General medicine

Editorial Sceptical medicine To admit to not knowing, or to being unsure until the evidence is gathered or accessed, is the beginning of sceptical wisdom MJA 1999; 170: 99-100 The 1998 Skeptic of the Year, awarded by the Australian Skeptics Inc, is Michael Archer, a palaeontologist and professor of biological science at the University of New South Wales, who has recently been appointed Director of the Australian Museum. His interests listed on his Internet home page include "all aspects of zoology and palaeontology that relate to the development of the Australian biota, particularly mammals", and "pseudoscience such as creation science".1 The award is presented to Australians whose work contributes substantially to the promotion of critical thinking.2 Perhaps there should be an equivalent award given each year to the doctor who has best practised lifelong sceptical medicine! Some confuse sceptical medicine with the practice of a nihilistic, cynical clinical code. But Archer, in a recent radio interview, made a clear distinction between scepticism and cynicism: the former pursues evidence and is built on humility; the latter reflects arrogance and seeks to destroy virtue. The distinction could hardly be plainer. The Health Advisory Committee of the National Health and Medical Research Council and the Menzies Foundation recently convened a workshop* to define the current state of the art of evidence-based medicine, and potential implications of and barriers to an evidence-based approach to healthcare in Australia. The aim was to develop ways of incorporating an evidence-based approach into the Australian healthcare system for the next millennium. Different perspectives were explored, including those of healthcare professionals, consumers, health policymakers, researchers, lawyers and funding agencies. David Pencheon, the UK National Health Service's Associate Director of Research and Development, spoke of a recent encounter with new medical students beginning clinical training in Cambridge after intense preclinical education. He asked them questions about simple clinical observations, and their mechanism and meaning. He recalled that it took a long time before he had exhausted their knowledge and one of them finally uttered that most important of all phrases for the future practice of scientific medicine "I don't know!". To admit to not knowing, or to being unsure until the evidence is gathered or accessed, is surely the beginning of sceptical wisdom. Without it, clinical practice guidelines, and ready access to relevant databases or information about the appropriateness of investigations and treatments, are useless -- because the mind of the clinician is not sceptically engaged. Just as a palaeontologist fails who ceases to look for evidence in fossil deposits, so a clinician who forsakes evidence in favour of intuition or half-remembered ideas runs a significant risk. Learning to say to oneself, one's patients and one's colleagues "I don't know" is a vital element of medical education. Papers presented at the workshop examined how healthcare decisions are made, how evidence is synthesised and disseminated and how evidence-based treatment is implemented, and the impact of using an evidence-based approach. Evidence-based medicine is a provocative term, not least because it begs the question whose evidence? While formal and standard definitions of evidence-based medicine show due deference to patient values and evidence from clinical experience,3 there remains a suspicion in the minds of many that this is a new way for purveyors of randomised controlled clinical trials to take over the world.4 This fear may be as straightforward as a professional territorial concern or as complex as the insight held by patients, members of the community and behavioural and social scientists that there is more to the clinical decision omelet than randomly cracking a few clinical trial eggs. Thus, Ian McDonald (Director, Study of Clinical Practice, St Vincent's Hospital, Melbourne) argued that clinical decisions, if properly understood, have a base of scientific evidence familiar to the biological scientist, but that we often fail to understand that other forms of evidence, from studies in sociology, behavioural science and anthropology, are helpful in achieving a full understanding of medical care. His challenge, echoed by Hilda Bastian (Chairperson, Consumers' Health Forum) and Sophie Hill (PhD student, School of Public Health, La Trobe University), was to a new form of scepticism, questioning the completeness of our definition of evidence-based medicine if it does not include knowledge generated from these other disciplines. Likewise, Sydney University's George Rubin (Professor of Public Health and Community Medicine) reminded participants of the relevance of a scientific understanding of motivators of behavioural change in other human settings (eg, business, which refers regularly to the relevant literature and is based on due scepticism) when contemplating how to encourage behavioural change among clinicians. The Australian National University's Bob Douglas (Director, National Centre for Epidemiology and Public Health) proposed that all health facilities and administrative units employ health information analysts, or "Cochrane-ologists", to assist health professionals to make use of evidence and manage scepticism. Multiple pressures operating on practitioners can lead them to ignore what they know to be best practice in their clinical and public health decision-making. These pressures include well-coordinated commercial interests, time and financial constraints, and the potential for litigation. Workshop participants asked that the Health Advisory Committee consider the following recommendations and develop an action plan to support their implementation: To recognise that systematic reviews underpin evidence-based healthcare. Systematic reviews should be required for all future healthcare-related research. They should be accepted as a legitimate form of research and developed to include a wide range of scientific evidence. Reviews should be eligible for research funding, and recognised in research performance assessment and as accreditation towards postgraduate training. To identify and overcome factors that hinder the generation, transfer and implementation of research knowledge into clinical practice. It is important to establish mechanisms and funding for ongoing communication and structural collaboration among groups involved in this area in Australia and overseas. To encourage the use of evidence-based approaches in areas outside clinical practice. These include the development of health and public health policy and practice and health-related litigation. If, as many believe, there needs to be a cultural shift to greater use of evidence in making not only life-critical but also day-to-day clinical practice and public health decisions, it will be important for the evidence to be immediately accessible either in hard copy or via computer to a range of potential users -- clinicians, consumers and health service planners. There is no point in providing clinical guidelines to clinicians about conditions or problems they will never encounter, or presenting them in a way that they can not be used. As Peter Joseph, immediate past president of the Royal Australian College of General Practitioners, has said, "I want guidelines in the form of charts that I can keep in an A4 folder on my shelf and pull down immediately when I have a patient to whom they refer. Then I can locate the patient in the decision matrix, explain to him or her where we are, and walk through the decisions that we then have to make together" (personal communication). The NHMRC's clinical practice guidelines for the management of early breast cancer5 is a fine example of guidelines prepared in a variety of formats to suit the needs of different end-user groups.6,7 Evidence-based medicine can only operate in a climate of healthy scepticism. Those who worry about their colleagues' scepticism towards evidence-based medicine should wait: if the doubters are genuinely sceptical, and if evidence-based medicine works, it will not be long before they, too, have begun to make the best use of it in an admittedly highly complex setting. Stephen R Leeder Professor, and Dean, Faculty of Medicine, University of Sydney, NSW Chris A Silagy Director, Australasian Cochrane Centre, and Professor of General Practice Department of Evidence-Based Care and General Practice Flinders University School of Medicine, Adelaide, SA George L Rubin Professor of Public Health and Community Medicine, and Director, Effective Healthcare Australia, University of Sydney, NSW http://www.unsw.edu.au/bioscience/archer.htm http://www.skeptics.com.au/ Sackett DL, Rosenberg WMC, Gray JAM, et al. Evidence based medicine: what it is and what it isn't. BMJ 1996; 312: 71-72. Lelorier J, Gregoire G, Benhaddad A, et al. Discrepancies between meta-analyses and subsequent large randomised, controlled trials. JAMA 1997; 337: 536-542. National Health and Medical Research Council. Clinical practice guidelines. The management of early breast cancer. Canberra: NHMRC/AGPS, 1995. National Health and Medical Research Council. Early breast cancer. A consumer's guide. Canberra: NHMRC/AGPS, 1995. National Health and Medical Research Council. All about early breast cancer. Sydney: NHMRC National Breast Cancer Centre, 1996. * Proceedings of the workshop are available on CD-ROM and via the Internet at <www.vicnet.net.au/~menzies> and <www.health.gov.au/nhmrc> Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Stephen R Leeder · Chris A Silagy · George L Rubin

Editorial Confusion about secondary prevention for bowel cancer: resolving issues at the front line MJA 1999; 170: 102-103 An effective, clearly enunciated national policy is needed for secondary prevention (screening and surveillance) of bowel cancer in Australia. Bowel cancer meets the World Health Organization criteria for screening, and is the commonest internal malignancy affecting both sexes in Australia, causing more deaths than any other cancer except lung cancer.1Three randomised controlled trials have shown that screening average-risk populations (aged 50 years and over) by the crudest of faecal occult blood tests (Hemoccult) is effective in reducing population mortality from bowel cancer on an intention-to-screen basis.1 Furthermore, calculations of cost-effectiveness using Australian cost data and screening outcomes of the poorly specific rehydrated Hemoccult test show that screening for bowel cancer is about as cost effective as screening for breast cancer.2Given that neither mortality from bowel cancer nor cancer stage at diagnosis has improved in various Australian States,3 we can assume that current secondary prevention activities are only minimally effective. Indeed, the incidence of bowel cancer continues to rise in men.3 Why are we not conducting screening and surveillance? Why are we missing out on their demonstrable benefit? From a national perspective, two key issues arise: How should we implement screening to reduce population bowel cancer mortality rates?; and While this question is being answered, what is reasonable action for individuals interested in being screened or for those at risk of bowel cancer? Unfortunately, failure to separate these two issues has led to confusion and misunderstanding of promulgated guidelines. The issue of an effective population screening program was addressed in the Australian Health Technology Advisory Committee (AHTAC) report released in April 1998.1 A recent editorial in the Journal called for the issues raised in that report to be addressed and resolved.4 The AHTAC report proposed "pilot and feasibility studies" to examine aspects of screening, such as logistics, choice of screening tool, risks, costs, acceptability, resources and education. It took an evidence-based approach and considered the issues from a population perspective. Early in 1998, the National Cancer Control Initiative submitted a proposal to government seeking funds for pilot and feasibility studies in the general population. These funds have not yet been provided -- we will not have an effective program for the general population until results of pilot studies are available. In the meantime, doctors, and especially general practitioners (GPs), remain confused as to what is reasonable practice. Evidence for this confusion is presented by Sladden and Ward in this issue of the Journal.5 They found that many GPs are unaware of the evidence that screening is effective and are uncertain about intervals for testing, the age to start, and how to apply the screening/surveillance tools to an individual in a manner appropriate to the individual's risk profile. Few GPs are "highly likely" to recommend faecal occult blood screening (and presumably any other type of screening for bowel cancer) during a health check, even though we know that people who have biennial screening with Hemoccult have about a 40% reduction in risk of dying from bowel cancer.6Sladden and Ward point out that guidelines available in Australia are partly responsible for the confusion, because of their inconsistency in recommendations. This inconsistency arises partly because the issue is complex and the evidence is incomplete. Also, there is a failure to appreciate the difference in the guidelines between what is acceptable as a population strategy and what is reasonable for the individual who seeks screening. Given that the value of early-detection programs in average-risk individuals is supported by three randomised controlled trials of faecal occult blood test-based screening and by several case-control studies of flexible or rigid sigmoidoscopy screening, it is difficult to ignore the individual seeking help. The soon-to-be-promulgated Guidelines for the prevention, early detection and management of colorectal cancer of the National Health and Medical Research Council (NHMRC) and the Australian Cancer Network have been developed by a process of consensus, incorporating a national workshop and analysis of the evidence. These guidelines should provide a path through the confusion, provided they are endorsed and used by the medical colleges and other professional and educational bodies. They will also partly solve the problem of access to, and resourcing of, the colonoscopies needed for effective secondary prevention. Adherence to guidelines for colonoscopic surveillance of those at increased risk of bowel cancer might then free this limited resource for more effective deployment to a larger proportion of the population. The issues for the primary healthcare provider are complex: the GP needs to check the presence or absence of symptoms, profile the asymptomatic individual's risk, tailor the screening or surveillance program to that risk, and deal with the population's aversion to things anal or faecal. The media have been unhelpful in this respect, with little publicity given to bowel cancer.1,4 As pointed out by Sladden and Ward, GPs' actions might be suboptimal if they cannot immediately recall the necessary (rather complex) detail or access the services needed. When a GP considers that secondary prevention might be indicated, support in terms of education and access to carefully coordinated secondary prevention services should be provided by regional health services. The GP's role is important to the success of secondary prevention, whether it is part of a future coordinated mass program, or dealing with the individual seeking guidance or needing motivation. Clearer guidance will come from the NHMRC-Australian Cancer Network best practice guidelines. However, the continued rise in the incidence of bowel cancer and failure to lower its mortality will not be adequately controlled by such an ad hoc approach;7 population pilot studies are desperately needed, and so is government funding! Graeme P Young Professor of Gastroenterology, Flinders University of South Australia Head, Gastrointestinal Services, Flinders Medical Centre, and Repatriation General Hospital, Adelaide, SA Australian Health Technology Advisory Committee. Colorectal cancer screening. Canberra: Commonwealth Department of Health and Family Services, 1997. Salkeld S, Young G, Irwig L, et al. Cost-effectiveness analysis of screening by faecal occult blood testing for colorectal cancer in Australia. Aust J Public Health 1996; 20: 138-143. Bell JC, McCredie M, Coates MS, Armstrong B. Trends in colorectal cancer incidence and mortality in New South Wales 1973-1992. Med J Aust 1997; 166: 178-181. Collett JA, Olynyk JK. Colorectal cancer screening in average-risk, asymptomatic Australians [editorial]. Med J Aust 1998; 169: 14-15. Sladden MJ, Ward JE. Australian general practitioners' views and use of colorectal cancer screening tests. Med J Aust 1999; 170: 110-113. Hardcastle JD, Chamberlain JO, Robinson MHE, et al. Randomised controlled trial of faecal-occult-blood screening for colorectal cancer. Lancet 1996; 348: 1472-1477. Neugut AI, Young GP. Screening for colorectal cancer: an overview. In: Young GP, Levin B, Rozen P, editors. Prevention and early detection of colorectal cancer. London: WB Saunders, 1996: 357-368. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Graeme P Young

Research Australian general practitioners' views and use of colorectal cancer screening tests Michael J Sladden and Jeanette E Ward MJA 1999; 170: 110-113 For editorial comment, see Young Abstract - Introduction - Method - Results - Discussion - Acknowledgements - References - Author's details - - More articles on Gastroenterology Abstract Objectives: To determine general practitioners' (GPs) current beliefs, knowledge and self-reported practices of screening for colorectal cancer. Design and setting: Postal survey of national random sample of 1271 GPs in 1996. Outcome measures: GP views on effectiveness of faecal occult blood testing (FOBT) and flexible sigmoidoscopy in reducing premature death from colorectal cancer in "average-risk" patients (asymptomatic with no family history); views on frequency of tests and target group; use of these tests; and independent predictors of views and use. Results: Response rate was 67%. FOBT and flexible sigmoidoscopy were said to be effective as screening tests by 38% and 61% of GPs, respectively, but 30% and 25% were unsure. Independent predictors of belief in screening effectiveness were State of practice (for FOBT), male sex and awareness of Gut Foundation guidelines (for flexible sigmoidoscopy) and increasing age (for both). Most often chosen screening frequencies were every year for FOBT (29%), and five-yearly for flexible sigmoidoscopy (24%), although 19% and 26%, respectively, were unsure of the appropriate screening interval. Most often cited target group was people aged over 40 years with first-degree relatives with colorectal cancer: 63% of GPs would offer FOBT and 74%, flexible sigmoidoscopy. Fewer than 3% of GPs were likely to adopt an opportunistic approach to screening, yet 15% would be highly likely to recommend FOBT during a dedicated health check-up for a 58-year-old male patient, and 9% for a female patient. Conclusion: The absence to date of a coherent national policy on colorectal cancer screening is associated with wide variations in views and practice that are inconsistent with the available evidence. If GPs are to be involved in implementing population screening, national policy must be widely and effectively promulgated. Introduction The past decade has seen a saga of unfinished policy initiatives on screening for colorectal cancer in Australia. As early as 1990, screening by faecal occult blood test (FOBT) was being promoted for people with "average risk" of colorectal cancer, in the absence of convincing evidence or national policy.1 Since then, a range of bodies have produced guidelines with quite different recommendations, particularly for this "average risk" group.2-8 Examples are shown in Box 1. More recent among these was the 1997 report of the Australian Health Technology Advisory Committee (AHTAC) Working Party on Colorectal Cancer Screening. This working party was formed after a 1994 call for a national symposium to develop "recommendations about early detection of colorectal cancer" as part of Australia's national health goals and targets,9 and a 1995 deputation to the Commonwealth from the Australian Cancer Network. The Network recommended pilot projects of screening and, if these were successful, implementation of national screening. AHTAC found that FOBT was effective in reducing mortality from colorectal cancer in the average-risk population (defined as the "well population aged over 50") and recommended studies to determine the effectiveness of different screening strategies, particularly how best to involve general practitioners (GPs). Meanwhile, in 1998, another set of draft guidelines, not yet nationally endorsed, was circulated by the Clinical Oncological Society of Australia and the Australian Cancer Network.8 Despite the unresolved status of national policy, research has continued to involve Australian GPs overtly or covertly in colorectal cancer screening.10-14 Most recently, a survey of Perth GPs reported high uptake of this screening.15 As no national studies have been conducted, we designed a postal survey to assess GPs' perceptions of the effectiveness of screening for colorectal cancer and self-reported levels of screening. Method GP sample and survey administration A covering letter, questionnaire and reply-paid envelope were mailed in May 1996 to a national random sample of 1271 GPs, as described elsewhere.16 Standardised response-aiding strategies were used to follow up non-respondents.16 Questionnaire Questions on colorectal cancer screening were part of a larger questionnaire on current status of cancer screening in general practice. Respondents were asked to tick the response that matched their views on: Effectiveness of FOBT and flexible sigmoidoscopy in reducing premature deaths from colorectal cancer in "average risk" patients (ie, asymptomatic patients with no family history); Frequency of screening; Who should be screened; Likelihood of their initiating a discussion about FOBT or flexible sigmoidoscopy with a well 58-year-old male, and next female, patient during non-urgent consultations for ear syringing as well as during scheduled health check-ups; and Usefulness of three guidelines available at the time of the surveys (first three items in Box 1). The final section of the questionnaire included eight sociodemographic questions. Data analysis Descriptive, cross-tabulation and logistic regression analyses were performed with SPSS for Windows 7.17 Logistic regression analyses were performed to determine independent predictors of knowledge and practice outcomes. Fourteen potential predictors were considered: GP's sex; age; State; full- or part-time practice; practice type (solo or group); membership of a Division of General Practice; Royal Australian College of General Practitioners (RACGP) affiliation; membership of the Australian Medical Association; personal history of cancer; family history of cancer; awareness of RACGP guidelines; Australian Gastroenterology Institute/Australian Cancer Society guidelines; and Gut Foundation of Australia (GFA) guidelines; and practice location (metropolitan or other18). All independent variables were included in the full model. A further variable -- belief that FOBT/flexible sigmoidoscopy is an effective screening test -- was included in the model to predict behaviour. A backwards stepwise modelling strategy was used to identify significant independent variables, whereby all dependent variables were initially included and non-significant terms were progressively eliminated. Significance was assessed using the Wald chi-squared statistic. Results We received 855 usable questionnaires from 1271 eligible GPs (67% response rate). The response rate for women (75%) was significantly higher than that for men (63%) (chi-squared = 15.4, 1 df, P < 0.001), but did not vary with age, vocational registration status, RACGP affiliation, or practice size and location. GP views about screening GP views about the effectiveness of screening for colorectal cancer in preventing premature deaths are shown in Box 2. More GPs believed flexible sigmoidoscopy to be effective (61%) than believed FOBT to be effective (38%), but there was substantial uncertainty about both screening tests, with 25% and 30% of GPs unsure. Independent predictors of believing either test to be effective are summarised in Figure 1. For FOBT, these comprised increasing GP age and State of practice (specifically, South Australia). For flexible sigmoidoscopy, they comprised increasing GP age, male sex, and awareness of the Gut Foundation guidelines (which favour screening). GPs' views on appropriate screening frequencies and target groups are shown in Box 2. Most often chosen frequencies were every year for FOBT (29%), and five-yearly for flexible sigmoidoscopy (24%). However, 19% and 26%, respectively, were unsure of the appropriate screening interval. The most often cited target group was people aged over 40 years with first-degree relatives with colorectal cancer: 63% of GPs would offer FOBT and 74%, flexible sigmoidoscopy. Self-reported practice Likelihood of suggesting colorectal cancer screening is shown in Box 3. Fewer than 3% of GPs were "highly likely" to adopt an opportunistic approach to colorectal cancer screening for a 58-year-old patient (by either test) or to recommend flexible sigmoidoscopy screening during a dedicated health check-up. More would be "highly likely" to recommend FOBT during a dedicated health check -- 15% if the patient was a man and 9% if a woman. This sex difference was significant (McNemar's chi-squared = 43.7, 1 df, P < 0.0001). Independent predictors of being "highly likely" to include FOBT in a health check-up are shown in Figure 2. They comprised increasing GP age, State of practice, and belief in the effectiveness of the tests. Usefulness ratings of guidelines available at the time of the survey are shown in Box 4. While RACGP, AGI/ACS and GFA guidelines were rated as "very" or "somewhat" useful by 33%, 50% and 45% of respondents, respectively, they were unable to be recalled by 52%, 35% and 41%. Discussion Our study suggests considerable confusion about colorectal cancer screening at the "front line" of general practice. About a third of respondents believed that FOBT was an effective screening test in average-risk individuals, while two-thirds believed this of flexible sigmoidoscopy. These beliefs are inconsistent with the evidence available at the time of our study: level II (randomised controlled trial) evidence19 that FOBT reduced colorectal cancer mortality, but only level III (case-control study) evidence20 supporting flexible sigmoidoscopy. A wide range of responses were given about appropriate screening frequency. This is not surprising, as the three guidelines available at the time offered different and contradictory advice, and none met the criteria for being systematically evidence-based. Further confusion is likely if yet more guidelines8 are published that contradict the evidence-based AHTAC guidelines.7Far fewer GPs reported using the screening tests than reported they were effective; most respondents did not use the tests. This discordance was greater for sigmoidoscopy than for FOBT. Again, it is likely that the lack of clarity and the variation between guidelines, as well as availability of conflicting information and educational material, have caused uncertainty among GPs, with concomitant inconsistency in their behaviour. Perhaps FOBT is used more often than sigmoidoscopy because it is easier to arrange. Increasing GP age and physician belief in screening effectiveness independently predicted self-reported provision of screening. South Australian GPs were more likely to advocate screening, perhaps because of research studies and community-based initiatives in that State.10 GPs also favoured screening men rather than women for colorectal cancer. Sex bias not been reported previously in colorectal cancer screening, and may reflect the higher incidence of colorectal cancer among men.21 Alternatively, perhaps GPs place a lower priority on colorectal cancer screening in women, for whom cervical and breast cancer screening are widely performed, but a higher priority in men, for whom there is, as yet, no "male cancer" screening of proven benefit. National levels of self-reported use of screening tests were less than previously reported,15,22,23 although the higher levels in South Australia were consistent with earlier data.10 GPs' wider endorsement of screening for "above-average-risk" individuals with first-degree relatives with colorectal cancer (63%-74%) was similar to the levels found in recent studies (80%-94% GP support),10,15 but considerably higher than in a similar 1982 study (23% GP support).22 Screening of relatives is apparently becoming more acceptable. Usefulness and recall of guidelines was low, similar to other recent findings.15 Our results suggest an urgent need for a national colorectal cancer screening policy. As GPs remain the most respected source of health information,24 it is vital they have access to timely and accurate information. The AHTAC report, released in 1998, was necessary but insufficient. If GPs are to be involved in implementation of colorectal cancer population screening (which, by definition, will target average-risk individuals), strategies are needed to inform them of the importance of screening and to facilitate appropriate changes in behaviour. When there has been a concerted effort to communicate agreed policy to Australian GPs (eg, about mammographic screening), uniformity of GP views has been achieved.25 However, when evidence is lacking (eg, for clinical breast examination),25 or State-based initiatives are patchy,26 it appears that GPs differ considerably in their views of screening effectiveness and self-reported behaviour. Our study concentrated on screening average-risk individuals, for which previous guidelines have been confusing, non-evidence based and at variance with each other. Most guidelines distinguish between screening for average-risk and above-average-risk individuals, generally recommending colonoscopic screening for above-average-risk groups (eg, those with familial adenomatous polyposis and hereditary non-polyposis colorectal cancer). Clearly, strategies for effective evidence-based screening of above-average-risk groups must also be promoted. Thus, our results reveal our failings to date as an organised healthcare system to provide GPs with timely, consistent and evidence-based health policy, as they and their patients deserve. Our study provides a baseline against which the effectiveness of future dissemination of colorectal cancer screening policy may be measured. Acknowledgements A Commonwealth General Practice Evaluation Program seeding grant funded this study. We thank the GPs who participated in our research with no financial incentive, Phoebe Holt for contributing to questionnaire design, and Tracey Bruce for diligent survey administration. The study was approved by the Ethics Committee of the Royal Prince Alfred Hospital, Sydney, NSW. References Woodward A, Weller D. Colorectal cancer: implications of mass screening for public health. Med J Aust 1990; 153: 81-88. Guidelines for screening for colorectal cancer. Sydney: Australian Gastroenterology Institute, 1991. Australian Cancer Society. National cancer prevention policy, 1993. Sydney: Australian Cancer Society, 1993. Bolin T, Collopy B, Cowen A, et al. Colorectal cancer: prevention, diagnosis and treatment. Sydney: The Gut Foundation and Colorectal Surgical Society of Australia, 1993. Goulston K, St John DJ, Bokey L, et al. Guidelines for early detection, screening and surveillance for colorectal cancer. 2nd ed. Sydney: Australian Gastroenterology Institute and Australian Cancer Society, 1994. Guidelines for preventive activities in general practice. 3rd ed. Sydney: Royal Australian College of General Practitioners, 1994. Australian Health Technology Advisory Committee (Standing Committee of the National Health and Medical Research Council). Colorectal cancer screening. Canberra: Commonwealth Department of Health and Family Services, 1997. Clinical Oncological Society of Australia and Australian Cancer Network. Guidelines for the prevention, early detection and management of colorectal cancer. Draft 3. June 1998. Better health outcomes for Australians. Canberra: National Health Goals and Targets Section, Department of Human Services and Health, 1994. Cockburn J, Thomas R, McLaughlin S, et al. Acceptance of screening for colorectal cancer by flexible sigmoidoscopy. J Med Screen 1995; 2: 79-83. Rae L. Community screening for colorectal cancer in north-eastern New South Wales, 1987-1996. Med J Aust 1998; 168: 382-385. King J, Fairbrother G, Thompson C, Morris D. Colorectal cancer screening: optimal compliance with postal faecal occult blood test. Aust N Z J Surg 1992; 62: 714-719. King J, Fairbrother G, Thompson C, Morris D. Influence of socioeconomic status, ethnicity and an educational brochure on compliance with a postal faecal occult blood test. Aust N Z J Public Health 1994; 18: 87-92. Olynyk J, Aquilia S, Fletcher D, Dickinson J. Flexible sigmoidoscopy screening for colorectal cancer in average-risk subjects: a community-based pilot project. Med J Aust 1996; 165: 74-76. Olynyk J, Aquilia S, Platell C, et al. Colorectal cancer screening by general practitioners: comparison with national guidelines. Med J Aust 1998; 168: 331-334. Ward J, Bruce T, Holt P, et al. Labour-saving strategies to increase response rates in general practice surveys. Aust N Z J Public Health 1998; 22: 394-396. Statistical Package for the Social Sciences. SPSS for Windows 7.5.1. Chicago (Ill): SPSS Inc, 1996. Commonwealth Department of Primary Industries and Energy and Commonwealth Department of Human Services and Health. Rural, Remote and Metropolitan Areas Classification: 1991 Census edition. AGPS, Canberra: 1994. Mandel J, Bond J, Church T, et al. Reducing mortality from colorectal cancer by screening for fecal occult blood. N Engl J Med 1993; 328: 1365-1371. Selby J, Friedman G, Quesenberry C, Weiss N. A case-control study of screening sigmoidoscopy and mortality from colorectal cancer. N Engl J Med 1992; 326: 653-657. Jelfs P, Coates M, Giles G, et al. 1996 Cancer in Australia 1989-1990 (with projections to 1995). Canberra: Australian Institute of Health and Welfare (Cancer Series No. 5). Macrae FA, Hill DJ, Dent O, et al. Colorectal cancer: knowledge and attitudes of doctors in Victoria. Aust N Z J Med 1982; 12: 278-283. Rolfe I, Pearson S. Screening recommendations in general practice: a survey of graduates from different medical schools. Med J Aust 1996; 165: 14-17. Cumming R, Barton G, Fahey P, et al. Medical practitioners and health promotion: results from a community survey in Sydney's western suburbs. Community Health Stud 1989; 13: 294-301. Young J, Ward J, Holt P. Breast cancer screening in Australian general practice: results of a national survey. Med J Aust 1998; 169: 364-368. Ward J, Donnelly N, Holt P. Impact in general practice of the policies of the organised approach to preventing cancer of the cervix. Aust N Z J Public Health 1998; 22: 336-341. (Received 25 Jun, accepted 28 Oct, 1998) Author's details Division of Community and Rural Health, University of Tasmania, Hobart, TAS. Michael J Sladden,FRACGP, MAppEpid, Honorary Senior Lecturer. Needs Assessment and Health Outcomes Unit, Central Sydney Area Health Service, Sydney, NSW. Jeanette E Ward, PhD, FAFPHM, Director. Reprints will not be available from the authors. Correspondence: Dr M J Sladden, Division of Community and Rural Health, PO Box 252-33, University of Tasmania, Hobart, TAS 7001. Email: M. Sladden@utas.edu.au Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> Figure 1 : Independent predictors of general practitioners (GPs) reporting that faecal occult blood testing or flexible sigmoidoscopy is effective in reducing premature deaths from colorectal cancer. Back to text Figure 2 : Independent predictors of general practioners (GPs) reporting they would be "highly likely" to discuss faecal occult blood testing during a deicated health check-up with a 58-year-old patient. (Adjusted odds ratios with 95% confidence intervals are available from the authors.)Back to text 1: Recommendations about colorectal cancer screening for average-risk* people Gut Foundation of Australia (1993)4 Screening by annual FOBT; consider 3-5-yearly flexible sigmoidoscopy Australian Gastroenterology Institute/Australian Cancer Society (1994) 5 Routine screening not recommended; can be performed at patient request Royal Australian College of General Practitioners (1994)6 Screening not recommended Australian Health Technology Advisory Committee (1997)7 Screening by FOBT; research required to determine method and frequency Clinical Oncological Society of Australia/Australian Cancer Network (draft 1998)8 Screening by annual FOBT; consider 5-yearly flexible sigmoidoscopy FOBT=faecal occult blood test. *Asymptomatic people aged over 50 years with no family history Back to text Back to text Back to text Back to text

