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author:("jia, moyen")
1.  A defining moment for medical research beyond 2015 
The Australasian Medical Journal  2015;8(12):378-380.
doi:10.4066/AMJ.2015.2573
PMCID: PMC4701899  PMID: 26759612
2.  Impact of geography on the control of type 2 diabetes mellitus: a review of geocoded clinical data from general practice 
BMJ Open  2015;5(12):e009504.
Objective
To review the clinical data for people with diabetes mellitus with reference to their location and clinical care in a general practice in Australia.
Materials and methods
Patient data were extracted from a general practice in Western Australia. Iterative data-cleansing steps were taken. Data were grouped into Statistical Area level 1 (SA1), designated as the smallest geographical area associated with the Census of Population and Housing. The data were analysed to identify if SA1s with people aged 70 years and older, and with relatively high glycosylated haemoglobin (HbA1c) were significantly clustered, and whether this was associated with their medical consultation rate and treatment. The analysis included Cluster and Outlier Analysis using Moran's I test.
Results
The overall median age of the population was 70 years with more males than females, 53% and 47%, respectively. Older people (>70 years) with relatively high HbA1c comprised 9.3% of all people with diabetes in the sample, and were clustered around two ‘hotspot’ locations. These 111 patients do not attend the practice more or less often than people with diabetes living elsewhere in the practice (p=0.098). There was some evidence that they were more likely to be recorded as having consulted with regard to other chronic diseases. The average number of prescribed medicines over a 13-month time period, per person in the hotspots, was 4.6 compared with 5.1 in other locations (p=0.26). Their prescribed therapy was deemed to be consistent with the management of people with diabetes in other locations with reference to the relevant diabetes guidelines.
Conclusions
Older patients with relatively high HbA1c are clustered in two locations within the practice area. Their hyperglycaemia and ongoing cardiovascular risk indicates causes other than therapeutic inertia. The causes may be related to the social determinants of health, which are influenced by geography.
doi:10.1136/bmjopen-2015-009504
PMCID: PMC4691756  PMID: 26674501
Diabetes mellitus; non-insulin dependent; general practice; geographic mapping; quality of health care
3.  Do Patients Treated for Colorectal Cancer Benefit from General Practitioner Support? A Video Vignette Study 
Background
Patients who have been treated for colorectal cancer in Australia can consult their general practitioner (GP) for advice about symptoms or side effects at any time following their treatment. However, there is no evidence that such patients are consistently advised by GPs, and patients experience substantial unmet need for reassurance and advice.
Objective
To explore the patient management options selected by GPs to treat a set of patients describing their symptoms following treatment for colorectal cancer.
Methods
This was an Internet-based survey. Participants (GPs) viewed 6 video vignettes of actors representing patients who had been treated for colorectal cancer. The actor-patients presented problems that resulted from their treatment. Participants indicated their diagnosis and stated if they would prescribe, refer, or order tests, based on that diagnosis. These responses were then rated against the management decisions for those vignettes as recommended by a team of colorectal cancer experts.
Results
In total, 52 GPs consented to take part in the study, and 40 (77%) completed the study. Most GPs made a diagnosis of colorectal cancer treatment side effects/symptoms of recurrence that was consistent with the experts’ opinions. However, correct diagnosis was dependent on the type of case viewed. Compared with radiation proctitis, GPs were more likely to recognize peripheral neuropathy (odds ratio, OR, 4.43, 95% CI 1.41-13.96, P=.011) and erectile dysfunction (OR 9.70, 95% CI 2.48-38.03, P=.001), but less likely to identify chemotherapy-induced fatigue (OR 0.19, 95% CI 0.08-0.44). GPs who had more hours of direct patient care (OR 0.38, 95% CI 0.17-0.84, P=.02), were experienced (OR 9.78, 95% CI 1.18-8.84, P=.02), and consulted more patients per week (OR 2.48, 95% CI 1.16-5.30, P=.02) suggested a management plan that was consistent with the expert opinion.
