General medicine

Objective: To determine the factors associated with general practitioners' current practice location, with particular emphasis on rural location.Design: Observational, retrospective, case–control study using a self-administered questionnaire.Setting: Australian general practices in December 2000.Participants: 2414 Australian-trained rural and urban GPs.Main outcome measure: Current urban or rural practice location.Results: For Australia as a whole, rural GPs were more likely to be male (odds ratio [OR], 1.42; 95% CI, 1.17–1.73), Australian-born (OR, 1.95; 95% CI, 1.55–2.45), and to report attending a rural primary school for "some" (OR, 2.21; 95% CI, 1.69–2.89) or "all" (OR, 2.79; 95% CI, 1.94–4.00) of their primary schooling. Rural GPs' partners or spouses were also more likely to report "some" (OR, 2.75; 95% CI, 2.07–3.66) or "all" (OR, 2.86; 95% CI, 2.02–4.05) rural primary schooling. A rural background in both GP and partner produced the highest likelihood of rural practice (OR, 6.28; 95% CI, 4.26–9.25). For individual jurisdictions, a trend towards more rural GPs being men was only significant in Tasmania. In all jurisdictions except Tasmania and the Northern Territory, rural GPs were more likely to be Australian-born.Conclusions: GPs' and their partners' rural background (residence and primary and secondary schooling) influences choice of practice location, with partners' background appearing to exert more influence.

Gillian A Laven BHSc · Justin J Beilby MB BS, MD · Heather J McElroy BSc(Hons) · David Wilkinson MB ChB, MD, PhD

Objectives: To describe the clinical features, antecedents and impact of chronic pain.Design: Telephone survey of randomly selected household respondents.Setting: Northern Sydney Health Area, metropolitan Sydney, July to September 1998.Participants: 2092 English-speaking residents aged 18 years or over.Main outcome measures: Age- and sex-adjusted prevalence of chronic pain (pain experienced every day for 3 months in the previous 6 months), pain-related disability, and use of health services and analgesic medications.Results: Chronic pain affected 474/2092 respondents (22.1%; 95% CI, 20.2%–24.0%), with high levels of pain-related disability in 129/439 (27%). Nominated causes of chronic pain were injury in 173 (38%), most commonly sports injury (54; 13%), and a health problem in 132 (29%). Pain was work-related in 62 (14%). A musculoskeletal condition was the leading diagnosis (127; 26%). Of the 474 with chronic pain, 374 (78%) had consulted at least one health practitioner for pain in the previous 6 months, comprising medical practitioners (consulted by 292 [60%] and including general practitioners [55%]), allied health professionals (245; 50%), and alternative practitioners (99; 21%). Current or recent use of oral analgesic medications (often over-the-counter preparations) was common (339; 70%). Higher levels of pain-related disability were associated with greater use of medications and health services.Conclusions: Our study shows that chronic pain is common and often results from injury. It highlights the importance of timely interventions to prevent progression from acute to chronic pain and the need for a coordinated approach to managing pain-related disability.

Fiona M Blyth PhD, FAFPHM · Michael J Cousins MD, FANZCA · Lyn M March PhD, FRACP

GPs are involved in long term care of patients and families with complex conditions. They juggle the need for medical expertise, the relationships between family members, the cost of expertise, limitations of access, and the medicolegal environment. With this background, the GP is ideally placed to play an active role in the "new genetics". GP consultations involving the new genetics will include diagnostic testing for patients with clinical problems, preconception and prenatal testing for couples in relation to pregnancy, predictive testing for families with some genetic conditions, and community genetic screening in some circumstances. GPs will need to understand the language of the new genetics, undergo continuing education, and receive ongoing support to enable them to communicate effectively with patients and their families. Different models of care incorporating GPs, specialists and allied health professionals can be developed to provide maximum delivery of relevant genetic data for both genetic and common multifactorial disorders.

Linda Mann DipRACOG, FRACGP

It is time for general practice to move into the 21st century Medicine in Australia seems to lurch from crisis to crisis. General practice workforce issues, Medicare and medical indemnity currently occupy centre stage,1 but as long as the need for reform remains high on the healthcare agenda, other crises are sure to follow. Current catalysts for change include the ongoing increase in health expenditure, the impending impact of chronic illness and ageing on healthcare, the need to address the community's demands for access to new drugs and technology, and medicine's abiding focus on cure rather than prevention. General practice in the 21st century will only prosper if its collective focus is on adapting and enhancing its unique characteristics — first contact, comprehensiveness, continuity and coordination of care . . . An important ingredient in this cauldron of crises is general practice. Healthcare systems in which primary care has a central role have higher patient satisfaction, lower overall health expenditure, better population health indicators, and lower per capita rates of drugs prescribed. In short, general practice, with its key elements of first contact, comprehensiveness, continuity and coordination of patient care, is central to the health of any healthcare system.2 However, all is not well with general practice. Australian GPs, along with their international colleagues, protest that they are undervalued, overworked and no longer in control.3 "They feel like hamsters on a treadmill. They must run faster just to stay still . . . The result of the wheel going faster is not only a reduction in quality of care, but also a reduction in professional satisfaction and an increase in burnout amongst doctors."4 Assemble any group of Australian GPs and talk will soon turn to how recent Federal Government policies regulating general practice have reduced their fiscal autonomy, increased red tape, eroded their professional time, and diminished the quality of their clinical care.5 This discontent and frustration is responsible, in part, for the current free fall of the Medicare bulk-billing rate.6 However, a more ominous threat to the future of general practice is its increasing unattractiveness as a vocation. Junior doctors in Australia7 and North America8,9 are increasingly dissatisfied with general practice, and are voting with their feet. Anecdotal reasons advanced for this discontent include the low remuneration and lack of prestige of general practice, the demands of practice that may preclude a life beyond medicine, and the advent of competing players in the delivery of primary care, such as nurse or alternative medicine practitioners.8-10 One determinant of a specialty's standing in the medical community is its performance in research. Australian general practice has some catching up to do in this area.11 Indeed, general practice research appears to be in the throes of an identity crisis. In March this year an international conference of WONCA (the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians, or the World Organization of Family Doctors, for short) was convened in Kingston, Canada, to draft a statement on the importance and future prospects of primary care research.12 It is surprising that such a conference was needed at all. But as noted in the Lancet, ". . . discussion at the conference also revealed the loss of direction — and confidence — that primary care research is presently experiencing. Very few examples of good family practice research were presented . . . The emphasis on reflection at the expense of action was telling — and disappointing."12 With all this doom and gloom, what to do? Our special issue on general practice attempts to address this question. Kamien (page 10) explores the collective wisdom of Australia's inaugural professors of "community medicine".13 Their achievements have been prodigious, but implicit in their reminiscences and counsel is the hope that deans of medical schools might support general practice more fully, and pursue more vigorously teaching environments beyond those found in esoteric tertiary-care and quarternary-care institutions.13 That this can happen with leadership and vision is illustrated by the continuing advances of general practice academia in the United Kingdom, wherein a third of all UK general practices are involved in community-based undergraduate education.14 Del Mar and his international colleagues (page 26) argue that part of the solution to the woes of general practice is to strengthen its "intellectual aspects" by encouraging "critical thinking" and the pursuit of clinically relevant research.7 The commentators on the contrived bleak scenario of general practice in 2020 — The destiny of general practice: blind faith or 20/20 vision — featured in this issue (page 47) argue that the antidotes to the 2020 poisoning of professionalism include structural reforms and independence of clinical agendas. Kidd (page 16) further stresses that involvement of the Federal Government in general practice vocational training needs to be long-sighted, flexible, and not merely an opportunity for implementing political solutions to current problems.15 If the guardians of this multitiered vocational training program were to get it wrong, they would risk fatally wounding general practice. General practice in the 21st century will only prosper if its collective focus is on adapting and enhancing its unique characteristics — first contact, comprehensiveness, continuity and coordination of care — so that these are in tune with patient and community expectations and the needs of the community's changing health challenges. General practice needs to change so that despondency, stress, loss of control and the perceived professional unattractiveness are things of the past. New GPs will need to embrace rather than suffer preventive medicine, exploit the power implicit in patient self-management, have responsive and flexible schedules of single or group visits, and be closely involved as members of interdisciplinary teams in care delivery within the community. They must also use the rich resources of information technology to reduce rather than increase work loads. Finally, general practice needs to accommodate the life-style aspirations of future doctors. Such developments can only restore the individual morale and professional pride of GPs. Donald Berwick (President and Chief Executive Officer, Institute for Health Care Improvement, Boston, USA) recently observed that "We are carrying the nineteenth-century clinical office into the twenty-first-century world. It's time to retire it."16 To effect such seismic changes in how general practice is provided and remunerated will, no doubt, produce upheaval, but the key to the management of any crisis is control — control of professional purpose, places of practice and pride. It is time for general practice to move into the 21st century.

