General medicine

We have the tools to improve prescribing — the challenge is to use them Australia's place among the world leaders in the quality use of medicines is exemplified by its National Medicines Policy, the framework of which was put in place over 10 years ago.1 At the centre of the policy is the goal that medicines are used wisely — the Quality Use of Medicines (QUM) acronym has since become somewhat hackneyed and maybe the time is ripe to replace it by a less pretentious label. This issue of the Journal contains three reports that address issues related to QUM. Liaw and colleagues (page 203) examined doctors' perceptions of the Authority Prescribing system of the Pharmaceutical Benefits Scheme (PBS) and found (among other things) that doctors generally do not perceive the system as promoting QUM.2 South et al (page 207) describe how the use of laminated cards, which list guidelines for prescribing antibiotics for infections commonly seen in a paediatric hospital, significantly improved prescribing.3 Newby et al (page 210) found that computer-generated prescriptions for antibiotics in general practice are more likely than handwritten prescriptions to contain repeats, many of which are probably unnecessary.4 Each of these reports shows that, even a decade after the introduction of the National Medicines Policy, aspects of prescribing in Australia can be improved. Thus, it is timely to reflect on what we have been doing right, what we have not been doing right, and where there is still room for improvement. We have developed robust structures to promote QUM in Australia. For instance, Australian Prescriber commenced publication in 1975, and, despite a rather stormy career, continues to provide independent information on issues related to drug therapy. The first edition of Antibiotic Guidelines was published in 1978, and the Therapeutic Guidelines series now covers all the major therapeutic areas. The Australian medicines handbook was first published in 1998. An important initiative was the establishment in 1991 of the Pharmaceutical Health and Rational Use of Medicines (PHARM) Working Party (later Committee),5 which used its modest budget largely to fund projects studying QUM. This committee has been an important stimulus for QUM projects, rather like an "NHMRC" of drug prescribing. However, the committee did not have a mandate to fund ongoing programs. More recently, the National Prescribing Service (NPS) has been established. One of its major mandates is to put in place ongoing programs to improve prescribing, particularly of drugs listed on the PBS. Its continued funding depends on the demonstration of savings to the PBS. To date, the NPS appears to have largely managed to combine quality use with cheaper use, although it is the latter on which its survival depends. It has also managed its recent assimilation of Australian Prescriber in a mature manner. However, the NPS might have increasing difficulty in the future combining its cost-saving mandate with QUM, as this is not necessarily synonymous with cheaper use of medicines. There is also still an element of being "the new (rich) kid on the block", and the NPS has yet to define fully its relationship with established organisations involved with QUM in Australia, such as Therapeutic Guidelines (centred in Victoria), the Australian medicines handbook and the Drug and Therapeutic Information Service (DATIS) group (centred in South Australia), and State groups such as the NSW Therapeutic Assessment Group and the Victorian Drug Usage Advisory Committee. These have been some of the QUM successes, but what are the failures? Undoubtedly one has been the concentration of the Authority system of the PBS on cost saving rather than QUM. This was probably inevitable given that the accelerating expenditure on the PBS cannot be offset by savings elsewhere in healthcare. However, it is a failed opportunity as far as QUM is concerned. Another failure has been the continuing secrecy of the data submitted by pharmaceutical companies to the relevant advisory committees (such as the Pharmaceutical Benefits Advisory Committee [PBAC]) and on which the decisions on registration of drugs, their scheduling, and subsidisation by the PBS are based. Most of this information is not in the public domain, yet would greatly assist doctors and organisations in making good decisions about whether or when a drug should be used. In short, there is no good justification for this bureaucratic secrecy, and it undoubtedly hinders QUM in Australia. The recent putative moves to open PBAC deliberations to public scrutiny are to be welcomed. Another failure is the dependence of our drug evaluation system on fees paid by the pharmaceutical company applicants. It is a tribute to the professionalism of the evaluators that they appear to have largely retained their independence (but the secrecy surrounding the system does not allow for a definitive judgement). However, no regulatory system dependent on fees can ignore the interests of its payers, which are not necessarily the same as those of the Australian public, whom the regulatory system is supposed to serve. A further failure has been our inability to grasp the opportunities presented for QUM by the introduction of computerised prescribing. Unfortunately, this strategy seems to be following the same path as the introduction of computing into hospitals, where it was introduced very much as a management tool and not as a means of improving the quality of clinical care. So, where do we go next? First, the process to make bureaucracy more transparent should be vigorously pursued. Second, we should develop a national forum, for QUM issues. The NPS cannot provide that forum, as it has an overt cost-saving agenda, and its survival depends on it "blowing its own trumpet", sometimes at the expense of other bodies. Perhaps all the different organisations involved with QUM should form a QUM Society, and have national meetings to share results and experiences. Not only would that encourage cooperation rather than competition, it would also promote better recognition of the work of individuals involved in QUM. Most are in academic institutions, and QUM tends not to attract the research grants and publications that academia use to judge success. Third, we must quickly grasp the opportunities presented by computerised prescribing. Advertising must not be allowed to intrude into the prescribing process, automatic repeats for antibiotic prescriptions should not be allowed, and suitable incentives should be provided to ensure that decision support systems are embedded into prescribing software. Last, and most important, we should not rest on our laurels. Australia has done well, but QUM is a fragile flower, easily crushed by other forces, such as the economic imperative to support the pharmaceutical industry. My recent new experience in a country with far fewer resources than Australia has already taught me that much can be achieved with the wise use of resources (such as an essential drug list) I would previously have considered totally inadequate. We should not be in the thrall of the new — we already have the tools, and the challenge is to use them to maximum effect.

Robert F W Moulds PhD, FRACP

Objectives: To examine whether the use of current prescribing software systems might raise rates of repeat prescribing, with a consequent increase in use of antibiotics in the community.Design and setting: A prospective audit of consecutive prescriptions for amoxycillin, cefaclor, roxithromycin and amoxycillin/clavulanate presented to community pharmacies in the Hunter region of New South Wales and a follow-up survey of people who received a repeat prescription, October to November 2000.Main outcome measures: The frequency of repeat prescription ordering on computer-generated and handwritten prescriptions; the proportion of people who filled their repeat prescription.Results: Data were collected for 1667 prescriptions presented to 35 pharmacies; 126 people who received repeat prescriptions completed the survey. The rate of repeat prescription ordering on computer-generated prescriptions was 69%, compared with 40% for handwritten prescriptions (odds ratio, 3.3; 95% CI, 2.6–4.2). Computer-generated repeat prescriptions were as likely to be filled as hand-written prescriptions (61% and 69%, respectively).Conclusions: The default settings on computerised prescribing packages result in a significant increase in the use of antibiotics. We estimate these settings result in about 500 000 additional prescriptions being filled annually in Australia for the four antibiotics in the study.