Michael J Sladden · Jeanette E Ward

Editorial Databases and evidence-based medicine in general practice We have built it, but will they come? MJA 1999; 170: 52-53 In the early 1990s, evidence-based medicine (EBM) became the focus for improving healthcare.1 Since then, there has been a steady stream of rigorously researched clinical practice guidelines,2 the birth of specialised extracting journals such as Evidence Based Medicine, Evidence Based Mental Health and Evidence Based Nursing and the inception and growth of the Cochrane Collaboration and the Cochrane Library. The latter includes the Database of Systematic Reviews and the Database of Abstracts of Reviews of Effectiveness, available either online or on CD-ROM.3 The essence of EBM is that decision making in healthcare should be influenced by the best available evidence and clinical experience, and the practice of EBM means integrating individual clinical expertise with the best external evidence from systematic research.4 Integral to this is access to, and interpretation of, the evidence in systematic reviews, meta-analyses, evidence-based practice guidelines and evidence databases. The usefulness of evidence databases in real-time clinical practice was recently highlighted in the Journal by the report that 72% of Australian neonatologists and 44% of obstetricians regularly used evidence databases to guide their care of patients.5 In this issue of the Journal, Young and Ward report on Australian general practitioners' use of the Cochrane Library.6 Although 43% of GPs (14% at work) had access to the Internet and 22% were aware of the Cochrane Library, only 6% had access to it and 4% had ever used it. These findings are mirrored in the United Kingdom, where the Cochrane Library Database of Reviews has a higher recognition rate among GPs (40%) but the rate of use (4%) is remarkably similar.7 What the findings of Young and Ward mean for the current use of EBM in general practice awaits a comprehensive national study on the usefulness, relevance and framework of the tools of EBM in Australian general practice. Simplistic explanations for their findings include the low connectivity of our GPs to databases or the limited relevance of these databases -- which emphasise therapeutic interventions rather than diagnosis and prognosis or other types of clinical questions8 -- to general practice. General practice, which centres on the individual patient-doctor relationship and the interaction between biomedical, personal and contextual perspectives, may require different research strategies and allowance for more "circumstantial" evidence rather than the "watertight" evidence accrued by randomised controlled trials.9 It is ironic that with the emphasis on evidence in EBM there is so little published information on the attitudes of Australian GPs towards EBM, the education and skills they require to access and interpret evidence, and the support they need to incorporate EBM into everyday general practice. A recent UK survey of GPs has shed some light on these issues by showing that, although most GPs welcomed the move to EBM and agreed that this would improve patient care, there was a low level of awareness of extracting journals, review publications and relevant databases such as the Cochrane Library.7 While UK GPs expressed a desire to increase their knowledge of the methods and vocabulary of EBM, the major barrier they perceived to practising EBM was a lack of time.7 This finding strongly suggests that for EBM to succeed in general practice information needs to be relevant and available in the clinic within minutes rather than hours.8 Such information might be provided by an intermediate service,10 in the way that pathology or radiology services are currently provided to support GPs. What are Australian GPs' perceptions of EBM? Although there is no information directly comparable with the UK findings, two local surveys11,12 have found that: Topics identified by health policymakers for the development of guidelines are not necessarily synchronous with GPs' perceived needs;12 The source of guidelines is critically important for the perceived credibility of guidelines (eg, in 1995 the Australian Cancer Society and the Australian Medical Association outranked nine other organisations, including the National Health and Medical Research Council [NHMRC] and the Royal Australian College of General Practitioners);12 and Online dissemination of evidence is perhaps before its time, as GPs express a strong preference for guidelines in a booklet compiled in one official document -- a preference perhaps consistent with the respondents' low rate of Internet access at the time of the survey.12 Nonetheless, there is a need for comprehensive information on the context and use of EBM in Australian clinical practice. This requirement has recently been addressed by the NHMRC through its Evidence Based Clinical Practice Program, which promotes and funds research into strategies for implementing and sustaining the use of EBM in different Australian healthcare environments, and into the effect of EBM on patient outcomes.13 Answers for these critical questions are not expected before the year 2000. Interventions to promote behavioural change among healthcare professionals Consistently effective interventions Educational outreach visits Reminders Multifaceted intervention combining two or more of: audit and feedback, reminders, local consensus processes, or marketing Interactive educational meetings in which healthcare providers participate in workshops Interventions of variable effectiveness Audit and feedback (or any summary of clinical performance) Promotion by local practitioners identified by their colleagues as influential Including participating practitioners in discussions to ensure that they agree that the chosen clinical problem is important and the approach to managing the problem is appropriate Any intervention aimed at changing the performance of healthcare providers for which specific information was sought from or given to patients Interventions that have little or no effect Distribution of recommendations for clinical care, including clinical practice guidelines, audiovisual materials, and electronic publications Didactic educational meetings such as lectures All of these considerations revolve, of course, around the perception and usefulness of EBM in general practice. Another prerequisite for the widespread use of the paraphernalia of EBM in general practice is a change in GPs' behaviour. Interventions for influencing behaviour which may have some bearing on introducing research into clinical practice have been identified by Bero et al,14 and are summarised in the Box (above). The effectiveness of such interventions among Australian GPs remains to be explored. In the movie Field of Dreams (1989, Universal Studios), a farmer (Kevin Costner) builds a baseball stadium in the isolation of the midwestern cornfields of the United States to summon the ghosts of past players. With poignant conviction, he says, "Let's build it, and they will come". Although the framework of EBM has been built, will our profession come? What are appropriate tools and interventions for encouraging doctors, and particularly GPs, to practise EBM? On these questions, we need some real evidence. Martin B Van Der Weyden Editor, The Medical Journal of Australia Evidence Based Medicine Working Group. Evidence based medicine: a new approach to teaching the practice of medicine. JAMA 1992; 268: 2420-2425. Smallwood RA, Lapsley HM. Clinical practice guidelines: to what end? Med J Aust 1997; 166: 592-595 The Cochrane Collaboration <http://wwwsom.fmc.flinders.edu.au/FUSA/COCHRANE/>. Sackett DL, Richardson WS, Rosenberg WR, Haynes RB. Evidence-based medicine: how to practice and teach EBM. New York: Churchill Livingstone, 1997: 2. Jordens CFC, Hawe P, Irwig LM, et al. Use of systematic reviews of randomised trials by Australian neonatologists and obstetricians. Med J Aust 1998; 168: 267-270. Young JM, Ward JEW. General practitioners' use of evidence databases. Med J Aust 1999; 170: 56-58. McColl A, Smith H, White P, Field J. General practitioners' perceptions of the route to evidence based medicine: a questionnaire survey. BMJ 1998; 316: 361-365. Glasziou PP. Applying the evidence to the individual. Evidence-Base Health Advice Workshop. Nov 4-5 Melbourne. Melbourne: The Menzies Foundation and National Health and Medical Research Council. 1998. Jacobson LD, Edwards AGK, Granier SK, Butler CC. Evidence-based medicine and general practice. Br J Gen Pract 1997; 47: 449-452. Fowler C. Evidence-based learning in general practice. Br J Gen Pract 1996; 46: 754-755. Gupta L, Ward JE, Hayward RSA. Clinical practice guidelines in general practice: a national survey of recall attitude and impact. Med J Aust 1997; 166: 69-72. Gupta L, Ward J, Hayward RSA. Future directions for clinical practice guidelines: needs, lead agencies and potential dissemination strategies identified by Australian general practitioners. Aust N Z J Public Health 1997; 21: 495-499. Rubin GL, Frommer MS, Vincent N, Phillips PA. Disseminating and implementing the evidence. Evidence-base Health Advice Workshop. Nov 4-5 Melbourne. Melbourne: The Menzies Foundation and National Health and Medical Research Council. 1998. Bero LA, Grilli R, Grimshaw JM, et al. Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. BMJ 1998; 317: 465-468. Make a comment Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Research General practitioners' use of evidence databases Jane M Young and Jeanette E Ward MJA 1999; 170: 56-58 For editorial comment, see Van Der Weyden Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - More articles on General practice and primary care Abstract Objective: To determine the awareness and use of the Cochrane Library and access to the Internet by general practitioners in New South Wales. Design: Cross-sectional postal survey in September 1997. Participants: 311 of 428 (73% response rate) randomly selected general practitioners in New South Wales. Main outcome measures: Proportion of respondents with access to the Internet at home or at work; proportion of respondents aware of, with access to, and ever using the Cochrane Library; independent predictors of awareness of the Cochrane Library. Results: 134 respondents (43%) had access to the Internet either at home or at work; 42 (14%) were "on line" at their workplace. Seventy (22%) were aware of the Cochrane Library, although only 20 (6%) had access to it and 13 (4%) had ever used it. Those in group practice and members of Divisions were independently more likely to be aware of the Cochrane Library. Conclusions: As patient outcomes will improve with systematic implementation of evidence-based treatments, these low rates of access to useful evidence databases raise issues regarding the best ways to support general practitioners with information technology. Introduction There has been increasing interest in the use by clinicians of evidence databases and other resources, such as systematic reviews, meta-analyses and evidence-based guidelines, as aids for clinical decision-making. The first report of Australian clinicians' use of evidence databases was recently published in the Journal.1 In that study, 72% of neonatologists and 44% of obstetricians reported using evidence databases, with higher rates of use among those familiar with computers. Although lack of awareness of evidence databases does not preclude evidence-based practice,2 the inability of practitioners to access research findings readily at the time of decision-making is a major impediment to best practice.3Because of the breadth of their work, general practitioners have diverse needs for evidence to inform their practice.4 Accessible evidence databases potentially represent an essential resource to meet these needs. The Cochrane Library, which includes the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effectiveness (Box 1), is recognised as one of the best resources for evidence. General practitioners can use it on CD-ROM or through the Internet. Research from other countries suggests that general practitioners are reluctant to embrace information technology to support evidence-based clinical decision-making. Two recent surveys both reported that, at most, 40% of British general practitioners were aware of the Cochrane Database of Systematic Reviews.5,6 Furthermore, despite positive attitudes towards evidence-based medicine, general practitioners reported low levels of use of either printed or electronic summaries of evidence, even among those who were aware of these resources.6 In 1995, it was reported that a quarter of a national random sample of Australian general practitioners had access to a computer with a modem but less than 10% had access to the Internet.7 No reports have been published more recently to assess the uptake of information technology by general practitioners. The aim of our study was to determine New South Wales general practitioners' current awareness of, access to, and use of the Cochrane Library, and their access to the Internet both at home and at work. Methods Survey content and administration We added the following questions to a statewide random postal survey of general practitioners in NSW conducted in September 1997:Are you aware of the Cochrane Library? Do you have access to the Cochrane Library? Have you ever used the Cochrane Library? Do you have access to the Internet at your practice? Do you have access to the Internet at home? Respondents could indicate "Yes", "No" or "Unsure" to each of these questions. Respondents also completed eight standard sociodemographic questions. A copy of the questionnaire is available from the authors on request. Four hundred and twenty-eight eligible general practitioners in NSW, randomly selected from a commercial list, were contacted by telephone in advance of our survey. Two mail reminders and a telephone prompt were used to maximise the response rate. Data analysis Proportions and 95% confidence intervals were calculated for responses to questions about the Cochrane Library and Internet. The univariate association between awareness of and access to the Cochrane Library and personal and professional characteristics of respondents were assessed using c2 tests, or Fisher's exact test where expected cell frequencies were less than five. Logistic regression using a backwards stepwise modelling strategy was then carried out to identify factors that significantly and independently predicted positive responses to these questions. All analyses were conducted using SAS for Windows.8 Ethics approval This study was approved by the Central Sydney Area Health Service Ethics Review Committee and the Human Ethics Committee of Sydney University. Results We received completed questionnaires from 311 general practitioners (73% response rate). Although the response rate for women (80%) was significantly higher than for men (70%) (chi-squared = 4.5; df = 1; P = 0.03), respondent characteristics were similar to those of general practitioners in NSW.9 Respondents ranged in age from 24 to 72 years (mean, 45 years), 96 (31%) were women, 236 (76%) worked full time, and 202 (65%) were in group practice. Professional characteristics of respondents included RACGP affiliation (141; 45%), AMA membership (109; 35%), and membership of a Division of General Practice (242; 78%). A third of respondents (107; 34%) had trained with the Family Medicine Program. Responses to the questions about the Cochrane Library and Internet are shown in Box 2. Less than a quarter of respondents were aware of the Cochrane Library and only 13 (4%) had used it. Nearly one in five respondents were unsure if they had access to this resource. One hundred and thirty-four respondents (43%) had access to the Internet either at home or work, significantly higher than the 9% reported previously (chi-squared = 86.6; df = 1; P < 0.001).7 Awareness of the Cochrane Library was unrelated to age (t = -1.1; df = 298; P = 0.2) or sex (chi-squared = 0.6; df = 1; P = 0.4). The only significant associations were with general practice Divisional membership and working in group practice. These variables remained independently predictive of awareness of the Cochrane Library following logistic regression analysis (Box 3). The number of respondents who had actually used the Cochrane Library were too few for further analysis. Discussion Overall, 22% of respondents were aware of the Cochrane Library. As awareness was greater among those in group practice and members of their local Division, peer contact appears to be an important mechanism to promote evidence databases. Nonetheless, the level of awareness in our study was considerably lower than that reported in the United Kingdom,5,6 where the Cochrane Database of Systematic Reviews has been available since 1992.10 However, our finding that only 4% of respondents had ever used the Cochrane Library is comparable. Our finding of a marked uptake since 1995 of Internet access by general practitioners is reassuring. Nearly half had Internet access either at home or at their practice. However, only 14% were "on-line" at their practices, where clinical decisions are likely to be made. Evaluation of strategies to support the uptake of information technology for desktop Internet access will be an immediate challenge in ensuring evidence databases are used in general practice. Access to evidence databases is crucial to support the scientific paradigm now advocated in healthcare.11 Having accessed an evidence database, general practitioners can focus on treatments for which there is Level I (meta-analysis of randomised controlled trials) or Level II (randomised controlled trials) evidence of effectiveness. By ensuring treatments with such compelling evidence are used, GPs can confidently anticipate that their patient outcomes will positively and predictably improve. Less confidence can be placed on interventions for which only Level IV (descriptive case reports) evidence exists. Measurement and improvement of care based on Level I or II evidence of effectiveness should also be emphasised in quality assurance activities.12 Three years ago it was argued that "the health care system needs an infrastructure for the dissemination of evidence-based medicine into clinical practice".13 Subsequently, some people have suggested that general practitioners need mediated search services.14 Other problems to overcome include training general practitioners to appraise evidence4 and to incorporate research findings into their daily consultations with patients.15 Our findings suggest we have a long road ahead. Since June 1998, members of the Royal Australian College of General Practitioners (RACGP) have had access to the Cochrane Library through the RACGP Virtual Resource Centre. Evaluation of the impact of electronic evidence resources, including evidence databases or Web-based guidelines, on decision-making in general practice is the next step. Initiatives to encourage evidence-based decision-making in general practice are likely to generate dissatisfaction with the limitations of currently available evidence.16 We are optimistic this will accelerate the quality and quantity of research conducted in general practice. Syntheses of current knowledge prevent the reinvention of wheels or repetition of past mistakes, minimising expenditure on populist strategies without strong evidence of effectiveness. Gaps in current knowledge of effective interventions in clinical practice are tellingly revealed in evidence databases, inviting a responsive academic research agenda. General practitioners adopting an evidence-based approach may be more inclined to participate in research which is relevant, rigorous and responsive to gaps in evidence sorely felt in clinical decision-making. Acknowledgements The participation of general practitioners in our research, without financial incentive, is acknowledged gratefully. We thank Nancy Harding for organisational support and Leonie Cambage for data entry. J M Y is supported by an NHMRC research scholarship. References Jordens CFC, Hawe P, Irwig LM, et al. Use of systematic reviews of randomised trials by Australian neonatologists and obstetricians. Med J Aust 1998; 168: 267-270. Phillips PA. Disseminating and applying best evidence. Med J Aust 1998; 168: 260-261. Haines A, Jones R. Implementing findings of research. BMJ 1994; 308: 1488-1492. Ridsdale L. Evidence-based learning for general practice. Br J Gen Pract 1996; 46: 503-504. Prescott K, Lloyd M, Douglas HD, et al. Promoting clinically effective practice: general practitioners' awareness of sources of research evidence. Fam Pract 1997; 14: 320-323. McColl A, Smith H, White P, Field J. General practitioners' perceptions of the route to evidence based medicine: a questionnaire survey. BMJ 1998; 316: 361-365. Gupta L, Ward J, Hayward RSA. Future directions for clinical practice guidelines: needs, lead agencies and potential dissemination strategies identified by Australian general practitioners. Aust N Z J Public Health 1997; 21: 495-499. SAS for Windows [computer program]. Version 6.11. Cary, North Carolina: SAS Institute, 1995. Commonwealth Department of Health and Family Services. General practice in Australia: 1996. Canberra: Commonwealth of Australia, 1996. Silagy C. Randomised controlled trials: the challenge of Archie Cochrane. Med J Aust 1993; 158: 656-657. Risdale L. How do you know? The process of scientific reasoning. In: Evidence-based general practice: a critical reader. London: WB Saunders, 1995; 160-169. Ward J, Del Mar C, Colmer P, O'Connell D. Quality and outcomes in general practice. In: General practice in Australia: 1996. Canberra: Commonwealth of Australia, 1996; 169-199. Ahmed T, Silagy C. The move towards evidence-based medicine. Med J Aust 1995; 163: 60-61. Fowler C. Evidence-based learning in general practice. Br J Gen Pract 1996; 46: 754-755. Jacobson LD, Edwards AGK, Granier SK, Butler CC. Evidence-based medicine and general practice. Br J Gen Pract 1997; 47: 449-452. Campion-Smith C. Evidence-based general practice. Br J Gen Pract 1997; 47: 462. (Received 18 May, accepted 15 Sep, 1998) Authors' details Needs Assessment and Health Outcomes Unit, Central Sydney Area Health Service, Newtown, NSW. Jane M Young, MB BS, MPH, Postgraduate Fellow; Jeanette E Ward, PhD, FAFPHM, Director. Reprints: Associate Professor J E Ward, Needs Assessment and Health Outcomes Unit, Central Sydney Area Health Service, Locked Bag 8, Newtown, NSW 2042. Email: jwardATnah.rpa.cs.nsw.gov.au Make a comment Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Jane M Young · Jeanette E Ward

Legal implications of clinical practice guidelines Clinical practice guidelines may be used as evidence, but this should not distract doctors from their advantages. MJA 1998; 169: 292-293 Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances.1 Formulated by the United States Institute of Medicine, this definition was used by the National Health and Medical Research Council (NHMRC) in its work on clinical practice guidelines. In 1995, the NHMRC published guidelines for the development and implementation of clinical practice guidelines.2 It described a worldwide focus on guidelines ". . . prompted by concern about unjustifiable variations in clinical practice for the same condition, the increased availability of new treatments and technology and uncertainty as to the effectiveness of many interventions in improving people's health and a desire to make the best use of available health resources".2 The NHMRC emphasised the need for clinical practice guidelines to be based on the best available evidence. Relevant to this need are principles of evidence-based medicine, which entail the explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.3 Since 1995, the NHMRC has published nine clinical practice guidelines: on early breast cancer, coronary heart disease, depression in young people, prevention of stroke, uncomplicated lower urinary tract symptoms in men, unstable angina, preterm birth, diabetic retinopathy, and acute pain management.4 Clinical practice guidelines are not intended to replace clinical judgement, nor can they. They are not prescriptive, but serve to guide practitioners in making relevant clinical interventions. Used correctly, they can assist more informed and meaningful patient participation in treatment decisions. They can enhance and maintain professional standards and quality assurance programs. By reducing unnecessary variations in practice they may encourage cost-effective healthcare. Despite these potential benefits, some doctors are uncertain about the legal implications of clinical practice guidelines. One study found that Australian general practitioners did not regard legal implications as very important to their decision to follow guidelines.5 In another survey, 32% of clinicians were unsure whether guidelines on managing early breast cancer would be used to sue doctors and 45% agreed or strongly agreed that they would.6 In a survey of surgeons' opinions about the NHMRC clinical practice guidelines for the management of early breast cancer (published in this issue of the Journal), 41% of surgeons felt that guidelines would protect clinicians from legal implications, whereas 37% believed clinicians would be exposed to increased medicolegal problems by using them.7 The risk of legal liability is not unimportant, but for medical practitioners to approach clinical practice guidelines from a defensive perspective may well deny them and their patients the opportunity to achieve optimal health outcomes, an objective of paramount importance to the medical profession. The law imposes on a medical practitioner a duty to exercise reasonable care and skill in the provision of professional advice and treatment. This duty is a single, comprehensive one covering all the ways in which a doctor is called upon to exercise his or her skill and judgement. It extends to the examination, diagnosis and treatment of a patient, the provision of information and the processes of obtaining the patient's consent to treatment.8 The word reasonable is important. As a former Chief Justice of the High Court of Australia observed: "It is easy to overlook the all-important emphasis placed upon the word 'reasonable' in the statement of the duty. Perfection or the use of increased knowledge or experience embraced in hindsight after the event should form no part of the components of what is reasonable in all the circumstances."9 The standard of reasonable care and skill required is that of the ordinary skilled practitioner exercising and professing to have the capabilities required in the particular field of medical practice under consideration.8 In ascertaining what, in a particular case, constitutes reasonable care and ordinary skill in the relevant medical discipline, a court will usually receive evidence of the practice of medical practitioners and the state of medical knowledge at the relevant time. This evidence is usually given as expert opinion from medical witnesses and is of considerable significance when there are allegations of negligence in diagnosis or treatment. However, evidence of professional practice cannot dictate to a court the standard of care applicable to the clinical facts before it. The court will determine the standard demanded by the law in the practice of medicine (or, indeed, in the practice of any other profession). Clinical practice guidelines might be introduced into evidence before a court either by a plaintiff or by a defendant doctor. If so, it is likely that they would be included within the evidence of an expert medical witness given in the usual way. Soundly based clinical practice guidelines may well serve to make medical expert opinion more reliable and acceptable to a court,10 but are unlikely to alter the usual evidentiary processes in litigation. In considering the probative value of any clinical practice guidelines in evidence before it, a court would need to be satisfied, by appropriate evidence of their manner of formulation, of the quality and reliability of the medical/scientific evidence upon which they are based as well as their currency, acceptance and use by the profession. In an appropriate case, a medical witness called to give expert opinion evidence on behalf of a plaintiff might refer to clinical practice guidelines, offering the opinion that the defendant doctor had wrongly departed from the guidelines in the treatment of the patient. It would be open to a defendant doctor to counter this with evidence that the guidelines were not available at the time, outdated or not relevantly endorsed, or that clinical factors justified departure from the guidelines in the exercise of professional judgement, or that the treatment given did in fact comply with the guidelines. Given their purpose and evidence-based foundation, it is unlikely that clinical practice guidelines will promote litigation. Arguably, they may well reduce it by reducing any uncertainty about what constitutes reasonable medical practice. The legal implications of clinical practice guidelines were considered recently at a forum convened by the New South Wales Department of Health, together with the NHMRC National Breast Cancer Centre and United Medical Protection Ltd. A summary of the recommendations arising from the forum and the basis for their formulation are reported in this issue of the Journal.11 When properly understood, clinical practice guidelines will be appreciated for the significant beneficial purposes for which they are designed. In considering acceptance and use of clinical practice guidelines, the medical profession should not be distracted by speculation about legal implications. Nevertheless, as it appears that patients have become more litigious and doctors more vulnerable to allegations that they have failed their patients,12 clinical practice guidelines may become an important part of clinical risk management. Ultimately, care may well come to be regarded as less than reasonable should clinical practice guidelines be available but not followed, unless this can be justified on appropriate clinical grounds. Peter Dwyer Barrister 11th Floor, St James Hall 169 Phillip Street, Sydney, NSW Field MJ, Lohr KN. Clinical practice guidelines: directions for a new program. Washington, DC: Institute of Medicine. National Academy Press, 1990. National Health and Medical Research Council. Guidelines for the development and implementation of clinical practice guidelines. Canberra: NHMRC, 1995. Sackett DL, Richardson WS, Rosenberg WR, Haynes RB. Evidence-based medicine: how to practice and teach EBM. New York: Churchill Livingstone, 1997: 2. Smallwood RA, Lapsley HM. Clinical practice guidelines: to what end? Med J Aust 1997; 166: 592-595. Gupta L, Ward J, Hayward RSA. Clinical practice guidelines in general practice: a national survey of recall, attitudes and impact. Med J Aust 1997; 166: 69-72. Ward JE, Boyages J, Gupta L. Local impact of the NHMRC early breast cancer guidelines: where to from here? Med J Aust 1997; 167: 362-365. Carrick S, Benevista B, Redman S, et al. Surgeons' opinions about the NHMRC clinical practice guidelines for the management of early breast cancer. Med J Aust 1998; 169: 300-305. Rogers v Whitaker (High Court of Australia) 175 CLR 479. Per Barwick CJ in Maloney v Commissioner for Railways (NSW) [1978] 52 ALJR 292 at 292. Tjiong RTT. Reforming the law on expert evidence. Med J Aust 1998; 168: 53-54. Pelly JE, Newby L, Tito F, et al. Clinical practice guidelines before the law: sword or shield? Med J Aust 1998; 169: 330-333. Tomkins C. Recent trends in litigation worldwide -- the implications for Australia. J Med Defence Union July 1998: 2-4. - Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Peter Dwyer

Retaining a medical workforce in rural Australia Professional satisfaction is a major concern for rural doctors MJA 1998; 169: 293-294 For at least 10 years, the imbalance of general practitioners in rural and remote areas of Australia has been addressed by successive health policies and strategies. These activities are driven in large part by a desire for equity of access to and quality of medical care in our rural and remote communities. Seminal in the early considerations in attracting and maintaining a rural medical workforce were the reports by Kamien1 to the Western Australian and Shehadie2 to the New South Wales departments of health. Both reports disclosed a need for support for rural doctors, particularly in access to continuing medical education (CME) and provision of locums. These reports were instrumental in the formation, in 1988, of the NSW Rural Doctors Resource Network and, in 1990, of the Western Australian Centre for Rural and Remote Medicine. In 1993, the Commonwealth Department of Human Services and Health launched the General Practice Rural Incentives Program (GPRIP), which aimed to attract doctors through relocation, retraining and remote area grants, and to retain them by addressing access to CME and locum support. This issue of the Journal includes two reports which have implications for Australia's rural workforce. Bruening and Maddern3 disclose a profile of rural surgeons that is one of predominantly middle-aged men whose major concerns include continual on-call work, lack of locum relief, and peer isolation. Although the majority of surgeons intend to remain in rural practice until retirement, the ageing of our rural surgical workforce has obvious implications. Kamien4 provides unique information on why doctors stay in or leave rural practice by examining the major concerns and practice intentions of rural doctors in 1986 and their practice locations by 1996. Those doctors who remained in rural practice had successfully resolved their 1986 concerns; those who left had not. For the latter, unresolved concerns included access to CME, overwork, forced deskilling, and professional isolation. Kamien also highlights the major concerns which would influence doctors currently in rural practice to leave; these include problems in achieving professional satisfaction as pressures (such as hospital closures) on the provision of rural health services increase. The whole issue of retention of doctors in rural practice is attracting renewed attention and recently several researchers have addressed this issue. Hoyal has proposed that important influences in this are professional factors influencing the doctor, social and other factors affecting the doctor's family, and community influences.5 While listing a range of professional factors, he also highlighted the need for community backing for the local hospital as well as emotional, professional and financial hospital support for the doctor. In a survey of Queensland doctors who had recently left rural practice, Hays and colleagues6 found that these doctors emphasised the positive aspects of rural practice to be professional autonomy and support, community relationships, work variety, family lifestyle and continuity of care. The downside included after-hours workload, poor access to CME and locums, personality clashes, and lack of family educational opportunities. In proposing retention strategies, Hays et al developed a conceptual model of a balance between influences to stay or to leave, and triggers that could shift this balance. While acknowledging that personal (eg, personality clashes) and family (eg, children's education) triggers may be difficult to address, they proposed professional retention strategies that could be readily addressed. These include provision of CME, locum cover, management training for doctors, and educational packages for families. They also suggested that local support and early intervention structures could be developed through Divisions of General Practice. A recent consultancy to GPRIP has produced a discussion paper on models of sustainable practice in rural and remote Australia.7 The focus on "sustainable practice" instead of "retention" helps to highlight another element of focusing on a continuity of rural medical service. The discussion paper proposes that strategies for sustainability include those issues that promote sustainability of the individual doctor (including access to CME, locums, and family support), those that promote sustainability of the practice environment (including the relationship with the local health service provider), and those that promote sustainability of the community. It is evident that the strategies for practice sustainability are largely concentrated on the needs expressed by rural doctors over the past 10 years. In many States these have been coupled with rurally targeted financial support for services provided in public hospitals. The concept of a continuous workforce by readily available replacement of doctors has been taken up in the short term with relocation and retraining support by GPRIP, and in the longer term by early exposure of undergraduates to rural medicine and support for entrance to medical schools of students from a rural background. At the national level needs have also been identified. Those proposed in a discussion paper of the Australian Medical Association and the Rural Doctors' Association of Australia8 include a national medical workforce recruitment and retention scheme; a nationally consistent system of granting clinical privileges; continued and increasing refinement of postgraduate, vocational and continuing medical education; the introduction of retention payments and development of information technology; innovative practice structures; and Aboriginal health strategies. Some or all of these can be developed or implemented at State level. The new Rural Workforce Agencies and Divisions of General Practice are ideally placed to develop the strategies that allow both long term and emergency impact on the triggers for leaving rural practice. It would seem that a major task for the Rural Workforce Agencies and Rural Doctors Associations in each State will be to bring cohesion to retention strategies while promoting regional and local flexibility. While those support strategies that have been working must continue, the major challenge will be in promoting the autonomy and self-esteem of rural doctors that Kamien suggests. This will need to be done by negotiating with health service provider organisations and communities to develop strategies that allow doctors the professional satisfaction of providing their medical skills to those communities, thereby maximising the health status of rural Australians. Ian Cameron Chief Executive Officer, NSW Rural Doctors Network Suite 19, 133 King Street, Newcastle, NSW 2300 Western Australian Health Department (M Kamien, Chairman). Report of the Ministerial Inquiry into the Recruitment and Retention of Country Doctors in Western Australia. Perth: Western Australian Health Department, 1987. Shehadie N. Report of the Committee of Enquiry Into Services Provided by General Medical Practitioners to Country Public Hospitals. Sydney: New South Wales Department of Health, 1987. Bruening MH, Maddern GJ. A profile of regional surgeons in Australia. Med J Aust 1998; 169: 324-326. Kamien M. Staying in or leaving rural practice: 1996 outcomes of rural doctors' 1986 intentions. Med J Aust 1998; 169: 318-321. Hoyal FMD. Retention of rural doctors. Aust J Rural Health 1995; 3: 2-9. Hays B, Veitch PC, Cheers B, Crossland L. Why doctors leave rural practice. Aust J Rural Health 1997; 5: 198-203. Models of sustainable practice in rural and remote Australia. Discussion paper. Rural and Remote General Practice Program, Commonwealth Department of Health and Family Services, Canberra, March 1998. Increasing rural medical services. Discussion paper. Australian Medical Association and Rural Doctors' Assocation of Australia. Canberra, March 1998. - Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Ian Cameron

