General medicine

Making health services more available to and appropriate for Australian men The 6th National Men’s Health Conference, held in Melbourne in October 2005, incorporated the 4th National Aboriginal and Torres Strait Islander Male Health Convention. Since 2003, the Australasian Men’s Health Forum — a not-for-profit peak body for individuals and organisations working with men and boys and their health and social issues, and the organising body of the biennial national conferences — had already been working collaboratively with the organisers of the National Aboriginal and Torres Strait Islander Male Health Convention. As a nation, we need to support Indigenous men, whose health is the poorest of all male population groups in Australia. Over the years of collaboration, it became apparent that the more holistic view of health that Indigenous men hold, as part of their cultural inheritance, could potentially benefit all Australian males. In 2005, a lack of national funding for the Indigenous Male Health Convention prompted a combined event with the National Men’s Health Conference, with some joint sessions and some sessions for Indigenous men on their own. This structured sharing led to an even greater empathy and understanding of the similarities and differences in Indigenous and non-Indigenous men’s health. The combining of the two conferences also enabled the National Men’s Health Conference to further broaden its perspective. Men’s health conferences in Australia have always taken a broad view of health. This is in contrast to international men’s health conferences, which have tended to have an almost exclusive focus on clinical dimensions — the prostate and erectile dysfunction featuring prominently — perhaps reflecting the funding sources of these conferences (World Congress on Men’s Health and Gender; Vienna, Austria <http://www.wcmh.info/>). Although important, a clinical perspective, if focusing too narrowly on disease and malfunction, can miss crucial dimensions, including psychosocial, spiritual and underlying political dimensions. Suicide, for example, is a major issue in men’s health, notably in Australia where, on average, five men a day kill themselves.1 For us to begin to understand and deal with this phenomenon adequately requires social and political perspectives, as well as clinical understanding. The Melbourne conference kept this broad focus on health, as well as the treatment of disease, with sessions on fathering, ageing men and gay men. From keynote addresses by international speakers, insights were gained into male-directed health services in Scotland (Mr Jim Leishman, the Men’s Health Service Coordinator, Northern Health Service, Forth Valley, Scotland — Developing services for men: the Scottish experience) and the building of a national men’s health policy in Ireland (Mr Noel Richardson, Coordinator of National Policy for Men’s Health, Ireland, and Dr Paula Carroll, Health Promotion Department, Irish Health Service Executive — Getting men’s health onto a policy agenda: setting a context to the development of a national policy for men’s health in Ireland.) The lack of a national men’s health policy in Australia was addressed by Micheal Woods in his paper, Dying for a policy: men’s health in Australia. The need for a national men’s health policy was also mentioned in the conference’s opening address, given by Dr Mukesh Haikerwal, President of the Australian Medical Association (AMA), whose presence was an indication of the growing acceptance in the medical profession of the need to consider male-specific issues in health. Of the states and territories, only New South Wales has a men’s health policy, and the AMA committed itself to a “round table” on the need for such a national policy. This has since taken place, and a position paper on men’s health has been issued.2 During the conference, Indigenous men launched the National Framework for Improving the Health and Wellbeing of Aboriginal and Torres Strait Islander Males (available from: Ms Jill Turner, Social Health, Health Strategies Branch, Office for Aboriginal and Torres Strait Islander Health, Jill. TurnerAThealth.gov.au). One of the main underlying themes of the conference was to question the assertion that poor health outcomes of men are a result of assumed “bad” male behaviour — typified by statements such as “Men don’t use doctors enough”, and “Men don’t get in touch with their feelings” — and to shift the focus to asking further questions such as: How can we make health services more available to and appropriate for Australian men? (Box 1). The effort to make services more “male friendly” was evident in many of the presentations (Box 2). Further initiatives in this direction would be welcome at the 7th National Men’s Health Conference, to be held in conjunction with the 5th National Aboriginal and Torres Strait Islander Male Health Convention, in South Australia in 2007, supported by the SA Health Department. In Melbourne, we had 303 delegates, including 75 Indigenous men. We look forward to having you join us next year at an even bigger gathering of all those with an interest in men’s health (Conference contact: Greg Millan, Conference Development Officer, Australasian Men’s Health Forum, gmillanATbigpond.net.au). 1 Where do I fit in? Created by Greg Gaul (reproduced with permission of Men’s Health Information and Resource Centre, University of Western Sydney). 2 Examples of presentations about “male-friendly” health service delivery Wow I’m a Dad. Development of a booklet for first-time fathers Alan Grochulski, Royal North Shore Hospital (booklet co-authored by Salih Ozgul) Indigenous men’s health and wellbeing — “there’s more than just football”. The Royal Flying Doctor Service Mental Health Program Brod Osborne and Johnathan Link, Royal Flying Doctor Service, Far North Queensland Driving to good health — commercial drivers encouraged to “think about it” Fiona Landgren, Clare Burns, Communicating for Health Building capacity for health promotion at Fairfax — a case involving the Men@Work Program Nick Petrunoof, John Fairfax Holdings Ltd HealthBreak: Sleep Safe–Work Smart–Health Program Howard, Lehrke, Wilson, Institute for Breathing and Sleep

John J Macdonald DipCD, Med, PhD · Greg Millan ADip Social Work · Mick Adams PhD Student

Objective: To identify sociodemographic factors associated with help-seeking behaviour for reproductive health disorders in middle-aged and older Australian men.Design: A cross-sectional, population-based, computer-assisted telephone interview exploring sociodemographic factors and general and reproductive health.Participants and setting: Analysis of data from the Men in Australia Telephone Survey (MATeS) of 5990 Australian men aged 40 years and older interviewed between September and December 2003.Main outcome measures: Self-reported diagnosis of prostate disease and erectile dysfunction (ED), help-seeking behaviour (including visiting a doctor, prostate-specific antigen testing, treatment of prostate disease, speaking to a health professional about ED and treatment of ED).Results: Age was a significant predictor of all help-seeking behaviour studied, other than treatment for ED. Controlling for all predictor variables, never-married status predicted a lower likelihood of visiting a doctor (odds ratio [OR], 0.68 [95% CI, 0.48–0.97]) or speaking to a health professional about ED (OR, 0.44 [95% CI, 0.21–0.93]), while divorced/separated status predicted lower likelihood of having a prostate-specific antigen test (OR, 0.63 [95% CI, 0.50–0.79]). Living in a regional or remote area or being from a non-English-speaking background predicted lower likelihood of receiving treatment for ED (ORs, 0.62 [95% CI, 0.42–0.92] and 0.41 [95% CI, 0.24–0.72], respectively), but did not influence screening for prostate disease.Conclusion: Seeking advice or treatment for male reproductive health disorders is predicted by sociodemographic factors specific to different reproductive health problems. As middle-aged and older men do attend doctors, opportunities exist for health professionals to optimise their consultations by routinely discussing reproductive health with all men, to identify under-reported male reproductive health disorders.

Carol A Holden PhD · Damien J Jolley MSc(Epidemiol), AStat · Robert I McLachlan MB BS, PhD · Marian Pitts PhD · Robert Cumming PhD · Gary Wittert MB BCh, PhD · David J Handelsman MB BS, PhD · David M de Kretser MB BS, PhD

Men are at highest risk of cardiovascular disease, chronic lung disease, some cancers, suicide and transport-related injury. An anticipatory approach to men's health in general practice should assess risk for these conditions and offer effective interventions, either to prevent them or manage them early. This requires attention to the barriers, not only to men accessing general practice, but also to appropriate assessment and management, especially among disadvantaged groups.

