General medicine

Objective: To assess trends in the first two years of prescribing of COX-2-selective non-steroidal anti-inflammatory drugs (C2SNs) by Australian general practitioners.Design: Retrospective analysis of deidentified electronic patient records from GPs enrolled in the General Practice Research Network (GPRN).Setting and participants: Overall prescription rates for C2SNs and NSAIDs were assessed for all GPRN participants (437 GPs) between 1 September 1999 and 30 September 2002. Also, three cohorts of patients, with at least 12 months of prescription data, who received their first prescription for celecoxib between August and October 2000 (Cohort 1, 2366 patients), celecoxib between February and April 2001 (Cohort 2, 640 patients), and rofecoxib between February and April 2001 (Cohort 3, 608 patients) were selected for further analysis.Main outcome measures: Age and sex of patients; reason for prescription; previously prescribed pain medications and concomitant use of medications that could predispose to an adverse renal or bleeding event.Results: Prescriptions for C2SNs increased dramatically after they were listed on the Pharmaceutical Benefits Scheme (PBS). C2SN prescriptions for patients aged less than 65 years accounted for 52.6%, 59.5% and 50.7% of those in Cohorts 1, 2 and 3, respectively; large numbers of patients in the study cohort had reasons recorded for prescription that did not comply with PBS restrictions, and between 36.7% and 61.3% of patients in the three cohorts had not received a prescription for any pain medication in the year before being prescribed a C2SN. Between 4.7% and 7.9% were coprescribed drugs that could cause renal complications.Conclusions: Rapid, early adoption of C2SNs by Australian GPs has resulted in prescribing and drug use patterns that were not in accord with quality use of medicine (QUM) principles.

Stephen J Kerr BPharm, PhD · Andrea Mant MD, MA · Fiona E Horn BSc, MPH · Kevin McGeechan BSc · Geoffrey P Sayer BSc(Psychol), MCH

Objectives: To examine the complexity of activities undertaken in general practice in relation to degree of rurality of the practice.Design and setting: National mail questionnaire survey across non-metropolitan Australia in July 2002.Participants: 1498 respondents out of 4406 GPs providing at least 375 Medicare-rebatable consultations in rural and remote locations during January–March 2002 (response rate, 35%).Main outcome measures: Responses to five sentinel measures of practice complexity.Results: In general, the proportion of GPs providing complex services increases with increasing rurality or remoteness. Isolated rural and remote GPs manage myocardial infarctions to a higher level than GPs in larger rural and regional centres, are more likely to administer cytotoxic drugs, perform forensic examinations, stabilise injured patients pending retrieval, and coordinate discharge planning more often.Conclusions: The more rural or remote the area, the more likely a GP is to be regularly engaged in complex care. These findings have implications for the workload, responsibility, vocational satisfaction, need for professional education and support, and costs and remuneration of practice.

John S Humphreys BA(Hons), PhD · Judith A Jones BA(Hons), MSPD · Michael P Jones BSc(Hons), PhD · David Mildenhall DANZCOG, DCH, FACRRM · Paul R Mara DipRACOG, FRACGP, FACRRM · Bruce Chater FACRRM, FRACGP, DRANZCOG(Advanced) · David R Rosenthal DipRACOG, FAMA, FACRRM · Nola M Maxfield MB BS, DipRACOG, FACRRM · Michael A Adena PhD, Astat, MACS

Ian Gardiner, the second son of Scottish immigrants, was born in Sydney on 30 December 1915. He attended Canterbury Boys High School and studied medicine at the University of Sydney, graduating in 1939. During his undergraduate years he was a member of the Sydney University Regiment and represented the university at baseball. Ian did his residency at Royal South Sydney Hospital, where he met Betty, a charge nurse, whom he married in 1941. After a stint in general practice at Cessnock, Ian joined the Royal Australian Air Force as a medical officer. Having a keen interest in what is now called “electronics”, he was seconded to the Neurophysiology Department of Sydney University for research on “g” forces. In 1945, he spent 6 months in Dayton, Ohio, to further this work. Ian, in conjunction with Geoff Trahair and Vince Bennett, assembled the first electroencephalographic (EEG) machine in Australia. A plaque at the Royal Prince Alfred Hospital, Sydney, records this event. Between 1946 and 1967, Ian worked as a general practitioner in Sydney and other parts of New South Wales: Lidcombe, Helensburgh, Berridale and finally Ryde. He developed a large practice specialising in psychosomatic illnesses. Although this was very demanding work, Ian was renowned for his great patience and understanding. He was a GP of the “old school” — surgeon, anaesthetist, obstetrician, family counsellor, physician and friend to so many of his patients. From 1967 to 1978, he worked as a Medical Officer in psychiatry for the NSW Health Commission. Ian was meticulous in all things, from his copperplate writing to his spotless car and impeccable personal appearance. He had several passions in life. Firstly, red wine, for which he had developed a taste during his early GP days in Cessnock (near the Hunter Valley wineries). Secondly, lawn bowls, for which he won the state No. 2 Pennant with the Ryde Bowling Club. Thirdly, driving in the outback. He combined this interest with his professional life by providing a visiting psychiatric service to Broken Hill and the far west of New South Wales. Fourthly, electronics, a lifelong hobby and passion. Ian built his own radiogram, obtained his ham radio licence at 15 years of age, had his own transmitter and receiver, and was a constant purchaser at Dick Smith electronics stores. But Ian’s greatest passion was his family. For them he was a constant source of inspiration — unconventional, questioning and challenging. He died on 2 April 2003 of heart-related illness and is survived by his wife Betty and children Judy, Ian, Fiona and Susan. Judith R Gardiner, David Pullen

Judith R Gardiner · David Pullen

Palliative care teams have made an important contribution to improving the care of patients with incurable illnesses in Australian hospitals over the past 20 years. Collocation of hospital-based palliative medicine specialists with other specialties allows communication and exchange of ideas on issues relevant to the medical care of such patients. Shared management of complex cases maximises comprehension of patient distress and optimises the support provided during hospitalisation. Tensions arising across the interface provide opportunities for both groups to improve the relief of suffering in the acute-care setting. Palliative medicine in the private sector has some advantages, but specialists also face specific challenges, including the cost of certain drugs, access to the multidisciplinary team and reimbursement issues.

Paul A Glare MB BS, FRACP · Katherine J Clark MB BS, FRACP, FAChPM · J Norelle Lickiss MD, MSc, FRACP · Kirsten A Auret MB BS, FRACP · Ghauri Aggarwal FRACP, FAChPM · Sarah E Pickstock MA, MB BS, FRACGP

Objectives: To explore doctors’ perceptions of the acceptable limits to self-treatment and to identify barriers to doctors seeking appropriate healthcare.Design: Self-completion, postal survey using three hypothetical case vignettes.Setting and participants: 896 Australian doctors randomly selected from the Health Insurance Commission database and stratified by sex, discipline (general practitioner or specialist) and location (urban or rural). Data were collected between May and July 2001.Main outcome measures: Doctors’ self-reported attitudes on illness behaviour and choice of medical care in response to case vignettes.Results: 358 (40%) doctors returned questionnaires. More participants believed it was acceptable to self-treat acute conditions (315/351; 90%) than to self-treat chronic conditions (88/350; 25%). Nine per cent (30/351) of participants believed it was acceptable to self-prescribe psychotropic medication. A greater proportion of GPs (206/230; 90%) than specialists (101/121; 83%) believed doctors are reluctant to attend another doctor, especially if the problem is psychological. Women and GPs were significantly less likely to report that it was easy to find a satisfactory treating doctor (women, 58/140 [41%]; men, 128/211 [61%]; GPs, 106/231 [46%]; specialists, 80/120 [67%]). Being a specialist was predictive of seeking appropriate healthcare for all three vignettes.Conclusion: Doctors have varying opinions regarding the acceptability of self-treating chronic conditions, and perceive considerable barriers to seeking appropriate medical care. Strategies are needed to challenge the culture of self-reliance.

