prematurely, or to pursue other career options. The profession. Subspecialisation of medical practice has hastened the decline of the generalist and led to compartmentalisation and segmentation of the profession, with extra burdens imposed by accreditation, registration and calls for recertification. But more daunting is an emerging identity crisis: firstly, what is a doctor?, and secondly, what does a doctor do? The first question has spawned a spate of definitions of what constitutes a doctor12,13 and what modern professionalism means.14,15 The second question has prompted calls for devolving medical practice through task transfer,16 which Shaw, with uncanny prescience, foreshadowed: “There are cases that present no difficulties and can be dealt with by a nurse or student, at one end of the scale, and cases that require watching and handling by the very highest existing skill, at the other.” The dilemma for the profession is to decide whether to continue down the subspecialisation route or to encourage a return of the generalist. The profession also needs to decide how task transfer will evolve. Trust in doctors. Trust underpins the doctor–patient relationship and is critical to society’s acceptance of medicine as a profession. In the words of Jerome Kassirer, former Editor of the New England Journal of Medicine, “Patients must be able to trust that their doctors’ motives are not subverted by financial gain, that their doctors are recommending treatments that benefit them, and that their doctors are involving them in research projects for the right reasons. Their doctors must not only be at their sides, but on their sides.”6 The entry of industry into medicine has raised questions about its role in continuous medical education, scientific and professional meetings, and support for travel and research. In these relationships, perfunctory declarations of conflict of interest by doctors are seen as the panacea for any concerns about honesty and transparency, but mostly they amount to little more than window-dressing. The dilemma for the profession is whether to confront conflict of interest head-on or persist with its comfortable approach of tolerating many “shoulds” but not many “musts”.6 Leadership. The Royal College of Physicians’ (London) recent report on professionalism stressed the need for a common forum that speaks with a “unified voice”.15 Nowhere is this more applicable than in Australia, if the conflict between professional bodies of general practice is anything to go by.16 Indeed, there are questions about whether the professional organisation of Australian medicine and its regulatory and representative bodies are appropriate to meet our current challenges, which include inexorable subspecialisation, the ability to absorb the projected increased output of our medical schools, and the development of a functional e-health system.17 The dilemma for doctors is whether they will continue to allow multiple leaders of multiple organisations to pursue multiple interests, or whether they will insist on an effective common forum that is proactive and speaks with a unified voice. Shaw’s report card on the medical profession of his time was a harsh and bruising affair. One can only surmise what he would make of medical practice and doctors in Australia today. But, in many ways, the fundamentals haven’t changed. The doctor’s dilemma remains that of how to deal with personal and professional conflicts of interest in order to maintain a position of trust and independence.

Martin B Van Der Weyden MD, FRACP, FRCPA

Objective: To identify the most common health issues diagnosed by general practitioners in newly arrived African refugees.Design: Descriptive study based on a purposive sample of six GPs to collate data from medical records of patients from African countries who had attended their clinics for the first time between 1 January and 30 June 2005.Setting: Two community health centres and two private general practices in metropolitan Melbourne.Participants: African refugee patients who arrived in Australia after 1 June 2004 and were seen by the six participating GPs between 1 January and 30 June 2005.Main outcome measures: Demographic characteristics, laboratory test results and final diagnoses.Results: Data were collected from 258 patient files. Most patients were from Sudan (57%) or Liberia (17%). Half were aged under 15 years. The most common health problems identified were inadequate vaccinations, nutritional deficiencies (vitamin D and iron), infectious diseases (gastrointestinal infections, schistosomiasis, and latent tuberculosis) and dental disease. Musculoskeletal, psychological and social problems were common in adults. 37% of patients were tested for latent tuberculosis, and 25% of these tested positive.Conclusions: African refugees require comprehensive health assessments for undiagnosed and untreated health problems. While most of the common diseases identified are non-communicable, if left untreated they will affect the long-term health and productivity of new settlers.

Albert C D Tiong MB BS(Hons), MAppEpi · Mahomed S Patel MB BS, FRACP, FAFPHM · Joanne Gardiner MB BS, DipRANZCOG, BTheol(MCD) · Rowena Ryan MB BS, FRACGP · Karen S Linton MB BS, DipRANZCOG, FRACGP · Kate A Walker MB BS, FRACGP · John Scopel MB BS, FRACGP · Beverley-Ann Biggs MB BS, FRACP, PhD

