It’s not about the nail

Why do people avoid mandatory self-isolation during the COVID-19 pandemic? The simple answer is because they don’t want to change. “The facts are important, but so are emotions,” says researcher Dr Holly Seale in this article in the Conversation.

A theme that often comes up in conversations with my patients is behavioural change. I discovered a long time ago – mostly through trial and error – that telling people to change, adopt a certain lifestyle etc, has a low chance of creating the desired outcome. There are other, strong factors that influence our willingness and ability to change.

Working against us is the ‘optimism bias’. As a result of unrealistic optimism, we tend to underestimate the probability that we are exposed to negative events, despite clear evidence to the contrary.

Dr Seal and her team found that quarantine compliance is often hampered by a lack of engagement and low levels of ownership within the community, complicated by information gaps, fear of social isolation and concerns about loss of income, job security and sick leave.

Supporting the adoption of desired behaviour appears to be a key element.

It seems to me that people should be invited to learn more about the risks, explore barriers and consider the benefits of taking a certain action. It is essential to help build confidence and develop a positive attitude towards change (the same principles used in motivational interviewing).

The pitfall is to jump straight to the solution. This point is well made in the classic video ‘It’s not about the nail‘.

I recently attended a workshop about behavioural change, where the video was used to demonstrate the ‘righting reflex’ – our strong but not very effective desire to make things right immediately.

The video illustrates the different needs people have when faced with a problem. In this case, the different approach of a woman and a man to the same issue (a nail). If you haven’t seen it, it’s worth having a look.

I don’t know how you make a living, doc

One of my patients often tells me that she used to say to my predecessor, “I don’t know how you make a living, doc, cause I’m never sick.”

Things changed when she was diagnosed with a TIA and we found an irregular heartbeat. She now often expresses her gratitude for the care available, close to home.

Like so often in life, we only value something when we perceive a need for it. Emeritus Professor Max Kamien recently reminded me of this when he quoted James Dickinson in a comment on this blog post.

Dickinson, a professor in family medicine, used to work in the Federal Department of Health. He said that health policy is devised by young, healthy, non-medical advisers who do not have a need for a personal GP and instead use impersonal walk-in practices.

They often regard these experiences as being substandard medical practice. As a result, he said, they do not understand the multiple tasks required for good quality general practice and do not perceive its relevance.

This could perhaps explain the incomprehensible decisions that often come out of the department, such as defunding ECGs in general practice (a test which was crucial in the diagnosis and management of my patient).

I sometimes wonder, is it worthwhile spending more time and effort on educating policy-makers in the department of health?

I wonder what’s going on at the Department of Health

Australia’s health system is based on a hospital-centric model. I doubt this will change anytime soon, as Government expenditure on hospitals continues to grow – at the expense of primary care.

The recent outrage about changes to the Medicare Benefits Schedule (MBS) is symptomatic: it looks like GPs will no longer be able to charge for electrocardiogram (ECG) item numbers that include reporting. The Department of Health (DoH) seems to believe this is a job for hospital specialists only.

Earlier this year, all hell broke loose after a departmental campaign targeted GPs who deliver mental health care to their patients alongside physical care. And then there was the DoH’s intimidating ‘opioid crackdown letter’ to GPs, affecting the effective delivery of palliative care.

The DoH continues to disrupt healthcare provision in Australia with a ‘penny wise, pound foolish’, management-by-spreadsheet approach. General practice remains largely undervalued.

Yet, the long-term benefits of primary care are well known. Adequate support for general practice is associated with slower growth in health expenditure and better system quality, equity and efficiency, as well as savings to the health system.

State hospitals are facing unsustainable cost blowouts and ever-increasing waiting lists in the face of significant population growth.

Increasingly, there is talk about supporting general practice to deliver more care in the community through collaborative models of care.

Yet the DoH believes GP should not be providing care that includes skills such as interpreting ECGs to ‘reduce low-value care’ and because it is ‘safe and best practice’. I wonder how safe the DoH’s new ruling is for patients presenting with cardiac symptoms to their GP.

It appears the recommendations by the 12-Lead Electrocardiogram Working Group, originally made four years ago, were reworked by DoH. The end result did not go down well at the time.

The RACGP responded in a submission in early 2018, stating that it ‘does not support the proposed recommendation … as it fails to recognise or acknowledge that GPs perform ECG interpretation, report results in the patient record and determine actions without referral’.

The feedback clearly fell on deaf ears. Stakeholder engagement by the DoH appears to be little more than a tick-the-box exercise.