Mark F Harris DRACOG, FRACGP, MD · Suzanne McKenzie MB BS, FRACGP, MMedSci(Clin Epi)

It often falls to general practitioners to identify and manage service-related mental health problems It has long been recognised that veterans may experience mental health problems after military deployments, and that these can be overlooked in the context of concern about physical injuries. Primary care practitioners, both military and civilian, are often the first port of call for affected veterans, and are best positioned to assess these patients and commence care when necessary. As over 85% of Australia’s trained forces are male, these health problems are particularly relevant for men’s health. American research on veterans from recent Middle East deployments shows high rates of psychological problems.1 Interestingly, British research on the same conflict found that problems are limited to reservists, with no elevated rates of mental health problems among regular personnel.2 Although local data are unavailable, it is reasonable to assume that Australian veterans from Afghanistan and Iraq will not be exempt. We learned much from the experience of Vietnam veterans, with their initial difficulties closely resembling those of younger veterans presenting today. While much attention is paid to post-traumatic stress disorder, evidence suggests that other anxiety, depression, and substance-misuse disorders are equally common.3 Providing effective mental health care for veterans presents particular challenges. For many reasons (including personality, military culture, deployment experiences, and adjustment to civilian life), veterans may be reluctant to acknowledge or report psychological problems. They may have poor mental health literacy, may avoid treatment, and can be hard to engage when they do present. Many have developed unhelpful strategies for managing distressing emotions, often channelling them into anger and aggression or covering them with substance misuse. Such strategies may have been adaptive in combat, but in civilian life they alienate the veteran from key sources of support. Veterans often present to general practitioners with physical health complaints that mask concerns about psychological issues. Early detection and appropriate intervention often become the responsibility of GPs. Once it is determined that the patient is a veteran, a few simple questions about sleep, family relationships, mood, anger, and substance use can provide an opening for intervention. The information in the Box identifies strategies and resources available to assist the mental health and wellbeing of veterans. Resources for veterans and their doctors The Australian Defence Force (ADF) has improved post-deployment screening, increased emphasis on mental health literacy and self-care, and attempted to improve the accessibility, acceptability and quality of care. This may help military personnel to not minimise health problems for fear of career damage. http://www.defence.gov.au/dpe/dhs/mentalhealth An enhanced career transition assistance scheme has been introduced by the Department of Veterans’ Affairs (DVA) and ADF for personnel discharging for medical reasons, to facilitate transition back to civilian life. http://www.defence.gov.au/dpe/dpectap The relatively new Military Rehabilitation and Compensation Act 2004 (Cwlth) focuses on vocational and psychosocial rehabilitation. This follows the Veterans’ Vocational Rehabilitation Scheme, which is designed to support veterans’ efforts to retain or return to employment while ensuring no loss of compensation entitlements in the process. http://www.dva.gov.au/health/younger/younger.htm In June 2005, the DVA released alcohol practice guidelines for practitioners helping veterans with alcohol problems. These guidelines cover screening and assessment through to treatment of comorbid alcohol misuse and post-traumatic stress disorder (PTSD). http://therightmix.gov.au/professionals.asp The DVA has produced an excellent self-help website for veterans with alcohol problems. http://www.therightmix.gov.au The Vietnam Veterans’ Counselling Service (VVCS) provides individual and group-based interventions to all veterans (not just from Vietnam), as well as their partners and children. VVCS also offers programs such as anger management, lifestyle management, heart health, and retirement preparation courses. http://www.dva.gov.au/health/vvcs Veterans with an accepted mental health disability are eligible for treatment from specialist mental health providers in the community, including psychiatrists and clinical psychologists. In addition, the DVA continues to fund high-quality treatment programs for veterans with PTSD across Australia. These accredited, group-based programs have demonstrated outcomes which match or better international equivalents.4 http://www.acpmh.unimelb.edu.au/mentalhealth/treatmentPrograms.html Other useful websites include: the US National Center for PTSD http://www.ncptsd.org the UK National Institute for Clinical Excellence PTSD guidelines http://www.nice.org.uk/page.aspx?o=248114 the US Veterans Affairs PTSD treatment guidelines http://www.oqp.med.va.gov/cpg/PTSD/PTSD_Base.htm the Australian Centre for Posttraumatic Mental Health http://www.acpmh.unimelb.edu.au

John A Cooper MB BS, FRANZCP · Mark C Creamer PhD · David Forbes MClinPsychol, PhD

The lack of an evidence base for formulating men’s health policies means existing programs and practices for men are influenced by prevailing cultural norms concerning men or habitual health service attitudes towards them. Factors impeding the development of an effective health policy for men include a preoccupation with limited clinical perspectives (an emphasis on the prostate and erectile dysfunction) and a common assumption that all health problems in men are a result of “masculinity” and “men behaving badly”. Viewing men’s health in terms of gender and health and the socially constructed differences between men and women is important, but does not provide all the perspectives required for meeting men’s health needs. A “social determinants of health” approach to men’s health would help Australia and Australian medical practitioners move away from policies and practices that perpetuate negative views of men and ignore the complexity of their health problems. The result would be a more evidence-based approach to men’s health policy, and the likelihood of improved health outcomes.

John J Macdonald

Complex societal factors unrelated to evidence of efficacy influence the increasing use of complementary and alternative therapies, which can be viewed as one form of health consumerism. The “therapeutic footprint” is a conceptual model that “plots” medical therapies and complementary and alternative therapies in relationship to one another and to their levels of risk and supporting evidence, acknowledging that medical therapies also entail risks. Philosophies about management of risk and adverse effects differ between complementary and alternative therapies and standard medical care, due to fundamental differences between professionalism within medicine and the demands of health consumerism. In standard medical care, patients’ risks are mediated prior to treatment via the doctor–patient relationship and informed consent. With complementary and alternative therapies, protection mechanisms for consumers come into effect mainly after a problem has occurred. Understanding this difference helps doctors whose patients are using complementary or alternative therapies to define the boundaries between these therapies and professional medicine and provide appropriate disclosure of risks. Discussing complementary and alternative therapies and how they differ from standard medical care can provide opportunities to explore patients’ concerns and improve the therapeutic relationship.

