General medicine

Sounds for silence. Babies settling and health guide + CD-ROM. Harry Zehnwirth. Melbourne: OKlDokie, 2005 (105 pp). ISBN 0 646 45384 X. Crying and settling problems are among the most common reasons new parents present to health professionals in the first few months of their baby’s life. Managing these problems can be a bewildering and exhausting process. This guide and CD, developed by Harry Zehnwirth, a Victorian paediatrician and father of four, are excellent value for money. The CD is a compilation of “white noise” and “environmental sounds” designed, when played loudly, to distract a baby from crying so they can then self-settle. Clinical experience suggests this is a cheap and almost certainly harmless approach to managing infant crying. The guide provides a sensible, practical and easy-to-read approach to sleep, crying and health in the first year of life. It covers normal patterns of sleep and crying, myths about causes of irritability (eg, wind), strategies for managing irritability, ways to encourage a baby to self-settle, and postnatal depression. Unlike other sleep and settling guides, this book covers a baby’s general health and development. One excellent section covers common parental concerns such as gastro-oesophageal reflux, skin blemishes and sticky eyes, and a section on “scary episodes” reassures parents about breath holding and choking. A separate section (titled “alarm bells”) provides clear signs for parents to identify an acutely unwell baby or a baby with possible developmental delay. There is great humour flowing throughout the book (for instance, the only stool colours to worry about are those of the St Kilda footy club — that is, red, white or black), and the text is complemented by bright photographs. The final pages include a trouble-shooting table in a question and answer format (eg, could cows milk protein intolerance be irritating your baby?), other sources of help (such as parenting centres and web-based resources, including http://www.soundsforsilence.com.au), and a behaviour diary to chart a baby’s sleep and crying patterns and response to intervention. Harriet HiscockPaediatrician, Centre for Community Child Health, Royal Children’s Hospital, Melbourne, VIC

Harriet Hiscock

To the Editor: We were interested to note that the evolution of morning handover at Launceston General Hospital, as described by Fassett and Bollipo,1 closely parallels our own experience at the Canberra Hospital, and we endorse their points about running a successful meeting. Our hospital has a large Geriatric Unit and all subspecialties are covered, but we do not have a general medicine unit. In 2002, we began a formal morning handover meeting from 08:00 to 08:30 for junior medical officers (JMOs) in the Department of Medicine, with the initial intention of providing an opportunity for Royal Australasian College of Physicians (RACP) basic trainees to present cases they had seen overnight. Scrutiny of the individual’s clinical approach by consultants, in preparation for the RACP examination, was the main emphasis, and “interesting” cases were chosen. The meeting was also used for case presentations by specialty units. Attendance was variable, and many junior staff reported feeling somewhat threatened by having their patient management approach examined in a public forum. Handover of most newly admitted patients did not occur during this meeting. The format was incrementally modified over the following 3 years so that, by 2005, the meeting had become a formal handover of all patients admitted during the previous evening and overnight. Attendance is now compulsory (except for staff attending medical emergencies), and breakfast of brewed coffee and tea with fruit and muffins is provided (funded by the Canberra Hospital). We have over 40 daily attendees (comprising registrars, residents, interns, medical students and 5–10 consultants). We have minimised the number of specialty presentations: these now usually take the form of “red flag” sessions, in which a specialist unit highlights areas of common and/or life-threatening importance (eg, a patient with unstable angina needs admission, regardless of their troponin level; recurrent rigors in a middle-aged person usually signal a bacterial infection). A survey of 57 of the attendees this year revealed that over 90% thought the format and duration of meetings and attendance by consultants was appropriate; 54% and 39%, respectively, said they learned new information every day or every week. Over the past 4 years, the handover has become embedded in the clinical culture of the hospital. The long-term commitment of a small group of consultants has demonstrated that this is a safe and encouraging environment for clinical teaching, and the level of discomfort of the JMOs appears to have receded. The morning handover has been an important means of ensuring that young doctors are exposed to a broad perspective on patient care and that their after-hours patient care can be supervised.

Francis J Bowden MB BS, FRACP, MD · Christian Lueck FRCP, FRACP, PhD · Mark Hurwitz MB BCh, FCCO, FRACP · Karina Kennedy MB BS, FRACP

To the Editor: The CanMEDS 2000 report1 and its 2005 revision2 have emphasised that effectiveness as a medical specialist requires competencies in addition to clinical and medical expertise. These include being a communicator, collaborator, manager, health advocate, scholar and professional. Building the non-clinical skills of doctors has been the focus of a professional development project in Australia that is targeting registrars. Junior doctors usually step up to the role of registrar in the 3rd year of their prevocational training. A national workshop convened by the Postgraduate Medical Council of Victoria in March 2004 agreed on a framework for the professional development of registrars, comprising the following 10 competencies: leadership; communication skills; supervision; mentoring; teamwork; self-awareness and empathy; time management; problem solving; professionalism and ethics; and safety and quality.3 To provide content for these competencies, a job-shadowing exercise involving two registrars at two different Victorian hospitals was undertaken in April 2005 to get a first-hand understanding of the roles of medical registrars as managers. The registrars were voluntary participants, and permission was obtained from all participants. I shadowed the two registrars during their entire 9-hour shifts. No major issues arose in relation to the shadowing process itself, and the consultants overseeing the two registrars were extremely accommodating in this process. The two observed registrars authenticated the veracity of the recorded observations. The observations from the job-shadowing exercise were clustered into competencies using the framework developed for the professional development of registrars discussed above. The Box summarises these observations and highlights the range of registrar interactions that are influenced by non-clinical competencies. While the small number of registrars is an obvious limitation of the study, this job-shadowing exercise did demonstrate that managerial skills, knowledge and behaviour represent a significant component of the work of clinicians, especially as they move up the medical hierarchy. This assertion should not be misconstrued as suggesting that the clinical skills and knowledge become any less important. As noted in the 2005 CanMEDS framework, the medical expert role is the central role for doctors. It is also worth noting here that some pilot professional development programs conducted recently as part of the registrar project show that registrars welcome training that enhances their non-clinical skills, especially when provided professionally in an environment conducive to learning. Observations during job-shadowing of two registrars at two Victorian hospitals Competency Observed interactions Supervision Reviewing patient treatment plans and test results and prescribing a course of action Ensuring that procedures are followed Coaching intern on test procedures, completion of patient records, etc Giving ongoing feedback to intern Delegating tasks to intern Coordinating patient treatment with other units Leadership Dealing with other health professionals, some of whom take directions from the registrar, as well others over whom there is no formal authority Providing advice to intern and role modelling desired behaviour Demonstrating the ability to respond quickly and with confidence Involving subordinates and providing opportunities for them to participate in decision making Using networking skills with other departments Using negotiating skills in dealing with other departments, hospitals, etc Communication skills Using communication skills with patients, intern, medical colleagues, other health care professionals, and service departments Dealing with cross-cultural diversity issues with patients, their families, and staff Using negotiating skills in dealing with other departments, hospitals, patients, and family members Using recording skills to ensure treatment plans properly documented for others Time management Prioritising patient list for ward rounds The constant need to re-assess priorities during ward rounds, in light of time constraints The ability to deal with constant interruptions from other colleagues, to provide necessary clarifications Problem solving Making decisions on patients’ continued treatment or discharge, and stipulating any follow-up action Task contingency management skills to deal with patient treatment plans not proceeding as planned Dealing with information gaps in patient historical records Involving intern and other staff to assist in the decision-making process and raising issues with consultant Professionalism and ethics Dealing with demarcation issues with other doctors and professionals Role modelling professional behaviour to patients, staff, and the public Balancing the interests of patients with hospital needs, without sacrificing patient trust Obtaining patient consent for procedures Teamwork Coordinating treatment plans with other doctors and health professionals Sharing information and agreeing on treatment plans with allied health staff Joint meeting with other colleagues to advise a patient and family members on surgical procedures and associated risks Ability to work in both collaborative and individual modes during the day Mentoring Providing advice to intern to be more assertive and confident when dealing with consultant Self-awareness and empathy Patience and empathy in giving bad news to family Dealing with patients who are aged or mentally or physically challenged Safety and quality Knowledge and application of safe practices in relation to patient management Ensuring that procedures are followed, such as obtaining consent, ordering of tests, etc Reviewing records before dispensing treatment Recording treatment plans and medications

