I am a great fan of your publications. I feel there has been a trend, however, toward publishing articles
written by specialists, apparently without going through a filter of assessing their relevance to the daily decision
making within a true general practice context. Articles authored by General Practitioners with some advice from specialists
are more valuable.
As one example, may I refer to the "How-to guide for a sexual
health check up”, in BPJ 52 (Apr, 2013). The guidance and recommendations in this article are relevant to practice
in a sexual health clinic, where there is a high prevalence of STIs in the patients seen, but this article does not
address the issues of pre-test probability and judgement around relevance and appropriateness in ordinary general practice
consulting. We see some patients for whom these recommendations are appropriate, but frequently make difficult judgements
about how far to take sexual health screening, and it would be very helpful if an article such as this helped us with
Working through this article, written by sexual health specialists, one reads that "A sexual health check should generally
be undertaken ... for females attending for routine contraceptive or cervical screening visits." Further on in the article
one finds, "Routine examination and testing for females should include ...serology for hepatitis B (if not immunised),
syphilis and HIV." In mainstream general practice, providing comprehensive care to patients and their families over
the years, faced with, for example, a 35 year old woman, well known to us in an apparently stable relationship and with
a family, who is seeking a repeat of her contraception, or a 50 year old woman responding to a recall for a now due cervical
smear, we need to employ a different set of skills, rather than follow a blanket over inclusive recommendation which
has relevance to a sexual health clinic. We know that with such familiar patients, the probability of an STI being present
is low, but not altogether negligible. What questions do we ask the patient and what tests do we offer and with what
wording in this context? The suggested lead-in statement, "We ask everyone the same questions, they may seem intrusive
but I'm just trying to find out risks and what tests you may need," may not seem appropriate.
Furthermore, if we do obtain a positive chlamydia result in an asymptomatic patient, with a personal profile which
suggests a very low pre-test probability, how likely is it that this is a true positive result? This article does not
address questions like this.
I wonder whether specialists, when invited to contribute, are aware of the nuances that we encounter on a daily basis?
In inviting them to contribute, would it be helpful to provide them with a set of vignette scenarios from general practice
which would help keep their idealised articles grounded?
Dr Greg Judkins
General Practitioner and Medical Educator, Auckland
All main articles for Best Practice Journal and Best Tests are authored by our in-house writing team, with assistance
and guidance from our clinical team, which consists of four General Practitioners and a Pharmacist. Each article is
externally reviewed by a relevant subject specialist (or group), who provides expert comment and correction as required.
The articles are also reviewed by our Clinical Advisory Group which is made up of primary and secondary care representatives.
We then edit the articles for publication, based on the balance of all of these comments.
The article you refer to ("A how-to guide for a sexual health check up") is considered a foundation article,
which is intended to give a general overview of all aspects of a particular condition/disease process. Foundation articles
are then followed up by more focused articles on specific aspects of managing a condition. Our foundation guidance is
intended to cover “what you should do” to manage a condition, in an evidence-based, New Zealand context. However, we
intend for clinicians to interpret the information based on the context of their individual practice, i.e. “what you
We endeavour to keep our information primary-care and practically based, while incorporating latest evidence and commentary
from those who specialise in treating the conditions we write about. Your feedback serves as a useful reminder to us
of the importance in getting this balance right.
We have asked Dr Jill McIlraith, an experienced General Practitioner from Dunedin, who teaches sexual health to GP
registrars, fellow GPs and undergraduates, to comment further on some of the aspects raised in this letter:
"I feel that the article strikes an excellent balance between the detailed knowledge required for a General
Practitioner faced with doing a required sexual health checkup, and that of reminding us all of the basics. I think
of it as a resource into which we can dip for information rather than a prescriptive guide that we as General Practitioners
should use for each and every patient. It was clear, concise and offered good reminders about the essentials of what
is often a difficult area for General Practitioners as well as touching on some of the current issues such as antibiotic
I disagree with the comment that in mainstream general practice, you would not at least discuss the subject of
STIs with each patient when doing smears or renewing contraception. I make opportunities to discuss it with my patients,
just as I do the same for smoking cessation. My policy has long been to ask all female patients in general terms whether
there “is anything else we need to check for while doing the smear”. Some patients then ask “what do I mean?” and I
reply that people lead complicated lives and it is my policy to ask everyone for whom I do a smear, whether they have
any other concerns that I can help with. In other words, I take on the responsibility of broaching the broader aspects
of sexual health. In 23 years of general practice, I have never had a patient indicate they are offended by me asking,
and most have appreciated my thoroughness and care - particularly those such as in the correspondents example, i.e.
a 50-year-old woman who usually find it very difficult to bring up the topic unless the doctor does so first. They
are often the ones who most need us to break the mold and be upfront.
It would be naïve of us General Practitioners to think we know all our patients so well that we don’t need to
broach such sensitive subjects. It is also worth reminding all our colleagues that the fastest rate of increase of
STIs in the western world is in those aged over 50 years, and that very little sexual health information is targeted
to this age group. They are also the least likely to broach the subject with doctor and nurses, least likely to use
condoms and most likely to confuse symptoms of STIs with age-related changes and put off talking to medical staff about
Regarding positive chlamydia tests, the NAAT tests used now are very sensitive and very specific and it would
be very rare to get a false positive. So a positive result is likely to be just that - positive. Any concerns are more
likely to surround the discomfort that the clinician may feel in that they now need to discuss how/when/who gave what
to whom. It is a similar comment to what we hear from midwives, i.e. that their “nice” patients wouldn’t have an STI
so why should they offer testing and if it did come back positive it would create difficulties for them in discussing
and stress the relationship.
I would highly recommend the article to my general practice colleagues. Each of them can quite easily filter it
through their own knowledge and comfort levels to do the best by their patients in an area that a lot of General Practitioners
do poorly in."
Dr Jill McIlraith
General Practitioner, GPEP teacher.
Dr Sunita Azariah, is a Sexual Health Physician from Auckland, who provided expert comment on the sexual health article
in Best Practice Journal. Dr Azariah offers some further insight:
"I agree that this article is an example of best practice recommendations in an ideal world. I appreciate
that General Practitioners have time constraints, as do all practitioners. Sexual health history and assessment and
screening of asymptomatic people fits well within the role of an experienced Practice Nurse. With widespread availability
of NAAT testing it doesn’t need much time to actually test people as they can do self-collected samples.
Different primary care practices will have different risk profiles for their patients. I think the need to establish
an environment where people will feel comfortable to talk about their concerns is what is most important, e.g., the
gay man who doesn’t know how his General Practitioner will react to disclosure of his sexuality. Many primary care
practices market themselves as “Family medicine” so routinely asking people about their sexual health concerns is a
way of breaking the ice and making people feel more comfortable to raise issues if they wish. It will also make them
aware that they can bring up concerns if their General Practitioner has signalled they are comfortable discussing these
issues with them.
I think too, as with any guidance, one has to use common sense as to what you actually do in clinical practice.
The point of the sexual history is to check risk factors as many people will not need to have comprehensive STI screening.
However, if you don’t ask you won’t find out relevant information. One can’t assume that the “nice married 30 year-old
professional woman” is not having concurrent sexual partners or that her husband is not having an affair. People won’t
get offended if things are discussed in the right way."
Dr Sunita Azariah
Sexual Health Physician, Auckland Sexual Health Service