http://lifeinthefastlane.com/2013/03/all-change-please-2/

So re-direct your bookmarks or RSS feed to the new URL

KIDOCS.ORG

Please re-direct your bookmarks and/or RSS feed to www.KIDocs.org

First up, the launch of a new website FOAM4GP.com – an idea that a few of us had been bouncing around for a while, in or enthusiasm to bring quality free open access medical education to a wider audience – not least primary health care clinicians.

As time goes on, Minh, Casey and I hope that more GPs will embrace the #FOAMed concept and contribute – particularly registrars and newly-qualified docs who have much to offer.

So – if you haven’t already – check out FOAM4GP.com

Meanwhile, Casey Parker over at BroomeDocs.com has commenced a new series “Lessons Hard Learned” as a series of podcasts.

This is a topic dear to my heart (but sadly, living in a small community and with easily identifiable patients, I dare not contribute content – yet).

The issue of error in medicine was discussed at some length at SMACC2013 – Prof Simon Carley (author of BestBETS.org and leader of successful Team GB in SimWars, as well as a nice chap) spoke well on difficulties of diagnosis in EM. Others spoke on medical error, human factors and checklists…

In the anaesthetic community, the Elaine Bromiley case is often used to discuss crisis management and the dreaded CICO situation. If you haven’t already seen the video, you can watch or download here from the ‘Resources’ section of KI-Docs.com.  However I think that one of the most interesting bits of Martin Bromiley’s discussion is that of uncertainty around the error rate in medicine. We simply DO NOT KNOW what error rates are for our trade.

An old adage is that the only way to avoid mistakes as a doctor is by experience … And the only way to get experience is by making mistakes ! Which is why “Lessons Hard Learned” is useful – it allows sharing of important, personal messages between clinicians with the shared goal of improving patient quality. Yes these are anecdotes, but sharing these intensely personal experiences has an educational benefit.

That said, if we are serious about reducing medical error, the real solution lies in recognising that as doctors we WILL make mistakes. Better to engineer safety into the system, to allow a chance to remedy physician error. Of course in a health system under pressure to churn through patients, with financial and resource limitations and with emphasis on medicolegal channels to pursue individuals when error occurs (rather than a no-fault system), this may be unrealistic. But one can dream…

For what it is worth, my ‘top tips’ on hard lessons are below. They may not be revolutionary, but they are errors that one sees again and again, even in experienced clinicians

• Don’t ever forget to measure a glucose
• Consider doing a pregnancy test in any female between 10-50 years of age
• Respiratory rate is a good marker of ‘being unwell’ yet is often poorly recorded. Ask for the Resp Rate and act if up or down.
• Trust your instincts. If a little voice is nagging at you, listen to it
• Never let the sun set on pus
• Remember that if you are either hungry, angry, late or tired (HALT) then your performance will be affected
• When you are in a rush, make an effort to SLOW DOWN
• Just because someone works in a teaching hospital, doesn’t mean that he/she knows more than you. As the clinician on the spot, you are best placed to determine if someone needs to be seen or not.
• Sepsis can sneak up on you and patients deteriorate with terrifying speed. Look for sepsis. Then look again.
• Beware the automatic BP reading in a resus – remember to set the frequency of recording at the start of a resus – otherwise you will be falsely reassured by seeing the same rock-solid BP. That’s because it hasn’t been measured since initial set of obs
• Don’t be afraid to ask for advice
• Use cognitive aids like checklists and #FOAMed resources
• It is OK to say “I don’t know” – whether to colleagues or your patients. Dealing with diagnostic uncertainty is challenging, but often things are NOT clear and opening up communication between doctor-patient to acknowledge this and establish criteria for concern/re-presentation/follow-up are vital

Finally, as one wise intensivist said to me “If you don;t know what to do with a sick patient, wait until he/she arrests – THEN you’ll know what to do” – kind of distills all of clinical medicine down into the one algorithm !

Readers of the blog will be in no doubt that I am a fan of FOAMed, the revolution in medical education that has swept through the Emergency Medicine & Critical Care world. Like may others, I have got back from the SMACC2013 conference with renewed enthusiasm for cutting edge medicine and promulgating ideas amongst colleagues.

To be truthful, as a rural doctor one can feel left out at conferences – particularly those with an EM or crit care focus, as working in a rural area may be seen as lacking in rigour. Of course this is far from the truth – after all, critical illness does not respect geography. Fellow rural physicians Dr Casey Parker of BroomeDocs and Dr Minh le Cong of Prehospitalmed.com bring concepts of relevance to us rural docs.