Conclusions
In this pilot study, years of experience and direct patient contact hours had a significant and positive impact on the management of patients. This study also showed promising results indicating that management of the common side effects of colorectal cancer treatment can be delegated to general practice. Such an intervention could support the application of shared models of care. However, a larger study, including the management of side effects in real patients, needs to be conducted before this can be safely recommended.
doi:10.2196/jmir.4942
PMCID: PMC4642383  PMID: 26541077
colorectal cancer; general practice; Internet survey; side effects; video vignettes
5.  How do general practitioners manage patients with cancer symptoms? A video-vignette study 
BMJ Open  2015;5(9):e008525.
Objectives
Determine how general practitioners (GPs) manage patients with cancer symptoms.
Design
GPs reviewed 24 video-vignettes and case notes on patients with cancer symptoms and indicated whether they would refer the patient and/or prescribe medication, and/or undertake further investigation. According to available guidelines, all cases warranted a referral to a specialist or further investigations.
Setting
Australian primary care sector.
Participants
102 practising GPs participated in this study, including trainees.
Interventions
The research was part of a larger randomised controlled trial testing a referral pro forma; however, this paper reports on management decisions made throughout the study.
Primary and secondary outcome measures
This paper reports on how the participants would manage the patients depicted in each vignette.
Results
In more than one-in-eight cases, the patient was not investigated or referred. Patient management varied significantly by cancer type (p<0.001). For two key reasons, colorectal cancer was the chosen referent category. First, it represents a prevalent type of cancer. Second, in this study, colorectal cancer symptoms were managed in a similar proportion of options—that is, prescription, referral or investigation. Compared with vignettes featuring colorectal cancer participants were less likely to manage breast, bladder, endometrial, and lung cancers with a ‘prescription only’ or ‘referral only’ option. They were less likely to manage prostate cancer with a ‘prescription only’, yet more likely to manage it with a ‘referral with investigation’. With regard to pancreatic and cervical cancers, participants were more likely to manage these with a ‘referral only’ or a ‘referral with investigation’.
Conclusions
Some patients may receive a delayed cancer diagnosis, even when they present with typical cancer symptoms to a GP who can access relevant diagnostic tests.
Trial registration number
ACTRN12611000760976.
doi:10.1136/bmjopen-2015-008525
PMCID: PMC4577966  PMID: 26369800
ONCOLOGY; MEDICAL HISTORY; PRIMARY CARE
6.  Impact of referral letters on scheduling of hospital appointments: a randomised control trial 
The British Journal of General Practice  2014;64(624):e419-e425.
Background
Communication is essential for triage, but intervention trials to improve it are scarce. Referral Writer (RW), a referral letter software program, enables documentation of clinical data and extracts relevant patient details from clinical software.
Aim
To evaluate whether specialists are more confident about scheduling appointments when they receive more information in referral letters.
Design and setting
Single-blind, parallel-groups, controlled design with a 1:1 randomisation. Australian GPs watched video vignettes virtually.
Method
GPs wrote referral letters after watching vignettes of patients with cancer symptoms. Letter content was scored against a benchmark. The proportions of referral letters triagable by a specialist with confidence, and in which the specialist was confident the patient had potentially life-limiting pathology were determined. Categorical outcomes were tested with χ2 and continuous outcomes with t-tests. A random-effects logistic model assessed the influence of group randomisation (RW versus control), GP demographics, clinical specialty, and specialist referral assessor on specialist confidence in the information provided.
Results
The intervention (RW) group referred more patients and scored significantly higher on information relayed (mean difference 21.6 [95% confidence intervals {CI} = 20.1 to 23.2]). There was no difference in the proportion of letters for which specialists were confident they had sufficient information for appointment scheduling (RW 77.7% versus control 80.6%, P = 0.16). In the logistic model, limited agreement among specialists contributed substantially to the observed differences in appointment scheduling (P = 35% [95% CI 16% to 59%]).
Conclusion
In isolation, referral letter templates are unlikely to improve the scheduling of specialist appointments, even when more information is relayed.
doi:10.3399/bjgp14X680509
PMCID: PMC4073727  PMID: 24982494
decision making; general practice; interdisciplinary correspondence; neoplasms; randomised control trial; referral and consultation
7.  Do patients with long-term side effects of cancer treatment benefit from general practitioner support? A literature review 
Background
Alongside specialist cancer clinics, general practitioners have an important role in cancer patients’ follow-up care, yet no literature summarises the nature, extent and impact of their involvement. This paper addresses this issue through a review of the literature.
