General medicine

We have a fabulous country out there, with lots of people who will benefit from our skills I was tired of seeing myself in my patients — white, middle-aged, middle-class, menopausal women — the “worried well”. It was time for a change. Time to leave my renovated terrace in inner Sydney. Time to put down the glass of champagne, cancel the subscription to the opera, put in storage my five pairs of boots from the Manhattan winter sales, and head off to “the bush” for a seachange. The bush was not an unknown entity for me. Although I’ve lived most of my life in cities, mainly Sydney, I was born in rural Wagga Wagga, the daughter of the first university-trained vet to practise west of the Blue Mountains. I spent my preschool days with my father, flying in a Tiger Moth to attend cows in obstructed labour, and delighting in watching his whole arm disappearing inside the birthing cow. So, my idea of what it would be like working in rural and remote Australia was partly based on these early experiences. Nonetheless, some of my friends were a little sceptical, viewing this decision as a whim, a blip in my middle-class, ABC Classic FM-saturated life. How wrong they were! I have ended up embracing wholeheartedly this wonderful life, committed to spending the rest of my working days facing the challenges of being a doctor in remote Aboriginal communities. It’s not all fun and games, of course. For a multitude of reasons, the health of Aboriginal people, as we all know from media reports and journal articles, is much worse that that of other Australians. In remote areas, the people often do not seek help until the advanced stages of an illness. A person with a toothache may first present with a huge dental abscess and a fever; another, with an unchecked ear infection, may be first diagnosed with a cerebral abscess; a pregnant woman may wander in for her initial check-up at 38 weeks’ gestation; painful joints are more likely to be lupus or rheumatic fever than osteoarthritis; and chest pain in a 26-year-old man must be treated as a myocardial infarction until proved otherwise. Flying over Arnhem Land. Photo courtesy Dan Armstrong. But medicine in the Northern Territory has grown up with an infrastructure geared to remote communities and to Aboriginal health. Having always believed in a public health system in which treatment priority is determined by illness severity (as in emergency departments in public hospitals), I was thrilled to find that the Northern Territory delivers the type of healthcare I believe in. Requests for outpatient appointments are faxed to the specialist in charge of that department and “triaged”. A woman with cervical intraepithelial neoplasia (CIN) grade III will be seen before one with grade I, and a woman with a history of breast cancer with recent weight loss and low back pain will be seen within a week. No preferential treatment linked to income or social standing. Just the sickest are seen first. Exactly how public medicine should be. Working in Aboriginal health in the Northern Territory is like working in a big cooperative family. I have never known such a sense of collegiality, and a lack of competition between healthcare providers. Help is always at the end of a phone. An emergency evacuation is organised via the district medical officer on duty for that day or night. There may be some input from a registrar or specialist to fine tune the patient’s treatment before air evacuation, and, if the patient’s condition is unstable, a registrar may accompany the nurse on the flight and perform the necessary resuscitation procedures before evacuation. Each time I have accompanied a patient to the airstrip for a medivac, I have watched the plane take off with tears in my eyes and an embarrassingly “proud to be Australian” lump in my throat. Not just the feeling that at last the patient is in safe(r) hands, but the feeling that not many countries provide such a fabulous service. But what of the communities I have worked in, the life I now lead, and the medicine I now practise. My favourite community is in western Arnhem Land, and I will return to this community in January 2005 to take up a 12-month contract. My first job there was in the “Wet”, that time of year when the skies become more ominously black as the day progresses, and the thunderstorms and lightning displays make the 1812 Overture and the Sydney Harbour New Year’s Eve fireworks display seem like child’s play. When the heavens open, the rain buckets down and the temperature drops a welcome 10°C. And, in the “Top End”, this is the time when tropical diseases blossom, and any person with symptoms of pneumonia or explosive fevers with skin lesions is diagnosed as having melioidosis until proved otherwise. This disease has a reasonably high fatality rate (the books say 17%), and the causative organism lives in the soil in the rainy season, so anyone with a cough and high fever is pumped with intravenous ceftriaxone and immediately evacuated. On a single day in this community during the Wet, our patients included a man with suspected melioidosis (which turned out to be septicaemia from a staphylococcus pustule on his leg); a 9-year-old with a huge, hard tonsillar lymph node and a massive cavity in a nearby tooth (I suspected osteomyelitis); and a 21-year-old girl who, as a child, had miraculously survived a gigantic brain abscess that developed from mastoiditis (which in turn developed from an untreated ear infection). She presented with headaches and vomiting, probably associated with a blockage in the shunt extending from her brain to her belly. And to top it off, there was a 17-year-old girl with active (treated) tuberculosis that appeared to have spread to her kidneys. All these people had to be either evacuated (with limited places on the Aerial Medical Service plane) or flown on a charter plane to Jabiru and then taken by bus to Darwin. A nightmare to organise, but somehow it gets done. One of my most memorable experiences involved visiting an outstation that, in the Wet, could only be reached by a small twin-engine plane. I had asked the outstation nurse what supplies to bring — lunch? water? stethoscope? “Just water and stethoscope”, she said. “Keep it light. Forget about the lunch. Rebecca and Samuel [at the outstation] have a pack of about 60 dogs, and they’ve become unmanageable. In fact, Rebecca and Samuel have moved out into the humpy outside, as the dogs have taken over the house. If you bring your lunch, they’ll smell it and eat you and your lunch for starters.” “Righto”, I said, always casual in the face of impending disaster. And she wasn’t far wrong. We flew over the Arnhem Land escarpment, some of the most beautiful wilderness country I have ever seen, and as the plane skidded to a halt on the very short airstrip we were prevented from getting out by a mob of about 20 ferocious dogs, who obviously thought the pilot, nurse and doctor were their breakfast, lunch and dinner by air express. Rebecca finally managed to call them off and we set up the clinic on the veranda, tending to the needs of eight people with a variety of disorders — chronic obstructive airway disease, rheumatic heart disease (requiring monthly penicillin injections and regular echocardiography and cardiology review), newly diagnosed hepatitis B, a child with anaemia, hypertension, as well as the usual smattering of hypercholesterolaemia, worms and diabetes. For all those urban GPs out there who are feeling sluggish and jaded, I thoroughly recommend considering a seachange to rural and remote Australia. If your emergency medicine skills are somewhat rusty (mine were totally obsolete), head off to your local ED and spend a few months eating humble pie while interns and residents show you the latest ropes. Book into a few courses, such as emergency life support (ELS) and early management of surgical trauma (EMST). If you’ve decided that remote Aboriginal communities might be your cup of tea, practise communicating with your neighbours from non-English-speaking backgrounds. Or, better still, travel to a country whose language and culture is totally different from your own, get ill (but not too seriously), and experience at first hand how difficult it is to describe your symptoms to a doctor or nurse who doesn’t speak your language. We have a fabulous country out there, with lots of people who will benefit from our skills. My best advice to anyone who wants to see Australia, and is ready to experience new challenges and work with some of the most disadvantaged people in the world, is to pick up the ball, run with it, and, in the words of a famous running shoe company, JUST DO IT!

