Chairman's Report

At a board level, the priority for CQRH over the last six months has been reviewing the constitution and improving the governance within the organisation.  The board recognised that the changing membership and obligations of the organisation need to be reflected and accommodated for within the constitution.  The board appointed a constitution review sub-committee that have worked diligently to draft a new constitution that meets the legislation and allows for an evolving membership base including allied health providers.  The draft constitution will be reviewed and should be ready to present to members for approval at the AGM later on in year.

Recently I had the opportunity to meet with the Professor Sarah Strasser (UQ Rural Clinical School) and discuss opportunities for student placements and education in Central Queensland.  CQ Rural Health support student education through scholarships and providing accommodation in Emerald so it was beneficial to meet with Sarah to ensure our region is considered for any future plans within UQ.

On Thursday April 6th I had an opportunity to meet with the federal opposition leader, Mr Bill Shorten and senator Chris Kitter from the Australian Labor Party.  Dr Ewen McPhee (Rural Doctors Association of Australia), Paul Bell (Central Highlands Health) and Emma McCullagh were also in attendance. I shared with them the importance of primary health care and the role of general practice, the importance of Medicare, access to health professionals in regional areas and the Rural Health Management Services (RHMS)  model of general practice in small communities. I attempted to emphasise that there are different models of general practice in rural communities and highlighted the RHMS as a shared general practice model in partnership with the hospital.

I also presented to Ken Wyatt MP – Minister for Indigenous Affairs and Aged Care (pictured below) on Tuesday 11th April.  He allocated 20 mins of his time to speak with me in the company of Ken O’Dowd MP for Flynn.  I raised the following key points;

  • the problems associated with the nursing homes in Emerald and Woorabinda;
  • the importance of general practice being the lynch pin for any health services outside the hospital;
  • the immediate need to open the Rural Locum Relief Program to Australian medical graduates and not only to overseas graduates.

Afterward, I spoke with Ken Waytt’s senior advisor, Paula Gelo, and covered the same topics that I covered with the Minsters and she listened attentively and asked me for an emailed version of the key points; which I have sent.  They both committed to informing me of the issues that they will be addressing as a result of our meeting.

Thanks again for your commitment to the organisation and for sharing your knowledge and expertise.

Michael Belonogoff

Chair

 

Progress Report: RHMS

Current Practices Managed

Baralaba

Dispensing doctor pharmacy no longer operational as a permanent pharmacy has opened in Baralaba, permanent locum arrangements continue with a permanent recruits not successful, part-time practice nurse commenced. Outreach clinics to Wowan continue funded through the RHOF grant. Permanent locum more engaged. Push to recruit to this position again.

Biggenden

Staffing is stable. Contract with QML has been finalised. No increase in nursing hours but practice more involved in developing increased capacity to deliver Chronic Disease programs.

Clermont

Part time GP appointed – Dr Sarah McLay, who is also interested in providing cover for Clermont Hospital. Practice nurse commenced December. Dr Josh Dally commences as MORPP in June 2017, due to delays in AHPRA approving General Registration. Approval to progress application to construct a three room demountable including consult and training rooms.

Eidsvold

Permanent GP with Obstetrics Dr Deb Smith has commenced and will finalise placement as ACRRM registrar. Recruiting for Practice Nurse or Indigenous Health Worker trainee has been finalised. Funding approved to the second stage to construct a purpose built facility located within the Eidsvold Hospital grounds was not possible – application submitted to renovate the house which is adjacent to the current practice.

Monto

Locum MSRPP Dr Harley Wilson continues, GP Registrar Dr Rob Pickham to commenced in January. He and his family have re-located to Monto. Dr Vish will commence on July 1st. Dr Tom Battison hopes to commence as a GP registrar in January and will share the MORPP Position.

Mt Morgan

Permanent MSRPP recruited – Dr Mario Soterio will job share with Dr Peter Kirkham. Mt Morgan has been accredited as a training practice with the potential to recruit to the MORPP position with the July rotation of registrars.

Nebo

Doctors clinic well supported. New visiting counselling services. Dental Chair has been purchased through Commonwealth grant. Discussions commenced with QAS to take on management of the building and relocate the local ambulance. The building will remain available for the use of the local and visiting Medical and Allied Health services.

Rolleston

Approval for RHOF through the practice nurse and Women’s health clinics in Springsure. Clinics now held one day most weeks. Work commenced to increase practice turnover and PIP Payments.

CQRH Happenings

CPD Update

In March, the Central Queensland, Wide Bay and Sunshine Coast PHN hosted a health practitioners network meeting. The topic was the implementation of the National Disability Insurance Scheme and the role of the health practitioner.

In April, CQ Rural Health hosted a Black Lung Update CPD event.  About 20 attendees including GP’s practice staff, radiographers and medical students listened to radiologist Dr Madhav Nagarkar and Dr Edward Foley present on the Black Lung.

If there is a CPD Event you would like held in your area or you wish to speak at future events, please contact Emma McCullagh (Emerald) by email a emma.mccullagh@cqrdgp.com.au or Louise O’Leary (Biloela) on 07 4992 1040.

 

CQRH Scholarship for Rural Health

There were three students awarded this year’s CQRH Scholarship for Rural Health. The successful applicants were Belynda Walsh (Bachelor of Medicine/ Bachelor of Surgery), Kate Morely (Bachelor of Physiotherapy, Honours) and Michael McLure (Bachelor of Medicine/ Bachelor of Surgey, Honours). These three students all showed outstanding commitment to their studies and to their future in Rural Health.

Belynda impressed the board with her community sprit and the hard work she has done because of it, as well as her passion for quality healthcare. Kate gave an insight into how she will practice in future, forming relationships with clients and working with them to achieve their health goals being a number one priority. Michael showed his passion for rural health, and his excitement at potentially being at the forefront of new technologies (such as telehealth) is infectious.

Overall, CQRH is proud to be helping these students achieve their goals. With Belynda, Kate and Michael part of the future of rural healthcare, it looks to be a bright future indeed.

 

Office Update

Exciting news! We are moving! Maybe… Well definitely, but the date of this move remains elusive. Nevertheless, excited staff have started stocking up on items essential for furnishing our new space.

We now have a water cooler (yes, the dream of office gossip around the water cooler has now become a reality), two conference tables which really, really don’t fit in our current space and, last but not least, a server rack (pictured). I’m not going to pretend I know what a server rack does or why we need it, but the tech guy has told us it is essential.

All joking aside, we are very exciting to be moving to a space which will be able to fit our needs. We are also really happy to be able to buy the things we have been missing which will have a place in the new office.

Concerning Findings from Survey of Doctors’ Mental Health

Beyondblue has released the results of its world first mental health survey of 14,000 Australian doctors and medical students. The survey was undertaken with the aims of:

  • Understanding issues associated with the mental health of Australian medical students and doctors
  • Increasing awareness across the medical profession and broader community of issues associated with the mental health of medical students and doctors
  • Informing the development of mental health services and supports for the medical profession

The survey results will serve as a harsh reminder to doctors and medical students of the personal psychological toll that is clearly evidenced amongst the medical profession.

The survey has revealed concerning and extreme findings which demonstrate that doctors and medical students are burnt out and more likely to experience psychological distress and suicidal thoughts than the general community and other professionals. Results also showed that doctors and medical students often choose coping strategies such as high risk alcohol and drug use.

When compared to the general community, doctors are five times more likely to have suicidal thoughts, with medical students and female doctors more likely to experience serious psychological distress. One in five students and one in 10 doctors reported having had suicidal thoughts in the pat year. This compares to one in 45 people in the general community.

The survey report stated that it is young doctors who are most at risk of mental illness and attributed this, in part, to long working hours. Doctors aged under 30 years reported working the longest hours (average of 50 hours per week), compared to the average of 43.6 hours per week. Doctors working in rural, remote and indigenous settings were also singled out as experiencing a higher prevalence of burn-out with survey respondents working an average of 50.9 hours per week. Furthermore, in relation to higher working hours, male doctors reported longer hours of 46 per week on average.

In comparing male and female doctors, the survey reported a higher number of male doctors engaging in more risky drinking behaviour and more female doctors experiencing psychological distress and having thoughts about suicide. Doctors practising in the specialty of Oncology were shown to be the most psychologically distressed as compared against other specialties.

Alcohol and drug consumption was a focus of the survey. Emergency Physicians were more likely to drink alcohol at moderate risk levels and rural doctors were more likely to drink at harmful levels. 10% of the medical students surveyed reported using illicit drugs two to three times per month and 6% of doctors self-prescribed medications to treat their anxiety and depression.

By way of coping mechanisms, female doctors reported that they were more likely to talk to others whilst male doctors relied more heavily on alcohol, tobacco and prescription medication. A more heartening finding of the survey was that doctors with depression were more likely than those in the general population to seek help and use medication.

Dr Mukesh Haikerwal, Beyondblue Advisory Committee member and former AMA President, highlighted the psychological difficulties of working in the medical profession with doctors dealing with extreme trauma on a daily basis. Bullying in certain parts of the training process was in evidence as was the particularly high working hours required of doctors as they go through the process of qualifying in their particular specialty. Dr Haikerwal highlighted the increasing burden of red tape in medical practice as a contributing factor in increased working hours and psychological distress. He stressed the need for urgent reform in medical workplaces to address these issues.

The survey findings are worrying and extreme and immediate action is needed to address issues of untenable working hours, to improve mental health training for medical students and doctors, to address the pervasive culture of workplace bullying and to eliminate the stigma of mental health problems amongst medical practitioners.

Even among the general community, the stigma that is evident in regard to doctors with mental health issues would be of great concern. It has been argued that this stigma is the most alarming finding of the Beyondblue survey, with many professionals having been shocked that it exists to the level that it does within the medical fraternity. Concern has arisen that these attitudes create barriers to medical students and doctors seeking hep due to fear of lack of confidentiality and privacy, personal embarrassment and possible impact on their medical registration or right to practice. Almost half of the survey respondents reported the belief that doctors with a history of depression or anxiety were less likely to be given jobs or appointed to positions.

The survey does show a positive result in that, despite having high levels of general and specific distress, doctors are more likely to seek treatment than the general population and are able to manage some of the negative effects of poor mental health.

