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FIJI

GENERAL

VOLUME 11 NUMBER 2 JUNE 2004


Journal of The Fiji College of General Practitioners

THE MEDICO-LEGAL CLIMATE IN FIJI MEDICO-LEGAL REPORTS DOCTOR & THE LAW: COMPLAINTS MECHANISM THE PHYSIOLOGICAL RESPONSES IN STRESS OSTEO-ARTHRITIS IN GP VIEWPOINT ON CONTRACEPTION
Theme: Doctor and the Law

General Practitioner Volume 11 Number 2 2004 25

26 General Practitioner Volume 11 Number 2 2004

DOCTOR & THE LAW: COMPLAINTS MECHANISM

CONTENTS
EDITORIAL ..........
MEDICO-LEGAL COLUMN

28

THE MEDICO-LEGAL CLIMATE IN FIJI ............................................................................ 29 Hon Justice Anthony Gates, Suva
Editor-In-Chief Dr N Sharma, MBBS, PG Cert Womens Health, DIP OBST, FFCGP Contributing Editors: Internal Medicine Dr G Rao, MB, BS, FRACP Rehab/Sports Medicine Dr J C Maharaj, DSM, MMed (UNSW), MPH, DCH, MASCH (Aust) Pathology Dr K Singh, DSM, FRCPA E.N.T., Head & Neck Surgeon Dr P Narayan, MB, BS, MS Rheumatology Dr S Sharma, MBBS, FRACP Cardiology Dr V Kapadia, MBBS, FRACP
General Practitioner is the professional journal of the Fiji College of General Practitioners and is published quarterly by Islands Business International Limited Advertising Correspondence to: Dr Ram Raju 2 Lodhia Street, Nadi, FIJI Tel: +679 6700-240 E-mail: rraju@connect.com.fj Editorial Correspondence to: Dr Neil Sharma Fiji College of General Practitioners Po Box 1297, Suva, Fiji Islands. Tel: +679 338 7181. Fax: +679 338 0107. Email: nsharma@connect.com.fj Statements, opinions and points of view expressed by the writers are their own and do not necessarily represent those of the publisher, editor or the Fiji College of General Proactitioners. Information contained in this publication may be correct only at the time it was originally obtained by the writers and may be subject to change without notice. Designed & Typeset by Islands Business International Ltd. Colour Separations by Graphics Systems. Printed by Star Printery Ltd. Copyright. 2004. All rights reserved. No part of this publication may be reproduced without the written permission of the publisher

MEDICO-LEGAL COLUMN

MEDICO-LEGAL REPORTS ....................................................................................................... 39 Vipul M Mishra, Ba


MEDICO-LEGAL COLUMN

DOCTOR & THE LAW: COMPLAINTS MECHANISM .............................................. 41 Aiyaz Sayed-Khaiyum, Suva
MEDICO-LEGAL COLUMN

DOCTOR & THE LAW: ABORTION LAWS ...................................................................... 44 Neil Sharma, Suva THE PHYSIOLOGICAL RESPONSES IN STRESS Rajeshwar Sharma, Suva
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OSTEO-ARTHRITIS IN GENERAL PRACTICE ................................................................ 52 Wahid Khan, General Practitioner, Suva VIEWPOINT ON CONTRACEPTION .................................................................................... 57 Neil Sharma, Suva
CLINICAL AUDIT

THE NATURE AND EXTENT OF MENOPAUSE SYMPTOMS IN A FIJI GP SETTING ................................................................................ 60 Neil Sharma, Suva

LETTERS TO THE EDITOR ........................................................................................................ 62 SUMMARY OF EVALUATION FOR FIJI MEDICAL WRITERS WORKSHOP 27TH/28TH MARCH 2004 ........................................................................... 64 Dr. Lyn Clearihan, Melbourne, Australia

CREATIVE CORNER ....................................................................................................................... 66 Nashika Sharma, Suva

General Practitioner Volume 11 Number 2 2004 27

EDITORIAL

COLLEGIALITY
Greetings from the Publication Team. This issue of the Fiji General Practitioner arrives on your desk after the successful annual conference of 2004. The last scal year has been a colourful series of events. We entered the eleventh year as a spirited force bringing out the journal despite widespread political instability and searching for funding sources to keep the journal alive. Islands Business International needs to be acknowledged for supporting our efforts as they made no prots in the last three journals published. The publication committee is indebted to managing director Godfrey Scoullar and his team. It has been my pleasure working with them. The current issue Vol. 11, No.2; June 2004, is the rst issue after the death of our Inaugural patron, Ratu Sir Kamisese Mara. Saddened by his loss, we pray for eternal peace for him and earthly comfort to his wife and family. May his spirit live in our hearts and minds. A contingent of General Practitioners representing the college paid further tribute to him as part of the traditional reguregu presented at Government House. As a further tribute we published a piece of writing that Ratu Mara enjoyed in his life. A piece of writing from the late Mother Teresa of Calcutta,titled, You and God, is in this issue. Each year the incoming college executive needs to take stock of the colleges progress or its lack in the previous year. When the eld gets muddy, vision limited, strategies unrealised and progress hampered, the incoming council needs to widen their portfolios and think laterally. New strategies and directions must be sought. That is what progress is about. In the end the membership must benet. To this effect the publication committee will need new blood and direction. I plan to take a career redirection and will not be in a position to continue as the editor-in-chief. The rst medical writers conference, conducted over the 27th-28th March 2004 weekend, was well attended and an evaluation of the event forms part of this issue too. A sizeable number of members participated along with staff members of the Fiji School of Medicine and three senior medical students. We commend Dr Lyn Clearihan for establishing an attractive, interactive session. Dr Tony Palmer with his technological logistical support complimented the role of Dr. Clearihan to make the learning process meaningful. I am condent that there is potential within that group of participants to carry the Fiji General Practitioner forward. Future publications committees need the support of executive council members in providing themes in advance, to provide time for contributors and sponsors to group and support the journal. A concerted effort at seeking an advertising base is also essential. Thirdly, members need to contribute by at least supporting the publication committee with Letters to the Editor at the very least. The role of editor-in-chief and a former past president sitting in on the executive council had its moments. The going has not been smooth. We have crossed swords and hurt ourselves despite commonalities. Some attacks have been labelled undiplomatic. One cannot always sit on the beach and see their sandcastle obliterated by the rising tide. I leave the editor's position with comfort that we have completed a decade of publication. The learning curve was steep, difcult but rewarding to the spirit. The journal is on hard copy and in electronic vision. Some day we possibly can set it up on our own website. That is a dream too which can be realised. We have no debts and have provided the medical school fodder for exchange of journals. This benets the Fiji medical student community. In the world there are some who sit and party with all, a few who stand up and are counted and fewer still who move on when the counting is over. Au revoir Neil Sharma Editor-in-Chief

28 General Practitioner Volume 11 Number 2 2004

MEDICO LEGAL COLUMN

THE MEDICO-LEGAL CLIMATE IN FIJI


The Hon Mr Justice Anthony Gates
1. Every learned profession nowadays regards it as essential that earnest efforts be brought to bear on the business of continuing education. Time has to be allocated not just for the task of reading the journals but also for the listening to and the delivering of papers with ones peers and for the making of contributions to current debate. New ideas and new methods often bring new ethical problems. Your contribution is required by the profession. It is encouraging therefore to see Fijis doctors attending conferences such as this. 2. Old dogs, so long as they are still allowed to wield a knife, if you will forgive the mixture of metaphor, must learn new tricks. Speaking as an old dog myself, it is surprising how stimulating rather than how daunting the learning or re-learning process can be, once you get on with it. 3. I see from todays lean programme that you have addressed topics of signicant operational relevance for general practitioners. Such self-analysis is refreshing. The duty to treat competently What is negligent treatment? The original Bolam Test 4. This test arose out of the case of Bolam v. Friern Hospital Management Committee (1957) 2 ALL ER 118. The report of the case simply set out McNair Js direction to the jury in a civil trial. The decision was not appealed, although the directions have been subject to some ne tuning. 5. The patient in that case suffered from the after-effects of a mental illness of a depressive type. He entered hospital and the consultant psychiatrist advised him to undergo electroconvulsive therapy. The psychiatrist did not warn the plaintiff of the risks involved, one of which was the risk of fracture. The plaintiff signed a form consenting to the treatment. 6. No relaxant drugs were administered to the plaintiff prior to the treatment. In the course of this treatment the plaintiff sustained severe physical injuries consisting in the dislocation of both hip joints with fractures of the pelvis on each side which were caused by the head of the femur on each side being driven through the acetabulum or cup on the pelvis. 7. The medical evidence showed that competent doctors held divergent views on the desirability of using relaxant drugs, and restraining the patients body by manual control, and also on the question of warning a patient of the risks of electro-convulsive therapy. The plaintiff contended that the defendants were negligent in permitting the doctor to administer electro-convulsive therapy without the previous administration of a relaxant drug, or without restraining the convulsive movements of the plaintiff by manual control, and in failing to warn the plaintiff of the risk which he was taking in consenting to have the treatment. 8. After the judges direction the jury found the Hospital authorities and doctors had not been negligent. In summary the judges direction had been as follows:(i) a doctor is not negligent, if he is acting in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art, merely because there is a body of such opinion that takes a contrary view. This principle had been stated by Lord President Clyde in Hunter v. Hanley (1995) S.L.T. at p.217 applied (see p.122, letter B, post). (ii) that the jury might well think that when a doctor was dealing with a mentally sick man and had a strong belief that his only hope of cure was submission to electro-convulsive therapy, the doctor could not be criticised if, believing the dangers involved in the treatment to be minimal, he did not stress them to the patient (see p.124, letter G, post). (iii) in order to recover damages for failure to give warning the plaintiff must show not only that the failure was negligent but also that if he had been warned he would not have consented to the treatment (see p. 124, letter I, post). 9. Put another way was the doctor acting in accordance with a perfectly well recognised school of thought? The courts recognised that in matters involving medical expertise, there is ample scope for genuine difference of opinion and that a practitioner is not negligent merely because his or her conclusion or procedure differs from that of other practitioners Rogers v. Whittaker (1992) 175 CLR 479 at p.484. 10. McNair J referred to the case of Roe General Practitioner Volume 11 Number 2 2004 29
Justice Anthony Gates, Suva

v. Ministry of Health (1954) 2 ALL ER 131 and cited two passages from the Court of Appeals decision upholding the primary judges nding that the anaesthetist had not been negligent. Two men in the prime of life required minor operative treatment, but after an anesthetic mishap, each came off the operating table paralysed. At p.137 in Roe, Denning LJ said: If the anaesthetists had foreseen that the ampoules might get cracked with cracks that could not be detected on inspection they would, no doubt, have dyed the phenol a deep blue; and this would have exposed the contamination. But I do not think their failure to foresee this was negligence. It is so easy to be wise after the event and to condemn as negligence that which was only a misadventure. We ought always to be on our guard against it, especially in cases against hospitals and doctors. Medical science has conferred great benets on mankind, but these benets are attended by considerable risks. Every surgical operation is attended by risks. We cannot take the benets without taking the risks. Doctors, like the rest of us, have to learn by experience; and experience often teaches in a hard way. Something goes wrong and shows up a weakness, and then it is put right. That is just what happened here.

11. And at p.139 his lordship concluded: One nal word. These two men have suffered such terrible consequences that there is a natural feeling that they should be compensated. But we should be doing a disservice to the community at large if we were to impose liability on hospitals and doctors for everything that happens to go wrong. Doctors would be led to think more of their own safety than of the good of their patients. Initiative would be stied and condence shaken. A proper sense of proportion requires us to have regard to the conditions in which hospitals and doctors have to work. We must insist on due care for the patient at every point, but we must not condemn as negligence that which is only a misadventure. 12. Lord Scarman interpreted the Bolam principle in these terms: The Bolam principle may be formulated as a rule that a doctor is not negligent if he acts in accordance with a practice accepted at the time as proper by a responsible body of medical opinion even though other doctors adopt a different practice. In short, the law imposes the duty of care: but the standard of care is a matter of medical judgment.

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30 General Practitioner Volume 11 Number 2 2004

Sidaway v. Governors of Bethlehem Royal Hospital (1985) AC 871 at p.881. 13. The Bolam test was applied by the House of Lords in Bolitho v. City and Hackney Health Authority (1998) AC 232. The patient was a 2 year old child called Patrick with respiratory difculties. He was admitted to the prestigious St. Bartholomews Hospital in London. On his rst admission he was treated for croup and discharged home on 15 January. His parents brought him back on 16 January. On 17 January at 12.40 pm the Senior Paediatric registrar was called by phone to attend by an experienced nurse. She told the doctor that the patient had awful respiratory sounds and she assessed something was acutely wrong. 14. The child then recovered and began walking. At 2pm another episode occurred, similar to the 12.40pm incident. It seemed as if something was stuck in the throat. The Registrar was again telephoned. She was on clinic this time and said she would send a Senior House ofcer instead. Then the child went pink again and became very chatty and lively. Neither doctor attended. The Senior House ofcer said the battery on her bleeper was at and she never got the message to attend. 15. At 2.30pm the patient suffered a collapse of his respiratory system which was entirely blocked and he was unable to breathe. As a result he suffered a cardiac arrest. 16.He was revived but there was a period of some nine or ten minutes before the restoration of respiratory and cardiac functions. In consequence the boy sustained severe brain damage, but before judgment was given in this case he died. 17. It was accepted by the defence that the senior paediatric registrar was in breach of her duty of care after receiving the telephone calls in not having attended the child or arranged a suitable deputy to do so. But the question was; would the cardiac arrest have been avoided if the registrar or a suitable deputy had attended as they should have done? The issue was causation. 18. It was common ground that intubation to provide an airway would have ensured that the respiratory failure did not lead to a cardiac arrest, and secondly that such intubation would have had to be carried out, if at all, before the nal catastrophic episode. 19. The judge heard from no less than 8 medical experts, all of them distinguished. Five of them were called on behalf of the child and were all of the view that, at least after the second episode, any competent doc-

tor would have intubated. The three for the defence all said intubation was not appropriate in this case. 20. Of the leading defence witness, Dr Dinwiddie, Consultant Paediatrician in Respiratory Diseases at the Hospital for Sick Children, Great Ormonde Street, the primary judge had said (at p.241): I have to say of Dr. Dinwiddie also, that he displayed what seemed to me to be a profound knowledge of paediatric respiratory medicine, coupled with impartiality, and there is no doubt, in my view, of the genuineness of his opinion that intubation was not indicated. [Will your efforts as an expert witness win such laurels from the judge, you may ruminate?] 21. The plaintiffs counsel submitted that the defence experts view was simply not logical and sensible: (at p.241 again): Given the recent and the more remote history of Patricks illness, culminating in these two episodes, surely it was unreasonable and illogical not to anticipate the recurrence of a life-threatening event and take the step which it was acknowledged would probably have saved Patrick from harm? This was the safe option, whatever was suspected as the cause, or even if the cause was thought to be a mystery. The difculty of this approach, as in the end I think Mr. Brennan acknowledged, was that in effect it invited me to substitute my own views for those for the medical experts. 22. Lord Browne-Wilkinson in Bolitho agreed with counsels argument that a defendant doctor cannot escape liability for negligent treatment or diagnosis just because he tenders evidence from a number of medical experts who are genuinely of opinion that the defendants treatment or diagnosis accorded with should medical practice. The practice to be acceptable had to be that approved by a responsible body of medical men. 23. The use of these adjectives responsible, reasonable, and respectable all show that the court has to be satised that the exponents of the body of opinion has a logical basis (Lord Browne-Wilkinson at p.242). 24. In Hucks v. Cole [1994] 4 Med. LR 393 (a case from 1968) a doctor failed to treat with penicillin a patient who was suffering from septic spots on her skin though he knew them to contain organisms capable of leading to puerperal fever. A number of distinguished doctors gave evidence that they would not in the circumstances have treated with pencillin. The Court of Appeal found the defendant to have been negligent. Sachs LJ at p.397 said:

General Practitioner Volume 11 Number 2 2004 31

When the evidence shows that a lacuna in professional practice exists by which risks of grave danger are knowingly taken, then, however small the risk, the court must anxiously examine that lacuna particularly if the risk can be easily and inexpensively avoided. And continued: On such occasions the fact that other practitioners would have done the same thing as the defendant practitioner is a very weighty matter to be put on the scales on his behalf; but it is not, as Mr. Webster readily conceded, conclusive. 25. One must guard too against the carrying on of practices sometimes known as Fiji Style. In Hong Kong a conveyancing practice was adopted amongst lawyers for the handling of mortgage transactions. It was known as Hong Kong style. This involved the paying over of purchase monies against an undertaking by the solicitors for the borrowers subsequently to hand over the executed documents. This practice opened the way for dishonest solicitors to abscond with the loan monies. Lord Wilkinson commented (Bolitho at p.242): The Privy Council held that even though completion in Hong Kong style was almost universally adopted in Hong Kong and was therefore in accordance with a body of professional opinion there, the defendants solicitors were liable for negligence because there was an obvious risk which could have been guarded against. Thus, the body of professional opinion, though almost universally held, was not reasonable or responsible. 26. In Bolitho, the House of Lords agreed with the judge and with Dr Dinwiddies opinion that it was the better course to run a small risk of respiratory collapse rather than to submit the child to the invasive procedure of intubation. They considered it to have been a logical opinion that the symptoms did not show a progressive respiratory collapse and that intubation was a major undertaking with mortality and morbidity attached that properly could have been avoided. Causation had not therefore been made out. The duty to provide relevant information and advice, and to warn of risk 27. In some cases, such as in a psychiatric case where it might be counterproductive to warn a nervous patient of all of the risks of treatment, or in an emergency when deciding to operate on a comatose patient, it will not be possible to comply properly, or at all, with such a duty. In other cases to provide information would be inconsistent with a doctors obligation to have regard to the patients best interests. This is called the doctors therapeu-

tic privilege. 28. In Rogers v. Whitaker [1992] 175 CLR 479 the plaintiff Mrs Whitaker had for many years been almost blind in her right eye. A consultant ophthalmic surgeon advised her that an operation would improve the appearance of the eye and probably restore signicant sight to it. The operation was conducted by the Appellant with the required skill and care. The plaintiff succeeded in her claim against the surgeon on the basis that he had failed to warn her of the risk that she might develop sympathetic ophthalmia in her good eye, the left eye. This in fact occurred, and she became blind in the left eye, leaving the Plaintiff almost totally blind. 29. In the Court of Appeal and the High Court, the Plaintiff retained her award of damages which was a little over A$800,000. 30. Even in Sidaway not all of the judges were content to apply the Bolam test to the doctors task of giving advice or a warning. Lord Bridge of Harwich (with whom Lord Keith of Kinkel agreed) though accepting that the Bolam test meant primarily the issue was to be decided on expert medical evidence, considered that disclosure of the risk may be necessary irrespective of the existence of a responsible body of medical opinion which would not have so disclosed. 31. Lord Scarman dissenting said (at p.456): In my view the question whether or not the omission to warn constitutes a breach of the doctors duty of care towards his patient is to be determined not exclusively by reference to the current state of responsible and competent professional opinion and practice at the time, though both are, of course, relevant considerations, but by the courts view as to whether the doctor in advising his patient gave the consideration which the law requires him to give to the right of the patient to make up her own mind in the light of the relevant information whether or not she will accept the treatment which he proposes. 32. But if a patient seeks answers to questions pre-operation the patient should normally be supplied with truthful answers. Such questioning by the patient alerts a doctor to the fact that the patient has thereby revealed concern for the risks involved and attached signicance to those risks. 33. The position on advice, at least in Australia, and probably in Fiji also, is as put by the court in Rogers v. Whitaker (at p.487): Further, and more importantly, particu-

32 General Practitioner Volume 11 Number 2 2004

larly in the eld of non-disclosure of risk and the provision of advice and information, the Bolam principle has been discarded and, instead, the courts have adopted the principle that, while evidence of acceptable medical practice is a useful guide for the courts, it is for the courts to adjudicate on what is the appropriate standard of care after giving weight to the paramount consideration that a person is entitled to make his own decisions about his life. 34. In F v. R (1983) 33 SASR 189, a woman, who had become pregnant after an unsuccessful tubal ligation, brought an action in negligence alleging failure by the medical practitioner to warn her of the failure rate of the procedure. The failure rate was assessed at less than 1 per cent for that particular form of sterilization. The court refused to apply the Bolam principle. King CJ said: The ultimate question, however, is not whether the defendants conduct accords with the practices of his profession or some part of it, but whether it conforms to the standard of reasonable care demanded by the law. That is a question for the court and the duty of deciding it cannot be delegated to any profession or group in the community. 35. King CJ considered (at pp.192-193): that the amount of information or advice which a careful and responsible doctor would disclose depended upon a complex of factors: the nature of the matter to be disclosed; the nature of the treatment; the desire of the patient for information; the temperament and health of the patient; and the general surrounding circumstances. Many subsequent cases followed this approach, including Rogers (at p.489) citing it as correct. 36. The choice to undergo an operation must be based on proper information, and the choice will be rendered meaningless if it is made on the basis of inadequate information or advice. In Rogers the risk to the Plaintiff was material. A reasonable person in the patients position would be likely to attach signicance to the risk, and thus required a warning. It would be reasonable for a person with one good eye to be concerned about the possibility of injury to it from a procedure which was elective. The duty to attend: Is there a doctor in the house? 37. I mention briey the case of Woods v. Lowns (1995) 36 NSWLR 344. This case traversed many issues but I mention it for one reason only. It dealt with the question of emergency treatment and the consequences

of negligence arising in such circumstances. 38. The Plaintiff was an eleven year old boy who suffered a major and prolonged epileptic t status eplilepticus that caused him brain damage and rendered him a quadriplegic. His elder sister ran to a nearby surgery of a general practitioner, the defendant, and informed him of the situation. The sister asked the doctor to come back with her immediately. The doctor refused. Eventually a specialist intensive care ambulance was called but by then the brain had been too long deprived of oxygen. 39. The doctor had been called between 8-9 am at his home and surgery. He told the boys sister to have the tting boy brought to the surgery. This was not practicable. On being pressed to come to the unit about 5 minutes walk away, the doctor had said No I wont come. The doctor in evidence denied all of this account. The judge accepted the young girls account. There was supporting evidence of the father also. The judge commented I did not form a favourable impression of Dr. Lowns who appeared extremely defensive and increasingly uncomfortable as the cross examination proceeded. 40. The position in law was summed up by the judge as follows (at p.354): In general the common law does not impose a duty to assist a person in peril even where it is foreseeable that the consequence of a failure to assist will be the injury or death of the person imperilled. Something other than the foreseeability of harm is required before the law imposes a duty to intervene. It has been held in other common law jurisdictions that a doctor is under no duty to attend upon a person who is sick, even in an emergency, if that person is one with whom the doctor is not and never has been in a professional relationship of doctor and patient. 41. There had been no Australian authority in which the general proposition had been specically applied in respect of a medical practitioner. The general principle was clear and there had been no Australian case in which a doctor had been held liable for damages because of a failure to attend upon and treat someone who was not already his patient. 42. The judge found that the doctor/patient relationship never came into existence between the doctor here and the Plaintiff. The Plaintiffs counsel urged instead that there existed a relationship of proximity between Patrick Woods and the doctor as to give rise to a duty of care on the part of the defendant. 43. Badgery-Parker J therefore concluded

General Practitioner Volume 11 Number 2 2004 33

that (at p.359): notwithstanding the general principle of the common law that there is no obligation of rescue, circumstances may exist in which a medical practitioner comes under a duty of care, the content of which is a duty to treat a patient in need of emergency care, such as will give rise to a cause of action for damages for negligence in the event of a breach of that duty consisting in a failure to afford such treatment as is requisite and as is within the capacity of the individual practitioner to give. 44. When would the duty of care, the duty to attend arise? Badgery-Parker approached it this way (given at p.359): I have no difculty in nding in the facts established by the evidence in this case, additional elements of physical proximity, circumstantial proximity and causal proximity which in combination with the more general matters to which I have referred, created such a relationship of proximity between the rst defendant and Patrick Woods as to attract a duty of care. As to physical proximity, I would identify the obvious fact that a specic request was made to the rst defendant by Joanna Woods to treat Patrick at a place which was in fact within 300 metres and within three or four minutes walk of the doctors house. In terms of causal proximity, I would identify the circumstance that the condition of the plaintiff as made known to the defendant by Joanna was one which the defendant recognised as a major medical emergency, life threatening and calling for urgent attention. Whether the following be characterised as aspects of causal proximity or circumstantial proximity matters not the facts are that Dr. Lowns knew what treatment was appropriate, knew what the consequence would be or was likely to be if the plaintiff and was equipped to treat him. Aspects of circumstantial proximity included that the rst defendant was at his place of practice (in a professional context) ready to begin his days work and not yet occupied in any other professional activity which would preclude his treating the plaintiff. He must surely have realised that the girl had come to him because he was the doctor closest to the patient. The circumstances were clearly such that any refusal or failure on his part, without reasonable cause, to attend on Patrick Woods would constitute professional misconduct within the denition in 27(1) of the Medical Practitioners Act. There were two relevant negative circumstances what was asked of him involved no health or safety risk to himself, and he was not disabled by any physical or mental condition from travelling to and treating the plaintiff (for example, he was not tired, ill or inebriated). 45. You will no doubt consider amongst

yourselves how best to deal with advice to patients concerning treatment, preventive measures, operations, and procedures. It would seem a safe procedure to record what was discussed, and of which risks you gave explanation and warning. Equally it would be sound to ask the patient to sign the note you make acknowledging the discussion, as well as signing a formal consent document for your procedure once decided. Fiji Case No.1 Jona Moli v B & 2 Others (unreported) Suva High Court Civil Action No. 335.98S; 4 April 2003 46 This was a decision of Mr Justice Pathik. The case concerned diagnosis and treatment. Jona Moli lived in a village 20 kms from Nausori Health Centre. On 1 January 1998 at about 4pm he brought his 10 year old daughter to the Health Centre. She complained of pain in her abdomen. A staff nurse took her temperature and gave her Panadol and oral re-hydration salt. Dr. A attended her. The father informed the doctor that his daughter was vomiting and had severe internal stomach pains. 47. Dr. A was said to have slightly pressed upon the girls stomach and then prescribed further Panadol, and ORS every 10 minutes. She was kept in a cubicle for less than half an hour. Dr A told the father that there was an epidemic of dengue fever and that his daughter had the same symptoms and therefore probably had dengue. 48. The father wanted his daughter kept in the hospital. Public transport from the village to Nausori was infrequent, only 2 buses a day. Dr. A declined to do so, but told him to bring his daughter back if the situation worsened. 49. The father returned home with the daughter. At rst her symptoms appeared to improve. But then the pain and the vomiting returned. First the father took his daughter to the Namara Health Centre before being advised to bring her on to Nausori. He arrived at Nausori by 9am on 4 January 1998. 50. This time they saw a Dr. B. The daughter vomited in front of the doctor. He prescribed more Panadol and ORS, and prescribed an intravenous and sponge bath. They spent the whole day at the Centre, the girls condition deteriorated until 4pm when she was taken by ambulance to the CWM Hospital. 51. At the childrens ward, blood samples and x-rays were taken. There was no evidence in the hospital folder to say what results were obtained. The doctors told the father they

34 General Practitioner Volume 11 Number 2 2004

were still assuming that she had dengue. After 2 hours she was moved to the Intensive Care Unit. A urinal plastic was attached to the girls urinal system. The father stayed with his daughter throughout the night until 3am, when he noticed she was having difculty breathing. There were no nurses or doctors around. He found and awoke a sleeping nurse who then called a doctor. 20 minutes later a doctor arrived. He started to pump the childs chest and stomach. There was no change in her condition. She died at 5am. 52. The post mortem revealed that she died of a perforated gangrenous appendicitis with diffuse peritonitis and subphrenic abscesses. It was estimated that the appendix would have ruptured on 2 January. 53. On the day of referral 4 January Dr B from Nausori had earlier contacted Dr C at the CWM by telephone to forewarn him of the possibility of the patient having appendicitis. This opinion was included in the referring doctors report also. When the patient was taken to the Intensive Care Unit she had not been referred for a surgical opinion. The medical folder bore no evidence of any results of stool, blood or urine tests. The court concluded Dr Bs forewarning was ignored by the CWM doctors. 54. Evidence for the State suggested that an appendicitis was a difcult condition to diagnose. This opinion nds some support in Tabers Cyclopedic Medical Dictionary 18th edition 1997 which estimated that of all appendices removed, between 10-30% were found to be normal. 55. Dr A admitted the ndings made at the Centre were not conclusive and that further tests should have been carried out. At the CWM, the consultant Dr D appears to have had nothing to do with the patient, though the patient was listed on the folder as being under that consultants care. The paediatrician Dr E did not immediately attend to the child upon her arrival by ambulance. When that doctor did see her, she admitted that she was unable to make a denite diagnosis. 56. At 9pm a Dr F saw the patient. He said she was in septic shock and not t for surgery. If an operation had been done at that time she would have died he said. He hoped to stabilize the patient rst and then consider if surgery was necessary or possible. It is not clear from the judgment what procedure was being contemplated since this doctor said if I had been able to diagnose appendicitis when I examined Mereseini I would not have been able to recommend a different treatment to that recommended. It appears that appen-

dicitis had still not been diagnosed until after the post mortem results were known. 57. A Dr G said there was no report from an anaesthetist in the folder stating an opinion as to whether this patient could have withstood an operation. He considered an operation could still be attempted even after an appendix has ruptured. This view was conceded by the defence medical expert also. 58. There appeared to have been a failure to diagnose all down the line here, a lack of thoroughness in getting to the root of the problems, a failure to expedite matters once the problem was getting out of control, and then nally a failure of will. The judge said (at p.17) Despite Dr. Bs intimation to the doctor at CWMH that he suspected appendicitis on 4 January. No attention was paid to this diagnosis. This clearly indicates how far off the beam the doctors at CWMH were in their own diagnosis if there was any (diagnosis). 59. One must not ignore the constraints of the medical profession in cases of this kind. Availability of beds, time, staff, the number of patients to see, time to make adequate notes of symptoms and ndings, ability to follow through on tests, can all prove unsatisfactory factors in diagnosis. Phillips in his text Medical Negligence Law at pp.16-17 summarised the cold rigour of what the law demands, in this way: The test for medical negligence is essentially objective, and does not therefore take formal account of a doctors experience, level of qualications, the resources available within that doctors practice or hospital, or even how many hours may have been worked prior to the incident. It therefore concentrates upon the relationship between the doctor and patient and generally excludes other considerations. 60. The Court found Dr A negligent. Of the doctors at the CWM, the Court said that they could also be tarred with the same brush as Dr A but the degree of blame attaching to them is much less than Dr A. As doctors, you may have a variety of opinions on where blame should rest in such circumstances. The court awarded damages and costs totalling $34,150. Fiji Case No. 2 Jone Maka and A-G v Broadbridge (unreported) Court of Appeal, Fiji, Civil App. No. ABU0063.01S; 30 May 2003 61. Mr Broadbridge as plaintiff had succeeded in a claim before Byrne J. An army truck had collided with his private car. Mr Broadbridge sued the army driver for neg-