Glynis A Johns MB BS, DPH, MPhil

Despite leadership roles being critical, we persist with outmoded models of organisations and pay inadequate attention to developing individual leaders and new models of leadership within the medical profession. New forms of leadership are required. Among many important roles, leaders are called on: to enhance the meaningful identity of a profession; to create effective linkages with other healthcare professionals and stakeholders, as well as with healthcare system managers; to interpret complexity so that their institutions and followers can operate successfully in uncertain times; and to consistently model ethical behaviour.

S Bruce Dowton MD, FACMG, FRACP

How can we restore some semblance of sanity to a world spinning out of control? Some years ago now, Terry Gilliam (of Monty Python fame) produced something of a screen gem, enigmatically entitled Brazil. It was set in some indeterminate period in the near future, at which we now seem to have arrived. The world of Brazil was a world out of control — a world in which the infrastructure of daily living had become so complex that it required the intervention of a quasi-supernatural being when things went wrong in the lives of its inhabitants. Played (brilliantly) by Robert de Niro, this being descends (like Superman) from nowhere to rip open the offending section of wall — behind which there pulsates an incredibly complex, almost organic, mass of wires, tubes and other assorted technological viscera — “fix” the problem and then disappear once more. While immensely grateful, the mortals whom he has thus aided are none the wiser as to how he has effected this minor miracle, which leaves them very much at his mercy the next time the system fouls up. This threat is never far off, as the more complex things are the more often they go wrong. It would be possible to run a society with such a quasi-supernatural saviour at hand, assuming, of course, that some terrible mishap does not befall your hero. The gamut of potential mishaps must be extensive: kryptonite, alien forces, death rays, evil geniuses, or even the appearance of a Bizarro-quasi-supernatural being. But, in Brazil, hero de Niro did not succumb to any of these. He succumbed to paper. Yes, you heard me: paper. One day, he is walking along a road when a wind springs up. A piece of paper blows up against his leg, then blows away. Then a second, then a third — before a veritable barrage. Some of these papers are whisked away, while others adhere to his flailing limbs as he struggles to free himself. Soon he is trapped, struggling to breathe in this swirling, smothering maelstrom. But the onslaught of the paper is relentless, torrential, unforgiving. Soon, his struggles falter, and he drops to his knees. We sense that he has lost the battle. His struggling figure wanes, the paper begins to disperse, and soon there’s nothing left where de Niro once stood. He has been utterly subsumed — drowned and obliterated — by paper. Any of this sound familiar to you? It should. Simply substitute “computerisation” for “complex infrastructure” and “red tape” for “paper”. But what is red tape? Red tape consists of the requirements of a complex bureaucracy. How is it manifest? As documentation. Why is it seen as necessary? In order to prove that we are doing what we say we are doing. But to whom are we demonstrating this proof? Ultimately, to a bunch of lawyers, whether they are the hired guns of a litigious patient or the hired “suits” of a government department. Our society is drowning. It is on the verge of being utterly subsumed by the complexity of its own systems. Anyone who doesn’t realise this is ready for a wake-up call. This is that call! Litigation was originally put in place to protect the rights of the individual, but it now oppresses the very people it was sent to protect! Every day around the world, billions of ordinary citizens — from doctors to nurses to accountants to engineers to shopkeepers to craftsmen to fishermen to you-name-it — spend a substantial part of every hour devoting themselves to the documentation of their job as opposed to its execution. And with every year that passes, the level of documentation becomes more exacting, more oppressive, more intrusive, less conducive to the effective management of the job and, perhaps most damaging of all, insidiously undermining of trust. Everybody out there is hurting. A patient of mine who runs a small woodwork workshop for children (in which no child has ever been injured) told me that he now finds himself paying out $15 000 a year in insurance to an insurer he had to hunt for interstate. A well-known fishing identity from Sorrento, near Melbourne, speaking on a local radio station, said that he spends half his working day on dry land filling out government forms. Another of my patients, a family accountant, has to drop all of her loyal, regular, small clients because the documentation requirements of even the simplest transaction have placed the cost of her accounting services out of reach of these people — the very people for whom she set up her business in the first place. On a macro scale, in my opinion, the productivity of modern society has been virtually halved by the requirements of documentation (while the consumption of paper has sextupled). The situation is no longer sustainable. As a society, we can no longer afford the luxury of mistrust. Yes, it’s nice to have the right to sue, but the other side of that coin is that each of us must expend half of our working lives in efforts to prevent others from suing us. Ironically, the exponential rise in documentation that was supposed to protect us from such litigation has failed miserably. We are being sued more than ever before. At a recent risk management seminar I learnt that the United States experience of capping damages is that it doesn’t work and that lawyers simply launched more actions so as to bring their total income back to what it was before the capping. We need to create legal systems that virtually exclude lawyers entirely (eg, the New Zealand system of compensation for medical mishap), and we need to limit their numbers quite sharply — as it seems to me that each lawyer will fill the litigious airspace available to him or her. And, we need to become aware of the price we pay for each so-called “right” we claim. Moreover, we need to trust one another more. The world is spinning out of control, and nobody is yelling: “Stop!” “The Brazil Project” is about doing just that. It is about bringing these issues into the public eye in a balanced fashion, without compartmentalising them to the point of meaninglessness. It is about calling a moratorium on worthless documentation — ie, any documentation that is not essential to the actual running of a particular enterprise. It is about loosening the stranglehold of lawyers, whom we ourselves have aided and abetted with our actions. It is about recognising that there is another way of conducting our society — a way based on trust rather than adversarial acquisitiveness. My intention is to make The Brazil Project a functioning reality — not an institution bound by meetings and minutes and mission statements, but a loose association of like-minded individuals whose aim it is to restore to the world some semblance of sanity. This will take time, effort, energy, faith, determination and, yes, some money. As a 70-hour-per-week medico, I can’t do it alone (although success in this venture would probably render me a 35-hour-per-week medico!). If you are interested in joining me in this endeavour, please contact me. I do not pretend to have all the answers, nor am I entirely certain of the way to proceed, but there has to be a better way, and I believe the first step in achieving a better way is a cry of protest. The more voices that join in this cry, the better it will be heard.

Ron Elisha MB BS

To the Editor: The articles in the General Practice issue are most interesting. Sadly, the articles on how general practitioners are paid1-6 have largely missed the point. It is not only how GPs are paid, but also how much that matters. No matter how ideal the incentive incorporated in the payment method may be, if the quantum is too little even the most idealistic GP will find it impossible to work in a professional manner. Payment here includes both direct personal income and the associated practice conditions. In most countries, changes in GP financing focus more on how to keep costs down than on rewarding quality. Green was the only author to address this issue, making the point that US family medicine organisations have recently changed from showing how good GPs can be to ensuring they are paid well enough to do that good work, and to provide incentives to encourage the next generation of family physicians.6 Since the introduction of the National Health Service (NHS) in 1949, the United Kingdom has gone through several cycles of declining incomes and conditions for GPs, followed by declining interest and recruitment, in turn followed by higher pay and conditions that attracted new recruits. Overall, UK GPs have been paid relatively well compared with their hospital specialist colleagues. It is no accident that the UK has developed the highest levels in the world of academic general practice, as well as research in practice, while the British taxpayers obtain the highest value from their overall health service.7 Currently, in Australia, the Journal classifieds confirm that there are vast discrepancies between expected salaries for specialist and GP services; perhaps there is a lesson for funding. Until salaries for GPs are similar to those for specialists, bright young medical graduates will prefer to work in higher-paying, hospital-based specialties. Merely altering the payment system will make little difference. The value potentially obtained from good primary care will remain out of reach unless the total resources put into this sector are increased.