Martin B Van Der Weyden MD, FRACP, FRCPA

Gains have been made, but many challenges remain In this issue of the Journal, Kamien, one of the foundation professors of general practice in Australia, adds an important contribution to the history of general practice as a discipline within Australian schools of medicine (page 10).1 He explores the views of his fellow foundation professors, appointed nearly 30 years ago, and the roles they played in the reform movements in Australian medical education. By their efforts, the foundation professors laid the groundwork for the continuous advancement of the academic discipline of general practice. Their work included the training of staff (some of whom are the present heads of general practice departments), and the establishment of research programs that continue to contribute to the evidence base, such as the Bettering the Evaluation and Care of Health (BEACH) study at the University of Sydney.2 Much of the initial opposition they encountered has dissipated. Academic general practitioners are now generally respected by their medical school peers, and innovative curriculum design in many schools (such as the programs at Newcastle, Monash and James Cook medical schools) has been spearheaded by GPs. They have achieved international reputations in their fields of expertise, and recently Australia has become an exporter to academia in the United Kingdom and Canada. Other influences have affected these developments. The general practice reforms in the early 1990s, introduced by the then federal health minister, Brian Howe, led to new avenues for research and research training through the General Practice Evaluation Program. This program spearheaded opportunities for individuals to pursue Master and Doctoral degrees, which were not always available within the founding departments of community practice. Since 1988, the Australian Medical Council (AMC) has insisted on a greater emphasis on general practice in the curriculum, and all medical schools now have chairs of general practice. In addition, they all have supporting infrastructure of teachers and researchers, funded by Commonwealth grants supporting teaching (eg, through the Rural Undergraduate Support and Coordination Programme)3 and research (eg, through the Primary Health Care Research Evaluation and Development Strategy).4 Kamien found that some foundation professors shared an ambivalent view of the Royal Australian College of General Practitioners (RACGP) and were "disappointed with the RACGP's failure to support . . . academic general practice". This has changed. In 2003, academic general practice is re-establishing its links with the RACGP. The current president of the RACGP is a professor of general practice. The chairperson and several members of the current RACGP council are general practice academics, as are the chairs of the college's national standing committees, such as the Research Committee and the Education Committee. If academic general practice has "arrived", what are the future challenges? Although the discipline has established itself in the medical schools, the problems outlined by Kamien and by others remain.5 Academic staff have impossible teaching loads and, consequently, little time for research or research training. Furthermore, the allocation of resources in medical schools tends to disadvantage general practice. In response to AMC requirements, the input of general practice across the whole medical curriculum has increased, but intramural funding has not kept pace with this increase. There are serious concerns about recruitment to the general practice workforce and poor morale among practising GPs.6,7 Reasons for these issues include a relative fall in remuneration for general practice compared with other medical disciplines, concerns about litigation in private practice, and the "red tape" demands of government with new programs (such as the Extended Primary Care Medicare items). Local solutions must be found. For a research culture to continue to expand, we will need to answer the criticism that "there is simply no rigorous evidence for many of the daily clinical decisions in general practice".8 Much of the research to date has been of a health services nature,9 and more clinical research, including robust randomised controlled trials located in general practices, needs to be pursued. The researchers themselves will need to be seen as relevant and helpful to the "bag-carrying practitioners"; there is a need to explore new ways to enable and promote research training among practising doctors who want to enhance their academic skills in practice. Those of us who are charged with the undergraduate education of medical students need to provide appropriate role models, who should emphasise professional competency and autonomy that is not undermined by the concerns of government. The discipline needs to be taught in a supportive environment, avoiding the impression of complexity and uncertainty sometimes gained by students, who are quick to compare it with the certainty of hospital-based teaching. The decentralised focus of medical education should enhance recruitment and retention of GPs. Mechanisms to achieve vertical integration include the sharing of staff and facilities, with joint appointments. Teaching programs and assessments need to be shared, and common processes used across regions to ensure uniformity of standards. The placement of students in practices requires careful management of complex databases and good personal communication with practices. The support of teachers at a distance is a constant challenge — innovative methods, such as videoconferencing and Web-based resources, are being trialled. Training opportunities for GPs in academic research and teaching are limited and difficult to achieve. The present scholarship arrangements, such as those of the National Health and Medical Research Council (NHMRC), are often inappropriate in terms of support and reimbursement. Links with postgraduate training consortia and the productive vertical integration of teachers, staff and curricula have the potential to enhance all involved. The same potential exists with departments of rural health and rural clinical schools, as shown in models already established (for example, in northern Queensland).10 Opportunities need to be developed for collaboration with the RACGP and training consortia for registrars to spend time in academic posts during fellowship training. The charter of the Divisions of General Practice is quite distinct from the functions of medical schools, and divisional roles in implementing programs of health improvement initiatives and practice support are well defined. However, the potential for collaboration with academic departments remains largely unfulfilled. General practice as a discipline is now represented on the Committee of Deans of Medical Schools and on the NHMRC assessment panels (although not on the council itself). Academic GPs will need to develop stronger leadership roles to consolidate our gains to date. The foundation professors had the courage and vision to begin the journey. Those with the responsibility of continuing leadership will need skill and flexibility to sustain the momentum in the changing and challenging environment of general practice.

Peter R Mudge FRACGP, FFAPHM

The 1973 inquiry into the "Expansion of Medical Education in Australia" resulted in the appointment of nine professors of "Community Practice". We (the foundation professors) have been leaders in a reform movement within medical schools and general practice and have had to fight hard for the right and resources to do the job for which we were appointed. Our most significant accomplishment has been to broaden the orientation of medical education beyond hospitals and laboratories to the community and those in the community who are underserved. Although small in numbers, our discipline fights above its weight and is essential for medical school accreditation by the Australian Medical Council.