David A Newby BPharm, PhD · Jayne L Fryer BMath, GradDipMedStats · David A Henry MB ChB, FRCP

To the Editor: I wish to draw attention to a draconian anomaly in the National Health Act 1953 (Cwlth). All GPs encounter patients "shopping" for narcotics and/or tranquillisers. The Doctor Shopper phone line (which enabled GPs to rapidly obtain information from the Health Insurance Commission to identify non-genuine patients) was a boon in guiding GPs' management of such situations. Concern over the new private sector amendments to the Privacy Act 1988 (Cwlth) led to an examination of the legal standing of the Doctor Shopper phone line, and it has now been cancelled. Concerned GPs are now limited to requesting that a "patient" sign a voluntary release of their Pharmaceutical Benefits Scheme record. This tells the "patient" that they have been rumbled, and they move on to the next practice on their list. If they have signed the Privacy Release Form, then the GP will receive a printout of the drugs they have received under the Pharmaceutical Benefits Scheme in the previous six months. This is accompanied by a letter informing the doctor that he or she "cannot make a record of, divulge or communicate to any person, any information with respect to the affairs of the person whose information has been released. To do so attracts a penalty of $5000 and/or imprisonment for a period not exceeding two years". So, under the provisions of the National Health Act (subsection 135A), even putting this information in the medical records of a multidoctor practice would appear to be illegal. It is clearly illegal to warn other doctors outside the practice. There is no corresponding legislation which affects doctor shoppers. So the "right-doers" can finish up in jail, while the "wrong-doers" can, with impunity, continue to play their dissembling, time-consuming, and sometimes harassing, games.

Max Kamien

To the Editor: Both adult and paediatric hospital emergency departments (EDs) are subject to inappropriate use.1,2,3 Some families use the ED as a primary care provider,4,5 often claiming that they have no regular general practitioner.6 Such families may experience poorer overall health.7,8 We hypothesised that providing such families with information about GPs in their area and emphasising the benefits of having a GP responsible for their long term healthcare might: facilitate the establishment of ongoing relationships between patients and GPs; and encourage families to use GPs more as their primary source of care. We conducted a controlled trial (week-on, week-off randomisation) of families identified as having no regular GP who presented to the Royal Children's Hospital ED over four months. Information about the GPs interested in seeing children was located on a computer database. Medical staff were able to search for a GP whose surgery was close to the patient's street address. Families were provided with detailed information about the GP's practice (eg, opening times, languages spoken, etc). Parents were given a list of GPs and a map showing the locations of their surgeries, together with a letter of introduction; the families decided which GP they would attend. Families in the control group were just treated as usual. Families were then contacted after two months to see if they had visited a GP and whether regular contact had been established. Over the four months, 216 families were enrolled; 96 were allocated to the intervention group. Despite our active encouragement, the ED medical staff provided the intervention material to families in the intervention group on just 49% of occasions. We found that, two months after the initial ED visit, intervention-group families were no more likely to have established an ongoing relationship with a GP than control families (46 [38.3%] and 41 [42.7%], respectively; P = 0.5), irrespective of whether or not they received the intervention material. In summary, this single intervention was not sufficient to alter healthcare-seeking behaviour of families with no regular GP. It seems the motivation to obtain a GP lies with the family. Thus, it would seem necessary to design and deliver an intervention that addresses the beliefs of families about the roles of various facets of the healthcare system. With time and work pressures, ED medical staff may not be in the best position to provide such intervention.

Michael K Marks · Daniel Steinfort · Peter LJ Barnett

To the Editor: The articles by Reid1 and Paterson,2 former bureaucratic leaders of the New South Wales and Victorian health systems, respectively, on the process for developing the 2003–2008 Australian Health Care Agreements (ACHAs) are disappointing. They offer few original conceptual insights or clear proposals. Reid's dream is that the 2003–2008 ACHAs will see "a new expression of national health policy on which funding decisions can be based". However, he presents only old ideas, such as "ACHAs will need to extend beyond public hospital issues to incorporate primary care", and, on the perennial cost-shifting between the two levels of government, "clearer lines of financial management of care and appropriate incentives are needed". Reid laments that the focus of all previous agreements has been "narrowly limited to one aspect of healthcare . . . the maintenance of universally accessible public hospital care free of charge". Paterson does propose something radical, and the core of his proposals is that "the payer must stand behind the patient and not between the patient and the provider". The way to Paterson's "outcome-enabled health system" is to "relieve the constraints that bind inputs and distort the 'production' system". Does he mean we need more doctors and nurses, or does he mean substitutes should perform some of their current activities? Patterson proposes more investment in "information and communications technology" to facilitate a gradual move to "patient-based funding". Does this mean capitation, medical savings accounts, or is he proposing non-insurable copayments? Whatever it means, there will be "no outcome-driven healthcare until the system recognises the whole patient", and this will only be achieved with "electronic patient record systems in routine and ubiquitous daily use by providers". Given their experience as senior health system administrators, it is a pity neither Reid nor Paterson provides any explicit suggestions that recognise the key factor that will determine the outcome of the ACHAs. This is the policy gridlock that any federal system almost inevitably imposes. A recent issue of the Journal of Health Politics, Policy and Law was devoted to health politics and policy in a federal system. The editor, Petersen, concludes with a view relevant to Australia: "You can love it, you can hate it, but . . . federalism thwarts uniformity and universalism, frustrates responsiveness and policy analysis, limits large scale innovation while churning more localized mills of idea generation and promotion, and offers a permanent employment plan for health policy researchers".3 Parts of Australian health arrangements certainly need an overhaul. An example is general practice. This sector, differently organised and financed, could deliver much more to the community, the rest of the healthcare system, the Federal Government and to general practitioners themselves. Change in this sector would not depend on improbable cooperation between levels of government, and would be more manageable than the multifarious whole-of-system reforms about which Reid and Paterson speculate.

