General medicine

Australian patients' delay in response to heart attack symptoms Kathleen Dracup, Sharon M McKinley and Debra K Moser MJA 1997; 166: 233 For comment see Langton and Thompson 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/>". Abstract - Introduction - Methods - Statistical analyses - Results - Associations with delay time - Discussion - Acknowledgements - References - Authors' details - - ©MJA1997 Abstract Objectives: To examine delay in seeking treatment among patients with an evolving acute myocardial infarction (MI), and to identify factors which contributed to this delay. Design: Patient interview combined with medical record review. Participants and setting: 317 patients with confirmed diagnosis of acute MI interviewed within 72 hours of admission to three hospitals. Main outcome measures: Delay from onset of symptoms to arrival at hospital, and cognitive, emotional, sociodemographic and clinical factors which contributed to increased prehospital delay. Results: Median prehospital delay was 6.4 hours; 41% of patients delayed less than four hours, while 28% delayed less than two hours. Prehospital delay was increased in patients with fewer years of education (P = 0.001), lower income (P = 0.003) and transportation to the hospital by private car rather than ambulance (P = 0.02). Delay time was increased by several cognitive and emotional processes (P < 0.001), such as waiting to see if symptoms would go away, being too embarrassed to ask for assistance, and not recognising the importance of symptoms. Delay time was increased with heartburn, breathlessness or intermittent symptoms and decreased with sweating and dizziness (P < 0.05). Independent predictors of increased prehospital time (P < 0.01) were fewer than 10 years of education, not wanting to trouble anyone, failing to recognise the symptoms of delay, and the intermittent nature of symptoms. Conclusion: Over 50% of acute MI patients delay seeking treatment by six hours or more. Many factors related to cognitive and social processes that contribute to this delay may be remediable with appropriate patient and community education. MJA 1997; 166: 233-236 Introduction Every year in Australia approximately 22 000 people suffer a heart attack and approximately half of these die. Most of these deaths occur out of hospital.1 The high mortality associated with acute myocardial infarction (MI) is dismaying, given that major large-scale clinical trials have shown that thrombolytic therapy can significantly reduce mortality from MI.2 With this therapy, the shorter the interval between the onset of symptoms and when the drug is given, the better the outcome.2 If therapy is started within three hours of symptoms, mortality is reduced by 23%;3 this becomes 45% if started within one hour of symptoms.3 Similarly, the earlier the treatment, the better the resulting cardiac function and the lower the incidence of morbidity after MI.4 Prehospital delay is known to be a substantial problem. Median delay times ranging from just under two hours5 to six-and-a-half hours have been reported.6 Overall, approximately 25%-50% of MI patients delay seeking medical care for cardiac symptoms for more than six hours.7,8 In other countries, the factors associated with increased prehospital delay are being older; being female; having a clinical history of hypertension, diabetes, angina or congestive heart failure; having low emotional or somatic awareness; consultation with a spouse or other relative; consultation with a doctor; and self-treatment. Decreased prehospital delay occurs when there is haemodynamic instability, large infarct size, sudden onset of severe chest pain, recognition of symptoms as heart-related and consultation with a non-relative.8,9 We do not know if the characteristics that contribute to delay in seeking treatment for acute MI symptoms are similar for Australian patients. Such information is important for designing appropriate patient and community education programs. Therefore our aims were, firstly, to describe prehospital delay time in Australian patients experiencing symptoms of evolving acute MI and, secondly, to identify the cognitive, emotional, sociodemographic and clinical factors which contribute to this delay. Methods We gained appropriate institutional ethics committee review and approval for the study from the study hospitals and the University of Technology, Sydney. Eligible patients admitted to three hospitals between 1 March and 31 July 1995 were invited to participate in the study and gave written informed consent. Patients were eligible if they were able to read and write English, lived independently, were free from malignancy or other complicating illness, alert and orientated, were within 24 and 72 hours of hospital admission, and had a diagnosis of acute MI, determined by:Chest pain lasting longer than 20 minutes; Serial electrocardiographic evidence of acute MI (i.e., appearance of new Q waves in at least two leads of a 12-lead standard electrocardiogram); and Elevations in serum creatine kinase-MB consistent with evolving MI. Only patients with Q-wave MI were studied. Patients were excluded if they were being mechanically ventilated. The hospitals were two metropolitan university-affiliated city teaching hospitals and a district hospital, chosen because their geographical catchment areas were relatively small, so transportation time would not add significantly to the time between symptom onset and arrival at the hospital. We reviewed medical records to obtain sociodemographic and clinical data. We assessed information about the cognitive, emotional and social processes surrounding the decision to seek treatment using the Response to symptoms questionnaire, designed to obtain information about patient delay and factors contributing to delay in six domains: (1) context in which MI symptoms appeared; (2) antecedents of symptoms; (3) affective response to symptoms; (4) behavioural response to symptoms; (5) cognitive response to symptoms; and (6) the response of others to patient symptoms.10 Based on growing evidence that cognitive, symptom-appraisal and social factors may be more important determinants of delay than knowledge about appropriate re sponse to symptoms,10 we modified the instrument to further assess cognitive, symptom-appraisal and social factors surrounding a patient's decision to seek care for acute MI symptoms. The resulting instrument assesses factors surrounding the onset of acute MI symptoms, the response of others to symptoms, and the patient's response to symptoms. We established the time from symptom onset to hospital admission by reviewing the medical record for the time stated in the admission record by the admitting physician and the time of admission to the hospital. Also, each patient was asked about the time of first symptoms. If symptoms had come and gone, patients were carefully interviewed to determine the nature of those symptoms and the exact time that cardiac symptoms began. Where the patient's account differed from the time recorded by the admitting doctor, cardiac enzymes and serial electrocardiograms were reviewed to identify the most likely time of symptom onset. The value that most closely matched the expected clinical course reflected in the tests was chosen. Patients were asked if they wanted to complete the questionnaire themselves or if they wanted the researcher to read the questions; 96% chose the latter. Statistical analyses Independent t tests or analysis of variance (with post-hoc t tests adjusted for multiple comparisons) were used to assess the impact of sociodemographic, clinical, cognitive and social factors. Delay time was markedly skewed, so we used square root transformations to obtain a normal distribution, and all analyses were performed on transformed values. Multiple logistic regression and χ2 tests were used to determine odds ratios for delays of more than two hours among several sociodemographic, clinical, social and cognitive variables. Variables that were significantly different (P < 0.05) on delay time were entered into the forward stepwise logistic regression. Criteria for entry and removal of variables were based on the likelihood ratio test, with enter and remove limits set at P < 0.05 and P > > 0.05. Results Of 321 eligible patients approached, 317 agreed to participate in the study; four declined, giving fatigue as a reason. Patients were predominantly older (mean, 63 years; standard deviation, 12 years), male, married and white. There was diversity in years of formal education and socioeconomic status. Most patients experienced their symptoms at home and most went to hospital by ambulance (Box 1). Many patients were at greater than average risk for suffering an acute MI, with previous medical histories of angina pectoris (43%), MI (28%), hypertension (53%) and/or diabetes mellitus (19%). Most MIs were inferior (46%) or anterior (32%). Median prehospital delay time was 6.4 hours (interquartile range, 1.9-19.9 h; mean, 17.3 h). Only 14% of patients arrived within one hour of the onset of symptoms, 28.5% within two hours and 41% within four hours. However, 54% arrived at the hospital more than six hours after first experiencing cardiac symptoms. One hundred and fifty-three patients (48%) received thrombolytic therapy; 29 within one hour of the onset of symptoms. Associations with delay time Sociodemographic factors: Box 1 shows that there were differences in delay time according to education, annual income and use of ambulance. There was no significant association with sex, age, ethnicity, the location where symptoms occurred or whether or not a spouse was present when they occurred. Symptoms and pain: We examined breathlessness, fatigue, weakness, vague chest discomfort, chest pain, neck pain, arm numbness, pain between shoulder blades, back pain, nausea, feeling that something was wrong, dia phoresis, feeling clammy, heartburn, and dizziness. Delay time was less if patients were dia phoretic (P = 0.001) or experienced dizziness (P = 0.03) and increased if they were breathless (P = 0.03) or experienced heartburn (P = 0.03). The remaining symptoms made no difference to delay times. If symptoms were intermittent, patients took longer to seek treatment (P = 0.0001), while those who believed their symptoms to be cardiac in nature delayed for shorter times (P = 0.001). However, 60% originally attributed their symptoms to another cause (e.g., muscle pain, fatigue, indigestion). Patients who appraised their pain as very serious delayed a shorter time than patients who appraised their pain as not serious (P = 0.001). However, patients who rated their initial chest pain as severe had similar delay times to patients who rated their pain as mild (P = 0.644). Knowledge of coronary heart disease: There were no differences in the average time to arrival at hospital related to previous myocardial infarction, previous cardiac surgery, diabetes mellitus, hypertension or angina. Forty per cent of patients reported that their source of information about MI symptoms was television or reading; 27% received their information from a friend; 23% from a doctor; and 10% from a nurse. Sixteen per cent of patients knew about thrombolysis therapy for acute MI and these, on average, came to the hos pital earlier than patients who did not know about this treatment (P = 0.001). Cognitive and psychological factors: Box 2 (below) shows significant associations between patients' responses and delays in seeking medical treatment. Independent predictors of delay: We tested factors that were significant on univariate analyses in a multiple regression model. The five independent predictors of delay are shown in Box 3. Discussion In 317 patients admitted to hospital for evolving acute MI, we found that median prehospital delay was 6.4 hours. Almost 60% of patients delayed more than four hours, while more than 70% delayed longer than two hours. These times are substantially longer than those recorded in most studies from other countries,4-6,8,11 as well as those documented in previous Australian studies.12,13 The disparity between this and previous Australian studies is un doubtedly related to a difference in the definitions used to characterise prehospital delay. In the first Australian study, time from symptom onset to the first attempt to get help was reported.12 In the second, the definition of total delay time was the period from the onset of chest pain to arrival at hospital; where there were multiple episodes of chest pain, the time from the last episode of pain was used.13 Both variations in definitions would shorten reported delay time relative to the definition we used. It is unlikely that longer transportation times to the hospital contributed to longer delay times in our study because of the geographic situation of the participating hospitals and the high rate of ambulance use. Moreover, all studies on this topic have found that home-to-hospital time, as well as in-hospital time, play a minor role in the delay that occurs before definitive treatment.8,14,15 We included only those patients who survived to hospital admission and who met our inclusion criteria, and hence our patients were clearly not representative of all patients with acute MI. Unfortunately, approximately 30% of such patients die of sudden cardiac death before reaching the hospital,1 and we excluded patients because they were unable to respond to questions within the designated 72 hours of hospital admission (e.g., because they required mechanical ventilation or had compromised mental status). In the past, most researchers have focused on identifying patients who are more likely to delay a decision to come to the hospital because of various sociodemographic and clinical characteristics. In our study, the most important factor predicting delay was years of formal education, a characteristic that health professionals cannot alter. However, it may be linked with other characteristics (e.g., income, age, coping styles or other underlying cognitive mechanisms affecting delay), some of which may be amenable to change. Many of our patients had difficulty identifying their symptoms as cardiac in nature, initially thinking they were gastrointestinal, musculoskeletal, or fatigue. Many patients knew the classic signs of acute MI but did not know the diversity of its presentation, notably its often intermittent nature. Patients should be told that the symptoms may come on gradually or may not be constant, as many believe that MI is accompanied by sudden, crushing chest pain and unconsciousness. As in other studies,5,12,16,17 experience of a previous MI did not result in patients coming to the hospital sooner. Thus, the public, particularly patients at high risk for a future MI, need to be informed that the manifestations of an evolving MI may vary, even within the same individual, and should be clear about the actions to take if and when symptoms occur. In most studies in the United States, less than half of MI patients arrive by ambulance,18 whereas in our study most patients in all three hospitals used this means of transportation. Ambulance is preferable to other types of transportation because of the early treatment available and because delay times are usually reduced.18 From the accounts of patients in this study, doctors and nurses played minimal roles in providing information about the symptoms of MI, compared with knowledge gained from television, reading and friends. Counselling strategies tested in other clinical populations support the assumption that individuals who are prepared for certain signs and symptoms will delay less in seeking care than individuals who have no such preparation.19-21 They also suggest that health professionals should take a more proactive and intensive approach to educating patients about the nature of MI signs and symptoms and the steps to take to receive early treatment. These data also indicate the opportunity for professional organisations to enhance the knowledge and beliefs of patients by community educational programs via television, radio and newspapers. Very few patients knew about thrombolysis and its effectiveness in treating acute MI, but those who did presented sooner than those who did not. Based on these findings, health care professionals should emphasise the rationale for early treatment to patients at high risk for future MI, and public campaigns should advertise the benefit of seeking early treatment. Patients need to know that their decision to seek immediate treatment has important future rewards as this may override whatever trepidation they experience in acknowledging that they might be having a heart attack. In summary, almost all the significant predictors of delay we identified related to social and cognitive processes that might be amenable to change. Health care professionals should recognise the reluctance of patients to recognise MI symptoms as cardiac and provide them with the necessary guidance, so that they will seek care as soon as possible. The availability of newer forms of treatment, particularly thrombolytic therapy, provides a compelling reason for physicians and nurses to encourage patients and their families to seek care early to preserve ischaemic myocardium and reduce infarct size in the face of an evolving MI. Acknowledgements Funding for this study was provided by a Fulbright Foundation Senior Scholars grant and from the L W Hassenplug Chair funds. We thank the following nurses who assisted with data collection: Patricia Cameron, Marie Droulers, Cameron Goodear, Jennifer Kidd, Jacqueline Padley, Rebecca Scammell and Jennifer Williams. References Heart and stroke facts. Canberra: National Heart Foundation of Australia, 1995. Fibrinolytic Therapy Trialists' (FTT) Collaborative Group. Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Lancet 1994; 343: 311-322. Gruppo Italiano per lo Studio della Stretochinasi nell'Infarto Miocardico (GISSI). Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Lancet 1986; 1: 397-401. Simoons ML, Serruys PW, Brand MVD, et al. Early thrombolysis in acute myocardial infarction: Limitation of infarct size and improved survival. J Am Coll Cardiol 1986; 7: 717-721. Maynard C, Althouse R, Olsufka M, et al. Early versus late hospital arrival for acute myocardial infarction in the western Washington thrombolytic therapy trials. Am J Cardiol 1989; 63: 1296-1300. Cooper RS, Simmons B, Castaner A, et al. Survival rates and prehospital delay during myocardial infarction among black persons. Am J Cardiol 1986; 57: 208-211. Dracup K, Moser D. Treatment seeking behavior among those with symptoms and signs of acute myocardial infarction. Heart Lung 1991; 20: 570-575. GISSI-Avoidable Delay Study Group. Epidemiology of avoidable delay in the care of patients with acute myocardial infarction in Italy. Arch Intern Med 1995; 155: 1481-1488. Dracup K, Moser D, Eisenberg M, et al. Causes of delay in seeking treatment for symptoms of acute myocardial infarction. Soc Sci Med 1995; 40: 379-392. Burnett RE, Blumenthal JA, Mark DB, et al. Distinguishing between early and late responders to symptoms of acute myocardial infarction. Am J Cardiol 1995; 75: 1019-1022. Schwarz B, Schoberberger R, Rieder A, Dunze M. Factors delaying treatment of acute myocardial infarction. Eur Heart J 1994; 15: 1595-1598. Bett N, Aroney G, Thompson P. Impact of a national educational program to reduce patient delay in possible heart attack. Aust N Z J Med 1993; 23: 157-161. Leitch JW, Birbara T, Freedman B, et al. Factors influencing the time from onset of chest pain to arrival at the hospital. Med J Aust 1989; 150; 6-8. Schroeder JS, Lamb IH, Hu M. The pre-hospital course of patients with chest pain: analysis of the prodromal, symptomatic, decision-making, transportation and emergency room periods. Am J Med 1978; 64: 742-748. Schmidt SB, Borsch MA. The prehospital phase of acute myocardial infarction in the era of thrombolysis. Am J Cardiol 1990; 65: 1411-1415. Turi ZG, Stone PH, Muller JE, et al. Implications for acute intervention related to time of hospital arrival in acute myocardial infarction. Am J Cardiol 1986; 58: 203-209. Weilgosz ATJ, Nolan RP, Earp JA, Biro E. Reasons for patients' delay in response to symptoms of acute myocardial infarction. Can Med Assoc J 1988; 139: 853-857. Meischke H, Ho MT, Eisenberg MS, et al. Reasons patients with chest pain delay or do not call 911. Ann Emerg Med 1995; 25: 193-197. Bandura A. Self-efficacy; toward a unifying theory of behavior change. Psychol Bull 1977; 84: 191-198. Bailey WC, Richards JM Jr, Brooks CM, et al. A randomized trial to improve self-management practices of adults with asthma. Arch Intern Med 1990; 150: 1664-1667. Avis NE, Smith DW, McKinlay JB. Accuracy of perceptions of heart attack risks: what influences perceptions and can they be changed? Am J Public Health 1989; 17: 1608-1611. (Received 28 Mar, accepted 20 Nov, 1996) Authors' details University of California, Los Angeles, CA, USA. Kathleen Dracup, RN, DNSc, L W Hassenplug Professor of Nursing. University of Technology, Sydney, and Royal North Shore Hospital, Sydney, NSW. Sharon M McKinley, RN, PhD, Professor of Critical Care Nursing. College of Nursing, Ohio State University, Columbus, OH, USA. Debra K Moser, RN, DNSc, Assistant Professor. Reprints: Professor S M McKinley, Level 6, Royal North Shore Hospital, St Leonards, NSW 2065. E-mail: smckinle AT doh.health.nsw.gov.au - - To top of article - ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Kathleen Dracup · Sharon M McKinley · Debra K Moser

Medical women and men are struggling with the problems of outdated work structures and geographic maldistribution 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". - ©MJA1996 Recent Australian medical workforce data indicate dramatic changes in the structure and culture of medicine in this country. Women now comprise some 47% of general practitioners under 35 years of age; 1 men are working fewer hours and retiring earlier; 2 and the proportion of women doctors in the medical workforce is forecast to increase by 12% from the present level by the year 2025. 3 Reports, such as that of the (then) Department of Human Services and Health, 4 usually emphasise the particular needs of women doctors, including family responsibilities, child care and spousal career needs. Such conclusions imply that women alone have family responsibilities and ignore the reality that men, too, are making adjustments in these areas. Women have made huge efforts to accommodate work structures that were designed for male workers with invisible domestic support The influx of women into all areas of paid professional work has brought about a cultural revolution, one that challenges the traditionally invisible personal life of the worker. "He" is no longer regarded, implicitly, as a sexless, childless, work-driven automaton. Except perhaps in medicine, where expectations persist that "dedicated" doctors will be infinitely available to their patients and immune to fatigue. Consequently, exhausted and demoralised young doctors -- both men and women -- are retreating from oppressive hospital posts. 5 Changes are needed, including the provision of options -- available to both men and women -- such as job-sharing and permanent part-time work. 3 The challenge in the future may be to match the community's needs with working patterns for health professionals that are closer to reasonable working patterns in the general community. For all doctors to work around 40 hours per week (and why shouldn't we?) would require an increase in the medical workforce of about 15%. 3 But Government policy is moving in the opposite direction (e.g., the restrictions on provider numbers aimed at limiting new graduates from private medical practice). Indeed, a two-tiered system may be evolving, with a predominantly young and female "cottage industry" 5 of general practitioners -- supplemented by (chiefly female) paramedicals -- functioning as "gate-keepers", 2 referring patients to the male-dominated, high-technology (high-prestige, high-income) medical specialties. Women comprise only 12% of all private specialists. 1 They are best represented in dermatology (29%), psychiatry (24%), radiology (19%), pathology (17%) and anaesthetics (16%). 1 (Figures vary somewhat according to source [e.g., those of the Australian Institute of Health and Welfare are slightly different]. 6 ) These career choices may reflect the attraction of more flexible working hours in these specialties, but they may also reflect structural constraints, such as resistance to women doctors in other fields, rather than female predilections. The fact that surgery remains 96% male, 1 while anaesthetics has a relatively high female representation, suggests that Colleges play a significant role in facilitating (or impeding) the participation of women. Both surgery and anaesthetics are more technical than relational -- perhaps one training program is more "woman-friendly" than the other? The same question might be asked about training in obstetrics and gynaecology. Women represent only 11% of this specialty in Australia, 3 whereas they comprise 70% in France. 7 Structural impediments to the progress of women, such as the lack of part-time or job-sharing posts and inadequate mentorship of women trainees, must also be significant in hospitals and in academic institutions; in both these arenas the increasing influx of women (35% of all hospital doctors and 50% of all medical undergraduates) is not reflected in a corresponding "upward mobility". Mostly, the findings of the various reports available come as no surprise and accord very much with my personal experience of women in medicine and psychiatry. 8 One notable exception is the data on retirement. Based on the 1991 Census figures of the Australian Bureau of Statistics, it appears that, beyond the age of 65, half of male doctors continue to work, compared with a quarter of female doctors. 2 For me (born in 1943), these figures were counterintuitive, and a quick "straw poll" of my peers brought forth responses similar to mine. No-one in good health was thinking of retiring. The only sense I can make of these data is that they refer to an earlier generation (born in or before 1926 [i.e., those aged 65 or over in 1991]) that differs from subsequent generations. These early-retiring older women are likely to have had a more traditional type of marriage, an older husband and more children. They may feel obliged to retire when their (older) husbands do, rather than (as my peers seem to) regard the postchild phase of life as a new opportunity for increased career activity. My guess would be that the retirement age for later cohorts of older women will not differ so dramatically from that of their male peers, given the economic imperative for two incomes, as well as the rising divorce rates, which will result in more women doctors who are sole parents. Women have made huge efforts to accommodate work structures that were designed for male workers with invisible domestic support. Male doctors are beginning to make lifestyle changes too, perhaps to accommodate family needs. Work structures must be redesigned to accommodate these changes. The result will be a medical workforce that is more expensive, but less exhausted. Without this redesigning, a two-tiered and gender-stratified system of general practitioners and specialists may develop. However, neither of these scenarios deals with what most reports identify as the single most resistant medical workforce problem: geographic maldistribution. 2,3,9 The poor supply of doctors outside metropolitan areas is a major political issue. While even fewer women doctors than men may be willing to accept a rural placement (with women comprising only 12.7% of rural general practitioners, compared with 27% of metropolitan general practitioners 3 ), the issues involved are common to both. Neither women nor men are keen to work the longer hours of rural practice, where they must offer more complex medical services and practise without the support of colleagues, but where, as general practitioners, they gain no more overall remuneration than they would in the city. The professional needs of spouses pose another problem with rural placements. Both women and men may have spouses to consider, and this problem seems to impact more upon women doctors than on their male counterparts -- accommodating to spousal career needs is reported to be a significant restraint for women. 4 "Conscription" is not a pleasant word, and neither women nor men practitioners are likely to welcome moves in that direction, but the new policy of regulating provider numbers, if successfully implemented, seems likely to usher in just such a system. The desirability, indeed the necessity, for doctors to be granted the same privileges as those that exist in the workforce as a whole should not be construed as a gender issue. A 40-hour week and reasonable allowances for family needs and obligations are the entitlements of all workers -- they do not reflect the "special needs" of women doctors. Carolyn Quadrio Visiting Fellow, School of Psychiatry, University of New South Wales, Sydney, NSW. Australian Bureau of Statistics, Private Medical Practitioners Survey 1996. Canberra: ABS, 1996. (Australian Medical Association Document 325/1/96.) Conn W. Medical workforce participation: males and females 1981, 1986 and 1991. Labour Force Unit, Australian Institute of Health and Welfare. Canberra: AIHW 1995. Australian medical workforce benchmarks. Australian Medical Workforce Advisory Committee (AMWAC) report 1996. Sydney: AMWAC, 1996. (AMWAC used the statistics of the National Health Labour Force for 1994 6 to arrive at this estimate.) Women in the medical workforce: the changing gender profile and its implications. Canberra: Commonwealth Department of Human Services and Health, State Financing Branch (Discussion paper) December 1995. Douglas RM, Dickinson J, Rosenman S, Milne H. Too many or too few? Medical practice and general practice in Australia. National Centre for Epidemiology and Public Health, Australian National University. Canberra: National Capital Printing, 1991. (Discussion Paper No 5.) Australian Institute of Health and Welfare. Medical labour force 1994. Canberra: AGPS, August 1996. Kincaid-Smith P. Where are the women specialists? Australian Medicine 1995; Aug 21: 10. Quadrio C. Women in Australian and New Zealand Psychiatry: the fat lady sings. Australian and New Zealand Journal of Psychiatry 1991; 25: 95-110. Papers from 1995 Australian Medical Association Medical Workforce 2000 Summit. Canberra: Australian Medical Association, August 25-26, 1995.

