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?
The other day I attended a leadership event at our local hospital. One of the speakers asked us “How many days of the week start with the letter T?”
The obvious answer is of course two, Tuesday and Thursday – but he said there’s another answer someone once gave him during a workshop, which is also correct: Tuesday, Thursday, today and tomorrow.
The point he made was that together people often solve problems in ways they wouldn’t have thought of on their own. Transformational ideas and break-through inventions are usually incremental processes that occur when different minds work together or build on each other’s work.
Steve Job’s iPod was based on existing mp3-players. Thomas Edison didn’t invent the lightbulb but improved it. The invention of the automobile and the airplane was the work of many; Henry Ford and the Wright Brothers just refined the ideas.
It never ceases to amaze me how people in a group – when the circumstances are right – develop creative ideas to solve challenging problems.
That evening, during dinner, I asked my children ‘Who knows how many days of the week start with T?” We had a bit of a discussion as a family until my 10-year old daughter said, “Seven days dad, because I always start my day with a tea.”
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.
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.
If we want to change bullying and abuse within the profession we have to move our tribal cultures to the next level.
The medical profession has come a long way in the past 25 years, but sadly seems to have difficulties eradicating issues of humiliation and abuse of colleagues and medical students.
One option to fix the problem is to make junior doctors and students more resilient, which seems like a good principle that is currently being applied by other organisations in other areas. Fore example, Beyond Blue has released a practice guide for professionals to help children deal with the adversities they experience early on to prevent mental health conditions later in life.
But teaching resilience alone is not enough.
Another option is to increase awareness and understanding among senior doctors and educate them about bullying, discrimination and sexual harassment. A good example is the mandatory education module, ‘operating with respect’, from the Royal Australian College of Surgeons (RACS).
Elephant in the room
The elephant in the room, however, is our culture – or at least certain aspects of it.
David Logan, a professor at the University of Southern California, said it a few years ago in his New York Times bestseller ‘Tribal leadership’: on the tribal culture scale of 1-5, most professionals around the world score a meagre three. This includes lawyers, doctors and professors.
According to Professor Logan and fellow authors John King and Halee Fischer-Wright, a stage-three culture or tribe is built around knowledge, personal accomplishments and individual expertise. The emphasis is often on winning. Although there may be talk of teamwork, the group interactions usually resemble those of a master-servant relationship.
The mantra of a stage-three culture is, ‘I’m great’. The language used is often along the lines of, “I’m good at my job,” “I try harder than most,” “Most people can’t match my work ethic,” and key pronouns used are ‘I,’ ‘me,’ and ‘my’.
This creates several problems. Professionals operating in this type of culture often feel unsupported, undervalued and frustrated, and those around them feel like a support cast.
Stage-three cultures cannot be fixed, but they can be abandoned. The answer is to upgrade the culture and move away from the ‘I’m great’ mantra to ‘We’re great.’
The next level
Instead of relying on personal achievements and expertise, at stage-four it becomes all about the accomplishments of the group. Partnerships, communication and transparency are recognised as essential ingredients for success. This is a healthier environment, in which people feel more valued and supported.
Professor Logan’s top level is stage-five. Highly functioning teams focus on maximising achievement – not in competition with other groups or tribes but with what’s possible. Stage-five teams can work with anyone.
Australian research has shown that hierarchical and stereotype behaviours largely dissolve when health professionals are working in a more collaborative, multidisciplinary environment.
Resilience training and anti-bullying education are essential, but if we really want to make a difference we have to move our tribal cultures to the next level.
Giving feedback is of course best done in person. However, in the digital era this may not always be practical or possible and a lot of feedback already occurs via email, text messages or social media.
There are many ways to give feedback, some more effective than others. I have probably made every mistake possible. I’ve also seen really good and some not so good examples, including on this blog.
Giving effective feedback requires more than stating errors or shortcomings. Problem identification, clarification and advice or suggestions for improvement are useful parts of the feedback process.