The fact this ECG news came out of the blue and amidst a second wave of COVID-19 is awkward.

Effective care provided in general practice reduces the need for more expensive hospital specialist care. Health systems with a greater focus on primary care are more equitable, have lower costs and better health outcomes.

The poor departmental decision-making of late sadly encourages health inefficiencies and deskilling of the general practice workforce. It goes against efforts to deliver patient care closer to home. It is highly demotivating for general practice teams, especially amidst the COVID-19 pandemic, and demonstrates a concerning absence of a long-term vision.

This article was originally published in NewsGP.

Towards a post-pandemic new normal

About twenty years ago when I was a GP registrar in the Netherlands, my day began with checking results and making phone calls to patients before the first patient arrived in the practice.

After I finished GP training I started working as a locum. I remember several practices that used electronic prescribing: the medication order was forwarded to the pharmacy, straight from the practice desktop software. No paper, handwritten signatures or printed barcodes required.

COVID-19 disruption

Much has been said about the extraordinary creativity and innovation the COVID-19 pandemic has generated and what this will mean for Australia’s healthcare system after the pandemic.

Looking at telehealth, it appears Australia is catching up with the Netherlands and other countries. The question is, will we be able to retain the innovations that came out of the COVID-19 disruption?

In the past months the wheels have stopped turning in many areas of non COVID-19 related healthcare. There is now a backlog of routine care which, according to Grattan Institute Health Program Director Stephen Duckett, creates an opportunity for a new way of doing things.

He recently argued that telehealth, earlier discharge for home-rehabilitation and private-public hospital partnerships could assist in waitlist management. When considering returning to business as usual, he said, the new post-pandemic normal should be nothing like the old.

This ambition is echoed by others, including Queensland Health’s Director-General, Dr John Wakefield, who wants to retain the efficiencies that have been created in the public health service. Rather than returning to business as usual, Dr Wakefield said in a recent message to all staff, we should be finding the new normal.

“This is not about getting back to business as usual.

“This is not about getting back to business as usual. In fact, we want to make sure that in recommencing services, we retain many of the amazing innovative ways of working that you have adopted since this pandemic arrived on our shores,” he wrote.

He mentioned in particular video calls for outpatient department consultations and primary care, shifting chronic disease care from hospital to community and primary care and keeping emergency departments for emergencies.

Although this is primarily about increasing access to secondary care, it could be good news for those who believe in the “right care, right place” principle. Appropriate funding and support of primary care is an essential element for the success of this strategy.

I believe there are four areas of change for general practice, some of which relate to routine care and others are applicable to crisis management:

  • E-health: this includes phone and video consultations, electronic prescribing, secure messaging and transfer of information such as images;
  • Connecting health services: our relationships and the way we work with other health providers including hospitals and state and federal governments;
  • Workspace and flow: the way we design the layout of our workplaces, such as separate entrances, waiting rooms, check-in/out areas, isolation rooms and outdoor/offsite clinics.
  • Policies and procedures: Crisis, disaster and pandemic plans and procedures.

Telehealth

Most would agree that telehealth offers advantages in a post-pandemic world, and there are medical, social, economic and environmental reasons to make this part of routine care – like it is in various other countries.

There is of course work to be done. Implementing video consultations is more than turning on a camera at both ends as we have seen in recent weeks. There are challenges with regards to for example software integration, billing and security.

Care provision via telehealth should mirror the fee-for-service consultation model. To ensure telehealth will become part of usual care after the pandemic, commercial telehealth-only business models should be discouraged.

There is not much point in doing a video consult if we have to use a fax machine to get a copy of a prescription to the pharmacy, followed by a mandatory transfer of the physical piece of paper containing a handwritten signature or barcode.

Electronic prescribing has benefits, such as accuracy, safety and convenience. We also need electronic transfer of referrals, imaging and other test requests, as well as a solution for patients to securely send for example pictures of skin lesions, without having to rely on regular email.

It is important to note that this should not be not be regarded as ‘just a wishlist’ but as a fundamental digital framework supporting safe patient care during the good and the bad times.

Collaboration after the pandemic

There is room for improvement of information exchange and coordination of care between general practice and state health services during times of crises. The role of GPs is often not formally integrated into emergency responses (as was also evident during the 2019-20 bushfires).

In recent months however, innovative collaborative arrangements have emerged across Australia, embedding general practice in the wider healthcare response to the pandemic, such as participation in emergency planning and emergency credentialing of GPs by public hospitals.