General Practitioner Volume 11 Number 2 2004 35

ligence. That part of the claim was upheld by the appeal court. He also claimed against the Government for negligent treatment he had received whilst at the CWM Hospital. The appeal court dismissed the claim for medical negligence. 62. Mr Broadbridge was admitted to the CWM Hospital on 20 April 1991. On the same day he was diagnosed as having a fracture of the forearm bone and a fracture of the hip joint. He was in considerable pain, particularly from the hip injury. He received treatment of traction and a plaster cast for the hip joint fracture. 63. On 24 May 1991 he was due to go home. The physiotherapist considered there was something seriously wrong. A doctor was called, who obtained another x-ray of the hip, following which Mr Broadbridge was re-admitted. He was seen by an orthopaedic surgeon. The hospital notes of 29 May recorded x-ray shows (posterior) dislocation of (right) hip. 64. The judge held Mr Broadbridge had been wrongly diagnosed at the CWM Hospital and that had impaired the chances of success of the operation which was later carried out. The plaintiffs lawyers relied on the allegation that there was a failure to diagnose the hip

fracture in a timely way. 65. The Court of Appeal said it was necessary to establish on a balance of probabilities three things. First it was necessary to prove there had been a failure to diagnose the dislocation prior to 28 May; second that the failure was a breach of the duty of care, and third, that the breach had contributed to his ultimate medical condition. 66. The evidence as to when the dislocation was diagnosed was unclear. Mr. Broadbridge eventually went to New Zealand for the hip operation. The surgeon at the Wakefield Hospital in Wellington said: Unfortunately the dislocation was not diagnosed and when he was referred to me in Wellington some two months later the hip was still dislocated. This presented a very severe situation with the opportunity of complete correction being zero. 67. The dates of diagnosis had not been adequately explored at trial. A diagnosis had been reached no later than 28 May 1991. On the one hand the judge concluded the diagnosis had not been made by the day the CWM was to discharge the patient, since they would not have discharged him if they were aware he had a dislocated hip. On the other hand, Broadbridge had said in evidence that he

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36 General Practitioner Volume 11 Number 2 2004

was initially diagnosed with a dislocated right hip and multiple lacerations. The consultant surgeon testied that the patient had been clinically assessed on the day of admission. But the consultant was unable to refer to any written record of such diagnosis. 68. At the trial the following exchange had taken place between judge and one of the surgeons in the course of evidence: Judge: Q: Mr X (a surgeon witness), look at 7.1 would you please. Youve already mentioned under the heading History, Unfortunately, the dislocation was not diagnosed. I ask you, in your experience, should it have been? Mr X: A: I would have been disappointed if I had missed that. Judge: Q: I s t h a t b e i n g e uphemistic? Mr X: A: Yes 69. There was no other evidence pointing to negligence by the doctors. The Court of Appeal found it to be insufcient. Had the surgeon witness gone on to say that in the 5 weeks period in which the patient had been in the care of the hospital the doctors should have been able to discover the hip fracture and the failure to do so fell below acceptable professional standards of care, the result might have been different. Similarly, evidence pointing to the adverse effects of late diagnosis was not presented to the court. Perhaps the Court of Appeal was generous to the medical authorities here, though the decision re-emphasises the need for explicit evidence before a court could safely reach findings that may have damaging professional consequences. 70. Mr. Broadbridges original award of $1.7 million damages was therefore reduced to $975,205 exclusive of interest. 71. The other recent cases I make bare mention of: Frank R.Eggers Junior v Blue Shield (Pacific) Insurance Ltd (unreported) Lautoka High Court Civil Action No. HBC0094.97L; 30 September 2002 (overseas treatment for ureteric stones, specialists opinion as to whether appropriate treatment for this patient available in Fiji, how insurance company might have

resolved conicting medical opinion, general damages, damages for medical distress, and under Fair Trading Decree, $58,285. Amina Shah v Narayan and the A-G (unreported) Suva High Court Civil Action HBC0098.94L; 19 September 2003. Needle left in perineum after delivery in 1978 and misdiagnosis of gynaecological symptoms; poor maintenance of hospital file; poor methodology thereby incapacitating doctors from arriving at accurate diagnosis; unnecessary removal of uterus; damages, aggravated damages and costs totalling $147,622. 72. As is the case with all professions and public ofcers, the expectations of the public have grown enormously. A doctor or a lawyer is no longer automatically worthy of respect and adulation. His work is to be questioned. Patients are quick to question, challenge and complain. As professionals we must expect to be held to account. That means we have to think about risk management and consider ways of avoiding unnecessary errors. This is a topic which you will have already thought about. Risk Management for GPs is a suitable subject for your next Seminar, indeed a topic for constant revisiting.

(This paper was delivered to the Fiji College of General Practitioners on 23 November 2003).

General Practitioner Volume 11 Number 2 2004 37

MEDICO-LEGAL COLUMN

MEDICO-LEGAL REPORTS
Vipul M Mishra Mishra, Prakash & Associates, Ba

In Fiji there are four main areas of litigation where Medical Reports are required:1.Negligence type cases where a client has suffered personal injury such as in a motor vehicle accident. 2.Workers Compensation where a person has suffered injury during or at his place of work. 3.Medical negligence cases. 4.Criminal cases such as Assault, Murder (Post Mortem) Rape and Abortions. DOCTORS EVIDENCE IS USUALLY REGARDED AS EXPERT OPINION A Doctors evidence whether by way of oral evidence or a written medical report is regarded as expert evidence. Some parts of your reports are necessarily opinion based on your medical expertise. Generally a witnesss opinion is not entertained or accepted as evidence by the Courts. However medical reports and medical expert opinion is accepted and therefore is an exception to the general law. As your Medical Reports are expert reports the expectation from the Courts and the legal profession of them are high. The facts and records on which your reports are based if soundly based is helpful as the value of your opinion is usually tested and has to be proved by adducing facts in a contested case. Doctors and nurses records are regarded as of value. Hospital notes and their reports are expected to be of a certain standard due to their training and ethical standards. Car accident cases are common and often a Doctor gives evidence. Usually the Claimant will give evidence that she was in a car accident on a particular date and she suffered a broken leg. She will say it was very painfully and she had a plaster for one month and she still moves awkwardly and it still hurts in cold weather and she still limps etc. The Doctors Report is usually exchanged or disclosed beforehand. In the High Court it has to be given pursuant to the High Court Rules. His opinion evidence is of great assistance as to the type of fracture she suffered, her restricted range of movement, the extent of pain she would have had, what x-rays were done, what percentage disability she has and so on. If the Doctor actually brings in the x-rays, his notes or the Hospital Record and shows where the fracture is and bases his opinion on factual matters it is usually of good probative value and is very helpful. If he can say she presented several times on various dates as she

had great pain with reference to the notes it is very likely to be accepted that the pain and suffering is considerable. FUNCTION OF OPINION OR EXPERT EVIDENCE IN THE LEGAL CONTEXT In the case of Davies v Edinburgh (1953) S.C. 34, at pg 40 the following is said in regard to the function of experts:Their duty is to furnish the judge or jury with the necessary scientic criteria for testing the accuracy of their conclusions, so as to enable the judge or jury to form their own independent judgment by the application of these criteria to the facts proved in evidence. Therefore a judge will take into account the qualications of the Doctor and his special experience. It will have a bearing on how much weight to give his evidence. If he has presented or written papers on certain subjects that also has some effect. But that does not mean that expert evidence will necessarily be accepted. The Judge will decide on all the evidence presented before him. QUALITIES OF AN EXPERT WHICH THE COURT TAKES INTO CONSIDERATION In the Textbook Medical Negligence by Charles J. Lewis the case of Loveday v- Renton [1990] 1 Med L. R pg 117 is quoted. In that case the Court identied the qualities of an expert which the Court will take into consideration in determining what weight it will give to the opinion of an expert:(1) Eminence of the expert (2) Soundness of his thought (3) His response to searching and informed cross examination (4) His ability to face up to logic and make concessions (5) His exibility of mind and willingness to modify opinions (6) Freedom from bias (7) Independence of thought and demeanour It would help if when preparing your reports and even when being cross-examined you will bear that in mind. When preparing Medical Reports it is helpful to have an idea as to the how the legal profession deals with the question of proof, facts and inferences that can be drawn. In the medical negligence case of Tevita Tabua Waqabaca vrs. Dr. Etika Vudiniabola and the Attorney General of Fiji, High Court Action

38 General Practitioner Volume 11 Number 2 2004

No. 60 of 1993 Justice Pathik of the High Court in his judgment quoted from the text book Medical negligence by Michael Jones (1991) on page 29 of his judgment when he considered the question of the breach of duty of care in medical treatment which led to severe injuries to a patient. He said:I conclude this topic with the following passage Medical Negligence (supra) 96-97 which is appropriate for consideration in all the circumstances of this case: Of course, to say that the plaintiff has a burden of proof does not necessarily mean that he must provide direct evidence that the defendant has fallen below the requisite standard of care. He may rely upon any legitimate inferences that can be drawn from the proved facts, and in the absence of evidence to the contrary the inference may well be that the defendant has been negligent. An inference is a deduction from the evidence, which, if it is a reasonable deduction, may have the validity of legal proof, as opposed to conjecture which, even though plausible, has no value, for its essence is that it is a mere guess. (JONES v GREAT WESTERN RAILWAY CO. (1930) 47 TLR 39, 45 per LORD MACMILLAN (emphasis added). I also refer to the case of Cassidy vrs Ministry of Health (1951) 2 K.B.p. 343 at 359 If a man goes to a doctor because he is ill, no one doubts that the doctor must exercise reasonable care and skill in his treatment of him: and that is so whether the doctor is paid for his services or not. But if the doctor is unable to treat the man himself and sends him to the hospital, are not the hospital authorities then under a duty of care in their treatment of him? I think they are. In my opinion authorities must use reasonable care and skill to cure him of his ailment.(emphasis added) That is the law regarding the standard of care which the Medical Profession must exercise and that is also the guide by which you must prepare your reports. It should show the reasonable care and skill. If there was a broken nose or laceration leaving scars the medical report should show it and not just be left in the Hospital Folder. HOSPITAL NOTES, POST MORTEM AND MEDICAL REPORTS Generally nurses handwriting is much better than that of Doctors. Although they also have some medical short-hand their writing tends to be more readable. Doctors handwriting is often difcult to read. Clients nd it difcult and we lawyers also nd it difcult. We nd it difcult to get copies of Medical Reports. There are often long delays sometimes over two years before we get the same despite several letters and requests. Often this

is an area of great frustration to the public. We often have to write complaints before we get the same. We as a profession are conscious of the severe strain that Doctors are under particularly in the Government Hospitals. However this problem with medical reports and continuous following up is a major cause of frustration for lawyers and their clients. However over the last 18 months or so there has been some improvement. So if there is to be an answer if the legal professions expectations are met from medical reports being given at present, that answer is no. Often medical reports are short. They leave out injuries; and they often are not in a form which shows clearly to the Court what the patient has been through or will go through. Medical Reports are important. An example is a Police Ofcer in the western division who was a diabetic. He received injury to his big toe and over a period of time he went through three amputations of his left leg. The employers were declining liability because they were not sure that it was the injury at work which caused the amputations. Usually Workers Compensation cases are relatively simple. You dont have to prove fault. You simply have to show that the injury occurred during work and a worker can get up to $32,000.00 depending on the level of the injury. However, medical reports are necessary to show that percentage of disability. In this case reports from a nurse and two doctors helped convince the Magistrate that the initial injury took place at work. This evidence was of course backed up by the claimant by his verbal evidence. It made signicant impact on the Magistrate when she saw that this person had gone to hospital and had received treatment where a pin had been removed from his left big toe which had penetrated his foot while on duty at work. EVIDENCE ON QUANTUM OF DAMAGES Your opinion is to help the Judge make up his mind. He will listen to you as he will to an injured plaintiff and determine the extent of the injuries. Lawyers will want to know if someones got a broken leg as to how much permanent disability he has. If the patient is a surgeon and due to his injury he cant perform operations he will suffer a substantial reduction of his income and ability to earn and this is reected in the damages he will receive. AGE OF THE PERSON INJURED IN DAMAGES CASES Judges want to hear about injuries and how it will affect a person. A medical report can

General Practitioner Volume 11 Number 2 2004 39

help greatly and the Judge often is able to make a far better and informed decision if he has a medical report before him stating how this person will be affected. For example if a lady of 22 is left handed and has suffered bad injuries to that hand that is signicant and will affect the amount of damages she will get. If someone is old and hasnt long to go he will not get as much damages for pain and suffering from a broken leg as would a young person who has much longer to live and consequently will suffer more. Often our medical reports are lacking in this aspect. Ideally the essentials of the disability or injury or the loss of amenities should be stated and there could be some elaboration of the same when the Doctor gives evidence on oath. When one deals with medical reports from overseas and compares them with ours there is a noticeable difference. PAIN AND SUFFERING AND LOSS OF AMENITIES Medical reports in Fiji are usually very brief on this aspect. When the claimant sees his medical report he often gets a bit of shock. We are aware that most Doctors in Fiji are overworked and this perhaps is part of the reason for the brevity in the reports. Patients are often disappointed that the effect of injuries on their lifestyle is not reected in their reports. There was a case in Suva where a broken nose had been completely left out of the Medical Report. Luckily there was some reference to it in some other document and the doctor himself was good enough to admit that he had omitted it. Otherwise the Plaintiff would have missed out on part of the damages she was entitled to. AN EXAMPLE OF HOW AMOUNT OF DAMAGES IS AWARDED BY THE COURTS I refer to the case of Sonam Sangeeta Kumar v- Sailasa Vueti and Attorney General of Fiji HCB No. 204 of 1995L. After nding that the hospital was negligent the judge assessed damages for a one year old girl whose toes got badly affected and got amputated and leaving scarring etc as follows:The outcome is that I award the plaintiff

the sum of $99,912.00 by way of damages apportioned as follows:(1) Special damage: $400.00 (2) Pain, suffering loss of amenities and expectation of life: $50,000.00 (3) Scarring/disgurement: $5,000.00 (4) Future nursing: $3,000.00 (5) Loss of earning capacity: $1,000.00 (6) Future medical treatment: $10,000.00 (7) Special shoes: $12,200.00 (8) Interest on (1), (2), (3), (6) and (7) from date of injury to date of judgment at the rate of 4% p.a $9312.00 (app.) TOTAL $99,912.00

REPORTS FOR TREATMENT ABROAD We often get complaints that we want to take our wife or husband or father or mother or child overseas and they wont let us. The doctor wont give a letter allowing him to go. They want to treat him here and they dont really know whats wrong. My respectful view on this is as far as possible, if facilities for treatment arent here or arent good enough reports should be provided so they can go where they wish. There is a feeling in claimants that the doctors in Fiji are reluctant to admit that they cant treat particular ailments. CONCLUSION What the claimant wants is a quick and fair disposal of his Medical case. For that he needs a medical report promptly. Secondly he wants quick discovery of hospital records relating to his case. Often he feels he is suffering twice over. First through his injury and second all over again because he cant get a medical report for months, sometimes over a year. Then when his case is led it is not heard for years on end because there is no judge. The Court is greatly assisted by a medical report which has the detail which it is looking for. When giving evidence or a report if a Doctor backs up his opinion by reference to the records, it lends credibility and force to his opinion.

NEXT ISSUE:
Optimizing General Practice Vol 11, No 3 September, 2004.