James A Dickinson

To the Editor: Proposals to manage the shortage of general practitioners by recruiting and training overseas-trained doctors and funding new medical schools will take years to take effect and be enormously expensive. The crisis is with us now. Support for properly trained practice nurses by Medicare, either as a rebate or a salary, could rapidly ameliorate the shortage of GPs, and would deliver improved patient care. I do not refer here to nurse practitioners — that is a different issue. Practice nurses in many developed countries undertake routine GP tasks. Increasing specialisation requires GPs to have more time to evaluate patients. Nurses can complete an initial case summary: these are time consuming and are often missing. Nurses can measure blood pressure; perform Pap smears, breast examination, and vaccinations; counsel people (who will often reveal important information to a nurse); sterilise instruments; explain asthma plans and puffers; give simple dietary advice; and supervise diabetes protocols. This is not a second-class option — it will improve care: doctors who have worked with the system find it improves the quality of their practice and saves them a great deal of time to do other tasks. New and bridging courses for these nurses, a few of which exist, would rapidly produce a workforce happy to work from 9 am to 3 pm, or job share. They need Medicare support. The Minister for Health and the shadow minister may wish to consider this.

Sandy L A Reid

To the Editor: Poor adherence to therapy with asthma preventer medications is common among teenagers with asthma. This is often simple forgetfulness rather than active non-compliance. One of our adherent patients shared his secret with us — the alarm mode on his mobile phone. He set this to be activated twice daily to remind him to take his medicine. A recent survey by Newspoll showed that about 90% of teenagers aged between 13 and 19 years in Melbourne and Sydney have a mobile phone, most of them on a prepaid plan.1 We have subsequently recommended this reminder system to other patients, who have expressed interest in adopting the practice. This could be useful for all patients required to take regular medications. In the absence of a mobile phone, many household appliances (such as microwave ovens) have electronic timers that could be programmed to sound an alarm on a regular basis.

Gaudenz M Hafen · John Massie

An important Australian initiative that sets an international precedent We’ve got major problems at a really early age . . . to do these elderly health assessments, are they going to dig us up? We’re dead and buried by then. We might as well set up a clinic next to the cemetery.1 These poignant words were spoken by Dr Puggy Hunter, recipient of the Human Rights and Equal Opportunity Commission’s Human Rights Medal in 2001 and former Chair of the National Aboriginal Community Controlled Health Organisation (NACCHO), who passed away at the age of 50 years in 2001. He made these observations after the federal government’s launch of the Enhanced Primary Care Package in November 1999. Among other things, the package was designed to assist general practitioners to provide preventive care for Australians over the age of 75 years through Medicare Benefits Schedule rebates. For Aboriginal or Torres Strait Islander people the age limit was lowered to over 55 years.2 As 53% of Aboriginal men and 41% of Aboriginal women die before reaching the age of 50 years,3 representatives from NACCHO,4 general practice groups and the Australian Medical Association expressed concern that relatively few Aboriginal people would benefit from these rebates. Moreover, an evaluation in 2003 found that few Aboriginal and Torres Strait Islander people over 55 years had accessed the Enhanced Primary Care rebates.5 In this population, preventive health assessments are obviously needed earlier, given the occurrence of preventable chronic disease at younger ages and higher rates than in other Australians.6 Preventive healthcare can both reduce costs to the health sector and enhance health equity for Aboriginal peoples and Torres Strait Islanders, as most of the factors underpinning health disparities relate to social disadvantage (Box). For example, if renal disease is detected early, end-stage renal failure can be avoided and treatment will reduce mortality by 50%.12 However, during 1997–2002, Aboriginal and Torres Strait Islander Australians (compared with non-Indigenous Australians) were twice as likely to be referred late for dialysis treatment. (Late referral is defined as first attending a renal unit or being seen by a nephrologist less than 3 months before the initiation of dialysis.) In the intervening years, NACCHO has lobbied hard for the Medicare Benefits Schedule to make preventive health checks accessible to younger Aboriginal people.4 On 5 May 2004, the Federal Minister for Health launched a new Medicare Benefits Schedule rebate for an adult health check of Aboriginal and Torres Strait Islander people aged 15–54 years (Item 710).13 The challenge now is for GPs to make use of this rebate. Firstly, they need to understand what comprises an effective preventive health assessment for this population. In 2001, NACCHO led an alliance of eight non-government organisations — the Chronic Disease Alliance — to undertake a review of the evidence for preventive interventions, with the support of the Royal Australian College of General Practitioners and the Australian Government Department of Health and Ageing. The outcome — The national guide to a preventive health assessment in Aboriginal and Torres Strait Islander peoples — was completed in 2004,6 and a pilot study has been conducted with over 40 GPs. The guide lists a range of health problems and risk factors that are amenable to prevention, and supplements the “red book” of the Royal Australian College of General Practitioners.14 It takes into consideration the differing demographic and epidemiological factors that influence the development of disease in Aboriginal and Torres Strait Islander populations and was the basis for the descriptor for the new rebate. Secondly, changing practice to align with the evidence requires more than guidelines. Multifaceted strategies are needed, including decision-support systems, clinical audit, feedback, and support from opinion leaders.15 A health system that relies on free market provision of preventive healthcare can perpetuate inequity, as those who need the interventions are least able to afford and access the provisions. Proactive encouragement of preventive health assessments requires incentives and penalties, as well as removal of administrative and legislative barriers. Even with the rebate, implementing adult health checks in general practice may not be easy. According to 2001–02 data from the BEACH study (Bettering the Evaluation And Care of Health), at least 70% of GPs in Australia have, to their knowledge, not provided care for a single Aboriginal or Torres Strait Islander person in that period.8,9 Thus, changing practice to maximise the uptake of adult health checks for this population will require a range of supportive activities, such as: Distributing the guide to every GP; Promoting a suite of resources to assist GPs to better identify Aboriginal or Torres Strait Islander people and to improve cross-cultural communication;13 Developing ancillary resources such as case studies; Upskilling GPs using the expertise of Aboriginal community-controlled health services through coordinator positions established within NACCHO affiliates; Enhancing and supporting the role of Aboriginal health workers; Developing a communication strategy for the broader Aboriginal and Torres Strait Islander population to increase the demand for adult health checks;8,10 and Introducing clinical audit points for professional development. Bulk-billing for these assessments is critically important given the significant socioeconomic disparity between Aboriginal and Torres Strait Islander people and the broader Australian population.16 Mechanisms for improving access to medications under the Pharmaceutical Benefits Scheme for Aboriginals and Torres Strait Islanders are also required. This has been proposed by the Australian Pharmaceutical Advisory Council, NACCHO, the AMA and the Pharmacy Guild in a series of new reforms.17 2004 is the final year of the United Nations International Decade of the World’s Indigenous Peoples, and the development of this Medicare Benefits Schedule rebate removes a significant cost barrier from the delivery of preventive healthcare to Australian Indigenous people. The adult health check is an important Australian initiative that sets an international precedent. A total of 1977 services were claimed against Item 710 (Health Insurance Commission data18) from May to August 2004. This appears slower than the initial claim rate of elderly health assessment items (Enhanced Primary Care) for which an extensive implementation strategy was funded by the government. It is now time to finance an appropriate implementation strategy for the adult health check. General practice groups, including Divisions, should assist GPs to use the new adult health-check rebate for the identification and timely management of unrecognised health problems among Aboriginal and Torres Strait Islander Australians — the populations in which this is most urgently needed. Justification for a Medicare Benefits Schedule rebate for adult health checks for the Aboriginal and Torres Strait Islander population Aboriginal people and Torres Strait Islanders: have lower participation rates in preventive health programs (eg, cervical screening and breast cancer detection).7 have high rates of undetected risk factors and chronic disease.6 are referred late for end-stage disease, making treatment options more expensive (eg, if renal failure develops).6 are less likely to ask for preventive health assessments (significantly lower rates of requests for check-ups).8 have unequal access to Medicare (rate of use of the Medicare Benefits Schedule by Aboriginal people and Torres Strait Islanders is less than half that of other Australians, yet their overall health needs are about three times greater).9 General practitioners: miss opportunities for prevention (eg, significantly lower rates of vaccination by GPs in encounters with Aboriginal and Torres Strait Islander people10), leading to higher rates of hospital admissions for preventable diseases.11 find the preventive assessment process complex (comorbidity, sociocultural considerations).6 experience difficulties in delivering preventive healthcare to the Aboriginal and Torres Strait Islander population (inadequate remuneration for the time required, lack of knowledge of relevant health issues and inability to identify Indigenous Australians).6

