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INTERNAL MEDICINE SOCIETY of Australia & New Zealand
From the President. Dear IMSANZ Members, "Another year over and what have we done…?" 2. Reforming the training program with a
sang John Lennon. Answer, in so far as IMSANZ Vice President AUS
view to creating more general physicians.
is concerned: heaps! Everywhere you look There has been a seismic shift in the attitude you see members of this society engaged in a of the col ege towards restoring equity diversity of activities that embody the strength of training opportunities for trainees who and vitality of our discipline. The article in this aspire to become general physicians. This issue from our Pacific correspondent, Dr Rob is in no small way due to the efforts of Les Moulds, is a terrific il ustration of just how Bolitho, Rick McLean and Geoff Metz who, Simon Dimmitt, WA important (and interesting) the practice of at senior levels of the col ege hierarchy, internal medicine is in countries such as Fiji. have brought an awareness (and increasing And we are no less active here in Australia Mary-Ann Ryall, ACT acceptance) of the need for a more even and New Zealand, as the following examples balance between the numbers of general physicians and pure subspecialists. At the level of curriculum development, Phil ippa 1. Creating new career opportunities for
Poole, Andrew Bowers, Peter Greenberg and general physicians. Just scan the RACP
Leonie Cal away have designed a curriculum and IMSANZ websites to see the numbers that, for the first time, explicitly states the Christian de Chaneet, WA of new positions for consultant general knowledge, skills and attitudes of general Michele Levinson, VIC physicians that are springing up everywhere physicians which wil guide the way training in throughout Australia and New Zealand. general medicine is provided and assessed. Vacancies exist in Bathurst, Gold Coast, David Hammill, NSW At the level of hospital training programs, Hervey Bay, Grafton, Wool ongong, Armidale, efforts are being taken by folk such as Peter Newcastle, Wagga Wagga, Perth, Adelaide, Nolan (Qld), Aidan Foy (NSW), David Russell and Auckland and Nelson in NZ. Some Justin La Brooy, SA (Vic), and Di Howard (NT) towards creating involve interesting new models of specialist Nicole Hancock, TAS regional trainee recruitment and training care that espouse a generalist approach to schemes that provide a training path for care delivery and co-ordination. One such general physician trainees which involve Advanced Trainee Reps
example is the ad for 5 general physicians at rotations in both metropolitan and regional Leonie Callaway, QLD Flinders Medical Centre in Adelaide to staff Patrick Gladding, NZ a new Assessment Unit and Acute Medicine Service which will provide comprehensive, 3. Expanding the opportunities for professional
general physician-led medical care to all development in general medicine. Various
acutely unwell medical patients. council ors together with local members Michael Kennedy, NSW SAC Representative As you turn the pages.
Skowronski Letter . 3
145 Macquarie Street 7th European School of Internal Medicine . 4
Book Review . 5
New Members . 5
Critically Appraised Topics (CATs) . 6
Like To Do Some Research? . 7
27th World Congress In Internal Medicine . 9
Executive Summary NRHP . 10
Letter From Fiji . 13
Forthcoming Meetings . 14
Notice to Members . 15


December 2004 are engaged in organising a host of 5. Building an academic base for general medicine. This
educational events for 2005 including issue contains an article which attempts to help those of the Wellington RACP ASM, the inaugural us wanting to do research. It is inspiring to note that one of IMSANZ Annual Scientific Meeting which the successful CSSP projects reported in a supplement of will be held in Alice Springs in September the Medical Journal of Australia in May this year was the next year, the Victorian Rural Physicians Brisbane Cardiac Consortium, led by general physicians meeting, the various New Zealand regional from three Brisbane hospitals. There are no doubt many conferences, and RACP state scientific general physicians who are involved in research in one form meetings. This is in addition to a number or other – as site investigators for multi-centre clinical trials, of workshops aimed at improving specific skil s of the as sponsors of quality improvement projects, as mentors general physician such as the Cardiology Skil s for Rural of physician trainees undertaking research activities. Physicians meeting recently held in Brisbane and the Opportunities for general physicians to contribute to research Evidence-based Practice Workshop last month in Melbourne can only but increase as more interest is shown in determining (with involvement of myself, Paddy Phil ips, Peter Greenberg the most effective and efficient ways of providing care for and Don Campbell). The Resources section of our website is ageing populations with multiple problems. to be redesigned with the aim of mounting a rapid-response So what might be some of the predictions for the New Year? I critically appraised practice topic page which will attempt to suspect that the role of general physicians in providing acute get synopses of new important research results relevant to medicine in hospital, acting as ‘hospitalists', or case managers, the general physician quickly on-line. A separate ‘Practice and assisting subspecialists in the care of those aspects of Improvement Tips' page wil provide evaluated strategies their patients' illnesses that lie outside their field of expertise, for improving practice efficiency in both hospital and clinic will come to the fore. A letter from an intensivist at St. George hospital reproduced on page 3 gives a hint of things to come. 4. Promulgating policies aimed at advancing and sustaining The need for more general physicians in outer metropolitan and
general physician practice. This issue of the newsletter regional hospitals will become a major public issue, as will the
contains an abridged version of the National Rural Health plight of rural and remote communities who find themselves Policy (NHRP) Sub-committee of the Australian Health increasingly unable to access any form of specialist medical Ministers Advisory Council (AHMAC) Taskforce. This care. Governments at both state and federal levels wil be document has been co-authored by a number of IMSANZ looking to the college and IMSANZ for tangible assistance in members and incorporates many of the recommendations remedying this situation. The recent (bad) publicity given to that IMSANZ has made in recent times about how to boost the perceived limitation of access, on the part of the RACS, to the supply of general physicians in rural and remote areas, positions in its training program for eligible trainees, in the face and better support those already practising in such areas. of clear population need to train more surgeons, is something At the current moment, one of the most important tasks the RACP will want to avoid at all cost. The review of the college that IMSANZ has ever undertaken is the development of training program and the start-up of the conjoint committees with a 5-year action plan that sets out, in clear terms, the goals specialty societies wil raise a number of operational issues which and methods that the IMSANZ membership has collectively will challenge orthodox views and not be easily resolved. decided are the means for restoring the proper role and Enjoy the festive interlude and get ready to hang on to your seats position of the general physician within the Australian and New for an interesting ride in 2005. Zealand healthcare system. As this newsletter goes to press, the draft plan has been electronical y sent for review and IAN SCOTT comment to all members who have provided us with e-mail addresses. The feedback received will be used to revise the President, IMSANZ
document prior to its public launch at the IMSANZ annual general meeting in Wellington in May next year. As much of December and January is usually down-time for most of us, I hope that everyone takes the opportunity to examine and think about this document as much depends on getting it right. Your future, and that of general medicine, will be influenced very significantly by the actions contained in this document. Circumstances have never been as good as they are now for resurrecting the status of general medicine and we must do everything we can in making the most of this opportunity. Anyone without e-mail who would like a hard copy of this document please contact the secretary.
