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www.racgp.org.au/goodpractice
Pain points
GPs are at the forefront of care in Australia’s growing
opioid problem
INSIDE
Online healthThe quality and efficacy of online prescription,
referral and medical certificate services
DisabilityGPs’ role in the continued rollout of the
National Disability Insurance Scheme
RACGP awardsSome of the best of general practice
ISSUE 11, NOVEMBER 2017
3Reprinted from Good Practice Issue 11, November 2017
2. The Royal Australian College of General Practitioners.
In practice newsletter, 28 July 2017. East Melbourne,
Vic: RACGP, 2017. Available at www.racgp.org.au/
yourracgp/news/inpractice/28-07-2017 [Accessed 4
October 2017].
Can you identifythe warning signs of family violence?
Listen between the lines. Family violence is
hard to talk about.
visit racgp.org.au/familyviolence to find out more
PAUL HAYES
‘So, what are your special interests?’
A common question asked of many GPs.
For long-time Tasmanian GP Dr David
Knowles, this line of enquiry stirs some
emotions about his love for general practice
and serving his community.
‘I often get asked and I always find it hard
to answer. I thrive on the comprehensive
and continuous care that I can provide in my
practice,’ Dr Knowles, the 2017 recipient
of the RACGP’s Rose-Hunt Award, told
Good Practice. ‘I see a lot of people with
diabetes and we run a dedicated nurse-led
clinic at our practice, I see a lot of patients
with haemochromatosis and manage their
venesections, I do dedicated travel sessions.
‘My community influences my skillset.’
This attitude also influences Dr Knowles’
approach to education, especially fitting
given his is also the RACGP’s 2017 General
Practice Supervisor of the Year.
‘I want to inspire our medical students and
registrars, just as I have been inspired by my
mentors,’ he said.
As a person who describes himself as ‘not
someone who likes the limelight’, Dr Knowles
took the news of winning the Rose-Hunt,
the RACGP’s highest accolade, in his stride,
though the significance of the award was
certainly not lost on him.
‘I am honoured and humbled that my
peers and the RACGP would deem I was
worthy of this award. Many of my GP heroes
and mentors are previous winners of this
prestigious award and to be included on a
list with them is hard to fathom,’ he said. ‘I
am actually delighted that my college would
have chosen someone who works more in
the background and whose primary job is
at the coalface.
‘I think for every member who is out there
working with their communities, this year’s
award is a recognition of what they do,
because that is what I do and I know this is
valued by our college and our Council.’
While the Rose-Hunt is a major honour,
acknowledgement as a general practice
supervisor ‘sits most comfortably’.
‘To be recognised for this role is a great
honour,’ Dr Knowles said. ‘Our practice
creates an environment where everyone
aims to be the mentor, and we create
an environment where medical students,
registrars, nursing students and pharmacy
students feel comfortable to ask any question,
challenge themselves and learn.
‘Is does not take long for everyone
to realise they are teachers themselves.
I am taught something new every time
I turn up to work.’
Amanda BethellWhen she answered a middle-of-the-day call
from RACGP SA&NT Immediate Past Chair
Dr Daniel Byrnes, Dr Amanda Bethell wasn’t
really expecting any big news. She certainly
wasn’t expecting to learn she had been
named the RACGP’s 2017 GP of the Year.
‘I didn’t know I’d been nominated, so it took
me a few minutes to adjust because I didn’t
know what the hell he was talking about,’ she
told Good Practice.
The news, however, was certainly
not unwelcome.
‘It’s pretty exciting.’
As an experienced rural GP, Dr Bethell’s
initial thoughts about taking up a life in
medicine were shaped (rather appropriately,
as it turned out) by what she saw in television.
18 Reprinted from Good Practice Issue 11, November 2017
This year’s RACGP award winners show some of the
best of general practice in Australia.
Honourroll
RACGP AWARDS
Image x
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XXX
‘My only knowledge of medicine was from
watching TV shows A Country Practice and
The Flying Doctors. As far as I was concerned,
that was medicine,’ she said.
Dr Bethell now practises in the rural South
Australian town of Port Augusta, about 320 km
north of Adelaide with a population of close to
14,200 people. She is very comfortable in this
type of setting and is drawn to the nature of
healthcare delivery it affords.
‘I really love the diversity. I like that in general
practice you get to meet the whole breadth
of humanity – different cultures, different
ages, a whole bunch of different health
problems,’ she said.
