WANTED: shared vision for primary care

“I do know that when primary care doesn’t connect, collaborate and work together – patients see and feel that disconnection. And I have a feeling that those working in primary care see and feel it too.

Belinda MacLeod-Smith, health consumer (BridgeBuilders.vision)

Labor’s health spokeswoman Catherine King announced that her party will create a permanent health reform commission if it wins the federal election. I thought this sounds like a step in the right direction as long-term planning of health reform is much needed in Australia.

On the other hand, there have been many government committees, task forces, reviews and reports that haven’t made a dent in the primary care landscape.

If only we could put together some of the ideas coming from Australia’s health and consumer groups. These organisations, often working at the coal face of primary care, have an excellent understanding of the urgent needs and requirements. 

I was pleased to see that some of this year’s pre-budget submissions by primary care organisations contain similar ideas. For example, the pre-budget submissions from AMA, ACRRM and RACGP all argue for funded telehealth services.

As expected, there is a strong push for adequate patient Medicare rebates and reduced patient out-of-pocket costs. The general practice profession also believes that spending more quality time with patients should be encouraged through better remuneration of longer consultations. 

One of the main themes is improving care for people living with chronic and complex conditions. The Australian Medical Association is proposing a chronic disease quarterly care coordination payment to GPs to support team-based care. 

The Royal Australian College of General Practitioners is advocating for comprehensive reform that includes blended funding, based on the Vision for general practice and a sustainable healthcare system.

The Pharmaceutical Society of Australia wants pharmacists in residential aged care facilities. The Consumers Health Forum argues for an Australian Co-Creating Health initiative to support people with chronic conditions to actively manage their own health.

Rural doctors, RDAA and ACRRM, are asking for more junior doctor training places in rural and remote settings and a move to the rollout phase of the National Rural Generalist Pathway.

This is just a selection of some of the budget submissions. What struck me is that there is a lot of merit in many of the proposals. They are often not mutually exclusive.

Unfortunately, most budget submissions seem to end up in a large pile on the minister’s desk. Many great ideas never see the light of day, because there is no sector-driven vision or strategy.

Is this the best we can do? I believe it is time to work towards a shared vision for primary care. Why not start by looking at what the various organisations and groups have in common?

A valuable lesson in ‘less is more’ from a Dutch patient

A few weeks ago one of my patients, Eva, asked about the treatment of urinary tract infections. In the course of our conversation I mentioned that in Australia antibiotics are recommended.

Eva had symptoms of a bladder infection and was after a diagnosis, but preferred not to take antibiotics. She was Dutch and said that cystitis in the Netherlands is often initially managed without antibiotics.

We decided to look it up (it has been a while since I practised in my birth country) and I googled the website of the Dutch College of General Practitioners. I had a feeling Eva was correct, as it was Dutch research that concluded middle ear infections can often be treated without antibiotics. The Netherlands, Norway and Iceland also top the charts when it comes to lowest rates of resistance to antibiotics.

Since 1989 the Dutch GP College has developed about one hundred independent, evidence-based guidelines for conditions managed in primary care. It didn’t take long to find the guideline on urinary tract infections, published in 2013.

Indeed, the document stated (freely translated from Dutch):

“Cystitis in healthy, non-pregnant women can be self-limiting. Leaving cystitis untreated seldom leads to bacterial tissue invasion.

But what is the risk of complications, like a kidney infection, I wanted to know after reading the advice to Eva (who didn’t look surprised at all).

“Apparently it is not very high, doctor,” she answered.

In the endnotes of the guideline I found a reference to two studies, indicating that pyelonephritis in non-immunocompromised, healthy women is rare, with no statistically significant difference in the occurrence of pyelonephritis between antibiotic treatment groups (0 tot 0,15%) and placebo groups (0,4 tot 2,6%).

The document further contained instructions about what to discuss with patients:

“The GP discusses the option of watchful waiting (drinking plenty of fluids and painkillers if needed) and delayed prescribing. The patient can then decide to start antibiotics if symptoms persist or worsen.

Some evidence indicates that, without treatment, 25–42% of uncomplicated urinary tract infections in women resolve spontaneously.

Eva was right about the Dutch approach. In healthy people with uncomplicated infections the Dutch College of GPs recommends consideration of no antibiotics.

Are the Dutch unhappy about a health system that often advises against antibiotics? My patient certainly didn’t seem to be. She was relieved when we decided not to treat her urinary tract infection with antibiotics.

The answer appears to be no. For years the Netherlands has led the Euro Health Consumer Index, which measures patient satisfaction with healthcare systems in Europe – including outcomes, access to healthcare and medications.

On the Choosing Wisely Australia website I found one sentence on the topic: “The management of urinary tract infections (UTIs) is changing, although it can still include antibiotics.” Lack of systematically reviewed placebo randomised trials seems to be a key factor for Australia.

Eva’s urinary tract infection cleared up without antibiotics.

I recommend sensible use of local clinical practice guidelines and treatment recommendations. Always seek timely advice from your doctor regarding any medical condition you may have, including urinary tract infections. For privacy reasons the name and details of the patient have been altered.

Who is the real winner in the latest stoush between pharmacists and doctors?

Last week a state Pharmacy Guild president made a few negative comments about general practice. I thought it was neither here nor there, but what happened next was interesting.

I could not find the original column (admittedly I didn’t look very hard) so I can’t verify his exact words but apparently, he said that increased funding for GPs will only incentivise five-minute ‘turnstile’ medicine.

Most GPs would not have read or been aware of the column until, on the eighth of February, Australian Doctor Magazine, owned by the Australian Doctor Group (ADG), posted an article on their website titled “Pharmacy Guild says GPs working ‘turnstile operations’ filling time-slots with easy patients.”

Then all hell broke loose. There were 170 comments on the article from mostly angry GPs.

A few days later, on the eleventh of February, Pharmacy News published this piece: “Guild takes aim at GPs who favour wealthy, healthy patients”. 

Interestingly, Pharmacy News is also owned by ADG.

Then the response came. On the thirteenth of February a reply penned by the RACGP president was published. And you guessed it, that same day Australian Doctor posted: “Turnstile, cream-skim medicine? RACGP hits back at Pharmacy Guild.”

