The scratch test for determining the inferior hepatic margin

Still a valuable component of the physical exam

Evaluation of liver size by palpation is a basic component of the physical examination. Suspicion of an enlarged liver should prompt the clinician to examine for possible causes (Box 1) and investigate further with appropriate imaging such as ultrasonography. Palpation to detect the inferior liver margin may not be accurate or possible in certain clinical conditions (eg, obesity, abdominal distension, tenderness, or guarding). In such cases the scratch test may be useful. We describe the technique of the test and review the evidence base for its use.

The scratch test is a type of auscultatory percussion which was described as far back as 1840, and used to ascertain the size and form of various organs, including the heart and liver.2 The principle behind the scratch test is that the sound from a scratch on the skin overlying the relatively solid liver will be transmitted to a stethoscope located at another point over the liver better than a scratch not over the liver (ie, separated from the stethoscope by bowel or air).

Method for performing the scratch test3

The diaphragm of the stethoscope is placed on the xiphisternum (point C in Box 2).
The examiner repeatedly and lightly strokes the skin with a single finger, parallel to the suspected liver edge, starting from the right lower quadrant and moving towards the costal margin along the midclavicular line (point A in Box 2).
The examiner will hear very little transmission of sound to the stethoscope until the scratches reach the liver edge (point B in Box 2), at which point there will be a sudden increase in volume and quality of the sound transmission.
A control manoeuvre is recommended to exclude a false positive finding, which can occur in up to 10% of cases.3
To ensure that the sound transmission is not purely through the skin, we suggest using the same stroking technique to scratch up the midline to the xiphisternum until the point of sound transmission is reached (point D in Box 2).
If the distance from the detected liver edge to the xiphisternum (BC) is more than the control distance (CD), then it can be assumed that the transmission of sound heard at point B was through liver.
If the distance from the detected liver edge to the xiphisternum (BC) is less than or equal to CD, then it can be assumed that the sound conduction was likely due to skin conduction and that the liver edge did not extend beyond the right costal margin.

A video demonstrating the use of the scratch test is available online at mja.com.au.

Is the scratch test still useful in practice?

Very few studies have formally evaluated the scratch test and yet, based on limited evidence, calls have been made to abandon this test.4,5 We believe this call is premature for a number of reasons, as follows.

Small numbers of participants in previous studies, leading to low precision.
Conflating the reference standard of the inferior hepatic margin with the overall hepatic span — the lower hepatic margin does not correlate with the overall liver span given the variation in the superior border of the liver.
Interobserver variation in choosing landmarks (eg, midclavicular line).4
Elementary statistical analyses restricted to correlation coefficients — the question with a physical examination manoeuvre is not absolute accuracy, but whether it is useful enough to yield some information. In our evaluation of the scratch test,3 we noted only a moderate correlation (Spearman correlation coefficient, 0.37) but that 37% of ratings fell within 2 cm and 53% within 3 cm of the ultrasound-located edge. This level of accuracy is still potentially clinically useful.
Lack of definition as to whether the start of the sound transmission was taken as the liver edge or the point of maximal sound transmission. In our study,3 we noted, anecdotally, a difference of about 2.5 cm between these two points, which could be an added source of error. We also noted that by using the point of initial sound transmission, the accuracy rate could increase to 43% of ratings falling within 2 cm and 76% falling within 3 cm of the ultrasound-located value.
Lack of any control site for auscultation to guard against skin transmission of sound.
The scratch test was sometimes performed by the same examiner who performed other manoeuvres, such as palpation, and so was not interpreted independently.
Lack of any training or standardisation of examiners.

Further, a Bland–Altman plot indicates that raters tend to overestimate small spans and underestimate large spans,3 so physicians should be aware of this bias. With some practice and an awareness of this bias, we believe the scratch test can still be a valuable part of the physical exam.

Box 1 –
Causes of an enlarged liver1

Hepatocellular carcinoma
Liver metastases
Fatty infiltration (alcoholic and non-alcoholic)
Haematological disease
- Myeloproliferative neoplasms
- Lymphoma
- Leukaemia
Infiltration
- Amyloidosis
- Haemochromatosis
Acute hepatitis
Biliary obstruction
Right heart failure or pulmonary hypertension (usually pulsatile)

Box 2 –
Landmarks on the abdomen in relation to the measurements used for the scratch test*

* The costal margin is marked with a solid line.

