General medicine

Family physicians (FPs) in Canada undergo specialised training, often in a Family Medicine Residency, and complete the College of Family Physicians of Canada (CFPC) national certification examination. Their payment is negotiated and administered separately by the 10 provincial governments and three territorial governments, using different funding arrangements in different settings. Under the Canada Health Act, provinces will be financially penalised if they permit private billing by physicians or copayments by provincially insured patients other than for certain services funded by third parties, such as insurance medical examinations, reports and travel services. In 2001, FPs reported practising in private offices/clinics (73.1%), community health centres (7.1%), emergency departments (6.7%), hospital in-patient units (3.3%), walk-in clinics (3.1%), and family medicine teaching units (2.5%).1 National surveys confirm that fee-for-service continues to be the main form of remuneration for physician services (Box), with little apparent change between 1997 and 2001.1 The drive towards alternative payment methodsUnder the current healthcare system, 12% of Canadians (with considerable geographical variation) report having unmet healthcare needs.2 Millions do not have access to an FP, and emergency department waiting times are long. FPs have identified high levels of dissatisfaction with current workloads and working conditions.1 Governments appear to believe that alternative funding arrangements will address these problems and are the key to involving FPs in primary healthcare reforms.2,3 Alternative payment approaches combine fee-for-service, capitation (lump sum payment per patient managed over a given period), salary, sessional and other funding arrangements.4 Other, less common funding arrangements include block funding and service agreements. In block funding, annual budgets are negotiated for a group of physicians, usually associated with an academic medical centre. Service agreements are often used to recruit and retain physicians in rural areas and take the form of: funding to regional boards for clinical services under arrangements by which boards have discretion regarding specific uses of the funds; contractual payments; and payment arrangements that incorporate both alternative remuneration and fee-for-service. Both the Canadian Medical Association and the CFPC advocate that all FPs should be able to choose the practice model that best meets their patients’, their co-workers’ and their own needs.5 In Canada’s largest province, Ontario, both the Ontario College of Family Physicians and the Ontario Medical Association (OMA) support FPs working in practice networks (Family Health Networks) funded through a blended payment model (which combines different methods), but recommend physicians have a choice. The remuneration model for Family Health Networks (FHN) preferred by the Ontario Ministry of Health is based on: a capitated rate for all registered patients; fee-for-service payments at a rate of 10% of the provincial schedule for most services; bonuses for targeted preventive care (theoretically up to C$8800/FP); payment for taking new patients; continuing medical education allowances; practice management fees; and some access to nurse practitioners paid by the government. This model encompasses on-call arrangements 24 hours a day, 7 days a week, and evening and weekend clinic access. Working in such networks with blended capitation payment is thought to provide incentives for promoting preventive healthcare and chronic disease management, and to improve professional satisfaction.1 However, uptake of the FHN model has been slow, prompting the Ontario government, in conjunction with the OMA, to introduce a simpler model, the Family Health Group. This model, based on virtual patient populations (either from the ministry health insurance database or patient registration), is paid on a fee-for-service model, with requirements to provide on-call arrangements 24 hours a day, 7 days a week, and after-hours clinic access. The Primary Health Care Transition Fund3 policy to shift physicians to a blended capitation model aims to improve access to care, quality, integration, health outcomes and cost-effectiveness. There is a strong desire that the most appropriate (least expensive) person deliver the service to the patient, invoking passionate debate about whether this means substituting for or supplementing FPs. The current policy position is that a collaboration of FPs with nurse practitioners, pharmacists and other professionals is more feasible with blended and capitation models than with the current fee-for-service arrangements. However, it is yet to be seen if blended payments and new models, with their additional administrative burdens on the FP and the practice, will add costs to the healthcare payer or improve health outcomes. Remuneration* among Canadian family physicians, 20011 Physicians receiving remuneration type† Mean (SD) proportion of total income accounted for by remuneration type Fee-for-service 23 070 (90.8%) 85.4% (24.9) Salary 3 775 (15.0%) 50.5% (37.4) Sessional 8 171 (32.5%) 35.0% (33.7) Capitation 469 (1.9%) 69.9% (31.0) Other 4 567 (18.2%) 14.1% (20.9) * Remuneration for clinical services other than on-call services. Based on a census survey of Canadian family doctors (n = 13 088) weighted to estimate the total population of Canadian family doctors. † The combined percentage may exceed 100% as some respondents checked off more than one answer.

Carmel M Martin PhD, MSc, FRACGP · William E Hogg MD, MClSc, FCFP

Underperformance of the healthcare system at great expense is the situation in the United States. The results are great inequity, problems with access, missed opportunities for prevention, fragmented rather than integrated care, relatively poor chronic disease care, and high expenses without commensurate improvements in health as compared with what would be expected from a well-functioning primary care system.1 Indeed, “. . . the need to manage escalating health care costs while maintaining reasonable access to care is becoming the salient challenge in US health care policy”.2 The diversity of healthcare arrangements in the US precludes a single, reliable answer as to how family physicians are paid. However, using national reports,3 including surveys done by the American Academy of Family Physicians,4 a generally accurate idea of “how it works” in the United States can be derived (Box). It is stunning how much is spent to accomplish occasionally spectacular results for some, but overall so little, for so few. Family physicians are not satisfied with the results of current payment arrangements in the US, as they undervalue family medicine and primary care in general; too often family physicians are unable to provide the care they think their patients need.5 Through research and deliberations by their national organisations, family physicians have concluded that, without significant changes in both the way they practise and the way family medicine is financed, family medicine in the US will probably become untenable in 10–20 years.6 In aggregate, the current payment systems are believed to contribute to a deterioration of primary care, with market forces rewarding commodity production and use of technology, while punishing sustaining relationships, listening to people, and sorting out and responding to troubles that may or may not be amenable to technological medical care. The solutionsFee-for-service payments alone are not sufficient, as this approach rewards doing more, not necessarily doing best. Capitation is no panacea, because it is subject to rewarding underservicing and may deter care for the sickest patients unless payments are adjusted for greater need. Paying for performance (outcomes) is intuitively attractive, but subject to factors well beyond the control of individual clinicians, or even, in many instances, an entire practice. A system of payment that blends these different approaches to capture their respective strengths while minimising their weaknesses is conceptually attractive, but difficult to define and implement. Such a blended system would presumably be based on capitation adjusted for population characteristics, additional premium payments based on services provided, and incentives based on achieving particular policy objectives.6 Currently, in the US, calls for a new model of family medicine, with a robust “basket” of services and the intelligence and performance attainable through information technology, have created an urgent sense that payment reform is necessary. A classic “chicken-and-egg” problem exists — the new model is not feasible until there is payment reform, and payment reform is not realistic without demonstrated improvements inherent in the fully implemented new model. Fortunately, both public and private payers recognise that steps need to be taken to assure entry to timely healthcare, health promotion, disease prevention, and care of chronic conditions.7-13 As a spokesperson for the US Medicare program (which provides health insurance for people aged 65 and older) noted at a recent policy forum in Washington, DC: “With very little friction, we will probably approve expenditures in the billions of dollars for biventricular pacing, yet we still don’t know how to pay for someone to have their own doctor.”14 A task force chartered by the Future of Family Medicine collaborative project is now at work, estimating the full cost of the proposed new model of family medicine and the amount and sources of revenues necessary to cover its cost and leave a margin sufficient to pay family physicians fairly and competitively. As concluded at the Keystone III Conference in 2000, family medicine in the US needs to spend less time justifying itself and more time acquiring the practical means to achieve its objectives.15 Indeed, another time to revise family medicine in the US is at hand — this begs for reform in how family physicians are paid. How it works (or not!) * Based on 35 965 respondents to American Academy of Family Physicians Survey.4 † Medicare is a federally funded national insurance program for people ≥ 65 years. ‡ Medicaid is a state-based insurance program (with federal and state funding) for people on low incomes. § Based on 32 321 respondents to American Academy of Family Physicians Survey.4

Larry A Green MD

H Stuart Patterson’s life was one of extraordinary achievement. He had a distinguished record of service to medicine, in war and peacetime, and to the community. Stuart was born on 17 September 1911 in Aramac, central western Queensland, where his father was the Medical Superintendent. He was educated at Ipswich Grammar School, where he described his academic achievements as “pretty undistinguished”. He did, however, excel at sport, playing cricket in the First Eleven and representing the school in tennis. Stuart began his medical studies at the University of Sydney in 1931, but in 1933 went to Scotland and enrolled at the University of Edinburgh, where he graduated in 1937. He also captained the Edinburgh University cricket First Eleven. He completed an internship at the Edinburgh Royal Infirmary and the Hospital for Sick Children. On his return to Australia just before the outbreak of World War II, he worked for a short period at the Brisbane General Hospital. Then, in 1940, he joined his father in general practice in Ipswich, where he remained for 35 years (apart from a period of war service as a Captain in the Royal Australian Army Medical Corps). In 1975, he moved to the Sunshine Coast, where he practised for a further 11 years. Stuart was a Foundation Member of the Royal College of General Practitioners (1953) and co-founder of the Royal Australian College of General Practitioners (RACGP) (1954), and served on their councils for 5 years and 20 years, respectively. He was elected to Fellowship and Life Membership of each college, and was awarded the prestigious Rose–Hunt Medal by the RACGP in 1981 for outstanding service in promoting the objectives of the College. He was President of the RACGP from 1961 to 1963. Stuart served as a Councillor on the Queensland Branch Council of the British Medical Association (later the Australian Medical Association [AMA]) from 1948 to 1968, and was President of the Branch from 1954 to 1955. He was elected to Fellowship of the AMA in 1970 (and later awarded an honorary life membership), and received the Citation of the Queensland Branch in 1990. Stuart was also a Foundation Member of the Paediatric Association of Queensland (1949) and worked as a Visiting Paediatrician at Brisbane’s Mater Children’s Hospital (1949–1961) and the Ipswich General Hospital (1961–1975). He served as a member of the Order of St John of Jerusalem for 22 years, and was an active Rotarian. He was named Paul Harris Fellow in 1986 for exceptional services to the Rotary Foundation and was made a Member of the Order of Australia in 1994 for outstanding and meritorious service to medicine and the community. He was a member of the Queensland Cricket Club, Queensland Rugby Club, Senior Golfers Society, Caledonian Society and the National Trust. Stuart had several papers published and wrote two books: The ordinary doctor (1990) and Friends of the ordinary doctor (1994). Those who knew him will agree with me that his self-appointed description of “the ordinary doctor” does not do justice to this remarkable man. He was no ordinary doctor, nor was he ordinary in any other sense. Stuart died in Ipswich on 15 May 2004, and is survived by two sons and three daughters. John A Comerford