Carolyn Quadrio

Caring for adolescents with asthma: do we know how to? What is needed now is research based on an understanding of adolescents MJA 1996; 165: 463 Readers may print a single copy for personal use. No further reproduction or distribution of the articles in whole or in part should proceed without the permission of the publisher. For copyright 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/>". - - ©MJA1996 Australian data show that the prevalence of asthma among teenagers is approximately 20%. 1 Estimated conservatively, at least half a million young adolescent Australians aged 10-19 years suffer from asthma. In Australian children the prevalence of asthma has increased substantially in the past three decades, 1,2 but most children with mild asthma do not have asthma in adolescence and adulthood. 3 However, for many, their childhood asthma per sists through adolescence into adult life. 4 Identified risk factors for this persistence of asthma into adult life include female sex, onset after two years of age, more than 10 attacks throughout childhood, lower peak flow rates in childhood, and parental atopy. 3 Personal atopy is also a major determinant of outcome. 2 Objective measurement of the physiological disturbances of asthma are well accepted as part of medical care for acute asthma. In addition, various asthma management plans imply that measurement of airflow obstruction has a role in ongoing interval asthma management. Indeed, in specialist practice this is a routine component of care. In this issue of the Journal, Hewson et al. ( page 469 ) provide firm evidence to support this view in a general practice setting. They found unexpectedly low values for forced expiratory volume in one second (FE V 1 ) and/or forced mid expiratory flow (FEF 25%-75% ), both calculated as a percentage of normal values, in patients in whom clinical and personal assessment had indicated no need to change asthma treatment. This occurred at 30% of assessment opportunities in general practice in adolescents undergoing review or attending for acute exacerbation of asthma. Presumably, had these results been available to their treating doctors, drug therapy would have been altered. That measurement of airflow obstruction by spirometry in general practice has the potential to contribute to fine tuning of asthma therapy is of substantial significance. Ambulatory monitoring of peak flow rate is promoted as assisting in diagnosing asthma, measuring its severity, assessing response to treatment and recognising any deterioration. 5 The limitations of peak flow rate monitoring are also well known, 5 and incidentally highlighted in the article by Hewson et al. While use of a peak flow monitor at home (70% of the study population) may have resulted in patients attending their general practitioner for assessment (reasons for consultation are stated only as acute deterioration or asthma management review), it did not result in appropriate medication change. Just as there are limitations in the testing of peak flow rate, there are also limitations in the use of spirometry. Training in the performance and interpretation of spirometry, as completed by the physiotherapist who performed the tests in the study by Hewson et al., is vital to the achievement of valid and reproducible results. 6 Although measurement of disease severity is an important factor in the management of adolescents with asthma, it is becoming increasingly apparent that assessment of the broad health status of adolescents with asthma is equally important. The evidence is only just emerging that the prevalence of smoking in young people with asthma appears to be the same as their peers without asthma. 7 Adolescence is a critical period for determining future smoking behaviour -- over 90% of adult smokers begin smoking by 19 years 8 -- and achieving an effective early intervention during adolescence has the potential to have an immense impact. Moreover, what is less well understood is that smoking in young people is more than just an exacer bating factor in asthma or a major risk factor for heart d isease and cancer. It is an important symptom of, or marker for, other adolescent health problems. Specifically, symptoms of anxiety and depression are strongly associated with smoking in adolescents, 9 and heavy tobacco use is a feature of concurrent abuse of drugs such as alcohol and marijuana. 10 Monitoring the health status of the adolescent process is of itself an important component in assessing the health status of young people. 11 A young person's development involves physical, cognitive and psychosocial maturation. Medically, we are well trained to assess the physical changes of adolescence, but we receive far less training in other aspects of adolescent maturation. How independent of their parents are these young people? How personally and socially responsible is their behaviour? What are their educational and vocational goals? What activities do they enjoy? In comparison with measuring airflow obstruction by spirometry, a suitable method of measuring adolescent developmental progress is less well defined. Frameworks have been promulgated to assist practitioners to obtain a psycho social history sensitively, 12 but it is only by placing these frameworks into the broader context of adolescent development that we can start to address adolescents' health needs. It is important that this lack of knowledge and competence in adolescent health, well recognised by general practitioners, 13 is redressed by improved training in adolescent medicine. Specific behaviours, such as smoking, or poor adherence to medication regimens or medical review appointments, are important factors because of their detrimental effect on asthma management in adolescents. However, they are also important as potential "beacons of distress". Putting these behaviours into the context of adolescent development can be more helpful in the development of key strategies to improve asthma management than the typical medical "disease-perspective" model. Research in asthma epidemiology has increased our understanding of the extent of asthma, and guided the development of major public health interventions for disease management. What is now needed is research based on an understanding of adolescents themselves. For adolescents with asthma, we need to define more clearly the problems they face as adolescents, not simply the problems they face because they have asthma. For example, research is required to determine the extent and nature of adherence to asthma medication regimens, and to identify young people's understanding of the effect of smoking on asthma. This may then be used to develop strategies that better engage young people in regular medical care and better target smoking. Appropriately, the recent National Asthma Week (6-12 October) targeted asthma and adolescents. We have a good understanding of the management of asthma. What we need now is an accompanying understanding of how best to care for adolescents with asthma. Susan Sawyer Senior Lecturer Glenn Bowes Professor Centre for Adolescent Health, University of Melbourne Royal Children's Hospital, Melbourne, VIC Robertson CF, Heycock E, Bishop J, et al. Prevalence of asthma in Melbourne schoolchildren: changes over 26 years. BMJ 1991; 302: 1116-1118. Peat JK, van den Berg RH, Green WF, et al. Changing prevalence of asthma in Australian children. BMJ 1993; 308: 1600-1604. Jenkins M, Hopper JL, Bowes G, et al. Factors in childhood as predictors of asthma in adult life. BMJ 1994; 309: 90-93. Oswald H, Phelan PD, Lanigan A, et al. Outcome of childhood asthma in mid-adult life. BMJ 1994; 309: 95-96. The Thoracic Society of Australia and New Zealand. Peak flow meter use in asthma management. Med J Aust 1996; 164: 727-730. American Thoracic Society. Pulmonary function laboratory personnel qualifications. Am Rev Respir Dis 1986; 134: 623-624. Wakefield M, Ruffin R, Campbell D, et al. Smoking-related beliefs and behaviour among adults with asthma in a representative sample. Aust N Z J Med 1995; 25: 12-17. Miller SK, Slap GB. Adolescent smoking. A review of prevalence and prevention. J Adolesc Health Care 1989; 10: 129-135. Patton GC, Hibbert M, Rosier MJ, et al. Is smoking associated with depression and anxiety in teenagers? Am J Public Health 1996; 86: 225-230. Patton GC, Hibbert M, Rosier J, et al. Patterns of common drug use in teenagers. Aust J Public Health 1995; 19: 393-399. Blum RW. Transition to adult health care: setting the stage. J Adolesc Health 1995; 17: 3-5. Goldenring JM, Cohen E. Getting into adolescent heads. Contemp Paediat 1988; July: 75-90. Veit FC, Sanci LA, Young DY, Bowes G. Adolescent health care: perspectives of Victorian general practitioners. Med J Aust 1995; 163: 16-18. - - To top of article - ©MJA 1996 <URL: http://www.mja.com.au/> © 1996 Medical Journal of Australia.

Susan Sawyer · Glenn Bowes

Routine pulmonary function tests in young adolescents with asthma in general practice Peter H Hewson, Elizabeth A Tippett, Danny M Jones, Justin P Madden and Peter Higgs For editorial comment, see Sawyer and Bowes Readers may print a single copy for personal use. No further reproduction or distribution of the articles in whole or in part should proceed without the permission of the publisher. For copyright 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/>". Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - ©MJA1996 Abstract Objective: To assess the value of performing routine pulmonary function tests by flow-loop spirometry in young adolescents with asthma. Design: A prospective clinical study comparing clinical assessment and patients' self- reporting of asthma severity with the results of pulmonary function tests. Setting: General practice in a small rural community of about 30 000 people. Patients: Young adolescents with asthma, aged 10-15 years, were enrolled in the study over a two-year period from July 1993 to June 1995 when they presented for either elective, interval assessments or with an acute exacerbation of asthma. Main outcome measures: Discrepancy between (i) the doctor's and the patient's perception of asthma control (six scale measures) and the consequent management plans, and (ii) the results of pulmonary function tests that indicated less than adequate airway function (i.e., forced expiratory volume in one second as a percentage of predicted vital capacity for height and sex [FEV 1 %] less than 65% or average flow rate over the middle 50% of forced vital capacity as a percentage of predicted normal value [FEF 25%-75% ] less than 65%). Results: Twenty-seven adolescents with asthma were assessed on a total of 37 occasions. The results of pulmonary function tests did not correlate with asthma symptoms and treatment in 11 of the 37 assessments (30%; 95% confidence interval [CI], 16%-47%). The 11 assessments were performed on eight patients. Conclusions: This small community-based study of adolescents with asthma supports the view that pulmonary function testing by flow-loop spirometry should be part of the routine assessment of acute and chronic asthmatics. Further study in a larger community is needed to clarify the frequency of over- and underestimation of asthma severity in this difficult age group. MJA 1996; 165: 469-472 Introduction Older children and adolescents often have difficulty assessing the severity of their asthma, 1 and consequently pulmonary function tests have been recommended for those with frequent or chronic asthma who are able to perform spirometry adequately. 2-4 Pulmonary function testing by flow-loop spirometry allows measurement of forced expiratory volume in one second as a percentage of the predicted vital capacity for height and sex (FEV 1 %), and forced mid expiratory flow (FEF 25%-75% : the average flow rate over the middle 50% of forced vital capacity). While peak flow monitoring and FEV 1 % have been used for decades as a measure of pulmonary function, forced mid expiratory flow is not as well known a measure, but is more sensitive than FEV 1 in detecting small airways obstruction. 2 Pulmonary function tests have been shown to be useful in adults, but there are few studies of their useful ness in children and young adolescents with asthma. One study found that 17% of apparently well children with asthma had a low forced expiratory volume in one second / vital capacity ratio (FEV 1 /FVC) and 54% had low forced mid expiratory flow (FEF 25%-75% ), suggesting that, without these tests, both patients and doctors were unable to detect mild degrees of broncho constriction, especially of the smaller airways. 5 To date, no study has described the use of pulmonary function tests as part of routine community medical practice in young adolescents. In fact, in some centres, spirometry tests are not yet done routinely in chronic asthmatics in this age group. We performed pulmon ary function tests in adolescents with asthma in an Australian country setting, comparing patients' and doctors' clinical assessment of asthma severity with the results of routinely performed pulmonary function tests. Methods This two-year study took place in Colac, Victoria (population, 14 000; regional population, 30 000) between July 1993 and June 1995. All young adolescents with asthma (recurrent wheeze responsive to bronchodilators) between the ages of 10 and 15 years pre senting to their general practitioner Monday to Friday either for an elective asthma management review, or because of an acute exacerbation of their asthma, were assessed by the general practitioner and included in the study. No adolescents were excluded from the study or refused to participate. Appointments for elective management reviews (interval assessments) had been made weeks in advance. An acute exacerbation of asthma was defined as an appreciably more severe wheeze and cough than usual (as assessed by the general practitioner). The severity of symptoms and the perception of asthma control were assessed by the general practitioner, giving day and night symptom scores (0-5), and a wheeze description, based on questioning of the patient. The doctor and the patient then separately graded asthma control as excellent, very good, fair, poor, or very poor. (The scoring system is given in the footnote to the Table). Forced expir atory volume in one second (FEV 1 ) and forced mid expiratory flow (FEF 25%-75% ) were measured -- on the same day if it was a daytime presentation (usually immediately after the clinical assessment) or the morning after if it was an evening presentation. An Alpha Vitalograph spirometer (Fisher & Paykel, Melbourne, Vic.) was used and the tests were conducted by the senior physiotherapist at Colac Hospital (E A T), who had attended the spirometry technician's course run by the Department of Respiratory Medicine, Alfred Hospital, Melbourne. The tests were repeated if the assessment was judged to be inadequate by the physiotherapist. The effect of bronchodilators on pulmonary function tests was determined in all patients, with recordings being taken 20 minutes (in one patient 25 minutes) after bronchodilator therapy. The pulmonary function tests were done without knowledge of the clinical status of the patient and the results were made available to the treating doctor if requested. The patients' previous home peak expiratory flow measurements were also recorded, as was peak flow measured with the spirometer. The results of the pulmonary function tests were considered not to correlate with asthma symptoms and treatment, and to be likely to lead to a change in asthma management, if: During an interval assessment: The patient complained of no, few or only moderate symptoms, the doctor felt asthma control was excellent, very good or reasonable, respectively, and did not change treatment, but FEV 1 % (normal, > >80%) or FEF 25%-75% (normal, > >65%) was less than 65%. The patient and the doctor thought control was poor, the dose of maintenance asthma therapy was increased, but pulmonary function tests revealed no evidence of bronchospasm. During assessment of an acute exacerbation: The patient and the doctor felt current asthma control was excellent or very good, no increase in dose of inhaled steroids was suggested and no oral corticosteroids were prescribed, but FEV 1 % or FEF 25%-75% was less than 65%. Results Twenty-seven adolescents with asthma (male : female ratio, 2 : 1) were assessed on a total of 37 occasions. On 22 occasions they were elective interval assessments and 15 were for an acute asthma exacerbation. Nineteen patients (70%) were monitoring peak flow at home. Twenty-nine (78%) of the pulmonary function tests were within two hours, four (11%) between two and four hours and four (11%) between four and 14 hours after the clinical assessment. Satisfactory spirometry measurements were achieved in all patients without difficulty (fewer than four repeats). Of the 22 interval assessments, 16 (73%) were in patients taking inhaled corticosteroids (in 11 of these the patients were taking more than 700 µg inhaled corticosteroids per day, and in five FEF 25%-75% values were less than 65%). In two (9%) interval assessments peak expiratory flows were less than 300 L/min (in only one of the assessments with FEF 25%-75% less than 65% were peak flows less than 300 L/min). Of the 15 acute exacerbation assessments, eight (53%) were in patients taking inhaled corticosteroids (in three of these the patients were taking more than 700 µg inhaled corticosteroids per day). In five (45%) acute exacerbation assessments peak expiratory flows were less than 300 L/min (four were unavailable). Details of the patients whose pulmonary function tests did not correlate with asthma symptoms and treatment are given in the Table. Overall, pulmonary function tests not correlating with clinical and patient assessment of asthma severity were found in 11 of 37 assessments (30%; 95% confidence interval [CI], 16%-47%). If only those tests performed within four hours of the clinical assessment are included, pulmonary function tests in 10 of 33 assessments (30%; 95% CI, 15%-46%) did not correlate with asthma severity. Pulmonary function tests in six of the 22 interval assessments (27%; 95% CI, 11%-50%) showed FEV 1 % or FEF 25%-75% to be less than 65% when management had not been changed after clinical assessment (Cases 1-6). During acute exacerbations, four of 15 assessments (27%; 95% CI, 8%-55%) showed FEV 1 % or FEF 25%-75% values to be less than 65% when no change in treatment had been made on clinical grounds (Cases 8-11). Tests in one patient (Case 7) showed normal pulmonary function after clinical assessment had suggested poor asthma control. Her pulmonary function tests were carried out within two hours of the clinical evaluation; her inhaled cortico steroid dose had been doubled. Discussion This community-based study of all young adolescent asthmatics presenting to their general practitioners in a country town found that in 30% of assessment opportunities the results of pulmonary function tests were likely to change management. This proportion was maintained even if slightly delayed pulmonary function tests (4-14 hours) were excluded. This result is comparable with previously published findings that 54% of apparently well asthmatics had lower than expected FEF 25%-75% values at follow-up, despite being asymptomatic. 5 At interval assessments in which management had not been changed and the results of pulmonary function tests were low, three of five adolescents (Table: assessments 1, 3-6) reported frequent wheeze. The other two thought their asthma was well controlled; however, their FEF 25%-75% values were 62% and 42%, respectively. In these patients peak flows, measured at home and by spirometry, were all above 300 L/min and this may have accounted for ALIGN=TOP the reluctance to change therapy. However, it has been shown previously that peak flow results can be misleading, and widely varying optimal values can be expected. 3 A low expectation of what can be achieved in frequently symptomatic patients may contribute to a less aggressive approach in adolescents with asthma. The rather frequent use of inhaled corticosteroids in relatively high doses in this small sample of asthmatics suggests that a more objective measure of asthma status should be used. Potential overuse of inhaled corticosteroids in these growing young people may not always safeguard those at risk of more severe asthma. Six of 11 patients (55%) taking more than 700 µg inhaled corticosteroids had FEF 25%-75% values less than 60%, suggesting that in these patients an even higher dose of inhaled corticosteroid may be required. More specific alterations to long term inhaled steroid use would be possible if pulmonary function tests were performed regularly. During assessments for acute exacerbation the rate of pulmonary function tests not correlating with symptoms was still high (27%) and the FEF 25%-75% was worryingly low in three patients in whom management was not altered (Table: assessments 8, 9, 10, and 11). These three adolescents all had frequent wheeze, but presumably were not distressed, with peak flows (measured at home and by spirometry) above 320 L/min. Pulmonary function tests gave an indication of small airways disease which they were not aware of or was not revealed by their peak flow measurements. Our study involved a small number of patients and the confidence intervals calculated suggest a larger study is necessary. Nevertheless, data on mortality in asthma indicate that underestimation of asthma severity can be extremely important. Robertson et al. found that about 35% of possibly preventable asthma deaths may have been related to medical practitioner underestimation of asthma severity. 6 The full implications of FEF 25%-75% values in the 55%-65% range is not yet certain. A long term follow-up of asymptomatic patients with values in this range has not yet been done. Most of our patients with low FEF 25%-75% values not correlating with symptoms had values below 55% (Table: 7 of 10 assessments). Thus, even if the implications of an FEF 25%-75% value between 55% and 65% is disputed, the frequency of the lower results suggests more aggressive treatment is required. This relatively small study of asthmatic adolescents in a small country town strongly supports the view that pulmonary function tests need to be part of the routine assessment of acute and chronic asthmatics. Acknowledgements We thank Professor P D Phelan, Department of Paediatrics, University of Melbourne, for his provocation, encouragement and support; and Mr Ross Gollan, Senior Lecturer, Department Mathematics and Statistics, Deakin University. References Sly PD, Landau LI, Weymouth R. Home recording of peak expiratory flow rates and perception of asthma. Am J Dis Child 1985; 139: 479-482. Landau LI. The value of lung function in guiding drug therapy in childhood asthma. Eur Respir Rev 1994; 4: 10-14. Phelan PD, Olinsky A, Robertson CF. Respiratory illness in children, 4th edition. Cambridge: Blackwell Scientific Publications, 1994; 152-156. Milner AD. Childhood asthma: diagnosis, treatment and management. London: Martin Dunitz, 1987; 18-38. Bye MR, Kerstein D, Barsh E. The importance of spirometry in the assessment of childhood asthma. Am J Dis Child 1992; 146: 977-981. Robertson CF, Rubinfeld AR, Bowes G. Deaths from asthma in Victoria: a 12-month survey. Med J Aust 1990; 152: 511-517.(Received 19 Sep 1995, accepted 4 Jul 1996) Authors' details 106 McKillop Street, Geelong, VIC 3220. Peter H Hewson, MD, FRACP, Consultant Paediatrician. Colac Hospital, Corangamite Street, Colac, VIC. Elizabeth A Tippett, DipPhys, Senior Physiotherapist. 2 Connor Street, Colac, VIC. Danny M Jones, MB BS, DA, DipRACOG, General Practitioner; Justin P Madden, MB BS, DA, DRCOG, General Practitioner; Peter Higgs, MB BS, General Practitioner. No reprints will be available. Correspondence: Dr P H Hewson. - - To top of article - ©MJA 1996 <URL: http://www.mja.com.au/> © 1996 Medical Journal of Australia.

