General medicine

Decision making in health and medicine. Integrating evidence and values. M G Myriam Hunink, Paul P Glasziou, Joanna E Siegel et al. Cambridge: Cambridge University Press, 2001 (xvi + 388 pp). ISBN 0 521 77029 7. Like the practice of medicine itself, this book is not for the faint-hearted. Not because it is difficult to read or to understand, but because, unless you are already skilled in decision analysis, you will find it new, thought provoking and rigorous. The consequences of embracing its message are profound. Its fundamental premiss is that medicine (defined in its broadest sense to cover clinical medicine, population research, policy development and health management) is about uncertainty and the need to make decisions despite this uncertainty. For example, you have just diagnosed a 58-year-old man with atrial fibrillation. If you prescribe warfarin you can reduce his risk of embolic stroke by 70%, but this benefit comes at the price of an increased risk of haemorrhage, and the need for regular blood tests and avoidance of activities that increase his risk of injury. How do you weigh up the probabilities and incorporate into the decision your patient’s individual values about what is important to him? This book presents an approach and a handful of tools for making complex, value-laden decisions such as this. The approach, PROACTIVE, is adapted from a generic approach to decision making. As the authors say, one of its greatest strengths is that it requires you to make the decision-making process transparent. By carefully outlining your decision, viewing it from other perspectives and considering what the important objectives are, the best decision may become readily apparent without having to go any further. If you need to work quantitatively with probabilistic data, to make trade-offs between benefits and risks (or length of life versus quality of life, or costs versus benefits), and to incorporate people’s values and preferences, the book provides detailed guidance on the tools that are available. It takes the novice from a definition of a probability and a proportion all the way to advanced microsimulation modelling. Decision making in health and medicine updates the 1980 book Clinical decision analysis. It has a broader framework, and covers population health decision-making. It also includes more information on diagnostic testing, methods for measuring and incorporating quality-of-life measures and newer approaches to modelling. To support it, there is an accompanying CD with solutions to exercises, decision-analytical software, examples of decision-analytic models using the software, spreadsheets and references with abstracts. It is an extraordinarily ambitious book that achieves its aim. Alexandra L BarrattEpidemiologistUniversity of Sydney, NSW

Alexandra L Barratt

The impact of stroke remains considerable, despite a modest decline in case fatality1 and an encouraging reduction in incidence on the west coast of Australia during the past decade.2 To the optimists among us, it appears that some efforts, particularly in public health and primary care, are paying off. However, population risk-factor surveys indicate that, although the prevalence of smoking has declined, the prevalences of hypertension and hypercholesterolaemia have changed minimally and the prevalences of obesity and diabetes have increased dramatically over the past decade.1,3 The role of the general practitioner is pivotal in identifying and managing these risk factors. The Avoid Stroke as Soon as Possible (ASAP) general practice stroke audit, published in this issue of the Journal (page 312),4 provides further evidence that modifiable risk factors for stroke and vascular disease are highly prevalent in the Australian community. Importantly, the ASAP audit has measured the prevalence of atrial fibrillation and transient ischaemic attack (TIA). These factors are unique to stroke pathophysiology and are associated with high absolute risk, but have received limited attention in previous risk-factor surveys. Sturm et al reviewed 16 148 general practice consultations surveyed from a random sample of 321 GPs across five States. Seventy per cent of patients aged 30 years or more had at least one major risk factor; 34% had two or more. Not surprisingly, hypertension (44%) and hypercholesterolaemia (43%) were the most prevalent modifiable factors. Importantly, the proportion of older patients at high absolute risk was considerable. For example, among the men, 14% aged 70–79 years and 16% aged over 80 years had atrial fibrillation. Reliable measurement of the occurrence of TIA is more difficult given the variability in presentation and clinical assessments. However, the figure of 4% for any history of TIA is valuable information and provides a baseline for further assessments. The high prevalence of vascular risk factors identified in the ASAP survey highlights the potential value of screening during all routine general practice consultations to identify individuals with high absolute risk of stroke. The use of absolute-risk estimates in guiding therapeutic decision making is a well-established paradigm and is being adopted increasingly often in national and international vascular disease management guidelines.5 The value of risk stratification is highlighted by the exercise of choosing the most appropriate antithrombotic agent for primary stroke prevention in atrial fibrillation. Although the risk of first stroke in atrial fibrillation averages 5% per year, risk varies from 1% or less per year up to 12%, depending on additional clinical characteristics.6 At 1% risk, any benefit from anticoagulation therapy would be nullified by the approximately 1% risk of major bleeding events. Antiplatelet therapy would be the more appropriate option in this setting. In contrast, at 12%, the reduction in risk of thromboembolic events achieved with anticoagulation far outweighs the risk of adverse bleeding events. In this setting, warfarin shows a clear net benefit and would be more appropriate. Absolute risk translates readily into clinically useful statistics, such as "number needed to treat" at the bedside, and, at the population level, the recently proposed "population impact number".7 At a practical level, however, owing to the complexity of interacting risk factors, risk stratification typically requires decision-assistance charts or computer programs (generally based on Framingham risk estimates).8,9 At present, such systems are still under evaluation or just beginning to be adopted in general practice. From the cost–benefit perspective, in the absence of a framework for risk stratification, identifying relatively low-risk populations with isolated risk factors increases the possibility that expensive drug therapies will be used as first-line options when low-cost, non-pharmacological interventions would be more appropriate. An example is a 58-year-old woman with moderate hypertension (repeated blood pressure readings 160/95 mmHg) and no other risk factors. Her absolute risk of stroke is 1.5% over five years.10 Although she is a potential candidate for antihypertensive drug therapy, the low absolute risk may suggest to the patient there is questionable value in complying with prolonged drug therapy with its attendant side-effects. It indicates to the clinician that the number needed to treat over five years in this type of patient exceeds 120 to prevent one stroke.11 Accepting the various difficulties and risks associated with screening in general practice, combining a "high risk" approach and an appropriately organised "mass" approach is likely to have a much greater impact on the overall burden of vascular disease. This combination helps minimise the problem of focusing efforts on very cost-effective treatment of small populations at high risk while ignoring the larger subgroup of the population at moderate risk, from where most vascular events emerge. Low-risk groups would also benefit from further surveillance for progression into higher-risk categories. The ASAP stroke audit provides further evidence that considerable opportunity exists to reduce the burden of stroke and other vascular diseases. Quite rightly, the authors emphasise the importance of making the most of this opportunity. However, a prerequisite for success is a framework to facilitate rational use of interventions, balancing absolute risk and potential benefit at both the individual and population levels. Although debate continues about the best decision-assistance tool to be used, any system will need to be simple and practical to use within the time and resource constraints of an already overburdened primary healthcare sector.

Christopher R Levi FRACP · Parker J Magin FRACGP · Balakrishnan R Nair FRCP, FRACP

Objectives: To determine the prevalence of stroke risk factors in a general practice population and to identify pharmacotherapies currently used in management of stroke risk factors.Design: Multicentre, observational study by 321 randomly selected general practitioners who each collected data on 50 consecutive patients attending their surgery.Patients and setting: 16 148 patients aged 30 years or older attending general practices across Australia during 2000.Outcome measures: Prevalence of hypertension, current smoking, diabetes, hypercholesterolaemia, atrial fibrillation, recent history of stroke or TIA; extent of pharmacotherapy use in risk-factor management.Results: 70% of patients had one or more risk factors and 34% had two or more. Hypertension was the risk factor with greatest prevalence (44%), followed by hypercholesterolaemia (43%) and current smoking (17%). The prevalence of risk factors generally increased with age, except for current smoking, where a decrease with age was seen. The most common pharmacotherapies were cardiovascular agents, followed by antiplatelet agents. Two-thirds of patients with hypertension were taking cardiovascular drugs, most commonly angiotensin-converting enzyme inhibitors.Conclusions: Stroke risk factors are highly prevalent in general practice patients and GPs are ideally placed for opportunistic case-finding. There is considerable scope for improving management of stroke risk factors. The Avoid Stroke as Soon as Possible (ASAP) general practice stroke audit provides a baseline against which progress in risk-factor management can be measured.

Jonathan W Sturm MB ChB, FRACP · Geoffrey A Donnan MD, FRACP · Stephen M Davis MD, FRACP · John G O'Sullivan MB BS, FRACGP · Miriam E Vedadhaghi BSc, PostGradDipNutr

Clinical question "What is the risk of taking oral contraceptives in patients with a history of migraine with transient neurological signs?" A woman with a history of migraine associated with hemiparaesthesia, and possibly dysphasia, attended her general practitioner suffering from irregular and frequent menstrual cycles. The doctor considered treatment with oral contraceptives to control her cycles and possibly relieve her migraine attacks. He asked about the risk of treatment with oral contraceptives, compared with no treatment, in a patient with transient neurological signs associated with migraine. Search question The interventions of interest were oral contraceptives. Ideally, we sought evidence from prospective follow-up studies of women taking oral contraceptives (OCs), in which groups were compared according to relevant outcomes. Case–control studies are a good research design to investigate the association between common exposures and rare outcomes, as in the current question. Unfortunately, this design is also subject to a range of possible biases that can distort the findings — recall bias, observation bias and various biases involving subject and control selection. Search PubMed and the Cochrane Library were searched for relevant articles with English abstracts published since 1989. Search terms included "migraine" combined with terms for oral contraceptives ("contraceptive agents"; "contraceptive agents, female"; "contraceptives, oral"; "contraceptives, oral, combined"; "contraceptives, oral, hormonal"; "contraceptives, oral, synthetic", "contraceptives, oral, sequential"; "progestational hormones, synthetic"), and "stroke" or "cerebrovascular disorders." Summary of findings This evidence search demonstrated the difficulties involved in, firstly, assessing the incidence of adverse effects of treatments and, secondly, in conveying these data to patients. We found no prospective studies comparing stroke risk in women taking OCs who did and did not have a history of migraine. Similarly, we found no prospective studies comparing stroke risk in women taking OCs who experienced migraine with neurological signs and those taking OCs who experienced uncomplicated migraine. Nevertheless, other kinds of evidence suggested that women taking OCs who had a history of migraine have a markedly increased relative risk of ischaemic stroke, although the difference in absolute numbers of women affected may not be as marked. A case–control study of women aged 20–44 years1 found that the relative risk of ischaemic stroke in women with migraine and taking OCs was 16.9 times (95% CI, 2.72–106) that of women without migraine and not taking OCs. Women with migraine who used low dose OCs (< 50 µg oestrogen) had 6.59 times (95% CI, 0.79–54.8) the risk of ischaemic stroke than women without migraine who did not take OCs, but this estimate came from a small number of cases and did not reach statistical significance. The relative risk of ischaemic stroke in women with migraine who took OCs and smoked cigarettes was 34.4 times higher (95% CI, 3.27–361) than in women with none of these risk factors. Similar results were found in a case–control study of women younger than 45 years.2 Ischaemic stroke was 13.9 times more likely (95% CI, 5.5–35.1) in women with migraine and taking OCs than in women without migraine and not taking OCs. A pooled analysis of two US population-based case–control studies3 found that women currently taking OCs who had a history of migraine were only twice as likely (95% CI, 1.19–3.65) to have any kind of stroke than women not taking OCs who did not have migraines. While this supports the general finding, it quantifies a much lower increased risk. The evidence from the identified research for an increased risk of stroke in these circumstances is convincing, but the size of the effect remains in dispute. Interpretation of the evidence in this case was complicated because the studies did not allow calculation of absolute-risk differences between groups. In giving advice to patients, the known increased relative risks for individuals must be balanced against the absolute effects at a population level. The identified studies show not only an increased relative risk of ischaemic stroke in women with migraine who take OCs, but also a greater than multiplicative increased risk introduced by coexistent smoking. On the other hand, since the overall risk of stroke for women in this age group is small (5.5 per 100 000 woman-years according to the World Health Organization Collaborative Study4), and is smaller still in younger age ranges, the observed risk estimates suggest ischaemic stroke will be a comparatively rare outcome in any of the identified risk groups. Clinical advice should incorporate these data as well. The ultimate decision remains with the patient. Outcome The patient was treated with OCs pending the outcome of the evidence search and gained relief of her gynaecological symptoms. However, she decided to discontinue taking OCs when the evidence became available.

Vivienne F Bernath · Ornella Clavisi · Jeremy N Anderson

Re: "What people say about their general practitioners' treatment of anxiety and depression", by Andrews G, Carter GL, in the 16 July Supplement on the SPHERE National Depression Project (Med J Aust 2001; 175: S48–S51, not available online). On page S49, column 1, the last sentence under the heading "Assessment" should be replaced by "'Perceived health need' was based on questions derived from the work by Meadows et al.1 These questions were asked principally of people who had not sought treatment. Similar concepts were used by the UK Survey of Psychiatric Morbidity questions." The authors apologise for this omission and would like to draw readers' attention to another article by Meadows et al2 for a more complete discussion of the development of the perceived need for care questionnaire.

G Andrews · and G L Carter

Increasing subspecialisation, driven by new knowledge, experience and technology, challenges the relevance of a broad discipline like general internal medicine. However, these same influences are also responsible for the worldwide renaissance of generalism in clinical practice.1 With an ageing population, an increasing prevalence of chronic disease, rising costs of healthcare, greater consumer expectations, and more awareness of the risks and errors of clinical practice, our society needs general internal medicine to provide integrated, cost-effective and high quality specialist medical care. This need is even greater for people with complex, multisystem problems, who account for most acute hospital admissions. Here, we outline the fields pioneered by generalists and now common to many clinical disciplines. Evidence-based medicine (EBM). The EBM movement encourages consistent and judicious integration of best available research evidence with clinical expertise and patient values in making clinical decisions.2 EBM has spawned whole new fields of study of the design, conduct and reporting of clinical trials, and the searching, appraisal, synthesis and dissemination of published research. Quality improvement. Within the past decade, the magnitude of clinical error and suboptimal care has become apparent.3 This has created new disciplines of health service research and quality improvement. These aim to study and enhance the appropriateness, effectiveness, safety and efficiency of healthcare delivery. Concepts such as peer-review, physician profiling, performance indicators, clinical audit, and practice guidelines are now accepted as credible tools for promoting a "systems-based" approach to improving care. Outcomes management. Since publication of Ellwood's sentinel paper in 1994,4 the "outcomes movement" has focused attention on scientific methods for determining the impact of modern medicine on patients' quality of life and functional status, as well as on adverse events and survival. Although many benefits have accrued from advances in high-technology, specialised medicine, more could be achieved if common chronic diseases were managed optimally within a continuum of care which spans hospital and ambulatory practice, and integrates acute care with health maintenance. Physicians in general internal medicine, with their broad knowledge and experience, are in an ideal position to lead disease-management initiatives, especially in communities away from major urban centres. Interdisciplinary care. Healthcare teams have become the dominant units of care delivery. They comprise a diversity of professionals, including specialists, but have one inherent weakness: fragmentation of care among "too many chiefs". For patients with multiple problems who are vulnerable to the effects of polypharmacy and overly invasive interventions, the coordinating and temporising role of a general physician to prioritise goals of management and appreciate patients' needs and preferences is mandatory for providing compassionate, cost-effective care. The establishment in many hospitals of acute medical assessment and intervention units run by general physicians, and appointment of those with procedural skills and subspecialty interests, are examples of this integrative approach to care. In primary care, more general physicians are needed to meet general practitioners' demand for specialists who can provide "whole-patient" care. Links with other disciplines. With advances in surgical and anaesthetic techniques, more older patients with multiple comorbidities are undergoing elective and emergency surgery. General physicians play prominent roles in preoperative assessment and perioperative management. Many general physicians have contributed to advances in clinical pharmacology, emergency and intensive care medicine, palliative medicine, geriatrics, occupational health, rehabilitation and obstetric medicine. Other contributions to care. Because of their skills in diagnosis and management of common medical conditions, general physicians undertake much of the undergraduate and postgraduate teaching in teaching hospitals. Most directors and visiting consultants of medical departments of community public hospitals (> 150 beds) are general physicians. Many possess procedural skills (echocardiography and endoscopy) otherwise unavailable to patients in many parts of regional Australia. The future. The broader interests, skills and vision of physicians in general internal medicine complement the necessarily deeper, focused expertise of subspecialists. In the future, such physicians will be forging new alliances with patients, general practitioners, geriatricians, subspecialists, healthcare funders and policy makers in researching, delivering and teaching better practice. Newer models of specialist care, such as "hospitalism", regional disease management programs, hospital-in-the-home programs, multidisciplinary care teams and outreach services, will have the active participation of general physicians.5 The discipline of general internal medicine will continue to play its part in assisting specialist medical care to meet the challenges of the 21st century.

Ian A Scott · Peter B Greenberg

General practitioners remain the linchpin of frontline medical care, and continue to aim for comprehensive, coordinated care for their patients. Recent advances in general practice have focused on equipping GPs to better provide such care. Both international and within-country comparisons show that healthcare systems based on primary care produce better overall health outcomes than systems based on specialists.1 Prevention and population health. General practice stands at the interface between specialised medical care and population care. Two factors facilitate GPs' achieving population health goals. The personal relationship between GPs and their patients is basic, but greater use of government-funded incentives that encourage quality primary care is a recent development. As an example, the National Childhood Immunisation Program, which supported and provided financial incentives for GPs, achieved higher childhood vaccination rates. The more recent Enhanced Primary Care Package provides Medicare rebates for health assessments of the elderly, and care planning and case conferencing for those with chronic illnesses and a need for multidisciplinary care. However, this initiative still requires careful evaluation to determine its efficacy. The "lifestyle diseases" of the modern world, such as obesity, dyslipidaemia and diabetes, require early detection by GPs and long-term control. There is now greater awareness that changing diet and exercise patterns may be more effective than drug therapy2 in treating cardiovascular risk factors. Consultation time is limited, but, in the supportive context of a GP's personal approach, even low-intensity messages can be effective.3 To balance risk and benefit requires combining all factors, as emphasised by the New Zealand risk charts,4 rather than treating each one in isolation. Divisions of General Practice. The advent of the Divisions has helped develop a collective local identity for general practice, and provided crucial support for GPs in developing the skills they need for preventive care and healthcare improvement at the community level. The Divisions are also the conduit for forging relationships between GPs, hospitals and community health services, and for testing new models of collaboration. Continuing care. Depression will become the commonest cause of chronic morbidity, but there will never be enough specialised mental health professionals. National campaigns have emphasised GPs' central role in caring for patients with mental illness, and the need for further improvement of their skills in recognising and treating psychiatric conditions. There is growing recognition that there are now more people with chronic illness, disability or special needs who require continuing care. Various shared-care and partnership programs between GPs and hospitals have proved effective (eg, for antenatal care and diabetes). Evidence-based medicine. Recent emphasis on evidence-based medicine poses many challenges in general practice. Extrapolating specialist and hospital-based evidence into community settings is not always possible. In the information age, GPs have to develop the critical skills necessary for evaluating the evidence for and against available screening tools or new interventions, and be able to interpret the evidence appropriately for their patients (who may also be up to date with new developments). On the other hand, practising with an evidence base now enhances confidence in our treatment decisions, such as in reducing antibiotic prescribing for common respiratory tract infections.5 Computerisation. The widespread use of computers in Australian general practice has changed the way many practices function. Electronic medical records, and interlinking of prescribing, test ordering, evidence-based management protocols, patient recall and follow-up programs and patient education are now possible. However, there is still a need for more user-friendly decision-support systems. Quality improvement. Vocational registration and practice accreditation have encouraged continuous quality improvement. Although these programs are research-based, continuing evaluation is needed to determine which aspects need further development and which provide the most worthwhile change for the effort applied. The future. It will always be difficult to resolve the conflict between all that could be done to enhance health, and what can be achieved by general practitioners. By its nature, general practice is dependent on healthcare policy to provide adequate resources for support programs, education, organisation and information. To promote efficient practice, greater investment is needed in vocational and continuing education, in strategic development, research training, and especially in building research capacity.