To make feedback acceptable and useful for the recipient, it is best delivered in a supportive way, including both positive and negative observations. We all know this is not always happening on social media, comments sections and blogs. Sometimes basic elements of respect and dignity are forgotten, which may undo the positive effects of feedback.
Most doctors and other health professionals are passionate about what they do, but we also experience excessive occupational demands and sometimes lack of personal support. Electronic means of communication can play an important support role, but can also be a source of stress.
Some research suggests that doctors have high expectations of self, are achievement-oriented and have a tendency to self-blame. Together with the often non-disclosure of personal distress, this makes the profession vulnerable for burnout. Let’s be kind to ourselves and our peers.
Consequences & effect
We all appreciate helpful and constructive feedback, so it is good to think about the way we give feedback to others and the consequences our comments may have in the digital space.
The Medical Board’s Code of Conduct mentions ‘communicating respectfully’ and ‘behaving professionally and courteously to colleagues and other practitioners, including when using social media’.
An honest, well-formulated feedback message can be powerful and may have a positive impact. To achieve this I recommend the following 10 do’s and don’ts:
Be kind & respectful
Help create positive, safe environments at work and in the digital space
Base comments on direct observations and facts, not rumours or hear-say
Be specific and to-the-point (and try to separate multiple issues)
Apply the feedback rules of constructive criticism (e.g. include positives and negatives)
Try to use positive words such as appreciate, suggest, improve, assist, solution, like, right, thanks
Before posting on public forums try to give direct feedback first
Only say things on social media you would be prepared to repeat face-to-face
Be prepared to listen and examine your own actions and behaviour
Always keep the social media policies and code of conduct of your organisation or profession in mind.
Don’t just list problems, propose solutions too
Don’t psychoanalyse or judge people, instead focus on actions & effect
Don’t give feedback before fully understanding the issues (there are always two sides to every story)
Try to avoid using words such as should, never, always, why, you(r), but – and especially the stronger ones like dumb, fail, ludicrous, crazy, farce, ridiculous, shambles
Don’t press the send/post button when you are upset, angry or tired
Avoid using exclamation marks and capital letters midsentence (comes across as shouting)
Avoid giving the same feedback multiple times
Avoid irony and humour as it may be misinterpreted
Don’t phrase feedback as a question
Don’t speak for others unless you are a representative.
What is your preferred method of giving effective feedback?
Video: 10 Common mistakes in giving feedback (Source: Center for Creative Leadership):
A majority of members of the Royal Australian College of General Practitioners (RACGP) voted against the proposed modernisation of their 16-year old governance structure.
As the saying goes, in the end we only regret the chances we didn’t take – I sincerely hope this will not be one of them.
At yesterday’s RACGP member meeting 45.87 percent voted for, and 54.13 percent voted against the resolution. As a result the College will continue with its 13-member representative Council model.
The modernisation proposal was the result of a member-initiated governance review process that started 3 years ago. The proposed model would have introduced skills-based board positions and a representative council that would have better reflected the membership.
The two GP-led governance structures were set up to hold each other accountable. The model was designed to create a greater diversity of voices and thinking within the College.
But it wasn’t to be. Some of the arguments against the proposal were that the board of 7 members was too small, would contain non-GPs, and that the Board-Council model was wrong.
In the end RACGP members have decided and that needs to be respected. It looks like College records have been broken with regards to voter turnout which is always a good thing – and possibly the result of the technology which allowed members to participate in the online member meeting and vote from their digital devices anywhere in Australia.
I thought it was great to see so many GPs participating in the various discussions about governance and I’d like to thank everyone for their input.
The current model has served us well. It has allowed the RACGP to grow successfully over the past years – even though it has its flaws. At some stage the College engine will need replacement, but for now we’ll continue to drive with the old one. Time for reflection.
A wise quote, one of my favourites, for all decision makers, leaders and ‘doers of deeds’:
“It is not the critic who counts; not the person who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the person who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly.
As the Royal Australian College of General Practitioners (RACGP) has been growing rapidly to 34,000 members, one of the big issues the College grapples with is the perceived ‘disconnect’ between the College and its members. A new proposed governance model aims to better connect the membership with College leaders.