Peter H Hewson · Elizabeth A Tippett · Danny M Jones · Justin P Madden · Peter Higgs

Is a general practitioner legally bound to render assistance to a stranger? Paul Gerber The finding that a general practitioner has a duty to attend any person in a medical emergency, in the absence of any previous professional relationship, is brand new law MJA1996; 165: 159-161 Readers may print a single copy for personal use. No further reproduction or distribution of the articles in whole or in part should proceed without the permission of the publisher. For copyright 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/>". Register to be notified of new articles by email - - ©MJA 1996 The case of Woods v. Lowns and Procopis (decision of the Court of Appeal of NSW, handed down 5 February 1996: unpublished to date) is likely to have wide implications for the future practice of medicine in Australia. The trial involved two main issues: (i) should judges decide cases of medical negligence by acting on unproven scientific evidence contrary to the weight of expert medical opinion; and (ii) is there a legal obligation upon a general practitioner to attend a person with whom he or she has no professional relationship? I have dealt in the Journal with the first aspect of the case, 1 involving Dr Procopis. I was highly critical of the trial judge's finding against this specialist, concluding that his Honour had misconceived his role, and predicting that the "Procopis" component of his judgment would be reversed on appeal. My analysis did not meet with universal approval. 2 My criticism of the judge's handling of the evidence against Dr Procopis proved justified -- the verdict against the specialist was set aside on appeal. A majority of the Court of Appeal of the Supreme Court of New South Wales held that, while it is for the courts to decide the content of the duty of care which a medical specialist owes to a patient, it does not follow that a judge "will simply or readily put aside the considered judgment and/or experience of those skilled in the field and their opinion of what the care of the patient warranted" ( Woods v. Lowns and Procopis on appeal ). This concession has come some way toward attenuating the more extreme view generally ascribed to the decision in Rogers v. Whitaker 3 (i.e., that, generally speaking, the answer to the question whether the patient has been given all the relevant information to choose between undergoing and not undergoing the proposed treatment does not depend on medical standards or practice). Here I deal with the case against Dr Lowns, the general practitioner, who, at first instance, was held liable in negligence for failing to attend the plaintiff when allegedly requested to do so. The finding against him was upheld by majority of the Court of Appeal of the Supreme Court of New South Wales (Kirby P and Coles JA), who concluded that Dr Lowns, albeit a stranger to the plaintiff, was nevertheless liable for the unfortunate medical misadventure which resulted in the case, all said to be attributable to Dr Lowns' failure to attend the plaintiff at his home when requested to do so. The plaintiff, a boy aged ten years at the time, had a history of epilepsy and suffered an attack of status epilepticus in 1987 while on vacation with his family. Briefly, the relevant facts, taken from the trial judge's findings, were these: when the boy's mother -- after some considerable delay -- discovered that her son was fitting, she directed her older son "to go for an ambulance", and told her daughter (then nearly 15 years of age) "to go and get a doctor". The girl insisted that she went to Dr Lowns' surgery and spoke "to a man who answered the door". She claimed that she told that man that her mother had sent her because her brother was having a bad fit, that they had called for an ambulance, and "that we needed a doctor and could he come up?". The girl identified this man in Court as Dr Lowns, and claimed that he had refused to come, telling her instead to bring her brother to the surgery. By the time the ambulance arrived and took the boy to another medical practice (where he was injected with diazepam) and then to hospital (still fitting), he had suffered severe brain damage. The boy sued both Dr Procopis and Dr Lowns (as well as the two doctors who injected him with diazepam, a claim later withdrawn). At first instance, both Dr Procopis and Dr Lowns were found to have been negligent: Dr Procopis for having failed to instruct the parents in the use of rectal diazepam, and Dr Lowns for failing to attend the plaintiff at his home. At the trial, Dr Lowns denied that the girl had ever been to his surgery. His case was that the alleged conversation had never occurred. However, he made a number of fatal concessions: (i) that if he had been requested to attend the boy, he would -- and should -- have gone, (ii) that if he had attended the boy, he would have injected him with diazepam, and (iii) that if the boy had been treated at that point in time, it is probable that the tragic consequences would have been avoided. The identification of Dr Lowns by the boy's sister must be treated with considerable scepticism: she alleged that Dr Lowns was smoking a pipe (he does not), and there is little doubt that the doctor is not easily recognisable from her initial description of him. For good measure, the girl's ex- planations of these discrepancies lack conviction. This notwithstanding, the judge chose to believe her and rejected Dr Lowns' denial. (This finding was not challenged on appeal.) In the result, the judge entered a verdict in favour of the plaintiff in excess of $3 million. The finding that a general practitioner has a duty to attend any person in a medical emergency, in the absence of any previous professional relationship, is brand new law. With a stroke of a pen, the Court "discovered" a duty which did not previously exist. The origin of this so-called duty is found in the seminal speeches in Donoghue v. Stevenson, 4 where a majority of the House of Lords held, some 60 years ago, that a soft-drink manufacturer was liable in negligence to a plaintiff who claimed to have suffered an attack of gastroenteritis as a result of drinking the defendant's ginger beer (alleged to have contained the decomposed remnants of a snail). This case discovered the "neighbour" principle, "based upon a general public sentiment of moral wrongdoing for which the offender must pay" (per Lord Atkin, at p 580). 4 This "general public sentiment", excavated from the Old Testament, commanding that you are to love your neighbour, has mutated into law that you must not "injure" your neighbour. The legal question "who is my neighbour?" receives the restricted reply "persons so closely and directly affected by my act that I ought reasonably to have them in contemplation as being so affected when I am directing my mind to the acts and omissions which are called in question" (per Lord Atkin, at p 580). 4 This "neighbour" principle had never previously been applied to doctor and stranger. Indeed, the trial judge himself (in Woods v. Lowns and Procopis ) noted: Something other than the foreseeability of harm is required before the law imposes a duty to intervene. It has been held in other common law jurisdictions that a doctor is under no duty to attend upon a person who is sick, even in an emergency, if that person is one to whom the doctor has not and never has been in a professional relationship of doctor and patient: see Jones, Medical Negligence , Sweet and Maxwell 1991 at p 24, par 2.21; Kennedy & Grubb, Medical Law , Butterworths (2nd ed) 1994 at p 79. His Honour cited a number of United States decisions, all of which held, firstly, that there can be no liability to attend to members of the public and, secondly, that there can be no negligence unless and until the relationship of doctor and patient has been established. How, then, did the majority impose this hitherto unknown legal obligation? The answer is that their Honours confused a moral duty with a legal one. The Medical Practitioners Act 1938 (NSW) s 27 (1) (now re-enacted in s 37 of the Medical Practice Act 1992 [NSW]) does state that "professional misconduct" in a registered medical practitioner is, inter alia: (h) refusing or failing, without reasonable cause, to attend, within a reasonable time after being requested to do so, on a person for the purpose of rendering professional services in the capacity of a registered medical practitioner in any case where the practitioner has reasonable cause to believe that the person is in need of urgent attention by a registered medical practitioner. However, while the legislation describes the contents of professional misconduct which will attract professional sanction, there is nothing in the Act which imposes a statutory obligation to attend a stranger, and it would be quite wrong to elevate "professional misconduct" to a breach of statutory duty, thus giving rise to an independent cause of action. It follows that those who maintain that the decision in Woods v. Lowns and Procopis is relevant only to medical practitioners in New South Wales are on shaky ground. I believe that, on appeal, only the dissenting judge (Mahoney AJ) correctly summarised the position when he stated: "We are concerned with whether the moral obligation to which (as I assume) the doctor was subject should be a legal obligation" ( Woods v. Lowns and Procopis, at p 13). His Honour noted that: Counsel have not been able to find any case in support of the present existence of such an obligation. Nor has any member of the Court. No case has been put to the contrary. I am conscious of the fiction that what the law creates has always been the law. But the implications of this case are great. . . . In this, as in other areas of law, the Court now faces squarely the nature of its decision: it prefers reality to fiction. Therefore, it is not inappropriate that I describe what the Court is here asked to do is imposing a legal obligation which presently does not exist ( Woods v. Lowns and Procopis, at p 15). I suggest that both the trial judge (Badgery-Parker J) and the majority of the Court of Appeal of the Supreme Court of NSW have not only "discovered" a relationship of proximity between doctor and stranger hitherto unknown to the law, but that they were wrong to hold that a doctor is under a legal duty to attend a person with whom he or she has had no previous professional relationship, a duty said to be based on the "proximity" or "neighbour" test, so that the only remaining question was whether the damage in suit was reasonably foreseeable if a doctor, otherwise in a position to do so, refused to render medical assistance. I submit that this is not only bad law; it is a blatant usurpation by the Court of what is solely the function of Parliament. If the Legislature wants to impose such a duty, so be it. It is not the business of judges to do so. While this is not the place to examine the history and development of the law of negligence, it is with no disrespect to the majority of the Court of Appeal to say that in the case Woods v. Lowns and Procopis Homer nodded,* and that the majority's reasoning was simplistic. It has long been held that the tort of negligence does not include -- save in a special relationship -- an obligation of rescue. The claim against Dr Lowns was argued in negligence and only in negligence; no breach of any other civil obligation was, or could have been, demonstrated. The answer to the plaintiff's claim must surely be that the tort of negligence does not extend to a failure by a doctor to attend a stranger. If there is such a duty, it must be sought elsewhere and, in this area, none of the cases to date have ever suggested that a person having goods or skill must provide them for the benefit of another. In this case, the majority sought to make a great deal of Dr Lowns' concession that, had he been requested to do so, he would and should have attended the plaintiff. The doctor went further, admitting in cross-examination that he could well foresee harm to a fitting child if he did not attend immediately and administer treatment. But that concession could not amount to an admission that he was under a legal obligation to attend the plaintiff, as the majority appear to have thought. After Dr Lowns indicated that he would seek special leave to appeal the decision to the High Court of Australia, the parties settled their claim. The medical profession is thus deprived of obtaining a more definitive pronouncement on a controversial decision in which, in my opinion, the majority of the New South Wales Court of Appeal came to a wrong conclusion, "bending" the law to reach a socially compelling result. References Gerber P. Has informed consent become a legal nightmare? Med J Aust 1995; 163: 262-264. Bates PW. Social and legal changes in medical malpractice litigation. Med J Aust 1995; 163: 264-268. Rogers v. Whitaker (1992) 175 CLR 479. Donoghue v. Stevenson [1932] AC 562 . Author's details 6 Devaney Lane, Corinda, QLD 4075. Paul Gerber, LLB, DJur, Adjunct Professor of Law, University of New South Wales. < URL: http://www.mja.com.au/> © 1996 Medical Journal of Australia.

Paul Gerber

Editorial Migraine: then and now Better understanding of the neurobiology of migraine is leading to better treatment MJA 1996; 164: 519-520 Migraine is debilitating for its victims and frustrating for their friends and relatives. The Australian National Health Survey of 57 000 people in 1989-1990 found that 12.2% had experienced a headache in the preceding two weeks.1 Extrapolation to the entire Australian population implies that 280 000 people suffered a migraine attack and two million some lesser form of headache in that two-week period. The annual cost of migraine to the community, considering loss of productivity and cost of medical services, has been estimated at $302-$721 million by the Centre for Applied Economic Research, University of New South Wales.2National Migraine Week (12-18 May) may help to increase public awareness of this problem. In addition, the Migraine Foundation, a subsidiary of the Australian Brain Foundation, has recently been established to promote education and to encourage research and the formation of self-help groups in the community. When is a headache a migraine? Whether migraine has a place at one end of a headache spectrum or is a separate entity remains controversial. The International Headache Society has established criteria for the diagnosis of migraine, to standardise headache classification for surveys and clinical trials.3The Classification Committee's general description of migraine is "an idiopathic headache disorder manifesting in attacks lasting 4-72 hours", with the characteristics of common unilateral location, pulsating quality, moderate or severe intensity, aggravation by physical activity and association with nausea and photophobia. Nevertheless, a third of migraine headaches are bilateral, and not all throb or are accompanied by nausea and photophobia. About 25% of those affected describe premonitory symptoms the night before -- a feeling of elation, craving for sweet foods or excessive yawning. Between 25% and 40% experience a visual aura at some time, but only 10% describe typical fortification spectra (zigzag visual hallucinations) or spreading scintillating scotomas. Such neurological symptoms usually precede the headache, but may occur without an ensuing headache or may appear while a headache is in progress. However, most migraine headaches occur without such symptoms. Varieties of migraine are designated hemiplegic, basilar, ophthalmoplegic or retinal, depending on the area of the brain rendered ischaemic. A migraine headache lasting longer than 72 hours is termed "status migrainosus". Neurological symptoms persisting for more than seven days indicate a migrainous infarction. Genetic factors contribute about half of the susceptibility to migraine, and the gene for some kinships with familial hemiplegic migraine has been localised to chromosome 19.4 Neurobiology of migraine Modern techniques have improved our knowledge of both aura and headache mechanisms. Aura: Regional cerebral blood flow studies show a reduction in cortical perfusion, starting in the parieto-occipital region during a visual aura and spreading forward at 2-3 mm/min. This corresponds to the speed at which fortification spectra appear to move over the field of vision and that of "spreading cortical depression" observed by Leâo as an artefact in experimental animals in the 1940s.5 Recently, magnetic resonance imaging and positron emission tomography (PET) showed a similar spreading pattern of diminished metabolism in a patient with migraine with blurred vision but no classical aura.6 Although needing confirmation, this raises the possibility of cortical oligaemia in migraine attacks that lack an aura; this would account for the impaired vision, loss of concentration and poor memory that often accompany migraine headache. Headache pain: Since the work of Wolff and his colleagues in the 1940s and 1950s, dilatation of the superficial temporal artery and its branches has been regarded as the main cause of headache pain. However, recent studies have shown that this applies to only about a third of migraine patients. Measurements of velocity of blood flow with transcranial Doppler ultrasound have shown that the middle cerebral artery dilates during migraine headache and returns to normal when the headache resolves after the injection of sumatriptan.7 Cerebral oedema may also be a feature of some migraine attacks, as there have been two reports of skull defects bulging during the headache phase.8 "Neurogenic inflammation" (with extravasation of protein from dural vessels) has been implicated, brought about by release of vasodilator peptides, such as calcitonin gene-related peptide (CGRP) and substance P.9,10 This effect can be blocked by sumatriptan and dihydroergotamine. It is also possible that the blood-brain barrier breaks down during migraine headache, allowing access of drugs that are normally excluded. When sumatriptan is administered during the aura phase it does not prevent the ensuing migraine headache, despite its prompt action once headache is established, suggesting that it can enter the brain only after the headache starts. How can we link the initiating cerebral events and the vascular changes? Stimulation of the brainstem nuclei, locus coeruleus and raphe dorsalis has been shown in animals to alter both intracranial and extracranial blood flow.11 In humans, some patients with implanted electrodes which stimulate the periaqueductal grey matter or thalamus for relief of bodily pain have developed migraine-like headaches, some associated with visual symptoms.12 PET scans during and after migraine headache have shown increased metabolic activity in the region of the periaqueductal grey matter and locus coeruleus on the side of the migraine headache, which persisted after the headache.13 What has happened to the "serotonin story"? It is now thought that the discharge of serotonin (5-hydroxytryptamine, 5-HT) by platelets at the onset of migraine headache14 may reflect similar changes in the central nervous system, as serotonin plays a key role in pain control. Serotonin is also a potent vasoconstrictor in the cranial circulation. Increase in knowledge of the many 5-HT receptors has led to the synthesis of agents which act as agonists of these receptors. Prophylactic medications, such as pizotifen and methysergide, act predominantly on 5-HT2 receptors in the central nervous system. The newest antimigraine drug, sumatriptan, is a highly selective agonist of the D-subtype of 5-HT1 receptors. It constricts cranial arteries, interferes with the release of vasodilator peptides and may also have central actions (as yet unknown), if, as has been proposed, the blood-brain barrier breaks down during migraine headache. Already other 5-HT1D agonists, such as 311C90 (zolmitriptan) and MK462, are undergoing clinical trials for the management of migraine headache. Continued research on these drugs and on the receptor sites for serotonin and other neurotransmitters involved in the migraine syndrome promises new therapeutic avenues in the treatment of migraine. James W Lance Consultant Neurologist, Institute of Neurological Sciences Prince Henry and Prince of Wales Hospitals, Sydney, NSW Australian Bureau of Statistics. National Health Survey: summary of results. 1989-1990. Canberra: ABS, 1991. (Catalogue No. 4364.0.) Parry TG. The prevalence and costs of migraine in Australia. Centre for Applied and Economic Research working paper. Sydney: CAER, University of New South Wales, 1992. Headache Classification Committee of the International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia 1988; 8 Suppl 7: 13-96. Merikangas KR. Sources of genetic complexity of migraine. In: Sandler M, Ferrari M, Harnett S, editors. Migraine: pharmacology and genetics. London: Chapman and Hall, 1996: 254-274. Leâo AAP. Spreading depression of activity in the cerebral cortex. J Neurophysiol 1944; 7: 359-390. Woods RP, Iacoboni M, Mazziotta JC. Bilateral spreading cerebral hypoperfusion during spontaneous migraine headache. N Engl J Med 1994; 331: 1689-1692. Friberg L, Olesen J, Iversen HK, Sperling B. Migraine pain associated with middle cerebral artery dilatation: reversal by sumatriptan. Lancet 1991; 338: 13-17. Lance JW. Swelling at the site of a skull defect during migraine headache. J Neurol Neurosurg Psychiatry 1995; 59: 641. Moskowitz MA, Cutrer EM. Trigeminovascular system and migraine. Semin Headache Manage 1996; 1: 7-9. Goadsby PJ, Edvinsson L. The trigeminovascular system and migraine: studies characterizing cerebrovascular and neuropeptide changes seen in humans and cats. Ann Neurol 1993; 33: 48-56. Lance JW, Lambert GA, Goadsby PJ, Zagami AS. Contribution of experimental studies to understanding the pathophysiology of migraine. In: Sandler M, Collins GM, editors. Migraine: a spectrum of ideas. Oxford: Oxford University Press, 1990: 21-39. Raskin NH, Hosobuchi Y, Lamb S. Headache may arise from perturbation of brain. Headache 1987; 27: 416-420. Weiller C, May A, Limmroth V, et al. Brain stem activation in spontaneous human migraine attacks. Nature Med 1995; 1: 658-660. Anthony M, Hinterberger H, Lance JW. Serotonin in migraine and stress. Arch Neurol 1967; 16: 544-552. ©MJA 1999 © 1999 Medical Journal of Australia.

