General medicine

To the Editor: International medical graduates on temporary residency visas now make up a substantial proportion of the rural medical workforce. Anecdotal reports suggest that many make the transition to professional life in Australia reasonably well, in terms of both cultural adaptation and applying their professional skills, even though the level of educational assessment and support may vary considerably. However, there are some disturbing reports of a few such medical practitioners who perform poorly and are moved on, perhaps to another state. A survey conducted for Tropical Medical Training, the regional general practitioner training provider for North Queensland, found that international medical graduates were often the only doctors in some rural communities, and their lack of teaching confidence and connection to a medical school was a significant barrier to expanding medical student and registrar training in the region. 1 As part of a follow-up project that aims to identify the educational needs of international medical graduates in rural northern Queensland and design support programs for them, several organisations were approached to gain access to this group, rumoured to be perhaps 50–100 individuals. Because of the Privacy Act, the survey was to be distributed by one or more organisations that knew how to contact these doctors. However, no single organisation appeared to have an accurate database that included the target group. Queensland Health, a major employer of international medical graduates, had no central record. Divisions of General Practice stated that few international medical graduates joined them, and most were ineligible to join a college. The Queensland Rural Medical Support Agency probably had the largest database, but its accuracy cannot be verified. The lack of access to international medical graduates will place constraints on the research project (there is no denominator and response rates cannot be measured). However, the broader issue is that international medical graduates, at least in rural and remote communities, appear to have no single organisation monitoring their recruitment, educational qualifications and needs, or retention. They appear to be an almost invisible workforce. This somewhat chaotic situation cannot be in the best interests of either the workforce or the quality of Australian healthcare.

Richard B Hays

Prevention and intervention programs are up and running, but the work is far from over The sudden acute respiratory syndrome (SARS) epidemic in Canada exposed the vulnerabilities of our public health system, and demonstrated the strength of its caregivers. In addition to the devastating effects of this illness on patients and their families, SARS also highlighted the importance of professional health. The impact of SARS on healthcare professionals was high, with key factors for doctors including the potential risk of death, placing one’s family at risk of infection, and being treated differently by others because one worked in a hospital setting. 1 Before SARS, there had been increasing recognition and awareness of the health and wellness needs of Canada’s doctors and medical students. In 1997, the Canadian Federation of Medical Students (CFMS) produced a position paper on the health and well-being of medical students,2 and others quickly followed. 3 Our healthcare system continues to struggle with constraints on financial and human resources in the face of ever-increasing need and expenditure. Indeed, as funders and providers struggle to manage, doctors are reporting rates of advanced burnout approaching 50%. 4 This struggle has been acknowledged at some of the highest political levels, including the head of the recent Commission on the Future of Health Care in Canada, former Premier Roy Romanow, who, in an address to the General Council of the Canadian Medical Association in August 2003, stated, “If we don’t look after the health care of our providers, they can’t look after the health care of [us].” Overall scope of doctors’ health initiativesPhysician health is being tackled nationally, provincially and municipally. At a national level, the Canadian Physician Health Network (CHPN) was founded in 2001 and represents a working alliance of the Canadian Medical Association (CMA), provincial physician health programs, the Canadian Association of Interns and Residents (CAIR), the CFMS, and academic faculty wellness programs. Its purpose is to develop and strengthen a network of informed individuals involved with doctors’ health, and facilitate ongoing evolution and improvement of physician health initiatives. In 2003, the Canadian Medical Association launched the CMA Centre for Physician Health and Wellbeing to be an information resource for physicians, medical students and their families, to help them maintain health and prevent illness, and to provide national leadership and advocacy. In 2003, the Centre also announced $C100 000 for research into doctors’ health. These collective national efforts are proving to be powerful and critical components of an overall strategy to help the culture of Canadian medicine evolve. Each Province and Territory has access to a Physician Health Program (PHP), each of which has its own unique attributes and format. The largest PHP is based in Ontario, and is one of many services offered to members of the Ontario Medical Association. Since the program began in 1995, over 1100 doctors have used it. Like many physician health programs in Canada, the Ontario program reports that service needs have moved from a primary focus on substance use and substance-use disorders to include services for broader mental health problems. Canada’s Atlantic provinces (Newfoundland and Labrador, Prince Edward Island, Nova Scotia, and New Brunswick) are home to a small number of doctors spread over a large and diverse geographic area. While each province’s medical association operates a form of doctors’ health program, the region has elected to investigate the possibility of evolving a unique regional program to maximise limited resources, and provide services appropriate to local practice styles and sensitive to local culture. Finally, there has been innovative growth in doctors’ health at the grass roots, municipal level. Canada’s cities have partnered with doctor organisations to enhance recruitment and retention by acknowledging and recognising the value doctors have in their communities. In Ottawa, Physician Appreciation Day has been celebrated since 2002. This effort was designed to encourage the community’s citizens and institutions to recognise and acknowledge the various roles physicians play, from healers and advocates to parents and partners. Ottawa is also home to many national doctor organisations, many of which use the day to recognise the efforts of their physician-employees. Ottawa’s hospitals host events for their physicians, and the University of Ottawa has an event for its medical faculty members. Many Ontario communities are developing their own versions of this event. The impact of such initiatives on physician health is unknown, and warrants evaluation. In addition, in May 2004 the Ottawa Academy of Medicine launched a unique “Code 99” program to develop a network of physicians who are comfortable caring for their colleagues, and to help physicians and medical students find a family physician or specialist. 5 This program is already proving to be a well used resource. Special target groupsOne of the biggest drivers of change in Canadian medical culture has been resident associations. Each province has an organised association, the Provincial Housestaff Organization (PHO), which negotiates salary and working conditions for postgraduate trainees with the provincial teaching hospitals. These discussions have facilitated significant system changes, including improvements in working conditions, salaries, benefits, educational expectations, leave entitlements (illness, disability, parental, educational, and vacation), and work hours (including on-call demands). One natural outcome of these changes is a workforce of early-career and mid-career doctors who view their identity and obligations to the profession differently than preceding generations, and strive to balance personal, family, and professional obligations. Indeed, data suggest newer generations of doctors are working fewer hours. 6 There is also a growing body of data on the impact of work on the health and wellness of trainees. An observational study of 11 paediatric fellows working within Ontario guidelines revealed they worked an average 69 hours a week, and roughly 25.5 hours per shift. Per shift they received an average of 41 pager calls, slept 1.9 hours, and walked 6.3 km. Physical tests showed that 7 developed ketonuria, and 6 developed heart rate abnormalities. 7 These data have led to calls for further investigation into the impact on sleep deprivation and other factors on physician health and patient care. 8 The Canadian Association of Interns and Residents is also leading a national “Happy Doc” study to better understand resident health and well-being. Student health and wellness has been promoted with great vigour by the Canadian Federation of Medical Students (CEMS). One of their initiatives, at Dalhousie University’s faculty of medicine, helped students gain access to a unique peer support program, which sponsors activities focused on the humanism of medicine and themes of personal health and wellness. In addition, CEMS also focuses on the role of partners and family members during an annual “Significant Others” night. 9 Another program, at the University of Ottawa, offers access to a mentorship program, and a student health initiative. One of the greatest challenges for Canadian medical students is skyrocketing tuition costs and massive student debt. As tuition approaches $C20 000 per year in some provinces, students are increasingly reporting financial distress. 10 The impact of such debt is largely unknown, but it has been linked to the decline in interest in family practice. 11 Women comprise 59% of medical students in Canada, and 30% of physicians in practice. In spite of many successes, women in Canadian academic medicine struggle to balance work and family responsibilities. 12 In response, Canadian medical schools have been creating increased opportunities for women in leadership; increasing sensitivity to issues such as gender and equity; and looking seriously at the need to provide harassment-free work environments, work flexibility, and daycare. Indeed, there is a growing recognition that these issues increasingly affect both sexes, particularly given the changes in the role of men and male doctors in Canadian society. University initiativesThe Faculty Wellness Program at the Faculty of Medicine, University of Ottawa, the first program of its type in Canada, was founded to promote the well-being of all members of the faculty. 13 Since its inception in 2000, it has served an average of 150 individuals per year with a broad array of physical and mental health concerns. The program also participates in the development and evaluation of workshops and presentations on physician health, and is increasingly being used to help divisions and departments of the faculty of medicine. Current initiatives include the development of a standard policy on doctors with disruptive behaviour, development of strategies to assess resiliency of applicants to medical school, and promotion of physical fitness. Other Canadian medical schools are also developing their own programs. The Association of Canadian Medical Colleges has been helping to develop a national network of academic wellness programs since 2002, with a goal of increased collaboration between academic physician health programs and those operated by physician organisations. Canada has launched an innovative initiative — the Northern Ontario Medical School — to train physicians to work in Canada’s rural areas for the long term. While rural training experiences are important, rural doctors are also reporting that other factors, such as recreation, employment opportunities for their partners and educational opportunities for their children, are not as good as they were in the early 1990s. 14 Given the importance of recruitment and retention of doctors in Canada’s rural regions, the issue of physician wellness warrants attention. ConclusionA revolution in physician health is taking place in Canada. Since early efforts at policy development, the profession has created national networks, centres of excellence, research opportunities, and educational programs. Yet, a recent survey by the Canadian Medical Association showed that up to 46% of Canadian physicians are in an advanced state of burnout and 58% felt their family life suffered because they had chosen medicine as a career. 15 While the nation’s physicians have begun to develop prevention and intervention programs, it is clear that the work is not over.

Derek G Puddester MD, FRCPC

Despite the many services now on offer, doctors’ special problems in seeking healthcare advice and treatment remain unsolved Since the 1970s, when the Association of Anaesthetists responded to much-publicised suicides by setting up the first dedicated service for its members, much has changed in the provision of special help for “sick doctors” (those stressed and in need of professional psychological support, as well as those with physical and mental illness) in the United Kingdom. Now there are over a dozen national “sick doctor” services (details can be found at www.ncssd.org.uk) and many more local ones. This growth has led to increased choice, but has also raised questions about why they are all needed and how effective they are. Local servicesDoctors in the UK are entitled to use the National Health Service (NHS), and, as most provide services to patients under the NHS, are also entitled to use the NHS occupational health service. Their past reluctance to do so lay in the perceived closeness to management and general lack of availability. This was compounded by incorrect and unsubstantiated concerns about confidentiality. Local services are largely provided by government-funded organisations, including primary care trusts (which are responsible for the governance of primary care services provided by general practitioners and other healthcare staff) and postgraduate deaneries (which are responsible for doctors in training). 1,2 These local entities usually contract with an independent body, usually staffed by professional counsellors and sometimes by doctors, to provide services for discrete groups of doctors. The services often emphasise psychological counselling for those experiencing difficulties at work. National servicesAlthough many of the national services concentrate on problems related to drugs, alcohol, stress and mental health, they vary considerably in their characteristics. None receives permanent government funding, although several had start-up support from the Department of Health. The National Counselling Service for Sick Doctors (NCSSD) was established in the mid-1980s through the vision and leadership of the eminent psychiatrist Kenneth Rawnsley. It was set up partly to provide an alternative to the statutory health procedures operated by the profession’s regulatory body, the General Medical Council (GMC). 3 The NCSSD was the first, and remains the only, independent doctor-to-doctor service dealing with all health issues, and available to all doctors. 4 In the mid-1990s, the NCSSD was receiving about 400 calls per year and had a panel of about 80 medical advisers (now it receives 250 calls per year and has 50 advisers). The NCSSD’s main aim remains helping doctors gain access to appropriate healthcare before their health problems prejudice their ability to work safely. It does not provide a healthcare or (despite its name) a formal counselling service for doctors. Its advisers and management committee are volunteers. Other national services have been set up to meet specific needs. The medical defence organisations provide support for their members who get into difficulties over professional matters. The British Medical Association (BMA) has a counselling service, established in 1996, which receives about 200 calls a month from members, who are provided with 20–35 minutes of telephone counselling by a professional counsellor and, if necessary, given help in gaining access to further one-on-one counselling. The BMA has recently developed its own “doctors for doctors” service, which primarily supports the BMA’s industrial relations officers in their dealings with BMA members in difficulty, and also provides a signposting service to other sources of help. A distinctly different approach is adopted by other organisations which rely on volunteers who have themselves been ill and are in recovery. These include the British Doctors and Dentists Group (a support group for addicted doctors and dentists, reached through the Medical Council on Alcohol, which also provides information about alcohol-related problems and promotes alcohol education in medical school curricula); the Sick Doctors’ Trust,5 which helps addicted doctors; and the Doctors’ Support Network,6 which helps doctors with mental health problems. These organisations provide direct interventions, one-on-one, and group support. The Doctors’ SupportLine is a telephone helpline staffed by trained volunteer doctors, which provides a first step for doctors in getting help with personal or work-related problems. Two medical colleges have recently identified the need to provide extra help for their members — the Royal College of Surgeons of England has launched a national, confidential support and advice service providing surgeon-to-surgeon telephone and face-to-face help, and the Royal College of Obstetricians and Gynaecologists offers the services of members and fellows who are trained mentors. The British International Doctors’ Association also provides mentors and a health panel for doctors whose problems may be caused by cultural or linguistic factors. A web-based service has been created through British Medical Journal Careers, part of the BMJ publishing group, offering mentors for doctors with chronic illness and those who have suffered discrimination in their careers. Finally, the Royal Medical Benevolent Fund provides much-needed financial help to sick doctors and their families. All these organisations maintain appropriate confidentiality, but operate within the governing ethic that patient safety is a pre-eminent consideration. Doctors who continue to practise, but whose state of health is a danger to patients, should be reported by their colleagues to their employer and/or to the General Medical Council. It is the NCSSD’s experience that this sanction is rarely needed, and, once doctors are helped to recognise that they are ill and to seek appropriate treatment, they respond well. Challenges and the futureThe need to preserve confidentiality about doctors as patients has made evaluation of the effectiveness of services difficult. In future a more open approach may be needed. The smaller organisations rely heavily on the unpaid commitment of enthusiasts and long term funding is always a problem. Their future is not secure. The plethora of services presents a confusing picture. Some rationalisation is probably needed. And still there are unmet needs. Doctors often remain reluctant to acknowledge their need for help. Despite GMC policy to the contrary,7 they continue to self-diagnose and self-prescribe,8 and to present late when they are ill. Virtually all the services are reactive, becoming involved only after problems have arisen. A statement produced by European experts in 2000 describes doctors as “one of the most unattended populations, in terms of health”. 9 Certainly, in the UK, it is often difficult to arrange appropriate care for sick doctors away from the area where they work. A new initiative by the umbrella organisation the Clinicians’ Health Intervention Treatment and Support (CHITS)10 to provide dedicated addiction treatment centres for healthcare professionals may help, but substantial government funding is required. The NHS occupational health service is being strengthened, but this will take time and gaining doctors’ trust may take even longer. Where specialist services have been established for some time, use by doctors has increased, although the changing climate of medical practice may also be a factor. In some occupational health services, use by doctors is now greater in proportion to the numbers of staff than by any other occupational group (Kit Harling, Consultant Occupational Physician, Director, NHS PLUS, personal communication, 2004). The ability of specialist occupational health services to influence employers to make job changes to facilitate return to work after illness is a key benefit. There is now a greater knowledge of the stressors that doctors have to cope with,11,12 suggesting primary prevention is possible. The shortage of doctors in the UK and the high cost of early retirement13 may provide incentives for better services. The GMC’s statutory health procedures will soon cease to exist as a separate entity and, whatever happens in terms of independent sick-doctor services, it is essential that all organisations that employ, support, guide and control doctors have clear policies and practices that take full account of the impact of stress and ill-health on doctors’ performance. The special problems that doctors have in seeking healthcare advice and receiving timely and appropriate treatment have not yet been solved. Doctors require services that they trust, will use and that meet their diverse needs. Doctors themselves could help greatly by continuing to explore their attitudes to their own healthcare needs and those of their colleagues. 14