Every organisation needs to review itself once in a while. The RACGP last did this 16 years ago so it’s about time for an organisational update. The proposal includes a GP-led, partly skills-based Board and a larger representative Council. The two structures would be set up to hold each other accountable.
One of the reasons behind the proposed governance model is that the old structure is somewhat conflicted. The problem all Councillors have had up to now is that they represent a group or state within the College on the one hand, and are directors on the other.
This can lead to Councillors having to take a position such as this: “The group I am representing wants A but, putting my directors hat on, I think we should do B in the interest of the organisation” (excuse the simple example to illustrate the point).
In other words: Council, at present, may be faced with situations where it is not able to represent the membership well because directors’ duties, by law, take priority. We can’t be good directors and good representatives at the same time – but are probably managing ok overall. However, this is one of the reasons why there is a perceived structural ‘disconnect’ in the organisation.
The proposed new governance model splits these two functions (representation vs directorship) between a Council and a Board which will hold each other accountable. This is an essential, but much overlooked, purpose of the new model.
It will improve the representative function of Councillors by freeing them up to work purely on behalf of our members, while Board members (directors) will mainly look after the business side of the RACGP. This model is not new and is used in other colleges and not-for-profit organisations to manage this very issue.
I believe the proposed model breathes new life into the RACGP and general practice by creating a Council that will better reflect its membership. The model creates places for New Fellows as well as Registrars and will foster new leaders with a greater diversity of voices and thinking.
Should the Royal Australian College of General Practitioners (RACGP) be lead by GPs only or a more diverse mix of directors? In the lead up to the College’s general meeting on May 30 board diversity has been one of the topics of debate.
The composition of boards and councils of other Colleges has been used as an example but, more important than what has been happening so far, is where we will be in 5, 10 or 20 years time. A new Governance Model should prepare the RACGP for future challenges. This requires more than just looking at what other Colleges do today.
The Trump response
When President Donald Trump ordered a closure of the US borders to prevent Muslim refugees and visitors entering the country, the Scientific American republished How Diversity Makes Us Smarter by Katherine Phillips, Professor of Leadership and Ethics and senior vice dean at Columbia Business School.
“Simply being exposed to diversity can change the way you think”
Professor Phillips argues that diverse teams are more innovative than homogenous teams, referring to a body of research by organisational scientists, psychologists, sociologists, economists and demographers.
“Diversity enhances creativity”, she says. “It encourages the search for novel information and perspectives, leading to better decision-making and problem solving. Diversity can improve the bottom line of companies and lead to unfettered discoveries and breakthrough innovations. Even simply being exposed to diversity can change the way you think.”
Vernetta Walker of BoardSource, an organisation based in Washington supporting nonprofit board leadership, says that achieving diversity on a nonprofit board is a challenging but doable and essential task.
“Don’t assume everyone agrees about what diversity and inclusion mean for the board,” she says. “Before asking ‘How do we become more diverse?’ boards must ask ‘Why do we need to become diverse?’
“Boards with a good gender balance perform better”
The evidence to answer that question is coming largely from the field of gender diversity. Louise Pocock, Deputy Executive Director of the Australian Governance Leadership Centre says that several studies have shown that boards with a good gender balance perform better.
Although board diversity often refers to gender, momentum is growing that diversity is also about other aspects such as ethnic and cultural background, age, education, skills, experience and boardroom behaviours and attitudes.
“A board comprised of diverse individuals brings a variety of life experiences, capabilities and strengths to the boardroom,” she says. “There is greater diversity of thought and a broader range of insights, perspectives and views in relation to issues affecting the organisation.”
“Diversity of thought may, in turn, encourage more open-mindedness in the boardroom, help generate cognitive conflict and facilitate problem solving, and also foster greater creativity and innovation. It also reduces the risk of ‘group think’ – where board members’ efforts to achieve consensus overrides their ability to identify and realistically appraise alternative ideas or options in relation to the organisation.”