IMSANZ DECEMBER 2004 AN INTENSIVIST'S PLEA FOR
(The fol owing is an edited version, reproduced with permission, Maybe the RACP has absolutely no interest in all of this. If so of an e-mail received from Prof. George Skowronski, intensivist I apologise for wasting your time. But if there is any interest I'd at St. George Hospital, Sydney.) be keen to participate in any discussions.
Dear Prof McLean, George A Skowronski FRCP FRACP FJFICM I'm not sure if you're the right person within the RACP hierarchy Senior Specialist, ICU, St George Hospital, Sydney, Australia to contact for this, but it seemed to me you might be. I have Conjoint Associate Professor, Critical Care, University of NSW followed for some time developments within the UK College (of Phone: +61 2 9350 1111 which I am also a Fellow) in relation to what they have termed Fax: +61 2 9350 3971 "acute medicine". In Australia we have had something of a Email: g.skowronski@unsw.edu.au debate about the US concept of "hospitalists" - a closely related idea. There were a couple of editorials and some correspondence Dear Prof Skowronski, involving Ken Hil man and Paddy Phil ips in the MJA in 1999, but it went no further. We're also now discussing the role of Medical Thankyou for your interest in this whole concept of acute in- Emergency Teams and so on. In all this the RACP is silent (at patient medicine and who is best served to provide it. Clearly least as far as I know).
there wil be debate on how you define acuity and complexity and at what level the intensivist or physician should assume primary With the decline in general medicine, increasing super- responsibility for care. I have argued along with Paddy Phillips specialisation, the ascendancy of procedural medicine, the in the MJA article you refer to (MJA 1999; 171: 312-314) that changing inpatient population, etc, I've become increasingly the general physician is ideally placed to deal with those parts conscious, as an intensive care physician, of a widening gap of the continuum of patient care that lie outside the provence of between the sort of inpatient care I'm used to providing and emergency medicine and intensive care. The inpatient situations that available outside the teaching hospital ICU. Many of my you list can be appropriately managed by the wel -trained general intensivist colleagues agree, and we talk about "ICU outreach" physician, and the presence of general physicians in hospitals services. The general wards are now full of frail, elderly, acutely who can co-ordinate aspects of medical care of surgical patients sick and unstable patients, yet the "physicianly model" of care for and the many different co-morbidities of elderly patients is, we this population has hardly changed in 50 years, with consultants believe, becoming a necessity.
pontificating on ward rounds or by phone, and most of the day-to- day care provided by poorly supported and inadequately trained How do we progress a constructive dialogue? I think a discussion juniors flitting between the wards and the outpatient clinics. (Am on this topic between representatives of my society, the Intensive I being too provocative?). Events like the Campbel town/Camden Care Society and the Australasian Col ege for Emergency debacle, notwithstanding the political overtones, have only Medicine, with input from RACP, might be the next step. We served to reinforce these concerns.
should be trying to build an alliance with the aim of developing integrated care and referral/transitional care guidelines, I think the UK Col ege has done a commendable job in reviewing the training curriculum of each group and how they confronting some of these issues and wonder whether the can be developed to better promote greater liaison between our RACP should take a lead in advancing a similar debate here. three groups, and defining the role of subspecialist physicians This would include, for instance, medical issues in the surgical in this continuum.
patient, acute multi-organ problems (often poorly managed by a ‘committee' of single-organ-doctors), medical urgencies The time is ripe to make inroads on the compartmentalised, and emergencies, acute fluid/electrolyte/acid-base disorders, disjointed (and in many cases omitted) care that we are etc. I would contend these areas have never been particularly currently providing in many of our hospitals, especially in outer well taught or supported in physician training (apart from the metropolitan and rural areas. Our efforts, as I'm sure you'll intensivists of course), whereas I think some of the ambulatory agree, should be directed at improving overall patient care and stuff once used to be, before many of the teaching hospitals not be undermined by professional turf wars. I look forward to privatised outpatient clinics to save money.
progressing these ideas with you and others.
While any changes would need support from the single organ Regards, specialties, the first step would be for them to acknowledge Ian Scott FRACP, MHA, MEd that they're actually not very good at it, for both cognitive and President, IMSANZ logistic reasons, and that something needs to change. Is this an opportunity for a rebirth of general medicine? Should we encourage the development of a new specialty of "hospital Postscript
medicine" or "acute medicine"? If so, how? Should this niche be The CEO of the college has been approached by Rick McLean filled via the Intensive Care College or the Emergency Medicine with the proposal that a meeting of representatives from Col ege rather than the RACP, or perhaps in combination? IMSANZ/RACP, Intensive Care Society and Australian College Is it something we don't want at all in Australia? What about of Emergency Medicine be convened early in the new year to undergraduate training in this kind of medicine? discuss this issue further.


7th EUROPEAN SCHOOL
of Internal Medicine Professor Merino spent time reviewing the more important and pressing issues for EFIM:• Training • Revalidation• Maintenance of professional standards/Professionalism• The establishment of a standardized European Internal Medicine examination (scheduled for 2005) The European Federation wil offer a course for trainees interested in performing clinical research. This is scheduled to occur for the first time in 2005 in Paris. Also promoted was the relatively newly established journal of the Federation, dedicated to Internal Medicine.
Thankful y, balanced against the lectures and clinical presentations was a wel -organised social schedule. On our first night we were (L to R) Heidi, Portugese AT, Prof Jaime Merino, and Patrick Gladding. honoured with a visit to Santa Barbara castle, given an official mayoral welcome and entertained by a Spanish college band, I had the privilege of attending the 7th European School of singing songs dating back to the Spanish civil war. The fol owing Internal Medicine recently in the coastal town of Alicante, Spain. night we were further spoiled with a performance by a group of The school is the innovation of Professor Jaime Merino and Andalusian singers and dancers.
is endorsed by the European Federation of Internal Medicine (EFIM). The work of Dr Chris Davidson, a General Physician/ These occasions were an excellent opportunity to discuss our Cardiologist from the UK has been integral to its creation and backgrounds, working conditions and training issues across Europe and the world. The European Working Directive has radically altered conditions for training in Europe. It was written Alicante, like many coastal Mediterranean towns, has a long by the newly developed EU government in Brussels and placed history beginning with Carthaginian settlement. Little remains of a limitation on hours worked for the benefit of employees across this period but the grand Santa Barbara castle which overlooks Europe. There was apparently no intention that it would cover the town from an oppressive pinnacle of rock is testament to doctors' employment. However, in two test cases in the European Alicante's glorious medieval period. The modern town was once court, litigation was settled in favour of the defendants, doctors, the gravitational centre for northern European tourists, seeking who had exceeded the Working Directives hours because of its sunny beaches, temperate climate and cheap living. However service commitments. as with many such tourist meccas it has become overdeveloped, with little in the way of natural structures left near the coast. Tall Internal Medicine training in Europe is either principally Internal apartment blocks obscure most views inland, and loom over the Medicine with a subspecialty, or early divergence into either pure sun-worshippers on the beaches.