Jolyon R Oxley MA, MB BChir, FRCP

Despite a still small evidence base, programs throughout the country are tackling doctors’ illness and doctors’ health In 1973 the American Medical Association’s (AMA) Council on Mental Health published The sick physician. Impairment by psychiatric disorders, including alcoholism and drug dependence. While a handful of programs were already operating, this report is generally regarded as the watershed for doctor health programs that now exist in nearly all states across the United States. The report noted that “the [profession’s] primary responsibility for ensuring safe, competent care to the patient population affected must be reemphasized.” In December 2003, the AMA’s Council on Ethical and Judicial Affairs (CEJA) issued a report to provide “guidance in the area of physician health and wellness insofar as it affects physicians’ professional activities, including patient care and trust in the profession.”2 In this article, we discuss what transpired with physician health in the United States in the 30 years between these two reports. State programsThe most visible effect was the development of programs in nearly every state. These programs typically evaluate doctors who may have problems and monitor them after treatment. They operate to ensure that a doctor complies with the provisions of treatment and is able to practice; few programs provide care per se, and a number have wellness programs. There are a variety of models, with some under the auspices of the state licensing board (generally known as diversion programs, as the doctors are diverted to treatment rather than to disciplinary action), and some being programs of the state medical society or independent agencies, which generally have ties to their respective medical societies or boards. Considerable variation is found with other aspects of the programs. Some are largely restricted to doctors (including doctors in training), while others deal with virtually all healthcare professionals, including veterinarians, chiropractors, nurses and medical students. The types of problems dealt with also vary, but substance-misuse disorders are routinely addressed in all programs. Other issues, such as malpractice stress, physical disabilities and behavioural (personality) disorders, are less frequently included. The level of funding and range of sources for program funding are even more disparate. Details of program comparisons are available on the Federation of State Physician Health Programs (FSPHP) website. 3 What do the programs share in common? There is unquestionably an emphasis on professionalism in the sense used by sociologists (ie, the programs are developing specialised knowledge along with special skills to apply to the problems they encounter). 4 Before 1990, the state programs were loosely associated with the AMA’s impaired physician program, which facilitated communication among the various state programs by means of a subscription-based newsletter, and encouraged the adoption of consistent policies (such as model legislation that would sanction cooperative relationships between licensing boards and the medical society), and hosted regular conferences on the impaired physician. In December 1990, as the AMA was refocusing its program on doctors’ health rather than impairment, the FSPHP was formed. The Federation of State Physician Health ProgramsThe FSPHP’s mission is “to provide a forum for education and exchange of information among state programs, to develop common objectives and goals, to develop standards, to enhance awareness of issues related to physician health and impairment, to provide advocacy for physicians and their health issues at local, state, and national levels, and to assist state programs in their quest to protect the public.”3 It offers state programs (44 states are full members, as membership is voluntary), regional and national meetings and an electronic forum (open only to those with direct involvement in state or provincial programs) for discussing issues such as drug screening, monitoring agreements, treatment options, and program policies, particularly in dealing with refractory cases. Despite program differences, consensus on key issues is the norm. For example, recently completed are guidelines for doctors’ health program development and enhancement, despite a limited evidence base. Gathering the evidenceRecognising the lack of good evidence on many of the issues, the AMA and the Canadian Medical Association jointly sponsor, in cooperation with the FSPHP, the Federation of State Medical Boards and the Federation of Licensing Authorities of Canada, a biennial conference on doctors’ health, the program of which includes plenary sessions and papers that are peer reviewed. Though small, the conference attracts an international audience, including Australian doctors. Divergent international norms have generated many discussions on the merits of some program standards. For example, abstinence from all psychoactive substances, including alcohol, is the norm for a physician recovering from a substance-misuse disorder in North America. 5 In a presentation at the 2002 conference, Jack Warhaft, of the Victorian Doctors Health Program, commented that abstinence from alcohol is not necessarily required for narcotic misuse or dependency. This is an area where the science needs to expand in support of practice. One effort to advance the science of physician health has been the establishment of a loosely formed physician-health research group, a process encouraged by the AMA, the FSPHP and other organisations. The group has developed a tool to collect reliable and valid data, which is based on well validated instruments used in psychiatric epidemiology, and will allow researchers to compare cases across programs while protecting doctors’ confidentiality. At the same time, doctor wellness is vital, with many examples of topics worthy of investigation, possibly for their effects on overall public health. 6-8 Future directionsAn emerging issue is the future direction of the state programs. Over the years, some have separated from their respective medical associations, largely for financial reasons. A more recent trend is outsourcing. Programs operated by licensing boards or those operating as independent corporations with financial support from the licensing board are being outsourced, with bidders most likely to come from the for-profit sector. The recent revelation that Vice President Dick Cheney’s personal doctor was being monitored by the physician health program of the Medical Society of the District of Columbia and that his care had been kept confidential9,10 may have as yet unknown effects. One might anticipate, for example, efforts to breach confidentiality for physicians undergoing treatment or a move to mandatory disciplinary actions such as licensure suspension or revocation. This matter was the subject of numerous editorials, although at least one of these advocated a system used in the New Jersey state physician health program, in which information is shared with the licensing board in a way that maintains confidentiality. 11 Less newsworthy perhaps will be the development of hospital-based committees that were established as required by the Joint Commission on Accreditation of Healthcare Organizations in 2001. In some states, hospitals are working with state programs, while in others services are probably duplicated. The value for doctors and their health is unknown. Progress has been fitful over the past 30 years, but things are moving forward. Today, the AMA and the various state programs deal with health issues, not just illness, and they support a variety of treatment models, recognising that the evidence base for this work is really just beginning to be built. As the evidence base expands, progress will be swifter.

Roger L Brown PhD · Barbara S Schneidman MD, MPH

Marital challenges are ubiquitous in the relationships of doctors. Common issues include overwork, a need for control, self-neglect, perceived and felt stigma, being a “wounded healer”, trouble with boundaries, chemical dependency, depression, and more. Knowing the hallmarks of a healthy relationship, recognising warning signals of trouble, and taking action through suggested strategies can be salutary. As a specialist in doctors’ health, I have noted that relationship concerns constitute one of the most common complaints in my practice. 1 Although there are no empirical data on the prevalence of marital problems in doctors, there are some data on divorce, albeit mixed. Doherty and Burge2 reported that divorce rates in doctors are lower than in other occupational groups. In contrast, Sotile and Sotile3 describe divorce rates among doctors as 10%–20% higher than those in the general population. Historically, the call of medicine has given short shrift to our personal and family lives. It is refreshing to observe today’s younger doctors giving much higher ascendancy to their relationships. 4 A healthy relationship is an alliance of two mature individuals who are developmentally ready to form a union that will meet their individual needs and ensure their personal growth in the years that lie ahead. 5 The texture of this “coming together” depends on many factors: love, affection, sexuality, companionship, communication, financial security, intimacy and commitment. When we feel intimate in a relationship, we are describing notions of connection, trust, mutuality, and a sense of being loved and honoured. 6 Given our humanness, our personal pasts, and the demands and responsibilities of a career in medicine, is it any wonder that all of us, in greater or lesser measure, struggle with our intimate relationships? Common problemsThe following are some common characteristics of doctors and their intimate relationships. Overwork as normative. The number of hours worked per week varies enormously from one doctor to another, and is influenced by the branch of medicine and the doctor’s sex and life stage. The bottom line, though, is that we work hard and this affects the quantity and quality of time left for our partners. It is hard to be relaxed, interested, energetic, creative and fun with loved ones if we are tired or preoccupied with the residue of our work day. And our intimates are masters at detecting this, despite our protests, denials and defensiveness. Overwork in doctors seems to be a result of both the doctor’s personality and the culture of medicine. Escape into work. Overwork is not always the cause of relationship difficulty, but may be the result. We may deliberately stay at work late or go in to work to avoid the painful awareness of tension or unhappiness at home. Medical work can be seductive — and there is usually plenty of it. Further, it may be easier to solve clinical dilemmas than domestic problems. A need to be in control. Our work requires being in control and taking charge if we are to be effective in our patient management skills. In greater or lesser measure, this attitude or personality trait may colour our intimate relationships. Other traits commonly seen in doctors are compulsiveness,7 perfectionism,8 and pessimism, passivity and self-doubt. 9 Most spouses do not appreciate feeling controlled by their doctor-partner or not respected as an equal. To quote one wife of a cardiologist: “My husband forgets that the kids and I are not always going to step to attention like his office assistant. Nor do we hold him in awe like his patients do. My philosophy is that we’re all equals in this family.” Self-neglect. Many other professionals take better care of themselves than we do. 10 If they are ailing, they consult their general practitioner. Many of the best doctors do not have their own GP, live lives that are desperately out of balance, diagnose and treat themselves (sometimes incorrectly), and do not recognise the pain and suffering of their partners. For example, a psychiatrist who came to me for a consultation began with these words: A month ago, when I concluded that I was depressed, I started myself on antidepressant A. I didn’t feel any better after about 10 days, but, instead of increasing the dose, I decided to try another sample, antidepressant B. Well, after 2 days, I was really anxious and my sleep was worse so I stopped it and put myself on antidepressant C. About a week later, when the anxiety hadn’t gone away and my sleep was even worse, I decided to double the dose. Then I got really sick. I didn’t know if it was the drug, the flu, or my depression getting worse. Then the pharmaceutical rep came by with some samples of antidepressant D. So I stopped what I was on and started it. I don’t like it though — I feel strange on it. But I feel strange these days anyway. I am so glad to be here. Relieved that I’ve got someone to look after me. I feel dreadful. Do you know how hard it is to treat yourself properly when your cognition is off and you’re worrying constantly and you can’t make proper decisions and you don’t know if you’re going to recover? I would never treat my own patients like this. Stigma. Most doctors admit to fearing judgement or disrespect if they admit to relationship problems or psychiatric symptoms in themselves. 11 Fear of stigma is why so many doctors refuse to seek help, or delay consulting others for a long time, or treat themselves. It is aligned with rugged self-determination, not wanting to bother others, a strong capacity for denial of trouble and problems, and mistrust of other caregivers. Sadly, these beliefs are too often reinforced by a culture of medicine that elevates us to “gods” and renounces our humanness. “Wounded healer” notion. 12 Many doctors are “wounded healers” who have themselves faced one or more of the following: poverty, hunger, war, forced migration, torture, family heartache, alcoholism, divorce, suicide deaths of loved ones, physical/emotional/sexual abuse, racial or ethnic discrimination, religious persecution, gay-bashing, life-threatening disease, or other traumas and losses. While these “sticks and stones” often strengthen us and enable us to practise better medicine, they also make us vulnerable and subject to the same problems as any other human being. Lack of firm boundaries between work and home. Despite the fact that medicine is rarely a “nine-to-five” job and, by its very nature, extends into our personal and family lives (especially when we’re on call or making weekend hospital rounds), we should strive for some demarcation. Here’s a quote from the 14-year-old son of a doctor-patient of mine: My dad and I have a pretty close relationship, but I don’t know why he wears his pager when he’s not on hospital call. It really bugs me. We often do sports together on Saturdays — I worry that our fun is going to get interrupted if his pager goes off with something that’s not an emergency. Unrecognised substance use disorders and/or mood disorders. The culture of medicine accords low priority to doctors’ mental health, despite evidence of untreated mood disorders and an increased burden of suicide. 13 Our proneness to alcoholism and other substance misuse is not diminishing. These maladies have pernicious effects on our intimate relationships, especially communication, sexuality, and trust. Listen to the plaintive words of one doctor’s wife: I’m really worried about my husband, a family physician. I think that he’s quite depressed and burned out. He’s drinking a lot. Our marriage is the pits. I’ve asked him to come in to see you and he refuses. He says he’s fine, that all doctors are burned out these days. His father was also a doctor — he had a nervous breakdown at this age. What should I do? Warning signs of a relationship in troubleDoctors need to ask themselves, and answer honestly, the following questions about their intimate relationships: Do you feel bored or lonely, especially when the two of you are alone? Does your partner complain that you don’t share enough of yourself? How does this criticism make you feel? Defensive? And do your reasons — “I’m tired” or “I don’t have anything new to tell you” or “I was born this way” — seem unsatisfactory or tend to fall short? Are you arguing without resolving the issues? Do you argue about the same matters over and over? Do your arguments leave you feeling exhausted, frustrated or demoralised? Are your arguments increasing in frequency or in intensity (eg, are they escalating to verbal or physical fights)? Are you not arguing at all but are silently seething, withdrawing into yourself, or using passive-aggressive manoeuvres (forgetting to meet requests, being stubborn, disappearing, coming home late, responding with sarcasm)? Or, if you aren’t doing this, is your partner? Do you make a beeline for the liquor cabinet when you get home, and not talk about your day at work — or present only a very abbreviated version once the alcohol takes effect? Are you working so hard that you can’t find the time to talk with your partner? Is it possible that immersing yourself in your medical work has become preferable to talking with your partner? That you find practising medicine more fun, rewarding, and ego-boosting than spending time alone with your partner? How is your sex life? Do you find that your sexual relationship doesn’t seem very intimate? That you “have sex” but don’t “make love” anymore? Strategies to create and maintain relationship intimacySafeguard time for communication in your busy life. Experiment with venues and situations in which you communicate in a more open and relaxed manner — kitchen or living room? at home or outside the home? while out for a walk or a bike ride together? morning or evening? sitting opposite each other or beside each other? with food/beverage or not? The vast majority of couples whom I see tell me that their best talks occur outside the home, away from distractions, interruptions and undone tasks. And if you go for a walk or ride, and you’re not on call, leave your pager, mobile phone, personal digital assistant, etcetera, at home! Read up on relationships. Visit your local bookshop or library and pick up one of the many manuals on improving communication techniques in relationships. Or browse the Internet for material. Try some of the exercises together for a month or two. Consider a marital enrichment weekend. Most faith communities offer these, as do community college continuing education programs and private corporations. What works in many of these endeavours is the basic message that you give to each other: “I care enough about us to go away with you and try to learn new ways of renewing our relationship”. Go for marital therapy if you feel that your personal efforts are not working, or are having limited success. It helps tremendously to have the expertise of a trained professional who can diagnose the problems, explain the “why”, appreciate the positions of both partners, relieve anxiety and sagging spirits, and offer guidance and hope. Take care of your health. If you don’t have a GP, get one today. Concluding wordsCaring for our relationships is good medicine. Having someone to love and nurture is an integral part of being human. Doctors with children find the challenges more manageable and the joys more intense when their primary relationship is happy. And doctors living with illness find the experience much less frightening and lonely when they are fortunate enough to have a loving partner at their side.

