Transportability of tertiary qualifications and CPD: a continuing challenge for the global health workforce.

BACKGROUND: In workforces that are traditionally mobile and have long lead times for new supply, such as health, effective global indicators of tertiary education are increasingly essential. Difficulties with transportability of qualifications and cross-accreditation are now recognised as key barriers to meeting the rapidly shifting international demands for health care providers. The plethora of mixed education and service arrangements poses challenges for employers and regulators, let alone patients; in determining equivalence of training and competency between individuals, institutions and geographical locations. DISCUSSION: This paper outlines the shortfall of the current indicators in assisting the process of global certification and competency recognition in the health care workforce. Using Organisation for Economic Cooperation and Development (OECD) data we highlight how International standardisation in the tertiary education sector is problematic for the global health workforce. Through a series of case studies, we then describe a model which enables institutions to compare themselves internally and with others internationally using bespoke or prioritised parameters rather than standards. SUMMARY: The mobility of the global health workforce means that transportability of qualifications is an increasing area of concern. Valid qualifications based on workplace learning and assessment requires at least some variables to be benchmarked in order to judge performance.

Does drug and alcohol use undermine concordance between doctors' assessments of major depression and patients' scores on a screening tool for depression among gay men attending general practice?

General practitioners (GPs) identify that depression can be difficult to diagnose in populations with high rates of alcohol and other drug (AOD) use. This is a particular concern with gay men who are a population known to engage in high rates of AOD use and who are vulnerable to depression. This paper uses data from 563 gay men and their GPs to describe concordance between assessments of major depression and, in particular, whether AOD use undermines concordance. Data were collected as part of a larger study of male patients and GPs at high HIV-caseload general practices in Australia. Concordance was measured by comparing patients' scores on the Patient Health Questionnaire-9 screening tool, which is based on the Diagnostic and Statistical Manual of Mental Disorders IV criteria, and GPs' ratings of the likelihood of depression for each participant. We observed high concordance between GPs' assessments of major depression and patients' scores on the PHQ-9 (79% agreement), although our analysis also suggested that concordance was better when it related to cases in which there was no depression. The high concordance observed in our study did not appear to be undermined by gay male patients' AOD use, with the exception of frequent use of crystal methamphetamine. Here, men who reported frequent use of methamphetamine were significantly less likely to have concordant assessments (adjusted odds ratio 0.3, 95% CI 0.1-0.8). Overall, GPs appear to identify depression among many of their gay male patients. While GPs should be aware of the potential complications presented by frequent crystal methamphetamine use, other AOD use may have less impact on the diagnosis of depression.

All-cause mortality of elderly Australian veterans using COX-2 selective or non-selective NSAIDs: a longitudinal study.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT: • Previous studies have found varying impact of exposure to COX-2 selective and non-selective NSAIDs. WHAT THIS STUDY ADDS: • Individuals receiving a COX-2 selective NSAID had an increased risk of all-cause mortality after correction for age, sex and cardiovascular risk as measured by co-prescription. • Despite differences in the pharmacokinetic properties of the COX-2 selective inhibitor drugs, our study lends no support to clinicians preferring any one COX-2 selective inhibitor drug, or substituting one for another on the grounds of mortality risk alone. • The Australian Department of Veterans' Affairs data sets make it possible to conduct timely record linkage studies of all-cause mortality from use of medicines in a large and clinically relevant population. AIM: To determine hazard ratios for all-cause mortality in elderly Australian veterans taking COX-2 selective and non-selective NSAIDs. METHODS: Patient cohorts were constructed from claims databases (1997 to 2007) for veterans and dependants with full treatment entitlement irrespective of military service. Patients were grouped by initial exposure: celecoxib, rofecoxib, meloxicam, diclofenac, non-selective NSAID. A reference group was constructed of patients receiving glaucoma/hypothyroid medications and none of the study medications. Univariate and multivariate analyses were performed using Cox proportional hazards regression models. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated for each exposure group against each of the reference group. The final model was adjusted for age, gender and co-prescription as a surrogate for cardiovascular risk. Patients were censored if the gap in supply of study prescription exceeded 30 days or if another study medication was initiated. The outcome measure in all analyses was death. RESULTS: Hazard ratios and 95% CIs, adjusted for age, gender and cardiovascular risk, for each group relative to the reference group were: celecoxib 1.39 (1.25, 1.55), diclofenac 1.44 (1.28, 1.62), meloxicam 1.49 (1.25, 1.78), rofecoxib 1.58 (1.39, 1.79), non-selective NSAIDs 1.76 (1.59, 1.94). CONCLUSIONS: In this large cohort of Australian veterans exposed to COX-2 selective and non-selective NSAIDs, there was a significant increased mortality risk for those exposed to either COX-2-selective or non-selective NSAIDs relative to those exposed to unrelated (glaucoma/hypothyroid) medications.

