General medicine

Information contained in letters of referral and reply often does not meet the information needs of letter recipients. Missing reports of previous investigations and insufficient detail in the referral letter to specialists are the most serious and common problems. General practitioners prefer structured, computer-generated letters to unstructured, dictated letters. Referring surgeons and GPs identify delay in receiving the reply letter and insufficient detail as relatively common problems after a new patient consultation. They want the reply letter to describe the proposed treatment, expected outcomes and any psychosocial concerns, yet these items are often omitted. A letter content and format prompt card has the potential to enhance the quality of correspondence between medical specialists and referring doctors. Specialist medical bodies should consider preparing prompt cards (setting out preferred information content and format for letters) to distribute to their members.

Martin H N Tattersall MA, MD, MSc, FRCP, FRACP · Phyllis N Butow PhD, MPH · Judith E Brown BA(Hons) Psych, GradDipPsych, DipEd BSc · John F Thompson MD, FRACS, FACS

To the Editor: The working group responsible for the recent chronic fatigue syndrome (CFS) guidelines needs to be congratulated for producing a sensible and well balanced document in a most controversial area.1 Larkins and Molesworth have contributed a somewhat predictable response.2 Some sufferers of CFS can be characterised by their capacity to react strongly to the suggestion that psychological factors may be involved in the pathogenesis of their condition.3 From the perspective of the consultation-liaison psychiatrist, their response can be written with the comments on physical and psychological issues substituted for one another. Hence it can read (1) there is no current evidence that the syndrome has a specific physical origin, and (2) there is evidence that a range of psychological issues occur in people with CFS, although it remains unclear whether these changes are primary or secondary. The mental health movement has worked hard in recent times to reduce the stigma associated with psychiatric conditions. The sufferers of chronic physical illness now accept the importance of looking after their emotional health as well as their physical well-being. Enlightened CFS sufferers and support groups accept the links between physical and psychological morbidity and do not mindlessly exclude the latter. There is ample evidence that cognitive–behavioural strategies and graded exercise programs assist those with CFS, and psychiatrists are skilled in providing these treatments.4

James D Hundertmark

To the Editor: The process of destigmatising chronic fatigue syndrome (CFS) is not advanced by either limiting enquiry to "acceptable" sciences or increasing the stigma already experienced by people with other neuropsychiatric disorders. Contrary to its intent, and in contrast to the recently published Royal Australasian College of Physicians (RACP) guidelines,1 the recent statement by the immediate past president of the RACP and the Chairman of the ME/Chronic Fatigue Syndrome Association of Australia2 is in danger of increasing the stigma for both people with CFS and people with other common mental disorders. Unfortunately, key propositions in their letter ("There is no evidence that the illness is primarily psychological in origin") are clearly at variance with the tone of the guidelines (see Box 1.5, p. S31; Box 1.7, p. S32; and, "Management" summary, p. S38). Their letter reinforces the classical "dualistic" and rather simplistic "biological" approach (eg, "There is significant evidence of a range of biological abnormalities occurring in people with CFS"). Unwittingly, it colludes with community-based beliefs that mental health problems are "not health",3 and often imaginary or under the voluntary control of the patient.4 There is no doubt that people with CFS share many experiences with people with other neuropsychiatric disorders. They both have daily experiences where their credibility is challenged, their disability is minimised and their needs for appropriate medical management are not met. Australian research and best practice have been recognised internationally for emphasising the integration of psychological, psychiatric and biological factors and respect for the experiences of persons with these debilitating disorders.5 Unfortunately, the major advances captured in the guidelines may now be undermined if the RACP is perceived to be backing away from supporting appropriate psychological assessment and provision of effective "psychological" treatments (such as cognitive–behavioural therapy and physical rehabilitation approaches). Similar equivocation has left clinical guideline processes in the United Kingdom in disarray.6 As demonstrated recently, prolonged fatigue syndromes are common in the Australian community, and the vast majority of those who seek healthcare services have concurrent depression or anxiety.7 Real progress towards destigmatisation, meaningful research progress and improved health services for people with CFS will only occur when the field is mature enough to deal with the clear relevance of psychological factors. Instead of rejecting "psychological factors" and associated treatments, relevant professional and consumer bodies should now join with the broader community movement towards increased community awareness of common neuropsychiatric disorders, genuine understanding of their (genetic, "biological", psychosocial and personal) causes and provision of effective (pharmacological and psychological) treatments.8

Ian B Hickie

To the Editor: In the recent letter from Larkins and Molesworth1 various statements are made on which I would like to comment. From time to time everyone becomes physically or mentally exhausted, whether or not it is related to activity. For some people this exhaustion becomes disabling. They deserve understanding and sympathy. We must do everything we possibly can to assist them to recover and to try to find possible causes. Larkins and Molesworth acknowledge that chronic fatigue syndrome is a serious, disabling illness. When does ordinary exhaustion become disabling? I would agree that at this stage there is no clinical evidence that the condition is primarily psychological. Nor is there evidence that it is primarily physical. There may be a mixture. What is the "significant evidence" of a range of biological abnormalities occurring in people with CFS? What are these biological abnormalities and what physiological evidence is there for each one of these abnormalities to produce fatigue? Larkins and Molesworth state that treatment plans should be "within the capabilities of the patient": is there evidence to indicate that stimulating each patient to do just that little more each day will do harm? It was stated that scientific evidence of the aetiology, pathology and treatment is grossly deficient. It is in fact absent. There is no evidence at all. Research is certainly required. One of the problems is that, as soon as a medical advisor informs a patient that investigations have shown no serious abnormality, the patient often goes away and says to himself or herself or family that the "doctor said there is nothing the matter with me and that it is all in my head". Nothing could be further from the truth. Something is the matter and it is up to us to find it out.

Donald D Beard

In reply: We thank the writers for their comments on the CFS guidelines1 and our joint letter about these guidelines.2 Hundertmark remarks on the interplay between physical and psychological factors in morbidity associated with CFS. We trust that our letter in no way contradicts this. Similarly, the inferences that Hickie drew from our letter are not supported by the text of the letter. Far from undermining the guidelines, our letter had the full support of the convenor of the working party responsible for the guidelines. As clearly discussed in the guidelines, in the absence of specific diagnostic tests it is likely that a range of factors may contribute to the pathogenesis of CFS. Assumption of a primarily "psychological" pathogenesis is as unjustified as assumption of a primary "physical" basis. There are "abnormal" test results in many people with CFS, including abnormalities of the hypothalamic–pituitary–adrenal axis and some abnormalities of immune function. As stated, it is controversial whether such abnormalities are primary or secondary. While cognitive–behavioural therapy with graded exercise is effective in some patients, the guidelines outline the deficiencies of the evidence which "significantly limit the generalisability of the findings". As the guidelines indicate, and as is supported by our letter, treatment should be designed in partnership with the patient, and tailored according to the patient's capacity and response. Finally, as implied by Beard's letter, we restate the need for further research into the aetiology, pathology and treatment of CFS. We believe that effective progress in the management of this complex and mysterious illness will be best achieved by positive and cooperative rather than adversarial relationships between those suffering from the condition and the doctors and researchers attempting to help them.