Staying in or leaving rural practice: 1996 outcomes of rural doctors' 1986 intentions Max Kamien MJA 1998; 169: 318-321 For editorial comment, see Cameron Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - ©MJA1998 Abstract Objective: To examine the 1996 outcomes of a sample of Western Australian rural doctors who in 1986 had indicated their intentions to stay in or leave rural practice. Design: Postal questionnaire survey in December 1996, semi-structured interview and feedback by doctors on a draft of this article. Participants: 91 respondents from the 101 doctors who in 1986 had filled in a questionnaire on their intentions to stay in or leave rural practice. Main outcome measures: Proportion of doctors whose actions by 1996 were at variance with their intentions in 1986, and the reasons for their change of direction. Results: 49% (22/45) of doctors who intended to leave had stayed ("stayers") and 24% (11/46) who intended to stay had left ("leavers"). Doctors' main concerns in 1986 were overwork, lack of locum relief, professional contact with colleagues, specialist backup in emergencies, downsizing of hospital facilities, continuing medical education, and income. By 1996 stayers had solved most of these professional problems and felt they were doing a special job which made a difference to their community. Conversely, more than half the leavers were unable to solve these problems and felt disempowered and dispirited. Their most potentially solvable problems were overwork, forced deskilling and conflict with other healthcare professionals. Conclusion: Professional satisfaction was the main reason for doctors staying in or leaving rural practice. Professionally dissatisfied rural doctors reach a critical phase which they have to surmount if they are going to stay. An examination of the positive experiences of the stayers points the way to retaining at least half the potential future leavers. Introduction Much is known about recruiting doctors to rural practice, but less on how to retain them.1-3 A difficulty in researching retention of doctors in rural practice is a lack of baseline data on the intentions of the doctors. In 1986, the Western Australian Minister for Health commissioned an inquiry into the recruitment and retention of rural doctors.1 Those doctors who did not make written or oral submissions to the 1986 inquiry were then sent a questionnaire which included an item on how long they intended to stay in rural practice. The focus of my study is on those doctors whose subsequent actions by the end of 1996 were at variance with their stated intentions in 1986. Methods In 1986, 121 doctors answered questions on their intention to leave or stay in rural practice and on factors which would influence their decision. At the end of 1996, various local and national databases were used to find these doctors. Twenty were either retired, overseas or not on any Australian medical register. The remaining 101 doctors were sent a questionnaire and 91 returned a completed reply. The 1986 responses of those doctors were used to classify these doctors in 1996. If, in 1986, the doctors stated they would stay another five years and were still there in 1996, they were classified as "stayers". If, on the other hand, they said they would still be in rural practice for 10 or more years but left before 1996, they were classified as "leavers" (Figure). The 1996 questionnaires to leavers and stayers contained similar questions but were worded according to the doctors' intentions in 1986 and their actions by 1996. For example, leavers were asked if a lack of locum relief had influenced their decision to leave, while stayers were asked if the availability of locum relief had influenced their decision to stay. Data were analysed with SAS for Windows,4 using Fisher's exact test. To improve depth of understanding of the questionnaire responses, five randomly chosen leavers and 10 stayers were interviewed by one research officer using a semi-structured questionnaire. A further random sample of 15 respondents were asked for comment on whether the findings of my study conformed with their experiences and those of their rural practice colleagues. Results Eleven (24%) of those who intended to stay in rural practice in 1986 had left by 1996 and 22 (49%) of those who intended to leave had stayed (Figure). Six of the stayers had moved from one rural area to another: two from one regional centre to another; one from one rural practice to another; one from one remote practice to another; one from a rural practice to a salaried position in a regional hospital; and one from a remote to a rural practice. This last doctor was the only one to mention medicolegal concern as a contributory reason for changing from a single-doctor practice to a rural group practice. The main reasons for relocating rural practices were to prevent deskilling, especially in anaesthetics, and to reduce workload. There was little difference in demographic characteristics between the leavers and the stayers (Box 1). The only statistically significant variable was the unexpected finding that the leavers were more likely to have completed a rural internship (P < 0.05). Other unexpected findings were that the leavers were more likely to be practising in the medical discipline of their first choice and stated, in 1986, that they would choose the same discipline given their life over again. Although both groups had equivalent postgraduate qualifications in 1986, all but two of the leavers had acquired further qualifications before leaving rural practice. The most commonly held qualifications were a Diploma of Obstetrics and Fellowship of the Royal Australian College of General Practitioners. In 1986, the two main professional satisfactions of both the leavers and stayers were providing full and continuous patient care and the ability to practise procedural medicine. A third professional satisfaction was the feeling of doing a special job for their community, and this was reported by 11 stayers but by only one leaver (P < 0.05). Seventeen stayers also reported the social enjoyment and esteem of being involved with the community, compared with only five of the leavers. This involvement was distinct from simply enjoying the quality of life from living in a rural area. In the words of one stayer: "I enjoy the feeling of being a big fish in a small pond." This was not a statement of arrogance but of self- efficacy. In 1996, five of the leavers reported their spouses' desire to move as a contributory factor, but only one as a definitive factor, in their decision to leave, while two stayers reported their spouse's view as a major influence in their decision to stay. However, there was little difference between the spouses (all were female) of the leavers and stayers with respect to rural background, work situation, attitudes to a rural lifestyle and 1986 intentions to stay in a rural area beyond 1996 (Box 2). Of those spouses with a professional qualification, all were nurses, except for two who were primary school teachers and who left before 1996. There was no statistical difference between families in which one or both partners were professionals with regard to staying or leaving rural practice. Box 3 shows the importance of various retention issues in doctors' decisions to leave or stay in rural practice. In 1986, the stayers were more concerned with being overworked, unable to find locums, the lack of specialist backup when managing emergencies, the adequacy of hospital facilities, and income. By 1996, the stayers had solved most of these problems, and this was important in their decision to stay. Conversely, the leavers had been influenced to leave because of these problems, and had left before 1994, by which time many of the problems were being addressed by the Western Australian Centre for Remote and Rural Medicine (WACRRM), the Rural Doctors' Association of Australia (RDAA), the Australian Medical Association (WA) Locum Services and the Federal Government's General Practice Rural Incentives Program. The leavers' mean age at leaving was 42 years and the mean time for leaving was 4.6 years from when they were surveyed in 1986 (range, 1-8 years). The final decision to leave rural practice was made after periods of deliberation ranging from two months to three years (mean, 10 months). The main reasons why leavers left rural practice were a desire to change professional direction through specialisation or to pursue a special interest (eg, medical education), burn-out, and disillusionment from the downgrading of hospital facilities resulting in an inability to fully use their skills (Box 4). The main social reasons for leaving were children's education and difficulties with marital relationships. Overwork, deskilling, conflict with other healthcare professionals, lack of privacy, poor income and inadequate housing (all potentially solvable) accounted for 60% of the problems and involved six of the leavers. Box 5 shows the main reasons why those who intended to leave stayed in rural practice. More than 60% of reasons for staying were related to job satisfaction, with the remaining reasons divided between social and financial issues. However, 12 stayers reported that interference with factors which contributed to their job satisfaction would make them seriously consider leaving rural practice. This included bureaucratic interference from State or Federal government (6 doctors), downgrading of local services (3), and overwork (3). The next-most-common reasons which could cause doctors to leave rural practice were personal and family difficulties (5). Discussion The number of doctors who were stayers was twice the number who were leavers. In agreement with a recent Queensland study, the main reasons for staying were the professional satisfaction of the variety of work, autonomy of practice and the social and personal satisfaction of rural life.5 Also important was the feeling of doing an important job. Conversely, some leavers felt disempowered and unable to regain control over their own life. Although both groups had comparable qualifications in 1986, the leavers had acquired more postgraduate qualifications by 1996. This gave them greater options and possibly greater confidence to change their professional direction. In 1986, the eventual stayers reported a much higher prevalence of problems than did the eventual leavers. By 1996, the stayers had solved most of these problems, including the provision of those hospital facilities which enabled the full use of their clinical and procedural skills. This indicates that professionally dissatisfied rural doctors have reached a critical phase which has to be negotiated if they are going to stay. The most common profile for such a doctor is a man aged 42 years, discouraged by deskilling from downgrading of hospital facilities or clinical privileges, with children aged 13 to 15 years (when the hard decisions about schooling and matriculation opportunities have to be made). Much effort is required to discover and assist these doctors; this is an important task for organisations such as WACRRM, RDAA and rural divisions of general practice. For Queensland rural doctors, the triggers to leaving were difficulties in coping with change, perceived problems with secondary education for children, poor housing, and personality clashes with colleagues. The ultimate pressures to leave were constancy of after-hours work, difficulty in obtaining locum relief, access to continuing medical education, bureaucratic requirements and family pressures.5 These factors also apply in Western Australia. But also important were professional isolation and the downgrading of hospital facilities, preventing the full use of the doctor's procedural skills. These two factors would also influence many stayers to leave rural practice. This is illustrated by the statements of a stayer who relocated in order to maintain his clinical skills, and by a leaver: "I am self-reliant, and have become disillusioned by interference from outside agencies like the Health Insurance Commission, Medicare, government, the Australian Medical Association, the Royal Australian College of General Practitioners, Divisions etc. I am waiting for the day when I will be asked to relinquish my duties in accident and emergency because I do not hold a fellowship in emergency medicine -- it just seems to be the way things are moving. I also wonder if the day will come when I can auction my provider number like a crayfisherman with a crayfish licence." "I would have stayed except that I was forced to be deskilled. Prior to commencing rural practice I spent three years training in emergency medicine, anaesthetics, surgery, caesarean sections etc. There were no medical mishaps, yet these procedures were stopped in the two country towns I worked in." It is therefore important not to create unnecessary problems and, where problems exist, to counter them. Health departments, in particular, need to be clear about their aims and should value rural doctors as a scarce resource and include them in deliberations about change. The ultimate criteria for decisions on rural workforce and hospital facilities should be the maintenance of essential services sufficient to provide safe medical care to rural and remote Australia and to use the full skills of doctors already resident in those areas. In turn, rural doctors need to be more innovative and flexible in devising methods to reduce their professional isolation, practise procedural medicine, and gain some relief from being constantly on call. Flexibility is also essential from medical organisations and statutory bodies. The doctor in this study who left for financial reasons had a recognisable qualification in psychiatry and wished to practise it on a 40% time basis. National Specialist Qualification Advisory Committee regulations did not allow him to be classified as a consultant psychiatrist, making his practice financially unviable and depriving 80 000 people of resident psychiatric expertise. He commented: "I had a specialist qualification and was happy to use it but got no cooperation from the Commonwealth Government to come to some accommodation to pay for consultant psychiatric services. So I could only charge the same fee as a dermatologist for prolonged consultations and this simply wasn't financially viable. I was sad to leave after 10 years, but the more of my speciality I did, the less I earned, and we were simply getting deeper into debt." The increasing accent on rural issues in undergraduate medical education, the rising proportion of women doctors and the decreasing migration of doctors trained outside Australia make it difficult to estimate the needs for the rural workforce in the next decade. A 1997 study of Australian rural doctors predicts that only 50% will be in their current practice in 2007 and, for Western Australia, only 20%.6 Western Australia will therefore have to recruit 250 doctors over the next decade simply to keep pace with anticipated loss. Attention to factors shown to be important in retaining doctors would have an appreciable effect on reducing this loss. In this study more than half the doctors who intended to stay left for professional and, to a lesser extent, for social reasons which were potentially preventable. Reducing this avoidable loss is therefore an important factor in maintaining the rural workforce. The other main factor in retention is to understand and facilitate the conditions which reinforce the autonomy, efficacy and self-esteem of rural doctors. Acknowledgements Thanks are due to Mrs Rosalind Woodcock, who was a Research Officer on this project, and to all the doctors whose participation and insights made the project possible. This project was funded by the Australian Rural Health Research Institute. References Western Australian Health Department (M Kamien, Chairman). Report of the Ministerial Inquiry into the Recruitment and Retention of Country Doctors in Western Australia. Perth: Western Australian Health Department, 1987. South Australian Health Commission, Royal Australian College of General Practitioners (SA), Australian Medical Association (SA). Review of general medical practice in South Australia. Third report: country general practice. Adelaide: South Australian Health Commission, 1992. Strasser R. Rural general practice in Victoria: the report from a study of the attitudes of Victorian rural general practitioners to country practice and training. Moe: Monash University Centre for Rural Health, 1992. SAS for Windows [computer program]. Version 6.11. Cary, North Carolina: SAS Institute, 1995. Hays RB, Veitch PC, Cheers B, Crossland L. Why doctors leave rural practice. Aust J Rural Health 1997; 5: 198-203. Strasser R, Hays R, Kamien M, Carson D. National rural general practice study. Draft report. Moe: Monash University Centre for Rural Health, 1997. (Received 16 Feb, accepted 1 Jun, 1998) Authors' details University of Western Australia, Perth, WA. Max Kamien, MD, FRACGP, Professor and Head of General Practice. Reprints: Professor M Kamien, Professor of General Practice, University of Western Australia, 328 Stirling Highway, Claremont, WA 6010. E-mail: mkamienATcyllene.uwa.edu.au - Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Max Kamien

Clinical practice guidelines before the law: sword or shield? Janet E Pelly, Liza Newby, Fiona Tito, Sally Redman and Amanda M Adrian Clinical practice guidelines are designed to improve patient care by promoting best practice. But what is the status of clinical practice guidelines in law? MJA 1998; 169: 330-333 For editorial comment, see Dwyer Subsequently cited in Maddern, Surgery and evidence-based medicine, MJA 1998; 169: 348-349. Introduction - Questions and answers - Where to next? - Acknowledgements - References - Authors' details - - ©MJA1998 Introduction The purpose of clinical practice guidelines (CPGs) is to achieve better health outcomes by improving the practice of health professionals and by better informing consumers about management options.1There is good evidence that CPGs can improve patient management. A review of 59 studies2 which evaluated the effect of CPGs on clinical care detected significant improvement in the process of care in all but four of the studies. Nine of 11 trials that assessed the outcome of care reported significant improvements.2 Despite the widespread recognition of CPGs' potential value in improving care, their legal status has been unclear and of growing concern to some health professionals. For example, the National Health and Medical Research Council National Breast Cancer Centre (NBCC) surveyed a representative sample of 150 surgeons to determine their views on the NHMRC Clinical Practice Guidelines for the Management of Early Breast Cancer;3 37% felt that the guidelines would increase their exposure to medicolegal problems, while 41% felt that CPGs would protect clinicians from legal problems.4 It is perhaps not surprising that there is a lack of clarity about how CPGs may be used in a legal arena. In particular, there is confusion about whether doctors will be more, or less, vulnerable to a successful lawsuit if they follow guidelines or depart from guidelines for sound clinical reasons. Will the guidelines be a shield, enabling doctors to show that they were not negligent because they followed the CPGs? Or will they be a sword, enabling a plaintiff's lawyers to establish negligence in court when they show that the doctor's treatment of the patient departed from the CPGs? How will the courts deal with the fact that proper clinical management of individual patients cannot always be achieved by strict adherence to guidelines? Because of the time lag before malpractice cases come to court, litigation currently before court often relates to incidents which occurred several years before CPG use became widespread. To date, CPGs have rarely, if ever, been used as evidence in medical litigation, and there is virtually no judicial comment on their legal status. There is little information available, even from the United States. In one of the few studies that looked at how guidelines are used in the US legal system,5 259 randomly selected insurance company malpractice claims were reviewed and 960 medical malpractice attorneys were surveyed. Clinical guidelines were important or used as evidence in only 6% of surveyed cases and, significantly, were used by both plaintiff and defendant. However, this study related to claims which were opened in 1990-1991, a period when rigorously developed, evidence-based guidelines were not common.5 Interestingly, CPGs did appear to play a role in the decision to settle; 27% of attorneys reported that the existence of guidelines in respect of a particular disease or condition had influenced their decision to settle, and 26% of plaintiffs' attorneys reported that guidelines were influential at least once in the previous year in a decision not to take a case.5 Against this background, and because of concerns by some clinicians about the adoption of the NHMRC's early breast cancer guidelines, the NBCC commissioned a research paper in June 1997 on the medicolegal implications of CPGs. A forum was then convened to address several issues relating to the law and CPGs (Box 1). Where do guidelines fit in the legal process? The commissioned research paper6 explored the Australian and international experience and concluded that: Clinical practice guidelines neither hinder nor encourage litigation directly -- they are simply likely to be considered another form of expert evidence; or evidence of practice in a court case. In considering CPGs as "just another form of expert evidence", the authors of the paper noted that the evidentiary value of guidelines depends on their purpose, development, ratification, dissemination, use, and whether they are current. For example, in the United Kingdom, judges do not automatically equate established guidelines with reasonable and proper medical practice. Questioning (in court) may address the scope of the guideline, how it was developed and adopted, the mandatory force of its recommendations, the existence of known exceptions to its application, and whether any school of medical thought rejects it and adopts a different approach to treatment.7 The same rules would apply in Australia and the United States. In Australia, the NHMRC has established a nationally credible and effective process for the development, ratification and endorsement of CPGs, and in October 1995 published Guidelines for the development and implementation of clinical practice guidelines,1 which is currently being updated. Endorsement by a recognised expert body such as the NHMRC may add weight to the evidentiary value of guidelines, as can formal evaluations which establish the clinical efficacy of the guideline. Where CPGs are accepted as good evidence of appropriate practice, it can be more difficult for a doctor whose actions and decisions are not consistent with the CPG's recommendation to defend a case simply on the basis of customary local practice.6 Recommendation of the forum: see points 1, 2, and 3 (Box 2). How will guidelines be considered as evidence? Some clinicians are concerned that courts will treat CPGs as inflexible rules of conduct, and thus reduce the scope for individual clinical judgement in particular cases. However, the result of any litigation will depend on the evidence brought before a court. The patient who is suing a doctor must prove negligence on the part of the doctor. Where a clinician has not followed a CPG, there is no automatic assumption of negligence. A clinician could show that the guideline was not relevant in a particular case. Alternatively, he or she could show that the treatment actually provided was supported by other good evidence, or that the guideline was sufficiently flexible to include the chosen treatment. Equally, following a guideline may not automatically prevent a doctor from being sued successfully for negligence. It will depend on all the evidence before the court. The authors of the research paper argue that, were CPGs not available, similar information could be adduced from the scientific information used to develop guidelines. However, there is little doubt that the meta-analysis and distillation of this often enormous volume of scientific evidence, as achieved in a rigorous guideline development process, make the research and clinical practice more understandable to a court, just as it does to an individual consumer or clinician. Therefore, guidelines can aid the legal process by presenting a clear summary of available evidence, rather than leaving the courts with the responsibility of distilling this information from expert testimony. Recommendation of the forum: see point 4 (Box 2). Will a doctor be medicolegally protected if he or she practises within the guidelines? CPGs are not designed to be prescriptive rules, but, rather, to provide guidance. They provide leeway for clinical judgement concerning the circumstances of the patient, the preferences of the patient and a range of other factors. This flexibility is explicitly stated in the introduction to the NHMRC's early breast cancer guidelines. Following them to the letter would not be possible or desirable; as such, words like "must" or "should" are not appropriate, and are not used in these guidelines. With appropriate ratification and credible standing in the health community, guidelines may well represent the agreed professional "standard of care", but the courts are the final arbiters of this standard, and retain the right to base judgments on information other than that in the guidelines. What will happen if a doctor practises outside of the guidelines? The content of CPGs pertain to the "usual" case, as CPGs are based primarily on evidence from randomised trials, which, because of inclusion and exclusion criteria and controlled clinical environments, produce an average result for the conditions studied. However, there may be many reasons for a clinician to provide care to an individual that departs from the guidelines' recommendations. The clinician may be aware of evidence other than that included in the guidelines, appraise the evidence differently to the guideline developers, be managing a person whose situation is different from that within the guidelines, or be treating a person who selects management outside of the guidelines. For example, the NHMRC's early breast cancer guidelines recommend that radiation therapy be offered after breast-conserving surgery. However, women who are carriers of a mutant ataxia telangiectasia (AT) gene have an extreme sensitivity to ionising radiation and can sustain severe normal tissue damage.8 In the rare case where a woman's AT status is known, radiation therapy would be best avoided. The paper concludes that:5 It is likely that departure from the practices advised in a guideline would be subject to the same test as any other departure from a generally accepted standard of care. Departure from practices recommended in guidelines because of ignorance of the guidelines would seem more likely to expose a doctor to risk of litigation, if a patient is damaged by a breach of the guidelines. Conscious departure from guidelines because of specific circumstances in a particular patient may be much easier to defend as consistent with an appropriate standard of care. If a clinician practises outside the guidelines, it is important to ensure that this is well documented and that appropriate strategies have been implemented. Recommendation of the forum: see point 5 (Box 2). Do consumer guides satisfy the criteria of informed consent? Australian law recognises the individual's fundamental right of self-determination,9 unless there is an overriding public policy issue to the contrary. Part of this is the right to have access to proper information on which to base decisions. Consumer versions of guidelines assist people by providing them with information about the choices available in their treatment. Just as a signed consent form is only considered to be one piece of evidence of consent, simply handing a patient a booklet about a particular condition or procedure is unlikely to be accepted as sufficient evidence of disclosure of risk by a doctor. There would also need to be evidence that the patient had had an opportunity to ask the doctor questions, as well as adequate opportunity to read and understand the material contained in the booklet. Recommendation of the forum: see point 6 (Box 2). Are guideline developers liable? Concerns have been raised that CPG developers such as the Australian Cancer Network, NBCC and NHMRC could be held liable if patient harm occurs as a result of a doctor following the guidelines. The NHMRC's Guidelines for the development and implementation of clinical practice guidelines addresses this issue:1 Normally a general publication, even where negligently collated, does not give rise to liability because the author does not owe a duty of care to the general public at large, although the guideline issuer could be held liable if a relevant close relationship can be established between them and the person who suffers a loss. If guidelines purport to be a definitive statement of the correct or appropriate procedure there would be a greater risk of liability than where the guidelines are expressly stated to be provided as a general guide subject to the medical practitioner's expert judgement in each case. As already outlined, guideline developers need to be able to demonstrate that the information in the guidelines has been properly developed and ratified. Additionally, the guidelines should clearly state that they are not a definitive statement, and note the date of development to make clear that the information is correct only to that date. Recommendation of the forum: see point 7 (Box 2). Where to next? The commissioned research paper and the forum agreed that changes should not be sought to the current legal status of guidelines. Rather, attention should be given to satisfying the criteria relating to appropriate development, ratification, evaluation and updating. If this is done, the likelihood of their acceptance within the current legal framework is enhanced. The general view at the forum was against legislating to define the status of guidelines within the legal framework. Rather, evidence-based guidelines should be used to inform the standard of care in courts of law. The forum recommended that a continuing legal education program be established to promote a better understanding in the legal profession of the role, development and use of CPGs among the legal profession. Recommendation of the forum: see point 8 (Box 2). Acknowledgements The authors would like to acknowledge the valuable contribution of The Hon. Justice Margaret Beazley of the NSW Court of Appeal to this paper. References 1. National Health and Medical Research Council. Guidelines for the development and implementation of clinical practice guidelines. Canberra: NHMRC, 1995. 2. Grimshaw J, Russell I. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993; 342: 1317-1321. 3. National Health and Medical Research Council. Clinical practice guidelines for the management of early breast cancer. Canberra: NHMRC, 1995. 4. Carrick SE, Bonevski B, Redman S, et al. Surgeons' opinions about the NHMRC clinical practice guidelines for the management of early breast cancer. Med J Aust 1998; 169: 300-305. 5. Hyams A, Brandenburg B, Lipsitz S, et al. Practice guidelines and malpractice legislation: a two way street. Ann Intern Med 1995; 122: 450-455. 6. Tito F, Newby L. Medico-legal implications of clinical practice guidelines. Sydney: NHMRC National Breast Cancer Centre, 1998. 7. Hurwitz B. Clinical guidelines and the law. BMJ 1995; 311: 1517-1518. 8. Appleby JM, Barber JB, Levine E, et al. Absence of mutations in the ATM gene in breast cancer patients with severe responses to radiotherapy. Br J Cancer 1997; 76: 1546-1549. 9. Review of professional indemnity arrangements for health care professionals [Tito F, chairman], Final Report. Compensation and professional indemnity in health care. Canberra: Commonwealth Department of Human Services and Health, 1995. Authors' details NHMRC National Breast Cancer Centre, Sydney, NSW Janet E Pelly, MA, Communications Manager. Liza Newby, LLB, MA, FAIM, former Health Services Commissioner, Victoria. Sally Redman, BA(Hons), PhD, Director. Enduring Solutions Pty Ltd, Waniassa, ACT. Fiona Tito, BA(Hons), LLB, Executive Director. NSW Department of Health, Sydney, NSW. Amanda M Adrian, RN, LLB, BA, Director, Private Health Care Branch.