In my area, GPs with a Special Interest (GPSIs) working in the public hospital were given the option to work in a Queensland Health virtual fever clinic after outpatient clinics temporarily closed. Flexible, collaborative workforce models like this should be explored further to encourage integration between primary and secondary care.

DoctorsBag Blog by Edwin Kruys

Dr Duckett and Dr Wakefield mentioned the hospital-in-the-home and hospital-in-the-nursing home models for routine care, as they are deemed cheaper and appear to reduce mortality and readmission rates compared with in-hospital care.

Indeed, it looks like care can often be transferred at an earlier stage from hospital back to the community, improving hospital access for those who need it most. An important step will be to engage the primary care workforce in these models and create capacity and incentives for GPs to be able to look after people that have been discharged from hospital wards, outpatient departments and emergency departments.

Consistent clinical handover procedures in combination with easy-to-use, two-way secure electronic communication tools between public and private sectors are a key factor to success.

There will no doubt be numerous other changes in the way we organise our work in the next twelve months or so. It is encouraging to see that permanent changes are being considered in many organisations and at all levels.

It will be necessary however, to agree on the priorities of the new normal and invest wisely. This may be challenging during a time of recovery, but not impossible.

This article was originally published in the Medical Republic.

What will general practice look like after the pandemic?

Will the GP surgery of the future have separate entrances and waiting areas?

Will it be partitioned and contain designated isolation areas to accommodate possible contagious and non-contagious visitors? Will reception staff be working behind Perspex screens or will the service counters keep patients at a distance of one-and-a-half metres?

Has the era of universal telehealth, where patients can interact with their GP or practice nurse from the comfort of their home, or anywhere else – facilitated by permanent Medicare item numbers, practice support payments and new affordable and trustworthy digital communication tools – finally commenced?

Will office and medical equipment be designed to enable more ‘no-touch’ interactions?

Will technology such as remote monitoring devices and health apps be able to provide us with the information we need when we cannot observe someone in-person?

And are we going to have to learn new skills, such as gathering data and making reliable assessments while the patient is not in the same room? Will GP training of the future place a greater focus on telemedicine skills? Will we meet, make decisions and deliver education more often via video conferencing?

Will doctors finally be able to issue paperless scripts and let patients pick up their medications without having to physically visit a medical centre? Are we going to demand more from our medical software systems, so it will perform these tasks for us, even under circumstances of high demand and from different devices and locations?

Is the way we keep stock of essential equipment and medications going to change? Do we want to be more aware of the strengths and weakness of supply chains? Will GP surgeries in the future be more prepared for pandemics and natural disasters?

Will the interaction with other parts of the health system change, facilitating for example, better electronic two-way communication and sharing of information with hospitals? Will our patients be able to access telehealth appointments with allied health or secondary and tertiary care facilities more often?

Will we be able to better align general practice and state health organisations during future natural disasters and pandemics? Is it possible that doctors, pharmacists, pathology providers and telehealth providers will pull together, putting aside personal or political gains?

DoctorsBag Blog by Edwin Kruys

A lot has been said about the impact of the coronavirus pandemic and how it has forced us to review, rethink and redesign almost everything we do.

The pandemic has exposed weaknesses and limitations of our healthcare system and, at the same time, stimulated creativity and innovation.

But some things will never change. To maximise the benefits of primary care, the long-term therapeutic doctor-patient relationship remains crucial. And, at some stage this will again involve shaking hands, even holding hands, as well as the necessary physical contact during examinations, tests and procedures.

There is of course a possibility that we revert back to business as usual when the pandemic is over. Medical conservatism would caution against rapid change or innovation unless the benefits are clear and supported by evidence.

Sometimes questions are just as important as the answers. It will be interesting to see how we come out of this crisis; who chooses to adapt and why – and who prefers to go back to the way we have always practised medicine.

As John F. Kennedy purportedly observed, in Chinese the word ‘crisis’ is composed of two characters – one represents danger, and the other represents opportunity. Nothing could be more applicable to the present coronavirus pandemic.

This article was originally published in NewsGP.

Departmental ‘GP hunt’ may affect mental health care

This week, hundreds of GPs will receive a warning letter from the federal Department of Health about Medicare claims related to care provided to patients with a mental health condition.

An unintended consequence of this latest departmental campaign – in which some GPs apparently will be asked to pay back Medicare money – will be a lower standard of care for people living with a mental health illness.

The problem appears to be coming from this MBS note:

“If a consultation is for the purpose of a GP Mental Health Treatment Plan, Review or Consultation item, a separate and additional consultation should not be undertaken in conjunction with the mental health consultation, unless it is clinically indicated that a separate problem must be treated immediately.