Methods
Studies were sourced from six academic databases - AustHealth (n = 202), CINAHL (n = 500), the Cochrane Library (reviews and trials; n = 200), Embase (n = 368), PHCRIS (n = 132) and PubMed/Medline (n = 410). Studies that focused on interventions designed for patients receiving follow-up care and reported cancer care provided by a general practitioner delivered alongside specialist care were reviewed.
Results
A total of 19 papers were identified as relevant for this review (3 randomised control trials; 4 cross-sectional, 5 cohort and 3 qualitative studies, and 3 systematic reviews). The reviewed studies indicated that providing general practitioner-led supportive interventions for post-treatment care of cancer patients is feasible and acceptable to patients. General practitioner involvement resulted in improved physical and psychosocial well-being of patients and continuity of care, especially for patients with concomitant health conditions.
Conclusion
Involving general practitioners in post-treatment cancer care is beneficial to patients. However, proactive initiatives that encourage and facilitate patients to consult their general practitioner about their needs or symptoms of recurrence should be considered.
PMCID: PMC4491325  PMID: 26150761
cancer; primary health care; follow-up care; supportive care; integrated care
8.  Providing general practice needs-based care for carers of people with advanced cancer: a randomised controlled trial 
The British Journal of General Practice  2013;63(615):e683-e690.
Background
Carers of patients with advanced cancer often have health and psychosocial needs, which are frequently overlooked.
Aim
To meet the needs of carers through a GP consultation directed by a self-completed carer needs checklist.
Design and setting
Randomised controlled trial in general practice with recruitment through specialist oncology clinics, in Brisbane, Australia.
Method
Intervention was (a) carer–GP consultations directed by a self-completed checklist of needs at baseline and 3 months; and (b) a GP-Toolkit to assist GPs to address carer-identified needs. Control group received usual care. Outcome measures were intensity of needs, anxiety and depression, and quality of life.
Results
Total recruitment 392. Overall, no significant differences were detected in the number or intensity of need between groups. Compared to controls, intervention participants with baseline clinical anxiety showed improvements in mental wellbeing (P = 0.027), and those with baseline clinical depression had slower development of anxiety (P = 0.044) at 6 months. For those not anxious, physical wellbeing improved at 1 month (P = 0.040). Carers looking after patients with poor functional status had more physical needs (P = 0.037) at 1 month and more psychological and emotional needs at 3 months (P = 0.034). Those caring for less unwell patients showed improved mental wellbeing at 3 months (P = 0.022).
Conclusion
The intervention did not influence the number or intensity of needs reported by carers of people with advanced cancer. There was limited impact in people with pre-existing clinical anxiety and depression. For the carer of those most severely affected by advanced cancer, it drew attention to the needs arising from the caregiving role.
doi:10.3399/bjgp13X673694
PMCID: PMC3782801  PMID: 24152483
Cancer; carers; general practice; palliative care; randomised controlled trial; self-assessment
9.  Management of behavioural change in patients presenting with a diagnosis of dementia: a video vignette study with Australian general practitioners 
BMJ Open  2014;4(9):e006054.
Objective
To test the impact of feedback on the proposed management of standardised patients presenting with behavioural change with a diagnosis of dementia in Australian primary care.
Materials and methods
A video vignette study was performed with Australian general practitioners (GPs) in 2013. Participants viewed six pairs of matched videos depicting people presenting changed behaviour in the context of a dementia diagnosis in two phases. In both phases GPs indicated their diagnosis and management. After phase 1, GPs were offered feedback on management strategies for the patients depicted. Analyses focused on identification of change in management between the two phases of the study. Factors impacting on the intention to coordinate care for such patients were tested in a questionnaire based on the Theory of Planned Behaviour.
Results
Forty-five GPs completed the study. There was significant improvement in the proposed management of three of the six scenarios after the intervention. Older GPs were more likely to refer appropriately (OR=1.11 (1.01 to 1.23), p=0.04.). Overall referral to support agencies was more likely after the intervention (OR=2.52 (1.53 to 4.14), p<0.001). Older GPs were less likely to intend to coordinate care for such patients (OR=0.89 (0.81 to 0.98) p=0.02). Participants who felt confident about their ability to coordinate care were more likely to do so (OR=3.79 (1.08 to 13.32) p=0.04).