Jagdishwar Singh PhD

Objective: To investigate the frequency, cause, and severity of adverse drug events (ADEs) among general practice patients.Design: Between May 2003 and February 2004, a subsample of 282 general practitioners in the BEACH (Bettering the Evaluation And Care of Health) data collection program recorded patient responses to questions about ADEs.Main outcome measures: Frequency, cause, and severity of ADEs; and frequency of hospitalisation and proportion of events that were preventable.Results: From 8215 encounters, GPs reported that 852 patients (10.4%) had experienced an ADE in the previous 6 months. Patients aged over 45 years (versus under 45 years), children aged 1–4 years (versus older children), and female patients (versus male patients) were significantly more likely to have experienced an ADE. Most patients (83.5%) had experienced only one ADE, with 10.7% and 5.8% experiencing two and three or more events, respectively. For 71.9% of patients, one reason for the most recent event was a recognised side effect, followed by drug sensitivity (12.4%) and allergy (11.0%). Over half of patients were rated as having a “mild” event, with 35.8% rated as “moderate”, and 10.0% as “severe”. GPs classified 23.2% of events as preventable, and 7.6% of events resulted in hospitalisation.Conclusion: Our study reveals the high frequency of ADEs in patients attending general practice. This level of morbidity makes ADEs one of the most significant causes of morbidity in the Australian community.

Graeme C Miller MB BS, PhD, FRACGP · Helena C Britt BA, PhD · Lisa Valenti BEc

GPs can play an important role in helping women to realise their plans for a family You don’t think of a first-time, breastfeeding mum experiencing hot flushes, but that’s how my story begins. I was 40 years old when I conceived my daughter — and very easily, I might add. When Abby was about a year and a half old, my husband and I began trying to conceive a second child. Deceived by our luck the first time, we assumed we’d have no problem. Misguided by the prevailing advice, we persevered for 12 months before seeking professional help. When we finally did, my general practitioner advised that I discontinue breastfeeding even once a day, and, a month later, sent me to have my serum follicle-stimulating hormone (FSH) level tested. We might have reversed those steps because the results showed, at 98 IU/L, that I wasn’t conceiving, not because I had been breastfeeding, but because I was menopausal. The penny dropped — the sweatiness I’d been experiencing while still breastfeeding had been hot flushes. My doctor was as surprised as we were that menopause would follow so closely upon the heels of immediate conception and birth, but the results were confirmed. A fertility centre informed us that the only real option for conception was with donated eggs. And, fortunate as we were to have a friend to donate hers (Box 1), after three failed in-vitro fertilisation (IVF) cycles we have resigned ourselves to the reality that Abby will be our one and only child. That resignation is not without some resentment, however, that my GP, knowing that I was already 41 and trying to conceive, didn’t intervene with a fertility assessment well before a crucial year was lost. Given my age and very sporadic cycles (which naively I had attributed to my still once-daily breastfeeding), my chances of becoming pregnant were slim to remote1 and conception at that point called for a more aggressive strategy. At the age of 40, or even 35, a basic infertility evaluation has been recommended after 6 (rather than the usual 12) months of trying unsuccessfully to conceive,2 as has early referral to a fertility specialist.3 In fact, given my age, rather than prescribing birth control pills postpartum, as you might with a younger woman, a candid discussion about whether I intended to try for a second child, while perhaps awkward in those early days, could have been key to conserving my chances. Why wait?But isn’t it a woman’s own responsibility, and not her doctor’s, to begin a family while she’s still fertile? Perhaps, but what if she lacks accurate information about how long to expect to remain fertile? The current trend to delay childbearing is the result of many factors.4 Maybe I did take my mother’s admonition not to marry early a bit too far — but not by choice. I was eager to start a family and would have done so well before turning 40 if I had I found a suitable partner. And I was in very good company. A full 50% of women surveyed at Monash IVF reported that they had delayed childbearing because they lacked a partner.5 Another study found that many women delay childbearing in favour of establishing careers, relationships and financial security (often believing fertility treatments will be available as a “backup” if needed).2 And if we take into consideration the tendency of women to overestimate their window of fertility,6 or to be unaware of the relationship between age and fertility,5 we can only expect my experience to be repeated many times over. I am writing this article to give a wake-up call to GPs and family planning professionals and to urge them to proactively address a suite of problems related to the rapidly ageing population of women seeking to become mothers for the first time. I hope that, in this way, my experience may help to prevent similar “missed conceptions”. “Positive” family planningThe feminist movement that helped to shape me and my choices was itself shaped by women escaping the confines of the traditional roles of wife and mother. Largely because of this, an emphasis has been placed on “negative” family planning — helping women to prevent unwanted pregnancy or to control the number and timing of children. Contraception and the availability of affordable, legal abortion have meant that women have been free to develop other important dimensions of their lives, such as robust careers and relationships, before having children. But times have changed — again. Years down the track, major advances in women’s ability to break through professional “glass ceilings” and the perception that we can extend indefinitely our ability to become parents have contributed to a growing number of women reaching “biological ceilings” that are even more difficult to break through. It is therefore now time that “positive” family planning be promoted as well. Health practitioners, particularly GPs, now need to provide guidance about the waxing and waning of fertility, preconception care and protective fertility — conception as well as contraception.7 A partnership between government, GPs and their representative organisations, as well as the family planning community, could help to educate women to have a more realistic understanding of their reproductive lifespan, enabling them to make more informed choices. Because although there may be many women who would not be surprised to find themselves infertile at 42, there are others, some as publicly prominent as ABC Television’s Virginia Haussegger, who have been as surprised as I was.8 The “misconception” seems to prevail, consciously or unconsciously, that we can expect to be able to naturally conceive throughout our forties, or if we can’t, that we can expect IVF treatment to “fix it” for us.6 And the truth is, not only does fertility take a nose-dive at about 30 years of age, but the success of IVF, as astounding as its results can be, dives as well (Box 2).7,10 Knowing betterThe media are teeming with fertility information. Books with names like What, no baby?,11 Inconceivable12 and Hot flashes, warm bottles13 have been published in recent years describing women’s experiences of meeting the challenges of subfertility, of being older first-time mothers, and of dealing with the social problem of infertility. While one news article might bust the “you can have everything” myth and report on the challenges of age-related infertility, another may announce a “miraculous” birth at 60, perpetuating the evergreen fertility myth still further. In the absence of individualised guidance by GPs, patients (as in many areas of medicine) arm themselves with information obtained on the Internet.14 Fertility consumers seek advice from sites such as the “Over 40 high FSH” discussion group (www.network54.com/Forum/53068) and “Mothers via egg donation” (www.surrogacy.com/online_support/mved). Such sites are replete with research, anecdotes and coaching about endocrinology, variations in protocols and success rates, and offer moral support to women wanting to take on the expertise of their reproductive endocrinologists, together with advice on how to discern valid treatments from quackery. Such sites also bring to the surface a widespread fervour relating to the desire to conceive, with some women willing to try almost anything to have a child. As in other areas, less scrupulous operators prey on this desperation and confusion. In another, parallel universe, new fertility innovations and studies are continually being reported in scientific and medical research. And while we medical consumers may be able to sift through to the best information on our own, how much more likely are we to find what we are looking for if we have the help of a GP who knows us? What’s a doctor to do?Because of their ongoing interactions with so many women, their knowledge and the resources available to them, GPs are uniquely well suited to convey from the medical world the current and reliable information a woman will need to realise her plans for a family — whether or not to have one, its timing and its size. GPs can play a central and vital role in educating women patients about our fertility’s natural expected lifespan while there is still time to act on it.5 Perhaps this is more important than ever, given the federal government’s recent attempts to restrict Medicare-funded access to assisted reproductive technology — especially for older women.15 The first step involves a doctor’s willingness to broach the subject. And if most Australian doctors are not inviting patients to discuss their family plans, they would not be alone. In one German study, many of the GPs surveyed viewed infertility as a private matter.16 In a related study of GPs and their infertile patients, most GPs did not ask childless patients about their plans to have children, even though 25% of infertile women and 50% of infertile men said they would prefer their doctor to raise the issue.17 Beyond that, I offer some suggestions for what GPs and others can do (Box 3). ConclusionThe growing tendency of women to delay parenthood either by choice or circumstance has implications as we have discussed for the likelihood of successful conception, for the wellbeing of the mother compressing her fertility, and for the children.21 It has repercussions not only for the individuals involved, but on the overall fertility rate.22 Sadly, there is cause for concern that patients may now be bypassing GPs and going directly to fertility specialists.23 This would be an unfortunate trend likely to lead to more heartbreak, more unnecessary individual and public expense and less holistic and continuous care for the woman or couple involved. All of these factors provide compelling reasons for GPs to engage in “positive” family planning by helping younger women to grasp the biological imperative to start their families earlier and helping older women to salvage their residual fertility. Of course, “positive” family planning will not solve all fertility problems. It will not be a treatment for endometriosis, chlamydia or polycystic ovaries. It will not necessarily help women to choose suitable partners during their more fertile years (although it may sharpen their focus). And it will not, in itself, effect the industrial and societal changes required to relieve mothers of the burden of having to compromise their professional lives so much more than fathers do. What it will do, however, is give women the information and tools they need to plan and create families responsibly. 1 Donor’s superovulation ultrasound image 2 Live births per transfer for ART cycles using fresh embryos from own and donor eggs, by ART patient’s age, 2002* ART = assisted reproductive technology. * Reproduced with permission from the US Centers for Disease Control and Prevention.9 3 “Positive” family planning* What an individual general practitioner could do When a childless woman comes for a health check-up or for contraceptive advice or prescription, take the opportunity to refresh her understanding of her reproductive lifespan, discuss her plans for children and make contraceptive recommendations commensurate with those plans.18 Advise women over 35 of the technological advances available for helping to salvage residual fertility. For example: Ovarian reserve screening by transvaginal sonography to establish when a woman’s fertility window is likely to close19 and whether she is a candidate for in-vitro fertilisation (IVF);20 Ovulation tracking by blood testing; Cryopreservation of embryos (or eggs, when the technology to achieve that becomes readily available). What organisations could do Family Planning Australia and its local affiliates could draw from relevant courses they currently offer to doctors, nurses and others to address “positive” family planning, the growing problem of the postponement of parenthood and age-related infertility. With government support, the divisions of general practice could incorporate fertility into their women’s health priorities and assist with informational posters, brochures and other strategies. The Royal Australian College of General Practitioners’ Women’s Health Committee could incorporate fertility into their agenda and urge fertility updates in continuing education programs. In light of Australia’s declining fertility,4 rather than simply cutting off access to IVF at a given age, the government should launch an educational campaign that would help to prevent the need to spend such large sums on IVF. * Planning for conception rather than contraception.