Max Kamien MD, FRACGP

Medicopolitical objectives must be distinguished from the training of high quality GPs The high standard of registrar training for Australian general practice has long been recognised,1-6 and our training model has been replicated overseas. The training program of the Royal Australian College of General Practitioners (RACGP) provided vocational training for GP registrars in Australia for nearly 30 years. In January 2002, the Commonwealth Government established a new provider model for the delivery of GP registrar training. These changes were in response to government perceptions that aspects of the former training arrangements were not fulfilling some of the needs of the Australian population, especially in meeting workforce requirements in rural areas. General Practice Education and Training Ltd (GPET) was established as a Commonwealth-funded company to manage a new contestable regional model of vocational training. Twenty-two new regional training providers now carry out the actual delivery of vocational training programs. Funding for training is allocated on behalf of the Commonwealth by GPET to these providers under contract. The regional providers have representation from the appropriate colleges (RACGP and, in rural regions, Australian College of Rural and Remote Medicine), local Divisions of General Practice, local university departments of general practice and rural health, registrars, general practitioner trainers, and in some cases, local consumer representation. While the methods of delivery have changed, the new training arrangements still follow the curriculum for general practice training set by the RACGP, are based on the standards of education delivery set and monitored by the RACGP, and lead to a single training end point — the Fellowship of the RACGP. The diversity in the new training arrangements provides the opportunity to reinvigorate GP vocational training. However, there are also risks associated with these new arrangements. These relate to (i) their funding, (ii) the need for widespread professional support for them to succeed, and (iii) concerns among potential registrars about the future viability of a career in general practice. The workforce shortages which have led to these new arrangements for general practice training also pose risks for the independence of the vocational training provided for other medical specialties. Funding of the new training arrangements: This is currently being provided through short-term contracts. Quality education delivery requires funding stability. Without this stability, the education programs are at risk. These new arrangements need a fair go. The Commonwealth has made a decision to establish a more expensive system of training which requires independent governance and administration in 22 regions across the country. The Commonwealth now has a responsibility to continue to provide adequate funding, and long-term policy commitments and support for the new regional training providers and the profession, to ensure that educational standards are not only maintained but continue to be developed. Professional unity: The profession also has a responsibility to unite behind the new training arrangements. Without such cooperation, there is a risk that factional differences could hamper the delivery of high quality training and the Commonwealth's new model of alternative governance will not be able to deliver valid outcomes. GPET cannot meet its workforce outputs unless the training programs it purchases meet RACGP standards. The RACGP cannot approve training programs unless they are of an appropriate standard.7 GPET and its key stakeholders need to develop a collaborative model, which guarantees equity of training standards and opportunities for registrars no matter where they train in Australia. The model also needs to guarantee unified work between GPET and each regional training provider with the relevant professional colleges. And the model needs to meet the community need for access to well trained general practitioners and well supervised registrars. The current image of general practice and its training requirements among potential registrars: This probably poses the major risk to the new training arrangements. There is a strong need to maintain and enhance general practice as an attractive career choice for medical students and recent medical graduates. This change in the training program structure has taken place at a time when general practice is facing many challenges, including workforce shortages, uncertainty surrounding medical indemnity, and a failure of Medicare rebates to match the rising costs of providing a high quality general practice service. General practice training is also seen as less flexible and less able to accommodate the personal and professional needs of many potential registrars compared with training for some other specialties. It is clear that the Commonwealth will no longer separate GP training from other challenges facing general practice, especially workforce shortages. All stakeholders must ensure that medicopolitical objectives are clearly distinguished from the work of preparing high quality GPs for the Australian community. There also needs to be public recognition of the importance of a strong, stable system of general practice, and of a well-trained GP workforce to the health of the nation. We need long-term sustainable solutions to the serious challenges facing general practice to ensure that all people in Australia have equitable and affordable access to high quality primary care in the future. General practice is experiencing the conflicting demands of the government's requirements for medical workforce against the profession's need for continuing high standards of vocational training. This conflict could also lead to enforced changes in training for other medical specialties. It remains to be seen how other colleges respond to the risks posed by similar challenges in the development of their own 21st century registrar training programs. When facing risks there is some cold comfort in knowing that you are not alone.

Michael R Kidd MD, FRACGP

Despite explicit support of the federal and state health departments, most prevocational trainees do not experience general practice or rural medicine. We have been running a program of prevocational placements of trainees working as rural general practitioners under supervision. From our experience, we have identified various barriers to implementation of such programs. These barriers include: funding issues (trainees are providing federally funded Medicare-rebatable services, while receiving state-funded hospital salaries); conflicts between the placement of trainees outside the hospital when hospitals are undergoing staffing crises; difficulties in coordinating the many organisations (funding bodies, practices, hospitals) involved in providing the placement; and the isolation experienced by trainees when they arrive in rural practice. Funding from a single administration and coordination by a locally appointed rural Director of Clinical Training are essential to overcome these barriers.

Alistair W Vickery MB BS, FRACGP · Richard Tarala FRACP

Provision of "Focussed Psychological Strategies" by general practitioners is one component of the recent Better Outcomes in Mental Health Care (BOiMHC) initiative. The BOiMHC initiative requires GPs to undertake minimum training requirements before they may provide services under the new Medicare Benefits Schedule item number. We argue that GPs need further training and ongoing clinical interaction with mental health specialists (beyond the minimum training requirements) for refinement of psychological skills. Research focusing on GP training and how GPs interact with specialist services in the provision of psychological treatments is urgently required.

Grant Blashki MD, FRACGP · Ian B Hickie MD, FRANZCP · Tracey A Davenport BA(Hons)

General practice is suffering a crisis of status, as shown by financial, power and intellectual markers. This is serious as a strong general-practice workforce is important to deliver cost-effective, high-quality healthcare. We argue that strengthening the intellectual aspects of general practice (particularly critical thinking) is essential. Most strategies to achieve this centre on research, with many initiatives in Australia and overseas to enhance research by general practitioners; there is still insufficient clinical research in general practice. Other ways to improve critical thinking include promoting use of evidence-based medicine, provided it is not implemented only via "cook-book" guidelines. Other innovations are desperately needed.

Chris B Del Mar MD, FRACGP, FAFPHM · George K Freeman MD, FRCGP · Chris van Weel MD, FRCGP

Objectives: To explore general practitioners' views on chronic-disease care: the difficulties and rewards, the needs of patients, the impact of government incentive payments, and the changes needed to improve chronic-disease management.Design: Qualitative study, involving semi-structured questions administered to 10 focus groups of GPs, conducted from April to October 2002.Participants and setting: 54 GPs from both urban and rural practices in New South Wales and South Australia.Results: Consistent themes emerged about the complex nature of chronic-disease management, the tension between patients' and GPs' goals for care, the time-consuming aspects of care (exacerbated by federal government requirements), and the conflicting pressures that prevent GPs engaging in structured multidisciplinary care (ie, team-based care involving systems for patient monitoring, recall, and care planning).Conclusions: Structured multidisciplinary care for people with chronic conditions can be difficult to provide. Barriers include the lack of fit between systems oriented towards acute care and the requirements of chronic-disease care, and between bureaucratic, inflexible structures and the complex, dynamic nature of GP–patient relationships. These problems are exacerbated by administrative pressures associated with federal government initiatives to improve chronic-illness management. Changes are needed in both policies and attitudes to enable GPs to move from episodic care to providing structured long-term care as part of a multidisciplinary team.

John Oldroyd PhD · Judith Proudfoot PhD · Fernando A Infante MPH · Gawaine Powell Davies MHP · Mark F Harris MD · Tanya Bubner GDPH · Chris Holton BSocSc · Justin J Beilby MD

Objectives: To explore how Australian general practitioners use pharmaceutical decision-support (PDS) systems; to determine GPs' perceptions of the deficiencies and strengths of these systems; and how they believe they can be improved.Design and setting: Qualitative analysis of discussion from three focus groups of GPs (from one rural and two urban Divisions of General Practice) between April and May 2002.Participants: 22 GPs selected to include users of the five most popular prescribing/clinical practice software products available in Australia.Main outcome measures: Advantages and disadvantages of using PDS software; ideas for improving PDS systems; attitudes to electronic evidence-based guidelines.Results: GPs believed that important interactions may be missed because of desensitisation resulting from too many alerts (which also intrude on workflow); that interaction alerts need to be severity graded and only significant ones should appear; and that improved computer–user interface design could enhance the usefulness of PDS systems.Conclusions: Our results will provide useful feedback to government, software vendors and software developers on the needs and expectations of end users and on the development of agreed software standards.