Despite all our efforts, the boulder is barely halfway up the mountain When I set up in practice at Kununoppin [Western Australia] in 1958, the hospital was administered by a teenage girl working 3 days per week, the bed average was 20 and if I had a problem, the Medical Department would solve it. Today, the bed average is 14.5, a number that includes 10 residents in the permanent care facility, the hospital administration requires 3.6 full-time employees and if ever I have a problem, the Medical Department has almost certainly caused it. — Dr John Radunovich, addressing the Country Medical Foundation in 1993, when country medicine was in danger of being “rationalised” by the government. Perhaps the problem of rural medical workforce in Australia is best represented by the Greek story of Sisyphos, King of Corinth. He was a mortal, an individualist and, like many rural doctors, disinclined to do the gods’ bidding. For interrupting one of Zeus’ amorous pursuits, Sisyphos was sent to the bottom of Hades as punishment, condemned to forever push a boulder towards the top of a mountain, only to have it roll down as he neared his goal, so he had to start again. For more than 70 years, Australia has been trying to solve the problem of a paucity of rural and remote doctors. We have not been helped by the vagaries of workforce planning, which most developed countries, including Australia, got wrong. Now there is a worldwide shortage of general practitioners, general physicians and surgeons (and nurses) and, as always, the rural areas bear the major brunt. In the past 20 years, a mass of descriptive research has been published, inquiries and conferences held, and programs put in place. A plethora of rural medicine organisations and institutions have been formed to implement them. But our boulder continues to roll back down the mountain, and we have to continually push it up. Fly-in/fly-out specialist services to rural towns have been in place for many decades, and are now supported nationally through the Medical Specialist Outreach Assistance Program. The Rural and Remote General Practice Program recognises the need for extra support for rural medicine, with programs for the recruitment of rural GPs and students, and programs for retention and succession planning. We have tried a variety of incentives with at least partial success. We have also reinvented many programs in a different form to be implemented by a new organisation. Truly, Sisyphos is an appropriate candidate for patron of Australian rural medicine. So where do we find solutions — in the rock, in the mountain, in Sisyphos, or in appeals to the gods to ease his eternal labour? The rockWe need to make Sisyphos’ rock smaller and smoother. The nature of general practice has changed. Many rural GPs are unwilling to take on the worries of business ownership. They prefer to go into a service environment that supports and rewards them, and allows them to use their skills and find their own balance between work, social and other priorities. The 1930s saw the rise of “collectivisation” in agriculture. In rural general practice, this is having its expression as integrated primary care, which combines individual and population health, with combined Commonwealth, state and local government funding sources. The New South Wales Government Integrated Primary Health and Community Care Services program is an example that shows promise of fulfilling the dual aims of providing a locally managed but state-supported base for GPs with a single integrated base for primary health care. GPs have the opportunity to retain their own practice, with clinical and professional freedom, while working directly with community-oriented nursing and allied health professionals. Crucial to the success of the project is a third governance structure, locally developed, which maintains the separation of the general practice from the state health department, but builds workforce and clinical care integration.1 Doctors who wish to continue in a traditional practice management structure have also been asking for assistance in management. The South Australian Government has, as part of its “Recognising the past — rewriting the future” program, funded the Rural Doctors Workforce Agency in SA to facilitate the availability of management and legal advice to rural practices.2 The mountainWe need to make the mountain smaller and the path easier. Government policies recognise the resource needs of rural practice and support programs that attract, recruit and retain rural doctors. These programs are spread across myriad administering agencies, from undergraduate programs such as rural clinical schools to relocation support and retention payments. All have had some success and need to be continued. However, on their own, incentives recognise the need without affecting the cause. Incentive programs need to take into account the work initiated by the Rural Doctors Association of Australia in defining the conditions necessary to run and sustain a viable rural medical practice.3 They also need to be matched with programs that reflect the environment of today’s doctors — a work environment that is attractive to the increasing number of women in medicine and general practice, that encourages a healthy lifestyle for doctors, and that educates communities to be more aware of doctors’ needs, as we educate doctors to be aware of patients’ needs. Overseas-trained doctors make up 35% of GPs in rural and remote Australia. Many have temporary registration in areas of medical need and have never had their medical skills assessed. Rural communities and medical regulatory bodies display ambivalent attitudes towards these doctors. But it is clear that medical services in rural Australia would collapse without them.4 The Australian Rural and Remote Workforce Agencies Group points the way forward: overseas-trained doctors “need to be viewed as colleagues and community members contributing to solutions — not outsiders contributing to problems”.5 SisyphosRural medicine is inextricably tied to generalism, but it is under extreme threat, as instanced by the following. Between 2000 and 2005, generalist doctors decreased by 1%, while specialists increased by 47%.6 Of Monash University medical graduates from 1980 and 1985, 50% were working in general practice 8 years after graduation. Of graduates from 1995, 33% were working in general practice 8 years after graduation.7 Only 4.9% of University of Queensland medical graduates from 1990 to 2004 are currently working in rural and remote Queensland.8 These figures support findings from NSW evaluation and exit interviews, which increasingly show cadets staying in rural areas but taking up specialties other than general practice.9 This march to specialisation is compounded by poor resource support for health sectors dependent on generalists. The states need to acknowledge that their rural hospitals are largely reliant on GPs providing services to the public health system. Primary medical care needs to be able to compete with the specialties on a more level playing field in terms of facilities, conditions of service, career structure and financial reward. The latter is increasingly important as more and more medical students graduate with large debts. At the macro level, there is a need to attract doctors into generalist careers. Beyond seeing rural general practice as a specialty requiring its own fellowship recognition is a need for young doctors to see advantage in general and rural practice. Undergraduate programs have had some success in achieving this aim. However, much of this is lost in the early postgraduate years, as new graduates are captured by hospitals and find exciting and rewarding alternatives. Eighty per cent of new doctors have not decided on their career choice before their PGY 1 year.10 There is a need to have challenging GP and rural GP terms incorporated into their early postgraduate training. The godsIn Greek mythology, the affairs of state were influenced by competing deities, exemplified today by government departments. However, their lack of coordination results in contradictory actions, such as Commonwealth programs to re-skill procedural GPs, while state health departments close down obstetric units and dismantle anaesthetic machines in those doctors’ hospitals. And even before the rural clinical school initiatives come to fruition, we dilute their possible effect by introducing similar programs for outer metropolitan regions. In Australia, there is federal government funding for mental health, diabetes, obesity and other chronic disease programs. These programs are laudable, but in rural areas there also needs to be a pool of primary medical care funding to effect prioritisation and provision of local health needs. Country doctors are intolerant of excessive centralisation and managerialism by state health departments. Increased respect from bureaucrats towards those working at the coalface will go a long way towards keeping them there. Many formerly involved country people feel alienated by state health departments which cannot provide them with GPs, let alone locally grown ones, but which at the same time reduce their opportunities to have a real say in the organisation of their health care. The shortage of doctors in rural and remote Australia has been and will probably always be a Sisyphean problem. We do not need any more questionnaire-based surveys of rural intention or one-off reviews that only add to the weight of Sisyphos’ rock. We do need a method to enable us to take a continuing and holistic overview of what is actually happening at the grass roots level in providing rural and remote communities with appropriate and safe health care. One possible process could be an independent Office of the Inspector of Rural Health Care. A comparable example is the state-based Office of the Inspector of Custodial Services, which is supported by legislation that enables direct reporting to parliament. The rural health inspector would monitor workforce, problems of coordination and red tape, and propose policy and mediation for getting individuals, government-funded organisations and sectional groups to see further than their own self-interest. Ultimately, we must ask the gods to move beyond our fragmented programs of the past 20 years and towards coordinated programs that address the major impediments to having a viable rural medical workforce.