Amy Bachrach BA

Delayed childbearing is not an issue to “keep mum” about For fertility specialists, there is no more difficult and depressing news to break to a woman seeking a baby than “Sadly, it’s too late. You’re menopausal.” In our experience, this situation is encountered with ever-increasing frequency as the age of first attempting to conceive increases. With 1% of the female population menopausal by 40 years and 5% by 43 years,1 and with many more perimenopausal, the rising number of disappointed older women is not surprising. Breaking the bad news requires compassion but realism. Pregnancies are extremely rare in “menopausal” women. Even for those still menstruating, a high follicle-stimulating hormone level in the early follicular phase sounds alarm bells. Pregnancy rates in such women are much less than 2% per cycle, even with “high-tech” approaches such as in-vitro fertilisation (IVF).2 How big is the problem of delayed childbearing?The average age of women bearing their first child in Australia has risen from less than 26 years in 1991 to nearly 30 years in 2003.3 First births in women over 35 years now account for 12% of all births, compared with 6% a decade ago — and those women are the lucky ones. The average age of women undergoing IVF treatment has risen from 31 years in 1993 to just over 35 years in 2003.3,4 The proportion of women commencing such treatment in their 40s has risen from 13% to almost 25% over the same period — that is, one in four women undergoing IVF treatment is at least 40 years of age. Why is childbearing delayed?Bachrach, in her Personal Perspective,5 raises the critical issues that lead to delayed childbearing — career goals, the perceived need for financial security, and/or delay in finding a long-term partner (either through distraction by the pursuit of personal development, or because of lack of interest from a man in forming such a relationship). While 20th century feminism carries significant responsibility for encouraging women to be more self-centred and independent, a changing male attitude to early childbearing also must be acknowledged.6,7 Life can be too much fun to be tied down by wife and children. What are the limits to what we can achieve?Belief in the ability of assisted reproductive technology (ART) to overcome the “biological clock” and achieve a pregnancy in most women and at almost any age is ill-founded. Despite great advances in ART (a woman at 40 years in 2006 now has the same chance of becoming pregnant with an IVF cycle as a 30-year-old woman in 1995),4 over 80% of women having ART treatment will not conceive in their first cycle. Even when a pregnancy occurs, older women have a substantially higher risk of miscarriage and fetal abnormality.4 One in six pregnancies miscarries in a 30-year-old, but by 40 years the risk is one in four. Down syndrome occurs in 1 : 1000 pregancies at 30 years of age but 1 : 100 pregancies at 40 years. The success of technology will always be limited and probably never be able to reverse the relentless deterioration in egg quality and number in the late reproductive years. What can the medical profession do?The general community certainly does not seem to sufficiently appreciate how age affects fertility. Our personal experience with referring general practitioners suggests that the concept of age affecting fertility is widely acknowledged but that the specific, current facts are not known, and there is some evidence to support this.8 Some GPs carry the message they learnt at medical school, that only after a year of trying is it appropriate to refer for help. This is fine for women younger than 35 years, but for older women, earlier referral should be the norm — even if only to confirm that there are no potential barriers to conception. As in Bachrach’s experience, blind reassurance for 12 months may be seen, in time, to have been a terrible mistake. We suggest that any GP, or appropriate other doctor, consulted by a woman over 30 years of age should initiate queries about any plans for parenthood. Doctors can educate women and their partners about the loss of fertility with increasing age and encourage early conception. Similarly, when a doctor sees a new couple over 35 years of age, the doctor should initiate a positive push to consider childbearing — if that is part of their life-plan — as a matter of some urgency.9 We need to reverse any view that raising this matter would be paternalistic or “not politically correct”.10 What can be done in the community at large?Increased public awareness of the risks of delaying childbearing is vital. Government concerns about the rising costs of ART could best be addressed by reversing the trend towards increasing age of first conception. We believe that a little money spent on education would be more than repaid by a reduction in the age-related demand for ART. In 2004, the Fertility Society of Australia initiated the concept of a national education campaign focusing on fertility preservation. As part of their presentation to the Abbott Committee on ART in October 2005, the Fertility Society of Australia and the IVF Directors’ Group urged the Committee to recommend the provision of federal government funding for the campaign. While it would cover many health issues that affect fertility (eg, smoking, obesity and sexually transmitted diseases), a major plank of the campaign could also be to encourage earlier childbearing. This would focus not only on women but also on men, who are often the procrastinating party.7 Barriers to the decision to seek pregnancy earlier need to be examined. For example, workplace reforms should encourage rather than discourage childbearing. Flexible hours and on-site, affordable childcare would bring women back into their jobs earlier and so assist in their desire to be successful on all fronts. But, ultimately, we need to spread the message that there are significant risks of long-term failure and disappointment if women delay attempts to conceive until they reach the age of 35 years or more. Early referral could potentially prevent the disappointment expressed in Bachrach’s Personal Perspective.5

Michael G Chapman FRANZCOG, MD, CREI · Geoffrey L Driscoll FRANZCOG, FRCOG, CREI · Bryony Jones MB BS, MRCOG