James A Dickinson PhD, FRACGP

To the Editor: As a geriatrician in the subacute sector with hospital medical officers (HMOs) rotating from a major teaching hospital, I am acutely aware of the cost to all concerned of inappropriate diagnostic testing. Discussion stimulated by Stuart et al1 and the editorial by Hammett and Harris2 may help elevate this issue into its rightful arena — quality care and clinical accountability. Donabedian,3 in looking at the assessment of quality care, describes "elements in the performance of practitioners", with technical performance defined as "knowledge and judgement used in arriving at the appropriate strategies of care". I believe that both these quality elements are deficient and that it is the responsibility of the senior clinicians to provide the necessary leadership in ensuring their acquisition. While I agree with Hammett and Harris that there are systems failures and that, as an example, improved feedback of results (particularly given changing HMO work practices and shorter length of patient stays) will provide some of the answers, there appears little doubt that a significant knowledge deficit exists among junior doctors regarding the use and interpretation of common tests and how often they should be ordered. The unfortunate fact is that we have known about these issues for many years and have yet to develop a sustained response. At our hospital we have attempted to modify the use of diagnostic tests by HMOs during their geriatrics rotation, with tutorials from biochemists and haematologists which are reinforced during consultant ward rounds and meetings. This is, however, doomed to failure unless the process is continued by all other clinicians who supervise HMOs. Emanuel and Emanuel4 define accountability in a number of domains. The least controversial of these, I suggest, is professional competence. It is incumbent on us as senior clinicians to "invoke, affirm and enforce professional standards",4 being accountable for the practices of those HMOs under our supervision. Appropriate use and understanding of diagnostic testing will reduce unnecessary patient discomfort while also reducing costs. As any geriatrician will tell you, additional years without insight simply provide grey hair, not improved clinical practice.

Michael J Murray

MJA 2001; 175: 613-616 Why medicine? - Why research? - Is research possible in country general practice? - Why Sydney University? - Reflections - References - Authors' details - - More articles on General practice and primary care I was delighted to read this description of research [organised curiosity] as I started my general practice career. Indeed, seeking answers to questions seemed a sensible approach to the whole of life. Why medicine? During my school years I had no career plans other than that I was not going to be a doctor like my father and grandfather, probably for no other reason than to reject what was expected. My wish to become a farmer was discouraged by my parents, as they could see no way for me to have a farm of my own immediately, and anything less was not to be thought of. When I was in my last year at school, my father needed an operation for cancer, and this turned my thoughts to medicine as a career. If I could not be a farmer, then I would be a country doctor. "Research in general practice might best be described as organised curiosity." Dr Tev Eimerl, 19601 In my first year at Melbourne University my father drew my attention to an article in the Medical Journal of Australia and suggested that I read it. The Arthur E Mills Memorial Oration for 1952, "The secret of living", by S W Pennycuick,2 struck several chords with me. His suggestion that the secret of living consists in more than avoiding the ABC of life — accidents, bacteria, and chronic degenerative diseases — fitted in with my feeling that the medical career I wanted was more than one of merely trying to keep people alive. His representation of a life of total security and freedom from fear and want as being akin to a "life of boredom in a zoo" was a vivid image of a life I did not want. But, most of all, I was struck by his suggestion that "To travel hopefully is better than to arrive", or, otherwise expressed, that "Our journey through life has little meaning unless we travel hopefully towards the ideals which we know full well we will never reach". It became my motto. I never met nor heard of Pennycuick again, but he has exerted a powerful influence on my life. Why research? In the fourth year of my medical course, during a microbiology lecture on infectious hepatitis, Professor Sydney Rubbo mentioned a book, Epidemiology in country practice,3 by an English general practitioner, William Pickles, in which Pickles reported on his work in tracing epidemics of infectious diseases through isolated villages in Yorkshire in the 1930s. I did not hear the book reference clearly, so at the end of the lecture I asked Professor Rubbo for the details so that I could get it out of the library. "I'll do better than that", he said, "Come to my office and I'll lend you my copy." After enjoining me to read the book and return it within a fortnight, he added, "And don't just leave it in my office. Make an appointment to see me, and tell me what you think of it." It was a challenge, but not an unkind one; he was a friendly and encouraging man, and a wonderful teacher. I was captivated by the book, and more or less there and then decided that as well as becoming a GP I wanted to do epidemiological research. After graduation I worked as a Junior Resident Medical Officer at the Royal Melbourne Hospital. The Honorary Medical Officer in charge of the medical ward was Dr John Bolton, whose twice-weekly ward rounds were unusual in a number of ways. While there was much talking with (definitely not to or at) the patient, and physical examination was done when needed, there was no medical discussion in the patient's presence. That took place in the side room during afternoon tea, a ceremony presided over by Sister in which everyone, including the lowly students, participated. After discussion, a member of the team was sent back to tell each patient the results of the deliberations. Dr Bolton himself then went around again to make sure no patient had further questions. During one of these ward-round afternoon teas I asked if patients who had had a long history of angina did better after a heart attack than those who did not, reasoning that those with angina might have developed more collateral circulation to prevent some of the damage resulting from the occluded artery. Dr Bolton suggested that I should find out by conducting a small research project using the hospital records. Under his guidance I studied the medical records of 100 consecutive patients admitted with myocardial infarction, correlating the presence of pre-infarction angina with the outcome of their hospital stay. He assisted me in formulating the research questions, in coping with the limitations of hospital records for the research purpose, in revising my rudimentary knowledge of statistics, writing up the results, and having the final paper published. "Shock in myocardial infarction" was my first research paper, published in the Royal Melbourne Hospital Clinical Reports in 1959.4 I disproved my hypothesis, as there was no evidence that a longer history of angina led to less shock or fewer deaths in hospital, but I did find that the overall death rate in hospital following myocardial infarction was an enormous 34%. Is research possible in country general practice? I commenced general practice as a partner in a rural medical group in Traralgon, Victoria, in 1960. I had not forgotten my idea of incorporating research into my professional career. Organising my curiosity described exactly what I wanted to do, and I immediately began keeping a "morbidity index" of all my patients (ie, a listing of patients under the diseases or conditions they had). The first question I addressed with my practice index was "What are the commonest conditions seen in my general practice?". It was soon obvious that these were acute respiratory infections, so I decided to investigate these, conscious that then, as now, there was great controversy about how these should be diagnosed and managed. I started by considering the epidemiology of acute respiratory infections, and presented the results at the 1963 Annual Convention of the Australian College of General Practitioners in Sydney.5 A seminal idea arose at a football match. Several of my friends there had colds of varying degrees of severity, coughing and spluttering amidst the cheering for our team. During the following week some of them came in for a consultation. However, it was not necessarily those who had seemed most sick who came in. It set me wondering, why? It was obviously more than just severity of symptoms that made sick people seek medical attention. What were the other factors? It also made me aware that my research into respiratory infections was biased towards conditions for which the patient sought attention. Were those who didn't consult a GP different? These questions led me into the fascinating realm of the sociology of medicine via David Mechanic's book Medical sociology.6 A statement that particularly caught my eye was: "Studies which begin with known or treated cases of particular disorders risk confusing aetiology with social and psychological processes leading to care unless the relationship between treated cases and untreated cases is known." I did not know this relationship in Traralgon, but hoped that I could find out. Since I had study leave due after five years in the practice, I used it to spend several months in the United Kingdom in 1966, meeting people who were doing the sort of research I now wanted to do. I visited the people I knew of already, and they recommended many others. At the end I reflected ruefully that some of their incisive and critical comments about my own research and ideas had been a little deflating, but that the depth of concern shown for a fellow researcher was encouraging. I was ready to go on. In 1966, the (by now Royal) Australian College of General Practitioners' Council advertised "one long-term Fellowship for conduct of a major research project approved by the College". I applied and was awarded it. From that time onwards my professional life included paid research time. We recruited from our practice 56 families with children, comprising 258 individuals, who were to keep a daily health diary for each family member for a year, and were willing to allow me to access details of all medical attention they received during that time. I was thus able to learn about all illnesses, particularly respiratory infections, including those for which no medical attention was sought. In 1968, I met Basil Hetzel, newly arrived at Monash University as the inaugural Professor of Social and Preventive Medicine. He was most interested in the research I was doing in Traralgon, and extremely supportive, inviting me to use the facilities of his department, the most helpful of which was access to the university computing centre to analyse my results. He also encouraged me to write up my study as an MD thesis, something that had never occurred to me. In the same year, I became Honorary Secretary of the Royal Australian College of General Practitioners' Research Committee of Council, a position I held for nearly 20 years. I was involved in the 1969-1974 RACGP national morbidity survey, which led me into research and development of appropriate classifications and to membership of the World Organisation of Family Doctors Classification Committee. In 1970 I commenced a new project, the Traralgon Health and Illness Survey. This was to be a major undertaking, based on my previous studies but much more representative of the community and more sophisticated. It preceded and in many ways foreshadowed the later triennial Australian Health Surveys that are now undertaken by the Australian Bureau of Statistics, for at that time there was relatively little information about community health status. The survey occupied me for the next three years, and three major articles resulting from it were my first publications in the international arena.7-9 All this time I had been a busy and fulfilled country GP, treating my patients in hospital and in the community. I loved the personal interaction with patients and the continuity of care that led to long-lasting relationships. It surprised me that so much of my research work was now a matter of epidemiological surveys and classification, as I did not see myself as a number cruncher, an academic theoretician. When, after 1974, advertisements began to appear for Chairs of General Practice or Community Medicine in Australian medical schools, I found the idea irresistible. I applied for several, although I felt torn between the challenge of taking up an academic position and the wish to remain in the country. I was going to miss the generosity of a country community and the space. Why Sydney University? I was short-listed for some positions and found the university meetings, and even the interviews, stimulating. I was becoming more and more convinced that I had something to contribute to academic life, and felt that it was a challenge that I wanted. I had not applied to Sydney — too big and brash a city, I thought, and I had no connections there — but that's where I ended up. It started with a phone call answered by my wife, Anne, one morning at home. She was impressed that the man at the other end introduced himself with perfect etiquette as "Richard Gye, Dean of the Faculty of Medicine at the University of Sydney". Did I realise that in phoning a stranger at home one should always introduce oneself with one's first name, Anne asked me when I came in to lunch. No, I replied. On returning the call, I was invited to come to Sydney to share my ideas about teaching general practice in universities. It never occurred to me that this might be an approach inviting me to apply for the Chair there, but I accepted the invitation to visit Professor Gye and his colleagues. One evening he took me to dinner, where we discussed many things other than professional issues. I had not expected to find an eminent neurosurgeon — narrowest of narrow specialties, I thought — an interesting human being, but I did. My formal interview must have gone well (I don't remember much of it), as I was offered the Chair. I had ascertained that, although it was a Chair of Community Medicine, its focus would be general practice. I was fortunate in being able to start a new department and ensure it had a clinical emphasis. To that end, the acquisition of a university general practice was important and rewarding. Here was a base from which we could initiate further research into medical records, respiratory infections, and emergencies in general practice. It was a great disappointment when the practice had to close in 1990 because a high quality teaching and research practice could not be made financially self-sufficient. Teaching came easily to me. It was also "organised curiosity", but in this case there was already an answer to be shared. We built a closeknit team of staff and emphasised experiential learning and small-group interaction. We established a widespread network of teaching GPs in both city and country whose support was invaluable. Our course always rated well in faculty teaching evaluations. My first major research task as an academic was to edit a report of the 1969-1974 RACGP national general practice morbidity and prescribing survey.10 This reinforced my interest in surveys and classifications and the international links that were to develop and provide so much interest and stimulus over the next 20 years, alongside the international friendships and travel in which Anne and I delighted. The evolution of the International Classification of Primary Care11 was one lasting achievement. The 1990-1991 general practice morbidity and treatment survey12 not only updated such information, but led to the continuing national BEACH ("Bettering the Evaluation and Care of Health") survey now contributing to information about Australia's health.13 There was even opportunity for creative activities. I was one of the editors and contributors to the book General practice in Australia,14 one of the last publications of Sydney University Press in 1986. About the same time I initiated and helped edit a video produced by the university about people living with terminal illness. I chose the title, A changed kind of reality, from a quote of one of the participants. We not only used it in our teaching program, but it also won a Penguin award and was broadcast by the Australian Broadcasting Corporation. Reflections I have been very fortunate to have been able to "travel hopefully" and enjoy a life of "organised curiosity", not only in my profession, but with family and friends. It is the people with whom I have been able to share my life and questions who have given me a sense of purpose and achievement, rather than the things I have done. There is still much to be curious about, and much to hope for, in the rest of life's journey. References Eimerl TS. Organised curiosity. J R Coll Gen Pract 1960; 3: 246-248. Pennycuick SW. The Arthur E Mills Memorial Oration. The secret of living. Med J Aust 1952; 2: 261-264. Pickles WN. Epidemiology in country practice. Bristol: John Wright and Sons, 1939. Bridges-Webb C. Shock in myocardial infarction. Royal Melbourne Hospital Clinical Reports 1959; 27: 26-29. Bridges-Webb C. A three-year study of respiratory infections. Med World 1965; May: 381-389. Mechanic D. Medical sociology: a selective view. New York: The Free Press, 1968. Bridges-Webb C. The Traralgon health and illness survey: method, organisation and comparison with other Australian surveys. Int J Epidemiol 1973; 2: 63-71. Bridges-Webb C. The Traralgon health and illness survey part 2: prevalence of illness and use of health care. Int J Epidemiol 1974; 3: 37-46. Bridges-Webb C. The Traralgon health and illness survey part 3: illnesses and their medical and hospital care. Int J Epidemiol 1974; 3: 233-246. Bridges-Webb C, editor. The Australian general practice morbidity and prescribing survey 1969 to 1974. Med J Aust 1976; October 2(Suppl): 1-28. WONCA International Classification Committee. International classification of primary care, ICPC-2. Oxford: Oxford Medical Publications, 1998. Bridges-Webb C, Britt H, Miles D, et al. Morbidity and treatment in general practice in Australia 1990-91. Med J Aust 1992; 157(Suppl): S1-S56. Britt H, Miller GC, Charles J, et al. General practice activity in Australia 1999-2000. Canberra: Australian Institute of Health and Welfare, 2000 (AIHW Catalogue No. GEP 5). Anderson N, Bridges-Webb C, Chancellor A, editors. General practice in Australia. Sydney: Sydney University Press, 1986. Authors' details University of Sydney, Sydney. Charles Bridges-Webb, MB BS, MD, FRACGP, MM, Emeritus Professor of General Practice. Reprints will not be available from the author. Correspondence: Professor Charles Bridges-Webb, University of Sydney, Sydney, NSW 2052. cbridgesATmail.usyd.edu.au Make a comment Short curriculum vitae Qualifications MB BS, University of Melbourne, 1957; MD, Monash University, 1971; MM (ad eundem gradum) University of Sydney 2001; FRACGP, 1971 Present positions Director (part-time), RACGP NSW Projects, Research and Development Unit, 1996- Professor of General Practice (now Emeritus), University of Sydney, 1975- External Clinical Teacher, RACGP Training Program Awards Faulding Prize for Research in General Practice, RACGP, 1967 RACGP Rose-Hunt Medal for service to general practice, 1993 Medical appointments General Practitioner, Deakin Street Clinic, Traralgon, 1960-1975 General Practitioner, Croydon General Practice Unit, University of Sydney, 1976-1990 Academic positions Honorary Secretary, Research Committee of Council, RACGP, 1968-1987 Member, International Classification Committee, World Organisation of Family Doctors, 1972-1999 (Chairman, 1991-1998) Member, NSW Faculty Research Committee, RACGP, 1976- (Chairman, 1983-1985) Member, World Health Organization Working Party to Develop a Reason for Encounter Classification for Primary Care, 1981-1984 Member, National Health and Medical Research Council, 1982-1984 Member, Australian Association for Academic General Practice, 1984- (President, 1989-1991) Member, Quality Assurance Committee, RACGP, 1986-1991 (Chairman, 1989-1991) Member, NSW Government Committee of Enquiry into Services provided by General Medical Practitioners to Country Public Hospitals, 1987 Member, Project Grant Assessment Panel, General Practice Evaluation Program, Commonwealth Department of Human Services and Health, 1994-1996 Criticism Editor, Acute Respiratory Infections Group, Cochrane Collaboration, 1997-1999 Professional interests Research in general practice, with special interest and expertise in classification systems for general practice, dementia and preventive medicine. Development of quality assurance programs for general practitioners, evaluation of quality of care, measurement of clinical patient outcomes, and evidence-based medicine. Personal interests Gardening; cricket and soccer; literature, music and art; philosophy and religion; Australian and medical history RACGP = Royal Australian College of General Practitioners

Charles Bridges-Webb

Letters The mystery of GP research output? MJA 2001; 175: 667 To the Editor: Askew et al ask why there is not more general practice research.1I think they would have come close to the answer had their analysis of publication rates by workforce sector included the relative rates of government salaried employment. The proportions of each group in salaried work are approximately: General practitioners, 18% (of whom only 2% are government employees); Physicians, 56%; Surgeons, 26%; and Public health physicians, 90%.2 While the Primary Health Care Research, Evaluation and Development (PHC-RED) program is a laudable and exciting strategy, it is hard to imagine that it will achieve much change in the rate of general practice research until research activity becomes part of the formal "job description" for a large proportion of GPs, as it is for many of our specialist colleagues. Of course, the incursion of corporatisation into Australian general practice will introduce important issues in regard to the amount of research undertaken and the nature of the research performed, as it has for Australian universities. As yet, PHC-RED has not developed a view as to how it might handle such influences. Phillip Gray General Practitioner, Central Queanbeyan Medical Centre, Focal Point Arcade, 25 Monaro Street, Queanbeyan, NSW 2620. gray.qbnATeffect.net.au Askew DA, Glasziou PP, Del Mar CB. Research output of Australian general practice: a comparison with medicine, surgery and public health. Med J Aust 2001; 175: 77-80. Medical masterfile [database]. Sydney: Australasian Medical Publishing Company, 2001.