Max Kamien MD, FRACP, FRACGP · W Ian Cameron DRANZCOG, FRACGP, FACRRM

The Primary Health Care (PHC) working group of the Department of General Practice of Maastricht University in the Netherlands was founded in 1998 specifically to introduce students to patient care, research and education in primary health care settings outside the Netherlands. Rural health care in Australia is appealing to international medical students because of its unique setting. In the past 5 years, 42 medical students from Maastricht University have pursued a medical elective in rural Australia, supervised by the PHC working group. Doctors and coordinators in primary care clinics across Australia have welcomed and supervised students from Maastricht and exposed them to the reality of rural health care. Future collaboration with other Australian primary care clinics is welcomed.

Jochen Cals MSc · Peter Joyner DRCOG(Obst), FACRRM · Robert J Tuffley FRACGP, DRANZCOG · Geert-Jan Dinant MD, PhD

To the Editor: Schattner’s call to resurrect history-taking and examination as the dominant means of clinical diagnosis1 is analogous to advocating a return to cave-dwelling and spear-hunting for food in the era of houses and supermarkets. Even the most ardent supporters of history and examination would acknowledge that they can be grossly inaccurate, in possibly up to 30% of cases.1 Clearly, without using further diagnostic tools, there would be an unacceptably high rate of missed, incorrect or delayed diagnoses with associated morbidity, mortality and financial costs to the patient, hospital and community. Therefore, there is an urgent need to challenge the “politically correct” and entrenched paradigm of history and examination as the initial approach to diagnosis and management. In my approach to acute abdominal pain, I have long since abandoned using the stethoscope to ruminate over the meaning of mysterious bowel sounds in favour of liberal use of computed tomography (CT) scanning. Gone are the days of inspection, palpation, percussion, auscultation and operation. This often arouses considerable opposition from traditionalist colleagues who are concerned about the cost and radiation dangers of abdominal CT. But their criticism ignores mounting evidence that the modern CT scan is rapid and accurate for nearly all conditions that require emergency surgical treatment.2 In every study comparing the accuracy of CT scans with history and examination, CT wins hands down.2,3 The CT scan takes the guesswork out of diagnosing the cause of abdominal pain and, most importantly, reduces the need for laparotomy procedures that frequently produce negative results. Similar conclusions could be drawn regarding the use of CT scans in head injury or the use of chest x-rays in acute respiratory conditions. Perhaps the new clinical paradigm should be “scan first and talk later”. So, why 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. Cost is not a valid excuse, as there is no reason for patients to accept second-best care. The explanation may lie in blind adherence to ancient dogma that has been unchallenged since Hippocrates. Failure to accept that history and examination have severe limitations; to actively embrace newer, more accurate diagnostic tools; and to revise established clinical paradigms may relegate clinicians to the relevance of dinosaurs outside museums of ancient history. At the risk of medical heresy, I would suggest that the obituary notice for history and examination as the dominant diagnostic tools may be long overdue.