Reluctance to adapt
Sally Freeman and Peter Nash from KPMG Australia state that boards of tomorrow need to be nimble, and responsive to the rapidly changing environment.
The authors say that, in order to create board diversity it is important for boards to recognise their conscious and unconscious biases. “The key to good diversity is getting the mix right to achieve a shared purpose – overcoming biases and assumptions – and then, how that mix is managed, which requires a chair who is adept at facilitating open and robust discussion. Boards don’t make a huge number of key decisions but the ones they do make need to consider the breadth of challenges and opportunities faced by the business.”
“Sometimes boards are reluctant to adapt”
“However, sometimes boards are reluctant to adapt. These are the boards that struggle to see how current social, environmental, geo-political or technological issues could impact their business – at times only recognising the consequences once it’s too late. There is further evolution required for those boards who take the view that these issues are ‘not real’ or do not impact their organisation. Diversity can assist with surviving this evolution.”
Suzanne Ardagh from the Australian Institute of Company Directors (AICD) says that board diversity is a component of a strong performing board and that research now shows that high performing boards are very much aware of how their board composition could contribute or detract from robust discussions, decision-making and ultimately, performance.
She says that a mindset shift is required to create more diversity on boards and that this is essential to set up an organisation for the future and for long-term success. “I would urge Chairs and Directors to make that change which society is seeking. Boards need to become more inclusive of the wide and diverse community that we are – it is an imperative that becomes more acute every day.”
“A mindset shift is required to create more diversity on boards”
Vanetta Walker advises boards to expand diversity, but limit board size. “Many organisations identify their needs for inclusiveness and diversity only to confront the biggest challenge of all: how to fill all those needs without weighing down the board with too many members. When a board is too large, some members may feel disengaged, and decision-making can become cumbersome.”
“Diversity really impacts decision-making, and good decision-making is good governance,” says CH2M Hill board member Georgia Nelson (see video). “Having diverse folks around the table really drives you to let go of conventional thinking. You get out of traditional boundaries and you begin to think about things in a different way, and by doing that innovation grows and prospers.”
Many GPs feel disempowered in the current climate of cuts and freezes. It is indeed hard to comprehend why governments slash funding to the most efficient and cost-saving part of the health system.
We are all concerned about the lack of continuity of care and increasing fragmentation in our healthcare system, but what about the divisions within our own ranks?
Part of what makes general practice attractive is its diversity, but it also makes general practice prone to divisiveness. Think, for example, of the stereotypical dichotomies: generalists vs partialists, private practice vs corporates, rural medicine vs metropolitan general practice, etc.
GPs are highly respected in the community, but have become an easy target because of marginalisation and fragmentation. It is a well-known secret that governments play different GP groups off against each other, choosing to include or ignore organisations in their deliberations and negotiations.
Lack of unity also opens the door for disruption by third parties.
It is clear that general practice needs an urgent cultural change. Just like surgeons are working on improving the bullying culture, we must address the disharmony and division that afflicts us.
How good would it be if practices worked together instead of competing? If GPs could get together and agree on issues important for their area? If peak bodies would team up and better coordinate strategy, policy development, campaigns, conferences and membership services?
There is a whole generation of GPs that don’t understand why we have so many representative organisations. These young doctors are concerned about the disadvantages. Why don’t general practice organisations support each other, why are there multiple memberships and so much duplication? I believe they are right.
We have much more in common than what sets us apart, so why are we so tribal?
I can think of a few reasons. The first that comes to mind stems from social psychology; our brains may be programmed to organise us into small tribes because of evolutionary advantages, such as social bonding and survival.
There are also economic motivations, for example, GP clinics currently compete for patients. Our peak bodies are based on membership and need to offer benefits; this encourages competition rather than collaboration.
Reform fatigue may be another reason why some of us have stopped caring about achieving common goals. Experienced GPs can tell us the tales of the many system changes they have witnessed over the years; reform comes and goes and often disrupts our day-to-day practice. The risk is that we become cynical about what our profession can achieve in Canberra.