Recommendations for primary prevention in women need to be different The efficacy of low-dose aspirin for the secondary prevention of cardiovascular disease among men and women is established.1,2 However, the risk-to-benefit ratio for aspirin in primary prevention is much less clear.2,3 The National Heart Foundation has recommended that low-dose aspirin be considered for people without symptoms but at increased (> 1% annual) risk of a coronary heart disease event.4 This recommendation is based on earlier primary prevention trials, with over 55 000 participants, showing a significant 32% reduction in the risk of myocardial infarction, but no significant change in risk of stroke or cardiovascular death.3 However, women comprised only 20% of trial participants, and fewer than 180 of the 2402 cardiovascular events occurred in women.3,5 Until recently, there has been limited direct evidence for the efficacy of aspirin in primary prevention among women. The Women’s Health Study (see Box) not only addressed this important sex issue, but suggested a significant difference in the cardiovascular response to aspirin between women and men.5 In this study, confined to healthy women aged 45 years or older, aspirin prophylaxis did not lower the risk of a first major cardiovascular event (non-fatal myocardial infarction, non-fatal stroke, or death from cardiovascular causes) — the primary endpoint. However, it did significantly reduce the risk of all strokes by 17%, and ischaemic stroke by 24%, without affecting the risk of myocardial infarction or cardiovascular death.5 This differs from previous aggregate data derived from mostly middle-aged men, and confirmed by a recent sex-specific meta-analysis, which showed that aspirin therapy significantly reduced the risk of myocardial infarction but not ischaemic stroke in men.6 Are there any apparent reasons for the seemingly opposite results for stroke and myocardial infarction in men and women? One possibility is that aspirin lowered the risk of stroke in women, but not men, simply because women have a higher risk of stroke than myocardial infarction. For instance, the ratio of incident stroke to myocardial infarction was 1.4 : 1 among women in the placebo group of the Women’s Health Study, compared with 0.4 : 1 among men of a similar age in the placebo group of the Physicians’ Health Study (a randomised, double-blind, placebo-controlled trial examining whether low-dose aspirin [325 mg every second day] decreases cardiovascular mortality and whether b-carotene reduces the incidence of cancer).7 Conversely, the Women’s Health Study may have lacked statistical power with respect to the risk of myocardial infarction. The study enrolled a group of largely healthy women, 85% of whom had a 10-year Framingham coronary risk score of less than 5%. Women also have a lower age-adjusted incidence of coronary heart disease than men; the rate of myocardial infarction among women in the Women’s Health Study was 97.3 per 100 000 person-years, about one-fifth the rate of myocardial infarction among men in the Physicians’ Health Study.7 Women tend to develop heart disease between 10 and 15 years later than men. This may explain why consistent benefits of aspirin on all major cardiovascular endpoints, including myocardial infarction and stroke, were observed only among women aged 65 years or older in the Women’s Health Study.5 This subgroup comprised 10% of the study population, but accounted for nearly a third of all cardiovascular events. In this subgroup, aspirin, compared with placebo, led to 44 fewer myocardial infarctions, strokes, or deaths from cardiovascular causes, but also caused 16 more gastrointestinal haemorrhages requiring transfusion, emphasising again the importance of balancing benefits and risks.5 A recent overview has also suggested that the risk of gastrointestinal and other bleeding with aspirin use may increase with age, and that the true balance of risks and benefits in the healthy aged population has not yet been established by randomised trials.8 The 100 mg alternate-day dose of aspirin used in the Women’s Health Study is lower than doses employed in previous trials. However, this regimen of aspirin was sufficient to reduce the risk of ischaemic stroke, and hence is likely to be an adequate dose for cardiovascular prevention. Nonetheless, sex differences in salicylate metabolism, platelet responses, vascular reactivity, and the nature of atherosclerotic disease may well cause different biological responses between men and women.9-11 This further highlights the need for women to be well represented in cardiovascular trials. What are the clinical implications of the Women’s Health Study? Overall, this study indicates that clinicians should be very cautious about advising women under the age of 65 years to take low-dose aspirin for primary prevention unless their global risk score is high. Even the benefit of aspirin for prevention of stroke in women needs to be carefully weighed against the increased risk of bleeding complications, and the low risk of stroke and other major cardiovascular events among apparently healthy women. To put this into perspective, the absolute risk reduction with aspirin therapy was about two stroke events per 1000 women treated.5 Thus, as with men, any decision about the use of aspirin for primary prevention among women requires an assessment of the net absolute benefit of therapy in an individual, and such a decision should be made only in association with an overall program of lifestyle measures to reduce cardiovascular risk.2 Reflecting these developments, the National Heart Foundation of Australia has recently amended its position statement on aspirin for cardiovascular disease prevention.12 Summary of the Women’s Health Study5 A large randomised placebo-controlled trial of aspirin (100 mg on alternate days) for primary prevention among 38 876 initially healthy women, aged 45 years or older, followed for 10 years for the occurrence of a first major cardiovascular event (myocardial infarction, stroke, or death from cardiovascular causes). The study recruited healthy women, 85% of whom had a 10-year Framingham risk score of less than 5%. The 10-year absolute cardiovascular event rate was low, and among placebo recipients there were more strokes than myocardial infarctions (266 v 193). At the end of the trial, major cardiovascular events (the primary endpoint) occurred in a non-significant 9% fewer aspirin recipients than placebo recipients (2.4% v 2.6%; P = 0.13). With regard to secondary endpoints, there was a significant 17% reduction in the risk of stroke in the aspirin group (1.1% v 1.3% with placebo; P = 0.04), owing to a 24% reduction in risk of ischaemic stroke; the two groups did not differ significantly in their incidence of myocardial infarction or cardiovascular death. Subgroup analyses showed that aspirin significantly lowered the risk of major cardiovascular events, ischaemic stroke, and myocardial infarction among women 65 years of age or older (6.4% v 8.5% with placebo; P = 0.008). The aspirin group had a higher frequency of gastrointestinal bleeding (4.6% v 3.8% with placebo; P < 0.001), and a non-significant increase in risk of haemorrhagic stroke (0.26% v 0.21% with placebo; P = 0.31). Overall, this trial indicates that caution is necessary when advising apparently healthy women to take low-dose aspirin for cardiovascular disease prevention.

Joseph Hung MB BS, FRACP, FACC

Garry J Walter Professor of Child and Adolescent Psychiatry, Coral Tree Family Service, University of Sydney, PO Box 142, North Ryde, NSW 1670. gwalterATmail.usyd.edu.au To the Editor: I read with interest Brooks’ letter on the value of professorial titles.1 It is not only in academic circles that the subject sometimes arouses passions. A short while ago, my wife had reason to speak sternly to our two young children. Losing the plot, my daughter replied, “What would you know, mum? You’re not a professor.” At that moment in this household, as I found myself slinking towards my study, the status of a professorial title — at least in my wife’s eyes — amounted to very little.

Garry J Walter

Objective: To examine the relationship between hospital and emergency department (ED) occupancy, as indicators of hospital overcrowding, and mortality after emergency admission.Design: Retrospective analysis of 62 495 probabilistically linked emergency hospital admissions and death records.Setting: Three tertiary metropolitan hospitals between July 2000 and June 2003.Participants: All patients 18 years or older whose first ED attendance resulted in hospital admission during the study period.Main outcome measures: Deaths on days 2, 7 and 30 were evaluated against an Overcrowding Hazard Scale based on hospital and ED occupancy, after adjusting for age, diagnosis, referral source, urgency and mode of transport to hospital.Results: There was a linear relationship between the Overcrowding Hazard Scale and deaths on Day 7 (r = 0.98; 95% CI, 0.79–1.00). An Overcrowding Hazard Scale > 2 was associated with an increased Day 2, Day 7 and Day 30 hazard ratio for death of 1.3 (95% CI, 1.1–1.6), 1.3 (95% CI, 1.2–1.5) and 1.2 (95% CI, 1.1–1.3), respectively. Deaths at 30 days associated with an Overcrowding Hazard Scale > 2 compared with one of < 3 were undifferentiated with respect to age, diagnosis, urgency, transport mode, referral source or hospital length of stay, but had longer ED durations of stay (risk ratio per hour of ED stay, 1.1; 95% CI, 1.1–1.1; P < 0.001) and longer physician waiting times (risk ratio per hour of ED wait, 1.2; 95% CI, 1.1–1.3; P = 0.01).Conclusions: Hospital and ED overcrowding is associated with increased mortality. The Overcrowding Hazard Scale may be used to assess the hazard associated with hospital and ED overcrowding. Reducing overcrowding may improve outcomes for patients requiring emergency hospital admission.