Jogging / exercise was the most commonly identified coping technique used by doctors. The survey also showed that, for most doctors with mental health problems, the impact on work and life was relatively modest. Doctors appear better able to withstand the negative impacts of mental health distress and have enhanced abilities to minimise the impact of high levels of distress on their functioning. The report attributes this potentially to a higher level of specialist knowledge and access to treatment services as would be expected in this group.

What the AMA is Doing

The AMA considers it a priority that, as the professional Association for doctors, it ensures that programs exist to assist medical students and doctors to access quality healthcare when they need it.

State AMAs provide financial and in-kind support and referrals to doctors’ health advisory services. However, these services are provided independently of the Association

In WA, the Colleague of First Contact (9321 3098) was established to assist doctors in crisis, or those who are not sure where to go for help with personal or health problems. Colleague of First Contact is a totally confidential 24-hr service available to all doctors and medical students. It can be contacted by the person themselves, or by a concerned family member, friend, colleague or staff member. Callers do not need to identify themselves.   The service consists of a group of experienced male and female GPs, and is independent, reporting back to no other medical organisation. Problems dealt with include stress, depression, suicidal thought, substance abuse, grief or concerns about illness. Sometimes the contact can be about impaired performance in a colleague. The doctors do not usually provide active medical treatment, their main function being to go through the options with callers when they are faced with a dilemma, or to advise the caller on the most appropriate referral services.

The AMA has been a strong advocate for Medical Board funding of more formal programs, whilst recognising that funding arrangements need to be independent and at arms’ length to ensure that doctors trust these services and seek the help they need.

The AMA has been vocal in calling for exemptions from mandatory reporting notification requirements for doctors treating colleagues and medical students.

The AMA provides an online fatigue risk assessment tool enabling doctors to evaluate the safety of their roster and to help make hospitals safer for patients and doctors.

The survey showed that young doctors appeared to be particularly vulnerable to poor mental health and high levels of stress. The transition from study to working may be a particularly difficult time for newly trained doctors and they may require additional support such as mentoring from experienced practitioners. The Association’s Doctors in Training Committee is part of a joint initiative to help junior doctors negotiate some of the difficulties they face after graduation. An on-line tool is available to self-assess professional quality of life of a junior doctor. Vignettes or ‘Case Studies’ are provided along with tools for coping and addressing the specific mental health risks. Topics addressed include nightshift, overtime, bullying, rural placements, relationships, anxiety, depression, drugs and alcohol, Obsessive Compulsive Disorder and eating disorders. The on-line tool incorporates the Kessler questionnaire – a single measure of psychological distress based on how the respondent has been coping over the past four weeks. Links and resources for obtaining help are available.

The AMA has published a guide to managing the risks of fatigue in General Practice – a resource targeted to GPs and GP Registrars, and a Position Statement on the health and wellbeing of doctors and medical students. Posters focusing on the health of doctors, asking the question ‘Who is Looking After You?’ have been developed for and distributed to communal areas in public and private medical practices.

If you or anyone you know is contemplating suicide call Lifeline on 13 11 14.

Australian Medical Association (Western Australia)

Fee for a Standard Consult? $65 at least, GPs say

What do GPs think the fee for a standard consult should be?

As rumours abound about Federal Government plans to end the MBS freeze, an Australian Doctor survey reveals it will fail to deal with the long-running underfunding of general practice, the sector governments say can help contain spiralling hospital costs.

Of the 1217 GPs who took part in the survey, some 70% said the fee for a level B consultation for adult non-concessional patients should be $65 or more.

And despite the political death of a GP co-payment policy, most doctors believe patients should be making a bigger contribution to their care from their own pockets.

Again, more than 80% of doctors say adult non-concessional patients should contribute at least $20

These figures dwarf the current standard consult rebate of $37.10, which, if the freeze ends, will rise by just 50-60 cents this year.

Dr Sally McDonald, a GP from Pakenham in Victoria who took part in the survey, said policymakers failed to understand the complexities of general practice.

“Payment for difficult, slow and complicated work — like the very elderly, palliative care, psychiatric, drug and alcohol — is appalling.

“I do a lot of palliative care and it takes time to do it well, but there is no recognition of this.

“It’s hard to ask dying patients for money. If I care for them in our local private hospital, the rebate is only 75%.

“It is no wonder so few people do it.”

Ministers have been in negotiations with both the AMA and the RACGP on a deal to end the indexation freeze rebates — a policy that is stripping out $925 million in GP funding, and which is due to run until 2020.

But no one expects the government to increase rebates beyond indexation any time soon, raising the question of where extra funding for general practice care will come from.

AMA vice-president Dr Tony Bartone (pictured) said: “It’s up to government to determine its spending priorities, although it is critical that we don’t debate taking funds from one part of the health sector to fund another.

“This is divisive and fails to recognise that there are funding pressures across the whole health system.

“Sadly, the government also mismanaged its approach to co-payment so that any discussion about patients who can afford to [make] a contribution to the costs of their care is now political poison.”

Many doctors who took part in the survey said they were concerned the end of the freeze would be sold as a declaration that the funding problems of general practice were fixed.

Dr Rita Vinten, a GP in Alstonville, rural NSW, said: “It will be useless to just add 55 cents to the rebate … Patients will think the freeze is ended and we are being paid well again — which will not be true at all.”

Paul Smith, Australian Doctor, 27 March 2017

Simply Paying GPs more or continuing the same rhetoric will not solve anything

Amid rumours about government plans to end the MBS freeze, we decided to gauge the temperature on the ground. We asked GPs how much they think their time should be worth.

Of the 1217 who responded to our survey, some 70% said the fee for a level B consultation for adult non-concessional patients should be $65 or more.

See the full results here.

We’ve already asked RACGP chief Bastian Seidel, AMA vice-president Tony Bartone and GP co-pay architect Terry Barnes for their thoughts.

Here, former RDAA president Paul Mara, a GP in Gundagai, NSW, responds to the results.

 

Are you surprised by the general results?

Not really. If anything I thought they were underdone. They tend to reflect the AMA fees and the acceptance of co-payments for all patients. In my opinion, $70 for a 15-minute consultation is not enough. For a five minute consultation it probably is excessive. GPs tend to underestimate the costs of practice. These must include the opportunity cost of capital.

 

It costs around $110 million every time the government increases the GP rebate for a GP attendance item by a dollar. The hard truth is that rebates are not going anywhere near where GPs say they should be. Do you think that assessment is correct?

Under the current economic circumstances facing the government that assessment is probably correct. One might argue that other government programs cost considerably more than general practice. GP rebates are around $7.5 billion, around the same gross income for Exon Mobile in Australia, but the government has inherited an annual $22 billion bill for the NDIS and significant billions for the NBN.

Consider that under Health Minister Tony Abbott GP rebates effectively increased 17% overnight with the rebate changing from 85% to 100% of the schedule fee. Also under Abbott, we saw the introduction of bulk-billing incentives. But these were in totally different economic circumstances.

 

Where will the money come from to fund general practice at the levels GPs say is needed?

Workforce control, freeing up the MBS so that bulk-billing and market driven co-payments can be charged and improved outcomes based payments in a blended payments package to protect young, old and disadvantaged.

Salaries should not be ruled out as an option in some circumstances and it must be acknowledged that much of the current GP workforce are de facto employees.

 

When rebates fall so far from what GPs believe is the real value, what happens in terms of care. Do patients get lower-quality care … what are the compromises in terms of what GPs offer as a result of under funding?

Practices compensate. The history of this suggests that we have reached the brick wall of how this can occur. Initially, GPs simply charged their non-bulk-billed patients higher fees. Generally, bulk billing was restricted to pensioners and socially disadvantaged — health care card holders. Cost control in practice and use of a real estate model followed with pathology and other services paying rents. These models actually meant that the professional services of GPs alone were increasingly devalued. Increased turnover and more creative use of the schedule inevitably followed.

 

What is the effective sale pitch to government to raise rebates (or increase funding generally)? If they increase rebates, what do they get in return from general practice that they don’t get now? Don’t governments want hard numbers on improved patient outcomes, reduced admissions and they don’t get that at present?

The current rhetoric about saving on specialist and hospital costs is not new. In fact, it has been used to justify every reform in general practice since before Medicare, including the RACGP Training Program, content based descriptors, Vocational Registration, specialist recognition of general practice, mandatory education and training leading to Fellowship and various other programs and structures.

While there is some evidence that improved management of some chronic diseases may prevent or reduce hospital-based care in individual circumstances or for some conditions, there is no evidence that hospital presentations or admissions have decreased.

The massive growth in after hours ‘dial-a-doctor’ type services in metropolitan areas has not decreased hospital ED presentations.

There are very powerful systemic drivers for secondary, tertiary hospital based care. These include workforce considerations, improved access and availability, new technologies, population demographics, culture.

Simply paying GPs more or continuing the same rhetoric will not solve anything.

 

Given the results of the survey, why is bulk billing so high — is it really about doctors wanting to protect patients from out of pocket costs? Surely it’s also a result of competition? GPs don’t raise fees because patients go to the clinic down the road?

In economic terms GPs have very little price elasticity. A small increase in fees in the context of very high bulk billing rates and workforce competition would lead to a significant loss of patients and immediate huge loss of income. This is why many practices think co-payments are a good idea but want the government to mandate them. This would not work.

GPs have compensated for the decline in rebates in a number of ways. All of these strategies are self-limiting and ultimately self-defeating either economically, professionally or clinically.

Many, but not all, other specialties have much greater price elasticity and this is leading to a growing gap between specialist and GP incomes.

Basically, it comes down to economics, structure of the schedule and workforce.

The key determinants of profitability in practice are

  • Number of patients
  • Number of services per patient
  • Fees per service

Under bulk billing, it is not possible to increase the fees per service, but it is possible to increase the number of services per encounter and encounters per patient. Practices are increasingly competing for the practice population.

 

Health Care Homes reforms are being sold as the alternative to fee for service for chronic disease care — funding to practices who can then spend the money on packages of care. Does that provide a mechanism for GPs to be adequately funded for their work? Or will practices simply look to drive down what it spends on GP involvement? The payer changes but the financial dynamics are the same?

As a rural doctor, I am a strong supporter of the benefits of continuity and provision of comprehensive care but opposed to regulated health care homes. The cynic in me says that much of the push for health care homes is a response to increasing competition and the notion that these will mean that patients will stick with their family doctor and not go to the corporate clinic for the easy stuff. It won’t happen. In fact larger practices will have capacity and efficiencies to specialize in providing chronic disease and other services, provide the data required to get payments and have the marketing potential to attract patients.

