General medicine

There is evidence from well designed randomised controlled trials that modern medical and conservative surgical therapies (including endometrial ablation) are effective treatments for heavy menstrual bleeding for many women. Submucous fibroids may be resected directly via the hysteroscope, reducing menstrual bleeding, although data are available only from case series. Endometriosis is common, may also occur in young women and may present with atypical or non-cyclical symptoms; conservative laparoscopic surgery increases fecundity and reduces dysmenorrhoea and dyspareunia. Randomised trials of the levonorgestrel intrauterine system in women with menorrhagia have shown that hysterectomy can be avoided in 80% of cases, and that this system is an effective therapy for menorrhagia. The levonorgestrel intrauterine system may also be useful for managing symptoms of endometriosis, adenomyosis and endometrial hyperplasia, based on observational data.

Martha Hickey MD, MRCOG, FRANZCOG · Cynthia M Farquhar MD, FRANZCOG, PGDipPH

Have recent controlled trials ended the debate? Each year in Australia over 10 000 women are diagnosed with breast cancer and around 2600 women die. Early diagnosis improves survival chances. Imagine the following scenario. You have just completed an annual examination of a married, 36-year-old mother of two, when she casually asks: "Doctor, would you recommend that I practise monthly breast self examination?" What do you tell her? What if this patient happened to be a healthy 59-year-old postmenopausal woman, or, for that matter, a "senior citizen" of 81 years, or a woman with a family history of breast cancer? What advice would you proffer? Would you rely on evidence-based data and diplomatically state: "Well, there really is no evidence that breast self examination reduces mortality rates", or would you say "We don't endorse breast self examination, but it would be advisable for you to develop an awareness of your breasts"? What "endpoints" are uppermost in your mind — mortality, detection, even prevention? Perhaps more significantly, what "endpoints" are uppermost in your patient's mind? This is a common dilemma confronting clinicians as they grapple with the vagaries of epidemiology, clinical experience and patients' needs for information and advice. For decades, public health campaigns have targeted women with the message that early detection of breast cancer translates into improved survival chances, and that examination of breasts and mammography are the first steps on the road to early detection. However, following recent trial results,1 those advising women appear to have forgotten this vital relationship between breast self examination, early detection and consequent improved survival. "Detection" has become the "poor cousin" of survival, mortality, and the teaching and practice of breast self examination. The result is confusion, ambivalence and, at times, contradictory or nonsensical advice. This is clearly reflected in the various statements promulgated by Australian cancer organisations, which now tread very carefully when using those three, once so helpful, words, "breast self examination". BreastScreen NSW has dropped them from its recommendations and state cancer councils, the National Breast Cancer Centre and the NSW Breast Cancer Institute are in the process of doing same, or are carefully rephrasing them to being simply "breast self aware". As an example, The Cancer Council NSW Fact Sheet2 recommends gaining awareness "by looking at your breasts in the mirror and feeling them from time to time". This sounds pretty much like self examination of breasts to us, only without the previous instructions on how to do it effectively. The Fact Sheet sensibly continues "some women feel that regular breast self examination is worthwhile. It's up to you". Advice from other cancer organisations contains similar hedging statements. These messages reflect the difficulty of interpreting evidence-based data derived from studies with differing endpoints — both for the clinical situation and for the commonsense advice sought by women. The National Breast Cancer Centre's position statement is largely based on the comprehensive 1999 literature review of studies of breast self examination by Clarke et al.3 Of considerable significance are the methodological shortcomings of those studies and their diversity of endpoints. But most compelling is that, of the seven trials reported, none provided National Health and Medical Research Council Level I evidence, two gave Level II and the others Level III — not overly convincing! In 2002, the eagerly awaited final report of the trial by Thomas et al1 became available. Despite the fact that Thomas and colleagues concluded that this was a trial of the teaching of breast self examination (ie, the specific technique), not the practice of breast self examination (nor, indeed, a trial of the breast examination that many aware women do whether or not they are trained in the "breast self examination" technique), the editorial in the Journal of the National Cancer Institute trumpeted the study's results as signalling the "death" of breast self examination.4 An editorial in the British Medical Journal 5 claimed that Thomas and colleagues had provided "conclusive" evidence that breast self examination was not effective in reducing mortality, and concluded that the study should put an end to a decade of controversy. We believe that this statement is most unhelpful and could lead to delayed detection of breast cancer, particularly in younger women, for whom mammography is less effective.6,7 While acknowledging that this was the largest trial ever conducted on the relationship between breast self examination and mortality from breast cancer, how transferable are results from women in Shanghai to women in Australia? A growing body of literature8-10 casts some doubt on the universality of the findings of Thomas and colleagues, as cultural context and associated values and behaviours were ignored. Potential confounding factors, such as attitudes towards breast self examination and healthcare, were not investigated. The position of the Breast Cancer Action Group (NSW and VIC) is the commonsense approach — that women should be physically familiar with their breasts and seek advice if they notice any non-normal changes. If you feel a lump or notice other changes — and how else can this be done other than by physically examining the breasts? — take the next step on the triple-test path of mammography, ultrasound examination and biopsy. Further concerns in this debate relate to the suggestion that encouraging awareness of breast changes will distress women, and will possibly increase the health dollars spent on unnecessary investigation. The first claim is patronising, even demeaning, and the second runs counter to the evidence-based public commitment to increase screening modalities for Australian women. What is indisputable for Australian women is that breast examination is the predominant method of detecting breast cancer. In Australia, mammographic screening accounts for just over 30% of detected breast cancers (37% of early disease, 14% of advanced disease);11 the remainder are found by women themselves and their medical advisers. How are they found? By examining their breasts! For younger women this is usually the only avenue for detection — early or late — as clinicians rarely offer clinical breast examination, and mammography is not effective. Our research priority in this area would be for careful and well designed studies of the relationship between breast self examination and early diagnosis. What interests us is increased early detection, whether this be via breast self examination, mammography, or ultrasound examination. It is imperative that clear and unambiguous messages are transmitted to give women the best chance of survival. Resorting to the semantics of "being breast aware" fails this imperative. Common sense suggests that it is not possible for us to somehow be "breast aware" without examining them.