40 General Practitioner Volume 11 Number 2 2004

MEDICO-LEGAL COLUMN

DOCTOR & THE LAW: COMPLAINTS MECHANISM


I would like to thank and congratulate the Fiji College of General Practitioners for organizing this seminar, which seeks to, I understand critically evaluate the role of general practitioners vis a vis the law. I believe such seminars and in particular seminars, which result in concrete steps being taken to assist in the evolutionary process of making a profession more accountable, increase its understanding of the contemporary environment it is to operate in, recognise demographic changes and become cognizant of the need to be more consumer friendly, is highly recommendable and a must for all professions including dare I say the legal fraternity. The topic I have been asked to speak on is as follows: Does the Fijian Constitution adequately provide a mechanism for the layperson to use if he/she feels that the health provider did not exercise proper care? If not, can we create a complaints mechanism? Are there models available which we can adapt/adopt As you will not there are a number of issues, which jump out immediately and indeed 30 minutes is not enough to address in detail and/or do justice to the topic. However, in this presentation I will seek to address the salient issues which have practical implications and provide the basis for discussion and hopefully contribute to bringing about systemic changes. Our constitution, which is the Supreme Law of the land or/the State of Fiji (section 2), many perhaps do not know this or ignore this fact, does provide a mechanism to facilitate complaints through supplementary legislation. Section 25(2), which falls under the Bill of Rights Provisions (chap 4), states that Every person has the right to freedom from scientic or medical treatment or procedures without his or her informed consent or, if he or she is incapable of giving informed consent, without the informed consent of a lawful guardian. Section 42 of the Constitution establishes the Human Rights Commission. Apart from educating the public about human rights and promoting it, the Human Rights Commission is assigned other functions specically under the Human Rights Commission Act 1999. Section 7(1)(b) of the Human Rights Commission Act gives the Human Rights Commission powers and duties to:invite and receive representation from members of the public on any matter affecting human rights. Section 7(1)(d) gives the Human Rights Commission the powers: to inquire generally into any matters including any enactment or law or any
Aiyaz Sayed-Khaiyum, BA. LLB, LLM. Barrister & Solicitor Suva

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General Practitioner Volume 11 Number 2 2004 41

procedure or practice whether governmental or non-governmental, if it appears to the Commission that human rights are, or maybe infringed. Section 7(1)(i) states that the Commissioner can: investigate allegations of contraventions of human rights and allegations of unfair discrimination, of its own motion or on complaint by individuals, groups or institutions on their own behalf or on behalf of others. In other words a person whose rights have been infringed can have an organization, other individuals le a complaint for him or her and still have locus standi or right of audience. Section 25 of the Human Rights Commission Act also states: any person may make a complaint to the Commission, including a representative complaint on behalf of other persons with a similar cause of complaint, about a contravention or alleged contravention of human rights. Section 29 of the Human Rights Commission Act also specially states that: a letter written by a patient in a hospital and addressed to the Commission must be forwarded immediately unopened and unaltered to the Commission by the person in charge of the place or institution where the writer of the letter is a patient. The Human Rights Commission may investigate any complaint unless: the complaint is trivial, vexations or not made in good faith; or the complainant has brought proceedings relating to the same matter in a court or tribunal I do not need to include all restrictions but these include lack of resources etc. I have set the about provisions, which give the Human Rights Commissioner the powers to receive, hear and investigate complaints in respect of Section 25(2) of the Bill of Rights. However, you will note that Section 25(2) is restricted to the issue of consent in respect of medical treatment and/or procedures. So it is limited in its application since consent could be given but there maybe an allegation of lack of proper care after the consent is given. The Medical and Dental Practitioners Act (Cap 255) creates a Medical Council (Section 3). The Medical Council deals with and administers the registration of doctors. Section 27 titled Misconduct deals with the de-registration of doctors if professional

misconduct is found by the Council or if the registered practitioner is convicted of a criminal offence. Professional conduct/misconduct is not dened nor are any guidelines set as to what constitutes misconduct apart from a criminal offence. Section 34, which sets out offences, does not address the issue of proper care in other words should lack of proper care be alleged, it is arguably not an offence. Section 36 of the Act states: Any complaint as to the conduct of the practitioner could be interpreted to mean that complains could be received from anyone and indeed lay persons. The question of course is whether conduct falls within the ambit of proper care. So for example I consent to medical examination as a result of which the doctor states that I need a tetanus injection and I tell her that I think I may be allergic to it because my mother told me that I came out in rashes when I was a child but the doctor still goes ahead and gives me the injection and I suffer side effects. I can in this instance, by virtue of Section 36 go to the Council but will the Council see it as falling within the ambit conduct and or more appropriately will the Council view it as a conduct issue. From what I have been informed, the Council did not previously deal with such cases and dealt with complaints by medical superintendents and complaints by doctors about other doctors. However, patient complaints were now heard. The question of course is, how many people know that the Council is entertaining complaints and has the Council made an effort to inform the public that such avenue is available. However, even if the Medical Council did hear a complaint, what sort of redress will the patient get apart from a disciplinary action against the doctor? There is no provision for redress for the patient. Indeed the anomaly with the Act and the Council that it creates is that the Council is both the administering and disciplinary body. Clearly there are issues of conflict of interest affecting natural justice and the 2 separate bodies should exist to hear different matters. The composition of the Council is also an issue since all the members of the Council are registered medical practitioners. There is no representation of members of the community or other professions.

42 General Practitioner Volume 11 Number 2 2004

Case 1

A complaint was made by a woman about the services provided to her late husband by a GP. The complaint was on the basis that the GP: 1. did not admit the patient to hospital for his shortness of breath; 2. did not consult with the patients respiratory specialist; 3. administered IV salbutamol (Ventolin); 4. did not keep the patient under observation after administering the salbutamol; 5. did not contact the police following the patients sudden death; and 6. certied the patients death as being a result of pulmonary failure. The Commissioner reasoned, after receiving independent expert advice from another GP, that the patient was suffering from a mild exacerbation of his Chronic Obstructive Pulmonary Disease (COPD), whereas an injection of salbutamol should be reserved for severe, life-threatening exacerbations. The Commissioner held that the GP breached Right 4(1) as he did not provide services with reasonable care and skill in that: 1. it is not standard practice to inject salbutamol, either intramuscularly or intravenously, for acute on chronic COPD and, in doing so, the GP introduced an unnecessary element of risk, which may have contributed to the patients sudden death; and, 2. having considered that the exacerbation was severe enough to warrant an injection of salbutamol, the GP should have provided oxygen therapy, monitored the patient closely, and arranged admission to hospital. It was also held that the GP breached Right 4(2) because his documentation fell below professional standards. However, the Commissioner held that there was no breach of the Code in not consulting the respiratory specialist, because patients experiencing a mild to moderate exacerbation of COPD are routinely treated in general practice. A copy of the Commissioners report was sent to the Medical Council with a recommendation to consider whether a competence review of the GP was warranted.

So to summarize, in Fiji at the moment the redress available to the patient/lay person is: if medical examination is carried out without consent, then the tribunal should take the complaint to the Human Rights Commission; if it relates to any other matter then the patient could technically lodge a complaint with the Medical Council composed of doc-

tors, which has an undened meaning of conduct or conversely proper care. And even if misconduct in respect of proper care were found, the consequence could be for the doctor and no redress for the patient; Accordingly, the only redress would be to pursue the issue of lack of proper care through the Courts. This obviously is time

General Practitioner Volume 11 Number 2 2004 43

Case 2

A complaint was made by a woman about the services provided to her by a GP.The complaint was on the basis that over a period of two and a half years the GP did not provide the patient with services of an appropriate standard in that she (1) was cursory in the examination of the patients facial mole and so did not properly assess and monitor it; (2) did not appreciate the signicance of changes in the patients mole; and (3) did not refer the patient for specialist advice. The Commissioner reasoned, after receiving independent expert advice from a GP, that: 1. it is not unusual for GPs not to record measurements or specic sites of moles unless they have a particular concern; 2. while the GPs clinical notes were brief and did not record the site, measurement or change in any of the moles, in the absence of specic concern the documentation was adequate; 3. having been informed that the mole had been removed by another GP, the patients GP had no need to follow through with her planned referral; and, 4. although earlier excision of the melanoma would have been preferable, there was no evidence to suggest that the delay in diagnosis could be attributed to inappropriate monitoring and management by the GP. The Commissioner held that the GP did not breach Right 4(1) of the Code because there was nothing to substantiate the allegation that (a) the examination of the mole was cursory; or that (b) there was a failure to appreciate the signicance of a change in the patients mole; or that (c) there was a failure to refer the patient for specialist advice.

consuming, in particularly if you live in the West and is a costly exercise. Therefore, it makes access to redress for the lay person prohibitive. In New Zealand following Judge Cartwrights 1988 report on the Inquiry on Cervical Cancer, it was recommended that an independent Commission be created as an independent complaint resolution and educational body. It also recommended that a Code of patients rights be put in place. Today, the Health and Disability Commission investigates complaints made by patients. When complaints are made or the Commission investigates on its own accord as can the Fiji Human Rights Commission, the Commission is guided by the Code of Health and Disability Services Consumers Rights, which governs all registered health professionals including doctors, nurses, dentists and even acupuncturists, naturopaths and homeopaths. The obligation under the Code is to take

resourceable actions in the circumstances to give effect to rights and comply with the duties. 1 Therefore, the onus is on the provider to show that such action has been taken. The Code itself states that every consumer has a right to, I am not listing all her: services to be provided with reasonable care and skill right to have services provided that comply with legal professional, ethical and other relevant standards; co-operation among providers to ensure quality and continuity of service; effective communication; be fully informed; services provided in a manner consistent with his/her needs; make informed choices and give informed consent. I will very quickly give a couple of examples of cases referred to the Commissioner.

44 General Practitioner Volume 11 Number 2 2004

Following investigations, the Commission gives its opinion and the act provides the Commissioner with a range of options to promote, change, both in respect of the conduct of individual providers and in the sector generally. The Commissioners options on nding a breach of the Code include the making of reports and recommendations to the provider, the health professional body, the Minister of Health, or any other person the Commissioner thinks t. This may include the professional colleges, the Ministry of Health, District Health Boards, ACC, and quality organizations. Recommendations to providers vary from case to case, but may include a written apology to the consumer; reimbursing the consumers costs; undertaking specic training; and implementing and reviewing systems to prevent further breaches. Where recommendations are made, the Commissioner follows up and monitors implementation. In Australia similar independent bodies exist. The Human Rights and Equal Opportunity Commission, which is a federally based organization hears complaints. In New South Wales, the Health Care Complaints Commission is an independent statutory authority facilitating complaints about health care practitioners and health care services. So then what are the options for us in Fiji? In my opinion, there are a number of amendments or creations required. However, the signicant issues to recog-

nize when pursuing the idea of implementing a complaints mechanism is that the body created: should be independent; accessible to the lay person staffed by professional persons; needs to have enforcement teeth to provide meaningful redress for the complainant and also to bring about systemic changes. In addition, a proper Code should be adopted, which serves as a measure or guideline by which issues of care could be addressed and monitored. There is no doubt that the medical profession is unique, since as the clich goes ones life is in the hands of the doctor. While lawyers maybe known to provide or for that matter take away material benets, the doctors can determine ones very life or health and no amount of material well being can remedy that. It is perhaps for this very reason that doctors have been far less under scrutiny and indeed lay persons reluctant to make complaints about those who have their lives in their hands so to speak. However, it must be recognized that patients have rights also and doctors are fallible. Patients are also becoming better educated and informed in this globalized world of ours. The creation of such a mechanism would only be fair and would lend itself to a better medical fraternity.

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Pylokit is indicated in the eradication of H. Pylori in Active chronic gastritis, dudonal and gastric ulcers.

Dosage: One of each tablet two times daily. Recommended duration of therapy is 7 days.

General Practitioner Volume 11 Number 2 2004 45

MEDICO-LEGAL COLUMN

DOCTOR & THE LAW: ABORTION LAWS


Doctor and the Law
Medical Interpretation of Abortion Laws - Definition: Termination of Pregnancy before viability resulting in death of the fetus - Classification: Spontaneous Induced:-Non Medical -Medical

Neil Sharma, GP-Obsterician, Suva

Global Picture - Restrictive


- Liberal - Restrictive with Liberal - Application

British Laws Commonwealth Law - Fiji Law

Historical Background

TimeLine
1803
Common Law

Ecclesiastical Courts Ellenbourough Act 1803 Landowners Act 1828 Offenses Against the Person Act 1861 Infant Life (Preservation) Act 1929 R v Bourne (Test Case) 1939 Abortion Act 1967 Human Fertilization & Embryology Act 1990

1861
Basic Law

1929/1939
Developed Law
Advanced Law

Fiji's Law

Penal Code - 172-174, 221, 234 - Restrictive but recognizes medical conditions where it can be carried out 1861 Act (Lawful Component) 1929 Act (Good Faith)

Test cases reference to R v Bourne (1939) / Abortion Act of 1967. Fetal abnormality on its own does not constitute reason for termination. Maternal life, health and emotional reaction to abnormality must be taken into account to constitute good faith.

46 General Practitioner Volume 11 Number 2 2004

Safe Procedure Offered

Holistic view of patient needed counselling physical emotional state social, economic, environment issues

Before age of viability (u/scam) Informed Choice Informed Consent ....DOCUMENTATION! adequate Pretreatment of Cervix Analgesia Post Operative Observation Follow up / Exist Review Contraception / Follow up

Demographic Data on Clients Requesting MTOP in GP (Fiji) - FGCP. Vol/No3, 1997. - Multi (18) 14 days 8/96

Basic Demographic Data Gestational age @ presentation. Review Indication for their request

283 - MTOP Counseling 73.8% - 20-34 yrs 67.8% - Indian 26.1% - Fijian 75.7% - multi-parous 24.3% - multi-parous

21.5% - Had undergone a MTOP previously 62.5% - failed contraception 37.4% - did not use contraception 72.5% - Stable relationship

27.5% - solo 91.1% - during 1st trimester 70.3% - multi-factorial indication for
request

General Practitioner Volume 11 Number 2 2004 47

Demographic data on Teenagers Requesting MTOP in GP - FGP Vol 5, No 3 1998: 9 CENTRE Study in 3/98

24 patients (15) 21/24 (G1 PO) Contraception not used Solo Fijian Children present late Socio - Economic indications

Contraception Counselling Post MTOP in GP (March 98 Study - 9 Centers) Default rate 15% Counseling on contraception effective
- 48% 88% safe

Conclusion
Laws in Fiji are clear
-legal profession ...! Medical profession...? -Abortion laws difficult to enforce -No social consensus -Females least heard -Abortion not publicized: denied by women/official services -Statistics difficult to come by -WHO (1991) 40-60 X 10(6) / annual (globally) -100,000 - 200,000 die due to illegal abortions

Fiji's Law

Penal Code - 172-174, 221, 234 - Restrictive but recognizes medical conditions where it can be carried out 1861 Act (Lawful Component) 1929 Act (Good Faith)

Ref Cases: RvEmberson & Emberson, High Court of Fiji No. 16, 1976

The Practicalities.
which from an illegal abortion remains The criteria subjectseparates 'legal' potentially inconsistent judicial to change and vague and interpretation and direction to juries particularly in the jurisdiction that have not being legislated. Medical practitioner is in a cloud of doubt with no guarantee of not being prosecuted. Repeal criminal law on Abortion -> civil regulation Regulation of MTOP through existing medical/legal/admin of the health care system and medical practice. - Abortion < viability - Reporting - Quality Centers - Standard Protocols - Data Collection