‘I love the intellectual challenge of seeing
undifferentiated problems; if you are a
sub-specialist you already know what a
problem is when it comes to you. I love, in
rural general practice, the ability to do both the
clinical work and the hospital work.
‘Since moving back to Port Augusta in the
last six years … I have to use so many different
skills that there wasn’t a call for in [my time in]
the city because people were going to different
places for different things.’
Dr Bethell also loves to express this love of
rural healthcare when she is teaching medical
students and general practice registrars.
‘I spend my whole time telling them that
rural general practice is the only way to go,’
she said.
‘I like the role of a mentor; I learn from the
registrars as well as they learn from me and, I
hope, the medical students.
‘A lot of the time my medical students
are at a stage where they have got all of their
[academic] knowledge, so you are seeing them
start to apply that and actually think about how
they would manage a situation, and helping
them with their practical skills.
‘So being able to, for example, take
somebody from not being able to take bloods
to being able to put a drip in really well.
‘That kind of thing is very satisfying.’
Adelaide Boylan Much like her fellow South Australian,
Dr Bethell, general practice registrar
Dr Adelaide Boylan has an immediate response
when considering what she loves about
general practice.
‘The diversity,’ she told Good Practice.
‘The opportunity to see different people at
different stages of their lives, with different
problems all day long.’
As the RACGP’s 2017 General Practice
Registrar of the Year, Dr Boylan has
embraced all that comes with entering
primary healthcare.
‘I think the diversity is so enjoyable and
makes for such interesting days, but it can
also be terrifying and a bit overwhelming at
times,’ she said. ‘It’s proven to be challenging,
but I love it.’
That diversity extends beyond the consulting
room for Dr Boylan, who divides her time
between a number of different areas of
healthcare. A typical week includes time at
a a private family general practice, in aged
care, and engaging in teaching and content
development at Adelaide University.
‘That’s the nice thing about being a
GP – having your finger in lots of different,
interesting pies. It keeps your mind open in
doing different things, while also being there
enough to contribute properly,’ she said.
Having trained and worked as a lawyer prior
to entering medicine, Dr Boylan has found
such a background can come in handy in
her new vocation.
‘I think my law training has been a good
background in communication aspects of my
job, having a little bit of an idea about risk
management and probably being less fearful of
the legal system,’ she said. ‘Sadly, in medicine
now people are terrified of the medico-legal
consequences of their decisions.
‘Hopefully that will change over my
professional lifetime.’
While she has only been in general
practice for a few years, Dr Boylan has
already experienced some of the best the
profession has to offer.
‘I’ve just come back to working at a
practice that I haven’t worked at since 2014.
It’s been particularly lovely to see a lady who
has had lots of problems with fertility, who
has had two babies in the interim,’ she said.
‘And also some adolescents and people in
their early 20s who were struggling with some
mental health problems, who have come
through the other side of that and seem to be
doing a lot better.
‘That’s really nice, to come back and
observe them after having not seen them
for a few years and feel like maybe you
were slightly involved in helping them
overcome that problem.’
Atticus Health Carrum
While some monikers are undoubtedly more
creative than others, general practices are
often furnished with names that are rather
straightforward – banal, even.
Melbourne’s Atticus Health Carrum,
however, is not one of those practices.
‘The practice was named after Atticus
Finch from the novel, To Kill a Mockingbird,’
Dr Floyd Gomes, GP and practice founder,
told Good Practice.
As Dr Gomes explained, lawyer
Atticus Finch’s efforts in defending
Tom Robinson, a black man in America’s
south in the 1930s, went a long way
in helping to determine the practice’s
overarching philosophy.
‘Atticus Finch has very little vested interest
in supporting this individual per se. He did it
as a statement of ethics,’ Dr Gomes said. ‘He
was happy enough to support an individual in
the midst of a lot of backlash.
‘The other part of that is to really empathise
or understand people from their points of
view … to try and take your lens off of the
world. I think that is the main thing that
we strive for at the practice, to try our very
best to view the world through the eyes
of our patients.
‘On the back of our business card, there is
a quote from the novel: you can’t understand
a person until you walk in his shoes.’
All of the staff members at Atticus Health
Carrum go to considerable lengths to live up
to this ideal, regularly working outside of the
practice to provide the local community with
high-quality healthcare services. This sees
them visit retirement villages, nursing homes
and even secondary schools.