Sally Crossing BEc · Rosetta Manaszewicz

Re: the 5 May 2003 supplement to the Journal, Comprehensive care for people with schizophrenia living in the community (Med J Aust 2003; 178: S41-S80). In some articles, authors referred, in the text or reference list, to other articles in the same supplement. In a few instances, the page numbers of the cited articles were omitted in the printed version. The web version published simultaneously ...

The care of a dying person requires qualities of a medical practitioner that do not sit neatly within the prevailing medical paradigm. "Don't just do something, sit there!" This twist on a well known adage was coined by the American social psychologist Richard Kalish,1 and at the time was directed to those whose task it was to care for the sick and dying. It is a novel, but pointed, statement that stresses the importance of being really present for people who are suffering, and truly hearing their pain. The statement may not have been made with the medical profession specifically in mind, but it is nonetheless as pertinent to doctors as it is to anyone involved in caring for the sick. For doctors, the challenge implicit in the statement is that patients, particularly those with a life-threatening illness, may not be well served by a model of care that concentrates on diagnostic and therapeutic interventions.2 Indeed, the threat of death creates needs that can never be met by attending to the physical domain alone. Pain relief and meticulous attention to troublesome symptoms certainly go a long way towards restoring comfort and dignity, but emotional and existential issues need to be approached in a more holistic way — one in which honesty, empathy, authenticity and the ability to communicate feature high on the list of qualities required of the doctor. "The physician is only the servant of nature, not her master" –Paracelsus (1493 – 1541) The emphasis in medicine over the past 50 years or more has been on cure, or at least on what can be done technically and pharmacologically. With the increasing number of tests and treatments now available, the tendency to intervene has reached a point where it is hard to imagine how we, as practitioners, could function in anything other than this model — a model described by Moskowitz as a "medical juggernaut driven by a logic of its own, one less focused on human suffering and dignity than on the struggle to maintain vital functions".3 As a young physician in the early 1970s, I vividly remember an elderly general practitioner reflecting on his 60 years in practice. It was both fascinating and enlightening to hear someone talk about the care of patients at a time when there were no antibiotics or specific treatment for chronic illnesses such as asthma, diabetes mellitus and hypertension. It was a time when morphine, mercurial diuretics, digitalis leaf, tourniquets and venesection were the only interventions available for heart failure, and treatment for most conditions was guided by clinical judgement rather than "numbers" and x-rays. By present-day standards, this doctor had little in the way of a medical armamentarium. But, although he may have been helpless to influence the course of many illnesses, he did not consider himself to be helpless. He comforted the sick, sat with them and their families during difficult times, and was a trusted and reassuring presence in the face of death. He may have had little to offer medically, but what struck me was that I, with my newly acquired specialist ticket and accompanying bag of tricks, felt more uncomfortable and helpless than he when faced with a dying patient. Times have changed, and many of the illnesses that claimed lives in the early part of the 20th century are now preventable, curable or more easily palliated. For many patients we have succeeded in postponing death and have hopefully improved the quality of their life. But have we improved the care of those who cannot be cured? Are we as skilled as my GP colleague in comforting and communicating with the sick and dying, or are we distracted by unnecessary tests and futile treatments that threaten to engage us in a form of subterfuge that serves only to conceal a sense of helplessness, while adding considerably to a patient's distress? In a retrospective study of 100 deaths at an Australian hospital, Middlewood et al4 noted that 74 of the patients were considered by the attending medical team to be dying, and "do not resuscitate" (DNR) orders were completed for 88 patients. Despite this, 78 were subjected to one or more tests after the DNR order, 67 received antibiotics, and 88 were given intravenous fluids. At the time of death, 27 of the patients were still receiving antibiotics and 49 had a drip in situ. Although most of the patients were thought to be dying, the approach to care did not appear to reflect this, or if so, only very late in the course of the illness. Similar outcomes were found in a study of 200 deaths within a large medical centre in the United States.5 In this study, comfort-care (palliative-care) plans were completed in just 46% of the patients and, once again, this occurred late in the admission, even though most patients had been identified as dying and DNR orders were completed well beforehand. In a report entitled Pursuing a peaceful death, Callahan6 intimated that the medicalisation of death has made the prospects of "dying well" more of a hope than an expectation. "Death", he says, "is now harder to predict, more difficult to manage, the source of more and more moral dilemmas and nasty choices, and spiritually more productive of anguish, ambivalence and uncertainty". Callahan is not making excuses for clinicians, nor is he suggesting a return to the days when death was more predictable simply because there was little that could be done to prevent it. Rather, he implores that we, individually and collectively, look at the way we care for the dying and reflect on whether our actions contribute to patients not dying well. He urges us to see death not as a failure of medical treatment but as one of the most important times in a person's life — a time that calls for respect rather than interference. It is a time when attention to suffering is more important than the maintenance of physiological function. We physicians can help patients die with comfort and dignity by withholding or withdrawing treatment that is clearly futile. Such a decision is never easy, and circumstances pertinent to each patient can make this more difficult. Our honesty, authenticity, and the way we impart information can effectively bridge such difficulties and allow the patient, his or her family, and the attending team to refocus on the broader issues. To inform a patient that he or she is dying is painful and traumatic, but it is not made any easier by deferring or avoiding the subject altogether. Our honesty only confirms what most dying people already suspect. If we ignore the truth, we deceive ourselves as well as our patients and deprive them and their families of the opportunity to say goodbye and prepare for death.7 Grahame Jones, writing about an illness that ultimately claimed his life, said, "let the healthy talk of illness; let the sick talk of more important things".8 Care modelled around tests and futile attempts at cure only succeeds in maintaining a focus on illness. This may be comforting to the clinician, but it effectively robs the dying patient of the opportunity to talk about the "more important things". In the many public talks that she has given in the past, Elisabeth Kubler-Ross, author of On death and dying,9 often spoke about a member of the hospital staff whom dying patients would invariably seek out when they needed comfort or someone to talk to. This person was not a doctor, nurse, social worker or counsellor. She was the cleaner, and, when asked by Kubler-Ross why she was so sought after, her reply was simple but direct. "Death", she said, "is an old friend". This woman had seen a lot of death, not just in the hospital but also within her own family, and, like the elderly GP who had so impressed me, was not afraid to journey with people as they were dying. Neither she nor the GP relished the task, but neither sought to abandon their responsibility during the difficult and sometimes frightening time leading up to death. Both are excellent role models and demonstrate the important role we can play in helping patients prepare for death. If we are able to do this, we not only play an important part in their healing but also heal a part of us that may be uncomfortable with death.