Kenneth Wong

In reply: Wong writes eloquently, and seems utterly convinced of the merit of the “testing first” medicine that he preaches. Yet his arguments are flawed and his system, appalling. Young physicians not wearing a white coat are a fairly common sight in hospitals these days. Without a coat, they no longer have a convenient means of carrying around essential tools such as a flashlight, reflex hammer or ophthalmoscope. Indeed, if all they have to do is automatically order computed tomography (CT) scans, they will not need such tools. It is exactly to oppose these negative trends in medicine that my article was written. What I was trying to say was not that history and examination should replace modern imaging, but rather, that the decision about whether and when to order a test, and what test to order, should more than ever be based on skilful verbal and physical contact with the patient. Careful interpretation of basic clinical data such as the proneness of the patient to develop certain conditions (“pre-test probability”), the behaviour of symptoms over time, and the results of very simple laboratory tests are also immensely valuable. Most of this information can only be gleaned from patient–physician communication.1 Would Wong’s approach to acute abdominal pain (do a CT scan first and then let the diagnosis sort itself out later) hold water in cases of acute gastroenteritis, renal colic, peptic ulcer, acute hepatic congestion, incarcerated hernia or Henoch–Schönlein purpura? All these not uncommon causes of acute abdominal pain can be confidently identified by their typical history and findings and successfully treated with no resort to imaging, which may be not only redundant but also costly and hazardous.2,3 An additional downside of imaging without forethought is that it is fraught with false negative findings (eg, early diverticulitis or pancreatitis) and false positive findings (eg, “incidentalomas”) that often result in diagnostic confusion, lost time and more unnecessary testing.4 When the indirect benefits of patient–physician communication and examination are also taken into account, the integral value of the clinical paradigm is even more strongly re-affirmed. Medicine is a humanistic profession. Patients experiencing pain, distress or uncertainty look up to the physician who talks to them, touches them, comforts them and is sensitive to their plight.5 Even the best, latest-generation CT scanner would never be able to do that.

Ami Schattner

To the Editor: Your thoughtful editorial comment1 in the 21 August issue laments that the essence of the art of our profession was potentially diminished recently by the report of a working party of the Royal college of Physicians of London.2 My medical dictionaries and textbooks are curiously silent on the notion of an “art of medicine”, so I went to “the source” and discovered that “Life is short, and the Art long” comes from quotes of popular Latin authors as “Ars longa, vita brevis” — in turn from Hippocrates’ original Greek,3 A native Greek-speaking medical colleague of mine points out that the Greek word used in the quote implies “long through to the end” — presumably the end of one’s career or the end of one’s life. So we (and Hippocrates) are evidently referring to a rather grand concept of the art of medicine, not just a narrow view implied by the term “judgement”, as proposed by the working party. I see judgement as being but one of many essentials of the art of our profession, and agree with Van Der Weyden’s assertion that the proposed use of the term “judgement” in place of “art” is indeed reductionist and should be rejected.

C Ross Philpot

To the Editor: I agree with Van Der Weyden’s quotation from Osler: “The practice of medicine is an art, based on science.”1 In my medical training in the 1960s, I was taught that medicine was both an art and a science — perhaps more the former than the latter, given that the technological age was not yet fully upon us. It saddens me that there is now an almost inexorable trend towards the use of advanced technology in medicine and away from human interaction between doctors and patients. I do not believe in reducing humans to mere numbers on a pathology results form or images on a computer-driven x-ray monitor. This is what helping patients “judge” which path to take “through the indeterminacies” back to health1 suggests. Gordon expressed similar sentiments in an earlier article:2 The arts, humanities and social sciences act as a counterbalance to the relentless reductionism of the biomedical sciences . . . [M]edicine will attract students who are interested in the biomedical sciences, many of whom are particularly good at processing and memorising information. Unless they have adequate time for reflection, such students may ultimately adopt a dogmatic or overly technical approach to clinical practice . . . As a “doctor” — in the sense of a modern version of an ancient healer — I accept that my role is “to cure sometimes, to relieve often, to comfort always”.3 There is cold comfort if we lose the “art” of medicine.

Norman Shum

A recent editorial discussed the issue of interactions between doctors and pharmaceutical companies (MJA 2006; 185: 299-300). The reactions ranged from agreement to offence. To the Editor: I would like to congratulate Tattersall and Kerridge on their recent editorial covering the issue of industry influence in medical education.1 Like the authors, I was dismayed on seeing the Australian Medical Association statement to the press regarding the recently revised Australian Competition and Consumer Commission guidelines for disclosure of industry support. Industry supports medical education because it pays, and we would be well advised to remain aware of this basic fact. It amazes me that anyone could subscribe to the view that doctors need industry freebies to remain informed of new therapeutic options in this age of electronic media. We are constantly inundated with information — the issue is to choose reliable, unbiased data. As a rule, industry-sponsored sources of information should be regarded as potentially biased and therefore suspect. In my view, direct industry sponsorship of continuing medical education activities is inappropriate and should not just be regulated, but abolished altogether.