‘We try to make it as efficient as possible,
but there are challenges in working in those
environments, be they IT or scheduling, that
add a layer of complexity when trying to get
out of the clinic and into the community,’
Dr Gomes said.
‘That takes people’s willingness to
be involved.’ >>
From left: Dr Amanda
Bethell was delighted to
learn she was named the
GP of the Year – even
if she didn’t know she’d
been nominated;
Rose-Hunt winner
and General Practice
Supervisor of the Year
Dr David Knowles
considers general
practice a special
interest unto itself;
General Practice
Registrar of the Year
Dr Adelaide Boylan has
embraced the challenge
– and excitement – of
primary healthcare.
19Reprinted from Good Practice Issue 11, November 2017
Images
Thin
kst
ock
; R
AC
GP
; A
manda B
eth
ell;
Adela
ide B
oyl
an
20 Reprinted from Good Practice Issue 11, November 2017
Images
Attic
us
Health
Carr
um
; C
hris
Harr
ison; G
ippsl
and P
HN
; D
enis
e P
ow
ell
RACGP AWARDS
2 nted from Good Practice Issue 11, N
CGP AWA
>> All of this effort is what makes
being named the RACGP’s 2017 General
Practice of the Year all the more validating for
Atticus Health Carrum.
‘It’s mainly at a team level because a lot
of members at Atticus Health Carrum go
outside their usual work, and it recognises
that extra effort that they put in outside the
clinic boundaries,’ Dr Gomes said. ‘The award
recognises that is something special that
they are doing.’
In addition to all of the work done externally,
the practice itself offers something of a single
point of access for locals.
‘We provide a range of different services
– GPs, specialists, a gym with an exercise
physiologist onsite, podiatry, psychology,
dietetics, massage,’ Dr Gomes said.
Atticus Health Carrum is also a teaching
practice, with general practice registrars
playing a key role in its services. This offers
the opportunity to not only educate the next
generation of doctors about the facts and
figures of healthcare, but also some of the
values behind its delivery.
‘I have a saying that I share with
registrars: remaining relentlessly solution-
focused,’ Dr Gomes said. ‘That has been the
mantra of our clinic and the way we do things
– to see things in an “as is” form, warts and all,
even though that is difficult at times, and find a
solution to that reality.’
Denise Powell
As GPs are often wont to do, Dr Denise
Powell’s first instinct was to defer praise when
discussing winning the 2017 RACGP Rural
Brian Williams Award, which acknowledges
a practitioner whose guidance and support
enables rural GPs to dedicate themselves to
their patients, families and communities.
‘It is a great acknowledgment of the work
that my colleagues have done,’ she told Good
Practice. ‘I was very surprised and honoured
that they thought enough of rural women to
nominate me when they have also done the
same amount of work towards progressing
rural medicine that I have.’
A long-time resident and GP in
Queensland’s Bundaberg region, Dr Powell
initially planned a career in psychiatry, but
came to love the frontline aspect of rural
general practice.
‘As I was progressing through medicine
as a student, I believed in my great naiveté
that it would be more useful to try to work
with people at the beginning rather that at
the significantly progressed and end stages
of mental health,’ she said. ‘I think working in
general practice suits me best.’
Dr Powell is passionate about general
practice education, and not just for medical
students and general practice registrars.
‘I think developing general practice for
people other than doctors is really important,
so I have had a number of nurses and a
physician’s assistant train in my practice,’ she
said. ‘Most of my administrative staff have
qualifications as medical assistants.’
Cassie Rickard
Gladstone Street Medical Clinic’s Dr Cassie
Rickard, the RACGP’s 2017 Rural Registrar
of the Year, has made herself a valuable
part of the workforce in Victoria’s Gippsland
region. A commitment to rural healthcare
has been evident from her time as a medical
student, seeking out remote placements in
East Gippsland and the Northern Territory.
‘I was impressed by the scope of practice
offered by rural GPs, and the satisfaction
of working in a small community,’ she told
Good Practice. ‘I feel privileged to share
patient journeys.’
Dr Rickard balances part-time practice
with teaching through Eastern Victoria (EV)
GP Training and the Monash School of Rural
Health. While acknowledging the difficulties of
medicine, Dr Rickard found being named the
Rural Registrar of the Year helped validate her
efforts and sacrifices, as well her husband’s.