Richard G Larkins · Simon R Molesworth

To the Editor: I am writing in response to the letter from Zardawi in the 19 August 2002 issue of the Journal.1 Zardawi suggests that radiologists and pathologists should not talk to patients, and that their contract is with the referring doctor, not with the patient. On both counts he is mistaken. Patients who are worried and anxious are certainly in need of some communication with the doctors carrying out their investigations. Most doctors of experience will know what is appropriate by way of conveying any results and what should be left to the patient's own doctor. Only those in bondage to corporate medicine will require a formula to instruct them in correct behaviour. That there is a contract with the patient is attested by the many cases of litigation against radiologists and pathologists. Of course, it is more efficient if the doctor does not speak to the patient, as valuable time is saved, and even more efficient if the doctor's staff do not speak to the patient either. This is common practice, as reported daily by patients and confirmed by my own recent experience. Nothing was communicated to me except that if I wished to rewrite my physician's referral to indicate that I had a palpable lump (which I did not) there would be a Medicare rebate, and that otherwise there would not, and I would thus have to pay the full amount. I declined the offer. I then waited two weeks to know that my results were normal. Some patients report that they will travel 20 km across the city to visit a practice where the staff look up and speak when patients enter, and where the doctor is not too busy to speak to them. No doubt such "inefficient" practices will disappear in time. The case of nuclear medicine differs in that the Health Insurance Commission schedule of fees requires the physician to see and assess the patient and to supervise the procedure in order for a benefit to be legally payable. The nuclear medicine physician is therefore in a position to know what is appropriate to communicate to the patient. Most patients are grateful for the opportunity to discuss the findings and to understand the implications of what has been found. In the case of serious abnormalities, such as pulmonary embolism, it is imperative that the patient be made aware of the importance of the findings and the need for immediate treatment.

Josephine C Wiseman

Max Dunstone was born in Adelaide on 6 July 1926. He was educated at Parkside Primary School, Prince Alfred College and Adelaide University, graduating in medicine in 1948. After a year as Resident Medical Officer at the Royal Adelaide Hospital, he entered general practice in 1950. Max could be described as one of the best general practitioners in South Australia. He had a substantial obstetric practice, was an excellent family doctor, and excelled in the academic and research areas of general practice. He was discerning and sound in clinical diagnosis, conscientious and thorough. His thoughtfulness, kindness and compassion were appreciated by his patients, family and medical peers, who regarded him with much respect and affection. He even learned to speak Italian to develop better communication and empathy with his Italian patients. Max was regarded by his colleagues as an excellent teacher. He recognised the wealth of medical information available in general practice and was able to use it in a practical way in developing the Research Committee of the Royal Australian College of General Practitioners (RACGP). His involvement with the RACGP was extensive. He was one of the first Board members (from 1958). Between 1958 and 1990 he served on eight College committees, his most notable work being in the capacity of Chairman of the SA Faculty Research Committee (1960–1990) and Chairman of the National Research Committee of the RACGP Council (1976–1979). He became a Fellow in 1972, and was Chairman of the SA Faculty Board (1974–1976) and Provost (1976–1978). Max held other notable appointments during his career, including that of Medical Officer for the City of Adelaide Central Board of Health (1979–1994), Board member for the SA Cancer Registry Board (1976–1986), and Chairman of the Medical Records Committee and Peer Review Committee of the North Eastern Community Hospital (1978–2000). Max's innovative approach to research was acclaimed by his peers. His research articles, some of which were published in the Medical Journal of Australia, were influential in the field of obstetrics in South Australia during the late 1970s. At that time, GP obstetricians delivered 84% of infants born in South Australia and Max made an assessment of their performance. His research was probably one of the contributing factors to the rise in standards of obstetric practice: by the early 1980s, South Australia had the lowest perinatal mortality rate in the world, at 5.5 per 1000 (compared with Sweden [8] and Australia [9]). In his leisure time, Max enjoyed tennis, golf and stamp-collecting. He was of strong religious persuasion and was a warden of St Aidan's Anglican Church in Payneham, SA. In 1986, he was made a Member of the Order of Australia "for service to medicine as a general practitioner for 36 years, with involvement in community-based medical research". Max died on 7 April 2002 of cancer of the urinary tract. Vale to a great doctor of high achievement, integrity, equanimity and humility.

Robert Cooter AM MB BS FRACGP

Edwin Cordeaux Blomfield was born on 25 December 1917 at Inverell, New South Wales. His early schooling was in the New England region and he completed his secondary education at North Sydney Boys' High School. While studying medicine at the University of Sydney (1936–1942), he stayed at St Paul's College. After graduating, he spent three years as a Resident Medical Officer at Hornsby District Hospital, where he met his future wife, Florence Kelsey, a nursing sister. They were married in 1945. In 1947, after two years in the army, Ted set up a general practice at Pambula, on the far south coast of New South Wales. He was the sole medical practitioner, prescribing and dispensing medicines, attending clinics in adjacent towns, and visiting patients in isolated areas. In 1949, Ted moved with his family to Bega. During his many years there, he delivered more than 3000 babies in the district, and was a great teacher to both nurses and doctors. He was highly skilled in surgery, anaesthesia and obstetrics, and, as there were no specialist doctors resident in Bega Valley until 1968, he had to deal with many emergencies of various kinds. He was also a foundation member of the Bega branch of St John Ambulance Australia in 1986, and over the years gave freely of his time teaching first aid and supporting the service. Ted had a gentle nature and was generous and friendly, with a quick wit and an endless supply of jokes. He affected the lives of many people in his community. He contributed greatly to the life of St John's Anglican Church in Bega and was a long-standing member of the Rotary Club, which recognised his contribution with a Paul Harris Fellowship, one of its highest awards. He was a supporter of Little Athletics, Meals on Wheels, and other organisations. He was a director of the Bega and District Nursing Home and was involved with the planning of "Casuarina Hostel", an assisted-care facility for the elderly. In 1998, he was awarded the Medal of the Order of Australia for his services to the community. Ted's hobbies included surfing and photography, and in later years, especially after his retirement in 1997, he enjoyed travelling to many parts of Australia. Ted will be remembered for his dedication, sense of humour and caring nature. He was a humble man who always had time for people — one of nature's gentlemen. Ted died on 12 December 2001 of pneumonia, a late complication of cardiac bypass surgery.