James W Lance

Reuse in sterile sites of single-use medical devices: how common is this in Australia? Peter J Collignon, Elaine Graham and Dianne E Dreimanis This article was published in the 6 May issue of The Medical Journal of Australia. Readers may print a single copy for personal use. No further reproduction or distribution of the articles in whole or in part should proceed without the permission of the publisher. For copyright permission, contact the Australasian Medical Publishing Company See also articles by Brook and Woollard Abstract - Introduction - Methods - Questionnaire - Definitions of cleaning/sterilising - Examination of devices - Results - Discussion - Reuse of medical devices - Cleaning and sterilisation - Recommendations for reuse - Cross-infection - Costs and cost benefit - Acknowledgements - References - Author's Details Register to be notified of new articles by email - - ©MJA1996 Abstract Objectives: To determine to what extent Australian hospitals reuse in sterile sites medical devices labelled "single use only"; to assess the adequacy of cleaning and sterilising procedures before reuse; and to estimate the possible incidence of cross-infection and the costs of not reusing these devices. Design: A self-administered questionnaire survey. Setting: All Australian hospitals (419) with more than 45 beds and undertaking medical and surgical procedures. Methods: Questionnaires were sent to hospital infection control practitioners in 1994 requesting information about reuse in sterile sites of single-use medical devices, the extent of reuse, the cleaning and sterilising processes involved, and the reasons for reuse. Results: Responses were received from 168 hospitals (40%). Reuse occurred in 64 (38%), and another 33 hospitals had been reusing medical devices 12 months before our survey (i.e., 97/168 hospitals [58%] were either reusing them at the time of our survey or had been doing so 12 months previously). More large (> 300 beds) metropolitan public hospitals (9/14; 64%) reported reusing than did smaller (50/143; 41%) or private hospitals (15/47; 32%). At six of the 64 hospitals where reuse occurred, the process of cleaning and/or sterilisation of these devices was not satisfactory; from the information we received, both cleaning and sterilisation were satisfactory in only 38 hospitals (59%). Examination of the 14 most commonly reused devices showed that the structure of 13 of these may compromise cleaning (and therefore sterilisation). The main reason given for reuse was cost saving. Assuming a 2% prevalence of transmissible infections in blood, and an infection transmission risk of 1/500, we estimate that each year in Australia there may be 40 cases of cross-infection for every one million procedures performed with reused devices (0.004%). Conclusions: Reuse of medical devices labelled "single use only" is common in Australian hospitals. Most devices appear to be unsuitable for reuse. Complete cessation of this practice of reusing single-use medical devices would stop potential cross-infection, but this would cost an estimated $2.5 million or more per case prevented. MJA 1996; 164: 533-536 Introduction Current guidelines generally recommend that medical devices labelled "single use only" should not be reused, but controversy arises because of their high cost and the belief that using them once only is wasteful as well as environmentally unsound.1,2 The United States Food and Drug Administration (FDA) maintains that there is a lack of data to support the general reuse of disposable devices.3 They consider that an institution or a practitioner reusing a disposable medical device should be able to demonstrate that it can be adequately cleaned and sterilised; that its physical characteristics or quality will not be adversely affected by the cleaning/sterilising process; and that the device will remain safe and effective for its intended use. In addition, the FDA believes that institutions or practitioners who reuse devices must bear full responsibility for their safety and effectiveness.3The Australian Confederation of Operating Room Nurses (ACORN),4 the Federation of Sterilising Research and Advisory Councils of Australia (FSRACA)5 and the Medical Industries Association of Australia (MIAA)6 strongly oppose the reuse of "single use only" medical devices. The Commonwealth, New South Wales, Queensland and Victorian health departments have all made recommendations against reuse,7-11 although most departments implicitly acknowledge that it occurs and they recommend guidelines for reuse similar to those of the FDA. Many refer to requirements of the Code of Good Manufacturing Practice (GMP) of the Therapeutic Goods Act 1989 (Cwlth).12 However, given the stringent quality control procedures, documentation and required sampling numbers of the GMP code, reuse of single-use devices in hospitals would not comply with GMP requirements. Despite these directions and recommendations by regulatory authorities, there is anecdotal evidence that reuse occurs frequently in the belief that it saves money. However, for most devices the total costs of reusing have either not been calculated or do not take into account staff time and potential legal liabilities; reprocessing can at times be more expensive than purchasing replacements. In view of the controversy surrounding this subject, and the lack of data, we aimed to determine both the extent of reuse of single-use medical devices in Australian hospitals and the perceived problems associated with this practice. Methods In August 1994 we sent a questionnaire to all Australian hospitals with 45 beds or more where medical or surgical procedures were performed; 419 hospitals were identified (208 with < 100 beds, 147 with 100-300 beds, 49 with 300-600 beds, and 15 with > 600 beds).13 If after three months no reply had been received, individual responses were sought from those infection control practitioners in the non-responding institutions who were known personally to one of the authors. Replies were sought until the end of March 1995. All respondents were given the option of returning the questionnaire anonymously and were assured that no identifiable data from their hospital would be released. Questionnaire As well as information about frequency of reuse of single-use medical devices, the three-page questionnaire asked about: location of the hospital; the hospital size and type; specific details about cleaning and sterilisation methods for reused devices; and any change in hospital policy for reuse of single-use devices occurring in the previous 12 months, the reasons for any changes and whether the publicity from documented patient-to-patient transmission of HIV and hepatitis C in Australia14-16 had influenced any changes in practice. Respondents were also asked whether they were aware of any cross-infection resulting from reuse of single-use medical devices. To questions about reuse of a list of medical devices that we considered had a high potential for reuse, respondents could answer "yes", "no" or "not used in this hospital". Details were requested from all areas of the hospital that may have been reusing. Specific areas and devices mentioned included: general surgery (diathermy pencils, other items); laparoscopic surgery (scissors, forceps, other items); gastroenterology -- endoscopic retrograde cholangiopancreatography (ERCP) (cannulas, stone-removing baskets, balloon dilators); gastroenterology -- colonoscopy (diathermy snares, sclerosing needles); gastroenterology -- endoscopy (upper gastrointestinal tract) (sclerosing needles, cytology brushes, other items); imaging (angiography catheters, other items); cardiology (cardiac catheters, pacing electrodes, other items); oncology (bone marrow trephine sets). Details of devices reused from other areas were also requested. We sought information only on devices labelled "single use only" and used in sterile sites. Devices that were used in non-sterile sites (e.g., in gastroenterology procedures) were included if the device was used to breach a mucosal surface (e.g., a sclerosing needle or diathermy snare) and therefore entered a sterile site. Definitions of cleaning/sterilising Physical cleaning may not remove all the biofilm, endotoxins and chemical residue from medical devices. If all organic material is not removed subsequent sterilisation may be compromised. Therefore, "satisfactory cleaning" required the use of ultrasonics and/or the use of a brush, detergent and a proteolytic enzyme. "Satisfactory sterilisation" required either autoclaving or "gassing" with ethylene oxide. Because reusing these devices entails entry to sterile sites, glutaraldehyde or other chemical disinfectants were not regarded as achieving sterilisation. These agents do not achieve sterilisation without very long contact times and there are organisms resistant to these agents. Examination of devices A visual examination was made of the structure of the 14 medical devices named above to assess potential problems with cleaning. Results Reuse of medical devices Of 419 hospitals sent the questionnaire, responses were received from 168 (40%). Of these hospitals, 64 (38%) were reusing medical devices. Thirty-three other hospitals were no longer reusing at the time of our survey but had been doing so 12 months previously. Twenty-one of the 64 hospitals reported that they had reduced the number of devices being reused. Overall, 97 of 168 hospitals (58%) either were reusing devices at the time of the survey or had been doing so 12 months previously. Sixty-two of the reports were returned anonymously. In 32 of these 62 hospitals (56%) reuse was occurring at the time of the survey or 12 months previously. Large metropolitan public hospitals (9/14; 64%) were more likely to reuse these devices (Box 1). Cross-infection No institutions reported any cross-infection caused by reuse of single-use medical devices in sterile sites. Cleaning and sterilising The cleaning and/or sterilisation processes in six hospitals were regarded as unsatisfactory. Twenty other hospitals reusing medical devices provided insufficient information on cleaning and sterilising. For 38 hospitals (59%) we considered that both cleaning and sterilisation were satisfactory. Infection control committees One hundred and nineteen respondents commented that their infection control committees were concerned about the reuse of medical devices; 20 committees were not concerned (including eight committees at whose hospital reuse was occurring). In 26 hospitals the infection control committee had recommended that reuse of single-use devices should not occur, but reuse was still occurring. At 20 hospitals, infection control committees thought reuse appropriate in some instances, but no reuse was occurring in their hospitals. Altogether, 101 infection control committees had recommended against the reuse of single-use medical devices. Fifty-two hospital committees had stated that single-use devices could be used under defined circumstances. Fifteen hospitals did not supply information on this question. Factors influencing reuse The main reason provided for reuse was cost saving. Other reasons given were waste minimisation and environmental concerns. At 45 hospitals the adverse publicity surrounding documented patient-to-patient transmission of HIV and hepatitis C in Australia14-16 had resulted in a decrease in both the types of devices reused and the overall incidence of reuse. Twenty-two hospitals had discontinued reuse altogether. The main medical devices that are being reused are listed in Box 2. Examination of devices We were able to examine all 14 of the medical devices named in the questionnaire (see Methods); 13 of these probably could not be adequately cleaned because they had either a complex structure or small hollow lumens or crevices. Only pacemaker electrodes appeared to us to be readily cleanable. Discussion Reuse of medical devices Reuse of single-use medical devices was a frequent practice in the Australian hospitals responding to our questionnaire, and it was more common in large metropolitan public hospitals. A Canadian study (examining reuse of all single-use devices, not just those used in sterile sites) also found more reuse in large hospitals.2 A recent draft report from the National Health and Medical Research Council (NHMRC) indicated that all 11 hospitals surveyed reused medical devices labelled as "single use only".17 Medicolegal implications and the media, however, appear to have had a major impact on reuse of single-use medical devices. Recent adverse publicity appears to have greatly influenced hospital practice, especially over the past one to two years. We believe our study underestimates the extent of reuse in Australia. The questionnaires were sent to infection control practitioners because of their knowledge and current understanding of the problem of reuse of single-use devices. We were surprised, however, that some institutions with well established infection control departments did not respond to our survey. This may be because of difficulty obtaining this information in large hospitals (with many different departments involved), or because of concerns about litigation and possible adverse publicity. Many questionnaires were returned with the proviso that the hospital's identity should remain strictly confidential. Although large metropolitan teaching hospitals were under-represented among respondents, trends indicated that expensive devices (such as cardiac catheters and electrophysiology catheters) are more likely to be reused in these hospitals. Both reports in the literature and informal sources (e.g., media reports) suggest that these devices are frequently reused.18-20 Cleaning and sterilisation Provided an instrument can be satisfactorily cleaned and sterilised, it should not transmit infection and it does not matter that it is labelled single-use only. However, the physical characteristics (e.g., of the plastic) may not withstand cleaning and sterilising, making the device less safe to use. Any devices with hollow lumens or crevices, or those that cannot be disassembled for cleaning, are very difficult to clean and sterilise reliably, either by autoclaving or with ethylene oxide. In our study, a number of medical devices for which reuse appeared reasonable at first (e.g., single-use diathermy pencils) were found on closer examination to have spring-loaded buttons and crevices that would be difficult to adequately clean, particularly if contaminated with blood. Most disposable laparoscopic equipment appears to be very difficult to adequately clean, and most cannot be autoclaved because it is made of heat-sensitive materials. Ethylene oxide is less satisfactory than heat because it is less likely to penetrate hardened vegetative or protein matter (possibly harbouring microorganisms) remaining on inadequately cleaned medical devices. Other studies suggest that even when our requirements for "satisfactory cleaning" are followed, organic material frequently remains on these devices.21 Our study looked only at medical devices labelled "single use" and used in sterile body sites, but some of our reservations about devices whose design compromises cleaning are also valid for devices labelled reusable (e.g., laparoscopic equipment). Recommendations for reuse The divergent views of infection control committees and hospital practice found in our survey reinforce our view that it is difficult or impossible for individual hospitals to assess in isolation whether reuse of single-use medical devices is safe and cost efficient. Our recommendations to deal with this dilemma are given in Box 3. We concur with the recent NHMRC draft report17 recommending that, if the Australian health ministers allow continuation of reuse, the institutions seeking to process devices for reuse should be licensed and comply with specific national standards and procedures, and that the cleaning/sterilising process should be cost effective.17 Cross-infection The frequency of cross-infections occurring from reuse of single-use medical devices is not known. There are no studies that address the "harmfulness" of reuse in a rigorous fashion (i.e., evidence-based medicine). No cases were reported in our study and there are none to our knowledge reported in the literature. If cross-infection does occur, it is likely to be infrequent. It may also go undetected because of the long incubation period and the asymptomatic nature of many blood-borne viral infections. The number of cases of cross-infection occurring will depend on the prevalence of infection in the community, the risk of transmission and the number of procedures performed (Box 4). Unfortunately, we do not have information on all these factors. The risk is likely to be low and would be expected to be much less than that for a needlestick injury. The risk of transmitting HIV with a percutaneous injury when the source person is infected with HIV is about 1/300.22 Other viruses such as hepatitis B have much higher transmission rates,22 but, considering that reused single-use devices are cleaned and disinfected and that cross-infections have not been documented, the risk rate is likely to be 1/500 or less (and possibly close to zero). If one million procedures are carried out in Australia each year with reused single-use medical devices and we assume a 2% prevalence of blood-borne infections (our estimate for the prevalence of blood-borne infections in the Australian patient population), then 40 infections will be transmitted. Costs and cost benefit The total extra costs involved in ceasing reuse are not known. One of the hospitals participating in the survey stopped reusing "single use only" medical devices which enter sterile sites. The estimated budget increases for consumables in that hospital's Gastroenterology Endoscopy Unit and Radiology Unit were $192 000 per year and $142 000 per year, respectively. Estimates have been made of additional costs of at least $100 million per year if reuse is to cease in Australia.20 Therefore, in Australia the maximum cost is likely to be $2.5 million per infection prevented. If the risk rate is much lower than 1/500 then the cost per infection prevented will be much higher. Another factor to be taken into account is how many times a device is reused. If it is reused on 20 different patients, the cumulative risk of the device becoming contaminated with a blood-borne infection will be higher than in our estimates. Banning the reuse of all "single-use" invasive medical devices will thus have major implications for health care costs, and it is unlikely that governments and third parties will contribute this extra funding. This may result in fewer diagnostic or therapeutic procedures being carried out, longer waiting lists for procedures, and the possibility of adverse outcomes for patients because procedures are not performed at the appropriate time. In addition to the direct dollar costs, these potential negative outcomes (associated with complete banning of reuse of single-use devices) need to be balanced against the infection risks and the risks of malfunction associated with reprocessing of these devices. The recent NHMRC report also stresses the need for extra resources if the Australian health ministers ban reuse of single-use devices.20 Acknowledgements We would like to thank all the infection control practitioners who provided information for our survey. We would also like to thank Dr Gerda Mark, Ms Sharon McAuliffe and Mr Martin Dwyer for their thoughtful critique of the information. To top of article Register to be notified of new articles by email - - ©MJA1996 See also articles by Brook and Woollard References Lacroix D, Lucas H, Stewart I. Anxiety, misinformation and greed. Aust Nurs J 1994; 2: 17-20. Campbell BA, Wells GA, Palmer WN, Martin DL. Reuse of disposable medical devices in Canadian hospitals. Am J Infect Control 1987; 15: 196-200. United States Food and Drug Administration. Compliance Policy Guide. Reuse of medical disposable devices. 7124.6. Washington, DC: FDA, 24 Sept 1987. Australian Confederation of Operating Room Nurses policy statement. Reuse of single use items. ACORN J 1992; Dec: 3. Federation of Sterilising Research and Advisory Councils of Australia (FSRACA) policy statement: reuse of single use items. Melbourne: FSRACA, 14 Feb 1994. Medical Industry Association of Australia (MMIA). Statement of Industry Policy: reuse of single-use medical devices. Sydney: MMIA, 6 Aug 1991. Adams A (Chief Medical Adviser, Commonwealth Department of Human Services and Health). Communication: reuse of single-use devices. Canberra: DHSH, 1 Aug 1994. de Souza D. Reuse of medical devices [letter]. Med J Aust 1984; 141: 394. 9. Owen JW (Director-General, New South Wales Health). Reuse of single use medical devices. Sydney: NSW Health, 22 Jul 1994. (Draft Circular 83/62.) Lange D (Chief Health Officer, Queensland Health Sterilising Services). The reuse of single use medical devices. Brisbane: Queensland Department of Health, 5 August 1993. (Medical Circular No. 16/93.) Lynch P (Acting Chief Medical Officer, Victorian Department of Health and Community Services). Re-use of disposable single use items. Melbourne: DHCS, 29 January 1993. (Circular No. 2/1993.) Commonwealth of Australia. Therapeutic Goods Act. Canberra: AGPS, 1989. Hospital and health services yearbook and equipment catalogue, 14th ed. Prahran, VIC: Peter Isaacson Publications, 1990. Chant K, Lowe D, Rubin G, et al. Patient to patient transmission of HIV in private surgical consulting rooms. Lancet 1993; 342: 1548-1549. Collignon P. Patient to patient transmission of HIV. Lancet 1994; 343: 415. Chant K, Kociuba K, Munro R, et al. Investigation of possible patient-to-patient transmission of hepatitis C in a hospital. NSW Public Health Bull 1994; 5: 47-51. Dunnigan A, Roberts C, McNamara M, et al. Success of reuse of cardiac electrode catheters. Am J Cardiol 1987; 60: 807-810. Anderson F, Heale, J Alison, Harper RW. Feasibility and cost effectiveness of reuse of electrophysiology electrode catheters [abstract]. The Cardiac Society of Australia and New Zealand Meeting 1994. Aust N Z J Med 1994; 24: 653. Myburgh RE, Eldridge KL, Weerasooriya HR, Davis MJE. Reuse of electrophysiologic and ablation catheters -- feasibility and costs [abstract]. The Cardiac Society of Australia and New Zealand Meeting 1994. Aust N Z J Med 1994; 24: 655. National Health and Medical Research Council. Report of the NHMRC Expert Panel on the Re-use of Medical Devices Labelled as Single Use. Draft report. Canberra: NHMRC, 26 Oct 1995. Atkins, R. Examination of single use items by scanning electron microscopy. J GENSA 1995; 5: 13-15. Henderson DK. HIV-1 in the health care setting. In: Mandell GL, Bennett JE, Dolan R, editors. Principles and practice of infectious diseases, 4th ed. New York: Churchill Livingston, 1995: 2632-2656. (Received 27 Nov 1995, accepted 21 Mar 1996) Authors details Woden Valley Hospital, Canberra, ACT. Peter J Collignon, FRACP, FRCPA, Microbiologist and Infectious Diseases Physician; and Head, Infectious Diseases Unit; Elaine Graham, RN, CIC, Clinical Nurse Consultant, Infection Control; Dianne E Dreimanis, RN, RM, BHSc(Nursing), Acting Clinical Nurse Consultant, Infection Control. No reprints will be available. Correspondence: Dr P J Collignon, Infectious Diseases Unit, Woden Valley Hospital, PO Box 11, Woden, ACT 2606. To top of article - - ©MJA1996 See also articles by Brook and Woollard < URL: http://www.mja.com.au/> © 1996 Medical Journal of Australia.

Peter J Collignon · Elaine Graham · Dianne E Dreimanis

Reuse of single-use medical devices: NHMRC deliberations Whether reuse is banned or condoned practices must change This article was published in the 6 May issue of The Medical Journal of Australia. Readers may print a single copy for personal use. No further reproduction or distribution of the articles in whole or in part should proceed without the permission of the publisher. For copyright permission, contact the Australasian Medical Publishing Company See also articles by Collignon and Woollard - - ©MJA1996 The reuse of medical devices labelled "single use only" is widespread in Australian hospitals, as it is in hospitals throughout the developed world. The practice generates both strong support and strong opposition among different sectors of the health care community, and there has been vigorous public debate about it in Australia.1,2 There are numerous reports of adverse outcomes associated with reuse of single-use medical devices. These are not restricted to infection, but include physical trauma, device breakage and toxic reactions.3-5 However, there are few systematic data examining reuse of medical devices or outcomes of this reuse in Australia, and the report by Collignon et al. in this issue of the Journal (page 533) is a welcome addition. Some professional groups1,2and, more recently, the public6 have raised serious concerns about the safety and efficacy of reuse. The National Health and Medical Research Council (NHMRC) established an expert panel in August 1994 to examine the policies, practices and standards which apply to reuse in Australia, and to make recommendations on future management of reuse.7 Recognising the lack of systematic data, the panel commissioned a survey to document the practices and standards for reuse of medical devices within 11 large public and private hospitals across Australia. The survey showed that, while reuse had decreased in recent years, hospital policies for reuse were often inconsistent with practices; standards for cleaning and sterilisation before reuse were unsatisfactory; quality assurance procedures for these processes were inadequate; and patients were not fully informed of hospital policies and practices for reuse. In almost all cases, the hospitals cited budgetary pressures as the reason for reuse. A major part of the NHMRC study was a physical and microbiological assessment, never undertaken before, of a selection of commonly reused devices. Observed deficiencies included physical damage, evidence of contamination and, in one case, bacterial growth (i.e., many of the processed devices were unsuitable for reuse). The results of this assessment made a significant contribution to the panel's further deliberations and recommendations. The NHMRC expert panel considered a range of options and concluded that the current practice cannot be condoned. Two basic principles underpinned the panel's decisions. Firstly, the dichotomy between policy and practice must be addressed; and, secondly, decisions must always be made on the basis of the most cost-effective allocation of scarce resources. The issue ultimately rests with the responsible health ministers. If they decide that the practice of reuse cannot be endorsed, the following consequences must be recognised and acceptedATBody1stpr:* Funding will need to be increased to allow for purchase of new devices, or a reduction in services will result. * Some form of regulation will be required to ensure compliance (this will apply also if reuse is endorsed). Other principles relate to reuse if it is condoned. * Any decision to reuse must be based on an assessment of the costs and benefits of reuse. If there is no significant economic benefit, reuse should not be contemplated. Economic assessment needs to be rigorous and to include adequate provision for quality assurance monitoring. * Processing for reuse needs to be of a standard which ensures the cleanliness, sterility and structural integrity of the devices. This requires that institutions processing devices for reuse must apply stringent quality assurance procedures to ensure their safety and integrity. The standards required must approach those of the Therapeutic Goods Administration's Code of Good Manufacturing Practice. Regulatory frameworks may be needed to ensure that these standards are met. * Institutions and practitioners who reuse devices must carry the responsibility for ensuring the quality and safety of those devices. * Patients' right to information about an institution's policy for reuse must be addressed. This may prove crucial if reuse is ever an issue in a personal litigation case. These principles for devices labelled "single use only" apply equally to devices designated for reuse. Indeed, data before the NHMRC expert panel suggested that shortcomings in cleaning and sterilising processes apply generally. The panel's draft report and recommendations8 are being revised in the light of public submissions, and the final report is expected to be released later this year. In Canada there has also been a lively debate on reuse of single-use medical devices,8 and for some time there have been strong proponents for reuse.9 The NHMRC panel's conclusions, however, parallel a recent policy statement by the Canadian Healthcare Association.10 Christopher W Brook Chair, NHMRC Expert Panel on the Re-use of Medical Devices Labelled as Single Use Director, Public Health, Department of Health and Community Services, Melbourne, VIC Australian Nurses Federation. Multiple use of single use items -- the Nurses responsibility. Abstracts. Heidelberg Repatriation Hospital, July 1994. Melbourne: ANF, 1994: 15p. Medical Industry Association of Australia. Reuse of single-use medical devices. Conference proceedings. University of New South Wales, August 1991. Sydney: MIAA, 1991: 57p. Jacobsen JA, Schwartz CE, Marshall HW, et al. Fevers, chills and hypotension following cardiac catheterization with single and multiple use disposable catheters. Cathet Cardiovasc Diagn 1983; 9: 39-46. Kundsin RB, Walter CW. Detection of endotoxin on sterile catheters used for cardiac catheterization. Clin Microbiol 1980; 11: 209-212. Case report. MMWR Morb Mortal Wkly Rep 1982; 31: 290-291. Australian Broadcasting Corporation. Television program. 7.30 Report. 1994: 8 Sep. National Health and Medical Research Council. Expert Panel Report on the Re-use of Medical Devices Labelled as Single Use. Draft report. Canberra: NHMRC, 26 Oct 1995. Reuse of disposable medical devices. Proceedings of the Fourth Canadian Co-ordinating Office for Health Technology Assessment. Regional Symposium; 1994 Oct; Montreal, Canada. Montreal: CCOHTA, 1994: 47p. The reuse of single-use catheters. Report submitted to: Ministre de la SantŽ et des Services Socieux du Quebec par le Conseil d'Žvaluation des Technologies de la SantŽ. July 1993. Montreal: CETS: 1993: 65p. Canadian Healthcare Association. The reuse of single-use medical devices. Guidelines for healthcare facilities. Ottawa: CHA Press, 1996. oSee also articles by Collignon and Woollard - - To top of article - ©MJA1996 < URL: http://www.mja.com.au/> © 1996 Medical Journal of Australia.