Christine R Sanderson BM BS, MPH, FRACP · Bogda Koczwara BM BS, FRACP, MBioethics · David C Currow BMed, MPH, FRACP

To the Editor: I was very concerned to read the letter from Mazza et al1 regarding “positive” family planning and feel I must make a comment. The authors are well known for their work in the area of women’s sexual and reproductive health, but I would like to challenge some of the points they have made. The first point: whether intervention by general practitioners would be appreciated by younger women not yet interested in motherhood. I believe it is part of the role of doctors to inform, even when a person may not be ready for the information. Telling 20-a-day smokers that they are not doing their body any favours doesn’t go down well with some people, but even this brief intervention can change behaviour and save lives. The second point: whether GPs can respect patients’ autonomy. Every day I speak to women who have been offended and upset by doctors who have said something awkwardly, or imposed their own values, or been downright offensive. That won’t change, and recommending that well informed and tactful doctors wait before imparting vital information until the rest of the world lifts its game means we will all be waiting a long time. Part of the art of medicine is judging the audience and knowing the perfect point in a consultation to speak, and how to say it. What can be more appropriate, when seeing a woman in her late 20s who has requested a repeat prescription for the contraceptive pill, than to ask casually (as one is unrolling the sphygmomanometer cloth), “So, do you think there might be any children in your future?” The usual response, as detailed in Cannold’s book,2 is an emphatic “yes”. The next question, “Have you got a time scale when you would be looking at that?”, may give the opportunity to mention such things as rubella vaccination, smoking and folate supplements. And if the woman indicates that pregnancy would be on her to-do list at age 38, then a reasonable and non-harassing response could be, “Could we talk about fertility rates at that age?” The third point: doctors reinforcing the dominant paradigm (of years ago) of the woman as childbearing machine, by asking about a woman’s intentions. This seems to me as misguided as not asking about suicidal ideation in case we make it happen. By all means do research, but don’t ask doctors to be silent about this important issue until the sociologists have spent another 10 years on it. By that time, it will be too late for a lot more women.

Angela M Cooney

Strategies to close the gap between development and implementation of guidelines In the past decade, evidence-based clinical guidelines have become a major feature of health care. Researchers and clinicians in many countries have established programs to summarise the evidence for managing specific health problems and to disseminate practice guidelines. However, clinical use of guideline recommendations does not necessarily follow. Numerous studies show that recommendations are frequently not applied in practice and that many patients do not profit from evidence-based insights.1 Large variations in performance between clinicians, practices and institutions are commonly observed. Two reports in this issue of the Journal (Bryant et al and Irving et al) illustrate this well.2,3 In the first, an audit in a hospital outpatient clinic showed that large numbers of patients with diabetes do not achieve recommended treatment targets for control of glycaemia, blood pressure and lipid levels, despite evidence that control of these risk factors produces better outcomes.2 The second, a study of six Australian dialysis units, showed that, despite high levels of awareness of iron guideline recommendations in participating units, there is considerable variation in achievement of targets and widely differing practices in unit processes for iron management.3 Guidelines are expensive — the cost of producing a single guideline may range from US$50 to US$500 000, not to mention the substantial donated time from many contributors.4 Given the lack of practical impact of many clinical guidelines, a critical observer might well ask, “Why spend so much money and effort on something that is so poorly adhered to in practice?” However, the question should really be, “What can we do to increase the use of best evidence guideline recommendations?” Guideline developers, research funders, health care managers and policymakers may need to consider a few key strategies: the need for greater focus on producing guidelines in formats that promote their use; the requirement for planned (and funded) implementation programs that take into account the complexity of change in health care; and the need to improve our knowledge about cost-effective methods of achieving sustained practice changes. Worldwide, many guideline developers give little consideration to the use of their products in the real world. The reality is that guidelines are too often “lost in translation”.5 Many current programs for guideline development seem to be “science-driven”, rather than scientifically based but “customer-driven”. Guideline developers would do a far better job if they focused on the needs of the end user and provided clear statements, decision aids, patient education materials and practical tools to manage difficult problems in practice. More guidelines need to identify specific evidence-based indicators and criteria for clinical performance (as the guidelines discussed in this issue of the Journal do). These provide the capacity to monitor performance and give feedback to clinicians. Public reporting of significant aspects of care quality would help meet the urgent need in society for more transparency about important aspects of health care provision, and would provide a clear imperative to improve implementation and ensure guideline recommendations are feasible and do not become outdated. There is also a need to seek a better balance between the resources devoted to summarising evidence and developing guidelines and those spent on finding the most effective ways to improve patient care. Evidence-based guideline development reflects just one specific approach to improving care — it assumes that professionals are rational decisionmakers who will act on convincing information about the pros and cons of specific routines. Most of the time, effective change in health care demands other models, ranging from those that emphasise patient involvement in decision making to those that focus on organisational development.6 Sadly, good evidence for the cost-effectiveness of many of these strategies aiming to change practice is lacking.6-8 Greater investment by research funders in studies that would improve this knowledge base would help direct implementation resources and effort to where they could be of most use. Policymakers who seek to change health care practices need to understand that some current expectations about the impact of clinical guidelines are unrealistic. A belief that developing and disseminating systematic reviews and guidelines will improve patient care ignores the complexity of change in health care. Guidelines do not implement themselves — most need well developed, well executed and sustained implementation programs,7 and even such programs usually have only a moderate effect on performance in terms of care improvement (around 8%–10%).8 Many factors play crucial roles in blocking or stimulating relevant changes in performance. These are not only related to professional decision making, but also to patient behaviour, interaction with colleagues, team functioning, organisational conditions for change, resources, and economic or legal conditions.7,9,10 This aspect was clearly demonstrated in the renal impairment study.3 For most complex changes in health care, we need to build bridges between the different approaches to better care — guidelines, performance indicators and feedback; patient empowerment; quality management; organisational change; improving culture, teamwork and leadership in the workplace; and creating the necessary financial incentives.6 So, with a change of focus in current guideline development and more realistic expectations of the role of guidelines in improving patient care, with better knowledge about costs and effects of change strategies, and with clinical guidelines embedded in comprehensive programs for change, evidence-based guidelines for clinical practice may become more relevant in the future.

Richard Grol PhD · Heather Buchan MB ChB, MSc, FAFPHM

To the Editor: Tan et al1 found that patients value key elements of successful weight management, including advice on healthy eating and exercise and regular follow-up. Accredited practising dietitians (APDs) provide all of these things and have the qualifications, skills and time to work with people to effectively manage weight. APDs use the Obesity Best Practice Guidelines of the Dietitians Association of Australia, providing evidence-based dietary therapy. By working alongside general practitioners to provide individual advice, APDs ensure the best outcomes for patients. A considerable number of patients surveyed said that referral to a dietitian would be useful and that they would be likely to follow their GP’s advice if referral was recommended. The weight management roles of GPs and APDs are complementary and, by addressing any patient concerns and providing a referral to an APD, GPs can help their patients achieve their weight management goals.

Claire Hewat

Objective: To determine the incidence of and risk factors for surgical site infections in general practice.Design: Prospective, observational study of patients presenting for minor excisions.Setting: Primary care in a regional centre, Queensland, October 2004 to May 2005.Participants: 857 patients were assessed for infection.Results: The overall incidence of infection was 8.6% (95% CI, 3.5%–13.8%). Excisions from lower legs and feet (P = 0.009) or thighs (P = 0.005), excisions of basal cell carcinoma (P = 0.006) or squamous cell carcinoma (P = 0.002), and diabetes (P < 0.001) were independent risk factors for wound infection.Conclusion: Our results indicate the high-risk groups for surgery in a general practice setting, such as people with diabetes and those undergoing excision of a non-melanocytic skin cancer or excision from a lower limb. Recognition of these groups could encourage more judicial use of prophylactic antibiotics and use of other interventions aimed at reducing infection rates.