Changes in medical education to help physicians meet future health care needs

Generalist training may be a solution for responding to future population health needs

Health care needs are changing due to the rapidly ageing population and the increasing number of patients with long term conditions and comorbidities.1 This has occurred at a time of continuing maldistribution of the medical workforce in Australia and increased specialisation and subspecialisation within the medical profession and the medical education system. As the next generation of doctors will need to serve an older population and those with more than one condition, a more useful focus would be “much less on narrow disease silos and … more on the breadth of possible permutations of co-morbidity”.1 Long periods of training and increasing subspecialism may also lead to difficulty in changing the scope of practice in times of surplus or reluctance to move to geographic areas with medical workforce shortages.2 For example, despite increasing numbers of medical graduates in Australia, there are existing shortages in generalist specialties, such as general practice, general medicine and psychiatry, and many rural communities still have reduced access to medical care compared with urban populations.2 Do current models and degree of specialisation encountered in medical training optimally prepare physicians to serve the needs of all patients?

Generalism, and the role of the generalist, has been proposed as one solution to reforming the nature and education of the health workforce. Generalism has been defined as “a philosophy of care that is distinguished by a commitment to the breadth of practice within each discipline and collaboration with the larger health care team in order to respond to patient and community needs,” and generalists have been defined as “a specific set of physicians and surgeons with core abilities characterized by a broad-based practice. Generalists diagnose and manage clinical problems that are diverse, undifferentiated, and often complex. Generalists also have an essential role in coordinating patient care and advocating for patients”.3

According to Reeves and colleagues,4 generalism includes continuity of care, principles of person-centred decision making, practice of interpretative medicine, and first contact care for a wide range of problems, such as undifferentiated and complex presentations. While specialists, who mostly provide condition-focused care, may use some features of generalist care, it is the whole-person focus that defines generalist expertise.4 In the Australian health care system, general practitioners and other generalist specialists provide continuity of care in community and hospital settings; they coordinate whole-person care and manage complex and chronic conditions. With the growing burden of multimorbidity, such generalists are likely to be of great value in urban and rural health care settings.

Generalism has been considered the opposite of fragmentation.5 In most medical education settings, the persistence of an organ- or disease-centred approach and clinical rotation structure encourages fragmentation, which tends to foster concepts and skills for continued subspecialisation and hinders the development of generalism in practice. Moreover, it may not equip graduates with the diversity of skills and experiences they will need to tackle multimorbidity or serve in locations and settings of most need.2 The Australian society contributes to the funding of medical education and there is an expectation that doctors will practice medicine and provide services that meet the needs of patients. A subspecialist may be efficient in managing a single clinical problem in a major urban area, but this may not be viable or cost-effective in regional and outer metropolitan settings.6

It is clear that generalists, specialists and subspecialists are needed in the medical system; however, if we aspire to develop more generalist physicians, learners must be exposed to role models who themselves are generalists.7 Albritton and colleagues7 offer several strategies to achieve this: reward and include generalist role models and mentors in all levels of medical education; incorporate generalists into patient care teams in tertiary care teaching settings; implement collaborative teaching programs involving generalists; ensure that accreditation requirements exist for generalist learning environments, with generalism as a fundamental requirement in all specialist training; and provide a thriving academic base for generalists within the academic environment of health education institutions.