Discourses of depression of Australian general practitioners working with gay men.

The data for this article are from a primary health care project on HIV and depression, in which the prevalence, nature, clinical management, and self-management of depression among homosexually active men attending high-HIV-caseload general practice clinics were investigated. One of the qualitative arms consisted of in-depth interviews with general practitioners (GPs) with high caseloads of gay men. The approach to discourse analysis was informed by Halliday's systemic functional linguistics. GPs constructed three discourses of depression: engaging with psychiatric discourse, engaging with the patient's world, and engaging with social structures. When GPs drew on the discourse of psychiatry, this discourse was positioned as only one possible construction of depression. This discourse was also contextualized in the social lives of gay men, and it was explicitly challenged and rejected. Engaging with their patients' social world was considered vital for recognizing depression in gay men. Finally, the GPs' construction of depression was inextricably linked to social disadvantage and marginalization. Depression is highly heterogeneous and constructed in terms of social relationships rather than as an independent entity that resides in the individual. There is a synergy between GPs' constructions of depression and men's experiences of depression, which differs from conventional medical views, and which enables GPs to be highly effective in dealing with the mental health issues of their gay patients.

Self-reported sexual difficulties and their association with depression and other factors among gay men attending high HIV-caseload general practices in Australia.

INTRODUCTION: Sexual expression affects physical, mental and social well-being. There is a lack of understanding of male sexual dysfunction in homosexually active men. Aim. We investigated gay men's self-report of a number of sexual problems. METHODS: The survey data were from a sample of 542 self-identified gay men, 40% of whom were HIV positive, recruited from six high HIV-caseload general practices in Australia. MAIN OUTCOME MEASURES: The reporting of experiencing three or more sexual problems over a period of at least 1 month in the 12 months prior to a survey was defined here as having "multiple" sexual problems. We explored a number of factors, including HIV status, depression, alcohol and other drug use, and sexual risk-taking with casual male partners, in association with multiple sexual problems. RESULTS: Rates of a range of self-reported sexual problems were high, with erectile dysfunction and lack of sexual desire being the most commonly reported. These high rates were consistent with the limited data from previous Australian studies. Men who had multiple sexual problems were likely to suffer from major depression (P < 0.001). A higher proportion of the HIV-positive gay men (48.4%) reported multiple sexual problems than the HIV-negative men (35.1%, P = 0.002). Factors independently associated with multiple sexual problems among the HIV-negative gay men were poorer general health and interpersonal isolation, whereas for the HIV-positive gay men, they were adoption of avoidant strategies to cope with daily life stress, sexual risk-taking in casual encounters, and the use of antidepressants. CONCLUSIONS: Our findings underscore the complex interactions between depression, sexual dysfunction, sexual risk taking, HIV infection, and general well-being among homosexually active men.

Features of the management of depression in gay men and men with HIV from the perspective of Australian GPs.