Perhaps there is also a selection bias. It is possible that GPs prefer more autonomy than our hospital colleagues, and although we work increasingly in teams, we may be less group-oriented or prefer smaller tribes.
Finally, doctors are trained to be leaders. We’re masters in problem solving and good at making difficult decisions, often in challenging and stressful situations.
We’re independent thinkers, skilled at arriving at our own conclusions and giving strong opinions. But we are not a profession of followers. The success of organisations depends on how well their leaders lead and how well their followers follow.
United General Practice Australia (UGPA) could connect the dots here. It’s an umbrella group for all the main groups, including the RACGP, ACRRM, AMA, RDAA. Those taking part have shown a desire to put aside their differences to a certain extent.
However, the status and governance of UGPA is somewhat vague. There is also no website or official spokesperson. But it is a start, and I would love to see this organisation be given the opportunity to grow and represent us all.
Lastly, we need to find common ground and partner with patient health organisations, as governments listen to the public more than they do to doctors.
The time has come to stop and think about where we want to go. More unity would require a cultural shift, excellent skills in following others, trust and willingness to compromise — not just from our leaders, but from all of us.
This article was originally published in Australian Doctor Magazine.
Is the family doctor who provides ongoing care a thing of the past? Not really.
In part 1 I mentioned the three types of continuity of care: informational, management and relational continuity. Continuity in primary care results in improved patient health outcomes and satisfaction. Evidence also shows that primary care, in contrast to specialty care, is associated with a more equitable distribution of health.
Receiving care from one general practitioner is beneficial for a variety of health outcomes. For example, relational continuity reduces both elective and emergency admissions. In other words, the rate of hospital admissions drops when people have their own GP.
6 mechanisms that improve our health
Primary care researcher Barbara Starfield identified six mechanisms that, alone and in combination, may account for the beneficial impact of primary care on population health:
Primary care increases access to health services for relatively deprived population groups
The quality of clinical care by primary care physicians is at least similar to specialist care for specific common diseases
The positive impact of primary care on prevention
The beneficial impact of primary care on the early management of health problems
The accumulated contribution of primary care characteristics to whole-of-person care
The role of primary care in reducing unnecessary or inappropriate specialty care.
Starfield: “There is now good evidence, from a variety of studies at national, state, regional, local, and individual levels that good primary care is associated with better health outcomes (on average), lower costs (robustly and consistently), and greater equity in health.”
General practice can deliver long-term, cost-effective continuity of care. A visit to the GP is on average ten times cheaper than a visit to the emergency department. Dr Sebastian Seidel mentioned at a Senate Inquiry last month that GP services in Australia cost taxpayers only $250 per person a year – cheaper than car insurance.
In Australasia, chronic conditions account for about 85% of the total burden of disease, and in 9 out of 10 deaths a chronic disease was a contributing factor.
Unfortunately there is currently inadequate support for the continuity of care required to improve outcomes for patients with complex or multiple chronic conditions and comorbidities.
The Australian government is developing a National Strategic Framework for Chronic Conditions and recently, the Primary Health Care Advisory Group has investigated options into the reform of primary health care to support patients with complex and chronic illnesses. The group’s reform paper is complete and handed to the Federal Health Minister. It will be very interesting to see what happens next.
Although I am more than likely biased, it is obvious to me that primary care has a lot to offer. Continuity of care by general practitioners and their teams has many proven benefits as outlined in part 1 and part 2 of this blog post series.
GPs see about 85% of Australians each year but general practice spending represents less than 8% of the overall government healthcare budget. What we need is better aligned funding that supports primary care practitioners to deliver long-term quality care.
A sustainable health system should free up GP teams and other health practitioners to deliver coordination and integration of care across disciplines, especially for people living with complex and chronic health conditions. Looking at the reform processes that are under way in Australia, we may be getting closer to a better and more sustainable solution.