Distributing learning out of the tertiary care centre into the community — and valuing the expertise available from generalists based there — is exemplified by the model of medical education adopted by Graduate Medicine (GM) at the University of Wollongong.8 In 2007, the university launched a new graduate-entry school with a shift in emphasis from teaching and learning in specialism to generalism.9 The GM aspired to deal with the shortage of generalist physicians (general practice and other specialties) in regional and rural communities. In addition, the Northern Ontario School of Medicine (NOSM), aiming to meet rural workforce needs in northern Canada, has also foregrounded learning in generalism.10

Extended immersion in the real world environment of generalism is a distinctive feature of the GM and NOSM educational programs.8,10 All senior students in these 4-year graduate-entry medical courses complete a community-based longitudinal integrated clerkship (LIC) in rural or non-capital city urban settings. While other medical schools have implemented LICs for a portion of their students, the year-long generalist clinical experience for the entire student cohort is a unique element for the Australian medical education. The term primary care captures most of the generalist learning environments in the LIC experience, namely general practice (at least 2 days per week) and hospital emergency practice (one shift per week and after hours). This gives students access to undifferentiated patients and the opportunity to accrue a panel of patients who consult them throughout the year under preceptor supervision. Students also learn and contribute to patient care in hospital wards, outpatient clinics, surgical theatres and delivery suites, and in many instances, following patients they have previously encountered in local primary care. In the hospital, students are supervised by generalists or specialists.

Generalism is valued as the professional philosophy of practice for these long term placements. Students learn from generalist solutions to the complex problem of person-centred care for people presenting with multimorbidity. Longitudinal participation also enables involvement in continuity of patient care. One GM preceptor lamented the lost educational opportunity he experienced with his own short term placements, remarking that “you never saw anyone for more than [a] week … and you never knew what happened to them”.8

The preceptor’s commitment to long term supervision and the patient’s engagement are fundamental for a quality student generalist experience; the preceptor legitimises student participation in the wider health care team, and patients trust the student as they trust their doctor.11 The broad experience of learning from, and working with, a range of patients and public and private health professionals is the foundation from which students can differentiate in post-graduate training.

Expansion of primary care-based medical education doesn’t mean “[throwing] the baby out with the bathwater”.12 Teaching hospitals remain a key learning environment for medical education. Primary Health Networks and Local Health Districts are focusing on smooth transitions for patients between the hospital and community. Longitudinal and integrated involvement in patient care allows medical students to learn from all stages of the patient journey through care.

Learning and working with generalists is likely to be beneficial across the continuum of medical education. In rural settings, specialists tend to be generalists by necessity, but generalists may be incorporated into patient care teams in tertiary care teaching settings. Although the GM is still too young to have gathered significant long term data about graduates’ career outcomes, data collected at the graduation of four recent cohorts revealed a generalist specialist career preference by 36.8% of graduates (Federation of Rural Australian Medical Educators [unpublished survey data 2010–2013]). Moreover, GM graduates are choosing internships in rural settings (43%) or non-metropolitan areas (61%),13 contributing to the health care of populations there. Likewise, 61% of NOSM medical graduates have chosen family practice (predominantly rural) training.10 These are promising signs from curricula offering students greater opportunities for generalist training.

In Australia, the Commonwealth has invested considerable funds in rural undergraduate medical education to manage the maldistribution of the medical workforce, which is a major driver for more generalist training. The funding increase to the Practice Incentive Program Teaching Payment to further support medical students’ exposure to community generalist settings has been greatly welcomed. A recent review of intern training in Australia has recommended expanding intern training settings; moving to a longitudinal integrated, transition-to-practice model; and giving interns clinical experience in the full patient journey. New initiatives are needed to replace the discontinued Prevocational General Practice Placements Program and give pre-vocational students greater exposure to generalist learning environments. The Murray to the Mountains Intern Program, in Victoria, is one example of applying continuity and generalist supervision to pre-vocational training.14

In a similar manner, the Rural Generalist Medicine program is a post-graduate initiative focused on training generalists with special skills to meet the health needs of rural and remote communities (http://acrrm.org.au/the-college-at-work/rural-generalist-medicine). Government funding will soon be available to build local resources to support regional- rather than urban-based specialist trainees. However, all post-graduate training programs need to examine whether they are building the skills and experience that future doctors will need to deal with the challenge of multimorbidity. Ahern and colleagues15 recently recommended a national integrated governance structure across all phases of medical training to support an integrated and consistent approach to medical training and workforce planning. This approach to accreditation will likely be influential in ensuring that all medical training programs foster sufficient flexibility and exposure to generalism to meet the health needs of all populations.