William Coote

To the Editor: Van Der Weyden has asked a provocative question about the relevance of what he calls "medicine's homage to health".1 In so doing, he pays his own homage to a world where boundaries are sharp and healing becomes reduced to a matter of applying "bioscience to matters of mind and body". While I daresay many editors of biomedical journals would share his view, he is only highlighting an age-old tension. Indeed, Crookshank wrote in 1926 about the Ancient Greek schools of Cos and Cnidus, and of their debate about doctrines of the natural/descriptive and the conventional/academic approaches to medical knowledge.2 The Coans promoted the importance of the influence of the individual and society on the presentation of illness, and managed illness holistically with regimens oriented towards the needs of the individual, while the Cnidans oriented their practice around the distinctions between diseases, treating specific diseases with specific remedies.3 These differing approaches to illness and disease highlight the conflict between cybernetic and linear thought which has underpinned medical history ever since. It is rarely understood that the linear doctrine of biomedicine has only become dominant in the last century or so. Medicine's isolation from contemporary scientific thought explains our long delay in confronting the challenges of systems thinking — challenges that the basic and applied sciences took on in the early years of the 20th century.4 Our contemporary error is in assuming that the accumulation of data that passes for modern medical knowledge is sufficient to deal with the tasks of medicine. The disquiet expressed by Van Der Weyden is only a symptom of the continuing inability of a mechanistic view of medicine to deal with caring for patients in the real world.

Grant M Russell

Measurement of clinical performance. Practical approaches in acute myocardial infarction. Robert West, Robin Norris (editors). London: Royal College of Physicians, 2001 (viii + 128 pp). ISBN 1 86016 152 9. Evaluating the quality of clinical care is now the accepted, indeed mandatory, duty of all who practise medicine. Medical colleges have introduced programs for maintaining professional standards, and many of these feature clinical audit as a necessary activity. For the busy clinician, however, finding both the time and the means to perform accurate and consistent audits poses major challenges. This work, from the Royal College of Physicians (RCP), offers pragmatic strategies at both a national and a local level for conducting meaningful clinical audit. While focusing on the care of patients with myocardial infarction, the messages contained in this book can apply to any area of medicine. The first half deals with clinical governance (UK style): use of performance indicators and league tables; the choice between process or outcome measures; and an overview of national benchmarking projects in the UK dealing with coronary heart disease, asthma and stroke. The second half covers the practicalities of auditing the care of patients with myocardial infarction, as exemplified by the Myocardial Infarction National Audit Project. This ambitious project aims to recruit all hospitals in England and Wales, and uses a nationally funded, RCP-sponsored data collection, analysis and reporting system which is standardised, computer-based and centrally coordinated. Such a system relieves local clinicians of the need to develop their own audit system from the ground up. The authors of each chapter speak authoritatively from personal experience about the good and bad in conducting clinical audit, and offer advice on what to avoid. Finding a "how to" book in performance measurement that is short (128 pages), easy to read, inexpensive and rich in practical applications is a rare delight for this jaded healthcare researcher. My only regret — I would have liked a little more on how to use the results of audit to full effect in improving quality of care at the local level. Ian A ScottDirector of Internal Medicine Princess Alexandra Hospital, Brisbane, QLD

Ian A Scott

Objective: To describe the changes in bulk-billing and out-of-pocket costs for Australian general practice consultations over the period 1995–2001.Design: Retrospective analysis of 1996–2001 survey data from the Australian Longitudinal Study on Women's Health (ALSWH), linked with Medicare and Department of Veterans' Affairs (DVA) data on general practice consultations from 1995 to 2001.Participants: 22 633 women who gave consent to linkage of their ALSWH data with Medicare/DVA records. In 1996, women in the "young" cohort (n = 6219) were aged 18–23 years, those in the "mid-age" cohort (n = 8883) were aged 45–50 years, and those in the "older" cohort (n = 7531) were aged 70–75 years.Outcome measures: Out-of-pocket costs paid by patients for general practice consultations, by calendar year, urban/rural area of residence, age, frequency of attendance, self-rated health, and education level.Results: For each age group and year studied, the use of bulk-billing was lower in rural areas than in urban areas. For example, in 2000, the percentage of women in rural and urban areas, respectively, who had all their general practice consultations bulk-billed was 31% v 52% (young women), 24% v 45% (mid-age women) and 58% v 79% (older women). There has been a steady decline in bulk-billing for general practice consultations in rural areas since 1995. The average out-of-pocket cost per consultation for women in rural areas was higher than the cost for women living in urban areas. After adjusting for age, health and socioeconomic factors, women living in urban areas were more than twice as likely to have all their consultations bulk-billed as women living in rural areas: odds ratio (OR), 2.4 (95% CI, 2.1–2.7) (young women); OR, 2.5 (95% CI, 2.3–2.8) (mid-age women); OR, 2.6 (95% CI, 2.3–2.9) (older women).Conclusions: In Australia, the geographic differential in the cost of general practice consultations is widening. Policy changes are required to enable women in rural and remote areas to have access to affordable healthcare services.

Anne F Young BMath(Hons), DipMedStat, PhD · Annette J Dobson BSc, MSc, PhD

To the Editor: I support Tattersall and colleagues1 in their attempt to use a wee bit of science and a dose of common sense to improve doctors' letters. While I would love to receive letters based on their proposed "prompt sheet", and should really try much harder myself to follow it, I'd be only too pleased — in the interim, while we await enlightenment — to receive any letter from some of my colleagues with whom I share what is supposed to be "multidisciplinary care" of patients. There is a research project in this for the brave to find out why, too often, communication is not merely inadequate but non-existent.

Alan Rodger

To the Editor: Colorectal cancer is, after skin cancer, the most common cancer in Australia, with 11 245 new cases diagnosed in 1997, and over 4600 deaths.1 In clinical trials, screening programs using faecal occult blood testing (FOBT) have been shown to reduce mortality. The Commonwealth Department of Health and Ageing estimates that implementation of effective FOBT screening programs would save around 400 lives per year.1 However, such screening programs have not been widely implemented because of perceived difficulties with patient acceptance, funding, and the complexity of support structures. General practitioners are in the front line of healthcare, and well placed to institute FOBT screening. Thus, we established an opportunistic screening program whereby patients over the age of 50 years attending surgery are asked by reception staff to complete a short questionnaire while in the waiting room. This questionnaire, developed locally to quickly establish whether a patient has symptoms or a family history of bowel cancer, is given to the GP by the patient during the consultation. If the questionnaire indicates colorectal symptoms, appropriate clinical assessment is undertaken. If a family history of colorectal cancer is elicited, the GP further defines the patient's risk by using the established National Health and Medical Research Council guidelines.2 If there are neither symptoms nor a family history, the patient is offered annual FOBT screening. From 17 June to 30 September 2002, 731 patients under the care of 29 GPs completed the questionnaire. Our findings are summarised in the Box. GP-based opportunistic screening can reach significant numbers of people. Moreover, unlike other strategies (eg, distribution of test kits by pharmacies), review by GPs of patients' questionnaires ensures that cases unsuitable for FOBT screening (such as those with previously undeclared symptoms or family history) are appropriately assessed. Data reported so far on patients who completed general practice questionnaires for eliciting family history or symptoms of bowel cancer FOBT = faecal occult blood testing.