John A Comerford

It was towards the end of 1963 — my final year of medical school at the University of Melbourne — when I read about the new contraceptive method in the Medical Journal of Australia. On our last day, after the Professor of Obstetrics and Gynaecology bade us farewell, I ran after him and asked: “Professor Townsend, what do you think about the Pill?” “It’s good stuff,’’ he replied, with a smile and a wink. And so I began my career just as the sexual revolution was poised to change society forever. One of my first patients was a migrant from Eastern Europe, who was raising two children as a single mother in the days before the safety net of generous social security benefits. She performed her own abortion with a knitting needle when I could not find a doctor to do it for her. But, as the years went by, struggling women and blushing teenagers came to me instead for “Anovlar”. Gradually, the unwanted pregnancy became less common, and so, thankfully, did the do-it-yourself abortion. In 1963 there were few female GPs. Indeed, some patients never came into contact with a female doctor. Once a 3-year-old child of one of my patients, staring with a puzzled look as I examined his mother, asked in Hungarian: “Mummy, is this lady a gentleman?”. Our family practice was situated in Elwood, a suburb that was then a bit “rough around the edges”. The practice started in a flat, with the living room serving as the waiting area. This arrangement did not worry our fellow compatriots and the other colourful immigrants of various religious and ethnic backgrounds who streamed through the doors. And Australian women came from all over Melbourne to see a female doctor for their “women’s problems”. Gifts of paintings, flowers, handcrafts, boxes of chocolates, and silver plates engraved with messages of gratitude all adorned our home. Every year I still receive a Christmas present from an Italian family I stopped treating long ago. We worked 6 days a week and attended emergency calls each night. There was no time to stop and smell the roses; I noted the changing seasons by the reappearance of patients with chronic peptic ulcers in the spring and autumn. What a difference the first histamine H2-receptor antagonist made! Not to mention proton-pump inhibitors. I often think about the patients who suffered penetrated, perforated or bleeding ulcers before the advent of these drugs. I can recall more recent cases too, but most of these were iatrogenic, as a result of taking non-steroidal anti-inflammatory drugs (NSAIDs). When I started practice, phenylbutazone was the only anti-inflammatory drug available, and I’ll never forget the life-threatening Stevens–Johnson syndrome that it caused in one of my patients. It was a relief when indomethacin and the other NSAIDs, and later still the COX-2 inhibitors, came along as alternatives. The way we viewed and treated cardiovascular disease changed over the years. In the early days our waiting room was awash with ashtrays. We doctors sometimes even smoked with our patients! We also knew all about the links between cholesterol and heart disease, but didn’t take it too seriously, as there were no effective cholesterol-lowering drugs. I remember attending patients with suspected acute coronary occlusions in the surgery, in their homes, on the street, and on garage floors. They were common occurrences, and neither ambulances nor hospitals had coronary care facilities or units. Still, I clearly remember saving the lives of two patients by rushing them to hospital and arriving just minutes before they had a cardiac arrest. The treatment for hypertension was straightforward and simple compared with the choices we have now. We used mainly Aldomet and chlorothiazide; our aim was a blood pressure of 140/90 mmHg, although 150–170/90–95 mmHg didn’t alarm us. In the elderly, high systolic pressure was generally not treated if the diastolic pressure was normal. In those days, near enough was good enough. The new and effective cardiovascular drugs came slowly, and a few decades later we began to notice that our patients were living longer and not succumbing to early heart attacks and strokes. I often think with great sadness of the friends and patients who died at that time, but might have been saved with better medications or bypass surgery. I still remember the suffering of patients with severe chronic asthma that I couldn’t adequately treat. All we had was ephedrine and phenobarbitone, combined with aminophylline or theophylline. We used adrenaline in emergencies, and also had prednisolone, but did not know how to use it safely. No wonder we embraced the first salbutamol and steroid inhalation devices, and later the individual asthma management plans, so enthusiastically! In the late 1960s, I saw a one-year-old baby with a minor complaint. To my horror, the next patient was an 8-year-old with a high temperature, cough and Koplik spots. I feared for the baby, who would surely catch measles from the 8-year-old. I knew the incubation period for measles was 2 weeks, but remembered reading about a new vaccine that gave protection within a week. I urged my pharmacist to try to obtain the vaccine for me, as it was not yet readily available. Luckily, it arrived and was given to the baby the same night. He never developed measles! I probably overprescribed antibiotics for many years, especially penicillin, but I am proud that no child in my practice ended up with damaged eardrums, rheumatic fever, nephritis or chronic chest infection, and I can’t remember many tonsillectomies either. On the other hand, a lot of patients developed thrush. I remember using antiviral drugs for the first time — to treat herpes zoster and a severe case of genital herpes — and dreading the side effects that, in fact, never came. We used barbiturates freely for anxiety, nervousness and sleeplessness. The 30 mg amylobarbitone (Amytal) was even more popular than Valium is today. The 200 mg dose Sodium Amytal was a good hypnotic — and a common cause of successful suicide! One of my patients took all 25 capsules, never to wake again. By contrast, not so long ago, one of my young patients reported downing 25 Mogadon tablets at once. “What happened?” I asked. “I woke up 2 days later,” she replied. “How did you feel?” “Very hungry!” No wonder, given their obvious safety (although, of course, it’s no excuse), we overprescribed the benzodiazepines. It is still an ongoing problem. The introduction of ultrasound, computed tomography scanning and endoscopy, and the new, less invasive surgical procedures, had a revolutionary effect. I remember the first of my patients who braved a laparoscopic cholecystectomy when it was still a very new procedure. Both of us were pleased with the outcome. Substance misuse, especially drug addiction, was always a problem in the Elwood area, and sadly remains so. The relationship between user and doctor was mutually unsatisfactory. The addict failed me by lying, cheating and stealing. They came not for help, but for drugs. I, in turn, failed them, because I refused to supply the drugs they craved. Even little things like disposable syringes, office pregnancy tests and one-drop blood sugar testers represented a great leap forward. Later still came the mobile phone and the computer, and no more arriving home only to be immediately called out again, and no more misplaced reports. Medicare deserves a whole chapter. For my practice, it meant I could order pathology or radiology services for pensioners, who previously had to attend public hospitals for these services. Sometimes, very poor patients were given free treatment, and this dilemma was also solved by bulk-billing. As the years flew by we had to learn about new diseases and their social impact, such as chronic fatigue syndrome, and new infectious diseases — AIDS, hepatitis B and C and, most recently, SARS. And diseases that were once less prevalent, such as type 2 diabetes mellitus and breast and prostate cancers, now became more common. As people ate more and exercised less, obesity reached epidemic proportions. Sleeping with multiple partners increased the prevalence of genital herpes. When I first started, choosing specialists was easy. Today, it is a matter of matching the right specialist to the right condition, as specialists themselves are now increasingly specialised. You have to know which orthopaedic surgeon is experienced at hip replacements, and which gynaecologist treats stress incontinence. But along with the new advances came the demise of the “old-style” doctor, devoted to treating several generations of the same family — the doctor who does home calls and has patients whom he or she has seen for 40 years or more. Now, fewer and fewer doctors are willing to do house calls, while the public expects service from early morning to late at night and during weekends, something no single doctor can provide. Doctors, whose only duty was to look after their patients, now spend a lot of time and money protecting themselves from potential litigation. With these pressures, I too eventually joined a mega-clinic with efficient, up-to-date, accredited services. The patient care is excellent, but also less personal. And while we look to evidence-based medicine, the public spends more and more money on poorly regulated and sometimes harmful “natural” therapies. So, how would a wish-list of a doctor nearing the end of her working life read? What do I want that we still haven’t got? Try this: a simple, non-invasive test for detecting colon carcinoma; clearer guidelines about when and how to investigate patients with high erythrocyte sedimentation rates and high C-reactive protein levels; still safer NSAIDs; guidance on when to stop postponing death and begin palliative care; a clever device for testing blood sugar that would administer insulin automatically; more places for taking long walks safely in our suburbs and towns; a society in which families take more responsibility for their elderly relatives; baby-friendly workplaces; and less violence in films, videos, computer games and, of course, in life itself. Yes, general practice has “all changed, changed utterly”*. *Easter 1916 — William Butler Yeats

