General practice and the New Zealand health reforms – lessons for Australia?

New Zealand's health sector has undergone three significant restructures within 10 years. The most recent has involved a Primary Health Care Strategy, launched in 2001. Primary Health Organisations (PHOs), administered by 21 District Health Boards, are the local structures for implementing the Primary Health Care Strategy. Ninety-three percent of the New Zealand population is now enrolled within 79 PHOs, which pose a challenge to the well-established Independent Practitioner Associations (IPAs). Although there was initial widespread support for the philosophy underlying the Primary Health Care Strategy, there are concerns amongst general practitioners (GPs) and their professional organisations relating to its implementation. These centre around 6 main issues: 1. Loss of autonomy 2. Inadequate management funding and support 3. Inconsistency and variations in contracting processes 4. Lack of publicity and advice around enrolment issues 5. Workforce and workload issues 6. Financial risks On the other hand, many GPs are feeling positive regarding the opportunities for PHOs, particularly for being involved in the provision of a wider range of community health services. Australia has much to learn from New Zealand's latest health sector and primary health care reforms. The key lessons concern: • the need for a national primary health care strategy • active engagement of general practitioners and their professional organisations • recognition of implementation costs • the need for infrastructural support, including information technology and quality systems • robust management and governance arrangements • issues related to critical mass and population/distance trade offs in service delivery model

The Influence of the Ignatian Pedagogical Paradigm on Instructors Integrating It into Undergraduate Courses in the College of Professional Studies at Marquette University

This is the initial installment of a two-part story narrating the process of embedding the Ignatian Pedagogical Paradigm (IPP) into the curriculum of four core courses in the College of Professional Studies at Marquette University in Milwaukee, Wisconsin. This article provides a template for faculty development when integrating the IPP into undergraduate courses at a Jesuit University. The trainer followed the recommendation of the 1989 International Commission on the Apostolate of Jesuit Education (ICAJE), which states “Teachers need much more than a cognitive introduction to the Paradigm. They require practical training that engages and enables them to reflect on the experience of using these new methods confidently and effectively.”1 The first part of this article provides the reader with the trainer’s immersion and utilization of the IPP by using the IPP constructs of context, experience, reflections, actions, and evaluation. In the second part of this article the four participants share their reflections regarding the challenges of understanding the IPP as well as the benefits of adapting their teaching, curriculum, and rubrics to insure the successful integration of the IPP into their courses. The second part of this article reports the participants’ thoughts and activities related to comprehending and developing the major constructs of the IPP: Context, Experience, Reflection, Action, and Evaluation. Therefore, it has a conversational tone of a shared learning experience to illustrate for the reader the deeply reflective process each participant experienced in becoming an IPP learning community. It includes a description of the process used to collect data to determine the impact of the IPP on the instructor as the courses were taught. A future article will describe the data analysis, conclusions and recommendations

Increased Whole-Body and Sustained Liver Cortisol Regeneration by 11β-Hydroxysteroid Dehydrogenase Type 1 in Obese Men With Type 2 Diabetes Provides a Target for Enzyme Inhibition

OBJECTIVE The cortisol-regenerating enzyme 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1) amplifies glucocorticoid levels in liver and adipose tissue. 11β-HSD1 inhibitors are being developed to treat type 2 diabetes. In obesity, 11β-HSD1 is increased in adipose tissue but decreased in liver. The benefits of pharmacological inhibition may be reduced if hepatic 11β-HSD1 is similarly decreased in obese patients with type 2 diabetes. To examine this, we quantified in vivo whole-body, splanchnic, and hepatic 11β-HSD1 activity in obese type 2 diabetic subjects. RESEARCH DESIGN AND METHODS Ten obese men with type 2 diabetes and seven normal-weight control subjects were infused with 9,11,12,12-[2H]4cortisol (40%) and cortisol (60%) at 1.74 mg/h. Adrenal cortisol secretion was suppressed with dexamethasone. Samples were obtained from the hepatic vein and an arterialized hand vein at steady state and after oral administration of cortisone (5 mg) to estimate whole-body and liver 11β-HSD1 activity using tracer dilution. RESULTS In obese type 2 diabetic subjects, the appearance rate of 9,12,12-[2H]3cortisol in arterialized blood was increased (35 ± 2 vs. 29 ± 1 nmol/min, P &amp;lt; 0.05), splanchnic 9,12,12-[2H]3cortisol production was not reduced (29 ± 6 vs. 29 ± 6 nmol/min), and cortisol appearance in the hepatic vein after oral cortisone was unchanged. CONCLUSIONS Whole-body 11β-HSD1 activity is increased in obese men with type 2 diabetes, whereas liver 11β-HSD1 activity is sustained, unlike in euglycemic obesity. This supports the concept that inhibitors of 11β-HSD1 are likely to be most effective in obese type 2 diabetic subjects. </jats:sec