Christopher W Brook

Reuse of single-use medical devices: who makes the decision? The controversy can be resolved by identifying the real risks of cross-infection This article was published in the 6 May issue of The Medical Journal of Australia. Readers may print a single copy for personal use. No further reproduction or distribution of the articles in whole or in part should proceed without the permission of the publisher. For copyright permission, contact the Australasian Medical Publishing Company See also articles by Collignon and Brook - - ©MJA1996 The transmission of infectious agents between patients during medical procedures is a matter of substantial public concern1 after two widely reported incidents of transmission of HIV infection (in a doctor's office and in a dental practice), and recent episodes of hepatitis B and C transmission.2,3 The usual explanation for these episodes is a breakdown of standard infection control procedures. These reports have increased pressure on Australian hospitals and doctors to cease the practice of reusing medical devices labelled by the manufacturers as "single use only". The Commonwealth and most State health departments also recommend that this practice should cease. The National Health and Medical Research Council (NHMRC) established an expert panel on "Re-use of medical devices labelled as single use" and recently has circulated a draft report.4 This recommends either a blanket ban on the reuse of such devices or the establishment by the Therapeutic Goods Administration of "a system for the formal licensing of entities wishing to process devices labelled as single use". I believe this could effectively prevent any such reuse. Needless to say the Medical Industries Association of Australia strongly opposes the reuse of these items. With such formidable opposition it should come as a surprise to many that reuse of single-use medical devices is widespread in Australian hospitals. Reuse was occurring in all 11 hospitals surveyed by the NHMRC panel, and Collignon et al. in this issue of the Journal (page 533) report that 64 of 168 hospitals responding to their survey were currently reusing single-use items; another 33 hospitals had been doing so 12 months previously. With only a 40% response to their survey, the authors believe that they have probably underestimated the extent of reuse. The results of these surveys indicate a rebellion against expert advice. The rebellion extends to the pages of this Journal, with a recent editorial advocating reuse of cryoprobe tips after mechanical cleaning and glutaraldehyde soaking.5 Australian hospitals are reusing a wide range of equipment, including cardiac pacing electrodes, diathermy pencils and colonoscopy snares. Reuse of cardiac catheters has been reported in Australia6 and reuse of angioplasty balloons is common in other countries and has been reported to be safe.7 The explanation for this resistance by doctors and hospitals against expert opinion and direction from higher authorities is based on two important factors: firstly, there are apparently no reported cases in the medical literature of transmission of infection between patients as a result of the reuse of single-use medical devices; and, secondly, in the absence of any demonstrated adverse effects on patients, hospitals and doctors are not prepared to divert funds from other areas of medical care. Collignon et al. estimated that somewhere between zero and 40 infections per year may be transmitted as a result of procedures involving reuse of single-use medical devices in Australia, although it is not clear that cessation of reuse would eliminate these potential infections. They also estimated that it would cost an extra $100 million per year (the total annual research grant allocation by the NHMRC is $142 million!) if reuse of medical devices were to cease, and that preventing one new infection (and many of these will be benign) would cost at least $2.5 million, and probably much more. When there are strongly conflicting views on the best way to provide medical care, a common underlying feature is absence of data. The appropriate professional response is to obtain such data. Concerns about possible transmission of infectious agents as a result of medical procedures would be addressed by establishing an Australian study; for example, this could involve serological testing of large numbers of patients before and after a range of invasive procedures to look for evidence of seroconversion for hepatitis agents. In this way the real risk of transmission could be identified. In the meantime, what should be done about reuse? Some (especially legal advisers) would advocate a perfect standard, requiring absolute proof of safety for every aspect of medical care. Only a minority of the processes involved in medical care have passed such a test. A more sensible approach might be for all doctors involved in reuse of single-use items to re-examine their own activities to ensure that they comply as far as practicable with current guidelines. If health care professionals believe in "evidence-based medicine" they should add their voices to the call for a proper study in this area before any firm recommendations are made by bodies such as the NHMRC. Keith Woollard Cardiologist St John of God Medical Clinic Murdoch, WA Robinson M. The patient's right to know. Sydney Morning Herald 22 Feb 1996: 15. Tedder RS, Zukerman MA, Goldstone AH, et al. Hepatitis B transmission from contaminated cryopreservation tank. Lancet 1995; 346: 137-140. Chant K, Kociuba K, Munro R, et al. Investigation of possible patient-to-patient transmission of hepatitis C in a hospital. NSW Public Health Bull 1994; 5: 47-51. National Health and Medical Research Council. Report of the NHMRC Expert Panel on Re-use of Medical Devices Labelled as Single Use. Draft report. Canberra: NHMRC, 26 Oct 1995. Tabrizi SN, Garland SM. Is cryotherapy treating or infecting? Med J Aust 1996; 164: 263-264. Dedman G, Hendricks R, Lane G, et al. Comparative costs of cardiac catheters -- a quality controlled assessment. Aust N Z J Med 1994; 24: 643. Burton J, Tymchak W, Dzavik V, et al. Cost of percutaneous revascularisation. Circulation 1995; 92(Suppl 1): 661. oSee also articles by Collignon and Brook - - To top of article - ©MJA1996 < URL: http://www.mja.com.au/> © 1996 Medical Journal of Australia.

Keith Woollard

Limited adverse occurrence screening: using medical record review to reduce hospital adverse patient events Alan M Wolff 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/>". Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - ©MJA1997 Abstract Objectives: To determine whether continuous detection of adverse patient occurrences followed by analysis and medical intervention can alter the rate of adverse occurrences. Design and participants: 15 912 patients discharged from one hospital were reviewed in two stages. Medical records were screened retrospectively by medical records staff for one or more of eight general patient outcome criteria. Those that screened positive for the criteria were reviewed by one of four doctors. If an adverse occurrence was confirmed, further analysis and recommendations for action to prevent its recurrence were made at meetings of the four doctors, and forwarded to a committee of visiting medical officers who decided on the appropriate course of action. Setting: A rural base hospital in Horsham, Victoria, between July 1991 and June 1994. Main outcome measures: The rate and severity of adverse patient occurrences in each year. Results: 1465 records were screened positive for one or more criteria, and an adverse patient occurrence was confirmed in 155. 88 cases were determined to be minor or not preventable and further action (mostly by changes to hospital policies) was recommended for the remaining 67. Over the three years, the number of adverse occurrences fell from 69 (1.35% of all patient discharges in the first year) to 33 (0.58% of all patient discharges in the third year) ( P < 0.0001) and there was no significant change in severity. Conclusions: The rate of adverse patient occurrences can be significantly reduced by their continuous detection using retrospective screening in conjunction with review, analysis and action to prevent recurrences. MJA 1996; 164: 458-461 Introduction The objective of medical quality assurance programs is to improve the quality of care provided to patients. However, "quality medical care" has proved difficult to define, leading some programs to attempt to detect "disquality", or events that should not happen under optimal conditions.1 Quality, then, may be defined as the absence or lowering of the rate of adverse patient events or occurrences. Many preventable adverse patient events occur in hospitals. The Quality in Australian Health Care Study, which reviewed over 14 000 patient admissions in 28 hospitals in New South Wales and South Australia, found 16.6% involved an adverse event; half of these were assessed as highly preventable.2 The Harvard Medical Practice Study, a review of over 30 000 inpatient medical records from 51 acute-care hospitals in the United States, showed that adverse events occurred in 3.7% of hospitalisations and that many of these were the result of substandard care.3 Both these studies used methods that required substantial resources in time and money to detect adverse patient events, and neither looked at the effect of intervention in preventing recurrence of an adverse event. Limited adverse occurrence screening is a continuous process of retrospective screening and review of inpatient medical records to detect adverse patient occurrences.4 It is referred to as "limited" because only eight general patient outcome criteria are used. When an adverse occurrence is found, appropriate action is taken to prevent its recurrence and the success of the action is determined by ongoing monitoring.4 Thus, the quality assurance feedback loop is securely closed. This study was designed to determine whether limited adverse occurrence screening could reduce the number and rate of adverse occurrences and therefore improve the quality of patient care. Methods The study was undertaken at Wimmera Base Hospital in Horsham, 300 km north-west of Melbourne. There are 11 specialists and 14 general practitioners on the medical staff who treat between 5000 and 6000 inpatients per year. Four doctors were chosen by the Hospital Medical Staff Group to be medical reviewers and to form a Patient Care Committee. All doctors held dual positions in the hospital and had postgraduate clinical qualifications. They were a physician (also Director of Intensive Care), a surgeon (also Chairman of the Medical Staff Group), a general practitioner (also Director of Postgraduate Education) and the Medical Director (also Director of the Accident and Emergency Department). The medical records for all inpatients discharged between 1 July 1991 and 30 June 1994 were screened by medical records staff using eight general patient outcome criteria (Box 1, below). An adverse patient occurrence analysis form was attached to any medical record that met one or more of the criteria. The record was reviewed by the doctor allocated to that criterion, who evaluated the care given to determine if an adverse patient occurrence had arisen before or during admission, and then completed the form. Adverse occurrences for which patients had had previous admissions were excluded. 1: General patient outcome criteria used for screening of medical records Death. Return to operating theatre within 7 days. Transfer from general ward to intensive care unit. Unplanned readmission within 28 days of discharge. Cardiac arrest. Transfer to another acute-care facility. Length of stay greater than 35 days (reduced to 21 days in 1993-1994). Theatre booking cancelled. An adverse patient occurrence was defined as "an untoward patient event which, under optimal conditions, is not a natural consequence of the patient's disease or treatment".1 I have described the limited adverse occurrence screening method in detail in an earlier paper.4 Medical care was evaluated using a six-point scale,5 to help the reviewer decide whether an adverse patient occurrence was caused by medical management: 1 = little or no evidence, 2 = slight evidence, 3 = not likely (less than 50:50 odds but a close call), 4 = more likely than not (greater than 50:50 odds but a close call), 5 = strong evidence, 6 = virtually certain. A score of four or more on this scale was regarded as an adverse patient occurrence. Severity of adverse occurrences was graded on a seven-point scale:1 0 = minor severity, 1 = minor temporary, 2 = minor permanent, 3 = major temporary, 4 = major permanent, 5 = potential major or major continuing, 6 = death. The medical reviewer wrote brief notes about the case for the Patient Care Committee. Adverse occurrences were discussed at the Committee's bimonthly meetings and recommendations for further action relating to patient care were made and forwarded to the Medical Staff Group, which consisted of all visiting medical officers in the hospital and the Director of Medical Services. All data from the adverse patient occurrence analysis forms were entered into a database program developed from the Clipper Dbase Compiler software package.6 A chi-squared test was used for statistical analysis, and confidence intervals were calculated for odds ratios using standard methods.7 Results A total of 15 912 inpatients were discharged between 1 July 1991 and 30 June 1994. Using the eight general patient outcome criteria, 1465 records (9.21%) were screened positive for one or more criteria by medical records staff. The commonest criteria among these were unplanned readmission of a patient within 28 days of discharge (3.4% of all records screened) and transfer of a patient to another acute-care facility (2.8% of all records screened) (Box 2). A medical record was most likely to be subsequently confirmed as containing an adverse patient occurrence when it was selected by the criterion "return to operating theatre within seven days" (odds ratio = 3.98; 95% confidence interval, 2.15-7.37) (Box 2). After medical review, 155 records (0.97% of all records screened) were found to contain an adverse patient occurrence using the six-point scale (Box 3). Of these adverse occurrences, 45 were minor and 110 were major (Box 4). Of the 155 adverse patient occurrences confirmed on medical review, no further action was recommended by the Patient Care Committee in 88 cases (56.8%) (i.e., the adverse occurrence was considered to be not preventable or of minor significance). Recommended action for the other cases included changing the relevant hospital policy; presenting the case at a postgraduate meeting; undertaking a quality assurance program to investigate the adverse occurrence in detail; discussion with, or counselling of, the doctor involved; and, rarely, review of the doctor's clinical privileges or reporting the case to the hospital's insurers. Over the three-year period of the study, 66 recommendations were made by the Patient Care Committee and almost all were accepted by the Medical Staff Group and became hospital policy. Changes in hospital policies were both clinical and administrative. Clinical policy changes included restricting some drug prescribing; revised protocols for reporting vital signs; eliminating use of multidose drug vials; formulating guidelines regarding fitness for general anaesthesia; and developing protocols for managing patients with alcohol withdrawal, haematemesis and melaena, and for patients who have had a cerebrovascular accident or who require analgesia. Administrative policy changes included sending copies of referral letters when patients were transferred to other hospitals; sending private antenatal notes to the obstetric ward before the patient's confinement; redesigning the preadmission form to allow consent for procedures to be obtained in the consultant's room; and routinely including a copy of the death certificate in the medical record (if the patient had died in hospital). (Examples of the types of adverse occurrences, more detailed recommendations for further action and their subsequent reduction in incidence are given in an earlier paper.4) The adverse patient occurrences were grouped by year to determine whether the actions instigated had any effect on the subsequent rate of adverse occurrences. The rate of adverse patient occurrences fell from 69 in the first year (1.35% of all patient discharges in that year) to 33 in the third year (0.58% of all patient discharges in that year) (Box 4). The proportion of adverse occurrences fell significantly with time (chi-squared = 17.11; df = 2; P = 0.0002) and this trend was linear (chi-squared = 16.87; df = 1; P< 0.0001). When the severity rating of adverse events was divided into minor (severity score 0-2) and major (severity score 3-6), there was no significant change in the severity of adverse patient occurrences between the first, second and third years of the study (Box 4). Also, the proportion of adverse patient occurrences detected in each year by screening did not alter significantly over time for patient age, sex or insurance status (Box 5). The commonest major diagnostic categories, using the ICD-9 classification,8 in which patients had adverse occurrences were injury and poisoning, followed by digestive and circulatory disorders (Box 6, below). Patient characteristics such as sex and age did not change significantly during the three years of the study, but the proportion of inpatients privately insured fell from 26.6% to 24.3% (chi-squared = 10.24; df = 2; P< 0.01). Discussion Limited adverse occurrence screening has been shown to be effective in detecting approximately 50% of adverse patient occurrences,9 a much higher proportion than found by traditional medical quality assurance programs. This study has shown that it is also possible to subsequently reduce the number of adverse occurrences by more than 50% over a three-year period. These results indicate that use of a more complex and expensive screening system is not required to achieve a significant reduction in adverse occurrences. Adverse occurrence screening has been shown to be valid and reliable, with a high level of agreement between reviewers as to whether a patient has had an adverse occurrence.10 Although in this study each medical record was reviewed by only one doctor, other studies using a similar methodology and rating scale have shown high agreement.5 Limited adverse occurrence screening is efficient as it requires the review of the medical records of slightly less than 10% of all patients discharged, costs only 0.1% of an acute-care hospital's total budget, and is fast and accurate (false positive rate, 2.0%; false negative rate, 0.4%).9 In this study, 9.21% of medical records were screened positive for one or more of the eight general patient outcome criteria and an adverse occurrence was confirmed in 0.97%. Little or no clinical judgement was required in the screening process. This compares with a rate of 8.4% (confirmed in 0.73%) in a study using similar screening criteria in a medium-sized New South Wales hospital.11 In the Quality in Australian Health Care Study, potential adverse events were detected in 43.7% of the medical records on initial screening (a much higher rate than in other studies) using 18 criteria, some of which required clinical judgement.2 Adverse events were confirmed in 16.6%, although, unlike in this study, 49% of these occurred before the sample admission. An average rate of potential adverse events of 13.2% was found in a study of 146 Veterans Affairs Medical Centers in the United States that used nine screening criteria.12 There was considerable variation between centres, with a 25th percentile of 8.6% (confirmed in 1.7% of records) and a 75th percentile of 27.2% (confirmed in 7.9% of records). In the Harvard Medical Practice Study, potential adverse events were detected on initial screening in 25.9% of medical records using 18 screening criteria.13 Adverse events were confirmed in 0.2% to 7.9%, depending on hospital complexity and location, with the rate in rural hospitals being 1%.13 Limited adverse occurrence screening can be adapted to all sizes of hospital. It has recently been introduced into 10 small hospitals in central western Victoria by the Division of General Practice in that area working with the Monash University Centre for Rural Health in Moe, Victoria. In larger hospitals, limited adverse occurrence screening could be introduced on a departmental basis. The program could be enhanced by combining its retrospective medical record review with prospective critical incident reporting. In the United States, adverse occurrence screening and incident reporting both detected a substantial number of adverse events; however, there was less than a 50% overlap in the adverse events detected by each method when used concurrently.14 Thus, a program that simultaneously uses both methods may detect the largest pool of adverse occurrences for analysis and development of preventive strategies. Acknowledgements I wish to thank Mr Ian Campbell, Dr David Leembruggen and Dr Grant Phelps for their enthusiastic participation in the Patient Care Committee; Mrs Cathy Dooling, Chief Medical Records Administrator, and her staff, for their support with the screening program; Mr Kieran Loughran, Computer Systems Officer, for assistance with data collection; and Mrs Naomi Uytdehaag for preparing the manuscript. References Craddick JW, Bader B. Medical management analysis: a systematic approach to quality assurance and risk management. Auburn (CA): Joyce W. Craddick, 1983. Wilson RM, Runciman WB, Gibberd RW, et al. The Quality in Australian Health Care Study. Med J Aust 1995; 163: 458-471. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. N Engl J Med 1991; 324: 370-376. Wolff A. Limited adverse occurrence screening: a medical quality control system for medium sized hospitals. Med J Aust 1992; 156: 449-452. Hiatt HH, Barnes BA, Brennan TA, et al. A study of medical injury and medical malpractice: an overview. N Engl J Med 1989; 321: 480-484. Clipper [computer program]. Version 5.0. Los Angeles: Nantucket Corporation, 1990. Daly LE, Bourke GJ, McGilbray J. Interpretation and uses of medical statistics. Oxford: Blackwell Scientific Publications, 1991: 398-424. US Department of Health and Human Services. The international classification of diseases. 9th revision. Clinical modification (ICD-9-CM). 3rd ed. Bethesda, Md: DHHS, 1989. Wolff A. Limited adverse occurrence screening: an effective and efficient method of medical quality control. J Qual Clin Pract 1995; 15: 221-233. Panniers TL, Newland J. The adverse patient occurrence inventory: validity, reliability and implications. Qual Rev Bull 1986; 12: 311-315. Britton S. A hospitalwide outcome study. Aust Clin Rev 1991; 11: 132-135. Goldman R, Walder DJ. An initial assessment of the Veterans Affairs Occurrence Screening Program. Qual Rev Bull 1992; 18: 327-332. 13. Brennan TA, Herbert LE, Laird NM, et al. Hospital characteristics associated with adverse events and substandard care. JAMA 1991; 265: 3265-3269. 14. O'Neil AC, Petersen LA, Cook EF, et al. Physician reporting compared with medical record review to identify adverse medical events. Ann Intern Med 1993; 119: 370-376. (Received 2 Sep 1995, accepted 2 Feb 1996) Authors' details Wimmera Base Hospital, Horsham, VIC. Alan M Wolff, FRACGP, MBA, Director of Medical Services, and Director of the Accident and Emergency Department. Reprints: Dr A M Wolff, Medical Administration, Wimmera Base Hospital, Baillie Street, Horsham, VIC 3400. ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Alan M wolff