Conclusions
The intervention described in this study promoted multidisciplinary management of patients with behavioural problems with a diagnosis of dementia. Increasing practitioner confidence in their ability to coordinate care may increase the proportion of GPs who will respond to patients and carers in this context. Older GPs may benefit in particular.
doi:10.1136/bmjopen-2014-006054
PMCID: PMC4179570  PMID: 25256189
PRIMARY CARE
10.  Rating general practitioner consultation performance in cancer care: does the specialty of assessors matter? A simulated patient study 
BMC Family Practice  2014;15:152.
Background
Patients treated for prostate cancer may present to general practitioners (GPs) for treatment follow up, but may be reticent to have their consultations recorded. Therefore the use of simulated patients allows practitioner consultations to be rated. The aim of this study was to determine whether the speciality of the assessor has an impact on how GP consultation performance is rated.
Methods
Six pairs of scenarios were developed for professional actors in two series of consultations by GPs. The scenarios included: chronic radiation proctitis, Prostate Specific Antigen (PSA) ‘bounce’, recurrence of cancer, urethral stricture, erectile dysfunction and depression or anxiety. Participating GPs were furnished with the patient’s past medical history, current medication, prostate cancer details and treatment, details of physical examinations. Consultations were video recorded and assessed for quality by two sets of assessors- a team of two GPs and two Radiation Oncologists deploying the Leicester Assessment Package (LAP). LAP scores by the GPs and Radiation Oncologists were compared.
Results
Eight GPs participated. In Series 1 the range of LAP scores by GP assessors was 61%-80%, and 67%-86% for Radiation Oncologist assessors. The range for GP LAP scores in Series 2 was 51%- 82%, and 56%-89% for Radiation Oncologist assessors. Within GP assessor correlations for LAP scores were 0.31 and 0.87 in Series 1 and 2 respectively. Within Radiation Oncologist assessor correlations were 0.50 and 0.72 in Series 1 and 2 respectively. Radiation Oncologist and GP assessor scores were significantly different for 4 doctors and for some scenarios. Anticipatory care was the only domain where GPs scored participants higher than Radiation Oncologist assessors.
Conclusion
The assessment of GP consultation performance is not consistent across assessors from different disciplines even when they deploy the same assessment tool.
doi:10.1186/1471-2296-15-152
PMCID: PMC4176849  PMID: 25218798
Radiation therapy; Prostate cancer; General practitioner; Consultation; Assessment; Side effects
11.  The Management of Acute Adverse Effects of Breast Cancer Treatment in General Practice: A Video-Vignette Study 
Background
There has been a focus recently on the use of the Internet and email to deliver education interventions to general practitioners (GPs). The treatment of breast cancer may include surgery, radiotherapy, chemotherapy, and/or hormone treatment. These treatments may have acute adverse effects. GPs need more information on the diagnosis and management of specific adverse effects encountered immediately after cancer treatment.
Objective
The goal was to evaluate an Internet-based educational program developed for GPs to advise patients with acute adverse effects following breast cancer treatment.
Methods
During phase 1, participants viewed 6 video vignettes of actor-patients reporting 1 of 6 acute symptoms following surgery and chemotherapy and/or radiotherapy treatment. GPs indicated their diagnosis and proposed management through an online survey program. They received feedback about each scenario in the form of a specialist clinic letter, as if the patient had been seen at a specialist clinic after they had attended the GP. This letter incorporated extracts from local guidelines on the management of the symptoms presented. This feedback was sent to the GPs electronically on the same survey platform. In phase 2, all GPs were invited to manage similar cases as phase 1. Their proposed management was compared to the guidelines. McNemar test was used to compare data from phases 1 and 2, and logistic regression was used to explore the GP characteristics that were associated with inappropriate case management.
Results
A total of 50 GPs participated. Participants were younger and more likely to be female than other GPs in Australia. For 5 of 6 vignettes in phase 1, management was consistent with expert opinion in the minority of cases (6%-46%). Participant demographic characteristics had a variable effect on different management decisions in phase 1. The variables modeled explained 15%-28% of the differences observed. Diagnosis and management improved significantly in phase 2, especially for diarrhea, neutropenia, and seroma sample cases. The proportion of incorrect management responses was reduced to a minimum (25.3%-49.3%) in phase 2.