Eva Szego MB BS

Reducing error is an ongoing process, always in need of fine-tuning A crucial challenge in efforts to prevent or reduce the occurrence of medical error is obtaining information about the diverse types of medical mishaps. “Mishap” is a useful term — it is neutral and broad enough to encompass the wide range of things that can go wrong in clinical practice. The types of medical mishaps include the “near-miss”, the “incorrect procedure or treatment which does not harm the patient”, the “adverse event” (either anticipated or unanticipated), and, finally, the “sentinel event” (a blatant error, such as a blood transfusion error). All these forms of mishap have the potential to provide important information to help minimise or prevent patient harm and enhance standards of medical practice. The need for a flow of information far outweighs fingerpointing There are arguments about the definitions of medical error, and my assertion — that lessons can be learned from all forms of medical mishap — deliberately cuts a broad swath. Close examination of each of these types of mishap provides different learning opportunities. Near-misses, or errors that cause no harm, can trigger a re-evaluation of correct procedures to prevent these events; Adverse events, both “anticipated” and “unanticipated”, can help clinicians develop more rigorous thinking about evidence and standards; and Sentinel events can show how the protective systems put in place can be breached. Collecting extensive information in all these mishap categories not only leads to interventions to minimise and prevent harm, but also allows detection of patterns of error. For example, if an inordinate number of errors occur during night shifts, or when the change of shift occurs, organisational changes may be required. Information about mishaps also provides material for teaching medical students, residents and community practitioners, with the aim of preventing future errors. If the information prevents errors then there will be impressive cost savings for hospitals and healthcare systems, as well as for patients and their families.1 Finally, information about errors and patterns of errors forearms clinicians to avoid patient injury, thus reducing the stress involved in suspecting or knowing their actions may have caused harm. But there remains an ongoing impediment: can healthcare data systems provide timely information for risk management and reducing medical mishaps? In the book Medical mishaps. Pieces of the puzzle contributors from several countries identified “multiple overlapping and faulty mechanisms for the revelation, investigation and mitigation of errors”. There was “clearly considerable scope for greater collaboration, integration and coordination”.2 And the situation in Australia appears to be no exception. One of the key priorities of the Australian Council for Safety and Quality in Health Care (ACSQHC) is enhancing processes for measuring local quality improvement and aggregate-level reporting of performance and outcomes.3 A report in this issue of the Journal by Kingston and colleagues (page 36)4 explores the attitudes of the two main health-professional protagonists involved in reporting medical error. It analyses the differential use of incident reporting by doctors and nurses, and attributes this to the different cultures of the two professions. This finding has been well substantiated. Nurses work in a culture that responds to directives, including the directive to report incidents; doctors work in a culture that values intragroup action and professional–cultural definitions of error or mistake.5 Other, systems factors also influence the decision to report incidents: time constraints, dissatisfaction with the process, inadequate feedback, and failure to value the process.5 In addition, there may be confusion about what should be reported, feelings of fear of retribution and doubts about the possibility of remediation. Finally, what are the views of healthcare consumers? In a study published in the 7 June issue of the Journal,6 a random sample of Australians supported vigorous reporting of errors, and 68% of those surveyed also wanted disclosure of the identity of the healthcare worker involved. While this is understandable, it shows the need to educate the public about the importance of a “no-blame” culture to ensure that reports will be made in the first place. The need for a flow of information far outweighs fingerpointing. Clinicians want error reduction, and favour anonymity. Patients and the public want error reduction and are likely to accept anonymity in the name of this goal. The ACSQHC supports the principle of “no blame”, and has recently published a document Open disclosure standard: a national standard for open communication in public and private hospitals, following an adverse event in health care. This provides clear guidelines for patients, healthcare professionals and organisations confronting and dealing with medical error, and the legal issues attending such events. Its major message is an open, blame-free culture.7 Despite the human and systems factors impeding reporting of medical error, many of these can be overcome by adequate incident-reporting systems. These have the following characteristics:8 they are anonymous and easy to use (computerised); they acknowledge receipt of a report and confirm that it is being investigated; they report back the results of the investigation in a timely manner; they use the information for programs of reduction; they provide feedback about successful reduction efforts; and they receive continual public support from key physicians in leadership positions. The process of error reduction involves long-term effort. There needs to be consistent and persistent emphasis on a cycle of attention to information, patterns revealed by information, error-reduction efforts, evaluation, more information and more reduction efforts. These efforts now also include producing informed patients, who are coached to ask the questions that might avoid errors. We should think about this cyclic process to reduce error as an ongoing one, always in need of fine-tuning. Its effectiveness depends on clinical leadership providing a continuing example in error reporting.

Marilynn M Rosenthal PhD

Objectives: (i) To examine attitudes of medical and nursing staff towards reporting incidents (adverse events and near-misses), and (ii) to identify measures to facilitate incident reporting.Design: Qualitative study. In March 2002, semistructured questions were administered to five focus groups — one each for consultants, registrars, resident medical officers, senior nurses, and junior nurses.Participants and setting: 14 medical and 19 nursing staff recruited using purposive sampling from three metropolitan public hospitals in Adelaide, South Australia.Main outcome measures: Attitudes and barriers to incident reporting; differences in reporting behaviour between disciplines; how to facilitate incident reporting.Results: Cultural differences between doctors and nurses, identified using Triandis’ theory of social behaviour, were found to underpin attitudes to incident reporting. Nurses reported more habitually than doctors due to a culture which provided directives, protocols and the notion of security, whereas the medical culture was less transparent, favoured dealing with incidents “in-house” and was less reliant on directives. Common barriers to reporting incidents included time constraints, unsatisfactory processes, deficiencies in knowledge, cultural norms, inadequate feedback, beliefs about risk, and a perceived lack of value in the process.Conclusions: Strategies to improve incident reporting must address cultural issues.

Marilyn J Kingston RN, RM, BAPsych(Hons) · Sue M Evans BN, GradDipClinEpi · Brian J Smith MB BS, GradDipClinEpi, PhD · Jesia G Berry BHSc(Hons), GDPH

Susan D Huckson Project Manager, National Institute of Clinical Studies, 499 St Kilda Rd, Melbourne, VIC 3004. shucksonATnicsl.com.au To the Editor: Stacey, in his recent editorial on preventing pressure ulcers, stated that it is a major challenge to successfully implement guidelines in clinical practice and that a combination of strategies is required.1 In this context, your readers may be interested in the new pressure ulcer resource guide, developed by the National Institute of Clinical Studies (NICS).2 The resource guide provides health professionals and consumers with easy access to: the latest guidelines; literature reviews; health professional and consumer information resources; current Australian research activities, journal articles and papers; and links to a range of groups undertaking significant work in this area. The guide was developed in consultation with leading experts and professional groups with a strong interest in the management of pressure ulcers in Australia. This guide is an example of the efforts of NICS to help healthcare organisations and practitioners improve patient care by providing them with access to the best available evidence, proven strategies, tools and resources. The guide can be freely accessed from the NICS website www.nicsl.com.au (under “Quick Links”).

Susan D Huckson

Objectives: To seek public opinion on the reporting of medical errors and the anonymity of healthcare workers who report medical errors.Design and participants: A random, representative survey of 2005 South Australians in April 2002, using telephone interviews based on a vignette provided.Main outcome measures: When a medical error occurs (i) whether the incident should be reported, and (ii) whether the report should disclose the healthcare worker’s identity.Results: (i) Most respondents (94.2%; 95% CI, 93.0%–95.2%) believed healthcare workers should report medical errors. (ii) 68.0% (95% CI, 65.5%–70.5%) of those in favour of reporting believed the healthcare worker should be identified on the report, while 29.2% (95% CI, 26.7%–31.7%) favoured anonymous reporting.Conclusions: Most respondents believed that, when a healthcare worker makes an error, an incident report should be written and the individual should be identified on the report. Respondents were reluctant to accept healthcare worker anonymity, even though this may encourage reporting.

Sue M Evans BN, GradDipClinEpi · Jesia G Berry BHSc(Hons), GradDipPublicHealth · Brian J Smith FRACP, PhD, DipClinEpiBiostat · Adrian J Esterman MSc, PhD, AStat

In patients hospitalised with acute coronary syndromes (ACS) and congestive heart failure (CHF), evidence suggests opportunities for improving in-hospital and after-hospital care, patient self-care, and hospital–community integration. A multidisciplinary quality improvement program was designed and instigated in Brisbane in October 2000 involving 250 clinicians at three teaching hospitals, 1080 general practitioners (GPs) from five Divisions of General Practice, 1594 patients with ACS and 904 patients with CHF. Quality improvement interventions were implemented over 17 months after a 6-month baseline period and included: clinical decision support (clinical practice guidelines, reminders, checklists, clinical pathways); educational interventions (seminars, academic detailing); regular performance feedback; patient self-management strategies; and hospital–community integration (discharge referral summaries; community pharmacist liaison; patient prompts to attend GPs). Using a before–after study design to assess program impact, significantly more program patients compared with historical controls received: ACS: Angiotensin-converting enzyme (ACE) inhibitors and lipid-lowering agents at discharge, aspirin and β-blockers at 3 months after discharge, inpatient cardiac counselling, and referral to outpatient cardiac rehabilitation. CHF: Assessment for reversible precipitants, use of prophylaxis for deep-venous thrombosis, β-blockers at discharge, ACE inhibitors at 6 months after discharge, imaging of left ventricular function, and optimal management of blood pressure levels. Risk-adjusted mortality rates at 6 and 12 months decreased, respectively, from 9.8% to 7.4% (P = 0.06) and from 13.4% to 10.1% (P = 0.06) for patients with ACS and from 22.8% to 15.2% (P < 0.001) and from 32.8% to 22.4% (P = 0.005) for patients with CHF. Quality improvement programs that feature multifaceted interventions across the continuum of care can change clinical culture, optimise care and improve clinical outcomes.

Ian A Scott MHA, FRACP · Annabel C Hickey MMSc(Clin Epi), BAppSc(OT) · Daniela C J Sanders BPharm(Hons) · Mark A Jones BSc(Hons) · Charles P Denaro MD, FRACP · Cameron J Bennett MB BS, MBiomedE, FRACP · Alison M Mudge MB BS, FRACP · Justine M Thiele BPharm · Judy L Flores BA, MD, FRACP · Beres Wenck FRACGP · John W Bennett BMedSc, MB BS, BA(Hons), FRACGP

David S Elder Occupational Physician, 517 St Kilda Road, Melbourne, VIC 3004. delderATbigpond.net.au To the Editor: In Bogduk’s review of the management of low back pain,1 he cited several international guidelines but did not address the effect of returning the patient to work. Disappointingly, return to work was mentioned only as an outcome of multidisciplinary therapy, with no mention at all of a planned and purposeful return to work in the suggested approach. This is surprising, given the literature available2,3 and the significant adverse effects of being out of work.4 Further, the algorithm in Box 3 (general practice management of chronic low back pain) appears to have a never-ending loop: I am cautious of the adverse effects that the reductionist model can have,5 and it appears possible in this algorithm to be forever stuck in the investigative loop. An additional pathway from this loop to intensive therapy would allow progression in some cases. The inclusion of a return to work in management of low back pain has been extensively analysed in the Australian setting and shown to significantly reduce disability.6 This advice should be included in any clinical update on management of low back pain.