Naomi R Mayers · Sophie Couzos MPH

To the Editor: I read with interest the article by Byles and colleagues that shows the minimal impact of health assessments in a section of the older Australian community.1 While these assessments may not be identical to the assessments covered by Enhanced Primary Care (EPC) items on the Medicare Benefits Schedule, my experience performing the latter in older people leads me to believe that they also have limited impact. I am now in part-time clinical practice, with a reasonably well-defined practice population, comprising mostly older patients with complex problems. My practice philosophy is closer to the (perhaps old-fashioned) notion of continuing, comprehensive care, which means I have not been afraid to spend the time needed to understand those patients and to document their health information. So far, I am not sure I have learned anything new in any of the EPC health assessments in which I have participated, although they have been useful for initial assessments of newer patients, as at least they remunerate practices better for the time-consuming task of doing this well. However, EPC assessments may be performed every 12 months. Is this really necessary, unless patient circumstances change? In my practice the answer is probably no, although they may be more useful in practices with less stable doctor–patient relationships. Would it not be a more effective use of resources to instead allow for better-funded initial assessments and assessments when a patient’s condition changes, irrespective of the timing?

Richard B Hays

Marcus (“Marc”) Faunce was born in Sydney on 5 December 1922, and died in the early hours of 14 June 2004 in Canberra, after a protracted struggle with renal cancer. After qualifying in medicine from the University of Adelaide in 1946, Marc served in the Australian Army Medical Corps in post-war Japan and trained at the British Postgraduate Medical School at Hammersmith. He became Senior Registrar at Sydney Hospital in 1949 and married Marjorie Morison in 1951, obtaining his membership of the Royal Australasian College of Physicians (RACP) in the same year. From 1954 to 1956 he did research at the Brompton Chest Hospital in London, becoming a Member of the Royal College of Physicians (RCP) (London) in 1955. Two years later, Marc and Marjorie moved back to Australia and settled in Canberra. Marc established himself as a consultant physician and salaried specialist with the Commonwealth antituberculosis campaign. He was elected a Fellow of the RACP in 1965 and of the RCP (London) in 1968. During his 35 years of full-time practice, Marc was much loved by his patients and admired by colleagues and students as a great general physician with a special interest in respiratory medicine. He co-founded the Canberra Medical Society in 1959. He served on the ACT Medical Board (1963–1974) and was Senior Physician Consultant to the Royal Australian Air Force Medical Directorate (1976–1980), with the rank of Group Captain. For these services he was made an Officer of the Order of the British Empire in 1969 and a Member of the Order of Australia (Military Division) in 1981. Marc was a staunch advocate for a medical school in Canberra. He served on the Board of Management of the Royal Canberra Hospital (RCH) from 1967 to 1974. He fought against the demolition of the RCH, situated adjacent to Lake Burley Griffin. The battle to save the hospital ultimately failed, and its units were progressively transferred to the Woden Valley Hospital (now the Canberra Hospital) from 1991 until its eventual closure in 1993, when Marc was given the honorary accolade of Emeritus Consultant to the RCH. It was a source of great satisfaction to Marc that his son, Thomas, was appointed Senior Lecturer and Chair of Personal and Professional Development at the new Medical School established at the Australian National University in 2004. Marc was renowned for his stringent adherence to medical confidentiality, being individually selected to be honorary personal physician to five prime ministers and six governors-general, for which services he was made a Commander of the Royal Victorian Order in 1995. He was a voracious and eclectic reader. Though distrusting spiritual conceptions, he heavily annotated many copies of the New Testament. His favoured social introduction was “Just sit down and let me tell you the story of my life”. Marc is survived by his sons Thomas and Marcus and daughter Charlotte.

Bryan S Furnass

A 74-year-old woman presented to hospital with dyspnoea of sudden onset. She was in cardiogenic shock, with blood pressure of 90/50 mmHg, and pulse rate of 115 bpm. The electrocardiogram (ECG) was difficult to interpret because of severe, persistent and inexplicable artefacts (Box 1A). Chest x-ray showed acute pulmonary oedema thought secondary to left ventricular failure. Echocardiography showed a left ventricular ejection fraction of 40% and anterior akinesia. Coronary angiography confirmed a proximal occlusion of the left anterior descending coronary artery, which was successfully treated by direct angioplasty and stenting. Review of the patient’s previous medical records revealed, on a thoracoabdominal image derived from computed tomography data, a foreign body in the central abdominal region (Box 2). Questioning of the patient after the angioplasty revealed that this was an electrostimulator (Itrel II, Medtronic, Minneapolis, USA) implanted a few years earlier as part of a dynamic graciloplasty to treat faecal incontinence. An ECG performed 12 hours after the angioplasty with the device deactivated (by the patient’s control programmer) produced an ECG tracing free of artefacts (Box 1B). Persistent and inexplicable ECG artefacts should raise the suspicion of interference from a device generating high frequency electrical impulses. Such devices may include minute ventilation rate-responsive pacemakers1 and central or transcutaneous neurostimulators (eg, deep brain neurostimulators used in Parkinson’s disease,2 and spinal neurostimulators used in chronic back pain3). Occasionally, when the vector of impulses is perpendicular to an ECG lead, the tracing from that lead may be free of artefacts (eg,Box 1A, lead I). Intrathoracic devices are usually discovered on physical examination or standard chest x-ray, but devices in other parts of the body may not be obvious. In dynamic graciloplasty to treat anal incontinence, the gracilis muscle is transposed around the anal canal and electronically stimulated by a device placed in a subcutaneous pocket in the abdominal wall.4 In our case, this device led to ECG artefacts potentially interfering with the ability to diagnose the acute myocardial infarction. Implanted electrostimulation devices are being used increasingly in medicine and should be considered as a possible source of ECG artefacts, especially by frontline clinicians confronted daily with such life-threatening conditions as acute coronary syndromes. Electrocardiograms in a patient with an electrostimulation device A. On presentation, showing artefacts. B. After temporary deactivation of the device. 2 Thoracoabdominal image calculated from computed tomography data, showing the device (arrow)