Conclusions
There was evidence that providing feedback by experts on specific cases had an impact on GPs’ knowledge about how to appropriately manage acute treatment adverse effects. This educational intervention could be targeted to support the implementation of shared care during cancer treatment.
doi:10.2196/jmir.3585
PMCID: PMC4213802  PMID: 25274131
breast cancer; treatment; general practice; adverse effects; patient care planning
12.  A randomised trial deploying a simulation to investigate the impact of hospital discharge letters on patient care in general practice 
BMJ Open  2014;4(7):e005475.
Objective
To determine how the timing and length of hospital discharge letters impact on the number of ongoing patient problems identified by general practitioners (GPs).
Trial design
GPs were randomised into four groups. Each viewed a video monologue of an actor-patient as he might present to his GP following a hospital admission with 10 problems. GPs were provided with a medical record as well as a long or short discharge letter, which was available when the video was viewed or 1 week later. GPs indicated if they would prescribe, refer or order tests for the patient's problems.
Methods
Setting Primary care. Participants Practising Australian GPs. Intervention A short or long hospital discharge letter enumerating patient problems. Outcome measure Number of ongoing patient problems out of 10 identified for management by the GPs. Randomisation 1:1 randomisation. Blinding (masking) Single-blind.
Results
Numbers randomised 59 GPs. Recruitment GPs were recruited from a network of 102 GPs across Australia. Numbers analysed 59 GPs. Outcome GPs who received the long letter immediately were more satisfied with this information (p<0.001). Those who received the letter immediately identified significantly more health problems (p=0.001). GPs who received a short, delayed discharge letter were less satisfied than those who received a longer delayed letter (p=0.03); however, both groups who received the delayed letter identified a similar number of health problems. GPs who were older, who practised in an inner regional area or who offered more patient sessions per week identified fewer health problems (p values <0.01, <0.05 and <0.05, respectively). Harms Nil.
Conclusions
Receiving information during patient consultation, as well as GP characteristics, influences the number of patient problems addressed.
Trial registration number
ACTRN12614000403639.
doi:10.1136/bmjopen-2014-005475
PMCID: PMC4091507  PMID: 25005597
PRIMARY CARE
13.  Unmet needs of patients with chronic obstructive pulmonary disease (COPD): a qualitative study on patients and doctors 
BMC Family Practice  2014;15:67.
Background
Chronic Obstructive Pulmonary Disease (COPD) is a chronic disease with repeated exacerbations resulting in gradual debilitation. The quality of life has been shown to be poor in patients with COPD despite efforts to improve self-management. However, the evidence on the benefit of self-management in COPD is conflicting. Whether this could be due to other unmet needs of patients have not been investigated. Therefore, we aimed to explore unmet needs of patients from both patients and doctors managing COPD.
Methods
We conducted a qualitative study with doctors and patients in Malaysia. We used convenience sampling to recruit patients until data saturation. Eighteen patients and eighteen doctors consented and were interviewed using a semi-structured interview guide. The interviews were audio-recorded, transcribed verbatim and checked by the interviewers. Data were analysed using a thematic approach.
Results
The themes were similar for both the patients and doctors. Three main themes emerged: knowledge and awareness of COPD, psychosocial and physical impact of COPD and the utility of self-management. Knowledge about COPD was generally poor. Patients were not familiar with the term chronic obstructive pulmonary disease or COPD. The word ‘asthma’ was used synonymously with COPD by both patients and doctors. Most patients experienced difficulties in their psychosocial and physical functions such as breathlessness, fear and helplessness. Most patients were not confident in self-managing their illness and prefer a more passive role with doctors directing their care.
Conclusions
In conclusion, our study showed that knowledge of COPD is generally poor. There was mislabelling of COPD as asthma by both patients and physicians. This could have resulted in the lack of understanding of treatment options, outcomes, and prognosis of COPD. The misconception that cough due to COPD was contagious, and breathlessness that resulted from COPD, had important physical and psychosocial impact, and could lead to social isolation. Most patients and physicians did not favour self-management approaches, suggesting innovations based on self-management may be of limited benefit.
doi:10.1186/1471-2296-15-67
PMCID: PMC3996170  PMID: 24739595
COPD; Qualitative; Self-management; Knowledge; Quality of life; Needs
14.  Supporting Patients Treated for Prostate Cancer: A Video Vignette Study With an Email-Based Educational Program in General Practice 
Background
Men who have been treated for prostate cancer in Australia can consult their general practitioner (GP) for advice about symptoms or side effects at any time following treatment. However, there is no evidence that such men are consistently advised by GPs and patients experience substantial unmet need for reassurance and advice.