Janet E Pelly · Liza Newby · Fiona Tito · Sally Redman · Amanda M Adrian

Acupuncture in Australian general practice: practitioner characteristics Gary Easthope, Justin J Beilby, Gerard F Gill and Bruce K Tranter MJA 1998; 169: 197-200 For editorial comment, see Komesaroff See also Acupuncture in Australian general practice: patient characteristics Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - ©MJA1998 Abstract Objectives: To ascertain the extent of the use of acupuncture and the characteristics of general practitioners using acupuncture. Design: Secondary analysis of 1996 Health Insurance Commission data on claims by all non-specialist medical practitioners for Medicare Benefits Schedule items for an attendance where acupuncture was performed by a medical practitioner. Main outcome measures: Use of acupuncture by general practitioners and the practitioners' sex, age, place of primary medical qualification, and the socioeconomic disadvantage index of the practitioners' practice. Results: 15.1% of general practitioners claimed for acupuncture. Acupuncture was more likely to be provided by male practitioners, by those aged 35-54 years, and by practitioners who have an overseas primary medical qualification. The socioeconomic index of the practice did not significantly affect the number of claims for acupuncture. Conclusion: Acupuncture is used by about one in seven general practitioners. Its use is associated with middle-aged practitioners, who presumably have more clinical experience. This level of use by experienced doctors suggests that a critical review of the appropriate role of acupuncture in general practice should be considered. Introduction There is interest among general practitioners (GPs) in therapies that are not part of traditional medical practice: alternative or complementary therapies.1-4 A recent MJA editorial stated that: "If 50% of Australians are using alternative treatments each year, it is essential that doctors recognise this fact and be prepared to discuss such use with their patients in a non-judgemental manner",4 while American physicians are exhorted "to begin now to integrate some aspects of alternative medicine into family practice".5General practitioners are heeding this exhortation; alternative treatments are used by 16% of GPs in Britain6,7 and Canada,8 and by 30% in New Zealand.9,10 In Germany, which has a tradition of incorporating alternative therapies into orthodox medicine, 95% of GPs use them.11 Even doctors who do not use such therapies refer patients to medical and non-medical practitioners, at rates ranging from 41% of doctors in Israel12 to 80% in New Zealand.9,10 Non-medical practitioners report that about 10% of their patients are referred from doctors.13 Acupuncture is frequently reported in studies of GPs' use of alternative therapies overseas.6,9,10-12 Meta-analyses on acupuncture,14 homoeopathy15 and spinal manipulation16 do not provide evidence for their efficacy, apart from acupuncture for adult postoperative and chemotherapy nausea and postoperative dental pain,17 and spinal manipulation for lower-back pain.18 Other explanations for adoption of these therapies by doctors must therefore be sought. The fact that medicine is a profession in which clinical judgement is considered paramount is important. Interviews with doctors using alternative therapies in Queensland found they justified such use on the basis of clinical experience.19 We studied use of acupuncture to examine doctors' use of alternative therapies. The primary reason for selecting acupuncture was that information on use was available from Medicare data; a specific item in the Medicare Benefits Schedule (now, item 173; before 1991, item 980) has been used at any attendance where acupuncture was performed by a medical practitioner since 1984. Other alternative therapies do not attract a rebate or are not clearly specified. Acupuncture is of interest in that its cost to Medicare is calculable. Methods The Health Insurance Commission (HIC) provided data on all acupuncture claims by GPs in Australia in 1996. Information was provided on the GPs' sex, age, HIC classification (Box 1) and whether their primary medical qualification was Australian or not. The postcode of each GP's major practice was also identified. To ensure no individual was identifiable, the postcode data were classified into 62 categories (later consolidated to 12 for presentation) derived from an Australian Bureau of Statistics list which allots each postcode an index of socioeconomic disadvantage (SDI).20 The postcode data are used as a surrogate measure of patient characteristics in relation to socioeconomic disadvantage on the assumption that patients generally visit doctors in their home area. Our data include the total population of GPs, and therefore any differences between categories are substantively significant. A logistic regression model was constructed using SPSS.21 Fifty-eight GPs who could not be classified either as vocationally registered or as non-vocationally registered were excluded from the logistic regression analysis. The HIC also provided data on the number of acupuncture claims made each year since 1984, and further data were extracted from the statistics on general practice provided by Medicare.22 The University of Tasmania Human Research Ethics Committee approved the study. Results Since acupuncture became a Medicare benefit item in 1984, claims have risen from 655 000 in the financial year 1984-85 to 960 000 in 1996-97 (Figure). Medicare reimbursements have increased from $7.7 million to $17.7 million. In 1996, 2997 (15.1%) of the 19 783 GPs in Australia claimed at least once for acupuncture, and 62 (0.3%) had acupuncture as their major claimed therapy (Box 2). However, acupuncture claims constituted only 0.7% of all claims by vocationally registered GPs22 and pertained only to 1.2% of patients. Doctors who provided acupuncture had a higher number of non-acupuncture claims than non-providing doctors (population mean, 5029; acupuncture providers' mean, 6632; non-providers' mean, 4743). Non-vocationally registered GPs were less likely than vocationally registered GPs to claim for acupuncture (odds ratio [OR], 0.5), while acupuncture providers were more likely to be men (OR, 1.7), aged 35-54 years (OR, 1.7) and hold primary medical qualifications from outside Australia (OR, 1.6) (Box 3). There was no significant linear or quadratic association between the odds of providing acupuncture and the SDI of the doctor's major practice. The sex and age differentials persisted, with marginally different odds ratios, when GPs were distinguished by whether they provided acupuncture infrequently (less than 1% of services), frequently (1%-25% of services) or extensively (25%-100% of services). However, for frequent and extensive providers, there was no significant difference in the odds of providing acupuncture between those qualified in Australia and those in another country. Discussion There were 960 000 Medicare claims for acupuncture in the 1996-97 financial year, costing $17.7 million in reimbursements. As the HIC data do not include acupuncture services funded by agencies such as Workers' Compensation and the Department of Veterans' Affairs or services provided in public hospitals, these figures understate the total use of acupuncture in Australia. In 1996, 15.1% of GPs in Australia claimed for acupuncture. The proportion of GPs using acupuncture in Australia is comparable to the proportion of German (15%)11 and New Zealand doctors (18%)9,10 who provide this service, but much higher than in the United Kingdom (3%).6 Acupuncture may be more accessible to patients in Australia than these results suggest because about 70% of GPs work in group practices.22 A survey of general practices in Hobart found that, although only 15% (27) of the GPs provided acupuncture, it was available in 31% (20) of practices.23 Interestingly, British research found that the use of alternative therapies was more likely in single or one-partner practices than in group practices.7 This difference between the United Kingdom and Australia may be a function either of the 10-year gap between surveys or of different payment systems. In the United Kingdom doctors are paid a set capitation fee; in Australia a fee-for-service model operates. Choice of therapy is independent of patient demand in the United Kingdom, whereas in Australia patients can "shop around". In Australia, offering a choice of conventional and alternative treatments in group practices may simply be good marketing, so that patients can select one or the other but the practice will not lose income. Doctors who provided acupuncture had a greater provision of all other medical services. This suggests that acupuncture is associated with a propensity to provide more services and a greater variety of services. Whether this means acupuncture is associated with practices that have a more complex mix of patients or presenting complaints can only be resolved by a detailed study. Men were more likely than women to provide acupuncture, and this was not a function of age (the difference remained at each age category except the eldest). In this, as in other respects, women appear to practise medicine differently from men.24 The greater likelihood of doctors aged 35-54 years providing acupuncture may be a function of experience. These practitioners may have had many patients with complaints that have not responded to conventional treatment. Given this experience, they are able to try other therapies and trust their clinical judgement as to efficacy. Those older than 65 years may have been less willing to try alternative therapies, or may have decided such therapies are not effective. There are a number of possible reasons why GPs qualified outside Australia may be more likely to provide acupuncture. These doctors may have studied acupuncture as part of their initial medical training, they may have practices in immigrant areas with high patient demand for acupuncture, or they may be subject to less peer pressure to conform to orthodox practice. Without a more detailed study no one explanation can be confirmed or disproved. Previous reports on consumers of alternative therapies suggest these therapies are the choice of young (aged 25-35 years), well-educated and financially secure people, particularly women.25 If acupuncture is an index of the use of alternative therapies, it should be provided in areas of least disadvantage (SDI categories 11 and 12). This is not the case: there was no clear difference between SDI categories (the least-disadvantaged areas, 11 and 12, having only seven frequent or extensive providers). One explanation may be that acupuncture is not claimed through Medicare in these areas. A survey of acupuncture-providing practices in Hobart suggests this is likely, as most providers (60%; 26) and practices (85%; 20) were in relatively affluent suburbs.23 Residents of such areas may also be receiving acupuncture from non-medical practitioners. Additionally, acupuncture may not be a reliable index of use of alternative therapies because it is available on Medicare. Low-income patients may try acupuncture in preference to orthodox treatments, such as physiotherapy, that they would have to pay for. Acupuncture services in Australia have risen steadily since 1984, and 2997 GPs are using acupuncture throughout Australia. Given this level of use, a study of the appropriate role of acupuncture in Australian primary care medical practice should be considered. Acknowledgements The researchers wish to thank the Government Employees Medical Research Fund, which provided funds to conduct the research. References Wardwell WI. Alternative medicine in the United States. Soc Sci Med 1994; 38: 1061-1068. Paterson C. Complementary medicine [letter]. Br J Gen Pract 1996; 46: 440. Murray RH, Rubel AJ. Physicians and healers -- unwitting partners in health care. N Engl J Med 1992; 326: 61-64. Shenfield GM, Atkin PA, Kristoffersen SS. Alternative medicine: an expanding health industry [editorial]. Med J Aust 1997; 166: 516-517. Gordon JS. Alternative medicine and the family physician. Am Fam Physician 1996; 54: 2205-2212. Wharton R, Lewith G. Complementary medicine and the general practitioner. BMJ 1986; 292: 1498-1500. Anderson E, Anderson P. General practitioners and alternative medicine. J R Coll Gen Pract 1987; 37: 52-55. Verhoef MJ, Sutherland LR. Alternative medicine and general practitioners. Opinions and behaviour. Can Fam Physician 1995; 41: 1005-1011. Hadley CM. Complementary medicine and the general practitioner: a survey of general practitioners in the Wellington area. N Z Med J 1988; 101: 766-768. Marshall RJ, Gee R, Israel M, et al. The use of alternative therapies by Auckland general practitioners. N Z Med J 1990; 103: 213-215. Himmel W, Schulte M, Kochen MM. Complementary medicine: are patients' expectations being met by their general practitioners? Br J Gen Pract 1993; 43: 232-235. Borkan J, Neher JO, Anson O, Smoker B. Referrals for alternative therapies. J Fam Pract 1994; 39: 545-550. Fulder SJ, Munro RE. Complementary medicine in the United Kingdom: patients, practitioners, and consultations. Lancet 1985; 2: 542-545. ter Riet G, Kleijnen J, Knipschild P. Acupuncture and chronic pain: a criteria-based meta-analysis. J Clin Epidemiol 1990; 43: 1191-1199. Kleijnen J, Knipschild P, ter Riet G. Clinical trials of homoeopathy. BMJ 1991; 302: 316-323. Shekelle PG, Adams AH, Chassin MR, et al. Spinal manipulation for low-back pain. Ann Intern Med 1992; 117: 590-598. Acupuncture. NIH Consensus statement online 1997 November 3-5 [4 February 1998]; 15. In press. Ernst E. Complementary medicine -- doing more good than harm? Br J Gen Pract 1996; 46: 60-61. Eastwood H. General medical practice, alternative medicine and the globalisation of health [doctoral thesis]. Brisbane: University of Queensland, 1997. Castles I, Information paper: 1991 census. Socio-economic indexes for areas. Canberra: AGPS, 1994. (Catalogue no. 2912.0.) SPSSx statistical package for the social sciences [computer program]. Chicago, Ill: SPSS Inc, 1997. Commonwealth Department of Health and Family Services. General practice in Australia: supplementary tables 1997. Canberra: AGPS, 1997. Bombardieri D. Convergence between orthodox and alternative therapies in Hobart, Tasmania [Honours thesis]. Hobart: University of Tasmania, 1997. Britt H, Bhasale A, Miles DA, et al. The sex of the general practitioner: a comparison of characteristics, patients, and medical conditions managed. Med Care 1996; 34: 403-415. MacLennan AH, Wilson DH, Taylor AW. Prevalence and cost of alternative medicine in Australia. Lancet 1996; 347: 569-573. (Received 7 Jan, accepted 17 Apr 1998) Authors' details Department of Sociology and Social Work, University of Tasmania, Hobart, TAS. Gary Easthope, MA, PhD, Associate Professor; Bruce K Tranter, BA, PhD, Lecturer. Department of General Practice, University of Adelaide, SA. Justin J Beilby, MPH, FRACGP, Senior Lecturer. Division of Community and Rural Health, University of Tasmania, Launceston, TAS. Gerard F Gill, MAE, FRACGP, Clinical Senior Lecturer. Reprints will not be available from the authors. Correspondence: Dr G Easthope, Department of Sociology and Social Work, University of Tasmania, GPO Box 252C-17, Hobart, TAS 7001. E-mail: Gary. EasthopeATutas.edu.au - Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Gary Easthope · Justin J Beilby · Gerard F Gill · Bruce K Tranter

General practice stress Winds of change buffet general practitioners MJA 1998; 169: 126-127 The long-running television series GP,1 with its changing cast of "general practitioners" and patients, nicely portrayed the enormous range and diversity of human problems which Australians expect their general practitioners (GPs) to help them solve. The series showed GPs to be ordinary humans, affected like the rest of the community by changing social and political pressures. In recent years, Australian GPs have felt particularly buffeted by their changing roles and feelings of being undervalued in comparison with their specialist colleagues. A national survey of GPs carried out in 19952 showed that, while about two-thirds were satisfied with their current role, 35 per cent indicated that they would leave general practice if they had somewhere else to go, with urban practitioners significantly more likely than their rural colleagues to report this view. The most common sources of dissatisfaction or frustration were a belief that the contribution of GPs is not appreciated by government, apprehensiveness about the changes and reforms in general practice, a belief that government was interfering in the ability to make clinical decisions, pressure to bulk bill patients, and the introduction of "blended" payments (remuneration through a mixture of fee-for-service and non-fee-for-service payments). In this issue of the Journal, Schattner and Coman3 report on a national sample of metropolitan GPs and their perceptions of stress in their work lives. One hundred and fifty-seven of the 296 respondents (53%) had considered leaving general practice because of occupational stress, and 32 (10.8%) claimed that they had experienced severe occupational stress in the past 12 months. Major work stressors (in terms of both frequency and severity) were time pressure to see patients, paperwork in general practice, and too much work to do in a limited time -- factors the authors define as linked to the context (ie, organisation and environment) rather than the content (ie, clinical duties) of general practice. Other frequent stressors were intrusion of work on family life, earning enough money, the pressure to bulk bill, the cost of practice overheads, phone interruptions during consultations, home visits during office hours, and unrealistic community expectations of the medical profession. There were complex relationships between frequency and severity of stressors -- for example, threat of litigation was ranked lowest for frequency but highest for severity. A third of respondents recorded General Health Questionnaire scores of 4 or more, and 12.8% recorded scores of 8 or more, suggesting that significant numbers of GPs are under real psychological strain. How serious is all of this? Should we be alarmed that those who are the first port of call for sick and stressed people are themselves often feeling stressed and unhappy? Or are GPs simply reflecting the fact that we are all being pushed by the pace of change and pressure to be more efficient and effective? Either way, policymakers would be unwise to ignore these findings. We are an affluent society and can afford a system in which GPs and their patients can spend relatively unpressured time together. The clinical decisions made at the first point of contact should not be made in the context of rapid throughput and time constraint. If our system is stressing the doctors, it is almost certainly also stressing their patients. So what are the solutions? The 1998-99 federal Budget4 contains a number of new initiatives in general practice which grew out of two major strategy reviews, the reports of which have recently been released: General practice. Changing the future through partnerships,5 and General practice education: the way forward.6 The Budget papers claim that these reviews mark a "watershed for general practice, providing a vision which will guide and support the work of the profession in the coming years". They argue that the achievement of this vision will depend to a large extent on building strong partnerships based on mutual trust between general practice, the community and government. The Report of the General Practice Strategy Review Group5 contained 174 recommendations, including a number relating to indexation of the GP benefits schedule, additional funding for rural workforce initiatives, incentives to promote microeconomic reform and practice amalgamations, support for expanded use of information technology, a new Practice Incentive Program to replace the unpopular Better Practice Program, and new funds for research. Most of the Review recommendations have been taken up by the Government, as outlined in the ministerial response to the Report, released on 10 June 1998.7 A report should also be available this year on the Relative Value Study, currently being undertaken under the auspices of the Department of Health and Family Services. This study is assessing the relative value of work (beginning with patient attendances) across craft groups within the medical profession, including an assessment of the relative cost structures of those activities. There are also some signs that GP leaders are talking to each other and that there is some mutual give-and-take by them with government. That, itself, is a healthy sign. Whether stress, dissatisfaction, and psychological strain for GPs working in their consulting rooms will diminish as a result of these and the many other changes on the horizon remains to be seen. Robert M Douglas Director Beverly M Sibthorpe Fellow, National Centre for Epidemiology and Population Health The Australian National University, Canberra, ACT GP [television series]. ABC Sydney: screened 1989 and 1994. Bailie R, Sibthorpe B, Douglas B, et al. Mixed feelings: satisfaction and disillusionment among Australian general practitioners. National Centre for Epidemiology and Population Health discussion paper number 12. ANU, Canberra: NCEPH, 1997. Schattner PL, Coman GJ. The stress of metropolitan general practice. Med J Aust 1998; 169: 133-137. Budget 1998-99 fact sheets. No. 4. Canberra: Department of Health and Family Services, 1998. General practice. Changing the future through partnerships. Report of the general practice strategy review group. Canberra: Commonwealth Department of Health and Family Services, 1998. General practice education: the way forward. Report of the ministerial review of general practice training. Canberra: Commonwealth Department of Health and Family Services, 1998. The Government's response to the reviews of general practice: general practice -- foundations for the future. Canberra: Commonwealth Department of Health and Family Services, 1998. - Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Robert M Douglas · Beverly M Sibthorpe

The stress of metropolitan general practice Peter L Schattner and Greg J Coman MJA 1998; 169: 133-137 For editorial comment, see Douglas & Sibthorpe Abstract - Introduction - Methods - Results - Sex differences - Discussion - Acknowledgements - References - Authors' details - - ©MJA1998 Abstract Objective: To identify the work-related stressors of Australian metropolitan general practitioners (GPs). Design and setting: A descriptive postal survey of metropolitan GPs from all States and Territories selected at random from the Health Insurance Commission database. Participants: 296 of 464 GPs (64%) surveyed in June 1996; 67% were male; 87% worked full-time (more than 6 sessions per week). Main outcome measures: Frequency and severity of work stresssors in general practice; overall feelings of stress at work in the past 12 months; effects of the stressors on work satisfaction; contribution of work stress to overall life stress; responses to the 12-item General Health Questionnaire (GHQ) as potential correlates of occupational stress. Results: "Time pressure to see patients" was the most frequently reported stressor. Threat of litigation was perceived as the most severe stressor. Of the top 10 severe stressors, seven were also in the top 10 for stressor frequency. Work was the major stressor in GPs' lives. The GHQ scores did not correlate significantly with major stress outcome measures, but 12.8% of GPs had scores indicative of severe psychiatric disturbance. Fifty per cent of respondents had considered leaving their current workplace and 53% had considered abandoning general practice because of occupational stress. GPs working 6 or more sessions per week were more likely to be moderately or severely stressed than those working part-time (P < 0.02, Fisher's exact test). Those who had considered leaving their current workplace or careers were also more likely to be moderately or severely stressed (P < 0.0001, Fisher's exact test). Conclusions: The most frequent and relatively severe stressful events in general practice involved time pressures. There are implications for government, which, through remuneration policies, might influence GPs to work at a rate beyond their capacity to cope. Strategies are required to manage or prevent stress in metropolitan GPs. Introduction Stress has been defined as a response to challenging events.1 It is usually thought of as "distress" or an inability to cope with an external factor (the "stressor"). In the workplace it is generally referred to as occupational stress. Australian and international studies suggest that general practice is a stressful occupation.2-7 The extent to which GPs feel stressed by various aspects of their occupation may affect the quality of patient care and may also affect practitioners' health. Health problems experienced by GPs include alcohol and drug abuse,8-10 marital disruption and divorce,3,11,12 anxiety,3,13 burnout,14 depression,15 as well as suicide and attempted suicide.16,17 The specific characteristics that make general practice so stressful are largely unknown, although anecdotal evidence would suggest that time and financial issues are major stress factors for Australian GPs. In our study we aimed to identify the sources, frequency and severity of occupational stress experienced by metropolitan GPs; the importance of occupational stress compared with other life stressors; the effects of the work stressors on GPs' job satisfaction; and the possible effects of these stressors on GPs' psychological health. Rural GPs were not included, as factors such as isolation and difficulty in obtaining locum relief suggest this group should be studied separately.18 Methods General practitioner recruitment and survey distribution A list of 500 potential survey participants was obtained from the Health Insurance Commission database of the Commonwealth Department of Human Services and Health (now the Department of Health and Family Services). Potential participants were randomly selected from the population of GPs in all States and Territories who had capital city practices only and more than 1500 consultations annually (the number generally accepted by the General Practice Evaluation Programme as the definition of "active" GPs). The Department advised that potential participants had not recently been surveyed through this database. Questionnaires were mailed to all 500 GPs in June 1996. Non-respondents to the first mailout were sent a second questionnaire in July 1996, and non-respondents to this prompter were telephoned to request their participation in August 1996. Survey instrument We used a four-part questionnaire to collect data on:(1) GPs' demographic and practice information. (2) The frequency and severity of potentially stressful events in general practice, using a 28-item list developed from an extensive literature review which included validated stress-screening instruments,4,5,6,18 and input from a Melbourne-based GP focus group. A four-point Likert-like scale was used, with 3 representing "frequently, at least weekly"; 2, "occasionally, at least monthly"; 1, "rarely, a few times a year"; and 0, "does not occur". Another four-point Likert-like scale, with 3 representing "severe stress"; 2, "moderate stress"; 1, "mild stress"; and 0, "no stress", was used to assess stress severity for each item. (3) The effects of stressors on GPs' job satisfaction, including asking them to (a) indicate on a four-point scale (from 0 = none to 4 = severe) their overall work stress levels in the previous 12 months; (b) rank six aspects of general practice in order of contribution to work stress levels, from 1 for the greatest contribution to 6 for the least; (c) distinguish between stressors related to job content (ie, clinical duties) and job context (ie, environmental and organisational factors) (see Box 1); (d) rank six potential sources of life stress in order from 1 for the greatest source of stress to 6 for the least stressful. (4) The 12-item General Health Questionnaire (GHQ),19 used to determine the presence of psychiatric disturbance, anxiety or depression as potential correlates of occupational stress. GHQ items have four response options, which were scored 0, 0, 1 or 1. This provides a GHQ score range from 0 to 12. Using this method, scores of less than four represent negligible psychiatric disturbance, scores between four and eight suggest moderate disturbance, and scores greater than eight indicate severe psychiatric disturbance. Data entry and analysis Data were computer-coded and analysed using the Statistical Package for the Social Sciences for Windows.20 Analyses included cross-tabulations of stress outcome measures with the demographic data shown in Box 2. Non-parametric tests were used to test for significant differences at the P = 0.05 level. Potential work stressors were ranked in order of reported frequency and severity. Ethical approval Ethical approval was granted by the Monash University Standing Committee on Ethics in Research on Humans. Results Characteristics of respondents Of the 500 questionnaires mailed, 36 were returned unopened; 296 of the remaining 464 GPs participated (response rate, 64%). Box 2 shows their demographic characteristics, which are similar to the demographic profile of Australian metropolitan general practice.21 General practice stressors Frequency of general practice stressors The most frequent stressors were related to perceived lack of time. "Time pressure to see patients", "phone interruptions during consultations" and "too much work to do in a limited time" were ranked 1, 3 and 4, respectively, in frequency, with "paperwork" the second most frequent stressor (Box 3). Severity of general practice stressors The threat of litigation (actual involvement in litigation proceedings was not an item), although perceived as one of the most stressful events in general practice, was reported relatively infrequently. However, seven of the 10 most stressful events (Box 4) were also in the top 10 for frequency. The GPs appeared to experience a number of stressors which were perceived as mild to moderate, but which occurred frequently. The mean ratings for the three most severe stressors -- "threat of litigation", "too much work to do in a limited time" and "earning enough money in general practice" -- were between "mild" and "moderate". Effects of stress Overall work stress The Figure shows that most GPs (273/296; 92%) reported some feelings of stress, with 241 (81%) labelling it "mild" or "moderate" and 32 (10.8%) "severe". When asked about levels of stress in the past 12 months, 121 (41%) of GPs said they had increased, 118 (40%) said they had stayed the same, and 33 (11%) said they had decreased. Fifty per cent of GPs surveyed had considered leaving their current workplace, and 157 (53%) had considered abandoning general practice because of occupational stress. Factors associated with high overall work stress levels When the GPs' reported experience of work stress was cross-tabulated with the demographic variables reported in Box 2, the only significant association was that GPs working six or more sessions per week were more likely to be moderately or severely stressed than those working part-time (P < 0.02, Fisher's exact test). Those who had considered leaving their current workplace or abandoning their careers were also more likely to be moderately or severely stressed (P < 0.0001, Fisher's exact test). Six major causes of occupational stress Of the six most stressful aspects of general practice high workload was rated worst, followed, in descending order, by economic factors (income, running a business) and "medicopolitical" factors (involvement with professional associations, government pressures). Clinical factors and the effect of work on outside life were rated fourth and fifth, respectively, and the physical working environment was considered the dimension which contributed the least to the stresses of general practice (Box 5). These rankings were based on the means of rank scores; the first two items ranked significantly ahead of the other factors (P < 0.05). Sixty per cent of the GPs said that their experience of stress arose mainly from "job context" rather than from "job content". Comparisons with other life stresses Work was the major source of overall stress in GPs' lives, followed closely by financial concerns (Box 6). General Health Questionnaire data The 12-item GHQ was used to assess respondents' levels of psychiatric morbidity, especially depression and anxiety. The mean GHQ score was 3.01 (95% confidence interval, 2.66-3.35), suggesting that, on average, GPs experience low levels of psychiatric disturbance. However, almost a third (30.7%) of respondents recorded GHQ scores of 4 or more and 38 (12.8%) recorded scores of 8 or more, suggesting that many GPs are clinically depressed, anxious, or experiencing other psychiatric symptoms. The responses to three GHQ questions were of concern. These were Item 5 ("Have you recently felt constantly under strain?"), to which 7.1% responded "much more than usual"; Item 9 ("Have you recently been feeling unhappy and depressed?"), to which 5.1% responded "much more than usual"; and Item 11 ("Have you recently been thinking of yourself as a worthwhile person?"), to which 6.1% responded "not at all". Box 7 shows that, while significant, correlations between GHQ scores and the stress measures were not high. The highest correlation (0.53) was with GPs' overall perception of stress in the past 12 months. Sex differences There were small but statistically insignificant differences in the responses of men and women. Discussion Our study indicates that, while the worst stressors in general practice are perceived to be of only mild to moderate severity, many occur frequently. The study cannot determine whether there is a cumulative effect, in which a series of minor frustrations leads to a pervasive level of significant stress in GPs, but this may be an explanation as to why so many GPs have considered leaving their practices or abandoning general practice altogether. Apart from the threat of litigation, work overload issues, such as time pressure to see patients, phone interruptions and too much work to do in a limited time, were the most common stressors for GPs. Both GPs and their patients have been reported to be dissatisfied with the amount of time spent in consultations.4,7,22-25 Time pressure may be a reason for patients' reporting that GPs are not listening to what they are saying and not explaining things to them properly.26 Effects of time constraints on GPs may include irritability, frustration and, possibly, mistakes in diagnosis and treatment.4 Practice administration issues, which have not been traditionally taught to undergraduates, were rated as causing much more stress than issues of clinical competence. This may add to the pressure of high patient loads. The intrusion of work on family life was a significant stressor. Presumably, GPs would be less stressed if work did not impinge on family time or if they could see more of their family by working fewer hours. Although our list of potential sources of life stress was not exhaustive, we have not found a similar ranking attempt in the other stress studies reviewed. It would be interesting to see how this group of GPs compares with other occupational groups and the community at large in this regard. Concerns about remuneration and other financial concerns, such as the cost of practice overheads, were considered to be among the most frequent and severe stressors in this study (although they were not rated as highly as some might expect). This should be of interest to governments, which continue to emphasise cost-cutting in healthcare expenditure. It is of concern that almost a third of the respondents (91; 30.7%) had GHQ scores of 4 or more, suggesting moderate psychiatric disturbance, and that 38 (12.8%) scored 8 or more, suggesting severe disturbance. To some extent this is an independent finding; work stress cannot be blamed entirely for the presence of psychiatric disturbance in GPs, although it is likely to be a contributing factor. Our 64% response rate and the similarity of our sample's demographic profile to that of Australian metropolitan general practice21 suggest that the survey results are generalisable to urban GPs. It is possible that highly stressed GPs are under-represented because they were too stressed to comply with yet another demand on their time (the completion of a questionnaire). General practice may be no more or less stressful than many other "caring professions".4 However, the specific stressors highlighted in this study do suggest that government, healthcare policymakers, organisers of vocational training and GPs themselves should be aware of the high levels of stress experienced by doctors who choose this vocation, and steps should be taken to institute stress prevention and management. Acknowledgements Our thanks to the administrative staff at the Department of Community Medicine and General Practice at Monash University, as well as Dr Lynne Ham and Dr Chris Peterson for their expert advice on occupational stress, and Dr Con Tsalamandris for statistical analysis. This project was funded by a grant from the General Practice Evaluation Program of the Department of Human Services and Health. References Selye H. The stress of life. New York: McGraw Hill, 1976. Mawardi B. Satisfactions, dissatisfactions and causes of stress in medical practice. JAMA 1979; 241: 1483-1486. Roeske N. Stress and the physician. Psychiatr Ann 1981; 11: 245-258. Porter A, Howie J, Levinson A. Stress and the general practitioner. In: Payne R, Firth-Cozens J, editors. Stress in health professionals. Chichester: Wiley, 1987: 45-70. Makin P, Rout U, Cooper C. Job satisfaction and occupational stress among general practitioners -- a pilot study. J R Coll Gen Pract 1988; 38: 303-306. Sutherland V, Cooper C. Job stress, satisfaction and mental health among general practitioners before and after introduction of new contract. BMJ 1992; 304: 1545-1548. Sutherland V, Cooper C. Identifying distress among general practitioners: predictors of psychological ill health and job dissatisfaction. Soc Sci Med 1993; 37: 575-581. Ball J. Alcohol and drug use and related problems in the medical profession. Aust Drug Alcohol Rev 1986; 5: 29-32. Baldwin D, Hughes P, Conrad S, et al. Substance abuse among senior medical students. JAMA 1991; 265: 2074-2078. Serry N, Bloch S, Ball R, Anderson K. Drug and alcohol abuse by doctors. Med J Aust 1994; 160: 402-407. Bird H. The physician's marriage: joys and sorrows: life transition points. Facets 1979; Summer: 18-20. Miles J, Krell R, Lin T. The doctor's wife: mental illness and marital pattern. Int J Psychiatry Med 1975; 6: 481-487. Cramond W. Anxiety in medical practice: the doctor's own anxiety. Aust N Z J Psychiatry 1969; 3: 324-328. Lemkau J, Purdy R, Rafferty J, Rudisill J. Correlates of burnout among family practice residents. J Med Educ 1988; 63: 682-691. Smith M, Andrasik F, Quinn S. Stressors and psychological symptoms of family practice residents and spouses. J Med Educ 1988; 63: 397-405. Craig A, Pitts F. Suicide by physicians. Dis Nerv Syst 1968; 219: 763-772. Steppacher R, Mausner J. Suicide in male and female physicians. JAMA 1974; 228: 323-328. Dua J. Development of a scale to assess occupational stress in rural general practitioners. Int J Stress Manage 1996; 3: 117-128. Goldberg D, Williams P. Manual of the General Health Questionnaire. Windsor (UK): Nfer-Nelson, 1988. Statistical Package for the Social Sciences [computer program] release 6.0. SPSS, Chicago, Ill, USA, 1996. Commonwealth Department of Health and Human Services. General practice in Australia: 1996. Canberra: AGPS, 1996. Cartwright A, Anderson R. General practice revisited. London: Tavistock, 1981. Bates E. Doctors and their spouses speak: stress in medical practice. Sociol Health Illness 1982; 4: 25-39. Richardson IM, Howie J, Durno D, et al. A study of general practitioner consultations in North-East Scotland. J R Coll Gen Pract 1973; 23: 132-142. Brooks M, Stewart-Weeks M. Integrating consumer views about quality in general practice. Canberra: Consumers' Health Forum of Australia, 1996. Myerson S. Doctors' methods of dealing with "on going" stress in general practice. Med Sci Res 1991; 19: 267-269. (Received 7 Oct 1997, accepted 31 Mar 1998) Authors' details Department of Community Medicine and General Practice, Monash University, Melbourne, VIC Peter L Schattner, MMed BS, FRACGP, Director, Research Unit; Greg J Coman, GradDipAppPsych, MSc, Psychologist. Reprints will not be available from the authors. Correspondence: Dr P L Schattner, Department of Community Medicine and General Practice, Monash University, 867 Centre Road, East Bentleigh, Melbourne, VIC 3165. E-mail: peter.schattnerATmed.monash.edu.au - Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Peter L Schattner · Greg J Coman

