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?
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?
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.
Accumulating possessions is not always associated with an improvement in wellbeing. It can actually lead to stress and health issues.
On the other hand, giving, donating and getting rid of stuff are usually described as positive experiences. Decluttering homes even has health benefits.
The Netflix series, Tidying up with Marie Kondo, brings a powerful message across: organising our homes and offices comes with rewards.
Marie Kondo, dubbed the Japanese Mary Poppins, creates happiness by helping people throw away stuff they don’t need and organise their belongings. As a result relationships seem to improve and families live happier together.
Whether it is a desire for simplicity, a need to create organised spaces to think, work and live, or just guilt reduction, the slowly disappearing clutter towards the end is satisfying.
Marie Kondo makes decluttering homes, and lives, a fun activity. But she does something else. By asking whether objects spark joy she reminds us about our priorities and what life is all about – something we do occasionally forget.
When I arrived last night for a meeting with Federal MP Mal Brough, I had to work my way through TV camera crews to get to my chair.
But contrary to what everyone thought, Brough didn’t come to challenge the prime-minister. The meeting with local hospital doctors, GPs and staff was about health reform and the Medicare rebate – and what he had to say was remarkable.
I was expecting the usual: Budget crisis, rising Medicare costs, price signals etc. But this was a different message coming from a liberal MP.
Brough first showed some figures comparing (combined commonwealth and state) hospital expenditure versus GP Medicare rebates: $39.9 billion vs $5.9 billion per year. He demonstrated that hospital costs are rapidly rising but GP Medicare rebates remain more or less static.
His 3 core messages:
1. This must be a debate on improving the health of the nation, not a debate on cost cutting or cost shifting
2. A co-payment or price point should not be the starting point of this discussion
3. There are tremendous efficiencies to be had in hospital, specialist services and aged care if Primary Health provision is enhanced and is the heart of the nation’s health system.
Health organisations are hammering this message: If you want to keep patients out of our expensive hospitals, strengthen general practice – don’t take money out of the industry.
Brough underlined this by showing AIHW data indicating that over one-third of emergency department presentations were for potentially avoidable GP-type presentations (see image). A GP co-payment will almost certainly drive more traffic to the hospital EDs.
In the ‘Blogging on Demand’ series you get to choose the topic. If you have a great idea you want the world to know about, send an email, contact me via social media or leave a comment below. Melissa Sweet suggested the topic of this post: ‘Social determinants of health’. She tweeted: “Interested in your take on SDOH & how they play out locally.” Thankfully, to make the task easier, Melissa suggested some background reading: 436 articles from the Croakey archives.
Note: ‘Social determinants of health’ are economic and social conditions that influence the health of people and communities.
“Doc, that’s not going to work.” The health worker was standing behind me. She had overheard my consultation with the elderly man. I thought I was doing a great job, as I had taken the time to explain what diabetes was all about – in layman’s terms – and how he should inject the insulin.
The indigenous health worker continued: “He lives mostly outside and keeps his medications under a tree.” I couldn’t believe what she had just said. When the penny dropped I realised she was, of course, right: the insulin wouldn’t last in the excessive heat of the Kimberley.
It was clear that I had no idea of my patients’ living circumstances. I felt like a fool.
The home visit
Another time, another place. I was doing a home visit in a Cape York indigenous community as part of a team consisting of two nurses, a social worker, a health worker, a police officer and a local government representative.
The verandah was covered with rubbish and furniture. It was hot inside. The room was empty, apart from a few mattresses. The concrete floor and walls were dirty. “How many people live here?” I asked. “Between 8-20, depending on when you visit,” said the social worker.
The patient was lying on a mattress – she clearly only had a short time to live. There was not much I could do apart from some small medication changes. Afterwards, we had a long chat on the verandah about fixing the air-conditioning and the tap, and making her last days as comfortable as possible.
All tip and no iceberg
The contribution of doctors and other health care professionals to our wellbeing is relatively small: Depending on what source you read, healthcare contributes for about 25 percent to our health. On the other hand, an estimated 50 percent of our health is determined by economic and social conditions (see image).
One of Australia’s leading researchers on the economic and social determinants of health is Professor of Public Health Fran Baum. “Typically,” she writes in this editorial, “responses to diseases and health problems are knee jerk and concerned with ameliorating immediate and visible concerns.”
Professor Baum calls this the ‘all tip and no iceberg’ approach. Instead of focussing on disease and unhealthy behaviours we should improve the conditions of everyday life.
To combat the chronic disease and obesity epidemic for example, we should not just be advising lifestyle changes and initiating medical treatment. These are tip-of-the-iceberg solutions.
Instead, says Baum, let’s look below the surface at things like urban planning, the availability of unhealthy food, our sedentary lifestyles at home and at work, and equal opportunities for all.
In my work the influence of economic and social factors is apparent. Some examples:
The 26-year old single mother who cannot afford medications for her children
The 38-year old machine operator who gained 10 kg of weight since he started a fly-in-fly-out job in a remote mining community
The 50-year old chief executive who makes 14-hour days in a high-pressure environment, and develops anxiety symptoms.
My role as a GP in these scenarios is modest. Ok, ‘all tip and no iceberg’ may be too harsh – apart from the fact that it sounds like ‘all icing and no cake’…
But Professor Baum has an important message: We must not close our eyes to what really makes us ill and, more importantly, change it.