Michael D Ahearn GradDipIT · Stephen J Kerr BPharm, PhD

Objective: To compare outcomes, costs and incremental cost-effectiveness of heroin detoxification performed in a specialist clinic and in general practice.Design and setting: Randomised controlled trial set in a specialist outpatient drug treatment centre and six office-based general practices in inner city Sydney, Australia.Participants: 115 people seeking treatment for heroin dependence, of whom 97 (84%) were reinterviewed at Day 8, and 78 (68%) at Day 91.Interventions: Participants were randomly allocated to primary care or a specialist clinic, and received buprenorphine for 5 days for detoxification, then were offered either maintenance therapy with methadone or buprenorphine, relapse prevention with naltrexone, or counselling alone.Main outcome measures: Completion of detoxification, engagement in post-detoxification treatment, and heroin use assessed at Days 8 and 91. Costs relevant to providing treatment, including staff time, medication use and diagnostic procedures, with abstinence from heroin use on Day 8 as the primary outcome measure.Results: There were no significant differences in the proportions completing detoxification (40/56 [71%] primary care v 46/59 [78%] clinic), participating in postwithdrawal treatment (28/56 [50%] primary care v 36/59 [61%] clinic), reporting no opiate use during the withdrawal period (13/56 [23%] primary care v 13/59 [22%] clinic), and in duration of postwithdrawal treatment by survival analysis. Most participants in both groups entered postwithdrawal buprenorphine maintenance. On an intention-to-treat basis, self-reported heroin use in the month before the Day 91 interview was significantly lower than at baseline (27 days/month at baseline, 14 days/month at Day 91; P < 0.001) and did not differ between groups. Buprenorphine detoxification in primary care was estimated to be $24 more expensive per patient than treatment at the clinic. The incremental cost-effectiveness ratio reveals that, in this context, it costs $20 to achieve a 1% improvement in outcome in primary care.Conclusions: Buprenorphine-assisted detoxification from heroin in specialist clinic and primary care settings had similar efficacy and cost-effectiveness. Buprenorphine treatment can be initiated safely in primary care settings by trained GPs.

Amy E Gibson BSc(Hons), BA · Christopher M Doran PhD · James R Bell FRACP, MD · Anni Ryan Grad Dip (AOD Studies) · Nicholas Lintzeris MB BS, PhD

Objectives: To examine the frequency of post-antibiotic vulvovaginitis (PAV); describe how women prevent and treat PAV; and determine whether concern about PAV affects their decisions about taking antibiotics.Design: Cross-sectional survey using a written questionnaire.Setting and participants: Five general practice waiting rooms in north-western Melbourne, in February 2000. 1298 women aged 18–70 years were surveyed.Main outcome measures: Self-reported symptoms and management of vulvovaginitis and PAV.Results: The response rate was 86%. Thirty-five per cent of women reported ever having PAV and 73% reported ever having symptoms suggestive of vulvovaginal candidiasis. Antifungal medications and lactobacillus products or yoghurt were most popular for both prevention (49%, 40%) and treatment (63%, 43%) of PAV. Other home remedies such as tea tree oil, vinegar, and dietary and clothing modification were infrequently used by the women surveyed. Twenty-three per cent of women who had taken antibiotics in the previous month had experienced symptoms of vulvovaginitis. Of women who had ever had vulvovaginitis, 35% were moderately to very concerned about developing PAV when prescribed antibiotics. Because of this concern, around a fifth of these women would not take prescribed antibiotics.Conclusions: Concern about PAV affects women's decision-making regarding antibiotic use. Many women use unproven complementary therapies to prevent or treat PAV. When prescribing antibiotics, doctors should discuss the risks of PAV and its management with patients.

Marie V Pirotta MMed, FRACGP, DRANZCOG, GradDipEpiBiostats · Jane M Gunn PhD, FRACGP, DRANZCOG · Patty Chondros BSc(Hons) GradDipEpiBiostat, MSc(Statistics)

We are all interested in the future, for that is where you and I are going to spend the rest of our lives. — Edward D Wood, Jr, director and screenwriter (from the movie Plan 9 From Outer Space) Nightmare in 2020: a day in the life of Dr Zen, FRACGP A tired-looking woman is sitting in the medical service bay at Corporation Enterprise (its motto: "Live long and prosper"). The electronic doors open to admit an overweight man. He faces her across a waist-high console. She scans his online medical record with her level 5 clearance. "Mr Unger, you have a five-minute consultation today. How can we help?" "I don't feel well —." "Chest pain?" "No, just not feeling myself. Since my wife died. My complementary practitioner can't help me. Can you?" "I'll try", Dr Zen replies. She selects the "Social stressor" option on screen. "Which of these symptoms do you have?" She reels off a list. He replies. They work their way through the appropriate algorithm pathway. "So, according to our evidence-based, Glerck-Pficham-sponsored guidelines, you have type III depression." A silent alert flashes on the screen: "Time's up!" "I'll prescribe you Ease, which [reading from the screen] has been effective in 360 hospital patients. You're also entitled to three telesessions with our cognitive behavioural therapist courtesy of Ease." The manufacturer of Ease has a Memorandum of Understanding with Corporation Enterprise. Dr Zen issues the script and patient education printout. Mr Unger walks out the door, triggering another screen message: "Consultation was two minutes over time — third infringement today. Action 1: repeat practice management module during your Quality and Education session." Dr Zen sighs. She had wanted to try the clinical research module instead. No wonder GP research in the Med e-J of Australasia is so dull: only non-clinicians and corporate administroids have time for it. But who wants to know about health service models and cost analyses? "Action 2: 5% deduction from today's pay for time infringements." Yeah, well what about patient care instead of the bottom line for a change? She makes an e-note to mention it again at the next corporation meeting with the Managers. Mustn't put them offside though. They may be heavy-handed but they're the ones doing the real work in general practice — administering new government health initiatives that appear monthly. Dr Zen is indentured to serve in this busy outer urban centre for another two years. Her husband is rural, but telemedicine clinics are making rural work easier these days. Like most doctors, he'd been put off becoming a GP by his compulsory term in "area-of-need" general practice. But beggars who miss out on other training schemes can't be choosers ... After her corporate session, Dr Zen drops in on the nurse-practitioner clinic in the slums to see medical referrals from the nurse. This government got in on the promise of "Primary care for the public". But the post-election reality: a teary 72-year-old whose Work-For-the-Aged benefits have been restricted as she can't afford a computer and missed the e-reminder for her Well-70s check. Dr Zen can't wait to do her taxi shift this evening. Thank goodness for time to talk to customers. It'll keep her going in more ways than one. Ann Gregory and Mabel Chew Deputy Editors, MJA This section of the MJA General Practice issue is pure fiction. That is to say, we created a futuristic general practice scenario and asked others to create more of their own. Why should a medical journal resort to science fiction, you ask? The answer: because the future is malleable. If you believe the popular fictions of time travel, you'll know that seemingly minor differences in our actions now can lead to destinies which are poles apart. To help us mould the future, we conceived a section which attempted to generate hypotheses and innovative solutions. We're not contending that the results represent accurate predictions, but neither are these idle speculations. By asking what forces currently drive general practice, we can imagine different futures that test the implications (good, bad and indifferent) of these forces, and advocate change that preserves the good, topples the bad and optimises the indifferent. Here are some driving forces we identified: The general practitioner Gatekeeper of medical care in Australia Desire to provide good care for the whole patient Health promotion and disease management Balancing work and personal interests Corporatisation Evidence–practice gap Information overload, information management Threat of litigation, indemnity woes Professional and financial under-recognition Autonomy versus structural straightjackets (regulation, red tape and time) Workforce shortages The patient More informed, with higher expectations of healthcare, its accessibility and affordability "Click-fix" mentality of instant gratification More likely to have (more than one) chronic illness More likely to require coordinated, continuous (not episodic) care Society Ageing and rise of grey power Mixing of diverse ethnicities, cultures and values More solo households and non-nuclear family groups Technological advances in everything Knowledge-based economy dictating labour market Widening gap between haves and have-nots: rich and poor, technologically literate and illiterate More government responsibility shifted to private enterprise Continued rise of political conservatism and the far right Globalisation of trade and thought Environmental concerns and hazards Ethical quandaries from technology and inequalities I don't try to describe the future. I try to prevent it. — Ray Bradbury, science fiction writer Next, we wrote a deliberately nightmarish scenario of general practice in the year 2020 (see the Box) showing the negative consequences of some of these forces. We sent the scenario to those involved in frontline and academic general practice, asking them to write short commentaries that identified values which had been lost in the nightmare suggested how to handle current trends to preserve these values offered a better future. Each commentator was asked to discuss a different facet of the general practice milieu: the consultation,1 practice management,2 training,3 workforce,4 society5 and research.6 We believe that the result is a rich vein of thought that shows us there are core values to hold fast and work for. The future need not be beyond us! → Go to the first commentary We must be the change we want to see — Gandhi