The ADG publications got hundreds of clicks and views of their website content out of the latest stoush between pharmacists and doctors.

Good on them, one could argue. But hang on, there’s more to it. The ADG website explains how it works:

“We know that GPs are increasingly time-poor and less reliant on [pharmaceutical] sales reps,” says Bryn McGeever, Managing Director of Australian Doctor Group. “They’re looking elsewhere for information.”

“While readership of medical print publications remains strong, digital channels are becoming increasingly popular with almost eight in 10 GPs now reading online medical publications monthly.”

“In recognition of this continuing shift in GP behaviour, Australian Doctor Group last week launched AccessPLUS, a bespoke digital sales channel designed to fill the space left behind as rep engagement continues to fall.”

And the real winner is….

It is sad, but not surprising, that the medical media are fuelling the tensions within primary care. Of course, like other media, ADG is just doing its job. I do wonder how many GPs and pharmacists are aware that they are the product on sale here.

I have had my fair share of altercations with the Pharmacy Guild – but it’s a road to nowhere. I prefer to listen to people like pharmacist Debbie Rigbie, who rightly says, “We must build bridges across our differences to pursue the common good.”

Shared decision-making is more than asking what patients want

Medical students are sometimes surprised that we don’t always follow the guidelines they have learned in medical school and instead use the patient as our guide when making decisions. Shared decision-making involves exploring patient preferences and what is important to them.

This sounds obvious but it’s actually not easy. As I said before in this blog post, I’m not sure I can always answer the 5 Choosing Wisely ‘questions to ask your doctor’, which form the basis of shared decision-making.

Apparently many doctors believe they already do this when they don’t. For example, a survey of US-based health practitioners observed high confidence in the face of limited understanding. There are many myths about shared decision-making (the 2-minute video below explains the most common ones).

Shared decision-making is more than asking what a patient wants. It also includes providing information about the pros and cons of available options, including the level of evidence around risks and benefits of tests and treatments. If I and many of my colleagues find this challenging, how do patients experience it?

Recognising the difference between normal and abnormal

“Would you mind if the medical student examines you as well?” It’s a common phrase in our practice (usually mentioning the medical student’s name too) and the common response from patients is positive. “Yes of course, we’ve all got to learn, don’t we?”

Although they prefer to see diseases, I also try to expose students to as many variants of normal as possible. Normal skin, normal heart sounds, normal ear drums, normal eyes, normal breathing sounds. Interestingly, ‘normal’ has a scale too – there is a wide variety.

Most students love to listen to the fascinating stories patients bring to the consulting room. They appreciate the opportunity to practise their skills on real patients – but it’s not always spectacular.

When the next person comes in with a similar problem I can see the facial expression of the student: why examine all these normal body parts? But I’ve known this patient for a while and there’s something not quite right. The patient and I both suspect it, but the medical student hasn’t picked it up yet because ‘abnormal’ is sometimes only evident when measured against normal.

“Can you feel this?” I ask, “Compare it to the patients we saw earlier.” The student tries again and eyes light up. When they learn the many presentations of normal, students become better at recognising significant deviations from normal.

Defining normality and abnormality can be challenging, even for experienced clinicians. Being able to make the call that something is a variant of normal is as valuable as identifying abnormal findings.

With the appropriate safety nets in place, it can prevent angst, misdiagnosis, overtesting, overdiagnosis and overtreatment.

Human interoperability

Health professionals often complain about software and IT. It doesn’t always do what we want it to do. It slows us down, makes us do extra work.

A common problem is lack of interoperability. Computer systems are not talking to each other, a bit like Microsoft and Apple many years ago. Patients have also noticed that important information is not always available, which leads to inconvenience, delays and sometimes more tests.

At the same time GPs are unhappy that the hospital doesn’t provide essential info, for example when a patient has passed away, and hospital staff complain that referral letters don’t contain important triage information. Etc etc.

This raises the question, how ‘interoperable’ are health professionals? Do we know how we can best facilitate transfers and improve clinical handovers? What information do our colleagues need and when? How often do we meet to sort out issues in a collegial way?

It’s good to see there are passionate people working on these issues – but they need help. Computer systems are a reflection of the silos we work in. First fix human interoperability and our IT systems will follow.

How many days start with the letter T?

The other day I attended a leadership event at our local hospital. One of the speakers asked us “How many days of the week start with the letter T?”

The obvious answer is of course two, Tuesday and Thursday – but he said there’s another answer someone once gave him during a workshop, which is also correct: Tuesday, Thursday, today and tomorrow.

The point he made was that together people often solve problems in ways they wouldn’t have thought of on their own. Transformational ideas and break-through inventions are usually incremental processes that occur when different minds work together or build on each other’s work.

Steve Job’s iPod was based on existing mp3-players. Thomas Edison didn’t invent the lightbulb but improved it. The invention of the automobile and the airplane was the work of many; Henry Ford and the Wright Brothers just refined the ideas.

It never ceases to amaze me how people in a group – when the circumstances are right – develop creative ideas to solve challenging problems.

That evening, during dinner, I asked my children ‘Who knows how many days of the week start with T?” We had a bit of a discussion as a family until my 10-year old daughter said, “Seven days dad, because I always start my day with a tea.”

MBS Review: A stronger primary care system in sight?

Implementing healthcare reform in Australia is always an uphill battle. After a disappointing outcome of the much-anticipated Healthcare Homes program, some of the members of the Primary Health Care Advisory Group regrouped when they were appointed to the Medicare Benefits Schedule (MBS) Review Taskforce.

The recommendations by the taskforce to improve the MBS are refreshing in many ways. There is a move towards strengthening GP stewardship, voluntary patient enrolment, more non face-to-face care, a simpler careplan program and increased support for home visits – which seems sensible and is addressing the frustrations of many about the current Medicare system.

It appears there are a few things missing. For example, there is no recommendation to spend more time with our patients by committing to an increase in the schedule fee of longer consultations (item numbers 36 and 44). This would have been more useful for most patient encounters than a new one-hour plus item number.