Phillip Gray

Letters Australian general practice at a fork in the road: which way forward? MJA 2001; 175: 667 To the Editor: There are a number of deceptions current in the debate over doctors in Australia. Unfortunately, some of these are expressed in your editorial of 16 July 2001.1You fail to acknowledge there are two classes of doctors, as has been the case in Australia for decades — consultants (the princes), doing very well, and general practitioners (the paupers), struggling to survive. You comment that there is "a new phenomenon . . . dispirited doctors". In Australia, consultants are certainly not dispirited (they have never had it so good). However, there are dispirited GPs, who are grouping together in corporations to solve their economic and social problems. Where, Dr Van Der Weyden, have you been hiding? All of a sudden you would have us believe there is a fork in the road for GPs. In reality, there is no fork — just the steady downhill journey that has gone on for years. Instead of supporting and fighting for an increase in the insulting rates of rebate paid to GPs, you are critical of the very reasons GPs are entering the corporate structure. The statement in your editorial that received the greatest hoots of laughter from my fellow GPs was the classic remark "second, there is the challenge of general practice research and education, which has received little attention in the corporatisation debate". Research has never received attention in general practice, and was certainly not a concern before the move to corporatisation. As you yourself have stated, GPs received a mere 1.6% of the National Health and Medical Research Council's research projects over the years 1996 to 2000. Certainly, such lack of funding has stifled what should have been a rich and flourishing research culture, but what has been done about it? Percy S Rodgers General Practitioner, 2/133 Wilson Street, Brunswick, VIC 3056 Van Der Weyden MB. Australian general practice at a fork in the road: which way forward? [editorial]. Med J Aust 2001; 175: 62-63.

Percy S Rogers

Letter Australian general practice at a fork in the road: which way forward? (In reply) MJA 2001; 175: 667 In reply: Despite Rogers' views to the contrary, disillusionment and disenchantment are pan-profession phenomena. Like general practitioners, consultants are unhappy with the deteriorating hospital conditions and working environment1 that are their lot. Further, I am not moved by Rogers' worn view of the profession as "them" (specialists) and "us" (GPs). Most modern GPs consider general practice a specialty. To qualify as a specialty, a branch of medicine needs to have a unique body of knowledge and techniques which are sustained and expanded by its members. Unfortunately, general practice lags behind other specialties in these requirements.2,3 It is depressing that the call for general practice to develop and enhance its educational and research programs occasioned "the greatest hoots of laughter" from Rogers and his fellow GPs. This destructive ethos persists in general practice, to its own detriment. In my editorial,4 I suggested that the trend to corporatisation in general practice presents an opportunity to address the lack of time, lack of critical mass and lack of recognition that are barriers to effective research in this field.5 If GP corporatisation simply replicates the current culture and barriers to research on a larger scale, what is the gain? Rogers' question "what has been done about it [research]?" reflects a passive approach — "important, but not my problem", "someone should do it, but not me". Unless research and education become the business of every GP, general practice as a specialty is in danger of disintegrating into multiple craft groups, not necesarily medically based. Such a development is certainly not a cause for hoots of laughter. Martin B Van Der Weyden Editor, The Medical Journal of Australia, Private Bag 901, North Sydney, NSW 2059. Perkins RJ, Petrie KJ, Alley PG, et al. Health service reform: the perceptions of medical specialists in Australia (NSW), the United Kingdom and New Zealand. Med J Aust 1977; 167: 201-204. Van Der Weyden MB. Promoting an evidence base for general practice [editorial]. Med J Aust 1999; 171: 60-61. McAvoy B. General practice research. Aust Fam Physician 2001; 30: 175-176. Van Der Weyden MB. Australian general practice at a fork in the road: which way forward? [editorial]. Med J Aust 2001; 175: 62-63. Kljakovic M. Flourishing research in academic general practice. NZ Fam Physician 1998; 25: 35-40. Make a comment

Martin Van Der Weyden

Editorial Are the new Lipid Management Guidelines good for Australia's health? Recommendations, possibly resulting in the long-term treatment of one million Australians, require a serious cost-benefit analysis MJA 2001; 175: 452-453 The new Australian Lipid Management Guidelines 2001, published as a supplement with this issue of the Journal, provide an excellent overview of the current evidence on the cardiovascular disease (CVD) benefits of cholesterol lowering. They also signal the acceptance by Australian experts that treatment decisions should be driven primarily by a patient's estimated "absolute CVD risk" — the probability of developing CVD over a specified time period — rather than primarily by his or her blood lipid level. The Guidelines comprehensively summarise the extensive evidence showing the benefits of cholesterol-lowering interventions in people with low-density lipoprotein (LDL) levels above about 2.5-3.0 mmol/L (equivalent to a total cholesterol level above about 4.5-5.0 mmol/L). But they don't tell us that over 90% of Australians aged 45-75 years have a total cholesterol level above 4.5 mmol/L (Dr Danny Liew, Department of Epidemiology and Preventive Medicine, Monash University, VIC, unpublished analysis). The Guidelines correctly emphasise the need to base treatment decisions primarily on absolute CVD risk rather than on lipid levels, as the benefits of cholesterol lowering are determined far more by individual absolute risk than by pre-treatment level of LDL cholesterol. But the advice provided on how to identify patients at high absolute risk, particularly those without previous symptomatic disease, is rather loose, as discussed below. Moreover, the potential size of the target group for drug-based primary prevention is not mentioned. ...it is estimated that this year statins will account for almost a fifth of the total Australian Pharmaceutical Benefits Scheme budget. Lipid-lowering drugs are appropriately recommended for secondary prevention when the total cholesterol level is above 4 mmol/L, given the high absolute risk and large potential benefit of treatment. This patient group includes about 5% of Australians aged 30-79 years (Professor Andrew Tonkin, National Heart Foundation Australia, personal communication). Aboriginal people and Torres Strait Islanders are appropriately identified as high-risk groups, as are people with diabetes (types 1 and 2), although the recommended treatment threshold for Indigenous people and people with diabetes is unclear. If the cholesterol threshold for treatment is also 4 mmol/L in these groups, I estimate this will add at least another 5% of the middle-aged and older Australian population to the numbers eligible for treatment. The authors of the Guidelines endorse the CVD risk charts used in New Zealand for estimating absolute CVD risk.1 This brings Australian lipid management recommendations more in line with those of the international community. Similar charts or risk calculators, all based on data from the Framingham Heart Study, are now included in most major national and international CVD management guidelines.2-6 The Guidelines state that people with an estimated five-year absolute CVD risk of 10%-15% or above (identified using risk charts) are the "at-risk" group who should be targeted for treatment. Alternatively, for doctors who don't use risk charts, the at-risk group includes everyone over 45 years of age with at least one of seven listed risk factors, some of which are ill-defined in the Guidelines (ie, "hypertension" and "overweight"), yet are very prevalent using some common definitions. For people less than 45 years of age, having two listed risk factors also places them in the at-risk group. This "count the risk factors" definition of at-risk is an unnecessarily crude approach and will identify some people with only a 5% five-year CVD risk and exclude others with a five-year risk above 15%. It is also difficult to find a clear statement in the Guidelines about when to initiate drug treatment in this "at-risk" group, and no mention is made of the potential size of the group. I estimate it will include at least another 20% of Australians aged 45-75 years if the cut-off for drug treatment is an LDL cholesterol level of 4 mmol/L or a total cholesterol level of 6 mmol/L (Professor Michael Hobbs, Department of Public Health, University of Western Australia, personal communication). The authors of the Australian guidelines are to be congratulated for their high quality review of the evidence of effectiveness of both population- and individual-level interventions, and for explicitly linking the level of evidence with their recommendations. However, they are remiss in not considering the implications of implementing the recommendations. For example, it is estimated that this year statins will account for almost a fifth of the total Australian Pharmaceutical Benefits Scheme budget.7 While this may or may not be good value for money, it is increasingly accepted that clinical leaders, as well as taking responsibility for individual patients, must also consider the wider resource implications of their recommendations. The practical implications and potential alternative uses of the substantial dollar and people resources required to implement these recommendations should have been considered. For example, it may (or may not) be better value to fund more coronary angioplasties, or to develop more comprehensive rehabilitation programs for patients who have had a myocardial infarction, than to give statins to hundreds of thousands of Australians with a modestly raised risk of CVD. It would also be illuminating to estimate the implications of these recommendations for health professionals, particularly general practitioners and dietitians. It may be that the implementation costs of the new Lipid Management Guidelines 2001 are justified by the magnitude of the benefits. But recommendations that could result in the long-term treatment of perhaps one million Australians, require a substantial amount of general practitioner and dietitian time and consume a significant proportion of the national pharmaceutical budget will require a serious cost-benefit analysis if they are to be endorsed by healthcare funders. Healthcare costs will be cut by insiders with a scalpel or by outsiders with a meat axe.7 In their current form, these Guidelines unfortunately present an exposed neck to a large axe. Rodney T Jackson Professor; and Head, Division of Community Health and Effective Practice Institute, Faculty of Medical and Health Sciences, University of Auckland, NZ Jackson R. Updated New Zealand cardiovascular disease risk-benefit prediction guide. BMJ 2000; 320: 709-710. Dyslipidaemia Advisory Group. 1996 National Heart Foundation clinical guidelines for the assessment and management of dyslipidaemia. N Z Med J 1996; 109: 224-232. Wood D, Durrington P, Poulter N, et al. Joint British recommendations on prevention of coronary heart disease in clinical practice. Heart 1998; 80 (Suppl 2):S1-S29. Wood D, De Backer G, Faergeman O, et al. Prevention of coronary heart disease in clinical practice: recommendations of the Second Joint Task Force of European and other Societies on Coronary Prevention. Atherosclerosis 1998; 140: 199-270. Guidelines Subcommittee. 1999 World Health Organization - International Society of Hypertension Guidelines for the Management of Hypertension. J Hypertens 1999; 17: 151-183. Expert Panel on Detection Evaluation and Treatment of High Blood Cholesterol in Adults. Executive Summary of the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults. JAMA 2001; 285: 2486-2497. Health Insurance Commission. Annual Report 1999-2000. <www.hic.gov.au/statistics/dyn_pbs/forms/pbs_tab1.shtml> Eddy D. What do we do about costs? JAMA 1990; 264: 1161-1170. Make a comment

Rodney T Jackson

Editorial Breaking the back of back pain Public policy initiatives directed towards managing the disability of back pain can be highly successful MJA 2001; 175: 456-457 Disability from low back pain is a growing public health problem in Australia and developed countries worldwide, and one of the major issues targeted in the Bone and Joint Decade (2000-2010).1 Most population-based surveys of back pain report a point prevalence of 15%-30%, a one-year prevalence of 50%, and a lifetime prevalence of 60%-80%.2 Although episodes of acute low back pain are mostly short-lived, back complaints still constitute the second most common symptom (after upper respiratory complaints) prompting general practice encounters.3 Furthermore, disability from back pain places a significant socioeconomic burden on the individual and the community. In Australia, back problems are the leading specific musculoskeletal cause of health system expenditure, with an estimated total cost of $700 million in 1993-1994.4 Moreover, these costs are rising: in Victoria alone, claims lodged for back injury with the workers' compensation scheme cost the community $510 million in the 1999-2000 financial year.5 Attempts to reduce the burden of disability associated with back pain have often been directed towards prevention of pain per se, particularly in an occupational setting. Although direct involvement of workplace management in primary prevention strategies has had positive effects, interventions such as education, training and exercise programs for the back, ergonomic interventions and screening potential employees for risk factors for the development of back pain or injury have had limited success.6 Paradoxically, interventions aimed at preventing chronicity, such as early exercise, physiotherapy, rehabilitation and education programs, when implemented early (ie, within the first few weeks of back pain), are largely ineffective for improving longer-term outcomes.7 Attitudes and beliefs, particularly fear-avoidance beliefs, pain-coping strategies and illness behaviours, are important issues to consider when treating patients with back pain.8 While psychosocial approaches that seek to remedy unfounded fears and poor coping methods have met with limited success in treating patients with established chronic back disability, these approaches may be effective when implemented early in the course of back pain and could even be of value when directed towards those who have yet to develop back complaints. Provision of positive messages, such as those designed to improve attitudes to back pain and diminish fear, reduce self-reported disability in patients presenting with low back pain in general practice.9 These interventions also reduce extended work absence in industrial settings.10,11 The Victorian WorkCover Authority's statewide media campaign "Back pain — don't take it lying down", which commenced in 1997 (Box 1), aimed to provide a new approach through prime-time television advertisements featuring health professionals, and sports and local television celebrities. The messages, all endorsed by the relevant professional healthcare organisations, were simple: back pain is not a serious medical problem; disability can be reduced and even prevented by positive attitudes; and treatment should consist of continuing to perform usual activities, not resting for prolonged periods, exercising and remaining at work. The campaign counselled individuals with low back pain, their doctors and employers to avoid excessive medicalisation of the problem, and unnecessary diagnostic testing and treatment. A three-part evaluation of this campaign (evaluating general population attitudes, general practitioners, and the WorkCover Authority claims database) suggests that there has been widespread adoption of these messages (Box 2).13,14 The campaign successfully managed to: "de-medicalise" a public health problem; ease the burden on general practitioners and specialists; empower workers to solve their own health challenges; and save workers' compensation payments. The success of the campaign has been attributed to many factors, including the simple, direct language used to convey the messages, and the evidence-based content, both pioneered by the authors of The back book.12 In addition, virtually every professional body with a stake in back pain in Australia supported the campaign. Before this campaign, there was limited empirical evidence that primary preventive interventions reduce the overall burden of illness associated with low back pain. Now, evaluation of the campaign has shown that a public policy initiative directed towards managing the disability of back pain can be highly successful. There are compelling arguments for this approach. These include, firstly, the impression that informative interventions may be of more value when initiated early, even before the onset of symptoms; and, secondly, predictive models of low back pain are not presently able to identify those at risk of disability. By targeting the entire population, this public health approach reaches those hard-to-identify high-risk groups. There is evidence that a population strategy of universal change has greater overall effect than targeted high-risk strategies. Finally, the population approach may be an effective way of modifying doctors' behaviour, both through direct influences as well as through a change in the attitudes of their patients. Media campaigns are an established strategy for delivering preventive health messages. They have been particularly successful in Australia in altering health-related behaviours, such as sunlight exposure through the Slip! Slop! Slap program and smoking through the Quit program. With good evidence that negative attitudes and beliefs are important predictors of disability related to back pain, altering societal views of back pain would seem a highly appropriate policy to adopt. The long-term impact of this campaign is not clear. Recent publicity by the Victorian WorkCover Authority has focused on ergonomic interventions in the workplace — strategies that the United States has controversially rejected. Clinical effectiveness is not the only influence on policy:15 policymakers' own interests and ideologies are often significant. We may have to look to other interested industrialised societies, such as Sweden, the Netherlands or Canada, for evidence of this novel campaign's long-term effectiveness. Competing interests We received funding from the Victorian WorkCover Authority to conduct an independent evaluation of the media campaign. Rachelle Buchbinder Director, Department of Clinical Epidemiology, Cabrini Hospital; and Associate Professor, Monash University Department of Epidemiology and Preventive Medicine, Melbourne, VIC Damien Jolley Associate Professor, School of Health Sciences Deakin University, Melbourne, VIC Mary Wyatt Occupational Physician, Melbourne, VIC Brooks PM, Hart JAL. The Bone and Joint Decade: 2000-2010. Med J Aust 2000; 172: 307-308. Nachemson A, Waddell G, Norlund A. Epidemiology of neck and back pain. In: Nachemson A, Jonsson E, editors. Neck and back pain: The scientific evidence of causes, diagnosis, and treatment. Philadelphia: Lippincott Williams & Wilkins, 2000: 165-188. Bridges-Webb C, Britt H, Miles DA, et al. Morbidity and treatment in general practice in Australia 1990-1991. Med J Aust 1992; 157(Suppl Oct 19): S1-S56. Mathers C, Penn R. Health system costs of injury, poisoning and musculo-skeletal disorders in Australia 1993-94. Canberra: Australian Institute of Health and Welfare, 1999. AIHW Catalogue No. HWE 12 (Health and Welfare Expenditure Series No. 6). Annual Report Victorian WorkCover Authority 1999/2000. Melbourne (VIC): Victorian WorkCover Authority, 2001. Frank JW, Kerr MS, Brooker A-S, et al. Disability resulting from occupational low back pain. Part I: What do we know about primary prevention? A review of the scientific evidence on prevention before disability begins. Spine 1996; 21: 2908-2917. Frank JW, Brooker A-S, DeMaio SE, et al. Disability resulting from occupational low back pain. Part II: What do we know about secondary prevention? A review of the scientific evidence on prevention after disability begins. Spine 1996; 21: 2918-2929. Waddell G, Newton M, Henderson I, Somerville D, Main CJ. A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain 1993; 52: 157-168. Burton A, Waddell G, Tillotson KM, Summerton N. Information and advice to patients with back pain can have a positive effect. A randomised controlled trial of a novel educational booklet in primary care. Spine 1999; 24: 1-8. Symonds TL, Burton AK, Tillotson KM, Main CJ. Absence resulting from low back trouble can be reduced by psychosocial intervention at the work place. Spine 1995; 20: 2738-2745. Indahl A, Velund L, Reikeraas O. Good prognosis for low back pain when left untampered. A randomized clinical trial. Spine 1995; 20: 473-477. Roland M, Waddell G, Moffat J, et al. The back book. London: The Stationery Office; 1996. Buchbinder R, Jolley D, Wyatt M. Population based intervention to change back pain beliefs and disability: three part evaluation. BMJ 2001; 322: 1516-1520. Buchbinder R, Jolley D, Wyatt M. Effects of a media campaign on back pain beliefs and its potential influence on management of low back pain in general practice. Spine 2001. In press. Black N. Evidence based policy: proceed with care. BMJ 2001; 323: 275-278. Make a comment 1: Victorian WorkCover Authority back pain campaign (1997-2000): "Back pain — don't take it lying down" The campaign was based on the messages outlined in The back book, an evidence-based patient educational booklet.12 Messages Positive advice to stay active and exercise, not to rest for prolonged periods, and to remain at work; Encouragement for patients to take responsibility for getting better and coping; Advice that physical activity and work won't cause harm, that investigations may not be helpful, and surgery may not be the answer. Campaign Concentrated campaign for 3 months initially, followed by a low-key maintenance campaign, with a top-up 3-month concentrated campaign 2 years later; Television commercials, aired in prime-time slots; radio and printed advertisements; outdoor billboards, posters, seminars; workplace visits and publicity articles; Promotion by recognised international and national medical experts, Australian sporting and television personalities, and endorsement by the relevant national professional bodies; The back book, translated into 16 languages, made widely available; and Management guidelines for compensable back pain provided to all Victorian doctors. Target audience The general community, health professionals, and employers. Back to text 2: Evaluation of the Victorian WorkCover Authority back pain campaign Study design Quasi-experimental, non-randomised, non-equivalent, before-after telephone surveys of the general population in Victoria, with New South Wales as the control group; Similar before-after postal surveys of general practitioners in both States; and Descriptive analysis of Victorian WorkCover Authority claims database Results Attitudes of the general population to back pain and its treatment in Victoria changed by more than 10%, while in NSW they remained essentially static. Doctors in Victoria, in contrast to those in NSW, reported much lower probabilities of instigating medical interventions for patients presenting with low back pain. There was an immediate and significant impact of the campaign on the patterns of workers' compensation back claims in Victoria. The rate of medical payments for back claims fell by more than 25% during the period October 1997 - October 2000, and the rate of compensated days for back claims dropped from 75 days per 1000 claim-days to 55 days per 1000 claim-days during the same period. Back to text