But the best reason for not having a patient registration scheme is simply that Patients actually move. In NSW over 5 years over 1 million people moved address within the state and over 250,000 moved interstate.   Imagine the cost to give us more (ie some within the professions term for government) to administer such a scheme. Try keeping track of that in your practice and having your income dependent on it!!

While it is likely that not everyone who changes address will change their GP it does give some idea of the issue.   The original Better Practice Program and Practice Enhancement Grants were much more sophisticated in supporting and funding continuity.

 

In your view, what is the politically practical solution for the long-term underfunding of General Practice?

There is no simple answer. Governments will not pay doctors any more than what they are prepared to charge themselves or where it can see solid returns on its investment.

You can’t bake a cake without the flour. All ingredients must be used.

My schema would involve:

  • Independent indexation of the schedule (note not individual fees or rebates) by a tribunal with opportunity for input from professional bodies under strict terms of reference;
  • Freeing up of the bulk billing requirements so that market driven co-payments can be charged (there are a variety of ways without legislation to do this); and
  • Protection through block grants or other blended payments for chronically ill, socially disadvantaged, young and old.

It would also include the following workforce reforms.

  • Licensing of practices;
  • Reform of training professional and industrial arrangements and parallel entry into general practice provisions; and
  • Support for improved data systems to bring about real-time outcomes evaluation and quality improvement

 

Medical Observer, 31 March 2017

Pathology rent deal up in the air; GP supergroup says

GP groups say there is “a likelihood” that the controversial pathology rent-capping deal will be scrapped.

The death of the plan would be welcome news to some 5400 GP clinics, which collectively stand to lose an estimated $150 million annually.

In a deal hastily struck in the lead up to the 2016 federal election, the government agreed to cut the rents pathology companies have to pay GP practices for co-located collection centres.

In return, pathology corporates promised the government they would drop a damaging lobbying campaign, and pledged to continue bulk-billing patients after the planned withdrawal of incentives.

But the new arrangements, originally scheduled to begin in January, were pushed back in December to allow further consultation.

Now, according to minutes from the March meeting of United General Practice Australia— the six-member supergroup including the AMA and RACGP — there is “a likelihood” the controversial deal will fall over.

“The group decided to not proceed with sending a letter to the [Federal Health] Department at this time,” it says.

The minutes, made public on Tuesday, add that the AMA and RACGP will continue to meet with department officials to discuss the issue.

Plans to axe bulk-billing incentives for pathology have been pushed back twice and are now scheduled for implementation in July 2017 — a year later than initially stated.

Antony Scholefield, Australian Doctor, 31 March 2017

Why the plan to punish medical errors will achieve nothing

Australian public hospitals will soon be penalised for serious errors, with the aim of improving the quality and safety of health services. The punitive measure was a core proposal in the pricing framework for Australian public hospital services presented to the Health Council of COAG (Council of Australian Governments) in March 2017.

Withdrawing funding for serious errors, known a “sentinel events”, was advised by the Independent Hospital Pricing Authority (IHPA) and will come into force in July 2017. Australia has eight nationally agreed sentinel events.

These include: “procedures involving the wrong patient or body part resulting in death or major permanent loss of function” and an “infant [being] discharged to the wrong family”. Such events are clear and unambiguous errors, which can be prevented.

But cases of maternal death associated with pregnancy and childbirth, also included in the list, are typically unrelated to deficiency of care. Penalising unfortunate events such as these is unlikely to improve the overall safety of the hospital.

Even where the event is a clear, avoidable error, there is little if any evidence their frequency reflects the overall quality of care provided by a hospital. IPHA’s recommendations are drawn from opinion rather than empirical evidence. While the idea may appear economically rational – we wouldn’t pay for faulty goods, for instance – it does not withstand scrutiny.

Policies on gross medical errors

The term “sentinel event” is generally considered to be a preventable event in health care that causes significant harm or death to a patient. It’s the kind of event that should not be seen in a modern health-care institution. For this reason sentinel events are sometimes referred to as “never events”.

In practice, very few errors actually fit the sentinel category. Most hospitals would have fewer than one such event per year. Only around 100 sentinel events are reported from well over 5 million hospital admissions across Australia each year.

The concept of sentinel events originated in the United States in 1996, when the Joint Commission – the body responsible for hospital accreditation – released its first formal policy. The purpose was to probe the cause of the mistake well beyond the individual; to explore the training of those involved, work pressures and the level of supervision offered.

This type of review would look particularly at the barriers and systems that should be in place to prevent such occurrences. Sentinel events would be pooled from multiple institutions and appropriate recommendations made to apply across the health system. Pooling information is important because sentinel events are so rare a single hospital is unlikely to see enough for common features to emerge.

For instance, a pooling of patients who took their own lives in US hospitals identified a high proportion who hanged themselves from door hooks or curtain rails. When the frequency of such events became evident it led to these fixtures being replaced with breakable plastic models.

These types of review programs grew through the 2000s and now exist in one form or another in Australia, New Zealand, the United KingdomCanada and US.

Do sentinel events reflect overall hospital quality?

There is no evidence sentinel events reflect the overall quality of care provided by a hospital. First, whether these events are in fact wholly, partially or not at all preventable is contested. While they are awful and we wish they were prevented, the idea that a perfect system could exist in human services with finite resources is unrealistic.

Second, understanding and addressing why one dramatic and unexpected event occurs does not make the whole system safer. That would be equivalent to saying because we know why the Titanic sank, all ships in the future would be safe.

Safety requires a comprehensive approach that addresses all domains of health care, including effectiveness, patient-centeredness, timeliness, efficiency and equity of access.

Why we shouldn’t punish hospitals

Most people accept we should receive a refund if we pay for a product or service that does not deliver as advertised; the idea being that mistakes should not be rewarded. It makes sense public hospitals are not funded when a sentinel event occurs for that patient’s episode.

But given the constant demand for health funding, it is somewhat surprising there was broad support for this idea from the state and territory governments. The cynic would argue there are so few events (0.002% of admissions) that it does not affect the bottom line.

So what does not paying hospitals do? Perhaps it sends a message about preventing unacceptable practice. But paying for performance remains a widely debated idea, which has not achieved the hoped for gains in health effectiveness and safety.

It may have some negative unintended consequences. A punitive environment may make health-care organisations and professionals less likely to report errors and more likely to practise in a defensive manner. This might mean gaming the system to select the patient population that generates the greatest financial benefit – essentially avoiding sicker, and therefore riskier, patients.

Setting standards for the quality and safety of health care is a community responsibility and one a mature society accepts. Improving safety and health outcomes will be achieved most effectively if incentives are provided for excellent care, rather than punishing rare instances where care may have lapsed.

Professor Joseph Ibrahim and Professor John McNeil, Medical Observer, 17 March 2017

Five key additions to AMA’s Code of Ethics

Australian doctors have been handed a new code of ethics — and it’s nearly double the length of the old one.

The AMA issued the first update to ethical guidance in a decade on Friday.

The idea is to provide greater clarity on a range of issues, from professional boundaries to control of patient information, says the association’s chief, Dr Michael Gannon.

Here are the key things to note:

 

  1. Close personal relationships:

In a nutshell, the new rules urge doctors to avoid exploiting their patients for sex, money or anything else.

“Maintain appropriate professional boundaries with patients and their close family members, not entering into sexual, exploitative or other inappropriate relationships.”

“Refrain from offering inducements to patients, accepting inducements from patients or encouraging patients to give, lend or bequeath you money or gifts.”

  1. Patients with impaired or limited decision-making capacity:

The new section on patient impairment advises doctors to always presume an adult patient is capable of making their own decisions until finding evidence to the contrary.

But impairment can vary, and the code counsels doctors to allow patients to participate in decisions about their care up to their capacity.

“A competent minor may have the capacity to make a specific health care decision on their own behalf.”

  1. Patients’ family members, carers and significant others:

The AMA position is they should be treated with respect and provided with support and information, particularly when a patient’s condition is serious or life-threatening.

“Provide them with information regarding respite care, bereavement care, carer’s support and other relevant services, where appropriate.”

  1. Working with colleagues:

Healthcare professionals are instructed to refrain from making comments which may unfairly damage their colleagues’ reputations.

Doctors are also told to keep an eye on their colleagues, and recognise when they are unwell or under stress.

“Know how and when to respond if you are concerned about a colleague’s health and take action to minimise the risk to patients and the doctor’s health.”

  1. Referrals:

The onus on specialists to consult with a GP before referring a patient to another consultant has been slightly watered down since 2006.

The older version told specialists to:

“only make the referral following discussion with the patient’s general practitioner — except in an emergency situation.”

In the new version, that “only” has been changed to “ideally” — an alteration designed to reflect the reduced role of GPs in many patient’s lives, the AMA says.

But the new version asks the rest of the profession to “respect the central role” GPs play in patient care and reminds specialists to communicate with family doctors in a timely fashion.

 

Everything else:

The updated Code also provides greater clarity on consent, conscientious objection, complaints, control of patient information, fees, professional boundaries, managing interests, stewardship, medico-legal responsibilities and protecting others from harm. Read it in full here.

 

Geir O’Rourke, Medical Observer, 17 March 2017

Colleges split over generalist vote

RACGP president Dr Bastian Seidel has slammed rural generalism “dogma” the day before a key vote in Parliament.

ACRRM and RDAA’s top brass are in Canberra lobbying the Senate to greenlight the creation of a rural health commissioner to devise generalist training pathways for the bush, with a vote scheduled for Tuesday night.

Establishing the independent position would fulfil a Coalition election promise and the new commissioner would be tasked with designing at least one rural training pathway within two years.

But on Monday morning, Dr Seidel warned that the creation of new national pathways could split GPs.

“My concern is it is going to lead to fragmentation of training and the profession of general practice, and that certainly can’t be healthy,” he told Australian Doctor.

Dr Seidel said the colleges already have an Australian general practice training program so the need for a separate pathway is “questionable”.

“We should be moving away from dogma, and rural generalism — as it was proposed 20 years ago — has become a dogma that seems to serve organisational needs but not necessarily those of communities,” he said.