Sandra K Davidson BA, GradDipBehlStudiesHlthCare · Peter L Schattner MD, MMed, FRACGP

Gavin Turrell,* Brian F Oldenburg,† Elizabeth Harris,‡ Damien J Jolley,§ Merel L Kimman¶ * Senior Research Fellow, † Head of School, ¶ Student, School of Public Health, Queensland University of Technology, Victoria Park Road, Kelvin Grove, QLD 4059; ‡ Director, South West Sydney Area Health Service, Centre for Health Equity Research, Training and Evaluation, Liverpool, NSW; § Director, School of Health Sciences, Biostatistics and Epidemiology Unit, Deakin University, Burwood, VIC. g.turrellATqut.edu.au To the Editor: Studies investigating the relationship between socioeconomic status (SES) and use of healthcare services suggest that, in metropolitan regions, low-SES groups consult general practitioners more frequently than high-SES groups.1 The primary reason is their poorer health and hence greater medical need (however, distributional, operational and financial factors associated with the provision of general practice services are also important). Is a similar relationship found between SES and GP use in non-metropolitan areas? We investigated this issue using data from the Social health atlas of Australia project.2 We defined “GP use” as unreferred services3 provided by general and vocationally registered practitioners (not specialist medical practitioners), delivered at a surgery or clinic, a patient’s home, or an institution such as a hostel or nursing home. Specifically, 952 statistical local areas (SLAs), comprising 98.6% of all SLAs for the six Australian states, were classified into four geographic remoteness categories (see Box) using the Accessibility/Remoteness Index of Australia (ARIA).4 Within each ARIA category, we grouped SLAs into tertiles of socioeconomic disadvantage based on their Australian Bureau of Statistics’ Socio-Economic Indexes for Areas (SEIFA) score. We then compared the average rates of GP use between tertiles for the 2-year period 1996–1997. Our analysis included a measure of the number of full-time equivalent (FTE) GPs per 10 000 population in each SLA as a test of equity: similar or higher rates of GP use in disadvantaged SLAs independent of GP availability suggest equity of access. In areas classified as “highly accessible”, rates of GP use were significantly (10%) higher in disadvantaged SLAs after adjusting for GP availability (Box). The reverse was found in “remote/very remote” areas, where rates of GP use were about 36% lower in disadvantaged SLAs. Also, the strength of the relationship between GP availability and GP use differed across the ARIA categories. In “highly accessible” areas, a unit increase in the number of FTE GPs per 10 000 population was associated with a 1% increase in GP use, whereas in “remote/very remote” areas it was associated with a 15% increase (data not shown). This suggests that disadvantaged groups in rural and remote areas experience disproportionate difficulty accessing GP services. These areas are underserved by GPs, who charge more for their services and are less likely to bulk-bill.5 It seems that in metropolitan regions the Medicare principle of equity of access to GP services is being realised (ie, people with higher levels of morbidity are making greater use of GP services), whereas in remote and very remote areas this is not the case. The findings might also reflect the fact that disadvantaged groups (especially in rural and remote areas) make greater use of emergency departments of local hospitals or other community-based or primary care outreach services — these services are not covered by Medicare and, therefore, are not taken into account in the rates of GP use presented here. Association between socioeconomic disadvantage and use of general practitioners within ARIA* categories† * ARIA (Accessibility/Remoteness Index of Australia) categories:4 Highly accessible: areas with relatively unrestricted access to a wide range of goods and services and opportunities for social interaction. Accessible: areas with some restrictions to accessibility of some goods, services and opportunities for social interaction. Moderately accessible: areas with significantly restricted accessibility of goods, services and opportunities for social interaction. Remote/very remote: areas with very restricted or very little accessibility of goods, services and opportunities for social interaction. † Relationship between area disadvantage and GP use is adjusted for number of full-time equivalent GPs per 10 000 population. ‡ Each tertile comprises approximately a third of the statistical local areas (SLAs) in the six Australian states. The high and low tertiles comprise the 33% least and most socioeconomically disadvantaged SLAs, respectively.

Gavin Turrell · Brian F Oldenburg · Elizabeth Harris · Damien J Jolley · Merel L Kimman

The Australian Institute of Health and Welfare, using the definition “a disability which restricts a child’s ability to perform tasks associated with daily living”,1 reported that in 2002 almost 300 000 Australian children (7.5%) had a disabling chronic illness. The disability was primarily physical in 54% of children, and intellectual/developmental/behavioural in 46%. Asthma comprised 31% of the physical conditions, the rest being other respiratory diseases and diseases of the ears and nervous system.1 It is estimated that, at any given time, 23% of Australian children have recent asthma, 10% have eczema, and 15% have emotional/behavioural problems. For comparison, 0.5%–1% of the whole population has epilepsy, of which about 60% begins in childhood; about two per 1000 schoolchildren have juvenile-onset diabetes mellitus; and the incidence of childhood cancer is about 14 per 100 000, with a 75% survival rate.1 Although advances in technology have greatly improved survival for many children (eg, those born prematurely, or those with cancer or cyanotic heart disease), they have also created a population of children living with disabilities. Without belittling these technological achievements, it is important that the quality of life of survivors also be considered. For example, over 50% of extremely low birthweight babies (500–999 g) now survive to discharge, but 15%–20% of survivors have a major disability (cerebral palsy; visual, auditory or intellectual impairment), and at least half the remainder have significant learning difficulties.2 For all children with disabilities, limitations to schooling, mobility and communication constitute the most significant restrictions of daily activity.1,3 Psychosocial impact of chronic conditions. Chronic conditions put increased stress on the child and the child’s parents and siblings. Children with any chronic condition have twice the risk of developing mental health disorders of healthy children, and three times the risk if they have an accompanying disability.3 The clinical “severity” of the condition is not necessarily the major psychosocial prognostic factor. For example, the stress on a family of caring for a child with moderate or severe eczema exceeds the stress related to insulin-dependent diabetes mellitus.4 Conditions that disrupt sleep for the child and the parents are possibly the most stressful. A child’s view of his or her quality of life may differ from the views of parents and others.2 Children born with chronic conditions may be more accepting of handicap, even while recognising their difference from other children,5 and they often adjust better to visible handicaps than to hidden ones.3 It is important to emphasise what disabled children can do, rather than what they cannot do. One positive approach to chronic illness is to consider the factors that enable most children and families with chronic illness to cope as well as they do. It has been advocated that we should focus on interventions to improve this resilience, although there is a dearth of supportive research.3 Robert Louis Stevenson, who had pulmonary tuberculosis, said that “life is not a matter of holding good cards, but of playing a poor hand well”. The prognosis for a child with chronic illness is highly dependent on how the family functions. The illness places stress on parents and siblings, who may themselves become exhausted and develop psychological problems such as anger and depression. It is vital to communicate well with the parents or carers of chronically ill children, and not to forget the siblings, whose needs are easily neglected if parents focus too much on the sick or disabled child. Avoidable risk factors for psychosocial problems include prolonged ambiguity about the diagnosis and poor communication to parents and siblings. Other risk factors include stressors such as moving house or changing schools, as well as the known underlying risks of low socioeconomic status, marital discord and parental mental health problems.3 Warning signs of distress in children include problems at school or in social relationships; low self-esteem, manifested as self-blame, helplessness or hopelessness; and denial, including poor compliance with treatment. Psychological problems may manifest as anxiety, depression, oppositional behaviour, suicidality or disorders of eating, conduct or sleep.3 Interventions that have been shown to be beneficial include family therapy, supportive counselling of children and parents, and the use of supportive protocols such as those blending advocacy and liaison work.3 Overall adjustment is better with family-centred interventions and when needs are met in the home.3 Prevention. Disruptive influences in early infancy can be particularly damaging to later emotional and psychological development. Studies are under way to see if strategies to improve the early childhood environment (eg, parenting support and universal early childhood programs) can effectively optimise development and prevent chronic mental health problems. Recommendations. Consensus guidelines, developed by an expert panel and based on best available evidence,3 include the following recommendations: Practical support. Families need clear communication, with healthcare professionals and with each other; opportunities for choice of supports; and practical assistance with finances, transport, respite care and recreation. Additional support may be needed for staff and peers at school. Many parents report benefits from involvement in self-help groups. Multidisciplinary teams. Assessments by well qualified teams can identify areas of immediate and future need and can improve communication between professionals, children and families. Self-determination. Young people with chronic conditions should be allowed to decide which professionals coordinate their care, what form of treatment they want, and what part they wish to play in their own treatment.