Robert F Bonvini MD · Edoardo Camenzind MD

Tim Woodruff President, Doctors Reform Society, Suite 207, 320 Victoria Parade, East Melbourne, VIC 3002 twoodruffATbigpond.com To the Editor: It is encouraging to see the Journal continuing its tradition of taking on contentious issues in publishing articles about the negative influence of the pharmaceutical industry.1 With respect to the practical suggestions to address this issue, I suggest that reliance on our profession to substantially improve the situation, although laudable and appropriate, is too optimistic given the gross denial by our colleagues that there is an issue. Our professional bodies simply do not have the support to enforce codes of conduct. The Royal Australasian College of Physicians (RACP) has published guidelines on this issue,2 but I doubt most of its members have read them. I fully support Breen’s comments relating to funding of educational activities, but I suggest that the pharmaceutical pseudo-educational dollar be bypassed by a major expansion in government funding.3 The provision of regularly updated, easily accessible treatment guidelines integrated into prescribing software (which most general practitioners use daily) would go a long way to decreasing our reliance on the drug dollar for information on appropriate treatment. This requires government investment and professional college cooperation, but would lead to recurrent savings to the Pharmaceutical Benefits Scheme and better treatment. Currently, the federal government spends $21 million on drug information to doctors,4 while the drug industry spends $1 billion on marketing.5 To partially redress this imbalance would, however, require both political will and pressure from the profession.

Tim Woodruff

Linda V Graudins Senior Pharmacist (projects), Prince of Wales Hospital, High Street, Randwick, NSW 2031 graudinslvATsesahs.nsw.gov.au To the Editor: Thank you for publishing the Viewpoint by Breen regarding pharmaceutical industry relationships with the medical profession1 — but please do not coin the word “pharmaproof”. This word unintentionally casts aspersions on fellow clinicians — pharmacists — who share the dilemma of aggressive pharmaceutical marketing influencing professional decisions. The relationship between the industry and pharmacists is actually more complicated, as we are not only advocates for patients and advisers to doctors on the safe and evidence-based use of medicines, but also the buyers of the pharmaceutical products. This last function means that most pharmacists cannot be removed from the business side of medicine supply and must work with the manufacturers to obtain supplies in a timely fashion and at the best price. In my work as a hospital pharmacist, the pharmaceutical industry helps in planning financial aspects of medicine supply, sponsoring various activities that the public health system and universities are unable to, and providing specific product information — be it for marketed, unregistered or trial medicines. Most pharmacists cannot choose to not see industry representatives. The formation of such relationships can indeed insidiously affect our clinical decision-making, as outlined by Breen. Unfortunately, the issue of industry’s influence on pharmacists’ decision-making has only rarely been discussed in the pharmacy literature.2-4 Both medical and pharmacy clinicians must be aware of this influence and act accordingly. Peter Mansfield’s Healthy Skepticism (www.healthyskepticism.org) is a good starting point to increase this awareness. However, the movement must include physicians and pharmacists on the same side. I have often been told that we must have the latest new drug on the hospital’s formulary because . . . and have been given a hefty manufacturer-prepared dossier as the sole reason for the request. I urge physicians to work with pharmacists and be “pharma(cist)friendly”, yet also “industryaware”.

Linda V Graudins

Scott Masters General practitioner, Musculoskeletal Medicine, Caloundra Spinal and Sports Medicine Centre, 39 Minchinton St, Caloundra, QLD 4551 cfmpATozemail.com.au To the Editor: The Journal recently published three interesting articles on the relationship between the medical profession and the pharmaceutical industry.1-3 With Medicines Australia (the pharmaceutical manufacturers’ association) setting up a strict code of conduct (tighter than for any other industry I know), a better balance seems to be on the horizon. Breen reminded us of our responsibilities to protect ourselves and our patients from slick marketing by pharmaceutical companies.1 One technique our surgery has found useful is to have a personal code of conduct. Our surgery has a guide for pharmaceutical reps (copies available from the author). It advises reps that we are not interested in seeing their promotional material, especially those useless coloured graphs. However, we are very happy to look at published trials regarding their product and associated diseases. Personally, I have found the resources available from many reps useful and time-saving. Breen is concerned about our professional leaders being in denial about the influence of the pharmaceutical industry on doctors’ prescribing habits. If this is so, then the same leaders have complete amnesia and catatonia about another influence that potentially threatens to engulf us. The sale of supplements and complementary medicines in Australia is a billion-dollar business now. Every month I receive more requests to use supplements for conditions varying from heart disease, cancer and fatigue to non-specific therapies such as detoxification, immune support, metabolic enhancer and anti-ageing. I can sell all these products directly to consumers (patients) at a mark-up I consider reasonable. Alternatively, I can recruit patients to become sellers in a multilevel marketing scheme (similar to pyramid selling). One doctor who practises nutritional medicine full-time has told me he buys $10 000 worth of vitamin E at the start of the year and manages to sell it over the ensuing 12 months for $100 000. I imagine most of that doctor’s patients are recommended vitamin E for their health complaints or health maintenance. This is entirely legal, although there are major ethical concerns about conflict of interest. To date, there has been little debate among our leaders regarding proper guidelines and regulation of this behaviour. With the enormous potential of the complementary industry to be a useful partner in health management, this needs to be sorted out sooner rather than later.

Scott Masters

Rosanna Capolingua Chair, Ethics and Medico-Legal Subcommittee, Australian Medical Association, PO Box 6090, Kingston, ACT 2604 Comment: I commend Masters on his personal code of conduct in dealing with the pharmaceutical industry. I also share his concerns about the ethical minefield that lurks in the interface between complementary and conventional medicine. Some of the issues involved have recently been explored in the Journal’s series on Complementary and Alternative Medicine.1 However, his scenario of a doctor selling vitamin E to patients raises specific concerns, and the Australian Medical Association’s Code of Ethics2 provides some ethical principles in this regard. Specifically, it states that a doctor should: “make sure that you do not exploit your patient for any reason” “exercise caution in publicly endorsing any particular commercial product or service not covered by the Therapeutic Goods Advertising Code”3 and “when referring your patient to institutions or services in which you have a direct financial interest, provide full disclosure of such interests”. Translating these principles into daily professional conduct means the practitioner must at all times declare pecuniary interest in the sale of products and be aware of the evidence base of the commercial recommendation so as to not mislead the patient. This involves clear communication of potential benefit, adverse effects, and possible drug–drug interactions of whatever product is promoted. But, above all, the whole thrust of the AMA Code of Ethics is to ensure that perverse incentives remain foreign to the patient–doctor relationship. Ultimately, it is an individual doctor’s choice.