The Huon Valley GP debated the issue over the weekend with the presidents of ACRRM and RDAA at a rural health conference in Tasmania, where a state-run rural generalist model of care has been proposed.

A pilot being run at the federally funded Mersey Community Hospital has been endorsed by ACRRM, but Dr Seidel said it ignored the true health needs of Tasmanians.

“Patients want to be treated in the community and not in hospital systems,” he said.

However, Dr Seidel denied that he was waging a battle for training places with the rival college.

“I don’t see that there is a turf war going on for the simple reason that the quotas are already determined by the Department of Health and the numbers are fixed,” he said.

Dr Seidel’s remarks will likely make it more difficult for RDAA to convince the Senate’s diverse crossbench to support the advent of a national rural health commissioner, but president Dr Ewen McPhee (pictured) is unfazed.

“I’m not going to buy into Bastian’s remarks because I think it is important to recognise that the RDAA represents members from both the RACGP and ACRRM who believe that rural practice does require extra training and support,” he said.

“We see this as complementary to what both colleges provide and will add another layer to their training.”

Huge swathes of country Australia remain underserved by GPs and those working in the bush need special skills, says ACRRM president Associate Professor Ruth Stewart.

“[Dr Seidel] wants people to take the training through his college, but rural generalism is different, provides a broader scope of practice and is not just office-based,” she said.

“A rural generalist is trained with basic surgical skills and to perform advanced life support so they can remove an ingrown toenail, drain an abscess and, if a woman walks in giving birth, they know what to do.”

Assistant Minister for Rural Health Dr David Gillespie told Australian Doctor that a national approach would be diverse and reflect the various needs of communities in different states.

“We are not creating anything that doesn’t already exist in a sense because we already have GPs who have advanced skills, and practise medicine in both a hospital setting and in the community,” he said.

“The terminology of ‘rural generalism’ is coming to reflect an emerging skill set, which is very well defined in some states more than others.

“There are many healthcare settings around the country that are enhanced by such practitioners and it is not one size fits all.”

Geir O’Rourke, Australian Doctor, 27 March 2017

Communicating about suicide in rural communities

Last week I was invited to the Sydney Royal Easter Show. Not to eat fairy floss (although I did buy a bucket on the way out) but to join with Ministers, members of parliament, commissioners and colleagues to talk about suicide prevention and rural communities at a forum hosted by the Centre for Rural and Remote Mental Health.

It was a short forum, but an important one. As David Perkins, the Director of the Centre for Rural and Remote Mental Health remarked in closing:

“today we have had a brief conversation and hopefully that will lead to longer and deeper conversations about suicide prevention and rural communities”.

I was privileged to be one of the people invited to present what was termed a 300 second presentation, or what I choose to refer to as a HALF-TED. A 5-mintue talk (half a typical TED talk) on a specific topic. My 300 second topic was communicating about suicide in rural communities.

Given the brevity of the talk and the need to be concise I made some notes (not something I do often). I thought I would share those presentation notes here for information and to keep the discussion from the forum going.

There can be very few people whose lives have not been touched in some way by suicide. Either because they have thought about suicide, attempted suicide, lost someone they know to suicide or had friends or colleagues that have been impacted in some way.

So I wanted to start this brief talk with addressing some assumptions up front:

  • Given suicide is a preventable cause of death which is important to communities, saying NOTHING about how to prevent it makes no sense.
  • If you are worried that someone may be at risk of suicide, saying NOTHING makes no sense.
  • If you know someone who has experienced a loss, saying NOTHING makes no sense.
  • Given suicide is an issue that affects everyone, having a media that reports NOTHING about the issue makes no sense.

But, saying whatever we like, whenever we like, with little concern about the impact those words may have also makes no sense.

As a sector we need to work together with our media and with our communities to help unpack what we should say, when we should say it and who should deliver the message.

Communicating about suicide is not like any other issue that people communicate about.

It can be an uncomfortable topic for many people, but more than that, what we say and how we say it can have an impact on people – either positively or negatively.

To make a real difference to communities – and specifically, rural communities – we need to ensure that we work with the media, with the community and with each other.

When preparing for this talk I was thinking about breaking up the talk into three sections and talking through what needs to change with our media, within our communities and within our sector that would make a change to the way rural communities communicate and talk about suicide and suicide prevention.

But upon reflection – I think that most of the work needs to be done within our own mental health and suicide prevention sector. Communities and the media are relying on our sector more than ever before to show leadership, to be consistent and to be empowering.

Our sector needs to understand what the evidence says and really commit to working together on our messaging, as ultimately this is the messaging that our media and our communities will follow.

So I thought I’d share what I believe should be five key priorities we need to address as a sector to better support rural communities.

Firstly, we need to harness the opportunity that rural media provides.

In working with media for many years and visiting news rooms across this state and the country, it doesn’t take long to appreciate that there are some real differences between metropolitan and rural media. Not always, but often their journalists are part of the community and feel a sense of responsibility to that community. But importantly, they also have an imperative to cover local stories. There is a real challenge when we only have our national media covering the issue of suicide, because sometimes the communities they present or the messages they use from our sector may not resonate with rural communities. So we need to ensure that working with the media in a proactive way is part of the job description of our mental health and suicide prevention leaders based in rural communities. We also need to ensure that those leaders understand best-practice reporting of suicide so they can work with and support local media….and the changing personnel in local media.

Secondly, If we are going to work with the media and with our communities then we must get our messages right.

Not all messages are good messages. And not all messages are good for everyone. And even good messages can be harmful if delivered at the wrong time.

As a sector, we need to work really hard on getting the messaging right. We need to work together, work with those with lived experience and with the community to unpack the types of messages that are going to increase hope rather than despair, that are going to mobilise action rather than make people retreat, and messages that support and engage rather than alienate. This must be done on a national level, and a local level and as a priority. To give you some examples to illustrate my point:

  • We need to target our messages and consider the impact on different sectors of the community that will hear them. When people roll out statistic like the following “we lose one farmer every four days to suicide” it has an impact. While it may be a helpful and powerful message to send to politicians and metropolitan services and communities, think about what the impact may be on other people living in rural communities doing it tough to hear that others, just like them, are finding the pressures too much.
  • We need to get our timing right. For example, most people would agree that the message that “suicide is preventable” is a helpful one. But that very message is not a safe one to deliver immediately after a suicide when the community is grieving and managing a range of feelings, including guilt.
  • We need to understand that continuing to raise awareness alone will not change behaviours – if people continue to hear about the extent of the problem without promoting what we can do to take action, then all we have created is despair and not hope. If we raise awareness without also ensuring we have a system and a community that can respond, then we have created false hope.

Thirdly, we need to harness the voice of lived experience.

People engage with the personal. A personal story will almost always hold more weight that a professional story.

It can move, it can inspire, it can connect. It can remind us that statistics are people. It can help to break down stigma. It can helps others to know that they are not alone.

But a story will be more likely to support suicide prevention when it is:

  • Linked to key messages about suicide prevention;
  • Matched to the needs and preferences of the target audience;
  • Encouraging people to take action;
  • Safe for both the person and the audience.

So we need to ensure we have a focus on not just putting forward those with lived experience, but integrating their stories into our messaging and planning. We also need to ensure there is support and training provided to those with lived experience, as telling your story can come with its impacts.

Fourthly, we need to have strong local communication protocols to help manage the impact of suicide in rural communities.

We now have national organisations, state organisations, local organisations funded by the state and local organisation funded by the Commonwealth through the PHN all working in rural communities. More than ever before we need to come together and plan our local responses – what we will say, what we won’t say and how we will connect to support the community following a suicide death, or a series of deaths.

We know that exposure to the death of another, and a feeling of closeness to that person, can increase the risk of suicide in others. In rural communities, where connections between people are close, our ways of working need to be even tighter. We need to think about how we communicate directly to the community, how media is engaged as well as the role of social media. We need to get on the front foot with this issue and not learn the hard way as some services and communities have recently.

Lastly, we need to think broader than just the traditional suicide prevention sector in rural communities.

We need to harness community leaders, industries and workplaces in rural areas and the community more broadly and give them the tools to talk about suicide in ways that are safe – in their families, at work, in the community and online.

People can avoid conversations for fear of saying the wrong thing. We need to reinforce messages and provide people with the tools they need to navigate these conversations and know where they can get back-up support.

To close, I will repeat something that I said earlier.

Communities and the media are relying on our sector more than ever before to show leadership, to be consistent and to be empowering.

It should start today with all of us.

 

These brief reflections are drawn from our work in suicide prevention – including work on the Mindframe National Media Initiative and Conversations Matter. Some useful resources for communicating about suicide can be found at www.mindframe-media.info and www.conversationsmatter.com.au

If you need support please reach out and talk to a friend, talk to a professional or call Lifeline on 13 11 14 or visit www.lifeline.org.au

 

Jaelea Skehan, Director of the Hunter Institute of Mental Health, 18 April 2017

 

 

Why GPs should be steering the palliative care process

The stereotype is the cancer patient for whom the oncologist can do no more. The patient returns to their GP, scripts for pain relief in their hand and survival curve statistics on their mind.

For such a patient, the role of a GP palliative care provider is to offer symptom relief and to organise support services, says Geoffrey Mitchell, Professor of General Practice and Palliative Care at the University of Queensland.

“A good, well-resourced and confident GP can probably look after a half to two-thirds of people in those situations.”

Professor Mitchell, however, is concerned about “the rest of us”. The 50% of the population who do not die from cancer or acute causes but, instead, die a slow and often unpredictable death from heart and lung diseases, dementia or the complications of multimorbidities.

“It is not as cut and dried and you can’t always predict what it will be that ends their life. It could be pneumonia next week,” he says.

Professor Mitchell is among those advocating for a better provision of palliative care services and for widening the definition of palliative care; to identify patients who are at risk of dying in order to help them and their families better prepare for it. It is a role for which, he says, the GP is ideally placed.

“There are a lot of GPs who feel uncomfortable about dealing with people towards the end of life. The truth is they are doing it anyway but they do not call it palliative care.”

Patients without malignancy require a different kind of care, he says.

“Palliative care people who live and breath it call it the palliative intent — to look at the whole person. Not only their illness. It is the relatives, bereavement. It is making sure there are advanced health directives in place so they don’t end up in ICU if they don’t want to.”

He says many doctors run a mile from things like spirituality. But these questions will come up.