Internal Medicine or a medical subspecialty. Training is general y as least as long as that experienced in Australasia, with the The meeting is a semiformal affair attended by representatives exception of the UK where a trainee intern year does not exist. from most European countries. This year delegates attended Remarkably in Denmark training is so prolonged that medical from Finland, Sweden, Belgium, Switzerland, Holland and Italy students leave medical school at about the age of 28 years. to name a few. More recent years have seen attendances from Nowhere did conditions seem as bad as in Italy where advanced Slovakia and the Czech republic. This year was the first year that trainees in Internal Medicine are still considered "students" and doctors from Estonia had attended, their country being new to the therefore have very poor representation on employment issues. EU. For those interested the Lancet has published an interesting This has led to a level of pay so meagre that many are stil reliant review of the status of healthcare in Estonia in the last month. on parental support until their late thirties. Other non-European countries were also represented such as Israel, United States and New Zealand.
The meeting was an excellent forum in which to discuss issues of training. One hopes that with standardisation and unification The meeting was entitled "Hot Topics in Internal Medicine". occurring across Europe, the lot of those who have the most to Lectures covered a breadth of issues in medicine, but time gain will improve. The strong emphasis on presenting clinical precluded a comprehensive coverage. Excellent reviews of the cases gave us all a chance to improve our presentation skills. management of atrial fibril ation, the pleiotropic ef ects of statins Remarkably al the Europeans apologised before their talks and malnutrition within hospitals caught everyone's attention. for their poverty of English, but then proceeded to present Occasional presentations were esoteric with an hour dedicated fluently and eloquently. I wish to thank IMSANZ for giving me to the many different types of porphyria.
the opportunity of attending the VIIth Annual European School The format of the meeting was heavy on clinical presentations of Internal Medicine and would recommend it highly to anyone and most appreciated this medium for presenting new material. who wishes to attend. I have only one added word of advice. Local physicians presented clinico-pathological correlations learn a little Spanish before leaving! that allowed delegates to voice their opinions over differential IMSANZ DECEMBER 2004


BOOK REVIEW
FENWICKE, R. (Ed).
General physicians will be heartened by the contribution from In Practice: The Lives of New Zealand Women Robyn Toomath, general physician, endocrinologist, medical
Doctors In The 21st Century
administrator and co-founder of FOE (Fight the Obesity Auckland: Random House. 2004 - NZD$29.99
Epidemic). When faced with a need to cut 20 hours per week of clinical work to accommodate an administrator role, she A physician poet colleague recommended this compendium. It dropped her general medicine commitments. In her words: "to my was duly added to the birthday book request list, and proved amazement I found I really missed the camaraderie of working itself up to the mark as a stimulating, and extremely interesting with a team on the ward. I missed reassuring frightened and read; wel -edited for a book of this type. The fourteen contributors sick people that all would be well and I missed the intellectual are wel -known New Zealand women doctors: three GPs, exchanges with the bright and eager registrars on word rounds. two surgeons, two physicians, a paediatrician, pathologist, So to everyone's surprise (and relief) I engineered a return to psychiatrist, public health specialist, sports physician, breast general medicine…". physician, and obstetrician and gynaecologist respectively. Through their accounts the contributors are concerned to The women invited by Fenwicke were medical undergraduates encourage the current generation of women medical students, at the University of Otago in the mid to late 70's. They document and to "breathe new life into how we can all try to make the their experiences from childhood, into medical school in the heady personal the political." While the contributors were undoubtably days of free education and feminism, through specialisation, and chosen because they have been successful and have survived into practice. They relate how they existed in systems where the system, the stark reminders of the particular barriers these most of the doctors were male, and how they combined medicine women faced, and the fights they won are timely, and challenge with family life and a raft of outside activities. Papaarangi Reid the next generation to continue the efforts. Papaarangi Reid, in and Erihana Ryan of er valuable Māori perspectives. Papaarangi particular, challenges the current complacency in New Zealand explains the young Māori women's code to "make the personal society.
the political" - making a personal stand in one's own sphere of Scattered through the contributions are highlighted inserts influence in order to make a great difference collectively. concerning the medical workforce, health statistics and society In reading this book I felt privileged to share the feelings of these in general. These inserts provide a commentary on the societal women as they laid open their lives, though good and dark times. changes occurring through the late 20th century, and a context The honesty, commitment and resilience they demonstrate is for the women's personal insights. The women are very quick humbling, but strengthens and encourages the reader through to acknowledge and name their, mainly male, mentors. A very the realisation that many others have similar experiences and minor drawback is that, at 189 pages it left one wanting more; survive. Another feature was the flexibility of these women's now surely that is a sign of a good book! medical lives, and how prepared they seem to be to make Proceeds of the sales go to establish the Women Doctors' Fund changes in their career directions, and be comfortable with those at the University of Otago.
decisions. Several have ended up in clinical leadership positions, perhaps motivated by a desire to make a greater contribution to PHILLIPPA POOLE the health of their patients. A warm welcome is also extended
to our New Associate Members:
• Dr Richard Everts, Nelson, NZ
• Dr William Harrison, Auckland, NZ
• Dr Vignakumar Ganesamoorthy,
IMSANZ would like to welcome
the following New Members:
• Dr Jamil Ahmed, Auckland, NZ • Dr Carl Eagleton, Wellington, NZ • Dr Derek Luo, Auckland, NZ • Dr Sok-Hui Goh, Myrtle Bank, SA • Dr Chandi Perera, Canberra, ACT • Dr Basim Nona, Palmerston North, NZ • Dr Alasdair Patrick, Auckland, NZ CRITICALLY APPRAISED TOPICS (CATs)
Intensive lipid-lowering with atorvastatin 80mg provides greater protection against
major cardiovascular events than pravastatin 40mg
Citation: Intensive versus moderate lipid-lowering with statins after acute coronary syndromes. Cannon CP et al. NEJM
2004;350:1495-1504.
Three-part Clinical Question: In patients hospitalized for acute coronarysyndromes, does more intensive (versus moderate)
lipid-lowering with statins result in better outcomes?
The Study: Multicentre (349 sites, 8 countries), double-blinded, randomized controlled trial with intention to treat analysis. Mean
follow-up 24(18-36) months.
Patients: 4162 randomized, 78% male, mean age 58.2yrs, 91% white, 18% prior AMI, 11% previous CAGS, 18% diabetes, 37%
smokers.
Included: Patients at least 18 years old who had been hospitalized for an acute coronary syndrome (AMI or high risk unstable
angina) in the preceding 10 days; total cholesterol <= 6.21mmol/L (or <= 5.18mmol/L if already on long-term lipid-lowering Rx).