Michael Barbato MB BS, FRACP

Patient care in the "new genetics" era encompasses not only the diagnosis of a genetic condition or risk, but also managing the psychosocial, familial and ethical sequelae. Partnerships between the medical professional and expert clinical genetics services, support groups, registries and genetics education services provide a framework for this management. More than 750 Australian support groups assist individuals and families with genetic conditions through contact with peers, information and education resources for patients and professionals, practical advice about coping and advocacy.

Kristine K Barlow-Stewart · Clara L Gaff

To the Editor: I was interested in the letter by Marks et al,1 indicating that the efforts of over-worked medical staff in emergency departments to introduce patients to local general practitioners had been largely unsuccessful. A few years ago I noted the success with which this problem was handled by the emergency department management at Huddinge University Hospital in Stockholm. All patients were charged 60 krone at triage. Those who sat in the waiting room were confronted by two large electronic signs. The first listed the waiting time for the 10 most common GP-type ailments. The second listed 10 local GPs, where the consultation fee was then 50 krone, with the offer to refund their initial payment if they chose to take their business elsewhere. I was told that this was the very successful first of eight "barriers" between the emergency department door and the intensive care unit. Since the middle of last century, Sweden has been held up as a model provider of an egalitarian and "free" healthcare service. Perhaps our country could benefit from the revisions and improvements that the Swedes have made over recent decades.