David Isaacs MD, FRACP, FRCPCH · Jill R Sewell MB BS, FRACP

Thirty years ago, Pless and Pinkerton1 highlighted the fact that, although children and adolescents experience a diverse range of illnesses, those with chronic conditions have great similarities in their life experiences and in the preventive and rehabilitative aspects of their lives. Since then, the intensity of treatment programs recommended for managing adolescent chronic illnesses has increased greatly. As a result, the daily lives of adolescents with chronic illness are often very different from those of their healthy peers. Adolescents with a chronic illness have usually lived with the illness for much of their lives. Although there is generally no prospect of a cure, they have to complete time-consuming and inconvenient treatment tasks every day. Treatment regimens now recommended for managing chronic illnesses are intensive and often tedious, but there is evidence that they can lessen the impact of some disorders (eg, in adolescents with diabetes, good metabolic control is associated with better quality of life).2 As adolescents take over management of their illness from their parents, they have to decide to what extent they will comply with treatment. Young people who develop a chronic illness during adolescence often have difficulty accepting their illness, and treating them can be quite a challenge for physicians. In a recent two-year prospective study of chronic illness conducted by our group,3 we found that adolescents with diabetes did not consider the restrictions on their regular food or drink intake a large inconvenience. However, managing their illness (including injecting insulin and monitoring blood glucose levels) took them an hour a day, on average. Adolescents with cystic fibrosis spent even longer (1.5 hours a day) managing their illness: typically, they began each day by consuming a large quantity of tablets, followed by other tasks including physiotherapy, the use of inhalers and nebulisers, and possibly overnight feeding. Managing chronic illness can be particularly difficult for adolescents while at school. Secondary schools find it hard to be flexible in accommodating students’ healthcare needs and doing so in a way that protects their privacy and dignity. Adolescents and their families feel frustrated when they have to explain their needs repeatedly to new staff or in new situations such as camps and excursions. These problems can be exacerbated when young people need the support of a visiting nursing service. Nursing roster changes may put adolescents in the position of having to explain their treatment needs more than once to an unfamiliar nurse in a school setting that is not designed to provide healthcare. The combined impact of their health support needs and increasing academic demands increases the risk that adolescents with chronic illness will leave school early and not fulfil their vocational potential. Chronic illnesses adversely affect adolescents in a range of ways. For example, the impact of recurrent asthma symptoms is widespread, with exercise-induced dyspnoea often limiting participation in sport and daily exercise. For those with diabetes, adolescence is perhaps the most challenging time for illness management: the physiological insulin resistance of puberty is exaggerated in adolescents with diabetes, and the first subclinical signs of microvascular complications are starting to appear. Adolescents with cystic fibrosis are more likely to be shorter and thinner than their peers and to have more difficulty with issues of intimacy and sexuality. Although most are socially competent, they tend to take less part in social activities outside the home.4 Epidemiological studies have shown that adolescents with chronic illness have twice the rate of mental disorders as their healthy peers.5 While there is evidence that intensive therapy improves the wellbeing of adolescents with chronic illness, careful organisation of daily activities is necessary to complete all the treatment tasks. This requirement conflicts with adolescents’ desire to participate in spontaneous activities being enjoyed by healthy peers and to experiment with new autonomy and freedom from parental control. A major challenge for those responsible for developing new treatment regimens is to achieve a partnership with adolescents to ensure that new programs are both effective and acceptable to the adolescents who will be responsible for implementing them.

Michael G Sawyer MB BS, PhD, FRANZCP · Jennifer J Couper MB ChB, MD, FRACP · A James Martin MB ChB, MRCP, FRACP · J Declan Kennedy MD, FRCP, DCH

The prevalence of degenerative chronic illnesses is low in Australian adults aged 25–44 years. Using the estimated number of years of life lost due to disability as a measure of the burden of disability, the most important chronic disabilities for this age group can be attributed to alcohol misuse, depression and anxiety disorders (particularly generalised anxiety disorder and social phobia).1 According to Australian general practice data collected in the 1999–2000 BEACH (Bettering the Evaluation and Care of Health) survey, a disproportionately high number of mental-health problems are managed in the 25–44 years age group (26% of all general practice consultations, yet 33% of all encounters involving one or more mental-health related problems, were for 25–44-year-olds).2,3 Excessive alcohol consumption and depression are also major risk factors for two of the principal causes of mortality in this age group — road traffic accidents and suicide. This age group coincides with the peak phase of life, during which most Australians would anticipate marrying, raising a family, purchasing their first home, advancing their careers and laying down financial security for the future. Depression, anxiety disorders and alcohol misuse have the potential to severely interfere with the achievement of these goals. The psychological, emotional and financial consequences affect individuals and their families, as well as the community (directly, via treatment and hospitalisation costs, and indirectly, via work absenteeism and reduced productivity).4,5 This is in addition to the known potential physical complications of these conditions. The impact of depression, anxiety disorders and alcohol dependency is confounded by the fact that each condition can coexist with the others, and indeed with many other harmful lifestyle factors and chronic illnesses. There is some evidence that depression is underdiagnosed and undertreated in primary-care settings,4 and this is almost certainly the case for anxiety disorders and alcohol misuse. It is also of concern that many people with these conditions do not regularly seek medical assistance.6 Given that various successful evidence-based treatments are available to assist in managing these conditions — including psychosocial interventions (cognitive, behavioural and/or interpersonal psychotherapies) and a range of pharmacotherapies5,7 — we need to ask ourselves why so many affected individuals do not seek professional assistance, or resist treatment. Issues that may prevent consumers from accessing effective management include lack of recognition of symptoms, lack of awareness of the treatments available, a mismatch between consumers’ and health professionals’ views of treatment, poor compliance with prescribed therapies, fear of stigma, and fear of dismissal from significant others.5 Healthcare providers, on the other hand, may be prevented from recognising and managing mental-health disorders by lack of skills/training, time pressures in general practice, and perceived lack of access to advice from specialist mental-health services.5 Effective management of these chronic conditions requires a coordinated response involving individuals, families, communities, workplaces, health professionals, health organisations and governments. The ability to recognise early symptoms, and to identify contributing psychological and social risk factors, as well as comorbidities and complications4 is important for health professionals, public health planners, and the general public. Guidelines from the Royal Australian College of General Practitioners recommend that clinicians should be constantly vigilant for depressive symptoms in high-risk patients and should ask all patients aged 14 years and over about the quantity and frequency of alcohol intake.8 It is essential that these conditions be destigmatised, and that patients have access to affordable therapies provided by adequately skilled health professionals within a reasonable timeframe. Finally, while chronic-disease risk factors such as obesity, tobacco smoking, hypercholesterolaemia and physical inactivity are responsible for a much greater burden of morbidity and mortality in people over 45 years than in younger age groups, a substantial number of 25–44-year-olds have at-risk levels of these factors.1 Opportunistic health promotion is encouraged when young adults present for other reasons in general practice.