Clare Heal MB ChB, DRACOG, FRACGP · Petra Buettner MSc, PhD · Sheldon Browning DRACOG, DipDerm, FRACGP

Objective: To examine factors influencing the identification of kidney impairment in patients with type 2 diabetes in Australian primary care.Design, setting and participants: 348 general practitioner investigators were asked to estimate kidney function and its severity in 10–15 consecutively presenting patients with type 2 diabetes (n = 3893). They were then asked, for each patient, whether they routinely estimated kidney function. No instruction was provided on how kidney function should be estimated or categorised. Data were collected between April and September 2005.Main outcome measures: Kidney function estimated by the Cockcroft–Gault equation using clinical and laboratory data provided by the GP; estimates of kidney function made by the GP.Results: In 24% of the patients with type 2 diabetes, their GP routinely estimated kidney function. However, few of these patients had impaired kidney function or risk factors for kidney disease. There was a good statistical correlation between the estimates made by GPs and the data-derived estimates (R2 = 0.72). GPs identified patients with data-derived estimates of kidney function < 60 mL/min in over 83% of cases, with a specificity of 90%. Impaired kidney function was reported by GPs in 34.4% of men and 36.4% of women. These figures were discordant with function categorisation using both GP estimates and data-derived values, overlapping in half of the patients. Despite GPs’ ability to assess creatinine clearance, “raw” (unstandardised) serum creatinine levels inappropriately influenced the perception of impairment of kidney function.Conclusion: GPs can accurately assess kidney function, without reporting of estimated glomerular filtration rate (eGFR). However, even in patients at increased risk of chronic kidney disease, routine estimates are seldom made. Our findings underline the value of the recent initiative recommending automatic reporting of eGFR in Australia.

Merlin C Thomas PhD, FRACP · Andrew J Weekes MD · Olivia J Broadley BSc, BCA · Mark E Cooper PhD, FRACP

To the Editor: We are delighted at the attention which the editorial by Hickie and Blashki1 has drawn to our clinical update on the management of bipolar disorder in general practice.2 However, we are bemused by a number of the sentiments, criticisms and statements of fact included in that robustly expressed editorial. We will focus only on a few of the major issues raised. Hickie and Blashki argue that there are too many “worthy” guidelines promulgated to general practitioners by “specialist colleagues” across the range of medical conditions, and that extrapolation from specialist centre studies “may particularly annoy GPs”. On the other hand, they bemoan the fact that “few [guidelines] have targeted general practice”. We are surprised by this insinuation that such issues pertain to our clinical update. Three of the authors of our article are GPs in either clinical or academic practice, and the document has been formally endorsed by the Royal Australian College of General Practitioners. Our article focuses on the practical issues concerning the role of the GP in the management of patients with bipolar disorder, and deals frankly with the respective contributions of the GP, psychiatrist, and psychologist. It is our experience that GPs are enthusiastic in enhancing their skills in the management of mental illnesses such as bipolar disorder in the primary care setting. Therefore, we have little doubt that updates such as ours will be viewed as helpful aids for GPs, who are often the main “port of call” for people with this condition. We strongly contend the statement that we ignore practice-based issues and thereby risk “an overall negative rating from the target audience”. Hickie and Blashki state that “the most useful mental health guidelines tackle the tough issues”, such as sources of self-help, self-monitoring, detailed illness descriptions, family education, quality e-health resources, and guidance when patients become a danger to themselves and others. We fail to understand the implication that our update does not address such issues, as these very practical matters are clearly highlighted in detail in our article. Finally, we are surprised at the negative tone concerning guidance for the management of mental illness in general practice by authors who have argued strongly for the value of evidence-based guidelines in specialist psychiatric practice.3 Although (as we clearly acknowledge) there is currently a limited evidence base for managing such conditions in primary care, there is still a major need for practical guidance for the practitioner in this setting.

Philip B Mitchell · James A Best · Bronwyn M Gould · Ian G Wilson

To the Editor: Hickie and Blashki are to be commended for their view that clinical practice guidelines in mental health should be relevant to a primary care setting.1 Unfortunately, such guidelines have little effect on clinical outcomes, as most general practitioners have not been taught how to use them to their best advantage.2 There is also little known about the best way to implement guidelines in mental health, let alone in primary care mental health settings.3 As a result, more guidelines, even those more attuned to the primary care environment, will be of little benefit to our community. The Royal Australian and New Zealand College of Psychiatrists (RANZCP) is actively promoting the use of clinical practice guidelines4 as a quality improvement tool that will allow mental health practitioners (including GPs) to assess their practice more carefully and measure and analyse variance. The next step is to fund research into how best to implement mental health guidelines at the coalface. It is only through practice-based research that the barriers to successful implementation of evidence-based practice can be identified and overcome. Such research could be funded via a National Health and Medical Research Council (NHMRC) or Australian Research Council (ARC) grant program and coordinated by groups such as the RANZCP or the National Mental Health Working Group Safety and Quality Partnership Group. Mental health has already been identified as a grant funding priority by the ARC.5 Once this has been achieved, then training and mentoring to help practitioners review their practice as part of a quality improvement framework is required, rather than more guidelines per se. Providing well researched, up-to-date and accessible information for GPs on “self-help, self-monitoring, [and] detailed illness descriptions”, as suggested by Hickie and Blashki, is commendable, but is not what is required for guidelines to truly improve the safety and quality of mental health care in Australia.

Andrew J Wilson · David Barton

To the Editor: A nationwide colorectal cancer (CRC) screening program will commence in 2006. It has been shown that general practitioners can influence their patients in the decision to have CRC screening.1,2 There are several screening test options in Australia, and the relative geographical isolation of rural centres may influence attitudes and participation. We sought to determine the attitudes of GPs towards CRC screening and test preferences. Between January and September 2005, all GPs in Western Australia (n = 1837; 1298 metropolitan, 539 rural) were sent a questionnaire, which was completed by 801 (43.6%). Overall, 62.8% of respondents believed that asymptomatic average-risk subjects should have CRC screening (67.1% of metropolitan GPs v 54.2% of rural GPs; P = 0.003). The questionnaire revealed major differences between which test GPs would recommend for their patients and which test they preferred for their own personal screening (Box). These differences were related to the factors GPs believed were most likely to influence choice of screening test. For colonoscopy, accuracy and speed of result were considered most important; for faecal occult blood testing, no need for bowel preparation or time off work and no discomfort were considered the strongest determinants. Previous studies that included patients’ views have found that physicians may incorrectly perceive certain factors in screening to be important to their patients.3 There were no significant differences in choice of test between rural and metropolitan GPs. Although the target age group for the Australian pilot study and the national screening program is 55–74 years,4,5 two thirds of GP respondents felt screening should be offered from the age of 50 years, and a quarter believed it should continue beyond 80 years. Many GPs (65%) indicated they would like further education on CRC screening. In summary, there is good support for CRC screening among Western Australian GPs, but the availability of different screening tests and variations in GPs’ opinions are likely to significantly influence clinical practice. Colorectal cancer screening methods and general practitioners’ recommendations and attitudes Test recommended by GP for patients GPs’ perception of patients’ choice of test GPs’ preferred test for their own screening Faecal occult blood testing 430 (53.7%) 396 (49.4%) 236 (29.5%)* Colonoscopy 285 (35.6%) 278 (34.7%) 479 (59.8%)* Flexible sigmoidoscopy 37 (4.6%) 20 (2.5%) 20 (2.5%) Computed tomography colonography 18 (2.2%) 69 (8.6%) 32 (4.0%) Barium enema 0 2 (0.25%) 3 (0.4%) * P = 0.004 (χ2)