A few years ago, when I was boarding a plane I picked up The Times newspaper and noticed a big headline stating: ‘The family doctor is going out of fashion’. In the article journalist Matthew Parris explained why young people prefer to go to the emergency department. I kept the article as I thought it would be a great blog topic, but for some reason I forgot about it – until something jolted my memory.
Last month I had the pleasure of meeting with the Board of Health Consumers Queensland. I enjoy conversations with consumer representatives as I always learn something, even though these exchanges are usually slightly confronting. One of the topics we touched on was continuity of care, or better, the perceived lack thereof in general practice by consumers. During the drive back home to the Sunshine Coast I suddenly remembered the article in The Times.
In 2013 Parris wrote: “Very gradually the era of the personal physician is drawing to a close.” He said he noticed a trend in the UK where younger, busier people were going directly to specialist accident & emergency departments and argued that they don’t want a local GP because working men and women in a hurry will be attracted to a place where they can walk from one room to another and access the specialism they need.
So, I wondered, is the family doctor who provides ongoing care a thing of the past? Am I really a dying breed – the last of the Mohicans?
What exactly is continuity of care?
In primary care literature continuity is often described as the relationship between a single practitioner and a patient that extends beyond specific episodes of illness or disease. To confuse the situation other terms are used synonymously, such as ‘care coordination’, ‘integration’, ‘care planning’, ‘case management’ and ‘discharge planning’. On top of that the experience of continuity may be different for the patient and the health practitioner, adding to even more misunderstandings.
Continuity is how individual patients experience integration and coordination of care.
The authors of an article in the BMJ titled ‘Continuity of care: a multidisciplinary review’ said that continuity is not an attribute of practitioners or organisations. They defined continuity as the way in which individual patients experience integration of services and coordination. And also: “In family medicine, continuity is different from coordination of care, although better coordination follows from continuity. By contrast, a trade-off is required between accessibility of healthcare providers and continuity.”
There are three types of continuity of care:
Informational continuity: The use of information on past events and personal circumstances to make current care appropriate for each individual
Management continuity: A consistent and coherent approach to the management of a health condition that is responsive to a patient’s changing needs
Relational continuity: An ongoing therapeutic relationship between a patient and one or more providers.
Continuity is more than just sending a message to another health practitioner, or uploading a piece of information to an e-health database. Understanding of individual patients’ preferences, values, background and circumstances cannot always be captured in health records; health providers who have a longstanding relationship with their patients often have this information in their heads.
“Poor continuity gives rise to high risk medicine
In 2010 Dr Frank Jones wrote in Medicus: “Poor continuity gives rise to high risk medicine. Ideally continuity should be personal and longitudinal – the essence of the traditional general practitioner. However the very concept of continuity gets more complicated nowadays. How does it apply to single-handed GPs or to group practices?”
Indeed, continuity of care exceeds disciplinary and organisational boundaries. The Royal Australian College of General Practitioners describes continuity of care as “the situation where patients experience an episode of care as complete, or consistent, or seamless even if it is provided in a number of different consultations by different providers.”
The benefits of continuity
There is abundant evidence that continuity in primary care results in improved patient health outcomes and satisfaction. Evidence also indicates that primary care (in contrast to specialty care) is associated with a more equitable distribution of health.
GPs often manage up to 4 problems per visit, which is of course more efficient than walking ‘from one room to another’ in an emergency department or hospital outpatient department. Overall, primary care is associated with lower total costs of health services.
Looking at the primary care reform processes that are under way in Australia, it is not unlikely that the multidisciplinary general practice team will be the key component in the care for people with chronic and complex health conditions.
In part 2 I will discuss the six methods GPs use to improve our health, according to world-renowned primary care researcher Professor Barbara Starfield, and why primary care plays an important role in a sustainable health system.
Image sources: The Family Doctor in 1948, Nedhardy.com and The Times.
When talking about the success of organisations, businesses or political parties, we often focus on leaders and leadership, but what about the followers? I’d argue that followers are just as important. There are no leaders without followers, and good leaders often have great followers. Yet, followership is an undervalued concept.