Peter C Sprivulis MB BS, PhD, FACEM · Julie-Ann Da Silva BPsych · Ian G Jacobs RN, PhD · George A Jelinek MD, FACEM · Amanda R L Frazer MB BS, LLB

Objective: To quantify any relationship between emergency department (ED) overcrowding and 10-day patient mortality.Design and setting: Retrospective stratified cohort analysis of three 48-week periods in a tertiary mixed ED in 2002–2004. Mean “occupancy” (a measure of overcrowding based on number of patients receiving treatment) was calculated for 8-hour shifts and for 12-week periods. The shifts of each type in the highest quartile of occupancy were classified as overcrowded.Participants: All presentations of patients (except those arriving by interstate ambulance) during “overcrowded” (OC) shifts and during an equivalent number of “not overcrowded” (NOC) shifts (same shift, weekday and period).Main outcome measure: In-hospital death of a patient recorded within 10 days of the most recent ED presentation.Results: There were 34 377 OC and 32 231 NOC presentations (736 shifts each); the presenting patients were well matched for age and sex. Mean occupancy was 21.6 on OC shifts and 16.4 on NOC shifts. There were 144 deaths in the OC cohort and 101 in the NOC cohort (0.42% and 0.31%, respectively; P = 0.025). The relative risk of death at 10 days was 1.34 (95% CI, 1.04–1.72). Subgroup analysis showed that, in the OC cohort, there were more presentations in more urgent triage categories, decreased treatment performance by standard measures, and a higher mortality rate by triage category.Conclusions: In this hospital, presentation during high ED occupancy was associated with increased in-hospital mortality at 10 days, after controlling for seasonal, shift, and day of the week effects. The magnitude of the effect is about 13 deaths per year. Further studies are warranted.

Drew B Richardson MB BS(Hons), FACEM, GradCertHE

Individual values sometimes lead patients to make lifestyle choices that have negative effects on their health. Doctors tend to feel responsible for delivering best-practice health outcomes to such patients, but also feel inclined to respect their patients’ values. The adoption of a harm reduction model may provide a strategy for delivering the best care that is compatible with each patient’s chosen lifestyle.

Bradleigh D Hayhow BA(Hons), BM BS · Michael Peter Lowe BMed, FRACP

Russell Stitz,* Michael R Kidd,† Liz M Kenny,‡ Anne M Howard§ * President, Royal Australasian College of Surgeons, Spring Street, Melbourne, VIC 3000; † President, Royal Australian College of General Practitioners, Melbourne, VIC; ‡ President, Royal Australian and New Zealand College of Radiologists, Sydney, NSW; § President, Australasian College of Dermatologists, Sydney, NSW. college.presidentATsurgeons.org To the Editor: The MJA is to be congratulated on promoting the debate related to the significant increase in the number of “skin clinics”.1 Standards are important in both the maintenance of the facilities and the formal training of the practitioners undertaking the assessment and care of patients. The four medical Colleges actively involved in treating skin conditions, who have their training programs accredited by the Australian Medical Council and their selection and assessment processes authorised by the Australian Competition and Consumer Commission, are the Royal Australian College of General Practitioners (RACGP), the Royal Australian and New Zealand College of Radiologists (Faculty of Radiation Oncology), the Royal Australasian College of Surgeons (RACS), and the Australasian College of Dermatologists. The Colleges already have established standards for accreditation of facilities (eg, Guidelines and standards for day surgery in Australia <http://www.surgeons.org/Content/NavigationMenu/FellowshipandStandards/ AustraliaDaySurgeryCouncil/Guidelines_and_Stand.htm>, or the RACGP Standards for general practice <http://www.racgp.org.au/document.asp?id=17623>) and have well established programs for training medical practitioners in the treatment of skin conditions. The Colleges base these programs on high standard “holistic” care that is not influenced by entrepreneurial medicine. Our Colleges encourage the development of improved training programs at all times. It is important that we maximise the benefit of the structures and standards that currently exist. Our Colleges have already begun discussion about the ways we can build on our work to date. Our members, and the Australian public, expect specialist medical Colleges to take a lead in ensuring the quality of health care, and we will continue to do so.

Russell Stitz · Michael R Kidd · Liz M Kenny · Anne M Howard

In January 2001, a daily morning handover meeting (“morning report”), involving medical staff and students, began at the Launceston General Hospital, Tasmania. Periodic questionnaire surveys have been conducted to assess whether the morning report is fulfilling the quality improvement and educational needs of medical staff. The format of meetings has been successively modified in response to feedback. Participants have expressed a preference for patient-focused meetings, with less emphasis on formal teaching. A 12-month pilot study beginning in January 2004 has assessed the impact of adding a bed-management focus to the morning report. Over the period of the pilot study, there has been reduced bed access block, reduced average length of stay and increased bed availability. This suggests that a longer, more formal study may be warranted.

Robert G Fassett FRACP, FASN · Steven J Bollipo FRACP

Objective: To describe the workload profile in a network of Australian skin cancer clinics.Design and setting: Analysis of billing data for the first 6 months of 2005 in a primary-care skin cancer clinic network, consisting of seven clinics and staffed by 20 doctors, located in the Northern Territory, Queensland and New South Wales.Main outcome measures: Consultation to biopsy ratio (CBR); biopsy to treatment ratio (BTR); number of benign naevi excised per melanoma (number needed to treat [NNT]).Results: Of 69 780 billed activities, 34 622 (49.6%) were consultations, 19 358 (27.7%) biopsies, 8055 (11.5%) surgical excisions, 2804 (4.0%) additional surgical repairs, 1613 (2.3%) non-surgical treatments of cancers and 3328 (4.8%) treatments of premalignant or non-malignant lesions. A total of 6438 cancers were treated (116 melanomas by excision, 4709 non-melanoma skin cancers [NMSCs] by excision, and 1613 NMSCs non-surgically); 5251 (65.2%) surgical wounds were repaired by direct suture, 2651 (32.9%) by a flap (of which 44.8% were simple flaps), 42 (0.5%) by wedge excision and 111 (1.4%) by grafts. The CBR was 1.79, the BTR was 3.1 and the NNT was 28.6.Conclusions: In this network of Australian skin cancer clinics, one in three biopsies identified a skin cancer (BTR, 3.1), and about 29 benign lesions were excised per melanoma (NNT, 28.6). The estimated NNT was similar to that reported previously in general practice. More data are needed on health outcomes, including effectiveness of treatment and surgical repair.