I believe the residential aged-care item numbers will need more investment when the SIP incentive ceases to exist. There is mention of outcome-based payments which requires an explanation. The lack of detail about the dollar values makes it challenging to predict the impact on general practice and primary care.

In an ideal world the recommendations could result in an invigorated, modern, patient-centred health system. However, if history repeats itself, the result will be a simple cost-saving exercise, dressed up as clinician-led, evidence-based healthcare reform.

A typical case of make it or break it.

Why our opinions get us in trouble

“The history of human opinion is scarcely anything more than the history of human errors,” Voltaire said a long time ago.

Health professionals are trained to give opinions. It’s what we do every day in caring for our patients and leading our teams. Sometimes, however, it’s better not to give an opinion – or at least sit on it for a while.

Admittedly this is not always easy to combine with busy clinics, fast-paced lifestyles, opinion-based social media and rapid news cycles.

Nobel Prize winner Daniel Kahneman described two ways of thinking in his well-known book ‘Thinking, Fast and Slow’.

The first method, which he called system one, is fast, intuitive, runs automatically and cannot be switched off. It generates first impressions and intuitions based on experience. It is however subject to errors and biases and is poor at performing statistical estimates.

The second way of thinking, referred to as system two, takes more conscious effort and time. It is normally in low-effort mode but when system one runs into difficulty, system two will be engaged.

The two systems can work effectively together, as long as we are aware that our first guess, based on system one thinking, may not always be right and that we need to verify it by applying more analytical system two thinking.

The challenge, as I see it is, to have an opinion and an open mind at the same time.

This is an edited version of an article originally published on NewsGP.

Why are doctors so unkind to each other?

Although doctors look after their patients, they don’t always look after each other.

What has happened to collegiality? Why are doctors so unkind to each other? Anaesthetist Dr David Brewster and surgeon Dr Bruce Waxman ask these questions in the Medical Journal of Australia.

The authors are of the opinion that doctors have become too judgemental of their peers and that constant negative commentary has affected the workplace environment.

They write: “We have all been guilty of uttering critical colloquialisms in the workplace that resist positive interdisciplinary relationships. Unfortunately, our apprentice junior doctors adopt these expressions that promote lack of collegiality. Doctors learn to criticise and blame each other, rather than understand the differences we all face in providing the best care to our patients.”

Kindness can be as simple as saying thank you or acknowledging the work of a colleague, and a smile or a cup of coffee also go a long way, they argue.

Reading this in our medical journal gives me hope. It is not easy to discuss this topic publicly in a highly judgmental culture.

Decluttering our homes and lives

Accumulating possessions is not always associated with an improvement in wellbeing. It can actually lead to stress and health issues.

On the other hand, giving, donating and getting rid of stuff are usually described as positive experiences. Decluttering homes even has health benefits.

A new Netflix series, Tidying up with Marie Kondo, brings a powerful message across: organising our homes and offices comes with rewards.

Marie Kondo, dubbed the Japanese Mary Poppins, creates happiness by helping people throw away stuff they don’t need and organise their belongings. As a result relationships seem to improve and families live happier together.

The concept is of course not new, as professional organisers, unclutter clinics and clean-up blogs have been around for a while. But there is something appealing about watching this show.

Whether it is a desire for simplicity, a need to create organised spaces to think, work and live, or just guilt reduction, the slowly disappearing clutter towards the end is satisfying.

Marie Kondo makes decluttering homes, and lives, a fun activity. But she does something else. By asking whether objects spark joy she reminds us about our priorities and what life is all about – something we occasionally forget.

Who is serving whom?

What are we going to do with the data once we have collected it? Often, when I ask this question, the answer is vague.

In the race for big data the purpose has sometimes been forgotten. It’s like doing research without formulating a question first.

I wonder who is serving whom: Are IT systems supporting health providers or are we increasingly following rigid templates and blindly harvesting information for reasons we often don’t even understand?

It is time to pause and gain a better understanding of where we want to go. How can data and IT best support patient care and public health into the future?

What can stakeholders agree on with regards to secondary use of data? Where are the trap doors?

The outcome should always be a win-win, or mutual benefit.

Knowing what life has in store for us

Living with uncertainty is not an easy task. It can be the source of many anxieties.

I often go through this with my patients, for example when we may have found something sinister but more time is needed to confirm the diagnosis.

Yet, when it comes to our lives and deaths, we always live in uncertainty. But what about the opposite: what if we knew what life has in store for us?

Chloe Benjamin deals with this theme in her book The Immortalists.

At the beginning of the story four young siblings visit a fortune-teller who gives them the dates when they will die. This knowledge influences the rest of their lives and the choices they make. It becomes a self-fulfilling prophecy. Three of the four siblings die on the predicted date, largely as a result of their own doing.

I wonder if the information increasingly available through genetic testing will influence our lives and deaths in a similar way. Would we live our lives differently knowing what may be ahead of us? Could this knowledge also create its own anxieties and problems?

Here are five things to consider before ordering a genetic test.

Mandatory reporting of health professionals: has COAG delivered on its promise?

On the one hand patients must be certain that health practitioners are fit to practice in a competent and ethical manner, but on the other hand practitioners should be able to seek treatment without fear of being reported, penalised or losing their jobs. Has the Council of Australian Governments (COAG) found the right balance?

The National Law contains mandatory reporting obligations for registered health practitioners, employers and education providers to protect patients. However, if you’re for example a midwife, psychologist, pharmacist, doctor or student with a mental health condition, it can be a challenging decision to seek help. Many don’t out of fear that the treating practitioner may believe they have to notify authorities.

Concerns have been raised that practitioners and students don’t seek or delay treatment – and when they seek care, there may be a reluctance to be open and honest with the treating practitioner, leading to suboptimal treatment eventually putting the health and safety of the practitioner and the public at risk.

For years the AMA, RACGP and other professional bodies have argued that the regulation needs to change to ensure health practitioners can, just like others, seek help.

In October 2018 an Amendment Bill was introduced to the Queensland Parliament, which if passed will automatically be applicable to most other States and Territories. The Bill introduces a higher threshold for mandatory reporting in an attempt to give registered health practitioners greater confidence to seek treatment for health issues.