John D McKee MB BS FRCS FRACS

A more proactive approach by GPs would help to ease the burden on family carers In Australia, up to 2.3 million people are involved in informal care of children, adults and older persons with disabling chronic and terminal conditions.1 Their role includes managing medications, therapies and medical emergencies; providing supervision and emotional support; and assisting with personal care, mobility and household tasks.1-3 While caring can provide considerable satisfaction and strengthen relationships, carers often feel exhausted, isolated and burdened by their responsibilities.1,3,4 In a recent survey of carers, 58% reported their physical health had been adversely affected, a third said they had sustained a physical injury, and over half reported depression, anxiety, high levels of stress and other impacts on their mental health.2 There have been many calls for general practitioners to be more proactive in addressing the support needs of carers,3-6 and carers have identified how this may be accomplished (see Box). A 1998 editorial on family carers in Australia3 called for strategies to raise health professionals' awareness about carers, to keep them abreast of programs available to carers, and to encourage them to be more proactive in helping carers to obtain support. Since then, there has been limited apparent progress in Australia (unlike Britain, where there has been considerable interest in the primary care team's designated responsibility for addressing carer needs7). Projects conducted through Divisions of General Practice to inform and educate doctors, to promote carer self-identification and discussion5-6 and to promote collaborative referral with regional carer respite services5 showed encouraging outcomes, but have failed to attract further funding from government. Carer associations have also acted by providing various resources. The GP information kit, Carer Checklist and Carers Profile assessment tools (trialled in New South Wales) are time-efficient and pave the way for discussion of carer issues.7,8 In Victoria, individual carers are encouraged to raise issues and to give their GPs a tailored service-provider kit, but this approach lacks systematic coverage. In South Australia, a GP working group is seeking to collaboratively explore various approaches, including GP education and involvement of practice managers. Government initiatives have focused on raising GPs' awareness of community services and referral pathways (eg, the Commonwealth CareLinks and Victorian Primary Care Partnership8). Supporting tools initiated by governments include service directories, consumer assessment and service coordination templates, referral mechanisms (both printed and Web-based) and consumer/carer charters. The full potential of information technology has not yet been harnessed. For example, including a "carer status" field in patient records would prompt early identification of care responsibilities. Software could also alert GPs to provide information or follow-up, and could even include (or electronically link to) carer fact sheets and resources, such as those produced by the national carer organisation Carers Australia. Even GPs committed to working with carers can face considerable barriers to implementing a proactive approach. The patient may not agree to the carer participating in the consultation, or the carer may be reluctant to discuss how he or she is managing, especially if the patient is present or the carer perceives the GP to be too "busy" or very medically focused.4,5,7,10 Either the patient or the carer may be reluctant to accept external assistance.5,6,10 The carer may forgo his or her own health checks or treatment plan because of the pressures of caregiving.2 Finally, in addition to lack of training, information and resources,5-7,11 GPs have to cope with increasing demands, time constraints and inadequate remuneration,5,7,9-11 problems that are often difficult to overcome. The Enhanced Primary Care (EPC) Medicare Benefits Schedule items provide an opportunity to focus on carers and partly address the issue of remuneration for GPs.12 With the patient's consent, carers can be formally included in care planning and case-conferencing activities. This enables GPs and other healthcare workers to hear carers' views on how well they and their patients are managing at home. GPs and carers can then jointly consider options for coordinated support. Where carer wellbeing is an issue, staff of regional carer respite services (or other workers assisting the carer) can usefully be involved.6 Health assessments, another EPC item, should also include screening for carer issues. However, GPs may still need to grapple with the thorny issues of consent, conflict and reluctance — interpersonal issues arising in the relationships between patients and carers and between patients/carers and their doctor. Much of the responsibility for monitoring patient records and maintaining information resources can be delegated to the practice manager or an allied health professional. For example, practice nurses have effectively undertaken health assessments13 and are well positioned to provide carer health education, service referral and coordination. A counsellor or carer-support worker attached to a general practice can assist with identifying carer needs and making referrals, as well as helping the carer to develop skills and to work through emotional or relationship issues.6 The Better Outcomes in Mental Health Initiative14 is relevant to assisting carers who are experiencing severe stress, anxiety or depression. The initiative provides incentive payments for mental health needs assessment, planning and review activities to doctors who register interest with their local Division of General Practice and receive training. We believe that including educational material on carer mental health issues in training packages would enhance this initiative. Given the absence of clear strategies and leadership on this issue over the past four years, the development of clinical practice guidelines and policy positions by governments and peak practitioner bodies is needed. The evolving Commonwealth-funded Primary Health Care Research Evaluation and Development Strategy15 provides an ideal opportunity to prioritise collaborative research in this area. The demonstration of the benefits to carers, those they care for, and the community generally, of an overtly aware and interventionist clinical approach is well overdue. What carers would like general practitioners to do6-8 Recognise their carer status and care responsibilities and include them in care planning and decision-making. Avoid assumptions about carer's capacity, confidence and willingness to provide home care. Provide plain-language information to the carer on the patient's condition, prognosis, treatment, care needs and management (including behaviour management). Provide information and referrals relevant to carers (eg, in-home and residential respite care options, counselling, peer support groups, financial entitlements, self-care and coping strategies). Give referrals to carer associations and state-wide condition-specific bodies as a starting point. Discuss and, where appropriate, assess the carer's own physical and psychosocial health needs. Engage other family members in understanding and sharing care responsibilities. Recognise grief and loss on cessation of caring.

Julie M Nankervis MSW MAPS · Peter J Waxman MB BS FRACGP · Denise A O'Hara MB BS MPH FAFPHM · Mary Burbidge MB BS