BACKGROUND: In contrast to the broad literature on depression in the general population, little is known about the management of depression affecting gay men and HIV-positive men attending general practice clinics. OBJECTIVE: This paper explores qualitative descriptions of how depression in gay men and HIV-positive men is managed by GPs. METHODS: As part of the qualitative component of a mixed method study on HIV and depression, semi-structured interviews were conducted with 16 GPs in three geographical settings in Australia: Sydney, Adelaide and a rural coastal town. RESULTS: GPs identified a range of features in their experience of managing depression in gay men and in HIV-positive men. Some were common to the care of other groups with depression, but this paper reports on features unique to this patient group. These include capitalizing on the high frequency of contact with this patient group, taking advantage of the specialist multidisciplinary teams who provide support, building upon the unusual willingness of this patient group to take medication, appreciating the central importance to many gay men of sexual functioning, and recreational drug use, responding to social isolation in this patient group and coping with increasing challenges for the HIV general practice workforce. CONCLUSIONS: Despite the identification of several key strengths in working with this patient group, the ability of GPs to develop their capacity to manage depression in gay men and men with HIV is uncertain in the context of a growing range of challenges for GPs in both mental health and HIV care.

Social factors associated with Major Depressive Disorder in homosexually active, gay men attending general practices in urban Australia.

OBJECTIVES: Social factors associated with Major Depressive Disorder (MDD) were identified among gay men attending high HIV caseload general practices in Sydney and Adelaide. METHODS: Men who visited four participating practices were invited to self-complete a survey. A self-screening tool (PHQ-9), based on the Diagnostic and Statistical Manual of Mental Disorders, version four (DSM-IV), was used to measure depressive disorders. RESULTS: The rate of MDD (PHQ-9 score 10 or above) among the 195 HIV-positive gay men was significantly higher than that among the 314 non-HIV-positive gay men (31.8% vs 20.1%, p=0.002). Current MDD was independently associated with younger age, lower income, recent major adverse life events, adopting denial and isolation as coping strategies, less social support, less gay community involvement and recent sexual problems. HIV-status, however, was not independently associated with MDD. CONCLUSION: Socio-economic hardship, interpersonal isolation and personal withdrawal were significantly and independently associated with major depression in this population of gay men. IMPLICATIONS: The study provides further evidence of health inequity affecting gay men in Australia. Structural health promotion approaches focused on homophobia and discrimination, as well as community-engaged primary health care responses are called for to mitigate this inequity.

Experiences in managing problematic crystal methamphetamine use and associated depression in gay men and HIV positive men: in-depth interviews with general practitioners in Sydney, Australia.

BACKGROUND: This paper describes the experiences of Australian general practitioners (GPs) in managing problematic crystal methamphetamine (crystal meth) use among two groups of male patients: gay men and HIV positive men. METHODS: Semi-structured qualitative interviews with GPs with HIV medication prescribing rights were conducted in Sydney, Adelaide and a rural-coastal town in New South Wales between August and October 2006. Participants were recruited from practices with high caseloads of gay and HIV positive men. RESULTS: Sixteen GPs were recruited from seven practices to take part in interviews. Participants included 14 male GPs and two female GPs, and the number of years each had been working in HIV medicine ranged from two to 24. Eleven of the GPs who were based in Sydney raised the issue of problematic crystal meth use in these two patient populations. Five key themes were identified: an increasing problem; associations with depression; treatment challenges; health services and health care; workforce issues. CONCLUSION: Despite study limitations, key implications can be identified. Health practitioners may benefit from broadening their understandings of how to anticipate and respond to problematic levels of crystal meth use in their patients. Early intervention can mitigate the impact of crystal meth use on co-morbid mental illness and other health issues. Management of the complex relationships between drug use, depression, sexuality and HIV can be addressed following a 'stepped care' approach. General practice guidelines for the management of crystal meth use problems should address specific issues associated with gay men and HIV positive men. GPs and other health practitioners must appreciate drug use as a social practice in order to build trust with gay men to encourage full disclosure of drug use. Education programs should train health practitioners in these issues, and increased resourcing provided to support the often difficult task of caring for people who use crystal meth. Greater resourcing of acute care and referral services can shift the burden away from primary care and community services. Further investigation should consider whether these findings are reproducible in other general practice settings, the relationship between depression, drug use and HIV medication, and challenges facing the HIV general practice workforce in Australia.

Lessons from the TAPS study--recall and reminder systems.