Budget at a glance

Significant health measures in the Budget

Lifting the freeze on the indexation of the Medical Benefits Schedule.
National Disability Insurance Scheme to be fully-funded by a 0.5 percentage point Medicare Levy increase from 2019.
Legislation to guarantee Medicare and the PBS.
Hospital funding increased by $2.8 billion over four years.
$1.4 billion to be invested in health research over four years.
$1.2 billion in new medicines to be made available

Other big measures in the Budget

Levy on big banks’ liabilities to raise $6.2b.
Negative gearing and depreciation changes to raise $2.1b.
First home buyers can get a deposit by salary sacrificing into super.
$300m to the Australian Federal Police to fight terrorism.
$10b to establish a National Rail Program.
Foreign worker levy to raise $1.2b over four years.
$18.6b for Gonski education funding.
$5.3b over 10 years for Western Sydney Airport Corp.
$8.4b for Melbourne to Brisbane Inland Rail Project.
$4b tax crackdown on multinationals.
$1b National Housing Infrastructure Facility for new homes
Federal Government to take control of Snowy Hydro
$90m to secure gas resources for domestic use

The Budget deficit is $29.4 billion in 2017-18, with the Government forecasting a return to surplus by 2020-21.

Indigenous health measures welcomed, but more needed

The AMA welcomes many of the Indigenous health measures in the Federal Budget, while recognising that there is still more to be done.

The Indigenous Health Budget line for the next financial year has increased to $881 million, an $83 million increase that the Close the Gap Campaign, of which the AMA is a proud member, attributes mostly to population increases and indexation increases in the Indigenous Australians’ Health Program. There was also a $2.4 billion increase in funding allocated to Medicare over the next four years, and a much welcomed early lifting on the freeze on Medicare rebates.

In particular, the AMA supports the Government’s measures to strengthen and expand their commitment to address Rheumatic Heart Disease (RHD), something we have been strongly calling for. Last year the AMA released its 2016 Report Card on Indigenous Health that focused on the devastating effects of RHD, an entirely preventable disease that affects hundreds of Indigenous Australians each year. In our Budget Submission, the AMA called on the Government to commit to eradicating new cases of RHD, and we are pleased to see the Government heed these calls.

It is unacceptable that Indigenous Australians are still 20 times more likely to die from RHD than their non-Indigenous peers. This measure provides $7.6 million in new funding in addition to the $11.2 million already provisioned by the Government, and focuses on improving clinical care, and using education and training for health care providers, patients and their families to raise awareness to improve the prevention and treatment of RHD. The measure also includes funding for focused prevention activities in high-risk communities.

We also welcome the Government’s allocation of $9.1 million to improve telehealth arrangements for psychological services in regional, rural and remote areas of Australia. Nearly one-third of Aboriginal and Torres Strait Islander adults report high levels of psychological distress in their lives – this is two and a half times the rate reported by other Australians. The AMA believes the mental health and social and emotional wellbeing of Aboriginal peoples should be given greater priority in the nation’s health policy agenda.

As the Government has said, this measure will help remove significant barriers faced by those people unable to access psychological services because of where they live. They will no longer have the inconvenience, time and expense of having to travel to large regional centres to receive the help that they need.

The Budget also commits $400,000 over four years to ensure that eligible pharmacists continue to be appropriately renumerated for supplying medicines under the Pharmaceutical Benefits Scheme (PBS) for individual clients of Remote Area Aboriginal Health Services. This measures ensures that pharmacists will be paid the regular PBS dispensing fee for each item provided, instead of the lower bulk handling fee.

While the AMA welcomes much of these measures, the budget remained quiet on many other important areas in Indigenous health. The gap in health and life expectancy between Aboriginal and Torres Strait Islander peoples and other Australians is still considerable, despite existing commitments to close the gap. However, Health Minister Greg Hunt indicated at the Health Budget Lock-up that there is going to be a ‘third wave’ of reform, which will include Indigenous health. The AMA looks forward to working with the Government in this process.

Alyce Merritt
Indigenous Policy Adviser, AMA

Medical Students say Budget missed opportunity for workforce investment

The Australian Medical Students’ Association (AMSA) welcomes certain elements of the federal budget, but is concerned by the Government’s lack of investment in medical education.