Mabel Chew

Sociologists tell us that "Autonomy is the acid test of professional status ... all other characteristics of a profession flow from it".1 Poor Dr Zen* has no professional autonomy. Mr Unger's management is determined, not by her, but by an electronic decision system which then reduces her pay for taking too long and directs her continuing education. How did Dr Zen get into this thankless situation? Let me answer that with some more of her story. Dr Zen's dream is to become a Clinical Controller with Corporation Enterprise. Competition is intense as the status and salary are so much better than those of the general practitioners who labour in the corporation's clinics. To be considered she has to obtain an MBA from the Corporation Enterprise School of Business. One cold, wet night in 2020, Dr Zen is at a taxi rank waiting for a fare, correcting her first draft of an assignment for the subject HX101 "History of Corporation Enterprise". The assignment topic is a challenge: "Why did the GP leaders of 2003 call for policies to dramatically increase the number of general practitioners?" The course notes suggest that in 2003 the policies pursued by GP leaders undermined real opportunities for GPs. Dr Zen has undertaken extensive research. Her essay hypothesises that the key mistake in 2003 was not to pursue policy and structural changes so that general practice could adapt in a positive way to changing community expectations. GPs ignored opportunities flowing from technological developments and changes elsewhere in the health system. They concentrated on defending the status quo and, behind a smokescreen of rhetoric, lobbied government for higher pay for each consultation and for more doctors.2 This maintained short-term cash flow but further entrenched structural problems. The cash flow of most GPs depended on habits developed between 1984 and 2007 under a financing system called Medicare. Medicare rewarded "down-market" activities, not "up-market" skills. The highest incomes came from providing many short consultations and not providing services requiring the very skills that differentiated GPs from other "healthcare workers". The seriously ill and those requiring minor procedures or time-consuming care drained profits and, under Medicare, could be deflected to specialists or emergency departments. The network of corporate clinics already emerging across Australia before 2003 grew rapidly following the increase in GP numbers between 2003 and 2007. These clinics were based in the cities and absorbed most new GPs. In 2008, the government admitted that the policy of expanding numbers to get GPs into rural and outer urban areas had failed. A retired bureaucrat, Gletkin, was commissioned to review the situation. He concluded the government was simply underwriting the profits of a few large GP corporations: the GP workforce was less evenly distributed than in 2003; GPs were being paid for work that could be undertaken more cheaply by others; and the government's commitment of millions of dollars to educating GPs through six years of university and three years of vocational training was of doubtful value because GPs were not using the skills taught. The government of Mustapha Mond adopted radical measures recommended by Gletkin. Medicare was abolished and Corporation Enterprise established as a government-owned monopoly. This entity compulsorily acquired all GP clinics and rigorously implemented its charter of ensuring an even distribution of GPs across Australia and providing primary care at the lowest possible cost, using protocols designed to refer all serious cases to specialist polyclinics or hospitals. The company operated to a strict formula of one GP per 1750 people. With a population of 25 million, only 14 250 out of 30 000 GPs were contracted. Minimal incomes were offered. GPs had to agree to adhere strictly to the corporation's treatment protocols. The education of GPs was rationalised. School leavers, after five years administrative and assistant experience with the Corporation, could apply for entry to the GP course at the Corporation Enterprise School of Medicine, a three-year web-based course supported by "on-the-job" training. Dr Zen was in the first graduating class. Dr Zen now understands the sadness on the faces of the elderly couple in the next flat to hers in the Housing Commission complex. They commenced careers as GPs in the early 1980s, full of hope and expectation, but were bankrupted in 2007, when found personally liable for a medical indemnity claim. Since then they had been unemployed. Dr Zen hopes she can afford to buy them a hamper again next Christmas. Dr Zen is pleased it is a quiet night on the taxi rank. She can think about the conclusion of her essay. Students are asked to imagine a different scenario for general practice after 2003. She will argue that GPs, rather than squabbling with government over a few dollars, should have thought more deeply about what the community wanted from general practice and how GPs could "add value". They should have lobbied for policy and structural change so that simple tasks could be delegated to other staff, while the highly (and expensively) trained doctors used their skills managing acute medical conditions and common chronic conditions; coordinated the care of patients with complex conditions; enhanced the procedural aspects of their practices; and established arrangements of value to others, such as early hospital discharge. Such a role would have required fewer GPs, but those GPs would have had much more rewarding careers.

William Coote FRACGP, BEc

Those of us who wear spectacles consider "20/20 vision" utterly desirable. The "2020 vision" presented here,* however, is a nightmare that we must strive to avoid. The story of Dr Zen suggests that several important values have been lost to general practice. Having once been a positive career choice for many medical graduates, in 2020 the discipline is at the bottom of the heap — training in general practice is for "beggars" who miss out on other schemes. No longer valued by other members of the healthcare system, nor practising with any degree of independence, nor able to advocate for her patient, Dr Zen is just a binary drone, condemned to the restraints of protocol-driven diagnosis and algorithmic management. Such reductionism was rejected long before 2020 as a foundation for general practice1 and other branches of medicine.2 Can our elegant craft of hypothesis testing and revision survive alongside the brutishness of digital diagnosis? The primary focus of her attention is the third party paying for her time — what patient would appreciate that? Her clinical independence is severely compromised by the control the Ease manufacturer imposes on her therapeutic decision making. Dr Zen has no supportive collegiate contact, and her supervisors are the sort of managerial bureaucrats who thrive in environments from which general practitioners have been removed. What inspiration for medical students and vocational trainees would Dr Zen's role provide? Dr Zen's Fellowship of the Royal Australian College of General Practitioners still marks her as being competent to practise as an unsupervised GP anywhere in Australia, and she demonstrates this by moving easily between her outer urban push-button practice and the challenges of practice in an inner urban slum (presumably the future Toorak or Darling Point). At least her apparent comfort in working as part of a primary care team with a nurse practitioner makes it sound as though she has been trained in accord with the CanMEDS 2000 principles,3 which describe the GP as a collaborator among other things. The strength of GP training in Australia has long been its "enhanced apprenticeship" model, the only logical way to impart the values and skills of general practice. This combination of supervised training and needs-focused education allows registrars to practise in a real environment alongside carefully selected supervisors, while receiving relevant teaching from those supervisors and professional medical educators. Although vocational training for general practice has undergone major changes in the past two years, this model has continued. Our approach to training the doctors who will join us in general practice has a huge impact on the future of the profession. So where could we be in the year 2020, and how many of the positive values of the past will carry through to the future? Dr Zen's training, re-imaginedThe CanMEDS principles, updated, were incorporated by 2020 into a completely integrated curriculum for general practice that guides GP education from undergraduate study through to retirement. This curriculum has enough breadth to address all the disciplines that Dr Zen employs, ranging from population health, evidence-based practice and information management to business management, clinical governance and disaster medicine. Just as importantly, it has the depth to be relevant in any of the contexts in which GPs work, be that in Aboriginal health, a Muslim community, a rural area or the Antarctic. Information technology is a tool in the hands of the competent practitioner, but never a substitute for the practitioner's "presence". Nor does real time access to guidelines and algorithms substitute for the vast amount of knowledge about a patient that the GP acquires through careful communication. Dr Zen's Fellowship is not the endpoint of her formal learning. She will add a number of graduate certificates, a graduate diploma in preventive women's health, and a master's degree in cognitive behavioural therapy to her brass plate over the next decade. The Corporation values the role of the competent medical generalist, incrementally rewarding Dr Zen for the extra competencies she acquires, uses and maintains throughout her career. An exciting career path with the Corporation includes opportunities to contribute to its quality assurance, research and development program and to its education and training program. As part of its commitment to succession planning, continuing professional development activities form part of Dr Zen's paid contractual arrangements. Her work in the nurse-practitioner clinic is supported by a contract with the government. She enjoys this aspect of her life — different challenges, different demographics and a different team. But her commitment to quality patient care is just as strong. No taxi shifts for this alternative Dr Zen. Her income is sufficient, her work occupies four days each week by her choice and she has time for her children, friends and social activities.