As the average life expectancy rises, more years are being spent living with disability. Death may be more predictable but it also takes longer.1

BEACH data from 2014–2015 shows that one in 1000 GP encounters are related to palliative care.2 However the researchers acknowledge that palliative care is not a diagnosis but a process. GPs record the problem that is being managed and might not record the palliative care process.

Associate Professor Joel Rhee, a Sydney GP who lectures on end-of-life care at the University of Notre Dame Australia, agrees with Professor Mitchell that the concept of palliative care needs to be expanded in general practice.

“Traditionally we think of cancer. With cancer you get diagnosed and then get a work-up towards a curative treatment. But if it spreads then you end up with palliative therapy, and if it continues to spread further, people understand you don’t have long to live. You don’t have to be a doctor to work that out,” Professor Rhee says.

“People with other conditions, such as congestive cardiac conditions or renal failure or who are frail, might have high mortality and might have a prognosis similar to people with end-stage cancer.

“While they might have a 50% chance of dying in the next 12 months, they might have a 25% chance of living for another three years. So it becomes very problematic.”

Professor Rhee says that as the number of Australians living longer and sicker increases, systemic changes are needed to properly provide for the dying.

“The palliative care specialists that we have don’t have the capacity to look after everybody,” he says.

Most of the dying process happens at home or in the community and it is only a small percentage of time that the patient is in hospital. The question is, who is going to look after these patients in their homes?

“What we know is that lots of GPs provide palliative care but there are questions in terms of what that means. Does it just mean home visits? Does it mean full supportive care and palliative care assessments?

“There is a lot of uncertainty about how much palliative care is being provided by primary care providers and how much is being provided by allied health.”

Professor Rhee says the current general practice system dominated by care plans for chronic diseases does not facilitate advanced care directives.

GP care plans are used to facilitate the patient seeing allied health professionals, what medications they are on or their exercise capacity. It is more geared towards the day-to-day chronic disease management. We are not at the stage yet where it is being used for contingencies.”

Introducing hypotheticals and contingencies into a care plan discussion with a patient requires time and courage.

“There is discomfort in raising these issues. The patient might get upset and the family might get upset.”

He says it’s uncomfortable to suggest that the patient start thinking about what they will do if they deteriorate.

“It is a hard conversation to have unless the patient brings it up.

“Developing a care plan requires a lot of thinking and motivation for the GP. You really need that extra incentive.”

Professor Rhee is among a group of doctors and advocates, led by Advance Care Planning Australia, who are pushing the federal government for a new item number for advanced care planning to provide an incentive for GPs to set aside time to discuss contingencies for patients with life-threatening illness.

The government insists there are already suitable item numbers.

“My answer is that those items numbers are being used for other things, such as health assessments. What they are really saying is ‘why don’t you do advanced care planning on top of it without any incentive’,” he says.

“Advanced care planning must become an item number and it shouldn’t be restricted to GPs.”

It would be used, for example, in cases where people who are on dialysis have their day-to-day care assessed by a renal team.

Professor Mitchell, meanwhile, is conducting a systematic review of 248 articles, published since 2000, of how well GPs perform palliative care.

The review will be submitted as five papers, dealing with concepts such as symptom control and how well patients feel GPs are meeting expectations.

“In terms of our findings, the short answer is that the more the GP is involved the better it is,” Professor Mitchell says.

The supportive literature includes population studies from Canada showing that continuity of care with a GP for a palliative patient is associated with fewer admissions to the emergency department.

In addition, a pilot study3 of 35 case conferences for patients with end-stage heart failure and lung failure, conducted by Professor Mitchell and others, found that a single case conference reduced ED visits by up to 85%.

He believes the case conference, where the GP invites a palliative care specialist and a nurse with specialist qualifications to help develop a care plan, gives the patient the tools to plan ahead.

“We estimated that the savings for a $1000 case conference were $40,000 per patient,” Professor Mitchell says.

The question that remains for GPs caring for the dying is when to refer a patient to a palliative care specialist.

Professor Rhee says this will depend on the individual GP, the patient and the palliative services that are available.

In areas where there is good coverage, the patient might be referred to a palliative care specialist, for example by an oncologist, without the GP’s knowledge.

In other areas, the GP will take on a very different role. If patients are symptomatic, difficult to manage or anxious, the palliative care specialists might play a more active role.

One of Australia’s first palliative care specialists, Dr Yvonne McMaster, says palliative care is something that needs to be available early in the course of an illness leading to death, and it requires frequent patient contact.

“The essence of palliative care is careful assessment of the patient, symptoms and their family situation, particular attention to detail … and frequent follow-up,” she says.

“If I started someone on pain management I would be in touch with them every day.”

Now retired, Dr McMaster, a former GP, is campaigning for better palliative care services in regional and remote locations.

A 2014 RACGP survey of rural and remote GPs found workload was a key barrier to providing palliative care for 64% of respondents. Home visits and inadequate palliative care education was a factor for about half of respondents.4

“We have the bare bones of a system. There is palliative care available in the acute hospitals, in the aged care facilities, or in people’s own homes, in prisons and mental hospitals but it is not everywhere,” says Dr McMaster.

“Communities need to have access to specialised units, where people can get care for complicated symptoms such as dreadful breathing problems [or] difficult family situations that

cannot possibly be managed without specialist help.”

Gregory Crawford, professor of palliative medicine at the University of Adelaide and president of the Royal Australasian College of Physicians’ chapter of palliative medicine, says death from chronic diseases can be more difficult than cancer when it comes to anticipating the end of life.

“Patients diagnosed with cancer are more likely to ask what the future holds,” says the former GP. “People with COPD or heart failure do not have it so much in the front of their mind.”

He says a large number of palliative care referrals from GPs come at the point when the GP feels the problem is beyond their level of skill or resources — difficult physical symptoms, difficult psychological symptoms, difficult conversations with families.

Or, he says, the GP might need to coordinate equipment and hands-on nursing. “If it is clear that the patient will struggle to maintain home care, the GP might ask the specialty palliative care service if they can put in supports to make the home safe.”

Dr McMaster says there is no reason why GPs cannot provide palliative care but often they lack confidence, particularly in pain management.

“When GPs can have training in palliative care they are the best people to do it,” she says. “What I am pushing for is for more specialist nurses in NSW and for each of the towns to have a palliative physician. When that happens it turns the situation around. A good palliative physician will work with the GPs.”

Dr McMaster says such a network is essential at a time when GPs are doing fewer home visits and less after-hours work.

“As much as we would like to engage the GPs, we still need to have the specialists out there.

“Dying is a bit like having babies, most of it happens at night.”

Professor Crawford supports a shared care model between specialists, GPs and nurses. He says this can work even without regular home visits.

“Many GPs might worry that might preclude them but most of our programs are based on home visits by a nurse who can be the eyes and ears.”

When a GP knows the patient, they are often the best person to initiate the conversation around advanced care directives and end of life planning, he says.

“It is not a quick and easy conversation, our society is still not a death-embracing one.”

Emily Dunn, Medical Observer, 28 April 2017

 

 

Physiotherapy making waves in treating mastitis

In her early physiotherapy career, Melinda Cooper was treating young mums experiencing common postnatal issues, such as back pain and pelvic floor problems. These breastfeeding women were often unable to follow through with their treatment because they were sick with fever, breast pain, redness or swelling – all symptoms of mastitis. Ms Cooper turned to therapeutic ultrasound, used by physiotherapists since the 1940s, and manual handling techniques to treat their mastitis. “I looked to my skills as a physiotherapist and realised there was a lot of stuff I could do to help these women get over their mastitis and to enhance their breastfeeding experience,” she says.“Then they were able to focus their attention on their other health concerns related to having had a baby. They could do their pelvic floor exercises and complete their postnatal recovery.”

Thirty years on, Ms Cooper remains a passionate advocate for the role of physiotherapists in treating mastitis and blocked ducts in the lactating breast. A physiotherapist at Melbourne practice, Inform Physiotherapy, Ms Cooper treats women and trains physiotherapists and other health care providers in the management of mastitis. She also has a teaching role in women’s health physiotherapy at the University of Melbourne, is the lead investigator with a team of Monash University researchers and collaborates with researchers from Curtin University and the University of Western Australia, investigating the effect of therapeutic ultrasound in treating mastitis.

Mastitis is an inflammation of the breast with symptoms that include redness, breast pain, swelling and generalised ‘flu-like’ symptoms. While all mastitis is characterised by inflammation, not all inflammation is due to infection. Ms Cooper says antibiotics are often empirically prescribed for mastitis even when there is no clear evidence of infection. In addition to local and global concerns surrounding the over-use of antibiotics, antibiotics will transfer through the mum’s breast milk to babies, which can result in the baby experiencing an upset stomach, she adds. Ms Cooper says therapeutic ultrasound is a quick and effective non-pharmacological treatment for the inflammatory symptoms of mastitis. If an infection is present, studies have shown that ultrasound can increase cell wall permeability of the biofilms caused by infections, making the antibiotic therapy more effective.

Ms Cooper says many women are being told to firmly massage the breast and use hot baths or showers to decrease the symptoms of mastitis – actions that can make their mastitis worse. “I recently saw a woman who was breastfeeding four-month-old twins. She had successfully breastfed her older child for nearly two years,” she says. “But in the month before I saw her, she had had repeated bouts of mastitis and was now on her fourth course of antibiotics. The breast lumps and pain were still present. “The first thing we got her to do was to stop the painful and vigorous massage that she was doing – she actually had bruises on her breasts. We got her to start treating her breasts as if they were the miraculous working instruments that they are and to treat them with respect – to stop hurting them. “With that first therapeutic ultrasound, the big lump that she had softened immediately. We saw her the next day, her pain scores had significantly improved, the mastitis was gone although some of the bruising remained. “I then taught her how to do an effective manual massage technique that uses the whole breast which it doesn’t hurt and is very soothing. “Within just three days, she had broken this awful cycle of recurrent mastitis by stopping the treatments that weren’t actually helping her. She had been stuck in a cycle of too much heavy-handed massage which was probably making the problem worse and the antibiotics were the ineffective attempt to help it.”