David S Elder

John Salmon,* Anna Hilyard† * Pain Management Specialist, Bethesda Hospital, 25 Queen Mary Drive, Claremont, WA 6010; † Director, Achieve Pain Control Group, Perth, WA. salmon8ATbigpond.com To the Editor: Bogduk’s article on management of chronic low back pain1 was disappointingly retrogressive as a guide for general practitioners. Compartmentalising back pain management as monotherapy, multidisciplinary therapy or “reductionism”, and favouring the last, reinforces the medical model which has singularly failed to stem the epidemic of low back pain disability affecting the developed world. The biopsychosocial model of chronic spinal pain is now widely accepted and rationally emphasises the multi- or interdisciplinary model of management.2,3 Bogduk’s preference for the reductionist approach may be reasonable in a specialised centre and as a basis for research, but must justify its practical relevance in the face of the following: Available data on the reductionism approach are meagre, conflicting and mainly derived from pain-clinic populations likely to differ from patients presenting to GPs. Diagnostic joint and disc injection procedures and radiofrequency treatment performed to the required standard are available in only a very few centres. Radiofrequency lesioning of the nerve supply to symptomatic joints has been shown to provide pain relief limited to 9–18 months.4 Repeat lesioning may be less effective and is impracticable in the long term. At best, these treatments could be considered palliative. Of course, patients can only benefit from accurate diagnosis and reduction of pain from identified peripheral generators. Unfortunately, for most people with chronic back pain, it is not that simple. Usually there are multiple pathologies and pain generators, multisegmental dysfunction, disrupted motor control and interacting peripheral and central neural sensitisation mechanisms. And that is just the “bio” of the biopsychosocial model. There is then the interplay with the individual’s psychological and social environment. It is often a challenge to communicate the diagnosis effectively in the face of conflicting input from other health providers, the media and patient preconceptions. Just “plonking” “the diagnosis” before a patient and dangling a seductive “techno fix” that does not deliver in the long term is precisely what renders patients with chronic pain increasingly bewildered, dysfunctional and desperate to try one passive treatment after another. The biopsychosocial model provides a basis for management in both general and specialist practice. Appropriate interventions to reduce pain-generator input are embedded in a cognitive behavioural management matrix that imbues patients with accurate, relevant knowledge of their conditions and commonsense self-management techniques to maintain appropriate activity levels, goal setting and psychological positivity. For a time-challenged GP, collaboration with an activation- and exercise-oriented physiotherapist can be effective. The GP’s role is to provide the “white coat authority” so vital in recruiting patient confidence.

John Salmon · Anna Hilyard

Nikolai Bogduk Director, Department of Clinical Research, Royal Newcastle Hospital, Newcastle, NSW 2300. mgillamATmail.newcastle.edu.au In reply: There is a difference between wishful thinking and evidence. Elder advocates a focus on return to work. Elsewhere, I have described how this should be pursued.1 However, the evidence supports success only in the context of acute and subacute pain. I was commissioned to write on low back pain. In that context, evidence is lacking. Even Waddell, whom Elder cites,2 conspicuously avoided the issue of chronic low back pain; his evidence pertains only to acute low back pain. Salmon and Hilyard promote the biopsychosocial model. Indeed, this model is now widely accepted. Even our own studies have shown how successful it can be to recognise and treat patients’ fears and mistaken beliefs.3 However, the evidence of success is limited to acute and subacute low back pain. The predictions of the biopsychosocial model have not been fulfilled in the context of chronic low back pain. Although better than no therapy, behavioural therapy is not more effective than other therapies, and does not “reduce pain generator input”, as Salmon and Hilyard contend. Insurers, who pay for this treatment, do not share their enthusiasm for it.4 Salmon and Hilyard also repeat the commonly held view that patients have multiple pain generators. There is no actual evidence for this assertion, while the available evidence indicates the opposite. When investigated comprehensively, fewer than 10% of patients have more than one simultaneous pain generator.5 Further, Salmon and Hilyard consider that complete relief of pain for 9–18 months amounts to palliative therapy. Yet the opposite is true. Not relieving pain by behavioural therapy is palliative. They also deprecate radiofrequency neurotomy with the accusation that it “may be less effective” when repeated, but fail to cite the literature showing that this is not the case. They are correct in stating that reductionist procedures performed to the required standard are available in only a few centres. However, this does not invalidate these procedures; it reflects only a political and ideological problem in healthcare delivery. They also fail to reveal that in many places where these procedures are available, they are not performed according to best-practice standards. It is not the procedures, but misguided and unscrupulous practitioners, who render patients bewildered and dysfunctional.

Nikolai Bogduk

Dealing with dementia. A guide to Alzheimer’s disease and other dementias. Brian Draper. Sydney: Allen and Unwin, 2004 (xvi + 255 pp). ISBN 1 86508 853 6. Dementia is a condition that is common and costly. It affects not only those with the disease, but also their carers and families. Public awareness of dementia has increased in recent times, but many aspects are still misunderstood. Dealing with dementia is a comprehensive, easy-to-read book that covers “all you need to know” about dementia and is primarily written for those living with the condition. The strength of the book is that Draper covers all aspects of dementia care, ranging from the purely medical to alternative therapies. He addresses often-asked questions such as those about nutrition and occupational exposures. Non-pharmacological approaches to management, such as reality and validation therapy, music therapy, and a myriad of others, are described and supported by research outcomes, if these are available. Ethical and legal issues associated with the care of a person with dementia are clearly explained. A glimpse into possible future treatments gives hope to readers. This book is primarily for Australian readers. It contains a comprehensive description of community care services and residential care processes available in this country, and this is particularly useful for stressed families trying to sort through the maze of available services. Even though specifically Australian-based, the information presented in the book is easily adapted for an international audience. A useful summary of national and international websites is included for further exploration. Draper is a respected researcher and clinician in the field of dementia, including the needs of carers, who writes with a personal and often humorous style. The book is reasonably priced and health professionals can recommend it as a useful reference for patients and carers. Dina C LoGiudiceGeriatrician, Extended Care and Rehabilitation Centre, Melbourne, VIC

Dina C LoGiudice

In diagnosis and prognosis, we should avoid intuitive “guesstimates” and seek a validated numerical aid One of the axioms of clinical practice is that, in medicine, there are few, if any, certainties. When assessing the likelihood of a specific disease in a particular patient, or the chance of a future adverse event in a patient with known disease, clinicians are estimating probabilities or risk. These estimates derive from a clinical gestalt — the process of interpreting findings from history, examination and simple investigations (diagnosis), or of disease-specific correlates of complications or death (prognosis). Clinicians use these estimates of probability or risk to decide whether they should intervene immediately, particularly if effective treatments are available. Alternatively, if the disease likelihood is low, or treatments toxic or only marginally effective, these estimates are used to decide whether to defer treatment and either observe expectantly or conduct more sophisticated tests whose results may substantially alter pre-test likelihood estimates. If the estimate is too high, patients may incur unnecessary treatments or confirmatory investigations, or, if the estimate is too low, they may suffer the consequences of delayed intervention. Thus, a fair bit is riding on how accurately we can judge the likelihood of current or future disease. Available research suggests that, for various reasons, we are not that good at it.2-4 Common pitfalls include: framing a clinical problem in a way that may exaggerate risk; overweighting or underweighting certain clinical features; erroneously extrapolating past, vividly recalled cases to current patients; or manipulating risk subliminally to better fit with a preferred course of action (or inaction). Overall, most of us, not surprisingly, are risk averse and will commit to action to avoid personal regret at witnessing an unfavourable but possibly preventable event, even if our perception of risk of such an occurrence seems low.5 In this issue of the Journal, Attia and colleagues (page 449) evaluate the extent to which clinicians’ estimates of probability or risk for commonly encountered case scenarios vary from the “correct” estimate, and which clinician-related factors may influence such variation.6 They distributed three hypothetical case scenarios to groups of general practitioners and physicians in Australia and the United Kingdom, and compared respondents’ estimated probabilities of angina (in a patient with chest pain), deep vein thrombosis (DVT) (in a patient with a swollen leg), and future stroke (in a patient with chronic atrial fibrillation) with the “correct” estimates derived from statistically validated clinical-decision rules. Two cautions come to mind: were the clinicians given sufficient information on which to base a reasoned judgement (keeping in mind that they could not examine the patients); and how accurate was the rule-based estimate as the reference standard? One could argue that, in the chest-pain scenario, few experienced clinicians would be comfortable estimating the likelihood of angina simply on being told of a 65-year-old man presenting with exertional chest pain, without more detail about the character of the pain, the existence of coronary risk factors, and any signs of vascular disease seen on physical examination. The decision rule applied to the same case is also suspect, as it includes, for example, rapid relief with nitrogylcerine as being positively predictive of angina, which recent evidence would challenge.7 In the other two scenarios, the clinical details provided were more complete, and the decision rules more robust. Another concern is that the “correct” estimate was stated as a single percentage, which clinicians were expected, perhaps unfairly, to closely approximate. This ignored the fact that, in developing the rule, the “correct” estimate is actually a mean within a range of observed frequencies, all of which would probably lead to the same clinical action. On the positive side, the strengths of the study were its large, representative samples of clinicians, use of three different scenarios, and use of logistic regression to identify clinician-specific predictors of accuracy. Setting aside methodological limitations, how did the respondents fare? Only slightly more than half of the whole group were within 20 percentage points of the “correct” probability estimate for the angina and stroke scenarios, and less than one in 10 achieved a similar result with the DVT scenario. In keeping with my earlier comments, most respondents overestimated rather than underestimated the risk, with estimates spread over a huge range, from 10% to 100% at least, for all cases. There was a notable lack of association between accuracy and experience as measured by age, years of practice, or field of specialty, with GPs performing as well as physicians. Unfortunately, the study by Attia et al did not have the power to determine whether graduating from a medical course that used problem-based learning — with emphasis on evidence appraisal — predisposed to better performance. The implications of this study and others are several. First, all clinicians, irrespective of experience, appear to have problems quantifying probability or risk of disease, and, while there may be exceptions, this difficulty is independent of the clinical circumstances. Consequently, we should avoid intuitive “guesstimates” and seek instead a validated decision-rule, scoring scheme or other numerical aid that gets us closer to the mark. Fortunately, an increasing number of such tools are becoming available8 and in a form compatible with hand-held computers. Second, if we are to choose the best rules and use them appropriately, we need to understand how such rules should be constructed and tested.9 Third, we may need to “unlearn” some of our cherished clinical “rules of thumb” if evidence arises that questions their validity.10 Finally, we should advocate for more research into decision aids that will help us to more accurately estimate and communicate likelihood of disease in individual patients. The results of such efforts should facilitate a more rational use of investigations and treatments and lead to better patient outcomes.