Excluded: Unstable patients (patients enrolled after PCI if one was planned); co-existing condition which rendered life
expectancy to <2yrs; therapy with statin at 80mg/day at time of index event or other lipid lowering Rx that could not be discontinued prior to randomization; concomitant use of strong cytochrome P450 inhibitors, risk of QT prolongation; prior PCI within 6/12, CABGS within 2/12 or CABGS scheduled; serious hepatic disease; unexplained CK elevation > 3 times normal or over 177umol/L.
Protocol: Pravastatin 40mg group (N=2063): Standard medical and interventional treatment (including aspirin +/- clopidogrel
or warfarin) + Pravastatin 40mg in a blinded double-dummy fashion. Atorvastatin 80mg group (N=2099): Standard medical and interventional treatment + Atorvastatin 80mg in a blinded double-dummy fashion.
The Evidence:
Combined endpoint of death (any cause),
AMI, unstable angina (requiring
15 (5-25)
26 (15-77)
(PCI or CABGS) or stroke
Death from any cause
31 (0-62)
Death from coronary heart disease
21 (-27-70)
333 (NS*)
11 (-10-32)
125 (NS*)
13 (1-26)
40 (21-528)
Unstable angina requiring hospitalisation
25 (1-50)
77 (39-2133)
CER* Control Event Rate
EER* Experimental Event Rate
RRR* Relative Risk Reduction
ARR* Absolute Risk Reduction
NNT* Number Needed to Treat for one to benefit
NS* Not Significant
Comments:
• Study designed to demonstrate equivalence rather than superiority. (Short follow-up duration, small numbers of patients [eg
Heart Protection Study had 21,000 participants].) • The two groups were reasonably well matched except for peripheral vascular disease: 6.6% of Pravastatin vs 5% Atorvastatin • 8 patients (0.2%) lost to follow-up.
• Significant benefit shown in reduction of revascularisation procedures, unstable angina requiring hospitalisation. Although combined endpoint was used as primary outcome measure, study may have been underpowered to detect specific individual • Benefit of Atorvastatin was evident from as early as 30 days.
• Decrease in LDL cholesterol: Pravastatin 10%, Atorvastatin 42%; this would be predicted to translate into a 20% reduction in clinical events. It is uncertain whether all of the benefit from statins comes from reducing LDL cholesterol.
• Generally well tolerated: ALT > 3x normal = 1.1% for Pravastatin, 3.3% for Atorvastatin (p<0.001); myalgias or CK: 2.7% of Pravatatin, 3.3% of Atorvastatin (p=0.23). No rhabdomyolysis.
• Note associated editorial (NEJM 2004;350:1562-4) and Nissen SE et al., "Effect of intensive compared with moderate lipid- lowering therapy on progression of coronary atherosclerosis: a randomised controlled trial." JAMA 2004;291:1071-80.
Appraised by: Dr Simon Lam, Medical Registrar, Royal Melbourne Hospital, May 2004
IMSANZ DECEMBER 2004 LIKE TO DO SOME RESEARCH?
Love to, but how? One of the defining properties of a profession or discipline is research. Currently I am involved in studies looking at the its demonstration of the capacity to generate and expand its appropriateness of use of CTPA scans in my hospital in own knowledge base through original investigation. Delivering diagnosing suspected PTE, of how effectively we use our the Arthur E. Mills Memorial Oration at the College Ceremony outpatient clinics in reducing waiting times for new patients, in Canberra earlier this year, Professor John Funder made a and of how we can provide better care for elderly patients impassioned plea to all the newly conferred fellows to involve presenting to hospital. Many of these projects have arisen themselves in research and contribute to the advancement of from everyday observations that suggest there might be a medicine.1 As someone who has conducted and published clinical better way of doing things which requires scientific study to studies, I felt sympathy for his call, but also reflected on another old aphorism: "Research is 10% inspiration, 90% perspiration." 2. Designing a research study. The key to success of any study
Yes, it does take effort and I, and I'm sure many others, have is in the design. The central issues are to: 1) be as specific as experienced the angst of wondering whether the effort spent in you can in the question to be answered (or the hypothesis to undertaking what is essential y a risky business was going to pay be tested), and define your population of interest, the study off. The good news is that, if the research question is relevant factor (clinical intervention, risk factor, or aetiological factor and the research is well designed and executed, there is no that is being investigated), and the outcome measures (what such thing as a ‘negative' (or non-publishable) study. There's are we going to measure that will answer our question and more good news in that we now know, through the efforts of the how to undertake such measurement); 2) define the dataset evidence-based medicine movement, how to go about doing i.e. each item of data that you wil need for your study and how decent research, and the message is – it's not as hard as it you are going to collect it; and 3) define your method of data looks, and you do not have to be a full-time academic or trained storage and analysis (i.e. how the data are going to be entered researcher to do it. and analysed in a way which allows valid interpretations or So how much research is being done by general physicians? As deductions). There are many books and papers available chair of the IMSANZ Research Portfolio and Internal Medicine which assist in study design3-6 but careful consideration of editor for the Internal Medicine Journal (IMJ), I thought I should try the issues mentioned using pragmatic common sense is all to get some answer to this question. So I did a quick handsearch you need (repeat: it's not as difficult as you may think). A final of all issues of IMJ over the last 3 years counting all the original caution is to scan the existing literature to ensure that your research articles that were authored by folk I deemed to be exact question has not already been answered, and which general physicians based on their title and institutional af iliation may give you ideas about how others have designed related and also cross-checking their names against the current IMSANZ but not identical studies. membership list. I concede this may under-estimate the GIM research output as there may be folk who publish under a 3. Recruiting others to help you. Rather than try to do all
subspecialty but also practice general medicine, or who publish the work by yourself, and to make sure you gather enough in journals other than IMJ. Nevertheless, for what it is worth, the patients or data to answer the question you've posed, invite results (Table 1) suggest that our research output relative to others to join you in the ef ort and thus divide the labour other disciplines, especially for a general journal such as IMJ, and make use of the ideas and talents of others. Building is not as strong as it might be based on our relative numbers. research networks or collaborations for general physicians So what's the problem? is something IMSANZ is keen to promote. Many folk express concerns about lacking skil s in databases, statistical analysis, Well it's not for lack of interest in doing research. In a survey or sample size calculations (i.e. how many subjects do I of the IMSANZ membership in 2002 which attracted a 60% need to study to answer my question definitively – the study response rate,2 at least half of the respondents were keen to do ‘power'). While there is now plenty of software around which more research. The problems seem to be those of limited time, can do all this,7-10 I sympathise with those who find it all a bit skills and resources, especially for those in private practice and daunting or again feel the pressure of time which prevents with no or little access to trainees or support infrastructure of a them sitting down with a manual in front of a computer and public teaching hospital. There may also be uncertainty about working it through. what might be worthy topics of research given that it is dif icult to equal the level of sophistication of the laboratory-based research But there is another way. Recently, a colleague of mine and or large-scale randomised clinical trials carried out in tertiary IMSANZ member, Dr Nick Buckmaster, had been col ecting research institutes. But these barriers are not insurmountable.