David Wilkinson MB ChB, DSc, FRACGP · Deborah A Askew BAppSci, MHlthSci, PhD · Anthony Dixon MB BS, FACRRM

A loved and respected general practitioner in Sydney’s Eastern Suburbs for many years, John Watson came from humble beginnings. Excelling in many intellectual pursuits, he was an eternal student. He loved teaching, and always had a close association with the University of Sydney and Sydney Hospital. John was born in Sydney on 26 May 1917. He always wanted to be a doctor, but during the Depression no child of a poor family could afford the fees. He won a Teachers’ College scholarship and became a science teacher. While teaching by day, he attended evening classes in economics at the University of Sydney. After serving in the Australian Military Forces from 1941 to 1946, John returned to teaching. At the same time, he completed Bachelor of Arts and Bachelor of Economics degrees as an evening student, while saving to enrol in medicine. In 1948, he began to study medicine at the University of Sydney, supplementing his income by working as a bookmaker’s clerk. His sharpness as a mathematician was valued, although his knowledge of and interest in racing was nil! In 1950, he married Rose Wicks, also a teacher, who helped to support him through medical school. After graduation in 1954, John was appointed Junior Resident at Sydney Hospital. In 1956, approaching the age of 40, he established a 24-hours-a-day, 7-days-a-week general practice in South Coogee, living on the premises. Many of his patients became lifelong friends. When Medicare was introduced, John felt he could not work under a system that “put the clock” on time spent with a patient, so he went into hospital administration, becoming Deputy Superintendent at Sydney Hospital. Although a capable administrator, he found some aspects of the work very tedious and missed the contact with patients, and so eventually returned to limited general practice in South Coogee. He served many years as an Honorary Medical Officer in the Sydney Hospital general medicine and neurology outpatient clinics. John’s love of learning, teaching and patient care continued all his life. He was one of the first “radio talk-back doctors” to answer listeners’ questions over the air. For many years he was a member of the Editorial Board of The Medical Journal of Australia. He taught medicine and medical principles at the School of Occupational Therapy, and later became a director of the Sydney Medical Emergency Service Co-op, which provided an out-of-hours locum service to GPs. He was also in great demand as an after-dinner speaker and as a lecturer for the University of the Third Age. His other interests, as a student and beyond, included debating (the University of Sydney’s J G Watson trophy for debating was named after him) and compering and scriptwriting for the annual Sydney University revue. He was President of the Sydney University Union and later a student representative Fellow of the University Senate. He had a keen interest in many sports, including surfing, fishing, cricket, rugby, athletics and hockey. At an advanced age, he took up piano playing and landscape painting. John died on 6 July 2005 after several cerebral vascular incidents and eventual multiple organ failure. He was a truly good man, who touched many people in his different roles. He will be sadly missed by Rose, his sons John, Ian and Andrew, and their families and many friends.

Frederick O Stephens FRCS, FRACS, MD

Men seek help and use health services less frequently than women do. Men’s help-seeking practices and health service use are complex issues involving biological, psychological and sociological considerations. Most discussion on men’s help-seeking positions them as reluctant consumers or “behaving badly” with respect to their health. Few studies have explored whether health service providers are equipped to deal with men’s health issues appropriately. The current health system appears not to be tailored to meet the health needs of men. Better collaboration is required across disciplines, to further investigate men’s health using both qualitative and quantitative research methods.

James A Smith · Annette Braunack-Mayer PhD · Gary Wittert MB BS, FRACP

David B Preen,* Belinda E S Bailey,† Alan Wright‡ * Research Associate, School of Population Health, University of Western Australia, 35 Stirling Highway, Crawley, WA 6009; † State Manager, Royal Australian College of General Practitioners — Western Australian Faculty, Perth, WA; ‡ Hospital Liaison General Practitioner, Department of General Medicine, Fremantle Hospital and Health Services, Perth, WA. davidpATsph.uwa.edu.au To the Editor: The care of patients at the time of hospital discharge and on returning home is often neglected, and has implications for those needing multidisciplinary care. Research has shown that discharge planning can produce better health outcomes, facilitate the patient’s and the general practitioner’s involvement with discharge care, and improve communication between hospital and general practice services.1-3 To encourage GPs to be involved in discharge care planning for patients with chronic diseases, there are Enhanced Primary Care (EPC)-specific Medicare Benefits Schedule (MBS) Items for contributing as a team member to EPC discharge care planning (Item 728), and for review at 3 months post-discharge (Item 724).4 However, the fact that < 1% of claims for EPC care plans are for discharge-related items has been attributed to barriers to GPs’ involvement in discharge planning, or their unwillingness or inability to initiate such a process rather than simply participate.5 Further, little evidence exists that, given the opportunity, GPs are willing to be involved as a team member in this process. In a recent study of ours investigating EPC discharge care planning for chronically ill patients,3 we required GPs to comprehensively review and comment (in writing) on discharge plans developed by the hospital. GPs also performed a follow-up consultation within 7 days of discharge and completed a questionnaire. We found that 90.1% of 91 GPs in the intervention arm of the study willingly contributed to discharge care planning for their patients, indicating that, when offered input into planning discharge and post-discharge care, GPs are willing to fulfil such a role. Further, this finding, in addition to the high questionnaire response rate of trial GPs (80.6%), indicates the importance of this issue to GPs and the belief that GPs are not sufficiently included in discharge processes. Additional results from a follow-up survey, at 28 days post-discharge, of those GPs who participated in discharge planning (n = 91, 70.3% response) showed that only 42% of GPs claimed the MBS Item 728 ($39.80 in 2002, at the time of the study). Results from a subsequent survey (n = 91, 45.1% response) suggested that even fewer (about 15% of respondents) claimed reimbursement for a 3-month care plan review (Item 724, $98.20), although we do not have data on the number of 3-month reviews performed. The reasons given for not claiming these Items included poor understanding of the Item and claiming procedures, and a belief that excessive administration was required to claim the increasing number of MBS items. In the light of sanctions for administrative claiming errors, this may explain the low claim counts for these Items. However, the most common response was that input into the discharge care plan was, in their opinion, not sufficient to justify reimbursement, even with the extra time required for care plan review and post-discharge follow-up. This suggests that GPs do not simply view EPC discharge care planning as a revenue raising exercise, but rather as quality patient care. Further, it may indicate an undervaluation by some GPs of their role in hospital-driven processes. Considering the evidence in support of discharge care planning for improving quality of care, focus should be directed towards ways of encouraging this process, other than simply providing a financial incentive.

David B Preen · Belinda E S Bailey · Alan Wright

Carel van Gend died of bowel cancer at his home on the Clarence River, in northern New South Wales, on 18 June 2005, after 27 years as a Consultant Physician to Grafton Base Hospital. Carel was born in South Africa on 24 March 1933. He distinguished himself at Rondebosch Boys’ High School for winning the mile — but in the slowest winning time on record. He graduated from Cape Town University in 1957, at a high point in that medical school’s fame. Among his anecdotes he recalls being instructed in donning surgical gloves by Christiaan Barnard, and notes that the link between dietary cholesterol and heart disease was clarified through Cape Town’s racially segregated Groote Schuur Hospital. Rejecting the prevailing racism, Carel spent his first decade working in black African hospitals. Two years after graduation, he was the sole doctor at a remote hospital in Northern Rhodesia. Five years there saw his marriage to Margaret Moffat and the births of two children. Over the next 14 years, he held hospital positions in South Africa, England, Scotland, Malawi, Canada and New Zealand. In 1978, Carel moved to Grafton, New South Wales, where he worked as a private and hospital physician and obtained his Fellowship of the Royal Australasian College of Physicians. He initiated a bowel-cancer screening campaign with support from the local Rotary Club and raised funds for the Life Education van. He also served on the NSW Medical Board’s Area of Need Panel from 1999 to 2005, assessing overseas-trained doctors for hospital positions and giving valuable advice to those who would be working in country hospitals similar to his own. His down-to-earth approach to medical problems ensured that those recommended for registration would be adequately prepared for those jobs. In his leisure time, Carel was a keen squash player, amateur actor, Rotary Club member, and president of the local arts festival. He dabbled in breeding exotic cattle, and for several years guided his own “Cattlemen’s Study Tour” of Central Africa. Carel will be deeply missed by colleagues, friends, and family around the world. He is survived by Margaret and their three children, Marie, David and Anne.