Susan J Harnett · SK Cyril Wong · Gavin W Lackey

To the Editor: To achieve greater dissemination of mental health education to general practitioners, the Adelaide Central and Eastern Division of General Practice developed a program to be taken to GPs, based on individual need and using a medical expert/facilitator. The "GP Meets the Psychiatrist Project" is an initiative of the Division in collaboration with the Eastern Mental Health Service, and supported by the Lundbeck Institute — a Danish foundation with a special interest in psychiatric education and pharmaceuticals (www.luinst.org). The specific objective of the project is to facilitate access by GPs to psychiatrist support, in the form of education and advice. This takes the form of a psychiatrist visiting a practice for a one-hour "open tutorial", on a topic preselected by the GPs in the practice. Lundbeck funded the psychiatrist's time. GPs were not funded, and no Continuing Medical Education points were sought for these sessions. The project began in February 2001, and during the year 75 GPs from 22 practices were involved. Following the tutorial, both the GPs and the psychiatrist completed an evaluation questionnaire that covered issues such as the topics chosen by GPs, discussion of medications, referral for psychiatrist support, the need for further sessions and how they rated the sessions.1 The main topics raised by GPs were depression, medication issues, difficulties with access to psychiatry services, psychosis, and management of acute situations or angry patients. GPs felt the sessions were very useful, and 87% were interested in having meetings with other specialists. From October 2001, 23 GPs rated the usefulness of the tutorial using a Likert scale of 1 ("no use") to 5 ("very useful"). The value of the tutorials was clearly demonstrated by the mean rating of 4.6. Three psychiatrists participated and all found the experience of attending general practices and running the sessions very rewarding. They found their assumptions about the nature of family medicine were often wrong; for example, they were interested to find that practices were often focused towards particular areas of health. The project has demonstrated the usefulness of tailoring education packages to the specific needs of GPs and has shown that this would be a suitable avenue to improve links between GPs and specialists. With specialist support, a similar session involving an endocrinologist discussing diabetes is now being run through the Division, with no funding, which suggests this type of program may be sustainable in the long term.

Greg A Lovell · Phillipa J Hay

To the Editor: Your enthusiastic comments accompanying the publication of a "physicians' charter" prepared by the Medical Professionalism Project1 do not acknowledge strikingly enhanced approaches to medical professionalism in Australia dating from the landmark Doherty Report in 1988.2 One of the most noticeable changes since that time is the emphasis now placed on professional development throughout medical school curricula3 and in the preregistration year.4,5 In addition, our medical colleges are poised to do more in this area in their postgraduate training and continuing professional development programs.6 You fail to point out that the "physicians' charter" contains nothing new, as an examination of the Code of Ethics of the Australian Medical Association will reveal.7 We are probably fortunate that an equivalent process of developing such a charter has not taken place in Australia. The document repeatedly speaks of a "contract with society", but it is an oddly one-sided contract, prepared without consulting members of the communities the authors purport to represent. The charter seems to be a response to frustrations and challenges caused by changes to healthcare systems, especially in the United States and Canada, and carries a tone of living in the past. There are effective means of engaging with our community to ensure that essential aspects of medical professionalism are valued and maintained.8 Many of these are already being used in Australia. I refer to such developments as community membership of medical boards, community input into selection of medical students, establishment of independent health complaints commissions and widespread engagement with the health consumer bodies by most sections of the profession. Additional initiatives that will assist the community to trust and value medical professionalism in Australia include the increased expectation that all doctors will engage in continuing medical education and the establishment by medical boards of pathways to identify and assist poorly performing doctors. Should the organised profession ever develop a similar charter for Australia, it is to be hoped that the authors will ensure that the concerns and needs of our broader community are taken into account and that we do not engage in the self-pity evident in the Medical Professionalism Project.

Kerry J Breen

To the Editor: You recently lent your support to the "physicians' charter" produced by the members of the Medical Professionalism Project.1 According to the document, the charter is part of the process of reforming healthcare systems. If the authors are hoping to use this document to change the way medicine is delivered, they should be prepared for criticism. The simplest criticism is that they present no evidence. Sweeping statements are made, without supporting documentation, about the potential for dishonest behaviour by physicians. Even broader generalisations are made about the appropriate way to run healthcare, again without evidence. The authors state that "physicians should never exploit patients for . . . personal financial gain or other private purpose". While the word "exploit" has a pejorative flavour, it is reasonable for doctors to be paid for what they do. The "sackcloth and ashes" version of medical practice appeals to a small minority. They then move deeper into socialist territory: "Medical professionalism demands that the objective of all healthcare systems be the availability of a uniform and adequate standard of care." But the standard of healthcare can never be uniform, and vigorous attempts to make it so could conceivably undermine its quality. "Political correctness" proceeds apace. "A commitment to equity entails the promotion of public health and preventive medicine . . .". Why, for goodness' sake? Preventive medicine is not always cost effective. The authors then propose their own version of health economics. In their view "the provision of unnecessary services not only exposes patients to avoidable harm and expense but also diminishes the resources available for others". This is not necessarily so. Some services will turn out to be superfluous. There are other areas of extravagance in our society (eg, fast cars, big houses, and all restaurants), but they still make an important contribution to the economy. Growth in healthcare expenditure expands the whole economy, and I am not aware of any evidence that spending in one area of healthcare necessarily deprives others. It could well be the reverse. Politically correct attitudes are widespread in the medical community,2 but should not be imposed on others, as the Editor was perhaps suggesting.