While the Budget will continue to fund the Specialist Training Program and support rural background recruitment, cuts to funding will impact quality of medical education.

AMSA President Rob Thomas said he was pleased to see there will be no increases in medical student places from new medical schools, and also that funding will continue for the Commonwealth Medical Internships Program.

“However, this Budget was a real opportunity for the Government to contribute to the future health workforce by increasing specialist training in regional and rural areas and ensuring medical schools are adequately funded,” he said.

“AMSA has called for more places in the Specialist Training Program to be delivered in rural and regional areas, as this is required to ensure a sustainable rural medical workforce.

“The Budget delivers no net increase overall, and a marginally increased proportion from 39 per cent rural places currently to 45 per cent by 2021.

“This means that those who want to work rurally will continue to have to undertake the majority of their training in metropolitan areas, decreasing the likelihood that they will be rural doctors in the long-term.”

Mr Thomas said AMSA was relieved university fee deregulation is off the table, but that the higher education reform announcement posed new concerns.

“According to the Medical Deans of Australia and New Zealand, funding for medical education falls short by $23,500 per student per year. This discrepancy places major strains on the training of future doctors in Australia,” he said.

“By reducing Commonwealth base funding for medical education by 2.5 per cent in each of 2018 and 2019, this figure will only expand, impacting the quality of basic medical education.”

AMSA welcomes the Government’s commitment of $5 million over the next two years to Orygen, the National Centre of Excellence in Youth Mental Health, and a further $10 million to the Black Dog Institute and Sunshine Coast Mind and Neuroscience.

“With medical students facing a disproportionate burden of mental illness, the Government’s increased funding for mental health research is to be applauded,” Mr Thomas said

“We are hopeful that a proportion of this funding will be devoted to the research of university student mental health.”

Chris Johnson

Better broadband needed for rural, regional health

Limitations in the roll out of satellite technology are impeding the take-up of the National Broadband Network (NBN) in regional, rural, and remote areas, the AMA has told a Senate committee.

In a written submission to the Joint Standing Committee on the NBN, AMA President Dr Michael Gannon said that all Australians, regardless of where they live or work, should have equitable access to high-speed and reliable internet services.

“Country Australians must have access to NBN services that enable them to conduct the same level of business via the internet as their city counterparts,” Dr Gannon said.

“These NBN services must also have the capacity to meet their future internet needs.

“This is particularly important for providers of vital health services. Data allowances and speeds must be sufficient to enable two-way applications for e-health and telehealth, including the transfer of high-resolution medical images, medical education, videoconferencing, Voice over Internet Protocol (VoIP), and other applications.

“However, it is widely acknowledged that there are significant cost, data allowance, and speed differences between fixed and satellite broadband services, putting some regional and remote areas at a significant disadvantage.

“While NBNCo (nbn) has advised the AMA that it is looking at how some of these issues can be addressed for critical services like health care, changes are yet to be detailed at this time.”

Dr Gannon said that nbn had advised the AMA that it was working to identify medical facilities and general practices within the satellite footprint in rural and remote areas that would qualify as Public Interest Premises (PIPs), and therefore be granted access to higher data allowances.

“This is a small step in the right direction, but the AMA remains concerned that, even as PIPs, these medical facilities will still not have sufficient data allowance to be able to fully utilise the e-health and telehealth opportunities that are taken for granted in metropolitan areas,” he said.

Last month, Minister for Regional Development and Regional Communications Fiona Nash announced that Medicare rebates will be paid for rural and remote Australians to access psychological counselling through teleconferencing.

Senator Nash said that mental health was a significant issue in rural and remote areas, but lack of easy access to a nearby psychologist often meant mental health issues went untreated.

“It’s difficult and sometimes impossible for rural and remote Australians to attend face-to-face counselling,” Senator Nash told the National Press Club.

“Today, I announce rural and remote Australians will, for the first time, have access to psychology through teleconferencing paid for by Medicare.

“This will mean rural and remote Australians can use Skype, FaceTime or video calling to access psychologists and psychiatrists all over Australia from their home or a local medical centre.”