Ian A Scott FRACP, MHA, MEd

Objective: To assess the accuracy and variability of clinicians’ estimates of pre-test probability for three common clinical scenarios.Design: Postal questionnaire survey conducted between April and October 2001 eliciting pre-test probability estimates from scenarios for risk of ischaemic heart disease (IHD), deep vein thrombosis (DVT), and stroke.Participants and setting: Physicians and general practitioners randomly drawn from College membership lists for New South Wales and north-west England.Main outcome measures: Agreement with the “correct” estimate (being within 10, 20, 30, or > 30 percentage points of the “correct” estimate derived from validated clinical-decision rules); variability in estimates (median and interquartile ranges of estimates); and association of demographic, practice, or educational factors with accuracy (using linear regression analysis).Results: 819 doctors participated: 310 GPs and 288 physicians in Australia, and 106 GPs and 115 physicians in the UK. Accuracy varied from about 55% of respondents being within 20% of the “correct” risk estimate for the IHD and stroke scenarios to 6.7% for the DVT scenario. Although median estimates varied between the UK and Australian participants, both were similar in accuracy and showed a similarly wide spread of estimates. No demographic, practice, or educational variables substantially predicted accuracy.Conclusions: Experienced clinicians, in response to the same clinical scenarios, gave a wide range of estimates for pre-test probability. The development and dissemination of clinical decision rules is needed to support decision making by practising clinicians.

John R Attia MD, PhD, FRCPC · David W Sibbritt PhD · Ben D Ewald BMed, MMedSci · Balakrishnan R Nair FRCP, FRACP · Neil S Paget MA, DipEd · Rod F Wellard MEd, PhD · Lesley Patterson · Richard F Heller MD, FRCP

This can’t happen to me! Tackling type 2 diabetes. Tim Bowden. Sydney: Allen and Unwin, 2004 (xiii + 207 pp). ISBN 0 86431 473 6. We know that type 2 diabetes is very common in Australia, that its prevalence is increasing, and that a very large minority of the Australian population have several risk factors for diabetes. These facts are now becoming a matter of public, not just professional, knowledge and will lead to increased public demand for information on the disease, and how to avoid it. There are many excellent sources of information for the person with diabetes, but the diversity of those developing the condition means that additional well-written and accurate accounts are welcome. A first-hand account by someone with a condition has the capacity to make a profound impression on others beyond that of medical texts. Tim Bowden has made an important contribution of this sort that can be recommended with confidence to those newly diagnosed as well as those at risk. Bowden is a broadcast journalist well known for his affable and direct style of communication. He brings these skills to an account of his own diagnosis of type 2 diabetes at a routine medical assessment at the age of 65, and his experiences in learning how to cope with it. This is combined with interviews recounting the experiences of others and with key Australian experts. He provides straightforward information on the range of symptoms, causation, principles of management, monitoring and surveillance for complications. His focus is on the person with diabetes and how he or she can and should deal with the problem, including psychological reactions to the diagnosis and the behavioural adaptations subsequently required. Perhaps another round of editing would have reduced some occasionally irritating repetitiveness, but this book appears to have successfully targeted a public health need and is a welcome addition to currently available publications. Duncan J ToplissDirector Department of Endocrinology and Diabetes Alfred Hospital, Melbourne, VIC

Duncan J Topliss

Mood disorders. Recognition and treatment. Peter R Joyce, Philip B Mitchell (editors). Sydney: UNSW Press, 2004 (xvi + 508 pp). ISBN 0 86840 447 0. This is a big book about a big topic. Anyone concerned with observing — or improving — the human condition must be informed about mood disorders. The book covers both depression, which is the most common disorder, and the various levels of mania, where depression usually presents intermittently. Medical practitioners, in particular, need to be up-to-date in their knowledge of mood disorders in order to improve and save lives. The editors begin wisely. Instead of starting their book with its subjects stretched out anatomised on dissecting room tables, they begin with descriptions of being depressed or being manic written by people who have experienced these conditions. Any reader who has escaped these painful and destructive disorders should read the descriptions carefully and reflect upon them. This book, of more than 500 pages, containing 40 essays by clinicians, covers everything from brain imaging and electroconvulsive therapy to psychotherapy. It is an encyclopaedia, worthy of its subject, and I used it like an encyclopaedia. I put it on my shelves and took it down when I wanted to expand my knowledge in a particular area, or to examine whether or not I was up-to-date on a topic. Professor Mulder’s contribution on the duration and natural course of depression is particularly important (it is often subdued but only occasionally totally vanquished). The book was both illuminating and helpful. Importantly, it is also very thoroughly referenced so that one can pursue a topic further if one wishes. I would like to make one personal observation. To my mind depression is, in some respects, like pain. All pains have a lot in common, but there are many different causes of pain and many different kinds of pain. In most cases the cause determines the management (eg, the pain of acute appendicitis is better dealt with by appendicectomy than by referral to a pain unit). So it is with depression, but some contributors (eg, in “Psychological therapies for depression”) could lead one to believe that there are some invariant aspects of depression which require psychotherapy of some complexity. Sometimes this is true and sometimes not. Many patients make a full recovery with appropriate medication, some commonsense support, and information and advice of the kind that we would give to patients with diabetes mellitus. Who should buy this book? Certainly all psychiatrists, but there are many other practitioners who have to deal with this common and lethal spectrum of disorders. For many it will not be their primary text, but it will be a very good resource when difficulties arise. John H T EllardPsychiatrist, Sydney, NSW

John H T Ellard

Project management in health and community services Judith M Dwyer, Pauline Stanton, Valerie Thiessen. Sydney: Allen and Unwin, 2004 (xxi + 200 pp) ISBN 1 74114 055 2. Would I be interested, the polite letter from the Journal asked, in reviewing a book about project management? I turned the letter over gloomily — I couldn’t think of a less interesting title. The sub-text, however, Getting good ideas to work, was a bit of a pull, as I have a big project just starting. One of the frequent deficits of doctors when they assume levels of seniority is a thorough incompetence at management. We are trained with quite different skills in mind, like caring for individual people. Project management is not always well done, even for medicos involved in research — projects often fizzle out not because of problems with design, or messing up the sample, but because of pragmatic failings. So this book might have relevance to all of us involved with projects, and — look! — written for us health folk, and by true-blue Aussies. The book comes in two parts: some of the research and thinking behind projects, and where they fit in organisations and their strategies. There is quite a bit of theory, but few pragmatic data on what works. The theory is littered with technical stuff: it was good to get my head around things I had come across but wasn’t really sure about, like PERT (Project Evaluation and Review Technique), Gantt Charts, WBS (Work Breakdown Structure) and PMBOK (Project Management Body of Knowledge). There isn’t anything here that is intellectually tricky. Don’t worry, they say, about all the technical stuff. Forget the acronyms, all you really need is buckets of common sense. We are introduced to tools (mostly software) that help manage projects, but the finger is wagged in our faces about not relying on them, and the plans they generate. “Project management is an art not an algorithm” (p63). So does any this stuff work? Empirical research is weak, but suggests the usual suspects for failure: insufficient planning, buy-ins from the organisation, planning and so on… The second part of the book is more of a workshop manual. What to do, and, more pertinently, what not to forget. It suggests telltale signs of things going wrong; how to spot the folk who might cause you problems (like the white-ant); and what to do about them. This is the sort of book in which you might pause, smile in recognition, and read on again. There are examples — some real — from Australian hospitals, community health settings, and also Divisions of General Practice. A good book. I am the better for having read it. I think. Christopher B Del MarDean Health Science and Medicine Bond University Gold Coast, QLD