Keith V Woollard

To the Editor: Young doctors and medical students are acculturated into healthcare systems in which governments, corporations, consumer groups and other stakeholders have an increasing presence. These forces have so significantly altered medical practice in the United States, for example, that many doctors have questioned the applicability of traditional patient-centred values. Whether or not Australian doctors have faced such adversity, medical practice is becoming increasingly complex, and the Medical Professionalism Project's charter1 encourages us to consider how we might best serve the future needs of patients, families and the community. To this end, the charter upholds traditional patient-centred values while embracing less familiar civic responsibilities. It challenges us to think outside the doctor–patient dyad about what it means to be a doctor in contemporary Australian society. The inevitable rationing of finite health budgets, inequalities in access to and quality of care, and growing recognition of social determinants of health are all compelling reasons for engagement with social processes. The Australian medical profession has served us well through its health policy leadership. We have no reason for complacency, however, given the appalling state of Indigenous health, the challenges posed by rural and refugee populations and the progressive infiltration of for-profit interests into the Australian healthcare system. Upholding the principle of social justice will require skills not often called upon in medical practice. If we are to remain respected public advocates we will need heightened awareness of population health issues and the ability to effectively collaborate with other players. We will need ways of translating time-honoured virtues such as altruism and compassion into public arenas. Partnerships may open new opportunities in a publicly responsive and outward-looking profession, while retaining the inherent worth of patient care. By its social orientation, the charter does more than exalt old values in the face of modern healthcare challenges. It helps to articulate the aspirations of a more broadly engaged profession. The charter will be valuable to those of us near the start of our careers, for whom professionalism will be as much characterised by its engagement with the future as it is by its links with the past.

Russell L Gruen

In reply: I welcome the comments on the physicians' charter. The purpose in publishing the charter was to promote a dialogue on medical professionalism, as, in contrast to the continuing discussion and debate on professionalism in North America1-3 and the United Kingdom,4 interest in the subject in Australia is virtually absent. Enter the terms "medical professionalism" and "Australia" in PubMed and the search yields eight publications in the Australian literature over the past 30 years. Despite this meagre tally, Breen informs us that all is well, through the efforts of bodies such as the Australian Medical Council (AMC). While the AMC's efforts are commendable, its recommendations for instilling professional attitudes in medical students and interns must compete with other priorities in an already crowded curriculum and with the pressures of the intern year. Under the daily stresses of real life, abstract concepts of professionalism are likely to be given low priority. Breen also suggests that the medical colleges are "poised to do more in this area". This may be so, but a search of college websites reveals that most are silent on matters of professionalism. Finally, Breen laments that the physicians' charter contains nothing new — but no one really expects revolutionary concepts in precepts of professionalism, which have evolved over hundreds of years. Besides, what harm is there in being exposed to the views of our colleagues in the northern hemisphere? As the comments of Gruen suggest, the charter is one of the more broad-ranging contemporary expositions of medical professionalism. Woollard wants evidence for the principles of the charter and its purpose. He also suggests that it is tinged with socialism and "political correctness". But the medical ethics that underpin our professionalism are dependent not on evidence but on humanistic principles. He hints that making the objective of all healthcare systems "the availability of a uniform and adequate standard of care" smells of socialism. Perhaps so, but I prefer to think of it as embodying the Australian ethos of a "fair go". Finally, "political correctness" is a subjective rather than an objective concept. I thank my colleagues for their insightful comments and for starting the debate on new professionalism. Long may it continue.

Martin B Van Der Weyden

To the Editor: I read with interest and alarm your comments on generalists and gerontology in the 16 September 2002 issue of the Journal.1 I believe the role of the general internal medicine physician in managing patients with complex multisystem disease is still important and will expand in the future. General physicians remain passionate about general medicine.2 General medicine has been threatened over the past 20 years by the emergence of the medical subspecialties. However, there is increasing recognition of the need for general medicine specialists, especially in North America and Europe. In Australia, general medical units are being established in the major teaching hospitals in capital cities. Sydney remains a unique exception — all of its general medical units were closed prior to the 2000 Olympics (for reasons that are unclear), and only one has subsequently been re-established (at Royal North Shore Hospital). The Internal Medicine Society of Australia and New Zealand (IMSANZ) has been active in promoting the role of the general physician. IMSANZ provides support for the professional profile and culture of general physicians throughout Australasia. We would welcome enquiries from trainees and physicians (<http://www.racp.edu.au/imsanz>). The Royal Australasian College of Physicians has recognised the necessity for a strong general physician workforce and will be holding a General Medicine Forum in March 2003 to examine the key issues confronting general medicine in Australia and New Zealand. By 2010 the majority of "baby boomers" will be in their sixties, or older, and will require the services of well trained general physicians to provide integrated, cost-effective, whole-of-patient specialist healthcare.

Leslie E Bolitho

Systematic reviews in health care: a practical guide. Paul P Glasziou, Les M Irwig, Christopher J Bain, Graham A Colditz. Melbourne: Cambridge University Press, 2001 (viii + 137 pp). ISBN 0 521 79962 7. Why should you choose this book in what is a relatively crowded market? The authors are Australian experts and well qualified to write it. It is an introductory text, presumably for Master of Public Health students or mid-career clinicians attempting to come to grips with one of the foundation stones of evidence-based medicine. The flyleaf states “this is a book for those with an interest in synthesising healthcare research and for those studying for a degree in public health”. The book provides an excellent overview of the general methods of systematic reviews and is a useful primer on the topic, particularly the chapter on diagnosis and the discussion concerning heterogeneity. The second part addresses question-specific methods. It has some exercises at the end of each chapter, but would benefit from the inclusion of worked examples. Inevitably with a text of this size, the question arises: What was left out that should have been included? I think a more substantial treatment of the relationship between study results reported as proportions, odds ratios, relative risks and the number needed to treat (NNT) is warranted, with appropriate references (a passing reference is provided in the question section at the end of the chapter on interventions). The chapters on interventions, frequency and rate could benefit from the incorporation of “look-up” answers to the questions. The chapter on diagnosis should discuss the diagnostic odds ratio as a summary measure of the accuracy of a test. The answer to the question “Should I buy this book?” is “Yes”, if you want to get started and wish to move beyond the User’s guide series in JAMA. I would also advise downloading the Cochrane review handbook. Donald CampbellClinical Epidemiologist Royal Melbourne Hospital, VIC NB: The reference (page 115 to the website for the Easy MA software) is incorrect (it should be www.spc.univ~lyon1.fr/mcu/easyma/).

Donald Campbell

To the Editor: In their editorial,1 Hammett and Harris have overlooked one of the most important contributory factors to the increased use of diagnostic tests by community-based practitioners (ie, GPs) — patient demand. It is not unusual for a GP to be faced with a request by a patient to be "tested for everything", or for a specific test that may be quite inappropriate ("I just want my hormones checked"). It takes far longer to explain to the patient that the tests are inappropriate than to give in and sign the appropriate pathology form. And then, if the patient a year later does come down with some obscure syndrome, he or she can come back in the courts and say, "If only the doctor had listened to my request for tests I would be okay now". The frontline GP is in a lose–lose situation, stuck between the Health Insurance Commission and its demands for reasonable levels of testing, the expectations of patients that everything can be detected by a blood test, and the excessively perfectionist ideals of the legal system.