The Threats to Australian Patient Safety (TAPS) study collected 648 anonymous reports about threats to patient safety from a representative random sample of Australian general practitioners. These contained any events the GPs felt should not have happened and would not want to happen again, regardless of who was at fault or the outcome of the event. THis series of articles presents clinical lessons resulting from the TAPS study.

Lessons from the TAPS study. Warfarin: a major cause of threats to patient safety.

The Threats to Australian Patient Safety (TAPS) study collected 648 anonymous reports about threats to patient safety from a representative random sample of Australian general practitioners. These contained any events the GPs felt should not have happened, and would not want to happen again, regardless of who was at fault or the outcome of the event. This series of articles presents clinical lessons resulting from the TAPS study.

Lessons from the TAPS study - management of medical emergencies.

The Threats to Australian Patient Safety (TAPS) study collected 648 anonymous reports about threats to patient safety by a representative random sample of Australian general practitioners. These contained any events the GPs felt should not have happened, and would not want to happen again, regardless of who was at fault or the outcome of the event. This series of articles presents clinical lessons resulting from the TAPS study.

Corrections in an electronic environment.

The need to publish corrections to scientific articles, and occasionally to retract them, has been recognized for decades. However very little emphasis has been attached to how this is done, provided that the retraction or correction is accessible. We are considering a policy to directly correct our online publications.

Groups or teams in health care: finding the best fit.

RATIONALE: In the evolution of the team concept, clear distinctions between 'groups' and 'teams' were made. In this paper we argue that these distinctions were not made explicit in the translation of team structures to health care. Even though teams are appropriate for many health care settings, this paper explores the notion that when teams may not be working, it is the concept of team that may not be appropriate, not the functioning of the team itself. METHODS: This paper reviews the differences between teams and groups, and identifies how these differences are expressed in health care settings using urban and rural examples from the UK and Australia. RESULTS: Some suggestions about matching structures to suit the unique nature of health care provision, particularly in community health settings, are made. DISCUSSION: Instead of concentrating on improving the process of teams, the focus could be better directed to ensure that whatever structure is utilized best facilitates the necessary outcomes in the most effective way. The team approach may not always be the best approach, and sometimes referring to a number of people working together as a group is sufficient.

Dosing frequencies in general practice--Whose decision and why?

BACKGROUND: Little is known about patient preference for dosing frequency (daily, weekly or monthly). Patient preferences and attitudes among women over 60 years of age were studied. Condition, medication experience and perceived control were assessed against preference. METHODS: One hundred and seven Australian general practitioners each recruited approximately 10 patients within three categories: those with preventable conditions (prevention of osteoporotic fracture), other chronic conditions, and acute or no conditions. RESULTS: While most patients (67%) preferred starting medications daily, differences were observed between weekly and monthly preference. Chronic/acute groups and those experienced in daily/intermittent medication preferred starting and continuing monthly. Experience of weekly preventive medication resulted in a preference for weekly dosing. Those women with more perceived control of decision making had a preference for monthly dosing. DISCUSSION: Patients prefer dosing schedules they have experienced. Condition type and perceived control in decision making also affect preferences. This study provides the first evidence about how patients determine preferences in dosing frequencies. It can assist GPs in their medication choice and patient education.

The use of reflective and reasoned portfolios by doctors.

RATIONALE: Reflective portfolios have been widely trailed in vocational programmes for health sciences education. While not raised explicitly yet, there is recognition that an essential part of a portfolio may still be missing - that is the experience of theoretical and analytic questioning that should occur after reflection. AIMS AND OBJECTIVES: In this paper, we argue that portfolios require both reflective and reasoned components to provide a more complete range of educational experiences for postgraduate doctors in the pursuit of higher qualifications. METHODS: We describe the differentiating features between the two components and conclude with some suggestions on how both reflective and reasoned components of portfolios may work synergistically through a series of case studies. RESULTS: The reflective style of portfolio, which is in current use, has been widely accepted as a major advance in postgraduate medical education at all levels. It provides an effective vehicle for encouraging self-consideration and generalizability. It is an important adjunct where it functions as a personal development tool as well as a sophisticated log book. A reasoned or pedagogic element encourages more analytic activities: adding an additional component that can ground the portfolio in theory or research. The portfolio is then able to function in a range of academic spheres and provide a theoretical platform for the wide range of non-clinical empirical work undertaken in clinical settings. The addition of a reasoned component also increases the emphasis on the introduction of new concepts outside the sphere of the learner's experience. CONCLUSIONS: A portfolio containing both reflective and reasoned components is then able to function in a range of academic spheres and provide a theoretical platform for the wide range of non-clinical empirical work undertaken in clinical settings. In an iterative mode, such a portfolio element can support a forum for questioning established concepts within a pedagogical environment - the essence of evidence-based practice.