Graham B Turner · Marcus W Chin · Noellene M Foster · Jon Emery · Geoff M Forbes

To the Editor: Australia’s imminent bowel cancer screening program will revolve around the general practitioner,1-3 whereas, in the United Kingdom, the GP will have virtually nothing to do with the national screening program now underway.4 It is curious that two programs with the same evidence base regarding effectiveness should be so fundamentally different. One explanation could be the differing health care systems in each nation. However, they are more alike than not, so the true explanation for the Australian methodology could rest with the outcome of the Australian pilot studies. If that is the case, then perhaps one should be both alert and alarmed. Given the inequity in access to GPs in Australia, it is not surprising that the Final Evaluation Report5 of the pilot national screening program stated that: Some GPs interviewed in Woolcott’s Qualitative Research focus groups . . . expressed concern over access to FOBTs [Faecal Occult Blood Tests] for people without a fixed address. It was mentioned that this group, particularly Aboriginal and Torres Strait Islander people and people in low socioeconomic groups, particularly homeless people, did not receive invitations to participate in the Pilot. Some GPs commented that the information packs, in both English and the translated versions, were too complicated for people with low literacy and those from culturally and linguistically diverse backgrounds.5 The same report noted that 38% of people overall (men, 42%; women, 34%) and 52% of non-English speakers did not visit their GP after a positive FOBT. Nevertheless, the report favours the continued central role of the GP.5 This is not the case in the UK screening program, which has a more direct approach, with program hubs and associated screening centres — all with defined accountabilities. The Australian approach is to simply add to the workload of GPs — a more pragmatic approach in the short term, but less imaginative. Our program will undoubtedly be a step forward in colorectal cancer prevention. The question is how large that step will be. Reliance on the existing system threatens to reinforce existing health care inequities.

Allan D Spigelman

To the Editor: The recent report by the Multicentre Australian Colorectal-neoplasia Screening (MACS) Group1 offered some intriguing findings. Participation in bowel cancer screening was lower than expected, despite a range of tests being offered. In addition, people offered a choice of different faecal occult blood tests (FOBTs) were less likely to participate than those not offered this choice. The accompanying editorial by Salkeld and colleagues concluded that “Informed consumers making smart choices about screening . . . would be a public health success”.2 We believe the available evidence indicates otherwise. As the MACS Group study showed, participation in FOBTs was lower than in the Australian Government FOBT pilot program,3 and participation in screening by colonoscopy was lower than for other studies, including our recent Australian study.4 They suggested this may be because local general practitioners were not engaged in the project. Our study was designed to address this issue, and concluded that involvement of GPs had a small, non-significant effect on participation rates and no effect on response to invitation.4 This is not to say that involvement of GPs is undesirable. The MACS Group study found participation in FOBTs of 27.4% when only an FOBT kit was provided and a significantly lower participation when a choice of four screening modalities was offered, with an FOBT kit provided (18.6%, P = 0.03). These data confirm the findings of a large multicentre study from the SCORE2 Working Group.5 In that study, participation in FOBT was 30.1%, while participation in either FOBT or flexible sigmoidoscopy, when a choice of the two was offered, was 27.1%. The authors did not offer this analysis, but the difference was again significant (P = 0.015, two-tailed Fisher’s exact test). The editorial by Salkeld et al suggested that the Australian bowel cancer screening program should incorporate decision-support systems to allow informed choice of screening options. The “choice paradox” reported by the MACS and SCORE2 studies argues against this. Further, there is no evidence that decision support improves rates of participation in screening, and some explicit evidence that it has no effect.6 This should not be troubling. At this time, most colon cancer screening is still performed after consultation between patient and doctor, and in this setting informed choice is possible and desirable. Decisionmakers such as the Australian Government Department of Health and Ageing use a different process, which is explicit and quantitative,7 in determining screening policy. With the evidence available, the Australian mass-screening program should offer and evaluate a single test modality.

Douglas R Taupin · Mike Corbett

In reply: Taupin and Corbett contend that the “choice paradox” reported by the MACS Group study argues against decision-support systems to allow informed choice of screening options. That would be true if the purpose of informed choice was simply to increase participation in screening.1 Our point is that the purpose of informed choice is to support an ethical basis for individuals’ decisions about screening.2,3 This can occur within the single-test modality (faecal occult blood tests) of the national screening program. It would be desirable to have decision-support systems embedded in a doctor–patient consultation. But this may not be feasible in terms of screenee access to a general practitioner, nor affordable for the Australian Government — hence our call for a self-directed decision-support system as an adjunct to a doctor-guided system. This is one way of applying the principle that patients should be given unbiased information on the benefits and harms of screening that enables them to make an informed choice about their own participation in screening.4

Glenn P Salkeld · Jane M Young · Michael J Solomon

To the Editor: Where is the evidence for the claim by Joyce, McNeil and Stoelwinder1 that there was a boom in medical workforce supply in the 1970s? They are perpetuating the accepted macroeconomic myth of there having been a surplus at that time. The microeconomic, marketplace truth was that there was a shortage of general practitioners throughout the 1970s.2 This was so severe that, after battling for some years after 1974 to find a partner for my suburban Sydney practice, I resorted to advertising overseas, finally importing an overseas-trained graduate. It is time for this myth to be laid to rest. There has been a marketplace shortage of GPs since the early 1970s. The truth is that federal governments have baulked at the expansion of payments through Medibank/Medicare. Rather than apply any controls on demand, they have obstinately rationed supply, repeatedly citing dubious statistics and invalid international comparisons to justify a diminution in the supply of GPs.

Peter C Arnold

In reply: Our reference to a boom in medical workforce supply during the 1970s was based on the marked increase in medical workforce entries in that decade. The number of Australian medical graduates rose from 851 in 1970 to 1278 in 1980.1,2 In contrast — and as a result of a shift to a policy of constraint — graduate numbers remained quite static during the 1980s and 1990s, at around 1200–1300 per year (Commonwealth Department of Education, Science and Training custom datasets RFI 03-312, RFI 04-360, 2004). Although the policy shift in the 1980s was based on a perception of surplus, judgements about workforce adequacy were contentious at that time and remain so. We did not intend to imply necessarily that there was a surplus in the medical workforce (or the general practice workforce specifically) during the 1970s. Rather, our historical reference was intended to show the parallels with the large influx that will result from current expansion in medical school intakes, and to highlight the cyclic nature of both medical workforce policy and perceptions of adequacy. We agree with Arnold’s implication that policies which attempt simply to adjust gross supply (up or down) are insufficient to ensure an adequate medical workforce.