Trial evidence best informs real-world medicine when it is relevant to the clinical problem Controlled clinical trials provide the most reliable evidence of whether treatments are effective, particularly when the effects of treatment are moderate. Without such trials, ineffective treatments or, even worse, harmful interventions may be accepted in medical practice. Yet medical practice is often not based on clinical trial evidence, because the evidence is considered not relevant or does not exist. Real-world medicine must not only consider the effectiveness of specific treatments, but must do so in the context of patients who have multiple problems and who are often already receiving many different treatments in a setting different from that tested in the trial.1 Throughout the history of medicine, many treatments have been considered effective until well-controlled trials demonstrated otherwise.2 Some recent treatments based on observational data that have been discredited by randomised controlled trials include hormone replacement therapy to prevent coronary heart disease events,3 vitamin supplements to prevent lung cancer4 or cardiovascular disease events,5 and arthroscopic surgery for osteoarthritis of the knee.6 Although data from observational studies may be of value,7 these data may sometimes suggest a harmful outcome for treatments that are known, from controlled trials, to be effective, such as blood pressure treatment.7 Applying trial results to individual patientsAlthough clinical trial evidence for the introduction and use of new drugs is widely accepted, the "real-world" uptake is often erratic. For patients with coronary heart disease, the merits of statins, angiotensin-converting enzyme (ACE) inhibitors, β-blockers and aspirin are well recognised from clinical trial evidence, yet these treatments are still significantly underused.8 The gap between evidence and practice is even wider in other areas. Evidence is an essential part of good medical practice, but it is not the only information needed for clinical decision-making. Real-world medicine may ignore clinical trial evidence if it does not seem relevant to the clinical problem at hand or if the benefit is uncertain. A drug that shrinks a cancer is not necessarily useful unless it also improves the patient's quality of life or prolongs survival. A treatment that lowers blood pressure or cholesterol has value only if these outcomes are translated into meaningfully fewer cardiovascular events, without a penalty of increased adverse effects. Hence, evidence from trials is most applicable in practice when the design and the outcomes chosen are directly relevant to real patients, the trials are undertaken against a background of standard medical care, patients in trials are broadly representative of patients in the real world, and evidence from trials is integrated with individual patient characteristics for meaningful risk–benefit assessment. Absolute differences in risk (or numbers needed to treat) are recognised as most relevant to decision making; yet clinical trial results are often reported as changes in relative risk. For example, recent clinical trial results of breast cancer risk in women taking hormone replacement therapy appeared exaggerated if the increased risks were considered in relative rather than absolute terms. Treatment resulted in a 26% relative increase in breast cancer, which equated to an absolute increase of just 0.08% per year.3 Nevertheless, the relative treatment effect is of value if applied appropriately (by combining it with the individual's baseline risk), providing a better guide to the absolute effect of treatment in specific patient groups.1 ParticipationDespite the need for high-quality clinical trials, few patients participate in them, even in areas where trials are common. For example, less than 5% of eligible patients participate in most cancer trials9 and less than 10% in many cardiovascular trials.10 Low participation rates raise concerns that the results from trials apply only to select groups of patients. Scant participation is not necessarily a problem if patients are representative, but patients in trials are often narrowly selected because of the eligibility criteria, the setting, or the patients agreeing to participate. Strategies such as public access to ongoing trials through registers and more pragmatic trial designs are needed to maximise participation and ensure treatments are assessed in a variety of settings. The need for wider use of clinical trialsWhenever a new drug treatment is discovered that has the potential to help many patients, prevailing systems support well-controlled trials addressing effectiveness and safety. Systems to assess new technologies or interventions other than drugs are equally important, yet more challenging and much less developed. Also lacking are sufficient trials of new devices, health service management decisions, and trials in community or Third World settings. It has been suggested that clinical trials are too expensive, and funding outside the pharmaceutical industry is limited. A randomised clinical trial, evaluating a moderate treatment effect on important clinical outcomes, may cost from $1 million to more than $50 million. However, this cost needs to be put in the context of healthcare generally (more than $50 billion in Australia each year11) and the cost of not undertaking trials before deciding which treatments to support. The Australian government has recognised the importance of basing funding decisions for new health technologies (through the Pharmaceutical Benefits Advisory Committee and the Medicare Services Advisory Committee) on the best evidence of the effectiveness, safety and cost-effectiveness of each treatment. But funding more research on the cost-effectiveness of new technologies is also warranted. Specific clinical trials in this context may be much more cost-effective than using funds to introduce therapies on the basis of less reliable evidence.12 Consequently, a more proactive funding strategy for trials should be considered, extending the model proposed by Glasziou: 13 up to 1% of the national healthcare budget could be used to test new and existing health technologies for which there is inadequate evidence, but potentially large benefits or cost savings.14 One approach to monitor and implement some of these strategies is through the use of a comprehensive national trials register to aid the planning of new trials, ensure all trials are identified when evaluating trial evidence, and maximise participation of patients and doctors in ongoing trials.15 Many clinical trials already play a central role in everyday clinical practice. However, if we seriously address each of the above issues, health outcomes could be further improved through clinical trials assessing new health technologies and existing treatments in the real world of modern medicine. It is time for us to look at how to make this more of a reality.

R John Simes

To the Editor: I thought it most appropriate that you juxtaposed the articles by Kilmartin et al1 and Fitzgerald2 in your General Practice issue (15 July). Missing from each article is a key aspect from the patient's point of view. As a patient, I value, above all else, continuity of care by my general practitioner. In this age of increasing sessional work (by both female and male doctors) and of increasing employment of doctors on a sessional basis by corporations, this feature of general practice is threatened. As a former GP, I am increasingly being asked to comment by lawyers (for both plaintiffs and defendants) on cases where patients have fallen through the cracks that are an inevitable aspect of sessional care. Patients are being seriously harmed because of poor communication and poor or no handover between sessional doctors. What is most disturbing is the absence of failsafe mechanisms to ensure that communication, both verbal and, more importantly, written, between the sessional GPs in a practice comes as close as possible to providing the continuity of care offered by the now nearly obsolete five- or six-day-a-week and after-hours family doctor.

Peter C Arnold

In contrast to curative therapies, preventive therapies are administered to largely healthy individuals over long periods. The risk–benefit and cost–benefit ratios are more likely to be unfavourable, making treatment decisions difficult. Drug trials provide insufficient information for treatment decisions, as they are conducted on highly selected populations over short durations, estimate only relative benefits of treatment and offer little information on risks and costs. Epidemiological modelling is a method of combining evidence from observational epidemiology and clinical trials to assist in clinical and health policy decision-making. It can estimate absolute benefits, risks and costs of long-term preventive strategies, and thus allow their precise targeting to individuals for whom they are safest and most cost-effective. Epidemiological modelling also allows explicit information about risks and benefits of therapy to be presented to patients, facilitating informed decision-making.

Danny Liew BMedSc, MB BS · John J McNeil FRACP, PhD · Anna Peeters BSc, PhD · Stephen S Lim BA, BSc · Theo Vos MD, MSc

Objective: To compare the quality of care provided by general practitioners participating in diabetes shared-care registers with that provided by GPs not using registers.Design: Cross-sectional comparison using Health Insurance Commission (HIC) data for patients attending the GPs.Participants and setting: 155 GPs using diabetes registers, 459 GPs not using registers, and their patients with diabetes (as identified by HIC criteria). The study analysed data for the period January 1996 to December 1998 and was based on Divisions of General Practice within the South Western Sydney Area Health Service.Main outcome measures: Frequency of visits to GPs and tests ordered within each of six six-month periods.Results: GPs using the registers had more patients with diabetes, and saw those patients more frequently, than GPs not using registers. "Register" GPs also ordered tests (for HbA1c and microalbuminuria) more frequently than "non-register" GPs.Conclusion: GPs who participated in diabetes registers were more likely to provide patient care that more closely adhered to evidence-based guidelines than those who did not. Further research is needed to determine whether this was the result of characteristics of the GPs themselves, or their practices, or a was a consequence of their participation.

Mark F Harris DRACOG, FRACGP, MD · Fernando A Infante MB BS · Brian I O'Toole PhD, MPH · Debbie Priddin RN, BSocSci · Warwick Ruscoe MB BS, FRACMA

Objectives: To investigate the circumstances that led general practitioners to refer dementia sufferers and their carers to community support services.Design: Qualitative study using semi-structured interviews, carried out between 1 September 1999 and 30 April 2000.Setting and participants: 21 live-in carers of patients with dementia referred for the first time to a Western Australian metropolitan Aged Care Assessment Team, and 19 of their referring general practitioners.Results: Most referrals occurred after the carers had been experiencing carer stress, and were precipitated by crisis situations. Carers failed to discuss their difficulties with the referring GP for a variety of reasons, including the belief that they should cope because it was their duty. The doctors found it difficult to know how the carers were coping or when to intervene, and some carers tended to resist their attempts to help. Time constraints were a significant problem for both groups.Conclusion: Attitudinal barriers in both carers of patients with dementia and GPs, combined with time constraints, often lead to inadequate assessment of carer problems. While it is important that strategies to improve communication between carers and GPs are developed, it would be sensible for GPs to assume that dementia carers are at risk of carer stress and should be encouraged to use community care services.