‘I also feel it recognises the efforts of
mentors and colleagues, who inspired and
supported me and helped make me the doctor
I am today,’ she said.
Honorary MembershipOriginally a psychologist, Dr Chris
Harrison has contributed much
to general practice. Receiving
the RACGP’s 2017 Honorary
Membership Award has helped
him feel even more a part of the
profession.
‘As a non-clinician researcher, it
really is an honour,’ he told Good
Practice. ‘This award makes me feel
like I am part of the club.’
Dr Harrison has been heavily
involved in general practice research
for 15 years, having worked as
a senior analyst on the Bettering
the Evaluation and Care of
Health (BEACH).
Dr Harrison has published almost
100 journal articles, contributed to
23 books and delivered close to 60
conference presentations, including
GP17, on the results of his research.
From left: Practice of the Year Atticus Health Carrum tries to see problems through patients’ eyes; Dr Chris Harrison said the Honorary Membership Award makes him feel ‘part of the
club’; Rural Registrar of the Year Dr Cassie Rickard also works to educate medical students; Brian Williams winner Dr Denise Powell believes her award is a reflection of her colleagues.
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GP PROFILE
The apple, as they say, doesn’t fall far
from the tree.
Rural GP Dr Michael Bartram’s mother
and father were doctors, which was one
of the catalysts for him to follow in the
footsteps of his role models and pursue a
life in medicine.
‘I was impressed by what they were
doing and the way they were doing it. They
were very passionate about their work,’ he
told Good Practice.
With this guidance to help lay the foundations
for Dr Bartram to study medicine, he recalls his
parents’ haste to also teach him that life is ‘not
all beer and skittles’.
By witnessing them trying to maintain that
balance between their family and professional
lives, Dr Bartram felt he was at least somewhat
prepared for the demands of life as a healthcare
practitioner.
‘I didn’t suffer any illusions that [being a
doctor] was going to be an easy job, but it
made me aware of not over-committing myself
along the way,’ he said.
Upon deciding on his career path, Dr Bartram
moved away from his hometown of Albury, in
southern New South Wales, to study medicine
at the University of Newcastle, graduating in
1988. With an initial interest in paediatrics, he
spent the next six years working in children’s
wards and emergency departments in various
hospitals around Sydney.
Soon after, Dr Bartram realised that primary
healthcare was his calling. He re-admitted
himself into general practice training and
spent six months based in the local hospital in
Coonabarabran, in north-west NSW.
This was a period Dr Bartram enjoyed,
particularly as he was still able to use some of
his paediatric skills.
‘On one occasion, my boss’ three-week-old
daughter had bronchiolitis so they called me in.
I ended up ventilating her because they realised
I was up to the challenge,’ he said. ‘I think my
paediatric skills were a good start to general
practice – they gave me a confidence in other
areas that I wouldn’t have otherwise had.
Images
Mic
hael a
nd A
nn B
art
ram
22 Reprinted from Good Practice Issue 11, November 2017
Family MORGAN LIOTTA
Dr Michael Bartram’s roots lie in rural medicine, where he continues his parents’ legacy.
‘For as long as I can
remember, I’ve been
fascinated with all things to
do with the human body and
human conditions, so general
practice was really something
I wanted to get in to.’
Dr Bartram continued
to work in general practice
around NSW, gaining valuable
experience along the way.
He finished his training and
started a private practice in his
hometown of Albury, where he has now been
for close to 20 years.
‘The lifestyle in a country area is great for
a young family,’ he said. ‘Our kids had plenty
of opportunities and have benefitted from
that over the years.
‘With my general practice training I
would have been happy moving anywhere
in the area, but my wife and I decided
that being close to family in Albury and
having opportunities for our family was an
important facet.
‘And I always really enjoyed the cradle-
to-grave care in general practice, having
ongoing relationships with the patient over a
number of years.
‘You see people grow up through good
times and hard times, and share that with
them. That’s the thing that stimulates me
and keeps me wanting to do it.’
Community support
Once established as a rural GP in
Albury, Dr Bartram became aware of
a workforce shortage and issues of
burnout occurring among some of his
colleagues in the area.
He soon saw an opportunity to start
an after-hours clinic, giving patients more
healthcare choices and allowing GPs the
chance to keep more regular hours.