Peter J Burke

In Australia there continue to be significant barriers to care and gaps in service provision for people with schizophrenia. The extent of these shortcomings is echoed in the National Survey of Mental Health and Wellbeing study on low-prevalence (psychotic) disorders.1 Of the 998 people with psychotic disorders surveyed, 84% were single, separated, divorced or widowed; 85% were reliant on welfare benefits; 72% did not have a regular occupation; and 45% were living in some form of hostel or supported accommodation, or were homeless. These unacceptable psychosocial outcomes were evident despite the fact that 91% of the people surveyed were currently receiving psychotropic medication. Furthermore, only 19% of patients had used any form of rehabilitation service over the previous year. It was not that they did not want to access such services; indeed, 47% of the survey cohort perceived the need for a particular type of service that was not accessible to them, either because it was unavailable or they could not afford it. The service provider with whom the majority of survey respondents did have regular contact was their general practioner: 81% had seen their GP in the previous year, and the average number of visits was 12 per year.1 Clearly, not all of these contacts were for mental health reasons, but the extent and regularity of contact with GPs by people with schizophrenia highlights the potentially crucial role GPs can play in their overall health. GPs are likely to have increasing involvement with managing medical comorbidity in patients with schizophrenia, especially now that newer "atypical" antipsychotic drugs are available. Thus, this Supplement, highlighting the latest developments in managing schizophrenia and delivering comprehensive care, is particularly relevant for GPs. Hocking (page 47)2 underlines the place of the community in schizophrenia management — highly pertinent in these "post-institutionalisation" days, when the vast majority of people with schizophrenia are resident in the community. It is important that GPs understand the functioning of the modern mental healthcare system, know what resources are available to assist in managing patients with schizophrenia, and have the information required to negotiate potential barriers to accessing support services. These issues are detailed by Harvey and Fielding (page 49).3 A model for GP participation in managing people with schizophrenia is outlined by Meadows (page 53),4 in the hope that the principles can be adapted more broadly. There have been substantial recent developments in pharmacological treatments for schizophrenia. No longer are treatments for psychosis inevitably associated with unpleasant and potentially debilitating extrapyramidal side effects such as parkinsonism, akathisia and tardive dyskinesia. The newer "atypical" antipsychotics are much less likely to have these disabling side effects, and are now first-line treatment for schizophrenia. However, the atypicals have been associated with other medical problems, including weight gain,5 diabetes6 and hyperlipidaemia.7 The decision about which drug to use for any individual patient requires a careful weighing of the side effects against potential therapeutic effects. An overview of the atypical antipsychotics is provided by Lambert and Castle (page 57).8 Despite pharmacological advances, some patients remain "resistant" to conventional treatments. However, we are increasingly able to offer such patients newer treatments that more effectively reduce psychotic symptoms and enhance quality of life. Indeed, the newer agents can have benefits in a number of domains, including those of behaviour, depressive and suicidal thoughts, and cognitive functioning, as well as improving social and vocational outcomes. The management of "treatment resistance" in schizophrenia is reviewed by Pantelis and Lambert (page 62).9 The physical health of people with schizophrenia is often suboptimal, and general medical conditions may either be missed, through inadequate screening, or treated suboptimally. The GP has a crucial role to play here. Lambert et al (page 67)10 outline the main medical problems encountered in people with schizophrenia and the barriers to detection and treatment. Many of the interventions for general medical conditions such as obesity and hypertension require educating the patient about "healthy living", including regular exercise, attention to diet, and stopping smoking. A common problem among people with schizophrenia is the misuse of alcohol and illicit substances. Substance misuse impairs the overall health of the individual, resulting in more severe symptoms, greater chance of relapse and re-hospitalisation and, in some instances, increased risk of crime and violence. Again, the GP has an important role to play in detection and management of comorbid substance misuse. Lubman and Sundram (page 71)11 provide practical guidance for GPs in dealing with this complex issue. Finally, Crosse (page 76)12 suggests ways in which people with schizophrenia can be helped to participate fully in society so that each day is full and meaningful. This should be the aim of all of us involved in the care of people with schizophrenia.

David J Castle MD, MRCPsych, FRANZCP · Christos Pantelis MRCPsych, FRANZCP

The stigma associated with schizophrenia is pervasive, both in the community and among healthcare workers, and forms a real barrier to optimal recovery from the illness. The negative consequences of stigma include discrimination in housing, education and employment, and increased feelings of hopelessness in people with schizophrenia. Health professionals have a responsibility to improve their own attitudes and behaviour towards people with schizophrenia so they do not contribute to the stigma. Educational campaigns aimed at people in the community and media personnel could help to demystify mental illness and reduce the portrayal of offensive stereotypes of people with schizophrenia.

Barbara Hocking BSc(Hons), DipEd, DipHEd, GAICD

In Australia, the configuration of public mental health services varies between States and Territories, but, overall, community-based services are increasingly integrated and responsive to people with schizophrenia. Community-based services include mobile crisis teams, providing home-based acute treatment, and case-management services for ongoing treatment. Service improvements have been uneven across Australia. Some people with schizophrenia in psychiatric crisis have had difficulty accessing either home-based acute psychiatric treatment or acute psychiatric beds. Social isolation and lack of meaningful occupation continue to be a problem for people with schizophrenia. Psychosocial interventions can enhance reintegration into the community. However, the number of community-based psychosocial rehabilitation programs is still inadequate.