Ms Cooper says physiotherapists, especially those working in women’s health, are once again embracing therapeutic ultrasound as an effective and time-efficient modality to help breastfeeding women. “Therapeutic ultrasound’s application goes back to the Second World War and like many treatment modalities they come and go almost like fashion and it’s now resurging again,” she says. “This resurgence is probably as much driven by women who don’t want to be taking drugs if there’s not clear evidence of an infective process, or they might have tried antibiotics repeatedly and they’ve still got mastitis. “Seeing a physiotherapist who is skilled in this field, who may offer therapeutic ultrasound, may give these women symptomatic relief and then they can go on to understand why they are vulnerable to this condition in the first place.”

Ms Cooper says therapeutic ultrasound works when extremely high frequency sound waves pass beyond the skin barrier, creating a vibration in the soft tissues which has an anti-inflammatory effect, reducing pain in the breast. “We think the pain settles down because the swelling is reduced but the ultrasound might also be having an effect on the sensory nerves in the area,” she says. “We think it helps by changing the permeability in the actual tissue cells, so the cells can then reduce the volume of inflammation around them, and we think it helps by improving the local circulation through lymphatics and the blood supply which also reduces the swelling. “It’s probably having an effect on the breast tissue cells but also by facilitating fluid drainage via the actual motion of the transducer.” While there are few studies supporting its benefits in the treatment of mastitis, physiotherapists and other allied health practitioners who use therapeutic ultrasound find it often delivers immediate results.

Australian researchers are now embarking on examining this modality on the lactating breast. In the first stage of the research project, Ms Cooper and her research team are validating a clinical tool, the Breast Inflammatory Symptoms Severity Index (BISSI), developed to measure inflammatory symptoms. Once validated, the tool will be used as an outcome measure in research to determine which treatments are effective for women with mastitis. “The beauty about this tool is that it’s really easy to use – it’s the woman who records the scale and it’s going to give us a clinical outcome measure that we can use in further studies to work out what treatments really do help women who’ve got mastitis,” she says. “We know therapeutic ultrasound is really helpful but it hasn’t been studied extensively. We know antibiotics can be helpful but often they are over-used and they might be used when they’re not really needed, and maybe we should save those drug treatments for when there really is an infection.”

Ms Cooper developed a course on the lactating breast for health professionals, and is running the course for the Australian Physiotherapy Association (APA) in Perth, Brisbane, Adelaide and Melbourne this year. Ms Cooper says breastfeeding women should see a physiotherapist, trained in the use of therapeutic ultrasound, as soon as they experience any of the main symptoms of mastitis. “It’s vital more health care providers including physiotherapists are able to help women reach their breastfeeding goals, giving babies a great start to life while helping to keep women healthier for longer,” she says. “Women who have successfully lactated are significantly less likely to have osteoporosis, breast cancer, ovarian cancer, diabetes and obesity problems. These are long-term health impacts that all health care providers including physiotherapists should be concerned about. “It’s not just about looking after the woman now with her little baby,” Ms Cooper says. “If she has a history of lactation, she’s going to be healthier when she’s in her menopausal years and that makes a big difference to long-term health outcomes across at least two generations.”

Karen Keast, Health Times, 12 April 2017

Bariatric Surgery

In recent media reports, Monash University researchers suggest (laparoscopic adjustable) gastric banding should be considered for overweight people with diabetes – not just those with a body mass index (BMI) of 35 or more, as per current guidelines. The research paper has sparked debate on whether the current guidelines for bariatric surgery should be reviewed.

What is clear is that good nutrition is crucial at all times – in attaining good health and managing weight on an ongoing basis and, in those who undergo bariatric surgery, pre- and post-operatively. Accredited Practising Dietitians (APDs) provide extensive education, counselling and support throughout the weight loss journey, as weight management does not stop with bariatric surgery.

What is bariatric surgery?

Bariatric surgery (or weight loss surgery) aims to reduce intake by restricting gastric capacity and/or reducing exposure to the area in the small bowel where nutrients are absorbed. A number of different bariatric procedures are used in Australia, and gastric banding is one of these.

Australia’s current guidelines

Bariatric surgery is an evolving area, and this new research from Monash University is certainly food for thought. It suggests gastric banding as a powerful tool for people who are overweight (rather than obese) with type 2 diabetes – improving measures such as blood glucose control (HbA1C) and HDL (good) cholesterol.

The current National Health and Medical Research Council (NHMRC) guidelines say that bariatric surgery may be considered in adults with a BMI >40, or in those with a BMI >35 together with associated medical conditions that may improve with weight loss. In both instances, an individual’s unique situation needs to be taken into account.

Diet and lifestyle changes should be the first port of call

Strong evidence tells us that diet and lifestyle changes should be the first option for improving health in people carrying excess weight. Most people need support over time to maintain such changes. This is where health professionals, such as APDs, have a lot to offer – using an evidence-based approach, and tailoring advice to each person.

Interestingly, some people who ‘fit the bill’ for bariatric surgery are malnourished. In fact, people who are overweight or obese are at risk of deficiencies in nutrients like iron and vitamins D, B12, E and C. For long-term good health (regardless of weight) consuming a wide variety of nutritious foods, in the right amounts, is vital in ensuring nutrient needs are met.

Considerations in undergoing bariatric surgery

  • People considering bariatric surgery should be assessed on a case-by-case basis by a medical professional. While it is an effective treatment in aiding weight loss, it’s not a blanket solution suited to everyone.
  • Bariatric surgery will only be effective in the long-term if it’s used in conjunction with healthy eating and regular physical activity. And people should be motivated, well-informed and compliant before being considered for surgery, as this will impact its long-term success.

For the best results, people undergoing bariatric surgery must be managed by a team of healthcare professionals, including pre- and post-surgery follow-up with an APD.

Input from an Accredited Practising Dietitian is pivotal

Achieving long-term weight loss relies on weight management strategies being continued after bariatric surgery has occurred. APDs provide a long-term nutrition management plan and help set a realistic picture of life and eating after surgery, which in turn can help prevent additional weight gain. APDs also help people cope with the problems that can result from surgery – such as nutritional deficiencies, which can follow obesity surgery procedures that reduce dietary intake.

The bigger picture

Tackling overweight and obesity requires a comprehensive, coordinated and evidence-based approach to address prevention and treatment across the community. DAA believes this includes better access to APDs, through Medicare rebates and private health fund rebates, so people receive the support they need. It also involves better regulating food marketing, improving the Australian food supply, effective on-pack information, and a host of other actions.

Wentworth JM et al. Five-year outcomes of a randomised trial of gastric band surgery in overweight by not obese people with type 2 diabetes. Diabetes Care. April 2017; 40.

Clinical Practice Guidelines for the Management of Overweight and Obesity

Dietitians Association of Australia, Hot Topics, March 2017

1 in 6 patients with type 2 diabetes have anaemia

Annual anaemia checks have been recommended for people with type 2 diabetes by endocrinologists, who say the condition is present in one in six patients.

People with type 2 diabetes have a threefold increased risk of anaemia and it is associated with a 57% higher risk of mortality, according to Dr Richard Gauci and colleagues at the Fiona Stanley Hospital, Perth.

Their study of over 1500 patients with type 2 diabetes finds that 12-18% have anaemia, compared with rates of around 5% in the general population.

Erythrocyte production may be reduced in diabetes for a number of reasons, including lower responsiveness to erythropoietin, oxidative stress and metformin-associated depressed serum vitamin B12 concentrations, they report.

Almost all patients with anaemia have modifiable risk factors such as low serum vitamin B12 or ferritin levels, or metformin or glitazone therapy, their study shows.

The risk of anaemia is related to the duration of diabetes and there is also a link between renal impairment and a “progressive and substantial increase in risk” of anaemia, their study finds.

“Based on the present data, we recommend periodic (yearly) haemoglobin measurement as part of regular assessment of patients with type 2 diabetes wherever they are managed,” the researchers write in the Journal of Diabetes and its Complications.

“Given the relationship with subsequent mortality, we also recommend that management of anaemic patients with type 2 diabetes should include increased efforts to optimise glycaemic control and non-glycaemic cardiovascular risk factors.”

The researchers also suggest lab tests such as serum magnesium, serum testosterone and haemoglobin electrophoresis may be appropriate, depending on patient characteristics and clinical context.

The RACGP’s guide to general practice management of type 2 diabetes references anaemia as a factor that could skew HbA1c results and the development of diabetic retinopathy.

Only lipid testing and urine microalbumin have been suggested as tests to be done during a patient’s annual cycle of care review.

However, the guide notes there is scope for further investigations based on clinical risk assessment of other factors.

Rachel Worsley, Australian Doctor, 11 April 2017

Painkillers like ibuprofen can increase the risk of heart disease and should be restricted

Medications such as ibuprofen and aspirin, known as non-steroidal anti-inflammatory drugs or NSAIDs, are widely available over the counter from pharmacies and supermarkets. But health providers have known for some time they can be unsafe for people with chronic health problems such as kidney disease, high blood pressure or heart failure.

NSAIDs can also have dangerous interactions with other commonly taken medications, notably many types of blood pressure and blood-thinning pills such as warfarin and aspirin.

Two recently published studies have brought back into the spotlight the possible heart-related side effects of NSAIDs. One found an increased risk of heart failure in users of NSAIDs, while another an increased risk of cardiac arrest.

Heart failure is a disease that presents with symptoms such as shortness of breath, fluid retention, leg swelling, and fatigue. This is a result of the heart not being able to pump blood around the body effectively. There are many causes of heart failure, including heart attacks, high blood pressure and excessive alcohol consumption.

A cardiac arrest occurs when the heart stops functioning abruptly and results in complete loss of effective blood flow through the body. The most common cause of a cardiac arrest is a heart attack, where heart muscle is damaged from loss of blood supply due to a blockage in a heart blood vessel. There are many other causes of a cardiac arrest that include structural heart abnormalities and inherited heart diseases of muscle and electrical function.

The recent studies are an important reminder that over-the-counter medicines are not without risk. This class of anti-inflammatory pain killers should no longer be available for sale in grocery stores, but instead restricted to prescription-only or behind-the-counter status in pharmacies.

How they work

Non-steroidal anti-inflammatory drugs are commonly used to relieve pain. They can be either prescribed by a doctor or purchased by the patient over the counter from a supermarket or pharmacy.

NSAIDs are used in a broad range of health conditions associated with pain and inflammation, including types of arthritis, headaches, musculoskeletal injuries and menstrual cramps. Their easy availability, effectiveness and presumption of safety contribute to their widespread use.