In other words, if someone goes to the doctor for a mental health issue, GPs are not supposed to claim for general health or wellbeing services provided on the same day (unless it is urgent or an emergency).

In my book, it is unethical to deny treatment of co-morbid health concerns because someone has a mental health condition. It also goes against the latest thinking around the benefits of optimising general wellbeing to improve mental health.

Mental health services across Australia are increasingly focusing on lifestyle and preventive physical health because of strong evidence that this assists their clients’ mental health – but at the same time GPs are not allowed to charge for doing just this.

“Evidence-based and effective lifestyle therapies are indicated for people with mental illness in addition, or as an alternative, to usual care. Strong evidence shows that lifestyle interventions, such as nutrition, movement, sleep, stress management and substance cessation, are efficacious and cost-effective therapies that improve mental health, physical health and quality of life.” Source: Australian Journal of General Practice.

Don’t forget the 10-20 years shorter life expectancy of people living with a chronic mental health condition.

If the GPs, targeted by the department for claiming mental and other health items on the same day, were taking the appropriate time to provide genuine care, they should receive recognition for outstanding services instead of a being treated like racketeers.

How GPs can assist with reducing hospital waitlists

Good news: GPs with a special interest (GPSIs) can help reduce public hospital waiting lists and increase our health system’s capacity.

Our recent pilot in Queensland found that the proportion of long waitlists were reduced in 66% of the specialties measured. For example, orthopaedic waitlists dropped by 42% and general surgery by 39%.

Long waits are defined as exceeding the clinically recommended waiting time, ie more than:

  • 30 days for Category 1
  • 90 days for Category 2
  • 365 days for Category 3.

The 24 experienced GPSIs – equivalent to three full-time equivalent (FTE) GPs – were responsible for 5000 extra episodes of care per year.

We found the pilot program improved collaboration and integration between general practice and hospitals by facilitating collegiate contact and inter-professional learning between GPs and specialty teams.

The UK has been experimenting with this model since 2000, defining GPSIs as GPs who continue with their core role, but who develop additional skills and knowledge in specific clinical areas.

In Australia, RACGP Specific Interests now has more than 5000 members and almost 30 individual networks.

So it appears there is no shortage of specific interests.

How did the trial come about?
The Queensland Specialist Outpatient Strategy set aside 361.2 million in 2016 to improve Queensland Health’s specialist outpatient appointments. This included an investment in new models of care.

In 2017, the Queensland Healthcare Improvement Unit selected the Sunshine Coast Hospital and Health Service (SCHHS) as a pilot site.

The GPSIs were recruited on a part-time basis and allocated to 12 specialties within the health service. GPs were required to hold vocational registration with the RACGP or ACRRM and have a minimum of five years general practice experience.

Specialties such as paediatrics and dermatology required GPSIs with additional qualifications, while other specialties provided on-the-job training.

The project was managed by the hospital’s General Practice Liaison Unit (GPLU) – where I and my co-authors, Dr Michelle Johnston and Dr Marlene Pearce work. The hospital’s Executive Director of Medical Services was executive sponsor.

The GPLU was responsible for advertising, promoting and recruiting the GPSI positions.

Role planning, selection and interviews were done collaboratively between the GPLU and the medical directors of each specialty. Consultants provided supervision.

GPSIs worked up to two clinic sessions per week, in addition to their work as community GPs.

Interestingly, discharge rates from GPSI clinics were higher on average than regular outpatient clinics. In combination with GPSI-facilitated follow-up plans for further care by the regular GP, this is an important strategy to reduce waitlists.

Three specialties saw an increase in waitlists, which was attributed to confounding factors such as the loss of consultants and the introduction of the new cervical screening program, which saw a significant increase in demand.

Feedback from GPSIs, consultants and patients demonstrated high levels of satisfaction. Common feedback themes included value gained from bidirectional inter-professional learning and co-design of new discharge planning models.

GPSIs can help build hospital team confidence in primary care handover and identify which patients can be appropriately transferred back to the regular GP, facilitating continuity of care.

Local upskilling opportunities support GPSIs to more confidently manage patients in primary care and may help horizontal referrals between GPs in the future, reducing hospital referrals and demand for specialist outpatient services.

We believe it is vital that GPSIs continue to actively work as community GPs, in order to avoid subspecialising and to improve integration between general practice and hospital care.

It is important to continue to develop and invest in integrated models of care, as they can be part of the solution to the ever-growing demand on Australia’s health services.

This article was originally published in NewsGP.