Many Australians who were going without mental health treatment will now receive it, Senator Nash said, praising Health Minister Greg Hunt for delivering the first outcome from the Regional Australia Ministerial Taskforce.

Despite criticism of the speed of the nbn’s SkyMuster satellite service, Senator Nash said it was fast enough to deliver the service, and said people in the bush understood that they were not going to have the same internet speeds as their city counterparts.

“For those wondering, high definition video conferencing requires internet speed of just 1.5 megabits a second. A typical Sky Muster plan delivers enough data for 66 hours a month of high definition video conferencing,” she said.

“Regional people are very pragmatic. They know they are not going to get the same equivalence across a whole range of areas their city cousins do, but they want access to services so they can get on their lives.

“The (internet) speed you are going to get in the western parts of Queensland is not going to be the same that you get in the CBD in Brisbane.

“They (rural Australians) get that … as I am travelling around and talking to people in the regions, I’m not talking about the speed, I’m talking, ‘Can you do what you want to do in the regions through your internet connection?’

“By and large, most of them are happy with the service they’ve got.”

Maria Hawthorne

World Medical Association meets in Zambia

AMA President Dr Michael Gannon represented Australian doctors at the 206th World Medical Association Council meeting.

Medical practitioners from national medical associations around the world gathered to debate a number of key issues in Livingstone, Zambia on April 20 to 22. The event was attended by almost 200 delegates from more than 30 national medical associations.

Medical cannabis was one of the key discussions at the meeting. A Position Statement was developed to be presented at the WMA’s General Assembly in October.

A debate also took place on proposals to revise the WMA’s long-held policy on boxing so as to include safety regulations until a ban could be put in place. A recommendation to revise the policy at the General Assembly was agreed.

The Council agreed they needed to update their position on availability and effectiveness of in-flight medical care, along with the idea of allowing physicians to provide emergency care during flights without fear of legal reprisals.

Discussions also took place on bullying and harassment in the medical workplace; updating ethical advice on hunger strikes for doctors; armed conflicts; medical education; alcohol; and water and health.

All new policy proposals will be forwarded to the General Assembly.

WMA leaders heard from the Confederation of Latin American National Medical Associations (CONFEMEL) that restrictions on the professional freedom of physicians to practice medicine was leaving patients without basic medical care. They reported that medical prescriptions and laboratory tests were being restricted, leading to disappointed and sometimes angry patients.

Dr Ketan Desai, President of the WMA, said: ‘We have been told that doctors in Venezuela feel helpless to resolve the situation, which is getting worse day by day. Junior doctors in particular are having to face angry patients and are often suicidal.

“For the sake of patients and physicians in Venezuela this situation cannot be allowed to continue. We urge the Government of Venezuela to allocate the necessary resources to the health care system and to ensure the independence of physicians to allow them to deliver high quality medical care to their patients. At the moment patients’ fundamental rights to health are being violated.”

WMA is now considering sending a delegation to Venezuela to express support to local doctors as well as report on the situation.

Extreme concern was expressed by the WMA as well as calling for the immediate release of a Turkish doctor, Dr Serdar Küni who is jailed in Turkey for providing medical treatment to alleged members of Kurdish armed groups.

Dr Küni, a respected member of the local community, and former chairperson of the Şırnak Medical Chamber was the Human Rights Foundation of Turkey’s representative in Cizre. He has remained detained since his arrest last October and is awaiting trial. Concerns have been raised by human rights organisations regarding his access to a fair trial and fair hearing rights at that trial.

The WMA believe the case of Dr Küni is one example among many of arrests, detentions, and dismissals of physicians and other health professionals in Turkey since July 2015, when unrest broke out in the southeast of the country.

The WMA moved an emergency resolution that condemned such practices that: “Threaten gravely the safety of physicians and the provision of health care services. The protection of health professionals is fundamental, so that they can fulfil their duties to provide care for those in need, without regard to any element of identity, affiliation, or political opinion.”

It added: “The WMA considers that punishing a physician for providing care to a patient constitutes a flagrant breach of international humanitarian and human rights standards as well as medical ethics. Ultimately it contravenes the principle of humanity that includes the imperative to preserve human dignity.”