The Professional Indemnity Review: what did it accomplish? Charlotta Blomberg In a previous article,* Richard Tjiong criticised the Professional Indemnity Review's specific recommendations for reform of professional indemnity insurance. But the Review covered many other issues, particularly to do with identifying, evaluating and reducing adverse outcomes of medical procedures. Charlotta Blomberg highlights some of the key findings (and failings) of the Review's Final Report. MJA 1996; 164: 502 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/>". Introduction - New research into health outcomes - Preventing adverse outcomes - Litigation crisis? - Compensation schemes - Drawing together medicine and law - In conclusion ... - References - Authors' details - - ©MJA1997 Introduction The Review of Professional Indemnity Arrangements for Health Care Professionals (chaired by Fiona Tito) was established against a background of increasing litigation, or fear of litigation, among health care professionals (see Box). Its purpose was to report to the then Minister for Health, Housing and Community Services on: the arrangements for patients injured through health care negligence or misadventure; the means of funding these arrangements; any problems with these arrangements; and proposed solutions and recommendations on the feasibility, appropriateness and estimated costs and benefits of these proposals.11 The last duty remains largely unfulfilled in the Final Report. Despite 168 detailed recommendations for changes of varying degrees, there is little discussion of feasibility, appropriateness or, more importantly, estimated costs and benefits. New research into health outcomes The Review embarked upon a 41/2-year investigation of the health care system and produced 19 publications (listed in Appendix C of the Report) in addition to the Final Report. The Review looked at the incidence and nature of health care injuries, compensation and structured settlements for personal injuries, facilities for the disabled, professional indemnity arrangements, "defensive" medicine and informed consent, birthing issues and information guidelines for patients and providers. At the start of the Review there was no information on the nature and extent of adverse outcomes, no readily available information on the number and types of health-related compensation claims and little publicly available information on the business operations of the medical defence organisations. The Report argues that lack of information on the issues under review required several individual studies to obtain the information required for decision making. Therefore, a major part of the Review was information gathering. It commissioned the Quality in Australian Health Care Study, which investigated the nature and extent of injuries suffered by patients in Australian hospitals. The preliminary results of this study were released in June 1995 and provoked considerable media attention. After peer review, the results were recently published in the MJA.12 With this study and others, the Review produced the first detailed analysis of the system of compensation for personal injury resulting from health care in Australia. The Final Report attempts to tie this considerable research work together with far-reaching recommendations which, if implemented in full, would radically alter the delivery and funding of health care in Australia. Preventing adverse outcomes The Quality in Australian Health Care Study defined an adverse event as "an unintended injury to a patient which resulted in a temporary or permanent disability, prolonged length of stay or death, and which was caused by health care management not by the patient's underlying disease".11 Under this broad definition the study found that hospital-based care produced over 400 000 adverse outcomes, with an estimated 230 000 of these being preventable. As a result, a considerable part of the Final Report concentrates on proposals aimed at preventing adverse outcomes. The solutions proposed involve the development of clinical practice guidelines based on evidence gained through the Cochrane Collaboration (which focuses on evidence derived from randomised controlled trials, conducted around the world and collectively analysed at the Cochrane Centre, Oxford University, UK). Medical services will be assessed on their efficacy and cost effectiveness. The Review recommends review of current services under the Medicare Benefits Schedule to establish their efficaciousness and cost-effectiveness. Commonwealth funding for those that fail these tests should cease (see Report recommendations 16, 19, 23, 28, 29 and 33).11 The emphasis on the development of clinical practice guidelines appears to stem from one of the findings of the Quality in Australian Health Care Study that system errors account for 16% of all adverse outcomes, with 53% of these due to the absence of or failure to use a policy, protocol or plan.12 However, the Study also concluded that "half of all AEs [adverse events] are deemed to have low or no preventability" and that this should be remembered "to avoid an inappropriate presumption of culpability when things go wrong".12 The Review does not address the difficulties associated with implementing a guidelines-based system of health care. The cost or cost-effectiveness of implementing these recommendations is not discussed, and no mention is made of what is involved (such as time and resources) in evidence-based reviews. There appears to be an underlying assumption that, if evidence-based guidelines are developed and followed, adverse outcomes will, in the main, be prevented. This "cookbook" approach to medicine has been criticised elsewhere.13 Without further debate of the issues, the Final Report fails to convince that strict adherence to evidence-based practice guidelines will achieve perfect outcomes. Litigation crisis? In the Final Report, the issues of professional indemnity, negligence actions and adverse outcomes were described as surrounded by myths and assertions supported by little hard data. Much of the information relating to the "litigation crisis" was anecdotal: "evidence for a so-called claims crisis is scant", said the Report, concluding that a crisis mentality has been fostered by some medical defence organisations to deflect attention from their own "irresponsible financial management".11 Although an increase in the rate of incident reporting was noted, the Final Report held that this did not appear to be reflected in an increase in claims filed in courts. It did acknowledge that there is often a considerable time lag between the reporting of an incident and the filing of a claim in court, which may imply recognition that the crisis may yet eventuate. The Review has rightly identified a lack of readily available information on common law negligence cases. A database of common law personal injury cases would be a valuable tool for monitoring the nature and frequency of legal claims, patterns of claims, the frequency of settlement and the amounts of awards and settlements. Such a project would require Commonwealth-State cooperation, as common law matters fall outside the Commonwealth's jurisdiction. The Report cites the register currently operating in South Australia and the National Practitioner Data Bank in the United States as models, but does not estimate the amount or nominate the source for funding of such a project. It does recommend that such a register would provide "a positive quality link between the tort system and the [practitioner] registration system" (Report, pages 154-155).11 This proposal must be studied further. It could mean registration would be subject to the frequency or value of claims incurred each year. It could mean a type of peer review that may establish that common law negligence is not to be equated with medical negligence. Unfortunately, the Report is not clear on what is meant. Compensation schemes In relation to compensation for those who have suffered personal injury as a result of health care, the Review recommended against the introduction of a "no-fault" scheme of compensation. Such a scheme would remove the need to prove negligence (fault) to receive compensation; proof of injury would suffice. It was rejected on grounds of inequity. The public interest is served by those who cause injury paying compensation. A no-fault scheme would mean that the full burden of assistance for injured persons would fall on the community as a whole through increased taxes and an overall reduction in resources available to those suffering injury as a result of health care.11 While recognising that there is inequity between the allocation of resources for those with compensable injuries and those with non-compensable injuries, the Report suggests that the overall public interest would be better served by the retention of the current system. The Review did investigate means of compensation other than the current lump sum awards. In many cases these, although seemingly generous, have proved to be inadequate when taken over the lifetime of a severely disabled person. Structured or serial payments in the place of lump-sum awards were offered as a solution. This is an alternative worthy of further consideration as it may provide security of assistance for those with severe permanent disabilities and solve the problem of awards being dissipated, eventually leaving the injured party relying on the public system. Drawing together medicine and law The Review has made useful recommendations in relation to the medicolegal system. Incorporating the study of legal issues into the training for health care professionals (Report recommendation 8), introducing a system of peer support for health professionals involved in negligence litigation (recommendation 89) and accrediting specialist health negligence lawyers (recommendation 94) are all worthy of further investigation. Greater positive and cooperative interaction between law and medicine is a desirable goal. Both professions would benefit from greater understanding and appreciation of each other's workings. Often people injured during medical procedures say that their main reason for pursuing legal actions is to find out what went wrong.14 This suggests that many potential actions may be prevented through appropriate advice at an early stage. A key factor in this process is access to expert opinions. The Review recommends a college-based system of encouraging high quality health professionals to provide expert opinions in medicolegal cases (Report recommendation 98). This type of system, along with appropriate legal training for medical experts, has been under review by the Australian Medical Association since last year. The existence of a pool of peer-recognised medicolegal experts available to give advice to plaintiffs, defendants and even the court itself may well have a positive effect on reducing litigation and delays inherent in the current system. Judges are keenly aware of the delays and costs attaching to civil actions and actively consider means to speed up their progress. The public interest is not served by lengthy delays and costly litigation. In conclusion . . . it's inconclusive The Final Report of the Review has not lived up to its high expectations. It has identified and investigated issues and proposed recommendations which raise more questions than they answer. There is little real assessment of the financial effect of the recommendations or the impact on current medical practice. The focus is on providing information for more effective decision-making. The legacy of the Review will be even more extensive consultations and reviews to develop practical solutions to the problems it has identified. References Tjiong R. The American litigation crisis is already here. Australian Medicine, 5 June 1995: 4. Bailie RS, Douglas RM. The future role and operation of Australian general practice survey results. Canberra: National Centre for Epidemiology and Population Health, 1995. Komesaroff PA, Keaney MA, Niselle P, Dunn IM. Is there a medical litigation crisis? MJA 1996; 164: 178-182. Keaney MA. Is litigation increasing? MJA 1996; 164: 178-179. Rogers v Whitaker (1992) 175 CLR 479. Lowns v Woods, by his next friend the Protective Commissioner & Ors Court of Appeal (NSW), unreported, 5 February 1996. O'Shea v Sullivan & Macquarie Pathology Services Pty Ltd (1994) Aust Tort Reports 81-273. Talbot & Anor v Lusby (1995) unreported, Supreme Court of Queensland, 14 July 1995. Litigation fears increase health bill. Australian Doctor, 1 September 1995: 48. Breen v Williams (1994) 35 NSWLR 522. 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. Wilson RM, Runciman WB, Gibberd RW, et al. The Quality in Australian Health Care Study. MJA 1995; 163: 458-471. Arnold P. The Tito Report -- medical practice re-invented. Australian Medicine, 19 February 1996: 6. Vincent C, Young M, Phillips A, et al. Why do people sue doctors? A study of patients and relatives taking legal action. Lancet 1994; 343: 1609-1613.* See: Tjiong RTT. The Professional Indemnity Review. A lost opportunity for reform. MJA 1996; 164: 371-374. Authors' details Australian Medical Association, Canberra, ACT. Charlotta Blomberg, BA(Hons), LLB, Legal Advisor. Reprints: Ms Charlotta Blomberg, AMA, 42 Macquarie Street, Barton, ACT 2600. E-mail: cblombergATama.com.au ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Charlotta Blomberg

Recent changes in Australian general practice Michael D Bollen General practitioners need to decide whether the recent changes to general practice are acceptable and whether they are willing to initiate and lead the process of change in concert with the communities they serve MJA 1996; 164: 212 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/>". Introduction - Recent developments in Australian general practice - Recognition of general practice - What has occurred as a result of this report and what is the future for GPs and general practice? - GPs being part of change - References - Authors' details - - ©MJA1997 Introduction During 1995, the Council of Australian Governments (COAG) released a discussion paper entitled "Meeting peoples' needs better".1 Subsequently, the Federal Government called for expressions of interest in programs for management of people with chronic illnesses which would apply the principles of coordinated care outlined in the discussion paper. These programs (which involve fundholding and care coordinators, not necessarily general practitioners [GPs]), are the most recent federal initiatives in reshaping community-based health care. "Coordinated care", "managed care" or "integrated care" (all are basically synonymous) have been introduced in other countries to ensure cost and service efficiencies or to maximise profit in the delivery of health care. Health planners in the United States have some difficulty understanding what we are seeking to achieve in Australia with coordinated care, as Australia is perceived as having a potentially very effective care coordinator called a general practitioner, a care coordinator which the United States is seeking to emulate! Given recent experiences (e.g., making private health insurance a more attractive product, or seeking acceptable ways to encourage quality care in general practice) in attempting to work in partnership with governments, it is not surprising that many in our profession, and GPs in particular, have major reservations about this latest proposal. Recent developments in Australian general practice General practice in Australia has changed significantly over the past six years and responses to these changes have varied widely. Recognition of general practice With the introduction of vocational registration in 1989, general practice was recognised as a distinct professional discipline. Entry to general practice now requires specific training, qualifications and commitment to ongoing education; it is no longer a career default option. Moreover, the establishment of departments of general practice in almost all Australian medical schools has signalled the recognition of general practice as an academic discipline. These developments have led to a blossoming of research within Australian general practice involving two distinct areas: the first is in clinical issues, such as hypertension and diabetes, using general practice data and resources; and the second concerns the framework of general practice and how it might function with different structures. In August 1991, the then Federal Health Minister, Mr Brian Howe, announced a number of "reforms" in general practice, which included fundholding (or budget holding) (see Box 1). 1: Federal Government general practice initiatives2 Address supply and distribution of medical practitioners; Introduce accreditation of general practices; Provide practice grants to complement fee-for-service reimbursement; Trial the use of practice budgets; Amalgamate solo and small-group practices into larger, more efficient entities; and Optimise use of information technology in general practice. Both the Australian Medical Association (AMA) and the Royal Australian College of General Practitioners (RACGP) declared that general practice fundholding was unacceptable, not only because of the perceived threat to traditional fee-for-service practice, but also because of the absence of linkage of patients to practices and the lack of effective information management in Australian general practices. Recent information on the experiences of GPs in the United Kingdom, 3 New Zealand (Professor Greg Coster, Chairperson, Royal New Zealand College of General Practitioners, personal communication) and Canada (Dr Reg Perkin, Executive Director, The College of Family Physicians of Canada, personal communication), where fundholding in various forms had been introduced, would appear to support this position. In response to the "reforms" proposed in 1991 and after extensive negotiations between the AMA, the RACGP and the Federal Government, a joint report entitled "The future of general practice: a strategy for the nineties and beyond" 4 was released in July 1992 (Box 2). 2: Key proposals of the report -- the future of general practice Address the oversupply and maldistribution of general practitioners; Provide support and recognition for appropriate postgraduate training for general practice; Establish local "divisions of general practice" under the control of general practitioners; Develop (by the profession) an independent, voluntary system of practice accreditation with links to regional divisions of general practice; and Introduce remuneration strategies designed to: -- reward quality care in general practice more appropriately; and -- enhance and encourage the role of general practitioners beyond the provision of individual patient care. This report was distributed widely to all GPs and to other interested parties, and working groups were formed to develop strategies to implement a number of these proposals. What has occurred as a result of this report and what is the future for GPs and general practice? Addressing the maldistribution of the GP workforce To address this issue credible answers are required to some key questions, which include: How many practising and non-practising GPs are there in Australia? How many identified general practices are there? How many additional GPs are required for rural and remote areas? What are the essential skills required for GPs to practise confidently and safely in the various areas of need? How many GPs are needed in Australia altogether? Is there a limit to the number of GPs Australia can support and afford? How many GPs are enough? Data on the general practice workforce are most unsatisfactory. The Health Insurance Commission reports that around 23 000 individual doctors use non-referred item numbers and could therefore be considered as GPs. There are about 16 500 "recognised general practitioners" who are either Fellows of the RACGP or who are vocationally registered. The increasing numbers of part-time GPs make estimation of the numbers required in the general practice workforce more difficult. The Federal Government has imposed an annual limit of 200 overseas-trained graduates entering the Australian medical workforce (almost all of whom seek to become GPs). 5 Entry to the RACGP Training Program has been restricted to 400 per year, 6 and the argument used by the government for limiting the number of GPs entering the workforce has been the reportedly unsustainable rate of growth in payments for GP services. There are allegedly too many GPs in most metropolitan areas and a very evident lack of GPs in many rural and remote areas throughout Australia. Despite various incentives, most Australian GPs appear reluctant to spend time in rural general practice. Many GPs have reported that, even in the cities, there is a shortage of both doctors willing to work as locums as well as skilled GPs available to fill vacancies resulting from practice growth or GP resignation or retirement. Recognition of appropriate training for general practice Vocational registration and restricting entry to general practice continue to be a source of anger and resentment. Medical students, recently graduated hospital doctors and those unsuccessful in specialist training had, in the past, an expectation of a right to enter general practice, together with those doctors who considered general practice as a retirement option or a retreat when their original career ceased to be satisfying or rewarding. Such doctors often still refuse to recognise that general practice requires any particular training. The terms "vocational registration" and "recognised GP" will remain a mystery to most consumers until we, as a profession, accept what much of the developed world, and the World Health Organization in particular, has already accepted: that general practice is a specific discipline in medicine and not merely the sum of special areas of knowledge from other more restricted disciplines. Only then can we unite to promote the excellence of general practice in Australia. It is ironic that Australia is regarded internationally as having one of the highest standards of general practice in the world, but yet is one of the last developed countries to afford real recognition to the discipline. Formation of divisions of general practice Contrary to popular opinion, the concept of divisions of general practice was not a government initiative but arose from within the profession. Divisions were conceived to provide GPs with a strong voice at a local level in their interaction with other local and regional bodies. Members of other Australian medical disciplines have been able to aggregate and organise in hospital "divisions" or departments. This permitted specialists to provide effective hospital clinical services, to undertake teaching and research collaboratively and to provide a professional interface with other disciplines and hospital administration while still retaining their independence. The RACGP had been keen to address the isolation and problems of fragmentation and marginalisation of Australian general practice. There was agree ment for a means to enable local GPs to work together more closely while still retaining t heir independence. In particular, at a local level GPs needed to not only plan their own futures as GPs but also have an input into the important area of health care planning for their communities. These concepts led to divisions of general practice and their proposed roles (Box 3). 3: Proposed roles for divisions of general practice Maintain and improve the standards of general practice in the region, including coordination of care between general practitioners and other service providers for the benefit of patients; Improve communication between general practice, hospitals, medical specialists and community health services; Encourage involvement of GPs in hospitals and other community health services; Foster cooperation between GPs in providing quality after-hours services; Take an active role in the continuum of education from undergraduate through to postgraduate vocational training in general practice; Undertake research in general practice by establishing local research networks; Involve GPs in health promotion and preventive activities; Ensure appropriate access to primary health services in consultation with consumers by sharing allied health resources; and Assist in the development of appropriate information management in general practice. During 1992, 10 groups of GPs from various parts of Australia obtained Federal Government funding to develop local GP organisations, later called divisions of general practice. By the end of 1995 there were 116 divisions of general practice covering 85% of the Australian community. The divisions, and projects promoted through divisions, have been subject to increasingly rigorous evaluation. Inevitably, some are proving more successful than others. The first ten divisions, formed in 1992, appear to be flourishing. Some more recently formed divisions may need a longer time to demonstrate their potential, and some of the early projects proposed by the divisions were poorly developed and sometimes only partially successful. To ensure that divisions of general practice have a future they will need to demonstrate that they are having a positive effect on community-based health outcomes and that this effect is sustainable. Development of practice accreditation The concept of the accreditation of general practices (i.e., the environment in which GPs work) has proved to be highly controversial. Perceived benefits are outlined in Box 4. To provide a basis for such accreditation required the development of agreed standards. 4: Benefits of general practice accreditation Raise general practice standards and consequently the quality of care provided to patients; Provide professional benefits for general practitioners; and Facilitate change in general practice. During 1993-1994 the RACGP Standards Development Unit developed "Draft entry standards for general practice", 7 with input from a wide variety of individuals and organisations. In 1994 these draft entry standards were tested in 199 practices through the RACGP Field Test of Standards. A further 500 practices, coordinated through divisions of general practice, undertook local demonstration trials to enable further evaluation of the standards and methods of assessment. While there has not been universal acceptance of the concept of accreditation, responses from participating GPs in both the RACGP field tests and the local demonstration trials strongly suggested that the standards were acceptable and appropriate, that the process was found to be professionally satisfying, and that a better understanding of the standards acted as a catalyst for change in the practices surveyed. One reason for Federal Government support of the concept of accreditation was that it might provide a basis for allocation of funding not dependent on number of patient consultations (i.e., rewarding quality care rather than throughput). The debate around accreditation should not revolve around money but around standards: How are the standards established? Are they are accepted by GPs as well as the rest of the profession? How they are applied? Do they have external credibility to consumers and others outside the profession? Remuneration strategies for general practice There was initial agreement that the existing fee-for-service funding for general practice had an inbuilt "perverse incentive" based on "the more you see and the quicker you see them the more you earn". The RACGP, the AMA and the government were not able to reach agreement on a method of remuneration that encouraged and rewarded the provision of high quality care, other than on a time basis. Agreement attempts were not aided by the Government's part-funding of the general practice reforms, including the introduction of the so-called Better Practice Program, from the funding pool for the fee-for-service rebate increases. That action was totally contrary to the agreed position stated in the general practice strategy document that "Funding for these payments would come from a pool of funds set aside by the Government but the establishment of this pool should not interfere with rebates for fee for service items for vocationally registered general practitioners", 4 and has resulted in the return of an atmosphere of mistrust of government by the profession. GPs being part of change Whatever changes are proposed to the provision of health care in Australia, the final and most important test will be whether such changes result in improved health outcomes. In seeking to apply this test there is a need for detailed criteria on which outcomes will be judged. "Coordinated care" and "budget holding" will remain no more than words or ideas unless the resulting health care is accessible and acceptable to the Australian community. With the advent of early discharge programs, whether as the result of improved technology, better therapeutic techniques or financial pragmatism, it is essential that high quality community-based care -- providing continuity of care as well as ongoing management of people with chronic illness -- be readily available. It is important for GPs to recognise that, to remain in a position of providing most of the community-based care, they will need to be not just responsive to change, but take the initiative and lead the changes in concert with the communities they serve. References Department of Human Services and Health. Council of Australian Governments Taskforce on Health and Community Services. Meeting peoples' needs better -- a discussion paper. Canberra: The Department, January 1995. Health Care in Australia -- directions for reform in the 1991-92 Budget. (Circulated by The Hon Brian Howe, Deputy Prime Minister and Minister for Health, Housing and Community Services.) Canberra: AGPS, 1992. (Budget related paper, No. 9.) Miller G, Booth N. General practice budget holding. What can the United Kingdom teach Australia? Med J Aust 1995; 162: 284-285. Department of Human Services and Health/Australian Medical Association/Royal Australian College of General Practitioners. General Practice Consultative Committee. The future of general practice: a strategy for the nineties and beyond. Canberra: Department of Human Services and Health, July 1992. Commonwealth Government Budget 1995-96. Fact Sheets -- Medical Workforce. Canberra: AGPS, 1995. Royal Australian College of General Practitioners. Program of Vocational Training -- Conditions of Grant Schedule 3. Specific outcomes for 1994-95. Canberra: Department of Human Services and Health, 1994. Royal Australian College of General Practitioners. Standards Development Unit. Draft entry standards for general practice. Sydney: The College, 1994. Authors' details Royal Australian College of General Practitioners, Sydney, NSW. Michael D Bollen, DObstRCOG, FRACGP, Secretary General. No reprints will be available. Correspondence: Dr M D Bollen, Royal Australian College of General Practitioners, PO Box 906, Rozelle, NSW 2039. ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Michael D Bollen