‘I did my homework, talked to people
in the neighbouring regional towns who
started up a successful model,’ he said.
‘We got the GPs in town together and
managed to get a grant and an after-hours
clinic off the ground. We’re here 10 years
later, still going strong with nearly 50
doctors on the roster.
‘I think that’s been a helpful experience
for all the GPs in town and it makes family
life a bit easier.’
Initiatives such as these have helped to
bring Dr Bartram satisfaction in knowing
that he is contributing positively to the
local community.
‘[Opening the after-hours clinic is]
an example of how you can see things
happening in a place this size and make
a difference,’ he said. ‘Being in a place
this small, you can get involved, have an
influence and see it all happen.’
Dr Bartram also derives great
satisfaction from his involvement with
general practice training, an area about
which he is passionate.
‘I enjoy seeing other people get a kick
out of what they are doing, hearing their
enthusiasm,’ he said.
Dr Bartram regards his role as a trainer
as a reciprocal one, learning skills himself
while teaching the students and general
practice registrars.
‘Having people who are learning and
asking questions, and then seeing them
grow brings me the challenge of having to
keep using my knowledge and having to
push myself a bit.’
He also attributes some of this experience
to his fellow trainers and general practice
supervisors.
‘You get advice and respect for what you
do, so it’s a great team feeling,’ he said.
‘If you enthuse enough people, others step
in and take over as well. Together we are
teaching the art of general practice.’
Now well and truly established as a rural
GP, Dr Bartram is content knowing that he is
an integral part of the community of which
he and his family form a key part.
‘Seeing my patients, it’s a great pleasure
and a privilege, but it’s only part of what gets
me up in the morning,’ he said. ‘I like to try
and make sure that everyone who needs a
bit of extra help has that available as well.
That keeps me going.
‘It’s lovely to get some recognition of the
work that you do.
‘The teaching and the time that you put
into these things – it’s a life job.’
23Reprinted from Good Practice Issue 11, November 2017
tiesI’m a member because …
Being a GP, as one of my
registrars has recently pointed out, is
hard. It is certainly a challenge to keep
on top of the variety of presentations
and then solve problems or address
issues with the resources at hand and
the networks we build over time.
My affiliation with the RACGP has
been one avenue of support and a
conduit to finding enthusiastic and well-
informed colleagues. The opportunity
provided through its training program
to teach and mentor young doctors,
and share my passion for my craft,
has been enriching over many years,
enabling me to continue to grow and
feel part of a broader community.
– Dr Michael Bartram, RACGP
member since 1989
IN MY PRACTICE
Gem of the northMORGAN LIOTTA
Preston Family Medical Practice prides itself on a personalised and holistic approach to community-based healthcare.
The biscuits and spanakopita supplied by the
Greek community of Preston, a suburb in
Melbourne’s inner north, may just be the best
homemade goods in town. At least they are
according to local GPs Dr Michelle Leadston
and Dr Catherine Keaney.
These treats, often brought in by patients,
represent just one of many perks of practising
at Preston Family Medical Practice, which is
part of the Independent Medical Practitioners
(IPN) group. Dr Leadston and Dr Keaney
view the personal relationships they have
formed with their patients over the course of
people’s lives as even more rewarding than
delicious biscuits.
‘I enjoy getting to know all of our patients
and their families,’ Dr Leadston told Good
Practice. ‘I find it interesting now that
I’m looking after grandchildren and great
grandchildren of some of the previous patients.
‘I like having a chat and enjoy the intellectual
challenge of trying to figure out what’s going
on [with each patient].’
The suburb of Preston has seen significant
changes in recent years. The wave of
gentrification has surged to Melbourne’s
north, with older generations moving out and
younger professionals and families moving in.
Many of the homes that were built to
accommodate the influx of predominately
European post-war immigrants are
being either taken over by the next
generation or knocked down to build more
modern townhouses.
Although this type of shift is inevitable
and the evolution of the local demographic
means the practice is increasingly catering
to younger families, Preston Family Medical
Practice remains home to many older patients.
Almost nine out of every 10 patients hold
either a Health Care Card or Pensioner
Concession Card.
‘We see a lot of older patients from
that post-war era. It’s very multicultural,’
Dr Leadston said. ‘We’re now looking after
four generations in one family, who have been
coming to our practice for about 40 years.’