How safe is Australian general practice and how can it be made safer? Current systems for preventing or responding to adverse events are inadequate MJA 1998; 169: 67-68 It is common knowledge that adverse events occur regularly in healthcare settings. While many of these events have no long term consequences or reach public attention, serious failures of modern medicine can be mortifying for patients, their loved ones and their healthcare practitioners. The risks and adverse events associated with hospital practice in Australia were documented in the Quality in Australian Health Care Study.1 In this issue of the Journal, Bhasale et al report the incident-monitoring study in Australian general practice2 -- the first reported systematic research of adverse events in general practice. Comparable research in general practice in the United Kingdom has focused on significant event auditing to provide clinical material for facilitated case discussions of specific health issues,3-5 while earlier Australian research considered the educational implications of critical events.6,7 This long-awaited study provides valuable insights into some key quality issues for Australian general practice. The authors report on 805 critical incidents submitted by anonymous, volunteer general practitioners (GPs). Each adverse event was described by the GP, who also estimated its potential for harm, immediate consequences, mitigating and contributing factors, and preventability. The study is based on an incident-monitoring method developed for anaesthetics,8 but is critical incident monitoring appropriate for general practice? We do not know whether some GPs reported only those incidents which they believed had serious potential outcomes and which they thought might be of particular interest to the researchers. Perhaps individual GPs deliberately avoided reporting cases which might have shown them in a bad light; perhaps the reverse is true. Bhasale et al acknowledge some of the methodological issues raised by their study: the non-random sample of GPs and sole reliance on GP selection and self-reporting of critical incidents. The low volunteer rate (42%) and the bias towards relatively experienced GPs may indicate that many GPs are reluctant to be involved in research of this nature. A key feature of general practice is the presentation of undifferentiated medical problems, so diagnostic uncertainty is present in many initial consultations. Vigilance is required to ensure that, where possible, such early symptoms and signs are investigated in an appropriate and timely manner, while the risks and costs of unnecessary investigations are avoided. This is often a very difficult balance to achieve in clinical practice. However, Bhasale et al report errors that arise from basic oversights rather than uncertainty: failure to review the patient's history, inadequate recognition of symptoms and signs, complications arising from drug treatments, poor legibility of prescriptions, and abnormal test results being missed or not acted upon by the practitioner. These problems may relate directly to lapses at the individual practitioner level or at the practice level. Some of these problems may soon be solved by the decision support features of computerised medical record systems and computerised prescribing. Of particular concern in the study is that 4% of the incidents were reported to result in a patient's death and 17% were reported to result in major harm, either organic or psychological. However, there is no clearly demonstrated causal link between the critical events and the deaths reported. The authors state explicitly that this type of study cannot measure the prevalence of potential or actual harmful incidents in general practice. We emphasise that it would be inappropriate to make any such generalisations from the data provided. Bhasale et al highlight key areas for quality improvement in Australian healthcare. Many of these have been alluded to in previous commentaries on hospital care,9,10 and include problems with communication between healthcare professionals and the potential dangers for patients as they move across boundaries in the healthcare system. Failure to provide hospital discharge information to GPs is a longstanding and fundamental flaw in the system. At present, there are no adequate mechanisms for reporting critical incidents or for providing feedback about outcomes, both negative and positive, to all healthcare professionals. It is encouraging to note that integration of general practice into the healthcare sector is currently the focus of considerable research effort in Australia. Problems of communication with patients, particularly the elderly, those with poor English language skills and those with mental health problems, are also highlighted by Bhasale et al. These groups must be deemed populations at particularly high risk of adverse events. General practitioners need support and awareness-raising strategies to enable them to better address the healthcare needs of these groups and other potentially high risk groups, such as people of Aboriginal or Torres Strait Islander origin and people with multiple chronic health problems. There are additional areas where quality improvement initiatives could take place. These include enhancement of the existing process for accreditation of general practices, refinement of the Quality Assurance and Continuing Education program of the Royal Australian College of General Practitioners, and development of systems for reporting critical incidents and negative outcomes to all healthcare professionals. It must be remembered that, even if the best available evidence were applied to every clinical decision made by healthcare workers in this country, critical incidents would still occur. Unfortunately, the current system does not assist individual practitioners to express concerns about errors they witness or make as, in the main, peer support is lacking when adverse events occur in general practice. Clearly, there is a need for processes that allow personal grieving while providing a systematic response to problems. Michael R Kidd Professor of General Practice, University of Sydney and Member of the New South Wales Ministerial Advisory Committee on Quality in Health Care, Sydney, NSW Bronwyn M Veale Senior Research Fellow, Department of Evidence-Based Care and General Practice Flinders University of South Australia, Adelaide, SA Wilson RM, Runciman WB, Gibberd RW, et al. The Quality in Australian Health Care Study. Med J Aust 1995; 163: 458-471. Bhasale AL, Miller GC, Reid SE, Britt HC. Analysing potential harm in Australian general practice: an incident-monitoring study. Med J Aust 1998; 169: 73-76. Pringle M, Bradley CP, Carmichael CM, et al. Significant event auditing. A study of the feasibility and potential of case-based auditing in primary medical care. Occas Pap R Coll Gen Pract 1995; 70: I-VIII. Bradley CP. Turning anecdotes into data -- the critical incident technique. Fam Pract 1992; 9: 98-103. Robinson LA, Stacy R, Spencer JA, Bhopal RS. Use facilitated case discussions for significant event auditing. BMJ 1995; 311: 315-318. Sim MGB, Kamien M, Diamond MR. From novice to proficient general practitioner: a critical incident study. Aust Fam Physician 1996; 25 Suppl 2: S59-S64. Holmwood C. How do general practice registrars learn from their clinical experience? A critical incident study. Aust Fam Physician 1997; 26 Suppl 1: S36-S40. Williamson JA, Mackay P. Incident reporting. Med J Aust 1991; 155: 340-344. McNeil JJ, Leeder SR. How safe are Australian hospitals? Med J Aust 1995; 163: 472-475. Wilson RM, Harrison BT. Are we committed to improving the safety of health care? Med J Aust 1997; 166: 452-453. - Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Michael R Kidd · Bronwyn M Veale

Analysing potential harm in Australian general practice: an incident-monitoring study Alice L Bhasale, Graeme C Miller, Sharon E Reid and Helena C Britt MJA 1998; 169: 73-76 For editorial comment, see Kidd & Veale Abstract - Introduction - Method - Results - Discussion - Acknowledgements - References - Authors' details - - ©MJA1998 Abstract Objective: To collect data on incidents of potential or actual harm to general practice patients and to evaluate the possible causes of these incidents. Design: An observational study of incidents of potential harm based on a modified critical incidents technique. A non-random sample of general practitioners (GPs) anonymously submitted incident reports contemporaneously. Setting and participants: Australian general practices between October 1993 and June 1995. During the study period, 324 GPs participated at some time. Main outcome measures: GP-reported free-text descriptions of incidents and structured responses for preventability, potential for harm, immediate consequences, predicted long-term outcomes, type of incident, contributing factors, mitigating factors, and additional resource use. Results: 805 incidents were reported -- 76% were preventable; 27% had potential for severe harm. No long term harm was predicted for 66% of incidents. Incidents could relate to pharmacological management (51 per 100 incidents), non-pharmacological management (42 per 100 incidents), diagnosis (34 per 100 incidents) or equipment (5 per 100 incidents). The most common contributory factors were poor communication between patients and healthcare professionals and actions of others (23 per 100 incidents each) and errors in judgement (22 per 100 incidents). Conclusion: Human errors and preventable system problems were identified. The incident monitoring technique provided useful data which could be applied to incident prevention strategies. Introduction Increased interest in quality improvement in healthcare has led to greater recognition that errors occur. The Harvard Medical Practice Study1,2 and the Quality in Australian Health Care Study3 retrospectively reviewed hospital medical records to identify and quantify adverse events caused by the hospital care provided. These studies have provided important insight into rates of adverse outcomes. In Australia, around 16% of admissions studied were associated with an adverse event.3Following the success of incident monitoring in anaesthetics,4,5 in 1993 the Commonwealth Review of Professional Indemnity Arrangements for Health Care Professionals initiated pilot incident-monitoring studies in six medical specialties. The aim of this study was to test the incident-monitoring method in general practice. An important difference between studies such as the Harvard Medical Practice Study and incident-monitoring studies is that no claims of generalisability are made in the latter. Incident monitoring cannot estimate prevalence. It provides detailed contextual information about specific processes and situations that can lead to adverse patient outcomes. Such information is then used to make specific recommendations. The objectives of this study were to test a mechanism for obtaining incident reports from GPs; to gain an understanding of the type of incidents occurring in general practice and hence areas of potential harm; and to identify areas which might benefit from intervention. Method The method has been described in detail elsewhere.6 Participating general practitioners reported incidents contemporaneously, on purpose-designed reporting forms. An incident was broadly defined as "an unintended event, no matter how seemingly trivial or commonplace, that could have harmed or did harm a patient". This criterion included "near misses" -- where the harm may have been averted, but the potential for harm existed. All GP members of the Australian Sentinel Practice Research Network and the Central, Southern, Western and Wentworth Area Health Sentinel Networks in Sydney were asked by letter to participate. Others volunteered when reporting was offered as a Quality Assurance option through the Royal Australian College of General Practitioners (RACGP). Reports were anonymous and information was protected from subpoena by the Health Insurance Act 1973 (Cwlth).7 The reporting form included both free text and fixed-response questions. Information requested included GP characteristics and the patient's age, sex and health problems associated with the incident. Free text descriptions were elicited of the incident, its consequences, and contributing and mitigating factors; the outcome; and the GP's opinion of the incident's preventability. Fixed-choice responses included the type of incident, contributing factors, mitigating factors, potential for harm, immediate consequences, and predicted long term outcomes. All fixed-choice questions included an "other" category to allow continuing development of categories. Quantitative descriptive analysis was used to describe the main features of the data for all 805 incidents received, using SAS.8 No significance testing was carried out as it would have been invalid because of the nature of the study and sample. Qualitative analysis of textual data was carried out for 500 incidents. This analysis involved examination of groups of events for common causes, situations and contributing factors. Results GP response Of 510 GPs initially approached, 214 accepted. A further 110 GPs volunteered during the study. Between October 1993 and June 1995, 805 reports were received from 324 enrolled participants. As all reports were anonymous, reporting rates could not be calculated. However, a GP-generated personal identification number on most reports allowed estimation of the number of reports received from each identification number. There were 241 GPs who submitted at least one report, and 82 unidentified reports. The proportion of each sex and the proportion from rural practices among the respondents were equivalent to the overall GP population at that time.9 However, only 16% of respondents had less than 10 years' experience, whereas in a national sample in 1990-1991 about 30% of GPs had less than 10 years' experience.10 Patients Of the 805 incidents, 58% involved female patients. Almost one-third of incidents involved patients over 65 years old (median age, 50 years; range, 0-98 years). Younger patients (0-24 years) were least likely to be involved in incidents (Figure). Compared with the overall age-sex distribution of patients attending GP consultations, women older than 75 years and infants were over-represented in the incidents reported.9 Age and sex of patients involved in reported incidents. Incidents Incidents were categorised as pharmacological, non-pharmacological, diagnostic or equipment events (Box 1). Pharmacological events were most frequent. The most common incident type overall was omitted or delayed treatment. A high degree of overlap between non-pharmacological and diagnostic events was noted -- 79 incidents involved both types. GPs thought 76% of the incidents were preventable (Box 2) and 11% were unpreventable. They were undecided about the remaining 13%. More than one-third of the incidents resulted in additional use of resources. While pharmacological incidents were most often reported, they were also largely considered preventable (79%) and the least harmful potentially and in the long term. In contrast, diagnostic events were less preventable and more harmful (Box 2). Of the 38 deaths reported, 30 involved a diagnostic incident. Major immediate consequences were reported in 17% of incidents, and 4% resulted in the patient's death (Box 2). GPs predicted that most incidents would cause no long term harm, but that 7% would result in the future death of the patient. Mitigating and contributing factors Incident outcomes were more frequently mitigated by chance factors than through systematised fail-safe or preventive procedures. The most frequently reported mitigating factors were good fortune, early intervention by the GP, and the patient's good physical condition (Box 3). Ineffective communication and problems in coordination between healthcare services were frequent contributing factors (Box 4). Actions or involvement of others in caring for patients were also frequently cited. Assessment-related mistakes constituted another cluster of contributing factors (eg, errors in judgement, failure to recognise significant signs and symptoms, and inadequate patient assessment). Insufficient use of standard resources and protocols by the GP was also recognised. GPs reported being tired, rushed or late in 10% of incidents, but GP memory lapses and stressful situations were least frequently cited as contributing factors. There were no obvious associations between specific contributing factors and incident type. Qualitative analysis Qualitative analysis of free-text responses identified four broad problem groups: communication, procedural, clinical and external problems. More comprehensive descriptions are available elsewhere.11,12Communication problems: Most communication problems between GPs and patients occurred when patients did not understand some aspect of their condition, the management plan or the treatment. Patients with mental health problems or lacking English language skills were particularly at risk. Some serious pharmacological incidents occurred when patients misunderstood instructions and took newly prescribed drugs in addition to, rather than instead of, a previously prescribed medication. Poor communication also manifested as clinical error in inadequate history taking. There were also problems with communication between healthcare providers. Clinical information about the outcomes of hospital referrals or admissions, the expected role of the GP in post-discharge care, specialists' recommendations for management and results of tests or investigations was often not communicated between GPs and other healthcare providers, or was too late to be of use. Unclear or uninformative medical records caused a number of incidents, and inadequate records resulted in poor communication within practices. Incorrect or unclear labelling of drugs resulted in administration of the wrong drug, and inappropriate drugs were dispensed because of poor handwriting on prescription forms. Such errors were often compounded by similar medication names (eg, Teldane/Feldene, Microlax/ Murelax). Procedural problems: The main procedural error was failure to check medical records. Diagnostically, procedural error manifested in poor application of the differential diagnosis, when the correct diagnosis was inappropriately rejected because of insufficient or incorrect examination, or was not included in the differential diagnoses and was therefore not evaluated. In non-pharmacological incidents, treatment procedures may have been neglected (eg, not checking for anaesthesia before an excision). In equipment incidents, machines were not properly checked before use (eg, leads or tubes were disconnected) or were not well maintained (eg, unfilled emergency oxyviva equipment). Lack of protocols for ensuring action on results of tests and investigations meant that important results were filed unseen or left until the GP who ordered the test was next in the surgery. Recall systems were often inadequate, preventing recall of patients for follow-up tests and investigations and resulting in missed or delayed diagnosis or management. Clinical problems: These consisted of incidents that could only be attributed to human error. In pharmacological incidents, clinical errors occurred where an inappropriate drug was chosen; in non-pharmacological incidents, where the wrong treatment was chosen; in diagnostic incidents, where symptoms and signs were not recognised (eg, chest pain considered to be musculoskeletal); and in equipment incidents, where equipment was used inappropriately. External problems: External problems involved factors outside the GP's control, such as actions of other healthcare providers, equipment faults or unavailability, disease-related factors, and unpredictable drug effects. Patient-related factors included non-compliance, age, level of comprehension, and psychological condition. Discussion The diversity of incidents reflects the heterogeneous nature of general practice and its context within the healthcare system. Nevertheless, it was possible to isolate recurrent themes and errors and to identify incidents that occurred because of system problems or other preventable factors. Pharmacological incidents were most frequent and could be prevented through clearer prescription writing, double-checking of doses and potential interactions, and improved patient understanding. Unexpected drug reactions (eg, to previously well-tolerated drugs) and idiosyncratic complications were largely beyond GPs' control. However, compilation of this information may be useful to reinforce or add to data collected elsewhere. Diagnostic incidents had the most serious outcomes. While management of test results and lack of recall systems contributed to these incidents, many occurred while the patient was under another medical practitioner's care, or were caused by the diagnostic decision-making processes of GPs. Patient misunderstanding was a factor in many incidents. This might be addressed by improved GP awareness to ensure full patient understanding. However, information management problems require "hard-wired" solutions -- structures and systems that ensure better outcomes. In particular, opportunities for errors may be reduced by better recall systems for follow-up and for regular tests and screening,13 better transfer of medical information between healthcare providers, clearer writing of prescriptions, and better maintenance and use of medical records. Information technology could help by streamlining some of the administrative functions, particularly prescription writing, which appears to be adversely affected when GPs are tired, rushed, or running late. Limitations to the validity of our data include the non-random nature of the sample, limited recognition of incidents, selectivity in reporting incidents, and the lack of an alternative perspective. (We did not seek the patients' perspective because of the controversial nature of the data.) However, issues we identified as important have been described by other researchers. Many of the issues pertaining to pharmacological incidents have been described in a study of adverse drug events in United States hospitals.14 Similarly, the problems of multiple prescribing in the elderly have been well summarised, and opportunities for improvement in the management of polypharmacy have been identified.15 Prescription clarity has also been recognised as an area of potential misunderstanding.16 In critical incident studies, incidents are sampled until "saturation" (until no new incident types are reported).17 While these 805 incidents may not reach saturation, they demonstrate at least some of the types of incidents occurring in Australian general practice. Logically, where inadequate systems are widely used, similar events are likely to occur regularly rather than being related to individual characteristics or techniques. Continued collection and classification of events will elucidate more causal factors, particularly for the less common types of incidents. This study also resulted in a number of suggested interventions.18 Incident monitoring studies are intended to be continually used in improving systems. It is important to use the data for formulating interventions. This study has shown that such data can be collected in general practice, but the translation of findings into active change remains to be addressed. Acknowledgements We gratefully acknowledge the funding provided by the Commonwealth Review of Professional Indemnity Arrangements for Health Care Professionals. The project was conducted under the auspices of the RACGP. Recruitment of GPs and administration of the GP participants was carried out jointly by the Family Medicine Research Unit and the RACGP Research and Health Promotion Unit, South Australia. Other members of the research team made considerable contributions to running the project. Thanks must go to the GP participants for so generously sharing their experiences with us. References Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med 1991; 324: 370-376. Leape LL, Brennan TA, Laird NM, et al. The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II. N Engl J Med 1991; 324: 377-384. Wilson RM, Runciman WB, Gibberd RW, et al. The Quality in Australian Health Care Study. Med J Aust 1995; 163: 458-471. Williamson JA, Mackay P. Incident reporting. Med J Aust 1991; 155: 340-343. Webb R, Currie M, Morgan CA, et al. The Australian incident monitoring study: an analysis of 2000 incident reports. Anaesth Intensive Care 1993; 21: 520-528. Britt H, Miller G, Steven I, et al. Collecting data on potentially harmful events: a method for monitoring incidents in general practice. Fam Pract 1997; 14: 101-106. Commonwealth of Australia. Health Insurance Act 1973. Declaration under section 106L. Commonwealth of Australia Gazette 1993; GN 31: 2269-2272. SAS [computer program]. Version 6.11. Cary, North Carolina: SAS Institute, 1995. General Practice Branch. Commonwealth Department of Health and Family Services. General Practice in Australia: 1996. Canberra: Commonwealth of Australia, 1996. 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: S1-S56. Miller G, Britt H, Steven I, et al. Incident monitoring in general practice: a pilot study. Report to the Professional Indemnity Review, Commonwealth Department of Human Services and Health. Sydney: Royal Australian College of General Practitioners, 1995. Bhasale AL. Collecting data on potentially harmful events: evaluation of an incident monitoring technique in Australian general practice [master's thesis]. Sydney: University of Sydney, 1997. Bhasale AL, Norton KJ, Britt H. Tests and investigations. Indicators for better utilisation. Aust Fam Physician 1996; 25: 680-694. Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. JAMA 1995; 274: 35-43. Teng Liaw S. Drug interactions among the elderly. Aust Fam Physician 1997; 26: 355-357. Liddell MJ, Goldman SP. Attitudes to and use of a modified prescription form by general practitioners and pharmacists. Med J Aust 1998; 168: 322-325. Flanagan JC. The critical incident technique. Psych Bull 1954; 51: 327-359. Bhasale AL, Britt H, Miller G. Developing interventions which could reduce the occurrence of adverse patient incidents in general practice. Report to the Taskforce on Quality in Australian Health Care, Department of Human Services and Health, Canberra. Sydney: Family Medicine Research Unit, University of Sydney, 1995. (Received 4 Aug 1997, accepted 26 Mar 1998) Authors' details Department of General Practice, University of Sydney, Sydney, NSW. Alice L Bhasale, BSc(Psychol), MSc(Med), Senior Research Assistant, Family Medicine Research Unit; Graeme C Miller, MB BS, FRACGP, Medical Director, Family Medicine Research Unit; Sharon E Reid, MB BS, MPH, Lecturer; Helena C Britt, PhD, Director, Family Medicine Research Unit. Reprints will not be available from the authors. Correspondence: Ms A L Bhasale, Acacia House, Westmead Hospital, Westmead, NSW 2145. E-mail: alicebATgenprac.wsahs.nsw.gov.au - Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Alice L Bhasale · Graeme C Miller · Sharon E Reid · Helena C Britt

Fundamental reform of hours worked by junior doctors is required It has long been recognised that the rites of passage for junior doctors in public hospitals require extended hours of work with inadequate provision for rest and recovery. Not only are the junior doctors on a very demanding learning curve, but, at the same time, they are required to establish effective working relationships with patients, families and senior colleagues, and deal with the complexity of the modern hospital administration. Add to this a stressful workplace environment and, at times, the necessity to make critical decisions within a limited time frame and you have a situation no other professional group would be prepared to tolerate. Yet the research1 indicates that this is the situation most doctors face at the beginning of their careers. While Olson and Ambrogetti2 in this issue of the Journal present some criticisms of the methods of such research, there is considerable evidence to support the view that junior doctors' hours of work are, at times, excessive.3 The most recent Australian survey, undertaken as part of the current AMA Safe Hours Project, has produced further evidence to support this view.4 Why is this practice, which exerts a very heavy personal toll on the health and work performance of doctors, allowed to persist? No doubt there are respected members of the medical profession who argue that it is an essential component of the "toughening up" process. Clearly the hospital environment and the professional medical work ethic contribute to the excessive hours of work so ingrained in the hospital culture. The depth of this tradition was demonstrated recently in New York, where amendments to the Health Code5 were introduced in 1989 following the death of Libby Zion in a New York hospital. The circumstances of this unfortunate event are outlined by Nocera and Khursandi6 in this issue of the Journal. Libby's father, Sidney Zion, a newspaper columnist, was instrumental in launching a successful campaign restricting the hours of work of junior doctors working in hospital emergency departments. However, recent reports in the New York Times7 indicate there are still a large number of hospitals flouting this law. While legislative reform is one part of the solution, there is clearly a need to look at the attitudes which continue to support the practice. Until recently, little attention was given to the statutory responsibility of the employer to provide a safe system of work for doctors employed in hospitals.8 Currently, under occupational health and safety laws, there is increased emphasis on employers undertaking a hazard identification approach, followed by risk assessment and the application of risk controls. Applying this approach to the work regimen of junior doctors will present particular challenges to hospital administrators. An added consideration is the increasing recognition of the extent to which latent organisational failures may contribute by creating the circumstances leading to mishap.9 A hospital administration which fails to identify hazards and assess risks arising from extended hours of doctors' work could be in breach of a duty of care owed to doctors. Further, permitting a doctor to carry out duties while so fatigued that a patient's safety is endangered could be a breach of duty owed to the patient. The comments of the acting coroner in the recent inquest into the death of a New Zealand woman, the innocent party in a car crash, reinforce the importance of addressing the issue of fatigue.10 The patient survived the accident, but died following a mishap while in hospital. A significant issue for the coroner was the extent to which the fatigue of one of her doctors may have played a part in her demise. The coroner remarked that there was a growing level of concern, both nationally and internationally, over the hours of work of doctors in hospitals, and suggested that the medical professional bodies address the issue of extended periods of work. The hospital work practices of junior doctors appear to be common to many countries. Although the weekly hours worked by doctors in training are variable, it is reasonable to conclude that these routinely exceed 55 hours per week in many European countries.11 While the European Union originally excluded doctors in training from its 1993 Directive on Working Time,12 the Union's Council of Ministers indicated more recently that the directive should also apply to doctors in training.13 In 1990, the United Kingdom adopted an agreement, the New Deal, to phase in reduced hours for junior doctors.14 In March 1996, the AMA Federal Council adopted a policy to promote a safer workplace for junior doctors and patients in public hospitals.15 Part of the strategy involves the development of a national code of practice for the hours of work and rostering arrangements of junior doctors employed in hospitals. The Commonwealth Department of Health and Family Services has provided financial assistance to undertake a number of research projects to support the development of this national code. A draft of the code should be available for public comment in June/July 1998, to be followed by a national symposium in November 1998. Undoubtedly the major challenge is the professional medical culture, which, while it recognises the hazards and risks of excessive hours of work, appears to lack the collective will to resolve the problem. Nocera and Khursandi raise the question "Can the medical profession afford to let the courts decide what is reasonable?". In the absence of the medical profession's commitment to support fundamental reform of hours worked by junior doctors, where else can the victims turn? Gerry Holmes Manager, Occupational Health and Safety University of Wollongong Legal Advisor AMA Steering Committee, Safe Hours Project Swan, N. Juniors' Hours: International Overview. BMJ 1990; 301: 830-832. Olson LG, Ambrogetti A. Working harder -- working dangerously. Fatigue and performance in hospitals. Med J Aust 1998; 168: 614-616. Williamson A. The effects of workload and long hours of work on medical officers. Sydney: National Institute of Occupational Health and Safety (WorkSafe Australia), 1995. Australian Medical Association (AMA). Systems of work and overview of current arrangements. Canberra: Australian Medical Association, 1998. In press. New York State Health Code (10 NYCRR 405.4). New York: Department of Health, 1989. Nocera A, Khursandi DS. Doctors' working hours: can the medical profession afford to let the courts decide what is reasonable? Med J Aust 1998; 168: 616-618. Fein EB. Flouting law, hospitals overwork novice doctors. New York Times, 14 December 1997; 1. Holmes G. Hospital medical officers: hours of work and workloads, A strategic approach to occupational health and safety. Canberra: Australian Medical Association, 1995. Department of Transport. Investigation into the Kings Cross Underground Fire. London: HMSO, 1998. Coroner's Court. In the matter of the death of Patricia Margaret Ross. Rotorua, New Zealand: 15-17 October 1997; 18-20. Permanent Working Group of European Junior Hospital Doctors. Working conditions for doctors in training. Conference Proceedings, Executive Summary. Brussels: European Union Publications Office, December 1995. European Union. Directive on Working Time, 93/104. Brussels: European Union Publications Office, 1993. European Union. Sectors and activities excluded from working time directive. Brussels: European Union Publications Office, 1997. NHS Management Executive. Hours of work of doctors in training: guidance on regional task forces. London: Department of Health; 1991. Federal Council, Australian Medical Association. Executive minutes, 1-2 March 1996. Canberra: Australian Medical Association; 1996. Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia ".