Michael F Myers MD, FRCPC

Issues confronting doctor-parents include the impact of parenting on career choice, special challenges faced by women doctor-parents, leave entitlements, and the unique strengths and challenges of two-doctor families. Experience from one Canadian doctors’ health program suggests that unique themes include communication within doctor-families, insight into doctor-parent dynamics, the relationship between doctor-parents and their child’s doctor, and potential boundary crossings and violations within the doctor-family. The relationships between medical workforce sustainability, medical human resources, and issues related to doctor-parents need further consideration and analysis.* My husband and I recently adopted a little boy. We’ve fallen in love with him, and have been rediscovering our play skills, singing voices, and sources of patience. It’s been life-affirming. We’ve also had a crash course in the medical politics of parenting — and so far so good. I am fortunate to have access to parental leave, and, in combination with holiday leave and unpaid leave, I can have almost 8 months to be with our son and maintain a reasonable income. My husband works in the private sector, but has access to almost a year of federally-funded parental leave. Equally important, we live in a community with early childhood centres, free playgroups, and accessible advice about nutrition and development. Professionally, we worry about the impact of our choice on our careers. While in different professions, we both feel pulled between roles and commitments. We are aware of reports from some authors that those who try to balance these roles are slammed, on the one hand, for lacking professional seriousness and, on the other, for lacking parental selflessness. We are also sensitive to some suggestions that doctor-parents are constrained by social assumptions about gender roles, and that parenting and children are undervalued. 1 We’re learning that we can’t be everything to all people and that we need to establish goals, have strategic priorities, and focus on our current life stage. We’ve also realised that we are proof that issues related to doctor-parenting are of equal importance to both women and men,2 are present in doctor-families of all forms, and are, in fact, human issues. The literature on doctor-family issuesCareer choiceParenting, in combination with gender, greatly influences workforce choices for doctors with young families, while gender alone has little impact on those choices. 3 In one US study of surgeons,4 women were more likely to delay having children, and, when they did have children, were more likely to take parental leave. During surgical practice, 12% of the male surgeons and 64% of the women surgeons had taken parental leave. Half of the institutions surveyed in the study had no formal parental leave policy. Studies like these suggest that parenting may have an impact on medical students’ choice to enter the profession, and that formal policies are required to accommodate the needs of doctor-parents. 4 Parenthood also influences the choice of whether to enter academia. Academic doctor-parents spend more than 90% of the time devoted to family responsibilities on child care. Women doctor-parents also have less institutional support (eg, research funding, secretarial support) than their male counterparts. Academic mothers have fewer publications, slower self-perceived career progress, and lower rates of career satisfaction. There appears to be much work to be done to achieve equity in academia. 5 Parental leaveThere has been an evolution in parental leave provisions in some parts of the world, particularly in Canada. Recently, the federal government began to provide 15 weeks of maternity leave and 35 weeks of parental leave (including adoption leave), for a total of 50 weeks of support. In Ontario, an agreement between the Ontario Medical Association and the provincial government provides for 17 weeks of maternity benefits for doctors not eligible for federal funding. Since its inception in 2000, over 900 doctors have taken advantage of the program, which has cost $11.2 million. Calls for paternity and adoptive leave have been less successful. Surveys of doctors who take parental leave suggest it can adversely affect their careers. 6 Institutional and academic culture may influence parents to take less leave than they are entitled to. Academic staff are concerned about the impact on their colleagues of taking leave, and fear that any substantial period of absence may impair their career advancement. One key strategy for easing this dilemma would be to employ temporary locum staff. 6 Given these tensions, parental leave must be a critical part of any discussion about medical resource planning. Any policy that reduces the tension between a doctor’s professional and personal lives should be part of a healthy recruitment and retention strategy. 7 Women doctor-parentsAs the doctors’ health movement evolves, it parallels significant changes in societal perspectives of gender roles. Not only are more women taking on leadership roles in medicine, but men are taking on more childrearing and domestic duties. 8 In spite of these social forces, women doctors, although spending the same amount of time at work as male doctors, spend twice as much time on family and household work. Women doctors are less likely than male doctors to recommend parenting, less satisfied with the time available for parenting, and more interested in flexible working hours. Women are also more likely to claim that the best time to have children is at the end of postgraduate medical training. 9,10 Compared with childless female academic staff and compared with male staff, female academic staff with children face major obstacles in pursuing an academic career. Some of these obstacles could be modified relatively easily (eg, by eliminating after-hours meetings and creating part-time career paths). It has been strongly advocated that medical schools address these obstacles and provide support for academic staff with children. 5 One review of women doctors over an 80-year period found that 82% of women doctors became mothers, and that women doctors without children were more likely to be in surgical specialties, less likely to be in primary care, and more likely to work full-time than their female colleagues with children. Although the length of formal maternity leave increased over the eight decades, the level of satisfaction with leave duration fell. 11 A US study of otolaryngologists revealed that women surgeons were more likely to be divorced or separated and to have fewer children than male surgeons. Women reduced their work hours in conjunction with having more children, while men relied more on their partner for household responsibilities and child care. Women earned less money for performing similar jobs, yet had increased family responsibilities, which potentially affected their career advancement. 12 One study that formally evaluated the time women doctors spend on non-medical work noted that they spend little time on domestic activities that can be done for them by others, such as cooking, housework and gardening. Women doctors spend less time on child care and substantially less time on housework than do other US women. In contrast to other studies, this study concluded that measures of career satisfaction and mental health were not adversely affected by time spent on domestic obligations. 13 Two-doctor familiesUp to 50% of doctors may be married to other doctors. 14 Both men and women in these partnerships earn less money individually, less often feel that their career should take precedence over their spouse’s career, and more often play a major role in childrearing compared with other married doctors. Benefits include more frequent enjoyment from shared work interests and higher combined incomes. In general, two-doctor families achieve their career and personal goals as frequently as other married doctors. 14 Men in two-doctor families tend to work fewer hours than other married male doctors. 15 Keeping things in balanceIn this section I describe some specific solutions that clients of our program, clinicians involved in clinical work with doctor-families, or attendees at our workshops have reported as valuable. The doctor-families we meet come from a wide array of medical backgrounds and represent different cultures, family compositions, and support systems, reflective of families around the world. What makes doctor-parents different?In general, doctor-parents have unique access to health information and knowledge. They are also trained in assessing normal and abnormal development in children. Most have strong career demands. Some need to carefully balance their public versus private roles (depending on the type of clinical work they practice) and their role in the community. Many work longer hours than most parents, including on-call demands. Many are self-employed, without benefits, and need to ensure that they set up and monitor financial safeguards. Finally, sources of rebellion, confusion, and tension can be unique to doctor-families as children gain insight into the elements of medicine that interfere with their ideal family life. Doctor-parents are often high achievers. They seem to be under-represented in the health consumer population, possibly because of their awareness of health promotion and disease prevention strategies. However, there are reports of doctor-parents having reduced quality time with their children, feeling guilt and remorse over their limited parenting roles, and having different attitudes towards childcare and rearing depending on their gender. CommunicationMany doctors report that their long work hours result in reduced contact with their children, particularly if they leave home before their children rise, and/or arrive home close to bedtime. This appears to be a common regret, with some doctor-parents feeling it is too late to learn how to communicate with their children. On-call duty is a common source of tension within doctor-families. Some doctors set their pagers to remind them to make a good-night phone call, while others leave a note in the bathtub, under the pillow, or next to an evening snack. Children of these doctors tell us such gestures send a strong and positive message. Some doctors who come to us about family problems report that they didn’t recognise the red flags of poor communication, and encourage us to emphasise that lack of spontaneity, silent shared time, or hearing of problems through others should raise a doctor-parent’s concerns and prompt intervention. Doctors’ children have emphasised their need to be able to contact their parents directly in a time of urgency. Yet, they feel uncomfortable asking for this, as they know how busy work is for their doctor-parents. Ensuring that children know clinic or hospital staff (particularly assistants or secretaries) is felt to be helpful, and some families have established a code word or phrase that sends the message that the doctor-parent is required urgently. Several doctors have taught their children how to responsibly page or email them, or carry a beeper or mobile phone just for their children to access. InsightMost parents have a healthy fantasy of how they want their children to grow and develop. However, some doctor-parents have disclosed to us that they wished they had been more careful in the expectations they projected onto their children. Some have made the link between being part of a profession that attracts perfectionism, dedication, determination, and obsessiveness, and subsequently expecting their children to follow a competitive path of education and training, enter a profession of parental choice, or engage in activities that meet parental approval. Doctor-parents also report that the combination of work and home responsibilities contributes to isolation from the broader community. A useful intervention has been to help the doctor find time to reconnect, gain support from other parents, access recreational resources, and develop insight into their children’s development outside the home. Working with your child’s doctorDoctor-parents, like all parents, need access to competent general practitioners and paediatricians. Yet, the unique information and knowledge doctor-parents have can be as much of a curse as a luxury. Usual defenses of intellectualisation and minimisation are no longer helpful, and doctor-parents report they are often surprised by the emotions they feel in a routine health scenario. Doctor-parents often have additional anxiety driven by the knowledge of the worst possible outcome. Some feel a need to “do something”, and are uncomfortable with both giving up medical control to a colleague and remaining within the parental role. Some doctor-parents feel guilt and a sense of failure at “allowing” their child to become ill. In addition, some are painfully uncomfortable with finding themselves on the other side of the white coat. Doctor-parents also need to recognise that their child’s doctor may feel intimidated by the parents’ dual role. In these cases, it seems to be helpful to frankly discuss boundaries, acknowledge the skill set and role of colleagues, avoid jargon and “shop talk”, include children and partners in all discussions, and respect advice given. It is also helpful to acknowledge the value of medical skills, such as asking good questions, being an advocate, negotiating access to resources and services, having insight into early warning signs of problems, and being aware of potential sources of solutions. Monitoring boundariesThere have been no large studies on the phenomenon of doctor-parents treating their partners or children. However, it is widely acknowledged that such behaviour occurs and that it can be linked to difficulties with boundaries in medical practice. Few would argue with a doctor-parent’s right to treat his or her child’s superficial abrasion or fever. But ethical overtones shift if doctor-parents treat their own children for such problems as cosmetic, mental, reproductive or oncological health. Yet, paediatricians and staff of doctors’ wellness programs have seen cases of such complex boundary violations, some of which resulted in the involvement of children’s protective services. Some Canadian regulatory bodies are drafting policy to discourage doctors from treating family members. Studies are also in progress to estimate occurrence rates, improve understanding of the issues involved, and promote healthy debate in the profession. ConclusionAs the doctors’ health movement continues to evolve, there is increasing awareness of the importance of the role of doctors in their families and the importance of family members to doctors. Women doctor-parents continue to face unique issues in their professional and personal lives, and male doctor-parents are also taking more of an active role in their personal and family lives. These trends pose opportunities and challenges to medical workforce planning, models of care, academic systems, and remuneration models. There is also a need to increase research into the sociology of doctor-families. Research data are urgently needed to develop strategies to promote doctor-family health and wellness, which is a critical factor in recruitment and retention efforts. In the interim, case and anecdotal data may be of value in helping doctors better balance the tensions between their important, and competing, identities.

Derek G Puddester MD, FRCPC

Addiction is a treatable disease and patients can enjoy rather than endure recovery My work is regarded in various ways by my colleagues. Some see me as a quixotic figure ranting futilely against the impregnable world of alcohol and other drugs, as in the cartoon. Others see me as a sort of medical Mother Teresa on Sydney’s North Shore, devoted to a life of cleaning others’ mess. I think most simply shake their heads, believing that I am delusional and beyond help. This article seeks to define and refine this “delusion”: that addiction is a disease, that it is treatable, and that patients enjoy rather than endure recovery. Do addicted doctors need special treatment?I sometimes feel that all the hard work and inconvenience of gaining a medical qualification is worth it for one short sentence: “Doctor is busy.” As doctors, we have a wealth of privileges not afforded other members of the community. Not only are we excused for lateness, we also have access to a wide range of medicines (many of them dangerous, even in prescribed doses), and are permitted, even expected, to examine people’s bodies and to ask intrusive questions. With these privileges come ethical dilemmas that are not new to the profession — abortion, euthanasia, inappropriate relationships with patients, confidentiality, and commitment to training the next generation of practitioners. All rate a mention in the Hippocratic Oath. However, Hippocrates did not have a protocol for addicted colleagues. The saying that addicts and alcoholics are just like other people except more so is attributed to Sylvester Minogue, a psychiatrist influential in the introduction of Alcoholics Anonymous to Australia. I believe that alcoholic and addict doctors are just like other alcoholics and addicts, except more so. The issues of shame and guilt, of inability to believe that an intelligent person could perform such irrational and obviously unintelligent actions, still abound. Furthermore, colleagues who are patients know and have opinions about many interventions, reducing any chance of a placebo effect and virtually eradicating the impact of medical advice. They’re in the club, and they look carefully for any hint of superficiality in explanations and advice. Are addicts simply adults behaving very badly?Understandably, the moral stance has been the traditional first response by families, communities and medical boards when learning of a doctor’s addiction. Attempts to keep the community safe from addicted doctors have traditionally involved the law and lawyers, in a process that selected out, then deregistered, the “bad apples”. The problem is that addiction also occurs in undeniably “good” colleagues, whose work and track record make it both unacceptable and unhelpful to deal with them punitively (Anecdote 1 and Anecdote 2). Addiction is not “like” a disease — it is oneThis is the heart of my fortifying “delusion” and a debate in which I participated in the Journal in 1992. 1,2 Then, as now, I believed that addiction is a disease because it has definable clinical features, a substantial genetic influence, a reasonably predictable natural history, effective treatments, and even potential biological markers. More recently, others have compared addiction with medical conditions like asthma, diabetes and hypertension. 3 These comparisons have yielded remarkable similarities in genetic heritability, pathophysiology, role of personal responsibility, and treatment response. The effectiveness of drugs such as naltrexone4 and acamprosate5 in the short- and medium-term course of alcohol dependence, and methadone in opiate dependence,6 also argues strongly for medical involvement. The issue of hopelessnessEven more important than whether addiction is a disease is the fact that prognoses are not nearly as hopeless as most medical colleagues believe. The natural history of alcohol addiction can include remission, mostly through long-term abstinence, and often associated with attendance at Alcoholics Anonymous (Anecdote 3). 7 However, the fact that psychosocial interventions work (as they do for many medical conditions) does not render addiction a “non-medical” problem, as some have argued. Sustained abstinence is not an end in itself. If prolonged abstinence merely resulted in a desert of joylessness, as so many people in active addiction fear, then my job would indeed be difficult. In fact, real recovery takes off once abstinence becomes comfortable. New relationships are formed or old ones improved. Central issues, such as what constitutes meaning in life, are addressed. That common core belief of self-inadequacy begins to wither. If addiction is a disease and resetting one’s neural “reward” pathway from the ventral tegmental area to the nucleus accumbens of the brain is a key feature,8 then the treatment is only complete when ego-syntonic activities are fully rewarding — that is, previously enjoyed experiences, such as the joy of relationships, work and recreation, are fully enjoyed once more. Patients of mine in longer-term recovery do not continue to mourn for the moments of pleasure experienced at the end of a needle or a drinking binge. Instead, they are grateful for each sober day. Often, they gladly provide me with assistance with newer patients. Rehabilitation: a more enlightened attitudeThe progress made in treating doctors’ addiction is obvious over my 20 years of practice. Medical or licensing boards worldwide have come to recognise that the safety of the community is enhanced by having a rehabilitative attitude to alcohol and drug dependence. 9 Unidentified doctors still drinking or using drugs pose a greater danger to the community than those who have been identified, are seeking treatment, and are supervised by a stringent medical board program. Medical boards have also come to recognise that monitoring impaired doctors in a process independent of the treatment process is likely to be more beneficial for both doctors and the community. Both treatment and monitoring are important and neither should interfere with the other. The NSW Medical Board was at the vanguard of this movement in developing the Impaired Registrants Program (IRP). Under this program, doctors identified as having breached laws or regulations (such as the NSW Poisons and Therapeutic Goods Act 1966 through self-prescribing of drugs of addiction) make certain voluntary undertakings, such as to attend for assessment by a Board-appointed psychiatrist (whose only role is to provide detailed feedback for the Board’s use). 10 One of the conditions imposed by the IRP is for the practitioner to concurrently undergo treatment. Soon after the establishment of the IRP, I decided that I would be a treating psychiatrist and never a Board-appointed one. I have become much more disposed to referring my medical colleague patients to the IRP, as I have found that assessments by independent psychiatric colleagues can augment and monitor my own assessments and treatment. My other (non-medical) patients do not have the back-up of an independent assessment every 6 or 12 months. My involvement in this process also means I receive regular reports from the Medical Board about my patients and any changes to their conditions. My own frisson of anxiety at receiving an unexpected piece of mail from the Board reminds me of just how trying this process is for my patients. Issues of concern for doctors on monitoring programsMany problems can loom larger than usual for doctors in medical board monitoring programs. For instance, confidentiality is absolutely paramount (Anecdote 4), a drug test result that has gone astray may be misconstrued as a deliberately missed test, and false-positive test results can be especially trying for someone in recovery and working hard to comply with every condition of the IRP (Anecdote 5). All NSW doctors in the IRP are identified as such on their medical registration cards, which bear the word “conditional”. This can be a great source of agitation, and, as some suspect, of prolonged unemployment. Lest I be seen as advocating greater freedoms for doctors on the IRP, let me also say that some doctors may show enough change to satisfy their supervisors, but seem to gain little real insight into their problems. The NSW program is unable, in its present form, to deal with this issue of reluctant compliance. The futureTrends in the United States are for programs that manage identified addict and alcoholic doctors to be handled by systems outside medical boards. These newer programs (including one in Victoria) are called “Doctors Health Programs” (DHP). Most of these are funded in much the same way as medical boards, by medical registration fees, but these programs are independently involved in monitoring, often at four levels (individual, group, workplace and pathology), leaving the medical board to perform disciplinary functions. These programs are probably more intrusive than the ones run by the medical boards, but, while disciplinary procedures may still be imminent if compliance with the DHP is found wanting, many find it an advantage that the term “conditional” is not emblazoned across the registration papers of a doctor in early recovery. Anecdote 1 Dr A was a trainee physician who had been practising in another jurisdiction. He returned to Sydney, unregistered, and was referred by a senior specialist. A had developed an addiction to pethidine in the context of major social upheaval while working, and had been found diverting some from the hospital. His registration was suspended for 9 months, but no treatment was offered. On his return to Sydney and referral to my care, he was only able to gain the benefit of the NSW Impaired Registrants Program (IRP) after his suspension elsewhere ended. He responded to a regimen including counselling, urine testing and regular review by the IRP. Initially, he worked in unfashionable posts, but later returned to his previous level, passed his specialist exams, married and had children. Anecdote 2 Dr B was an influential specialist who referred himself, saying that his principal problem was migraines, but he had begun to self-medicate with a variety of opiates, including pethidine. Representatives of the Pharmaceutical Services Section of the Department of Health (which monitors the dispensing of Schedule 8 drugs in New South Wales) had visited him and informed him that it would be best if he voluntarily surrendered his right to prescribe S8 drugs. On taking a history, I discovered that, some 20 years before, he had been identified as having misused opiates, been reprimanded by the Medical Board, and been sent for treatment, which was unconventional, unmonitored, and, as his current presentation showed, ineffective. Anecdote 3 A 22-year-old medical student’s drinking habits and poor exam results were a source of concern to his supervisors. He was called before the warden of the clinical school and reprimanded. He resentfully disregarded this advice, but soon after was serendipitously placed as a medical student at a drug and alcohol treatment facility, where he identified himself as an alcoholic. He became a member of Alcoholics Anonymous and has remained sober and happy for many years without treatment. I know of his story because he sometimes helps me in supporting my medical patients. Anecdote 4 Dr C, a Resident Medical Officer from another hospital, rang to say that he desperately needed inpatient treatment under my care. I agreed, not learning until later that he was due to commence a term at Royal North Shore Hospital in the 12 months after his discharge. Subsequently, a colleague and rival of C was found to have enquired about gaining access to C’s inpatient medical records. C’s initial distress was well managed, he became a dedicated Narcotics Anonymous member, and has now graduated from the Impaired Registrants Program and been drug-free for more than 5 years. Anecdote 5 A colleague referred his patient, Dr D, who had been self-injecting benzodiazepines and lying about his alcohol use. After a brief negotiation, D informed the Impaired Registrants Program. He began urine testing, attending the Doctors Recovery Group and Alcoholics Anonymous. D became distressed when, despite a month of abstinence, his urine was still testing positive for benzodiazepines. He sought detailed quantitative analysis of his urine benzodiazepine levels allowing for the urine concentration, which subsequently showed an exponential decline consistent with abstinence. After only a year, his work, marriage, parenting, physical health and leisure pursuits have all improved dramatically.