They work by inhibiting enzymes called cyclooxygenase 1 (COX-1) and 2 (COX-2). These are involved in a number of internal pathways that result in production of hormone-like substances called prostaglandins, which promote inflammation and increase pain perception.

Prostaglandins also protect the stomach lining from acid, by decreasing acid production and increasing mucus secretion and its neutralising properties. So inhibiting prostaglandins also reduces their protective functions. This is why frequent users of anti-inflammatories may suffer from gastric ulcers.

NSAIDs can either inhibit both COX-1 and COX-2 (non selective) or inhibit COX-2 only (selective). Drugs like ibuprofen and aspirin are non selective and inhibit both the COX enzymes.

COX-1 mediates gastrointestinal, kidney, and clotting function, while COX-2 is induced primarily in states of inflammation and tissue repair. That’s why blocking the COX-2 pathway reduces the effects of inflammation such as fever, swelling, redness and pain.

Importantly, COX-2 inhibition accounts for the anti-inflammatory drug effects of NSAIDs, while COX-1 inhibition can lead to side effects including gastrointestinal ulcers, prolonged bleeding and impaired kidney function. However, it’s not entirely safe for the drugs to inhibit COX-2 only.

Animal studies have shown blocking COX-2 and the subsequent pathway of prostaglandin production may have the unwanted effects of increasing the tendency of blood to clot inside arteries, and a reduced ability of the heart to heal after a heart attack.

In the early 2000s, a number of large studies found a significant association of negative heart events, such as heart attack and stroke, with the use of selective COX-2 inhibitors. This resulted in two of these drugs, Valdecoxib and Rofecoxib or Vioxx, being withdrawn from the market.

In Australia there are only a small number of COX-2 inhibitors available, including Celecoxib and Meloxicam. These are prescription-only medicines and the maximum prescribed dose is at a level at which the heart risks are minimal.

COX-2 inhibitors are used in people who require a non-steroidal anti-inflammatory but have a history of stomach upset or ulcers, or who were thought to be at risk of developing stomach ulcers.

Risk of heart failure

Non-steroidal anti-inflammatory drugs are associated with elevating blood pressure as well as sodium and fluid retention. Both of these effects may unmask previously undiagnosed heart failure, or worsen the symptoms in people known to already have heart failure.

Research published in the British Medical Journal in September 2016 studied 92,163 people admitted to hospital with heart failure, and found NSAID use in the two weeks prior to admission was associated with a 19% increased risk of hospital admission for heart failure. This was compared with people who had not used NSAIDs prior to admission.The association of NSAIDs with an exacerbation of heart failure was also seen in many older studies. For example, an Australian study in 2000, suggested almost 20% of all heart failure related admissions to hospital may be attributed to recent NSAID use.

Risk of cardiac arrest

Further heart safety concerns with NSAIDs were raised in a recent study from the University of Copenhagen, published in the European Heart Journal.

Data was collected from nearly 30,000 patients who had suffered cardiac arrest between 2001 and 2010. Of these, around 3,500 were found to have been treated with an NSAID within 30 days of having a cardiac arrest.

Use of any NSAID was associated with a 31% increased risk of cardiac arrest. The commonly used non-selective NSAIDs, diclonenac (Voltaren) and ibuprofen were associated with a 50% and 31% increased risk respectively.

A large proportion of cardiac arrest is a result of clot formation in the arteries of the heart and underlying plaque formation which can rupture. NSAIDs may increase the risk of cardiac arrest by raising blood pressure, forming blood clots and blocking the heart’s own blood vessels.

It is important to emphasise that in people with no known heart disease and who don’t have any heart risk factors, short term use of these anti-inflammatories carries a minimal increase in heart-related risk.

These recent studies should not create community panic about the safety of NSAIDs when used for short periods of time and at low dosage.

But the high burden of heart disease and heart disease risk factors, such as high blood pressure, obesity and diabetes (which are often unrecognised), warrant a personalised approach to NSAIDs, which weighs the benefits and risks of their use.

This was recommended in the Therapeutic Goods Administration review of the heart related effects of NSAIDs in 2014. These anti-inflammatories should be available for purchase through prescription by a medical practitioner or behind the counter at the pharmacy.

Michael Stokes, Cardiologist and PhD Candidate, University of Adelaide and Peter Psaltis, Co-director, Vascular Research Centre, South Australian Health & Medical Research Institute

This article was originally published on The Conversation. Read the original article.

Michael Strokes, University of Adelaide and Peter Psaltis, South Australian Health & Medical Research Institute

Here’s to the silent partners who make us better doctors

When I go to work I take a lot of things with me. Everyone has their ritual, right?

I take my backpack with my computer inside. I take my phone. I take charging cords, the true modern life-line. I take lunch. I carry a pen, flashlight and pocket-knife.

On a more abstract level, I take the wonderful education I received as a medical student and resident, coupled with my years of experience as a physician.

I take my drug-store +2 diopter glasses, not only to read and suture but equally important, to look venerable and wise.

But I take something else. It’s certainly as important as all of the other stuff, if not more so in the long run.

I take the love and support, encouragement and care of my wife Jan.

Now mind you, this is not some hyper-sentimental claptrap. A spouse, for better or worse, is part and parcel, warp and woof of our lives.

And in the best of circumstances (which I enjoy), my dear bride gives me encouragement, laughter, stability, passion and the not-so-rare kick in behind when I’m lazy, whiny or grumpy. (As I am so often wont to be.)

She reminds me of my priorities, reassuring me that I matter to her and the children however I may feel.

She reminds me that feelings are often terrible lies. (A lesson we would all do well to remember.)

In times past she has guided me through career changes because she could sense my unhappiness and dissatisfaction. This is because she loves me and knows what I need; often better than I do.

In short, she is my most dedicated advocate.

While I work in the ED, she works hard to manage the children (rather, the teens who require more diligence than mere children.)

She looks after the family finances, a thing which is useful in keeping me out of prison for delinquent taxes and in keeping the banker away from the door so that we keep our home.

And in order to keep me moving forward through busy, difficult runs of shifts, she ensures that I have things to look forward to with family when she does our ‘master schedule.’

Even though two of our children are in college, she tries to arrange family events around my days off so that I don’t feel left out.

In addition, so that I can enjoy our life together for a long time to come, she takes me to the gym. She sometimes makes me plank. I hate to plank but I do it.

This might sound, to the modern ear, as if my wife is living out some sort of domestic indentured servitude.

It is not. It is teamwork. It is unity. It is covenant. We are one. We have common cause in our marriage and offspring.

The result of her remarkable effort is that when I go to work, I can focus on my job. I can carry the love and care I feel at home into the exam room, into the resuscitation room.

I am secure and happy. This makes me a far more effective, calm, satisfied physician than I would otherwise be.

Thus, I make the money that we share equally as partners. Not only in our personal corporation but in our lives. I don’t get paid for me; I get paid for us and for ‘clan Leap’ as a whole.

When I come home from work, I come home to smiles, hugs and a welcome-home kiss. I come home to laughter and dinner, or date-night.

To stories of her day, and the many other lives she touches, in our family and beyond it.

Sometimes I come home to strategic family planning sessions. Occasionally I come home to a tired or angry or sad wife and it’s my turn to be the one in the supporting role.

My turn to fuss at teenagers or call about car insurance claims. My turn to shoo her to bed early and manage things. My turn, on days off, to send her for sanity breaks.

Those of us who are married, or in long-term committed relationships (which we in the South call a common-law marriage) must admit that without our wives or husbands, this whole gig would be much harder, and much more lonely than it is with our dear ones.

Furthermore, that the patients we care for are touched and loved on, vicariously, by those who love us.

Their role is not subordinate but intrinsic.

Through me, through our marriage bond, every sick child in my care has my wife’s eyes looking down on it gently.

Every struggling nursing home patient has some of her kindness. Every difficult, irritable complainer has her patience and every smart-aleck teenager (or grouchy consultant) has her raised eyebrows and crossed arms gazing firmly on their behavior.

All of us owe so much of our professional lives to the women and men brave and loving enough to stay with us through all of our stupid, arrogant, surly behaviors. 

And to those men and women, let me just say: you are as much a part of our practices as we are.

Thank you for being the other half, the silent partner, standing invisibly by us as we do the hard work of medicine.

We couldn’t do it half so well without you.

 

Dr Edwin Leap, Medical Observer, 17 March 2017

The difference between students and registrars? Fear

The best registrars develop an occasional pearl of sweat on their temple. This is a good sign.

A New Year. New medical students at the practice. New registrars. It’s all good.

They’re all brainiacs. I read their CVs and am completely daunted.

There is a special section for papers published; another for awards received.

I look back on my own career and recall winning best and fairest in the under-16s rugby semi-finals quite a few years ago, but that’s about it.

Now I’m expected to teach these 99.95 grads a thing or two.

Students are keen to do stuff. To assist in cutting out a skin cancer, or to put in the line for an iron infusion.

They are less enthusiastic about sitting in on long and muddled consults that require unpicking like old balls of wool.

They are keen to have “competencies” signed off and they know that, ultimately, they are observers. All care (well, a fair bit) and no responsibility.

No fear. Fair enough.

Registrars, on the other hand, learn rapidly about fear. They discover that they are no longer interested observers. People are paying dollars for their opinion.

They can — and will — be asked about anything.

Travelling to Cambodia with a cardiac condition? Could it be campylobacter? Can I get a Cantonese interpreter for the caterer with carpal tunnel? Cancer, or just a carbuncle?

And that’s just the group from the morning.

The afternoon will bring a four-year-old with foot pain, forceful vomiting in a 40-year-old footballer, and trying to not be fooled by a follicular rash on the foreskin.

The best registrars develop an occasional pearl of sweat on their temple. This is a good sign.

It returns throughout all our careers, but less frequently as the years pass. It tells us that we are in deep water. The troubling registrars are those who never sweat. They are untroubled by self-doubt. When it hits the fan, someone else (usually the patient) is at fault.

Some things reduce sweating.

I tell registrars to do a pre-consult consult. Look at the screen before inviting the patient in. Is Emily 3 months old, or 16 years old, or 93?

The answer helps when you cast an eye around the waiting room. Did you see Emily last week? If so, what was it about? With that knowledge, you can offer: “So, I had a good look at the results of those blood tests we did and blah blah blah”, or “How’s things?”