Rosanna Capolingua

Promoting psychological wellness in doctors requires tailored interventions Doctors’ health and wellbeing seems to be attracting increasing international attention by the medical profession. 1,2 Is this because doctors’ health is worse than it used to be? Is medicine becoming too overwhelming for its practitioners? Does health promotion targeted at the profession work? And what is the profession doing about the health of its members? Unhealthy doctors cannot be expected to deliver high-quality healthcare Doctors are physically healthier than the average person in the community,3 even though they do not always follow their own healthcare advice (see Kay et al, page 368). 4-7 At the same time, they have significant psychological vulnerabilities,8 and are more likely than the average person to suffer from one or more of “the three D’s” — drugs, drink and depression (including suicide). Whether this is predominantly due to the stress of the job or to pre-existing personality traits has long been debated (see Riley, page 350). 9 The relatively small proportion of doctors who experience mental illness or substance misuse are described as being impaired. Many of them ultimately come to the attention of state medical boards, usually through referral by concerned colleagues. The New South Wales Medical Board has established an Impaired Registrants Panel, whose members work with impaired doctors and medical students to decide on how they can continue to work or study while the public interest is being protected (see Wilhelm and Reid, page 372). Troubled doctors are a larger group who are significantly affected by stress, although their disability may not be such that they cannot practise. Screening Australian doctors for anxiety and depression using the General Health Questionnaire has revealed a high level of stress among general practitioners;10 similarly, in New Zealand, severe stress symptoms are much higher among GPs than in the general population. 11 This troubled group is at risk of becoming impaired in due course. The most visible group are the dissatisfied doctors. They complain about “the system” and its demands, and contemplate leaving the profession. 12 Nevertheless, they are able to function quite well and do not have a “health problem” in the strictly medical sense. Whether they can be said to have “hypo-wellbeingness” is an interesting philosophical question. Whatever one’s viewpoint, these doctors may be at risk of “burnout”. Strategies aimed at promoting health and wellbeing among doctors must firstly consider which of these three groups is being addressed, and then tailor the intervention accordingly. The impaired doctor needs an early intervention and rehabilitation program; the troubled doctor needs a preventive approach to stress, plus an easily accessible referral pathway;13 and the dissatisfied doctor needs social support together with reform of “the system” so that known deficiencies (eg, workforce shortages, excessive paperwork, low remuneration levels) are adequately addressed. What has been done in Australia to reach these groups of doctors? Most states have the equivalent of a doctors’ health advisory service (DHAS), which often has little funding and depends on considerable goodwill by a panel of treating doctors. However, in May 2004, the DHAS network formed an Australasian doctors’ health planning and reference group, which may help to coordinate and refocus efforts in this area. Since 1999, there have also been national doctors’ health conferences every 2 years. To try to provide a more sustainable service in Victoria, the Australian Medical Association (Victoria) and the Medical Practitioners Board set up the Victorian Doctors’ Health Program in 2001. The aim of the Program is to provide confidential medical services to doctors, as well as referrals to specialists, such as psychiatrists, if required (see Warhaft, page 376). However, Australia is some way short of the US model of Physician Recovery Networks, which, although having no statutory role, intervene in situations where doctors are considered at risk (see Brown and Schneidman, page 390). Several specialist colleges have established their own support services for members who are experiencing difficulties. For example, the Australian and New Zealand College of Anaesthetists has been particularly active in supporting colleagues, especially in the area of substance misuse. Similarly, the Royal Australian and New Zealand College of Psychiatrists has assisted its impaired practitioners to obtain help through colleague support panels. Divisions of General Practice have taken up various wellbeing programs covering areas such as stress management techniques, improving skills in the business aspects of running a medical practice, and providing opportunities for social support through peer networking. 14 Unfortunately, the causal links between the impaired, the troubled and the dissatisfied are not very clear, and this has implications for the type of preventive programs being pursued. For example, do the various “docs-4-docs” programs run by Divisions of General Practice (with the aim of supporting GPs to better withstand the stresses of their profession) do anything to prevent impairment?15 This seems unlikely, as doctors with psychological problems are less likely to engage in the relatively open forums that the Divisions organise. The challenge has also been taken up by several Australian universities, which have developed “personal and professional development” programs to deal with self-care for health professionals. 16 An innovative way of promoting psychological health has been introduced at Monash University, where first-year medical students undertake a single-semester subject that teaches “mindfulness”-based stress management techniques that they can practise on themselves. 17 Similar courses are also being offered at postgraduate level. We need a better understanding of which programs work best for which groups of doctors. In the meanwhile, we can use liberal doses of common sense to guide us on what is worthwhile. Useful approaches are likely to include the provision of well advertised but confidential referral pathways for medical students and doctors who need help, the enhancement of a “no blame” culture that accepts and supports those who are starting to falter (see Hayhow, page 365), and attention to solving defects within the healthcare system. Unhealthy doctors cannot be expected to deliver high-quality healthcare. The increased attention to this issue in recent years is timely for doctors, their families and their patients.

Peter Schattner MD, MMed, FRACGP · Sandra Davidson BA, Grad Dip Behav Studies Hlth Care · Nathan Serry MB BS, FRANZP

Stress in doctors is a product of the interaction between the demanding nature of their work and their often obsessive, conscientious and committed personalities. In the face of extremely demanding work, a subjective lack of control and insufficient rewards are powerful sources of stress in doctors. If demands continue to rise and adjustments are not made, then inevitably a “correction” will occur, which may take the form of “burnout” or physical and/or mental impairment. Doctors need to reclaim control of their work environment and employers need to recognise the need for doctors to participate in decisions affecting their working lives. All doctors should be aware of predictors of risk and signals of impairment, as well as available avenues of assistance. Relevant medical organisations (eg, the Colleges, hospital administrations, and medical defence organisations) need to develop and rehearse effective response pathways for assisting impaired doctors.

Geoffrey J Riley MRCPsych, FRACGP, FRANZCP

Objectives: To examine the uptake by general practitioners (GPs) of the five key components of the Better Outcomes in Mental Health Care (BOiMHC) initiative: education and training for GPs; the three-step mental health process; focussed psychological strategies; access to allied health services; and access to psychiatrist support.Setting: All Australian states and territories during the first 15 months of the initiative (1 July 2002 – 30 September 2003).Design: Retrospective survey of de-identified registration data held by the General Practice Mental Health Standards Collaboration (training uptake), de-identified Health Insurance Commission (HIC) billing data (provision of the three-step mental health process, focussed psychological strategies and case conferences with psychiatrists), and reports from “access to allied health services” projects to the Australian Department of Health and Ageing (project participation).Main outcome measures: Number and percentage of Australian GPs certified as eligible to participate in the initiative; provision of the three-step mental health process and focussed psychological strategies by GPs; participation in allied health pilot projects; and access to psychiatrist support.Results: Within 15 months of the BOiMHC initiative commencing, 3046 GPs (about 15% of Australian GPs) had been certified as eligible to participate, including 387 who had registered to provide focussed psychological strategies. GPs had completed 11 377 three-step mental health processes and 6472 sessions of focussed psychological strategies. Sixty-nine “access to allied health services” projects had been funded, with the original 15 pilot projects enabling 346 GPs to refer 1910 consumers to 134 individual allied health professionals and 10 agencies. In contrast, the “access to psychiatrist support” component was less successful, with the HIC billed for 62 case conferences at which a psychiatrist and a GP were present.Conclusion: The level of uptake of the main components of the BOiMHC initiative has expanded the national capacity to respond to the needs of people with common mental disorders, such as depression and anxiety.