Stephen C Trumble MD, FRACGP · Nicholas J Glasgow MD, FRACGP

Recent attempts by several corporate entities to secure more of Australia's primary medical care profits have so far been unsuccessful, but it is probably not the last we will hear from them. The 2020 scenario,* far fetched though it may seem, depicts general practice succumbing to the dollar lures of the Corporates. It is a primary healthcare model characterised by heavy regulation, structural division, detachment and constant change. An interventionist government bureaucracy and a ruthless commercial administration have effectively removed all autonomy and personalised attention from the individual's practice. Adherence to strict administrative protocols protects the commercial interests of the company, and both take priority over providing quality primary care. "Practice management" has become "policy management", and the general practitioner's needs are second to those of business managers who have become slaves to legislative conformity. GPs no longer have support staff to help them provide quality care; rather, the tables have turned and the doctors assist the administration in toeing the company line. As a result, Dr Zen has been forced to compromise on almost every value and ethic crucial to best care. Today, the profession is witnessing unprecedented bureaucratic proliferation. Multiple regulatory bodies, including federal and state governments, make demands of increasing quantity and complexity. The cost of practice administration, insurance and government regulatory compliance is escalating at an alarming rate.1 The financial pressure presently being brought to bear on general practice may ultimately precipitate the collapse of bulk billing and "universally accessible healthcare for all Australians". To prop up a dying primary healthcare system, the federal government may continue to add legislative "patches" that succeed only in transforming a once simple primary healthcare model into one that will ultimately be too complex and financially unsustainable for the medical profession.2 At that point, frustrated, overworked and underpaid doctors, no longer able to cope with the administrative convolution and burdensome regulatory demands being forced upon them, will finally abandon their practices in search of an easier way. The attraction of the Corporates lies partly in the promise of inexpensive, efficient, centralised administration.3 Yet, as a profession, we should recognise that a corporation's loyalty necessarily lies with its shareholders and that there are inherent dangers in "selling our souls" to these groups. Dr Zen's passing self reminder to raise the issue of quality care again at the next managers' meeting is illustrative of the gap that has opened up between our future practitioners and administrators. An increased administrative complexity demands attention from managers and diverts valuable human resources away from the patient's comfort, confidentiality and care, and from work relationships. A centralised administration is, by its very nature, one that operates remotely and, in this case, one that uses technology to monitor and control the performance of its human resources. The digital revolution will continue to influence virtually every aspect of our professional lives, but only time will tell if that influence will be for the betterment of general practice. Given the sheer volume of information in which we presently trade, it is inevitable that clinical records will ultimately pass between practitioners exclusively in a digital format. In the nightmare scenario, patient records have become an "online resource", with potential compromise of privacy. Therefore, as we develop systems in which confidential information is exchanged, "secure" communication channels must be among the highest priorities for software developers, the profession and law makers. At Corporation Enterprise, technology primarily serves the administration by monitoring the activities of practitioners inside the consulting room. Time has become the single most valuable commodity. Quality care comes a distant second to the commercial interests of the firm. Can we imagine a better future? 2020: extract from television newsThe Federal Government and general practice representatives emerged from their latest series of goodwill talks on regulatory reform today to confirm that the future of independent private practice was guaranteed. The restructuring of general practice under the "Red Tape" reform package has seen the elimination of inefficiency over the last three years by removing administrative complexity in general practice structures and payment systems. Outmoded bureaucratic systems were scrapped virtually overnight, and new payments systems, linked to better patient outcomes, were introduced. Dr I M Spock, National President of the AMA, said that "simplified administrative systems combined with a better use of technology" meant that the costs associated with practice would be halved by 2022 and that "the funding crisis could be averted after all". It looks like government-funded universal healthcare is back, and community groups around the country have applauded the initiative. A union representative from the Australian Medical Borg, an army of half-human, half-microprocessor humanoids, said today that "assimilation into this new system is inevitable and resistance is futile".

Mark V Lipscombe

Dr Zen's first words* capture the context perfectly. She and Mr Unger have a fixed time of five minutes available for their consultation, with penalties for Dr Zen if they run over. Dr Zen inquires how "we", not "I", can help. Chillingly, it quickly becomes apparent that "we" includes not just Corporation Enterprise but also their industrial sponsor of clinical guidelines and the manufacturer of Ease. Of course, five minutes is never going to give Dr Zen the opportunity to explore the wealth of possible meanings behind Mr Unger's words "I don't feel well". Like many doctors under pressure, Dr Zen takes the patient's first complaint as the principal one, and limits her attention to that.1 Even using this strategy, it is unlikely that there will be time for much in the way of health promotion during this consultation. This is a pity, as Mr Unger probably consults a doctor rarely, and is at particular risk following his bereavement. And yet Dr Zen, who likes talking with her customers on her taxi shift, tries to encounter Mr Unger as a person. All good doctors struggle continually to reconcile what have been called the biomechanical and the interpretive aspects of medical practice.2 Who would not wish to be offered care based on the best available scientific evidence? Symptom checklists, diagnostic algorithms and evidence-based guidelines provide the basis for optimising health outcomes. Furthermore, we cannot ignore the pressures of time. Even in private practice, every extra minute spent with one particular patient is a minute lost for others in the waiting room. There is more to care, however, than the efficient optimisation of outcomes. As doctors, by listening to the patient's story we help to clarify and define their distress. By responding empathically we validate it. By exploring and discussing their symptoms we help elaborate their understanding of their bodies, and hence of themselves. Through diagnosis we provide the patient and their family with a vocabulary for their suffering, helping to integrate the illness story into their life narrative. And when we offer a prognosis and treatment, we provide elements of the plot for the patient's story of their future. Doctors who work in primary care, like Dr Zen, have an additional function, that of working with the patient to define what is to be classified as illness — and hence treated as a health problem — and what is to be regarded as one of the vicissitudes of life.3 Much mischief can arise when patients and their doctors get this distinction wrong. Although the scenario is fictional, it is an extrapolation, if extreme, of recognisable current trends. The influence of Corporation Enterprise and its industry partners on the process of the consultation is so pervasive that they seem personified in the room.4 Dr Zen's agenda is determined almost entirely by the technologies of biomechanical medicine, even though the evidence base she mentions for Ease is quite irrelevant to a bereaved person consulting in a primary care setting. Mr Unger's agenda is crowded out; he is a case to be managed rather than a person to be cared for. The human interaction is constrained and reduced to the minimum needed to define the problem in a form recognised by a third party, and then to provide the matching treatment. And Dr Zen has little opportunity to display the qualities of sensitivity, empathy and compassion that we all need from our carers when we feel anxious and perplexed by illness. With more time at their disposal, Mr Unger and Dr Zen would have the opportunity to discuss Mr Unger's story of illness in more depth and to consider other issues that might be troubling him. The shared understanding constructed in this conversation might still lead to the illness being labelled as depression, but other, more creative, possibilities might emerge. Perhaps Mr Unger just needs to be heard and reassured, or perhaps he is seeking a new story for his life following the death of his wife. Perhaps, too, Mr Unger has troubling physical symptoms that he is reluctant to disclose until he comes to trust Dr Zen. A richer conversation would provide Dr Zen with health promotion opportunities and a context in which to propose age- and sex-appropriate screening. And Corporation Enterprise might find that Dr Zen prescribes less, while Mr Unger reports greater satisfaction with his care.5 Medicine is fundamentally an ethical activity, concerned with right action towards others; doing the right things in addition to doing things right. While diseases can be classified, albeit imperfectly, illnesses cannot; every ill person has their own fears and concerns, hopes and needs, values and preferences. Bioscience provides the tools, but it is in the conversation between persons that the proper use of those tools is defined.