Robert E. Kelly was one of the first researchers who pioneered the theory of followership. He proposed 5 categories of followers:
The sheep, who are passive and look to the leader for directions and motivation.
The yes-people. They are more active and positive, but still look to the leader for direction and vision.
Alienated followers think for themselves, but lack positivity. They often come up with many reasons why their leader or organisation is going in the wrong direction.
The pragmatics are fence sitters. They will follow, but only if others follow first and it is clear where the leader or organisation is heading.
Star followers are positive, independent thinkers. They are effective followers who will support their leaders if they agree, but will also challenge leaders if they disagree, offering constructive feedback.
Are you a good follower?
The success of an organisation depends partly on how well its leaders lead, but partly also on how well its followers follow. Most of us spend the majority of our time following others in one way or another. But we’re not always good at it. So how do you know if you are a good follower? And can we become better at it?
Star followers are sometimes viewed as ‘leaders in disguise’. According to Kelly, effective followers share the following qualities:
They think independently and can work without close supervision
They are committed to their organisation and to a purpose, principle, product or idea
They build their competence and focus their efforts for the greatest impact
They are courageous, honest, and credible.
Effective followers keep their leaders honest. Yet, followership has a negative connotation, almost to the point where it is seen as a weakness instead of a strength. But being a follower is more than just doing what you’re told. Kelly: “(…) our stereotype is ungenerous and wrong. Followership is not a person but a role, and what distinguishes followers from leaders is not intelligence or character but the role they play.”
Followers are leaders
In addition to the many available leadership courses, we should consider creating more followership training opportunities, focussing on topics like:
Improving independent, critical thinking
Aligning personal and organisational goals and commitments
Acting responsibly toward the organisation, the leader, coworkers, and oneself
Similarities and differences between leadership and followership roles
Moving between the two roles with ease.
If an organisation does not succeed, often its leaders are publicly criticised or changed. But there are alternatives. Having read Kelly’s classic publication ‘In praise of followers‘, it seems that becoming a better follower is an empowering experience.
Teamwork is essential in healthcare. Yet, too often, we act as individuals looking after our own interests. Solving problems together, even if the objectives seem opposed, is beneficial for all parties for many reasons.
Stephen Covey introduced the principle of win-win in his book the Seven habits of highly effective people. It’s still a great principle for conflict resolution, incl in teams, groups, organisations etc. Covey:
Win-win sees life as a cooperative arena, not a competitive one. Win-win is a frame of mind and heart that constantly seeks mutual benefit in all human interactions. Win-win means agreements or solutions are mutually beneficial and satisfying. We both get to eat the pie, and it tastes pretty darn good!
A win-loose outcome is bad for all parties. Even though the winner may feel triumphant, the loser may not want to deal with the winner ever again.
So what’s required for a win-win result? First of all it requires an open mind. Black & white or good & bad thinking is not helpful and often not realistic either. Secondly, understanding the other party is crucial: Where do they stand? What is important for them? Where is the common ground? And finally: flexibility, as there are always more solutions to a problem.
Win-win is not about being nice, as Covey said. It’s about being courageous and considerate at the same time.
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.
Over the years I’ve known several people who became ill shortly after their retirement. I remember one hardworking business man who suddenly died after he signed off. He left his wife behind with the tickets for their world trip.
Our emigration to Australia is part of the our dream. My wife and I feel privileged that we have been able to find a beautiful spot where we are truly happy. I try to teach my kids to do what they love and to enjoy the journey.
It’s a recurring theme in discussions with patients: how to give passion a place in your life, now, not later. It is easy to do and can be as simple as blocking off a few designated hours every week.
But sometimes I forget. It’s easy to lose myself in daily routines, busy schedules and tight deadlines. Everyday business sometimes seems more important than my dreams. There are always plenty of reasons why not to do something I’m passionate about.
So I remind myself, like some businesses do by writing their mission and vision on the wall. It can be a message on my home screen or a piece of paper on the mirror.
What change in your life makes you happier? Whatever it is, start today. Don’t wait.