Catherine M Joyce · John J McNeil · Johannes U Stoelwinder

The quest for certainty blocks the search for meaning. Uncertainty is the very condition to impel man to unfurl his powers — Erich Fromm General practitioners are many things but, as much as anything else, they are masters of uncertainty. From the problems behind the names on the appointment schedule, to whether the patients will actually show up, how much time they’ll need and what their expectations will be, GPs plunge daily into the great unknown. They take their patients with them. In the cold light of the consulting room, undifferentiated symptoms and a myriad of clinical dead ends can make a mockery of the clean lines of evidence-based medicine — which, after all, is merely a means of quantifying our uncertainty. GPs are called to stand in the breach between their own (justified) uncertainty and their patients’ wish for certainty. So the current uncertainties about the future of general practice, the need to adapt, and the directions for change are probably things most GPs take in their stride. This bumper General Practice issue of the MJA looks at some of the areas of uncertainty and concern. Workforce is a big issue. Many GPs are left wondering at the exodus from general practice and the tendency for existing GPs to subspecialise themselves out of the “general” part of their title. Joyce and McNeil confirm the prevailing impression that, at least among Monash University graduates, fewer new doctors are making the decision to enter general practice. Couple this with the projection for a flat growth in the GP workforce over the next 10 years,1 and the reason for all the uncertainty is obvious. The causes of the workforce shortage have been widely debated. More interesting is the debate surrounding how we should respond. How can we make general practice more efficient and effective? Smart use of information technology (IT) is an obvious avenue. As demonstrated by McInness et al and Henderson and colleagues, IT has been thoroughly pursued by the current cohort of GPs. More than 90% of general practices now use clinical software packages and about two-thirds keep at least some patient records electronically. But there are calls to make more use of computers. According to McInness et al, increasing the use of IT functions such as online decision support, registries of patients and progress notes will benefit patients, especially those with chronic conditions. Dowrick, a UK professor of primary care who has spent time considering strategies for dealing with chronic disease in Australia, echoes this sentiment: General practice will have a key role to play, especially in the early detection of disease and in providing integration and continuity of care. Registers and recall systems for patients with chronic diseases will need to be set up, preferably in electronic form. The Australian Government’s HealthConnect program, which enables health care providers to connect to business grade and advanced broadband arrangements, may provide a useful basis for efficient chronic disease care . . . Primary care teams will have to standardise medical procedures, provide information on local services and make links with patient self-management programs. These activities will need to be carefully coordinated for each patient. Tse and McAvoy and Bolton remind us that we are still far from this IT utopia, but the computers are on GPs’ desks, ready to be used for a variety of applications. Computers are only as good as the information available to them, and another problem in Australia is the evidence base for general practice. GPs publish far less research than their specialist colleagues, are less likely to obtain competitive research grants, and do not contribute extensively to the evidence base of their discipline.2 As noted by Yallop et al, “although improving patient care requires a sound evidence base, rigorously designed studies remain under-represented in primary care research”. This deficiency is at odds with the definition of general practice as “an academic and scientific discipline with its own educational and research base and clinical activity”.3 To its credit, in 2000 the Australian Government initiated a program to address this, with an injection of $50 million over 5 years through the Primary Health Care Research, Evaluation and Development (PHCRED) Strategy. Its purpose was to increase the research capacity of general practice through annual non-competitive grants to academic departments of general practice or rural health; to encourage the development of people with proficiency in primary health care evaluation and research through research development programs; and to establish a flagship — the Australian Primary Health Care Research Institute. The report of an independent evaluation of the PHCRED Strategy became available in April 2005,4 and in December 2005, the Australian Government committed a further $60.4 million to Phase 2 of the PHCRED Strategy, to run from 2006 to 2009.5 However, the evaluation of Phase 1 drew attention to a number of problems: involvement of practising GPs and GP registrars in PHCRED programs was minimal and not long term; an initial hesitancy to make decisions, implement components of the Strategy and elucidate appropriate outcome measures; a lack of depth and breadth in researcher training and development; a paucity of extensive research networks; and instances of suboptimal research relationships between universities and Divisions of General Practice. The need for extensive and effective research networks has long been recognised in the United Kingdom and the Netherlands. Zwar and colleagues argue compellingly for research networks in Australia, putting forward a hub-and-spoke model involving universities and Divisions of General Practice. Central to their plan are academic departments that already have a demonstrated strong role in capacity building; linkages to practice-based research networks through the Divisions of General Practice; and an adequately funded clinical research plan with appropriate remuneration of primary care practitioners for their participation in research. The key to the success of general practice research lies in the extensive involvement of GPs, including research involvement of GP registrars as a mandated part of their training, and the appropriateness of the research question. Indeed, the capacity of GPs’ involvement to make or break a clinical research project is poignantly recounted by Yallop et al. The time has come to test such a model in Australia. It should be open to competition, but restricted to a limited number of consortia so certainty of “proof of principle” is obtained by the end of Phase 2 of the PHCRED Strategy. Linkages between universities and Divisions of General Practice will be critical to this model — an issue explored by Kalucy and colleagues. Finally, if we are to ensure success at the end of the current PHCRED cycle, oversight by a national advisory committee composed of appropriate stakeholders will be imperative.4 Its absence in Phase 1 of the PHCRED Strategy is baffling. Strong general practice is “patient centred, consistently of high quality, safe and accountable”.6 In reality, this means using data to identify, learn from, and prevent error and system failure. In the interests of improving safety in Australian general practice, Makeham et al used data reported anonymously by GPs to surmise that about one error is reported for every 1000 Medicare-billed patient encounters, and about two for every 1000 individual patients seen. With similar intent, Hutchinson and Watts report on the acceptability of the complaints register component of the RACGP Standards for general practices. They found considerable variability in the use of complaints registers, but that GPs were not overwhelmingly adverse to their use. Both these studies indicate there is a healthy attitude to exploring indicators for safety in Australian general practice. There are many indications in this special issue of the Journal that general practice will move beyond the current uncertainty to emerge transformed but strong. We asked Jackson, and Harris and Harris to tell us what Australian general practice might be like in 2020. Both identified the need for a strategic approach to change, so that the GP’s role remains central in a society with changing needs, expectations and resources. In the future, what will make a good GP? In Dorothy H Cohen’s book The learning child,7 published in 1972, US educationalist Robert Havighurst is quoted as saying: The modern world needs people with a complex identity who are intellectually autonomous and prepared to cope with uncertainty; who are able to tolerate ambiguity and not be driven by fear into a rigid, single-solution approach to problems, who are rational, foresightful and who look for facts; who can draw inferences and can control their behavior in the light of foreseen consequences, who are altruistic and enjoy doing for others, and who understand social forces and trends. We are products of the modern world. The scenery has changed. But a good GP will be what a good GP has always been — a master of uncertainty.