Casey Parker, promiscuous FOAMed blogger and nom-de-plume of a Panamanian porn star (not related)

I try to do this with KI-docs, although the focus is more about dealing with an intransigent health bureaucracy and thoughts on airway stuff than 100% hardcore critical care. The “50 Shades of Brown” section is aimed at rural doctors who are keen to embrace FOAMEd concepts relevant to resuscitation in the bush…

I hope that my talk at SMACC2013 went down OK, despite the cringeworthy jokes. You can access it HERE.

Leading on from SMACC2013, I’ve set out my manifesto for 2013-14, namely to try and achieve the following:

- to spread the FOAMed paradigm amongst rural proceduralists & help develop new FOAMed content relevant to rural doctors

- to complete the “50 shades of brown” series of “what to do when sh** hits the fan”

- ensure simple resources like RSI kit dump, checklists and awareness of NODESAT/DASH-1a are used by rural ED docs and GP-anaesthetists in Australia

- to try and badger Country Health SA into adopting an airway registry to compare rural vs metro outcomes

- similarly to incorporate more sim into training using iSimulate

- to keep plugging away on development of a rural doctor ‘masterclass’ via ACRRM

and

- to firming up rural doctors as vital members of prehospital response where gaps exist in rural Australia

I also promise to work on decreasing my scatology!

Where to from here?

I think that FOAMed has the most to offer to rural doctors – traditionally isolated by virtue of the tyranny of distance – we can now engage in high quality, relevant education and help to deliver “quality care, out there”

One of the criticisms of the current FOAMed content is that it is heavily-skewed towards resuscitation themes. I don’t think this is unreasonable – after all EM & CritCare have these at their core – so this is where most debate, controversy and innovation happens. At SMACC2013 Victoria Brazil illustrated the lack of FOAMed resources on Indigenous Health and vital public health areas such as hand-washing. I reckon we should give it time – as the FOAMed paradigm is taken up by more and more specialities (dang it, even the urologists have come on board), these topics & more will be incorporated.

Mike Cadogan’s Global Medical Education Project (GMEP) is fast becoming the repository for FOAMed resources – check it out if you have not already done so.

How to use FOAMed?

Whilst SMACC2013 was a great EM/CC conference, there were a sizeable number in the audience who had no idea of how to incorporate social media (SoMe) into their practice. Understandably they fear information overload and the hurdle of having to grapple with technology in lives that are already bursting at the seams with important things to do. Fair concerns, but can be easily overcome with perhaps a 2hr investment in time to get set up.

With that in mind, I would recommend the following

(i) Get your head around FOAMed – see http://lifeinthefastlane.com/foam/

(ii) Set yourself up with some sort of mobile device (I like the iPad) and download relevant apps – Mail and Safari will allow Email and Browsing, use GoodReader to store and read PDFs and other documents for reading later.

The iPad makes a repository of all things medical and non-medical

Store apps in folders

According to usage

I use GoodReader to collate media for browsing anytime

(iii) Selecting sites – choose wisely

You should then navigate to blogs or sites of interest and subscribe to their content via RSS. You can get this content pushed to you and collated in an easy display, rather like a constantly updated newspaper, using FlipBoard – makes browsing content from several different blogs or sites a cinch.

FlipBoard acts like online newspaper – of all YOUR preferred content

A common criticism of FOAMed is that is is not peer-reviewed in the same way as a journal article. That’s specious, as Richard Smith (former Editor of the BMJ) demonstrates in this article on the process of peer-review.

I reckon that peer review by putting a concept out there via FOAMed and then the ensuing debate from the worldwide community of critics is a far more robust method – good ideas will rise to the top, bad will sink.

I put out a paper last year on difficult airway equipment – the journal process took nine months – whereas FOAMed allowed me to get the concept ‘out there’ in a few minutes. I still went for the perceived kudos of getting a paper published…but in the future, I don’t know if I would bother, unless there were consequence for not doing so (plagiarism by others, loss of research funding or other penalty).

(iv) Connect in real time when it suits you

As well as getting content pushed to you via RSS/email, you may want to take the plunge and get yourself a Twitter account. To be honest I would not bother with FaceBook (it’s so last year) – I was so sceptical about Twitter, thinking it was all about Paris Hilton inanity. Instead it allows real time communication between colleagues on subjects of interest. That is powerful and highly useful for physicians – we can now connect in real time.

