The depression puzzle. Do the pieces fit?

BACKGROUND: Depression is a common problem in the Australian community. It results in considerable disability. Currently screening tools promoted for detection of depression are nonspecific. They are not diagnostic tools. While people identified by screening are, by definition, at higher risk of depression, the diagnosis still needs to be based on interview findings. Screening tools do not substitute for time spent with patients developing rapport and an understanding of the causes of the depression and formulating possible management steps. Screening alone has not been shown to improve outcomes for people with depression. OBJECTIVE: This article examines the current prevalence of depression in Australia and whether screening tools ultimately contribute to a reduction in morbidity. DISCUSSION: Screening instruments have arbitrary cut off points for identifying patients with depression and their findings regarding prevalence should be applied with caution. If the thresholds are low then 'prevalences' are raised. It is unclear whether all 'cases' detected using screening instruments require clinical intervention.

Current approaches to diabetes control. How good are they?

BACKGROUND: How well are general practitioners currently managing their patients with diabetes and do systems of care have anything to offer? OBJECTIVE: This article examines the benefits and costs of recommended treatments. It looks at evidence on current standards of care for people with diabetes in Australia. It examines the evidence on systems of care and their effect on quality of care and outcomes. DISCUSSION: There is good evidence to support current recommendations regarding management of glycaemia, blood pressure, hyperlipidaemia and the use of aspirin. Early screening and appropriate management of retinopathy, microalbuminuria and at-risk feet is also supported. Despite this, management of diabetes within the Australian community remains suboptimal. Systems of care improve quality of care. The uptake of these more structured approaches to care requires an appropriate mix of incentives, education and support for GPs.

Overweight and hypertensive.

BACKGROUND: Hypertension and obesity frequently coexist in the same patient, with both conditions attracting considerable morbidity. There is also an established correlation between increasing weight and increasing blood pressure. OBJECTIVE: This article provides an overview of the interaction of these two conditions and provides some recommended strategies for dealing with them when they co-exist. DISCUSSION: In dealing with a hypertensive patient whom you consider overweight it is important to establish what their body mass index is, whether they are aware that they are overweight and if they understand the type of problems that may be associated with this. It is also useful to confirm that the patient is in fact hypertensive by checking the way the measurement was taken. Behavioural change is an extremely difficult undertaking and patients need to be ready to change before advice is likely to be heeded. Once a patient is at this stage, having a strategy in which to assist weight loss is more likely to see an effective outcome.

Insulin and type 2 diabetes. Last resort or rational management?

BACKGROUND: Recent evidence indicates that lower glucose levels in people with type 2 diabetes result in fewer complications. People with diabetes generally have sub-optimal glycaemic control. The natural progression of diabetes is characterised by increasing glucose levels requiring increasing therapy. OBJECTIVE: This article explores the possible role of therapeutic insulin in the management of type 2 diabetes. Arguments for earlier use of insulin, illustrative cases and common dilemmas faced when introducing insulin are examined. DISCUSSION: Findings from the United Kingdom Prospective Diabetes Study (UKPDS) are reviewed. It suggests that active and aggressive management of type 2 diabetes in general practice can have a role to play in reducing complications from diabetes. It now appears that insulin has a role earlier in the management of type 2 diabetes.

Challenges facing primary care mental health in Australia.

BACKGROUND: Changes to the organisation of mental health services in Australia and a recognition that general practitioners deliver the great bulk of mental health services to the community have necessitated a re-examination of the role of general practitioners in the clinical area. OBJECTIVE: This article examines controversies in mental health care such as the difficulties with detection, the nature of general practice psychiatry, the inappropriateness of undergraduate training, workforce related issues, mental health services in rural areas and continuing medical education. DISCUSSION: General practice based services for people with mental disorders are distinct in many respects from specialist psychiatric services. Systemic changes need to be made to training for general practitioners, to incentives for delivery of complex care and to the way in which the different health care sectors work together.

Direct observation. A primer for supervisors of doctors in training.