Gerry Holmes

Fatigue and performance in hospitals Patients in hospital don't stop requiring medical care at night. That means either overtime or shift work for somebody. "Somebody" is usually a junior doctor. The early postgraduate years are not easy -- the problems of professional responsibility, study and combining a career and a personal life are difficult enough, but to these challenges are added hours of work that society does not expect of any other occupational group. The routine 50- hour shifts of not so long ago have, we believe, disappeared, but hospital doctors still commonly work long hours and unreasonable shifts. What impact this has had in our hospitals -- how it contributes to mistakes, suicides, drop-outs and divorces -- is unknown. However, fatigue undoubtedly impairs professional performance, learning and quality of life. For legal, educational and humanitarian reasons, hospitals need to do whatever can be done to limit excessive hours of work. A physiological, not an industrial, problem How many hours are "excessive"? We do not know. It depends on what we are trying to achieve, and the answer will be different if we want to maximise teaching and learning than if we just want to avoid disastrous errors. How many hours are doctors working? We do not know that either. Most data derive from retrospective self-reports, which is obviously unsatisfactory, and concern average hours per week, which is not the issue. The issue is the existence of any work weeks that do not allow adequate recovery between shifts or which impose excessive periods of continuous work. The Association of American Medical Colleges has suggested that residents should not work more than 80 hours per week averaged over four weeks.1 This approach is irrational -- it is like saying you are fit to drive at any time if your blood alcohol level averaged over four weeks is less than 0.05%. We have practically no data on the frequency with which doctors work exceptionally long hours. Hospitals may have data on rostered hours, but this is only a portion of the total hours worked, and the information is not entirely accurate. Rosters change because swaps are unregulated, and unrostered overtime is usually not included in hospital estimates of hours worked. Time sheets would be a better source of data, but their use raises confidentiality problems, and they miss unpaid overtime. Unrostered overtime, whether obligatory or self-imposed, is unregulated and mostly unrecorded because the pressure to work and not complain is overwhelming. The only accurate source of data on total hours worked would be direct observation, and no such study has been done. It is critical that this is seen not as an industrial issue but as a physiological problem. An 80-hour work week including 40 hours of unpaid overtime and no days off, however unacceptable industrially, could be acceptable physiologically if the worker had eight hours' sleep between shifts. A 24-hour shift at double-time with paid meal breaks is not acceptable physiologically, however attractive it may be to a junior doctor with a mortgage. Imposing a 24-hour shift once a year because all the other medical staff are off sick may not be unfair, but it is unsafe. The body clock keeps ticking at night Humans have a marked circadian preference for sleep at night and, even under optimal conditions, being awake at night is associated with impaired performance. When long hours and sleep deprivation are added to the circadian problem, the performance deficit is exacerbated. The effects of fatigue on performance are well defined.2 Concentration, data processing and short-term memory are impaired. The variability of performance increases, so that normal performance alternates with periods of poor work, and astute decisions are mixed with lapses of judgement. Performance declines sharply as the duration of a task increases, and fatigued workers sacrifice accuracy to speed. Fatigue causes less performance decrement in workers with more control over their work because they can schedule non- urgent tasks for periods when they are at their best. Doctors will thus cope better than staff with less job flexibility, such as nurses. Effort can compensate for fatigue, but as fatigue worsens the ability to summon an effort of concentration declines and the time for which it can be maintained shortens. Performance in crises, however, is preserved until fatigue is extreme. Mistakes caused by fatigue are most likely to occur during routine tasks and tasks which require sustained vigilance, especially when the factors that trigger an effort of concentration (such as an obviously ill patient) are absent. Fatigue mistakes characteristically involve failure to recognise the existence of a serious problem. Giving the wrong antibiotic to a patient recognised as having sepsis is not a typical fatigue mistake, but failing to recognise sepsis at all is. For this reason fatigue-related errors of judgement are difficult to prevent and often disastrous. Are doctors seriously impaired by fatigue? We are not sure. Some studies have found performance decrements attributable to fatigue,3 but others have not.4 The methodological issues that make most existing studies of limited use are twofold. Firstly, the psychometric tests usually used to assess fatigue have never been shown to predict real-life medical performance.2Secondly, many studies use unrealistic definitions of fatigue. In one often-quoted study of junior doctors with work weeks of 100 hours, "fatigued" was defined as less than four hours' sleep in 24 hours, and "rested" as more than four hours' sleep in 24 hours.4 It is little wonder that no difference was discernible between the "fatigued" and "rested" doctors! Doctors and army officers are the only occupational groups reported to be unaffected by fatigue,2 but this is generally regarded as an artefact of methodology.2,5 A "healthy worker effect" is a possible explanation (people who need a lot of sleep don't last very long as surgical registrars or army cadets), but not needing a lot of sleep is hardly the best basis for choosing doctors. Willingness to work when fatigued is widely seen as "professional". This view goes back to acts of genuine heroism in wars and epidemics and to some of the noblest traditions of medicine. But the diurnal rhythm of alertness and the drive to sleep are basic physiological processes, and commitment does not affect physiology. Heroic workloads are out of place in the routine organisation of the urban teaching hospital. Many doctors, junior and senior, voluntarily undertake long hours of work for reasons of money, professional advancement or altruism. Neither money nor seniority is an antidote to fatigue, however, and fatigue is no less damaging to performance when it is incurred voluntarily. It is just as inappropriate for a consultant surgeon to perform emergency operations all night and a routine list the next morning as it is for a junior doctor to be forced to stay at work to assist. Hospitals must not only stop forcing staff to work dangerous hours, they must also prevent them choosing to do so. Hours ain't hours Given that night work is inevitable, and that it inevitably impairs performance and quality of life, it seems obvious to insist on the use of minimally damaging patterns of shift work. The reality in hospitals is different: a number of practices known to cause particularly severe impairment are common. The most obvious suspicion about shifts is true: long ones are worse than short ones.6 Data from a number of occupational groups suggest that eight-hour night shifts are optimal and that 12-hour night shifts are acceptable only if workloads are light. Night shifts longer than 12 hours, and daytime shifts longer than 16 hours, have consistently been found to be associated with reduced productivity and more accidents.6 It is also important to note that the later the night shift ends, the less sleep is obtained that day.7 Even when the night shift has officially ended, casual extension of night shifts into the morning for hand-over rounds and morning report is common. In addition, libraries and medical administration offices rarely have opening hours that allow night workers access without intruding on their sleep time. Physiological adaptation to night work is largely a myth8 and there is no reason to extend periods of night work in the hope that adaptation will occur. For intellectually demanding tasks, short periods of night work (one or two shifts) are better tolerated than longer periods because the accumulated sleep deficit is less. It is easy to demonstrate that the progressive sleep loss of a seven-night roster causes a progressive rise in accidents and a fall in productivity.9 Sleep deficits cannot be repaired immediately. Night-shift workers seldom sleep more than five or six hours in each 24- hour period, so that after seven nights the accumulated sleep deficit is 15 to 20 hours. At least 48 hours off duty are usually needed to recover this deficit,7,10and rosters that require workers to go from night shifts to day or afternoon shifts with no break are dangerous. The pattern of long work days followed by nights interrupted by calls is regarded as normal by the medical profession. These calls are, at best, simple telephone calls. At worst, they may entail returning to the hospital several times a night. Few other workers do this, and data on its long-term effects are entirely lacking. Being on-call impairs sleep even when there are no calls,11 and as five or six hours' uninterrupted sleep is needed to avoid performance decrement10 perpetual or frequent on-call work is probably damaging. Solving the problem We have very little of the knowledge that we need to understand fatigue in medical work. Studies are required to determine whether there is a serious problem of fatigue-related impairment of performance in some or all Australian hospitals. Such studies need to focus on how learning and quality of life, as well as professional performance, are affected by fatigue. Junior doctors are not the only ones affected by fatigue, and senior staff also need to be studied. We need controlled trials to determine optimal work schedules and to test countermeasures to fatigue (eg, benzodiazepines to assist daytime sleep, and bright light and caffeine for stimulation). We do know enough, however, to eliminate the worst abuses of the human sleep-wake cycle, and we need to see a shift by both hospital employers and the medical profession towards addressing this issue. References Executive Council, Association of American Medical Colleges. Resident supervision and hours: recommendations of the Association of American Medical Colleges. J Med Educ 1988; 63: 417-426. Dinges DF, Kribbs NB. Performing while sleepy: effects of experimentally induced sleepiness. In: Monk TH, editor. Sleep, sleepiness and performance. Chichester: Wiley, 1991: 97-128. Rubin R, Orris P, Lau SL, et al. Neurobehavioural effects of the on-call experience in housestaff physicians. J Occup Med 1991; 33: 13-18. Deaconson TF, O'Hair DP, Levy NW, et al. Sleep deprivation and resident performance. JAMA 1989; 260: 1721-1727. Leung L, Becker CE. Sleep deprivation and house staff performance. J Occup Med 1992; 34: 1153-1160. Rosa RR. Extended work shifts and excessive fatigue. J Sleep Res 1995; 4 (Suppl 2): 51-56. Kecklund G, kerstedt T. Effects of timing of shifts on sleepiness and sleep duration. J Sleep Res 1995; 4 (Suppl 2): 47-50. Dahlgren K. Long-term adjustment of circadian rhythms to a rotating shiftwork schedule. Scand J Work Environ Health 1981; 7: 141-151. Knauth P. Speed and direction of shift rotation. J Sleep Res 1995; 4 (Suppl 2): 41-46. Carskadon M, Roth T. Sleep restriction. In: Monk TH, editor. Sleep, sleepiness and performance. Chichester Wiley, 1991: 155-167. Torsvall L, Akerstedt T. Disturbed sleep while being on call. An EEG study of apprehension in ships engineers. Sleep 1988; 11: 35-38. Authors' details Sleep Disorders Centre, Royal Newcastle Hospital, Newcastle, NSW. Leslie G Olson, FRACP, Sleep and Respiratory Physician. Department of Medicine, University of Newcastle, Newcastle, NSW. Antonio Ambrogetti, MD, FRACP, Sleep and Respiratory Physician. Reprints will not be available from the authors. Correspondence: Dr L G Olson, Department of Medicine, University of Newcastle, John Hunter Hospital, Locked Bag 1, Hunter Region Mail Centre, NSW 2310. Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>".

Leslie G Olson · Antonio Ambrogetti

Doctors' working hours: can the medical profession afford to let the courts decide what is reasonable? Antony Nocera and Diana Strange Khursandi Fatigue is no defence for negligence by a doctor in an action by a patient MJA 1998; 168: 616-618 For editorial comment, see Holmes See also Olson & Ambrogetti Fatigue caused by long working hours can impair doctors' judgement and competence, and may result in harm to both patients and doctors. Preventable errors resulting from fatigue may lead to patient mishap, which may in turn lead to litigation. The impact of litigation upon individual doctors is enormously stressful. Fatigue is no defence for negligence by a doctor in an action by a patient.1,2 The courts, both in Australia and overseas, have already expressed concern about the role of fatigue as a contributing factor in medical mishap. A nationwide policy on doctors' hours must be preferred to the current practice, where legal judgments impose recommendations on an individual basis after mishaps. Out-of-court settlements may be economically expedient for insurers, but not necessarily to the advantage of either doctors or their patients. Fatigue results in bad medicine Arduous duty schedules for doctors have traditionally been viewed as part of the rites of passage into the medical profession. Doctors work long hours, sometimes extending into meal breaks, rest and leisure time. The effect of lost sleep (sleep debt) accumulates over time and does not dissipate.3 The cognitive psychomotor impairment after 17 hours of sustained wakefulness is equivalent to that caused by a blood alcohol concentration of 0.05%; after 24 hours of sustained wakefulness it is equivalent to a blood alcohol concentration of 0.1%.4In the first 4000 reports to the anonymous voluntary register of anaesthetic adverse incidents (Australian Incident Monitoring Study [AIMS]),5 20% of adverse incident reports identified "stress-related" factors (Table 1). Incident reports relating to errors in drug administration or equipment checks were disproportionately associated with reports of fatigue (Table 2). Medicolegal aspects of fatigue Doctors have an ethical and medicolegal obligation to provide an acceptable standard of medical care. A doctor's professional obligations are not abrogated by hospital directives or policy. Tired doctors may make errors, fail to spend adequate time with patients, fail to communicate effectively with patients and fail to complete appropriate case notes.6 Psychological mismanagement of patients can generate complaints and litigation even when the medical management has been exemplary.7 The impact upon a doctor's professional and private life of receiving a complaint must not be underestimated. The enormity of an error, whether fatigue-related or not, can lead to the doctor committing suicide.8-11Hospital management has a duty of care in preventing fatigue-related incidents, and a vicarious liability for actions by employees. The hospital also has a legal obligation to provide a safe working environment for its staff. Work-related travel accidents, or events such as needlestick injuries, could result in significant liability issues for hospital management if they occur after excessive periods of duty. The following cases illustrate aspects in the division of responsibility between doctor and hospital management in litigation involving fatigue. Case 1: Brotherson v Royal Perth Hospital (Australia)12 Robert Brotherson was a 12-year-old boy who underwent open heart surgery in 1978 for congenital heart disease. His postoperative course was complicated by hepatic dysfunction and renal failure requiring peritoneal dialysis. While on dialysis, he developed glucose intolerance which was treated with an insulin infusion. Eight days after his initial surgery, Robert's condition improved, and dialysis was ceased at about 0600. During the medical hand-over between 1800 and 1900 that evening, a consultant decision was made to reduce the frequency of blood sugar monitoring. The decision was based on blood sugar levels (13.1 mmol/L at midnight and 9.05 mmol/L at 0700), and the desire to give Robert an opportunity to sleep. A further blood sugar level of 4.2 mmol/L had been measured at 1612, but not recorded in the notes until the following day. As a result of this omission, the significance of the downward trend in blood sugar level may not have been fully appreciated. At 0550 the following morning Robert had a hypoglycaemic fit resulting in permanent brain damage. In 1995, when Robert was 29 years old, the District Court of Western Australia awarded damages of $2.75 million against Royal Perth Hospital. After a trial which lasted four weeks, Judge French observed that it was difficult to avoid the conclusion that the long shifts the staff worked, with an overwhelming workload, had contributed to their oversight. Case 2: The Libby Zion case (USA)13 Libby Zion was an 18-year-old woman who died in a New York hospital in March 1984. In January 1984, Ms Zion had begun psychiatric treatment for stress, and was taking phenelzine up to the day before her admission. She was admitted by an emergency department junior resident with a tentative diagnosis of "viral syndrome with hysterical symptoms". At the time of her admission at 0200, both the emergency department resident and the medical intern had been on duty for 18 hours. At 0330 Ms Zion received pethidine 25 mg intramuscularly for agitation and shivering. Between 0400 and 0430 she became increasingly agitated, confused and began thrashing around in bed. The medical intern, attending another patient, was twice notified about the patient. He first gave a telephone order for physical restraint, then another for haloperidol 1 mg intramuscularly. At 0630 Ms Zion was found to have an axillary temperature of 42¡C, for which the intern ordered cold compresses and a cooling blanket. Shortly afterwards she had a respiratory arrest and could not be resuscitated. The postmortem findings were bilateral bronchopneumonia with presumptive evidence of cocaine use. Her father, an attorney and a writer for the New York Times, claimed that his daughter had received inadequate care from overworked and undersupervised medical staff. He successfully lobbied for a grand jury investigation into his daughter's death. The grand jury returned no criminal indictments against the hospital or its physicians, but found much at fault with resident training and staffing. As a result of these findings, New York State implemented legislation which limits a doctor's shift in emergency services to a maximum of 12 consecutive hours. Case 3: Johnstone v Bloomsbury Health Authority (UK)14 An obstetric senior house officer was employed in 1988 by University College Hospital in London to work a basic 40-hour week with an additional 48 hours per week "on-call" (working overtime while residing in the hospital). He was subsequently required to work 32 hours over one weekend, with only 30 minutes' sleep. On another weekend he worked for 49 continuous hours, taking over 60 calls, and was able to sleep for only seven hours. In 1989, Dr Johnstone took the Bloomsbury Health Authority to court, successfully arguing that he had sustained personal injury as a result of his work schedule. In upholding the damages awarded, the court of appeal found that the health authority could not lawfully require the doctor to work so much overtime in a manner which constituted a threat to his health. In this case, the court rejected the argument that "if you cannot stand the heat in the kitchen, you should get out, or not go in". It noted that it was "a matter of grave public concern that junior doctors should be required to work such long hours without proper rest that not only their own health may be put at risk but that of their patients as well". Case 4: Wilsher v Essex Health Authority (UK)15 Martin Wilsher was born in December 1978, nearly three months premature. At birth he was described as a "very floppy blue baby". He was initially intubated, but was able to be extubated after eight minutes and was admitted to the Special Care Baby Unit on supplemental oxygen via a face mask. In the Special Care Baby Unit, a junior resident doctor mistakenly inserted a catheter into an umbilical vein for arterial blood gas sampling. The error was subsequently missed by both a senior registrar and a consultant radiologist. The resident and registrar involved were either working continuously or had been "on call" (working overtime) every second night and weekend. When the catheter was changed by the senior registrar after 24 hours, it was again placed into an umbilical vein instead of the artery. Due to being supersaturated with oxygen for approximately 32 hours, the baby developed retrolental fibroplasia, resulting in near-total blindness. The court of appeal dismissed an application by the health authority contesting the damages awarded in the subsequent action by the child's parents. The judge concluded that "a health authority which so conducts its hospital that it fails to provide doctors of sufficient skill and experience to give the treatment offered at the hospital may be directly liable in negligence to the patient... I can see no reason why, in principle, the health authority should not be so liable if its organisation is at fault". Looking forward While the effect of fatigue on performance is being increasingly recognised, traditional attitudes to working hours have become inappropriate, especially in the current climate of growing complexity of medical practice and increasing patient expectations. Other bodies, such as the airline industry, have already recognised the importance of regulating working hours and rest periods to minimise fatigue. At present, none of the Australian specialty colleges has recommendations on duty hours, despite the adverse effect fatigue could have on training. Based on overseas experiences, the introduction of duty time limits in Australia would require an upward revision of the current estimates for future medical workforce requirements. In the Netherlands, the introduction of duty time limits for doctors in training increased medical employment, while in the United Kingdom it has resulted in the creation of over 1000 new consultant positions.16 The Wilsher v Essex Health Authority judgment centred on the issue of inadequate supervision of junior doctors. The health authority was found to be at fault because its organisation failed to provide appropriate care. This principle of hospital management liability due to organisational failure is even more applicable to an incident occurring due to doctors being required to work excessive hours, thus exposing patients to the potential risk of injury.2 Hospital indemnity insurers would have grounds to introduce penalty premiums if a hospital "organisational failure" resulted in an increased risk of litigation due to either fatigued medical staff or undersupervised junior doctors. The medical profession must take the initiative and accept the responsibility for continued investigation of the impact of fatigue on performance. There is an urgent need for widespread discussion involving government, the health authorities, the AMA and the specialty colleges so that strategies may be developed to minimise the potential for fatigue-related incidents. Setting duty time limits (together with mandatory rest periods, and rostering that minimises fatigue) will represent a practical and timely investment in patient care, sensible risk management for hospitals, and a safer working environment for doctors. It would give physician and patient safety a clear priority in a climate of increasing financial constraint and conflicting political pressures upon the healthcare system. Unless the medical profession and the health authorities introduce and police "safe working hours", they risk both compromising patient care, and increasing scrutiny by the courts. References Powers MJ, Harris NH, Lockhart-Mirams A (editors). Medical negligence. 2nd ed. London: Butterworths, 1994. Jones MA. Medical negligence. London: Sweet and Maxwell, 1991. Dement WC. The perils of drowsy driving. N Engl J Med 1997; 337: 783-784. Dawson D, Reid K. Fatigue, alcohol and performance impairment. Nature 1997; 388: 235. Garden AL, Currie M, Gander PH. Sleep loss, performance and the conduct of anaesthesia. Aust Anaesthesia 1996; 43-51. McCall TB. The impact of long working hours on resident physicians. N Engl J Med 1988; 318: 775-778. Condon JT. Medical litigation. The aetiological role of psychological and interpersonal factors. Med J Aust 1992; 157: 768-770. Charles SC, Wilbert JR, Kennedy EC. Physicians' self reports of reactions following malpractice litigation. Am J Psychiatry 1984; 141: 563-565. Charles SC, Wilbert JR, Franke KJ. Sued and nonsued physicians' self-reported reactions to malpractice litigation. Am J Psychiatry 1985; 142: 437-440. Birmingham PK, Ward RJ. A high risk suicide group: the anesthesiologist involved in litigation. Am J Psychiatry 1985; 142: 1225-1226. Wenokur B, Campbell L. Malpractice suit emotional trauma. JAMA 1991; 266: 2834. Templeman D. Oversight by tired doctors, not failure to keep up-to-date, caused brain damage. Aust Health Law Bull 1996; 5: 35-36. Asch DA, Parker RM. The Libby Zion case. N Engl J Med 1988; 318: 771-775. Johnstone v Bloomsbury Health Authority [1991] 2 All ER 293. Wilsher v Essex Health Authority [1986] 3 All ER 801. Federal Secretariat. Overview of overseas experience in regulating hours of work of doctors in training. Canberra: Australian Medical Association, 1998. (Received 15 December 1997, accepted 20 April 1998) Authors' details Careflight, Westmead Hospital, Westmead, NSW. Antony Nocera, FACEM, Emergency Physician. PO Box 1105, Caboolture, QLD. Diana Strange Khursandi, FANZCA, Anaesthetist. Reprints will not be available from the authors. Correspondence: Dr Antony Nocera, Careflight, PO Box 159, Westmead, NSW 2145 E-mail: tonynoce@ozemail.com.au Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Antony Nocera

Children are currently being denied vaccines for inappropriate reasons The most recent edition of the National Health and Medical Research Council's Australian immunisation handbook gives very clear guidelines about the contraindications to vaccination with pertussis vaccine and measles-mumps-rubella vaccine (MMR).1 This was necessary because many children have been denied these vaccines for inappropriate reasons, such as previous reactions at the injection site, fever or irritability after pertussis vaccine, or a history of egg allergy (for ruling out measles vaccine).2 The guidelines now recommend only two absolute contraindications to pertussis-containing vaccines -- encephalopathy or severe allergic reaction following a previous dose. However, over the past two years the Australian Childhood Immunisation Register has recorded that more than 32 000 doses of combined diphtheria-tetanus vaccine (CDT) have been administered to children in place of diphtheria- tetanus-pertussis vaccine (DTP), suggesting that doctors are not following this advice. In addition, based on substantial local and overseas evidence, the guidelines also recommend that "egg allergy, even anaphylactic egg allergy, is NOT a contraindication to immunisation with measles vaccine or MMR".1,3 The previous concept that egg allergy contraindicated MMR came from the manufacturers' product insert and was based on the incorrect assumption that, as it was cultured in chick fibroblasts, it could contain egg antigens. It is likely that inappropriate caution about vaccinating children with previous reactions to pertussis vaccine has been partly responsible for the re-emergence of pertussis over the past four years.4 There were more than 10 000 notified pertussis cases in Australia in 1997, and nine deaths between October 1996 and November 1997.5 Similarly, unnecessary caution about children with egg allergy may have contributed to our measles outbreaks.6 In this issue of the Journal, Andrews and colleagues show how children with previous severe reactions to pertussis vaccine (convulsions, apnoea, hypotonic-hyporesponsive episodes, high fever and persistent screaming) were safely vaccinated in a special clinic at The Canberra Hospital.7 This clinic was the first of a number of similar services now operating or about to begin operating in other centres, including Sydney, Melbourne, and Adelaide. Information about these services is available from State and Territory health departments, which have encouraged their establishment. These clinics plan to collaborate and share expertise nationally. What does this mean for the doctors and nurses who provide routine vaccinations? It means that they should be confident about the guidelines in the Immunisation handbook.1 Children with previous mild to moderate non-anaphylactic reactions (including persistent screaming and high fever) can be vaccinated (with routine precautions) by their usual vaccine provider. Paracetamol should be given prophylactically (15 mg/kg body weight for each oral dose1) to reduce the rate of local and systemic reactions to vaccines containing the whole-cell pertussis component. Children who have had severe reactions (prolonged hypotonic-hyporesponsive episodes and seizures, each seen about once every 2000 doses of whole-cell pertussis vaccine) can also be vaccinated safely,8,9 but may need to be assessed and vaccinated at (or, for rural families, in consultation with) a special clinic. The few children with a history of anaphylaxis following vaccination -- said to occur in about 1/50 000 doses of DTPw (diphtheria-tetanus-whole-cell pertussis vaccine)10 -- and children with underlying medical conditions who may be at special risk (eg, severe neurological disorders) should also be referred for assessment and advice. A new vaccine containing acellular pertussis components (DTPa -- diphtheria-tetanus-acellular-pertussis) is now approved in Australia for use in infants and children. It is funded nationally for the doses given to children aged 18 months and 4 to 5 years, and by some States and Territories (at present South Australia and the Northern Territory) for the three infant doses. Acellular vaccines are associated with a significantly lower rate of reactions at the injection site, hypotonic-hyporesponsive episodes, convulsions and screaming.11 For this reason they are recommended for infants who have had a previous severe reaction to DTPw. Acellular vaccines were not available when The Canberra Hospital clinic was established, so DTPw was used and found satisfactory. Since the use of acellular vaccines for the fourth and fifth doses (at 18 months and 4 to 5 years) in the United States, the rate of serious side effects after vaccination has been reduced by 60% to 70%.12 The availability of acellular pertussis vaccine should remove any need for general practitioners to use CDT vaccine. In Australia, as in many other countries, the States and Territories have established a formal reporting system for vaccine adverse events. Providers report vaccine reactions either to their local public health units or to central disease control units of State or Territory health departments. This information is then supplied to the national Serious Adverse Events Following Vaccination Surveillance Scheme (SAEFVSS), which commenced in March 1995 and is run by the National Centre for Disease Control in Canberra.13 Many vaccine providers do not realise that they should be reporting serious reactions -- so, for example, the number of hypotonic-hyporesponsive episodes being reported is less than would be expected from vaccine trials in which there is active follow-up.11 Other forms of adverse event surveillance should now be used to supplement the SAEFVSS. This would include transmission of data to the SAEFVSS from the special clinics and from hospital admissions, or active surveillance, through such initiatives as the Australian Paediatric Surveillance System, of specific rare serious events. These measures would help make the system more sensitive,14,15 and this would further reassure both providers and the public about the good safety record of the vaccines used in the current childhood immunisation schedule. We must conclude from The Canberra Hospital clinic report that most children with previous severe reactions can be safely vaccinated and that no child should be deprived of pertussis or MMR vaccines without consultation with a specialist advisory service. Margaret A Burgess Director Peter B McIntyre Deputy Director Timothy C Heath Research Fellow National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases, Royal Alexandra Hospital for Children Westmead, and The University of Sydney, Sydney, NSW National Health and Medical Research Council. The Australian immunisation handbook. 6th ed. Canberra: AGPS, 1997. MacIntyre CR, Nolan T. Attitudes of Victorian immunisation providers to pertussis vaccine. Med J Aust 1994; 161: 293-294. Aickin R, Hill D, Kemp A. Measles immunisation in children with allergy to egg. BMJ 1994; 309: 223-225. Burgess MA, McIntyre PB, Heath TC. Pertussis re-emerging: who is responsible? Aust N Z J Public Health 1998; 22: 9-10. Communicable Diseases Surveillance. Pertussis epidemic continues. Commun Dis Intell 1997; 21: 359-360. Communicable Diseases Surveillance. Measles. Commun Dis Intell 1995; 19: 562-563. Andrews RM, Kempe AE, Sinn KK, Herceg A. Vaccinating children with a history of serious reactions after vaccination or of egg allergy. Med J Aust 1998; 168:491-494. Miller E. Collapse reactions after whole cell pertussis vaccination. Pertussis remains a bigger risk than collapse after vaccination [editorial]. BMJ 1998; 316: 876-877. Vermeer-de Bondt PE, Labadie J, RŸmke HC. Rate of recurrent collapse after vaccination with whole cell pertussis vaccine: follow up study. BMJ 1998; 316: 902-903. Peter G, editor. Pertussis. In: 1997 Red Book: Report of the Committee on Infectious Diseases. 24th ed. Elk Grove Village, Ill: American Academy of Pediatrics, 1997: 401. Cherry JD. Comparative efficacy of acellular pertussis vaccines: an analysis of recent trials. Pediatr Infect Dis J 1997; 16 (4 suppl): S90-S96. Committee on Infectious Diseases. American Academy of Pediatrics. Acellular pertussis vaccine: recommendation for its use as the initial series in infants and children. Pediatrics 1997; 99: 282-288. Communicable Diseases Surveillance. Surveillance of serious adverse events following vaccination. Commun Dis Intell 1995; 19: 273-274. Farrington P, Pugh S, Colville A, et al. A new method for active surveillance of adverse events from diphtheria/tetanus/pertussis and measles/mumps/rubella vaccines. Lancet 1995; 345: 567-569. Chen RT, Glasser JW, Rhodes PH, et al. Vaccine Safety Datalink Project: a new tool for improving vaccine safety monitoring in the United States. Pediatrics 1997; 99: 765-773. Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia ".

Margaret A Burgess · Peter B McIntyre · Timothy C Heath

Prescriptions, practitioners and pharmacists Better communication and teamwork for improved patient outcomes MJA 1998; 168: 317-318 Medicines are clearly an important component of healthcare. In Australia, prescriptions are written in 63.8% of general practitioner consultations,1 and in 1996 approximately 178 million prescriptions were dispensed. With the potential for adverse reactions and reported suboptimal use of drugs,2-5 it is important to work towards the best possible use of medicines. There are a number of indicators of inappropriate drug use in Australia, including the large quantities of unused medicines collected in the Return of Unwanted Medicines campaign,6 and studies showing that between 5.7% and 16.6% of all hospital admissions are drug-related events.7,8 Further, a recent report of the South Australian Community Pharmacy Model Practices Project showed that, at entry to the project, 90% of patients at high risk of medication misadventure (usually those taking more than four medications) had unresolved health or medication problems, two-thirds of which were medication related.3 Medication care can be improved by enhancing communication between doctors, pharmacists, other health professionals and consumers. Indeed, a number of intervention studies have found that quality of medication care can be improved through further building of the healthcare team, academic detailing (promotion of rational prescribing through detailing visits from pharmacists), medication review by pharmacists and doctors and feedback of prescribing patterns to doctors.2-5,9 In this vein, the Royal Australian College of General Practitioners (RACGP) and the Pharmaceutical Society of Australia (PSA), in their draft joint statement about communication between GPs and pharmacists,10 proposed a range of conventions and abbreviations aimed at improving the prescription as a communication medium. In this issue of the Journal Liddell and Goldman report the findings of the pilot study11 on which the final version of the joint statement, published in 1996, was based.12 In their study, Liddell and Goldman11 trialled the use of certain prescription notations by GPs as a means of providing the pharmacist with information for enhancing patient understanding and medication care. A modified prescription form was preprinted with the abbreviations recommended in the draft RACGP-PSA joint statement.10 These abbreviations were intended to alert the pharmacist to patient needs for counselling and assistance, and to the existence of written instructions given to the patient by the GP to enable the pharmacist to label the medicine accordingly and reinforce the patient's understanding. The prescription conventions trialled were (i) writing the general purpose for which a medication was prescribed on the form, (ii) indicating when this should not be written on the label, (iii) underlining and initialling unusual dosages, (iv) indicating that an unusual pack size was intended, and (v) noting that therapy with an ongoing medication had been stopped. Liddell and Goldman11 examined the use of and attitudes towards these new notations and found that at least one of the new notations was used on 45% of the 3464 prescription items, and that one in particular -- the general purpose of the medication -- was noted on 35%. Some preprinted notations were used so rarely that they were excluded from the final joint statement,12 and the "cease" notation was also so rarely used (14 times) that it was relatively ineffective. However, consumers felt that writing the purpose of a medication on its label was generally appropriate and helpful. Participating GPs and pharmacists were positive about the notations, especially the indication of a medication's purpose. Effective communication and collaboration between specialists, GPs and pharmacists, beyond simply changing the way prescriptions are written, are likely to result in advances in medication care. A range of collaborative interdisciplinary primary care models have been developed and trialled both here3,5,13 and in the United Kingdom.14 In the Community Pharmacy Model Practices Project (mentioned above), protocols were defined by pharmacists, with input from GPs and consumers, to optimise quality pharmaceutical services for patients with a high risk of medication misadventure; more than 80% of consumers felt that the pharmacists' service had made a significant contribution to their health and there was an estimated net societal saving to the health system of $110 per patient.3 The Commonwealth Department of Veterans' Affairs has attempted to facilitate communication in its medication management program through written referrals between specialists, general practitioners and pharmacists, with the consent of veterans, and through education programs.13 In the UK, models of pharmacists' input to primary care include (i) review of repeat prescriptions, (ii) total medication review, (iii) drug use evaluation, (iv) development of drug formularies (or drug lists) for general practices, (v) development of prescribing policy, and (vi) audit of prescribing by disease or condition.14 Not surprisingly, it was found that rational and cost-effective prescribing was best achieved when pharmacists and general practitioners worked together.14 Successful models of interdisciplinary collaboration need to be implemented cautiously, as rapid imposed change can create conflict and resistance. Relationship building, stakeholder involvement (at both "grass roots" and organisational levels) and communication between the professions have been key components associated with Australian studies of medication care.3-5,9 There are dangers in ignoring these components and other recommendations in translating trials into practice. For example, selective implementation of recommendations in providing consultant pharmacist services to nursing homes without the recommended involvement of and support to GPs,4 has resulted in some justifiable concern by GPs (personal, unpublished data). Clearly, any national effort to facilitate optimal medication care should mandate the involvement of all key stakeholders. Communication and relationships are the keys to balancing collaboration and optimal patient care with autonomy and privacy issues. Effective communication depends both on its being a two-way process, and on how the relationship between the two parties influences the interpretation of "messages" by each. Trust, confidence, involvement and a mutual respect for each professional's role and competence are therefore essential in any functioning team. The development of these elements should start during interdisciplinary undergraduate (and postgraduate) clinical education of doctors, pharmacists and other health professionals.15 Interdisciplinary clinical teaching, recognition of emerging practice models and the need for interprofessional student interaction are sadly lacking in Australia. With the introduction of the four-year pharmacy course and the graduate medical courses nationally, now is the time to grasp the opportunity offered for interdisciplinary development. Further, electronic prescribing links16 and newer avenues of interprofessional communication, such as regular joint medication reviews,9 consumer medicine information and the National Prescribing Service, are opportunities for overcoming the barriers to communication and information sharing, and to nurturing professional relationships. Facilitating information sharing between specialists, medical practitioners and pharmacists through interprofessional collaboration and better communication (including through the prescription form10-12) should lead to improved patient care and outcomes, easier and more effective communication between health professionals, and high quality, cost-effective use of medicines. The Australian healthcare system must build and maintain relationships between professionals and with consumers if it is to improve. Michael S Roberts NHMRC Senior Principal Research Fellow, and Professor Julie A Stokes Research Scholar Department of Medicine, University of Queensland, Princess Alexandra Hospital Brisbane, QLD Bridges-Webb C, Britt H, Miles D, et al. Morbidity and treatment in general practice in Australia 1990-1991. Med J Aust 1992; 157 Suppl Oct 19: S1-S56. Parkes AJ, Coper L. Inappropriate use of medications in the veteran community. How much do doctors and pharmacists contribute? Aust N Z J Public Health 1997; 21: 469-476. Gilbert A. Final report of the Community Pharmacy Model Practice Project. Canberra: Federal Department of Health and Family Services, 1997. Roberts MS, Stokes J, Bonner C, et al. Clinical pharmacy intervention and resident outcomes in Australian nursing homes. Proc Austral Soc Clin Exp Pharmacol Toxicol 1995; 2: 158. McNeece J. The drug and therapeutics information service. Aust J Hosp Pharm 1994; 24: 28-31. Goodman M, Lazzarini R. Examination of the feasibility of an ongoing strategy for disposal of unwanted and outdated medicines [abstract]. The Pharmaceutical Education Program 1995 Work in Progress Conference; Sydney Aug 24-26. Canberra: Commonwealth Department of Health and Family Services, 1995. Dartnell JG, Anderson RP, Chohan V, et al. Hospitalisation for adverse events related to drug therapy: incidence, avoidability and costs. Med J Aust 1996; 164: 659-662. Blackbourn J. Readmission to Fremantle Hospital. Part 2. Drug-related readmissions. Fremantle Hosp Drug Bull 1991; 15: 13. ACT Division of General Practice. Managing medication in nursing homes -- GP involvement in medication reviews. A report of the outcomes of the "Aged Care Assessment Project". Canberra: ACT Division of General Practice, 1998. In press. Ruth R, Constable V, Dammery D, et al. General practitioners' and pharmacists' interprofessional communication. Aust Fam Physician 1994; 23: 1544-1546. Liddell MJ, Goldman SP. Attitudes to and use of a modified precription form by general practitioners and pharmacists. Med J Aust 1998; 168: 322-355. Bollen M. Improving communication between general practitioners and pharmacists. Aust Fam Physician 1996; 25: 1011-1013. Coper L. Pharmaceutical Management Program. Canberra: Commonwealth Department of Veterans' Affairs, 1997. Bradley CP, Taylor RJ, Blenkinsopp A. Developing prescribing in primary care. BMJ 1997; 314: 744-747. Greene RJ, Cave I, Jackson SMD. Interprofessional clinical education of medical and pharmacy students. Med Educ 1996; 30: 129-133. Getting connected. Newslet Nat Pharm Intranet Demonst 1997; 1: 1-8. - Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Michael S Roberts · Julie A Stokes