To whit, during the SMACC2013 conference I was listening to Brian Burns (@hawkMoonHEMS) talking about life-&-limb saving interventions used at GSA-HEMS. He mentioned exciting stuff like thoracotomy, lateral canthotomy, field amputation, resuscitative hysterotomy and surgical airway (three of which procedures I’ve done so far)…but did not mention decompressive procedures for extradural. If you think about it, all of these are about making holes – so why not include craniostomy? A quick tweet to my mate Mark Wilson (former rural doc, anaesthetist, London HEMS doctor and now neurosurgeon) and Mark kindly sent through to me (and a few followers) a PDF of his recent ‘How to do it’ paper on Burr holes.

That is gold – to be getting this content from a respected specialist from the other side of the world, whilst sitting in a conference in Sydney.

Similarly Minh le Cong got feedback from Karim Brohi of trauma.org on the usefulness of ROTEM/TEG in Cath Hurn’s talk on massive transfusion, after a few questions from Casey and myself on value (or not) of point-of-care INR in determining progression of ACOTS.

Summary

So Twitter is allowing clinicians with a like mind to share conversations. I am humbled to be able to talk to respected EM people like Simon Carley, Cliff Reid, Minh le Cong, Joe Lex, Mike Cadogan, Karim Brohi, Casey Parker and get a response – truly FOAMed is a meritocracy.

But to be honest, I wish that I could share these conversations with other rural doctors – there is but a handful of us involved in FOAMed – and yet the true power of FOAMed will not necessarily be in the cutting edge ‘sexy’ arenas of resuscitation – but in sharing experiences and frustrations that affect front line doctors. Traditionally operating in relative isolation, perhaps coming together once a year for an annal refresher conference, we could be so much more connected … to the benefit of our patients.

A shout out here to Gerry Considine of the Rural Flying Doc website and others like him – they are using FOAMed to cover course content in twitter study groups, to allow remote supervision (exemplified by Dr Tim Senior & Dr Michael Bonning’s forays as “supertwision”) and to effect change.

Rural doctors need to get on board and embrace the FOAMed. I am more than happy to help get you started…

Come on in and join us!

SMACC2013 has changed all that.

No doubt Minh over at prehospitalmed.com and the lifeinthefastlane.com crew will feed out snippets, so I won;t give an exhaustive breakdown.

Suffice it to say, SMACC2013 was noticeable for

- incredible collegiality between ED, ICU, prehospital and rural clinicians, be they student, paramedic, nurse or doctor

- opportunity for meritocracy-type interaction between colleagues from both Australia and overseas

- memorable for Gerard Fennessy delivering part of his anaphylaxis talk in song (ya’ muppet)

- moving and inspiring talks from the likes of Weingart, Lex and Reid

- SCAT paramedics abseiling in from the rafters as GSA-HEMS (lead by Karel Habig) made a surprise last minute showing in SimWars

- excellent organisation and venue. Thanks to the organising committee for all their hard work.

SMACC2014 will be in Brisbane 17-19 March 2014. Book now. Rural doctors – you NEED to embrace FOAMed. Casey “not the porn star” Parker and I have been banging on about this now for sometime – we need to raise the bar and bring “quality care, out there”

So, my mission for 2013-14

(i) to try and persuade ACRRM and RDAA that we need to embrace FOAMed as rural doctors

(ii) to try and implement an Australian version of BASICS – to improve the current gap in rural prehospital care (rural docs with airway/resus skills are well placed to provide appropriate interventions before retrieval arrive – but need to be equipped, trained and have formal call out criteria)

(iii) to ensure that EVERY small rural ED (and better still , every ED, ICU in Australia) is familiar with and engaged in processes such as

- Toby Fogg’s excellent airway registry

- RSI kit dump and checklists

- adequate difficult airway kit and knowing how to use it

- checklists for crisis management and ‘logistics not strategy‘

- regular sim and resus room management training

- NO-DESAT apnoeic diffusion oxygenation and DASH-1a for all RSIs, whether in ED, OT, ICU or prehospital

None of the above ideas (and more) will be unfamiliar to FOAMites – indeed, they’ve been bounced around for a few years now..but still they are not out there where they are most needed. This must change.

Concomitant with that will be more FOAMed relevant to rural docs – not just ‘airway’ and ‘shock’ but of relevance to critical care in the bush

Might seem a big ask..but I can dream.

After all, critical illness does not respect geography!