Stephen M Jurd MB BS, FRANZCP, FAChAM

Despite suffering bouts of deep depression at certain times of her life, Helen Tolhurst has survived to tell the tale. With the help of close friends and a caring and supportive therapist, she is learning to find a balance between pursuing her medical career and taking time out to relax and experience life’s small pleasures My first memories of depression are of black periods as a child during which I hated myself and would hide under the blankets at night, thinking that if I held my breath for long enough maybe I would die. Having had many further episodes of depression since that first childhood experience, I often think how fortunate I am to have been born in the latter part of the 20th century rather than the earlier part, like my grandmother. Not for the reasons that you might at first think — such as the convenience and ease of so many aspects of modern life — but because of the wonders of modern psychiatry. My grandmother (see Box) had her first “nervous breakdown” at the age of 17, when her brother was killed at Gallipoli. From that time on, her life was punctuated by episodes of disabling depression for which she was admitted to hospital and often given electroconvulsive therapy. Her life was transformed by the advent of tricyclic antidepressants in the 1950s — at last there was an effective medication to treat her illness. Like me, several of my family members have inherited a vulnerability to depression, with which some of us have struggled for much of our lives. Different events have triggered each episode of depression. There was an episode of feeling desolate and losing a lot of weight because of problems in a relationship in my late teens, but mostly I just got on with life, studied medicine, married in 1973, and graduated in 1975. We moved to Alice Springs in 1978 and soon had two beautiful daughters. However, all was not well. After returning to work when I had a 2-year-old and a 6-week-old baby, I found the struggle to balance work and family overwhelming and, after a miscarriage, fell into a black hole of depression. Because of past severe hyperemesis gravidarum, I had not wanted another baby and felt guilty about what I saw as my failures as a mother. I can remember thinking, as I drove around the town, that deliberately crashing into a telegraph pole would be a way out of the blackness. I felt as if I was desperately hanging on to life only for the sake of my husband and children. It is difficult for a doctor to seek help for mental health problems in a remote community like Alice Springs. I felt ashamed of my inability to cope and unable to talk to my colleagues about the desperation I was feeling. My practice partners were totally overloaded with work, and I felt that to tell them how miserable I was would just sound like whingeing. So I struggled through my depression, trying to hide how I was really feeling from those around me. Looking back, I sometimes wonder how I survived. Recognising our need for family support, we moved closer to my parents in 1984. Again, just getting on with life, I bought a general practice, while my husband worked as a teacher and our girls started school. But, feeling torn between work and family, I slipped again into the black hole of depression. Help was now more readily available, and I saw a psychologist who suggested I take antidepressants. Too embarrassed to consult any colleagues, I committed the cardinal sin of self-medicating. By 1995, I realised that, although I had always loved general practice, I was completely “burnt out”. I sold my practice so I could pursue interests in research and teaching. However, there were now problems in my marriage and difficulties coping with the needs of my teenage daughters and the demands of a stressful situation at work. For 6 months I scarcely managed to sleep more than 3 or 4 hours a night, waking in the early hours of the morning, feeling completely alone in the darkness, tortured by black thoughts. I felt guilty about my inability to cope with work and family life and my failure to be the perfect doctor, perfect wife and perfect mother. There were also conflicts at work that recalled past unhappy times during my childhood. As I woke each morning, I felt like a wrung-out rag and it took enormous effort to get out of bed. By this time, I had admitted to myself that I needed professional help. I recovered from this episode of depression with the help of a psychologist and antidepressants prescribed by my general practitioner. The tremors, sweating and increased appetite caused by the antidepressants were a small price to pay for relief from the depression. For the first time, on the advice of my therapist, I took some time off work when the depression was at its most severe. Although I was relatively well by now, I realised that just wishing to remain so would not make the depression go away. I needed some long-term expert help. Finding a psychiatrist with whom I felt comfortable and confident was more difficult than I had anticipated. I was initially referred to a senior psychiatrist who had an angry and aggressive manner and, without taking a proper history, told me to stop taking the antidepressants, at a time when I was quite suicidal. I think it can be difficult for psychiatrists to find the right balance between empathy and professional objectivity, and I found some psychiatrists so distant that they made me feel as if I were carrying some sort of contagious disease. But at last I found a skilled, caring doctor, who treats me like an intelligent human being and is empathic and understanding about the pain I feel. Thanks to his help, I have recovered more rapidly from subsequent episodes of depression. Recently, after almost 30 years of marriage, my husband and I separated, and, grief-stricken, I plunged again into deep depression. As I worked my way through many past hurts, I wept and wept until I wondered why I wasn’t dehydrated. The wound inflicted by the end of my marriage is slowly healing and at last I am well, but I know now that staying well will take more than just medication. There are many things I need in my life to manage my depression: loving, supportive relationships; the right balance between work and other parts of my life; enjoyable work and leisure pursuits; regular exercise; meditation; and even the company of my cats. I am still learning how much work I can manage, having recently courted a relapse by working 7 days a week for 3 weeks. I need to anticipate stressful events in my life and think about ways to best cope with them. I am learning to be kinder to myself. I am coming to accept that for me there will be side effects with a therapeutic dose of medication. Hoping to reduce the stigma that members of the community and even the medical profession attach to depression, I am now more open and honest about my condition. The responses of my colleagues to this vary. Some who also have depressive illnesses welcome the opportunity to share their experiences with a fellow depression sufferer, while some offer support and sensible advice. But others react with awkward silence, or rapidly attempt to change the subject with looks that say “Don’t mention the war”. I wonder why they find open discussion with a colleague about her experience of a mental illness so difficult. Is it so different from diabetes or asthma? Do they think emotional difficulties are too private and personal to discuss with a colleague, or do they really see depression as a manifestation of weakness that I could overcome if I tried a bit harder to “pull myself together”? Still, I continue to hope that being more open about my illness will make life easier for my family members who also suffer from depression. If I had had some say in the matter I would never have chosen to have a depressive illness — yet, at the same time, I don’t regret it. There are two reasons for this. The experience of depression has given me some understanding of the pain my patients suffer when they descend into that black hole, and has made me more able to be empathic about their illness. And emerging from the blackness into normality, which sometimes seems like dazzling light, I have discovered joy in the smallest of life’s pleasures. So, how can a depressed doctor find much-needed help? For me, a supportive relationship with a therapist has been one of the most important factors in getting well. Sometimes you may know of a GP, psychiatrist or psychologist whom you like and trust, or about whom you have heard good things. Sometimes it requires enormous effort to take that first step in seeking help — but you can’t, and shouldn’t, treat yourself. If you think you need professional help, don’t hesitate to seek it. If you don’t know someone appropriate you may prefer to contact an organisation such as the NSW Doctors’ Health Advisory Service (tel: [02] 9437 6552; website: www.doctorshealth.org.au) that can refer you to an appropriate therapist. There are other helpful resources, such as the website (www.beyondblue.org.au) and the book Beating the blues, by Tanner and Ball. But paramount in recovering from depression is the help of a competent and caring therapist. A familial illness A: The author’s grandmother, who suffered crippling bouts of depression before the advent of tricyclic antidepressants. B: The author enjoying life, with the help of antidepressants and a supportive therapist.

Helen M Tolhurst MB BS, FACRRM

Forty-five years as a doctor with diabetes has given Alan Stocks personal insight into how to manage life and practice when living with a chronic illness. Diabetes has proved beneficial to his career, rather than a disadvantage. As a final-year medical student in 1959, over a 2-week period I experienced increasing thirst, polyuria and lassitude, and lost 5 kg in weight. Suspecting diabetes, I performed a urine test using Clinitest. The test was negative for glucose, and, believing my symptoms were caused by pre-examination stress, I took no action. Golden Jubilee meeting of Diabetes Australia – NSW, 1987 The meeting marked the 50th anniversary of the foundation of the first Diabetes Association in Australia. Shown in the photo are John Townend, Chairman of Diabetes Australia – NSW; Phyllis Lush, the first person to receive insulin in Australia; Kempson Maddox (her physician); and the author. Over the next 4 weeks my symptoms worsened rapidly, and I failed a pathology examination. I was so ill that, like all medical students at some time or other, I was convinced I had some sort of malignancy. Finally it dawned upon me that the first test might have been wrong. A repeat test showed high glucose and acetone levels — a random blood glucose level of 25 mmol/L established the diagnosis. Immediate admission to a diabetic ward was advised, but I asked if I could delay admission until the next morning, as I had a date that evening (diabetics often rebel against their condition, but not usually as quickly as that!). There followed a hurried discussion, and my request was granted, provided I first gave myself an injection of insulin. This accomplished, I had a most enjoyable evening, and can still remember being able to sit through the first act of an opera without having to visit the toilet. Already I had learned several valuable lessons about clinical medicine, and diabetes in particular: Urine-testing equipment has a limited shelf-life (in retrospect, that first test tablet must have deteriorated); Always trust your clinical judgement, rather than laboratory tests alone; People with insulin-dependent diabetes should take immediate responsibility for their condition, and should give their own first insulin injection; self-injection is easy, and not to be feared; The effect of insulin is dramatic; Wherever possible, diabetes management should be adapted to fit the patient’s lifestyle. Given my initial fears, to learn that I had a treatable condition came as a great relief, and since that first day I have never resented my diabetes, regarding it more as a constant companion than an illness. In fact, diabetes has proved beneficial to my career, rather than a disadvantage. I had originally hoped to become a surgeon, but was advised at the time that this path would be unwise, in view of the unpredictable hours and mealtimes it would entail. Therefore, I decided to specialise in diabetes. This has allowed me better to understand my own condition. Moreover, I believe that many patients derive comfort and confidence from knowing that their diabetes specialist, who also has diabetes, is apparently in good health! Now semi-retired, I walk 30–60 minutes daily, and am much fitter than when I worked 12-hour days. Apart from some symptomless vascular calcification, I am completely free of long-term complications. I look after the day-to-day management of my diabetes myself, but visit an endocrinologist once a year (for a full medical check-up and complications screen) and an ophthalmologist every 1–2 years. Speaking personally, my wonderful wife has been of inestimable support over the years, and we have two splendid children and two grandchildren. I play golf, which is an ideal sport for the diabetic, as the amount of exercise is moderate and predictable (unlike tennis or cricket) and safe (unlike football). I am also active in madrigal singing. Although I am interested in motor racing, my diabetes precluded me from holding a racing licence; I also had to surrender my glider pilot’s licence on diagnosis. However, I have been able to enjoy membership of a Beefsteak & Burgundy Club, learning to adjust my insulin doses to cope with some remarkable dining extravaganzas! I have found it easy to deal with most of the usual problems of living with diabetes. The need to eat regularly and diet carefully has lessened in more recent years with the advent of ultrashort-acting insulin and the basal-bolus insulin regimen. I am able to avoid jetlag on long trips by travelling business class and combining alcohol and temazepam to ensure 12 hours’ sleep (contrary to textbook advice!), plus aspirin to prevent deep venous thrombosis. My biggest problem is the ever-present risk of hypoglycaemia — in particular, the problem of hypoglycaemia unawareness, which remains the “Achilles’ heel” of type 1 diabetes. Perversely, the harder one tries to avoid hyperglycaemia and achieve an HbA1c level low enough to prevent vascular and neurological complications, the greater becomes the risk of hypoglycaemia unawareness. Now, after 45 years of living with diabetes, I have total unawareness of nocturnal hypoglycaemia, and limited ability to recognise daytime episodes. Regrettably, like most diabetics, I deny that I am hypoglycaemic, even when it is obvious to all around me, and I may become obstreperous when asked to consume carbohydrate! The reason for this denial response is obscure, but may relate to the strict warning given to all newly-diagnosed diabetics (and indelibly etched on their consiousness) to avoid sugar — a message that floats to the surface during hypoglycaemic confusion. The reason for the violent, uncooperative behaviour is equally obscure, but may simply represent release of the underlying personality from inhibition by the superego, much as occurs with alcohol intoxication. When acutely drunk, some people become aggressively antisocial, while others become quiet and morose. International Diabetes Federation meeting in New Delhi, 1976 The author (left) enjoys himself with colleague Brian Hirschfeld and elephant. My wife has rescued me from countless episodes of nocturnal hypoglycaemia, and has saved my life on several occasions. Fortunately, I have rarely become violent when hypoglycaemic, and have learned — admittedly slowly — that when my wife says “You’re hypo!” (a) she is always correct, and (b) it is easier to eat the jelly beans than to argue! Certainly, the frequency of daytime and nocturnal hypoglycaemia can be reduced by using newer long-acting insulin analogues such as insulin glargine or insulin detemir, and can be virtually abolished using a continuous subcutaneous insulin infusion (CSII) — but at a price! Insulin glargine, not yet available under the Pharmaceutical Benefits Scheme, costs $800–$1200 a year. CSII costs about $2500 a year for the consumables alone, but the Federal Government, in its May 2004 Budget, promised to subsidise these costs to the value of $20 per month from September 2004. I have tried CSII on three separate occasions and, while my glycaemic control was undoubtedly better, the inconvenience, high cost, and risk of skin infections were unacceptable. A basal-bolus insulin regimen using Novorapid three times a day via an Innovo pen injector suits me well, and the Innovo memory feature is of great assistance on the occasions when I can’t remember if and when I gave the last dose. Insulin glargine at bedtime allows me much smoother glycaemic control than isophane insulin. Of course, not all diabetics feel as positively as I do; many fear injections, fingerpricks, blindness and gangrene (but, interestingly, not heart attacks!). My view is that injections using 31-gauge needles really don’t hurt, that fingerpricks are a small price to pay for good health, and that long-term complications should be preventable without sacrificing an enjoyable lifestyle. However, diabetes is a constant companion, and one is reminded that one is diabetic every hour of every day. The ability to cope with that certainty goes a long way towards being able to live successfully with diabetes.