Warwick Carter

In reply: As Murray notes, appropriate test ordering belongs firmly in the domain of quality care and clinical accountability. In his seminal article on clinical leadership of healthcare system improvement, Berwick lists appropriate use of testing and therapy as the first challenge facing people who wish to improve healthcare systems in the developed world.1 Murray also identifies the paucity of structured educational programs aimed at providing junior medical staff with the skills to exercise "knowledge and judgement" in test ordering. The Royal Australasian College of Pathologists is seeking to address this deficiency through the development of educational modules on test ordering. It is unlikely, however, that education alone will curb the increase in test ordering in Australia. Educational programs for junior medical staff are notoriously resource-intensive and difficult to sustain. In addition, they rarely provide the point-of-care guidance that seems to be more effective in sustainably modifying behaviour. Such guidance may require test-ordering software that provides guidelines for ordering and feedback of individual performance, or the use of structured test-stratification programs such as that described by Stuart et al.2 Improved education, supervision and point-of-care guidance will prove ineffective if fears of litigation continue to drive the behaviour of clinicians. As Carter points out, concerns about litigation must be considered in any program aimed at improving practice. However, although litigation related to missed diagnosis is a recurring theme, this may relate more to time pressures rather than a failure to perform investigations. Indeed, many malpractice suits result from failure to adequately check and act upon the results of the barrage of tests ordered. Attempts to reduce medicolegal risk by ordering all conceivable tests may increase practitioners' risk unless they have extremely well-designed follow-up systems. It is important that clinicians not sacrifice high-quality, evidence-based investigation and treatment in an attempt to minimise perceived litigation risks. By testing inappropriately, clinicians may in fact expose themselves to greater risks of litigation, as their patients are exposed to the risks of the tests themselves, the chance of false-positive results and inappropriate treatment, and the failure to follow up on investigation results. It is unfortunate, and an indictment of our current reimbursement system, that the financial realities of community practice make it difficult for clinicians to take sufficient time to communicate with patients about the appropriateness of an investigation or treatment. If we continue to allow this to become the way we practise, we will continue to see a diminution of our professional role as we become merely booking agents for tests. As Berwick says, "Efforts to reform the health system from the outside can help motivate and set the stage for improvement. Yet, if clinicians do not wish to make specific changes in their own work to better meet society's need for better outcomes and lower cost, no-one outside the health system can be clever enough or powerful enough to make them do it."1

Rohan J H Hammett · Roger D Harris

To the Editor: The rate of growth of pathology and radiology testing over the last decade has surpassed the average growth of most other medical services.1 Pathology Medicare items processed per capita between 1996–97 and 1998–99 demonstrated the largest increase (8%) of all item types. The interventional program for reducing diagnostic testing reported by Stuart, Crooks and Porton shows promise in addressing this increase in the emergency department, and has significant potential across other hospital departments.2 The program's focus on initiating behavioural change among test-ordering staff as a precursor to effecting significant long-term reduction of test use is important. Views differ as to the reasons for excessive clinical testing among hospital staff. Medicolegal issues, level of experience, fear of the consequences of inadequate testing and the desire to diagnose within a single presentation have been previously described.3 These issues were dealt with to some extent via the described educational component of the authors' intervention program and seem to explain the apparent sustainability of the intervention. The authors report a "40% decrease in ordering of tests in the emergency department, with test utilisation falling from a mean of $39.32/patient to $23.72/patient." Other measures reported include reduced time taken for result review, with a resultant availability of additional resources for "other critical areas of service delivery". An assertion is made that "improvements to quality care" are "likely". Issues relating to improvement in quality of care, however, still remain: Although "no adverse patient outcomes relating to underutilisation of investigations" were identified, what follow-up was performed to ascertain "adverse outcomes"? What proportion of patients for whom further testing was requested via a general practitioner or outpatient clinic did not follow through with these investigations? Is there the potential for sufferers of undiagnosed chronic disease to develop more serious disease, requiring eventually more expensive therapies? What is the cost of patients' attending GPs and outpatient clinics for further investigations? Are the investigators' "evidence-based list of clinical indicators for ordering . . . tests" appropriate and are they rigid enough to prevent operator bias? Test utilisation measured by cost was the primary outcome measure for this study. Based on this measure, the results appear promising; however, important quality-of-care issues need investigation before more widespread implementation is considered.

Peter Gambell

In reply: Our intervention1 was developed following concerns with the quality of test ordering in our department, and resulted in a significant improvement in the checking and documentation of test results. Quality of care is also influenced by test over- and underutilisation. The study demonstrated a marked reduction in test ordering and accorded with the current estimates for test overutilisation.2 Test underutilisation was monitored using established mechanisms for reporting critical incidents (including missed or incorrect diagnoses) and patient complaints, as well as feedback from staff, general practitioners and other departments and hospitals. Patient outcome factors (eg, readmission rates, length of stay) were confounded by the dramatic onset of access block during the intervention period, making retrospective comparisons unreliable. The intervention is unlikely to have increased GP and outpatient referrals, as the previous practice of the department had been to refer patients having non-urgent tests (where the result was not immediately available) to a GP or outpatient clinic for follow-up of the test result. The department did not have the resources to ensure all patients attended for follow-up of the test result, raising medicolegal concerns and quality-of-care issues. The intervention, by deferring the ordering of non-urgent tests until after review, has the potential to reduce test duplication and the ordering of inappropriate (specialised) tests by junior emergency department staff. In addition, this process allows the patient's condition to be reviewed to determine whether further or alternative testing is required. Gosbell and colleagues speculate on the potential adverse outcomes that may follow from a reduction in the routine ordering of blood cultures. Blood cultures change patient management in only a fraction of cases, and the clinical situations where this occurs have been defined.3 A major concern is the high rate of false positive results and the consequent economic and social cost of additional unnecessary testing, treatment and prolonged hospital stay.4 As with any clinical tool, the use of blood cultures must be supported by evidence-based guidelines rather than based on expert opinion. The widespread use of blood cultures to limit the prescribing of broad-spectrum antimicrobial agents and development of disease resistance needs to be subjected to scientific examination and a cost–benefit analysis. If, as Gosbell et al seem to argue, the value of blood cultures lies predominantly in their public health role, the public have a right to be informed of the evidence used to substantiate the "test-all" approach being advocated to allow proper debate on the opportunity costs to public health.