Objective
The intent of the study was to evaluate a brief, email-based educational program for GPs to manage standardized patients presenting with symptoms or side effects months or years after prostate cancer treatment.
Methods
GPs viewed six pairs of video vignettes of actor-patients depicting men who had been treated for prostate cancer. The actor-patients presented problems that were attributable to the treatment of cancer. In Phase 1, GPs indicated their diagnosis and stated if they would prescribe, refer, or order tests based on that diagnosis. These responses were compared to the management decisions for those vignettes as recommended by a team of experts in prostate cancer. After Phase 1, all the GPs were invited to participate in an email-based education program (Spaced Education) focused on prostate cancer. Participants received feedback and could compare their progress and their performance with other participants in the study. In Phase 2, all GPs, regardless of whether they had completed the program, were invited to view another set of six video vignettes with men presenting similar problems to Phase 1. They again offered a diagnosis and stated if they would prescribe, refer, or order tests based on that diagnosis.
Results
In total, 64 general practitioners participated in the project, 57 GPs participated in Phase 1, and 45 in Phase 2. The Phase 1 education program was completed by 38 of the 57 (59%) participants. There were no significant differences in demographics between those who completed the program and those who did not. Factors determining whether management of cases was consistent with expert opinion were number of sessions worked per week (OR 0.78, 95% CI 0.67-0.90), site of clinical practice (remote practice, OR 2.25, 95% CI 1.01-5.03), number of patients seen per week (150 patients or more per week, OR 10.66, 95% CI 3.40-33.48), and type of case viewed. Completion of the Spaced Education did impact whether patient management was consistent with expert opinion (not completed, OR 0.88, 95% CI 0.5-1.56).
Conclusions
The management of standardized patients by GPs was particularly unlikely to be consistent with expert opinion in the management of impotence and bony metastasis. There was no evidence from this standardized patient study that Spaced Education had an impact on the management of patients in this context. However, the program was not completed by all participants. Practitioners with a greater clinical load were more likely to manage cases as per expert opinion.
doi:10.2196/jmir.3003
PMCID: PMC3961707  PMID: 24571952
medical education; prostate cancer; general practice; email; video
15.  Video Consultation Use by Australian General Practitioners: Video Vignette Study 
Background
There is unequal access to health care in Australia, particularly for the one-third of the population living in remote and rural areas. Video consultations delivered via the Internet present an opportunity to provide medical services to those who are underserviced, but this is not currently routine practice in Australia. There are advantages and shortcomings to using video consultations for diagnosis, and general practitioners (GPs) have varying opinions regarding their efficacy.
Objective
The aim of this Internet-based study was to explore the attitudes of Australian GPs toward video consultation by using a range of patient scenarios presenting different clinical problems.
Methods
Overall, 102 GPs were invited to view 6 video vignettes featuring patients presenting with acute and chronic illnesses. For each vignette, they were asked to offer a differential diagnosis and to complete a survey based on the theory of planned behavior documenting their views on the value of a video consultation.
Results
A total of 47 GPs participated in the study. The participants were younger than Australian GPs based on national data, and more likely to be working in a larger practice. Most participants (72%-100%) agreed on the differential diagnosis in all video scenarios. Approximately one-third of the study participants were positive about video consultations, one-third were ambivalent, and one-third were against them. In all, 91% opposed conducting a video consultation for the patient with symptoms of an acute myocardial infarction. Inability to examine the patient was most frequently cited as the reason for not conducting a video consultation. Australian GPs who were favorably inclined toward video consultations were more likely to work in larger practices, and were more established GPs, especially in rural areas. The survey results also suggest that the deployment of video technology will need to focus on follow-up consultations.
Conclusions
Patients with minor self-limiting illnesses and those with medical emergencies are unlikely to be offered access to a GP by video. The process of establishing video consultations as routine practice will need to be endorsed by senior members of the profession and funding organizations. Video consultation techniques will also need to be taught in medical schools.
doi:10.2196/jmir.2638
PMCID: PMC3713911  PMID: 23782753
videoconferencing; general practice; patient appointments; health care
16.  Medicine an evolving profession 
The Australasian Medical Journal  2013;6(4):196-202.