So was good to put names to a few faces (and apologies to those I have not yet caught up with). Importantly it is good to see a coming together of intensivists, emergency physicians and a smattering of country doctors – all with a common theme – using FOAMed to improve the delivery of patient care. ‘Quality care, out there”

The T shirts also got a few laughs…

THEY WANT TO MODERATE FOAMed

I was a little perplexed to hear a lot of … well fear is perhaps too strong a word..but concern is too weak… whatever, there seems to be a desire to regulate the FOAMed community. If you don’t know what FOAMed is, take a wander over to LIFE IN THE FAST LANE for a crash course. As Joe Lex pointed out, the concept of free meducation has been with us since Hippocrates and is embedded in the eponymous Oath “…and to teach them this art – if they desire to learn it – without fee and covenant; to give a share of precepts and oral instruction and all the other learning”

Simon Carley from BestBets and St Emlyn’s gave an inspiring talk on the perils of SoMe – not so much from within, but the fact that it may unsettle existing power bases and be subject to a set of rules by those who do not understand it. He also warned of the danger of ‘preaching to the converted’ – we need to get the message out to a wider audience and, as Joe Lex suggests, lead by example.

So here are my thoughts on some of the criticisms of FOAM. NB: Minh le Cong has blogged on the future of FOAMed recently.

Criticism No 1 : FOAMed is not really free – people will want to get paid (in money, or in kind) for their time.

I hear this a lot. After all, sharing info for free in an open environment is antipathy in the cut-throat grant-based world of academia. Whilst there will be some who blog for self-aggrandisement (although I am hard pushed to think of any), most FOAMites do so because they believe in sharing knowledge, enjoy debating (especially those of us, like rural docs, who operate in isolation) or have a genuine desire to help their colleagues. Me, I have a self-interest at heart – if I can persuade colleagues in rural medicine to adopt some of the practices I have learnt about through FOAM, my job will be so much easier as I move around the country. Not just doctor s- but fellow clinicians like nurses and radiographers…and institutions.

Criticism No 2 : There is no ‘quality’ – how do we know that people blogging are who they say they are, do the things they say they do etc?

Um, not really. If using Twitter, can click on a user to see his/her name. Like a hawker selling his/her wares in the marketsplace, you will soon develop an eye for the trustworthy ones. People who use real names behind their twitter handle, give a good descriotion of who they are and what they do are generally to be trusted. Similarly, those with lots of followers are probably worth reading. But beware group think…

As for quality…well, this is the old Encyclopaedia Brittanica vs Wikipedia debate. I know which one has most share nowadays – the strength of FOAM lies in rapid ability to change and peer-review. Which leads on to …

Criticism No 3 : FOAM has no peer-review. How can it be trusted?

Well it DOES have peer review – the crowd. When people say daft things, or there is major dissent, then the crowd (usually through online comments to blogs) will allow discussion.

I’ve been involved with Doctors.Net.UK since it’s inception back in 1998. The power of that medium (essentially a bulletin board) is active (and sometimes heated) discussion between the 180,000 UK Doctors who use it. But that is where the BEST learning happens.

Besides, is the learning from wise old professors of medicine peer-reivewed? I had a gutful of ‘my way or the highway’ teaching as a junior – in fact, I encountered it again recently when doing a year of anaesthetic upskilling in NSW – not just learning via humiliation, but an insistence that ‘their way’ was best way despite evidence to contract from literature (and colleagues). Yet such behaviours tolerated as ‘good at blocks’ or ‘just his way’. All I learn from these individuals is how NOT to be!

Criticism No 4 : Without a curriculum, FOAM may encourage novices to do “crazy things”

An example was cited of an ED reg ‘doing something unfamiliar because they’d read about it on a blog’ with the implicit suggestion that FOAMed content needs to be moderated.

Oh bollocks!

Look, for me the whole POINT of FOAMed is that it caters to the discerning palate. It is NOT entry-level – that’s what medical school, textbooks, journal clubs and primary/exit examinations are for. They give you the framework to practice the art of medicine.

But along with getting one’s ‘ticket’ in whatever field, is the commitment to lifelong learning. We won’t get that from books..nor conferences. Information moves too quick. Same with the process of publishing papers (don;t get me wrong – this is important, just takes a while)

I can illustrate with examples from my experience of FOAMed – in past 18 months, concepts such as apnoeic oxygenation during RSI, use of checklists, switch to rocuronium over sux for trauma RSI, considering resus room management and human factors have changed the way I practice medicine. I think that is a good thing. But theses concepts have been gleaned by conversations with experts via the blog-o-sphere….not through books/conferences.