Peter J Stuart

In reply: It is pleasing to note that a senior psychiatrist is looking at the practicality of general practitioners (GPs) measuring the clinical outcome of patients with mental disorders. However, Dinnen's concerns may be groundless. For example, the Kessler Psychological Distress scale (K10) consists of 10 simple questions that patients can complete in two minutes in the waiting room and doctors can then score by summing 10 numbers between one and five.1 This takes less time than writing a progress note. The websites www.gpcare.org, www.beyondblue.org.au and www.mentalhealth.gov.au1-3 are the simplest places for doctors to familiarise themselves with the proposed outcome measures and with other new initiatives for better outcomes in mental healthcare. For the K10, the website1 advises GPs that if, after treatment, a patient's score remains above 25 the GP should review the patient and consider seeking a second opinion from a psychiatrist. In a specialist clinic (St Vincent's Hospital, Sydney) the average K10 score of a cohort of patients was 26.1 before treatment and 21.7 after treatment (indicating the effect of sound treatment). Nevertheless, the scores of a fifth of patients remained above 25 after treatment. Psychiatrists might therefore familiarise themselves with the measure so they understand when a GP refers a patient for a second opinion "with a K10 score above 25 after treatment".

Gavin Andrews · Ian B Hickie · Tracey A Davenport

On changing careers midstream An identical plea for help marked both the beginning and the end of my career as a general practitioner, and I think that the particulars of these two events reflect the great changes that took place during my decade or so spent as a GP. In 1959, I returned to Australia from England and began working as an assistant in a general practice in the eastern suburbs of Sydney. In the middle of the night, in the middle of winter, I received a phone call from a man who politely identified his mother as a patient of my boss. He asked me to come to the house, and said, "Mother can't breathe, doctor"; he surmised that mother might have a bad cold. I took down the name and address, and got dressed, cursing myself for agreeing, without closer inquiry, to see someone who might have nothing worse than coryza at that hour. The patient's home was not far away, but it was a bitterly cold night, with a howling westerly wind blowing; in those days, cars did not come with a heater as standard equipment! When I reached the house, the son (much older than me) took me to his mother, a very elderly woman who was, at once, seen to be in extremis as a result of acute left ventricular failure. A quick history was taken from the son, the standard remedies of the day given — intravenous theophylline, morphine, and digoxin, as I recall — and an explanation of the condition and its bleak prognosis given to the son. The patient died soon after. The son thanked me for attending promptly and for doing what I could. I felt ashamed for my unspoken resentment at the time of agreeing to make this house call, but I also felt a sense of great relief that I had attended. The old aphorism "to cure sometimes, to relieve often, to comfort always" came to mind. I left the practice at the end of that year to join a group practice — still in the eastern suburbs — where I remained for the next 11 years. During that time, my initial indifference to the psychiatric aspects of illness was gradually replaced by a growing realisation of the importance of emotional factors in medical practice. Eventually, I decided to undertake specialist training in psychiatry, and it was agreed that I would leave the practice at the end of 1970. I was on call for the practice on a weekend late in 1970 —perhaps my last weekend on call. The Sunday evening was warm and still. Towards midnight, there was a phone call, and a woman asked me to make an urgent house call, saying, "Mother can't breathe, doctor!". My mind went back to the incident of years before, and I simply took the address without getting any medical details and got there as soon as I could. I found that, this time, Mother was a middle-aged woman with a head cold, who could not breathe through her nose. Respiration through the mouth was unimpeded and examination of the respiratory and cardiovascular systems was otherwise normal. I wrote a prescription for ephedrine nose drops. Both mother and daughter protested that the chemist shops would not be open until the next morning. I suggested that the medical "urgency" of the situation would justify waiting until then. A pensioner medical service voucher was signed, and I left with gritted teeth and, no doubt, seriously high blood pressure. When the red mist settled, I was able to reflect that this might have been a suitable valediction to general practice, an appropriate omega to the alpha of the earlier incident. The two incidents encapsulated some of the reasons for my ever-increasing dissatisfaction with general practice. I had seen the role of the GP move from that of front-line treating doctor — as my training, experience and inclination had taught me to be — towards that of gatekeeper or signpost-man. I had given some thousands of general anaesthetics as a GP, but could see that the days of the GP-anaesthetist were limited, and, in any case, I had decided that I preferred to be dealing with patients who were conscious and inclined to talk. "Blood tests" and medical imaging were insidiously displacing clinical skills as the primary methods of diagnosis. It took a long time, 20 or 30 years, but ultimately I came to be almost glad that I had experienced that second house call. Changing horses in midstream is something to avoid, so it is said, but these two episodes seemed to me to help justify changing my career when in darker moments I had doubted the wisdom of doing so.