Alan E Stocks AM, FRCPE, FRACP

The death of William McLaren (“Dr Will”) on 23 January 2004 ended a long and dedicated life of service to the people of Cowra. He was a Cowra person in the truest sense, being born at Cowra District Hospital on 25 May 1914, attending school in Cowra, and spending most of his working life there. He was the youngest child of Hugh McLaren, a physician. He studied medicine at the University of Sydney, graduating in 1940. After a period of training at the Royal North Shore Hospital, Sydney, Will left to join the Australian Army. He spent most of his wartime service in New Guinea on the Kokoda Track and with Z Force, working behind enemy lines on intelligence operations. His intrepid character, dedication and innovative ability saved many lives. His distinguished war service and contribution to wartime and postwar medical services in New Guinea are well documented in the official history of World War II. In 1947, Will joined the family medical practice in Kendal Street, Cowra, and in 1975 he was joined by his son John, thereby continuing the McLaren medical tradition into a third generation. Will was a practitioner with exceptional skills in all areas of medicine and surgery and had a wonderful ability to communicate with his patients. He was immensely loved for his great charm and roguish wit, which remained intact to the end. Will was also involved with many community organisations in Cowra, especially Alcoholics Anonymous and the Mentally Handicapped Association. He helped to set up the Lachvale School (now the Holman Place School) for students with intellectual disabilities. Although not a Rotarian, he had the honour of being awarded a Paul Harris Fellowship by the Cowra Rotary Club for his services to the community. In his spare time, he loved being with his grandchildren and pursuing his hobby of raising ducks. The Anglican priest, Susanne Pain, who had been delivered by Dr Will, officiated at his funeral service — surely a rare event. He is survived by his son John and daughter Ann.

William Muggridge

Medical management of acute and chronic low back pain. An evidence-based approach. Nikolai Bogduk, Brian McGuirk. Amsterdam: Elsevier, 2003 (viii + 224 pp). ISBN 0 444 50845 7. Low back pain is a topic that has not enjoyed the publicity that it deserves in medical circles. With its limited coverage in medical curricula, both in hospital and GP training programs, one would be forgiven for thinking it is an uncommon or unimportant complaint. Yet it is a popular topic in the media where cure claims abound. It is also the leading cause of disability in the workplace and a very common cause of presentation to healthcare providers, often non-medical practitioners. The authors are well qualified to write about this topic: Bogduk is Professor of Pain Medicine at Royal Newcastle Hospital and McGuirk is a specialist in musculoskeletal and occupational medicine for the Hunter Area Health Service. They seek to redress many of the common misconceptions about low back pain by presenting an approach to diagnosis and management firmly supported by the evidence. Many readers may be surprised to hear that the evidence base for low back pain is stronger than that for most other common conditions, but that this evidence gives little support for the traditional orthopaedic approach. The evidence is presented with great clarity and links very logically with the algorithms for diagnosis and management. These algorithms gravitate towards precision diagnosis and treatment of the anatomical sources of back pain when conservative therapy has failed. This book is essential reading for people involved in musculoskeletal medicine and medicolegal work, for rehabilitation providers, physical therapists, WorkCover and other insurance providers, and for independent medical assessors. It would also be a very useful reference text for general practitioners and supersedes most other books in this area. Especially useful are the sections on history, imaging and management. These sections will save a lot of nail-biting among practitioners who are nervous of missing dangerous conditions, or who think they need to routinely refer low back pain patients to orthopaedic surgeons or rheumatologists. Health economists may also find the concepts in this book informative, as cost savings abound in this billion-dollar heath expenditure pit. C Scott MastersPresident, Australian Association of Musculoskeletal Medicine, Caloundra, QLD Order this book

C Scott Masters

GPs are inadequately reinforced and poorly funded — and don’t mention the paperwork “To tell you the truth, I thought of all the damned paperwork this was going to mean in the morning,” said United States General Walter Bedell Smith, recalling the signing of the armistice that ended World War II (New York Times, 8 May 1965). He might have been describing a typical afternoon in general practice. I timed myself one day: a fifth of the 2 hours seeing seven patients had been spent in skirmishes with paperwork. Soldiers fight, surgeons operate, and physicians treat — but GPs? We practise consultatio interruptus (courtesy M Van Der Weyden, MJA Editor). Illustrator: Futcher. First appeared in Australian Doctor, 2002. Paperwork is an occupational hazard for GPs. One GP counted a barrage of 1574 individual communications monthly.1 In cold cash terms, the Productivity Commission found that GPs’ administrative costs from government programs in 2001–02 were an estimated 5% of GPs’ total income in the base case (ie, $13 100 annually for a GP working at least one day a week).2 Putative financial incentives for GPs to provide quality care, such as vocational registration, the Practice Incentives Program (PIP), and Enhanced Primary Care (EPC) Medicare items, accounted for over three-quarters of these costs. The report also acknowledged the stress and frustration experienced by GPs in filling out forms and complying with government programs. In response to the Commission’s report, a GP Red Tape Taskforce has emerged.3 This cross-government group includes staff from the senior ranks of the departments of Health and Ageing and Veterans’ Affairs, Centrelink and the Health Insurance Commission. After consulting GPs, GP groups, consumers and other stakeholders, a draft of possible responses was released in October last year. These included streamlining the government’s information requirements, enhancing GP use of information technology, simplifying programs such as PIP, and minimising administrative costs.3 Discussions with GP groups since then have focused mostly on reworking PIP and EPC items. Predictably, actual reform is yet to materialise. Furthermore, within a year of the Taskforce becoming operational, the government announced its Medicare Plus package, which included tying allied healthcare services access to the EPC program.4 While laudable in its intent, it promised yet another salvo of red tape for GPs. Countermeasures raised since by GP groups will diminish this,5 but it remains an inherently flawed initiative. This war on paper is allied to major themes in the 2004 MJA General Practice issue: general practice funding and workforce pressures. Are fragmented government payments in a fee-for-service system really the way to go? Data furnished by Britt et al (page 100) have implications for current negotiations on restructuring Medicare items. We also asked our Dutch (Van Weel, page 110), British (Weller and Maynard, page 109), Canadian (Martin and Hogg, page 111), American (Green, page 113) and New Zealand (Malcolm, page 106) colleagues to tell us how they fared with funding. The only constant in their replies is that of change, and change can be difficult. Nor is it often well evaluated, say Van Weel and Del Mar (page 98), marshalling the evidence for various payment systems. It is also clear that most of the countries featured in this issue favour deploying capitation (lump sum payment per patient on the GP’s “list”) to pay their GPs. As for workforce pressures, they’re unlikely to improve in the near future (Charles et al, page 85). Some rural communities continue to favour doctors more than other healthcare services (Smith et al, page 91). So find out how a few rural GPs successfully outflanked their workforce problems (Joyner et al, page 96). This issue doesn’t neglect clinical problems — for example: why we shouldn’t panic about avian influenza (Isaacs et al, page 62); what we learnt in the aftermath of Implanon (Wenck and Johnston, page 117; Nisselle, page 64); who should eat which fish (Bambrick and Kjellström, page 61); what dilemmas GPs face in diagnosing and treating heart failure (Phillips et al, page 78); where the luxury of on-site psychologists seemed to benefit patients (Vines et al, page 74); how chronically ill patients like their GPs and their practices (Infante et al, page 74); how GPs can realistically tackle respiratory disease (Beilby et al, page 67) and childhood obesity (Wake and McCallum, page 82). In this issue, we have attempted to enter the fray of real general practice. The campaign against red tape aims to free GPs for what most of us really want to work at — patient care. The battle against red tape is part of the healthcare war.

Mabel Chew MB BS(Hons), FRACGP, FAChPM

The IPCRG is fostering international links between primary care clinicians and researchers Over 450 primary care clinicians and researchers from around the world gathered for the second conference of the International Primary Care Respiratory Group (IPCRG) in Melbourne in February 2004. The IPCRG is an international umbrella organisation for national primary care respiratory interest groups.1 It was established as a charitable company in June 2000 by general practitioners (GPs) and other primary care health professionals from several countries, including Australia, at a meeting of the United Kingdom GP asthma group. Australian GPs have been actively involved in all aspects, including the executive, since its inception. The organisation currently has 21 member countries, represented by national organisations. Australia is represented by the National Asthma Council. The aims of the IPCRG are to provide an international network for research in community settings, to guide and disseminate evidence-based guidelines appropriate for primary care professionals (eg, GPs, nurses, pharmacists and healthcare workers), and to provide practical resources for “respiratory professionals” in community settings around the world. Those involved in IPCRG include such diverse groups as GPs, respiratory scientists, asthma educators, pharmacists and physiotherapists. The theme of the 2004 conference was “the way forward” in managing respiratory disease in primary care. Major topics were asthma, allergy and chronic obstructive pulmonary disease (COPD), while tuberculosis, community-acquired pneumonia and quality-of-life measurement also received substantial attention. Topics were covered from the perspectives of clinical care, people and public policy, and practical training, with plenary sessions, workshops and submitted papers and posters. Core issues arisingProactive models of care should be developed and tested. Most primary care respiratory management is reactive, and not organised or systematic. Different models of evidence-based proactive care need to be developed and tested. New models presented at the conference included telephone consultations for asthma review, integrated decision support, nurse-led asthma clinics, practice-based professional development programs linked to patient audits, and community-based pharmacy outreach programs. Guidelines need to be translated into daily practice. Several internationally developed guidelines for asthma, COPD and rhinitis cannot be implemented in primary care (Professor Onno van Schayck, Faculty of Medicine, University of Maastricht and University of Nijmegen, The Netherlands). Several plenary sessions discussed how best to link guidelines to clinical practice in general practice and other forms of primary care, including nurse-run asthma clinics and Aboriginal community-controlled health services. The “consensus” was that a model centred on the respiratory complaints described by the patient at presentation is more sustainable and may be more effective (eg, a model centred on “cough” may be superior to one centred on “COPD”). The link between allergy and asthma must be applied in clinical practice. Evidence is emerging that effective management of allergic rhinitis may ameliorate and prevent asthma (Associate Professor Mini Tang, Head, Department of Immunology, Murdoch Children’s Research Institute, Melbourne, and Dr Jacques Bouchard, St Joseph’s Hospital, La Malbaie, Quebec, Canada). As almost 45% of the Australian population is atopic, and about a third suffer allergic disease (Professor Robyn O’Hehir, Head of Allergy and Respiratory Medicine, Alfred Hospital, and Monash University, Melbourne, and the Cooperative Research Centre for Asthma, Sydney), a number of speakers stressed the need to consider allergy assessment in all patients with asthma. Undiagnosed asthma and chronic obstructive pulmonary disease must be identified more efficiently. Effective management is now available for people with early signs of asthma and COPD and will substantially improve their quality of life (Dr Christine Jenkins, Director, Clinical Trials Unit, Woolcock Institute of Medical Research, Royal Prince Alfred Hospital, Sydney). More precise assessment of disease severity is needed. The severity of asthma and COPD needs to be specified more precisely to maximise the benefits and minimise the risks of interventions. Smoking-cessation programs, appropriate use of inhaled corticosteroids and long-acting bronchodilators, pulmonary rehabilitation, and self-management strategies all have a role, depending on severity of the condition (Dr Christine Jenkins). Major topics discussedAsthma. With the recent release of the report on the global burden of asthma,2 Professor Richard Beasley (Director, Medical Research Institute of New Zealand, Wellington, New Zealand) highlighted the increasing prevalence of asthma, particularly in Asia. He maintained that the explanation is still uncertain, but multifactorial, with environmental factors, increasing urbanisation and the increasing prevalence of allergic disorders all implicated. This suggests that addressing the increase in prevalence will require multifaceted responses by clinicians, public health physicians, consumers, industry and governments (eg, by providing all essential drugs to treat people with asthma in all Asia-Pacific countries). He argued that primary care is a substantial part of the solution and has specific challenges, including development of simple algorithms for patients who present with vague symptoms of cough, shortness of breath and wheezing. Emerging evidence pointed to a need to ensure that the lowest dose of inhaled corticosteroid is used to control symptoms. Some newly recognised side effects include dental and vision problems. Up to 45% of people taking moderate amounts of inhaled corticosteroids report some side effects (Professor Thys Van der Molen, Department of General Practice, University of Groningen, The Netherlands). Van der Molen commented that primary-care clinicians often do not have the time or tools to identify these less well known side effects. Severe acute respiratory syndrome. Associate Professor Cheong Pak Yean (Family Physician, Faculty of Medicine, National University of Singapore) described Singapore’s response to the epidemic of severe acute respiratory syndrome (SARS). The strategy involved detecting, isolating and “ring-fencing” the virus at four levels — the border, hospital, community, and primary care. Border defence involved screening travellers for possible SARS as they entered Singapore. The hospital defence involved managing all people with SARS (or possible SARS) in hospital, with use of personal protective equipment by staff (masks, gloves, gowns, and goggles) plus barrier nursing in single-patient isolation rooms. Community defences included mass education, twice-daily temperature measurement for any suspected cases, and closure of “at-risk” gatherings, such as markets. In primary care, strategies used included GP education campaigns, telephone information hotlines, and “fever and evacuation” rooms in GP surgeries (separate rooms for patients with suspected SARS awaiting evacuation to hospital). Chronic obstructive pulmonary disease. Identifying people with early smoking-related lung damage would seem a major task. The number of people with COPD in Australia will increase significantly over the next 10–15 years; the estimated prevalence may well exceed 300 000 cases (Professor Justin Beilby, Department of General Practice, University of Adelaide, SA), and the total number of COPD sufferers (both diagnosed and undiagnosed) could range from 620 000 to 2.6 million cases.3 A GP-friendly algorithm based on the recently completed COPDX guidelines4 was presented. Fitting on two A4 pages, this has since been refined and released (Box). Symptom-based questionnaires. There was much discussion about GPs identifying specific conditions, such as undiagnosed COPD. Professor David Price (General Practice Airways Group, Professor of Primary Care Respiratory Medicine, University of Aberdeen, UK) reported on a study of the link between symptoms and results of spirometry testing in 417 current or former smokers recruited from primary-care practices in the United Kingdom and the United States. Predictors were identified that may be useful in identifying early COPD, as measured by spirometry, including: Age group (in years). Pack-years smoked (How many cigarettes do you currently smoke each day [if you are an ex-smoker, how many did you smoke each day]? What is the total number of years you have smoked cigarettes?). Recent cough (Have you coughed more in the past few years?). Breathing-related work loss (During the past 3 years, have you had any breathing problems that have kept you off work, indoors, at home, or in bed?). Hospitalisation for breathing problems (Have you ever been admitted to hospital with breathing problems?). Recent breathlessness (Have you been short of breath more often in the past few years?). Cold usually goes to the chest (If you get a cold, does it usually go to your chest?). It was agreed that these questions require validation among other communities before they can be used as predictors in everyday clinical practice. ConclusionThis was the second IPCRG conference, the first being held in Amsterdam in 2002. The developing international IPCRG networks have now begun developing innovative research programs, such as further validation of the symptom-based questionnaires discussed above. These programs will become the platform for the next conference, to be held in Oslo in 2006. The IPCRG research subcommittee has begun developing a strategic plan for the group — a challenge, because of the diversity of the member countries and the variable access to resources and research expertise across the group. However, meeting the challenge through sharing expertise and skills may also be a great opportunity for IPCRG. Main steps of COPDX checklist for diagnosis and management of chronic obstructive pulmonary disease5 C – Confirm diagnosis Presence and history of symptoms Smoking – history and willingness to quit Spirometry – measure FEV1 and FEV1/FVC and assess reversibility of airflow limitation O – Optimise function Including check of smoking status, optimal therapy and exercise status P – Prevent deterioration Essential steps (including pneumococcal and annual influenza vaccination) Risk-factor reduction (including help with smoking cessation) D – Develop self-management plan Including referral for pulmonary rehabilitation or to respiratory physician or hospital, if appropriate X – Manage eXacerbations Including ensuring understanding of importance of early treatment for exacerbations; regular review