Reputed drunkard Alan Grayson used the illustration of a kitchenhand moving from scut work, through sous-chef to masterchef. We are all on that journey – and whilst initially have to learn the ropes, FOAMEd helps masterchefs share recipes. Over time the info will be disseminated downstream into protocols etc … but FOAMed is really about keeping the pot bubbling and generating new innovative dishes for the discerning palate. It ain’t McDonalds!

Which leads on to…

Criticism No 5 : Without moderation, people will say ‘bad’ things.

Yes, they will. But people may say ‘bad things’ anyway. As one who approaches almost Gordon Ramsay-like profanity at times, I recognise the need to exercise caution.

That said, sometimes people NEED to say things. Those in the UK may be familiar with the ‘Scot Junior’ affair a few years back, where a relatively junior trainee made criticism of a senior member of the medical establishment on a closed forum (Doctors.net.uk) under a pseudonym. When pulled up, he immediately apologised and withdrew the comments…but was subject to a witchhunt by senior meducationalista that affected his career and went well beyond the bounds of acceptable reprimand. Sadly the mediculationalista involved lack insight into their own behaviours – and it is these sort of people who are watching FOAMed VERY closely. Still sometimes as TISM say, you have to call a spade a spade.

But is moderation really needed? We already have a code of conduct – guidelines of ‘being a good doctor’ from the likes of GMC and AHPRA. Stick to those, don;t say anything that you wouldn’t mind either prefacing with “M’lud” or splattered over the front page of local paper, and you will be right. Karel Habig from GSA-HEMS suggested that the journalism code of conduct might be best way forward. As long as it’s not leading to a ‘News of the World’ scandal we should be alright.

Actually, perhaps the ‘masterchef’ analogy is incorrect – we should compare ourselves to cub reporters, then specialist reporters in different arenas…then those who have the courage to go off (FOAMEd) and do something different – perhaps picking up a Pulitzer on the way.

Criticism No 6 : Without a curriculum, we will miss important topics.

An example as given of the fact that AIRWAY and SHOCK predominate in FOAMed resources. I agree, but I think FOAMites have enough insight to realise that there are far more topics that could (and should) be discussed. But the uptake has mostly been by EM and ICU docs – who, guess what, mostly want to talk about airway and shock. This will change – Mike Cadogan’s GMEP project will allow a fine repository of all sorts of info – and up-and-coming stars like Gerry Considine will be pumping out content.

Actually, the more I think about it, I reckon the broad brush knowledge base of the true generalist (the rural doc or EM physician) is the best mining ground for more material.

But you know what – the danger of FOAMed is not that it is anarchic and unmoderated – that is it’s strength. The danger is that the users are converts…we DO need some form of body to articulate the strengths of FOAMed to other agencies…and we do need to get the message out there to other doctors.

Most of all, we need to lead by example. So tomorrows talk at SMACC2013 will be my last nod to Anglo-Saxonisms in a presentation…

What do YOU think about FOAMed? Comments welcomed….

Criticisms are that SA looks like the largest open cut mine, visible frm space…or a series of doors….or a Pope’s hat.

Regardless, it has got people talking.

Meanwh the KI Doctors are trying to get media attention for their plight with the SA Health Department. We simply cannot get any sense out of the CHSA Health Bureaucrats and are trying to get the Health Minister Jack Snelling to take action.

Latest media release plays upon the ‘doors’ theme of the SA logo. My fear is the door is closing to get a resolution on this issue.

Media interest this week in the profound wait (up to six weeks) to see a doctor in rural SA. Currently KI Docs have a mix of pre-bookable and ‘book-on-the-day’ appointments, meaning we can meet most demand on the day, and patients can see ‘their’ doctor within a few days for non-urgent consults. All this will change if CHSA do not resolve the crisis.

Read the Media Release here …. and make your own comments known by either hitting the airwaves (891 Adelaide, fiveAA), writing to the media (The Islander, The Advertiser), or telling the State Health Minister what you think.

Meanwhile the KI Docs dispute is spilling out into the media. Hopefully some common-sense will prevail and the current status quo will be allowed to continue. Sadly I am learning that common-sense is not that common. Rather than retain local doctors’ services in A&E for 21 out of 28 days and 24/7/365 cover for both obstetric and anaesthetic rosters, it seems that the faceless bureaucrats at CountryHealthSA would prefer to sack the lot of us, pay locums bucket loads (going rate is reputedly $1700-2500 per day) and collapse anaesthetic and obstetric services on Kangaroo Island

Not good.

You can read more about the dispute here, here and here.