Viewpoint Caring for a vulnerable population Who will take responsibility for those getting a raw deal from the health care system? Helen P Beange MJA 1996; 164: 159-160 Introduction - References - Author's details - - More articles on General practice and primary care Introduction In Australia, there is a minority population of about 70 000 people. Their mortality rate is at least 10 times that of the general population. They attend doctors twice as often, are admitted to hospital at twice the average rate, and have many more operations. More than half take prescription drugs daily, a third are taking multiple drugs, and 5% take more than four drugs. As 30% of this group have epilepsy, the commonest medications are anticonvulsants. On physical examination, they have an average of five serious medical disorders, but, astonishingly, only half of these conditions have been detected or treated. Although people in this minority group attend general practitioners frequently, they rarely see specialists, despite the fact that most of their disorders need specialist care. Blindness affects 4.4% (20 times the usual rate in Australia) and deafness affects 25% (compared with the average 2%) of people in this group, yet there are no special services for those who are blind or deaf. Although 9% have a psychiatric disability (compared with 2% of the general population), there are no special psychiatric services for them. Dental disease is the most frequent problem, affecting 86% of this group, but there are few special dental services. With such a gross difference in health when compared with the general population, it would be very reasonable to ask whether there are any modifiable risk factors for these diseases. The answer is yes -- surveys show that, while people in the group smoke very little and drink less than the general population, this minority group is generally unfit, obese and often hypertensive. So at least with exercise and better nutrition, it is likely they could avoid developing some diseases. Exercise opportunities improve the quality of life for people with an intellectual disability. (Reproduced with permission of the Stockton Centre, Newcastle, NSW.) How can this apparently disgraceful situation exist? Is Australia a Third World country? Is this a neglected and persecuted ethnic minority? No, not at all -- but this minority group does have problems accessing health care when compared with their fellow citizens. They are poorer and nearly all are dependent on social security. They tend not to marry or have children, and live mainly in public housing. Educational levels are low and illiteracy is the rule rather than the exception. They do not drive cars and many do not have an occupation. They are less mobile; 10% either need assistance to walk or use a wheelchair. One of the greatest barriers to health care is that many cannot speak at all and only half can communicate in complete sentences. The non-ideal social conduct of some of the group is such that doctors are nervous about keeping them waiting and reluctant to expose them to their other patients for fear of losing customers. Another barrier is that members of this group usually have to negotiate health care through another person, which only works successfully if their agent is trained and empathic and does not underestimate their complaints. Unfortunately, Australia has few doctors specially trained to understand this minority group. Australian doctors, although a decent lot, are (as a group) a bit impatient, are seldom able to fathom the language or unique culture of this group, and may not even recognise the names of most of the rare conditions from which they suffer. These conditions include fragile X syndrome, Rett syndrome and Angelman's syndrome. Further, because many of these patients take at least twice as long in consultation as the average patient, the more minority patients a doctor sees, the less the doctor's income. By now, you will have realised that the minority population I am concerned about is composed of people with an intellectual disability, which is defined as an IQ below 70. The figures given above are from a population study of adults between the ages of 20 to 50 in the lower North Shore of Sydney.1 All intellectually disabled adults living in a population of about 200 000 were identified and a random sample of 202 adults was examined. The lower North Shore is regarded as an affluent area of Sydney with good health services; it is thus reasonable to assume that conditions elsewhere in Sydney (and Australia) were either similar or worse. Studies on mortality and morbidity in people with intellectual disabilities in other parts of the world show similar results to the Sydney study.2,3,4 How can we improve the medical care of people with intellectual disabilities? I believe it is simplistic to think we can solve the problem by changing medical undergraduate training alone. Doctors currently treat intellectually disabled patients fairly well, but they are mainly dealing with minor illnesses and injuries. Serious problems are rarely recognised because these patients are used to suffering and cannot articulate their symptoms, and thus seldom complain. The woman with a slowly developing breast tumour, the man with anaemia as a result of a bleeding peptic ulcer, the child with Down's syndrome who is going deaf, the disturbed person having fluphenazine injections who is developing parkinsonism all depend on someone else to take them to a doctor. Young disabled people living at home are in less danger because there is a greater chance that their parents will badger the health system until something is done to help the child. But when a grown child leaves home, who will arrange medical care? Most Australian adults can be responsible for their own health, but we can rarely expect this of people with an intellectual disability. In the heyday of mental institutions, the medical superintendent was responsible for the health of people with an intellectual disability. Now, there is a question mark over just who is responsible. Local general practitioners, group home managers, area health service managers, heads of the Departments of Health and Community Services, perhaps even the Ministers, all disclaim responsibility. After all, the person is intellectually disabled, not sick. People with disabilities need access to the health system (a system which is becoming exceedingly complex). Once within the system, they need interpreters and advocates, and more time and resources than the average patient. General practitioners should obtain additional remuneration for the extra time spent with each patient. The health system needs to follow guidelines for improving the medical care of people with intellectual disabilities (see Box). The medical care of people with an intellectual disability should be set up in the mainstream of hospital medicine, not in academic backwaters. We need additional information about special health risks among people with disabilities and management protocols for the commonest syndromes. Preventive health services and health promotion would save enough money to make other special services available, such as dental clinics, psychiatric and neurological services and eye clinics. In the meantime, we are neglecting the health of people with developmental disabilities and, as a result, they are dying earlier and spending more time with doctors and more time in hospital than is necessary. If we valued the health of people with disabilities their lives would be longer and happier. References Beange H, McElduff A, Baker W. Medical disorders in adults with intellectual disability: a population study. Am J Ment Retard 1995; 99(7): 595-604. Fryers T. Mortality and cause of death. In: The epidemiology of severe intellectual impairment. The dynamics of prevalence. London: Academic Press, 1984: 139-141. Asberg KH. The need for medical care among mentally retarded adults. A five year follow up and comparison with a general population of the same age. Br J Ment Subnormality 1989; 35: 50-57. Howells G. Are the medical needs of mentally handicapped adults being met? J R Coll Gen Pract 1986; 36: 449-453. This article is based on a paper presented at the conference of the Australian Society for the Study of Intellectual Disability (NSW), Sydney, 12 May 1995. Author's details Stockton Centre, Developmental Disability Service, Hunter Area Health Service, Newcastle, NSW. Helen P Beange, MPH, FAFPHM, Visiting Medical Officer. No reprints will be available. Correspondence: Dr H P Beange, 23 Alpha Road, Willoughby, NSW 2068. Guidelines for improving medical care of people with intellectual disabilities Each patient with an intellectual disability should receive comprehensive and continuous health care, with primary care shared between clinical nurse specialists and general practitioners. They should have access to medical specialists and receive adequate attention in hospital. Clinical nurse specialists should be attached to the local group homes that are replacing institutional care. (Group homes usually house four people and are staffed either part-time or full-time.) These nurses would be responsible for health maintenance, preventive health care, arranging vaccinations and checking drugs. They would also make appointments for patients with acute and chronic health problems and maintain the medical records. General practitioners should be encouraged to review their disabled patients' drugs every three months and perform annual physical examinations. Full medical and genetic histories should be made available to these doctors. Health promotion clinics for people with disabilities should be established at teaching hospitals to provide back-up for the general practitioners in the area. These clinics should have formal links with genetic, paediatric and psychiatric departments and provide access to specialists who have expertise and empathy with disabled people. Clinics should offer medical, dietary and exercise advice, and opportunities for exercise after fitness testing. Protocols for dealing with particular syndromes should be developed (e.g., regular hearing and thyroid function tests for people with Down's syndrome, and regular surveillance for hip dislocation and urinary tract infections in people with cerebral palsy). All residential staff should be trained in basic health care, first aid, pharmaceutical treatment and nutrition. Staff should know how to treat fits and choking episodes. Courses in developmental disability medicine for medical students and interested family practitioners should be provided, utilising the skills of doctors who have experience in the field. A medical specialty in developmental disability medicine should be developed, so that these specialists could act as generalists in the same way as geriatricians care for the elderly. Back to text

Helen P Beange

Research Physical, sexual and emotional violence against women: a general practice-based prevalence study Danielle Mazza, Lorraine Dennerstein and Vicky Ryan Abstract - Authors' details - Introduction - Methods - Results - Discussion - Acknowledgement - References - Box 1 - Box 2 - Box 3 - Box 4 - Box 5 - ©MJA1996 - Abstract Objective: To determine the prevalence of domestic violence, childhood abuse and sexual assult experienced by women attending general practitioners. Design: A cross-sectional, questionnaire-based prevalence survey. Setting: 15 general practices in metropolitan Melbourne between November 1993 and February 1994. Subjects: 3026 women over the age of 18 attending for a consultation. Results: The response rate was 72%. Over a quarter of women in relationships had been victims of physical or emotional partner abuse in the previous year, one in 10 having experienced severe physical violence. Thirteen percent of women had experienced rape or attempted rape, 10% had been severely beaten during childhood and 28% had experienced childhood sexual abuse involving physical contact. The abuse had been disclosed to the woman's doctor by only 27% of those who had experienced partner or childhood physical abuse (mostly because the doctor had never asked) and 9% of those who had experienced sexual abuse (mostly because the woman did not see it as relevant to the consultation). Conclusion: There is a high prevalence of physical, sexual and emotional violence against women as well as poor communication about this violence to their general practitioners. Recommendation: Medical practitioners should be more proactive in questioning women about violence. (MJA 1996; 164: 14-17) Introduction Violence experienced by women results in significant morbidity and, in some cases, mortality. The experience of sexual abuse as a child has been linked to later development of psychological disorders1 and drug abuse and dependence.2,3 Domestic violence has health effects beyond the acute injuries; battered women are more likely to suffer from somatic complaints, anxiety and depression,4 pelvic pain,5 and sexual and gynaecological problems.6 They also use health services more often than women not subjected to domestic violence.7 Because of these associations and because victims of violence are more likely to turn to doctors for help than to any other person,8 they are highly likely to frequent a doctor's surgery. However, doctors are not skilled at recognising them and have been estimated to diagnose only one battered woman in 25.7 This may occur because doctors are unaware of the extent of physical and sexual abuse experienced by their female patients; while the prevalence has been studied in the United States and Europe, Australian data are sparse. The single authoritative study on the prevalence of childhood sexual abuse in Australia was conducted by Goldman and Goldman on a population of university students: 28% of female students and 9% of male students had experienced sexual abuse.9 Two recent studies have looked at the prevalence of domestic violence in Australia, but only in select populations: 23.3% of women attending an emergency department disclosed histories of domestic violence,10 while 8.9% of women in a hospital antenatal clinic stated that they had experienced physical abuse during their pregnancy.11 The aim of our study was to determine the prevalence of domestic violence, childhood abuse and sexual assault experienced by women attending general practitioners and to provide doctors with accurate information on the extent of the problem. Methods The study was a questionnaire-based prevalence survey carried out between November 1993 and February 1994. It was approved by the ethics committee of Monash University. Study population The study population comprised women over the age of 18 attending their general practitioner for a consultation. Fifteen general practices in metropolitan Melbourne were selected in a two-stage random sampling design described previously.12 The design incorporated practices that were broadly representative of all social classes, from all regions of metropolitan Melbourne. A total sample size of about 3000 women was calculated to be necessary to ensure adequate power, based on results of a pilot study; 220 questionnaires were therefore distributed to each practice. Questionnaire Consecutive women attending the practice for a consultation were invited to participate by the practice receptionist. The questionnaire was introduced by a covering letter, which explained the nature of the study, that it was voluntary and confidential, and that the information disclosed would not be entered in their medical file or given to their doctor. It was acknowledged that some questions might cause distress, and the questionnaire could therefore be completed either in the waiting room or at home and returned in a reply-paid envelope. Respondents were also given contact phone numbers of support services for the different forms of abuse, and informed that their doctor was happy to discuss with them any issues that might arise as a result of the survey. Before the study, doctors were given an information package with details of local support services for abused women. The self-administered questionnaire asked first for demographic details. Respondents then completed the Conflict Tactics Scale,13 with the modification that they were asked whether the tactic had occurred never, once or more than once in the last year, and with the addition of questions on emotional abuse. In accordance with the Conflict Tactics Scale, physical violence was classified as minor or severe (see Box 1). Questions about sexual abuse were derived from the studies of Wyatt14 and Russell,both of 15 which used multiple screening questions to allow time for the respondent to become accustomed to the nature of the questions. Childhood sexual abuse was classified as contact or non-contact (Box 1). Data were entered into a Microsoft Access database. Frequency tables were generated and prevalences calculated. Because the data came from 15 different general practices and not a simple random sample, confidence intervals (CIs) were adjusted for the effects of clustering.16 Results Of 3026 questionnaires distributed, 2181 were returned (response rate, 72%). Most questionnaires were completed in the waiting rooms of the practices, with only 18% of those answered returned by post. Domestic violence Prevalences for the different categories of domestic violence in the previous year are shown in Box 2. Only those women in a current relationship were asked to complete the section about domestic violence, so that the sample size was smaller than for other parts of the study. A total of 28% of these women had experienced either physical or emotional partner abuse, or both, in the previous year, and (notably) almost one in 10 had been victims of severe physical violence in that year. Among respondents in a current relationship 6% had been kicked, bitten or hit with a fist; 7% had been hit or their partner had tried to hit them with an object; 4% had been beaten up; 4% had been choked; 2% had been threatened with a knife or a gun; and 1% had actually had a knife or gun used against them. Twenty per cent of those in a current relationship had experienced emotional abuse in the previous year; 4% had their partner threaten or try to kill them; 8% had money withheld; 7% were prevented from leaving their home; 6% were stopped from seeing their friends and family or speaking to them on the phone; and 17% were constantly called names or humiliated. Adult sexual abuse Overall, 30% of women had been victim to some form of sexual abuse since the age of 16. Prevalences of different forms of abuse are shown in Box 3. Just over half of those who reported adult sexual abuse (356/626) had experienced more than one kind. Childhood abuse Overall, 10% of women experienced childhood physical abuse (95% CI, 8%-12%); 3% were severely beaten on one occasion and 7% repeatedly. Almost 40% of women had experienced some form of sexual abuse before the age of 16 (Box 3). Communication in general practice about violence The question about whether respondents had ever discussed the issues of domestic violence or childhood physical abuse with their doctors was answered by 1177 women. Among these only 27% had done so, although it was more likely among victims of domestic violence than among non-victims (Box 4). Most women (73%) said that their doctor had never asked them about these things, although this was less likely for victims than for non-victims. If respondents had experienced either childhood or adult sexual abuse, they were asked if they had ever disclosed this to their doctor; 1009 responded, only 87 (9%) in the affirmative. Reasons given for not disclosing are shown in Box 5. Discussion We believe that this study is the first to show the prevalence of physical, sexual and emotional abuse of women in an Australian general practice population. While we recognise that domestic violence and sexual abuse are not exclusively directed by men against women, the study found a high level of violence against women. Over a quarter of women in relationships had been victims of partner abuse in the previous year and one in 10 had experienced severe physical violence; 13% of women had experienced rape or attempted rape; 10% of women had been severely beaten during childhood; and 28% had experienced contact childhood sexual abuse. Despite these levels, few women disclose these events to their doctors. Our findings are similar to those of a family practice-based study in the United States, which found that 23% of women had been physically assaulted by their partners in the last year.17 In contrast,population-based studies in the United States and Canada estimate that between 10% and 14% of women in relationships experience physical abuse over a one-year period; for 3%-5% of women, the abuse is severe.18-22 Because domestic violence is associated with injury and illness, women sampled in medical environments would be expected to have a higher prevalence than women sampled in community settings. In fact, our findings may underestimate the true prevalence of domestic violence, as women who were separated or divorced were not questioned about their experience of it. We found a slightly higher prevalence of sexual abuse than that in a recent New Zealand community-based study, which found the prevalence of childhood sexual abuse overall to be 32%, with contact abuse in 25% and penetrative abuse in 4%.23 The differences are again probably due to the different populations sampled. Potential sources of bias exist. Because of the secret nature of physical and sexual abuse and the stigma attached, there is much controversy over whether self-disclosure by victims can give a true indication of prevalence. A self-administered questionnaire gives no opportunity for clarification of responses by an interviewer. It is also argued that victims will not respond because they fear that disclosure will cause further trauma. These factors would lower apparent prevalence.24 An alternative argument is that victims respond preferentially to surveys when given the opportunity to disclose; non-victims fail to respond as they feel they have no valid information to contribute.24 This would have the reverse effect on apparent prevalence; the two effects could simultaneously counterbalance each other. Another possible source of bias is that the self-administered questionnaire format may have precluded the participation of women from non-English-speaking backgrounds. However, with a sample size of over 3000 and a response rate of 72% (with over 80% of the surveys completed in the general practitioner's surgery), the questionnaire appears to have been well accepted by the subjects. Importantly, about three-quarters of respondents had never been asked by their doctors about domestic violence or childhood physical abuse. This is consistent with results of studies in other countries, which show physician enquiry rates into spouse abuse to be suboptimal.22,25 Contrary to prevailing belief,26 the main reason women did not discuss these issues with their doctor was not because they were afraid, embarrassed or untrusting, but because they were never asked. In addition, 53% of women had not disclosed their experiences of sexual abuse to their doctor because they had never found it relevant to the consultation. Either women are failing to make the connection between sexual abuse and their symptoms or their doctors lack knowledge of the short and long term health effects of sexual abuse. Doctors are crucially placed to deal with the problem of abuse. Our study suggests that medical practitioners must be more proactive in questioning women about violence. While many may hesitate to identify something they may be unable to directly treat,27 it is important to consider that when a diagnosis of abuse is missed treatment is likely to be inappropriate and potentially harmful.28 Detection is the first step in successful management to deal with both the immediate and long term effects of violence against women. This requires that medical practitioners not only develop the skills to diagnose violence perpetrated against women, but have knowledge of local agencies for referral as well as the legal and criminal options available to the woman. Acknowledgement This work was supported by a grant from the Shepherd Foundation in the Department of Community Medicine at Monash University. (©MJA 1996; 164: 14-17) References Mullen PE, Romans-Clarkson SE, Walton VA, Herbison GP. Impact of sexual and physical abuse on women-s mental health. Lancet 1988; 1: 841-845. Burnam MA, Stein JA, Golding JM, et al. Sexual assault and mental disorders in a community population. J Consult Clin Psychol 1988; 56: 843-850. Winfield I, George LK, Swartz M, Blazer DG. Sexual assault and psychiatric disorders among a community sample of women. Am J Psychiatry 1990; 147: 335-341. Jaffe P, Wolfe DA, Wilson S, Zak L. Emotional and physical health problems of battered women. Can J Psychiatry 1986; 31: 625-629. Schei B. Psycho-social factors in pelvic pain: a controlled study of women living in physically abusive relationships. Acta Obstet Gynecol Scand 1990; 69: 67-71. Schei B, Bakketeig LS. Gynaecological impact of sexual and physical abuse by spouse. A study of a random sample of Norwegian women. Br J Obstet Gynaecol 1989; 96: 1379-1383. Stark E, Flitcraft A, Zuckerman D, et al. Wife abuse in the medical setting. An introduction for health personnel. Domestic Violence Monograph Series No. 7. Washington, DC: US Government Printing Office, 1981. Dobash RE, Dobash RP. Violence against wives - a case against the patriarchy. New York: Free Press, 1979. Goldman R, Goldman J. The prevalence and nature of child sexual abuse in Australia. Aust J Sex Marriage Fam 1988; 9: 94-106. Roberts GL, O-Toole BI, Lawrence JM, Raphael B. Domestic violence victims in a hospital emergency department. Med J Aust 1993; 159: 307-310. Webster J, Sweett S, Stolz TA. Domestic violence in pregnancy. A prevalence study. Med J Aust 1994; 161: 446-470. Mazza D, Dennerstein L, Ryan V. Psychotropic drug use by women: current prevalence and associations. Med J Aust 1995; 163: 86-89. Straus MA. Measuring intrafamily conflict and violence: the Conflict Tactics (CT) Scales. J Marriage Fam 1979; 41: 75-88. Wyatt GE. The sexual abuse of Afro-American and white-American women in childhood. Child Abuse Negl 1985; 9: 507-519. Russell DEH. The incidence and prevalence of intrafamilial and extrafamilial sexual abuse of female children. Child Abuse Negl 1983; 7: 133-146. Rao JNK, Scott AJ. A simple method for the analysis of clustered binary data. Biometrics 1992; 48: 577-585. Hamberger LK, Saunders DG, Hovey M. Prevalence of domestic violence in community practice and rate of physician inquiry. Fam Med 1992; 24: 283-287. Rollins BC, Oheneba-Sakyi Y. Physical violence in Utah households. J Fam Violence 1990; 5: 301-309. Schulman MA. A survey of spousal violence against women in Kentucky. Study No. 792701 conducted for the Kentucky Commission on Women. Washington, DC: US Government Printing Office, 1979. Smith MD. The incidence and prevalence of woman abuse in Toronto. Violence Vict 1987; 2: 173-187. Straus MA, Gelles RJ, Steinmetz SK. Behind closed doors: violence in the American family. New York: Anchor, 1980. Straus MA, Gelles RJ. Societal change and change in family violence rates from 1975 to 1985 as revealed by two national surveys. J Marriage Fam 1986: 48; 465-479. Anderson J, Martin J, Mullen P, et al. Prevalence of childhood sexual abuse in a community sample of women. J Am Acad Child Adolesc Psychiatry 1993; 32: 911-919. Finkelhor D. A sourcebook on child sexual abuse. Beverley Hills: Sage Publications, 1986. Martins R, Holzapfel S, Baker P. Wife abuse: are we detecting it? J Wom Health 1992; 1: 77-80. Queensland Domestic Violence Task Force. Beyond these walls. Brisbane: Queensland Government, 1988. Brown JB, Sas G. Focus groups in family practice research: an example study of family physicians- approach to wife abuse. Fam Pract Res J 1994; 14: 19-28. Council on Ethical and Judicial Affairs, American Medical Association. Physicians and domestic violence. Ethical considerations. JAMA 1992; 267: 3190-3193. (Received 19 May, accepted 6 Oct 1995) Authors' details University of Melbourne, Melbourne, VIC. Danielle Mazza, FRACGP, DRACOG, Lecturer, Key Centre for Women's Health; formerly Assistant Lecturer, Department of Community Medicine, Monash University, Melbourne, VIC. Lorraine Dennerstein, AO, PhD, FRANZCP, Director, Key Centre for Women's Health. Vicky Ryan, MSc, Statistician, Statistical Consulting Centre. (©MJA 1996; 164: 14-17)