Justin J Beilby MD, FRACGP · Nicholas J Glasgow MD, FRACGP, FAChPM · H John Fardy DRCOG, FRACGP

Objectives: To explore the perceptions of patients with chronic conditions about the nature and quality of their care in general practice.Design: Qualitative study using focus group methods conducted 1 June to 30 November 2002.Participants and setting: 76 consumers in 12 focus groups in New South Wales and South Australia.Main outcome measures: Recurring issues and themes on care received in general practice.Results: Three groups of priorities emerged. One centred on the quality of doctors, including technical competence, interpersonal skills, time for the patient in the consultation and continuity of care. A second concerned the role of patients and consumer organisations, with patients wanting (i) recognition of their knowledge about their condition and self-management, and (ii) for GPs to develop closer links with consumer organisations and inform patients about them. The third focused on the practice team and the importance of practice nurses and receptionists.Conclusion: GPs should consider the amount of time they spend with chronically ill patients, and their interpersonal skills and understanding of patients’ needs. They need to be better informed about the benefits of patient self-management and consumer organisations, and to incorporate them into their care. They also need to review how their practice nurses and receptionists can maximise the care of patients.

Fernando A Infante MPH · Judith G Proudfoot PhD, MA, BEd(Hons) · Gawaine Powell Davies MHP · Mark F Harris DRACOG, FRACGP, MD · Tanya K Bubner BSocSc · Chris H Holton GDPH, GDAcc, BA(Acc) · Justin J Beilby MD, MPH

Objective: To evaluate whether a collaborative model of mental healthcare involving general practitioners and clinical psychologists benefits patients with common mental disorders in primary care.Design and participants: Cohort study of 276 general practice patients with mental health problems receiving collaborative treatment from clinical psychologists and GPs compared with a normative sample of 198 patients attending the same general practice surgeries.Setting: Nine general practices in three regional cities (Bathurst, Armidale and Ballarat) and two single-doctor practices in two rural and remote townships (Rylstone and Trundle). Data were collected in Bathurst, Rylstone and Trundle during 2001 and 2002 and in Ballarat and Armidale in 2002.Intervention: Full assessment, case formulation and “focussed psychological interventions” relevant to the patient’s condition.Main outcome measures: Level of psychological dysfunction assessed before and after the intervention, using the DASS (Depression, Anxiety and Stress Scales), GHQ (General Health Questionnaire) and GWBI (General Well Being Index) scales.Results: After the intervention, average scores in the treatment group decreased significantly (P < 0.001) on all DASS and GHQ measures and increased on the GWBI, indicating a positive change in the patients' mental health. The follow-up scores of the treatment and normative groups did not differ significantly on any of these measures.Conclusion: Preliminary findings suggest that collaborative care involving GPs and clinical psychologists provides significant gains in patients’ mental health.

Robyn F Vines MSc, FAPS · Don Thomson PhD, FAPS · Michelle Kluin BLMC · Louise Vesely · Jeffrey C Richards PhD, FAPS · Margaret Brechman-Toussaint PhD

Objective: To explore potential barriers to the optimal diagnosis and management of heart failure in primary care.Design and setting: Qualitative study involving semi-structured focus groups or telephone interviews with general practitioners, in three urban and one rural Division of General Practice with above-average elderly resident populations, conducted between 1 April and 31 July 2002.Participants: 31 self-selected GPs who responded to a general invitation and four GPs who were personally invited to participate in the study.Main outcome measures: Issues identified by GPs as barriers and GPs’ ratings of their importance.Results: GPs reported that most of the difficulties in accurately diagnosing heart failure were associated with masking of the disease by other conditions and the lack of specificity of the symptoms, particularly in the early stages. They felt that echocardiograms can be difficult to access, were of unclear benefit and may not be warranted in obvious cases. Concerns about possible side effects and reliance on other forms of therapy were common reasons for the suboptimal use of angiotensin-converting enzyme inhibitors. Underuse of β-blockers was associated mainly with concerns about side effects, contraindications and comorbidities, and a lack of experience with initiating therapy, particularly in community settings.Conclusions: This study identified specific barriers to GPs implementing evidence-based recommendations in managing heart failure. Tailored strategies that address the practical concerns of GPs about applying research evidence in the primary care setting and that facilitate better linkages between GPs and specialists are needed.

Susan M Phillips DPhil · Geoffrey H Tofler MB BS, MD · Richard L Marton PhD

At least a quarter of primary school children in Australia are overweight or obese; the long-term impacts are likely to include chronic morbidity and loss of life-years. Universal preventive strategies have so far had limited effectiveness, while secondary and tertiary referral services would be overwhelmed if they attempted to systematically manage a problem with such high prevalence. Primary care services could play an important role in secondary prevention of overweight and mild obesity in children. While reports of child obesity research have burgeoned since 1995, effectiveness trials of primary care interventions in primary-school-aged children have been neglected. Randomised controlled trials of a primary care approach, although challenging, are essential to determine whether it does more good than harm.

Melissa A Wake MD, FRACP · Zoë McCallum FRACP

W Ian Cameron Chief Executive Officer, New South Wales Rural Doctors Network, Level 3, 133 King Street, Newcastle, NSW 2300. icameronAT.nswrdn.com.au To the Editor: Bourke is a small rural town in far northwest New South Wales with a population of about 3500. The Bourke Shire Council has recently published a fascinating small book entitled 100 lives of Bourke, which uses Bourke cemetery as a “window to the past”.1 Included in the 100 vignettes based on headstones in the cemetery is one for Dr George Faithfull, Bourke’s third doctor. Dr Faithfull was born in Calcutta, India. He started medical studies in Edinburgh, Scotland, but did not complete them. He travelled to Australia, arriving in Victoria, and worked his way north (Dr Don Faithfull, grandson of George, personal communication). By 1885, he was working as a chemist in Bourke.2 In view of his experience as a “medical man” and his previous medical studies, he later became registered as a medical practitioner under Clause 3 of Act 70, The Medical Practitioners Further Amendment Act of 1900, where it was stated that: It shall be lawful for the Medical Board or its Doctors to place upon a separate register the name of any person who has passed through a course of study as Medical Practitioner in NSW during five years before the passing of this Act. Dr Faithfull was a doctor in Bourke and Goodooga from 1900 to 1908. He must have been one of the very first doctors to have gained what is now termed in NSW “conditional registration in an area of need”. To have become conditionally registered while practising as a chemist in Bourke, he must also be an early example of rural-based distance learning — a cornerstone of our new regionalised general practice training. Dr George Faithfull and his wife, Mary Faithfull (née Whitfield). (Photo, Dr Don Faithfull.) It is sobering to think that the changes made over the last few years by medical boards, and the streamlining of processes outlined in MedicarePlus, had precursors over a hundred years ago. Doctors and their families were not exempt from the morbidity and mortality of the time. Three of Dr Faithfull’s 11 children died young and are buried in Bourke cemetery. Another Bourke doctor, Dr Sides, had three children die in infancy, and Dr Dey lost a six-month-old son. In 1901, a locum doctor died of heat stroke. More recently, in 1992, Bourke cemetery became the final resting place for another overseas-trained doctor, Professor Fred Hollows, who achieved international recognition for his work in ophthalmology in disadvantaged populations, particularly Indigenous Australians.

W Ian Cameron

Robert W Pegram,* Lisa Valenti† *Senior Lecturer, Department of General Practice, University of Adelaide, Adelaide, SA; †Senior Analyst, General Practice Statistics and Classification Unit, University of Sydney, Wentworthville, NSW. robert.pegramATadelaide.edu.au To the Editor: Young and Dobson’s article1 examining the bulk-billing status of services provided to women generated much debate.2,3 To add to that debate we undertook an analysis of 5546 Medicare-claimable general-practice encounters. Data were provided by 200 general practitioners between May and July 2002, using the BEACH (Bettering the Evaluation and Care of Health) methodology.4 We examined which encounter, GP and patient characteristics determine billing status (patient-billed or bulk-billed). From time and day of service we determined which consultations were “after hours”. Over two-thirds of services (69.8%; 95% CI, 65.4%–74.3%) were bulk-billed. One in fourteen services (7.1%; 95% CI, 2.2%–12.1%) were delivered “after hours” as defined by the Australian Government Department of Health and Ageing5 (ie, between 6 pm and 8 am on weekdays or between 1 pm Saturday and 8 am Monday on weekends). The results after simple and multiple logistic regression analysis are shown in the Box. After-hours consultations were significantly more likely to have been bulk-billed than those held during standard office hours (odds ratio [OR], 1.9). Patients aged < 15, 15–24 years and > 75 years were significantly more likely to be bulk-billed than working-age adults (P < 0.0001). Also significantly more likely to be bulk-billed were patients from non-English-speaking backgrounds (OR, 7.3), living in an urban area (OR, 2.6), holding a healthcare card (OR, 3.5) and/or coming from a low socioeconomic status background (OR, 2.3). There was no significant association between the likelihood of being bulk-billed and the age or sex of the GP, the practice size or the number of problems managed at the encounter. Interestingly, the variable with the largest impact on bulk-billing rates was whether patients were from a non-English-speaking background. These patients were over seven times more likely to be bulk-billed than patients from an English-speaking background. This study adds further support to the findings of Young and Dobson1 that patients in urban areas were significantly more likely to be bulk-billed for general practice consultations than their rural counterparts. We can go one step further and say that consultations given after hours were also significantly more likely to be bulk-billed. The conclusion is that bulk-billing decisions by GPs are not uniformly influenced by timing, location and patient characteristics. This has implications for assessing the likely impact of bulk-billing strategies such as MedicarePlus.6 Factors influencing the likelihood of bulk-billing in Australian general practice* Simple logistic regression analysis Multiple logistic regression analysis OR (95% CI) (n = 5546) Adjusted OR (95% CI) (n = 4793) Time of consultation “After hours” status (standard hours : after hours) 1.5 (0.9–2.5) 1.9 (1.1–3.3) Other variables Non-English-speaking background (no : yes) 8.8 (4.8–16.3) 7.3 (3.8–14.0) Aboriginal or Torres Strait Islander descent (no : yes) 2.0 (0.7–6.0) ns Patient new to practice (new : not new) 1.5 (1.0–2.2) ns Rural/urban place of residence (rural : urban) 2.2 (1.3–3.7) 2.6 (1.5–4.7) Having health care card (no : yes) 3.4 (2.4–5.0) 3.5 (2.3–5.2) Socioeconomic status† (higher SES : low SES) 3.2 (1.8–5.7) 2.3 (1.2–4.5) Practice size (5+ GPs : solo GP) 2.4 (1.0–5.8) ns (5+ GPs : 2–4 GPs) 1.4 (0.9–2.3) ns Patient age (years) (25–64 : < 15) 1.5 (1.1–2.0) 1.4 (1.0–1.9) (25–64: 15–24) 1.4 (1.2–1.8) 1.4 (1.1–1.9) (25–64 : 65–74) 1.8 (1.4–2.5) 1.2 (0.8–1.6) (25–64 : ≥ 75) 2.5 (1.7–3.8) 1.7 (1.1–3.8) Patient sex (female : male) 1.1 (0.9–1.3) ns GP age (years) (25–54 : ≥ 55) 1.6 (1.0–2.8) ns GP sex (female : male) 1.1 (0.7–1.8) ns Number of problems managed per encounter‡ 1.0 (0.9–1.2) ns GP = general practitioner. ns = not significant at 5% level. OR = odds ratio. * For each variable, the first-mentioned category is the reference. † Assessed by SEIFA (Socioeconomic Indexes for Areas) categories of the Australian Bureau of Statistics. ‡ The reference point for this variable is the number of problems managed (1, 2, 3 or 4), measured against whether the patient is bulk-billed. The OR here indicates that for each unit increase in problems managed the odds of the encounter being bulk-billed do not change.