Marie-Louise B Dick MB BS FRACGP MPH

Middle age is when the accumulated interactions of genetic predisposition, environment and lifestyle commonly start to impact on health. Ischaemic heart disease and chronic obstructive pulmonary disease, for example, often become symptomatic in these years. The World Health Organization predicts that by 2020 these two conditions will be among the five leading causes of disease burden globally. Ischaemic heart disease is already the leading cause of disability in Australia and is the most common cause of death among Indigenous Australians. Over the past three decades, it has become clear that aggressive medical and surgical treatment of ischaemic heart disease improves quality of life and reduces mortality.1 Medical treatment improves quality of life in chronic obstructive pulmonary disease.2 Exercise rehabilitation and lifestyle modification are beneficial in both conditions, even after symptoms develop. Stopping smoking remains the key to reducing mortality from chronic pulmonary disease, and is similarly important in ischaemic heart disease. The WHO has pointed out that across the world most healthcare systems fail to implement fully the knowledge we already have to redress the growing problem of chronic illness. Five deficiencies are identified: Care is fragmented and focused on acute and emergent symptoms; The patient’s role in management is not emphasised; Follow-up is sporadic; Community services tend to be ignored; and Prevention is underused. Although there have been significant developments in Australia in recent years, including the introduction of Enhanced Primary Care Medicare items (which allow general practitioners to devote more time to managing chronic illness), as well as initiatives by states and territories, the deficiencies identified by the WHO are all too evident in many parts of the Australian healthcare system. And yet we know what is needed.3 Continuity of care, by a single general practitioner if possible, can provide the basis of a therapeutic alliance and enhance adherence to an agreed treatment plan. In a condition such as ischaemic heart disease, which may require treatment with multiple drugs, the patient–doctor relationship is an important factor in promoting and sustaining adherence.4 In chronic obstructive pulmonary disease, where the single most effective treatment is lifestyle change, many patients are helped by support in goal setting, action planning and discussion of the reasons for relapse. Patients and their families need access to information and resources to help them deal with chronic illness on a day-to-day basis, as well as contingency plans for when problems arise. Optimal management of some chronic diseases, such as diabetes mellitus and asthma, depends on patients having the means for self-monitoring their condition. Most chronic diseases require regular medical review for optimal management, and evidence suggests that active and sustained follow-up is associated with improved outcomes.3 Of course, the care of chronic disease requires input from patients, family and non-medical health professionals, as well as from general practitioners and other specialists. If this extended healthcare team is to function optimally, then all members require timely access to relevant information. Clinicians must be able to obtain details of treatment and the results of investigations by others, and emerging solutions such as the electronic health record will fill this need. As we wait for this technology to mature, innovations such as the New South Wales patient-held “My Health Record” plug a significant gap. These developments alone will not rectify the appallingly high morbidity and mortality of Indigenous Australians in the 45–64-year age group. Indeed, it is inappropriate to describe these as the “middle years”, when most Aboriginal people die during them. It is a national disgrace that the median age at death of Indigenous Australians remains almost a quarter-century less than that of the remainder of the population. However, there are some promising developments. The revised National Strategic Framework for Aboriginal and Torres Strait Islander Health is expected out this year; it is hoped it will build on and expand the scope of the current Primary Health Care Access Program, and will also look beyond the health sector to the need for a national infrastructure plan to rectify the continuing deficiencies in many communities in water supply, sanitation, education and other basic services.5 The Aboriginal and Torres Strait Islander Health Workforce National Strategic Framework has already been published;6 if fully implemented, this will do much to enhance the capacity of the health sector to respond to the needs of Indigenous Australians. In addition, the health of the population as a whole will be greatly improved if politicians find the will to do far more to reduce smoking and to combat the growing epidemic of obesity in Australia today.

Tim Usherwood MD, FRACGP, FRCP

The majority of older people remain in good health until a relatively short period before their death. Most of those who acquire chronic illness tend to have only mild to moderate disability and are not dependent on others for life’s basic tasks. Common chronic diseases associated with mild disability include arthritis, hypertension, ischaemic heart disease and diabetes mellitus. However, the minority of older people who have chronic illness associated with severe disability have a large impact on our healthcare and welfare systems. Depression, Alzheimer’s disease and other dementias, stroke with residual disability, and various progressive neurological disorders contribute greatly to the overall burden of disability experienced by our society. Although circulatory, neoplastic and respiratory diseases are the most common causes of death, nervous-system disorders contribute the greatest proportion of years of life lost to disability in the older population.1 Disability-adjusted life-years (DALYs), which combine the effects of shortened life expectancy and years lost to disability, enable an assessment of the overall burden of illness. In terms of DALYs, ischaemic heart disease and stroke rank first and second, respectively, in both sexes, followed by lung cancer in men and dementia in women.1 While the experience of chronic illness is different for each individual, its impact may be experienced in two broad dimensions, depending on the nature of the illness and the type of disability it produces. The patient may experience predominantly somatic symptoms, such as dyspnoea, pain, weakness, lethargy or nausea. The resulting discomfort interferes with enjoyment of life. Many people with conditions such as cardiac, respiratory and neoplastic disorders may remain relatively independent, at least in the confines of their own home, until late in the progression of the illness. However, they live with the constant threat of exacerbation and associated visits to hospital, and uncertainty about their life expectancy. Our challenge with these patients is to ameliorate distressing symptoms, halt progression of the disease, and prevent complications and unnecessary hospital admissions. On the other hand, the patient experience may be dominated by disability and handicap. Patients in this situation become distressed by their lack of independence in various life skills, which ultimately reduces their ability to survive in their “usual” living environment. Chronic conditions such as stroke and degenerative neurological disorders cause profound disturbances of personal functioning that increase as the illness progresses, such that dependence on others becomes continuous. Basic tasks such as walking, bathing, dressing and feeding become impaired. The situation is exacerbated by the presence of cognitive dysfunction. Ultimately, survival at home is dependent on the support of family members, often with the assistance of community services. It is these illnesses that drive the demand for nursing home places. Some 70% of residents of nursing homes have moderate to severe cognitive impairment. These clinical scenarios highlight the predicament that faces all societies as the proportion of older people increases. With smaller families, and greater numbers of people entering old age either divorced or never married, there is a considerable challenge to provide the care that is so vitally needed. The paucity of family-member carers will be accompanied by declining numbers of people in the workforce. Similarly, the number of taxpayers who provide funds for care will decline in relation to those requiring it.2 Ultimately, the challenge will be to minimise the period of discomfort and dependence on others towards the end of life. This will require advances in prevention, management of disability and technology to reduce the reliance on others. It will also require robust social service support networks and public utility infrastructure that are sensitive to the needs of elderly people and provide adequate high-quality residential care for people who can no longer live independently.

Leonard C Gray PhD FRACP · Ian A Scott FRACP MHA MEd

Information and communications technology (ICT) is increasingly being used in management of chronic illness to facilitate shared services (virtual health networks and electronic health records), knowledge management (care rules and protocols, scheduling, information directories), as well as consumer-based health education and evidence-based clinical protocols. Common applications of ICT include home monitoring of vital signs for patients with chronic disease, as well as replacing home visits by nurses in person with telemedicine videophone consultations. A patient-managed Home Telecare System with integrated clinical signs monitoring, automated scheduling and medication reminders, as well as access to health education and daily logs, is presented as an example of ICT use for chronic disease self-management. A clinical case study demonstrates how early identification of adverse trends in clinical signs recorded in the home can either avoid hospital readmission or reduce the length of hospital stay.