Western Australia exempts treating practitioners from mandatory reporting for all forms of notifiable conduct if their patient is a registered health practitioner. The WA model or similar has always been the preferred option of health providers. There is no evidence to suggest patient safety in WA is worse.

In addition to mandatory reporting requirements, practitioners have ethical and professional obligations to report other practitioners who may pose a risk to the public.

Brief history

On 13 April 2018, after the COAG Health Council meeting in Sydney, the federal, state and territory Health Ministers, issued a press release stating that the law regarding mandatory reporting of health professionals would be strengthened ‘to remove barriers for registered health professionals to seek appropriate treatment for impairments including mental health.’

The ministers further agreed to a nationally consistent approach to mandatory reporting which would propose exemptions from the reporting of notifiable conduct by treating practitioners, noting Western Australia’s current arrangements would be retained.

Explicitly mentioned in the COAG press release was the fact that in WA health practitioners in a treating relationship based on the reasonable belief can make a voluntary notification as part of their ethical obligations in relation to any type of misconduct.

Health Ministers agreed that the reforms should ensure that registered health practitioners can seek help when needed, but must also protect the public from harm. On 12 October 2018, COAG Health Council approved the reforms to mandatory reporting by treating practitioners in the Amendment Bill. The WA model was not adopted.

The Council concluded that the amendments would achieve the right balance between encouraging practitioners with an impairment to feel confident that they can seek treatment, while protecting the public from harm by requiring treating practitioners to make mandatory reports about other registered health practitioners that pose a substantial risk of harm to the public or are engaging in sexual misconduct in connection with the practice of their profession.

What’s good?

A treating practitioner will only be required to make a mandatory report if their practitioner-patient’s conduct involving impairment, intoxication or departure from professional standards meets a higher threshold of risk of placing the public at substantial risk of harm (this threshold does not apply to mandatory reporting of sexual misconduct).

Only serious impairments that are not being appropriately managed through treatment or mitigation strategies need to be reported if the safety of patients would be at risk.

The amendments also include guidance factors; in considering whether the public is at substantial risk of harm, a treating practitioner may consider the following matters relating to an impairment of the health practitioner or student:

  • the nature, extent and severity of the impairment;
  • the extent to which the health practitioner or student is taking, or is willing to take, steps to manage the impairment;
  • the extent to which the impairment can be managed with appropriate treatment;
  • any other matter the treating practitioner considers is relevant to the risk of harm the impairment poses to the public.

According to the explanatory note a treating practitioner may make an overall assessment about a practitioner-patient’s conduct relating to impairment, intoxication or departure from professional standards in deciding whether a mandatory report should be made. All three types of conduct are measured against the same threshold for reporting.

If an impairment issue is connected to, or a significant cause of, intoxication or departure from professional standards, a treating practitioner is able to take into account the effectiveness of treatment or engagement in treatment of an impairment by the practitioner-patient in deciding whether there is likely to be an ongoing risk of harm to the public.

“Also, in cases where an impairment may be impacting on, or causing, instances of intoxication at work or departure from professional standards, a treating practitioner may consider the guidance factors related to the impairment first, such as the extent to which treatment is likely to be successful and the practitioner-patient’s engagement with treatment. If the treating practitioner is satisfied the impairment issue is being managed appropriately and does not reach the threshold of ‘substantial risk of harm’, the treating practitioner would not be required to make a mandatory report for the impairment.

“The treating practitioner could then consider, in light of the impairment issue being managed, whether future instances of intoxication at work or departure from professional standards are likely to recur. If, given appropriate management of the impairment, they are not likely to recur, the mandatory reporting threshold of ‘substantial risk of harm’ would not be met. In this way, the current provisions provide adequate flexibility for a holistic assessment of risk.

“It would be possible for a practitioner to have a substance abuse or dependence disorder, but it may be something that only affects their personal life or only occurs while they are away from their workplace. This type of conduct should be considered as an ‘impairment’ for which it is appropriate to apply the guidance factors. However, the risks associated with a practitioner being intoxicated at work are considered significant, so that if a treating practitioner becomes aware that a person is practising while intoxicated, they should be subject to mandatory reporting if their conduct reaches the threshold.

Source: Health Practitioner Regulation National Law and Other Legislation Amendment Bill 2018 — Explanatory Note.

The explanatory note further states that the guidance factors included in the legislation send a clear signal to practitioners and students that, provided they are engaged in treatment and willing to take steps to address their impairment, a treating practitioner is not required to make a mandatory report, unless the safety of patients would be at risk.

Seeking treatment may indeed become easier as the explanatory note of bill explicitly states that the test of ‘substantial risk of harm’ is not intended to require reporting of low-level or trivial types of harm or mere inconvenience. Only serious impairments which are not being appropriately treated are intended to require reporting. This means that harm would need to be ‘material’ to reach the threshold of ‘substantial risk of harm’.

What’s not so good?

Some have argued that although the wording ‘substantial risk of harm’ may have increased the risk threshold, the harm threshold is low, and it appears that all levels of harm, including trivial harm and inconvenience, need to be reported even though the explanatory note states the opposite.

The explanation may be reassuring but the bill itself raises questions. The wording has the potential to create confusion around the interpretation of the legislation and, worse, may prevent health practitioners from seeking help or being open and honest with their treating practitioner.

Doctors and other health workers have the highest suicide rate in Australia’s white-collar workforce. Legislation is of course not the cause of mental illness and suicide and we need to continue to look at other factors, including our professional cultures and how we communicate and treat each other. This is a shared responsibility of the profession and policy makers.

It remains vital that health practitioners can seek help without fear of repercussion no matter where they live and work. The Health Practitioner Regulation National Law and Other Legislation Amendment Bill 2018 is a welcome step in the right direction, but there is room for improvement if the COAG Health Council wants to deliver on its promise to remove barriers for registered health professionals to seek appropriate treatment for impairments including mental health.