Andrew R Robertson MB BS, FRANZCP

The second round of trials may provide more answers The coordinated care trials were nothing if not ambitious! In 1994, the Council of Australian Government proposed that the organisation, funding and management of health and community services could be restructured into three streams: 1 a general stream for individuals needing either occasional or uncomplicated healthcare; an acute stream for patients needing specialised services for acute illness; and a coordinated stream for patients requiring a mix of healthcare services over an extended period. It was assumed that in the last stream patients would benefit by having their care managed and coordinated. Following a national tender process, nine trials of coordinated care were activated and funded by the Commonwealth (Box 1). A central premise of the trials was that better coordination of the care of people with chronic or complex needs would reduce hospitalisation, and the savings could cover the costs of coordination. The coordinated care trials were the largest and most ambitious experiment of a new method of organising healthcare services ever attempted in Australia. The trials ran for two years. Evaluation was undertaken both nationally and at the local level. Much of the trial documentation and evaluation reports are available on the Commonwealth Department of Health and Ageing's website.3 Despite this effort and expenditure, the outcomes were disappointing (Box 1). In general, the trials did not demonstrate improved health and well-being of the participants. A significant reduction in hospital admissions in the intervention compared with the control group was seen in only three of the trials, and for most trials an accrued operating deficit was found. Was this ambitious healthcare experiment a failure? It is hard to say because, unfortunately, the design of the trials made it difficult for them to achieve their stated objectives. The trials included the following design shortcomings. Each trial was funded for two years, but the first six months were devoted to recruitment and the last six months were a wind-down phase. Thus, in many trials, the actual intervention was for 12 months or less, a very short period in which to make an impact on complex illnesses. Difficulty in recruiting sufficient numbers of participants forced many trials to relax inclusion criteria, with the result that many individuals entered in the trial were inherently unable to benefit from coordinated care, since they were not sick enough, or had insufficiently complex problems to warrant care coordination.4,5 In many trials, the same intervention was applied to all participants regardless of the severity of their condition or ability to respond to the intervention. Interventions varied markedly between trials. The chosen measure of well-being, the SF-36, was not optimal to assess the types of intervention, especially over the relatively short trial periods. Despite these shortcomings, the trials provided a number of benefits. Fundholding allowed trials to fund strategies such as quit smoking interventions that otherwise would not have been possible.6 Because of the evaluation needs, many service organisations received major technology upgrading of information systems. The trials received the full cooperation of the Health Insurance Commission, enabling the use of Pharmaceutical Benefits Scheme and Medical Benefits Scheme (MBS) information for evaluation purposes. New enhanced primary care MBS schedule items were announced shortly before the publication of the final results. Finally, much of the qualitative evaluation showed that participants in the intervention groups appreciated the extra coordination of their care. The new round of coordinated care trials that has just commenced (Box 2) has taken on board much of what has been learnt from the first round. The trials are for three years rather than two, have better-targeted interventions, and outcome measures have been carefully selected for their sensitivity to the type of intervention. The possibility remains, however, that the essential premise that better coordination reduces hospitalisation is misguided. It may be that lack of coordination in a complex care system operates as a functioning rationing system, so that better care coordination reveals unmet needs rather than resolving them. Experience in the mental health field implies that this may be so.7,8 With an ageing population and increasing burden of chronic diseases, the government has given priority to increased service coordination, vertical integration and cost containment. The coordinated care trials are just one of several strategies aimed at achieving these objectives. It might well be that the objectives are mutually exclusive and that improved coordination comes at a cost. 1: First round of coordinated care trials General coordinated care trials Nine trials in six States and Territories were funded, involving 10 967 intervention and 5571 control participants. Trials were designed as either randomised (where individuals were assigned at random to the intervention or control group) or geographically controlled (where two matched regions were used, one receiving the intervention). The trials ran from June 1997 to December 1999. Only the SA HealthPlus trial based participant inclusion on specific diagnoses, which included respiratory disease, diabetes, cardiovascular disease, stroke and somatisation. Primary hypothesis Coordination of care of people with chronic or complex needs results in improved participant health and well-being within existing resources. Eligibility Varied by trial, based on one or more of age, complex care needs, or specific diagnosis. Intervention Varied by trial, based on different models of care coordination, care planning and funds pooling. Outcome measures SF-36 measured at baseline, 12 months and 24 months. Health and community service use and expenditure from the Health Insurance Commission and other sources. Results Intervention groups did not perform better than control groups for either SF-36 scales or reductions in hospitalisation, readmission, or length of stay for those hospitalised. Trials were unable to fund coordinated care out of savings from reduced hospitalisation. Aboriginal coordinated care trials Four trials among Aboriginals and Torres Strait Islanders involved 6600 participants. The trials were located in Katherine West (NT), the Tiwi Islands (NT), Wilcannia (NSW) and Perth/Bunbury (WA), and were conducted between 1997 and 1999. Primary aims related to community empowerment and capacity building. The National Evaluation Summary outlines the background, description, experiences and outcomes of the trials.2 The national evaluation found that all trials showed enhanced service access, progress in infrastructure development, and improved individual and community empowerment. Funds pooling was successful in providing greater flexibility in resource allocation. 2: Second round of coordinated care trials Six trials (three general, three Aboriginal community). Began in late 2002 to run for three years. General trials Northern Venture: Continuation of Care 21 first-round trial, Adelaide. Team Care II: Continuation of Team Care first-round trial, Brisbane. Coordinated Health Care: Continuation of North Eastern first-round trial, Victoria. Coordinated Health Care has included specific diagnoses (respiratory disease, heart failure and complex diabetes) as part of its inclusion criteria. Team Care II and Coordinated Health Care are randomised controlled trials with about 2000 intervention participants and 1000 control participants expected. Northern Venture is a prospective intervention cohort trial using matched population controls. It will have about 2000 participants. Objectives 1. To identify people who are most likely to benefit from coordinated care. 2. To identify processes and infrastructure for effective integration and coordination of care. 3. To enhance the health status, quality of life and functional status of participants, and reduce the burden on carers. Outcome measures A range of quality-of-life, functional status and health assessment tools, plus carer instruments measured at baseline and at regular intervals. Health and community service use and expenditure from HIC and other sources. Aboriginal trials South West Aboriginal Medical Service (SWAMS): Continuation of SWAMS first-round trial, WA. Sunrise: Katherine East, NT. Mid North Coast: NSW. Objectives of Aboriginal trials 1. To improve the health of communities. 2. To improve community understanding or control of health and related services. Intervention Different models of care coordination, care planning and funds pooling. Outcome measures Access to primary healthcare services Involvement in population health programs Preventable hospital admissions Length of stay in hospital Improved processes of care Involvement of individuals in decisions about care Social concerns Preventable mortality

Adrian J Esterman MSc, CStat · David I Ben-Tovim PhD, FRANZCP

Objective: To systematically review surveys of clinicians' attitudes to clinical practice guidelines.Data sources: MEDLINE, HealthStar, Embase and CINAHL were searched electronically for English-only surveys published from 1990 to 2000.Study selection: We included surveys with responses to one or more of seven propositions (see below). Studies were excluded if they had fewer than 100 respondents or if the response rate was less than 60%.Results: Thirty studies included responses to one or more of the seven items, giving a total of 11 611 responses. The response rate for the included studies was 72% (95% confidence interval [CI], 69%–75%). Clinicians agreed that guidelines were helpful sources of advice (weighted mean, 75%; 66%–83%), good educational tools (71%; 63%–79%) and intended to improve quality (70%; 60%–80%). However, clinicians also considered guidelines impractical and too rigid to apply to individual patients (30%; 23%–36%), that they reduced physician autonomy and oversimplified medicine (34%; 22%–47%), would increase litigation (41%; 32%–49%) and were intended to cut healthcare costs (52.8%; 39%–66%).Conclusions: Surveys of healthcare providers consistently report high satisfaction with clinical practice guidelines and a belief that they will improve quality, but there are concerns about the practicality of guidelines, their role in cost-cutting and their potential for increasing litigation.

Cynthia M Farquhar MB ChB, MD, FRANZCOG · Emma W Kofa BA · Jean R Slutsky PA, MSPH