Branko G Celler PhD · Nigel H Lovell PhD · Jim Basilakis MB BS, Research Associate

Seven of every 10 general practice encounters are for chronic conditions. Three common chronic conditions managed by GPs are depression, diabetes and asthma. Two of these are National Health Priority Areas (NHPAs), while depression is the focus of the mental health NHPA. General practice care for people with depression is being strengthened by the “Better outcomes in mental health care initiative”, which includes a 3 Step Mental Health Process — assessment, mental health plan, and review. GPs have the opportunity to screen patients for diabetes and manage their condition. For those with risk factors who screen negative, GPs are well placed to encourage lifestyle interventions. Two of the four components of the National Integrated Diabetes Program focus on general practice. The Asthma 3+ Visit Plan, which incorporates diagnosis and assessment of asthma, development of a written asthma plan, and review of asthma management, has been shown to improve GPs’ management of asthma. These initiatives to improve general practice interventions for chronic illness, although welcomed, put further pressure on already overstretched GPs coping with multiple changes in the primary-care sector.

Bronwyn M Veale

Patient-centred care is about sharing the management of an illness between patient and doctor; it is not new but is increasingly evidence-based, especially for chronic problems such as diabetes, asthma and arthritis. Systematic reviews show that patient-centred care results in increased adherence to management protocols, reduced morbidity and improved quality of life for patients. Key features of the doctor–patient interaction are shared goal setting, written management plans and regular follow-up. Supportive community-based services and programs, combined with healthcare system commitment, are also required to make this approach effective in improving population health.

Adrian E Bauman MPH, PhD, FAFPHM · H John Fardy DRCOG, FRACGP, GradCertPH · Peter G Harris FRACGP

Healthcare workforce shortfalls require a rethinking of models for delivering care to people with chronic disease. Chronic disease needs to be managed by a multiskilled team of healthcare professionals with specialist input. Education at undergraduate, graduate and postgraduate levels needs to prepare healthcare professionals for this new paradigm. Some tasks currently seen only as part of a doctor’s purview could be performed by other trained professionals to allow doctors to concentrate on more appropriate activities. We need to explore new collaborations to deliver multidisciplinary healthcare for chronic disease and evaluate these for patient outcomes and cost effectiveness.

Peter M Brooks FRACP, FAFRM, FAFPHM

“Accept and adapt and never give up” I had to think long and hard before I “came out” to the world that I had scleroderma. Since my diagnosis 8 years ago, I have tried to carry on as normal and not let my “label” affect my life and work. However, when I wrote my editorial discussing a new scheme I had set up for doctors who have chronic illnesses (Box),1 I wanted to show solidarity with them. Because, believe me, I know what it is like. The chronic illness matching scheme When I was first diagnosed with scleroderma, it would have been helpful to talk to other doctors with the condition to discuss how they were coping and listen to any advice they had about work conditions and career options. It would also have been useful to talk honestly to another doctor working in some of the more feasible career areas before launching myself into them only to discover too late that they were not suitable for my health needs. The aim of the scheme is to provide the opportunity for doctors who have a chronic illness or disability to receive informal careers advice from another doctor. You can request to be matched by illness/disability, specialty, grade or country in any combination. The scheme is entirely web-based (web.bma.org.uk/public/chill.nsf). When a doctor who meets your requirements applies, you will each be sent the other’s email address. The rest is up to you. The scheme relies on your patience and goodwill: goodwill because the scheme also relies on doctors with or without chronic illness to be prepared to give career advice to other doctors, based on their own knowledge and experience, and patience because I do all the matching work manually. I first realised something was not right when I was a junior doctor working in a general medical ward. My hands were so black that I could hardly use them, but being a typical doctor I ignored it and carried on working. After a while, the consultant I was working with insisted that I get myself checked out. And I was soon labelled by the rheumatologists, who did not mince their words when they told me what was ahead. I chose not to pay heed to them. It wasn’t that I didn’t believe them, but they were quoting statistics and didn’t know me as an individual, with a marathon runner’s endurance. Long distance running was the love of my life and had instilled in me the mentality of “What’s this? — Pain — Carry on”, so I was determined to continue with my original career plan: paediatrics. But it soon became clear that working with neonates when you have black, clumsy hands is not feasible. Undeterred, I decided to become a general practitioner, and embarked on a 3-year GP vocational training course. After completing this course, I had a brief spell in psychiatry (because I thought it would be better for me health-wise), but decided after 6 months that it definitely wasn’t for me. I then worked as a GP in Glasgow for 2 years. However, by this stage, weird musculoskeletal symptoms made driving very difficult, so I gave up general practice and started training in public health, again thinking that this would be easier health-wise. But it wasn’t, and I really missed contact with patients. After a lot of heart searching, I gave it up and started training in tropical medicine, after being accepted by a charity to work in a developing country. I had worked in Bangladesh and Romania as a junior doctor and medical student, and had promised that I would go back one day. Unfortunately, I took a turn for the worse — one of my fingers became gangrenous and had to be amputated. The charity then said they didn’t want me, and I was left with nothing. No career, no job, no place to live and no money. Nevertheless, I still had my determination and my pride. I was considering retraining as a counsellor when I saw an advertisement for the post of editorial registrar with the BMJ. It was as if the advert had neon lights round it saying: “This is the one, Rhona”. To my absolute amazement, I got the job. This was even more surprising as I was in hospital when they emailed me about the interview, so I didn’t know until 24 hours before it, when my dad (who had checked my emails) phoned me in a panic. My consultant let me out for the day, I bought a suit from a charity shop (as all I had was my pyjamas), wrote the 800-word editorial they requested, unhooked myself from my treatment, and jumped on a train to London with nothing to lose. I have now been in this job for more than 2 years and feel so privileged. I see this job as such a bonus and want to do as much as I can to help other doctors. That’s why the chronic illness matching scheme (Box) is so important to me. Throughout my medical career, I have faced prejudice, pity and, worse still, the “doing well, despite health” reports. The most painful incident was when I had been off work for 4 weeks receiving treatment. As the human resources department did not organise locum cover for my absence, my colleagues had to do extra work. When I came back, they marched me into a room and said they didn’t want to work with me any more. This can still bring tears to my eyes when I think about it. So the matching scheme is my way of doing something, however small, which might help other doctors who may be in a similar situation one day. It would be better if we could stamp out all discrimination, but this is a first step. My future is uncertain. A few months ago my remaining left fingers were amputated, and a bowel operation and more finger amputations are on the cards. However, I believe I will be fine if I stick to my motto: “Accept and adapt and never give up”. I just hope that other people can also do this for me.

Rhona MacDonald MRCGP, MPH

Abdullah Demirkol,* Jan Ritchie,† Pippa Craig,‡ on behalf of nine co-researching patients * PhD Candidate, † Associate Professor in Public Health, ‡ Conjoint Lecturer, School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW 2051 j.ritchieATunsw.edu.au To the Editor: Oldroyd et al provide some revealing views of general practitioners on the many difficulties and few rewards arising from their care of chronic disease patients.1 As co-researchers in a participatory action research inquiry, exploring how nine of us living with Type 2 diabetes can better manage our condition, we read the article with interest and wish to give our perspective, as patients, on the issues addressed. Oldroyd et al report that many GPs describe chronic disease management as a “burden”. We are only too aware of this negative response when we present with our chronic conditions. GPs are usually our first, and often only, regular contact with the healthcare system. Although we would like to rely heavily on them, we rarely find they have enough time for us. The standard consultation is barely long enough for renewal of our prescriptions. Yet, for a couple of us who have recently wanted extended assistance, the situation has been exacerbated when our GPs have resisted specialist referral, on the assumption that their care is sufficient. The article reports the conflict felt by many GPs concerning implementation of clinical management guidelines, many of which they felt were not feasible in their everyday practice. Again, we share the discomfort this brings when we are informed of the guidelines, yet know that they do not fit with our own personal situation. We would dearly love more collaboration and negotiation in developing workable solutions best suited to our own unique circumstances. As one of us states, “none of those clinical, scientific studies can possibly be as long, complex and complicated as real life”. We believe we have accumulated a considerable amount of experience and knowledge about living with diabetes, and feel disappointed that our experience is not considered of value. It is apparent that we share the same goals as GPs in seeking effective chronic disease management, but the different knowledge bases and perspectives of doctors and patients have not coalesced. Involvement in this current participatory inquiry has given us the confidence to speak out and to propose that, as patients, we should become legitimate members of the treatment team. We await an invitation to be part of the process in implementing initiatives.