Holistic care
Preston Family Medical Practice currently has
up to six full-time GPs, as well as two general
practice registrars, two practice nurses, a
practice manager and a handful of reception
staff members. The clinic is able to offer
services such as intrauterine device (IUD)
insertions and vasectomies, acupuncture and
shared pregnancy care.
‘There’s some procedural stuff that might
be outside of the usual city-based general
practices, where there are specialists readily
available who might do that,’ Dr Keaney told
Good Practice.
‘It’s about accessibility for our population
base – those [procedural] things are really
important to access.
‘We aim to provide that one-stop shop.’
This ‘one-stop shop’ helps to support the
local community, particularly those who use
concession cards. These patients can
get procedures done with their trusted family
GP, and be bulk billed for it, rather than
potentially paying more to see a specialist.
24 Reprinted from Good Practice Issue 11, November 2017
Images
Pre
ston F
am
ily M
edic
al P
ract
ice
Above: Preston Family
Medical Practice aims
to provide local patients
with a one-stop-shop for
healthcare. Right: Dr Cath
Keaney (L) and Dr Michelle
Leadston (R) value the
diversity – and homemade
snacks – patients bring to
the practice.
25Reprinted from Good Practice Issue 11, November 2017
The clinic is also hoping to
expand its allied health services
to better provide for the varied
patient demographic
of older residents and
younger families, and to
embrace a growing focus on
team-based healthcare.
‘It will be great to have us all
in the one building to be able
to facilitate the communication
and holistic approach to any of
our patients, so we’ve got the
capacity to address issues as
they come up,’ Dr Keaney said.
Fresh eyes
Preston Family Medical Practice
takes great pride in its history
of teaching general practice
registrars, who help add to the
practice’s range of services.
‘We are an accredited practice and teaching
is a significant part of that,’ Dr Leadston said.
‘One of our doctors who recently retired has
seen 150 registrars in his time, including
myself,’ Dr Keaney added.
‘We certainly see the medical students and
registrars as an asset to our practice, as well
as us providing a service of giving back to
general practice.’
Patients have provided positive feedback
on the educational component at the practice,
something that motivates both the junior and
senior doctors.
‘It’s something that our patient population is
fine with,’ Dr Keaney said.
‘They expect to be seen by junior doctors
and have commended our teaching. They
realise that it’s an investment and an advantage
for them, because they can get a fresh
and enthusiastic view on an issue that may
have had for a while, and it’s great to get a
new set of eyes.’
Dr Leadston is putting her own fresh
views to good use as she continues the
general practice legacy of her father,
Dr William Leadston, following his retirement
earlier this year.
Father and daughter had worked closely for
more than a decade.
‘It was fun, we have a good relationship,’
Dr Leadston said. ‘Over the last few years
we didn’t work on the same day, but a lot of
patients, particularly the older ones, kind of
saw us as one entity.
‘If Dad was not there then they would say,
“Gosh, you look and sound so much like your
father”. So I think they were quite at ease
straight away and it provided a bit of continuity
for the patients, a sort of legacy.’
Dr Leadston and Dr Keaney feel this type
of family connection has helped to foster
Preston Family Medical Practice’s loyal
following of patients, many of whom often
come to see the GPs for an informal chat
about their health over longer consultations.
‘The medical service that we offer is
different to your quick “10-minute medicine”,’
Dr Keaney said.
‘We have longer appointments and we take
time to consider things.
‘So what tends to happen is that patients
return and report back that we care and
listen to them.
‘It is about being acceptable and providing
personalised, sensitive healthcare.’
Perhaps the homemade biscuits are
another way patients express their gratitude.
Either way, as Dr Leadston simply puts it,
‘We’re very lucky’.
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26 Reprinted from Good Practice Issue 11, November 2017
NUTRITION
Managing goutMELANIE REID
Diet as adjunctive therapy.
Gout is a form of inflammatory arthritis,
typically characterised by recurrent incidence
of joints that are red, tender, hot and swollen.
It is generally managed by drugs that either
control inflammation during acute episodes
or reduce serum uric acid levels in the longer
term; however, dietary measures can also help
reduce serum uric acid levels and risk of gout.