David G Bruce MD, FRACP · Glenys A Paley BSc, Dip Hlth Prom · Peter J Underwood MB BS, PhD · David Roberts RN, PhD · Duncan Steed MB BS

Objective: To implement and evaluate a collaborative medication management service model.Design: Participatory action research.Setting and participants: The study was conducted from March 1999 to March 2000; 1000 patients, 63 pharmacists and 129 general practitioners from six Divisions of General Practice in South Australia participated.Interventions: A collaborative service delivery model, involving a preliminary case conference, a home visit and a second case conference, was agreed through discussions with medical and pharmacy organisations and then implemented.Outcome measures: Medication-related problems; actions recommended; actions implemented; and outcomes after actions taken.Results: Overall, 2764 problems were identified. The most common medication-related problem (17.5% of all problems) was the need for additional tests. Thirty-seven per cent of problems related to medicine selection, 20% to patient knowledge, and 17% to the medication regimen. Of 2764 actions recommended to resolve medication-related problems, 42% were implemented. Of the 978 problems for which action was taken and follow-up data were available, 81% were reported to be "resolved", "well managed" or "improving".Conclusion: This implementation model was successful in engaging GPs and pharmacists and in assisting in the resolution of medication-related problems.

Andrew L Gilbert BPharm, PhD · Elizabeth E Roughead BPharm, PhD · Kathy Mott BA · John D Barratt BPharm, BAppSc (Comp Studies) · Justin Beilby MB BS, MD, FRACGP

Physicians' dual roles — as healer and professional — are linked by codes of ethics governing behaviour and are empowered by science. Being part of a profession entails a societal contract. The profession is granted a monopoly over the use of a body of knowledge and the privilege of self-regulation and, in return, guarantees society professional competence, integrity and the provision of altruistic service. Societal attitudes to professionalism have changed from supportive to increasingly critical — with physicians being criticised for pursuing their own financial interests, and failing to self-regulate in a way that guarantees competence. Professional values are also threatened by many other factors. The most important are the changes in healthcare delivery in the developed world, with control shifting from the profession to the State and/or the corporate sector. For the ideal of professionalism to survive, physicians must understand it and its role in the social contract. They must meet the obligations necessary to sustain professionalism and ensure that healthcare systems support, rather than subvert, behaviour that is compatible with professionalism's values.

Sylvia R Cruess MD · Sharon Johnston LLM · Richard L Cruess MD

It is time to focus on reducing inappropriate test ordering The complexity of modern medicine has promoted an excessive reliance on the results of empirical tests rather than clinical acumen. In Australia, this is reflected in the fact that the rise in the costs of diagnostic testing in pathology and radiology is second only to the rise in cost of pharmaceutical prescriptions, the fastest-growing sector in our healthcare budget. Many reasons have been cited for this increase in clinicians' reliance on pathology and radiology testing. Among community-based practitioners, ordering patterns are most likely to be influenced by medicolegal concerns, time constraints, screening needs, or ingrained practice habits. Among hospital-based clinicians, test-ordering practice may be determined by level of clinical experience, fear of censure for lack of testing, medicolegal concerns, and the desire to provide a "one-stop" service to evaluate all possible physiological parameters.1 In addition, the pressures of shorter consultation times in community practice and diminishing hospital beds have led to the increased use of investigations to fast-track patient throughput. In acute hospital settings, it has been estimated that as many as a third of all tests ordered are inappropriate in terms of their ability to contribute to the diagnosis and treatment of individual patients.2 This overtesting is not without consequences. If a healthy individual is subjected to 10 unnecessary tests, there is a 40% chance of at least one false-positive result.3 As well as exposing the patient to potential harm from unnecessary tests and treatment, this may expose the clinician to an increased, rather than a decreased, medicolegal risk, as patients are exposed to greater risks of complications while they proceed along an unnecessary testing spiral. In a community that is struggling to cope with the financial demands of modern healthcare, the wastage of resources on unnecessary pathology and imaging testing has an adverse effect on the provision of services that are legitimately required. Furthermore, in most settings, it is the relatively cheap, common tests that account for the bulk of testing expenditure. In our own institution, about 80% of the costs of biochemistry and haematology testing are accounted for by full blood counts and testing of electrolytes, urea, creatinine, liver function and cardiac markers. Although more complex investigations, such as gene testing, may individually be more expensive, the sheer volume of common tests drives the overall costs of investigations, and suggests that attempts to reduce inappropriate testing should focus on these tests. In this issue of the Journal, Stuart and colleagues (page 131) report on a comprehensive program of education, audit, feedback and structural change to reduce the number of investigations performed in a public hospital emergency department.4 Although their program focused on reducing inappropriate testing and improving result follow-up in an emergency department, the lessons learned about how to produce sustainable change in clinician practice are equally applicable to the rest of the acute hospital environment, and to the community sector. There has been a plethora of reports on the implementation of educational or other programs aimed at curbing the costs of inappropriate testing. Most describe utilisation of tools such as education programs,5,6 incentives for clinicians,7,8 information about costs of testing, audit of ordering profiles, feedback on ordering patterns, guidelines, decision-support systems, and process changes.9,10 The study by Stuart et al demonstrates the key features required for sustainable improvement in test-ordering behaviour. A multifaceted approach that results in alteration to the core processes of test ordering is more likely to promote lasting improvements than strategies aimed just at increasing awareness or knowledge among individuals. In public hospitals, where the junior medical staff who are responsible for most test-ordering rotate through departments at three-monthly intervals, it is essential that whatever changes are made to improve test-ordering are capable of affecting a mobile workforce. It is unlikely that educational programs alone could cope with the demands of this rostering pattern, unless concomitant process changes are implemented hospital-wide to ensure applicability in all clinical settings. As conceded by Stuart et al, the effects on patient outcomes of attempts to reduce overtesting were not addressed. No data are provided on readmission rates, length of stay, adverse events and rates of missed or incorrect diagnoses. It is possible that attempts to reduce numbers of tests performed could result in harm to patients through underinvestigation of symptoms. Therefore, future studies in this area should include measures of patient outcomes to ensure that an overall improvement in patient care accompanies the reduction in costs of investigation. Computerised systems are widely available in general practice for prescribing, and, in some places, for test ordering, but have yet to be widely implemented in the acute care sector. At present, these systems have focused on facilitating the ordering process rather than ensuring its appropriateness. The future is likely to see implementation of computerised order-entry systems that provide real-time feedback on ordering patterns, guidance on test appropriateness, improved result checking, and information on the costs of tests ordered. Such systems already exist, and are currently being tested in several Australian hospitals. It is hoped that overcoming existing deficiencies in information systems will enable clinicians to order tests and check results more efficiently and more appropriately than they currently do. An academic analysis of current test-ordering practices might suggest that further research is needed into why doctors order tests the way they do, whether there really is such a high rate of unnecessary testing, and what value current ordering patterns add to our highly complex healthcare system. A pragmatic view, however, would suggest that there is enough published evidence that overtesting is a characteristic of healthcare systems in the developed world, and enough information in existing research to guide what should be done to reduce waste and harm resulting from inappropriate testing. It is time that the focus of work in this area shifted to development of practical, sustainable means of improving the appropriateness of testing. Future research may be best directed to understanding the place of sophisticated decision-analysis models, the role of point-of-care guidance and feedback systems, and effective clinical change-management strategies. In the meantime, hospitals around Australia have already embarked upon attempts to change current practice. In Melbourne, the National Institute of Clinical Studies is sponsoring a 12-month project, involving hospitals from four States and Territories, aimed at developing transferable and sustainable changes in test-ordering practices. Similarly, hospitals involved in the Health Roundtable in Sydney have been involved in exchanging information on effective strategies to improve test ordering. The Royal Australasian College of Pathologists is developing undergraduate education programs aimed at improving ordering practices. The lessons learned from these groups should inform national strategies to deal with the problem of inappropriate testing. As in the study by Stuart et al, it is likely that a coordinated, multifaceted, sustained approach to this problem will be required to achieve lasting success.