Hans Peter Dietz

To the Editor: Tattersall and Kerridge make the argument that any interaction between industry and clinicians must, of necessity, compromise the decision as to the appropriateness of the particular treatment prescribed.1 The more common situation is that interactions do exist, and this is covered by a process of disclosure of, for example, honoraria or shareholdings. However, this situation is also inadequate, in that the extent of the potential for influence is not disclosed (eg, the size of the honoraria, or the volume of shares held in the company). This is also relevant when it comes to evaluating potential conflicts of interest in medical publications. As the authors note, the health care industry is complex, and interactions do occur between clinicians and industry. In this situation, full and frank disclosure — rather than the mere indication that a relationship exists — is far more appropriate.

Charles M Fisher

To the Editor: I am critical of the article by Tattersall and Kerridge.1 In my opinion, the article comprises a series of pompous announcements from an ivory tower, which hint without actually saying that doctors who attend educational symposia organised by pharmaceutical companies, and who subsequently order the product, are acting improperly. As I see them, the facts are quite otherwise. Medical practitioners have an obligation to do their best for their patients by giving them the most appropriate treatment available, and to keep up to date with their profession. Both these objectives can be achieved by educational symposia organised by the research-based pharmaceutical companies, which introduce new concepts in medicine as well as new products. Research-based pharmaceutical companies play a major role in the development of modern therapeutics through the introduction of new drugs. The development and manufacture in commercial quantities of life-saving compounds in the future, such as, for instance, the new biological agents and the new anticancer drugs that we need so urgently, would not be possible but for the pharmaceutical industry. One cannot imagine this important work being done by other agencies, such as the universities or the government. The Australian Government, in fact, sold its own pharmaceutical company (Commonwealth Serum Laboratories, now CSL Ltd) some years ago. Doctors attend educational symposia run by pharmaceutical companies so as to obtain information that will be useful for their patients, not because they can get a few free drinks and a dinner. The suggestion to this effect is offensive. I note that one of the authors is Director of the Centre for Values, Ethics and the Law in Medicine. I would value his opinion on doctors who advertise directly to the public, such as the eye surgeons who advertise repeatedly on talkback radio, and the promoters of alarming cardiovascular articles that predict catastrophes if one does not apply to the sponsors of the program. To criticise doctors for prescribing products promoted at educational symposia while allowing these other examples to flourish without criticism is, to my mind, hypocritical.

Ian S Collins

To the Editor: I would like to comment on two articles that appeared recently in the MJA. “Doctors behaving badly?”1 was an anticlimax. It was not, as would be expected, an exposure of misconduct by doctors, but dealt with the potential conflict of interest that occurs when they interact with the pharmaceutical industry. No evidence of doctors “behaving badly” was provided, yet a solution to this potential problem was proposed — “disclosure” (ie, yet more paperwork), accompanied by a disclaimer that this was unlikely to work. This is an important issue, but the content of the article cannot justify such a misleading title. I can only assume it was the result of editorial intervention, in which case there is some hypocrisy at work, given that the inside front cover and the outside back cover of the same issue of the Journal are taken up with full-page drug advertisements, and within, a $10 000 prize was offered for the best original research article published in the Journal (sponsored by a drug company). The second article, From the Editor’s Desk “Tilting at titles”,2 which cited the dreaded Australian values, suggested that titles such as “doctor” should be trashed altogether and replaced by an introduction such as “Hello. I’m Jean Smith. I am a urologist and together we will confront your prostate problem” — a statement that is unlikely to give great confidence to the average digger. Doctor Samuel Johnson put this argument to rest in 1775:3 What is implied by the term Doctor is well known. It distinguishes him to whom it was granted, as a man who has attained such knowledge of his profession as qualifies him to instruct others. A Doctor of Law is a man who can form lawyers by his precepts. A Doctor of Medicine is a man who can teach the art of curing diseases. My concern is that there appears to be an editorial assumption that doctors are preoccupied with titles and are willing to treat patients unethically for a few glasses of Kooyong Pinot Noir and a good feed. This might be good press, but not in the MJA. Perhaps some disclosure is required. To return to Johnson: There are but two reasons for which a physician can decline the title of Doctor of Medicine, because he supposes himself disgraced by the doctorship, or supposes the doctorship disgraced by himself.