Comparing 'doctor' and 'patient' beliefs about the role of illicit drug use in gay men's depression.

High rates of both illicit drug use and depression are consistently reported among gay men. However, little is known about how beliefs about drug use shape clinical encounters between gay men and health professionals, and that in turn affect clinical communication and care, particularly in relation to depression. We compared 'doctor' and 'patient' beliefs about the role of illicit drug use in gay men's depression. Semi-structured interviews were conducted during August-December 2006 with 16 general medical practitioners working in seven 'gay-friendly' practices in Sydney, Adelaide and a rural-coastal city in New South Wales, and during February-May 2008 with 40 gay men with depression recruited through four Sydney and Adelaide practices. A thematic analysis of these two sets of interviews found that doctors expressed the beliefs that: illicit drug use is related to depression in gay men; illicit drug use impedes effective diagnosis and treatment of depression in gay men; and illicit drug use increases the level of complexity involved in caring for gay men with depression. Gay men expressed the beliefs that: illicit drug use is closely related to depression; illicit drug use can be helpful in dealing with difficult experiences; and illicit drug use is just what you do as a gay man living in a big city. Both groups believed drug use and depression were related, but doctors emphasised the negative outcomes of drug use and interpreted these in relation to health. Gay men believed that drugs could have both negative and positive uses and differentiated between health and social outcomes. While the doctors articulated a pragmatic position on drug use, which is consistent with harm reduction principles, communication with gay male patients could be enhanced if both groups acknowledged their divergent views of illicit drugs and their potential role in mental health.

HIV generations? Generational discourse in interviews with Australian general practitioners and their HIV positive gay male patients.

The introduction of highly active antiretroviral therapy (HAART) is typically represented as a turning point in the social and medical history of HIV/AIDS, leading to a conceptual division into pre- and post-HAART eras. This paper explores how generational discourse is produced in interviews with general practitioners (GPs) and their HIV positive gay male patients in making sense of this moment and related changes in the Australian HIV epidemic. A theme of 'HIV generations' was identified in in-depth interviews with GPs who have HIV medication prescribing rights (based in Sydney, Adelaide and rural-coastal New South Wales) and the HIV positive gay men who attend their practices. In a closer analysis, generational discourse was identified across the interviews with GPs, characterising pre- and post-HAART HIV generations through three main features: treatment histories, socioeconomic status, and modes of survivorship. While generational discourse was less common in the accounts of HIV positive gay men, many of their examples wove together two narrative forms - 'a different time' and 'difference today' - suggesting that concepts of time and inequity are deeply embedded in these men's understandings of the HIV experience. Our analysis indicates that generational concepts play a significant role in shaping both professional and 'lay' understandings of changes and patterns in the HIV epidemic.

Case reports and the fight against cancer.

Some of the earliest case reports describing individual patients afflicted with cancer can be traced all the way back to the papyrus records of Ancient Egyptian medicine of approximately 1600 B.C.. Throughout the centuries physicians have continued the practice of writing case reports. Case reporting has provided significant advances in the knowledge of cancer on several fronts. It is without question that case reports do not replace well designed randomized clinical trials in advancing medical knowledge about cancerous diseases. However, case reports have their unique role in evidence-based medicine and often constitute the first line of evidence. This editorial reviews the many useful aspects of case reports and describes specific reports known to have revolutionized cancer management. Journal of Medical Case Reports is committed to publish well written case reports from around the world and be a source of inspiration for clinicians and scientists about newer research directions.