data on consecutive patients with suspected acute coronary syndrome admitted to two community hospitals and he was 1. Deciding what to research. In recent years whole new trying to prove if a clinical pathway strongly promoted at one
schools of what may be cal ed ‘implementation' research (intervention) hospital reduced inappropriate use of clexane have grown up i.e. research dealing with how wel we compared to its use in another (control) hospital. Nick heard integrate the findings of clinical science into the routine that I had access to a biostatistician and sent me his raw data practice of medicine. Clinical epidemiology, quality and in an Excel file, asking if we could make something of it. What safety improvement science, clinical informatics, the study of transpired were some cleaning and transformation of the data, clinical reasoning, clinical systems analysis, health services some additional suggestions as to patient subgroup analysis, research and production of systematic reviews (including and then statistical analysis including logistic regression which Cochrane reviews) are some examples. The many clinical turned uninterpretable raw data on more than 400 patients into a questions that currently remain unanswered within the realm very publishable set of results. What I suspect would have taken of evidence-based medicine are prime targets for applied Nick weeks of work to do was done within a couple of days. It was a win-win situation in that both parties had benefited from References
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rigorous. The Introduction is essentially the background and rationale for your study which should involve an existing 5. Ovretveit J. Evaluating health interventions. Open University literature search as previously mentioned; Methods is the Press, Buckingham, 1998.
study design using the headings outlined above; the Results 6. Black N, Reeves B, Fitzpatrick R, Brazier J. (eds) Health are what you found (I often go so far as writing the sentences Services Research – A Guide to Best Practice. BMJ Books, leaving blank spaces in which to enter numerical data); and London, 2004.
the Discussion is your interpretation of the findings and how 7. Australian Centre for Evidence-based Clinical Practice. they relate to the findings of others (which you've already read Auditmaker. Available at: www.acebcp.org.au/audit.htm as part of your literature search), plus some acknowledgement of any limitations to your study. There, it's done, and with an 8. Steward A, Rao J. Clinical audit and Epi Info. Radclif e Medical average word limit of 2500-3000 for most journals you don't Press, Oxford, 2003. Epi Info version 3.2.2 accessible at: have to write much – indeed I often find the multiple revisions trying to get down to the required word count one of the most 9. Stat View from SAS Institute, Carey, North Carolina. Accessible at www.statview.com So what are you waiting for? It's immensely satisfying seeing 10. SPSS for Windows. Accessible at www.spss.com/ something you've worked on in print and adding to the knowledge base. IMSANZ is encouraging advanced trainees and young fel ows to undertake research with its $10,000 research fel owship (contact the secretary for an application form), is raising awareness of published research done by general physicians through its website, and is promoting networks of Regretful y there was a problem with the general physician researchers and affiliated institutions (Table August newsletter design. The problem 2) who are prepared to assist members in undertaking specific research projects. We welcome suggestions as to how IMSANZ has now been fixed. Hopeful y you stil could provide more practical assistance to those wishing to add enjoyed the newsletter content.
to the knowledge base of GIM. Arnold Espinola, Designer Table 1. Relative contribution by discipline to research articles submitted to IMJ for publication 2000-2003.
Data on articles kindly supplied by Virginia Savickis, editorial manager, IMJData on numbers of fellows obtained from: Dent O. Clinical workforce in Internal Medicine and Paediatrics in Australasia, 2003. RACP, May 2004.
Cardio=Cardiology; Endo=Endocrinology; GE=Gastroenterology; Haem=Haematology; ID=Infectious Disease; Neurol=Neurology; IMSANZ DECEMBER 2004 27th WORLD CONGRESS IN INTERNAL MEDICINE
26th September – 1st October 2004 The 27th World Congress in Internal Medicine was held in There was a well organised social program which included the Granada, Spain from September 26 to October 1, 2004, and Opening Reception, tours of the Alhambra palace in the evening, was hosted by the Spanish Society of Internal Medicine (SEMI and the Closure Dinner at the ‘Palacio del Caprichio' attended - Sociedad Espanola de Medicina Interna), in conjunction with by over 2,400 delegates and partners the International Society of Internal Medicine (ISIM), and the The RACP/IMSANZ Bid Committee, consisting of Prof Napier American College of Physicians - American Society of Internal Thomson, A/Prof Geoffrey Metz and Dr Leslie Bolitho, in Medicine (ACP-ASIM). Professor Blas Gil Extremera (Granada), conjunction with Caroline Thompson (Melbourne Convention was President of the Organising Committee and Visitors Bureau, the Melbourne Exhibition and Convention Nearly 3,500 physicians attended the Congress. There were 28 Centre) and Mr David Buckingham (Agent-General, London for plenary sessions, 8 update sessions, 10 lectures, and 2 satel ite the Victorian Government) was successful in the submission to sessions. There were 1290 Posters and Abstracts, and 286 oral hold the 30th ICIM in Melbourne, Australia from March 20-25, presentations covering al aspects of Internal Medicine presented 2010 despite stiff competition from Turkey and Chile. We look over the five days of the meeting. forward to working with the College to produce a stimulating, Dr Alex Fisher, Department of Geriatric Medicine, Canberra challenging and ‘International' Congress in 2010. Hospital presented the paper "Altered blood pressure homeostasis in older people in residential care: types, prevalence, relation to DR LESLIE E BOLITHO medications and falls" on behalf of A A Fisher, D G LeCouteur, IMSANZ
Wangaratta, October 2004
M W Davis, A J McLean and M M Budge. They were awarded the prize for the Best Oral Presentation for the Congress and received a generous prize. Congratulations to Dr Alex Fisher and his colleagues.
(From Page 8)
Table 2. Examples of research organisations or programs involving general physicians.
Clinical Services Evaluation Unit A/Prof Ian Scott Tel: (07) 3240 7355 Princess Alexandra Hospital, Brisbane, QLD Fax: (07) 3240 7131 Internal Medicine Research Unit, A/Prof Charles Denaro Tel: (07) 3636 5385 Royal Brisbane Hospital, Brisbane, Qld Dr Cameron Bennett Fax: (07) 3636 2642 Clinical Epidemiology and Health Care Dr Peter Greenberg Tel: (03) 9342 7459 (EBM Project Director) Fax: (03) 9342 8082 Royal Melbourne Hospital, Melbourne, VIC Australian Centre for Evidence-based Prof Paddy Phillips Tel: (08) 8204 6061 Clinical Practice, Flinders Medical Centre, Fax: (08) 8204 5268 Department of Medicine A/Prof Phillippa Poole Tel: 64-9-373 7599 University of Auckland, NZ – Involvement Fax: 64-9-373 7555 in systematic reviews Mood Disorders Research Foundation A/Prof Simon Dimmitt Tel: (08) 9224 1474 Fax: (08) 9224 1477 Cunningham Centre for Rural and Tel: (07) 4688 5482 Remote Health Research Fax (07) 4688 5481 EXECUTIVE SUMMARY NRHP
Improving access to specialist medical services in rural
Preferred model for specialist service provision
and outer metropolitan Australia
•There was consensus support for a focus on a strengthened Recently, the National Rural Health Policy (NHRP) Sub- resident specialist service based on "hub and spoke" or
committee of the Australian Health Ministers Advisory Council "networked" service delivery. In general, the model focuses
(AHMAC) released a discussion paper "Improving access to on having a ful range of core specialties in a rural area of 20,000 specialist services in rural Australia."1 Production of this report to 50,000 population including Medicine.