Tim Usherwood MD, FRACGP

Dr Zen's experience of life as a doctor seems much closer than 2020.* Many of her tribulations are already sapping the morale of clinicians in 2003. It is significant that Dr Zen is a woman. We continue to live in a sexist world, and as the medical workforce, particularly the general practice workforce, becomes more and more female, it is likely to become increasingly subject to exploitative working conditions. Those responsible for recruitment into medical school must ensure that all sectors of society are represented proportionately and that men and women are equally represented. It will then be important to try and ensure that women are given equal opportunities within every branch of medicine and that general practice remains equally rewarding and challenging for men and women. The working conditions within Corporation Enterprise seem unlikely to attract the brightest and best medical graduates of either sex. The clinical encounter between Dr Zen and her unfortunate patient is an emaciated shadow of a genuine, general practice consultation. The doctor is constrained by her management and financial context and by the technology that she is obliged to use. As medical science develops, clinical practice necessarily becomes more difficult.1 In the future, doctors will need to be more skilful, not less so. As people live longer, more will suffer multiple illnesses, both physical and mental, and will suffer them simultaneously and inseparably. The patient who is overweight, depressed and hypertensive does not have these conditions in separate compartments of his life. He has all three inseparably and he may also be lonely and frightened — all of this is a single condition. The permutations of comorbidity are complex and individual outcomes are always unpredictable.1 Practice based on algorithms pretends that none of this is true and that healthcare is simple. The reductive use of information technology ossifies the processes of care, stifles innovation and fails to realise the potential of computers to model complexity. Dr Zen works in a context within which the agendas of the pharmaceutical industry and of government leave no room for the needs of the patient or the professional aspirations of the doctor. The result, clearly seen in Dr Zen, is a loss of enthusiasm for education and the disappearance of original research that is inspired and directed by clinicians. Governments, dependent on systems of democratic voting, are driven by the utilitarian imperative of the greatest good for the greatest number. Within healthcare, we are seeing the rise of a new utilitarianism underpinned by modern epidemiology and imposed through systems of healthcare that are supported by information technology and sponsored by pharmaceutical companies. This new utilitarianism treats both doctors and patients as standardised and replaceable units, and would have us believe that a smoker is not an autonomous adult who has chosen to smoke but a patient who has been inadequately treated by their general practitioner. The waning of professional power has been regarded as promoting patient autonomy, but its replacement by corporate power compounded by centralised political control seems likely to be much more destructive of individual patient autonomy, dignity and, ultimately, health. Current health policy is driven by a view of health defined as the absence of disease and measured by the prolongation of life. This view works to the advantage of the pharmaceutical industry. The interests of corporate profit underpin the trends which are already shifting attention and investment within healthcare from the sick to the well and from the old to the young, and replacing care mediated by touch with a system driven by paper and computers. Only a minority of most populations is acutely ill at any one time, whereas the majority are healthy and can be persuaded of a need to take action to remain so by undergoing screening or taking preventive medication. There is more money to be made from selling healthcare interventions for the healthier, richer majority than for the sicker, poorer minority, both globally and nationally.2 Similar forces drive the widening of health inequalities seen by Dr Zen in a nurse-led service for the poor and a doctor-led service, however attenuated, for the more affluent. The events of 2025: people powerReturning to the not so distant future and confronted by the fear that is enduringly implicit in the human experience of illness, we find that the need for a trusting relationship between doctor and patient is so strong that, by 2025, Australia has witnessed the so-called Taxicab Revolt. More and more people realised that doctors like Dr Zen were being forced to supplement their incomes by driving taxis. Frustrated by the minimal and standardised healthcare offered by commercially sponsored organisations like Corporation Enterprise, worried patients began to seek out GP taxi drivers who gave them time to talk about the real extent of their fears and anxieties, and advice about how to begin to sort them out. An alliance was formed which eventually led to widespread civil unrest and demands for a health service free of commercial interference and offering personal and continuing care of named patients by named doctors.3 The alliance bridged social divides and produced a renewed social solidarity based on the recognition that the need for healthcare is fundamental to human thriving.4 Different services for rich and poor were no longer acceptable. The rest is history. Tyranny will always bring forth its opponents as the rain does grass.5