The state v Sefanaia B. Tabua, Fiji Court of Appeal No 6, 1991 The State v Sachida N. Mudaliar, Criminal case No.8, 1992 \Offences against the Persons Act 1861 Infant Life (Preservation) Act 1929 Abortion Act 1967 Articles. Savage W. Abortion: methods and sequelae British Journal of Hospital Medicine, Oct 1982 Bhiwandiwala P et al, Menstrual therapies in Commonwealth Asian Law Int. J Gynaecol. Obstet 1982, 20:273-278 Fiji General Practitioner articles: 1.demographic data - vol 4 n 3 1997, 220-221 2.original research vol 5 n 3 1998, 354-355 3.contraceptive counselling vol 5, n 3 1998, 356 LAW FOR THE PACIFIC WOMEN - IMRANA JALAL, 1998. chap 6, p181-187 PERSONAL COMMUNICATION: DR. S. TABUA, 18/7/94 SUBMISSIONS by FCGP: Fiji Law Reform Commission 1996
ACTS;

Acknowledgement 1.Ramesh Patel and D. Sharma: 2.Imrana Jalal:

R.PATEL AND CO. R . R . R . T, S u va

48 General Practitioner Volume 11 Number 2 2004

THE PHYSIOLOGICAL RESPONSES IN STRESS


Abstract Hypothalamus mediated neuro-humoral responses form the basis of three phased General Adaptation Syndrome. Normally necessary for survival, over-stimulation of these somatic processes can result in illhealth. Since inappropriate responsiveness not only contributes to disease aetiology but also compounds with pathologies to make up Problem Complexes, the physiological stress responses need to be dealt with accordingly. Further research needs to be done in preventive as well as therapeutic interventions. Introduction Stress, dened as any circumstances that threaten or are perceived to threaten our well-being and tax our adaptive capabilities. (Weiten 1986:75), incorporates psychological - cognitive, emotional and behavioural - as well as physical components. Although the mental aspects are usually highlighted - for instance most stress assessments involve subjective judgement - the somatic processes are very important. Well dened physiological responses play momentous role in illness as they fuse with pathological processes to generate Problem Complexes. Furthermore, somatic stress responses, and indeed all physiological processes, are not always in awareness. That is, subjective assessment of stress may not give the total picture. Study of stress physiology was formally initiated by Walter Cannon (1929) who, after observing outpouring of adrenaline and noradrenaline in response to a variety of stressors, became impressed by the extra ordinary adaptive system that he termed ght or ight. (Myers 1992). To this sympathetic overactivity other physiologists have added endocrine stress response. Much credit goes to Canadian scientist Hans Selye (1936, 1974) who began his quest to discover a new hormone but ended up with a grand theory of stress. His more than forty years of research and three phased theoretical model of stress are great contributions to medicine. With additional research we can now outline somatic stress processes and advance implications for General Practice. The General Adaptation Syndrome (GAS) When Selye injected rats with Ovarian hormone extract he detected adrenal cortical hypertrophy, thymus gland atrophy and bleeding gastric ulcers. (1936 in Myers 1992). Overcoming his initial dejection of not dis-

With additional research we can now outline somatic stress processes and advance implications for General Practice.
covering a new hormone, he re-interpreted the results as a single non-specic reaction to damage of any kind. (110). Application of other stimuli, - electric shock, surgical trauma, immobilizing restraint - with similar somatic responses validated his theory. He named the stress response General Adaptation Syndrome (GAS) and divided it in three phases. Phase 1: Alarm Reaction Pounding heart, rapid respiration, profuse sweating, dilated pupils, tenseness of muscles and mental alertness are characteristic of rst phase of GAS. Faced with a threat - actual or perceived - the body undergoes an alarm reaction with mobilization of resources to defend or escape - ght or ight - against the menace. Two major pathways activate multitude of physiological reactions that lead to the alarm reaction. (Weiten 1986). First, the autonomic nervous systems (ANS), the involuntary viseral functional controller, is modulated. Its sympathetic division is spurred. At the same time, the parasympathetic subdivision is inhibited. Sympathetic hyperactivity results in release of large amounts of catecholamines (adrenaline and nor-adrenaline) from adrenal medulla. These hormones are primarily responsible for the changes in heart rate, blood ow shunting to emergency systems, and respiratory rate increase with net effect of being prepared for any danger. Simultaneous parasympathetic inhibition shuts down nonemergency systems such as the gastrointestinal and reproductive ones. This enhances pooling of blood, with its vital energy expanding components, to emergency organs that include the heart, lungs, liver, brain, sweat glands, and of course the skeletal muscles. The endocrine systems master gland, the pituitary, is involved in the second pathway. It produces adrenocorticotrophic (ACTH) hormone in response to stimulation by corticotrophin-releasing hormone (CRH) from the hypothalamus. In turn ACTH stimulates secretion of corticosteroids from adrenal cortex. Corticosteroids - hormones of which cortisol is the prototype - boost access to energy stores by increasing protein, fat and glycogen mobilization. Much needed glucose is availed for the imminent crisis. Cortisol also inhibits tissue inammation in anticipation of allergic reactions and injuries. Both these pathways are under inuence of the brain, of course. Higher centres eventually impact the hypothalamus. In particular, the paraventricular nucleus is stimulated in response to any stressor. It secretes corticoRajeshwar Sharma Korovou Prison, Suva

General Practitioner Volume 11 Number 2 2004 49

tropin-releasing hormone (CRH). (Vale et al 1981 in Englert 2004). CRH plays central role in mediation of stress as it affect both the long arm - Hypothalamic - pituitary - adrenal axis - as well as the autonomic systems shorter arm. CRH docks on to the type 1 receptor molecules of cell membrane coating of the pituitary to stimulate ACTH secretion. CRH also impacts locus coeruleus, a small area in the brain stem that functions as a neural relay linking CRH producing brain regions with the ANS. Excessive CRH stimulates the sympathetic division and inhibits the parasympathetic one. Thus locus coerueles coordinates the short arm of stress responses. Hypothalamus, upon receiving signals from locus coerueles inuences the autonomic bers in the brain stem. Locus coerueles also triggers the ANS directly. It receives input from the Limbic System: - Amygdala amplies memory processes and is involved in emotionality; -especially aggression. That is, it augments stress responses. All these structures are under inuence of the higher brain centres. In addition, feed-back loops continuously modulate all physiological responses. The soma soon ghts back to lead to the second phase. Phase II: The Resistence The human body has remarkable resilience. It attempts to adapt to any stressor as soon as stress responses begin. However initially these modulating processes are overpowered by the intense neuro-humoral reactions to give rise to the alarm stage. After a while the soma is able to lower the over-excited state and stabilize the physiological responses. This is the resistance phase. In this adaptive stage the autonomic and endocrine systems continue to be active but their activities are much less than the rst phase. (Weiten 1986). This second phase is brought about by physiological actions throughout the body. At each level inhibitory feedback modulate the stress responses. Cortisol, for instance, has restraining effect on the pituitary. ACTH has inhibitory effect on Hypothalamic CRH. Septum of the limbic system controls Amydala. Parasympathetic subdivision balances the sympathetic one. All these are under inhibitory inuence of higher brain centres. To a limited extend these processes are under voluntary control. Resistance is generally benecial. It allows for adaptation to stress and improves survival. However, it can become a problem when the adaptive processes are allowed unchecked. It is because of resistance that stressed persons begin to over eat and become fat. Although at best resistance enables us to adapt to our circumstances, we do have to pay a price if the stressor persists and is not dealt with appropriately. The soma disintegrates bit by bit.

Phase III: Exhaustion Selyes research revealed that if the stressor was long lasting and the individual was unable to deal with it, various detenomental consequences resulted. He noted damage to crucial organs such as the heart and kidneys. The Gastrointestinal tract also showed bleeding ulcers. He named these changes as diseases of adaptation (1974). In addition to these alterations, chronic stress also leads to depletion of the bodys resources. Eventually parasympathetic shut-down leads to collapse and even death. Further research has supplemented Selyes work. In fact, all parts of the body seem to be affected by chronic stress (Zegans 1982 in Weiten 1986). Stress has extensive impact on the brain itself. Prolonged stress has been shown to bring about hypocampal shrinkage, reduced noradrenaline and serotonin secretion from raphe nucleus, and dopamine depletion (Salzano 2004). Severe depression can result. Indeed long standing stress is implicated in a variety of mental disorders as well as behavioural problems. Chronic stress also suppresses immune functions (Rathus 1997). The affected not only get ill more often but take longer to recover. Chronic stress also contributes to aetiology of non-communicable diseases. Secretion of Growth Hormone is suppressed by excessive CRH from prolonged tenseness. In children this results in slowed growth whereas in adults general metabolism is affected. Hyperactive HPA axis also affects carbohydrate metabolism; subcutaneous fat redistributes to abdomen and insulin resistance is enhanced. Overt diabetes may result in certain people. (Englert 2004). Exhaustion effects predominate in gastrointestinal tract. Blockage of vagal nerve shuts down digestion after major trauma of any cause. Stress ulcers appear in phase III of burnt victims. Peptic ulcers have well established association with prolonged tenseness. Irritable bowel disease has also shown to be correlated with chronic stressful situations; abuses in early life in particular. (Fazer and Gwendolyn 2001). Indeed, intense long standing physiological reactions have the potential to affect the entire body. They can induce detrimental reactions that can result in life-long suffering. The GP sees exhaustive phase in various forms everyday. Stress Producing Stimuli The brain mediates all stress responses. It receives input from three potential sources. The rst source of stress generating stimuli is from the external environment. Reverberating sounds, horrifying scenes, pungency and the like all induce distress. Stimuli from within the soma also lead to strain. Diseases cause pain

50 General Practitioner Volume 11 Number 2 2004

and misery. A ruptured ectopic pregnancy will activate the alarm reaction, for instance. The nal source of stress producing stimuli emanates from memory. Recall of past traumatic experiences - as classically demonstrated in post traumatic stress disorder - activate the neuro-humoral systems. These three sources are integrated at cerebral level. Energy from external events are transmitted via the ve senses to the brain. There, the reflexive brain waves induce retrieval of related parts of past memory in accordance to the principle of Hologram. For example, when PD sees any tough looking man, the memory of her brutal rape, that occurred half a decade previously, oods back to intensify her physiological stress responses. The outside eventualities can also cause tissue damage that compounds the stress processes. Indeed, all stress generating stimuli can combine to produce powerful brain impulses that literary jolt the hypotralamus to activate the two arms of stress responses. It follows that effects of stress are cumulative. That is, pressures from work, school, home, personal life, illnesses, growth and developmental issues, future aspirations - physical and psychological factors - all combine to produce diseases of adaptation. Stressful events that follow closely to one another appear to be even more harmful. Interviews of kin of acute myocardial infarct fatalities revealed that cumulative stress had tripled - when compared to their baseline two and half years prior to the fatal even - in the period of six months immediately prior. (Rahe and Lind 1971 in Weiten 1986). Research also demonstrates that collective escalation of stressors are associated with increase in the probability as well as the seriousness of all illnesses. The percentage of health crisis increases from 37% to 79% when the Social Readjustment Rating Scale (SRRS) raises from mild (150-199) to major (300+). Multi stressful stimuli may act directly as well as indirectly as stressed individuals tend to engage in more self-harming activities such as over-indulgence, smoking, and the like. Although, on the whole a larger stimulus gives a bigger physiological response, - compare: death of a close relative vs demise of an unrelated person -, psychological factors are able to modulate all stress generating stimuli. An insignicant stimulus can induce an enormous response if the controlling pathways are unable to regulate the intense memory retrieved holographically. On the other hand, a considerable stimulant can be coped with by the brains modulating pathways. The key psychological factors that influence stress generating stimuli are outlet for frustration, sense of control, social support and future expectancy. (Mason et al in Sapolsky 2003). Thus, the same stimulus would affect different individuals stress responsiveness differently.

Even in the same person, a similar stimulus can activate the physiological stress responses heterogeneously. Study of stress generating stimuli and their interactions with the affected have therapeutic importance as both the stimuli as well as the psychological processes can be modied to control the physiological stress reactions. Clinical Implications Although stress is dened differently by various researchers, most denitions emphasize the subjective appraisal by the affected. This leads two clinical problems. First, not all stress responses are in awareness. A person can be severely stressed but not be aware of it. Stress causes very intense brain waves that affect the Consciousness Devices activity and even inuence the Reticular Activating System to shut them down. Shock, numbness, and disorientation are all obvious but many of the affected deny being stressed! Long - standing sub-clinical stress is even more difcult to appreciate. Even those who develop the diseases of adaptation may not be aware of the stress. In general subjectivity is not an accurate guide for stress assessment. Second, emphasis on subjectivity portrays a false impression - both in professionals and lay people - that stress is primarily a psychological phenomenon. This has therapeutic implications. Patients, embarrassed at being labelled as mentally ill, are not keen to bring up emotional issues. The health care giver, on the other hand, views stress as too abstract. Highlighting the physiological aspect exposes the genuine state of proceedings. Stress incorporates mental and somatic components. In fact, the physical processes are more important as they form the basis of all facets of stress. While the psychological factors modulate the responses it is the physiological aspect that gives rise to the mental reactions. The somatic responses affect the end organs directly. With emphasis on the physical aspect stress needs to be assessed objectively. Unfortunately this can be very difcult. Nevertheless, focussing on the somatic component enables both the patient as well as the doctor to regard it more seriously. For instance, the intense physiological responses that occur after an acute loss - death of loved ones, separation, divorce, heart breaks and the like - needs to be addressed. Another clinical problem especially with subacute longstanding pressure - is difculty in determining the levels at which stress becomes detrimental. Obviously we require the physiological responses for day to day functioning. We also need sudden burst of hormones for emergencies and substained release for extra case load during viral epidermics, for example! Selye (1974) called the benecial responses eustress. We can also call it positive stress.

General Practitioner Volume 11 Number 2 2004 51

Stress may be compared to blood pressure. We require certain levels to survive. However, beyond certain levels the impact is harmful. Unfortunately, unlike blood pressure, we do not have objective assessment of stress. This area needs further research. In addition to stress increasing the risk for development of many diseases, all pathological processes activate the physiological stress responses. The effects of these reactions are compounded to produce Problem Complexes. Simply put, stress worsens the severity of any illness. It follows that all GP should consider simultaneous stress management in all cases. It is most unfortunate that no magic pill exists - yet - to reduce stress. Counselling and psychotherapy remain the main stay of treatment. Both require competence and time. Nevertheless, research is showing some optimism in development of stress-less drugs. Clinical studies on drugs that suppress the pituitary type 1 CRH receptors are underway in Europe (Englert 2004). These drugs attack the heart of physiological responses. Beta blockers are also being investigated for prevention of post traumatic stress disorder (Salzano 2003). Substance P antagonists, glucocorticoid synthesis blockers, brain-derived neurotrophic factors, and gene therapy are also being investigated. Stress counselling with life style changes will always be necessary. Selected patients - particularly those who

have undergone severe traumatic experiences and/or have several simultaneous stressors will need intensive psychotherapy and need to be dealt with accordingly. Conclusion External and internal environmental stimuli, augmented by memory, induce neuro-humeral ght-ight alarm reaction. The negative feedback mechanisms modulate the physiological responses. However, unmodulated longstanding stress leads to diseases of adaptation. Stress not only promotes development of diseases but compounds with pathological processes to produce Problem Complexes. Further research on physiological basis of stress is vital for prevention of many illnesses. Stress management also needs to be considered in all serious sickness.
References 1. Englert H. (2004) Sussing out Stress. Scientic American Mind. Vol. 14 No. 1 (special edition) PP 56-61 2. Frazer R. and Michell G. (2001). Drug Therapy of Irritable Bowel Syndrome. Australian Prescriber Vol.24 No.3 PP 68-71 3. Myers D. (1992). Psychology 3e. N.Y: Worth 4. Salzano J. (2003). Taming Stress Scientic American (Special issue) Vol. 289 No.3 PP 67-75 5. Selte, H. (1974) Stress without distress N.Y: Lippincott 6. Rathus S.A. (1997) Essentials of Psychology. 5e. F.W: Harcourt Brace 7. Weiten W. 1986). Psychology Applied to Modern Life 2e. cal. Brook/cble Publishing Company

A Tribute to Ratu Mara 1920 2004


What you spend years creating, others could destroy overnight. Ratu Sir Kamisese Maras life was characterised Create anyway. by a self-less answer to the call of service to his If you nd serenity and happiness, some may be people and his country. jealous. Be happy anyway. The late Tui Nayaus life was highly inuenced by The good you do today, will often be forgotten. Mother Teresa of Calcutta whose life of service Do good anyway. saw no boundaries. Give the best you have, and it will never be enough. Give your best anyway. YOU AND GOD In the nal analysis, it is between you and God. People are often unreasonable, irrational, and It was never between you and them anyway. self-centered. A life of service Forgive them anyway If you are kind, people may accuse you of selsh, ulterior motives Be kind anyway. If you are successful, you will win some unfaithful friends and some genuine enemies. Succeed anyway. If you are honest and sincere people may deceive you. Be honest and sincere anyway.
Mother Teresa was the epitome of kindness and love for ones fellowmen and her philosophies of life as outlined in one of her most famous quotes was often used by him to guide him through his public and personal life.