Doctors from overseas

“G’day doc, I’m right off me tucker and crook azadog. Yesterday arvo me neighbour said it’s just the collywobbles but crikey, he’s mad as a cut snake so I thought I’d better find out what the doc has to say. I know youse are flat out but waddaya reckon, she’ll be right? I feel weak as a wet whistle. Not droppin off the perch yet am I? Probably just old age. Howyagoin anyway, settlinin all right? Gotta love the top end mate, heaps better than the big smoke.”

When I arrived in Australia – in Cooktown of all places – one of my biggest challenges was understanding the accent and the slang. I also struggled with basic expressions. I remember being invited ‘for tea’ one night – so after dinner I went over expecting a cup of tea or coffee only; to my surprise our host had prepared a delicious roast. On another occasion I was asked ‘to bring a plate’; I took a few plates and, just to be sure, some cups and cutlery too.

I thought the communication was problematic because I come from a non-English speaking country. It turned out that most immigrants struggle with language, communication and the often slightly different meaning of common expressions, not to mention the bureaucratic jargon. For example, as doctor Jennifer May wrote in the Medical Journal of Australia, a term such as ‘reciprocal recognition of qualifications’ has a different meaning in different jurisdictions.

The first six months were a crash course in ‘Strine’. The patients were wonderful and seemed to strangely feel sorry for the new overseas doctor in town. They taught me all the basics; some gave me Australian slang dictionaries and Indigenous Australians told me stories about their culture. Still, it took a few years before I could fully understand most conversations.

The preparation

For most immigrants the challenges begin long before entry to Australia. The paperwork and background checks required by the Australian government and healthcare organisations – which can take one to two years to complete – are only a small part.

Croc drama: A crocodile dragged a fisherman from his tent on the riverbank and a woman jumped on its back in an attempt to stop the giant reptile. Source: Cooktown Local News

Even though the decision to emigrate is mostly a voluntary one, and it is a privilege to be welcomed to Australia, it doesn’t mean that there are no downsides. Emigrating doctors and their families have to give up their lives in the home country and say goodbye to loved-ones, familiar neighbourhoods, cultures, customs and careers.

It is not uncommon for overseas doctors and their family members to experience some adjustment problems. Many tears have been shed when settling in a remote Australian outback town or new suburb. It can be stressful when a spouse struggles or the children have problems at the local school.

Often well-established and respected at home, immigrant doctors start all over again. They are initially temporary residents with limited rights and no access to Medicare. Their medical registration is conditional, they have to work in places where many Australian trained health professionals don’t want to work, and their future is uncertain and dependent on passing health checks, police checks, language tests, assessments and exams.

My arrival in Cooktown reported in the local newspaper (2004). Full story below.

It can be difficult to negotiate employment conditions or discuss real or perceived injustices – as a conflict may lead to cancellation of sponsorship or visa. Financial challenges are common as starting over in a new country does not come cheap. There are all sorts of legal and tax problems, such as dual taxation. I had to give up my Dutch citizenship when I became an Australian citizen.

For the immigrant there is always ‘the other world’ of their home country. They often use the holidays to fly ‘home’ and visit family and friends for a few weeks, which is joyful but can be intense and emotional. Migrants may never feel one hundred percent part of the Australian society and at the same time they often don’t fit in anymore in the home country, which can affect their sense of belonging and create feelings of loneliness.

Rural medicine

For me another culture shock was rural medicine. The contrast with Amsterdam, where I trained as a doctor, could not have been greater. I quickly had to learn about tropical diseases, snake bites and Irukandji – just to name a few. Shortly after I arrived a 4.2 meter saltwater crocodile dragged a fisherman from his tent on the riverbank when a woman jumped on its back to stop the giant reptile; the story appeared in all the newspapers.

Although many of the medical textbooks back home were written in English, learning to speak the medical jargon in another language was yet another challenge. Names and doses of commonly used drugs differ between countries, not to mention the different guidelines.

I was able to do a few up skilling courses including trauma and emergency medicine and with assistance from helpful and skilled colleagues – sometimes over the phone – and a great nursing team, we were able to manage many problems locally. I am grateful for all those who have welcomed and taught me over the years – patients, staff, nurses, fellow doctors and others.

Not unique

For a long time I thought my ‘adventures’ were unique but over the years I learned about similar stories, not only from overseas doctors but also from Australian graduates, all struggling during their first placements in rural and regional hospitals and GP practices.

These stories are often tales of incredible resilience and courage and what always amazes me is to hear how valued health professionals are in their communities – even though we may often feel ill-prepared or have doubts about our skills and knowledge.

The demands on doctors in small towns can be high, not seldom 24 hours per day. Working towards another degree or fellowship is taxing for anyone, but for international medical graduates coming from a different background there are many extra challenges. The working hours and fatigue don’t go well with training and exam preparation.

The workload and the tyranny of distance can make supervision suboptimal; there is often limited support and the amount of bureaucracy can be perceived as overwhelming.

On the bright side, there are many people who warmly welcome and support the newcomers. Professional bodies and colleges offer introductory, support and exam preparation programs, but often the local and individual initiatives make the difference. An example is Dr Farooq Ahmad who, after passing his Australian fellowship exam, decided to support others and has helped hundreds of doctors pass their exams.

In the video below Kenyan born Dr Ken Wanguhu describes the importance of being welcomed by a community as well as the rewards of contributing and ‘giving back’.

Concerns

Although many areas of Australia are relying heavily on international medical graduates, not everyone is happy with the influx of doctors from overseas. Critics of the Australian skilled immigration policy have often mentioned the ‘brain drain effect’ on developing countries: the recruitment of healthcare professionals compromises the, often already struggling, healthcare systems in the developing world.

Concerns have publicly been expressed about doctors from non-Western training backgrounds and the uncertainty around standards and relevance of knowledge and skills to the Australian situation.

The regulation changed in the aftermath of the Dr Jayant Patel case. Dr Patel, nicknamed ‘Dr Death’, was permanently barred from practising medicine in Australia in 2015. Legislation introduced in 2009 now protects patients by ensuring that only health practitioners who are suitably trained and qualified to practise in a competent and ethical manner can be registered.

This example is not unique to Australia nor to international medical graduates. Many countries have similar stories, think for example about Dr Harold Shipman in the UK and Dr Christopher Duntsch in the US.