“I think we were going to check Emily’s weight today, and see how that rash is going,” is a whole lot better than “so, Emily, my name’s Jon, and how can I help you today?”

The latter risks receiving the response: “Well , you know how I told you I on Monday about being bullied at school, and mum’s drunk all the time and I was cutting and getting pretty smashed and you said you would talk to a counsellor that I could see and…”

Did we? Did you? That’s when the pearl of sweat forms — or it should.

We all slowly learn tricks to reduce excess sweating, and then the job is fun, and fulfilling, and just occasionally a bit scary.

Dr Jon Fogarty, Medical Observer, 3 March 2017

In defence of the new selection exam for aspiring GPs

It seems like a reasonable piece in the selection jigsaw, writes Dr Justin Coleman.

I’m seeing a fair bit of whinging about the new entrance test for aspiring GP registrars, but people seem to forget that selection and rejection is as old as Darwin.

My better half, a deputy principal at a private school, notes that by definition some students miss out when enrolments are oversubscribed.

Yet every parent seems able to name a child who would, by rights, have ‘got in’ had the selection system not conspired against them — usually because they weren’t sufficiently connected/local/clever/rich/sporty/religious/mainstream.

When selecting large groups of people, it is far easier to mount moral arguments as to who deserves a guernsey than to justify exclusions.

Yet any particular filter is only unfair to the extent that you can propose a fairer one. At some point, someone has to make all the ‘no’ calls, and it probably shouldn’t be done alphabetically.

I don’t know if the new RACGP selection exams will be the fairest way of selecting 1500 young doctors from 2000 applicants. I haven’t seen the exams, and no candidates have yet sat them to provide feedback.

But an exam seems to me to be a pretty reasonable piece in the selection jigsaw.

I also like the concept of interviews, CVs, and professional referees. No doubt other selection criteria also have merit, including positive discrimination where necessary.

All these components have some predictive value — a junior doctor who excels is more likely to make a good GP than someone who does poorly.

All of them have inherent flaws too, of course. Someone who does brilliantly on an exam, or nails an interview, may end up being a disappointing GP. Conversely, a young doctor with a scanty CV and a reference from an unenthusiastic consultant might still make a superb contribution as a community clinician.

But we no longer live in an era where every doctor who fails or chooses not to sit a specialty exam can simply walk into a lifelong job as a vocationally registered GP. Those complaining that the RACGP is somehow playing God need to offer a better alternative.

I can’t yet back this specific exam without having seen it, but exams are not exactly unfamiliar turf for doctors. I must have sat almost a hundred of them since primary school, and not one doctor would have their current job without them.

Somewhere along the line, we passed through a final filter to get where we are; whether that was year 12, an undergrad course, UMAT, GAMSAT, or the GP fellowship exam.

Every exam rejected a whole bunch of people, a few of whom would probably have otherwise gone on to do our job just fine.

And every exam cost money, either from our own pocket or someone else’s. Those arguing that the RACGP exam should be free need to come up with a fairer solution. Who else should pay – the taxpayer, the health department, the RACGP (i.e. current GPs)?

No system should be immune from criticism, and perhaps this new RACGP exam will prove problematic.

However, those arguing for the status quo should at least think about the 500 hopefuls who will be excluded next year, regardless. Someone will have to select 500 educated, clever young doctors, and say ‘no’ to every one of them.

How sure are we that the current system does that more fairly than an exam?

Justin Coleman, Medical Observer, 12 April 2017

Rural Radar - UQ

“You can become really good if you have the right conditions” Prof P. Berggren (Burra 2016) from Sweden where 1:800 in one village are Olympic medal winners. We need to ensure barriers are removed and the right conditions exist to train rural practitioners so that they can then work as generalists. Barriers include scope of practice issues such as lack of facilities and perverse incentives, while enablers include distance bridging technology providing ‘5A’ local support (Affordable, Available, Accessible, Appropriate, & Assured timeliness). The aim of the rural generalist is to be able to address chronic issues, comorbidities, health promotion & prevention, and not just address immediate acute needs that you expect to be dealt with in an ED. In addition they manage both individual patients, their families and also their communities with continuing, continuous, comprehensive care in their own context. Even if in some areas in Australia we may no longer complain of lack of doctors, where there is a constant turnover of doctors this creates problems with lack of patient centred care, knowing where things are, who’s who (referrals and patient history) and having local “herd” intelligence (Dr A. Lembke ACRRM ehealth 2017). Rural generalists connect all the dots to improve patient care.

What is true for optimal patient care parallels optimal conditions for learning. Over the last twenty plus years we have learnt a lot about rural medical education and the learning behaviour of students; much of what we intuitively thought was the case, research has proven to be true. “Rural Doctors are naturally effective teachers” B. Mifflin 1996. Rural training provides more exposure to real life and death situations, ‘hands on’ experience and more community exposure. Students who undertake rural training are found to be more resilient, innovative and are leaders (change agents). Those who undertake research are more likely to keep up to date and adopt changes in practice. A log book of activities indicates their level of self-directed learning and likelihood of continuing to learn throughout their career and, those who undertake regular frequent review of their learning and challenge their recall are more likely to pass high stakes exams than those who cram at the end.  Continuity of supervision, patients and curriculum helps connect the dots for learners and increases their likelihood of success. Thank you to all the UQRCS clinical teachers and supervisors for teaching UQ MD students: a great job well done, even when this seems to be an Olympian task!

Professor Sarah Strasser, Head of Rural Clinical School, The University of Queensland

The CSIRO low-carb diet

CSIRO has just launched a new diet book ‘The CSIRO low-carb diet’, by Associate Professor Grant Brinkworth and Accredited Practising Dietitian (APD), Pennie Taylor, based on their research.

DAA supports quality nutrition research, such as clinical studies from the CSIRO, as a way of better understanding how nutrition affects health. Accredited Practising Dietitians (APDs) have university-level qualifications in nutrition science and many APDs are working in nutrition research. Nutrition is an evolving area and the CSIRO research (and accompanying book) certainly provide food for thought. Read more in this Hot Topic.

The science underpinning the new CSIRO low-carb diet book

In their book, the CSIRO authors highlight a clinical study they conducted[i], involving 115 overweight or obese adults with type 2 diabetes – divided into two groups. They were randomly assigned to either:

  • Low carb diet’: 14% of energy as carbohydrate (<50g/day); 28% of energy as protein; 58% of energy as fat (<10% saturated fat); 24.7g fibre; or
  • ‘High carb diet’: 53% of energy as carbohydrate (205g); 17% energy as protein; 30% energy as fat (<10% saturated fat); 31.1g fibre.

Both diets were equally restricted in energy (kilojoules).

Study participants were monitored over 12 months. Both groups received intensive nutrition support throughout the study period (dietetic visits every two weeks for 12 weeks, and monthly thereafter – translating to 15 sessions with an APD over 12 months), as well as exercise sessions three times a week.

At the end of the study, they found no difference between the ‘low carb diet’ group and the ‘high carb diet’ group, in measures such as:

  • Weight (both groups lost about 10 kg)
  • HbA1c* (reduced by 1% in both groups)
  • Fasting glucose
  • Blood pressure
  • Total and LDL (bad) cholesterol.

However, the medication score and glycaemic variability both improved on the ‘low carb diet’, compared with the higher carbohydrate diet.

The HDL (good) cholesterol and triglyceride levels were also slightly better on the low carbohydrate diet. That is, HDL cholesterol was increased by 0.1mmol/L on the low carbohydrate diet and by 0.06mmol/L on the higher carbohydrate diet. And triglycerides were reduced by 0.4mmol/L and 0.01mmol/L, respectively.

In the book, the authors say ‘The CSIRO low-carb diet is specifically designed to ensure that it’s nutritionally complete and provides adequate intakes of all essential vitamins, minerals and trace elements’.

Their diet is one of many different low carb approaches that are currently popular. Australians should be aware that the research findings underpinning the CSIRO low-carb diet are specific to that diet, and cannot be generalised to other low carb approaches.

No one-size-fits all

The CSIRO research tells us that a low carbohydrate, high healthy fat diet may be one option for people with diabetes, but the truth is that there are many ways to have a healthy diet.

For example, research shows that a vegetarian diet, which is very high in carbohydrates, is just as effective as a low carbohydrate diet in improving blood glucose control (HbA1C). Similarly, Mediterranean-style diets, low glycaemic index (GI) diets and high protein diets have all been shown to also work in lowering HbA1C.

So, there is no one-size-fits-all approach for everyone, as we’re all different.

Support from an APD: Crucial in the CSIRO research (and more broadly)

The participants in the CSIRO study had access to regular professional nutrition support throughout the 12 month study period. DAA would like this to have been mentioned in the book, as well as in media stories promoting the launch of the book – as it is likely to have been crucial to the success of participants in both groups of the CSIRO study.

Participants in the CSIRO study had plenty of support, including:

  • Tailored diet plans developed for them at the start of the study
  • Consultations with an APD: every two weeks for 12 weeks, and monthly thereafter
  • Key foods provided for the first 12 weeks, and after this (on alternate months) either further key foods or $50 vouchers to buy foods (in other words, healthy foods were subsidised)
  • 60-minute exercise classes (free of charge) three days each week, for the duration of the study.

Having that tailored, professional advice and a regular touch point for support from an APD helps people to adhere to diet changes, and that’s a key finding from the CSIRO research.

This has been shown in other studies too. For example, studies comparing different diets, such as the 5:2 diet and a reduced-kilojoule diet, show that weight loss (for instance) slows once dietitian follow-up stops, regardless of the diet followed.

DAA would like to see better access to APDs, through Medicare rebates and private health fund rebates, so people can receive the tailored advice and support they need. At the moment, people with chronic medical conditions, such as diabetes, who are managed under a care plan through their GP, can access just five visits to allied health professionals (such as APDs) through Medicare – and for most people, that’s nowhere near enough.

See our previous Hot Topic on Low carb, high fat diets for diabetes.

*HbA1C is an average of our blood glucose levels over a period of weeks/months – and gives an indication of how well diabetes is being controlled.

[i] Tay J. et al. Comparison of low- and high-carbohydrate diets for type 2 diabetes: a randomized trial. American Journal of Clinical Nutrition. 2015; 102:780-90.

Dietitians Association of Australia, Hot Topics, February 2017

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