Rachelle Buchbinder · Damien Jolly · Mary Wyatt

Death and the Physician Doctors, medicine and the care of the dying patient MJA 2001; 175: 523-524 Assisted suicide and euthanasia continue to spark debate both in the community and within the profession. The clinical problems surrounding the request for these acts, the impact of such interventions on medical practice and what it means when a dying patient asks for euthanasia or assisted suicide, or when a doctor provides such assistance, remain either poorly researched or largely unexplored. The capacity of a clinician to predict the prognosis for patients with severe and chronic illness is limited, as are the ways doctors and patients often communicate about these issues.1 Doctors experience significant emotional distress in caring for such patients2 and this may relate to inadequate training in communication skills, particularly in the care of the dying.3 In caring for a dying patient, the doctor is often ill-prepared for his or her own powerlessness over death, helplessness and uncertainty, and coping with the patient's dependency and the loss of control that illness can signify — themes that mirror some of the elements of the suffering experienced by the patient.4 How doctors respond to the suffering of patients and their families underpins much of the debate on euthanasia and assisted suicide. The care of the dying patient places even greater emphasis on the boundaries and frameworks that doctors need in order to provide good care.5 These boundaries demarcate the role of the doctor in a framework that promotes trust, a duty of care and protection from harm. "Compassion" can become a dangerous motivation alone when such frameworks and principles are lost.6 The emotional "disorientation" that can occur for the doctor can affect the way decisions are made, how a patient's condition is evaluated, and the doctor's perception of the benefits or risks and purpose of their interventions.5 Demoralisation is increasingly identified as an important clinical syndrome among patients with advanced illness, and, as discussed by Kissane,7 such demoralisation among doctors may affect their interactions with patients. It may diminish their capacity to effectively assess and intervene in the patient's hopelessness, depression and demoralisation, and family distress that are associated with the wish to die.8 The article by Haverkate and colleagues in this issue of the Journal9 raises a number of the problems in this field. The study reports a wide variety of emotional responses in doctors to the common interventions they use in caring for dying patients (eg, the perceived "life-shortening effects" of common treatments to alleviate pain and other symptoms). It describes the discomfort and relief reported by the clinicians involved, and concludes that their actions in deliberately hastening death may reassure the doctors of their ability to assist a dying patient and to help the patient die in the way he or she wished, even though, in some cases, the patient had not requested hastened death. Indeed, deliberate intervention to end life without request from the patient is reported to have occurred in 74 of the 558 cases (13.3%), yet this receives little critical discussion. The report does not describe the type of care patients received. This is an important issue if doctors felt euthanasia was a means of improving "the quality of dying". In addition, we know nothing of the patients' views, nor how they were expressed or interpreted. Finally, it is also noteworthy that the "discomfort" of some doctors varied according to other characteristics of the patient. That doctors experienced less discomfort in ending the life of a female patient, or a patient whom they believed was closer to death, than those who are male, younger or believed to have a better prognosis should also raise serious concerns about the processes that might underlie these decisions. How do we respond to such findings, and what meaning do we attach to them? The conclusion reached by Haverkate et al, that by providing euthanasia a doctor is left with the satisfaction of having contributed to the quality of the dying process, is symptomatic of the depth of the problem facing medicine in the care of the dying. The provision of death comes to be viewed as one of a doctor's therapeutic tools. Death becomes a commodity within the therapeutic relationship, even a "right", and the deliberate ending of a life becomes a medical treatment. Research such as that of Haverkate et al also raises questions about the impact of broader societal values on the doctors' actions, motivations and perceptions of their role. What social pressures come to bear on doctors' actions and beliefs about what they do, including the limitations in health resources? How readily do the behaviours and views of doctors accommodate to, reflect, or even shape these prevailing forces (such as views on acceptable care of a dying patient, and broader attitudes towards the dying and the aged)? Does the interest in, or even "comfort" in, euthanasia tell us more than we can comfortably acknowledge about doctors' (and the broader society's) views on the sick and dying? Other questions are raised. To what extent is the issue of assisted suicide or euthanasia symptomatic of the failure to equip doctors with better skills in the care of the dying patient? The reactions of doctors tell us less about the appropriateness of euthanasia, or the needs of doctors following a death by euthanasia, than they do about how troubled and problematic the medical responses to a dying patient can be — a "symptom" of the problem modern medicine has with dying rather than the solution.10 The report by Haverkate and colleagues provokes a question that has long been asked in this field: When we talk of relief of suffering, whose suffering are we referring to?11 Is it also the suffering of the doctor, pained by proximity to death and a sense of helplessness and demoralisation when feeling ill-equipped to respond to the needs of the patient and his or her family? A pressing task is presented by the research of Haverkate and colleagues — to address the limitations of medical training; to provide better access to supervision and support for doctors and other health professionals while they are engaged in the care of seriously ill and dying patients; to develop better systems of care that identify and respond to patients' psychological and social needs alongside the skilled care of physical illness; and to improve patients' access to such care. The provision of professional support and supervision before assisted suicide or euthanasia occurs aims to better identify the needs around the dying patient, the interventions required, and aims to prevent assisted suicide. Guidelines to help doctors have been published. These include those developed by the National Health and Medical Research Council for the psychosocial care of patients with breast cancer,12 guidelines for improving communication skills in end-of-life care,13 and recommended approaches to a request for euthanasia or assisted suicide.14 Acquiring such skills can improve the care by clinicians, and provide much-needed alternatives to the promotion of euthanasia or assisted suicide. Brian J Kelly Associate Professor, and Director Consultation-Liaison Psychiatry, Department of Psychiatry, School of Medicine University of Queensland, and Division of Mental Health Princess Alexandra Hospital, Brisbane, QLD Christakis NA. Death foretold: prophecy and prognosis in medical care. Chicago: University of Chicago Press, 1999. Ramirez AJ, Graham J, Richards MA, et al. Burnout and psychiatric disorder among cancer clinicians. Br J Cancer 1995; 71: 1263-1269. Billings JA, Block S. Palliative care in undergraduate medical education: status report and future directions. JAMA 1997; 278: 733-738. Hendin H. Seduced by death. New York: Norton, 1998. Miles SH. Physicians and their patients' suicides. JAMA 1994, 271, 1786-1788. Pellegrino ED. Compassion needs reason too. JAMA 1993; 270: 874-875. Kissane D. Demoralisation - its impact on informed consent and medical care. Med J Aust 2001; 175: 537-539. Chochinov HM, Wilson KG. The euthanasia debate: attitudes, practices and psychiatric considerations. Can J Psychiatry 1995; 40: 593-602. Haverkate I, van der Heide A, Onwuteaka-Philipsen BD, et al. The emotional impact on physicians of hastening the death of a patient. Med J Aust 2001; 175: 519-522. Annas GJ. Physician-assisted suicide: Michigan's temporary solution. N Engl J Med 1993; 328: 1573-1576. Goodwin JS. Mercy killing: mercy for whom? JAMA 1991; 265: 326. National Health and Medical Research Council. Psychosocial clinical practice guidelines: information, support and counselling for women with breast cancer. Canberra: NHMRC, 2000. von Gunten CF, Ferris FD, Emanuel LL. Ensuring competency in end-of-life care: communication and relational skills. JAMA 2000; 284: 3051-3057. Emanuel LL. Facing requests for physician-assisted suicide: toward a practical and principled clinical skill set. JAMA 1998; 280: 643-647. Make a comment

Brian J Kelly

Death and the Physician When our patients die MJA 2001; 175: 524-525 It was a long time ago now. I had been a doctor but three days. Mrs Gilmore (not her real name) had been brought to the emergency department with chest pain. As I took her history, her voice was soft, but her eyes were frightened. When I had finished, I clasped her aged hand comfortingly. "Don't worry", I said quietly, "It'll be alright". At that moment the light left her eyes. The monitor called the arrest, and white coats descended upon her like carrion birds to beat upon her lifeless chest. When it was all over, when it was all written up, I needed a moment and ambled, dazed, to the tea-room to sit. I am still upset when a patient dies. We all are. Doctors tend to see healing the sick as their raison d'être, and when a patient dies it is hard to escape the notion that we have somehow failed. Even those who claim they are comfortable with a patient's death often wear such proud comfort emblazoned on their sleeves that we are prone to doubt they truly know their minds. How much more upsetting is it when we feel we have played a part in the death? In this issue of the Journal, Haverkate and colleagues report on a survey that, among other things, addresses that question.1 For the survey, Dutch doctors were questioned on their emotional reactions to their most recent cases of euthanasia, assisted suicide, ending a patient's life without explicit request or the use of medications in doses that the respondents believed were large enough to have hastened a patient's death. Physicians' responses were recorded as either "of comfort" (satisfied, relieved, etc) or "of discomfort" (upset, burdened, etc). While 75% of doctors who reported on a euthanasia case felt emotional discomfort, this figure dropped to 58% for cases of assisted suicide. In cases where an end-of-life- hastening medication had been administered with the primary aim of symptom relief, a mere 18% reported discomfort. What are we to make of these figures and what are their implications for Australian doctors? I would argue that, in general, the more a doctor perceives herself or himself as an active participant in a patient's death, the more upsetting she or he will find the death. While previous generations of physicians would only rarely have seen themselves as active agents in the dying process, this perception must now be increasingly common. Our increasing ability to send death away when it calls (or at least to detain it at the door) has also meant that we are, more than ever before, in a position to judge that further efforts are futile and that we should stand back and let death in. This feeling of being an active agent is only magnified when we take active steps in the process and help our patients to die with euthanasia or assisted suicide. In this context, the relatively low rate of negative emotional response when life was ended without explicit request (34%) is worthy of special consideration. Surely here the doctor is as active a participant as she or he is in euthanasia, but now without a specific request from the patient? Why is she or he then less often upset? The important factor in an emotional reaction is, however, not what happened but how it was perceived. I suspect that emotional discomfort is low in these cases because doctors generally believe that death is already upon the patient and that they are doing little more than to ease its way. Much as in the cases where medication is used primarily for pain relief, the physician does not feel a strong sense of agency in the patient's death. The finding by Haverkate et al that end-of-life decisions thought to shorten life by more than one month were much more troubling than those judged to shorten life by a lesser time seems also to support this the-more-agency-the-more-upsetting model. Doctors must deal with their role in their patients' deaths in Australia as much as in the Netherlands.2 While Dutch doctors can, and do, openly seek support for their emotional reactions to the death of patients, such support is likely much harder won in Australia. It is not only that the current legal situation means that Australian doctors who help their patients to die place themselves at risk of harsh penalty if discovered. It is also, and perhaps more importantly, that there is a culture within the Australian medical community that a good doctor simply copes and gets on with it. This culture deserves scrutiny and perhaps change. This issue of the Journal is a good place to start. I did not actively contribute to Mrs Gilmore's death, but as I sat in the tea-room I must have wondered if I could have done more. After 20 minutes, I was back in the fray. Christopher J Ryan Consultation-Liaison Psychiatrist Department of Psychiatry Westmead Hospital, Westmead, NSW Haverkate I, van der Heide A, Onwuteaka-Philipsen BD, et al. The emotional impact on physicians of hastening the death of a patient. Med J Aust 2001; 175: 519-522. Kuhse H, Singer P, Baume P, et al. End of life decisions in Australian medical practice. Med J Aust 1997; 166: 191-196. Make a comment

Christopher J Ryan

Glucosamine is not invariably effective for osteoarthritis, and its use should be approached with a degree of realism MJA 2001; 175: 399-400 Osteoarthritis is the most common chronic joint disease worldwide.1 It generates a considerable healthcare burden, and has been identified by the World Health Organization as one of several musculoskeletal disorders for special study during the Bone and Joint Decade, initiated in January 2000.2 In recent years, osteoarthritis has attracted increasing attention, with the development of classification criteria,3 radiographic standards,4 clinical trial guidelines,5 core set measures (ie, a minimum set of required outcome measures),6 responder criteria (ie, quantitative changes which differentiate treatment successes from treatment failures),7 and the conduct of clinical trials to evaluate the efficacy of treatments for symptom-modifying or structure (disease)-modifying effects. Enthusiasm for the use of complementary medicines is not new, but recent years have seen formal evaluation of compounds that historically were not subject to the rigorous assessment standards required of commercial pharmaceuticals. Glucosamine sulfate is one such example. In the community of arthritis sufferers, products such as glucosamine sulfate are often viewed as having the potential for benefit with little or no risk of adverse events. Extensive marketing of these types of products exists within the popular literature and on the Internet and may drive consumer interest, particularly given the relatively low cost and emphasised "benefits" of these products. However, expectation and other forms of bias can distort an accurate appreciation of both the benefit and risk, distortions which can only be resolved by properly executed, double-blind, randomised controlled clinical trials. A small number of such trials have been conducted with glucosamine, and, over the short term, the general conclusions are that evidence exists for some degree of efficacy (measured by pain reduction and improved functional outcome) of glucosamine products. A recent meta-analysis of glucosamine and chondroitin8 noted that quality issues affect many available trials, and publication bias is likely to exist. Current glucosamine trials may suffer from one or more of the following limitations: patient selection not based on standard classification criteria;9 small sample sizes;10 short duration of follow-up;10 poor or absent description of radiographic grade of damage at point of entry;10 heterogeneous patients,5 and non-use of standardised primary clinical outcome measures, such as the WOMAC or Lequesne indices (both used as primary outcome measures for lower-limb osteoarthritis studies).5 It is not surprising, therefore, that the most recent American College of Rheumatology management guidelines for knee osteoarthritis11 state that: While a number of studies support the efficacy of both glucosamine and chondroitin sulfate for palliation of joint pain in patients with knee OA, the subcommittee [on osteoarthritis guidelines] believes that it is premature to make specific recommendations about their use at this time because of methodologic considerations, including lack of standardized case definitions and standardized outcome assessments, as well as insufficient information about study design in a number of these published reports. A recent Cochrane systematic review concurs with the College's position. The authors state, "Further research is necessary to confirm the long term effectiveness and toxicity of glucosamine therapy in OA".12 Reginster and colleagues13 recently reported a methodologically rigorous three-year study of glucosamine versus placebo in 212 patients with knee osteoarthritis, which demonstrated statistically significant, symptom-modifying and structure-modifying effects favouring the glucosamine group. The symptom-modifying effects appear to be clinically important in the short-term. However, the authors acknowledge that the long-term clinical efficacy remains to be established, and consensus has not yet been reached on the clinical importance of structural conservation effects. There is thus a growing body of evidence for the efficacy of glucosamine in symptom modification, and, given the low level of adverse side effects noted from these products and the relatively low cost, it may be reasonable for some patients with knee osteoarthritis to try taking glucosamine. It should be noted, however, that a very recent review co-authored by a senior and highly respected academic rheumatologist in the United Kingdom concluded "there is more confusion and hype than magic about glucosamine". The authors cautioned against its wholesale use and recommended the need for "further large clinical trials without company interference".14 From a practical standpoint, glucosamine is not invariably effective for osteoarthritis, and its use should be approached with a degree of realism. It is well recognised that there is considerable interindividual variability in the response to treatments for osteoarthritis based on non-steroidal anti-inflammatory drugs (NSAIDs),15 and glucosamine is not likely to differ in this regard. It is likely that glucosamine may meet the symptom-modifying needs of some, but not all, patients. Furthermore, the patient profile and determinants of a glucosamine "responder" are yet to be discovered. Given the severity and multiplicity of joint involvement, it is likely that glucosamine will be taken as a monotherapy in some patients, but as a co-therapy in others. Furthermore, given the long time course of osteoarthritis, it is likely that glucosamine, even in respondents, may be suitable at some points in time, but not others, and discontinuations due to inefficacy can be anticipated. To date, there does not appear to be a substantial basis for major concerns about safety, although this issue continues to attract occasional attention (concerning the effect of glucosamine in glucose metabolism).16 It is likely that, together with non-pharmacological therapies, analgesics, NSAIDs, selective and specific COX-2 inhibitors, viscosupplements, and intra-articular steroids, glucosamine will be useful in the management of patients with knee osteoarthritis, as all of these therapies have been shown to be superior to placebo in symptom-modifying studies. Whether glucosamine is efficacious in advanced disease, in particular patient subgroups, or, indeed, whether it is superior to any of the aforementioned interventions, remains to be evaluated. The study of Reginster and colleagues raises the question of whether glucosamine may have structure-modifying potential, but this issue requires considerable further study before any general recommendation can be made for the use of glucosamine in this context. The best current advice for the use of glucosamine in osteoarthritis is for practitioners to be aware of, and follow, the general spirit of the American College of Rheumatology guidelines for the management of knee osteoarthritis, which include not only the use of pharmacological agents and devices, but also the role of non-pharmacological interventions such as patient education, self-management programs, weight reduction, aerobic exercise, muscle strengthening, and physical therapy.11 For more information on the Bone and Joint Decade, see <www.bonejointdecade.org> Nicholas Bellamy Professor and Director Sean G Lybrand Musculoskeletal Research Associate Centre of National Research on Disability and Rehabilitation Medicine The University of Queensland, Brisbane, QLD nbellamyATmedicine.uq.edu.au Felson DT. Epidemiology of osteoarthritis. In: Brandt KD, Doherty M, Lohmander LS, editors. Osteoarthritis. New York: Oxford University Press, 1998. Brooks PM, Hart JAL. The Bone and Joint Decade 2000-2010. Med J Aust 2000; 172: 307-308. Altman RD. Criteria for classification of clinical osteoarthritis. J Rheum 1991; 18: 10-11. Altman RD, Hochberg M, Murphy WA Jr, et al. Atlas of individual radiographic features in osteoarthritis. Osteoarthritis Cartilage 1995; 3(Suppl A): 3-70. Osteoarthritis Research Society (OARS). Task Force Report: Design and Conduct of Clinical Trials of Patients with Osteoarthritis: Recommendations from a Task Force of the Osteoarthritis Research Society. Osteoarthritis Cartilage 1996; 4: 217-243. Bellamy N, Kirwan J, Boers M, et al. Recommendations for a core set of outcome measures for future phase III clinical trials in knee, hip and hand osteoarthritis. Consensus development in OMERACT III. J Rheumatol 1997; 24: 799-802. Dougados M, LeClaire P, van der Heijde D, et al. Response criteria for clinical trials on osteoarthritis of the knee and hip: a report of the Osteoarthritis Research Society International Standing Committee for Clinical Trials Response Criteria Initiative. Osteoarthritis Cartilage 2000; 8: 395-403. McAlindon TE, LaValley MP, Gulin JP, Felson DT. Glucosamine and chondroitin for treatment of osteoarthritis: a systematic quality assessment and meta-analysis. JAMA 2000, 283: 1469-1475. Hochberg M, Altman R, Brandt K, et al. Recommendations for the medical management of osteoarthritis of the hip and knee. 2000 update. Arthritis Rheum 2000; 43: 1905-1915. Qiu GX, Gao SN, Giacovelli G, et al. Efficacy and safety of glucosamine sulfate versus ibuprofen in patients with knee osteoarthritis. Arzneimittelforschung 1998; 48: 469-474. Towheed TE, Anastassiades TP. Glucosamine and chondroitin for treating symptoms of osteoarthritis: evidence is widely touted but incomplete. JAMA 2000; 283: 1483-1484. Towheed TE, Anastassiades TP, Shea B, et al. Glucosamine therapy for treating osteoarthritis (Cochrane Review) [abstract]. In: The Cochrane Library, 2, 2001. Oxford: Update Software. Reginster JY, Deroisy R, Rovati LC, et al. Long-term effects of glucosamine sulphate on osteoarthritis progression: a randomised, placebo-controlled clinical trial. Lancet 2001; 357: 251-256. Chard J, Dieppe P. Glucosamine for osteoarthritis: magic, hype, or confusion? Lancet; 2001, 322: 1439-1440. March L, Irwig L, Schwarz J, et al. N of 1 trials comparing a non-steroidal anti-inflammatory drug with paracetamol in osteoarthritis. BMJ 1994; 309: 1041-1045. Rovati LC, Annefeld M, Giacovelli G, et al. Glucosamine in osteoarthritis [letter]. Lancet 1999; 354: 1640. Make a comment