Carol A Harvey MRCPsych, FRANZCP · John M Fielding MD, FRANZCP

Many people with schizophrenia are in regular contact with their general practitioners. GPs commonly play a sentinel role in management, but may require support from Area Mental Health Services (AMHSs). The CLIPP (Consultation and Liaison in Primary-care Psychiatry) shared-care model of patient management combines a collocated consultation/liaison service for managing referrals from GPs to specialists with a carefully structured approach to long-term care of patients transferred from AMHS care to GPs. The CLIPP model uses the concept of a "relapse signature", involving recognition of early warning signs of relapse, to simplify clinical monitoring of patients with schizophrenia.

Graham N Meadows MBChB, MRCP, FRANZCP

Pharmacological treatment remains the mainstay of the management of schizophrenia. Older, "typical" antipsychotics carry a significant burden of side effects, notably extrapyramidal and neurocognitive side effects. Newer, "atypical" agents carry a lower risk of extrapyramidal side effects. They appear to have added benefit for treating negative and cognitive symptoms of schizophrenia, and hence can enhance the quality of life of some patients. The choice of particular agents for individual patients requires a balancing of efficacy and side effects. Medication is only one element of what should be an individualised comprehensive treatment plan for people with schizophrenia.

Timothy J R Lambert BSc, MB BS, FRANZCP · David J Castle MD, MRCPsych, FRANZCP

Patients who fail to respond adequately to pharmacological treatment present an ongoing therapeutic challenge. The term "incomplete recovery" (IR) is preferred to the current term "treatment resistance" to describe these patients. IR should be considered from a multidimensional perspective that includes a broad range of symptoms and functional disabilities that are relevant to schizophrenia. The approach to the incompletely recovered patient needs to be systematic, with consideration given to the factors that may hamper recovery. "Atypical" (second-generation) antipsychotic drugs target various domains of symptoms relevant to IR. Adjunctive treatment strategies (eg, mood stabilisers, antidepressants, combinations of antipsychotics) may be useful, but should be undertaken in specialist psychiatric settings. Although pharmacological treatment is a necessary first step in managing incompletely recovered patients, adjunctive psychosocial interventions are needed to optimise treatment success.

Christos Pantelis MB BS, MRCPsych, FRANZCP · Timothy J R Lambert BSc, MB BS, FRANZCP

Schizophrenia has been described as a "life-shortening disease", and physical comorbidity accounts for 60% of premature deaths not related to suicide. People with schizophrenia and other mental illnesses have a higher rate of preventable risk factors such as smoking, high alcohol consumption, poor diet, and lack of exercise. Recognition and management of morbidity in people with mental illness are made more difficult by barriers related to the patient, the illness, the attitudes of medical practitioners, and the structure of healthcare delivery services. Improved detection and treatment of medical illness in people with schizophrenia will have significant benefits for their psychosocial functioning and overall quality of life.

Timothy J R Lambert BSc, MB BS, FRANZCP · Dennis Velakoulis MB BS, FRANZCP · Christos Pantelis MB BS, MRCPsych, FRANZCP

Smoking presents a substantial health and economic burden to people with schizophrenia. Comorbid use of other substances is common, under-recognised, and associated with a number of serious adverse consequences, such as psychotic relapse and poorer social outcomes. All patients with schizophrenia need to be screened for substance misuse. Effective interventions involve integrated, modified pharmacological and psychosocial strategies.

Dan I Lubman PhD, FRANZCP, FAChAM · Suresh Sundram PhD, FRANZCP

While many of the overt symptoms of schizophrenia may be controlled by medication, the associated psychiatric disability requires ongoing psychosocial rehabilitation and support in the community. The general practitioner can play a crucial role in this rehabilitative process, through

Caroline Crosse BA (Hons)