52 General Practitioner Volume 11 Number 2 2004

CASE STUDY

OSTEO-ARTHRITIS IN GENERAL PRACTICE

The patient started experiencing knee joint pains since 1987 and it was denitively diagnosed as Osteoarthritis in 1994.
PATIENT PROFILE R.D. is a 75 years old Indian male who retired from active employment in July 1985. He is married to the same woman for the last 50 years and has 5 children. All his sons are resident abroad, whilst his 2 daughters live in Fiji. Born in Nausori, Fiji, the patient describes his upbringing as full of hardship being the eldest in the family all the farming chores fell to him. From a young age he started working on his fathers farm and managed to school himself up to class seven only. As a youngster he loved to play soccer and played as a goalkeeper at the district level. In 1951 RDs left knee was injured and he gave up playing soccer. The patient started experiencing knee joint pains since 1987 and it was denitively diagnosed as Osteoarthritis in 1994. This brought limitations to his farm work and he reduced the active farming acreage to half the normal. His mobility was affected and he started using a walking stick from 1999. RD is devoid of other co-morbidities; his blood pressure, blood sugar and cholesterol are within normal parameters. He currently experiences pain on a daily basis and cannot do without the daily massage his wife gives him. He laments those good old days. Since being diagnosed a case of Osteoarthritis, RD has tried many treatment modules. These include the following: Intra-articular steroidal injections NSAIDS Paracetamol Intra-articular gel injections Herbal medications Glucosamine-chondriotin sulphate preparations This patient has tried a multitude of nonpharmaceutical anti-arthritic measures. Some of the interesting ones are as follows: Warm mud application by a Fijian female and an overseas visiting faith healer Special massage by a local South Indian black magic man Acupuncture The interesting herbal medications have been: Boiled okra pieces with the juice and meat ground to a pulp Raw okra juice Bele leaves and bele root ground and drunk in the kava drinking fashion Castor oil massage Powered methi fenugreek HADJOR a cactus like saprophytic plant. The outer layer is peeled and the meat is pulped to produce a very gooey drink. This item is also heated and used as a heated poultice. RD has been advised to undergo knee replacement surgery, but has put it off by saying that it would be a waste of money on an old man like him as the procedure is too expensive. He has been advised that bilateral knee replacement will cost him approximately $30,000.00 in Fiji and about the same amount if done in New Zealand. When prompted as to what he thinks is the cause of his illness, he instantly replies that his joints have dried up due to all the hard work and the long distance walking he had to endure as a child. His wife, sitting next to him, retorts that all the alcohol he has drunk over the years has dried up his joints. DISCUSSION The above clinical patient prole is not an atypical story of osteoarthritis (OA) in general Practice. The only atypical feature is that RD is currently devoid of other co-morbidities that would be a norm in approximately 60% of persons in this age group. OA is the commonest of the arthritidis encountered in my practice. An assessment of cases on le in my clinic shows a greater female (63%) preponderance. It is also common to nd that patients do the therapeutic rounds in search for the ultimate treatment modality. In the Fijian setting, folklore medicine/herbals, witchcraft, over the counter medications and prescription medications are a norm. The usage of Traditional Herbal products is based on the utilisation of products that produce a viscous pulp, juice or mixture. In most instances these items are freshly prepared and ingested orally. It is somehow perceived that these viscous and gooey mixtures will eventually nd their way into the affected dry joint a gastronomically impossible miracle to those who understand the physiology of digestion. Some pertinent issues in the management of OA Risk factors for OA: Risk factors work through either causing Dr. Wahid Khan, General Practitioner, Suva

General Practitioner Volume 11 Number 2 2004 53

abnormal biomechanical loading OR by increasing the susceptibility of joint and cartilage damage. As with pain, nearly all studies nd x-ray evidence of OA increases markedly with age at all joints (1). The increased susceptibility of joint damage in the older population is multifactorial muscle weakness and ligament laxity and a compromised repair and replace mechanism in the joint. Obesity and overweight are clearly associated with development of OA in the knees in both sexes (2), but the relationship is much stronger in women where a 7-fold increment is noted when measured against the Body Mass Index. The increased susceptibility in women is not entirely mass dependant as other factors such as hormonal abnormalities may be contributory towards, the development of OA (3). It is seen that every unit increase in weight, there is a corresponding 2-3-fold increase in the force applied across knee and hip joints whilst walking. Analgesics OR anti-inammatory agents? Recent controversies regarding the early management of OA surrounds the debate whether OA is an inammatory process or whether it is a pain syndrome (4). The PAIN SYNDROME theorises that OA is a primarily a repair process with all joint tissues (bone, cartilage and synovium) involved in the repair process. The pathophysiologic alterations in the circulation and the joints are regarded as normal repair work. The INFLAMMATION theory rests on the evidence of the great numbers of inammatory indicators (interleukin, growth factors, CRP, nitric oxide, leptin etc) and the presence of radiological and histological changes. Acetaminophen merits a trial as the rst oral agent (5). It is cost effective, efcient and has low toxicity. Unfortunately, acetaminophen, due to its easy availability is generally quickly discarded in the Fijian society where the general perception in the populace is that the more expensive a product is, the more efcacious it is. A recent review and meta analysis (6) shows that the combination Tramadol and acetoaminophen tablets are extremely effective during are ups in Osteoarthritis, particularly in the elderly. The safety prole of this combination will most probably popularise this regime in the future. NSAIDS are mainly reserved for moderate to severe disease states and dosage is generally titrated upwards to nd a level with the minimum side effects. Unfortunately, most patients with OA also have other co-morbidities and care must always be taken in patients with renal impairment. Combining NSAIDs with misoprostol or proton pump inhibitors is useful in patients with gastrointestinal disease. The introduction of COX-2 selective inhibitors has given the clinician a potent weapon to counterattack OA on the inammatory and 54 General Practitioner Volume 11 Number 2 2004

the pain spectrums with minimal side effects to the patient. Intraarticular injections Intraarticular corticosteroids are a good adjunct to oral treatment, but should be limited to 3-4 times per year. Intraarticular injections of viscosupplements like hyaluronana cushion the joint from the deleterious pressure effects. It is not readily available in Fiji, is expensive and is generally reserved as a last measure prior to denitive surgical treatment. Naturocetic Compounds Over the last several years we have heard a lot about Glucosamine Sulphate (GS) and Chondriotin Sulphate (CS). These products are available over the counter in Fiji and most are imported from Australia or New Zealand. Chondriotin sulphate is a sulphated aminoglycan, which is a major component of the extracellular matrix of many connective tissues. Research shows that CS reduces collagenolytic activity (7), has a protective effect on damaged cartilage (8), and stops progression of OA to the erosive phase in patients with previous stationary OA (9). Glucosamine Sulphate is an aminosaccharide that acts as a preferred substrate for glycosaminoglycans chains and subsequently for the production of aggrecans and cartilage (10). It is intensely hydrophilic. GS has been found to create a balance between synthesis and degradation of extracellular cartilage (11), have anti-inflammatory properties (12) and improve the repair process in OA cartilage (13). In Europe CS and GS are regarded as medicines and their production is under strict control. Elsewhere in the world these products are sold over the counter and are not subject to strict checks. With this concern, a study done by authors on 14 commercially available products showed that against the stated doses, the free base varied between 41.5 to 108% and the glycosamine level varied between 59 to 138% (14). If patients request for GS and CS, it is recommended that a 12 week trial run be made with patient keeping symptom scores and not modifying other treatment modalities during this period. If symptomatic improvement is made then indenite continuance is recommended (15) Surgical Procedures Surgical procedures are recommended for failed medical treatment of OA. The denitive treatment is arthroplasty, with osteotomy, and arthrodesis as alternative measures. These procedures are currently only available at the

Suva Private Hospital and does attract some considerable cost. CONCLUSION OA remains a disease entity that attracts a considerable level of morbidity and unwellness. The socio-economic implications and the demographic patterns of this illness have yet to be elucidated in the Fijian scene. The high treatment expenses and the non-availability of support systems leaves the general practitioner oundering when faced with OA with erosive elements. Perhaps it is time for the College of General Practitioners to activate a support group that can harness all the current community resources into meaningful measures in providing the necessary palliation to OA in the community at large.
References: 1. Van Saase JL, van Romunde LK, Vandenbroucke JP, Valkenburg HA, Epidemiology of osteoarthritis: Zoetermeer survey. Comparison of radiological osteoarthritis in a Dutch population with that in 10 other populations. Ann Rheum Dis. 1989; 48: 271-280. 2. Felson DT, Anderson JJ, Naimark A, Walker AM, Meanan RF. Obesity and knee osteoarthritis: the Framingham study. Ann Intern Med. 1988; 109: 18-24 3. Felson DT, Zhang Y, Van Saase JL, van Romunde LK, Cats A, Vandenbroucke JP, Valkenburg HA. Update on the epidemiology of knee and hip OA with a view to prevention. Arthritis Rheum. 1998; 41:1343-1355. 4. Issues in Osteoarthritis Care: Concepts and Controversies CME Author: Roland W. Moskowitz, MD. Medical Writer: John A. Smith, PhD. Posted MEDSCAPE January 5, 2000 5. Recommendations for the medical management of osteoarthritis of the hip and knee. American

6. 7. 8. 9. 10. 11. 12. 13. 14.

15.

College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum. 2000; 43:1905-1915 Rosenthal R.N., Silvereld J.C, Shu Chen Wu, Jordan D., Kamin M.: Tramadol/Acetoaminophen combination tablets for the treatment of pain associated with Osteoarthritis are in an elderly patient population: J Am Geriatr Soc 52(3):374-380, 2004-05-25 Bassleer CT, Comban JPA, Bougaret S, et al: Effects of chondroitin sulfate and interleukin1[beta] on human articular chondrocytes cultivated in clusters. Osteoarthritis Cartilage 1998, 6:196-204 Uebelhart D, Eugene JM, Thonar A, et al: Protective effect of exogenous chondroitin 4, 6-sulfate in the acute degradation of articular cartilage in the rabbit. Osteoarthritis Cartilage 1998, 6:6-13. Verbruggen G, Veys EM: Numerical scoring systems for the anatomic evolution of osteoarthritis of the nger joints. Arthritis Rheum 1996, 39:308-320 Setnikar I, Cereda R, Pacine MA, et al: Antireactive properties of glycosamine sulfate. Arzneim Forsch/Drug Res 1991, 41:157-161 Imenez SA, Dodge GR. The effects of glycosamine sulfate (GS04) on human chondrocyte gene expression. Osteoarthritis Cartilage 1997, 5S: 72 (abstract). Sandy JD, Gamett D. Thomson V, et al: Chondrocyte-mediated catabolism of aggrecan: aggrecanase-dependent cleavage induced by interleukin-1 or retinoic acid can be inhibited by glucosamine. Biochem J 1998, 355: 59-66 Piperno M, Reboul P, Hellio Le Graverand MP, et al: Glucosamine sulfate modulates dysregulated activities of human osteoarthritis chondrocytes in vitro. Osteoarthritis Cartilage 2000, 8:207-21 Naturecetic (Glucosamine and Chondriotin Sulfate) compounds as Structure modifying Drugs in the Treatment of Osteoarthritis. Jean-Yves Reginster, MD, PhD, Olivier Bruyere, MSc, Marie-Paul Lecart, MD, Yves Henrotin, PhD Curr Opin Rheumatol 15(5):651-655, 2003. 2003 Lippincott Williams & Wilkins What Are The Optimal Strategies in the Management Of Osteoarthritis? Karen Kline, PA-C. Posted Medscape 22nd May 2001.

General Practitioner Volume 11 Number 2 2004 55

VIEWPOINT ON CONTRACEPTION
Neil Sharma GP Obstetrician, Suva

Best Method of Contraception for a Perimenopausal patient @age 42 years is sterilization


Introduction: There is no question that contraception is essential for all peri-menopausal women who are sexually active or are potentially at risk of an unwanted pregnancy. There are several methods of contraception available to a 42 year old Peri-menopausal woman. However, the concept of which is the best method for the patient remains a subjective one. As health care providers, our role is one of providing the best possible option available. The most suitable contraceptive is decided after a risk-benet analysis based on the needs of the individual, the level of acceptance by the couple (1) and the clinical information and knowledge readily obtainable. This follows adequate client counselling on the possible risks of an inadvertent pregnancy. Best as in contraceptive technology The choice of the best method of contraceptive technology is based on a number of selection criteria. These include epidemiological and economical factors as well as availability, ease of use, and a good safety prole. From an epidemiologic angle, this equates to a method that offers a very high rate of protection and a very low failure rate as compared with other techniques in use. An additional advantage is to use a contraceptive method that involves a one-off expenditure and which does not entail long-term expenses to State, Healthcare funding agencies and possibly to the Consumer. However, from a patient centered perspective, the best method is one that is tailored to the individuals need. Macro-economic overview At a macroeconomic level, sterilization is probably the method of best choice. This, in fact, is the most common method of contraception in many developed and developing countries. The idea is to maintain control of the population at a macro level. Female sterilization is the most common method of contraception for the age group between 40-49 years in United Kingdom (2). Recent statistics from Fiji also indicate 27.7% of the total population use sterilization as their method of choice. The total percentage of the population using any methods is only 43.7%. That is equivalent to a 63% user rate for female sterilization (3). Micro-economic level This paper deals with the care of individual clients, as we are primary healthcare providers. General practitioners work at the microeconomic (client) level and advocate holism. Due consideration to the individuals need must be evaluated in light of the clinical history, clinical examination, reproductive intensions, previous experience with any method of contraception and/or complication that may have arisen out of that encounter [Patient vs method] The Peri-menopausal Patient Peri-menopausal patients have specific needs and associated risks as with regards to the standard methods of contraception available. General Practitioners need to evaluate these factors in the light of the total equation offered to their clients. Hormonal methods such as the combined pills, injectables and intrauterine methods need to be assessed closely. It is also important to consider the risks of possible side effects and adverse reactions. The associated risk of thrombo-embolism with perimenopausal pill-users is one such example and so is the use of standard intrauterine devices, which may aggravate menorrhagia and dysmenorrhea in the perimenopausal patient. Peri-menopausal and Medical conditions Peri-menopausal patients may have medical conditions that have already been diagnosed and sometimes as yet to be diagnosed and these need to be addressed prior to considering the different methods of contraception. However some patients need these variables factored into the contraceptive decision making process. An example would be a perimenopausal patient with heavy periods who can be better managed with a mirena intrauterine device rather than a standard intrauterine device, such as a multiload 375. The various options available can be arrived at after taking these specics into account by history taking and examination. Permanent Methods The permanent methods of contraception available are tubal ligation and/or vasectomy of the male partner. Vasectomy In a monogamous stable relationship one should consider vasectomy of the male partner as a tangible option for contraception. The non-scalpel technique under local anesthesia is available. The method is safe, efcacious and permanent. There are few short term side effects associated with this method and