Nicholas Bellamy · Sean G Lybrand

To benefit from the US experience of corporatisation, Australia must focus on the clinical advantages rather than the financial windfalls M Kevin Outterson MJA 2001; 175: 426-427 Clinical independence - Efficiency - Access to capital - The opportunity in Australia - References - Authors' details - - More articles on General practice and primary care From the annual reports of two publicly traded physician practice management corporations: . . . The Company enhances clinic operations by centralizing administrative functions and introducing management tools such as clinical guidelines, utilization review and outcomes measurement. The Company provides affiliated physicians with access to capital and advanced management information systems . . . The Company offers medical group practices and independent physicians a range of affiliation models. These affiliations are carried out by the acquisition of [practice] entities or practice assets, either for cash or through an equity exchange, or by affiliation on a contractual basis. In all instances, the Company enters into long-term practice management agreements that provide for the management of the affiliated physicians by the Company while assuring the clinical independence of the physicians. . . . As an integral element of these alliances, the Company utilizes sophisticated information systems to improve the operational efficiency of, and reduce the costs associated with, operating the Company's network and the practices of the affiliated physicians. . . .1 . . . [The Company] acquires and operates multi-specialty medical clinics . . . [Its] objective is to organize physicians into professionally managed networks that assist physicians in assuming increased responsibility for delivering cost-effective medical care, while attaining high-quality clinical outcomes and patient satisfaction. . . .2 As you may have guessed, these companies are not operating in Australia, although their plans may sound familiar. When these reports were written in 1997, the United States had 26 publicly traded physician practice management corporations.3 The two US public corporations described above employed 5650 physicians, with over 25 000 additional affiliated physicians. These two companies enjoyed peak stockmarket value in excess of US$6 billion. In the 10 months following December 1997, the 15 largest publicly traded physician practice management companies lost US$4.8 billion in stockmarket value.4 Today, MedPartners has utterly abandoned its physician division, while PhyCor is currently trading at less than 10 cents per share, down from a high of over US$37. Most other companies are either delisted or in bankruptcy. A few became dotcoms. Something went terribly wrong with corporatisation of physician practice management in the United States. Given the current developments in Australia,5 perhaps some lessons can be learned from the US experience. This article will briefly examine three claims that physician practice management corporations make to attract physicians to corporate practice: clinical independence, efficiency gains, and access to capital. Clinical independence Physicians selling to a corporate practice are promised clinical independence — that the allure of profits will not impair their clinical judgement. However, strong corporate pressures are brought to bear on referral patterns. If the practice owns a pathology or imaging centre, physicians are naturally inclined to use these facilities. For practices owned or affiliated with hospitals, the hospital benefits from inpatient admissions. Physicians owning equity in outpatient surgery centres likewise perform procedures in these centres. Primary care physicians employed by a multispecialty corporate practice may be encouraged to refer patients to specialists within the group. For example, one of MedPartners' large multispecialty clinics was the Summit Medical Group in New Jersey. After a concerted effort to redirect referrals, the use of outside specialists dropped from 30% to 18% of total referrals over a two-year period ending in 1996.6 Defenders of these practices make two points: (i) that existing independent practices are subject to the same financial pressures — a solo surgeon makes money by performing surgery, not by prescribing pharmaceuticals — and (ii) that quality is not compromised, even as referral patterns change.3 Given the poor quality of truly comparable data on outcomes of medical treatment in the United States, this quality assertion can not be proved.7 But, if one assumes that physicians were choosing high quality providers before, then why switch? If financial incentives under managed care can compromise quality,8 the same may be true under corporate ownership. The first argument is more difficult to counter. Physicians in independent practices have a direct financial incentive to see many patients and provide intensive and expensive treatments. This is a moral hazard for physicians, tempered by their ethical commitments to patients. The difference with corporations is the institutionalisation of ethical conflicts. Instead of answering to their own conscience, physicians in a large corporate practice must answer to a corporate superior, who will be analysing practice patterns. This could also be an advantage. If a corporate review using an evidence-based medicine system identifies physicians with inappropriate clinical practice patterns, then quality may improve in a corporate system.6 However, if the review is primarily with an eye to profitability, the opposite could result. Federal regulations in the United States discourage financial incentives for both referrals and some forms of cost cutting, unless the pool of physicians and patients involved is large enough to give the physician a negligible financial incentive with regard to any particular patient.9 The premise is that while a physician might subject a patient to unnecessary and potentially dangerous treatment for a $1000 financial reward, the same amount of money, spread over dozens of patients, will prove to be an inadequate incentive to overcome professional ethics. Efficiency Corporations were supposed to bring modern management practices to the cottage industry of physician practices. In retrospect, they added management layers as well as costs,4 where before there had been a single decision-maker. The cost of overheads was very difficult to control,10 particularly once corporate physicians became agitated and combative. Many corporate physicians chafed under what they called micromanagement. Nurse staffing levels, operating hours, and innumerable management details were modified to suit corporate objectives. Physician productivity also lagged behind expectations: the entrepreneurial energies of solo physicians were dissipated in the salaried corporate environment, particularly after receiving large payments for the sale of practices and goodwill.11 Some physicians who sold their practices to corporate entities in the late 1990s repurchased them at a fraction of the price a few years later. Others filed suit against their corporations, seeking damages for broken promises and a return to private practice.11 One article which is required reading for anyone considering involvement with a physician practice management corporation is The rise and fall of the physician practice management industry, by Professor Uwe E Reinhardt of Princeton University.4 He describes the "Ponzi schemes" and "pyramid scheme" (two fraudulent schemes which falsely lure an ever-increasing group of victims to invest money) which eventually characterised the US industry. The corporations chased unsustainable earnings per share growth, primarily through acquisitions, and neglected actual efficiency gains through "same store" growth (ie, increasing the size of each physician's practice).4 Optimists continue to point to the clinical efficiency of an integrated, multispecialty group practice, particularly if the practice maintains a single medical record. This practice model may offer the opportunity for quality and efficiency gains, but does not require corporate ownership. In the United States, many successful multispecialty group practices, such as the Mayo Clinic, are owned either by non-profit foundations or by physicians, without any equity investment of non-physicians. Access to capital Public companies by definition can access public capital markets that are closed to independent medical practices, and can deploy the capital to improve services. During the rapid growth phase of the American practice management sector, when company shares were trading at 40 times their earnings, promises of lavish clinical spending were easy to make and believe. When the bottom fell out of the market, the capital markets abandoned the sector quickly.11 Some clinics found their projects cancelled or delayed without warning. Capital spending decisions should be made for clinical reasons, with financial projections based on return on investment, not unrealistic multiples of projected earnings. The opportunity in Australia Australian corporations have the opportunity to improve quality and efficiency of care. Robust investment in clinical information systems and adoption of best business practices may be more likely in a corporate environment. However, so, too, will be ethical conflicts, short-term focus on profits, and opportunists who care little about healthcare. If Australia is to benefit from the US experience, then its focus must be on the long term and on the clinical advantages of consolidation rather than the US preoccupation with earnings growth and financial windfalls. References MedPartners, Inc. 1996 Annual report, Form 10-K, filed with the US Securities and Exchange Commission on 31 March, 1997. Available on Edgar at: <http://www.sec.gov/cgi-bin/srch-edgar> (accessed June 2001). Phycor, Inc. 1996 Annual report, Form 10-K, filed with the US Securities and Exchange Commission on 31 March, 1997. Available on Edgar at: <http://www.sec.gov/cgi-bin/srch-edgar> (accessed June 2001). Heller Financial. The physician practice management company. Alternative to the solo practice (winter 1998). Chicago: Heller Financial, 1998. Reinhardt UE. The rise and fall of the physician practice management industry. Health Affairs 2000; 19 (Jan/Feb): 42-55. Catchlove BR. GP corporatisation. The why and the wherefore. Med J Aust 2001; 175: 68-70. Robinson JC. Consolidation of medical groups into physician practice management organizations. JAMA 1998; 279: 144, 148. McGlynn EA. Six challenges in measuring the quality of health care. Health Affairs 1997; 16 (May/June): 7-21. Grumbach K, Osmond D, Vranizan K, et al. Primary care physicians' experience of financial incentives in managed-care systems. N Engl J Med 1998; 339: 1516-1521. Department of Health and Human Services, Health Care Financing Administration, Center for Health Plans and Providers, Medicare Managed Care Group. Physician Incentive Plan Regulations, 42 CFR. § 417.479 (2001). Baltimore, MD: DHHS, 2001. Moody's Investors Service. Not-for-profit health care: 1999. Outlook and medians. September 1999, pp 9-10. New York: Moody's Investors Service, 1999. Bank of America. Healthcare industry review and outlook: 1998 third quarter. October 1998, p 37, 34-40. New York: Bank of America, 1998. Authors' details Lauterpacht Research Centre for International Law, University of Cambridge, Cambridge, UK. M Kevin Outterson, BS, JD (Northwestern University), Visiting Scholar; and Partner, Baker, Donelson Bearman & Caldwell, Nashville, Tennessee, USA. Reprints will not be available from the author. Correspondence: Mr M Kevin Outterson, Lauterpacht Research Centre for International Law, University of Cambridge, 5 Cranmer Road, Cambridge, CB3 9BL, UK. kouttersonATbdbc.com Make a comment

Medicine and the Community The physical, sexual and emotional violence history of middle-aged women: a community-based prevalence study Danielle Mazza, Lorraine Dennerstein, Corrine V Garamszegi and Emma C Dudley MJA 2001; 175: 199-201 Abstract - Methods - Questionnaire - Study participants - Statistical analysis - Results - Domestic violence - Unwanted sexual experiences with someone other than a husband or partner - Childhood abuse - Discussion - Acknowledgement - Reference - Authors' details - - More articles on Obstetrics & gynaecology and women's health - More articles on Social issues Abstract Objectives: To determine current and lifetime rates of the experience of partner abuse and sexual violence in a community-based sample of middle-aged women and compare these to figures obtained in a general practice setting. Design and methods: This research was part of the Melbourne Women's Midlife Health Project (MWMHP), an observational, longitudinal, population-based study of 438 Australian-born women conducted over nine years. In 1996, during the sixth year of the study, we asked the MWMHP participants to complete a self-administered "violence questionnaire", incorporating a modified Conflict Tactics Scale and questions on sexual abuse experienced during childhood and adult life. Results: Of the 395 women remaining in the sixth year of follow-up of the MWMHP, 362 (92%) completed the questionnaire. Overall, 28.5% (n = 101) of the women had experienced some form of domestic violence (physical, sexual or emotional) during their lifetime; 5.5% (n = 15) of women had experienced severe physical abuse in the past year at the hands of a partner; and 11.8% (n = 42) of the women had experienced rape or attempted rape between the age of 16 and the time of our survey. Regarding abuse in childhood, 8.9% (n = 32) of women had experienced physical abuse, 42.3% (n = 152) had experienced non-contact sexual abuse, and 35.7% (n = 128) contact sexual abuse. Compared with the general-practice-based study, rates of childhood physical abuse and penetrative sexual abuse were similar, but rates of less intrusive child sexual abuse were significantly higher in our study. Conclusions: Doctors in all areas of medicine who are dealing with middle-aged women need to be aware of the levels of violence sustained by women throughout their lives. Such experiences may have a substantial impact on women's physical and mental wellbeing. Over the past 20 years, the high prevalence of violence against women has been exposed by rigorous research. Women's Safety Australia,1 a large community-based survey of 6300 women undertaken by the Australian Bureau of Statistics, found that 2.6% of women who currently had partners had experienced an incident of physical violence in the previous 12-month period; 8.0% reported an incident of physical violence at some time during their current relationship; and 1.9% of women had experienced an incident of sexual violence during the 12 months prior to the survey. Mazza and colleagues2 examined the prevalence of physical, sexual and emotional violence experienced by women attending general practitioners in metropolitan Melbourne. Their study found that, of women aged 18 years and over who were in relationships, more than a quarter had been victims of physical or emotional abuse by a partner in the previous year, with one in 10 experiencing severe physical violence. In two Australian studies undertaken in hospital emergency departments,3,4 about 19% of female attendees disclosed histories of domestic violence. It is now recognised that domestic violence has an important influence on the morbidity and mortality of women. Increased utilisation of healthcare facilities,5 chronic pain (particularly pelvic pain),6,7 functional gastrointestinal disorders,8 drug and alcohol dependence or misuse,9-11 attempted suicide11 and psychopathology12-14 are all strongly associated with the experience of violence. The aims of our study were to determine current and lifetime rates of the experience of partner abuse and sexual violence in a community-based sample of middle-aged women and to compare these to figures obtained in a general practice setting in a previous study.2 Methods Questionnaire The "violence questionnaire" that was handed to participants for self-completion was the same as that used in a prevalence study of domestic violence experienced by women attending general practices in Melbourne,2 with which we wanted to compare our study data. The questionnaire incorporated the Conflict Tactics Scale,15 with the modification that respondents were asked whether the tactic had occurred never, once or more than once in the past year, and with the addition of questions on emotional abuse. Physical violence was classified as minor or severe.2 Questions about sexual abuse were derived from the studies of Wyatt16 and Russell,17 both of which used multiple screening questions to allow time for the respondent to become accustomed to the nature of the questions. Childhood sexual abuse was classified as "contact" abuse (involving physical contact) or "non-contact" abuse. (For the purposes of our study, a "child" was defined as a person under 16 years of age.) Study participants The subjects of our study were participants in the sixth year of the Melbourne Women's Midlife Health Project (MWMHP),18 a longitudinal study of a community-based cohort of Australian-born women aged 45-55 years at the beginning of the study. An initial cross-sectional study undertaken in 1991 of a randomly selected community-based sample of 2001 women gathered baseline information regarding women's health experiences and variables related to these experiences.19 The MWMHP study was approved by the Human Research Ethics Committee of the University of Melbourne. Eligibility for the longitudinal phase of the study included women who at baseline were premenopausal, were not taking the oral contraceptive pill or hormone therapy, and had an intact uterus. Of the 779 women eligible to enter the longitudinal study, 56% (n=438) chose to do so. Volunteers for the longitudinal study were more likely than non-participants to report better self-rated health, paid employment, more than 12 years of education, having ever had a Pap smear, exercising at least once a week, and having undergone dilatation and curettage.19 In the MWMHP study, women were interviewed annually face-to-face in their own homes by trained interviewers. Information was collected on a range of variables, including sociodemographic factors, health status, lifestyle behaviours, menopausal status and hormone therapy use. By 1996, when our study was conducted, the retention rate of MWMHP participants was 90% (n = 395). Of these women, 23 who had experienced surgical menopause were not given the violence questionnaire, and a further 10 women refused to complete the questionnaire, leaving 362 women who took part in our study. Statistical analysis The Statistical Package for the Social Sciences (SPSS)20 was used to analyse the sample and determine the prevalence of different forms of violence reported by the women. A statistical comparison was made between the results of our study and the data (previously unpublished) for the subset of women aged 50-69 years (n = 411) from an earlier, general-practice-based study of violence2(Box 1). Ninety-five per cent approximate confidence intervals were used. Results Of the 362 questionnaires available, there were missing data for eight women who did not answer questions on adult violence, four who did not complete the adult sexual abuse questions, and four who did not answer either one or more questions on childhood violence. At the time of completing the violence questionnaire the women were between 51 and 62 years of age (mean, 54.6; SD, 2.42). Sixty-six per cent (238/362) were in paid employment and 77% (277/362) were married or living with a partner. The median parity was 3 (range, 0-9), and 35% of the women had had more than 12 years' education. Domestic violence Overall, 28.5% (101/354) of the women in our study had experienced some form of physical or emotional violence over their lifetime (Box 2). A comparison between our sample and the general-practice-based sample with regard to prevalence of violence experienced in the past year is shown in Box 1. Unwanted sexual experiences with someone other than a husband or partner Overall, 40.8% (146/358) of respondents had, between the age of 16 years and the present, experienced either unwanted sexual advances or been in a situation in which the threat of sexual assault was associated with violence or threat of violence. This included one or more of the following: experiencing rape or attempted rape; encountering sexual advances from someone in authority; or narrowly missing being sexually assaulted. A comparison between the responses in our study and the general practice study is shown in Box 1. Childhood abuse Childhood physical abuse had been experienced by 8.9% (32/358) of the women in our study, and more than one in three women had experienced some form of childhood sexual abuse. Our study showed similar levels of physical abuse and penetrative sexual abuse in childhood, but significantly higher levels of less intrusive child sexual abuse, compared with the general practice sample (Box 1). Discussion Using a longitudinal cohort study such as the MWMHP provides many benefits in a prevalence study. Principal among these is that the women surveyed have been interacting with the research staff for over six years and have therefore built up a degree of trust and comfort with these people. This may facilitate disclosure of sensitive issues such as domestic violence and sexual abuse. A limitation of the study is that in order to obtain some comparative value with other work the questions were delivered by self-administered questionnaire, allowing no opportunity for clarification or exploration of the issues being recorded. Also, the additional questions about emotional abuse had not previously been validated. Of interest is the fact that, despite the participants being a self-selected group of relatively well-educated and health-conscious women, there is a considerable lifetime prevalence of domestic violence among them. The fact that our community-based survey results were similar to those of the general-practice-based survey2 confirms that violence affects the lives of all kinds of women and that it may be a very important contributor to concurrent morbidity occurring at the menopause. In the area of child abuse, our data show similar levels of physical abuse and penetrative abuse but significantly greater levels of less intrusive sexual abuse than those found in the general practice sample. This is surprising given that prevalence rates of most forms of abuse are usually lower in community-based settings than in general practice.2 The greater levels in our sample may reflect a cohort effect or may be owing to the long-term relationship developed over six years of follow-up that may have led to more disclosures. Many studies have demonstrated a relationship between experience of violence and long-term morbidity. Our findings of a high prevalence of violence experienced by women over their lifetime suggest that doctors practising in all areas of medicine need to recognise and explore violence issues when considering middle-aged women's reasons for presenting with ill health. Acknowledgement This study was funded by the National Health and Medical Research Council, the Victorian Health Promotion Foundation, and the Australasian Menopause Society. References Australian Bureau of Statistics. Women's Safety Australia 1996, Canberra: ABS, 1996. (Catalogue No. 4128.0.) Mazza D, Dennerstein L, Ryan V. Physical, sexual and emotional violence against women: a general practice-based prevalence study. Med J Aust 1996; 164: 14-17. de Vries Robbe M, March L, Vinen J, et al. Prevalence of domestic violence among patients attending a hospital emergency department. Aust N Z J Public Health 1996; 20(4): 364-368. Roberts GL, O'Toole BI, Lawrence JM, Raphael B. Domestic violence victims in a hospital emergency department. Med J Aust 1993; 159: 307-310. Stark E, Flitcraft A, Zuckerman D, et al. Wife abuse in the medical setting: an introduction for health personnel. Monograph No. 7. Rockville, Maryland: National Clearinghouse on Domestic Violence, 1981. Schei B. Psycho-social factors in pelvic pain. A controlled study of women living in physically abusive relationships. Acta Obstet Gynecol Scand 1990; 69(1): 67-71. Walling MK, Recter RC, O'Hara MW, et al. Abuse history and chronic pain in women: I. Prevalences of sexual abuse and physical abuse. Obstet Gynecol 1994; 84(2): 193-199. Drossman DA, Leserman J, Nachman G, et al. Sexual and physical abuse in women with functional or organic gastrointestinal disorders. Ann Intern Med 1990; 113(11): 828-833. Burnam MA, Stein JA, Golding JM, et al. Sexual assault and mental disorders in a community population. J Consult Clin Psychol 1988; 56: 843-850. Winfield I, George LK, Swartz M, Blazer DG. Sexual assault and psychiatric disorders among a community sample of women. Am J Psychol 1990; 147: 335-341. McCauley J, Kern DE, Kolodner K, et al. The "battering syndrome": prevalence and clinical characteristics of domestic violence in primary care internal medicine practices. Ann Intern Med 1995; 123(10): 737-746. Gleason WJ. Mental disorders in battered women: an empirical study. Violence Vict 1993; 8(1): 53-68. Mullen PE, Romans-Clarkson SE, Walton VA, Herbison GP. Impact of sexual and physical abuse on women's mental health. Lancet 1988; 1: 841-845. Beitchman JH, Zucker KJ, Hood JE, et al. A review of the long-term effects of child sexual abuse. Child Abuse Negl 1992; 16: 101-118. Straus MA. Measuring intrafamily conflict and violence: the conflict tactics (CT) scales. J Marriage Fam 1979; 41(1): 75-88. Wyatt GE. The sexual abuse of Afro-American and white-American women in childhood. Child Abuse Negl 1985; 9: 507-519. Russell DEH. The incidence and prevalence of intrafamilial and extrafamilial sexual abuse of female children. Child Abuse Negl 1983; 7: 133-146. Dennerstein L, Smith A, Morse C, et al. Menopausal symptoms in Australian women. Med J Aust 1993; 159: 232-236. Burger HG, Dudley EC, Hopper JL, et al. The endocrinology of the menopausal transition: a cross-sectional study of a population-based sample. J Clin Endocrinol Metab 1995; 80(12): 3537-3545. SPSS for Windows. Statistical package for social sciences. Version 9.0. Chicago, Ill: SPSS Inc, 1999. (Received 2 Mar 2000, accepted 29 Mar 2001) Authors' details Office for Gender and Health, Department of Psychiatry, University of Melbourne, VIC. Danielle Mazza, MD, FRACGP, Research Fellow; Lorraine Dennerstein, AO, PhD, FRANZCP, Director; Corrine V Garamszegi, MWH, SRN, Research Assistant; Emma C Dudley, BSc(Hons), GradDip Epidemiol, Research Fellow. Reprints will not be available from the authors. Correspondence: Professor L Dennerstein, Office for Gender and Health, Department of Psychiatry, University of Melbourne, Royal Melbourne Hospital, Charles Connibere Building, Parkville, VIC 3050. ldennATunimelb.edu.au Make a comment 1: Number of women experiencing various types of violence among MWMHP* participants compared with the number of women aged 50-69 years reporting these experiences in a general practice setting† Type of abuse MWMHP study (%) General practice study (%) Difference in prevalence between the 2 studies (95% CI) P Adult experience of violence Overall physical and/or emotional abuse by partner in the past year 57 (20.9%) 80 (29.6%) -8.7% (-16.0%, -1.4%) Minor physical abuse by partner in the past year 46 (16.9%) 61 (22.8%) -5.9% (-12.6%, +0.8%) 0.088 Severe physical abuse by partner in the past year 15 (5.5%) 18 (6.7%) -1.2% (-5.2%, +2.8%) 0.550 Emotional abuse by partner in the past year 31 (11.3%) 54 (20.0%) -8.7% (-14.8%, -2.6%) All forms of sexual assault between 16 years of age and the present 146 (40.8%) 135 (33.3%) +7.5% (+0.6%, +14.4%) Unwanted sexual experience between 16 years of age and the present 85 (23.7%) 79 (19.8%) +3.9% (-2.0%, +9.8%) 0.189 Rape or attempted rape between 16 years of age and the present 42 (11.8%) 43 (10.7%) +1.1% (-3.4%, +5.6%) 0.640 Childhood experience of violence Physical abuse 32 (8.9%) 34 (8.6%) +0.3% (-3.7%, +4.3%) 0.856 Non-contact sexual abuse 152 (42.3%) 103 (25.5%) +16.8% (+10.2%, +23.4%) Contact sexual abuse 128 (35.7%) 110 (27.2%) +8.5% (+1.9%, +15.1%) Penetrative sexual abuse 24 (6.7%) 17 (4.2%) +2.5% (-0.8%, +5.8%) 0.129 * MWMHP = Melbourne Women's Midlife Health Project (our study was based on the cohort of women participating in the MWMHP study18 in its sixth year). † The group of women aged 50-69 years was a subset (previously unpublished data, n=411) of the 2181 women aged over 18 years who took part in a general-practice-based study of violence against women.2 ‡ Missing data from incomplete questionnaires were excluded when calculating prevalences. Back to text 2: Lifetime prevalence of domestic violence among middle-aged women (MWMHP* participants) Type of abuse Number of women Prevalence† (95% CI) Overall physical 101 28.5% and/or emotional (23.8%-33.2%) abuse Minor physical 79 22.4% abuse (18.4%-26.2%) Severe physical 31 8.8% abuse (5.9%-11.8%) Emotional abuse 60 17.0% (13.1%-20.9%) * MWMHP = Melbourne Women's Midlife Health Project (our study was based on the cohort of women participating in the MWMHP study18 in its sixth year). † Missing data from incomplete questionnaires were excluded when calculating prevalences. Back to text