David van Gend MB BS, FRACGP, DipPallMed

The last well person. How to stay well despite the health-care system. Nortin M Hadler. Montreal: McGill-Queen’s University Press, 2004 (viii + 313 pp) ISBN 0 7735 2795 8. Somewhat paradoxically, reading this book left me disturbed and critical, despite my wholehearted agreement with most of the imperatives presented in this critical analysis of modern medical practice. The basic message is accurate and important: too many with minor ailments who enter the health care system are convicted of being ill when in fact they are healthy. Well people, Hadler suggests, are those individuals yet to be investigated by a doctor! The health care system is, he argues, poorly evidence-based in far too many areas. Over-diagnosis and the reflexive resort to the prescription pad, rather than reassuring dialogue, is endemic. There is much truth in this of course, but he “doth protest too much, methinks”. For example, Hadler’s views on modern cardiological practices fail to avoid the bias and selective reporting of data he so strongly criticises in others. Individuals with suspected angina are advised to enter into a contract with their doctor that will exclude both angiography and bypass surgery as diagnostic or therapeutic options. In warning patients that much of what a doctor recommends may be of questionable benefit, he fails to educate the lay reader of the possible advantages of early diagnosis and intervention in a person who indeed still feels “well”. Hadler tells us that the book is written for those who are well but nonetheless tempted to stray into a doctor’s office from which they will undoubtedly emerge medicalised. In fact, the contented well are unlikely to pick up this volume while the worried well are unlikely to be persuaded that their concerns are baseless. No, this book is one for students and practitioners of clinical medicine. It is laudably academic in discussing most of the topics covered, with an extensive bibliography and no less than 56 pages of annotated critiques of the studies that, when analysed accurately, support the author’s contentions. Being challenged to re-analyse investigative and therapeutic approaches that are entrenched but by no means evidence-based is, of course, no bad thing, nor hardly revolutionary. Hadler’s challenge to improve statistical analysis to provide outcomes that are undoubtedly clinically relevant is welcomed. Meta-analyses and the Cochrane library have not served our patients well, he argues, wanting us to better define real rather than relative risk. A rheumatologist, Hadler is perhaps at his best when discussing the myriad dubious approaches to the management of musculoskeletal discomfort, turning many patients into invalids entangled in a nightmare of medico-legal wrangling. Such patients, he argues, will receive more help from their therapist than their pharmacist. It is modern medicine’s emphasis on investigations and pharmacy that is driving many patients, who want to ventilate their problems, into the offices of unscientific “alternative” practitioners. Hadler is on shakier ground when he argues that most of us have genes that program us to live for 85 years (plus or minus a few), and will do just that whether or not we treat high cholesterol or moderate hypertension. He doubts the ability of human strategies to have us live longer (a brave assumption given the remarkable increases in longevity achieved even in the post-antibiotic era), and opines that we have made too much of the obesity epidemic in modern societies. He argues that our approach to the diagnosis and management of prostate cancer is often too aggressive, but fails to call for better decision-making that may well save the lives of many who currently die in much discomfort from this malignancy. I’m glad I read this book and have no hesitation in recommending it. We have a long journey ahead of us before we consistently avoid the pitfalls forthrightly identified by Hadler. Doing so will give us our best chance of having many more people remain chronically well because of rather than despite the health care system. John M DwyerEmeritus Professor of Medicine, Sydney, NSW

John M Dwyer

The number of skin cancer clinics functioning within Australia’s primary care environment is increasing rapidly, and significant concerns have been raised about the type and quality of work done by some doctors in some clinics. Mainstream general practice is threatened by perceived fragmentation, and specialist practice in dermatology and plastic surgery is threatened by encroachment into their domains of practice. We propose an agenda of training, standards, accreditation, audit and research to ensure that skin cancer clinics provide optimal health outcomes for patients.

David Wilkinson MB ChB, FRACGP, DSc · Scott Kitchener MB BS, DrPH, FAFPHM · Peter Bourne MB BS · Anthony Dixon MB BS, FACRRM

Objective: To survey the use, cost, beliefs and quality of life of users of complementary and alternative medicine (CAM).Design: A representative population survey conducted in 2004 with longitudinal comparison to similar 1993 and 2000 surveys.Participants: 3015 South Australian respondents over the age of 15 years (71.7% participation).Results: In 2004, CAMs were used by 52.2% of the population. Greatest use was in women aged 25–34 years, with higher income and education levels. CAM therapists had been visited by 26.5% of the population. In those with children, 29.9% administered CAMs to them and 17.5% of the children had visited CAM therapists. The total extrapolated cost in Australia of CAMs and CAM therapists in 2004 was AUD$1.8 billion, which was a decrease from AUD$2.3 billion in 2000. CAMs were used mostly to maintain general health. The users of CAM had lower quality-of-life scores than non-users. Among CAM users, 49.7% used conventional medicines on the same day and 57.2% did not report the use of CAMs to their doctor. About half of the respondents assumed that CAMs were independently tested by a government agency; of these, 74.8% believed they were tested for quality and safety, 21.8% for what they claimed, and 17.9% for efficacy.Conclusions: Australians continue to use high levels of CAMs and CAM therapists. The public is often unaware that CAMs are not tested by the Therapeutic Goods Administration for efficacy or safety.

Alastair H MacLennan MD, FRCOG, FRANZCOG · Stephen P Myers PhD, BMed, ND · Anne W Taylor BA, MPH

Peter M Brooks Executive Dean (Health Sciences), University of Queensland, Royal Brisbane Hospital, Edith Cavell Building, Herston, QLD 4006. p.brooksATmailbox.uq.edu.au To the Editor: Van Der Weyden raises an interesting issue in his recent column From the Editor’s Desk.1 It has long been known that the collective noun for academics is “an absence of”! He is absolutely correct in pointing out that research is valued far more than teaching. That is the reality of current university funding and is at risk of becoming more so, given the research assessment exercise currently being introduced by the federal government.2 This raises the whole issue of profess-orial titles. In a world where elitism is considered not politically correct, we should perhaps dump these titles entirely. I have long yearned for a system like that in the United States, where an individual enters the academic stream at the level of Assistant Professor, progresses to Associate Professor and then Professor (finally being offered tenure after winning the Nobel Prize). This leads to the situation where the “professorial denominator” is not used — individual academics (like other staff) are introduced as “Doctor”. In Australia, many Associate Professors drop the “Associate”, and most “clinical” title holders seem very keen to add their academic titles to their private practice shingles and letterheads. I have often considered doing an economic analysis of the annual value of a title to a doctor’s practice (which I suspect is considerable), and charging appropriately. A decade ago, the then President of the Royal Australasian College of Physicians and myself, as Honorary Secretary, decided to replace professorial titles with “Dr” in all College mail-outs. This lasted about 6 weeks, with a veritable flurry of responses pointing out that we had failed to address these Fellows appropriately. What Van Der Weyden highlights are the real pressures currently on academic medicine, and the need for real debate in the medical community about the worth of academe and the absolute essential building blocks — research, learning and ser-vice — of any credible health system.