Padraic J Grattan-Smith

In reply: We agree with Dietz that unbiased sources of information about new therapeutic options are increasing, and many are available electronically. Virtual Mentor, the American Medical Association’s ethics journal, has suggested reducing drug company influence on doctors’ prescribing by stopping companies paying for continuing medical education,1 and the Australian Competition and Consumer Commission is exposing this issue. Fisher recommends full and frank disclosure of links with industry, but he does not state to whom these disclosures should be made. The revised Royal Australasian College of Physicians guidelines recommend that employing hospitals create a Conflict of Interest Committee to receive employees’ declarations, and to advise when a duality of interest may be construed as a conflict of interest.2 The Box shows the disclosure statement that one of us displays in his consulting room, copies of which are sent to referring doctors when letters are written about patients. Grattan-Smith felt the title of our article was misleading. However, the title is stated as a question precisely because the assessment of professional behaviour, and particularly the assessment of possible conflicts of interest, is a matter of considerable dispute. It is clear that the relationships that doctors have with industry may constitute bad behaviour in the eyes of some, including the editorial writer in the Sydney Morning Herald.3 We do not, as Fisher suggests, contend that interaction with the pharmaceutical industry inevitably compromises prescribing decisions, but agree with him that full and frank disclosure, rather than the simple notification that a relationship exists, offers at least some reassurance that the possibility of influence is being acknowledged and managed. Collins asserts both that we hinted that doctors who attend educational symposia organised by pharmaceutical companies and subsequently order the product are acting improperly, and that doctors attend such meetings for the free food and wine. We do not believe that either statement is correct, and accept that the choices that doctors make to attend such events are generally motivated not by gluttony, but by a range of complex factors, including a desire for education, clinical feedback and professional collegiality. Nothing in the interaction between doctors and the pharmaceutical industry is simple. Although the editorial from the Sydney Morning Herald suggests that avoidance is the simplest response to this dilemma, we would argue that such a complex issue requires a complex response and that support for adequate disclosure should be a necessary (but insufficient) component of the medical profession’s response, if it hopes to maintain the high regard in which it is held by the Australian public. Example of a disclosure statement displayed in the consulting room and enclosed with letters about patients Disclosure of interests that might influence my prescribing and treatment of cancer patients Pharmaceutical companies I have received no honoraria or financial support for more than 10 years from pharmaceutical companies for: serving on advisory boards consultancies providing patients' data relating to drug use enrolling patients in a clinical trial speaking at a company-sponsored event During the past 10 years I have not: received financial or other support from pharmaceutical companies for my research activities or staff received travel, registration, accommodation or other support from pharmaceutical companies for me or my staff to attend regional, national, or international conferences or meetings received research support from pharmaceutical companies received personal gifts from pharmaceutical companies attended company-sponsored meetings, launches of new drugs I am not a principal investigator on trials supported by pharmaceutical companies. I do invite eligible patients to consider entry on some pharmaceutical company sponsored trials, but I derive no personal financial benefit. I do not accept free samples of drugs from pharmaceutical companies. I do not welcome visits from representatives of pharmaceutical companies. Martin Tattersall

Martin H N Tattersall · Ian H Kerridge

1 Café-au-lait spots with “coast of Maine” appearance 2 Computed tomography scan of the thorax showing multiple rib lesions A 46-year-old man presented with generalised bone pain which had been present for approximately 15 years. His past history was significant for a precocious puberty, with full development of secondary sexual characteristics by 9 years of age. His adult height was 165 cm. Physical examination showed multiple café-au-lait spots with typical “coast of Maine” appearance (Figure 1). Routine laboratory tests gave normal results, except for levels of inorganic phosphate (0.71 mmol/L; reference range, 0.81–1.45 mmol/L) and alkaline phosphatase (286 U/L; reference range, 31–93 U/L). A chest x-ray showed multiple ill-defined radiolucent lesions in the ribs. A computed tomography scan of the thorax showed multiple expansile lytic rib lesions, with a peripheral rim of calcification consistent with polyostotic fibrous dysplasia (Figure 2). The coexistence of precocious puberty, café-au-lait spots and polyostotic fibrous dysplasia constitutes the McCune–Albright syndrome.1 The pathogenesis involves mutation in the Gsα gene located at chromosome 20q13.2-13.3. All cells carrying this mutation manifest dysplastic features. This case highlights the importance of history and physical examination in establishing a correct diagnosis, which in this case was missed for several years.