The United Nations Security Council has declared, states should not punish medical personnel for carrying out medical activities compatible with medical ethics, or compel them to undertake actions that contravene these standards.

Meredith Horne

[Comment] Medication Without Harm: WHO’s Third Global Patient Safety Challenge

In 1960, Alphonse Chapanis, turned his attention from engineering to health care. In a study of medication-related errors in a 1100-bed hospital,1 he and his colleague identified seven sources of such errors potentially leading to harm to a patient: medicine omitted, or given to the wrong patient, at the wrong dose, as an unintended extra dose, by the wrong route, at the wrong time, or as the wrong drug entirely. Almost 60 years later, these same types of errors still happen worldwide. Later that year in a follow-up policy paper,2 Chapanis identified four areas of recommendations that could prevent harm and remain relevant today: written communication, medication procedures, the working environment, training, and education.

[Review] A rapid evidence review of the effectiveness and cost-effectiveness of alcohol control policies: an English perspective

This paper reviews the evidence for the effectiveness and cost-effectiveness of policies to reduce alcohol-related harm. Policies focus on price, marketing, availability, information and education, the drinking environment, drink-driving, and brief interventions and treatment. Although there is variability in research design and measured outcomes, evidence supports the effectiveness and cost-effectiveness of policies that address affordability and marketing. An adequate reduction in temporal availability, particularly late night on-sale availability, is effective and cost-effective.

Clinical experience of patients with hepatitis C virus infection among Australian GP trainees

Since March 2016, new direct-acting antiviral agents (DAAs) for treating infection with hepatitis C virus (HCV) have been available in Australia under the Pharmaceutical Benefits Scheme (PBS). This represents a revolution in the treatment of hepatitis C, as DAA regimens have cure rates of more than 90%, minimal adverse effects, and low treatment complexity. In contrast to previous HCV treatments, general practitioners are authorised to prescribe HCV DAAs. The Fourth National HCV Strategy emphasises that, to maximise the impact of HCV DAAs, most HCV treatment will need to move from hospital-based clinics to the primary care setting.1

An estimated 230 000 Australians live with chronic HCV infection,2 with annual notification rates about twice as high among males as among females, and highest for people aged 30–50 years.3 Eliminating hepatitis C as a public health problem by using highly efficacious, well tolerated DAAs is possible, but would require a major increase in the number of people treated.4

Registrar Clinical Encounters in Training (ReCEnT) is a prospective cohort study that collected detailed data on more than 150 000 consultations by GP trainees in five Australian GP training programs during 2010–2015. ReCEnT documents the content of trainees’ consultations, and both informs and evaluates training program changes. Our methodology, described in detail elsewhere,5 and statistical analysis are summarised in the online Appendix. As most learning by GP trainees is acquired in an apprenticeship model in the workplace (supplemented by away-from-practice educational sessions),6 we aimed to determine prevalence of management of and testing for HCV in the consultations of trainee GPs.

Although at least 1.2% of the Australian population are infected with HCV,7 hepatitis C was managed as a problem (eg, discussed, investigated, referral of the patient) in only 0.08% of consultations (online Appendix, Table). This indicates that the current exposure of registrars to the diagnosis and management of HCV infections during training is very limited. Patients for whom HCV was managed were older than other patients, and more likely to be male or Indigenous Australian. HCV testing was performed in 0.7% of consultations, and the patients tested were significantly younger (mean age, 32 v 40 years; P < 0.001), and more likely to be female, Indigenous Australian, or from a non-English speaking background than those who were not (online Appendix, Table). Doctors who tested for HCV were younger, and were more likely to be female, graduates of Australian universities, and practising in a city (online Appendix, Table).

Our data indicate that the clinical exposure of GP trainees to patients infected with HCV is limited, and that their experiential training in this condition may be inadequate. Further, HCV testing was only infrequently ordered, and the wrong groups were targeted; we found that males and older patients were less likely to be tested, despite higher HCV seroprevalence in these groups. If hepatitis C is to be eradicated as a public health problem in Australia, it is important that diagnosing and treating HCV infections are prominent in the GP training curriculum.