Robert W Pegram · Lisa Valenti

When I (P J) explained to one of my younger colleagues that I was writing an article about recruitment and retention of doctors to the country, I finished by asking what made her come and stay here. “I want to work and still have a life” was her spontaneous answer — a response that encompasses most of what we have tried to achieve in this medical practice. Mannum Medical Centre In 1976, after working as an urban general practitioner for 5 years, I moved to Mannum, a delightful small town of about 3000 people, situated on the Murray River some 80 km due east of Adelaide. I formed a partnership with Dr Owen Crompton, who was of a similar age and background, and we worked together until 2000, when he decided to move to (literally) greener pastures in Victoria. Mannum has an annual rainfall of 10–11 inches in a good year and goes through a drought every 4–6 years — Owen despaired of ever being able to raise horses or cattle in such an environment. After some 3 years of unsuccessfully advertising for another doctor to join the practice, we realised that we would need to adopt a different approach if I was to be able to remain in practice in Mannum. The world had changed since I graduated from medicine in 1969. Medical graduates were no longer predominantly male, white and anglosaxon, with a wife and family willing to follow the doctor wherever life took him. Making some changesOver the next few years, we made some significant changes, and the practice now has six GPs, working various hours, up to two GP registrars at a time, and a thriving relationship with Flinders University. To summarise the main changes: We moved the surgery from a small house in the main street where it had been for 40 years to a converted area in the hospital. The operating theatre was no longer in use and could be converted into a more than adequate accident and emergency area. We then built on this to give us a total of five consulting rooms, two clinic nurse rooms, and new reception, office and waiting areas. The extra space allowed registrar training for the first time, as a way of exposing the practice to new graduates. In 2000, our first Registrar, Stephen Napoli (Box 1), returned to Mannum after moving around the state to experience work in other areas. We became (and remain) enthusiastically committed to being a high-quality training practice, encouraging both registrars and students to spend time with us. To that end, we were able to access a federal grant to have two residential units built close to the hospital grounds. We work enthusiastically with the Sturt–Fleurieu GP Education and Training and the Flinders University Medical School and have hosted a range of students to give them an insight into the pleasures of rural practice. Doctors are able to join the practice as associates, and are thus free to come and go, not financially bound to the practice. The practice offers maximum flexibility of working hours, which can be tailored to meet changing family and other commitments. We have a philosophy of mutual respect, that in our practice we are all equally valuable (even though I am ancient compared with the younger doctors) and we are a practice of equals. Our flexible workforceAs present, there are several qualified GPs here, besides Stephen and myself (Box 2). We are lucky to have three women in the practice. Kylie Booth was a registrar here, who left saying she would “come back if she had a room with a river view and if we could organise a youth clinic service for her”. Although Kylie is now married and her husband is committed to work in Adelaide, she works here 2 days a week, returning to a youth clinic in Adelaide on other days. Sonia Schutz trained as a registrar in a practice near here, went to work for further experience in Broken Hill with the Royal Flying Doctor Service, and moved back into the area to work with us. Besides working on their newly acquired farm, her husband, Terry, is employed here for 3 days a week as our office manager. The youngest doctor here is Rebecca George, who, after passing her FRACGP exams last year, has increased her working days from three to four. It was she who gave me the quote I have used to introduce this article. Brian Moore, the only doctor here who is older than me, has had vast experience in Alice Springs and, more recently, in the Adelaide Hills area. He helps with the registrar teaching and works Thursday, Friday and Saturday mornings, being a valuable part of our ability to offer 6-day-a-week consulting and 24-hour, 7-day-a-week medical services. We have had up to two registrars at times, plus doctors in their mentor time, which certainly increases the teaching load but is very enjoyable. At this stage, we have Ethan Tieu — another great registrar, enthusiastic, very competent and very keen to learn all he can of rural general practice I contrast our current situation with the 20-odd years when I was the only doctor offering obstetric services here, and so was on call all the time and juggling holidays around the times when no “mids” were due. At that time we had a saying that “if you needed to be seen you would be seen at some time through the day”, even if it was at 10 o’clock at night at the end of a full day’s consulting. This is now neither practical nor sensible, and is certainly not desirable for either patients or doctors. Why Mannum “works”We have developed a firm policy of trying to encourage other doctors to work with us, either full-time or part-time, in ways that are mutually supportive. Working with younger doctors is one of the joys of life, as the combination of questions, answers, learning, teaching, and sharing their enthusiasm for a balanced life has helped me to totally enjoy the past few years here. The practice has changed when the notice in the toilet now reads “How to practise your pelvic floor exercises”! I believe the future of rural practice depends on being totally involved at all levels of medical training (undergraduate students, postgraduate students, registrars, etc), advertising the good points of where you work and live, always looking for ways to change and improve, and being positive and flexible in supporting any doctor who comes your way. Overall, if new doctors feel supported and valued in the practice and have access to a full life out of surgery and on-call hours, then they are more likely to stay and encourage other doctors to come. Younger doctors give us the great example of wanting both to practise high-quality, satisfying medicine, and to enjoy that part of their life that is outside of medicine. 1 Working and staying in the country as a GP depends on a healthy balance between work and personal life Dr Stephen Napoli In 1999, I had my first taste of working in Mannum in my mentor time as a rural GP registrar and locum. I was married with two young children and must admit did not really enjoy my “introduction” to the town. I replaced one of the then two doctors for 2 weeks, and found the hours long, arduous and not conducive to family life. While working as a rural locum in various towns in South Australia, I quickly became aware of certain aspects of rural practice which reinforced my desire to work in the country. Establishing links with a community, developing relationships with patients, and the opportunity to maintain broad clinical skills was both rewarding and stimulating. But I also realised that in some practices it was difficult for a younger GP, with a young family and an approach to life that put family before work, to feel comfortable. Returning to work in Mannum as one of three and a half doctors was a more positive experience. Mannum also offered the opportunity to fulfil my strong desire to practise obstetrics. I was able to reduce hours when needed to complete my GP registrar exams, following the births of our children (now four). In addition, my wife was able to further her career interest in family therapy and rural mental health. Having a strong teaching and training focus involving both students and registrars has obviously brought vibrancy and a dynamic character to the practice, while keeping us up to date with current approaches to medicine. Good relationships with the reception staff and local hospital staff have aided in creating a harmonious and efficient working environment. Staying in Mannum has been very much affected by my particular family needs, but has also been based on a strong working relationship with Peter. I have felt a strong sense of mutual respect, allowing for a flexible approach to our working relationship as associates, while maintaining an equitable approach to our business relationship. Although we are happy in our current practice team, change is paramount in this modern era. Having a positive, proactive approach will, we hope, allow us to accommodate the changing needs of the future. 2 Why do some medical practices keep their registrars? The Mannum team: Left to right; Dr Brian Moore, Dr Peter Joyner, Dr Rebecca George, Dr Sonia Schutz, Dr Kylie Booth, Dr Stephen Napoli, Dr Ethan Tieu (Registrar). Dr Kylie Booth As a medical student at Flinders University, I was a member of the “rural club”, and visited a variety of country practices. When I applied and was accepted into the RACGP training program to start as a basic registrar in January 2001, Mannum was my second choice as a placement. My first choice was a town that I had worked in as a sixth-year medical student, during my rural GP term. I think that practice familiarity is a very important thing for registrars — past students will often return. In 2001, the college gave most applicants their second choices, so I started my basic term as a GP registrar at Mannum. For a registrar, Mannum has a few practical advantages. The town is only 1.5 hours’ drive from Adelaide, and is a popular tourist destination for water skiing. There is a strong community feel to the town. The community respects the medical practice, which, in turn, provides 24-hour emergency care in addition to daily general practice clinics. The Mannum Medical Clinic initially provided me with appropriate orientation to the practice. The reception staff welcomed me and soon adapted my bookings to my growing abilities. I loved the fact that the practice principals had previously decided that “full time” is 4 days a week, as we all work one night and one weekend in three on call. I did not feel — as some registrars do — that I was a “process worker”, just there to bring money into the practice. I have always felt part of a team. The doctors, whether associates or registrars, all share the same vision and are highly supportive of each other. The supervision and support I have received is ultimately the reason I have stayed. The practice as a whole was particularly supportive during the FRACGP examination period. Peter’s diplomatic optimism, even in difficult situations, is a skill I wish all GP supervisors could develop. Rosters, contracts and salary are all important issues for registrars, and I believe that all of these were fair, and negotiated with the registrar’s interest in mind. To all the staff at Mannum Medical Clinic, I say, “Thank you — and congratulations for being such a great place to work”. They have found the right balance.

Peter Joyner MB BS, FACRRM, DRCOG(Obst) · Stephen Napoli MB BS, FRACGP, DRCOG(Obst) · Kylie Booth BMBS, FRACGP

We need evidence that can underpin fundamental change General practice and the rest of the primary care team, rather than specialist or hospital care, deliver the lion’s share (90%) of healthcare.1 They also provide the anticipatory care necessary for early and better management of the chronic diseases that characterise modern industrial societies. A strong, self-reliant primary care workforce increases quality as well as cost-effectiveness.2 Thus, the way a country remunerates its primary care workforce is vital. This is a good time to debate the options in Australia — a federal election year in which healthcare is likely to be a central issue. Changes to the administrative system can have enormous implications for primary care. So far, planned changes in Australia have been tentative, consisting of “add-on” improvements such as payments to general practitioners (GPs) in addition to the traditional fee-for-service arrangements. These include Practice Incentive Payments (PIPs), which pay GPs who can demonstrate using set protocols for managing some chronic diseases (eg, asthma, diabetes), and Service Incentive Payments (SIPs), which are specific payments for certain services such as mental health care and vaccination. The complexity of administering these programs has prompted complaints from GPs, and in response a Red Tape Task Force has been convened.3 Healthcare systems differ hugely from country to country, as we see from the articles that follow. Reimbursement is perhaps its most emotionally highly charged aspect and, however contentious an issue, some system has to be chosen. Strong primary-healthcare-led systems like those in the United Kingdom4 (page 109) and The Netherlands5 (page 110) use capitation systems as the basis of paying GPs: they contract to assume the obligation to provide care for a group of patients, and their financial rewards are independent of the actual service and care delivered. In the former Yugoslavia, with its socialist origins, remuneration took the form of a salary, accompanied by planning (and restriction in the number) of GPs. A more market-driven way of paying GPs is for GPs to “deliver” before payment (fee-for-service), and in competition with each other, as in Australia and the United States (page 113).6 Canada (page 111) has opted for a combination of methods,7 and New Zealand (page 106) is experimenting with a variety of interesting models in quick succession.8 Fee-for-serviceFinancial incentives have a direct influence on GPs’ behaviour. For example, in Belgium, 46% of GP–patient encounters are home visits,9 whereas in The Netherlands this is only a small proportion of GPs’ clinical activities. The population health status and infrastructures of the two countries hardly differ, so the difference can only be explained by incentives: under Belgian fee-for-service, a home visit is chargeable. It also strengthens patient satisfaction with the GP in a competitive environment. On the other hand, the Dutch GP receives a capitation fee irrespective of whether the patient is seen at home or at the practice (or not at all). One problem with fee-for-service payment is that the way GPs are funded is confounded by other innovations that Australia should be considering, such as patient registration. Although theoretically this could be separated from how doctors are paid (capitation, for example), nowhere does this occur. A second problem is that fee-for-service can be inflexible about who is remunerated. This has held back the proper utilisation of nursing in general practice in Australia simply because nearly all services in general practice are ineligible for a Medicare rebate if provided by nurses, even though for many services (eg, preventive10 or protocol-driven chronic care11) nurses may be better suited. A third problem is the need for a business mind with fee-for-service general practice. Many doctors want to practise unencumbered by a “small shopkeeper” role. One consequence was the evolution in the 1980s of “entrepreneurial practices” (those whose owners were more interested in making a profit than serving their communities). These offered greater flexibility for the increasing numbers of doctors who, wanting “just to practise medicine” and happy to abdicate their commercial role, flocked there. “Perverse incentives” reward some clinical activities better than more valuable ones.12 For example, a GP who delivers many short consultations will earn more than one who has fewer and longer consultations — even though longer consultations are associated with better attention to preventive healthcare and psychosocial problems.13 Attempts to address this by providing less reliance on fee-for-service (to the fury of the Australian Medical Association)14 with additional alternative payment systems (so-called blended payments) such as PIPs and SIPs — funded by what might have otherwise gone to increased fees — are probably only partly successful. It is too early to tell if the complexity of administering them is any better than the fee restrictions that arose to discourage entrepreneurial practices. Do we need more fundamental reforms of the GP system? What are the alternatives? CapitationCapitation payment and its associated patient registration (the “list”) feels like clinical freedom for many GPs in the UK and The Netherlands: the GP accepts an obligation to provide care for the patients on the list and do what is in their best interests. It has offered GPs a level platform to counter medicalisation, overdiagnosis, over-referral and spurious prescribing, without the tilt of having to please the patient (something usually miscalculated in any case15). But there are disadvantages. A capitation system can be a haven for laziness, because payment comes irrespective of the quantity (let alone the quality) of care. GP-initiated activities — like anticipatory (chronic disease management) and preventive care — are particularly sensitive to this. Perhaps this is the basis for the reforms currently under way in the UK NHS.16 Disciplinary hearings against GPs in the UK and The Netherlands are, to a large degree, occupied with GP failure to provide enough care — in particular, failure to visit patients in a (perceived) emergency at home. In Australia, the focus of disciplinary hearings is on overservicing. The issue for capitation systems is deciding what is enough care; for fee-for-service, deciding what is too much. The solutionBlended payments (a mixture of fee-for-service and payments for good practice) sound sensible (the best of both worlds), but there is little evidence17 to reassure us we might not get the worst of both: entrepreneurial GPs learning which mix of activities yields the highest earnings, and government reacting by over-regulating the system to avoid this. GPs are at the forefront of evidence-based patient care. It would be good if GPs’ financing systems were established by good evidence, but little exists regarding the effects on service of different payment systems (Box). Thus, we need to trial different systems, not simply enact the latest political ideology. The current flux in the Australian healthcare system is surely an ideal environment for such experiments. Possible alternatives would be payment systems that allow for patient registration, that include the option of salaries for doctors uninterested in running a business, and that encourage doctors to collect and analyse clinical data about the services they provide. There is no doubt that such trials would be hard to conduct politically,17 and perhaps randomised controlled trials would have to give way to the pragmatics of quasi-experiments. But we need changes to the system that are fundamental, rather than the lean-to sheds propping Australia’s current archaic system. The evidence base for different primary care payment systems The best evidence comes from a Cochrane review.18 This is in need of update (last search date was 1997). The review compared four payment systems (fee-for-service, salary, capitation, and mixed), and accepted studies that were randomised controlled trials (RCTs) or controlled before–after (CBA) studies if there were at least two measurements before and two after the intervention (nine studies were excluded for failing this test). Two RCTs (total of 98 doctors) and two CBAs (216 doctors) were included: all had potential biases in their methods. Compared with capitation, fee-for-service was associated with more services, tests and referrals to specialists, but fewer referrals to hospital. Compared with salaried payment, fee-for-service was associated with more services and more continuity of care, but less patient satisfaction with access to care. A more recent narrative review (conducted at an international conference on the subject) reached the same conclusions.19

Chris Van Weel PhD, FRCGP · Chris B Del Mar MD, FRACGP

Objective: To examine relations between consultation length and content, and general practitioner choice of claiming level B or C when billing consultations > 20 minutes through Medicare.Design and setting: A secondary analysis from a cross-sectional national general practice survey (1 April 2000 to 31 March 2003) of 101 112 consultations with 2811 GPs, comparing level B consultations ≤ 20 minutes with consultations > 20 minutes (claimed as level B or C), and consultations > 20 minutes claimed as level C with those claimed as level B.Main outcome measures: Consultation length, encounter, patient characteristics; number, type of problems managed; type and frequency of treatments provided in relation to consultation level charged.Results: There were 80 476 level B consultations ≤ 20 minutes and 14 893 > 20 minutes claimed as level B or C (5725 [38.4%] level B; 9168 [61.5%] level C). Longer level B+C consultations differed from shorter level B consultations in patient sex, Department of Veterans’ Affairs card status, and new-patient status, and involved more reasons for encounter, problems managed, chronic problems, clinical treatments, therapeutic procedures, referrals and pathology and imaging orders. Longer consultations claimed as level C were significantly longer (0.9 minutes) than those claimed as level B and involved more reasons for encounter, problems managed (particularly new, chronic, psychosocial and gynaecological) and more clinical treatments.Conclusions: Patient characteristics and consultation content differ at longer consultations. Consultations charged as level C are more complex than those charged as level B. GPs use both time and content when choosing item number, rather than relying only on specified time thresholds. This has implications for future restructuring of MBS attendance items.