Mehdi Hamadani MD · Lubna Chaudhary MD

New guidelines extend opportunities for GPs to respond In July 2006, new international consensus clinical guidelines — Management of the whole family when intimate partner violence is present: guidelines for primary care physicians — were launched simultaneously in Melbourne by the Victorian Community Council on Crime and Violence and at the General Practice and Primary Health Care Research Conference in Perth (Box).1 Partner violence is prevalent globally, exacerbated by poverty, war and gender inequality.2 In Australia, while 3% of women in the community report partner violence in the previous 12 months, the proportion among primary care patients is 8%.3 Men can also be victimised, but the evidence suggests that women suffer most of the significant harm, especially in the early child-rearing years, affecting the health of the whole family. Partner violence is no less prevalent among gay and lesbian families, and Indigenous families are particularly at risk of harm from partner or family violence, including murder of female partners.4 Abused women are more likely than non-abused women to experience physical and psychological symptoms and seek health care for stress-related and chronic ailments.5 There is also evidence of the damaging effect partner violence can have on children’s emotional, behavioural and cognitive development, as well as on their physical and mental health.6 Perpetrators can exhibit significant comorbidities, especially drug and alcohol misuse, and there is growing concern about early childhood development in this context. Increasing rates of depression and mental illness focus attention on the contribution partner violence makes to adverse social and economic circumstances.7 With a pattern of poor health and increased health care attendances by victims, perpetrators and their children, there are potential opportunities for health care providers to intervene. However, barriers to identification and management include lack of training, time and effective interventions.8 Advice for general practitioners in the medical literature focuses mainly on victims; there is a little on abusive male partners, but children or the wider dilemmas of whole-family management are rarely included.9 As recent systematic reviews concluded that there was inadequate evidence to guide clinical care,10 a Melbourne group of primary care researchers brought together, in a rigorous consensus process, an international collaborative team of clinical experts in partner violence. A systematic review of existing guidelines identified those of best quality, when assessed according to the Appraisal of Guidelines Research and Evaluation (AGREE).11 AGREE helps readers assess, firstly, whether the potential biases of guidelines development are adequately addressed; secondly, whether the recommendations are externally and internally valid; and finally, whether they are feasible for practice. Recommendations endorsed by more than three guidelines were supplemented by those addressing key gaps. These gaps included advice about investigating harm to children and adolescents, and parenting issues (addressing any parenting difficulties that the victim faces as a consequence of the abuse). Further gap recommendations deal with clinic management, including training of all staff in safety protocols when doctors are seeing different members of the family. With each recommendation, further narrative offers clarification and practical advice to strengthen the recommendation’s applicability. The controversial issue of screening had experts in Europe, the United Kingdom, Canada and Australia arguing that the guidelines should recommend case finding only. This was based on the need to obtain evidence that intervention does not harm women and children in the longer term, and the available evidence that practitioners are largely untrained and unsupported. In contrast, participants from the United States believed that, in view of the prevalence of the problem, screening was still vital, and that not screening was bordering on unethical. The majority recommendation resolved that physicians should routinely ask all pregnant women and girls about partner violence, because of their particular vulnerability and the association between partner violence and adverse pregnancy outcomes; they should undertake case finding with all other women and with men. While primary care intervention trials are only just underway, these guidelines offer the best current advice. Clinicians need to be mindful of the range of issues within the family that they may face. Many doctors continue to feel that asking about partner violence is “opening Pandora’s box”.8 There is increasing evidence that partner abuse is an underlying issue in many serious, recurrent symptoms in primary care, and that the damage to the family’s health creates continuing harm. Consequently, federal and state governments should ensure that doctors are provided with sustainable and effective training, support and resources to play their part in society’s efforts to prevent ongoing generations of damaged families. The partner violence whole-family guidelines are endorsed by the Royal Australian College of General Practitioners and available on the College’s website.1 Key selected recommendations from the guidelines on managing partner violence (as numbered in the document)1 Screening 1. Family practitioners should routinely ask all pregnant adult and adolescent women about partner violence 2. In other situations, doctors should ask patients with symptoms of partner violence and those with symptoms of abusive behaviour (case finding only) Men 5. Encourage a patient who has disclosed their abuse of a partner to take responsibility for their behaviour and change Children 14. Discuss any parenting concerns in the partner abuse context 15. Assess the risk to and adult perception of the impact on children 16. Consider the risk to and children's perception of the impact on their lives 17. Consider children's access to significant supportive others Clinic 27. Seek own and staff family violence training for management of all family members experiencing violence 29. Use a clinic protocol for monitoring danger to patient and other family members by any clinician seeing patient

Angela J Taft PhD · Kelsey L Hegarty MB BS, PhD · Gene S Feder MD, FRCGP

General practice will play a key role in both prevention and management of an influenza pandemic. Australian pandemic plans acknowledge a role for general practice, but there are few published data addressing the issues that general practitioners and their practices will face in dealing with such a crisis. The outcome will revolve around preparation in three key areas: Definition of the role of general practice within a broad primary care pandemic response, and adequate preparation within general practices so they can play that role well. Planning exercises and forums must include GPs, and rehearsals must include practical experience for general practices and their staff. Local Divisions of General Practice and GP practices can advocate for this, can define their role, and can prepare by using pandemic preparedness checklists. Definition and enactment of communication strategies to facilitate transfer of useful clinical and administrative data from practices and rapid dissemination of information into the community via general practice. Resource provision, which should be centrally funded but locally distributed, with personal protective equipment, vaccines and antivirals readily available for distribution. Resources must include support for human resource management to ensure appropriate health care professionals reach areas of workforce demand. Administrative, clinical and financial resources must be available to train GPs and practices in pandemic awareness and response.