To the Editor: At the Australasian Schizophrenia Conference in Sydney in October 2002, Professor Patrick McGorry of the Orygen Research Centre, University of Melbourne, presented draft guidelines on the management of schizophrenia and early psychoses.1 One of the recommendations was that atypical antipsychotic drugs should be used as the first-line pharmacological treatment in preference to typical antipsychotics and depot antipsychotics. With a shift in management of schizophrenia to community-based care, the number of patients with schizophrenia managed by general practitioners has increased over the past decade (from 36 per 10 000 encounters in 1990–91 to 45 per 10 000 in 2000–02).2 With the pending introduction of the guidelines, a baseline measure of GP prescribing rates of antipsychotics, both typical and atypical, will allow future measurement of the impact of the guidelines. We analysed the 1998–2002 data from the Bettering the Evaluation and Care of Health (BEACH) program, a continuous national cross-sectional survey of general practice.3 About 1000 GPs participate in this program every year, each providing details (on structured forms) about 100 consecutive patient encounters. Data collected include GP and patient characteristics, problems managed and treatment provided. We examined 401 300 encounters from 4013 GPs, with 431 537 medications recorded. Prescription rates were calculated and regression analyses performed using SAS software4 to adjust for the cluster effect of the study design. There were 1988 schizophrenia or psychosis problems managed in the four years of data collection (a rate of 49.5 per 10 000 encounters); 1883 medications were prescribed (94.7 per 100 contacts), of which 926 (49.2%) were typical antipsychotic drugs and 484 (25.7%) were atypical antipsychotic drugs. In 1998–99, the prescription rate of atypical antipsychotics was 15.7 per 100 contacts with patients with schizophrenia or psychosis (95% CI, 11.8–19.7). This rate increased to 31.1 per 100 contacts (95% CI, 26.3–36.0) in 2001–02. In the same period, the prescription rate for typical antipsychotics fell from 51.3 per 100 contacts (95% CI, 45.6–56.9) in 1998–99 to 40.6 per 100 contacts (95% CI, 35.4–45.8) in 2001–02. Linear regression showed that the prescription rate of atypical antipsychotics had increased by an average of 5.1 per 100 contacts per year over the four years (P < 0.0001), while the prescription rate of typical antipsychotics had decreased by an average of 3.8 per 100 per year (P < 0.005). Over the four-year period, there was no significant increase in the rate of overall prescriptions for people with schizophrenia (92.0 prescriptions per 100 contacts [95% CI, 83.4–100.7] in 1998–99 v 96.3 [95% CI, 89.4–103.3] in 2001–02). Between 1998 and 2002, the relative prescribing rate of atypical antipsychotics for schizophrenia and other psychoses in general practice nearly doubled. These results show that, even before the introduction of the guidelines, there has been a shift towards prescribing atypical antipsychotics in preference to typical antipsychotics. This change may reflect a change in specialist behaviour, as specialists have a direct effect on GP prescribing.5 The BEACH study will be able to assess the effect of the guidelines on the prescription rate of atypical antipsychotics by GPs.

Christopher M Harrison · Helena C Britt

To the Editor: I would like to comment on a recent article by Young and Dobson on the decline of bulk-billing and the increase in out-of-pocket expenses.1 It is true, as the authors state, that "Australia has no legislation restricting how much a general practitioner can charge for a consultation". It is a shame that they did not take equal time to point out that there is no binding requirement on governments to ensure that Medicare rebates remain within striking distance of the real cost of service provision. Policy change is required — with as much political and moral urgency as Young and Dobson advocate for patient access reform — to enable doctors to provide affordable healthcare under a fee-for-service system without being penalised for accepting a substantial number of elderly or socially disadvantaged patients. Primary healthcare policy needs to be adjusted to maintain rebate justice for low-income patients by linking patients' rebates to their doctors' real-life market costs (or even to relative value studies), not budget "bottom lines". Is the patient to be out of pocket, or the doctor? Surely, both positions are equally unfair, and equally unlikely to bring about an equitable system.

Warwick H Ruse

To the Editor: Young and Dobson1 have confirmed what has been long suspected by many rural doctors and patients — that women (and patients in general) in rural areas are paying higher out-of-pocket costs for general practice consultations than those in urban areas. I wonder whether the authors have considered analysing the data by State and Territory, as the structure of a State healthcare system often has a significant impact on healthcare costs to individuals. I am also interested to know whether total costs of healthcare (including on-costs, referrals, specialist fees, hospital and investigative care) were analysed. There is a long held view that rural doctors have a more holistic approach to patient care than their urban colleagues, who are more inclined to recommend unnecessary investigations and specialist referrals. It would be fascinating to know whether urban women would actually be more "out-of-pocket" than rural women if total contact with the healthcare system (not just general practice consultations) was taken into account.

Chris A Harrison

To the Editor: Do the data in Young and Dobson's study of general practice consultation fees1 support their conclusion that women in rural and remote areas lack access to affordable healthcare services? The declining prevalence of bulk-billing by general practitioners suggests that healthcare may be becoming increasingly unaffordable for people on lower incomes. But affordability is not only income-related — it depends also on choices regarding discretionary expenditure. Considering median levels of disposable weekly income, together with the prices of basic daily commodities such as milk or bread (not to mention a $10 pack of cigarettes!), how "unaffordable" is an occasional $5–$10 out-of-pocket fee for a GP consultation? As Young and Dobson concede, a further complicating factor in their study was that "the consenters . . . tended to have higher socioeconomic status and so may be less likely to be bulk-billed". It would have been helpful if the authors had defined affordability of GP care in relation to family income (perhaps analogous to advice that rental or mortgage repayments should not exceed a third of household disposable income) and identified just how much their frequent attenders' GP costs exceeded a specified limit of affordability. Services free at point of delivery are overused, both by patients and doctors, as evidenced by the Commonwealth's implementation of the Professional Services Review Scheme and the States' legislating to curb the costs of workers compensation and third-party motor vehicle insurance claims. There is probably an optimal price range that would facilitate affordable access without penalising the less affluent or encouraging "inappropriate practice". Closer attention to the affordability of GP services for individual households would help target resources to people who truly need the services but cannot afford them. This may be a better alternative to the authors' suggestion of simply making policy changes (taxpayer-funded?) to lower the price of GP services for all women in rural and remote Australia.