Medical informatics meets medical education There's more to understanding information than technology MJA 1998; 168: 319-320 The decades-long predicted arrival of the information revolution in healthcare has taken perhaps no more than four years to go from a matter of minority opinion to one of general consensus.1,2 Not long ago, medical journals rarely discussed information technology, but now most carry regular articles on the subject. Indeed, all the major journals are now available in electronic form on the Web, and some argue that the paper journal is a dinosaur at the end of its time.3 Evidence grows for the value of using the computer to assist in routine tasks like prescribing4 and reminding general practitioners to carry out screening procedures.5 It is conceivable that, in the future, failure to use such tools could come to be regarded as negligent practice. Change such as this can often be abrupt and distressing, no matter how beneficial it may ultimately be. Existing skills become redundant and the young, who have time and energy to learn, have the advantage over those who may be more experienced but are constrained by existing clinical responsibilities. Clinicians with years of experience might thus be forgiven for throwing up their hands in despair at the sudden enthusiasm for computers and telemedicine, apparently at the expense of hard-won clinical skill and human empathy. However, if the scenarios that Carlile and Sefton paint in this issue of the Journal come to pass, then our dependence on information and communication technology can only deepen over the years.6 They draw our attention to the need to prepare medical graduates for work in a world where the inability to use this technology would be as debilitating as the inability to read or write is today. The ambitious new graduate medical program they describe at the University of Sydney is almost entirely structured around teaching material in the form of multimedia documents on the Web. Whether this move to a computer-based and problem-oriented curriculum will produce better-prepared graduates will no doubt become clearer with time. Certainly, all students in this program should graduate with proficiency in using the technology. In comparison, at the beginning of this decade only 25% of medical students at a comparable institution felt they could use computers well.7 While such an educational program is to be lauded, there is probably a greater educational challenge within the community of practising clinicians, most of whom have never had any formal training in information technology (IT). Nevertheless, they will be expected to work for many decades in an environment in which IT illiteracy will become increasingly burdensome. It is for these individuals that the immediate urgency lies. Certainly there is a case to be argued for basic postgraduate education in the use of IT in patient care, and if some medical colleges do not consider IT literacy a core component of their continuing education programs then perhaps they need to think again. Just how much training is needed depends on the systems clinicians need or want to use, and their current skills in doing so. If we are optimistic, these barriers for working clinicians will diminish over time as the technology becomes easier to use, and progressively develops into a commonplace and natural part of the clinical environment. However, we have no guarantees that such optimism is warranted. There is at least one major caveat in this rush to master the new technologies -- we must not forget that basic computer skills are not the same as being skilled in the management of information. Simply teaching practising clinicians or medical students to use IT is not enough. Just as the ability to suture doesn't make one a surgeon, the ability to surf the Web does not imply that one understands the principled use of information. With the current emphasis on evidence-based practice highlighting the skills needed to collate, distil and apply clinical research, we have a powerful example of the broader information and communication skills needed in healthcare. Information skills are basic to good medical practice. Every clinician needs to understand the principles of data interpretation, the logical foundations of the diagnostic process, and the management of uncertainty in clinical knowledge.8 The problem-oriented medical record is just an information instrument, and clinicians need to know when it is appropriate, and when indeed other formulations might be better choices. The dynamics of communicating with patients and with colleagues are altered when the exchange moves from a face-to-face interaction to the telephone, e-mail, voicemail or video.9 Understanding the implications of using one medium rather than another is central to developing effective communication skills as these communication options become commonplace in the community. Medical informatics is the name now given to the study of clinical information and communication processes. It is the rational study of the way we think about patients, and the way that treatments are defined, selected and developed. It is the study of how medical knowledge is created, shaped, shared and applied. Ultimately, it is the study of how we organise ourselves to create and run healthcare organisations.10 Understanding how to use information technology appropriately can only ever be one small component of this wider discipline. Where once these disparate elements of informatics were taught piecemeal, there is now growing consensus about the essential information skills needed by clinicians, and medical informatics is now appearing on more curricula as a distinct entity.11 A proposal for 10 essential clinical informatics skills is provided to give flesh to these ideas, and to stimulate debate about the role of informatics in medical education. So, the computer, the telephone, the Web, video -- these, and all that is still to come, are unquestionably powerful tools. Used badly, they do indeed waste time and money, create inefficiency, and dehumanise our interactions with each other. Used well, they are neither to be feared, loved nor loathed. They are simply to be used. And in the next century, the study of informatics will become as fundamental to the practice of medicine as anatomy has been to the last. Enrico Coiera Senior Project Manager Hewlett-Packard Laboratories, Bristol, UK E-mail: ewc AT pobox.com Coiera E. Medical Informatics. Med J Aust 1994; 160: 438-440. House of Representatives Standing Committee on Family and Community Affairs. Health on line: a report on health information management and telemedicine. Commonwealth of Australia. Canberra: The Committee, 1997. LaPorte RE, Marler E, Akazawa S, et al. The death of biomedical journals. BMJ 1995; 310: 1387-1389. Walton RT, Gierl C, Yudkin P, et al. Evaluation of computer support for prescribing (CAPSULE) using simulated cases. BMJ 1997; 315: 791-794. Shea S, Du Mouchel W, Bahamonde L. A Meta-analysis of 16 randomised controlled trials to evaluate computer-based clinical reminders for preventative care in the ambulatory setting. J Am Med Informatics Assoc 1996; 3: 399-409. Carlile S, Sefton AJ. Healthcare and the information age: implications for medical education. Med J Aust 1998; 168: 340-343. Kidd MR, Connoley GL, Cesnik B, McPhee W. What do medical students know about computers? Med J Aust 1993; 158: 283-284. Haynes RB, Ramsden M, McKibbon KA, et al. A review of medical education and medical informatics. Acad Med 1989; 64: 207-212. Coiera E, Tombs V. Communication behaviours in a hospital setting -- an observational study. BMJ 1998; 316: 673-677. Coiera E. Guide to medical informatics, the Internet and telemedicine. London: Chapman and Hall, 1997 ( see also http://www.coiera.com). Greenes RA, Shortliffe EH. Medical informatics -- an emerging academic discipline and institutional priority. JAMA 1990; 263: 1114-1120. - Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Enrico Coiera

Attitudes to and use of a modified prescription form by general practitioners and pharmacists Merilyn J Liddell and Sue P Goldman MJA 1998; 168: 322-325 For editorial comment see Roberts Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - ©MJA1998 Abstract Objective: To evaluate the rate of use and acceptance of a new prescription form designed to provide more information to pharmacists and patients. Design: Prospective descriptive study. Setting: A semi-rural community outside Melbourne, Victoria, in November 1994. Participants: GPs and pharmacists working three or more sessions per week in the locality, and 21 consumers who formed two consumer focus groups. Intervention: An education session for GPs and pharmacists, followed by a one-month trial of new prescription forms which included notations to facilitate interprofessional communication. Main outcome measures: Rate of use and acceptability of the new prescription notations. Results: Eighteen GPs and 10 pharmacists participated; 3600 forms were issued and 2521 prescriptions, including 3464 prescription items, were analysed. GPs and pharmacists used at least one of the new prescription notations in 45% (1559) of prescription items; 35% of prescription items (1222) were notated with the general purpose of the medication. Qualitative findings suggested that GPs, pharmacists and consumers considered the new prescription form to be beneficial and useful. Conclusions: A modified prescription form to increase communication between GPs and pharmacists is acceptable in clinical practice. Introduction Over recent years professional standards for prescribing have emphasised the need for a more patient-centred approach,1 as shown in such documents as the National Health and Medical Research Council's guidelines for medical practitioners on providing information to patients,2 the Policy on the Quality Use of Medicines developed by the Commonwealth Government,3 and regulations on the provision of written consumer information with dispensed medication.4 Research on how to provide more patient-centred pharmaceutical information and counselling shows that closer collaboration between general practitioners (GPs) and pharmacists would help to ensure that medication information is both comprehensive and relevant for consumers.5,6 A joint working party of the Royal Australian College of General Practitioners (RACGP) Victoria Faculty and the Victorian Branch of the Pharmaceutical Society of Australia (PSA) was formed in 1993 to consider how to improve communication between GPs, pharmacists and consumers. A series of recommendations were developed and endorsed by the national executives of the RACGP and the PSA, and published in a joint statement.7 The major recommendation was the use of a new prescription form to aid communication between GPs, pharmacists and patients. Here, we describe a pilot study to determine the rate of use of, and the attitudes of GPs, pharmacists and patients to, a modified prescription form for use in normal clinical practice. No similar study has been reported in the literature (based on the following searches: MEDLINE, January 1982 - June 1997; International Pharmaceutical Abstracts, January 1970 - December 1996; HEALTH, January 1975 - December 1996; EMBASE, January 1994 - December 1996; Pharmaceutical News Index, January 1974 - December 1996). Methods Ethical approval for this study was received from the Monash University Standing Committee on Ethics in Research on Humans and all subjects gave informed consent for their par ticipation. The study was conducted in November 1994 in a semi-rural community on the outskirts of Melbourne with a population of 25 000. All 24 GPs and 13 pharmacists working three or more sessions per week in the locality were invited to participate; 18 GPs and 10 pharmacists agreed. Twenty-one consumers from existing heart and arthritis support groups at the local community health centre were recruited for two focus groups of eight and 13 participants. Before the intervention, the 18 participating GPs and 10 pharmacists completed separate questionnaires (29 questions for pharmacists and 28 for GPs), which covered demographics and assessed (on a scale of 1 to 5) attitudes to professional roles, interprofessional collaboration and consumers' needs for medication information and counselling. Intervention The intervention began with an educational session for GPs and pharmacists to introduce the modified prescription form on which GPs could notate the purpose of prescribed medications, changes to existing medications and specific patient needs. Some of these notations were unprompted, requiring freehand additions to the prescription, while others were prompted, appearing as abbreviations on the form which could be circled when appropriate (see Box 1). A glossary of the new prescription notations was provided. Box 1 shows the glossary which was provided to pharmacists. During the education sessions, the new notations were explained as follows. The major change was that GPs were encouraged, where they considered it appropriate, to indicate the purpose of each prescribed medication as part of the written directions. For example, -adrenoceptor blocking agents might be notated as "for arrhythmias" or "for blood pressure". Pharmacists could then ensure that their medication counselling was relevant to that particular indication and would include the medication's purpose on the medication label for the patient's information. There was provision for GPs to request that the purpose not be written on the medication label by the pharmacist in certain circumstances (such as to preserve patients' privacy if the nature of their illness was not known to family members). GPs were also encouraged to indicate to the pharmacist if therapy with an ongoing medication was to cease (enabling pharmacists to update their computer records to show that a drug was no longer to be taken, and attempt to withdraw any unpresented repeats from circulation), or if the directions intentionally specified an unusual dosage or quantity to be dispensed. Finally, GPs could circle abbreviations printed on the prescription form to indicate specific patient needs or changes in the medication regimen. Pharmacists could then check the patient had understood changes to directions and amend the computer records accordingly. At the end of the educational session, 200 triplicate prescription forms were issued to each GP for use over one month. The third copy of each prescription dispensed (minus identifying patient details) was collected to determine the use of the new notations. After one month, individual one-hour open-ended, semi-structured interviews were conducted with all participating GPs and pharmacists, covering their overall views on the reformatted prescription, specific issues of practical application and suggested changes. Two separate one-and-a-half-hour focus group discussions with consumers dealt with aspects of the use of the reformatted prescription which would directly affect patients. Data analysis For frequency analysis of the questionnaires and of the prescription data, we used, respectively, the statistical package Genstat8 and the computer database program Access.9 Transcripts of interview data and focus group discussions were coded according to emerging themes around the prescription format and particular notations. The analysis, with the NUDIST program for qualitative analysis,10 concentrated on direct testimonies of views held about the new prescription form. Results The median age of the 18 GPs was 35 years (range, 20-29 to >70 years) and 14 were male. Their median workload was 175 patients per week (range, 50-99 to >200) and 13 had postgraduate qualifications. The GPs' age and sex distribution was similar to that of respondents in a national general practice population survey.11 The median age of the 10 pharmacists was 40 years (range, 20-29 to 50-59 years) and eight were male. Their median workload was 125 prescriptions dispensed per day (range, 50-99 to >200) and three had postgraduate qualifications. Attitudes to interprofessional communication In the questionnaire, 16 GPs (89%) and all of the pharmacists stated that they were in favour of more collaboration with one another. GPs had a reasonably high regard for the local pharmacists -- 13 (72%) did not agree that pharmacists' advice conflicted with their own; 17 (94%) agreed they had a good working relationship with the pharmacists, and none believed that pharmacists contacted them unnecessarily. Seven pharmacists (70%) stated that they enjoyed a comfortable working relationship with GPs; only three (30%) agreed that GPs were not always receptive to inquiries about prescriptions, and five (50%) expected the GP to be responsive to contact about a potential drug interaction. Before the intervention, the concept of including the general purpose of a medication on the prescription was not recognised by seven GPs (39%) and seven pharmacists (70%) as useful or necessary for the pharmacist. However, nine pharmacists (90%) stated that to counsel patients adequately they often needed to ask a patient for more information than was on the prescription. Use of the new prescription form Of a total 3600 prescription forms distributed to the GPs, 70% (2521 prescriptions for 3464 individual prescription items) were collected and analysed. Forty-five per cent of individual prescription items (1559) included one of the new notations. The rate of use of the new notations by the GPs is shown in Box 2. The purpose of the medication was notated for 35.3% of all prescription items (1222), with use of this notation by individual GPs ranging from 1% for the lowest user to 92% for the highest user. In only 0.3% (range, 0-4.5%) of cases where this notation was used did doctors request that the information be omitted from the label of the medication container. Attitudes to the new prescription form Overall, the new system was positively received by most GPs and pharmacists, and they suggested it should be widely implemented. Also, most GPs and pharmacists saw indicating the purpose of the medication on the prescription as the most substantial and important focus of the new prescription notations, and suggested that this would enhance the quality of information provided to consumers and minimise irrelevant or inappropriate advice. Further, some suggested that compliance may be improved because patients would receive consistent advice from GPs and pharmacists. Most GPs and pharmacists considered it useful to note when therapy with a long term medication was to be ceased, as patients may forget verbal instructions by the GP. Although the need did not often arise in practice, both GPs and pharmacists were in favour of specifically informing the pharmacist when an unusual dosage or a special quantity of medication was being prescribed. Most GPs and pharmacists thought it appropriate to indicate a new treatment, primarily for ongoing management. Noting a change of directions was considered useful by doctors and pharmacists alike, particularly with elderly patients or those who might still have unused prescriptions. The pharmacist could then be sure the change was intended, check the patient had understood the change, amend any unpresented repeats available, and note the change in the pharmacy computer record. Many GPs, pharmacists and consumers regarded preprinted abbreviations for specific patient needs as unnecessary; it was suggested that longhand could always be used for these or other specific requests to the pharmacist. The abbreviation for noting when separate written instructions had been given to the patient was considered a simple and useful quality control mechanism by doctors, pharmacists and consumers. The consumer focus groups indicated that pharmacists needed to know why someone was being prescribed a medication to enable them to provide appropriate counselling. They expressed reservations about conditions of a very personal nature; in such cases they expected the doctor to either ask their permission or omit the information from the prescription. In general, they considered it both appropriate and helpful to have the purpose of the medication included on the medication label. Discussion In this study the questionnaire findings gave basic data about pre-existing attitudes of the GPs and pharmacists to their respective roles, while the qualitative data explored, in much more depth, the strengths and weaknesses of the new innovation. A 70% return rate of prescriptions was satisfactory, as non-redemption of prescriptions can range from 5%-20%.12 Our most notable finding was the utilisation rate of the new notations, with 35% of prescription items indicating the purpose of the medication to the pharmacist. This was somewhat unexpected, as such a strategy had not previously been considered necessary by GPs or pharmacists. Further, such a high utilisation rate requires considerable behaviour change, and behaviour change strategies generally have much more modest outcomes (eg, 6% for minimal intervention smoking cessation programs13 and 8%-25% for group counselling14). The benefits of asking GPs to indicate the purpose of the medication on the prescription were supported by the qualitative data suggesting that when this strategy was employed it was highly valued. Both GPs and pharmacists indicated that the new prescription form would improve the quality of information given to patients by ensuring that information given by pharmacists was consistent with the advice already given by the GP. It would also enable more information to be given to patients on the medication label. It was of particular interest that, while some of the GPs and pharmacists had very high workloads, they were able to use the new prescription conventions easily in their normal daily practice. There was a high level of utilisation of the new prescription form as a whole, with some notations being used frequently, and others barely at all. This is to be expected as the appropriate circumstance for the use of some notations (such as unusual dosage) would be infrequent. The notation to pharmacists that drug therapy was to be ceased was not widely used, possibly because this affected only a small number of patients, but more likely because there was no specific reminder on the prescription form itself and doctors may have simply forgotten to use it. While some variation in the use of notations may have related to differing perceptions of their value, it was probably also a result of the difficulty of altering ingrained behaviour. Some participants stated that they would try to increase their use of the strategies if they were implemented in the future. Indicating the purpose of the medication is easily misinterpreted as being the same as including the diagnosis, and thereby providing unnecessarily detailed and confidential information to the pharmacist. Participating GPs, however, reported that they provided general information at an appropriate level for the pharmacist and, subsequently, the patient. From the pharmacists' perspective, information about the purpose of a medication was most useful for drugs with multiple indications. It enabled them to target their information appropriately without asking questions to ascertain the precise indication for a particular patient. Generally, consumers thought that including the purpose of the medication on the container label was likely to enhance patients' understanding of their own medication. Confidentiality needs always to be considered, but there are clear advantages in having a drug's purpose included on the label in most situations. As we used only two small consumer focus groups, they could provide only a limited indication of what consumers may think of the proposed system. However, consumers did suggest that the new system would help them gain access to appropriate information and advice. Any future implementation should be made with adequate consumer input, to ensure attention to their requirements. In conclusion, this study showed that it is possible to modify the prescription form to include more information in a way that is acceptable to GPs and pharmacists in their daily practice. GPs, pharmacists and consumers found such changes worthwhile and believed they could lead to better medication management and patient care. Acknowledgements We thank the Royal Australian College of General Practitioners and the Victorian Branch of the Pharmaceutical Society of Australia, and the members of the joint working party -- Val Constable, John Daffey, David Dammery, Chris Hogan, Alistair Lloyd, Mary Murray and Denise Ruth -- as well as the GPs, pharmacists and consumers in the study. Finally, we thank the Department of Health, Housing, Local Government and Community Services for financial support for the project. References Liddell M. Rational prescribing and professional standards. Med J Aust 1994; 160: 564-567. Working Party of the Health Care Committee, National Health and Medical Research Council. General guidelines for medical practitioners on providing information to patients. Canberra: National Health and Medical Research Council, 1993. Commonwealth Department of Health, Housing and Community Services, in conjunction with the Pharmaceutical Health and Rational Use of Medicines (PHARM) Working Party. A policy on the quality use of medicines. Canberra: Commonwealth Department of Health, Housing and Community Services, 1992. Part 2A, Schedule 12 of the Therapeutic Goods Regulations under the Therapeutic Goods Act 1989, Section 63. Murphy B, Ruth D, Murray-Hodge M. The use of qualitative research in the development of the HEARTWISE program for general practitioners. Med J Aust 1993; 158: 626-628. Ruth D, Hodge M, Murphy B. Improving the relationship between general practitioners and pharmacists. Aust Fam Physician 1994; 23: 1536-1540. Royal Australian College of General Practitioners and the Pharmaceutical Society of Australia. General practitioners' and pharmacists' interprofessional communication. Aust Fam Physician 1994; 23: 1544-1546. Genstat [computer program]. Version 5 Release 3.1. Lawes Agricultural Trust (Rothamstead Experimental Station, UK), 1993. 9. Access [computer program]. Version 2.0. Redmond, Wa.: Microsoft Corporation, 1994. Richards T, Richards L. The NUDIST qualitative data analysis system. Qual Sociol 1991; 14: 307-325. Bridges-Webb C, Britt H, Miles D, et al. Morbidity and treatment in general practice in Australia 1990-1991. Med J Aust 1992; 157 Suppl Oct 19: 14. Beardon P, McGilchrist M, McKendrick A, et al. Primary non-compliance with prescribed medication in primary care. BMJ 1993; 307: 846-848. Kottke T, Battista R, DeFrieze G, et al. Attributes of successful smoking cessation interventions in medical practice: a meta-analysis of 39 controlled trials. JAMA 1988; 259: 2882-2889. Curry S, Marlatt G, Gordon J, et al. A comparison of alternative theoretical approaches to smoking cessation and relapse. Health Psychol 1988; 7: 545-556. (Received 5 Jun, accepted 10 Nov, 1997) Authors' details Department of Community Medicine and Department of General Practice, Monash University, Melbourne, VIC. Merilyn J Liddell, MB BS, FRACGP, Senior Lecturer; Sue P Goldman, BEd, GradDipSoc, Research Fellow. Reprints will not be available from the authors. Correspondence: Dr M J Liddell, 867 Centre Road, East Bentleigh, VIC 3165. E-mail: merilyn.liddell AT med.monash.edu.au Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Merilyn J Liddell · Sue P Goldman

Disseminating and applying best evidence Does use of systematic reviews equal evidence-based medicine? MJA 1998; 168: 260-261 There are two purposes to medical research: one abstract -- the pursuit of knowledge for its own sake -- the other practical -- to improve health outcomes. To achieve the latter, research results must be disseminated and implemented, but this process may be slow, inaccurate and incomplete, resulting in varying clinical practice and outcomes. This is not through wilful disregard of medical advances; no active clinician expects to practise without needing new information and skills as health advances occur. Yet it is not humanly possible to keep up with all advances in all areas of medical research. Medical practitioners may use different forms of evidence to enlighten decisions but, until recently, were not taught how to ask the relevant questions about the new knowledge needed, how to sieve the medical literature and access information efficiently, nor how to assess success in applying new knowledge. Recognition of these deficiencies led to the discipline of evidence-based medicine (EBM). However, the recently emerged centres and departments of EBM are distrusted by some, perhaps because of visions of "cookbook" medicine, or the implied deficiencies in existing knowledge and practice, but often through misunderstanding of the nature of EBM. EBM is "a process of lifelong, self directed learning in which caring for our own patients creates the need for clinically important information about diagnosis, prognosis, therapy and other clinical and health care issues, and in which we: Convert these information needs into answerable questions; Track down with maximum efficiency the best evidence with which to answer them (whether from the clinical examination, the diagnostic laboratory, from research evidence or other sources); Critically appraise that evidence for its validity (closeness to the truth) and usefulness (clinical applicability); Apply the results of this appraisal in our clinical practice; Evaluate our performance."1 EBM is a structured process through which all available evidence is used to support clinical decision-making. Most active clinicians would support this philosophy, and data show that much clinical decision-making is in keeping with current knowledge.2-4 In this issue of the Journal, Jordens et al5 address the issue of how well Australian neonatologists and obstetricians access and use one such source of information -- systematic reviews, which aim to review all available clinical trial data in a structured way, often including meta-analyses. It is implicit in the research of Jordens et al that use of systematic reviews is "a good thing" and should be encouraged. They found that 72% of Australian neonatologists and 44% of their sample of Australian obstetricians reported using systematic reviews on average once per month. Is this a "good" result? Or should it be expressed as 28% of neonatologists and 56% of obstetricians report not using systematic reviews, with the implication that systematic reviews should be used by more? I believe neither is the issue. It remained unclear from the study whether using systematic reviews objectively improved practice, or whether respondents who used systematic reviews more also practised better, as judged by external benchmarks. Furthermore, Jordens et al found that, for keeping abreast with new clinical developments, respondents relied primarily on journals, followed (in decreasing order) by conferences and meetings, colleagues, and MEDLINE, with systematic reviews last. For clinical problem-solving, respondents relied on colleagues, MEDLINE, journals and other printed medical literature, again above systematic reviews. Does this mean that systematic reviews are not valuable? Of course not. It merely identifies them as one of many sources of information. Choice of sources will depend on the existing skills and knowledge of the individual practitioner. Although systematic reviews undoubtedly have a place in continuing medical education and may be more informative than traditional opinion-based, narrative reviews,6 we rarely acknowledge their flaws. As with any summary, they have a finite life span and must be updated obsessively and regularly. Systematic reviews on the same topic may be inconsistent.7 They are often based on meta-analyses, which may be flawed in design8 or incorrect.9 In 35% of instances, meta-analysis results are not corroborated by subsequent large scale randomised clinical trials.9 For these reasons, systematic reviews must be seen as one source of information, and not as the only or best source. They are merely a structured way of reviewing other investigators' data. Documenting and disseminating the evidence is only the beginning of continuing medical education. It does not matter how advances are disseminated, as long as it is done accurately and efficiently. More importantly, it is not the dissemination per se that is crucial, but the appropriate application and use of the information. Effective strategies for changing clinical practice include use of reminders, academic visits, opinion leaders and combinations of these.10 Other sources of information known to be important include university-sponsored continuing medical education, hospital rounds, and pharmaceutical representatives.11 Conferences and lectures are in general least effective, while colleagues and journals consistently score highly.10,11 Different strategies will work for different clinicians in different environments12 and must be adapted to the specific practice change desired, the target, setting, and obstacles to change. A series of staged alterations will usually be needed, including review of whether practice has changed and appropriate further alterations as necessary. Unfortunately, it is clear that there are still major problems with dissemination and application of evidence. For example, only 36%-42% of patients in the United States may be receiving b -blockers after myocardial infarction,13 despite their well known benefits. Systematic reviews certainly have a place in improving the dissemination and application of current best knowledge, but it is worrying when it is implied that these reviews equal EBM and that if practitioners do not use them routinely their knowledge base or clinical practice is flawed. Jordens et al have shown that systematic reviews are accessed as one source of clinical information and may alter clinical practice. However, whether or not clinicians use a particular source of information is not the important issue. The challenge is to improve further the application of best knowledge. Paddy A Phillips Professor, and Head of Medicine, Flinders University of South Australia Flinders Medical Centre, Adelaide, SA Sackett DL, Richardson WS, Rosenberg W, Haynes RB. Evidence based medicine: how to practice and teach EBM. New York: Churchill Livingstone, 1997. Ellis J, Mulligan I, Rowe J, Sackett DL. Inpatient general medicine is evidence based. Lancet 1995; 346: 407-409. Geddes JR, Game D, Jenkins NE, et al. What proportion of primary psychiatric interventions are based on evidence from randomised controlled trials? Qual Health Care 1996; 5: 215-217. Gill P, Dowell AC, Neal RD, et al. Evidence based general practice: a retrospective study of interventions in one training practice. BMJ 1996; 312: 819-821. Jordens CFC, Haw P, Irwig LM, et al. Use of systematic reviews of randomised trials by Australian neonatologists and obstetricians. Med J Aust 1998; 168: 267-270. Cook DJ, Mulrow CD, Haynes RB. Systematic reviews: synthesis of best evidence for clinical decisions. Ann Intern Med 1997; 126: 376-380. Jadad AR, Cook DJ, Browman GP. A guide to interpreting discordant systematic reviews. Can Med Assoc J 1997; 156: 1411-1416. Bailar JC. The promise and problems of meta-analysis. N Engl J Med 1997; 337: 559-601. LeLorier J, Gregoire G, Benhaddad A, et al. Discrepancies between meta-analyses and subsequent large randomized, controlled trials. N Engl J Med 1997; 337: 536-542. David DA, Thomson MA, Oxman AD, Haynes B. Changing physician performance: a systematic review of the effect of continuing medical education strategies. JAMA 1995; 274: 700-705. Felch WC, Scanlon DM. Bridging the gap between research and practice: the role of continuing medical education. JAMA 1997; 277: 155-156. Grol R. Beliefs and evidence in changing clinical practice. BMJ 1997; 315: 418-421. Rogers WJ, Bowlby LJ, Chandra NC. Treatment of myocardial infarction in the United States (1990 to 1993): observations from the National Registry of Myocardial Infarction. Circulation 1994; 92: 2103-2114. - Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Paddy A Phillips