Abdullah Demirkol · Jan Ritchie · Pippa Craig

Ethics and evidence-based medicine. Fallibility and responsibility in clinical science. Kenneth W Goodman. Cambridge: Cambridge University Press, 2003 (xii + 168 pp). ISBN 0 521 79653 9. Goodman explores the links between scientific knowledge, clinical practice and ethics in this well-written and enthusiastic book. The main argument of the book is that practitioners are constantly faced with clinical decisions characterised by uncertainty — decisions with serious implications for patients. This uncertainty about the right course of action can be reduced through the use of evidence, making it morally blameworthy not to use evidence. For Goodman, an uninformed practitioner is a negligent practitioner, whose patients are “no longer seeing a physician, but visiting a museum”. A series of well-informed chapters engage with some of the major criticisms of evidence-based medicine (EBM). Issues such as flawed research, redundant publishing, publication bias, and the shortcomings of research synthesis are tackled squarely. Despite these problems, argues Goodman, the use of research is well founded both conceptually and practically, creating the imperative to improve the quality of research production and synthesis rather than abandon EBM. The only weakness in his reasoning is the lack of evidence that using EBM leads to better patient outcomes, or discussion of how this might be demonstrated. The author’s expertise in philosophy and computing are evident in the discussion of ethical issues raised by internet use in research, for data collection and for recruiting. As well as a chapter on clinical EBM and guidelines, the relationship between policy and evidence is explored through three case studies, providing concrete examples of the promises and problems of evidence-based public health. Overall, this is a thoughtful and sympathetic exploration of the moral imperative to use EBM. The detailed analyses are supplemented with practical suggestions, making the book of interest to academics and practitioners alike. This is a valuable early contribution on the ethics of EBM; no doubt further contributions will engage with some of the wider ethical issues that were beyond the scope of this text. Wendy A RogersNHMRC Research Fellow Flinders University, Adelaide, SA

Wendy A Rogers

Therapeutic guidelines. Antibiotic. Version 12. Melbourne: Therapeutic Guidelines, 2003 (xv + 406 pp). ISSN 1329 5039. This edition of Australia's Therapeutic guidelines — Antibiotic marks 25 years of continuous publication for the Therapeutic guidelines series and this volume has certainly matured over time — now it really can call itself a book! Not only has it grown from 31 to 406 pages, it has also developed into a more considered and better quality text. Thankfully it is still not a Cochrane review — I shudder to think of its size if that had happened — but it contains clearly enunciated and authoritative guidelines on the management of a broad range of infections. Cardiovascular, gastroenterology and respiratory physician groups have collaborated in writing the relevant chapters, and endorsements have been obtained from infectious diseases, HIV medicine, dental, nursing, sexual health and general practitioner societies, the Royal Australasian College of Physicians, the National Prescribing Service and several state and territory health departments. There are major changes in the sections on bone and joint, genital, upper and lower respiratory tract infections, HIV/AIDS, hepatitis, and biological warfare. Community acquired pneumonia has been dealt with in a more methodical and sensible way than in the book’s widely quoted North American and European counterparts. The section outlining the principles of antimicrobial use should be compulsory reading for all students and doctors — with a refresher course every 3 years! The appendices contain an encyclopedia of valuable information on drug toxicity and interactions, doses for children, pregnant women and those with renal impairment, and on how to monitor drug levels, as well as much more. I was disappointed to find only a short, noncommittal section on prosthetic joint infections. A recommendation to refer such patients to an infectious diseases physician would be wise. Some of the print has become small, although it has not achieved anything close to the eye-straining properties of the Sanford guide to antimicrobial therapy. Very few of the chapters contain further reading suggestions. All these criticisms are minor — this is a great book! It is traditional to say that a book should be on everyone's shelf, but I would strongly recommend keeping this one in a more secure place, otherwise it may disappear! Joseph G McCormackDirector of Infectious Diseases Mater Misericordiae Hospital, Brisbane, QLD

Joseph G McCormack

David Simmons,* Amanda Fieldhouse,† Leslie E Bolitho,‡ Grant J Phelps,§ Rob Ziffer,¶ Gary J Disher** * Professorial Fellow, Department of Rural Health, University of Melbourne, Shepparton; and Professor of Medicine, University of Auckland Waikato Clinical School, Waikato Hospital, Hamilton, New Zealand; † Health Care Consultant, South Yarra, VIC; ‡ Physician, Wangaratta, VIC; § Physician, St John of God Hospital, Ballarat, VIC; ¶ Physician, Sale, VIC; ** Deputy Director – Health Policy, Royal Australasian College of Physicians, Sydney, NSW. simmonsdATwaikatodhb.govt.nz To the Editor: Rural Australia has a substantial shortage of specialist physicians. In 1999, Victoria had 52 specialist physicians for 1.3 million people (a physician to population ratio of 1:25 000).1 The Australian Medical Workforce Advisory Committee recommendation is 1:10 000.2 Although much has been written about the shortage of rural general practitioners, there is little about rural specialist physicians. However, evidence from Western Australia showed that advanced trainee physicians interested in rural practice were diverted to city-based practice during their training.3 Here, we outline a state-wide approach to encourage advanced trainee physicians to complete their training in rural Victoria. The University of Melbourne Department of Rural Health in Shepparton provided support for rural Victorian physicians to develop a state-wide network, the Victorian Rural Physicians Network, under the Victorian State Committee of the Royal Australasian College of Physicians (RACP). A pilot survey in the 14 major rural Victorian centres demonstrated capacity for at least nine Advanced Physician Trainee positions across rural Victoria. The RACP accredited five positions initially, with others to be reviewed for accreditation if required. These positions were funded largely by the joint Federal–State Government Advanced Specialist Training Program in Rural Australia. Four trainees completed 12 months of rural training in 1999–2000, and three are now working as rural physicians. These trainees were recruited through advertisements in the RACP newsletter and personal contacts. The trainees provided substantial benefits, both in service delivery, as their presence reduced the load on other doctors in the same hospital, and in medical education, as they provided more education and supervision for junior doctors and doctors from overseas. In 2001, a similar approach to recruitment identified eight potential applicants, but none came to interview. In 2002, three new strategies were therefore introduced: Flexible, joint rural–metropolitan positions were created; A rural physicians’ conference was organised;4,5 and A management consultant was employed to contact personally all 99 Victorian basic physician trainees expected to enter advanced training. The response to the new approach is shown in the Box. A third of contactable trainees indicated an interest in rural practice at the end of their basic training. Ten applications were received for the rural training positions, and seven trainees were appointed (three withdrew). We believe that our new strategies have merit, and that the personal touch has created goodwill which may improve the response for 2004. Recruiting for the 2003 Advanced Physician Training Programme for Rural Victoria

David Simmons · Amanda Fieldhouse · Leslie E Bolitho · Grant J Phelps · Rob Ziffer · Gary J Disher