Rohan J H Hammett MB BS, FRACP · Roger D Harris MB BS, FACEM

Objective: To evaluate an intervention developed to improve test-ordering practice.Setting: Public hospital emergency department with an annual census of 42 500. The study comprised a six-month pre-intervention stage (November 1998 to April 1999), which was compared with a similar post-intervention period (November 1999 to April 2000), and trends were examined over an 18-month post-intervention period (May 1999 to October 2000).Intervention: The intervention comprised three integrated components: implementation of a protocol for test ordering; education program for medical staff; and audit/feedback process.Main outcome measure: Test utilisation (assessed as cost per patient).Results: There was a 40% decrease in the ordering of investigations in the emergency department (95% CI, 29%–50%), with test utilisation falling from a mean of $39.32/patient to $23.72/patient. The decrease was similar for both laboratory and imaging tests and was sustained for the duration of the 18-month follow-up.Conclusions: Our intervention appears to have produced long term modification of test ordering in the emergency department of a public teaching hospital.

Peter J Stuart MB BS, FACEM · Shelley Crooks BA(Hons.Psych) · Mark Porton BAppSc

To the Editor: Safety is a rather subjective concept, so to use the word without definition, as Clarke et al did,1 is somewhat misleading. One possible definition is that the complication rate for general practitioners is no greater than for anaesthetists in the same circumstances. In the study by Clarke et al,1 the GPs were allocated the lower-risk cases and the anaesthetists were allocated the more difficult ones. Direct comparison was made without any adjustment for this difference. The data suggest that the GPs had similar or higher rates of adverse events or interventions despite handling lower-risk cases. The most recent data on anaesthesia-related mortality reports 20 deaths at endoscopy from 1994–1996, with a note that this is likely to be an underestimate.2 Using the authors' denominator of 430 000 endoscopies per year, an estimated risk of anaesthesia-related death is therefore about 1 in 64 000. The risk of anaesthesia-related death for all surgery is quoted as 1 in 63 000, which implies that anaesthesia for endoscopy is of average risk. The sample size of 28 000 lacks sufficient power to make any comment on safety as regards the risk of death. Although I applaud the clinical standards of the authors' institution and fully agree that propofol has many clinical benefits over other agents, Clarke et al do not prove safety in the use of propofol by non-anaesthetists.

Patricia Mackay · Patrick J Hughes

To the Editor: We read with interest the article by Clarke et al1 and the accompanying editorial by Knoblanche,2 and are concerned that they may be interpreted as endorsing the use of the anaesthetic agent propofol in sedation techniques by personnel inadequately trained in anaesthetic techniques. Cases reported to the Victorian Consultative Council on Anaesthetic Mortality and Morbidity confirm the risk of serious morbidity and mortality associated with these procedures. Our report for the triennium 1997–1999 will include two deaths at endoscopy where a non-specialist administered the sedation or anaesthetic. In both of these cases, propofol was used. The circumstances described by Clarke et al are exceptional. They combine a scrupulous adherence to the professional guidelines3 and a significant involvement by the administration of the endoscopy centre in the selection, education and on-going training of the general practitioner sedationists. They include incident reporting of adverse events and non-standard treatments as part of a quality assurance program. Although not specified, there is also, presumably, access to high-quality back-up. This level of attention to detail is by no means universal. We would like to endorse several observations made in the articles: For a procedure to be considered sedation, it is imperative that the drugs used are not intended to, and do not, cause loss of consciousness or the loss of protective reflexes or spontaneous ventilation; by definition, this would be anaesthesia. Proper selection and careful medical assessment of patients is very important, and training must enable the identification of patients at higher risk. People administering sedation must have knowledge of the pharmacology of the agents being administered and modifications necessary because of concurrent therapeutic regimens or disease states. They must also ensure adequate intraprocedure monitoring is provided, that they have experience in interpretation of abnormal indices, and that they can manage any complications arising from the procedure, with particular emphasis on airway management and cardiovascular resuscitation. There may be benefits with the use of propofol, but the guidelines, designed for patient safety, clearly state: "Intravenous anaesthetic agents such as propofol must only be used by an anaesthetist."3 Technological advances in non-invasive and minimally invasive procedures have led to an explosion in demand for sedation of increasing complexity in areas removed from the traditional operating room environment. Consequently, demand for sedation by non-anaesthetists is likely to grow. It is important that the standard of care and patient safety be maintained in all these circumstances. The concern is not whether the practitioner administering the sedation is a general practitioner or a specialist, but whether he or she has the training and skills necessary to function as an anaesthetist. The terms "general practitioner sedationist" and "non-anaesthetist" might give an impression of diminished risk, which is not supported by the experience of this committee.

Jon P Clarke · Anthony C Clarke FRCP, FRACP · Lybus C Hillman MD, FRACP

In reply: We thank Clarke and Mackay and Hughes for their interest and comments. We accept that a sample larger than the 28 000 endoscopies we reported1 would be required to establish the true incidence of death or other catastrophic complications of our sedation service. As the mortality rate is expected to be so low, it would take many years to achieve an adequate sample size. It is even difficult to determine the mortality from endoscopy in Australia, as quantifying all the endoscopies performed is problematic, and the Royal Australian and New Zealand College of Anaesthetists believes that not all deaths occurring from endoscopy are reported to anaesthetic mortality committees.2 It is essential that any sedation service is carefully planned, and that all doctors providing sedation receive adequate training and follow the protocols and guidelines of the endoscopy centre. However, we challenge the opinion that only anaesthetists should use propofol. We have not been able to find any clinical safety studies that demonstrate that only anaesthetists are able to use propofol safely. We believe the results of our study show that, when propofol is used in the manner described in the article, the rate of ventilatory and other complications is low (but clearly not zero). There is no reason to believe that the propofol component of the sedation regimen increased the rate of ventilatory problems. Indeed, it might, through its short duration of action, minimise such problems. To arbitrarily exclude the use of propofol by appropriately trained GP sedationists would deny many patients the manifest benefits of this drug. Importantly, our GPs have been shown capable of successfully managing the problems of airway obstruction and apnoea that were encountered — whatever the cause. We agree with Mackay and Hughes that the GP sedationists need to have the anaesthesia skills necessary to maintain patient ventilation, as well as an excellent understanding of all the drugs they use. Anaesthetists play a major role in improving safety standards in the provision of sedation for endoscopy through codifying the standards required,3 assisting the training of staff, and delivering sedation services to high-risk patients. But many patients can be successfully sedated without a specialist anaesthetist being present. We argue there is no evidence that these patients should receive a suboptimal regimen. Most specialist anaesthetists have a more valuable role to fill than providing sedation for straightforward endoscopies.

