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.
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:
Doubting the other’s motivation in providing care and the perceived benefit for him/her
Feeling threatened by the other’s involvement and being afraid of losing some territory
A difference in philosophies and scope of practice
Negative images of the profession
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?
“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.
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 Pharmaceutical Society of Australia wants pharmacists in residential aged care facilities. The Consumers Health Forum argues for an Australian Co-Creating Health initiativeto 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 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.
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.
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. TheADG 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.”
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?
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.
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.
“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 onNewsGP.
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.
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?
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.
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.
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.
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.
“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.
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.
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.
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.
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.
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’.
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.
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.
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.
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.
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.
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.
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.
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.
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?
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.
Community pharmacy groups are lobbying for pharmacy prescribing, a topic that has been on the wish list for a long time. Medical groups are concerned about patient safety and fragmentation and are pushing back. Is this Australian conflict model what we want or is there a better way forward?
Some pharmacists want to be able to write prescriptions as they believe it is in the scope of practice of a pharmacist and more convenient for patients.
Examples from abroad are used as an argument why Australia must follow suit. A ‘collaborative prescribing pilot’ is underway and the pharmacy sector is looking forward to the soon-to-be released results.
Pharmacists expect that their proposal will be cost-saving as people will not need to see the family doctor for prescriptions.
Not surprisingly, medical groups are upset and believe the proposal is not helpful and not in the best interest of patients.
Doctors are concerned that soon the head doesn’t know what the tail is doing or, in other words, that more prescribers will lead to more fragmentation and adverse health outcomes.
Concerns have been raised that warning signs or significant (mental) health conditions will be missed and screening opportunities lost. Some have also argued that pharmacists prescribing and selling medications at the same time creates commercial conflicts of interest.
As a result there will likely be pushback from medical groups. It is to be expected that when the debate heats up some unpleasant words will be said in the media before the Health Minister of the day makes a decision based on evidence, opinion or political expedience.
Then there will be a loser (usually not the Health Minister) and a winner, and the relationship between pharmacists and doctors remains sour at the expense of patient care.
A better way
This series of events has become a familiar scenario in Australian healthcare. What’s missing is of course a joint strategy or a solution that would benefit both parties as well as our patients (a win-win-win solution).
Community pharmacists play an essential role within primary care teams. The pharmacy sector is under pressure and is attempting to implement strategies to remain viable into the future, such as introducing services currently provided by doctors, nurses and others.
An obvious way forward would be for pharmacists and doctors to explore models that are not competitive but complement each other. This is a joint process that requires broad support from both parties.
We desperately need genuine collaborative models of care, such as pharmacists working in general practice, but there may be other models too.
This is of course easier said than done. It is, however, time to leave the Machiavellian era of Australian healthcare behind. Who’s going to take the first step?
Would you visit a doctor who has, next to his or her name in the public register, a mention of a court proceeding or tribunal hearing?
Or would you prefer to see another doctor, even if the small print on the register stated ‘allegations not proven’?
I often find the legalese speak on AHPRA’s website difficult to understand. A recent report recommended that the register should include web links to published disciplinary decisions and court rulings – which AHPRA has been implementing.
However, and this is not immediately clear from the explanation on the website, apparently proceedings will also be published when a doctor or other health practitioner was found not guilty.
Complaints that have been dismissed in a tribunal as without merit will still be listed with a link to the relevant court or tribunal ruling, according to this article on DoctorPortal. The issue was also flagged at the national AMA Conference last month.
This measure is meant to ‘build trust between doctors and patients’. I’m not sure it is protecting the public but I can imagine that publishing complaints that have been dismissed is confusing for the public – and can also be misinterpreted.
It has the potential to not only affect the reputation of health professionals unfairly, but also their mental health and general wellbeing.
We need to have another long hard look at this.
“The Medical Board of Australia (the Board) has decided to publish links to serious disciplinary decisions by courts and tribunals on the public register of practitioners only when there has been an adverse finding against the doctor.
The Board will not publish links from an individual doctor’s entry on the register to public court and tribunal decisions when no adverse finding against the doctor has been made.
The Board has removed links to tribunal decisions in which there was no adverse finding about the doctor that had been published on the register since March 2018.”
Immature tribal cultures create silos and distrust, and sustain undesired behaviours. How can we change a dominant culture and become more effective?
My mother spent years of her childhood in Tjideng, a Japanese internment camp for women and children run by the cruel Captain Kenichi Sone.
She was born in the former Dutch East Indies, now Indonesia. The Dutch occupied and exploited the country for over four hundred years, but in 1942 things changed dramatically as a result of the Invasion by the Japanese imperial army.