Ruth M Armstrong BMed · Martin B Van Der Weyden MD, FRACP

Why try a doctor when you need a dentist? Oral conditions have some of the highest prevalence and incidence rates of all health problems in Australia.1 They are frequently associated with pain, functional limitations and interference with usual activities. Most people experiencing oral symptoms will visit, or at least contemplate visiting, a dentist. But why are some patients with oral conditions presenting to general practitioners? While signs and symptoms associated with dental caries and periodontal diseases are usually understood to be problems for dentists, sequelae of these conditions, such as abscesses, facial swelling, altered taste and halitosis, may sometimes be considered more of a medical than an oral problem. Furthermore, differences in the way dental and medical services are organised and delivered may provide a greater incentive for patients to present to GPs rather than dentists. This applies not only to conditions for which an ill-defined boundary exists, but also for management of acute symptoms of common oral conditions. Mansour and Cox outline some of these common oral conditions in this issue of the Journal (page 64).2 One result of the evolution of the medical and dental professions over the past century is a “separateness” that has diminished both professions’ understanding of the other’s discipline. While it is highly desirable to reduce this knowledge gap, it seems unlikely to be readily closed, given the existing curriculum pressures created by scientific and technological advances. A logical response to the inappropriate presentation of patients with oral conditions to GPs would be to both remove the incentives for this type of presentation and to provide more certain pathways for dental referral when they do occur. Indeed, Mansour and Cox recommended dental referral for most of the cases described and for all possible outcomes of their decision-making algorithm. But while the need for referral to dentists is generally well recognised, the ability to refer may be limited. Both the initial presentation to a GP and the difficulties in referral to a dentist are shaped by problems in accessing dental care in Australia. There are only about 9000 practising dentists in Australia (approximately 50 per 100 000 population),3 the vast majority of whom work in either the central business districts or middle-class residential suburbs of the major population centres, leading to significant maldistribution. Equally important is the fact that 86% of dentists work in the private sector, where they alone determine location, hours worked and fees charged. Outside normal business hours, the number of available dentists is very limited, and access is frequently restricted to existing patients of a practice. In some instances, major public hospitals and the limited number of dental hospitals do provide after-hours access to on-call dentists, but this is the exception rather than the rule. Publicly-funded dental care is usually restricted to holders of concession cards, which reduces those eligible to about 34% of the adult population. Further rationing of dental treatment occurs because of the limited facilities and shortage of dentists in the public sector. Only 19% of eligible dentate adults (ie, those with natural teeth) receive any dental care from public dental services in any year.4 An overall shortage of dentists makes access to dental treatment even more difficult. Within 4 years, Australia is predicted to be short of some 1500 dental care providers, mostly dentists.5 This shortage creates a bottleneck in the supply of dental treatment. It is most harshly felt by people already having difficulty obtaining dental treatment — low income Australians and those living in rural areas. However, the bottleneck also extends to dentistry in the “main street”; that is, private general dentists in middle-class residential areas. Increasing the number of positions in our universities for dental students may eventually overcome this problem — assuming there are academics to teach them and funding to competitively employ some of them in the public sector at the completion of their education. However, the current national output of less than 250 graduates a year does not begin to address the shortfall. Increased education of auxiliary dental personnel (hygienists and therapists) should lead to increased prevention programs, but is unlikely to address the problem of adults presenting with acute conditions. Cost is another significant barrier to accessing dental care. An estimated 25% of dental patients delay seeking treatment because of the expense.6 Public funding for dental treatment is dramatically less than for medical treatment. At present, public funding from the federal government is directed at the 30% private health insurance rebate, while state and territory government public funding is directed at low income adults and schoolchildren. The outcome is an inequitable pattern of public assistance in accessing dental treatment. Ironically, the average taxpayer may well pay the most and receive the least in terms of support in accessing dental treatment. The majority of patients will face the full cost of any dental treatment. The current average hourly rate for dental practices is $350 (of which overheads represent 73%).7 Thus it is likely that any substantial care (be it diagnostic or therapeutic) will represent a significant financial burden to the patient. The incentive for patients with oral conditions to present to a GP is obvious. GPs are more available, obtainable out of hours, and can be seen without the need to pay substantial out-of-pocket costs. The corollaries of these same issues are often the substantial barriers to dental referral for patients presenting to GPs. Recently, the federal government recognised the need for dental care among patients with a GP Management Plan and Team Care Arrangements or an Enhanced Primary Care multidisciplinary care plan. Essentially, approved patients may be referred to a dentist for an assessment and two other services within a 12-month period. In 2005, there were only 2055 referrals for dental assessment (Item 10975),8 and these resulted in 2500 items of treatment or referral to a dental specialist (Items 10976, 10977). The total cost of dental diagnostic and treatment procedures was just over $500 000 (or $250 per 100 000 population). These data indicate a negligible level of referral under these plans. Specific issues within these plans act as further barriers to referral for dental care. For GPs, the cost and time involved with administrative requirements far exceed the value of the remuneration. Referral cannot proceed until the original care plan has been completed and paid for, which largely negates treatment of acute conditions. The relatively small number of appointments permitted, dentists’ unfamiliarity with the Medicare remuneration system, and the level of remuneration make dentist participation professionally and financially unrewarding. The result is that current referral plans available under Medicare are unlikely to provide a simple or effective pathway for dental referral and treatment. Currently, patients with acute oral conditions should hope that the problem occurs during normal hours in a major population centre, that the condition is not part of a larger problem, and that they are wealthy enough to have a regular dentist who has the time to see them. For patients who are not so fortunate, presentation to a GP is likely to remain an option. As outlined by Mansour and Cox, on most occasions, little, if any, effective help can be offered beyond referral to a dentist. The short-term results are frequently only palliative, at best, and without appropriate follow-up care — resulting in increased costs to the public purse and ongoing suffering to the patient.