Jon P Clarke

eTG complete. Melbourne: Therapeutic Guidelines, 2002 (CD-ROM: Subscription $220). Therapeutic guidelines (10 at last count) are based on world literature, published by a group without commercial, government or pharmaceutical dependence or sponsorship and have been an essential reference for over 20 years. The various Guidelines have been distributed as pocket-sized books and, more recently, as individual electronic versions. This CD-ROM is the next step: integrating a series of Guidelines into one electronic product, with a master index. Subscribers are offered updates three to four times a year. The versions which are used are noted (eg, Analgesic version 3, Antibiotic version 11), but the search capability gives access across all guidelines. The disc is easy to load, and appears on the desktop as an icon. Search characteristics are clear, reasonably intuitive and speedy, meaning that use in a GP consultation is at least as quick as looking up one of the paper-based guides. It is also better, as searches access information from more than one guideline. A search for pregnancy and depression, for example, yields information from the Neurology, Respiratory and Psychotropic Guidelines, all of which have relevant sections. The advice includes non-pharmacological information. It is also printable, to provide a basis for discussion with patients. My room has lots of books, but I find that I get up from my desk to find them less often than I used to because of desktop resources like this one. If a tool is easy to use, I am more likely to use it, rather than rely on memory, particularly for uncommon things. But the cost is high — for our five-doctor practice the cost of eTG is $220 for the first user and $110 for each subsequent user, compared with $264 for one set of the books — which we can all share. Whether the convenience is worth the cost is a question we will wrestle with. Linda MannGeneral Practitioner Leichhardt, NSW

Linda Mann

But let’s not forget that our main goal is improving our patients’ health Medical research, like football, can be played many different ways, and in general practice the code of choice is definitely the survey! A flick through the research papers published in the Medical Journal of Australia between 1997 and 2001 will reveal that nearly half of those with GPs as primary authors were based on questionnaire surveys, compared with nearly a fifth of papers authored by physicians and about a quarter of those by surgeons. This phenomenon is not resticted to this Journal — a review of the medical literature between 1980 and 1999 showed that 41% of Australian general practice research was purely descriptive, comprising mainly surveys of GPs' views.1 Why this preponderance of surveys? One of the reasons is historical. From 1990 to 1999, after the Commonwealth Government introduced structural changes to general practice, the government-funded General Practice Evaluation Program (GPEP) allocated over $13 million as the main source of funding for general practice research.2 The criteria for receiving and the short-term nature of the funding favoured descriptive studies such as surveys. Thus, 90% of all 248 GPEP projects funded between 1990 and 1999 were descriptive studies, while 13% were interventional studies.2 Other reasons relate to the nature of general practice itself. Research expertise and capacity are less evolved in general practice than in most other disciplines. Moreover, general practice does not lend itself easily to the methods of randomised controlled trials.3 Our patients often have problems that are multiple, multidimensional (with psychosocial as well as biological components), and undifferentiated, lacking set diagnostic criteria. Our interventions may be correspondingly complex, often involving non-drug therapies.3 A (very appropriate!) survey of British GPs supports the need for relevant research: at least 61% of GPs surveyed considered that clinical topics, such as dealing with chronic or acute illness, patient behaviour and treatment, should be priority areas for general practice research.4 In this issue of the Journal (page 74), Queensland GPs echo this belief.5 Yet, the research being performed does not reflect this "wish list". More than half of all GPEP-funded projects focused predominantly on service organisation and supply, education, training and research methods.6 While these are important issues to tackle, how immediately relevant are they to the nucleus of general practice activity, the doctor–patient encounter? Moving beyond surveysIn December 2001, general practice research funding appeared to join the big league. A new program of National Health and Medical Research Council Project Grants to support primary healthcare research arose as part of the Primary Health Care Research, Evaluation and Development (PHC-RED) Strategy funded by the Commonwealth Government (with $50 million over five years), replacing GPEP.7 However, it is still unclear how much of this will be spent on actual research projects. Results of the assessment of grant applications for the new funding (to start in 2003) are not yet available, and our attempts to determine the exact funding allocation from government sources have hit a bureaucratic wall. It seems GP researchers, like football teams, are at the mercy of the sponsors, who hold the purse strings. Also at question is the extent to which the new program will meet the research needs of general practice. Priorities have been set for the allocation of the grants (Box), but many of these appear to reflect existing government policy rather than the priorities of "bag-carrying" GPs. The PHC-RED standing committee of the ministerial advisory body, the General Practice Partnership Advisory Council, has recommended that the next stage of the priority-setting process for the PHC-RED Strategy should have more emphasis on clinical research (Professor Max Kamien, Department of General Practice, University of Western Australia, personal communication). We would argue that, if the ultimate purpose of medical research is to improve the health of the population, such research must: pose research questions relevant to daily practice; and use appropriate and rigorous study methods to answer these questions. How can general practice research meet these criteria? A day's consultation may bring three patients with vertigo, but different histories, social contexts, values and expectations, and not much by way of physical signs. Few data exist on the predictive value of particular clinical features in the general practice population, particularly those features which are "red flags" for serious conditions, warranting early intervention.9 We need research that documents the natural history of the undifferentiated presentations in general practice. This may be achieved, for instance, through cohort or case–control studies; the large samples required should be possible through collaborations involving Divisions and research networks, as espoused by Gunn10 (page 63) and van Weel11 (page 62) in this issue of the Journal. The process will be facilitated by the increased computerisation of general practice, allowing large-scale data collection. In assessing interventions, observational studies,12 cluster randomisation (where the unit of randomisation may be the practice, not the patient)13 and pragmatic trials (that measure the effectiveness of a treatment in routine practice rather than explanatory trials that measure treatment efficacy in ideal conditions)14 may also have a place. NHMRC assessors of applications for the new primary-care grants will need to avoid perpetuating poorer-quality research (as in many questionnaire surveys), yet appreciate that methods that are rigorous and appropriate to general practice are still evolving.15 The right moves: building research culture and capacityNot all GPs will want to be active researchers, but there should be funding and infrastructure to train and support those who do. This forms an integral part of the PHC-RED Strategy (for instance, through the new NHMRC fellowships and scholarships and the Researcher Development Program),7 and should build on the recommendations of the General Practice Strategy Review Group in 1998,16 including master's or doctoral programs, dedicated career pathways, research "mentors", and research networks. Practical issues, such as adequate remuneration and locum provision while GPs take time off from practice for research, also need to be managed.5 GPs need to be engaged in research throughout their careers, with fostering of critical appraisal and research skills from medical school onward. Clinical audits (now a requirement of the Royal Australian College of General Practitioners Quality Assurance and Continuing Medical Education Program17), coupled with the possibilities of information technology, will also encourage us to evaluate our practice and refine our craft, even if they do not constitute "true" research. The endgameGeneral practice research may have reached the big league, but let's not forget the endgame. The point of promoting the evidence base for general practice is to improve the health of our patients. Increasing general practice research culture and capacity is crucial to this process, but should not be an end in itself. The gap between evidence and practice is more likely to be bridged if the gap between researcher and clinician is bridged, with greater ownership of the research agenda by clinicians5,18 rather than government committees. Whether the stated priorities of the new Project Grants will be discordant with clinical priorities remains to be seen. GPs are, however, pragmatists at heart: we will be more likely to practise with reference to an evidence base if the research underlying it is directly relevant to our practice. Our patients expect no less and neither should we. National Health and Medical Research Council Project Grants in Primary Health Care (part of the Primary Health Care Research, Evaluation and Development [PHC-RED] strategy)8 Preference is given to: Applied research that will advise policymakers, planners and service providers on improvements to primary healthcare delivery Research operating within an integrated and multidisciplinary framework Thematic research areas for primary healthcare include: Evidence-based practice (including development and implementation of evidence for primary healthcare) Measurement and improvement of quality Evaluation and development of models of organisation and delivery Integration and multidisciplinary practice Optimal use of economic resources Health inequalities and the determinants of health (including access issues) Illness prevention and health promotion (including risk factors and early interventions for chronic disease) The eligibility criteria are the same as those for other NHMRC Project Grants.