Danielle Mazza · Lorraine Dennerstein

The establishment of NICS is an ambitious attempt to promote quality improvement at both practice and organisational levels. MJA 2001; 175: 124-125 Nearly 10 years since its inception, evidence-based healthcare (EBH) remains focused on encouraging informed decision-making by integrating clinical expertise with the explicit and judicious consideration of the best available "scientific" evidence. The language and concepts of EBH are being institutionalised in almost every facet of the healthcare system, from medical education, policy development and resource allocation to research funding and consumer advocacy. But has EBH delivered on its promises? Despite the explosion in the number of controlled trials, systematic reviews and clinical practice guidelines, there remain large gaps between what should be done and what is actually done. Clearly, we can't hold EBH responsible for the outcomes of the entire healthcare system, but we should be asking why the gap between the best available evidence and current practice persists. We now have in place many of the "upstream" strategies to support EBH. For example, clinical research is being strengthened and more strategically aligned to target the areas where evidence is required.1 Systems are in place through organisations like the Cochrane Collaboration to provide up-to-date summaries of rigorous research in an accessible format.2 Organisations such as the clinical colleges and societies have embraced the concepts of EBH through initiatives such as evidence appraisal of new technologies and procedures and development of clinical guidelines, as well as refocusing much of the content and methods used in their continuing education and quality assurance programs. But what about the "downstream" strategies? What happens to the endless sets of evidence reports, guidelines and audits? What strategies are in place to ensure effective uptake and implementation of the evidence? How can clinicians' behaviour be changed where necessary? What systems are in place to collect the necessary data to monitor the effect of applying evidence in daily practice? The further downstream we look, the greater the challenges. Generating and synthesising the evidence is the easy part; effectively implementing it is not. Our understanding of the effective methods of implementing evidence is limited. Research into behavioural and organisational change in healthcare has been poorly funded, so, while we may have access to some of the best treatments and technologies in the world, our understanding of the strategies needed to promote their effective use is rudimentary. Enter the new National Institute of Clinical Studies Ltd (NICS). Established in December 2000 as a Commonwealth-owned company (with the Federal Minister for Health and Aged Care as the sole shareholder), NICS aims to provide a national, integrated focus for work being undertaken to continuously improve the quality of clinical practice and its delivery to patients. Its terms of reference are broad ranging Box. Unlike international bodies with similar names (such as the National Institute of Clinical Excellence in the United Kingdom), NICS is not a disguise for a new form of rationing or a new national guideline development agency. Rather, NICS, by fostering a scientific approach to the implementation of evidence, will help to turn evidence into action by working in partnership with consumers, healthcare professionals, researchers and organisations to close the gap between evidence and practice. NICS enters an arena in which there is already much activity to do with quality improvement and best practice. Clearly, NICS will need to develop a close relationship with groups such as the National Health and Medical Research Council, the Australian Council for Safety and Quality in Health Care, the Medicare Services Advisory Committee, the Pharmaceutical Benefits Advisory Committee and the National Health Priorities Action Council. Each of these has a different focus from NICS, whose purpose will be complementary to such groups. NICS will engage clinicians from all disciplines and practice settings to identify and prioritise the gaps between evidence and practice, and then develop strategies to close or minimise the gaps, using a scientific approach to quality improvement. These strategies, together with the findings of related initiatives in Australia and internationally, will help to develop practical resources to support clinicians in providing best clinical practice. Finally, NICS will work with other public and private organisations to create an environment in which these resources can be used to maximum effect. NICS is in its early days and is still very much engaged in dialogue and planning. Its challenge will be to use its modest funding to stimulate innovative approaches to promoting the use of best clinical practice. If NICS can't deliver, it runs the risk of becoming just another forgettable acronym! Chris A Silagy Professor, and Director, Monash Institute of Health Services Research, and Chair, Board of National Institute of Clinical Studies Ltd Monash Medical Centre, Melbourne, VIC chris.silagyATmed.monash.edu.au Wills P, Chairman. The virtuous cycle. Working together for health and medical research. Health and Medical Research Strategic Review. Canberra, 1999. Bero L, Rennie D. The Cochrane Collaboration. Preparing, maintaining, and disseminating systematic reviews of the effects of health care. JAMA 1995; 274(24): 1935-1938. Make a comment Terms of reference and composition of the National Institute of Clinical Studies (NICS) Terms of reference Map current activity around improving quality and clinical care, and provide a focus for the consolidation and dissemination of that work; Support research to assess and evaluate aspects of the system within which care is provided — including the processes, interactions and relationships — to identify mechanisms to improve care delivery and the most effective means to influence their implementation; Identify the best mechanisms to influence and improve clinical practice, in concert with the profession; Establish working groups and advisory structures to report and advise on a wide range of matters relating to clinical improvement in the Australian healthcare system; Champion best practice within the healthcare system through education and training; Build links between professionals, consumers and other stakeholders to improve exchange of information and experience about the operation of the healthcare system and minimise duplication of effort; In collaboration with the relevant agencies and bodies, promote the collection and analysis of data and the development of effective data systems; Build links both nationally and internationally with organisations with similar objectives, and identify and assess relevant overseas approaches to clinical practice improvement. Composition of NICS A nine-member Board has been appointed by the Minister for Health to oversee NICS, of whom eight are medical practitioners (three general practitioners, a surgeon, a cardiologist, a paediatrician, a medical administrator and an emergency medicine physician). A Chief Executive Officer is to be appointed to take responsibility for NICS's day-to-day operations. NICS will operate with a small core staff managing a series of outsourced projects and working groups, collaborating as much as possible with other relevant professional and government organisations. By virtue of its company structure, NICS will maintain some distance from direct government involvement, although it remains publicly accountable for the expenditure of its funds (initially $3.5 million per year, provided by the Federal Government for a three-year period). The performance of NICS will be reviewed after the first two years. Back to text

Chris A Silagy

Editorial Systemic lupus erythematosus: current management Use the available agents innovatively, and aggressively treat the risk factors for premature vascular disease MJA 2000; 173: 125-126 Systemic lupus erythematosus is an autoimmune disease that may affect many organs, especially the skin, musculoskeletal, vascular and renal systems. It occurs predominantly in women of childbearing age, but also affects people in their sixth decade or older. In these patients, female predominance is less marked and renal disease less common. The natural history of the disease has changed over the past 20-30 years; survival rates have increased from 50% at five years in the 1950s to 80%-90% at 10 years in the 1990s. The explanations for this improvement include earlier diagnosis, recognition of milder disease, advances in medical therapy, and better supportive care, including renal replacement therapy. Despite these advances, the standardised mortality ratio for lupus remains at 3. Morbidity and mortality rates are bimodal, with early events related to disease activity or infection and later events often due to premature vascular disease such as stroke and myocardial ischaemia. Currently, minor manifestations of systemic lupus erythematosus (cutaneous, musculoskeletal, fatigue) are managed with non-steroidal anti-inflammatory drugs (NSAIDs), antimalarial drugs (particularly hydroxychloroquine) and low-dose corticosteroids. The selective COX-2 inhibitors, celecoxib (a sulfonamide) and rofecoxib, are now available in Australia. With their lower gastrointestinal toxicity, they represent a significant advance. Patients with lupus, however, have a high prevalence of sulfonamide allergy (20% in some studies) and 30%-50% have antiphospholipid antibodies, which are associated with arteriovenous thrombosis and miscarriages (the antiphospholipid syndrome). Case reports of thrombotic events in patients with antiphospholipid antibodies taking COX-2 inhibitors necessitate judicious use of these drugs until further data are available.1 Hydroxychloroquine should no longer be restricted to those with minor disease. Data from the Canadian Hydroxychloroquine Study Group suggest that taking hydroxychloroquine causes a reduction in flares and a lower risk of organ-threatening dissemination.2 An ability to lower blood glucose and cholesterol levels, combined with an antiplatelet effect, makes this drug an attractive therapeutic option for all patients with lupus. The risk of retinal toxicity with hydroxychloroquine may have been overstated in the past, and the Royal College of Ophthalmologists, London, recommends routine ophthalmic screening in adults only if the dosage of hydroxychloroquine is greater than 6.5 mg/kg lean body weight per day, if there is impaired renal or hepatic function, if visual symptoms develop, or if the duration of therapy extends beyond five years.3 Patients refractory to hydroxychloroquine may show improvement with chloroquine, although with chloroquine the risk of retinal toxicity is greater. Treatment-resistant cutaneous lupus has been treated with thalidomide, with improvement in up to 84% of patients.4 However, its use will remain limited because of the risk of fetal abnormalities and the high rate of neuropathy. There is increasing concern about the long term use of steroids, including low-dose therapy, in patients with lupus. With time, musculoskeletal damage, including avascular necrosis and osteoporosis, heads the organ damage list. Petri has shown that avascular necrosis is strongly associated with the highest prednisolone dose used and osteoporosis with the cumulative dose. She has also shown that an increase in prednisolone dose is associated with an aggravation of cardiovascular risk factors. If the prednisolone dose is increased by 10 mg, the average weight gain is 2 kg, and increases in serum cholesterol level and mean arterial blood pressure occur.5 The management of major organ involvement (eg, renal, neuropsychiatric) necessitates combining steroids and immunosuppressants such as cyclophosphamide and azathioprine, and, more recently, cyclosporin A and mycophenolate mofetil. Intermittent monthly pulses of intravenous cyclophosphamide is the standard treatment for diffuse proliferative nephritis and results in a significant improvement in outcome compared with steroid use alone. The appropriate treatment for other classes of lupus nephritis has not been subject to the same level of scrutiny, and uncertainty exists as to what is the optimum management of membranous nephropathy. Although successful in the management of lupus nephritis, high-dose pulse cyclophosphamide (0.75-1.0 g/m 2 monthly) and steroids have been associated with significant toxicity, including premature ovarian failure in 55% and infection in 29% of patients.6 Understandably, fertile women are reticent to accept such therapy and alternatives need to be considered. In retrospective studies, a short, low-dose cyclophosphamide regimen followed by azathioprine has been found to be a successful combination, with reduced incidence of ovarian failure and infection.7 A European prospective study comparing high- and low-dose cyclophosphamide for treating lupus nephritis has now completed recruitment; initial short-term remission rates are comparable in both groups.8 In small series, mycophenolate mofetil has been found to be effective, including in some patients who have shown resistance to cyclophosphamide. Chan et al found mycophenolate to be equal in efficacy to oral cyclophosphamide in patients with diffuse proliferative lupus nephritis.9 Long term data (at least five years' follow-up) will be necessary to determine the incidence of relapse and complications. Cyclosporin has been shown to reduce proteinuria in patients with membranous and diffuse proliferative nephropathy. However, concern continues about nephrotoxicity and relapse on ceasing to take the drug. Cyclophosphamide combined with plasmapheresis has not been shown to provide additional benefit compared with cyclophosphamide alone, and its use is now limited to patients who develop a thrombotic thrombocytopenic purpura-like illness or who have very treatment-resistant disease.10 There is growing interest in the use of immunoablation and stem-cell transplantation in a variety of autoimmune disorders. Autologous stem-cell grafting is feasible in systemic lupus erythematosus and anecdotal reports of success exist. The appropriate timing of stem-cell transplantation, however, remains difficult. Ideally, transplantation should occur in patients who have shown resistance to standard therapy, but before they develop significant irreversible damage. At this stage, the prognostic markers are not sufficiently refined to allow early identification of patients likely to fail immunosuppressive therapy.11 Increased understanding of the pathogenesis of systemic lupus erythematosus has led to the development of numerous novel therapeutic agents. Several of these are in phase II and phase III studies and show promise. However, manipulating the immune system is not without risk, and the expense, particularly of biological agents, will initially limit availability to those with severe disease. While we eagerly await the arrival of such agents, the care of lupus patients in the early years of the 21st century involves innovative approaches with available agents, as well as recognising and aggressively treating the risk factors for premature vascular disease. Timothy R Godfrey Rheumatologist, Rheumatology Unit The Alfred and St Vincent's Hospitals, Melbourne, VIC Peter F J Ryan Clinical Associate Professor of Medicine; and Head Rheumatology Unit, Alfred Health Care Group, Melbourne, VIC Gupta S, McCune WJ, Kaplan M, et al. Thrombosis and ischaemia in patients with systemic lupus erythematosus treated with celecoxib: a series of two cases. Arthritis Rheum 1999, 9(Suppl): S149. Tsakonas E, Joseph L, Esdaile JM, et al. A long term study of hydroxychloroquine withdrawal on exacerbations in systemic lupus erythematosus. The Canadian Hydroxychloroquine Study Group. Lupus 1998; 7: 80-85. Royal College of Ophthalmologists. Ocular toxicity and hydroxychloroquine: guidelines for screening. London: RCO, 1998. Ordi-Ros J, Cortes F, Cucurull, Mauri M, et al. Thalidomide in the treatment of cutaneous lupus refractory to conventional therapy. J Rheumatol 2000; 27: 1429-1433. Petri M. Hopkins Lupus Cohort 1999 Update. Rheum Dis Clinics 2000; 26: 199-213. Gourley MF, Austin III HA, Scott D, et al. Methylprednisolone and cyclophosphamide, alone or in combination, in patients with lupus nephritis. Ann Intern Med 1996; 125: 549-557. Martin-Suarez I, D'Cruz D, Mansoor M, et al. Immunosuppressive treatment in severe connective tissue diseases: effects of low dose intravenous cyclophosphamide. Ann Rheum Dis 1997; 56: 481-487. Houssiau F, Vasconcelos C, Abramovicz D, et al. The Euro-Lupus Nephritis Trial: comparison between a low dose and a high dose cyclophosphamide regimen. Ann Rheum Dis 1999 (EULAR abstracts): 116. Chan TM, Li FK, Tang CS, et al. Efficacy of mycophenolate mofetil in patients with diffuse proliferative lupus nephritis. N Engl J Med 2000; 343: 1156-1162. Schroeder J, Schwab U, Zeuner R, et al. Plasmapheresis and subsequent pulse cyclophosphamide in severe SLE: preliminary results of the LPSG Trial. Arthritis Rheum 1997, 40(Suppl): S325. Formiga F, Moga I, Pac M, et al. High disease activity at baseline does not prevent a remission in patients with systemic lupus erythematosus. Rheumatology 1999; 38: 724-727. Make a comment