Peter C Arnold

In reply: We thank the authors of these letters for raising many of the complex issues that underlie the current geographical inequities in costs of general practice consultations. Ruse is concerned that we did not point out the inadequacy of the current Medicare rebates to practitioners. An appraisal of the adequacy of Medicare Benefits Schedule fees was beyond the scope of our study. We presented data on the out-of-pocket costs of general practice consultations, according to demographic and health-related characteristics of consumers, for consideration by all interested parties — practitioners and patients. As suggested by Harrison, we could also look at differences in bulk-billing and costs by State and Territory. However, as Medicare rebates are a Commonwealth issue, looking at national data seemed a sensible first step. We cannot examine total costs of healthcare, as the Medicare data do not include all costs related to care. Arnold argues that "affordability" should be better defined by us and questions, "how unaffordable is an occasional $5–$10 out-of-pocket fee for a GP consultation?". We have three responses. Firstly, many medical practices require an "up-front" payment. As written by one older respondent living in a rural area, "Small country town medical clinics do not give bulk-billing to aged pensioners and insist on cash payment on the day of the visit . . . many pensioners would not seek medical help when needed if at the time no cash was available". Our second response is that, regardless of how "affordability" is defined, the issue is one of equity. Is it reasonable that a major factor identified in our study as influencing access to bulk-billing is whether you consult a practitioner in an urban area or a rural area? Finally, "affordability" can only be assessed in relation to income and other expenditure and commitments. In our surveys we ask women how satisfied they are with the costs of GP care and, while the responses are subjective, they are likely to take into account these contextual issues. These data have not yet been fully analysed.

Anne F Young · Annette J Dobson

A "new genetics" has emerged driven by knowledge gained at the DNA level. In clinical practice, a practical application of the new genetics is DNA testing, which can be expected to expand with the completion of the Human Genome Project as the functions of new genes are discovered. Genetic DNA testing scenarios include diagnostic DNA testing, prenatal DNA testing, predictive (presymptomatic) DNA testing and screening DNA testing. The challenge for genetic DNA testing and clinical practice will be to define the roles to be played by the general practitioner, the specialist, and other healthcare professionals. From the patients' and families' perspective, the new genetics will best be implemented if a planned approach is adopted in the ordering of DNA tests and the associated counselling and support processes.

Ronald J A Trent FRACP, FRCPA · Robert Williamson FRS, FAA · Grant R Sutherland FRS, FAA

To the Editor: The recent articles about spirituality and health1,2 provide a welcome discussion about the very soul of medicine as well as the soul of the individual healthcare practitioner. If spirituality is "whatever is left over when the doctor, social worker, psychologist, community education officer or psychiatrist have had a go",3 then indeed spiritual questions should be left to the particular expert on that fragment of the person. However, if spirituality is the integration of every aspect of the person, the plumbing of depth, the search and discovery of meaning and purpose, the exercise of compassion and love often in relation to the divine,4 then our whole practice of medicine needs to be spiritually conceived and executed, both for our patients and for ourselves. We need to pause and reflect on the quality of our care of ourselves as well as of our patients.5 We need to rescue healthcare delivery from the reductionism of a mere science of "fixing bits" according to economic criteria. We need to deliver healthcare with humanity, compassion and wisdom. Some would include godliness. This is not an optional extra, but the core of true healthcare, in which each of us will need to freely contribute, without imperialism, from the depths of our own spiritual journey.