The number of medical practitioners in the developed world has increased but in relative terms their incomes have decreased. Published comments suggest that some doctors are dissatisfied with what they earn. However doctors are still perceived as having a high status in society. Publicly available data suggests that doctors chose to live and work in affluent suburbs where arguably the need for their skills is less than that in neighbouring deprived areas. The gender balance in medicine is also changing with more women entering the workforce and a greater acceptance of parttime working arrangements. In some countries doctors have relinquished the responsibility for emergency out of hours care in general practice and personal continuity of care is no longer on offer. The profession is also challenged by policy makers’ enthusiasm for guidelines while the focus on multidisciplinary teamwork makes it more likely that patients will routinely be able to consult professionals other than medical practitioners. At the same time the internet has changed patient expectations so that health care providers will be expected to deploy information technology to satisfy patients. Medicine still has a great deal to offer. Information may be readily available on the internet, but it is not an independently sufficient, prerequisite for people to contend with the physical and psychological distress associated with disease and disability. We need to understand and promote the crucial role doctors play in society at a time of tremendous change in the attitudes to, and within, the profession.
doi:10.4066/AMJ.2013.1683
PMCID: PMC3650312  PMID: 23671466
Doctors; profession; income; working hours
17.  Innovating for General Practice 
This editorial will consider the challenge of innovation for healthcare from three perspectives: the general practitioner (GP), the patient and the policy maker. The knowledge, attitudes and beliefs of each, respectively, are likely to affect the type of innovation adopted in practice. Each stakeholder has priorities and needs that must be reflected in the design and implementation of innovations.
doi:10.4066/AMJ.2013.1593
PMCID: PMC3575065  PMID: 23424611
18.  Health care innovation: Working with General Practitioners 
The development of innovations for clinical practice warrants active engagement of clinicians in the research process. This requires attention to factors that serve as incentive to participate. The explanation for the success of factors that encourage practitioners to participate in research can be found in sources of satisfaction and dissatisfaction with clinical practice. It is also important to consider intrinsic incentives such as common and troublesome clinical presentations that are related to workload or unsatisfactory clinical encounters. This review will consider each of these factors and suggest ways in which clinicians, especially general practitioners, may be invited to assist on research projects.
doi:10.4066/AMJ.2013.1594
PMCID: PMC3575066  PMID: 23422871
Research; general practice; innovation; workload
19.  Doctors and the media 
The Australasian Medical Journal  2012;5(11):603-608.
doi:10.4066/AMJ.2012.1562
PMCID: PMC3518778  PMID: 23289051
20.  Does prognosis and socioeconomic status impact on trust in physicians? Interviews with patients with coronary disease in South Australia 
BMJ Open  2012;2(5):e001389.
Objectives
There is concern across a range of healthcare settings worldwide that trust in physicians is declining. Decreased trust may lead to lesser tolerance of prognosis uncertainty and an increased demand for tests, referrals and second opinions. Literature suggests that there has been a recent cultural shift towards decreased trust in, and increased questioning of, medical advice. We investigated the impact of varying prognosis and socioeconomic status (SES) on trust in physicians, and patient questioning of medical advice.
Design
Semistructured, audio-recorded transcribed interviews were conducted. The interview schedule was developed with reference to the Health Belief Model. Interviews were conducted between October 2008 and September 2009.
Setting
Participants were recruited via general practitioner clinics and hospital cardiac rehabilitation programmes.
Participants
Participants consisted of patients either receiving preventive treatment or active treatment for established cardiovascular disease.
Outcome measures
A coding structure was developed based on the aim of the research, to investigate the impact of varying prognosis and SES on trust in physicians.
Results
Older participants are more likely than their younger counterparts to be unquestioning of medical advice. Higher SES participants are more likely to question medical advice than lower SES participants. Also, unlike primary prevention participants, established pathology increased participants’ trust, or decreased questioning behaviour. Participants who perceived themselves at risk of a poor or uncertain outcome were unlikely to doubt medical advice.