Viewpoint Importance of retaining a national dietary guideline for sugar The Australian Dietary Guidelines are currently being revised and updated. There has been public discussion about the advisability of retaining a guideline for sugar because of insufficient evidence linking sugar consumption to ill health. However, there are concerns about the quality of the self-reported food intake data on which this conclusion is based. In addition, the doubling in diabetes prevalence in Australia in the past 20 years, which is linked to increased obesity from consumption of energy-dense foods, including those with added sugars (sugar-sweetened drinks being particularly important), provides a strong rationale for retaining a dietary guideline for sugar. Kerin O'Dea and J I Mann MJA 2001; 175: 165-166 A Working Group convened by the National Health and Medical Research Council's Health Advisory Committee is currently reviewing the Australian Dietary Guidelines, and reconsideration of the New Zealand dietary guidelines is also likely. Because of insufficient scientific evidence to link sugar consumption with ill health, a case has been made to abandon the guideline referring to sugar, "Eat only a moderate amount of sugar".1 Discussion of this issue is timely as sucrose consumption appears to be increasing. For example, New Zealand national nutrition surveys suggest that, between 1988 and 1997, self-reported sucrose intake increased on average from 42 to 62 g/person per day in males and from 27 to 45 g/person per day in females.2 Even more striking increases were evident in the age group 15-24 years. Dietary studies: Much of the evidence relating diet and disease comes from epidemiological studies, both cross-sectional and prospective. The nutritional and epidemiological methods currently available are insufficiently robust to accurately assess intakes and disentangle the effects of interrelated nutrients. Prospective studies have advantages over cross-sectional surveys, but there are still problems with assessment of dietary intake (which is usually only assessed on one occasion and by methods which are seriously flawed). Much of the evidence on which diet-disease relationships is based is self-reported, and there is substantial under-reporting of foods perceived to be unhealthy (eg, those rich in sugar, fat and alcohol). In particular, people who are obese tend to under-report, and do so selectively.3 Even randomised controlled clinical trials can be difficult to interpret, an excellent example being the CARMEN study.4 In this multicentre trial, 398 moderately obese adults were allocated at random to a seasonal control group (no intervention), a control diet group (dietary intervention typical of the average national intake), or one of two low-fat, high-carbohydrate groups (in which the carbohydrate was derived primarily from "simple" or "complex" carbohydrate). The weight changes on the latter two diets were not significantly different statistically, and the authors therefore concluded that the nature of carbohydrate is a relatively unimportant determinant of body weight. However, closer examination of the data reveals interesting trends: body weight loss on the low fat/high simple carbohydrate diet was 0.9 kg (P < 0.05) and on the high complex carbohydrate diet 1.8 kg (P < 0.001). A similar trend was apparent for change in fat mass. With a larger sample size, these differences might have become significant. Obesity and diabetes: The prevalence of obesity has risen sharply in Australia and New Zealand over the past 20 years. The recently released Diabesity and associated disorders in Australia 20005 draws attention to some of the devastating consequences of overweight and obesity. The association between type 2 diabetes and adiposity is arguably of even greater importance than the previously well described association with cardiovascular risk factors (hypertension and dyslipidaemia). Diabetes prevalence in the Australian adult population has doubled since 1980, the increase occurring in parallel with the rising prevalence of obesity. The estimated number of Australians with diabetes has reached almost one million, of whom less than 500 000 are aware of the diagnosis. The greatly increased risk of coronary heart disease and other vascular diseases, as well as the microvascular complications of diabetes (eg, retinopathy and nephropathy), emphasise the consequences of this disease, which has now reached epidemic proportions. This serious public health issue brings obesity to centre stage. It is caused by a complex interaction between genetic predisposition and environmental trigger factors, but the current epidemic of obesity has to be attributed to the "obesogenic environment"6 — the human genome has not changed in this period! The environmental facilitators of obesity are food intake and energy expenditure. While acknowledging the undoubted contribution of our increasingly sedentary lifestyle to the obesity epidemic, our discussion will focus on diet. Diet: Much of the discourse on the role of diet in the development of obesity highlights the role of fat, due to its high energy density (kJ/g of food or beverage) and its propensity, if consumed in excess, to be deposited as adipose tissue. However, there is now evidence that fat gain is similar with overfeeding of carbohydrate or fat.7 Energy intake is strongly influenced by energy density. Covert manipulation of energy density (ie, providing diets of different energy density without participants' knowledge) results in sustained changes in energy intake.8 The increased use of low-fat products, many of which are energy dense due to their high sugar content, and sugar-containing beverages now contributes significantly to total energy intake and are examples of the means by which sugar may enhance the energy density of the diet. If sugar does contribute to excessive energy consumption and to the problems of overweight and obesity, then clearly retention of a guideline is important. Evidence is accumulating that the form in which the sucrose is consumed is also important. A recent prospective study from Ludwig and colleagues9 showed a clear-cut, graded relation between the consumption of sugar-sweetened drinks and the development of obesity in children. The prevalence of obesity among children in the United States doubled between 1980 and 1994; 11% are now above the 95th reference percentile of body mass index (BMI) for age and sex. The observation that this increase paralleled the increase in sugar-sweetened soft drinks prompted Ludwig et al to enrol 548 ethnically diverse schoolchildren in four Massachusetts communities in a prospective study for 19 months. The difference in measures of obesity was related to change in consumption of sugar-sweetened drinks and other possible determinants of obesity, including physical inactivity and fat intake. For each additional serving of sugar-sweetened drinks both BMI (mean, 0.24 kg/m2) and frequency of obesity (odds ratio, 1.6) increased, after adjustment for anthropometric, demographic, dietary and lifestyle variables. Changes in diet soft drink intake were not related to obesity incidence. Of course, an observational study does not prove causality, but it is of interest that another recently published study in an entirely different group of older individuals produced similar results. Elmslie and coworkers10 compared a group of bipolar (manic depressive) patients and matched controls; the patient group had higher rates of overweight and obesity than the controls. The bipolar patients reported a higher energy intake, the increased energy being derived almost entirely from sucrose in sweetened drinks. Energy from drinks (regardless of whether it is from sugar, fat or alcohol) adds to total energy intake, and does not displace energy from other forms.11 Furthermore, compensation at subsequent meals for energy consumed in the form of liquid (drinks) appears to be less complete than for energy consumed in solid form (food) (ie, people overconsume more easily when excess energy is in the form of energy-containing beverages).12 While these new data suggest an obesity-promoting effect of sugar-containing beverages, it may also be relevant to recall data published some 30 years ago.13 Middle-aged men were asked to replace, as far as possible, sucrose with foods rich in starch to maintain energy balance. Despite regular advice and encouragement from a dietitian they were unable to maintain energy balance and lost weight, presumably because of the greater satiety-promoting qualities of the starchy foods. While not providing direct evidence for sugar as an aetiological factor, these observations do suggest that recommending a reduction in sugar may be a potentially useful public health measure in countries where obesity and its comorbidities have reached epidemic proportions. Implications for Indigenous populations: Our discussion has particular significance for Australian and New Zealand Indigenous populations, who have very high rates of lifestyle-related chronic diseases occurring at much younger ages than the non-Indigenous population.14,15 Indigenous people often have poor-quality diets, high in sugar and fat, and depleted in fruit and vegetables. For example, Lee and coworkers16 analysed the food supply at six remote Aboriginal communities in the Northern Territory using the "store turnover" method, and found a very high consumption of sugar per se and in soft drinks. The diets had high levels of animal fat (mainly from poor-quality meat) and very low levels of fruit and vegetables (ie, energy-dense and nutrient-poor). Most of the sucrose was consumed in liquid form as sugar in tea and in carbonated beverages. Retention of a dietary guideline for sugar: The evidence we have assembled here leads us to strongly advocate the retention of a dietary guideline for sugar in Australia and New Zealand. In fact, given the marked rise in consumption of carbonated beverages in Australia over the past 30 years (47.3-114.4 L/person per year between 1968-69 and 1996-97), we also advocate an addition: "Consume only moderate amounts of sugars and foods and beverages containing added sugar". This is in line with the recently revised US dietary guidelines,17 which include the recommendation "Choose beverages and foods that limit your intake of sugars". There is also a strong population health rationale for mandatory labelling of foods with clear information, including sugar, fat, and total energy content. References Williams P. Sugar: is there a need for a dietary guideline in Australia? Aust J Nutr Diet 2001; 58: 26-31. New Zealand food: New Zealand people. Key results of the 1997 National Nutrition Survey. LINZ Activity and Health Unit, University of Otago for the Ministry of Health. Dunedin, NZ: University of Otago, 1999. Heitmann BL, Lissner L. Dietary underreporting by obese individuals - is it specific or non-specific? BMJ 1995; 311: 986-989. Saris WHM, Astrup A, Prentice AM, et al. Randomized controlled trial of changes in dietary carbohydrate/fat ratio and simple vs complex carbohydrates on body weight and blood lipids: the CARMEN study. Int J Obesity 2000; 24: 1310-1318. Dunstan D, Zimmet P, Welborn T, et al, on behalf of the AusDiab Steering Group. Diabesity and associated disorders in Australia: the accelerating epidemic. Report of the Australian Diabetes, Obesity and Lifestyle Study. Melbourne: International Diabetes Institute, 2001. Egger G, Swinburn B. An "ecological" approach to the obesity pandemic. BMJ 1997; 315: 477-480. McDevitt RM, Poppitt SD, Murgatroyd PR, Prentice AM. Macronutrient disposal during controlled overfeeding with glucose, fructose, sucrose or fat in lean and obese women. Am J Clin Nutr 2000; 72: 369-377. Stubbs RJ, Johnstone AM, O'Reilly LM, et al. The effect of covertly manipulating the energy density of mixed diets on ad libitum food intake in "pseudo free-living" humans. Int J Obesity 1998; 22: 980-987. Ludwig DS, Peterson KE, Gortmaker SL. Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective observational analysis. Lancet 2001; 357: 505-508. Elsmlie J, Mann JI, Silverstone JT, et al. Determinants of overweight and obesity in patients with bipolar disorder. J Clin Psychiatry 2001; 62. In press. Poppitt SD, Prentice AM. Energy density and its role in the control of food intake: evidence from metabolic and community studies. Appetite 1996; 26: 153-174. Mattes RD. Dietary compensation by humans for supplemental energy provided as ethanol or carbohydrates in fluids. Physiol Behav 1996; 59: 179-187. Mann JI, Truswell AS, Hendricks D, Manning EB. Effects on serum lipids in normal men of reducing dietary sucrose or starch for five months. Lancet 1970; 1: 870-872. Daniel M, Rowley KG, McDermott R, et al. Diabetes incidence in an Australian Aboriginal population: eight year follow up study. Diabetes Care 1999; 22: 1993-1998. Simmons D, Harry T, Gatland B. Prevalence of known diabetes in different ethnic groups in inner urban South Auckland. N Z Med J 1999; 112: 316-319. Lee AJ, O'Dea K, Mathews JD. Apparent dietary intake in remote Aboriginal communities. Aust J Public Health 1994; 18: 190-197. Nutrition and your health: dietary guidelines for Americans. 5th edition, 2000. Home and Garden Bulletin No 232. Washington, DC: Department of Agriculture, Department of Health and Human Services; 2000. Authors' details Menzies School of Health Research, Darwin, NT. Kerin O'Dea, PhD, Professor and Director. University of Otago, Dunedin, New Zealand. J I Mann, PhD, DM, FRACP, Professor in Human Nutrition and Medicine. Reprints will not be available from the authors. Correspondence: Professor Kerin O'Dea, Menzies School of Health Research, PO Box 41096, Casuarina, NT 0811. kerinATmenzies.edu.au Make a comment

Kerin O'Dea · J I Mann

Editorial Australian general practice at a fork in the road: which way forward? An opportunity to respond to the challenges and choose renaissance MJA 2001; 175: 62-63 Worldwide, there is a new phenomenon — dispirited doctors.1 They are afflicted with a debilitating disease characterised by disinterest, disillusion and despair. The roots of this disease are embedded in the havoc wrought by constant change and uncertainty, and the inevitable clash between doctors' professional and personal ideals and the changing circumstances of their practices. Australia has not escaped this disease. That it is endemic in Australian general practice is evidenced by reports of GPs' discontent and despondency.2,3 They see themselves as overworked, undervalued, unsupported and over-regulated. They are no longer in control.1-3 This issue of the Journal, celebrating Family Doctor Week, explores some of the crucial challenges facing Australian general practice as it arrives at a defining fork in the road. How GPs and their leaders respond to these challenges will determine whether Australian GPs continue down the road of despondency, or choose a road of renaissance and rid themselves of this malaise. First, there is the accelerating trend to corporatisation of Australian general practice, and for this issue of the Journal we sought out an eclectic array of views on this development. Catchlove explores the triggers for and potential outcomes of corporatisation;4Sprogis suggests alternative corporate models;5Fitzgerald examines ethical dilemmas;6 and Mott provides a pragmatic consumer perspective.7 The corporate sector's aggressive invasion into general practice comes as no surprise. It is symptomatic of a global movement in which governments, chanting the mantra of cost containment and consumer choice, have abrogated their public roles and responsibilities to the private sector.8 Moreover, as doctors seek "the right balance in life: enough money and enough time off",9 medicine is increasingly regarded less as a vocation and more as a job. Any job that promises professional satisfaction in the provision of high quality care, with the added bonus of more time for partners, family and friends, is undeniably attractive. These are the human appeals of corporate practice, which unquestionably has other benefits both for the profession and the community. But clouding these benefits is the uncertainty of the long term effects on professional autonomy and discretionary practice. Crucial questions need to be answered, such as the content of and compliance with corporate codes of conduct, and the precise nature and impact of corporate-doctor agreements. Then there is the uncharted impact on healthcare delivery and funding of vertical integration of general practices with diagnostic and specialist services, hospitals, pharmaceutical suppliers and health insurance organisations. Ultimately, what will be the attractiveness of such seamless healthcare coverage to governments? These are all questions for the future, but the consequences of unbridled corporatism for our profession are unlikely to be entirely benign. As Milton Friedman, a Nobel Prize laureate in economics, once observed ". . . there is one and only one social responsibility of business — to use its resources and engage in activities designed to increase its profits . . . ".10 Second, there is the challenge of general practice research and education, which has received little attention in the corporatisation debate. One of the defining characteristics of a viable medical discipline is its capacity to enrich itself through research, and this is sorely deficient in Australian general practice, and contributing in part to the malaise. The reasons for this impoverishment include: GPs are patient- and service-oriented and have to ensure practice profitability. Any activity such as research that is not fiscally rewarded is understandably of low priority. GPs attract a low level of research funding. Between 1996 and 2000, general practice received only 35 (1.6%) of the 2116 newly funded National Health and Medical Research Council (NHMRC) research projects, and a mere $3.7 million (0.5%) of the $795 million allocated to NHMRC-sponsored research activities (Dr Greg Ash, Director, Research Policy, NHMRC, personal communication). According to Kamien, Australian academic general practice departments are the "poor relations" in the medical faculty family, with their inadequate infrastructure and low research output,11 as instanced by their publication performance.12 Indeed, Askew and colleagues show that this performance lags considerably behind that of other Australian health specialties, namely medicine, surgery and public health.13 In short, poor resourcing, a deficient research capacity and little recognition of general practice in our universities have all combined to stifle what should be a rich and flourishing research culture. More than a year ago, Michael Wooldridge, the Federal Minister for Health, announced the Primary Health Care Research and Development Strategy to address these shortcomings. Its aim is to build a research capacity in general practice through multiple strategies (Box). However, the success of this strategy is not assured — the devil is always in the detail. Success depends on the strategy's ability to engage GPs in research performed in and relevant to general practice. Success also entails changes in our medical faculties — in attitudes, structures and resource allocation — acknowledging the pivotal role of general practice in disease prevention, in coordinating community care of patients with chronic disorders, and in caring for our ageing population. All these initiatives provide an opportunity for corporatised general practice to be involved in the renaissance. If, however, our experience of corporatism mirrors that in the United States, with adverse effects on research14 and educational outcomes,15 Australian general practice will be the loser and its renaissance will be stymied. I hope that these fears are ungrounded and Australian corporatism affirms education and research as integral to the social contract between medicine and society. As our dispirited colleagues stand at the fork in the road, unsure which direction to take and uncertain of what lies ahead, the words of Robert Frost seem apt: I shall be telling this with a sigh Somewhere ages and ages hence: Two roads diverged in a wood, and I — I took the one less traveled by, and that has made all the difference. (The road not taken — 1916) Martin B Van Der Weyden Editor, The Medical Journal of Australia BMJ survey: why are doctors so unhappy? <http://www.bmj.com/cgi/content/full/322/7294/DC4#league>(accessed May 18 2001). Schatter PL, Coman GJ. The stress of metropolitan general practice. Med J Aust 1998; 169: 133-137. McGlone SJ, Chenoweth IG. Job demands and control as predictors of occupational satisfaction in general practice. Med J Aust 2001; 175: 88-91. Catchlove BR. GP corporatisation. The why and the wherefore. Med J Aust 2001; 175: 68-70. Sprogis A. GP corporatisation. The divisional alternative. Med J Aust 2001; 175: 70-72. Fitzgerald PD. GP corporatisation. The ethics of doctors and big business. Med J Aust 2001; 175: 73-75. Mott K. GP corporatisation. The consumer perspective. Med J Aust 2001; 175: 75-76. Funnell W. Government by fiat. The retreat from responsibility. Sydney: University of New South Wales Press, 2001. Dworkin RW. Why doctors are down. Commentary (New York) 2001; 111 (May): 43-47. Friedman M. Capitalism and freedom. Chicago: University of Chicago Press, 1962: 133. Kamien M. Has Australian academic general practice really come of age? Med J Aust 2001; 175: 81-83. Ward AM, Lopez DG, Kamien M. General practice research in Australia. Med J Aust 2000; 173: 608-611. Askew DA, Glasziou PP, Del Mar CB. Research output of Australian general practice: a comparison with medicine, surgery and public health. Med J Aust 2001; 175: 77-80. Moy E, Mazzaschi AJ, Levin RJ, et al. Relationship between National Institutes of Health research awards to US medical schools and managed care market penetration. JAMA 1997; 278: 217-221. Ludmerer KM. Time to heal. American education from the turn of the century to the era of managed care. Chapter 17: Medical education in an era of containment and managed care. New York: Oxford University Press, 1999: 349-369. Make a comment The Primary Health Care Research Evaluation and Development Strategy* Priority setting A comprehensive program of consultation with stakeholders — to establish research priority areas (commenced in 2000). Development and research capacity building Funding over five years for Departments of General Practice and Rural Health — to develop or augment research infrastructure. Grants program Contestable Primary Health Care Research Grants — to be added to the NHMRC research funding pool (commencing in 2001). GP Fellowships (postdoctoral) and Primary Health Care Scholarships (for higher degrees) — to be offered annually by the NHMRC (commenced in 2000). Capacity development grants — to build research experience. Research secondments — to enable researchers to undertake six-month placement in relevant primary care organisations. The Institute for Primary Care Research To provide leadership and support in primary care research. *Ms M MacDonald, Director, Research and Quality Section, General Practice Branch, Commonwealth Department of Health and Aged Care, personal communication. Back to text