Alan J Gijsbers

To the Editor: In their systematic review of clinicians' attitudes to clinical practice guidelines, Farquhar et al1 found that, although healthcare providers reported high satisfaction with guidelines, a significant number also expressed concerns about their practicality, their role in cost-cutting and their potential for increasing litigation. The review, however, did not address other potentially significant concerns of clinicians regarding the perceived validity of guidelines and the influence of external agencies (such as the pharmaceutical industry) on treatment recommendations. In April 2002, I conducted a survey of 155 full-time nephrologists and renal medicine trainees practising in Australia and New Zealand about their attitudes to the Caring for Australians with Renal Insufficiency (CARI) clinical practice guidelines (www.kidney.org.au/cari). The response rate was high (90.3%), with the majority (89%) of doctors agreeing or strongly agreeing that CARI provided a useful evidence summary. However, only 39% indicated that their practice had been significantly influenced by these guidelines, and just 14% felt that patient outcomes were improved as a result of CARI. While a minority expressed concern about the applicability of guidelines to individual patients (16%) and the potential for augmenting litigation (44%), the most significant worry was that 49% did not agree that the treatment recommendations matched the available evidence. Of those who felt that the recommendations were not justified, most believed that erroneous conclusions had been drawn from the evidence and that working parties had been affected by external influences, principally the pharmaceutical industry (74%). This view was significantly more common among nephrologists who were guideline authors (odds ratio, 3.6; 95% CI, 1.5–8.5; P < 0.01). Choudhry et al2 similarly reported that guideline authors frequently felt that their coauthors' recommendations were influenced by financial relationships with the pharmaceutical industry, despite the fact that only 7% believed that their own recommendations had been influenced by such factors, and that conflicts of interest were disclosed in only a minority (< 5%) of instances. In fact, 47 (59%) of the 80 guideline authors surveyed had financial relationships with companies whose drugs were considered in the guideline they authored. Other studies have further demonstrated that most clinical practice guidelines published in the peer-reviewed literature in the past decade did not adhere well to established methodological standards of identifying, evaluating and synthesising scientific evidence.3,4 Any review or survey of clinicians' attitudes to clinical practice guidelines should therefore include an assessment of their opinion as to the quality of those guidelines and the extent to which outside agencies (such as drug companies) may have influenced them.

David W Johnson

In reply: Johnson's letter raises an important point about the influence of external agencies such as pharmaceutical companies in the development of clinical practice guidelines. Although our systematic review1 of 30 studies of clinician attitudes to clinical practice guidelines did not identify this issue as a major barrier, it is possible that the surveys used overlooked this concern. Conflict-of-interest statements and the source of funding for clinical practice guidelines and their development teams are not always published. In the AGREE2 questionnaire (a measurement instrument developed for clinical practice guidelines), reporting conflict of interest and source of funding is encouraged. The New Zealand Guideline Group has a policy of declaring conflicts of interest, and pharmaceutical industry representatives are not included in guideline development teams.3 Choudhry et al4 reported that 59% of guideline authors had financial relationships with companies whose drugs were considered in the guideline they authored. Although these figures are not surprising given the role of the industry in research and educational activities, they do present a challenge to guideline development teams. The New Zealand Guideline Group approach (apart from declaring conflicts of interest and not including industry representatives on guideline development teams) is to take an evidence-based strategy. This involves considering all available evidence, publishing search strategies, linking evidence tables to evidence statements and recommendations, developing the recommendations by using a "considered judgement form" (which takes into account evidence, cost, generalisability and applicability), and drawing on representatives from a broad range of stakeholders (including consumer and allied health groups). By taking such an approach, it is hoped that the influence of external agencies can be minimised.

Cynthia M Farquhar

In reply: The fundamental purpose of clinical practice guidelines is to improve patient outcomes. Thus, as members of the CARI (Caring for Australians with Renal Insufficiency) Guidelines Steering Committee, we welcome Johnson's letter, which gives us reassurance and renewed enthusiasm to move forward with improving and refining the CARI clinical practice guideline process. The most gratifying revelation in Johnson's survey was the near-90% endorsement of the CARI guidelines as a document providing a useful evidence summary — clearly very reassuring in those areas in which that evidence relates to treatment interventions for patients with renal disease. Of additional interest was the range of responses to questions about matching the recommendations with available evidence. This seems to reflect both an awareness among renal medicine health workers of the importance of evidence-based medicine and a maturing understanding of the need for the evidence to be of high quality. The CARI guideline process has a relatively short history (just over three years), and before Johnson's survey the CARI Steering Committee had adopted a number of strategies that anticipated some of the issues his survey raises. These strategies included: establishing a formal link with the Renal Cochrane Organisation (to produce the best possible search outcomes of all the available evidence); adopting the National Health and Medical Research Council (NHMRC) evidence levels I (systematic reviews) and II (randomised controlled trials) as the minimum requirement to justify definitive guidelines (to assess the quality of evidence available and match appropriate guidelines with that evidence); adopting a peer-review process to evaluate draft guidelines to complement newly revised requirements for guideline writers' conflict-of-interest declarations (to assess perceptions of guideline validity and the influence of external agencies); broadening the multidisciplinary nature of guideline working parties. In addition, the Australian Kidney Foundation has moved to further disseminate the guidelines, and the CARI guideline process has been reformed with the aim of meeting the standards required to achieve NHMRC endorsement. Furthermore, feedback obtained from legal advisers suggests that the CARI guidelines and the process of establishing them are far more likely to obviate litigation than to promote it. The next important phase for the CARI guidelines will be the development of an implementation process. As the acceptance of evidence-based medicine increases and the knowledge base among healthcare workers of the nature, quality and relevance of evidence in patient care expands, the CARI guideline process is likely to be enhanced. The results of future surveys of the type carried out by Johnson will be keenly anticipated.

Rowan G Walker