The women in the Japanese internment camps are sometimes called the ‘forgotten women’ of the war in the East. These camps, as well as Dutch colonialism, are some of the worst examples of tribalism.
Tribalism comes of course in many shapes and forms including, as we all know, in the medical world.
Tribes & organisations
Most leaders know that tribal cultures are a key factor in the performance of organisations. Some leaders are experts at creating close-knit cultures, but only a few can change a culture that doesn’t perform optimally.
Tribalism is the natural way we organise ourselves into social groups. Our ‘tribes’ are part of who we are. They offer support, security and a sense of belonging an there’s nothing wrong with that.
However, tribalism can also refer to a false sense of superiority, sometimes leading to exclusion, bullying and discrimination.
We can change a dominant tribal culture and upgrade our organisations to more collaborative, healthy stages. History shows that goal-oriented groups and organisations that work well with others are more successful.
5 tribal cultures
In the book ‘Tribal leadership’, Professor David Logan et al describe five stages of tribal culture. As he points out, the medical profession is only half way, at stage three of five.
Logan’s tribal stage one is the mindset of gangs and war criminals – people who come to work with weapons. There is hostility and violence and no cohesion.
People working in a stage two culture may have coffee mugs with slogans like: “I hate work,” or “I wish it was Friday”.
There is often a high suspicion of management and authority in general, and team-building efforts are not effective in this culture.
Stage three is the dominant culture in almost half of all organisations, including many professional workplaces. Quite often doctors fall into this category. In stage three it is all about personal success and being the smartest. Stages four and five are the collaborative cultures.
Let’s have a closer look at the most common culture, stage three.
I’m great (and you’re not)
The mantra of stage three is ‘I’m great’, often followed by the unspoken words ‘and you’re not’. There’s a long history in medicine of stage three cultures with a strong focus on individual expertise and success.
One of the earliest examples I could find is this well known Rembrandt paintingtitled, ‘The anatomy lesson of Dr Nicolaes Tulp.’
Dr Tulp was a highly respected surgeon in Amsterdam in the seventeenth century; he is clearly the central figure in this painting. He’s the only one wearing a hat. Sadly but not surprisingly there are no women present.
You could argue that this scene demonstrates the dominant culture of the exclusive Amsterdam Guild of Surgeons. These days, almost four hundred years later, the dominant culture in medicine hasn’t changed all that much.
Professionals working in a stage three culture are often very good at what they do as individuals but what they don’t do is bringing people together.
They may think they are. Interestingly people in stage three often think that they are at one of the collaborative stages. They may talk about collaboration and teamwork – hallmarks of stage four and five – but their actions firmly put them in stage three.
The issue with a stage three culture is that it cannot be fixed – it can only be abandoned. The solution is to move your tribe to the next stage, stage four.
How to upgrade
People working in a stage four culture don’t talk about themselves. They first start listening. It’s no longer about being the smartest or about personal success.
There’s a move from ‘expert’ to ‘partner’. The language used is not “I’m great” but “We’re great”. There’s tribal pride.
Eventually, later in stage four, organisational boundaries become less important and cross-pollination between organisations may occur.
So how do we upgrade our culture from stage three to the more collaborative stage four? Logan describes several principles, including:
Focus your team on tribal success instead of personal success
Point out the superior results of stage four tribal cultures
Describe role models in the organisation that show stage four behaviour, for example people who are talking about ‘we’ instead of ‘me’
Encourage transparency and sharing of knowledge & information as much as possible.
There’s one main problem with stage four, reflected in the unspoken sentence that often follows “We’re great,” and that is: “… and you’re not,” referring to other groups or organisations. That’s where stage five comes in.
Stage five is the dominant culture in two percent of work places. In this stage there is no ‘they’.
‘Them & us’ thinking has gone out of the window and there is a focus on inspiring purposes. These are often universal values, taking away the need to compete.
People working in stage five cultures can work with any group that has a commitment to universal core values – even if these values are different from their own.
More collaboration in medicine has many benefits, including for direct patient care, mental health of doctors and healthcare reform.
We always talk about leadership but effective followership is just as important.
Effective followers don’t blame their leaders when things don’t go as planned; instead they offer support and gently, but persistently, steer their leaders in the right direction to help them achieve the organisational goals.
What the medical profession needs is people who build bridges.
I’d encourage you to review your own organisation(s) and look for opportunities to collaborate. Don’t accept non-collaborative cultures.
Find role models and like-minded people, people who talk about ‘we’ instead of ‘me’, and together take your dominant culture to the next level.
This is an adaptation of a presentation given at GPDU18.