GP Corporatisation The why and the wherefore Barry R Catchlove MJA 2001; 175: 68-70 For editorial comment, see Van Der Weyden Abstract - What is corporatisation? - Why corporatisation now? - What do GPs think? - What are the consequences of corporatisation? - Alternative models? - References - Authors' Details - - More articles on General practice and primary care Abstract Through their clearly defined gatekeeper role, GPs have considerable market power to influence the flow of revenue associated with referrals and prescriptions. For this reason, and because the whole healthcare industry is going through a transition from a cottage industry to a more commercially sophisticated structure, corporatisation of general practice is on the increase. If properly and ethically run, corporatised general practices can provide high-quality, efficient primary care. There are four far-reaching, potential consequences of general practice corporatisation — an increase in healthcare spending; limitation of GPs' choice of practice environment; difficulty justifying GPs' legitimate fee increases; and de-skilling of GPs. Over the past two years there has been a huge upsurge in corporatisation of Australian general practice. It began in Perth, Western Australia, and is now spreading across metropolitan Australia. An estimated 2500 GPs (about 10% of those in practice) now work in practices owned by large corporations.1 What is corporatisation? Definitions of corporatisation vary, but all include the concept of changing the traditional ownership and practice structures to improve the profitability of general practice.2 In terms of what is happening now in Australian general practice, a working definition would comprise: A third party — doctor(s) or non-doctor(s) — acquires an interest in one or more general practices. Whatever the equity arrangements, GPs enter into a contract whereby they assign a proportion of their gross income in return for management of their practice, provision of support services, and a goodwill payment. The third party then gains access to the flow-on services of the practice (eg, pathology and radiology) and may benefit financially from the GPs' referrals. The practices are merged into a single medical centre, which is generally separately owned by the same third party. In Australia, corporatisation of medical services is not a new phenomenon. Large corporations own many private hospitals and most pathology and radiology services, and third parties, be they entrepreneurial doctors or people from outside healthcare, have been acquiring general practices for years. The current situation is therefore not unique, because: GPs are being offered previously unheard of goodwill payments. The rate of practice acquisitions has increased dramatically. Ownership of diagnostic services by corporate entities is now common. Specialists are now joining these corporate medical centres. The new corporate owners are often listed companies and may have "big name" investors, adding further to the high profile of the new structure. There is a clear intention to capitalise on the GPs' market power (in addition to achieving some economies of scale). Why corporatisation now? The interesting question is not why corporatisation is happening, but why it is happening now. After a review of corporatisation commissioned by the Commonwealth Department of Health and Aged Care in 2000,3 the answer to this question is still not entirely clear. As is often the case in the commercial world, there is no obvious trigger. It is worth recalling the 18th-century economist Adam Smith's famous remark about the "invisible hand of the market".4 However, two important and relevant issues, external to the medical profession, shed some light on the upsurge of corporatisation. Firstly, GPs have considerable market power, which, in this context, means the ability, through a clearly defined gatekeeper role, to influence the flow of revenue associated with referrals, prescriptions and suchlike. We know that for each dollar of Medicare revenue earned by a GP, another $1.60 is generated directly in diagnostic and specialist consultations. Based on the flow-on effects of one GP's initial decisions, it is estimated that 20 GPs' decisions could be responsible, directly and indirectly, for as much as $50 million of healthcare expenditure per annum.3 In the past, the cottage industry nature of general practice, with an average of fewer than two doctors per practice, made it difficult to exploit collective market power. Secondly, the whole healthcare industry is going through a transition from a cottage industry to a more commercially sophisticated structure. Ironically, this started in the public sector — public hospitals were grouped into areas, regions and networks. In the 1990s, it spread to the private sector with the involvement of large third party commercial organisations, the rationalisation of pathology then radiology services, and it is now having an impact on general practice. Even the charity hospitals have been forced into merging and forming corporatised structures. This process appears inevitable and unstoppable. What do GPs think? Despite widespread concerns being voiced within the profession and in the media, GPs currently involved in corporate-run practices are not complaining. At this early stage of corporatisation most appear happy. There is no evidence to suggest they are being pressured into overservicing or into directing patients to particular diagnostic services or specialists. GPs who previously owned practices have received a relatively large and unexpected goodwill payment. They are probably earning about the same as they did before corporatisation, but they have been freed from the administrative tasks of running their practice. In a business sense many would agree that GPs from inefficient and grossly undercapitalised practices needed to be dragged into the 21st century. If properly and ethically run, corporatised general practices can provide high quality, efficient primary care. On a more sober note, it must also be remembered that all these new entrants into corporatised general practice have only existed for a short time and therefore can only be judged on short-term performances. What are the consequences of corporatisation? At this stage, the real issues of corporatisation are not about the compromise of clinical autonomy (although there is no denying this could be a problem but not necessarily associated with corporatisation alone). I believe that, apart from some of the more obvious issues such as ownership of records and freedom to refer, there are four far-reaching, albeit subtle, consequences of corporatisation. Although corporatisation will get the blame, these four are in reality consequences of the inevitable changes associated with transforming healthcare from a cottage industry to a more rational, market-driven service sector. These include limitation of choice, increases in healthcare spending, difficulty justifying legitimate fee increases, and de-skilling of GPs. Limitation of choice There is a real risk that the corporate model will become so dominant that future GPs will have little choice about the sort of practice in which they wish to work. This is already happening to some extent in metropolitan Perth.5 For general practice to attract doctors, it needs to offer a range of alternative models from solo general practice right through to large corporate medical centres. The only way is to ensure viable alternatives offering equivalent benefits and advantages. Crucial to this is the creation of saleable goodwill. Increases in healthcare spending The real profitability in owning a general practice is not in the direct revenue, but in the "downstream" revenue, which is the product of GPs' gatekeeper role. The corporate groups believe that access is the key (not coercion). If a pathology collection centre or pharmacy is placed within the confines of a medical centre, then about 95% of the referrals can be assumed without any need to adopt overt pressure. The corporate practice benefits from ownership of diagnostic services, but, even if it doesn't (as is often the case for pharmacy and allied health services), it benefits from being able to demand premium rentals for floor space. Specialists who take consulting space in these medical centres may also be prepared to pay excessive rentals to gain access to a large number of GPs. The real concern is the subtle impact on referral rates, diagnostic and pharmaceutical expenditure. Take as a hypothetical example the presence of a full time dermatologist in a large medical centre (please forgive me for selecting a dermatologist, it could equally apply to other specialists). It is inevitable that many of the patients previously managed, and managed quite effectively, by GPs will now be referred. Again, access is key, with higher patient expectations, convenience, and perhaps even medicolegal concerns about not referring when the service is so readily available. Given the cost differential between GP and specialist consultations, both the referral rate and the cost per patient attendance will inevitably rise. If this situation is extrapolated to other possible diagnostic and specialist referrals, there is a potential for considerable increases in Medicare and Pharmaceutical Benefits Scheme spending. How will governments react to this? Very simply, they will encourage the already developing move to fund-holding, coordinated care, fund pooling — call it what you will. All these mean a move away from fee-for-service and towards managed-care models and the associated transfer of risk. If GPs control the budget, will government allow corporatised practices to share the savings, and if GPs have a vested interest in reducing referral rates what will be the impact on the downstream revenue? Could this undermine the viability of the corporate players already paying high prices for general practice acquisitions? Difficulty justifying legitimate fee increases Being owned by high profile, often publicly listed, successful corporate entities might decrease the ability of the medical profession to argue a case for legitimate fee increases. Imagine the situation — two large publicly listed corporate practices, perhaps partly owned by high profile entrepreneurs, announce record profits at the same time that representatives of general practice organisations are meeting with government to discuss increases in the fee schedule. De-skilling of GPs If every conceivable diagnostic test, specialist and ancillary service is available on site, and this results in increased referrals, then there is a likelihood that GPs will become nothing more than a postbox, and there is a real potential for de-skilling of GPs. A GP's clinical judgement will become largely unnecessary. Taking this situation to extremes, someone might eventually ask whether the GP's gatekeeper role is working and mightn't a much cheaper nurse practitioner fill the same role? Alternative models? What corporatisation has demonstrated is that there are more efficient ways to deliver primary healthcare. For those who acknowledge this, the challenge is to provide alternative models, drawing on the lessons of corporatisation. The KPMG report to the Commonwealth Department of Health and Aged Care asked some searching questions about the use of GP market power. Properly managed and with due regard to ethics, this market power can be used to improve care, reduce costs and improve the quality of practice. If GPs are prepared to responsibly manage their gatekeeper role, which often requires increased time and effort, they should be rewarded. GPs should be best suited to manage and control their market power. However, it is something of a truism that if you have such power and do not use it or control it then someone else will. Corporatisation in general practice is merely one aspect of the movement of health services from the cottage industry to a more rational and rationalised model. To argue a return to the good old days and the status quo would be attempting to do what King Canute proved was impossible — holding back the tide. References Corporate structure [news review]. Australian Doctor 2001; 27 April: 29-31. Australian Medical Association. General practice corporatisation. AMA scoping paper. Canberra: AMA, November 2000. Commonwealth Department of Health and Aged Care. Corporatisation of general practice: scoping paper. KPMG Consulting, May 2000. Smith A. An inquiry into the nature and causes of the wealth of nations. London: W Strahan, T Cadell, 1776. Kron J. Risky business. Australian Doctor 2001; 16 Feb; 45. Authors' Detials Barry R Catchlove, MB BS, FRACP, Director. No reprints will be available from the author. Correspondence: Dr Barry R Catchlove, Director, Padua Consulting Pty Ltd, Health Services Consulting, 11 Burton Street, Mosman, NSW 2088. bcatchloATbigpond.net.au Make a comment

Barry R Catchlove

GP Corporatisation The divisional alternative Arn Sprogis MJA 2001; 175: 70-72 Abstract - Divisions as corporations - "Divisional corporate model" versus "for-profit corporate model" - Conclusions - References - Authors' details - - More articles on General practice and primary care Abstract GPs working together in groups, with a corporate body providing the organisational framework, is an inevitable outcome of healthcare system changes. Divisions of General Practice — regional corporations owned and operated solely by local GPs — should be seen as the logical alternative to the non-regional, for-profit, often publicly listed corporations. The divisional model combines economies of scale and organisation with clinical and practice autonomy and a regional focus, as well as an emphasis on patient values, quality of care, and equity of access. The Hunter Urban Division of General Practice is exploring the possibility of a Division-based general practice cooperative. In the Australian healthcare system, particularly in general practice, major structural change occurs about every 30 years.1 The move to corporatisation, which has been evolving slowly for the past 10 years or so, is clearly the next major structural change. GPs, as the entry point into the healthcare system, are the most important part of the change process — their corporatisation completes the process for medical practitioners. General practice responses to these changes will determine the final form and outcome for the health system as a whole and, most importantly, the type and availability of care that patients can expect in the future. GPs working together in large groups, with a corporate body providing the organisational framework, is an inevitable outcome of healthcare system changes2 and part of an international trend.3 The factors influencing these changes include: A shift away from hospital-based to community-based care; Increased use of health teams in the community (eg, as part of the Enhanced Primary Care package); Greater use of drug treatments; An emphasis on population-based activity (eg, General Practice Immunisation Incentives scheme);1,4 Increased accountability for outcomes; Efficiencies resulting from improved management techniques; and Renewed interest by government and non-government groups in integrating health funding.2 In Australia, an additional factor has been pressure on the financial viability of general practice, particularly in capital cities. Divisions as corporations Most GPs have participated in a form of corporatisation since 1 August 1992, when the Commonwealth Government funded the pilot group of 10 Divisions of General Practice. Over the next two years, more than 120 Divisions were formed covering most of Australia.1 These regionally based, GP-owned, patient- and community-focused, not-for-profit corporate entities afforded an opportunity to further develop general practice corporate activity, but this opportunity was not grasped by governments for the next seven years. Indeed, this policy vacuum allowed the emergence of "for-profit" general practice corporate groups and should be seen as a public health policy failure. "Divisional corporate model" versus "for-profit corporate model" If a corporate approach to general practice is accepted as inevitable, then Divisions of General Practice — regional corporations owned and operated solely by local GPs — should be seen as the logical alternative to the non-regional, for-profit, often publicly listed corporations. If general practice is a private-sector activity, why not allow market forces to play their role and let the most efficient corporations, regardless of structure and ownership, dominate the field? The real question is: Can the for-profit, publicly listed corporations meet the challenges integral to the ethical and value systems of the GP-patient relationship? Overall, I do not believe that the for-profit corporation model sits well with individual and community-based healthcare or that the conflict-of-interest issues can be satisfactorily overcome using this model. There are a number of clear advantages to patients, doctors and to the health system of a divisional corporate model approach. Ethical issues The basic tenet of the GP-patient relationship is that the GP has the patient's best interests in mind.5 Although all GPs experience ethical tensions, those working for publicly owned corporations (as opposed to a divisional corporate model) may not be able to reconcile their own and their patients' values with the demands of the corporation's shareholders. The primary responsibility of corporations is to their shareholders. GPs may be induced to put corporate profits before the interests of their patients. Practice structure A clear distinction between a divisional model and a publicly owned corporate model is that the divisional model seeks to retain and build on the strengths of the current diverse practice structure, with its equally diverse operational types. It emphasises the autonomous operation of each practice, which makes its own business and clinical decisions within an overarching supportive divisional framework. A publicly owned corporation has to take control of individual practices and make them fit into the broader corporate strategy. Clinical and practice autonomy The ability of GPs to act independently for their patients' benefit must be preserved in corporatised general practice.6 A divisional model's overarching corporate goals and structures would respect, strengthen and reward individual practices. For a practice or GP to forgo any autonomy, there would have to be a clear benefit for both the GP and his or her patients. The divisional regional approach meets the needs of individual GP shareholders, both practice owners and employees. Regional focus and ownership GPs are part of the community in which they work, live and send their children to school. Publicly owned corporations, on the other hand, may not be based in the same region, or even the same country, as their corporate general practices. Few shareholders live in or have any commitment to the local region. Patients and communities already have strong feelings about the lack of regional responsibility of large corporate entities (eg, banks and oil companies). The divisional model enhances the capacity for population-based activity and increases the possibilities for enacting public policy. GPs involved in making decisions within the local divisional corporation are able to guarantee that the interests of their patients are also represented at the regional level. Quality of care The capacity to provide quality care, a key element of professional general practice,4 should not differ according to ownership structure. Several of the Divisions are already leaders in the field of "evidence-based and best practice" treatment,7 but publicly owned, general practice corporations have yet to demonstrate their capacity or their commitment in this crucial area. Equity and access This is a point of major differentiation between the divisional corporate model and the publicly owned corporate model. The Divisions are committed to offering participation within their structure to all GPs, both owners and employees (as well as to all their patients), regardless of their potential for profit generation. In the publicly owned corporate model, GPs' acceptance may be the result of a selection process, with preference given to those most likely to generate a profit. Finance and third-party relationships Improvements in GPs' remuneration and practice finances will require more than increases in individual consultation fees. It will require resource-sharing arrangements with third-party providers (eg, preferred-provider arrangements with pathology laboratories) and government agencies (eg, general practice fundholding). These arrangements must be mutually beneficial (for reasons of efficiency, competition, or public policy). GPs and patients potentially benefit from third-party partnerships as a means of redistributing healthcare resources5 (eg, pharmaceutical companies supporting evidence-based drug use by GPs). The ethical challenge presented by funding relationships between general practice corporations and third parties (eg, pathology services, pharmaceutical companies, and government departments) has yet to be resolved.5,8 The financial relationships of public corporations are often based on "commercial in confidence" and secrecy, whereas those of the divisional model are transparent and open to public scrutiny. Conclusions A Division-based, general practice regional cooperative model appears to be the only corporate option combining the benefits of economies of scale and organisation, but at the same time maintaining congruence with regional patient and community interests, general practice autonomy and public policy imperatives. The experience of the Hunter Urban Division of General Practice in exploring a regional general practice cooperative is shown in the Box. References Commonwealth Department of Health and Aged Care. General practice in Australia: 2000, Canberra: Office of the Medical Advisor, DHAC, 2000. Commonwealth Department of Health and Aged Care. The Australian Coordinated Care Trials: Interim Technical National Evaluation Report, 1999. Canberra, DHAC, 1999. King J, Wilson M. General practice: building on quality literature review. Melbourne: Monash Institute of Public Health, 2001. Commonwealth Department of Health and Family Services. General Practice: changing the future through partnerships 1998. Report of the General Practice Strategy Review Group. Canberra: DHAC, 1998. Smith D. Reconciling the ethics of general practitioners and third party incentives, part 2, 2001. <http://www.hudgp.org.au/ethics/thirdparty/part2.asp> (accessed June 2001). RACGP corporatisation taskforce. Heywood L (chair). <http://www.racgp.org.au/taskforces/corporatisation/keyissues.htm> (accessed June 2001). Magarey A, Rogers W, Sibthorpe B, et al. Dynamic divisions: a report of the 1997-98 Annual Survey of Divisions. Adelaide: National Information Service, Department of General Practice, Flinders Medical Centre, 1999. Marshall D. Beneficial ownership of Approved Pathology Authorities and medical centres. HIC Forum 2001; Vol 12. Authors' details Hunter Urban Division of General Practice, Newcastle, NSW. Arn Sprogis, FRACGP, DRCOG, DipClinEpi, Executive Director. Reprints will not be available from the author. Correspondence: Dr A Sprogis, Executive Director, Hunter Urban Division of General Practice, PO Box 572, Newcastle, NSW 2300. drarnAThudgp.org.au Make a comment Divisional corporate model in action The Hunter Urban Division of General Practice (HUDGP) is exploring the possibility of a Division-based general practice cooperative. The HUDGP encompasses the regions of Newcastle, Lake Macquarie, Maitland and Port Stephens in New South Wales. The region contains urban, industrial and rural sectors within the Lower Hunter Valley with a population of about 400 000 people. The HUDGP represents 380 GPs in 160 practices. HUDGP currently has several successful divisional projects, including: A general practice cooperative after-hours service in the Maitland district (population 70 000). The service, which operates from Maitland Hospital, is staffed by the 70% of local GPs who are members. The service is funded by a divisional grant. There is a plan to form five similar services to cover the entire Lower Hunter region. Support services for Division members, including information technology, immunisation, accreditation and professional development. A nursing service, providing a contract nurse on request. Since late 2000, the HUDGP has been consulting with its members about forming general practice cooperatives as an alternative to joining "publicly listed" corporations. The cooperative model is strongly preferred. Key characteristics would include: Coverage of the Hunter Urban region only. The HUDGP providing practice management support and expanding on current services (above). Individual GPs retaining clinical and practice autonomy. Support for all practice sizes and styles (rather than selecting GPs who fit the corporate model). Issues such as structure and funding are currently being explored. Back to text

Arn Sprogis