Direct observation and review of videorecordings of registrars in practice are valuable for learning clinical skills. They also engender an atmosphere of disclosure and professional honesty within the discipline of general practice. The theoretical background to direct observation, barriers to carrying it out, and strategies for enhancing the process are discussed.

Common dilemmas in diabetic care.

This article looks at some commonly encountered problems faced by doctors managing diabetes. The increasing prevalence of diabetes, dilemmas relating to insulin use, the use of insulin pens and home blood glucose technologies, concerns with commonly prescribed drugs in the diabetic patient, and advice regarding travel, are discussed.

How do general practice registrars learn from their clinical experience? A critical incident study.

OBJECTIVE: This preliminary study of RACGP registrars in the period of subsequent general practice experience examines the types of clinical experiences from which registrars learn, what they learn from the experiences and the process of learning from such experiences. METHOD: A critical incident method was used on a semi structured interview process. Registrars were asked to recall clinical incidents where they had learnt something of importance. Data were sorted and categorised manually. RESULTS: Nine registrars were interviewed before new categories of data ceased to develop. Registrars learnt from the opportunity to follow up patients. An emotional response to the interaction was an important part of the learning process. Learning from such experiences is haphazard and unstructured. Registrars accessed human resources in response to their clinical difficulties rather than text or electronic based information sources. CONCLUSION: Registrars should be aware of their emotional responses to interactions with patients; these emotional responses often indicate important learning opportunities. Clinical interactions and resultant learning could be made less haphazard by structuring consultations with patients with specific problems. These learning opportunities should be augmented by the promotion of follow up of patients.

Value-adding in the rural training stream: a release program for hospital-based rural training stream registrars.

This paper describes a release program developed in 1995 for year I hospital based GP registrars in the Rural Training Stream of the Royal Australian College of General Practitioners Training Program in South Australia. Background, objectives, content and organisation, and evaluation are described. The 1996 program that developed from this pilot is also described.

Critical thinking within the RACGP Training Program and the college examination.

Current developments with the formalisation of the Program's curriculum provide the opportunity for the College to clarify its position on this important educational area. While not all GPs want to be involved in research, increasing demands for accountability for expenditure of insurer's (ie the government's) funds are inevitable. Skills related to audit of actual practice process and outcomes are likely to be required in the near future. The option of developing an audit project segment for the College examination should be considered. Critical appraisal skills could be assessed in the context of the development of standards for the audit. Similarly the efficacy of the Training Program in the development of accurate self-assessment skills in trainees should be researched. If found lacking, steps should be put in place to ensure that these educational processes become effective.

The importance of assessing risk in prevention.

So all is not as simple as it seems! When instituting some preventive strategy, be it screening or treatment, one needs to pay particular attention to the initial level of risk. Treating low risk patients can be a high risk strategy.

The gentle art of feedback.

In itself giving feedback effectively is not difficult. However, it requires time, planning and good communication skills. It is labour-intensive. It is an essential part of supervision. Adequate supervision needs to be a high priority in all our teaching institutions. People do not learn by 'osmosis' as many claim. Learning can be accelerated and enhanced to a great degree by improving our feedback skills.

Diet and Type 2 diabetes. Guidelines for general practice.

Type 2 diabetes (NIDDM) is common and increasing and results in enormous costs to all concerned. The average Australian diet is inappropriate for this condition, which regular exercise and healthy eating could delay or prevent even in high risk groups (family history, age over 50 years, over-weight). This article outlines a practical programme that general practitioners can use for people with, and people at risk of, Type 2 Diabetes and provides a comprehensive Further reading list.

Chronic fatigue syndrome. A review from the general practice perspective.

There is no doubt that the chronic fatigue syndrome exists. It is a condition that is debilitating and of unknown cause. Research into chronic fatigue syndrome demonstrates possible psychiatric or organic causes. The truth may be somewhere in between. Evidence for the existence of an ongoing chronic infection is now not convincing. Treatment should be based on supportive counselling, explanation, psychiatric help (both pharmacological and non pharmacological) and a graded programme of increased activity with the eventual aim of resumption of full functioning.