Conclusions
Blind trust in physicians remains strong in older participants, participants who perceive their prognosis to be uncertain and a proportion of lower SES participants. This is important for practitioners in terms of patient agency and points to the importance of moral and ethical practice. However, physicians also need to be aware that there are a growing proportion of patients for whom trust needs to be developed, and cannot be assumed.
doi:10.1136/bmjopen-2012-001389
PMCID: PMC3488703  PMID: 23035015
Preventive Medicine; Medical Education & Training
21.  Doctors and Medical Training 
The Australasian Medical Journal  2012;5(9):513-516.
doi:10.4066/AMJ.2012.1512.
PMCID: PMC3477781  PMID: 23115587
22.  Doctors and Medical Science 
The Australasian Medical Journal  2012;5(8):462-467.
doi:10.4066/AMJ.2012.1491
PMCID: PMC3442191  PMID: 23024721
23.  When only a doctor will do 
The Australasian Medical Journal  2012;5(7):414-417.
doi:10.4066/AMJ.2012.1446
PMCID: PMC3413005  PMID: 22905066
Generalist; Doctor; impersonator; skills; innovation
24.  Impact of the Presence of Medical Equipment in Images on Viewers’ Perceptions of the Trustworthiness of an Individual On-Screen 
Background
It is now common practice for doctors to consult patients by means other than face-to-face, often appearing before the patient on a computer screen. Also, many websites are using depictions of health professionals to increase the credibility of their services. Being trustworthy is an essential attribute for successful ehealth services. Little is known about which depicted accessories make a health professional appear more trustworthy.
Objective
To estimate the odds of an individual on-screen being rated trustworthy when viewed in a static image holding or wearing specific items of medical equipment.
Methods
We surveyed consecutive people attending community pharmacies to collect prescriptions in Western Australia. Respondents were presented with a series of 10 photographs, generated at random, of a man with varying numbers and combinations of medical equipment: stethoscope, reflex hammer, surgical scrubs, otoscope, and pen. They were then invited to rate the man as honest, trustworthy, honorable, moral, ethical, or genuine, or a combination of these, on the Source Credibility Scale.
Results
A total of 168 of 250 people gave informed consent, for a participation rate of 67.2%. There were 102 female and 66 male respondents. Of the 168 respondents, 96 (57%) were born in Australia and 102 (60.7%) were attending medical practices with more than one general practitioner. The mean age of respondents was 47 (SD 16) years (range 26–92 years). When only 1 item was present in an image, the stethoscope was associated with the highest odds for the person being considered honest (odds ratio [OR] 2.6, 95% confidence interval [CI] 1.6–4.3), trustworthy (OR 2.3, 95% CI 1.4–3.8), honorable (OR 2.7, 95% CI 1.6–4.5), moral (OR 2.4 95% CI 1.4–4.1), ethical (OR 2.6, 95% CI 1.5–4.6), and genuine (OR 1.8, 95% CI 1.0–3.1). The presence of a stethoscope increased the odds of the person being rated in a positive light in all photographs in which it was included.
Conclusions
When an individual is portrayed in a static image, concurrent presentation of 3 or more items of medical equipment, and especially a stethoscope, is likely to exert a positive influence on the viewers’ perceptions of the qualities of the person depicted.
doi:10.2196/jmir.1986
PMCID: PMC3409609  PMID: 22782078
Icons; semiotics; stethoscope; doctors; trustworthiness
25.  The health of women treated for breast cancer: A challenge in primary care 
The Australasian Medical Journal  2012;5(6):316-321.
At least one in a hundred consultations in general practice in Australia involves women being treated for breast cancer. The challenges presented during these consultations test the quality of primary care. Firstly, women are reported to prefer to discuss their breast cancer-related problems with a specialist even though research suggests that patients generally prefer to consult with a general practitioner (GP). The extent to which these patients will have maintained or return to their previous level of functioning will be a reflection on the quality of primary care, as some breast cancer-related health issues may persist beyond the time period when they are undergoing specialist review. Further, psychosocial matters, sexuality and relationships may require repeated review and perhaps consultations involving family members and would therefore be better addressed by a GP. An increasingly urgent need exists to review how best to support people who are successfully treated for life limiting illnesses, such as breast cancer.
doi:10.4066/AMJ.20121344
PMCID: PMC3395290  PMID: 22848330
Breast cancer; primary care; cancer morbidity

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