56 General Practitioner Volume 11 Number 2 2004

additional contraceptive barriers are necessary for up to 90 days post surgically. One needs to undertake a post surgical semen analysis to confirm permanent occlusion of both the vas deferens. The vasectomy procedure is a lot less complicated then a laparoscopic sterilization under general anethesia, in the female partner. Laparoscopic Sterilization Sterilization using Flichie clips are permanent. As part of the preliminary and ongoing counselling preoperatively the woman/couple needs to be explained about the permanent nature of the procedure. Any element of doubt must be addressed as the chief complication of sterilization can be the regret factor with a request for reversal. This is more so if a new relationship develops after the sterilization (4). The reversible, laparoscopic sterilization with lschie chips is treated as permanent also. The reversal can be a complicated microsurgical procedure with poor fertility rates in the peri-menopausal patient. The major causal factors are due to the poorer quality of oocytes and higher miscarriage/obstetric complication rates rather than the recreated, patent fallopian tubes. Permanent method overview in a third world country-Fiji In a developing country setting such as Fiji, our resources are nite, to say the least. Sterilization is a permanent procedure and the availability of microsurgical techniques are non-existent. Unfortunately, the medical profession has not encouraged vasectomy. Men have avoided any surgical method and have depended on their female partners to request for tubal ligation which are mostly done postpartum. The fear being that surgery will affect their manliness and their future erectile capability. This myth is hard to obliterate in this day and age. The only vasectomies we have performed are on expatriate men in Fiji. Even when the local boys agree to vasectomy, they are often given the lowest priority and the longest waiting time in the public hospitals. An associated problem is the issue of condentiality in our small community (5). We largely undertake postpartum sterilization, as it is an opportune time to undertake the procedure when the patient is still in hospital and resting after a connement. Sometimes if the opportunity is lost, we do not see the patient till sometime later in a subsequent pregnancy or subsequent labor. Even with this setup, we loose patients when the surgical time is restricted and patients need to get home to their families (6). Due to major nancial restraints and manpower shortages in the public system following political upheavals of 1987 and 2000, the ability to undertake laparoscopic-sterilization

as an interval procedure has been compromised. We can only offer puerperal sterilization now. The private sector is limited by the patient needing to pay for services and this is limiting on its own, as costs of basic living can be a problem. To pay out $300 for a laparoscopic procedure is expensive to say the least in our poverty stricken nation where 60% of the population live below the poverty line of $F6000 per annum. Temporary Methods There are several newer methods of temporary contraception that offer protection for periods for upto 5-10 years and these are options that are available for the perimenopausal patient to provide the necessary contraception as the menopausal transition moves to menopause proper. Devices like Progestasert, mirena, impregnated vaginal rings and implanon can be considered and utilized fully with good efcacy. These non-permanent methods can be used when a permanent method is being considered by the patient. Some problematic psychosocial relationships exist at times. In such cases, one needs to widen the options available to the couple and client. Non-permanent methods may be the better option in these circumstances. The idea is to reduce the incidences of regret and future requests for reversal of a permanent method later. These non-permanent methods have the advantage of reversibility and can take the peri-menopausal patient into the menopause very satisfactorily. Several newer non-permanent methods have become available recently. Combined oral contraceptive pills (COC) The new third generation 20 mcg combined pills are suitable for healthy, non-smoking perimenopausal clients without cardiovascular risks and who are age 50 years and younger. Benets Benefits include the cycles remaining regular, pain free and light. There is some reduction in the menopausal transition and gynaecological symptoms of menorrhagia, premenstrual symptoms, dysmenorrhia and dysfunctional bleeding. There appear to be some protective effects from ovarian and endometrial cancers as reported in the review document no 2000/01 by The Faculty of Family Planning and Reproductive Health Care of The Royal College of Obstetricians and Gynaecologists titled Perimenopausal Contraception. The mechanism of protection is unclear but ovarian suppression appears likely. The protective effect last up to 15 years after discontinued use (2). Risks The risks of COC use are a marginal in-

General Practitioner Volume 11 Number 2 2004 57

creased incidence of venous thrombosis. The incidence is higher compared to non-users (5/100,000) and standard combined pill users (15/100,000). Gestodene, Mercilon and Femodene are three of the third generation agents now available in Australia and Fiji with a thrombo-embolic risk of 25/100,000. The risk in pregnancy is 60/100,000. The association of breast cancer and COC is complex. Cancer of the breast in COC users are picked up earlier and are localized without evidence of cumulative excess that have spread beyond the breast. Current users have an increased relative risk of 1.24 whilst using COC and this returns to 1.07, 5-9 years after stopping its use. These are comforting gures at least for the perimenopausal client. Progesterone only pill Use of the progesterone mini-pill can be considered in the peri-menopausal client very effectively. This method remains underutilized, as it carries no risk of thrombo-embolism. The action is on the mucus plug in the cervix. With decreased fertility, associated with aging this method can be considered if the client is reliable and prepared to take medication daily. The practical problems with progesterone pills remain as in younger women with spotting and erratic bleeding as the limiting factors. Intrauterine impregnated devices: Mirena has recently been introduced in Australia. It remains unavailable in developing countries like Fiji. Mirena has the advantage of a locally active progestogenic levo-norgestrel release at the rate of 20mcg/day over ve years. This does away with the main side effect of standard intrauterine devices that is menorrhagia in the small % of patients who nd this bothersome. Mirena is without doubt is of great value. The initial cost of a unit is $A220, if a patient needs it in a developing country as compared to a subsidized rate of $38 to a client in Australia. The frameless medicated intrauterine device Gynex is being studied in some developing countries and is something to keep an eye out for, in the not to distant future. Placement is the essence of success. Expulsion rates are even better then Mirena with all the advantages of long term protection and provision of a rich progestogenic milieu in the uterus with all it inherent advantages in the peri-menopausal client (7). Implanon Implanon, the single rod implant which releases etonogestrel, inserted subdermally is an effective long-term contraceptive agent for the peri-menopausal client. It has a life of ve years and can be retrieved earlier if side effects of erratic spotting presents as a

problem. This spotting is a side effect with other progesterone contraceptive agents too. The development of a biodegradable delivery system will be a milestone in sub-dermal contraceptive technology. Medicard vaginal rings and Contraceptive Patches These are newer ,methods under study currently. Large longitudinal studies are needed before we can consider them for use in the peri-menopausal client. The clinical evidence remains controversial currently. Further research is needed prior to wide-scale use in the peri-menopause (8). Emergency contraception The peri-menopausal client can use the Yupze method or the Prostinor option like her younger colleagues. Use of an Intrauterine device insertion within ve days of unprotected coitus can also be applied. Alternatively the peri-menopausal client could use the RU486/ misoprostone regimen in countries where this is allowable by an Act of Parliament. This may not be an option in Australia but is widely used in China, India, France and some parts of the Pacic Oceania. In parts of China the combination RU486/Misoprostone is used once a month as a means of contraception even in the peri-menopausal client. In summary, these new temporary methods with their long duration of protection and high efcacy add to the armamentarium we provide to our female clients and their partners. The concept of providing a wider range of option is contemporary and very much female centered. It can improve the quality of life for our female clients. Temporary methods available in a developing country setting-Fiji The practical issues in a developing country like Fiji, is that over sixty percent of patients will complete their family and seek a female sterilization. The rest continue having pregnancy terminations as a method of contraception till their fertility drops off. Recently more women are seeking advice on newer non-permanent options. As a professional group we can offer these perimenopausal clients: Implanon, Intra Uterine Devices (multiload/Cu T380A) and injectable noristerat and/or depo medroxyprogesterone acetate to see them successfully into their menopause. The practicality is that this is the only choice of methods available to us. The newer and better methods cost much more and possibly indented at a substantial cost to the consumer, if required. This seldom happens. Part of our responsibility is to be aware of the technology, its developmental upgrades and to measure up the risk and benets in a meaningful way to provide the

58 General Practitioner Volume 11 Number 2 2004

necessary information to our clients. That too, within the nancial limitations of a developing country. Client Counselling Client counselling pre-operatically is very essential to reduce any possible regret with permanent methods. Temporary methods are reversible and with newer technological advances the agents can be tailored to provide the individual with a wider option in the area of contraception needs. Medical supervision is still essential. On the subject of a peri-menopausal patient at 42 years of age one must not forget to counsel the patient on the risk associated with an inadvertent pregnancy and all its ramications. These include: [A] Age related risks of chromosomal aberrations are of genuine concern as the risk become real. Trisomy Screening is mandatory with consideration to: * Chorionic Villous Sampling @ 9-11 weeks in the rst trimester * Ultrasound scanning for nuchal canal assessment @ 12 weeks * Triple test @ 14-16 weeks * Genetic amniocenteses and/or structural ultrasound scanning @ 16-18/40 The possibility and need for medical termination of pregnancy must also be laid out for such patients. Their personal/philosophical view on termination must also be ascertained. [B] Medical Risks associated with aging includes * Increased propensity to cardiovascular diseases including hypertension * Metabolic diseased including Diabetes Mellitus * Osteoarthritic diseases [C] Associated/Specic Obstetric complica-

tions in >38 year olds include: Specically in our 42-year- old peri-menopausal client under discussion. * Miscarriage rate [+30%] * Preterm labor * Hypertension in pregnancy * Diabetes in pregnancy * Antepartum Hemorrhage * Unstable lie * Operative delivery such as a c-section and/or forceps delivery * Atonic Uterus resulting in post-partum hemorrhage * Psychiatric disorders in pregnancy In conclusion the transition into the menopause is not without concern about fertility control and the associated risk of an inadvertent pregnancy outcome. The individual needs adequate protection from a method that is best to her individual need. Sterilization by laparoscopy offers a near ideal choice in most cases. However in the individual case other options need to be discussed. The eventual method must cause her minimal stress, side effect and toxicity. She should be able to address these issues as quality of life issues and be supported with her decision-making. The interim of the peri-menopause has its own specic risks. Maximum benets can only be reaped through wider consultation on what is best in the individual case.
Reference: 1. Kovacs GT. Management of the transition between contraception and hormonal replacement therapy. Gynaecology forum 1999; 4:22-27 2. Brechin S.Perimenopausal Contraception. Review no 2000/01 Faculty of Family Planning and Reproductive Health Care of The Royal College of Obstetrics and Gynaecologists. 3. Ministry of Health, Fiji. Family Planning Protection Rate and Percentage by Method 2001. 4. Kovac GT. Female sterilization. Med J Aust 1994; 161: 612-614 5. Prakash.R.Vasectomy II. Fiji General Practitioner: Vol 5. No.4 1998, pg 380. 6. Personal Communication. Dr. James Fong, HOD, Obstetric services, Central/Eastern Area Health Board, Suva, Fiji. 7. Personal communication. Dr. Wildermeersch D. Contrel, Gynex; A revolutionary IUD, @ The Marie Stopes rst Asia Regional Clinical Conference 4-10th March 2004 8. New contraceptive options. American Family Physician, 15/2/04 http://wwwglobaldoctor.com/ClinicalReviews/item46.hmt

Call us on 132 888 for more information.

General Practitioner Volume 11 Number 2 2004 59

CLINICAL AUDIT

THE NATURE AND EXTENT OF MENOPAUSAL SYMPTOMS IN A FIJI GP SETTING


Neil Sharma GP-Obsterician, Suva

INTRODUCTION As part of the Post-Graduate Certicate in Womens Health module of study Menopause, an audit of 50 consecutive female patients aged 50-65 years, was undertaken. All patients presenting in our practice during the six-week period of the menopausal module of study, were questioned about their menopausal experience. These questions were regardless of the primary reason for consultation. A structured questionnaire was lled using the personal interview technique. The clients gave informed consent. A frequency analysis of the results was then carried out. This included basic demographic data. Questions relating to symptoms and the various management options and their underlying reasons were analysed. Based on the analysis, aspect of current management was quantied. Possible changes in light of current patient view along with topical literature ndings needs to be evaluated. The impact of these processes will identify the direction of future consultation and professional advice. METHOD An audit of 50 consecutive female patients aged 50-65, was undertaken during the sixweek period of the menopause course. The co-ordinators of menopause module provided a Structural Questionnaire. At the end of each consultation the patients were asked a number of questions which related to current or past menopause experience. A frequency analysis of the variables were carried out and reported. RESULTS: DEMOGRAPHIC DATA: Age Range 50-65 Average age 53.5yrs Average age of normal menopause: 50yrs See graphs DISCUSSION The result of this in-house audit is a great interest to support staff and the practitioners in the practice. Our practice is a reproductive health center. We deal with younger clients. Although we are the rst center with a menopause clinic component, we still had great difculty in recruiting the 50 clients for the study. This exercise extended over an eight week period. Whilst the study age range was 50 65yrs, our clients average age was 53.5yrs. The aver-

age life span in Fiji for women is only 67 years. This variation is possibly due to the population age structure pyramid in Fiji. We still have a pyramid shaped age structure with more young people than older individuals. The average age of natural menopause was computed as 50 years. There is a group of women who had surgical menopause secondary to hysterectomy for various gynaecological reasons. The experience of this subgroup was not separated from the ones experiencing normal menopausal transition. There is a possibility that the experiences of the two groups could possibly be different with surgical menopause and its abrupt onset. One of our patients experienced endocrinologic menopause due to an auto-immune disorder at chronological age 22 years. She was rightly diagnosed and followed up with hormonal replacement therapy (HRT) till recently. She has subsequently developed multi-endocrinopathies which are well controlled with replacement therapies. 42 of the 50 patient experiences vasomotor symptoms. The numbers were equally divided in the current and past categories. Interestingly the distribution of symptoms ranged from mild (14) to moderate (16) to severe (12). Vasomotor symptoms of hot ushes, night sweats and insomnia can leave a patient with a poor sleep pattern, lethargy, general disability and inability to cope emotionally. It is disconcerting that we have continued to miss this in our current patient management. Even with the recent Womens Health Initiative study results (WHI 2003) which withdrew use of Hormonal Replacement Therapy (HRT) for cardiovascular reasons we can possibly consider its use in women in the short term ( <3 years) to improve vasomotor symptoms provided patients are agreeable to such therapy (1). Possibly some patients would have beneted with improved quality of life without the vasomotor debility. 36 of our 50 patients experienced uro-gynaecological symptoms in the current phase (21) and in the past (15). Vaginal dryness and diminished libido were experienced by (31) and (28) patients. Associated dyspareunia (24) was also noted. We have continued to miss this in our clinical assessment. Consideration to local hormonal replacement and/or testosterone for libido may need to be reconsidered in all future consultation. Testosterone is not available in gel form yet locally. Intra-muscular testosterone can be used as replacement in a dose of 50mg, 3 monthly. That would possibly be part of our future scheme of management for individuals with moderate severe libido loss.

60 General Practitioner Volume 11 Number 2 2004

1. Menopausal prole Perimenopausal Menopausal 8 42 Surgical Endocrinopathy Natural Menopause 7 1 34

TOTAL 2. Vasomotor Symptoms Current Past Nil 21 21 8 42/50

50

Severity of Vasomotor Symptoms 14+ (mild) 16++ (moderate) 12+++ (severe) 42 3.