was recommended during the course of the 2004-2006 Health The "hub" population may vary with the degree of remoteness, Care Agreements, based on the concern that inadequate access with some towns of less than 20,000 developed as "hubs". to specialist services in rural and remote areas may result in The need for specialists will be influenced by the availability poorer health outcomes due to missed detection or delayed of, and policy towards, procedural general practitioners (GPs). treatment of serious and chronic conditions. Representatives The intent of the model is that resident specialists based in from IMSANZ assisted in the drafting of this paper, which regional centres (population 50,000 or more) will be the primary encapsulates a cal to Australian health ministers for new models source for outreach services and be supplemented by visiting of general specialist training and service delivery. Below is an subspecialists. As the size of the population served extends abridged version, with emphasis (in bold) on aspects relevant to beyond 20,000, some subspecialties become increasingly viable, general physicians, which I hope wil stimulate further discussion and at a population of 50,000 a full range of subspecialty clinical and feedback from our readers. Please forward your comments practice is possible. The associated clinical service levels can to Prof Rick McLean, Chair, RACP Rural Taskforce, or the be considered in terms of the approximate population base, IMSANZ members of the Taskforce: Les Bolitho, Grant Phelps although proximity to other towns and community morbidity will and Bob Ziffer.
lead to variations.
Core resident specialist services
The common issues
Agreement around the most appropriate service model is The available evidence points to a serious and continuing important in order to harness effort and direct resources. shortfall of medical specialists in rural areas and, increasingly, Recruitment of resident and visiting specialists has not been outer metropolitan sites. Indigenous communities and remote coordinated or integrated with an overal service model for areas experience the largest gap between health need and rural and outer metropolitan areas. The absence of strategic available services.
management of specialist services has placed regional The absence of strategic plans for the provision of specialist managers in a difficult position in determining priorities and has services in most jurisdictions, the disjointed response through led to inequities in the access to specialist services.
Commonwealth, State and Territory funded programs to address In providing core resident specialist services (eg general issues of access to specialist services, and the absence of any internal medicine), it is general y accepted that sustainable
workforce planning on the part of the Medical Colleges leads specialist services require a minimum of 2 but preferably
to a perplexing series of initiatives without clear direction, goal 3 general physicians. However, there is widespread support
or coordination. for an after hours roster that is no more than one in four. The The lack of clear responsibility by any one agency for the relative numbers needed wil depend on the availability of ongoing supply of Australian graduate specialists and linking of procedural GPs (including those in rural sites maintaining their workforce with demand and need, and the ongoing growth of skil s in hospital care al owing the specialist to operate as a subspecialisation, point to a continuation of shortages in rural true consultant), nurses with special skil s and al ied health and outer metropolitan areas and reliance on overseas trained professionals. It is clear however that no rural or regional area specialists into the future. While these issues are on the agenda would be able to support sufficient specialists to maintain such of the Medical Colleges, little progress is being achieved. In a rostering arrangement unless the majority of subspecialists
particular, the demand for more ‘generalist' specialists is at odds in regional areas contribute to a general specialist roster.
with the predominant emphasis on the part of Col eges and [This in turn has training and credentialing implications-IS].
metropolitan hospitals to produce subspecialists. Outreach and regional specialist services
The attitude of metropolitan tertiary hospitals to their responsibilities for clinical support for rural areas and backup for The way in which outreach and regional specialist services the fragile rural specialist workforce is at best variable and often are provided wil vary depending on the specialty and local limited to fly in fly out services. Their role is crucial to improving circumstances. For general physicians, clinics in surrounding access to and availability of rural specialists as the rural health towns may be appropriate. In some specialties, such as geriatrics services are unable to address the issues in isolation.
and mental health, a regional multidisciplinary service may be more appropriate than outreach visits by a solo specialist. Given In improving access to specialist services there is considerable the increasing prevalence of patients with multiple medical consensus and commitment amongst the State and Australian problems including diabetes, cardiovascular disease, obesity government representatives on the actions required. The and renal disease, a regional vascular service may also be dif iculty wil lie in implementation and particularly the approaches appropriate.
to integrate the respective government funding and programs. IMSANZ DECEMBER 2004 Such regional services need to be multidisciplinary and While most specialist colleges have attempted to establish and have a preventive and early intervention role, in addition to fund some rural and regional specialist training posts, they are a therapeutic one, and to work closely with resident health few in number. Also, the growth in numbers of metropolitan professionals. In general, such a role is not compatible with subspecialist training posts has depleted the available pool of a private medical specialist dependent on Medicare fee for trainees, and metropolitan hospitals in turn have withdrawn a service reimbursement and requires salaried specialists or at number of rural rotations because of vacancies within their own least sessional payments.
ranks. In addition, many rural centres do not have the critical mass of specialists required for accreditation for training. An Relationship between rural services and metropolitan
added complication results from increased dependency of rural areas on overseas trained specialists, who, if not recognised In the ideal model, specialist outreach services from by the Australian col ege, are unlikely to be approved as
metropolitan hospitals should only be provided to the larger supervisors.
centres in which resident specialists are based, al owing City based specialists are in a position to make a major
resident specialists to provide services within their catchment contribution to provision of specialist care in rural areas
area. Resident specialists should be closely involved with through their influence on the career patterns of younger
the planning and implementation of any visits by specialists medical graduates, their expressions of support for
from metropolitan areas. Much of the criticism of metropolitan generalist specialists, and their control over access to
subspecialists visiting small towns - as private clinics or funded subspecialty training posts on the part of trainees wishing
through the Medical Specialist Outreach Assistance Program to pursue a generalist career in rural areas.3
[MSOAP] as fly-in, fly-out services - is that this is associated with by-passing of resident general specialists in the larger regional It is critically important to the future of Australian health care centres who inevitably have ongoing responsibility for continuing that the Universities, teaching hospitals and Col eges which
care of patients when problems develop after metropolitan embrace the concepts of excellence accept the challenge
specialists have returned to the city. Resident specialists are to extend their responsibility for such excellence beyond
also concerned at the de-skilling that such activities contribute the limits of the city, and to understand that different models
to. There is an argument for considering on a case-by-case of physician training and service provision will be required if this basis whether access to visiting subspecialists should be is to be achieved.
restricted to referrals from resident general specialists.