Let’s not fool ourselves about the PIP QI

It looks like patient care and quality improvement have taken a backseat in the new Practice Incentive Program (PIP QI).

To be eligible to receive payments under the revamped quality improvement program, practice owners need to show Primary Health Networks (PHNs) that they are recording information such as smoking status or influenza immunisations, and hand over de-identified patient data to their local PHN.

It is important that practices record this kind of information but the requirements are set at a rookie-level – a bit like learning how to write, no, how to hold a pencil.

Not surprisingly, the new program is regarded by many practice owners and managers as ‘easy money’. I don’t blame them as the Medicare freeze has affected us all – but the Federal Department of Health is fully aware it is dangling a carrot in front of a profession in dire need of adequate funding.

It is unlikely that in its current form, PIP QI will improve the quality of patient care. The profession rightly has second thoughts: Is this the beginning of performance management? Is this part of the department’s general practice data extraction plan?

What’s next? As there is no transparent, long-term vision here, your guess is as good as mine. The department is playing its cards close to its chest and appears to be effectively applying salami-slice tactics.

Professional organisations should have been given more responsibility to execute an agreed quality improvement strategy, acceptable to all stakeholders, including custodianship of patient information and access to raw data.

This was however clearly not on the department’s agenda and professional bodies were not successful in reaching agreement on a profession-led solution (general practice needs a shared vision). As a result, the focus appears to have been on data extraction.

After having been postponed twice, the practice incentive program has now been launched, even though several best-practice data governance principles have not yet been met.

For example, practices have been given little insight into what patient data is exactly being extracted from their databases and what happens with it afterward.

Red flags about the scheme have been raised at grassroots level. When going live last week, there were, and still are, many unanswered questions.

The practice incentive program should be about improving patient care in an acceptable, sensible and meaningful way. I’m concerned the scheme will instead be remembered as a government data grab.

Why external rewards undermine internal motivation

In my last post, I mentioned the issue of lack of trust in institutions. It appears that our world is increasingly running on financial incentives and regulation. Psychologist Barry Schwartz states that this undermines our will to do the right thing.

This week Dr Todd Cameron, GP and practice owner in Victoria, posted an excellent four-minute LinkedIn video about why financial incentives are not as effective as we sometimes think. He mentioned the following issues with financial performance systems:

  • They assume people are lazy
  • They are not supported by scientific evidence
  • They ignore activities that are difficult to measure
  • They reduce the flexibility of organisations
  • They take away resources for system improvement
  • KPIs often work against each other or against other goals, values or purposes
  • KPIs can undermine collaboration.

Research confirms that incentives, big or small, usually backfire. Like punishments, they affect internal motivation and creativity. Social scientist and author Alfie Kohn wrote about the ‘bonus effect’ in Psychology Today:

“When people are promised a monetary reward for doing a task well, the primary outcome is that they get more excited about money. This happens even when they don’t meet the standard for getting paid.”

Kohn states that rewards not only make people lose interest in whatever they had to do to get the reward but incentive systems also reduce the quality of their performance.

I believe Todd is right, money should be the byproduct of doing a great job. Pay is clearly not a motivator to improve performance. Most people get out of bed in the morning because they want to do the right thing – this is usually something we’re good at or passionate about.

Great examples and a work environment that gives people freedom and sets a clear direction at the same time are more powerful than monetary bonuses. Todd recommends that KPI funds should be used to improve systems and collaborative platforms and that targets should not be tied to financial rewards.

5 reasons why health providers don’t trust each other

Trust is an essential ingredient of effective healthcare delivery. It’s important for interprofessional as well as inter-organisational collaboration.

A 2018 literature review concluded that collaboration leads to more job satisfaction, improved morale and a better working atmosphere. Unfortunately, health providers don’t always trust each other. The authors of the review found 5 sources of distrust:

  1. Doubting the other’s motivation in providing care and the perceived benefit for him/her
  2. Feeling threatened by the other’s involvement and being afraid of losing some territory
  3. A difference in philosophies and scope of practice
  4. Negative images of the profession
  5. Lack of confidence in the other’s skills and lack of awareness of the other’s role in patient care.

Other ingredients of effective collaboration include adequate communication, respect, mutual acquaintanceship, equal power-distribution, shared goals, congruent philosophies and values, consensus, patient-centeredness and environmental factors.

The authors did not explore the level of importance of each factor but I am putting my money on trust as the secret ingredient. If we continue to distrust each other, collaboration will remain a challenge. The question is, how to change this?

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?

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.

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.

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.