Ian B Hickie MD, FRANZCP · Tracey A Davenport BA(Hons), GCM · Jane E Pirkis PM(Psych), PhD · Grant A Blashki MD, FRACGP · Grace L Groom DHSc

All of us fear crossing the invisible line that separates “us” from the less fortunate “them” Recently, seated in the audience of Michael Moore’s film Fahrenheit 9/11, I was struck, yet again, by a thought that has inspired much of my writing over the years — that life is a protracted exercise in defining the line between us and them. In the case of Fahrenheit 9/11, the us and them refers to the haves and the have nots, or — according to Moore’s central thesis — those, on the one hand, who wield power and those, on the other, whose sacrifice on the battlefield secures that power. The intriguing thing about the line between us and them is that it is fluid. With a simple smile on the part of Fortune, it is possible for “one of them” to become “one of us” — or, in this case, for a have not to become a have. The maddening thing about such fluidity is that it is exceedingly rare for a nouveau-have to imbue their new-found havitude with the attributes of have not-edness. In other words — and this time in accordance with the rules of grammar — those who have the good fortune to cross over that thin line tend to travel light, rarely thinking to pack their ethics. Power corrupts. Absolute power corrupts absolutely. Orwell’s “Animal Farm” lives and breathes. In the world of medicine, we see the phenomenon of the thin line operating at its most poignant in institutions that practise “ageing in place”, where the haves are possessed of their faculties, while the have nots are not. (“Ageing in place” refers to the practice, in some institutions, of allowing residents whose condition has declined to below hostel level to remain at the same institution, rather than being uprooted to a distant nursing home.) In a strange inversion of the traditional social structure, it is the resident haves within this community who are the most dissatisfied. They are dissatisfied because they perceive themselves to be both besieged and beleaguered, by day and by night, by the frightening, zombie-like intrusions of the have nots, for whom they profess pity, while at the same time expressing fear, loathing, disgust and contempt. But, more to the point, they are dissatisfied because they know that the only thing that can possibly save them from an eventual slippery descent into the same loathsome condition is death. And yet, as sincere and as heartfelt as may be the pity and empathy felt for these poor creatures by both their peers and their carers, there is no denying the doggedness and the sheer ferocity of the contempt. “He’s lost it”, we caring professionals say, shaking our heads with what passes for concern. The terminology is crucial. — Lost what? — What the rest of us still have. — How could he have been so careless? — He’s no longer to be trusted with anything of value. Take away his car. Remove him from his home. Take away his independence. Remove him from his family. — This person is no longer fit to enjoy the privileges earned by those cautious enough not to lose what they still have. And all of this masquerading under the banner of care. It is not something that we are aware of doing, nor is it the sort of behaviour we would ever admit to. But, if you listen carefully, you will hear a thousand examples of it every day. But why? Why do we interpret as active and negligent a loss so utterly passive and ill-deserved? The answer is the same answer that comes back to us every time we question the iniquity of humankind — fear. We fear illness. We fear incapacity. We fear loss. We fear death. And what we humans do with the things we fear most is to subject them to the rigours of our most virulent contempt. But there is another, far more prickly and elusive example of the us and them mindset that pervades medicine, and this is the dichotomy that exists between doctor (have) and patient (have not). In this context, the terms have and have not are used not so much in a socioeconomic sense as in the sense of having knowledge and empowerment. Nowhere does the dichotomy between doctor and patient express itself with a more powerful sense of irony than in the mind of that most singular of individuals: the medico. For it is only within the person of the medical practitioner that doctor and patient meet head-on — buck naked and unadorned — with not so much as a privacy screen, a desk, a computer, a stethoscope or even a gusset behind which either can hide. This doctor can hide no secrets. No matter how dire or how remote the possibility, no diagnosis is withheld from the patient, no potential side effect hidden, no sequelae suppressed. The burden of fear and concern is not lifted by the professional hand but, rather, transmitted by it. Unexpurgated. For, regardless of the best efforts of the sundry medical bodies and boards to encourage doctors to seek arm’s-length professional help for their illnesses, each doctor consults daily, hourly, momentarily with his or her own inner patient. We engage in this nefarious practice under the shameful cloak of daily living. We do it as we chew on our toast, or as we strain at stool, or cleanse our bodies, or fall, exhausted, onto our beds. We do it when no one else is looking, or listening, or paying us the slightest attention. For we know that it is unseemly. Unforgivable. But we cannot help ourselves. Pain is no sooner suffered than interpreted, dyspnoea no sooner experienced than analysed, fever no sooner endured than investigated. But even the most ambitious, astute and adroit of procedural cardiologists remains powerless in the face of his or her own unremitting chest pain. And even the most introspective of haematemetic gastroenterologists baulks at the prospect of visualising his or her own entrails. There comes a time when the psychological defences crumble and the half of the medico that remains a practitioner must cross that thin line, thereby joining the frightened half that screams “patient!”. No amount of prodding and reassurance from the Medical Board can remove the stigma from this crossing. We are now become the object of contempt. And the more strenuously the opinion-makers of the medical fraternity deny it, the more corrosively the contempt seethes beneath the surface. For this is the nature of the human condition. Whatever we cannot control, we fear. Whatever we fear, we strive to control. Whatever we seek to control, we subject to the most heinous contempt. It is endemic, among patient and doctor alike. Nothing has changed since the coming of the first bubo.

Ron Elisha MB BS

Objective: To determine the prevalence of psychiatric morbidity and burnout in final-year medical students, and changes in these measures during the intern year.Design: Prospective longitudinal cohort study over 18 months, with assessment of psychiatric morbidity and burnout on six occasions.Participants: All 117 students in the first graduating cohort of the University of Sydney Graduate Medical Program were invited to participate in the study; 110 consented.Outcome measures: Psychiatric morbidity assessed with the 28-item General Health Questionnaire and burnout assessed with the Maslach Burnout Inventory.Results: The point prevalence of participants meeting criteria for psychiatric morbidity and burnout rose steadily throughout the study period.Conclusions: Internship remains a stressful time for medical graduates, despite initiatives to better support them during this period. The implications for the doctors themselves and for the communities they serve warrant further attention, including programs specifically aimed at reducing the rate of psychological morbidity and burnout during internship.

Simon M Willcock MB BS(Hons), FRACGP · Michele G Daly BSc(Hons), MSc · Christopher C Tennant MD, MPH, FRANZCP · Benjamin J Allard BA, MB BS