New models of service provision
The role of metropolitan specialists in supporting new
New models of service provision establishing more formal models of rural specialist training and service delivery
networks between metropolitan and outer metropolitan/rural The demand for specialists outstrips the supply of doctors. There areas need to be considered in addition to the traditional ‘fly are now over 400 more advanced training specialist posts than in-fly out' model. Although the nature of the networks wil depend there are Australian medical graduates. The number of training on the organisational structure of the services provided through posts has increased by 28% in the past 6 years, but the number the state health departments, they should, where possible, build of graduates has remained relatively constant. Despite these on the links established by the creation of the Rural Clinical increases, only 5% of physician trainees are training in general Schools and University Departments of Rural Health, through medicine and a further 5% are training in geriatrics. Only 3% of which 25% of medical students from each metropolitan medical advanced physician training positions are reported in rural areas. school are required to undertake 50% of their clinical training in By comparison, 40% of physician trainees in New Zealand are rural medicine. The links between the University medical schools
training in general medicine, with many also undertaking and the metropolitan tertiary referral hospitals are already well
subspecialty training with dual certification. One reason for established.
this is that the Health Boards in New Zealand recognise the Examples of the new models are:
importance of general medicine in cost-ef ective service delivery and general medical expertise is recognised as a positive 1. Agreements to assist with provision of specialist services
attribute in securing hospital positions.
based on hospital or university departments rather than The forces favouring the growth of metropolitan subspecialists at the expense of rural generalists are multiple: increasing • The tertiary hospital department recruits an additional subspecialisation, concerns about safe working hours, increasing specialist and each member of the department rotates feminisation of the medical workforce, lifestyle choices, issues to the rural area for periods of up to one year.
around schooling, spouse occupation, and concerns about being • For specialties in which full time 24 hour cover is not unable to re-enter the metropolitan workforce in later years.2 This required, the tertiary hospital department agrees to has led to an increasing dependence on overseas trained doctors provide a regular outreach service for a number of days (OTDs) in rural and regional areas. Other western countries are per week or month as required.
experiencing similar demands and Australia is now competing with these other countries in recruiting such persons. • The tertiary hospitals/Universities support and staff a rural/remote department in a particular specialty.
It is generally acknowledged that a positive rural experience during training assists in a decision to enter rural practice. 2. Longer periods of outreach visits in which the visiting specialist A further problem is the degree of specialisation in the
tertiary hospitals, which has resulted in many specialists
• Contribute to student supervision and training.
being fearful of undertaking the more general work required in rural areas without the range of diagnostic and clinical • Undertake a locum for the rural specialist either for support available in the cities. However, a swing back to
leave or for continuing education.
promoting generalist skills in tertiary hospitals will become
• Undertake an exchange with the rural specialist to enable more necessary to meet the needs of an ageing population him/her to augment their skil s in a metropolitan hospital.
with increasing incidence of co-morbidity, accelerated further by workforce shortages and economic pressures.
• Undertake a practice review for rural specialists (an activity supported in the CPD programs of most Workforce Planning and Distribution
Initiatives required to ensure adequate training of specialists 3. Cross appointments of al rural specialists to tertiary hospitals able to meet the health needs of residents of rural, regional and to facilitate participation in CPD activities, opportunities for outer metropolitan Australia will include: rural specialists to spend several weeks every two or three years in a tertiary hospital, and professional liaison either by • Maintenance or re-establishment of general specialist
telephone, videoconferencing or personal attendance.
units in tertiary hospitals.
4. A more coordinated approach to selection of advanced • Requirements for subspecialists to maintain generalist
trainees and to accreditation of rural training posts to ensure skil s and contribute to care of patients from outside their
that an appropriate proportion of trainees selected for advanced training are those with an interest in rural training • Opportunities for general specialty trainees to be
and practice, and that rural training opportunities are not exposed to emergency departments and intensive care
withdrawn when city vacancies occur. units, and to rotate through subspecialty units to gain skills
5. Formal, co-ordinated regional efforts involving college, rural in the management of acutely ill patients to prepare them for clinical schools and local specialists in setting up schemes for practice in areas with insufficient populations to support units recruiting and training specialist trainees in rural practice.4 fully staffed by specialists in those fields.
Al of these initiatives have occurred informal y at different Creation of salaried positions with academic responsibilities
in teaching and research for generalist specialists in
locations and different times. Some have been more successful metropolitan and regional hospitals.
than others and sustainability can be a problem when the initiative has been introduced informally. These initiatives could • More appropriate triaging and referral of patients to
be supported by funding currently available through different state and Commonwealth programs that at present operate • Review of financial incentives and Medicare rebates
independently rather than as components of an integrated that disproportionately reward procedural specialists in strategy. These include the federal y funded MSOAP, the comparison with non-procedural specialists such as general Support Scheme for Rural Specialists (SSRS), and the Advanced physicians and geriatricians.
Specialist Training Posts (jointly funded with the states). There is considerable consensus amongst jurisdictions on the The barriers to new models of care are probably not most effective and sustainable model that will improve access
predominantly those of funding. However, the chronic inability to specialist services in rural Australia.
to recruit staf has led to reductions in the budgets of many Agreement on a model will assist to: rural health services. If rural residents were to gain access to specialists comparable to that of city residents, costs would • integrate and coordinate the direction of specialist support inevitably increase. With the increasing tendency to salaried positions, this increase would be felt largely by State and Territory • provide a basis for engagement with Medical Colleges on The commitment of the metropolitan hospitals however • provide a basis for engagement with tertiary hospitals on
may be the most difficult to obtain. However, many medical
clinical support required schools, colleges and tertiary referral hospitals already have • form a foundation for strategic service planning substantial commitments to assist development in overseas countries. Such initiatives are professional y stimulating and can • structure services to address special needs of remote and be financial y rewarding for the institution. It would be unfortunate if similar commitments could not be obtained to improving the health of rural and remote Australians. At the same time, the AHMAC Rural Health Policy Sub-committee creation of the rural clinical schools has considerably reduced April, 2004 the teaching load but not the budgets of the metropolitan clinical schools, and it may be reasonable to ask for some assistance with teaching in return. IMSANZ DECEMBER 2004 LETTER FROM FIJI
One of the "joys" of working in a country like Fiji is coming to Should our faith in the whole terms with the lack of resources. One's initial response is horror pharmaceutical industrial – how can you treat patients only with the drugs on an Essential enterprise – the faith that Drug List which is just that? Most new drugs are simply not we have the ability to create real y useful new drugs Having commenced life as a clinical pharmacologist as wel as a – be seriously questioned? general physician, and having chaired the Drug and Therapeutics In other words, are we committee at the Royal Melbourne Hospital for more years than I reaching (or have we care to remember, I am very familiar with the evaluation of drugs, already reached) the end and sympathetic to the need to limit drug availability on financial of the road in our ability grounds. However I have not had the experience previously of to usefully and safely treating patients from such a restricted drug list. chemical y manipulate The Fijian Essential Drug List (EDL) is like the Australian PBS in its function to limit prescribing. If a drug isn't on the EDL, then There are important you basical y can't prescribe it, as most patients cannot af ord the questions that arise if full cost of the drug as purchased from a pharmacy. But the EDL our faith in our ability is much more restricted than the PBS. It usually only contains to create useful new drugs is discarded: one or two representatives from each drug group; for example, for instance, should we still have such a strong patent system?; only one ACE inhibitor (enalapril), one H2 antagonist (ranitidine), should we continue to subsidize drugs on the PBS? two beta-blockers (propranolol and atenolol), and two NSAID I have often wondered at the apparent equanimity of economists (indomethacin and ibuprofen). Most are purchased as generics in accepting the patent system which so radical y distorts from India or Malaysia, and all must meet basic pharmaceutical markets. One would have thought that the proponents of the standards. The EDL contains virtually no drug less than twenty "free market" would more loudly question awarding a monopoly years old because drugs still under patent are unaffordable. So to manufacturers of new drugs who can then charge whatever there are no statins, COX2 inhibitors, angiotensin II receptor they think the market can bear. No doubt it is a reflection of the antagonists, long acting beta2 agonists, and no low molecular strength of our faith in the need for new drugs that the argument weight heparins, just to name a few.