Christopher B Del Mar

The debate over prostate-specific antigen (PSA) testing for prostate cancer has been prolonged, public, and sometimes acrimonious. Despite this, a common theme is present in most evidence-based guidelines produced to date: while population-based screening cannot be advocated currently, individuals considering a test should be fully informed about the pros and cons and make their own decisions. 1-3 The US Preventive Services Taskforce adds that individuals “be assisted in considering their personal preference and risk profile”.4 However, none of these guidelines address the issue of how to ensure such “informed choice”. * The Australian Prostate Cancer Collaboration is a national organisation of clinicians, researchers, consumers and non-government organisations with an interest in prostate cancer. It receives project-based sponsorship from non-government organisations and commercial sources. The Australian Prostate Cancer Collaboration* (APCC), with support from the National Cancer Control Initiative, convened a workshop on informed choice for prostate cancer testing. The meeting was part of the Conjoint 4th National Prostate Cancer Symposium and the 5th Annual APCC Meeting held at Royal Melbourne Hospital in August 2003. The workshop participants (about 50 people) comprised urologists, GPs, nurses, members of non-government cancer organisations, patients and consumers. The diverse views presented at the workshop suggested that an active approach to managing the PSA testing issue in general practice is needed. What is currently happening?Jeanette Ward (Director, Division of Population Health, South West Area Health Service) summarised the current status — that PSA testing is widespread in general practice (in a Western Australian study, 48% of men aged 45 to 60 years had ever been tested).5 Furthermore, men overestimate their risk and make decisions without being fully informed. 5-7 Max Gardner (Chair, Prostate Cancer Foundation of Australia) and several workshop attendees made it clear that some men with prostate cancer felt they did not have an opportunity for informed testing when their cancer may have been localised. Paul Nisselle (Health-Law Consultant; formerly Chief Executive, Medical Indemnity Protection Society and general practitioner) described the medicolegal exposure arising from this situation, as well as when men feel that they have been harmed by unnecessary screening. A common theme was that a climate of anger, frustration and, increasingly, litigation is arising from men feeling inadequately informed about prostate cancer testing. Addressing this issue, speakers described barriers that prevent men being fully informed. These include: time constraints for the GP; lack of knowledge of the issues (Murray Barson, general practitioner with interest in men’s health; Debra Rowett, Chief Investigator, DATIS trial of academic detailing for PSA testing in general practice); lack of understanding of medicolegal obligations, particularly what is prudent and what is sufficient in terms of information provision (Nisselle); and wide ranges in patients’ awareness, concerns, levels of comprehension and life circumstances (Barson; Suzanne Steginga, Director, Community Services, Queensland Cancer Fund). Lack of understanding of how to communicate the complex areas of risk and uncertainty (Barson; Rowett; Ward) is also a barrier to fully informing men. What constitutes “informed choice”?Niselle revisited the medicolegal precedent set by Rogers v Whitaker and suggested that three tests are needed to determine if a patient has been fully informed: The reasonable patient test: information has been given that a reasonable person as a patient would think relevant; The reasonable doctor test: extra information has been given, which a reasonable doctor would add, having regard to the particular circumstances of the patient; and The individual patient test: additional information has been given, that that particular patient sought, having been given the opportunity to seek it. “Informed refusal” is as important as “informed consent”. A patient needs to be made aware that there is information he should consider before deciding not to have a test. How patients make decisions is crucial in determining how they should be informed. Steginga reported research which suggests that patients more commonly use non-systematic processes (eg, anecdotes or analogies, old beliefs, salient experiences and expert opinion) to make health-related decisions rather than systematic processing (the weighing up of the medical risks and benefits of the decision). As a consequence of these issues, Nisselle and Steginga maintained that providing a patient with written material and telling him to go away and make a decision is not enough. A discussion between doctor and patient has to take place, in which the patient’s views and beliefs are elicited, medical information is individualised to the patient’s circumstances (eg, age, family history), and the patient’s specific information needs are responded to. In short, “shared decision-making”. Pinnock outlined effective communication strategies to support this shared decision-making. These include establishing the preferred amount of information, the preferred role in decision-making,8 graphical representations of risk, and checking patient understanding. Ward noted that preference for a shared decision-making has been found in studies of men and GPs alike.9 Rowett reported results from the DATIS trial (a three-state study of academic detailing, which is a form of educational outreach as a means of informing GPs about issues concerning prostate cancer screening). Unprompted comments from GPs suggested that, although secondary, written materials can be useful in supporting the discussion. This was reinforced by Ward,9 who found that written materials increased knowledge gain by patients, particularly in those who prefer an active decision role. Pinnock discussed quality criteria for decision aids,10 including neutral framing, explicit evidence base, and evidence of effectiveness. High-quality written materials may reduce the length of the consultation (Rowett), improve patient knowledge,9 and reduce decisional conflict,9 but their effect on the decision outcome is variable (Steginga). The content of the informed-choice discussionGardner (providing a patient perspective), Pinnock (from the perspective of published research), and Ward (based on her group’s research) addressed the categories of information that should be presented in written materials. These include: Basic information on the prostate and its function, the individualised risk of developing prostate cancer and dying from it, and the way in which the man’s age, health status and family history may modify these risks; The potential benefits of early detection (can detect disease at a stage when treatment is potentially curative) and uncertainties (not sure whether active treatment prolongs life); and The performance of the PSA test in detecting prostate cancer (sensitivity, specificity and positive predictive value).9 The outcome of informed choicePinnock suggested that the outcome of this process of discussion and decision support is not a decision whether or not to test, but a management plan, which may involve review only, a single test, or testing at specified intervals. It should be individualised to the patient’s situation, sense of his risk, and preference when balancing the potential benefits, risks and uncertainties of early detection for prostate cancer. Providing resources and skills to GPsThe DATIS study suggests that academic detailing is successful in reaching GPs (80%–90% penetration), acceptable to GPs, and effective in increasing knowledge and perceived ability to inform patients. Ward revealed that a NSW trial of a peer-led 3-month education program will also look for improvements in understanding the evidence, perceived medicolegal risk and self-efficacy in promoting informed decision-making. Improved health literacy schemes in the community may reduce GP time required to explain basic background information. Furthermore, improving prostate health literacy is likely to improve decision-making regarding lower urinary tract symptoms,11 which are more common than prostate cancer. Sharing the educational task with non-government organisations, such as cancer councils, could spread the cost across sectors. These and other strategies to make the informed-choice discussion time-efficient need to be explored. Addressing inequity in accessWorkshop attendees raised the issue of men who are unconcerned about their health, who do not visit their doctor, and others (eg, rural men), who have poor access to medical services. These groups have an imposed, or default, uninformed refusal of prostate cancer testing. Education programs targeting general practice will not address this problem, but a community education program can reach such groups. Community education focusing on male reproductive and prostate health is also likely to promote a more active role for men in maintaining their health and reduce stigma associated with some of these disorders. Should this wait until 2008?Two speakers (Pinnock; Greg Neerhut, urologist, Victoria) addressed whether the need for informed choice will change once the results of the US and European randomised controlled trials on prostate cancer screening become available from 2008. Even if a screening benefit is detected in trials, the need for a man to make a fully informed decision will remain. This is because any survival benefit of active treatment of localised disease is likely to be evident only after 10 years or more.12 It is also likely that the poor performance of the PSA test, in particular the high rate of false positive results, will continue or increase with widespread early detection. In summary, the workshop established that there is a pressing need to support and resource GPs assisting men in making an informed choice about prostate cancer testing, to disseminate knowledge of how patients make these decisions, medicolegal issues, and provide access to decision support resources. A community education program on men’s prostate or reproductive health will help to reduce the burden on the GP as the sole agent responsible for community and patient understanding of these issues.

Carole B Pinnock PhD

Adequate staffing and devices to impIement active strategies are the key Pressure ulcers significantly reduce the quality of life of patients and increase the costs of patient care, as well as length of hospital stay. The most notable feature of pressure ulcers is that most are preventable. Prevalence studies in Australian acute-care hospitals have found their prevalence to range from 4.5% to 27%.1 . . . The most notable feature of pressure ulcers is that most are preventable. Guidelines for preventing and treating pressure ulcers have been developed in many countries, beginning with the Netherlands2 and the United States.3 Guidelines specifically tailored to Australian healthcare were released in 2001 by the Australian Wound Management Association.4 A major limitation of all these guidelines is the level of evidence on which they are based. Using the evidence-grading system of the National Health and Medical Research Council,5 only one recommendation in the Australian guidelines achieved level 1 (evidence obtained from a systematic review of all relevant randomised controlled trials) — the recommendation that pressure-reducing or pressure-relieving mattresses or beds be used in place of standard hospital mattresses in high-risk patients. As is common with many guidelines for preventing pressure ulcers, much recommended practice is based only on consensus statements from experts in the field. In this issue of the Journal, Jolley and colleagues (page 324) report a randomised controlled trial of a newly developed pressure-reducing surface, the Australian Medical Sheepskin, compared with standard care in the prevention of pressure ulcers.6 The trial was in 441 hospital patients considered at low to moderate risk of developing pressure ulcers. Patients using the sheepskin developed new pressure ulcers at a rate half that of patients receiving standard care. Clearly, in this group of patients, the Australian Medical Sheepskin is better than standard care. However, it must be appreciated that standard care in this study was itself suboptimal. It consisted of “any other pressure-relieving device or prevention strategy deemed appropriate by ward nursing staff, comprising standard hospital mattress and sheet, with or without other low-technology constant pressure-relieving devices and repositioning as determined by nursing staff”. Standard care resulted in 16.6% of patients developing a pressure ulcer. The answer to reducing the prevalence of pressure ulcers lies not in implementing any one strategy, but in providing an institution-wide prevention program. Common to guidelines for preventing pressure ulcers is identification of patients at risk. It is imperative that some form of structured method to identify those at risk is applied to all hospital inpatients. Assessments need to be repeated regularly throughout a patient’s hospital stay and when there is a significant change in health status. A number of risk-assessment tools can be used, the most common being the Norton Risk Assessment Score,7 the Braden Scale8 and the Waterlow Risk Assessment card.9 The major risk factors for developing pressure ulcers are immobility, sensory loss, impaired cognitive state, urinary and faecal incontinence, age over 65 years, male sex, European background, chronic illness, poor nutritional status, impaired oxygen delivery to tissues, raised skin temperature, skin dryness and the presence of pressure, shear or friction forces. After establishing a patient’s risk of developing a pressure ulcer, the next step is to implement preventive strategies to reduce that risk. This requires the support of hospital administrations in providing both the necessary trained staff and pressure-reducing or pressure-relieving devices. It is also imperative that staffing levels are adequate to ensure that nurses have sufficient time to provide the “hands-on” care necessary for these high-risk patients. For patients at low to moderate risk of developing pressure ulcers, the ideal preventive strategy may include any one of a wide range of pressure-reducing or pressure-relieving surfaces, including the Australian Medical Sheepskin, combined with a repositioning strategy. The Australian Medical Sheepskin has yet to be compared with other surfaces and devices in this group of patients. A major challenge in many areas of medical practice is to successfully implement guidelines for clinical practice. A recent review of effective strategies for implementing pressure-ulcer guidelines concluded that active strategies were more successful in reducing ulcer prevalence.10 The most effective strategies used targeted educational sessions and, in particular, multiple approaches. Such a strategy was recently shown to reduce pressure-ulcer prevalence in a multicentre Australian study.11 This indicates that developing guidelines alone is not sufficient to influence outcomes, but that they need to be linked to educational strategies to ensure their successful implementation and subsequent influence on clinical outcomes.