Nick Collins FRACGP · John Litt FRACGP, MSc(Epid), DipRACOG, FAFPHM · Michael Moore FRACGP, GradDipPH · Tania Winzenberg FRACGP, PhD · Kelly Shaw FRACGP, MPH, PhD, FAFPHM

To the Editor: Your 3 July issue featured task substitution and task transfer. It is a principle of commercial organisation that if a task can be standardised, it can be delegated, automated or computerised, provided there is good central management, supervision and communication. However, I suspect that this is only a part of the new face of general practice, as we are being expected to undertake tasks for which my age cohort (I am 54) was neither trained nor prepared. Practice administration is far more complex than ever before, and most of the clinical caseload has shifted from episodic care of infections and surgical conditions to the long-term systematic management of chronic cardiovascular, respiratory, musculoskeletal, endocrine, and other illnesses. Diabetes is a good example. Managing patients with diabetes requires high-level skills in practice management and protocol-driven chronic disease care. I suggest that a basic and fundamental difference between doctors and allied health personnel is that allied health personnel are extremely comfortable with protocol-driven chronic management while doctors, especially of my age cohort, are more focused on detecting and dealing with difference, variation and abnormality in our patients’ health. Rather than force all groups to do the same tasks, is it not better to build on their skills and interests in a logical and structured manner? General practices are no longer only places where general practitioners work; they are evolving into teams of GPs, other doctors, administrators, allied health personnel and office and information techno-logy staff, who work together in an integrated and coordinated way for the benefit of patients. This provides mutual support, flexibility of work hours and increased job satisfaction for all. Our practice has been steadily working towards this for the past 20 years.

Christopher D Hogan

Objective: To investigate whether responses to a previously validated four-item medication adherence questionnaire were associated with adverse cardiovascular events.Design: Survey conducted among a cohort of participants in the Second Australian National Blood Pressure Study.Setting: Australian general practice.Participants: 4039 older people with hypertension.Main outcome measures: All major cardiovascular events or death; first specific cardiovascular event.Results: Subjects who adhered to their medication regimen (compared with non-adherent subjects) were significantly less likely to experience a first cardiovascular event or a first non-fatal cardiovascular event (hazard ratio [HR] for both, 0.81; 95% CI, 0.67–0.98; P = 0.03); a fatal other cardiovascular event (HR, 0.68; 95% CI, 0.48–0.99; P = 0.04); or a first occurrence of heart failure (HR, 0.58; 95% CI, 0.37–0.90; P = 0.02). Those who answered yes to “Did you ever forget to take your medication?” were significantly more likely to experience a cardiovascular event or death (HR, 1.28; 95% CI, 1.04–1.57; P = 0.02); a first cardiovascular event or death (HR, 1.31; 95% CI, 1.07–1.60; P = 0.01); a first cardiovascular event (HR, 1.34; 95% CI, 1.09–1.65; P = 0.01); or a first non-fatal cardiovascular event (HR, 1.35; 95% CI, 1.09–1.66; P = 0.01). Those who answered yes to “Sometimes, if you felt worse when you took your medicine, did you stop taking it?” were significantly more likely to experience a first occurrence of heart failure (HR, 2.06; 95% CI, 1.16–3.64; P = 0.01).Conclusions: Subjects who adhered to their medication regimen were less likely to experience major cardiovascular events or death. The question relating to forgetting to take medication identified non-adherent subjects likely to experience a cardiovascular event or death. Clinicians could use this question to identify patients with hypertension who are likely to benefit from medication adherence strategies.

Mark R Nelson MFM, FRACGP, PhD · Christopher M Reid MSc, PhD · Philip Ryan MB BS, FAFPHM · Kristyn Willson BSc(Hons) · Lisa Yelland BMa

David Henderson was an outstanding physician and teacher who made a significant contribution to medical education in Australia. Born in Gympie on 23 January 1921, he grew up in Queensland. After graduating from a war-shortened course at the University of Queensland in May 1943, David served his obligatory year as a Resident Medical Officer at Brisbane General Hospital, before joining the Australian Imperial Force. He was sent to Bougainville in August 1945, just as the war was ending. He served during the occupation of Japan until he was discharged from the Army in 1947, when he began training as a physician. Education at all levels played a central part in David’s life. A generation of doctors remembers him for his patient and provocative teaching. He was Senior Physician at Brisbane Women’s Hospital from 1955 to 1968 and Senior Visiting Physician at the Royal Brisbane Hospital from 1958 to 1981. He was Chief Medical Officer to the Australian Mutual Provident Society in Queensland for some 20 years. As First Research Fellow at the Queensland Institute of Medical Research (QIMR), David’s complex and detailed retrospective study of lead poisoning, which earned him a Doctorate of Medicine in 1959, is regarded as a “world first”. He later served on the QIMR Council for two decades, and was made a Fellow for his role in developing the Institute. In 1979, at David’s urging, the Medical Board of Queensland appointed the Thompson Committee to enquire into the future training needs for medical practice in Queensland. His farsighted advice contributed greatly to the Thompson Report. Published in 1981, it was largely this report that led to the radical changes in medical courses in Australia over the past 20 years. His concern with medical education also led him to a seat on the University of Queensland Senate from 1966 to 1974. In 1984, David and his wife Kay moved to Rockhampton for 2 years while he served as Coordinator of the Central Queensland Continuing Education Committee. The idea was to use information technology to provide information to isolated rural doctors — a potential use of computers that David had long recognised. David had a great variety of interests. He loved opera, the sporting activities of his children, dismantling and reassembling his Land Rover, and an outdoor life shared with family and friends. David died of pneumonia on 1 May 2006, after a long illness. He is survived by his wife Kay and children David, Richard and Margaret.

Daniel R L Hart