I took a sickie the other day. Nothing serious, but when you’re in the line of fire you get burned now and then. Patients always respond the same. They may say, half-surprised half-joking: “I didn’t know doctors could get sick.”
I can kind of see the humour of a sick doctor, but unfortunately finishing medical school doesn’t make us immune. Yes, I had my flu shot this year. No, I didn’t write a doctor’s certificate for myself. I also don’t have a secret cure that prevents me from falling ill.
Have a look at the headlines in the news this week, and you will be forgiven for thinking that medical science can cure anything:
“Implantable device ‘lowers blood pressure’ through electrical brain pulses”
“Duchenne muscular dystrophy may be treated with erectile dysfunction drug”
“DNA used to build tool that may literally shine light on cancer”
“3D-printer hearts ‘in 10 years’”
“Immunotherapy may work in cancers: study”
Hope vs false expectations
Health news is usually positive, which is great as most other news is depressing. News about scientific discoveries and new medical treatments gives us hope. Hope that one day, we may be able to live without suffering. But it also creates false expectations.
I would like to see more headlines that reflect reality, like:
“Doctors often don’t know cause of illness”
“Lifestyle just as important as medical treatment”
“Many diseases still without cure”
“If you eat healthy you probably don’t need supplements”
“Doctors get sick too”
Writer and philosopher Alain de Botton wants the news to take on new roles. I think he’s got a point. He warns about our appetite for the latest news: “We constantly want a new update on things and it’s become very hard to talk to ourselves… the news is from outside and any of that quieter news that bubbles up from within is being squashed by endless stories.”
The news often only tells part of the story and this may cause anxiety. It would be good if the news could educate us a bit more and help us to put things into context.
Is the grass always greener on the other side of the fence? Most people will answer ‘no’ to this question. Yet we often want what we don’t have. Against better judgement, we sometimes hope that happiness lives on the other side of the fence too.
The commercial world thrives on selling happiness: it’s not the new phone, car or dress, but the dream of a better life that’s on offer. And we all fall for it, thinking that somehow we will be happier after the purchase.
The reason for this is that we’re not good at predicting what makes us happy. Unfortunately, happiness as a result of a treat, purchase, or even winning the lottery, is short-lived – probably less than three months. Spending money on others makes us happier than spending it on ourselves, according to a study published in Science magazine.
Interestingly, happy people enjoy themselves without expensive treats. One happiness study showed that it’s the simple, cost-free things in life that matter, like listening to music, reading a book, going swimming, or enjoying a hobby.
What makes you happy? There’s a good chance that it’s an inexpensive, relaxing activity, or an act of kindness.
The previous Christmas parties at work were always nice. We sat down and were served a nice dinner. There was nice live music. We were fed and entertained – what more can you ask for?
Last year our management team took a different approach. We were not fed. We had to prepare our own food: Select the toppings for our pizza and bake it in the wood fired pizza oven. We waited patiently in line. We were the chefs.
There was no band. We had to sing ourselves – on stage. We were the entertainment. There were sumo suits; there was a gladiator ring. It was the best Christmas party ever.
Participation is fun. It creates a sense of ownership, responsibility and improves team spirit. That’s why social media works. Social media empowers. We have become participants instead of spectators.
This is how it should be in health care. I love it how some of my patients take ownership of their health. They are actively engaged, do research, ask questions and understand their treatment. As a doctor I’m not telling them what to do, I’m just part of their team.
Participation is the secret sauce. As health care professionals we must do everything we can to encourage participation.
It happens regularly: people visit a doctor but have difficulty providing essential details about their health.
Sometimes people incorrectly assume that all information is always at my fingertips. I don’t blame them; the healthcare sector is complicated and going to the doctor is understandably not everybody’s cup of tea.
And in all fairness, it’s not easy to remember when we had our last tetanus vaccination or in which year we were in the local hospital.
I hope the following five tips will help to make the most of your doctor’s visit.
1. Gather information
Write facts down, together with your questions. The doctor may ask a few things such as: when you first noticed the problem, what made it better or worse, and what your main concerns are. Make sure you know what your questions and expectations are.
Tip: Feel free to do your research on the Internet and check your findings with the doctor. Remember that online health information may not be applicable to you.
2. Allow enough time
If you want to discuss a complicated issue or a few problems, consider booking a long appointment to avoid running out of time.
3. Ask a friend or family member to join you
Having someone with you is helpful in many ways: to ask questions, to remember what has been discussed, for support and to give you a lift to and from the clinic if you are unwell.
4. Keep a record of all your past and present health problems
This is important. Doctors always need background information about your health. Don’t automatically assume the doctor always has all the required information.
Tip: Your own record could include a list of your medical problems, diagnoses, hospital admissions, operations, medications, vaccinations, allergies to or side effects from certain medications, products or food. Outcomes of important tests are always helpful. Keep a paper record or store the information in a safe place on your computer, phone or preferably electronic health record.
5. Never leave things to the last moment
A doctor’s visit just before a holiday trip, or on a Friday afternoon may cause problems – for example if your doctor needs to do more tests or the recommended medications are not available in the pharmacy. Sometimes a last-minute visit is unavoidable but often good planning goes a long way!