Although there is anecdotal evidence that patients sometimes avoid seeking treatment by international medical graduates, research indicates that there is no difference in patient satisfaction with, and acceptance of, care by Australian and international medical graduates.

Diversity

The ‘doctors from overseas’ bring diversity, expertise, experiences, cultures, innovation and stories to Australia. Cross-cultural experience appears to be valuable in many ways; some have argued that immigrants are more entrepreneurial, resilient and creative. Whether this is true or not, one thing is for sure, starting a new life in a different country takes courage and perseverance.

My wife Nancy and I have never looked back. Although we miss our family and friends in The Netherlands, we’re grateful for the opportunities Australia has given us. I can only hope I am able to give back what I have received.

Source: Cooktown Local News (2004).

My Health Record: what’s next?

The end of the My Health Record opt-out period is in sight. Unless the government decides otherwise, next month the vast majority of Australians will have a digital national shared health record. What’s next?

A while ago I saw a patient who was passing through my town, on her way home from Cairns to Sydney. She had been seen at the emergency department in Cairns and was told to visit a GP for follow-up. She had no hospital letter or medical records but with a few clicks I was able to get access to the hospital discharge summary through the My Health Record, which included results of blood tests, ECG and chest x-ray, and I could see what medications were prescribed.

This is a rare example of the benefits of the MyHR; once the system will be used at a larger scale this could become an everyday reality.

The Australian Digital Health Agency (ADHA) says that about 1.14M Australians have opted out and apparently the opt-out rate is slowing down. At the same time others are signing up and there is an expectation, based on the opt-out trials, that many of those who opted out will eventually opt back in.

The Australian My Health Record is a compromise between a consumer record and a clinical record. This means that there will always be people in both camps who are not completely satisfied. Despite everything we’ve come a long way.

Work in progress

The My Health Record, currently in version 9.4.2, continues to evolve. Looking back over the years progress has been slow but significant.

For example, the software is far less clunky these days; accessing a record or preparing and uploading a shared health summary can now be done within seconds; we got rid of the dreadful participation contracts; there is a secondary use of data framework and users can choose to opt-out of secondary use of their data.

It is expected that more pathology and imaging providers will come on board next year and the legal framework will be further adjusted to improve privacy of Australians, including complete deletion of data if people decide they don’t want a record anymore.

Awareness?

According to ADHA over 87% of Australians know about the record and more than 85% of general practice is registered.

It is likely though that this awareness is rudimentary despite hundreds of engagement activities by the agency and Primary Health Networks (PHNs). Most Australians will not be aware that they have control over who-can-access-what in their records and how to change the privacy settings.

The RACGP has held many PHN-based peer-to-peer workshops across the country as well as webinars for general practitioners and staff, and around 2000 people attended – which is a lot but probably not enough. Most non-GP specialists are not yet on board.

Then there are still the concerns about for example privacy, workflow and accuracy, many of which are summarised in this year’s senate inquiry report. It appears there is still work to do.

The next stage

The agency has started preparing for the ‘post opt-out period’. As it stands around mid December empty shell records will be created, and activated once accessed by providers or consumers.

ADHA says the aims of the next stage of the consumer campaign will be maintaining awareness, taking control of the My Health Record and encouraging consumers to discuss the MyHR with providers.

The provider campaign will focus on the expected benefits including improved efficiency, such as less search-time, and better health outcomes – although skeptics will question the latter claim by the agency.

There will also be a focus on getting specialists on board, aged care access, improved family safety and child protection and education for vulnerable consumer groups.

International review

Meanwhile ADHA has released an international review of digital health record systems. The findings show that the Australian MyHR empowers consumers to access and personally control their information, including what’s in it and who can see it.

ADHA emphasised that, although many countries have laws that allow users to view their health information, only Australia and a limited number of other countries allow citizens to control who sees their information and request corrections to their own health data.

The MyHR PR machine is in full swing. It will be interesting to see what the response to the senate inquiry will be and what happens next year. I hope the momentum of recent times will continue.

What needs to change?

From a usability point of view the wow-factor is still missing and although that’s nothing new in healthcare, some work in this area would go down well.

For example, it would improve workflow and safety if doctors could download MyHR information not just as PDF but import new medications straight into a local medication list.

The secondary use of data framework is fairly broad, and could be tightened up a bit further. Many have commented that the messaging around the MyHR should be less promotional and more about benefits versus limitations – but I’m not holding my breath here.

What change do you want to see?

Details have been changed in the case above to ensure patient confidentiality.

10 podcasts for GPs (and their patients)

I always enjoy a good podcast. There is something appealing about listening to people’s stories via the cloud – and at a convenient time and place. I usually listen in the car on the way to work.

In 2014 I posted 6 great podcasts for primary care, one of the most visited articles on this blog. As podcasting seems to be more popular then ever and new podcasts for family doctors have been launched since my last post, it is time for an update (October 2018).

So here is my top 10. Since I’ve been involved with the BridgeBuilders podcast (shamelessly placed @ no.4) my respect for podcasters has grown even more; it takes many hours to edit one episode.

Click on the iTunes or SoundCloud logo to listen, and feel free to share your favourites in the comments section. Big thanks to all podcasters – keep going!

#1: The Good GP

The Good GP

The Good GP has been around since September 2016 and has grown into one of the most popular education podcast ‘for busy GPs’, hosted by Western Australian GPs Dr Tim Koh and Dr Sean Stevens, in collaboration with RACGP WA.

Guests are GPs or other specialists and a range of mainly medical topics is covered, for example: acute pain, allergies, immunisations, the future of general practice, euthanasia and the registrar -supervisor relationship.

Listen on iTunes or SoundCloud

#2: The GP Show

This is another popular medical education podcast – hosted by Queensland GP and medical educator Dr Sam Manger.

Sam interviews guests covering a wide variety of topics including case studies and guideline reviews. The podcast is aimed general practitioners, family physicians, other specialists, allied health, nurses, registrars/residents, medical students and anybody interested in health, science and medicine.