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

How general practice is funded in New Zealand depends upon an answer to the question “This week or next?”! General practice, and primary healthcare generally, is currently undergoing a revolution greater than anything since the early 1940s, when government funding of general practitioners was introduced. GPs then successfully argued for the “sacred” right to charge a fee commensurate with their services, making them unique compared with similar countries, including Australia. Substantial patient copayments resulted, rising at times to more than 80% of practice income. In the early 1990s, the government introduced a “community services card” (CSC) for people on below-average incomes. Currently, the threshold for this is NZ$21 913 for a single person and NZ$31 225 for a married couple, and rises with number of children. The CSC entitles holders to higher subsidies, including for prescriptions, but the quid pro quo was the removal of all government subsidies for adults on above-average incomes, including the elderly. However, the government proportion of GP funding remained low, averaging about 30% of practice income.1 With this underfunding, many GPs became Robin Hoods, charging minimal or no fees to patients who could not afford to pay, with some compensation from their well-off patients. Many (understandably) located themselves in more affluent areas.1 Hence, central Aucklanders have 800–900 population per GP, whereas more disadvantaged populations have almost twice as many people per GP.2 Of course, the Robin Hood system did not work for practices serving predominantly poorer and disadvantaged (including rural, Mäori and Pacific Islander) populations. Radical organisational reforms in 19933,4 encouraged GP leaders to voluntarily form independent practitioner associations. Similar to Australian Divisions of General Practice, these primary care organisations (PCOs) rapidly expanded to include 85% of GPs by the end of the 1990s. PCOs took on the financial management of pharmaceutical and pathology services to improve quality use.1,3-5 Savings from this were used to promote other services, such as vaccination, smoking-cessation programs, chronic disease management and terminal-care services. They were also used to remunerate GPs and associated services (eg, free nursing and radiology services for community-based alternatives to hospital admission). This was never called fundholding, the term for a scheme implemented, then abandoned, in the United Kingdom. The real revolution began in 2000, with the New Zealand Public Health and Disability Act. This established 21 decentralised and population-based district health boards (DHBs) providing public hospital services and managing government funding of all health and disability services, including primary healthcare. In 2001, a new government primary healthcare strategy launched the evolution of PCOs into broader primary health organisations (PHOs).6 These are needs funded and serve defined populations enrolled in member GP practices. They provide population healthcare as well as treatment services, involve communities in their governance, and are multidisciplinary. GP membership is voluntary. This strategy is supported by the New Zealand Medical Association and the Royal New Zealand College of General Practitioners, but there is ongoing criticism over the implementation process. Two forms of PHOs have been established, the first (Access PHOs) serving disadvantaged populations. The remainder are called Interim PHOs, in the expectation that Access funding will eventually apply to all PHOs. An alternative strategy, Care Plus, is being launched to fund the needs of individual high users. The different levels of funding are shown in Box 1. Disadvantages of the current systemThe additional funding still covers less than half of the cost of running a general practice. More has been promised after 2005 by the Health Minister, “subject to the availability of funding”. A particular issue is the inequity between the two forms of PHOs, with funding being based upon the level of disadvantage of the enrolled population rather than individual need. Hence, poorer patients in Interim PHOs remain disadvantaged. The Care Plus strategy is an attempt to rectify this. From late 2004, PHOs will be required to manage equitably funded budgets for pharmaceutical and pathology services, commonly called “referred services”,7 in a more formal process than PCOs used. There is clear evidence of serious inequities in current referred-services expenditure.2 This will mean significant shifts of expenditure from practices, PHOs and DHBs serving well-off populations to those below equity, but the funding distribution may be vital to improving the health of the disadvantaged. Relevance to AustraliaIs this relevant to the future of Australian general practice? Almost certainly, given the recommendations of the 2003 Review of Divisions.8 A comparison of primary care in both countries (Box 2) suggests that New Zealand is some 10 years ahead,9 with a more integrated and influential primary healthcare service. Although the organisational upheavals and additional paperwork have been traumatic for many GPs, the prospects of improved care and better outcomes for patients and communities, while yet to be proven, appear to be good. 1 General practice funding in New Zealand, by type of organisation to which GPs belong Non-PHO organisation and individual GPs Access PHOs serving high-need patients Interim PHOs serving other populations Current and expected GP membership 20%–25%, diminishing rapidly 20%–25%, increasing 50%–55%, increasing Current government subsidy for GP (includes practice nurse at $1.70 per consultation) Fee-for-service claims $0–$35 Capitation payments for enrolled population Average $13 per consultation Average $24 per consultation Average $15 per consultation ACC subsidy per consultation* $2.00 $2.00 $2.00 Patient copayment† $0–$45 $0–$20 $0–$45, and reducing Special funding groups Extra funding for low-income and high-need patients Aged under 6 years, $35 per consultation; aged 6–17 years and high users, and (from 1 July) aged over 65 years, $26 per consultation Expected subsidy trends over next few years Expected to diminish to insignificance over next year All to be based on Access formula To become equivalent to Access PHOs over time ACC = Accident Compensation Corporation. PHO = primary health organisation. * ACC funding for treatment of injuries is paid as fee for service, averaging $2 per consultation, or $30 for all consultations. † Patient copayment is paid as fee for service. 2 Features of New Zealand primary health organisations contrasted with Australian Divisions of General Practice Feature Australia New Zealand Organisation Divisions of General Practice Variable, but primary care organisations forming into PHOs Roles Largely GP focused Broad primary health/population focus, multidisciplinary, strong community participation Membership of organisation Based on geographic location Chosen by practice from local options Health services funding Fragmented between federal and state levels Fully integrated through district health boards Government payment/subsidy for services Open-ended fee for service. AMA strongly opposes capitation Rapid progress towards universal capitation Patient copayment Small but increasing Large but decreasing Organisational accountability for primary-care-related expenditure (eg pharmaceuticals) No direct financial accountability and resisted by AMA Well accepted. Expenditure to be in PHO budgets Ability to shift resources (including savings) from low- to high-priority services Nil. No referred-services budgets and hence no incentives or ability to make savings Substantial. Expected to increase with global budgets for PHOs Models of service integration, including primary/secondary Limited to selected high-risk diseases and local initiatives Wide-ranging developments (eg, community alternatives to acute hospital admission) Relative power balance between primary and secondary care Hospitals in a much stronger position than primary care Improving balance through government policy and DHB and PHO collaboration Quality improvements in primary care Largely “top down” and through local initiatives Major improvements driven by clinical leadership AMA = Australian Medical Association. DHB = District health board. PHO = Primary health organisation.

Laurence A Malcolm MD, FRCPE, FFPHM

The National Health Service (NHS) has undergone fundamental reform since 1948, but the fabric of UK general practice remains more or less intact. Fundholding was probably the most significant change in financial arrangements (Box). Essentially, this was an experiment for the NHS to contain costs, stimulate competition and bring resource allocation decisions closer to the patient — fundholding general practitioners assumed significant roles in local healthcare economies. Nevertheless, there was much debate over whether it was equitable. Many saw it as a basis for partnerships with the private sector and fragmentation of the healthcare service.1 Others showed that it reduced non-emergency medical admissions.2 Fundholding grew from the Thatcher government’s strongly held belief that markets are the best way to achieve efficiency in healthcare. At the same time, fundholding established general practice as the cornerstone of the NHS.3 Further, it brought a questioning of the “status quo” in the NHS, and the prospect of higher standards of care. These expectations remain in the eyes of the public, government and the profession. Reforms aside, under “standard” contracts, UK general practitioners have been rewarded for increasing patient list size, and for providing specific services to achieve target payments. Unlike in Australia, there is no incentive to overservice, but an incentive to limit the availability of appointments, and pressure to keep appointment times to a minimum. Interestingly, salaried GPs in the personal medical services pilots (Box) have similar productivity without affecting other GP behaviours or quality of care.4 The new contractThe new GP contract, operative from April 2004, brings more funding, fundamental structural change, greater regulation and performance monitoring. There are concerns that many of the quality targets (eg, the incentive to diagnose, investigate and treat hypertension) have not been adequately costed.5 Further, this new environment has a strong emphasis on performance management and holding doctors to account. Some people see this as an erosion of public trust in the medical profession, which could undermine doctor–patient relationships; others see it as an essential mechanism of delivering proven, cost-effective care. For patients, NHS general practice is well integrated with the wider health service, and gives access to a multidisciplinary primary care team, including health visitors and practice nurses. On the downside, a non-competitive system means there are not the same incentives to attract patients as exist in Australia’s fee-for-service environment, and there is a culture of demand management, which often takes precedence over making services attractive and convenient to patients. In many ways, the NHS places GPs at the centre of the healthcare service and gives one a sense of being part of a team, with less of the fragmentation and isolation that often exists in Australian general practice. Whether the new GP contract will improve experiences and outcomes for patients, at a cost the NHS can afford, remains to be seen. On the downside, many GPs believe the wider healthcare service has not been able to accommodate the needs of patients in recent years; this may, despite the best efforts of individual primary care teams, lead to a demoralised workforce. Towards the end of New Labour’s second term, the NHS is being pulled in several directions — involving performance management, quality payments, new contracts, and greater engagement with the private sector, including American managed care organisations. The competition and “constructive dissonance” of these changes is very reminiscent of the Thatcher reforms. How general practice will fare in this turbulent environment is unpredictable, but no doubt being a GP or a patient in the NHS will be a very different experience in 2010. How it works Most UK general practitioners are independent contractors with the National Health Service. They own their own premises, hire their own staff, and supply general medical services. Remuneration is based mainly on capitation (ie, a payment dependent upon list size), supplemented by fees for certain specific services (eg, maternity care) and for achieving certain “target” levels of service (a complex system, although it only involves childhood vaccination and cervical cytology). Payments are also made for seniority and postgraduate education activities. Alternatives: the NHS (Primary Care) Act of 1997 allowed GPs to provide “personal medical services” (PMS) on a salaried basis through local service contracts that are designed to meet the particular needs of the locality. More than 35% of GPs are now salaried. Fundholding was a system of general practice purchasing services from secondary care. It operated between 1991 and 1999. Fundholding practices were given greater autonomy over aspects of practice expenditure such as drugs, diagnostic testing and staffing (within defined budgets), and could “shop around” for the best deal on procedures such as hip replacement. A further initiative, “total purchasing”, allowed practices to purchase a wider range of services from both primary and secondary care — for example, community nursing. Primary care trusts were established in 1997 (they began as primary care groups; in England, these became trusts in 2002, but have taken different forms in Scotland, Wales and Northern Ireland). Individual practices were replaced as purchasers by regional organisations, which could assess and plan for local needs. A new GP contract took effect in April 2004, with GP payments more closely linked to “quality targets” for both clinical and organisational activity. This has been coupled with increased funding and structural change — for example, GPs are no longer obliged to provide out-of-hours services, and the contract is with whole practices rather than individual GPs.

David P Weller FRACGP, MPH, PhD · Alan Maynard DSc, FAMS, MFPHM

The strength of Dutch healthcare is that the general practitioner’s role is enshrined in the primary care structure and the personal listing of patients (Box).1,2 Primary care is delivered through a personal working relationship with the patient over time and the payment system reinforces this to some extent. Capitation fee payment encourages delivery of care that is tailored to individual needs, rewarding powerful primary care strategies such as “watchful waiting” and the follow-up of the natural course of signs and symptoms.3 It takes considerations of financial reward out of the consultation. The profession of general practice considers the capitation fee payment as the prevailing frame of reference on which professional standards of care are based. Healthcare policymakers’ attempts to change capitation payment are usually resisted by the profession. Although private insurance and fee-for-service might theoretically invoke different professional behaviour, in practice there are few differences in the care received by privately insured patients and that received by those who are Sickfund-insured. In general, GPs do not like fee-for-service payment, because it does not acknowledge strategies such as “masterly inactivity”.3 Over the years, Dutch GPs have been jealously protecting capitation payment and tried to exclude any financial biases that might affect their performance. Allowances in the actual money received have been made for the number of elderly and migrants on the practice list, compensating for the extra burden of illness and GP care needed. This has maintained relatively equal status among Dutch practices and helped to strengthen the corporate identity of GPs. The most recent proposal by the Minister of Health to change healthcare financing aims to introduce a form of patient copayment for healthcare received, at 25% of GP costs for consultations, and more for secondary care. The objective is to encourage patients to take more responsibility for their own health and consult less often. This proposal is still in its early stage of political decision making, and it remains to be seen if it will be introduced. If it is, it will be interesting to see whether this financial approach rewards valued primary care approaches such as watchful waiting. An alternative form of payment that has developed in recent years is GPs in the salaried service of colleague GPs. Although there has been a long tradition of locum services by young GPs before selecting a practice of their own, more GPs now seem to prefer salaried employment. This indicates dissatisfaction with the combined role of both practitioner and practice manager. As a consequence, practice has to be reorganised to make it more attractive for younger GPs, and salaried employment may become more prominent. Disadvantages of the systemThe trend towards salaried GPs highlights an obvious disadvantage of capitation fee payment, which covers practice costs and GPs’ income at the same time, without conditions attached. For example, the fee covers a full-time-equivalent practice assistant for a standard practice, irrespective of actual hours of employment. Thus, general practice was poorly prepared for the rapid increase in female GPs, who prefer part-time, salaried positions to full-time, private contractor status. The need for general practice to accommodate this change, together with the additional resources needed to train more part-time GPs, is one of the factors leading to increased GP costs. Another disadvantage is that new developments in medicine have to be included in the package covered by the capitation fee. As a consequence, there are few (financial) incentives for GPs and practices to innovate their care. This has particularly affected proactive aspects of care such as illness prevention and high risk screening, and investment in practice support (such as practice assistants and nurses; providing technical equipment). The package of care that the capitation fee should cover is critical. This should be based on the effectiveness of diagnostic and therapeutic interventions. In reality, the package has to flow with the political and economic tides. For a long time, the level of the capitation fee was fixed, irrespective of the patient’s health status. In recent years, the fee has been increased for certain groups (eg, the elderly), becoming an indirect incentive to provide more proactive services (such as preventive home visits) for these groups. However, this is as far as the system has come in enhancing the capitation principle with financial stimuli. ConclusionGiven the lack of financial incentives, it is surprising how strong general practice care is. For a long time, hospital specialists were paid on an item-for-service basis, in conjunction with GPs’ capitation fee. Yet, although this payment system did reward the transfer of patients to secondary care, rates of GP prescribing and referral in The Netherlands were among the lowest internationally.1,4 Furthermore, more than 80% of Dutch practices are computerised in the absence of direct financial support.5 This may indicate that the payment system is not the sole determinant of GP performance, and that corporate identity and healthcare structure may also play a vital role. How it works General practitioner payment is based on a two-tiered system depending on patients’ income: Capitation fee for Sickfund-insured patients (70% lowest income; in 2004, up to €32 600/year for people younger than 65 years. As the insurance includes the period after retirement (“pensioners”), the cut-off income for people 65 years and older is €20 750/year. Fee-for-service payment by the 30% highest-income privately insured patients, who do not contribute to the Sickfund. Capitation fee is the payment a GP receives from the Sickfund for each patient on the practice list, regardless of whether the patient decides to consult the GP. Sickfunds pay the capitation fee out of the insurance contribution received from their insured members. This fee fully covers all GP services for that patient, including the GP’s income and a proportionate contribution for practice costs. The capitation fee is extended to family members who do not generate income of their own. Employee and employer pay 8% of the income for Sickfund contribution (1.25% by the employee, 6.75% by the employer). There is no direct government involvement. Key to access to general practice care is registration of the patient with the GP or practice, establishing continuity of care over time. For Sickfund-insured patients, registration is obligatory for access to care. For privately insured patients, registration is usually not required, but most patients do list with a practice and obtain care from the same GP or practice over time. Through registration with a GP, primary care remains the foundation of healthcare: patients receive their basic medical care through the GP and the primary care team, and specialist care is only available through referral by the GP.

Chris Van Weel PhD, FRCGP