A medical student poses some searching questions Recently I’ve been thinking a lot about the issue of supporting junior medical officers in distress, and I can’t help coming back to the thought that the lack of a sense of “community” in the workplace is an important contributor to the problem. In some ways, this is a vague and idealistic observation to make — let alone act upon — but it is strength of community that so strongly springs to mind when I consider the difference between institutions in which people are seen to flourish and those in which they are not. Perhaps this problem is especially acute for the professional. It strikes me that a key value of community — interdependence — grates against some doctors’ perceptions of themselves as exceptional, independent and self-determined. I think the competitive spirit of traditional medical education (both undergraduate and postgraduate) tends to engender a cautious, if not fearful, attitude towards one’s behaviour in the medical system. In particular, I think many doctors fear being identified for their human weaknesses, their academic shortcomings, and their occasional (but inevitable) clinical failures. Our clinical teachers are often better at pointing these things out than giving advice on how to cope with them, and we have all, at some time, felt small beside the consultant who takes perfection in his stride. Clinical uncertainty and human fallibility are facts of life and, at any level, it takes a special effort to deny that this has a personal impact. Yet this is clearly happening when so many doctors fail to seek help despite experiencing deep personal distress. A renewed emphasis on the values of community and the institutions that enact them may prove protective against such maladaptive behaviour. While this is probably a broader issue than the Council for Early Postgraduate Training in South Australia (CEPTSA) is likely to address, and although the huge scale of the healthcare system may work against our efforts, it still seems to me that we should encourage positive cultural changes in our hospital work environments. Big institutions can lack a sense of connectedness between the individuals that comprise them; this is unfortunate, as connectedness can produce a network of support that works between the lines of formal (often vertical) avenues of redress. The redress models we discussed recently were steps towards a better system for identifying and managing junior doctors in distress, but I wonder if it struck anyone else that one disadvantage of a system that attempts to maintain anonymity as its first priority is to reinforce the perception that to be seen to have a problem is the worst of all outcomes. Will it not, in other words, reinforce the underlying fear that perpetuates these problems? As in medicine more generally, treatment has its place, but prevention is preferred. A broad intervention aimed at changing the culture in which problems arise ought to be implemented alongside more direct strategies for supporting our doctors. Although they require further specification, I consider the proposition that we work on parallel cultural solutions practical and tenable. I was impressed, for instance, by the degree to which community spirit was fostered by administrators during my pre-clinical years at medical school. While recognising, once again, that the more widespread engineering of such initiatives may fall beyond the scope of CEPTSA, it may be something CEPTSA can contribute to in concert with other agencies such as the Australian Medical Students Association, the Australian Medical Association, other interest groups and hospital management. These thoughts seemed rather too abstract to raise during the last meeting of our group, but I was prompted to write to you after a cynical friend (also a cynical psychiatrist) suggested I enjoy the last of my youthful idealism before it is eroded during my own years as a junior medical officer. I prefer to imagine that anyone who cares to stop and consider the environments in which they too have felt supported to work creatively and effectively will find themselves imagining an instance of something similar to what I’ve tried to outline above.

Brad Hayhow BA(Hons)

Studies of doctors’ health have emphasised psychological health, and limited data have been collected on their physical health status. Doctors often fail to follow current preventive health guidelines for their physical health. About half of doctors do not have an established relationship with an independent general practitioner. This would enhance their health and provide a means of ready access to the healthcare system should a problem arise.

Margaret P Kay FRACGP, DipRACOG · Geoffrey K Mitchell MB BS, FRACGP · Christopher B Del Mar MD, FRACGP, FAFPHM

Giving and receiving peer-group support After coming to terms with the stress in my life as a busy suburban GP, I joined my local Doctors’ Health Advisory Service in 2002. One of the events this group organised late that year was a doctors’ health information evening. A panel of experts was arranged to speak on topics such as substance abuse, depression and suicide among doctors. Despite a thorough marketing campaign, only the organisers showed up! From this experience I concluded that doctors, probably like most people, prefer a positive message to a negative one. One of the consequences of that evening was my development of a self-care workshop for doctors that I have conducted for three medical groups in Australia and New Zealand over the past year. The main objective of the workshops was to raise awareness of relevant stress and lifestyle issues (doctors have been shown to be a highly stressed group, with long working hours and poor habits in areas such as exercise). Other goals were to provide an experience of peer-group support and to help individual doctors develop strategies for changing their health behaviour. At the most recent event, doctors were asked to identify two areas of self-care they wished to improve. They were then divided into three groups, based on what they perceived to be the principal barrier to making change: about half the participants chose to be in the group who lacked motivation, while equal numbers of the remainder chose either the group who feared change or the group who could not move past the expectations of others. No one felt that a lack of knowledge or skills was a barrier to making the changes. Often after some heated dialogue, each of the groups came up with several strategies to overcome their perceived barrier to change. Many of those who lacked motivation felt all they needed was help and encouragement from a “buddy” to get them started. Others felt they would be more likely to succeed if the change process included a reward. The group that feared change reported that they needed to have more confidence to say no, to review their priorities with regard to earning money, and to stay on top of their overdeveloped work ethic. The group who felt the burden of others’ expectations concurred with the importance of learning to say no, and also perceived a need to clarify their priorities with regard to patients and family and to manage their time better. Both of these latter groups reported that the core issue seemed to relate to managing guilt rather than being controlled by it! My most lasting memory of these events has been the great enthusiasm and resourcefulness of the doctor participants, who generally found the workshops enjoyable and helpful. It was good to see the notorious reluctance of doctors to seek help put aside and to note the ease with which warm and intelligent collegial support can be offered and received.

Richard S Hetzel FRACGP

The New South Wales Medical Board has developed the Impaired Registrants Program to deal with impaired registrants (doctors and medical students) in a constructive and non-disciplinary manner; the program is now well established. The Program enables the Board to protect the public, while maintaining doctors in practice whenever possible. Disorders that commonly lead to referral of impaired doctors include alcohol and drug misuse, major depression, bipolar disorder, cognitive impairment and, less commonly, psychotic and personality disorders and anorexia nervosa. Pathways in the program are individualised according to the impact of the specific disorder, the registrant’s career stage, stage of involvement in the program, insight and motivation. Critical points in the program include entry, easing of conditions, breach of conditions, return to work after suspension, and exit from the program. Decision-making at these points takes into account the nature of the impairment, compliance, professional and personal support available and the registrant’s insight and motivation.

Kay A Wilhelm MD, FRANZCP · Alison M Reid MHA, FAFPHM

The Victorian Doctors Health Program (VDHP) was established in November 2000 to provide a confidential and compassionate service for doctors and medical students with health concerns, including alcohol, other drug and mental health problems. Although funded by the Medical Practitioners Board of Victoria, the VDHP is completely independent of the Board. Its staff include a director with experience of North American Physician Health Programs and a case manager/psychologist. In its first 3 years of operation, the VDHP had 438 contacts: 218 requests for advice and information, and 220 contacts resulting in provision of services (to 92 doctors and students with alcohol or other drug problems, 82 with psychiatric problems, and 40 with stress-related or emotional problems). 99 participants received standard care (assessment, referral and up to two consultations with the program) and 56 extended care (three or more consultations with the program). 65 participants (most with substance use disorder) entered the more intensive Case Management, Aftercare and Monitoring Program (CAMP); 57 of these have had outcomes considered satisfactory, with 50 returned to work.

Naham (Jack) Warhaft MB BS, GradDipSustanceAbuse, FANZCA, FAChAM

While some cases of sexual exploitation involve predatory doctors, many other cases represent the culmination of a series of boundary crossings (non-exploitative departures from usual practice). The deliberate move to reduce formality in medicine has increased the likelihood of boundary crossings and violations. There are also individual doctor risk factors; boundary violations appear more likely when doctors are under stress, with insufficient emotional support. Preventive strategies include continuing education about ethics and the management of professional boundaries, along with appropriate psychological support structures for doctors. Doctors are often involved in other professional relationships as teachers, supervisors and team leaders; inappropriate sexual behaviour in these relationships is harassment. Public pressure for more punitive responses is likely if the profession is not seen to be doing all it can to deal with these issues effectively, and to be cooperating with other responsible agencies.

Cherrie A Galletly FRANZCP, PhD