Roderick I Marshall BDSc, MDSc, FRACDS(Perio) · A John Spencer MDSc, PhD, MPH

There is a considerable mismatch between evidence and policy The Australian National Chronic Disease Strategy The National Chronic Disease Strategy is a nationally agreed agenda to encourage coordinated action in response to the growing impact of chronic disease on the health of Australians and the health care system. It has five health priority areas: asthma cancer diabetes heart, stroke and vascular disease osteoarthritis, rheumatoid arthritis and osteoporosis. It is structured to reflect the phases of illness: reducing risk finding disease early managing acute conditions long-term care care in the advanced stages of disease. Implementation of the strategy will be the responsibility of individual jurisdictions. Chronic diseases now have a major impact on Australian society, accounting for about two-thirds of health care expenditure (more than $35 billion) in 2000–01. Last November, the Australian Health Ministers’ Conference endorsed a national strategic policy approach to manage and improve chronic disease prevention and care in the Australian population. The approach has three elements: a national chronic disease strategy; a set of five national service improvement frameworks; and a blueprint for nationwide surveillance of chronic diseases and associated determinants.1 The policy focuses attention on five chronic disease groups: asthma, cancer, diabetes, cardiovascular diseases and musculoskeletal conditions. These have been identified because they are common and lead to substantial levels of disability among Australians. The authors propose a multilayered strategy aimed at preventing or delaying the onset of chronic diseases, intervening early in disease processes to minimise harm and improve quality of life, ensuring integration and continuity of care, and encouraging the active participation of people in their own health care. People living with chronic medical conditions are clear about the elements they require from a modern health care system. They need access to high quality information about their condition, care which is continuous and well coordinated, effective management of their symptoms and — perhaps most importantly — help in managing the social, economic and psychological consequences of their symptoms.2 This ambitious Australian strategy is timely and well considered. If successfully implemented, it will go a long way towards meeting these requirements. The key question is, what must be done to translate it from a worthy set of words to an effective set of deeds? What steps must be taken to give it the best chance of success? First, there is a need to promote chronic illness on the agendas of policymakers so that the necessary political and economic changes can be made to the Australian health care system.3 Structures must be put in place to reduce health care inequalities and to maximise efficient resource allocation. It is not yet clear whether such structures are best situated at federal or at state level, nor what role the private sector should play. Assuming a degree of competition is both inevitable and healthy, it may be best to base such decisions not (as historically) on answers to the question “who pays?”, but rather on answers to the question “who provides best value?”.4 Second, primary health care must change. General practice will have a key role to play, especially in the early detection of disease and in providing integration and continuity of care. Registers and recall systems for patients with chronic diseases will need to be set up, preferably in electronic form. The Australian Government’s HealthConnect program, which enables health care providers to connect to business grade and advanced broadband arrangements, may provide a useful basis for efficient chronic disease care, insofar as it enhances the ability of health providers to share information about patients.5 Primary care teams will have to standardise medical procedures, provide information on local services and make links with patient self-management programs. These activities will need to be carefully coordinated for each patient. Australian general practice is not currently configured to deliver this strategy to maximum effect. Models of good practice, such as the South Australian HealthPlus experiment,6 show what can be done with the injection of energy and imagination, and the provision of adequate resources (particularly at the care coordination level), but there remains a substantial mismatch between evidence and policy.7 It will be necessary for managers and practitioners to resolve the complex structural problems inherent in realigning a fee-for-service system that is designed to provide acute medical care towards a managed care system which must inter alia provide adequate financial support for high-quality electronic information systems, and generate funding models which enhance multi-disciplinary care rather than encouraging individualistic approaches to health care delivery. Recent policy developments in the United Kingdom offer useful guidance, and provide evidence for their success.8 Third, new programs of education will have to be put in place for patients and carers, and also for health professionals. Education for patients and carers can be provided to an extent through the mass media or via the Internet,9 but the main focus is likely to be through the expansion of facilitated self-management or “expert patient” programs.10 It is important to ensure that such programs enable patients with chronic diseases to actively engage in promoting their own health, and to make effective links with relevant health professionals. They must also avoid the tendency of becoming the preserve of a motivated minority, as this increases the risk of health inequalities.11 The focus of health care education has already begun to change, with a gradual shift of location from hospital to community, and increased recognition of the value of scientific perspectives drawn from psychology and sociology. Learning outcomes also need to be reviewed, as symptom control and quality-of-life issues become the priority in effective management of chronic medical conditions. The next generation of health care professionals will have to become more experienced in pain management and in understanding the psychosocial aspects of long-term conditions, the needs of carers, best practices for coordinating care, and how to work well in partnership with patients.12 Finally, there will be a need for new research. Care coordinators are likely to be central to new models, but we do not yet know enough about their best role definitions, nor their economic costs and benefits. Do self-management programs work best when run by and for patients, or when they habitually involve health professionals? What are the principal barriers to a reorientation of general practice to meet the needs of patients with chronic diseases, and how can they be overcome? Questions about the cost-effectiveness of new models of chronic care also need to be asked. To address these questions, researchers must better understand the context in which they are operating: how health care functions as a complex adaptive system,13 and the processes which enable (or hinder) the implementation of new technologies into routine clinical practice.14

Christopher Dowrick BA, MD, FRCGP

Dentofacial pain is a common presentation in general practice, and more than 50% of cases arise from dentally related pathology. In a carious tooth, pain that is site-specific, severe and spontaneous usually denotes extension of caries into the tooth pulp. Caries does not always appear as a cavity in the tooth, but may lie beneath intact enamel or on surfaces between teeth. Examination of tooth pain should include firm percussion (eg, with a tongue depressor). Tenderness on percussion denotes progression of infection into the subdental tissue. Pain occurring 24–48 hours after a tooth extraction is commonly caused by superficial osteitis in the exposed alveolar bone. Examination will reveal the absence of a blood clot in the extraction socket and severe tenderness on local palpation. Severe pain related to impacted wisdom teeth is frequently caused by pericoronitis, an infection in the gingival tissues surrounding the tooth. The surrounding gingiva is erythematous and tender to palpation. Localised facial swellings of dental origin require immediate referral to a dentist. Progressive facial swelling requires aggressive antibiotic therapy and referral to hospital for definitive management.

Mohammed H Mansour MSc, MD · Stephen C Cox OAM, MSc, FRACDS

Objective: To assess the impact of structured diabetes care in a rural general practice.Design and setting: A cohort study of structured diabetes care (care plans, multidisciplinary involvement and regular patient recall) in a large general practice in a medium-sized Australian rural town. Medical care followed each doctor’s usual practice.Participants: The first 404 consecutive patients with type 2 diabetes who consented to take part in the program were evaluated 24 months after enrolment in July 2002 to December 2003.Main outcome measures: Change in cardiovascular disease risk factors (waist circumference, body mass index, serum lipid levels, blood pressure); change in indicators of risks associated with poorly controlled diabetes (glycated haemoglobin [HbA1c] concentration, foot lesions, clinically significant hypoglycaemia); change in 5-year cardiovascular disease risk.Results: Women had a lower 5-year risk of a cardiovascular event at enrolment than men. Structured care was associated with statistically significant reductions in mean cardiovascular disease risk factors (waist circumference, − 2.6 cm; blood pressure [systolic, − 3 mmHg; diastolic − 7 mmHg]; and serum lipid levels [total cholesterol, − 0.5 mmol/L; HDL cholesterol, 0.02 mmol/L; LDL cholesterol, − 0.4 mmol/L; triglycerides, − 0.3 mmol/L]); and improvements in indicators of diabetic control (proportion with severe hypoglycaemic events, − 2.2%; proportion with foot lesions, − 14%). The greatest improvements in risk factors occurred in patients with the highest calculated cardiovascular risk. There was a statistically significant increase in the proportion of patients with “ideal” blood pressure (systolic, < 130 mmHg; diastolic, < 80 mmHg) and LDL cholesterol level (< 2.5 mmol/L) of 6.4% and 20.5%, respectively.Conclusions: Implementing structured care in this rural general practice coincided with improved risk factor management, and may have contributed to the improvement. The greatest benefits were in patients with high cardiovascular risk.

Evan W Ackermann FRACGP, DRACOG · Geoffrey K Mitchell FRACGP, PhD

Objective: To explore patients’ views of the role of general practitioners in weight management.Design: Waiting-room questionnaire survey, including measurement of height, weight and waist circumference, May–August 2005.Participants and setting: 227 patients from five general practices located in metropolitan and rural New South Wales.Main outcome measures: Patients’ views on: the role of GPs in weight management; the usefulness of weight-loss strategies; and the likelihood of following the GP’s advice about weight loss.Results: Most patients (78%) felt that GPs had a role in weight management, but only 46% thought that GPs would be able to spend enough time to provide effective weight loss advice. Over 80% of patients perceived advice on healthy eating and physical activity to be useful or very useful, and were likely to follow weight-loss recommendations; 78% were in favour of regular review. Patients indicated they would be less likely to see a dietitian or to attend information sessions, and unlikely to take weight-loss medication. Views of overweight and obese patients were generally similar to those of normal weight patients, but there were significant differences in perceptions of the usefulness of information on weight and weight-related medical conditions, as well as willingness to change lifestyle, possibly reflecting resistance to change among obese or overweight patients.Conclusion: These findings have implications for the design of primary care interventions for managing obesity.

Daisy Tan MB BS, DCH, FRACGP · Nicholas A Zwar MB BS, PhD, FRACGP · Sarah M Dennis MSc, PhD · Sanjyot Vagholkar MB BS(Hons), MPH, FRACGP