Mabel Chew MB BS(Hons), FRACGP, FAChPM · Ruth Armstrong BMed

Research networks can change the culture of biomedical science When my predecessor Frans Huygen, the Founding Chair of General Practice of the University Medical Centre, Nijmegen, the Netherlands, stood to give his first lecture (on measles) in 1968, the head of paediatrics had tabled an official complaint before he reached the rostrum. Measles was part of the paediatric domain, and intrusion by a general practitioner was not acceptable. It would have been easy, even in the 1960s, to state that most cases of measles were treated in general practice and GPs were the best qualified to teach students about it. But such anecdotal information could not officially be acted upon. The experience triggered a project at the Nijmegen Department of General Practice for collecting morbidity data.1 This has since developed into a unique database for research,2 with an influence on general practice and undergraduate teaching that continues today. What was founded in Nijmegen in 1971 would now be called a "practice-based research network". In fact, the systematic exploration of the content of daily practice is the vital first step in the process of developing general practice.3 Founding practice-based research networks can enhance this process. But the role of research networks stretches beyond this initial development phase. General practice research networks in the United States, the United Kingdom and the Netherlands have, by tapping into patient care, made it possible to recruit large numbers of unselected patients from different practices for epidemiological and clinical research, to conduct effectiveness studies, and to study the process of care in general practice.2 To meet the local or regional needs of general practice, research networks have had to adapt. For instance, whereas networks in north-western Europe have focused on non-communicable chronic diseases,4 the South African practice-based research network, not surprisingly, concentrates on care of patients with HIV/AIDS.5 These different targets can lead to different organisational requirements, and should make us wary of standardised models. In this issue of the Journal, Gunn (page 63) reviews general practice research networks for Australian primary care, building from the UK and Dutch experience.6 Given the strong historic links, it is attractive to base Australian developments on the vast experience in the UK, but Gunn rightly emphasises that the important thing to consider is what networks produce, rather than how they are constructed. This is in line with European experience, where research networks have had to be flexible — not just in their clinical orientation but, more importantly, in how they fit the way biomedical research is organised, because research networks are part of the broader academic development of general practice. In the UK,7 the National Health Service is an important financial supporter of research and development, including research networks. More recently, the US has seen similar developments.8 In the Netherlands, where universities have traditionally played a key role in general practice research, research networks are linked to university departments of general practice.9 These organisational differences have implications: a university-based structure places practice networks in direct contact with academic research programs, suggesting a "top-down" approach, whereas stimulating practitioners to initiate research would enhance a more "bottom-up" generation of questions from actual patient care. Research networks need both links. A strong grassroots general practice link is vital to generate research questions to improve patient care. However, a connection to the overall organisation of biomedical research is essential to ensure scientific rigour. In the UK, Australia, the US and the Netherlands, practice networks are closely connected to centres for advanced education for research in primary care,10 and these centres of excellence, with their comprehensive research programs, can play a pivotal role in ensuring quality research. Research networks are a tool, not a means in themselves, so their organisational structure should be secondary to scientific and healthcare considerations. The complexity of general practice lies in the context of disease: the interaction between the disease and the patient's family and socioeconomic circumstances, the setting of the doctor–patient encounter, and values attached to illness and treatment.11 A major challenge for research networks is to include this context in their data. A successful example is the International Study of Errors in Family Practice, in which practice-based research networks in six countries — including Australia12 (page 68) — were able to collect data on errors in a way that allowed the contribution of medical and patient-related factors to be analysed. From this it will be possible to draw realistic recommendations to prevent errors in the general practice setting. The World Organization of Family Doctors (WONCA)13 has formed a group that brings together the research leaders and participating GPs from practice-based research networks in different countries.5 This group is open to any general practice research network in the world, and is particularly trying to include networks in developing countries. Meetings are organised to share experience and develop methods for data collection. In addition, an Internet mailing list provides an ongoing forum. This group is testimony to the coming of age of general practice, and its mission is likely to reach beyond general practice — scientists are increasingly aware of the need for community-based longitudinal data to evaluate innovative developments such as advances in genetics. Research networks can change the culture of biomedical science by shifting the focus of research from technology in the hospital to patients and their diseases in the community. Furthermore, networks can build general practice research capacity. The Dutch university-based research networks are a case in point, having made a substantial contribution to academic primary care research capacity and output, and the development of evidence-based general practice guidelines.9 General practice research networks can have substantial impacts on research, and their structure and financing require the attention of the scientific community. Ultimately, though, their future depends on the quality of their contribution to biomedical research.

Chris van Weel FRCGP

Primary care research networks have emerged in other countries over the past decade. Rigorous data to determine the level of their achievement are lacking. Research networks are a part of the current Australian primary healthcare research capacity building program, yet we have no systematic approach to their introduction. Australian networks should build upon international experience and should not duplicate the role of Divisions of General Practice. Each network should have clearly defined aims, strategies and key indicators against which to evaluate performance.

Jane M Gunn PhD, FRACGP