that drug innovation needs protection against competition holds So how handicapped do we feel in our care of patients by not such strong sway.
having access to al these new drugs? The answer is remarkably The original basis of the PBS was to make available new drugs little. There are undoubted problems – for instance the lack of a that were essential, but unaffordable, to most Australians. But statin clearly disadvantages patients who have had a myocardial if the expensive new drugs aren't essential, why should they infarct or a stroke, and we see some patients with severe gastro- be subsidized? Few truly useful drugs have been developed oesophageal reflux who are unresponsive to ranitidine and might in the last 20 years, and unless new products are developed be improved with a proton pump inhibitor- although the individual which have a clear advantage and are able to withstand market disadvantage seems relatively small when one considers the forces, the patent system should be either abandoned or at huge extra costs that would be involved if patented drugs were least modified. to be widely used. We learn to use the drugs that are available One could argue that a new drug must be shown to be cost- and usually in lower doses to avoid side effects.
effective to obtain PBS listing, so that takes care of whether or Our lack of a sense of handicap sets one thinking about how not it is "useful". However, in cost-effectiveness studies the new necessary are the drugs introduced over the last twenty years. treatment is compared to treatments currently available, most of which themselves haven't ever been shown to be cost-ef ective. So comparative cost-ef ectiveness doesn't necessarily mean the (From Page 12)
new drug is useful.
Perhaps we should be limiting patent protection to innovative new agents, and only subsidize on the PBS drugs judged essential. 1. National Rural Health Policy Sub-committee. Improving access to But what government would have the strength to stand up to the specialist services in rural Australia. Discussion paper. April 2004. combined force of the pharmaceutical industry and the medical Copies of complete document available from IMSANZ secretariat (imsanz@racp.edu.au) or So undoubtedly my observation that our lack of access here in 2. Simmons D, Bolitho LE, Phelps GJ, et al. Dispelling the myths about Fiji to new drugs doesn't seem to badly handicap us in our care rural consultant physician practice: the Victorian Physicians Survey. of patients wil remain just that – an observation. However I hope Med J Aust 2002; 176: 477-481.
it at least stimulates thought on our attitudes to new drugs and 3. Kanaragarajah D, Page JH, Hel er RF. Changes in job aspirations during how much we should pay for them.
physician training in Australia. Aust NZ J Med 1996; 26: 652-657.
4. Simmons D, Fieldhouse A, Bolitho LE, et al. Addressing the shortage of From your Pacific correspondent, rural physicians in Victoria: maximizing rural trainee recruitment. Med J Aust 2003; 179: 219-220.
American College of Physicians - Annual Session 2005
14th - 16th April San Francisco, USA
For further information visit: www.acponline.org/cme/as/2005/index.html
RACP Annual Scientific Meeting
8th - 11th May Wellington, New Zealand
For further information visit: www.racp.edu.aum
Society of General Internal Medicine 28th Annual Scientific Meeting
11th - 14th May New Orleans, USA
Visit the website: www.sgim.org/am/index.htm
IMSANZ Annual Scientific Meeting 2005
1st - 4th September Alice Springs, Northern TerritoryEmail: imsanz@racp.edu.au Annual Scientific Meeting of the Canadian Society of Internal Medicine
2nd - 6th November Marriott Eaton Centre, Toronto, Canada
Information: Canadian Society of Internal Medicine
Ottawa, ON K1S 5N8 Tel: 613-730-6244 Fax: 613-730-1116 Email: csim@rcpsc.edu MORE (McMaster Online Rating of Evidence) Project
Other IMSANZ members might consider involvement in this "Clinical Relevance On-line
Rating System", developed by the McMaster University Health Information Research Unit.
"Sentinel Readers" are emailed carefully selected recent publications to rate for both their relevance to clinical practice and for their newsworthiness. Ratings are collated and used to choose and develop evidence based materials tailored to the interests of practising clinicians.
"Sentinel Readers" also benefit directly by receiving current publications as often as they choose, by seeing the ratings and comments of their peers and by having access to highly rated "Stellar Articles".
For us this project has been educational, interesting and enjoyable.
Further details of the MORE project are available at http://hiru.mcmaster.ca/more.
Peter Greenberg (Melbourne)Ian Scott (Brisbane) IMSANZ DECEMBER 2004


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Source: http://www.imsanz.org.au/documents/item/92

Concepto de tesis

Seminario de Metodología de la Investigación Dr. José Manuel Carrillo Hernández UNIVERSIDAD AUTÓNOMA DE DURANGO DIVISIÓN DE ESTUDIOS DE POSGRADO CENTRO DE INVESTIGACIÓN Y DESARROLLO SEMINARIO DE METODOLOGÍA DE LA ELABORADO POR: DR. JOSÉ MANUEL CARRILLO HERNÁNDEZ INVESTIGADOR DEL CENTRO DE INVESTIGACIÓN Y DESARROLLO DE LA U.A.D.

The transcrestal hydrodynamic ultrasonic cavitational sinuslift: results of a 2-year prospective multicentre study on 404 patients, 446 sinuslift sites and 637 inserted implants

Open Journal of Stomatology, 2013, 3, 471-485 OJST http://dx.doi.org/10.4236/ojst.2013.39078 Published Online December 2013 (http://www.scirp.org/journal/ojst/) The transcrestal hydrodynamic ultrasonic cavitational sinuslift: Results of a 2-year prospective multicentre study on 404 patients, 446 sinuslift sites and 637 inserted implants