Australia is lagging behind other developed countries in efforts to control chlamydial infection Australian politicians are concerned about the falling fertility rate and are debating measures, such as cash incentives and paid maternity leave, to reverse the “baby bust”.1 If enacted, these measures are expected to cost several hundred million dollars per year — perhaps several thousand dollars per extra baby. Yet, Australia is at high risk of — if not already undergoing — a silent epidemic of preventable infertility and foetal loss through ectopic pregnancy caused by Chlamydia trachomatis infection. This condition can be detected by a $24 test and effectively treated with a single dose of antibiotics. Some commonly held assumptions about chlamydial infection in men need to be addressed. Chlamydial notifications have increased fourfold over the past decade (Box). However, as most infections are asymptomatic, the 26 000 cases reported in 2002 probably represent only a fraction of the true incidence and prevalence.2-4 This trend may be partly due to a reporting artefact or greater numbers or sensitivity of tests.5 Yet, if these factors were the complete explanation, the graph of notifications should have plateaued long ago. The passage of time and enhanced surveillance data6,7 indicate that most of the increase is real. The proposed National Sexual Health Strategy was shelved before the last federal election, and state-initiated Chlamydia programs designed to enhance case-finding through selective testing by general practitioners (and, therefore, Medicare) were discouraged. Australia is overdue to follow the lead of other developed nations by getting serious about controlling chlamydial infection.8 Because infected women are usually asymptomatic, and because they incur the bulk of the serious morbidity, Chlamydia programs have traditionally focused on screening women.9 Selective testing criteria for women include combinations of age under 25 years, reported change of sexual partner, non-use of condoms, unintended pregnancy, and an inflammatory Pap smear result. However, this testing is only secondary prevention — some women identified in this way will already have silent damage to their fallopian tubes and their fertility. True primary prevention mandates that women never acquire chlamydial infection. As there is no vaccine, this means avoiding infection either by behavioural means (use of condoms, non-penetrative sexual practices or sexual abstinence) or by having male partners who are not infected. In this light, some commonly held assumptions about chlamydial infection in men need to be addressed. The first is that men are less likely to be infected than women. Recent population-based surveys in Scandinavia, the United Kingdom and the United States have consistently shown similar chlamydial prevalences among heterosexual men and women.3,4,10 Higher notification rates for women (Box) probably reflect more testing of women than men.7,11,12 Longer duration of infection in women could also be part of the explanation, although how long untreated chlamydial infection can persist in either sex remains uncertain.13 Another apocryphal belief is that the bulk of men with chlamydial infection present for treatment, driven by genital symptoms.9 However, studies in the community have revealed that most men with urethral chlamydial infection, like women, are symptom-free3,4,10 — perhaps as many as three-quarters10 — and that asymptomatic men are less likely than asymptomatic women to present for testing.10 Although there are few data on the duration of chlamydial infection in men,13 it may be months or years. A better understanding of the duration of infection would enhance our ability to model potential interventions. Sweden has a long and much-acclaimed history of screening women for chlamydial infection. This has reduced the prevalence of chlamydial infection and the incidences of both pelvic inflammatory disease and ectopic pregnancy. However, these successes have begun to reverse recently, with the suggestion that Sweden’s failure to test men is a significant reason.8 Since the advent of urine tests for chlamydia, screening men has become feasible and potentially cost effective (using US parameters).12 Without this screening, the success possible with interventions aimed exclusively at women may be limited.8 To determine whether screening of men is justified, more population-based research is required on chlamydial infection in Australian men. The prevalence of infection in different subpopulations would help determine where future screening initiatives are most needed and provide a baseline for evaluating control measures. Factors associated with infection should be identified and assessed as criteria for selective screening. Studies on the natural history of infection and the cost-effectiveness of interventions would also be of global interest. While definitive screening guidelines cannot be promulgated without such data, clinicians could be remiss if a urine test for C. trachomatis was not part of the routine assessment of a young man who reports unprotected sex with a new sexual partner (female or male), regardless of symptoms. More generally, we should be asking what other factors are contributing to the re-emergence of chlamydial and other sexually transmissible infections in Australia. We also need to debate whether single-sex health models can sometimes ultimately harm women. Most women live in an environment that is also populated by men. Chlamydia trachomatis notifications in Australia Source: National Centre in HIV Epidemiology and Clinical Research (http://www.med.unsw.edu.au/nchecr/)

Marcus Y Chen MRCP, DTM · Basil Donovan MD, FACSHP

Objectives: To provide detailed projections for the prevalence of disability and associated common health conditions for older Australians for the period 2006–2031.Design: Secondary analyses of datasets (national 1998 Survey of Disability, Ageing and Carers; and projections of Australia’s population from 2006–2031) collected by the Australian Bureau of Statistics.Outcome measures: (i) The projected number of people with differing levels of disability (core activity restrictions in self-care, mobility or communication) up to 2031; (ii) The projected number of people with the main health conditions associated with disability in 2006 and 2031.Results: Projections indicate a 70% increase in the number of older people with profound disability over the next 30 years. The main conditions associated with profound or severe core activity restriction in older Australians are musculoskeletal, nervous system, circulatory and respiratory conditions and stroke.Conclusions: In the future, there will be many more older Australians requiring assistance because of disability. This will present a challenge to families, friends, volunteers and paid service providers. The Australian planning ratio for residential aged-care services and community aged care services should be changed to take account of the shift to an older population with greater need of support.

Lynne C Giles MPH, AStat · Maria Crotty PhD, FAFRM (RACP) · Ian D Cameron PhD, FAFRM (RACP)

Colleen T Bruce,* Margaret M Sanger,† Paul S Thomas,‡ Jonathon R Petkus,§ Deborah H Yates¶ * Research Assistant, ‡ Senior Lecturer, Faculty of Medicine, University of New South Wales, Randwick, NSW; † Deputy Medical Director, Concord Repatriation General Hospital, Concord, NSW; § Medical Student, ¶ Senior Lecturer, Faculty of Medicine, University of Sydney. Correspondence: Dr Deborah H Yates, Department of Respiratory Medicine, St Vincent’s Hospital, Darlinghurst, NSW 2010. deborahy88AThotmail.com To the Editor: The demands of practising medicine can have significant effects on general health, work satisfaction, professional and non-professional life.1 We conducted a survey among senior medical staff in a metropolitan teaching hospital. The survey explored the pressures of work, social and family demands on consultants, and whether there was a difference between sexes. Participants completed a self-reported questionnaire on quality of life, levels of stress and feelings of work satisfaction, using previously validated questions and scoring from the General Health Questionnaire (GHQ-28, a 28-question subset of the GHQ)2 and Specialist Doctors Stress Inventory (SDSI).3 (Questionnaire available from authors on request.) Respondents answered anonymously and gave informed consent. Fifty-seven per cent of consultants (54/94) returned surveys, of whom a third (18/54) were women. The response rates were comparable to those of other physician surveys.4 On average, consultants had been employed at the hospital for 10.8 (SD, 8.0) years, had been qualified for 22.2 (SD, 9.6) years, and were working 47.7 (SD, 14.0) hours per week. Eighty-one per cent (44/54) were married, 74% (40/54) had children and 54% (29/54) lived in a double-income household. Half (27/54) reported an unreasonable ratio between work hours and leisure time, and 50% (27/54) reported feeling stressed. Despite this, 65% (35/54) believed they had or would achieve their ideal medical career. Female consultants worked fewer professional hours, but more hours in unpaid domestic work, than male consultants. Furthermore, female doctors were more likely to have had their career modified by family or social factors; more likely to use paid support to cope with their domestic workload; and, if they had children, more likely than men to have modified their careers to look after dependants (see Box). Consultants who reported feeling stressed were more likely than other consultants to report an unreasonable ratio between work hours and leisure time (74.1% [20/27] v 48.1% [13/27]; P = 0.05). Forty-one per cent (22/54) scored above 4 on the GHQ-28, indicating that a high level of stress and psychiatric “caseness” (ie, clinically significant levels of psychiatric disturbance) is experienced by senior doctors. This result is similar to that of a UK study in which 46% (30/65) of senior doctors reported experiencing high levels of stress.5 From our data there appears to be a significant relationship between stress, psychiatric “caseness” and hours worked (P < 0.001). Our study and others have identified potential reasons why women work fewer hours in medical work and have a shorter working life. These include having and caring for children, stress, dual-career marriages, personality and social expectations.6 Our survey highlights the fact that female consultants in Australia face undue pressure in balancing their medical and domestic roles compared with male consultants. There is a continuing need for flexibility in workplace and training environments for women in medicine to ensure equal career choice, balance between work and domestic commitments, and professional satisfaction. Comparison of self-reported factors between female and male consultants (n = 54) Female consultants (n = 18) Male consultants (n = 36) P value Mean age in years (SD) 45.3 (10.5) 47.7 (8.1) 0.43 Mean hours in medical work per week (95% CI) 33.4 (28.5–38.4) 54.7 (51.5–58.0) < 0.001* Mean hours in unpaid domestic work per week (95% CI) 22.9 (8.0–37.8) 10.6 (7.6–13.5) 0.02* Uses paid domestic support 14/18 (78%) 18/36 (50%) 0.05* Has children 11/18 (61%) 29/36 (81%) 0.12 Expects to achieve future medical goals 12/18 (67%) 24/36 (67%) 0.78 Has had career expectations modified by: Workplace 8/18 (44%) 22/36 (61%) 0.25 College/training 4/18 (22%) 7/36 (19%) 0.81 Family/social factors 12/18 (67%) 14/36 (39%) 0.05* Illness 1/18 (6%) 4/36 (11%) 0.51 Has had career opportunities modified by care for dependants 9/11 (82%) 10/29 (34%) 0.02* Reports partner is inconvenienced by respondent’s career goals 10/18 (56%) 9/36 (25%) 0.03* Mean score on GHQ-28 (95% CI)† 2.24 (1.81–2.68) 2.10 (1.95–2.26) 0.45 Psychiatric “caseness”‡ 8/18 (44%) 14/36 (39%) 0.30 Median job satisfaction score§ 3 (range, 3–4) 3 (range, 1–4) 0.15 Median life stress score§ 2 (range, 1–2) 1 (range, 1–3) 0.13 GHQ-28 = 28-item General Health Questionnaire. * Difference between men and women significant. † Minimum score = 0; maximum score = 28. ‡ ie, Clinically significant psychiatric disturbance (GHQ-28 score > 4). § Minimum score = 1; maximum score = 4. Data were analysed by Pearson’s χ2 test, Student’s t-test or the Mann–Whitney test and stratified by sex.