Listen on iTunes or Libsyn

#3: Just a GP

Just a GP is a popular newcomer in 2018, run in collaboration with RACGP New South Wales. Hosts Dr Ashlea Broomfield, Dr Charlotte Hespe and Dr Rebekah Hoffman discuss leadership, quality in clinical practice, self care and wellbeing, difficult consultations, starting or running a private practice and GP research.

They explore the layered complexities with each other and other GPs with expertise in these areas. In each episode they share a favourite resource or clinical pearl.

Listen on iTunes or SoundCloud

#4: BridgeBuilders

Hosted by Dr Edwin Kruys, Dr Ashlea Broomfield and Dr Jaspreet Saini, the themes of the BridgeBuilders podcast are collaboration in healthcare, fragmentation, team care and working together to the benefit of our patients.

A wide variety of guests, including some of our healthcare and thought leaders from e.g. the RACGP, ACRRM, Consumers Health Forum (CHF) and the Pharmaceutical Society of Australia (PSA), give their view on trust, integrated care, quality care, leadership and what needs to happen to make Australian healthcare an even better connected place.

The BridgeBuilders podcast was launched in 2018.

Listen on iTunes or SoundCloud

#5: GP Sceptics

GP ScepticsSuperstar GPs Dr Justin Coleman and Dr Liz Sturgiss team up to ‘dissect, analyse and sometimes trash’ medical research relevant to GPs.

A common theme in their broadcasts is the influence of the pharmaceutical industry and other big corporates on doctors and our health.

Liz and Justin have a good sense of humour and recommend their podcast to ‘sceptical clinicians and their patients’.

Listen on iTunes or SoundCloud

#6: The Medical Journal of Australia

The Medical Journal of Australia (MJA) needs no introduction. Listen to interviews with leading health professionals and authors of MJA articles.

Listen on iTunes

#7: Broomedocs Podcast

Broome GP & emergency doctor Casey Parker has been podcasting since 2012. He discusses topics related to emergency medicine and (procedural) general practice . In the Broomedocs journal club relevant research studies are critically appraised, often with guests.

Listen on iTunes

#8: The Health Report

The Health ReportThe Health Report by Norman Swan and other ABC reporters features health topics such as ‘fishy fish oil’, insomnia, asthma, chiropractic controversies, the cranberry myth and lyme disease. Often several national and international guest discuss various topics in one episode.

Listen on iTunes

#9: BS without the BS

Best Science Medicine PodcastThe Best Science (BS) medicine podcast is a Canadian show which critically examines the evidence behind commons drug therapies. GP and associate professor Michael Allan and professor James McCormack present many myth busters and topics relevant to general practice, such as the treatment of back pain, osteoporosis and common cold.

Listen on iTunes

#10: Inside Health 

A BBC podcast discussing several topics per episode with UK GP Dr Mark Porter, demystifying myths about everything health: vitamins, supplements, obesity, smoking, organ donation, and much more.

Listen on iTunes or SoundCloud

An earlier version of this post was published in March 2017.

Pharmacists and doctors: Let’s change the script

This week saw another low point in the communication and relationships between health groups in Australia. We must find a better way.

It began after the release of a report from the Queensland parliamentary inquiry into pharmacy, which recommends that pharmacists should be able to prescribe and dispense ‘low-risk emergency and repeat prescriptions’ and ‘low risk vaccinations’, subject to consultation with a ‘13HEALTH GP’ or checking ‘the patient’s medical record’ through MyHealthRecord.

Medical groups including the AMA and RACGP indicated they will not support the recommendations. This is hardly surprising as the results of the deliberations by the parliamentary committee led by Chair Aaron Harper MP are not based on mutually agreed principles or a collaborative care model.

Although the report repeatedly mentions a shared prescribing model, the recommendations, if implemented, will not result in effective collaboration. For example, checking the MyHealthRecord (which is not always available or complete) or calling a health-line can hardly be seen as supporting team care and collaboration with treating doctors. Cooperation between pharmacists and medical teams should be more than a box ticking exercise.

I believe we can do better than this.

Community pharmacists feel that their scope of practice is restricted and that they can contribute in a more meaningful way to patient care. Medical groups are concerned that more prescribers can lead to fragmentation of care and poor health outcomes, especially in the absence of meaningful collaboration.

Both arguments are valid and should be explored further. There is always a better way but this requires a willingness to work together and find mutually agreed solutions. Indeed, not an easy task, but we can’t leave this to a group of parliamentarians.

I’d also like to think we are able to move beyond strongly worded media releases, open letters, lobbying and political donations.

On a positive note, it was good to see that the Pharmaceutical Society of Australia (PSA) recently organised a low-key summit between medical and pharmacy groups to discuss patient safety. PSA president Shane Jackson said that the summit will seek to develop a set of principles to support respectful and collaborative practice between pharmacists and doctors.

Reaffirming these principles is a useful exercise and a good place to start. My colleague Dr Ashlea Broomfield and I spoke with Shane Jackson about collaborative models of care (listen to the BridgeBuilders podcast here). Although doctors and pharmacists may never agree on everything, which is absolutely fine, we must find a better way forward in the interest of our patients.

Has Australian general practice moved one step closer to the British NHS?

In 2019, the Department of Health, via its practice incentive scheme, will not only start setting the key performance indicators of general practice but also further tighten its grip on practice data. It is not unlikely that the Department’s strategy will create the same issues the National Health Service is currently encountering: loss of patient-centeredness of care, unreasonable KPIs and low doctor morale.

The redesign of the Practice Incentive Program (PIP) has been in the cards for a while. The introduction of a new quality improvement (QI) payment system was deferred for 12 months in May 2018 because of concerns that it was not fit for purpose.

Central role of PHNs

If it goes ahead in May 2019, the impact of the new scheme will be significant. The big change will likely be that Primary Health Networks (PHNs) become exclusive “QI providers” for general practice. This means that they will extract, analyse and store practice data and present GPs with benchmark reports. Many PHNs have already started collecting data in anticipation of the changes.

To be eligible for quality improvement incentive payments, practices will have to demonstrate to PHNs that their performance is on par with the Department’s KPIs. Although analysis and benchmarking of clinical data are becoming increasingly important to improve patient care, there are many issues with the proposed PIP overhaul.