Peter M Brooks

Sustainability of reforms is the key to progress According to Starfield,1 the birth of contemporary interest in primary health care can be traced back to the 30th annual meeting of the World Health Assembly in 1977. This meeting set in motion a series of activities including, in the subsequent year, the Declaration of Alma-Ata.2 Drawing on the principles enunciated in this Declaration and a more recent review,3 the Australian Primary Health Care Research Institute (APHCRI) has defined primary health care as: . . . socially appropriate, universally accessible, scientifically sound first level care provided by a suitably trained workforce supported by integrated referral systems and in a way that gives priority to those most in need, maximises community and individual self-reliance and participation and involves collaboration with other sectors. It includes health promotion, illness prevention, care of the sick, advocacy and community development. In the face of the pressures associated with ageing populations (and related rises in comorbid, chronic health conditions), increasingly expensive health care technologies, changing community expectations and increasing inequalities in health outcomes, many countries are undergoing significant health system reform.4,5 Strategies to control costs and improve health outcomes have frequently strengthened the role of primary health care,4 a reorientation well demonstrated by the national health policies of the United Kingdom and New Zealand. Australia has also seen a plethora of large and small-scale initiatives aimed at strengthening primary health care, although these are not enshrined in a national health policy. Large scale efforts include the national Coordinated Care Trials of funds pooling and care planning, the Indigenous health Primary Health Care Access Program and, more recently, the Australian Primary Care Collaboratives Program. At a more local level, Divisions of General Practice6 and Area Health Services have implemented a wide range of programs and activities to strengthen general practice and primary health care. However, all too often, we know little about the sustainability of these reforms. Yet this question is the key to progress; the alternative is a health system landscape littered with short-term programs, projects and interventions which are developed and tested but do not survive. Sustainability is an inherently dynamic construct that has to do with keeping going; enduring without failing or giving way; bearing up or withstanding (Shorter Oxford dictionary). Although questions about the sustainability of primary health care initiatives are of paramount concern in developing countries,7,8 there has been limited interest elsewhere. In their systematic review of diffusion of innovation in health systems, Greenhalgh and co-authors found so few studies addressing sustainability that they did not include it in their journal article based on the review.9 Despite this, it has been considered within Australia in relation to services in rural and remote settings,10-13 and in after-hours services in New South Wales14 and Queensland.15 The APHCRI was established in 2003 with core funding from the Australian Government Department of Health and Ageing. The Institute is expected to: Provide national leadership in improving the quality and effectiveness of primary health care through the conduct of high quality priority-driven research and the support and promotion of best practice. It focuses on important sectoral questions relating to the organisation, financing, delivery and performance of primary health care, including its interaction with public health and the secondary and tertiary health care sectors. The Institute’s priorities, determined by its Research Advisory Board are: Innovation in state–Commonwealth relationships; Innovation in funding arrangements for new or existing services/models; and Innovation in organisation and linkages within the primary health care sector. To get started, the APHCRI decided to address the question of sustainability of existing initiatives that represented innovation in one or more of these areas. For the purposes of this program of work, we are adopting Greenhalgh et al’s9 definition of innovation as a “novel set of behaviors, routines and ways of working that are directed at improving health outcomes, administrative efficiency, cost effectiveness, or user’s experience and that are implemented by planned and coordinated actions.” Five initiatives, diverse in nature and scope were selected, becoming the first “spokes” in the APHCRI’s “hub and spoke” model. They were: The Care and Prevention Programme for people living with HIV; A trial of smoking, nutrition, alcohol and physical activity interventions; A regional integrated Aboriginal mental health program; Two related initiatives investigating pathways of primary mental health care; and The Sharing Health Care Initiative implemented in an Indigenous community-controlled health care setting. Spoke initiativesThe Care and Prevention Programme began in 1998 with time-limited Commonwealth funding from the Divisions and Project Grants Program (to the Adelaide Central and Eastern Division of General Practice), state support through Public Health Outcomes Funding Agreements, and pharmaceutical company support. In 2000, it became a focus of activity of the Department of General Practice at the University of Adelaide, and has since received funding from the HIV, Hepatitis C and Related Programs Unit of the South Australian Department of Human Services. It provides an integrated primary health care service for about a third of HIV-positive people in South Australia, drawn from Adelaide and surrounding regions. Smoking, Nutrition, Alcohol and Physical Activity (SNAP) is a behavioural risk-reduction model developed for the Australian Government in 2002 and trialled in an urban (Sutherland) and rural (Hastings Macleay) Division in New South Wales in 2003–04. It focuses on people with existing or high risk of chronic disease and examines systematically how primary-care teams in general practice can provide more effective interventions for the prevention of chronic disease, and link with other services, especially health promotion units and non-government organisations that provide, for example, nutrition services, exercise programs and counselling for at-risk drinking. The Regional Integrated Aboriginal Mental Health Program in Port Augusta, SA, seeks to improve primary mental health care services to Aboriginal people through a partnership between Pika Wiya (the Aboriginal Community Controlled Health Service) and the mainstream Community Mental Health team. Program activities include the development of appropriate primary mental health care, joint casework and referral protocols; staff skills development; and the development of an integrated service-delivery model across and between Aboriginal and mainstream organisations. The mental health pathways initiative has explored two approaches to mental health care: the Primary Care Evidence Based Psychological Interventions (PEP) project and Panic Online. The PEP study, which is being undertaken in Victoria, is evaluating the effects of training general practitioners in focused psychological strategies for the management of mental health disorders in their patients. It is funded by the beyondblue Victorian Centre of Excellence in Depression and Related Disorders, a collaborative initiative by beyondblue: the national depression initiative and the Victorian Department of Human Services. Panic Online is an online therapy program developed and maintained at Monash University (http://www.med.monash.edu.au/mentalhealth/paniconline) by a team of investigators. It is designed to evaluate the use of online mental health resources by GPs who have been accredited to deliver focused psychological strategies in their treatment of patients with common mental disorders. The Sharing Health Care Initiative is trialling a model of self-care in the management of chronic disease under the direction of the Katherine West Health Board in the Northern Territory. It involves employment of local Aboriginal Community Support Workers, supported self-management for individuals and their families, community-based health promotion initiatives, and training health professionals to teach chronic disease self-management. ApproachThrough an iterative process that included face-to-face meetings in Canberra in October 2004 and February 2005, APHCRI hub and spoke staff collectively developed an overall approach and common set of questions to underpin the work, the dominant question being “How sustainable are these initiatives?” We agreed to approach this question by breaking sustainability into six domains: political, institutional, financial, economic, client and workforce. Each spoke was asked to identify key inhibitors and facilitators of sustainability for their respective initiatives, using the defined domains as reference points. They were to use a combination of existing and new data (the latter collected using the APHCRI funding) and approach the task in a way that made sense locally, while remaining within the defined parameters. Their reports follow. In keeping with the diverse nature of the initiatives, the spokes have taken different approaches to the question, with different emphases. However, within the six domains of sustainability some common themes emerge. These are addressed elsewhere in this Supplement (Sibthorpe et al).16

Beverly M Sibthorpe NZRN, BA(Hons), PhD · Nicholas J Glasgow MD, FRACGP · Robert W Wells BA

“SNAP” is a model for the general practice management of four common behavioural risk factors: smoking, nutrition, alcohol and physical activity. The SNAP program was developed for the Australian Government in 2002. In 2003 and 2004, a feasibility study was conducted in one urban and one rural division of general practice (DGP) in NSW, in partnership with their local area health services. Information technology support and referral directories were developed, based on an initial needs assessment, SNAP guidelines, a clinical summary chart, patient education materials, and general practitioner and staff training. GPs reported that the SNAP approach fitted general practice consultations well. After its implementation, they were more confident in using motivational interviewing and SNAP interventions and referred more frequently. The impact and sustainability of the SNAP program were limited by a lack of effective practice teamwork, poor linkages with referral services, and the lack of a business model to support SNAP in the practices. DGPs could play an important role in providing practice visits and resources to improve communication, education and collaboration to support SNAP programs.

Mark F Harris DRACOG, FRACGP, MD · Coletta Hobbs BSc(Psych)(Hons), PhD · Gawaine Powell Davies BA, MHP · Sarah Simpson BA(Hons), BAppSci(Health Ed), MPH · Diana Bernard BSocStud, Grad Dip Early Childhood Studies, MPH · Anthony Stubbs BA(Health Ed)

The Care and Prevention Programme (CPP) began in 1998. It is based on the philosophy of primary health care, and has improved health among homosexually active men, including about a third of HIV-positive South Australians. The CPP was assessed using financial analysis and qualitative methods. Participants wanted to access care where they could feel comfortable and safe to talk about issues of sexuality and lifestyle. The CPP model is “economically” sustainable, but not “financially” sustainable within the Medicare Benefits Schedule. It is vulnerable to changes in political environment. The financing model for the CPP has been adapted by including state funding. General practitioners have adapted by lowering their personal incomes (but not quality of care). These adaptations have achieved fragile financial viability. Facilitators of sustainability for the CPP included: It is part of the community that it serves; The creation of deeply integrated networks of diversity-competent service providers; and “Virtuous non-adaptability” of service providers in refusing to compromise care standards despite financial pressure to do so. Threats to sustainability included: Difficulty maintaining a diversity-competent workforce skilled in HIV medicine; Marginal financial viability; and Political vulnerability.

Gary D Rogers MB BS, MGPPsych, FACPsychMed · Christopher A Barton PhD, MMedSci, BSc · Ann C Lawless BA, GradDipEd · Joy M Oddy · Rebecca Hepworth MB BS · Justin J Beilby MD, MPH, FRACGP, DRCOG, DA · Brita A Pekarsky BEc(Hons), GradDipHealthEcon