Colleen T Bruce · Margaret M Sanger · Paul S Thomas · Jonathon R Petkus · Deborah H Yates

Mai Maddisson General Practitioner, Mitcham North Clinic, 188 Mitcham Road, Mitcham, VIC 3132. mmaddisson.nmcATwdgp.com.au To the Editor: I read with interest McFarlane’s article on post-traumatic stress disorder and debriefing,1 which reminded me of a long-term patient. Over a decade ago, I discovered that this patient was a Vietnam veteran, and expressed concern that he had not told me previously. His reply came thus (although, of course, I no longer remember the exact words): “How would you know what it feels like to be, by sheer chance, the only man left alive in a group of soldiers?” I acknowledged that he was correct, that I had no idea. With that poignant remark in mind, I planned his care. He is doing OK. Can we really address an abstraction that we cannot conceptualise, or predict the resulting obstacles in a person’s journey through life? This is equally valid at the beginning of the journey or anywhere along its course. Perhaps the notion of debriefing at an appropriate time is not the problem; perhaps it is the formula we use.

Mai Maddisson

The multisector approach to reducing smoking may be a good model for tackling physical activity Over the past year, the signals that physical activity is a critical community issue in Australia have become overwhelming. The increasing obesity of Australians has attracted the attention of our politicians and spawned obesity summits in New South Wales and Victoria; these both recognised that the energy expenditure imbalance (physical activity versus diet) is key to the obesity epidemic.1 Related to obesity is an inexorable increase in the prevalence of type 2 diabetes. The recent seminal Diabetes Prevention Program trial demonstrated that physical activity and dietary modification are effective lifestyle strategies for curbing this problem.2 In the area of cancer control, a notable event in the past year was the Eat and Run Conference hosted by the New South Wales Cancer Council, where evidence was presented that regular physical activity contributes to preventing colon and breast cancer.3 The past year has also seen reports that reinforce the benefits of regular physical activity in preventing coronary heart disease4 and falls in the elderly,5 and in reducing depression.6 Thus, physical activity is a pivotal public health issue, contributing to the prevention and management of at least six of Australia's seven current national health priorities: cardiovascular disease, cancer, mental health, diabetes, injury and musculoskeletal problems. However, the prevalence of inactivity in our communities is high and increasing. In 2000, 42% of Australian men and 44% of women did not partake in the levels of physical activity recommended by the National Physical Activity Guidelines (30 minutes of moderate-intensity activity, accumulated in bouts as short as 10 minutes, on most days of the week, or 20 minutes of vigorous-intensity activity on at least three days).7 These data revealed an increase in the prevalence of inactivity from 1997, when it was 37% among men and 39% among women.7 Over the past decade, there have been numerous calls for general practitioners to address physical activity and other behavioural risk factors. Along with these calls have come an increasing number of studies evaluating physical-activity interventions delivered in primary care. The National Institute of Clinical Studies (NICS) in Australia funded a systematic review of published studies, which was completed late in 2002 and included 20 studies.8 While most interventions entailed verbal advice and written information materials, they differed in scope (some targeting physical activity only, others addressing multiple risk factors); intensity (brief advice through to more intensive counselling with multiple contacts); method of delivery (physicians, nurses, health educators or exercise scientists); and target audience (all adults, older people only, interested volunteers or whole patient populations). The review concluded that there is evidence that interventions in primary care can increase physical activity in the short term. Notably, brief interventions appeared to be as likely to succeed as intensive interventions, although there was insufficient evidence to identify other attributes of successful interventions. The NICS review is one of several recent reviews that support the contribution that GP interventions can make to promoting physical activity.9,10 A notable dissenting opinion came from the recent United States Preventive Services Task Force review of clinician counselling to promote physical activity,11 but this review included only eight studies published since 1994. Overall, the level of supporting evidence for GP interventions offers encouragement. However, much still needs to be done to promote greater attention to physical activity in general practice, given that lack of time and a perceived lack of patient interest are major barriers reported by GPs.12 The NICS review offers a practical way forward in light of these barriers. It recommended brief physical-activity interventions specifically for patients with risk factors or health conditions that could be modified by increased activity. This approach should not require a major investment of time from already busy GPs and, by directing interventions to patients with current health problems that could be alleviated by physical activity, is more likely to be well received by patients. Despite the growing evidence about general practice-based physical-activity counselling, until recently there had been no efforts to disseminate intervention materials or protocols for GPs to use. However, agencies like the National Heart Foundation and the Victorian Council on Physical Activity and Health have been working with health authorities in several states to develop tools to help GPs to promote physical activity. An example of these is the Active Prescription protocol disseminated by the National Heart Foundation in NSW.13 It provides a format for delivering brief advice to patients about physical activity and also serves as a written record of this advice for doctors and patients. An electronic version has been included in the latest version of the Medical Director clinical management software (Health Communication Network, Sydney, NSW). These efforts are promising and require continued support, together with continued research on the effectiveness of the interventions, as well as dissemination strategies. Numerous social and environmental factors lead to physical inactivity in Australia. Thus, addressing this public health priority will require the sustained involvement of a range of sectors in addition to primary healthcare (eg, transport, urban development, education, sport and recreation). We can look to the past three decades of efforts to reduce smoking as an example of an integrated, multisector approach that has significantly reduced population levels of smoking. As with smoking, GPs — the preferred source of health information for most Australians — have a key role to play in promoting physical activity.

Ben J Smith PhD · Elizabeth G Eakin PhD · Adrian E Bauman PhD, FAFPHM