Urinary Incontinence was volunteered by 16 clients. Generally we see little symptoms related to the urine incontinence locally in Fiji compared to Caucasian population groups. We would need to reconsider our strategies with close to 16/36 clients having symptoms related to urine incontinence in this audit. Kejel exercise will need to be taught on a more regular basis to peri-menopausal/ menopausal clients as a preventative measure. The psychological component of the audit was an eye opener. 45/50 clients experienced psychological manifestations of the menopausal transition. Irritability (36) topped the list, with depression (28) a close second, followed by mood swings (25). Close to 1/3 of the symptoms in this subgroup were moderate to severe. These ndings open up a Pandoras Box with need for multi-discipline counselling to assist future clients. Hormonal Replacement therapy (HRT) was utilized by 18 clients. The breakdown was as follows: Currently (15), (3) in the past. 32 clients had no information on HRT and its options despite recent media coverage on the subject of menopause and establishment of a menopause clinic in Fiji. Only 10 clients opted to use natural methods to improve their physical aliments arising in the menopausal transition. 40 out of the 50 clients opted to carry on without assistance stating managing ok. A recent study by Yee Chief et al reported in the Fiji General Practitioner, the multi-ethnic component of knowledge, attitudes and beliefs with respect to menopause in Fiji being very uniform. These women have demonstrated a healthy, balanced and non-pharmacological approach towards menopause.
REFERENCE 1. Grady D. Postmenopausal Hormones Therapy for Symptoms Only. N Eng J Med: 348; pg 1835-37 2. Yee Chief et al: A Survey of Beliezfs and Practices about the Menopause Middle Aged Women in Fiji. F.G.P. Vol 8, No. 3, 2001 pgs 712-715

Urogynaecological Symptoms 36/50 > Current 21 > Past 15 31/50 Vaginal Dryness (++ = 5/50) 28/50 Libido 24/50 Dyspareunia 16/50 Urine Incontinence 4. Psychological 45/50 > Current 18/50 > Past 27/50 36/50 Irritability 28/50 Depression 25/50 Mood swings 5. HRT Usages 18/50 > Current 15/50 > Past 3/50 Non usage 32/50

6. Other Therapies > Current 7/50 > Past 3/50 No use 40/50

General Practitioner Volume 11 Number 2 2004 61

LETTERS TO THE EDITOR


Not a childs candy
Sir, The maroon and yellow capsules have always fascinated me. They seem to be The Wonder Drug for any little u, fever or discomfort. So much so that people think of these magical capsules even before visiting the doctor they often consider next to God. And to reafrm its status, even the local pharmacist does not ask a single question before respectfully handing it over-the-counter to the pleased customer. Amoxicillin is probably the commonest antibiotic used by the public though it may not be the commonest one prescribed. Before joining medical school, I was aware that one needed to produce a prescription in order to get any antibiotic, and seeing that this was not practiced all the time arose questions about consumer rights in my mind. Unfortunately, the consumers are themselves innocent victims due to ignorance and it looks something like committing suicide. The general public is unaware of the basic difference between viral and bacterial illnesses and the increasing problem of resistance due to inappropriate and incomplete consumption of antibiotics. Among several possible complications, the incidence of tonsillitis, particularly not responding to antibiotics, is quite high and these patients consequently end up having tonsillectomies. It is hightime that pharmaceutical laws are enforced in Fiji and both the general public and the health professionals realize the difference between OTC (over-the-counter) drugs and PoM (prescription only medicine), and the need to do so. Maureen F. Yashmin (MBBS 5) FSM individually. It is important for the health provider to have such web addresses available. In addition to providing, immunisation, preventive medications and travel kits, health personnel should advise on personal safety and protection and source availability of local health facilities at destination. Students travelling abroad have needs of their own which should be addressed. Their purse governs their travel and their interaction with their peers inuence their activities. All travelling students should be extensively counselled on the risks associated with transmission of infectious diseases such as Hepatitis C and Sexually Transmitted Illnesses. Additionally, there are immense psychosocial implications in these disease processes that need to be addressed. There is a need for greater awareness in the community to address the increasing incidence of Hepatitis C in travelling students. Students travelling to other countries for studies are at a greater risk for developing infectious diseases and there is an urgent need to educate them on risky behaviour and risks involved. There are great psychosocial problems associated with these illnesses and the students need support. Such support could be forthcoming from the family, the society and the health carer. Medical Writers Workshop Participants

Medical writers conference


Sir, Coming together with ideas, yet doubtful, ambitious yet hesitant, creative yet not condent writers conference is the co-enzyme to aid clinicians to put pen to paper! For the love of medical research and writing, a group of busy yet hard-working and enthusiastic general practitioners set out on the quest for better knowledge and skills in this eld. The Fiji College of General Practitioners organized this rst Pacic Medical Writers Conference, which was held from March 27th 28th at the Naviti Resort on the Coral Coast. The two day workshop was attended by general practitioners, Fiji School of Medicine lecturers and three medical students. The participants gathered to draw on the expertise from Dr. Lyn Clearihan, a Senior Lecturer at Monash University and co-editor of Asia Pacic Family medicine Journal, who was the guest resource person. This conference brought unity in diversity through the wide variation in age, race, social and cultural background, and geographical origin of the different participants, as everyone saw the need to explore ways of improving local and regional input towards clinical research and medical writing. Hence, this

Increasing infections in the traveller are we doing enough?


Sir, There are a great number of students who travel abroad for further studies. Are they aware of their health risks? Travelling to new environments exposes the students to new health risks; hence adequate health information is required. The family Physician is the best source for such information. Healthcare providers have an enormous responsibility to supply health info to travellers. The health advice should be tailored according to destination, the mode, the time and the route of travel and the needs of the individual. WHO, local authorities, airport authorities and travel agents provide sources of such information. The health providers and the travellers can also source such information

62 General Practitioner Volume 11 Number 2 2004

LETTERS TO THE EDITOR


unique team took off diligently to tackle the issue of lack of research evidence suitable for our Island populations. Not denying the fact that research and writing are not easy and quite demanding with regards to time, nancial and personnel resources, and effort, the journey began with making the participants realize that they do possess the art of writing. Building self-condence was the rst step towards capturing their interest. A series of interactive lecture sessions then followed on key aspects of writing skills, enhanced by group activities. By the end of the two days, participants felt enriched and had a better perspective of medical writing. Their views of their own capabilities had been transformed positively, which came as an encouragement for the FCGP that has been tirelessly maintaining its quarterly publication. Just as well as this conference rekindled academic interests, it also provided an opportunity for doctors, lecturers and future doctors to mingle. From the students point of view, we got an insight into the lives of general practitioners and what all being a GP offers in contrast to other career opportunities in medicine. Above all, everyone went back with some lessons learnt to be able to at least appreciate written papers and appraise them, or to start writing even if it meant submitting a letter to the editor in this issue itself, and to perhaps ponder the prospect of undertaking medical research and writing on a larger outlook. Thanks to the organizers and the resource person, it was a fruitful weekend, in which everyone had something to learn and everyone had something to teach to each other. Maureen F. Yashmin (MBBS), FSM We strongly encourage you to take a look and if possible, send us your comments. We hope you can send us a brief greeting to the readers in your national language to be included in the welcoming message. Another good news is that Blackwell has forwarded the PDF les of the rst two volumes and they will also be available at the site. Imagine, all our issues in one site. It is the same journal: The Editors, the Editorial Board, International advisers, Peer Review Process, content and cover. The process for applying for indexing will be pursued. The journal can be accessed on-line, with full text. For the moment, it is open to all, meaning it can increase visibility and accessibility. It shall be in PDF format so that it can be easily transformed into printed versions. The Editors and the WONCA Leadership are still studying the possibility of having a printed version. The articles will be in printready copy and will be downloadable in PDF format. However, member organisations who wish to publish an article from APFM in their journal may do so provided permission is secured from the editors with an acknowledgement as follows: This article was originally published in Asia Pacic Family Medicine, volume ________ issue ________. This is printed with permission from editor. There are some requests we hope you can do for the APFM. As members of the editorial board, can you help us in getting a list of all academic departments in your areas, together with the contact person and their contact addresses? We hope we can write to them to invite them to send papers to the journals. In addition, we hope we can write to them to look into possibility of collaborative works, which in the future can be included in our journal for dissemination. In addition, it is possible for you to give support as we request all member organisations to include in their newsletter, circular and journal announcements regarding the APFM. This is all for now. We wish to thank you for your continuing support. Thank you and we hope to hear from all of you. Lyn Cleanhan and Zorayda Leopando

Editorial Board/ International advisers


The moment we are awaiting for is here! We, the editors of Asia Pacic Family Medicine, met in Melbourne this month to review and nalize some plans related to the journal. In addition, we also met with Lesley Pocock, Managing Director of Mediworld International. As agreed upon during our meeting in Beijing last November, the APFM shall be an online journal and the editors, with the support of the Regional President, shall look for a provider who shall host and produce APFM. After a series of exchanges of letters, teleconference and nally a face-to-face meeting, the plans for online version of APFM has been nalized. Mediworld International shall be the host. Mediworld is also doing the Global Family Doctor. Launching will be soon. However, it is a pleasure to inform you that you can now access the Asia Pacic Family Medicine through www.apfmj.com.

General Practitioner Volume 11 Number 2 2004 63

SUMMARY OF EVALUATION FOR FIJI MEDICAL WRITERS WORKSHOP 27TH/28TH MARCH 2004
Dr. Lyn Clearihan, Melbourne, Australia

List of participants key objectives 1. seeking some formal teaching in medical writing. 2. desire to foster college involvement in medical writing 3. currently preparing thesis and hoping this may help write it up 4. has had a request to prepare an article and needing help to prepare it 5. wanting to put experiences onto paper 6. currently undertaking postgraduate studies and needing help writing essays 7. needing increased motivation to write 8. hoping that the workshop provides some intellectual stimulation 9. hoping that this will enhance current medical studies 10. looking for personal and professional improvement 11. encourage writing skills 12. to learn to write and prepare something professionally 13. to learn to write a formal article 14. wanting to contribute to the College journal 15. increasing condence to write 16. to improve writing skills 17. wanting to pass on experiences See graph 1 Comments There were 22 evaluation forms completed. 2 members of the group left early and thus may not have completed the form. Not every participant completed each component of the quantitative evaluation, suggesting some confusion about to how to ll it out, with 6 participants merely naming the presenter (correctly, I might add!) Similarly 2 people described the nature of the content, rather than rating it and 3 people described the method of delivery (ie

a powerpoint presentation). 17/20 [85%] participants rated the content as either excellent or very good; 17/19[89%] rated the presentation/format as either excellent or very good and 14/16[87.5%] rated the speaker as either excellent or very good, with the vast majority rating each category as excellent. Whilst one participant gave all categories a rating of 1, it is possible that there may have been some confusion over how to use the scale as under the subsequent question please rate the running of the workshops the comment was excellent 1 Qualitative assessment See graph 2 2. What has been the most useful aspect? Condence in writing Writing for publication Gave good overview of the area The whole presentation and more exercises please Outline of acceptable writing (exercise, especially 1) New information on medical writing Stimulation Eye opener for me that I can actually start writing now through our local journal and build on required skills and learn more The encouragement to write sharing of information; why we should be writing and reading continuously learning the editors expectations in a submission for publication the ability to criticise motivation to start writing organised approach the group interaction during the exer-

Graph 1
Quantitative Assessment
5 Content Presentation/Format Speaker 11 12 13 4 6 5 2 3 2 1 2 1 1 1 1 total 20 19 16

5= excellent; 4= very good; 3= good; 2=fair; 1=poor

64 General Practitioner Volume 11 Number 2 2004

Graph 2 Qualitative assessment 1.Participants were asked to name 3 key points that they had taken away from the workshops. Individual key points made were: Style of writing Organisation Writing plan Communicating effectively Writing for publication Reviewing CBS - clarity, brevity, simplicity Less is best Tabulate results or have a graph Clarity, brevity, and simplicity Writing for an audience Editors function Acceptable writing Inspiring Informative Interesting All capable of writing What medical writing is dont sit back - read a lot and write what to write about planning and structuring writing skills how to approach what information to provide Distinguished speaker, good local input Encouraging and empowering ... motivating for future ventures Enriching - new knowledge, useful format Put pen to paper - sort out the style, nesse afterward How to get an article published was learnt The encouragement to write Sharing information The message The audience stimulation to write Condence to submit Scientic approach to writing writing style how to criticise articles how to write appropriately logical ow in writing style of writing appraising of articles Motivation to start writing CBS know your reader key idea, and link everything to it clarity, brevity and simplicity write a lot have no fear encouragement to write never mind the language barrier helpful hints to enable us to be able to write (very resourceful) write a lot have no fear encouragement to write never mind the language barrier helpful hints to enable us to be able to write (very resourceful) How to do it read a lot CBS dont be afraid to write be dedicated once you start clear writing - CBS Organising CBS concept critical appraisal techniques writing skills development organising properly need audience focus Letter writing

cises variety of ideas key points tips and tricks everything delineating the ow of ideas in a paper how to write clearly, not using fancy words how to write an interesting article writing an article clinical aspects developed critical appraisal/writing skills development excellently 3. What has been the least useful aspect? Communicating effectively, I felt that I did not need this as much nothing really certain participants comments lack of follow up aspects of English language personally I already knew them none

I think the conference covered many important issues that are sometimes forgotten, so I didnt nd anything that was not useful perhaps nothing nothing all seems relevant need more audience mikes hand book? nil all was useful none none nil A number of participants left this question blank or put a line through it 4.Were your objectives met? 16 participants answered yes. Comments from the other 6 were as follows: denitely, I got more than I expectGeneral Practitioner Volume 11 Number 2 2004 65

ed I cannot ask for more very much absolutely near enough partly 5. In terms of rating the running of the workshops 10 participants rated them as 5 3 participants rated them as 4 1 rated them as 3.5 4 participants gave a qualitative rating of excellent (including the participant who gave a quantitative assessment of 1) 1 participant rated them as very good 1 participant rated them as good 1 participant stated they were well organised and on time 1 participant left this question blank 6. would you attend future workshops? 20 participants answered yes one requesting part 2 in 6 months time 1 participant stated yes, with different input, such as angle of writing etc 1 participant stated if other topics were covered, I would consider it. 7. Is there anything that you would change? 8 participants answered no

2 participants left this question blank The following are individual responses to this question: duration increased more examples of written literature discussed may be once I start writing there is no previous experience of such conferences to compare with . I guess this was very good for a rst time. Probably a formal presentation of certicates would be nice at least, getting a certicate is honourable in itself. variety of speakers to have the program run a bit longer, as there is a lot to be discussed and have more ideas tossed around. more expertise and longer time per subject critical analysis of article/appraisal more grammar it is my rst workshop on medical writing, so I wouldnt have found anything I didnt particularly dislike. interactive workshop is very good and I suggest more of it. I would love to have more resource person and hear from other editors too. It can be even bigger next time. 2-3 day workshop. probably not, all of the presentations were needed if not by me then by some others.

CREATIVE CORNER
LOVE
LOVE is special for you and me LOVE is like a ower in the tree LOVE is great not like you and me BUT LOVE is like a pot of tea LOVE is sweet like sugar but stings as a bee LOVE, LOVE, LOVE is perfect as Me BROTHER Brothers are cool because They swim in a pool Round and Round like a merry go around Up and down like a cockroach in town Brothers are fun rather dum Like a big headed plum By: Nashika Sharma Suva

66 General Practitioner Volume 11 Number 2 2004

INSIDE BACK

General Practitioner Volume 11 Number 2 2004 67

BACK COVER

68 General Practitioner Volume 11 Number 2 2004