Danielle Mazza · Lorraine Dennerstein · Vicky Ryan

Abstract Domestic violence is a complex pattern of behaviours that may include, in addition to physical acts of violence, sexual abuse and emotional abuse. Women experience domestic violence at far greater rates than men do, and women and children often live in fear as a result of the abuse that is used by men to maintain control over their partners. Domestic violence is a major public health problem and is very common in women attending clinical practice. Women present most commonly with a range of chronic symptoms to unsuspecting general practitioners, emergency department doctors or medical specialists. Women who have experienced partner abuse want to be asked about it and are more likely to disclose if asked in an empathic, non-judgemental way. Doctors can make a difference. In the past decade, domestic violence has been recognised as a major public health problem. It affects all people, irrespective of economic, educational, social, geographic or racial background,1 resulting in significant morbidity and mortality.2 However, lack of agreement about the basic features of domestic violence makes case identification difficult.3 In view of these uncertainties, we attempt to define "domestic violence" and explore how current attitudes influence measurement and estimated prevalence of domestic violence, and how it presents in clinical practice. How do we define "domestic violence"? The terms "violence", "abuse" and "battering" are frequently used interchangeably. In studies of the Australian community, "domestic violence" is usually taken to mean partner abuse, specifically physical violence between a male and female partner, most commonly perpetrated by the male partner.4 (A "partner" is a person who has been or is having an intimate relationship with another person -- ie, a married or de facto partner, a boyfriend or girlfriend). However, "domestic violence" (or "family violence") may also be used to refer to abuse that occurs in any relationship within households (ie, including abuse of children, elders or siblings). Much of this article deals with partner abuse against women, as women are most commonly the victims,5-7 but this is not to deny that there are rare cases of men being beaten by women.8 Under Australian law, use of the term "domestic violence" refers exclusively to violence committed by a heterosexual partner and includes physical injury, intimidation or serious harassment, wilful damage to property, indecent behaviour without consent, or a threat to commit any of these acts.9 However, from a health perspective, domestic violence can be better understood as a chronic syndrome characterised not only by episodes of physical violence but also by the emotional and psychological abuse that perpetrators use to maintain control over their partners -- ". . . most women experiencing partner abuse report that the physical violence is the least damaging suffered: it is the relentless psychological abuse that cripples and isolates the woman".10 The Australian Medical Association recently produced a position statement asserting that "Domestic violence is an abuse of power. It is the domination, coercion, intimidation and victimisation of one person by another by physical, sexual or emotional means within intimate relationships."11 The Australian Public Health Association employs a comprehensive definition of "domestic violence", outlining examples of abusive behaviour:1 Physical abuse, causing pain and injury; denial of sleep, warmth or nutrition; denial of needed medical care; sexual assault; violence to property or animals; disablement; and murder; Verbal abuse, in private or in public, designed to humiliate, degrade, demean, intimidate, subjugate, including the threat of physical violence; Economic abuse, including deprivation of basic necessities, seizure of income or assets, unreasonable denial of the means necessary for participation in social life; and Social abuse, through isolation, control of all social activity, deprivation of liberty, or the deliberate creation of unreasonable dependence. How common is domestic violence in Australia? It is now accepted that domestic violence is very common in Australia. An estimate of the magnitude of the problem can be obtained from public records (police reports, hospital records, applications for protection orders, lists of refuge positions, and spousal homicides), clinical samples and community surveys. Although public records have inherent bias in their non-random selection and under-reporting of samples, they do show that women are the main victims of domestic violence: Police figures reveal that women are over eight times more likely to be victims than males;12 Crime surveys show that a third of all assaults on women are by partners, whereas the number of assaults on men by their partners is too small to produce reliable estimates.12,13 Victorian public hospital figures show that 1.3% of women and 0.14% of men admitted to emergency departments are there as a result of partner-inflicted injury.14 Each year, more than 20 000 women in Australia seek shelter in women's refuges and take out protection orders.9 A recent review in Western Australia showed that the incidence per 100 000 adult women of injury from domestic violence varied according to the source of public records used: 1.6 (police-recorded homicides), 129.2 (hospital admissions data), 183.5 (recorded crime), and 248.1 (restraining order data).12 In Australian survey research, women are three times more likely than men to experience an episode of physical violence by their partners.6,7 Domestic violence rates vary depending on the definition used15 and whether the data are from community crime victim surveys12,13 or prevalence studies in clinical samples6,7,16-19 or community samples.20 Clinical studies in emergency departments and antenatal clinics indicate that between 19.3%7 and 25.0%17 of women will be subjected to domestic violence over their lifetime. Surveys of women attending general practice in Australia reveal varying partner abuse rates of 8.0%16 and 28%18 in a 12-month period. The only population-based study that investigates physical and sexual violence, the Women's Safety Survey,20 found that 2.6% of women who currently had partners had experienced an incident of violence in the previous 12 months, and 8.0% had experienced violence at some stage in their relationship. How does domestic violence present in practice? There are major barriers to women disclosing situations of domestic violence.21,22 Reasons given include fear, denial and disbelief, emotional bonds to their partner, commitment to marriage, hope for change, staying for the sake of the children, "normalisation" of violence, social isolation, depression, stress, and feeling that they will not be believed or that services will not be able to help.22,23 When women come to the realisation that they can not change the situation however hard they try, and that they need help, relatively few present to domestic violence services or the police in the first instance.24 They may seek help from family or friends, general practitioners, personal and relationship counsellors, child specialists, psychiatrists, teachers, hospital staff, solicitors, family support services, self-help groups, church representatives or charity organisations.23 It is important to realise that women who have been abused want to be asked about domestic violence and are more likely to disclose if asked.15,25 However, most women present to doctors with a variety of complaints without disclosing that there is a background of domestic violence. The wide range of potential clinical indicators of domestic violence (see Box 1) can make it difficult to detect, but if women present frequently with some of these problems over time the clinician should be alert to the possibility of domestic violence. While some abused women report that they specifically sought help for such symptoms, others say that they sought help for the perceived underlying cause of the abuse (eg, marital conflict, their partner's mental health, a drug and alcohol or gambling problem) or wanted information about how to deal with the violence.23 Women may present with overt physical injuries, but more commonly with a range of chronic symptoms, to unsuspecting GPs, emergency department doctors or medical specialists. Women are at higher risk if they are less than 40 years of age; have a past history of child abuse or have a child who is currently being abused; have undergone recent separation or divorce; are socially isolated; have an accompanying partner who is overattentive; present frequently; delay in seeking treatment or are non-compliant.26 The diagnosis of domestic violence is an important challenge to all doctors in clinical practice26 because patients increasingly point to positive interactions with medical professionals as one of the important elements in their recovery. The stories in Boxes 2 and 3 (based on actual cases) illustrate situations that clinicians may encounter. Screening for domestic violence Researchers have developed several scales to measure domestic violence (see Box 4). Although the American Medical Association has suggested routine screening, this is not recommended for a general population, as tested and proven interventions to reduce morbidity and mortality are lacking.43 Nevertheless, opportunistic screening in practice settings such as emergency departments, psychiatric clinics, antenatal clinics and general practice is still considered worthwhile.43 Health professionals need to use a variety of questions to elicit women's experiences of domestic violence, taking into account different types of women (eg, women with disabilities, Indigenous women, women in lesbian relationships and women of non-English-speaking background). Examples of questions doctors could ask a patient if they suspect domestic violence are given in Box 5. ConclusionsDomestic violence is a complex pattern of behaviours that may include, in addition to physical acts of violence, sexual abuse and emotional abuse, such as social isolation and financial deprivation. In spite of the lack of agreement on definitions, domestic violence is clearly a very common, hidden problem for many patients attending clinical practice. Doctors need to be aware of the many potential indicators of domestic violence26 and should ask about abuse in an empathic, non-judgemental way.25 At an individual level, domestic violence can cause physical and emotional ill health; the underlying abuse needs to be recognised and dealt with directly if women and their children are to be safe. Domestic violence is clearly a significant public health problem that all clinicians need to be aware of to enable them to act as advocates for their patients. References Australian Public Health Association. Domestic violence. Canberra: Australian Public Health Association, 1990. Centers for Disease Control and Prevention. Emergency department response to domestic violence - California, 1992. JAMA 1993; 270: 1174-1175. Knowledge and social change. In: Dobash RE, Dobash RP. Women, violence and social change. London: Routledge; 1992: 251-283. ANOP Research Services. Community attitudes to violence against women. Canberra: Office of the Status of Women, 1995. Candib LM. Violence against women: no more excuses. Fam Med 1989; 21: 339-341. Roberts G, O'Toole B, Lawrence J, Raphael B. Domestic violence victims in a hospital emergency department. Med J Aust 1994; 159: 307-310. de Vries Robbe M, March L, Vinen J, et al. Prevalence of domestic violence among patients attending a hospital emergency department. Aust N Z J Public Health 1996; 20: 364-368. Johnston JR, Campbell LE. A clinical typology of interparental violence in disputed-custody divorces. Am J Orthopsychiatry 1993; 63: 190-199. Alexander R. Wife-battering - an Australian perspective. J Fam Violence 1993; 8: 229-251. Sassetti MR. Domestic violence. Prim Care 1993; 20: 289-304. Australian Medical Association. Position statement on domestic violence. Canberra: AMA, 1998. Ferrante A, Morgan F, Indermaur D, Harding R. Measuring the extent of domestic violence. Sydney: Hawkins Press, 1996. Womens Policy Unit. Women's experience of crimes of personal violence. A gender analysis of the 1991 Queensland crime victims survey. Brisbane: Office of the Cabinet, 1992. Sherrard J, Ozanne-Smith J, Brumen IA, et al. Domestic violence: patterns and indicators. Melbourne: Monash University Accident Research Centre, 1994. Hegarty K, Roberts G. How common is domestic violence against women? The definition of partner abuse in prevalence studies. Aust N Z J Public Health 1998; 22: 49-54. Hegarty KL. Measuring a multidimensional definition of domestic violence: prevalence of partner abuse in women attending general practice. Brisbane: Department of Social and Preventive Medicine, University of Queensland, 1999. Bates L, Redman S, Brown W, Hancock L. Domestic violence experienced by women attending an accident and emergency department. Aust N Z J Public Health 1995; 19: 293-299. Mazza D, Dennerstein L, Ryan V. Physical, sexual and emotional violence against women: a general practice-based prevalence study. Med J Aust 1996; 164: 14-17. Webster J, Sweett S, Stolz T. Domestic violence in pregnancy: a prevalence study. Med J Aust 1994; 161: 466-470. McLennan W. Women's safety survey. Canberra: Australian Bureau of Statistics, 1996. Brown JB, Lent B, Brett P, et al. Development of the Woman Abuse Screening Tool for use in family practice. Fam Med 1996; 28: 422-428. Head C, Taft A. Improving general practitioner management of women experiencing domestic violence: a study of the beliefs and experiences of women victim/survivors and of GPs. Canberra: Department of Health, Housing and Community Services, 1995. Keys Young. Against the odds: how women survive domestic violence. Canberra: Office of the Status of Women, 1998. Roberts G. Domestic violence victims in the emergency department. Brisbane: University of Queensland, 1995. Friedman L, Samet J, Roberts M, et al. Inquiry about victimisation experiences: a survey of patient preferences and physician practices. Arch Intern Med 1992; 152: 1186-1190. Eisenstat S, Bancroft L. Domestic violence. N Engl J Med 1999; 341: 886-892. Straus MA, Gelles RJ, Steinmetz SK. Behind closed doors: violence in the American family. New York: Doubleday/Anchor, 1980. Straus MA, Smith C. Family patterns and primary prevention of family violence. In: Straus MA, Gelles RJ, editors. Physical violence in American families. Risk factors and adaptations to violence in 8145 families. New Brunswick, New Jersey: Transaction Publishers, 1990: 507-525. Yllo K. Through a feminist lens: gender, power and violence. In: Gelles RJ, Loseke DR, editors. Current controversies in family violence. Newbury Park, California: Sage Publications, 1993: 47-63. DeKeseredy W, Hinch R. Woman abuse: sociological perspectives. Toronto: Thompson Educational Publishing, 1991. Tolman R. The development of a measure of psychological maltreatment of women by their male partners. Violence Vict 1989; 4: 159-177. Hudson W, McIntosh S. The assessment of spouse abuse: two quantifiable dimensions. Journal of Marriage and the Family 1981; 43: 873-888. Rodenberg F, Fantuzzo J. The measure of wife abuse: steps toward the development of a comprehensive assessment technique. J Fam Violence 1993; 8: 203-217. Yegidis BL. Abuse Risk Inventory for women. Palo Alto, California: Mind Garden, 1989. Hegarty KL, Sheehan M, Schonfeld C. A multidimensional definition of partner abuse: development and preliminary validation of the Composite Abuse Scale. J Fam Violence 1999; 14: 399-414. McFarlane J, Parker B, Soeken K, Bullock L. Assessing for abuse during pregnancy. Severity and frequency of injuries and associated entry into prenatal care. JAMA 1992; 267: 3176-3178. Sherin KM, Sinacore JM, Li X, et al. HITS: A short domestic violence screening tool for use in a family practice setting. Fam Med 1998; 30: 508-512. Straus MA, Gelles RJ. Societal change and change in family violence from 1975 to 1985 as revealed by two national surveys. Journal of Marriage and the Family 1986; 48: 465-479. Headey B, Scott D, Vaus D. Domestic violence in Australia: are men and women equally violent? Australian Social Monitor 1999; 2: 57-62. Candib LM. Naming the contradiction: family medicine's failure to face violence against women. Family and Community Health 1990; 13: 47-57. Johnson MP. Patriarchal terrorism and common couple violence: two forms of violence against women. Journal of Marriage and the Family 1995; 57: 283-294. Saunders DG. Wife abuse, husband abuse or mutual combat. A feminist perspective on the empirical findings. In: Yllo K, Bograd M, editors. Feminist perspectives on wife abuse. Newbury Park, California: Sage Publications, 1988: 91-113. Lawler VA. Routine screening for domestic violence: a review of the literature. Melbourne: University of Melbourne, 1996. Authors' details Department of General Practice and Public Health, University of Melbourne, VIC. Kelsey Hegarty, MB BS, PhD, Senior Lecturer. Women's Health, Royal Australian College of General Practitioners, Sydney, NSW. Elizabeth D Hindmarsh, MB BS, FRACGP, Chairperson. Public Health Unit Gascoyne, Carnarvon, WA. Marisa T Gilles, BSc, MB Chb, MPH, Director. Reprints will not be available from the authors. Correspondence: Dr K Hegarty, Department of General Practice and Public Health, University of Melbourne, 200 Berkeley Street, Carlton, VIC 3053. k.hegartyATgpph.unimelb.edu.au ©MJA 2000 Make a comment 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/> © 2000 Medical Journal of Australia. We appreciate your comments. 1: Potential clinical indicators of domestic violence26 Psychological Insomnia Depression Suicidal ideation Anxiety symptoms and panic disorder Somatoform disorder Post-traumatic stress disorder Eating disorders Drug and alcohol abuse Physical Obvious injuries, especially to the head and neck or multiple areas Bruises in various stages of healing Sexual assault Sexually transmitted diseases Chronic pelvic pain Chronic abdominal pain Chronic headaches Chronic back pain Numbness and tingling from injuries Lethargy Pregnancy and childbirth Miscarriages Unwanted pregnancy Antepartum haemorrhage Lack of prenatal care Low birthweight of infant Back to text 2: Presentation of domestic violence to a general practitioner Jane*, aged 38, has two children aged 5 and 9, and is now 20 weeks' pregnant. She is well dressed, slightly overweight, and presents for review of her blood pressure, which was high on a previous visit to the obstetrician the week before. She has been married nine years to Theo*, a plumber. She is not in paid work. Background: No previous history of hypertension with pregnancies. One previous miscarriage and an antepartum haemorrhage with her last pregnancy. Recurrent presentations for vaginal discharge to a GP in the past few years. Multiple presentations with the children for behavioural problems. Consultation: Her blood pressure was again slightly raised, which she explained was because she had been a bit busy. GP:How are things at home? Jane: [angrily] Fine, thanks. GP:It must be hard at home with two other children. Does your husband help? Jane:He only makes things worse. GP:Can you tell me more about it? Jane:Look, after years of putting up with him I moved out, and last week, on my son's birthday, I let Theo come around to give the boy his present and he became angry and abusive again. He smashed a plate glass window and it fell onto the boy's head. GP:This is serious. Are you and the children safe? Jane: I'm not sure. How was abuse recognised? Looking back through the patient's notes, there was mention of "matrimonial disharmony" - direct questioning at the time might have resulted in an earlier disclosure. However, it may be that Jane was only ready to disclose after she had left Theo. Breaking the silence breaks the isolation and provides a way out for when the woman decides to take it. * Actual names have been changed. Back to text 3: Presentation of domestic violence to a general practitioner Rebecca*, aged 30, attractive and well dressed, presents requesting a referral for breast enlargement. She has been married eight years to John*, a busy lawyer. She does some secretarial and accounting work for him. Background: A number of previous referrals for plastic surgery. Consultation: GP: Can you tell me what concerns you about your breasts? Rebecca:I hate them. I have nothing there and I look ugly. GP:Do you really believe that? Rebecca:My husband does. GP: What does he say to you about it? Rebecca:He doesn't like the way I look now even though he used to. I try so hard to please him and I've had operations before but he is still not happy with me [in tears now]. It's horrible - he tears off my clothes in front of the mirror and says "Would you sleep with this?". GP: What else does he do that makes you upset? Rebecca:He tells me frequently that I am stupid and ugly. GP:That must be difficult for you. Do you feel in control of your life? Rebecca:No, he controls all the finances and tells me what to wear every day. He throws my clothes on the fire if he doesn't like them. GP:Has he ever physically hurt you? Rebecca:He has never hit me, although he has kicked the wall, smashed things and threatened to punch me a few times. GP: What is the worst thing that has happened to you? Rebecca:He forced me to have sex on several occasions against my will, but the worst was when he poisoned my dog because I had grown too fond of the dog. GP:Are you afraid of him? Rebecca:Yes ... She had tried to leave him on a number of occasions but had returned each time, as she had few economic resources of her own and little confidence in her own abilities to survive without him. She had few people to confide in. How was abuse recognised? Abuse was recognised because of a high level of suspicion, followed up by direct questioning. * Actual names have been changed. Back to text 4: Measuring domestic violence The Conflict Tactics Scale Researchers in family violence have defined "violence" as "an act carried out with the intention of, or perceived intention of, causing physical pain or injury to another person".27 To measure "violence" they have developed the Conflict Tactics Scale (CTS). Although the CTS is the scale most commonly used,28 it has been widely criticised for measuring conflict tactics (ie, overt actions used by persons in response to a conflict of interest) rather than coercive tactics, and for concentrating on physical violence alone and not eliciting information about the intensity, context, consequences or meaning of the action.3,9,29,30 Other scales Several other scales (eg, the Psychological Maltreatment of Women Inventory, the Index of Spouse Abuse, the Measure of Wife Abuse, the Abuse Risk Inventory for Women31-34) have been developed to broaden the definition of domestic violence to include emotional and sexual abuse. Apart from the Composite Abuse Scale,35 which has been validated across three Australian clinical populations,16 these scales have only been validated on small samples. All of these scales are long and would be difficult to use as a screening tool in a busy clinical setting. Several researchers16,21,36,37 have trialled shorter screening tools to measure domestic violence in clinical settings on small, selective samples. Quantitative v qualitative research Each researcher and practitioner appears to define "domestic violence" according to his or her own perspective. Quantitative research using the CTS utilises the physical abuse concepts outlined by Straus,38,39 while qualitative research uses a broader definition of domestic violence.3,40 Not all violent behaviour between partners may constitute domestic violence. Johnson41 argues that some families suffer from occasional outbursts of violence from either husbands or wives ("common couple violence"), while other families are terrorised by systematic male violence ("patriarchal terrorism").42 Back to text 5: Suggestions for how the subject of domestic violence could be raised with a patient Has your partner ever physically threatened or hurt you? Is there a lot of tension in your relationship? How do you resolve arguments?21 Sometimes partners react strongly in arguments and use physical force. Is this happening to you? Are you afraid of your partner?16 Violence is very common in the home. I ask a lot of my patients about abuse because no one should have to live in fear of their partners. Within the last year, have you been hit, slapped, kicked, or otherwise physically hurt by someone? Or has anyone forced you to have sexual activities?36 Back to text

Kelsey Hegarty MB BS, PhD · Elizabeth D Hindmarsh MB BS, FRACGP · Marisa T Gilles BSc, MB Chb, MPH