Use of systematic reviews of randomised trials by Australian neonatologists and obstetricians Christopher F C Jordens, Penelope Hawe, Les M Irwig, David J Henderson-Smart, Margaret Ryan, Deborah A Donoghue, Roger G Gabb and Ian S Fraser MJA 1998; 168: 267-270 For editorial comment see Phillips Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - ©MJA1998 Abstract Objective: To determine what proportion of Australian neonatologists and obstetricians report using systematic reviews of randomised trials. Design: Cross-sectional survey using structured telephone interviews. Setting: Australian clinical practice in 1995. Participants: 103 of the 104 neonatologists in Australia (defined as clinicians holding a position in a neonatal intensive care unit); a random sample of 145 members of the Royal Australian College of Obstetricians and Gynaecologists currently practising in Australia. Main outcome measures: Information sources used in clinical practice; reported awareness of, access to and use of systematic reviews, and consequent practice changes. Results: Response rates were 95% (neonatologists) and 87% (obstetricians); 71 neonatologists (72%) and 55 obstetricians (44%) reported using systematic reviews, primarily for individual patient care. Databases of systematic reviews were used with a median frequency of once per month. Among neonatologists, systematic reviews were used more commonly by those who were familiar with computers, attended professional meetings, and had authored research papers. Among obstetricians, they were used more commonly by those who were familiar with computers, had less than 10 years' clinical experience, attended more deliveries, and were full-time staff specialists in public hospitals. Of neonatologists who reported using systematic reviews, 58% attributed some practice change to this use. For obstetricians, the corresponding figure was 80%. Conclusions: There is evidence that Australian neonatologists and obstetricians use systematic reviews and modify their practice accordingly. Dissemination efforts can benefit from knowledge of factors that predict use of systematic reviews. Introduction Randomised controlled trials are widely accepted as the best method of evaluating the effectiveness of medical interventions. However, their findings are slow to change medical opinion and practice.1,2 The communication of clinically important research findings is hampered by the volume and geometric growth of the medical literature.3 Reviews address this problem, but conventional review methodology is unscientific4,5 and open to selection biases inherent in the publication process.5,6 This has led to the development of systematic reviews. A properly conducted systematic review begins with an exhaustive search for published and unpublished randomised trials addressing a well defined research question. The second step is to identify trials of adequate quality to contribute to decision-making. The results of included trials are then pooled, or "meta-analysed", to arrive at a quantitative estimate of the benefits and harms of treatment. Systematic reviews published by the Cochrane Collaboration are also continuously updated by specialist review groups.7 Systematic reviews in pregnancy and childbirth have been available for some years. In 1988 a comprehensive trial register became commercially available in database form as the Oxford database of perinatal trials.8 Effective care in pregnancy and childbirth, 9 a textbook based on this research synthesis, was published the following year, with a guide for non- specialist readers.10 A companion textbook, Effective care of the newborn infant,11 appeared in 1992. From 1993, systematic reviews relating to pregnancy and childbirth were available electronically in the Cochrane pregnancy and childbirth database.12 All these reviews are currently being updated for The Cochrane library.13 These new publications represent prototypes for future publications in other fields of practice. However, their impact on clinical practice remains uncertain, despite several surveys to ascertain the extent of their dissemination and uptake.14-18 To make a practical difference, systematic reviews must be readily available to clinicians who are aware of them, who use them, and who implement their findings. To ascertain whether this is occurring in Australia, we conducted a survey of neonatologists and obstetricians with the aims: To gauge awareness of, access to, and use of the Oxford database, Cochrane database, and Effective care textbooks; To place these resources in the context of other information sources that inform practice in obstetrics and neonatology; and To ascertain how often and why these resources are consulted, predictors of their use, and whether their use has led to reported changes in clinical practice. Methods Participants Clinicians who held a position in one of Australia's 23 neonatal intensive care units were eligible for the survey. The Australian and New Zealand Neonatal Network (ANZNN), which covers all neonatologists, provided a current listing. The Royal Australian College of Obstetricians and Gynaecologists (RACOG) drew a simple random sample of 20% of Fellows from its membership. Those sampled were eligible if they were currently practising obstetrics. Any clinicians not currently practising in Australia, not on the telephone network, or who were involved in designing this survey, were ineligible. Eligible clinicians were sent an introductory letter, telephoned, and invited to schedule a confidential, 10-minute telephone interview about information sources used in clinical practice. Systematic reviews were not mentioned until the interview was under way. Interviews An existing interview schedule15,16 was modified in consultation with the ANZNN and the RACOG. Respondents were first asked to name the three main sources of information they used for keeping up with new developments in their field, and for dealing with uncertainty about a specific treatment decision. They were also asked which of the three information sources they considered the most important or useful for each task. Respondents were then asked about their access to and use of computers, and asked directly whether they had heard of, had access to, and used the Cochrane database, Oxford database, and Effective care of the newborn infant (neonatologists) or Effective care in pregnancy and childbirth (obstetricians). Those who reported using any of these resources were asked what a systematic review was, how often they consulted that resource, what they used it for, whether they thought using it had made any difference to their clinical practice and, if so, whether they could name a treatment policy they had altered in response to evidence from a systematic review. To count as users of systematic reviews, respondents had to mention randomised trials or meta-analysis in their description of a systematic review. The final questions sought demographic information on clinical experience, place of education, attendance at professional meetings, research publications, academic appointments, and qualifications. A research degree was defined as a doctorate, relevant master's degree, or bachelor's degree of science in medicine, held in addition to basic medical and specialty qualifications. Reports of authorship were verified by searching MEDLINE and by screening abstracts. For neonatologists it was noted whether they held full- or part-time positions, whether they worked in a hospital with an obstetric unit, whether they headed a neonatal unit, and in which unit they worked. For obstetricians, it was noted whether they held a position as a full-time staff specialist in a public hospital. They were asked how many deliveries they attended each year, and whether they worked at any hospital with an accredited RACOG training post. The interview schedule was modified after a pilot study with seven neonatologists in New Zealand. The main survey was conducted between August and December 1995, with ethics approval from the ANZNN, RACOG and the University of Sydney. All interviews were conducted by the first author (C F C J). Analysis Confidence intervals for the proportion of obstetricians who reported using systematic reviews were calculated with a finite population correction. Confidence intervals were not calculated for the corresponding proportion of neonatologists, as this was ascertained for all Australian neonatologists. Descriptive and c 2 analyses were conducted. Then, using a backwards stepwise modelling procedure, a multivariate logistic regression analysis was used to determine which study factors predicted the reported use of systematic reviews. With the neonatology data, this modelling procedure was repeated using binomial generalised estimating equations to adjust for clustering of respondents within neonatal units.19 Results Of 106 listed neonatologists, three were ineligible (one had retired, one was not practising in Australia, and one was involved in designing this survey). Of the 103 eligible clinicians remaining, 98 completed interviews (95% response). From a sample of 210 obstetricians, 65 were ineligible for the survey (51 no longer practised obstetrics, 13 were not practising in Australia, and one could not be located on the telephone network). Of 145 eligible obstetricians, 126 completed interviews (87% response). Respondent characteristics are shown in Box 1, with comparative data on computer use. For the purpose of keeping up with new clinical developments, respondents favoured journals, conferences and meetings, colleagues and MEDLINE (in that order) over systematic reviews. For the purpose of clinical problem-solving, colleagues, MEDLINE, journals, and other printed medical literature were favoured over systematic reviews as sources of information. Although the percentages favouring each source varied between the two specialties and according to whether the respondent was simply nominating the resource or nominating it as the most important resource, the rank order of the resources remained consistent. In each specialty, 21% of respondents mentioned systematic reviews without prompting from the interviewer when naming the information sources they used, or when describing their computer use. When questioned directly about systematic reviews, 71 neonatologists (72%) and 55 obstetricians (44%; 95% confidence interval, 36%-51%) reported using them in either electronic database or textbook form. The confidence interval indicates the reliability of the sample prevalence as an estimate of the population prevalence. The Figure shows reported levels of awareness of, access to and use of systematic reviews by specialty. Predictors of use of systematic reviews Results of the multivariate analysis are shown in Box 2. Among neonatologists, three factors significantly (P<0.05) and independently predicted use of systematic reviews: attendance at meetings of the Australian Perinatal Society, authorship of at least one research paper, and familiarity with computers (our index of this was use of a computer for word-processing). Results from cluster analysis agreed with those from logistic regression. Among obstetricians, four factors sig nificantly and independently predicted use of systematic reviews: familiarity with computers, mode of practice (full-time staff specialists were more likely to use systematic reviews than others), clinical experience (recent graduates were more likely to use systematic reviews), and number of deliveries per year (likelihood of using systematic reviews increased with this number). Descriptors of use of systematic reviews Both neonatologists and obstetricians reported using databases of systematic reviews with a median frequency of once per month. The main purpose for using systematic reviews (irrespective of their format) reported by respondents from both specialties was individual patient care. Systematic reviews were also said to be used for (in rank order of frequency of reporting) teaching, preparing a pre sentation, reviewing current management or developing evidence-based protocols or guidelines, settling disputes, background information, reviewing a topic, research, as a source of references, and patient information. Of the 71 neonatologists who reported using systematic reviews, 58% said that this had changed their clinical practice in some way, and 44% gave at least one example of a treatment policy they had altered in response to a systematic review. The most common examples were treatment of respiratory disorders, and use of steroids and indomethacin. Corresponding percentages for obstetricians who reported using systematic reviews were 80% (reported a change in practice) and 71% (gave at least one example). The most common example was use of steroids in management of preterm rupture of membranes. Discussion We found that 72% of neonatologists and 44% of obstetricians reported consulting systematic reviews, primarily for the purpose of individual patient care. Databases of systematic reviews were used at a median frequency of once per month. Systematic reviews were used more commonly by those who were familiar with computers in both specialties, by those who attended professional meetings and had authored research papers among neonatologists, and by those who had had less than 10 years' clinical experience, attended more deliveries, and who had a position as a full-time staff specialist among obstetricians. The findings of this survey are based on self-reporting. Although the survey was designed to minimise over-reporting, it was still subject to imprecision in respondents' recall about (for example) the frequency with which they used systematic reviews, and to difficulties in attributing practice changes to their use. Nevertheless, this was the first study of the use of systematic reviews by Australian clinicians, and the findings have immediate and practical relevance for organisations such as universities, government agencies and specialty colleges that are trying to improve access to the best available evidence and to promote its use.20-23 The association between use of systematic reviews and attendance at Australian Perinatal Society meetings among neonatologists could reflect greater receptiveness to innovations among clinicians who attend professional meetings. However, it also supports the perception (reported elsewhere13 ) that professional organisations play an important role in disseminating research findings. Future dissemination efforts could usefully concentrate on these organisations. In both specialties, familiarity with computers predicted use of systematic reviews. Better access to digital information technology and training in its use is therefore likely to enhance uptake of these reviews. This might include improved access to The Cochrane library and the Internet, and training workshops for searching specialist databases. The remaining predictors of use of systematic reviews, as well as the overall contrast between neonatology and obstetrics, suggest that specialists practising primarily in public hospitals are more likely to use systematic reviews than those working primarily in private practice. Special efforts are therefore needed to reach the latter. As systematic reviews do not appear to rank highly among the information sources used in clinical practice, it is important to stress their relative advantages. Uptake of this innovation appears more likely among recent graduates, with senior clinician researchers acting as "product champions".24 Although debate persists as to whether practising clinicians accept the innovations of evidence-based medicine,25 our survey found evidence that Australian neonatologists and obstetricians use systematic reviews, and appear to modify their practice accordingly. Efforts are needed to enhance the use of these reviews, and to conduct further evaluations of their influence on clinical practice. In attempting to improve practice standards, it is important to pursue methods which have been shown to be effective.26 Acknowledgements We would like to thank the many clinicians who gave up their time to participate in this survey. Infrastructure support for this project was provided by the Department of Public Health and Community Medicine at the University of Sydney. Special thanks are due to Petra Macaskill, who conducted the cluster analysis, and Jeanette Ward and Mary Osborne, from the Central Sydney Area Health Service Needs Assessment and Health Outcomes Unit, who provided helpful advice on survey procedures. References Antman EM, Lao J, Kupelnick B, et al. A comparison of results of meta-analyses of randomized control trials and recommendations of clinical experts: treatments for myocardial infarction. JAMA 1992; 268: 240-248. Stross JK, Harlan WR. The dissemination of new medical information. JAMA 1979; 241: 2622-2624. Warren KS. From papyrus to parchment to paper to pixels: information technology and the future of biomedical publishing. In: Lock S, editor. The future of medical journals. London: BMJ, 1991: 127-146. Mulrow CD. The medical review article: state of the science. Ann Intern Med 1987; 106: 485-488. Light RJ, Pillemer DB. Summing up: the science of reviewing research. Cambridge: Harvard University Press, 1984. Dickersin K, Berlin JA. Meta-analysis: state-of-the-science. Epidemiol Rev 1992; 14: 154-176. Sackett DL. The Cochrane Collaboration. ACP J Club 1994; 120 Suppl 3: A-11. Chalmers I, editor. Oxford database of perinatal trials. Version 1.2, disk issue 7 (Spring). Oxford: Oxford University Press, 1992. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989. Enkin M, Keirse MJNC, Chalmers I. A guide to effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989. Sinclair JC, Bracken MB. Effective care of the newborn infant. Oxford: Oxford University Press, 1992. Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP, editors. Cochrane pregnancy and childbirth database. Oxford: Update Software, 1993. The Cochrane Library [database on disk and CD-ROM]. The Cochrane Collaboration. Oxford: Update Software; 1996. Updated quarterly. Lomas J. Retailing research: increasing the role of evidence in clinical services for childbirth. Milbank Q 1993; 71: 439-475. Stocking B. Implementing the findings of effective care in pregnancy and childbirth in the United Kingdom. Milbank Q 1993; 71: 497-523. Paterson-Brown S, Fisk NM, Wyatt JC. Uptake of meta-analytical overviews of effective care in English obstetric units. Br J Obstet Gynaecol 1995; 102: 297-301. Paterson-Brown S, Wyatt JC, Fisk NM. Are clinicians interested in up to date reviews of effective care? BMJ 1993; 307: 1464. Hyde C. Who uses the Cochrane pregnancy and childbirth database? BMJ 1995; 310: 1140-1141. Zeger SL, Liang K-Y. Longtitudinal data analysis for discrete and continuous outcomes. Biometrics 1986; 42: 121-130. Rychetnik L. Evidence-based medicine in the GMP (Graduate Medical Program). Focus: graduate medical degree news and events. Sydney: 1995: 1-2. Liddle J, Williamson M, Irwig L. Method for evaluating research and guideline evidence. Sydney: NSW Department of Health, 1996. National Health and Medical Research Council. Clinical practice guidelines: the management of early breast cancer. Canberra: NHMRC, 1995. Commonwealth Department of Human Services and Health. Guidelines for the development and implementation of clinical practice guidelines. Canberra: the Department, 1995. Rogers EM. Diffusion of innovations. New York: MacMillan, 1983. Miles A, Bentley P, Polychronis A, Grey J. Evidence-based medicine: why all the fuss? J Evaluation Clin Pract 1997; 2: 83-85. Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993; 342: 1317-1322. (Received 11 Jun, accepted 11 Sep, 1997) Authors' details University of Sydney, Sydney, NSW. Christopher F C Jordens, MPH, Postgraduate Student, Department of Public Health and Community Medicine; now Researcher, Centre for Values, Ethics and the Law in Medicine, Department of Surgery, University of Sydney; Penelope Hawe, MPH, Senior Lecturer, Department of Public Health and Community Medicine; Les M Irwig, FFPHM, PhD, Associate Professor, Department of Public Health and Community Medicine; David J Henderson-Smart, PhD, FRACP, Professor, and Director, NSW Centre for Perinatal Health Services Research, and Department of Neonatal Medicine, Royal Prince Alfred Hospital, Sydney, NSW; Deborah A Donoghue, RN, BSocSc, Senior Research Assistant, Australian Institute of Health and Welfare National Perinatal Statistics Unit; Ian S Fraser, MD, FRACOG, Professor in Reproductive Medicine, Department of Obstetrics and Gynaecology, Queen Elizabeth II Research Institute for Mothers and Infants. Royal Australian College of Obstetricians and Gynaecologists, Melbourne, VIC. Margaret Ryan, MSW, PhD, Research Officer. Centre for Professional Development, Victoria University of Technology, Melbourne, VIC. Roger G Gabb, PhD, Professor, and Director. Reprints: Mr C F C Jordens, Department of Surgery, Blackburn Building D06, University of Sydney, NSW 2006. E-mail: cjordens AT surgery.usyd.edu.au Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Penelope Hawe · Les M Irwig · David J Henderson-Smart · Margaret Ryan · Deborah A Donoghue

General internal medicine in Australia and New Zealand -- a renaissance A new society challenges potentially excessive subspecialisation MJA 1998; 168: 104-105 Last year in Auckland the Internal Medicine Society of Australia and New Zealand (IMSANZ) arose from the merger of the Australian Society of Consultant Physicians in General Medicine and the Internal Medicine Society of New Zealand. The new society, with 400 Australian and 100 New Zealand members, is now the regional voice of consultative general medicine. Its birth coincides with the renaissance of this discipline in Canada, the United States and Europe. Hospitals, health care managers and funders are reconsidering the likely benefits to both quality and efficiency of health care when medical services are provided by a team in which the "breadth" skills of generalists complement the "depth" skills of subspecialists.1 Outcomes of care Who achieves better outcomes -- general or subspecialty physicians? There are two relevant Australian studies, both in tertiary hospitals. One was not completed because of lack of enthusiasm by busy clinicians and doubts about the value of consensus evaluation following case note audit.2 The second, a randomised study, showed no differences between general medical and specialist geriatric care in acutely ill patients older than 70.3 Although comparisons with the US are problematic because "general" in the US includes primary care as well as consultative general medicine, US subspecialists have better outcomes for the care of rheumatoid disease and myocardial infarction,1 while for hypertension and non-insulin-dependent diabetes outcomes for generalists and specialists are similar.4 However, specialists consume more resources.5 Health care costs In the US, swelling numbers of physician subspecialists reportedly increase health care costs, unmatched by proportional outcome benefits.6 Excessive subspecialisation may lead to economic blow-out, especially in the uncapped, fee-for-service private sector. With "managed care" to contain costs, there is a resurgence of training and career opportunities for generalists.7,8 Is there too much subspecialisation in Australia and New Zealand? In Australian capital cities, subspecialisation, especially in procedural subspecialties, may be excessive. Of 2611 Australian consultant physicians in adult medicine in 1995, only 399 described themselves as "general", compared with 371 cardiologists and 286 gastroenterologists.9 In State capitals in the period 1988-1995 physician numbers (excluding paediatricians) increased from 1729 to 2146, while general physician numbers dropped from 412 to 281.9 In 1996, of 552 Australian advanced trainees of the Royal Australasian College of Physicians (excluding those in paediatrics), only 42 (8%) were in general medicine, with 84 in cardiology and 51 in gastroenterology. However, in New Zealand, 25% of the trainees were generalists. Despite the subspecialisation in Australia's biggest cities, there are shortages of consultant physicians in country areas. Up to 50 additional consultant physicians are needed in provincial and rural Queensland alone.10 Most would need to be generalists. Why do tertiary hospitals need general medical units? Tertiary practice, now dominated by technology and procedures, is becoming organisationally and financially based on discrete episodes of care involving single diagnoses. In this climate, the general medical unit may be seen by some as unnecessary; three teaching hospitals in Sydney as well as the Canberra Hospital, ACT, now have no such units. Compartmentalisation of care by medical specialty means that significant comorbidities and patient concerns unrelated to the particular specialty are easily overlooked, misdiagnosed or inappropriately managed. Gains in efficiency through greater throughput of patients with similar problems may be offset by more consultations and unnecessary investigation. Further, the continuity of care is disrupted. Generalists, with skills in managing undifferentiated problems and conditions that cross subspecialty barriers and an awareness of both the psychosocial and the biological aspects of illness, offer "whole person" patient care and can act as advocates for the patient.11 While many subspecialists practise in a similar way, general units are needed to provide training positions and role models for both basic and advanced training in general medicine. The generalists' integrated view of patients is an absolute requirement for undergraduate and early postgraduate education in a setting where illness is not arbitrarily framed by such overlapping criteria as age (e.g., geriatrics), organ system (e.g., cardiology), pathological process (e.g., oncology), aetiology (e.g., infectious disease) and treatment goal (e.g., palliative care). New agenda for general internal medicine General internal medicine has the breadth and the capacity to embrace new challenges. Generalists can continue to learn from experienced subspecialists and can acquire both the knowledge and procedural skills that might be necessary in particular city or rural, hospital or office settings. They can also lead the way, as in North America,12 in clinical epidemiology and decision-making, ethics, clinical informatics, health technology assessment, clinical audit, and health service research. General physicians can act with other colleagues (e.g., in general practice, surgery, emergency medicine, psychiatry, geriatrics) to help integrate medical care and provide an overview of medical management that may be lost with exclusive specialty care.13 Barriers to the realisation of this new agenda include negative perceptions of generalists by some influential subspecialists in hospitals, by professional societies and by patient support groups; difficulties faced by general trainees in competing for coveted subspecialty training positions;14 and competition among institutional units for limited resources under casemix funding. Lack of confidence and leadership among generalists themselves may set up internal barriers. While the need for subspecialisation in consultative physician practice is recognised and supported, it seems the pendulum has swung too far. Our health care systems stand to benefit from a more vigorous contribution by well-trained and committed general physicians. For a winning team, we need outstanding players -- some with specialised talents and others who are versatile.1 Ian A Scott Director General Medicine Princess Alexandra Hospital, Brisbane, QLD Peter B Greenberg Director General Medical Services North Western Health Care Network, Melbourne, VIC Nash DB, Nash IS. Building the best team. Ann Intern Med 1997; 127: 72-73. Douglas RM, Blood A. Evaluation and peer review of the role of specialist and general medical units in a teaching hospital. Aust N Z J Med 1978; 8: 337-343. Harris RD, Henschke PJ, Popplewell PY, et al. A randomised study of outcomes in a defined group of ill elderly patients managed in a geriatric assessment unit or a general medical unit. Aust N Z J Med 1991; 21: 230-234. Greenfield S, Rogers W, Mangotich M, et al. Outcomes of patients with hypertension and non-insulin-dependent diabetes mellitus treated by different systems and specialties. Results from the medical outcomes study. JAMA 1995; 274: 1436-1444. Welch WP, Miller ME, Welch HG, et al. Geographic variation in expenditures for physician services in the United States. N Engl J Med 1993; 328: 621-627. Schroeder SA, Sandy LG. Specialty distribution of US physicians -- the invisible driver of health care costs. N Engl J Med 1993; 328: 961-963. Wartman SA. Managed care and its effect on residency training in internal medicine. Arch Intern Med 1994; 154: 2539-2544. Weiner JP. Forecasting the effects of health reform on US physician workforce requirement. Evidence from HMO staffing patterns. JAMA 1994; 272: 220-230. Dent O. The Royal Australasian College of Physicians Clinical Workforce in Internal Medicine and Paediatrics in Australia 1988 and 1995. Fellowship Affairs 1989; 8: 9-20, and 1997; 16: 17-30. Hadfield C. Rural manpower in Queensland -- a start to tackling the problem? IMSANZ Newsletter June 1997: 6-7. Guidelines for members and advanced trainees in general medicine, 1997. Sydney: Internal Medicine Society of Australia and New Zealand, 1997. Greenbeck MR. Educating physicians for the 21st century. Acad Med 1995; 70: 179-185. Ward JD. The hospital general physician in the 1990s. J R Coll Physicians Lond 1996; 30: 209-210. Smith BJ, Darzins P, Heller RF. RACP Survey of advanced trainees' job aspirations: the fate of those who pass the clinical exam of the RACP. Fellowship Affairs 1993; 12: 31-33. Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Ian A Scott · Peter B Greenberg

Medicine, modernism and after: a new role model for the doctor? "Everyone has something to contribute to the truth . . ." Aristotle 1 MJA 1997; 167: 570-571 Mainstream philosophy, which is characterised by the philosophical ideas of the Enlightenment, has been strongly criticised in the past 30 years or so for being too "rational" and too "empirical". Its critics have insisted that the basis for knowledge is much less secure than these schools of philosophy, which include logical positivism and scientific realism, would have us believe.2 Side by side with this critique, there has developed a critique of the North-West European (specifically, Scandinavian) Welfare State, which has been called a modernist attempt to achieve the "good life" or a "good society" by rational, empirical means, such as equal distribution of goods meeting "basic human needs". The Welfare State has been characterised as the welfare expression of one kind of economic rationalism. The most radical of "postmodern" critics, however, claim that the rationalist project has failed. We cannot even define things like "truth", let alone legislate to achieve "the good", says this line of argument: everything has to be determined by discourse among local communities; it is up to the individual citizen to decide how to live his or her life; one claim is as good as another -- relativism rules. This negative critique has been directed at the State in general, under the ideological motto "Less State, more community". Combatants in politics and political philosophy should learn, however, from combatants in branches of philosophy, particularly the philosophy of science. They have had to learn the dangers of throwing out the baby with the bath water. Thus, it has not been possible to jettison concepts of truth and rationality, but it has been necessary to repolish them and repair the damage done by the critiques.3 It is true that the institutions of the Welfare State have become paternalistic, have suppressed the autonomy of citizens and neglected the diversity of perspectives and values within pluralistic societies. There is no doubt that all this should be opposed. But there is little reason to think that nations will benefit from dismantling State institutions, and replacing them with entrepreneurial services operating within the marketplace. What is needed instead is a radical understanding and disclosure of the mechanisms which have sometimes made the State a controller rather than a system promoting human well-being.4-6 Instead, critics have claimed that a dangerous symbiosis has developed between paternalistic welfare systems and irresponsible citizens, who perceive opportunities to accumulate wealth by exploiting the system. There is, however, absolutely no reason to believe that a politics which defends the rights of citizens and which provides necessary services should in any way undermine human autonomy. Equally, there is no reason to believe that people living in local communities without State interference would be any more responsible than citizens in a State devoted to providing security and opportunities. The "Less State, more community" catchcry assumes that the Welfare State has systematically corrupted its citizens. There is little evidence to support this claim. The German philosopher Hegel argued that there were strong reasons to believe that the activities of the State were perfectly compatible with the development of autonomy, 7 and there is no reason to doubt that he was right. Hegel claimed that the modern idea of the self-conscious individual, with ideas of freedom and autonomy, is based on the presupposition of a social structure, with institutions that included social and public services. To put this in a European context: what makes a Danish citizen a Dane is his or her being part of a society where institutions of social justice have been created, in which it would not in principle be accepted that any individual in that society should fall by the wayside, and that everything possible should be done to allow individuals and groups to flourish. It is not the citizenry that is in decline. The decline is in politics and politicians. It is the gradual destruction of the political institutions built over the past century or so that undermines individual autonomy and social cohesion, and diminishes the notion of social justice. Has medicine a part to play in reconstructing the performance of the body politic and a respect for politicians? To begin, it might need to broaden its view of its knowledge base, taking a more generous view of the truths that come to it from outside its very reductionist science. Its concern with human welfare would then start to look rather like the avowed concerns of the Welfare State. However, there may be a more direct role for medicine. From at least the time of Aristotle, Western medicine has inherited the idea of an analogy between medicine and politics. Both have practical goals: medicine, the health of the patient; politics, the conditions for human security and well- being. They are both (or should be) responsive to the individual. In medicine, there is a perceived inequality of power between the doctor as expert and the patient as supplicant. The person of practical wisdom (the ideal politician), on the other hand, "engages you actively in the 'treatment', taking your view of things as seriously as his own; he leads you on through the interchange of calm and clarifying argument to what he hopes will be an articulated picture of the good".8 In an age when politicians and planners often do not live up to this model, medicine might try to realise an even closer analogy between the doctor and the person of practical wisdom than Aristotle thought possible. Medicine might play a role in redeveloping the Welfare State as a system realising the Aristotelian ideal that "everyone has something to contribute to the truth . . .".1 We are left with two final questions, which are also challenges. Do doctors in general have the capabilities needed to act according to this ideal of practical wisdom? And, if not, how should medical education be changed to legitimate and encourage these capabilities? Uffe Juul Jensen Professor, Department of Philosophy University of Århus, Århus, Denmark Aristotle. The ethics of Aristotle: the Nichomachean ethics. London: Penguin, 1976. Rorty R. Philosophy and the mirror of nature. Princeton, NJ: Princeton University Press, 1979. Putnam H. Reason, truth and history. Cambridge: Cambridge University Press, 1980. Jensen UJ. Practice and progress -- a theory for the modern healthcare system. London: Blackwell Scientific Publications, 1987. Jensen UJ, Mooney G. Changing values: autonomy and paternalism in medicine and health care. In: Jensen UJ, Mooney G, editors. Changing values in medical and health care decision making. New York: John Wiley and Sons, 1991: 1-15. Jensen UJ. The year 2017: a revolution for democracy? The future of general practice in Europe. Copenhagen: European Union of General Practitioners, 1992: 18-24. Hegel G. The philosophy of right. Oxford: Oxford University Press, 1952. Nussbaum MC. The therapy of desire -- theory and practice in the Hellenistic era. Princeton, NJ: Princeton University Press, 1996. - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.