Michael C Stacey DS, FRACS

Practical contributions towards solving the medical workforce problems of rural Australia A viable practice is one that meets the particular medical needs of the community by providing appropriate services in a way that takes account of the financial and personal costs to both the practitioner and the community at large.1 Since 1978, there has been a plethora of inquiries, conferences and symposia on how best to recruit more rural doctors.2-6 These endeavours have resulted in a series of loosely articulated initiatives such as affirmative medical school entry for rural high school students, scholarships, decentralised medical education and other support mechanisms. It is envisaged that these initiatives will eventually ease the rural workforce shortage and diminish our reliance on overseas-trained locum doctors, many of whom are from underdeveloped countries with doctor shortages of their own. However, there is not much sense in recruiting and training rural doctors if the conditions under which they are expected to practise are not viable. In this context, two recent reports — Viable models of rural and remote practice and Easy entry, gracious exit — break new ground in defining the conditions necessary to build and ensure a viable rural medical practice.1,7 The reports are based on two separate studies. The larger study, the basis of the viable models report, was initiated and managed by the Rural Doctors Association of Australia, funded by the Australian Government Department of Health and Ageing and carried out under the guidance of the Bendigo branch of the Monash University School of Rural Health. The investigators used a rigorous, triangulated methodology, which included a national survey of all 4403 rural and remote general practitioners in Australia, focus groups and detailed site visits to a representative sample of 53 practices across Australia. There was a 34% response rate (1498 GPs), representing 53% of all practices. And what did the study find? Demographics: The major finding was the large proportion of ageing and overworked rural GPs, a matter of obvious concern to governments charged with providing healthcare for all people in Australia. Doctors over 50 years of age comprised 40% of the current workforce, and 61% of all rural doctors worked in areas with a shortage of GPs. A quarter of all doctors in the study were trained overseas, predominantly in the United Kingdom, Africa and Asia. Doctors in towns of 10 000–20 000 people need between two and three extra GPs, while those in towns of less than 10 000 people require an extra four to five GPs. Female doctors are now making an increasing contribution to the rural and remote workforce: they comprised 27% of the 1498 doctors responding to this study.8 Contrary to popular belief, they work the same number of hours as their male counterparts. This demographic picture has a fluid element, as a third of all rural and remote GPs intend to leave their current practice in the next 5 years. The proportion intending to leave ranged from 31% in the bigger towns to 66% in the more isolated communities. Capabilities: The ability to cope in depth with procedural presentations and emergencies, both in the consulting room and in the hospital, defines the rural and remote doctor. Over 50% of doctors working in population centres of between 5000 and 25 000 were involved in accident and emergency work outside of their surgery, 22% were doing obstetrics, 12% major surgery and 15% provided general anaesthesia. Work conditions: Rural and remote practitioners worked an average of 48 hours per week in patient-related activities and 8 hours in non-patient-related activities, mostly patient and practice administration. The weekly workload consisted of an average of 160 consultations per week, with a mean of 14 minutes per consultation. In addition, the practitioners were on-call one day and one weekend in three. Their vacation time averaged 24 days per year. Economics: A detailed economic and staffing analysis was performed for 91 of the participating practices. The average full-time rural doctor earned $266 000 per annum from all sources, including hospital work. Of this, 33% was consumed by staff costs and 19% by practice costs. The net taxable income was $127 680, which equates to $47.50 per hour net for a 56-hour week. Half of the GPs surveyed were practice principals and their yearly average profit was $201 000. From this, they paid for motor vehicles, medical indemnity, and continuing medical education. However, a quarter of all practice principals were financially unviable, with a net profit of less than $120 000 per year. Nearly all practices had a manager, and 72% had at least one practice nurse. In response to increasingly complex regulations and red tape, most managers had resorted to a reactive rather than a strategic approach to management. Dimensions of viability: Viable models of rural and remote practice identified a hierarchy of three core interrelated dimensions of viability that are amenable to systematic intervention. These are: A level of remuneration that reflects rural GPs’ skills, workload and commitment; A sufficient number of medical colleagues to limit after-hours workload to one night and one weekend in four, as well as adequately skilled locum support to enable annual recreation and study leave; and The physical facilities and administrative support to do their job. The habit of state governments of closing country hospital obstetric and anaesthetic facilities has been shown to be a major factor in procedural country doctors leaving their practice.9,10 Previously identified family, social and environmental factors were significant, but were found to be dependent on the above three dimensions and therefore less important in a doctor’s likelihood of remaining in rural practice.2-4 Benchmarks: These data have been used to derive benchmarks for models of viable practice. The authors of the report stress that these benchmarks are not a wish list, nor an ambit claim, and explain clearly how they have reached their conclusions. For example, income benchmarks of $110 per hour are derived from the median incomes of private GPs, government salaried GPs, rates for locum GPs, and the hourly rate paid to GPs engaged in divisional activities. Other benchmarks cover education, workforce numbers according to emergency and after-hours requirements, and various forms of leave. They also include purpose-built practice premises, a required number of support staff, and business systems which enhance practice management and include broadband internet access. The final chapter of the report illustrates the use of the viability framework in three different geographical locations. Easy entry, gracious exit complements the viable models report. It is a case study of an innovative model piloted in the towns of Brewarrina, Collarenebri, Lightning Ridge and Walgett in the far west of New South Wales.7 The unique feature of this model is a third-party provider as the owner and manager of the practice. This relieves doctors of the hassles of being a small-business owner, worried about a low return on infrastructure investment, and allows them to concentrate on practising medicine. In addition, this project is supported by the New South Wales Rural Doctors Network, which provides for safe working hours, regular holidays and promotes a guilt-free “walk-in, walk-out” approach by concentrating on continuity of the practice rather than continuity of the doctor. This model has proven to be an important factor in recruiting and retaining doctors. Both these reports make major conceptual and practical contributions towards solving the medical workforce problems of rural and remote Australia. They provide clear guidelines for health planners, consumers and medical stakeholder groups on what is required to give their particular geographical area the best chance of obtaining a viable and ongoing medical service.

Max Kamien MD, FRACP, FRACGP, FACRRM

Objective: To estimate the effectiveness of a new high-performance Australian medical sheepskin (meeting Australian Standard 4480.1-1998) in preventing pressure ulcers in a general hospital population at low to moderate risk of these ulcers.Design: Open-label randomised controlled clinical trial.Setting: A large metropolitan teaching hospital in Melbourne, Victoria, in 2000.Participants: 441 patients aged over 18 years admitted between 12 June and 30 November 2000, with expected length of stay over 2 days and assessed as at low to moderate risk of developing pressure ulcers.Intervention: Patients were randomly allocated to receive a sheepskin mattress overlay for the duration of their hospital stay (218 patients) or usual treatment, as determined by ward staff (referent group, 223 patients).Main outcome measures: Incidence rate and cumulative incidence of pressure ulcers, assessed daily throughout hospital stay.Results: 58 patients developed pressure ulcers (sheepskin group, 21; referent group, 37). Cumulative incidence risk was 9.6% in the sheepskin group (95% CI, 6.1%–14.3%) versus 16.6% in the referent group (95% CI, 12.0%–22.1%). Patients in the sheepskin group developed new pressure ulcers at a rate less than half that of referent patients (rate ratio, 0.42; 95% CI, 0.26–0.67).Conclusions: The Australian Medical Sheepskin is effective in reducing the incidence of pressure ulcers in general hospital inpatients at low to moderate risk of these ulcers.

Damien J Jolley MSc(Epi), MSc · Robyn Wright RN, GradDipAppSci(SM) · Sunita McGowan RN, MAppSci · Mark B Hickey BAppSci(Hons) · Kenneth C Montgomery BSc, PhD · Don A Campbell MD, MMedSci(ClinEpi) · Rodney D Sinclair FACD

GPs need a means to easily and accurately identify prescription shoppers The Health Insurance Commission (HIC) defines “doctor shoppers” as people who have 30 or more Medicare consultations a year or see more than 15 different general practitioners to obtain more Pharmaceutical Benefits Scheme (PBS) prescriptions than appear to be clinically necessary. In 1995–96, there were 13 240 Australians who met this definition, and in 1999–2000 this figure had fallen to 8780.1 The current system places the legal standing of prescription shoppers above that of the doctors who are trying to deal with them. Recently, the HIC introduced a new definition of “prescription shopper” as a person who has, in a 3-month period, been supplied prescription drugs by six or more different prescribers, or has been prescribed a total of 25 target pharmaceutical benefits or 50 or more pharmaceutical benefits in total. These broadened criteria have resulted in a new figure of 22 000 prescription shoppers.2,3 The agenda of doctor shoppers is to obtain benzodiazepines and opioid analgesic drugs, either for their own use or to swap or sell. The upper quartile of doctor shoppers work hard at their task, and will have seen up to two different GPs a day for every working day of the year.1 Doctor shoppers confront GPs with a confusion of our usual roles and trouble us in many ways. They are not like our usual patients and only want drugs, not help.4 Their dissembling destroys trust and, when unsuccessful in obtaining prescriptions, they can become aggressive and unsettle regular patients and reception staff. They are also quick to spread the word about any new doctor who has been a “soft touch”. Although many doctors have ethical and humanitarian concerns for the wellbeing of these patients, most do not want to get involved. Even reputable and dedicated doctors who espouse a philosophy of harm minimisation can face disciplinary proceedings if they are accused of prescribing excessive amounts of drugs of addiction.5 Strangely, prescription shopping is not illegal, and doctor shoppers are not subject to the same legal constraints as those who prescribe for them. For an experienced GP, making a diagnosis of “doctor shopper” can be easier than diagnosing the trickier presentations of cholecystitis. But for less-experienced doctors, used to giving patients the benefit of the doubt, it can be a problem, and requires educational input. Doctor shoppers are of either sex, and most are between 20 and 40 years old. They often present with fairly transparent stories involving severe pain of some description, stress, insomnia, or a request for benzodiazepines to help them withdraw from opiates or alcohol.4 They often claim to have recently arrived from interstate and present a letter, which may be forged on a stolen letterhead, attesting to their diagnosis and need for opiates and tranquillisers. They are usually much more medically sophisticated than the average patient and are quite explicit about the medication they want.4 They will tell the GP that tramadol is useless for their pain, which only responds to various derivatives of morphine. Similarly, temazepam tablets do not help them to sleep, but capsules do. Subsequent attempts at getting further prescriptions involve a variety of unlikely stories about the loss of previous prescriptions through various forms of theft, washing machine mishaps, and prescription-devouring dogs. In this issue of the Journal, Martyres et al (page 211) analyse the doctor-shopping behaviour of 202 people aged 15–24 years, who died between 1994 and 1999 after using heroin.6 Martyres et al found that the frequency of doctor shopping over a 4-year period increased threefold in the year before death. They see this rapid escalation of doctor shopping as both a cry for help and as an opportunity for GP intervention — even if this is only advice on the options available for help and treatment.6 They are also of the view that the government sees doctor shopping (which costs the PBS more than $30 million a year) as more of an economic than a medical problem. Indeed, the focus of the HIC’s Prescription Shopping Project has a large economic component aimed not only at doctor shoppers, but also at people who hoard drugs or send PBS drugs to relatives in other countries.7 Besides its economic cost, doctor shopping is a public health and ethical problem for the medical profession. Most GPs do not write prescriptions for doctor shoppers — half these prescriptions are written by 7.5% of Australian GPs, most of whom practise in one of 10 residential postcode areas.1 These GPs appear to have an irresponsible, laissez-faire approach to prescribing. The Prescription Shopping Project will provide feedback and educational intervention to excessive prescribers, with the aim of changing their prescribing practices.7 The Prescription Shopping Project also gives the HIC “special authority to contact the patient or to give drug information to their doctor without the patient’s consent”.7 However, if a young heroin user can see up to 613 GPs in a year,1 how will the HIC know which of the 613 GPs is that patient’s doctor? The Prescription Shopping Project legislation empowers the HIC to assist a “prescriber to make decisions about prescribing to the prescription shopper, if that prescription shopper is visiting that prescriber or is a patient of that prescriber”,3 but the immediate need of the busy GP is quick access to information. And the easiest and fastest technology to assist the busy GP is access to a dedicated prescription shoppers’ telephone line. Until August 2002, a doctor could quickly confirm, to a high level of probability, who was a known doctor shopper by using a dedicated telephone line, “The Doctor Shopping Line”. This was the diagnostic equivalent of the ultrasound in confirming the diagnosis of cholecystitis and the number and type of gallstones involved. Indeed, the HIC won a Government Technology Productivity Award for developing the software for generating the required doctor-shopping information within 30 seconds.8 Budgetary constraints, fears about privacy provisions, and a re-examination of the secrecy provisions of the National Health Act 1953 (Cwlth) led to a cancellation of this dedicated telephone line. Its replacement requires patients to sign a voluntary release-of-information form and it takes 7–10 days for the GP to receive the prescription-shopping history. The current system places the legal standing of prescription shoppers above that of the doctors who are trying to deal with them,9 and may have placed these individuals’ fragile lives at greater risk than is necessary.6 If Martyres et al are correct in seeing an escalation in prescription shopping as a cry for help, GPs must have the information on which to act. The success of the federal government’s Prescription Shopping Project also depends on GPs accessing quick and accurate prescription-shopping information. The necessary legislation and technology to reactivate the previously effective dedicated doctor-shopping line is already in place. 3,8 There is no logic in further governmental delay in its reintroduction. Doctors want it and need it, and will not in the least mind if the new politically correct term is “Prescription Shoppers’ Line”.