The European League Against Rheumatism
(EULAR) and the American College of
Rheumatology (ACR) recommend diet and
lifestyle strategies as adjunctive measures for
the management of gout.1,2
Gout is often associated with common
and serious comorbidities, such as
obesity, cardiovascular disease (CVD),
dyslipidemia, hypertension, hyperglycaemia
and renal impairment. Dietary advice
for specific patients therefore needs to
include recommendations related to any
comorbidities.1,2
There is a general lack of specific evidence
from prospective, blinded, randomised clinical
intervention trials regarding dietary strategies
for gout. The replication of hazardous lifestyle
risk factors in a conventional clinical trial would
potentially pose design and ethical difficulties.
The majority of evidence comes from
epidemiological/observational studies,
including the Health Professionals Follow-up
Study, NHANES III, the Nurses Health Study,
and the Shanghai Men’s Health Study.3
GPs can offer patients several pieces of
dietary advice for helping to manage gout.
Keep weight in check
While gout is far more common in people
who are overweight, those patients should
be advised to lose weight gradually. Rapid
weight loss (more than 1 kg per week) can
increase uric acid levels and actually trigger an
attack of gout.3
An accredited practising dietitian
(APD) can help patients design a healthy
weight loss plan.
Limit alcohol
Observational studies have found that alcohol
intake is positively associated with serum
uric acid, risk of gout and recurrent gout
attacks.1,3,4 Experimental studies show that
beer, in particular, significantly raises serum
uric acid levels.3
It is best to avoid alcohol completely during
an acute attack of gout.
Eat regularly
Skipping meals or fasting will increase uric acid
levels.3 Advise patients to eat moderate-sized
meals regularly throughout the day.
Limit sugar-sweetened drinks
Large observational studies generally find
a positive association between intake of
sugar-sweetened drinks and fruit juice, serum
uric acid levels and risk of gout.3,4
Meta-analysis of controlled feeding studies
shows that adding fructose to the diet raises
serum uric acid.
Limit added sugars to a maximum
amount of five teaspoons per day and avoid
fructose-based sweeteners.
Limit purine-rich animal foods
Purines break down into uric acid. Most large
observational studies show that intake of
purine-rich meat and fish is correlated with
risk of developing gout, as well as risk of
recurrent attacks.1,3,4
Advise patients to limit intake of meat,
poultry and seafood to one moderate serve
(eg palm-sized) per day, and avoid offal. It is
prudent to avoid meat extracts (eg Bonox and
Bovril), brewer’s yeast and yeast extracts
(eg Vegemite), as these are very rich in purines.
Note: there is no association between
plant-based purines and gout risk.
At least 2–3 cups of low-fat dairy daily
Observational studies have found that higher
intake of low-fat dairy products is associated
with lower uric acid levels and reduced
risk of gout.1,3,4
Coffee in moderation
Observation studies find that higher coffee
intake3,4 is associated with lower serum uric
acid levels and risk of gout. However, a large
sudden increase may trigger an acute attack in
a manner similar to xanthine oxidase inhibitor
drugs. Coffee should be consumed regularly
and in moderation.
Vitamin C supplement
Vitamin C supplements of 500 mg/day have
been used experimentally to reduce serum uric
acid.3 Observational studies have found that
vitamin C intake over 500 mg/day is associated
with lower risk of gout.
A serve of cherries
Limited evidence from small trials and
observational studies suggest a lower uric acid
level and risk of acute gout attacks with daily
intake of 1–2 serves of cherries (one serve is
10–12 cherries).3
Keep active
People who exercise regularly are less likely to
experience gout. Ensure that running shoes are
supportive and fit well.
Drink plenty of water
High uric acid levels can also increase the
risk of kidney stones. Adequate fluid intake is
important to reduce risk of stone formation.
Related problems
People with high blood uric acid levels are
also at greater risk of heart disease, insulin
resistance and diabetes. Weight loss,
healthy eating and being physically active
all reduce the risks linked with these related
health problems.
References
1. Richette P, Doherty M, Pascual E, et al. 2016 updated
EULAR evidence-based recommendations for the
management of gout. Ann Rheum Dis 2017;76(1):29–42.
2. Khanna D, FitzGerald JD, Khanna PP, et al. 2012 American
College of Rheumatology guidelines for management
of gout part 1: Systematic non-pharmacologic and
pharmacologic therapeutic approaches to hyperuricemia.
Arthritis Care Res 2012;64(10):1431–46.
3. British Dietetic Association, Dietitians Association of
Australia, Dietitians of Canada. Gout evidence summary.
PEN: Practice-based evidence in nutrition. Available at