Iona Heath

What's wrong in this scenario* is that Dr Zen's practice has been hijacked by guidelines, economic imperatives and intrusive technologies. Evidence-based medicine may be a comfort to Zen in the five minutes she has and may improve the look of the annual report of Corporation Enterprise, but the value of her skilled interpretation of the patient's narrative has been ignored. She remains a world away from her patient, with little time to weigh and integrate the research evidence on her screen. Algorithms and hospital-based trials cannot care compassionately for a man grieving for his lost wife, but narrative-based research may provide guidance. In Corporation Enterprise, the role of team care and the balance between managers and clinicians have been lost. Managers have implemented research-based reforms focused on efficiency, with little regard for the clinical needs of patients.1 In this context, the relationship between Ease and Corporation Enterprise is dangerously ill-directed and reduces the credibility of Ease's research. General practitioners are naturalists by training, spending many hours each day observing and summarising the multiple encounters they have with patients. Research that is not patient focused will simply entrench the cultural divide between researchers and practitioners. Dr Zen needs to reintegrate clinical research using observational data into her practice, and this can only happen if Corporation Enterprise revalues such research. To balance her own experience, Zen needs evidence on the natural history of the diverse presentations she encounters and on the use of diagnostic tests, therapies, and screening and prevention activities.2 For this evidence to be relevant to Zen, it has to be generated by networks of GP researchers using appropriate information technology.3 Narrative research is also needed, where the patient's story, including where they live and work, their family, culture, and past health experiences, can form the subject of enquiry.4 By its very nature, such research requires the active involvement of GPs like Zen, and it must value their story as part of the final result, just as it values evidence of patient empowerment and preferences,5 as well as the more conventional morbidity and mortality measures. We see that GPs will embrace the world of relevant research, given time, support and leadership. Establishing networks of research practices across Australia with strong and positive relationships with key academic centres and GP divisions is a priority. These research groups need to be cross-disciplinary and embrace multiple methods to answer the complex everyday problems that present in general practice. They must train their members to ask focused and answerable questions. Protected (funded) time is vital for those GPs who want to spend time answering these questions. Three- to five-year career paths for new researchers and passionate visionary mentors are other important elements. Above all, we need GPs to constantly question what they do in everyday practice and feed these queries into these research networks. Clinically important studies will follow. How to manage tiredness in a 55-year-old man, night sweats in a 17-year-old teenager and headache in a 10-year-old girl are some of the everyday priorities facing Zen and all practising GPs for which there is no evidence. What will the future look like? We hope — with some justification — for something better than Dr Zen's nightmare. 2020: Better findings for GP research2020 is a good year for general practice research. All 20 established GP research groups, in collaboration with other primary care organisations and consumer groups scattered across Australia, have secured large National Health and Medical Research Council grants, many being cross-disciplinary. Five of the projects from these groups have just won awards for "excellence in societal impact". These new awards were established in 2010 for projects judged most likely to improve the quality of care provided to the community. Twenty new GP and primary care fellowships of five years' duration have been secured. Corporation Enterprise has just announced the extension of a Professorial General Practice position in Primary Care Leadership and Practice-Based Research. Dr Zen has just logged on to the Professor's website and found new information from research programs on back pain in young men, headache in teenagers and the role of exercise in patients with rheumatoid arthritis. She downloads a new decision support algorithm for the management of tiredness. She emails the professor's personal assistant about a new question she has concerning the palliative care management for her patient in heart failure, and receives a return invitation to apply for funding for protected time to explore the research potential of this question. She takes a taxi home with a smile on her face as she contemplates how to fit this new opportunity into her working life.

Justin J Beilby MD, FRACGP · John S Furler MB BS, MRCGP

William Lancashire*, Craig Hore† and Jennifer A Law‡ *Conjoint Senior Lecturer, †Senior Lecturer, ‡Lecturer, School of Rural Health, University of New South Wales, PO Box 2466, Port Macquarie, NSW 2444. Bill.lancashireATmaynegroup.com To the Editor: We read with interest Hillman's editorial on the hospitalist movement.1 As our group includes a couple of recent expatriates from the Canadian healthcare system,* we can give some historical perspective on the evolution of the hospitalist in Canada, some of which parallels what is happening in Australia. Traditionally, family physicians (general practitioners) in Canada were able to manage their patients in hospital, either as the primary care doctor or in consultation with a specialist. Not infrequently, the specialist would assume primary care and consult with the family doctor. Continuity of care was assured, and both the family doctor and the specialist benefited socially and professionally from the interaction. The "corridor consultation" thrived and the doctor's lounge was a source of medical education and social interaction as GPs and specialists met over a morning coffee before rounds. Around 10 years ago, the family doctor became increasingly unwelcome in the hospital, particularly in teaching centres. As there was never a financial incentive to be involved in hospital practice, this atmosphere persuaded most family doctors to resign their hospital privileges. However, it soon became apparent that a visiting-consultant-based service could not cope with the numbers of patients being admitted to hospitals. Patients with no apparent "teaching value" were becoming difficult to admit into teaching units. Consequently, those few GPs who had retained hospital privileges were increasingly being asked to accept patients primarily under their care. As the system became more stressed, they found that they were managing more and more acutely ill patients. These experienced GPs evolved to become hospitalists — essentially, primary care doctors who were prepared to look after acutely ill inpatients, often in consultation with a specialist. Unfortunately, attempts to encourage GPs back into the hospital system have generally proved unsuccessful. The College of Family Physicians of Canada, recognising that there may no longer be ready access to specialist services or hospital beds, is starting to train its residents accordingly. We agree with Hillman that the complexities of acute medicine require specialists (such as emergency physicians, intensive care specialists and general physicians) with training and skills in acute medicine, resuscitation and multisystem problems. Indeed, our experience in rural Australia suggests that hospital-based multidisciplinary critical care physicians are already undertaking some of the hospitalist roles that Hillman describes. Perhaps we are witnessing the emergence of hospitalists in Australia.

William Lancashire · Craig Hore · Jennifer A Law

F Frank Pyefinch Director of MD Development, Health Communication Network, 2 Santa Fe Drive, Bundaberg, QLD 4670 frank.pyefinchAThcn.com.au To the Editor: I would like to comment on the recent article by Newby et al.1 They conclude that the default settings in computerised prescription packages result in a significant increase in the use of antibiotics. I do not believe this is a valid conclusion. As the authors state that 85% of general practitioners generating computerised prescriptions are using Medical Director (MD), it is reasonable to assume that the default settings in MD would contribute significantly to this effect if their conclusion is correct. I have installed and tested MD v.2.3 from February 2000, MDW v.1.85 from February 2000 and MD v.2.4 from May 2000. These were the versions that would have been in use at the time of this study. All versions default to printing "once-only" prescriptions without repeats. In fact, when a "once-only" prescription has been selected, MD's default behaviour is to display a prompt for the quantity and repeats with the default repeats field set to "0". This is very easy to verify simply by installing a copy of MD onto a "clean" computer and printing some scripts. As this was evidently not done, it casts doubt on the quality of the whole study. How can the authors reach a conclusion about the effect of the default settings in computerised prescription packages without first ascertaining what those default settings are? They appear to have assumed that the default behaviour of all computer prescription packages is to print the maximum number of repeats allowed by the Pharmaceutical Benefits Scheme. No attempt appears to have been made to verify whether this is the case. Whatever the reason for the observed increase in repeat antibiotic prescriptions, it is incorrect to conclude that it is due to the default settings in computerised prescribing packages. No discussion of other possible explanations for the observed increase is presented and it appears as though the data have been used to support a conclusion that had been decided before the study was commenced.

F Frank Pyefinch

David A Newby,* Jayne L Fryer,† David A Henry‡ * Lecturer, † Statistical Analyst, ‡ Professor, Department of Clinical Pharmacology, University of Newcastle, Newcastle Mater Misericordiae Hospital, Newcastle, NSW 2298 mddanATalinga.newcastle.edu.au In reply: As Pyefinch notes, if the "once only" option in Medical Director (MD) is chosen during prescribing, the doctor must enter the quantity and number of repeats that he or she wishes to order. However, if the doctor chooses the "regular" medicine option (both options are offered during prescribing), then the maximum Pharmaceutical Benefits Schedule quantities and repeats are inserted. There are various reasons why doctors may be using the "regular" option rather than the "once only" option when prescribing antibiotics using MD. Some of these have been discussed on the General Practice Computing Group Listserv,1 and include factors such as confusion regarding the terms "regular" and "once only" and difficulties recalling patient medication histories if the "once only" option is used. Another explanation is that doctors commonly prescribe chronic medications, and therefore use of the "regular" option may become a habit. Whatever the cause, there is no obvious explanation for the differences observed, except for the use of prescribing software. Our recommendation that prescribing software be altered to avoid these shortcuts was made because it represents the most immediate way of resolving the problem.

David A Newby · Jayne L Fryer · David A Henry

The range of contraceptive options and consumer awareness of new contraceptive methods have both increased significantly over the past 10 years. New methods available in Australia include lower-dose oral contraceptive pills, new oral progestogens, progestogen implants, a progestogen-bearing intrauterine device and polyurethane female condoms. Contraceptive options which may soon be introduced in Australia include novel methods of administering combined (oestrogen–progestogen) contraception, such as dermal patches and vaginal rings.

Therese M Foran FACSHP