Max Kamien MD, FRACGP, RACP

Specialist palliative care services and services involved in the pre-palliative phase of a patient’s disease must accept GPs as an integral part of the care team The number of Australians requiring palliative care is set to rise as the population ages. Although specialist palliative care services now cover most regions of Australia, rationing will be inevitable. Addressing the gaps and shortfalls to enable successful care of dying people will always require general practitioners to shoulder most of this clinical load. Unfortunately, specialist palliative care services report that some GPs are disinclined to continue to care for patients who need palliative care. They also report variability in the palliative care skills GPs possess, and struggle to work out how to support the GP colleagues whose care they perceive to be suboptimal. In 2002, the Commonwealth Department of Health and Ageing commissioned research to identify the barriers and propose solutions to this perceived problem. The outcome of this exercise provides a series of options for managing the engagement of GPs in palliative care.1 Most of the barriers to GP participation in palliative care are complex structural factors that will take some time to address (Box 1). GPs are increasingly opting for part-time work and there is a rising proportion of female GPs. In view of family responsibilities and safety issues, female GPs may have to consider their willingness to undertake home visits and after-hours work.2 For some GPs, regardless of gender, performing the time-consuming services involved in palliative care is becoming socially, financially and professionally non-viable.1 Practice costs, and the pressures arising from them, continue to increase. Several interim measures may improve GP participation in palliative care. Financial incentives (in the form of palliative-care-specific item numbers, or a substantial Special Incentives Program payment that recognises the intense work required in palliative care) may help. Items within the Enhanced Primary Care Program that encourage multidisciplinary care need to be simplified if they are to be used more often.3 For some GPs, exposure to only a small number of palliative care patients each year,4,5 combined with rapid advances in the evidence base for palliative care, undermines their confidence in managing patients appropriately. Given these disincentives, GPs may well ask, “Why should I be involved when there is a specialist palliative care unit in the district?”. Education providers, specialist palliative care services, governments and GPs themselves can all play a part in reinforcing the central role of GPs in palliative care. Defining a minimum set of palliative care skills to be taught to all doctors at undergraduate and intern level would ensure that all GPs have the knowledge and confidence to manage most common problems in palliative care. Medical schools should accept the challenge of embedding the national undergraduate palliative care curriculum6 into their programs. Currently, neither the national intern training curriculum7 nor the Royal Australian College of General Practitioners vocational training curriculum8 includes palliative care as a distinct entity. Many parts of both curricula could be covered by structured teaching of palliative care. Educational strategies aimed at established GPs should take into account the variable level of their skills and interest in palliative care. Such strategies include: reinforcing the core skill set, especially during vocational training; opportunistic case-based education, based on adult learning principles; accessible and available local teaching; financial support to attend educational sessions (including locum fee support); and funded longer-term placements for GPs interested in making palliative care a major part of their practice. Both specialist palliative care services and services involved in the pre-palliative phase of a patient’s disease (when the focus is on curative measures) must accept GPs as an integral part of the care team and work towards integrating GP input into patient care planning, patient review and management. Maintaining clear lines of communication between hospitals and GPs is important, but, unfortunately, not always done well.1 When patients are discharged from curative care, GPs need to be informed and their responsibilities delineated. Direct transfer of patients to palliative care units without keeping GPs informed and without giving them a defined role sends a message that they are not valued in this setting. Case conferences at the point of transfer can be useful. Furthermore, offering GPs responsibility during care planning and seeking their involvement in routine surveillance of patients during the pre-palliative phase (with clear protocols in place)9 might facilitate their involvement when patients enter the palliative phase of the illness. Specialist palliative care services should not take on the role of finding an alternative GP or acting as primary care provider for patients whose GP will not or can not accept this responsibility — rather, this role should be referred back to the GP.10 GPs, in turn, should accept this responsibility and embrace or initiate shared-care models (Box 2). Such models have been established successfully here and overseas.11-13 Divisions of General Practice could play a key role (not yet well exploited) in encouraging formal shared-care arrangements — only 9% of Divisions were involved in palliative care shared-care projects in 2002.14 A significant proportion of Australians are from minority ethnic backgrounds, including Indigenous Australians. Many GPs who care for people from minority cultural groups require cross-cultural training relating to issues of death and dying. Many GPs who care for people of their own cultural group, while understanding the barriers to care that different cultural beliefs may pose, nevertheless have difficulty reducing the impact of these beliefs. Some GPs and communities require assistance in participating in and benefiting from mainstream models of palliative care. Palliative care should be a rewarding part of general practice,15 and indeed the skills of good palliative care closely mirror those of good general practice care. It is essential that this core task is not diminished by, or lost in, the current rapid evolution of consumer needs, financial uncertainties, structural changes and increasing training imperatives. 1: Barriers to greater general practitioner participation in palliative care Structural barriers GP undersupply and uneven distribution Time constraints for adequate service provision Changing demographics (eg, increased proportion of female and part-time GPs) Safety fears around home visits Cost inefficiencies of providing quality palliative care Rising practice costs and related pressures Knowledge barriers Sporadic patient load Rapidly expanding knowledge base of palliative care Competing educational priorities Practical barriers to undertaking training (eg, time, cost, availability of locum support) Lack of structured basic training undergraduate curricula national intern training curricula culturally specific palliative care Service barriers Suboptimal planning of palliative care provision after attempted curative measures Lack of active GP involvement in care during curative phase or in transition from curative to palliative care “Specialisation” of palliative care Unclear role definition for GPs in specialist palliative care service environment or among multiple service providers with palliative care brief 2: Roles of general practitioners and specialist palliative care services in palliative care General practitioners Provision of contextual knowledge of patient, family dynamics, history of illness to team’s care plan Routine medical surveillance Early intervention to prevent or control symptoms Medical care of carers Specialist teams Provision of specialist advice on symptoms and treatment to team’s care plan Nursing and allied health services Pastoral care Access to inpatient admission Either GPs or specialist teams (by negotiation) Care coordination After-hours emergency care Bereavement surveillance of carers

Geoffrey K Mitchell FRACGP, FAChPM · Elizabeth J Reymond PhD, FRACGP, FAChPM · Barry P M McGrath MB BS, MPH, PhD

Objective: To identify prescription drug-seeking behaviour patterns among young people who subsequently died of heroin-related overdose.Design: Linkage of Medicare and Pharmaceutical Benefits Scheme and Coroner’s Court records from Victoria.Subjects: Two hundred and two 15–24-year-olds who died of heroin-related overdose between 6 January 1994 and 6 October 1999.Main outcome measures: Patterns of use of medical services and prescription drugs listed on the Pharmaceutical Benefits Scheme in the years before death, and use of all drugs just before death.Results: Polydrug use was reported in 90% of toxicology reports, and prescription drugs were present in 80% of subjects. Subjects accessed medical services six times more frequently than the general population aged 14–24 years, and more than half of all prescribed drugs were those prone to misuse, such as benzodiazepines and opioid analgesics. A pattern of increasing drug-seeking behaviour in the years before death was identified, with doctor-visitation rates, number of different doctors seen and rates of prescriptions peaking in the year before death.Conclusions: An apparent increase in “doctor shopping” in the years before heroin-related death may reflect the increasing misuse of prescription drugs, but also an increasing need for help. Identification of a pattern of escalating doctor shopping could be an opportunity for intervention, and potentially, reduction in mortality.

Raymond F Martyres MB BS, MMed, FRACGP · Danielle Clode BA(Hons), DPhil(Oxon) · Jane M Burns BA(Hons), PhD