Initially, there was talk about more organisations becoming QI providers, such as the Royal Australian College of General Practitioners (RACGP) and the Improvement Foundation, but, according to Medical Observer, it looks like there will be no profession-led alternative to the PHN model and, as a result, practices will not be given a choice of QI providers.

General practice is at risk of gradually losing control over its quality improvement processes, which will no doubt leave many grassroots GPs dismayed.

Professional buy-in?

The main issue with the scheme is related to professional buy-in. The Department of Health has gone through the usual process of consulting the profession, but it has always been clear that the PIP redesign was going to occur regardless of the opinion of GP groups.

The Department may claim in its communications that the KPIs are supported by the various professional bodies, but the level of engagement, trust and satisfaction with the new QI system will be low for various reasons.

First, this is an example of a top-down government solution, largely designed by the Department of Health. As we have seen with the My Health Record and Health Care Homes, this approach usually creates just as many problems as it is trying to fix.

Similarly, there has been a lack of engagement with the e-health PIP (ePIP) scheme, which requires practices to upload shared health summaries to the My Health Record to remain eligible for incentive payments or ePIP. This may have given the Department a countable number of uploads, but there is no evidence to suggest that it has improved meaningful use of the My Health Record or quality of care in general practice.

Weak evidence

In the PIP redesign process, only payments to practices have survived. For example, the aged care incentive payment to GPs providing care to patients in residential aged care facilities will be scrapped. This incentive is worth $3000–$5000 per doctor. Many have argued that it is incomprehensible that funding benefitting aged care is removed at a time when residential aged care facilities need more support to provide the medical care required.

By stopping these service payments to individual doctors, the incentives will be one step further removed from those who are responsible for the actual quality improvement activities. Again, this does not inspire confidence in the Department’s new QI system.

Measuring performance against KPIs in combination with performance payments will almost certainly create new problems. Quality indicators used by governments around the world are often easy to measure isolated parameters that have limited valuefor complex systems such as general practice.

The evidence to support financial incentives is weak, and the British Quality and Outcomes Framework (QOF) pay-for-performance system has illustrated what can go wrong: QOF has not improved care but did result in the loss of the patient-centredness of care and has created a significant decrease in doctor morale.

No funding priority

The new QI PIP will be subsidised by a shift of funding from other PIP and SIP incentives — which has been labeled as “robbing Peter to pay Paul” by the Australian Medical Association. In 2016, $21 million were removed from the PIP budget to partially fund the Health Care Home trials. The last budget announcements made it clear that there will be no increase in PIP funding in the near future. The PIP scheme, introduced in the 1990s, has never been indexed.

The Department of Health has not yet provided clarity on what the PIP scheme will look like beyond May 2019. This lack of transparency about long term planning creates uncertainty for practices. Although the expectations will start off low, it is to be expected that the Department will adjust the KPIs upwards over time, wanting more for less.

One of the PIP eligibility criteria for practices is accreditation against the RACGP’s Standards for general practices, and it will be interesting to see if upcoming changes to the PIP scheme will affect the percentage of practices that take the effort to go through the accreditation process.

Data extraction

Finally, general practice is not only facing loss of control of quality improvement but is also about to miss out on an opportunity to become custodians of its clinical data. Although the QI PIP data will be extracted from GP practices, it will likely be managed and controlled by PHNs and other government agencies, such as the Australian Institute of Health and Welfare.

When the government defunded the Bettering the Evaluation and Care of Health (BEACH) study in 2016, general practice lost its most important longitudinal source of data. It doesn’t take much imagination to figure out what will happen with the QI PIP data when, in a future reform cycle, PHNs or other government agencies involved are subject to funding cuts or cease to exist altogether.

The Department of Health’s underlying thinking seems to be that the responsibility for quality and data should be taken away from the profession, even though the government’s own data governance practices don’t always inspire confidence.

Professional response

The department should have given professional organisations the responsibility to execute a mutually agreed strategy, acceptable to all parties, including custodianship of data for quality improvement purposes.

Our peak bodies are working hard behind the scenes to negotiate the best possible outcome. It is more important than ever for the profession to work through any differences and present a united front. The question remains, can we stem the tide of increasing departmental control or has general practice definitely moved one step closer to the NHS?

This article was originally published in MJA Insight.

5 ingredients for effective collaboration

Collaboration can be very rewarding. It is often talked about but not easy to achieve, and it doesn’t always make the top of the priority list.

Although it’s not the solution to everything, effective collaboration can be a source of satisfaction and has the potential to make work, and life, more fun. Of course, collaboration does not mean that we have to agree on everything.

I’d like to share some thoughts on the ‘ingredients’ of successful collaboration:

#1: Letting go of control

No one is as smart as all of us, said Ken Blanchard. It’s ok to not have all the answers. In collaborative cultures outcomes are largely dependent on organic group processes. It is important to empower others and trust in the wisdom of the group and diversity of thought.

#2: Celebrating diversity

Interesting things happen when people bring different backgrounds, disciplines, skills and ideas to the table. We need to be open to a dialogue that celebrates differences. This is not always easy as our tendency is to engage with like-minded people.

Diversity improves decision-making as it stimulates critical evaluation and prevents groupthink. Diversity also means accepting that we can have differences of opinion.

#3: Aiming for mutual benefit

In collaborative cultures mutually beneficial solutions become more important than winning and personal gain. We need to attend to the needs of all parties and not just our own.

Consensus improves the quality of decision-making through genuinly addressing individual concerns. Asking questions and finding out what outcome the other party needs is key to finding common ground for agreement.

#4: Formulating shared values or goals

Often we want to jump to the ‘how’ without having explored the ‘why’. Universal values are motivating! They answer the why question and are the reason we get out of bed in the morning. Providing excellent care to our patients is an example of a universal value/goal most of us share.

#5: Building relationships

If we focus on outcomes without investing in relationships, there is a good chance that we will fail. Building trust and relationships are key components of effective collaboration. This is never a once-off tick-box exercise but should be an ongoing activity.

This post was originally published on BridgeBuilders.