At the heart of the dispute is almost a philosophical question – whose responsibility is it to staff the roster for the State-owned public hospital? Whilst rural doctors have always fulfilled that role, the insistence that they are responsible for the entire roster even to the point of paying a locum to do the job does stick in the craw – on KI we have enough doctors to run our Clinic…but not enough to cover three rosters for each of A&E, Obs and Anaes…unless we work ourselves into the usual outcome of days gone past – early death, alcoholism, relationship breakdown, major depression and medical error.

So, here is a round up of media reports (to date) on the KI crisis – CLICK on the links to read associated news articles or media releases.

4 March 2013

Adelaide Now “Locum cut unhealthy for Kangaroo Island say GPs”

See also the comments section – mostly supportive, although one Islander did wonder why the six local doctors could not work as hard as the 3 doctors 20 years or so ago. Fair comment and I would encourage such questions. Suffice it to say that the three doctors are no longer working on KI – one has left rural medicine entirely. When we talk to them, they cite the unbearable workload and not one wishes he had worked as hard. New doctors want to spend time with family, to relax…they still work a 40 hour week in the Clinic plus are on-call another 30-90 hours per week depending on the roster.

The Islander – “GPs in new hospital row“

Leading with a photo from the dispute some years ago, The Islander will no doubt invite comments (both positive & negative) from readers.  Regardless of what you think of the Doctors, it is important to realise that this is happening and will affect delivery of services. The docs simply cannot work more than they are currently. 

ABC News “GPs upset as locum withdrawn”

Sadly no ‘comments’ section, but hopefully local ABC will continue to repo this both on line and on radio.

RADIO NEWS BROADCASTS

KI doctors say the State Govt wants them to work dangerously long hours

“Doctors on Kangaroo Island say that the State Government wants them to work dangerously long hours because it won’t cover the cost of a locum.  The island’s six GPs work normal hours in a clinic and then provide around the clock services to the Emergency Department at the Kangaroo Island Hospital for 40 weeks a year.  Country Health SA employs a locum to staff the Emergency Department for one week a month to provide respite for the doctors, but that will stop at the end of this month.  Negotiations over a new arrangement for the island’s doctors have failed.  The doctors are hoping the Government will reverse its decision.

Local Kangaroo Island GP Mark Raines says doctors could compromise their standards of care by picking up their workload:

(891ABC 7.45am & 639ABC 7.45am/8.30am) “It’s about keeping the job sustainable and a position where we can provide a good quality service where we’re not sleep deprived and over-stressed and burnt out.”

(891ABC 9am & 639ABC 9am) “If somebody has been up all night dealing with a problem and then they have to go to work the next day to work in their general practice, or they get called back and they’re sleep deprived, then yeah I think it’s been well and truly shown in clinical studies that sleep deprivation leads to mistakes.”

KI GPs say a new workplace agreement will see them working dangerously long hours

Country Health SA has disputed claims by GPs on Kangaroo Island that a new workplace agreement will result in them working dangerously long hours.  From next month Country Health SA won’t be funding a part-time locum to staff the Emergency Department at Kangaroo Island’s hospital.  It means that the island’s six GPs, who already provide on-call Emergency Services most of the year, will have to pick up the locum’s workload.

Country Health SA’s Peter Chapman argues that standards of care won’t be compromised:

(891ABC 11am & 639ABC 11am) “If they did have to work significantly overnight and therefore were feeling ‘how can I do my clinic in the morning’, they are able to cancel that clinic in the morning so they can get their sleep et cetera and we make a payment for that.”

(891ABC 12noon) “Obviously for us to pay for them to cancel their clinic and reinvest in the morning is a very major initiative of the GP agreement so yes, we do understand very much the requirements of general practitioners.”

6 March 2013

Local MP Michael Pengilly has been working in the corridors of Parliament to raise the issue and issued a media release and was interviewed on 5AA with Leon Byner, transcript below.

Michael Pengilly, Member for Finniss   (5AA 12.12-12.15)   Reduction of locum support for Kangaroo Island GPs

(Byner: … the Weatherill Government’s inability to negotiate a sensible deal with local General Practitioners on Kangaroo Island … has threatened future health services … this Member of Parliament … is demanding that the Government disclose what arrangements are being put in place to install an adequate team of doctors into the local hospital on KI from March 31. Michael … what’s your understanding of what’s happened here?) … it’s like a long playing record that’s run off the track … I’ve been on this before, I’ve been on it again recently. What’s happened is that Country Health are trying to bulldoze the doctors into signing an agreement they don’t really want to sign. The current situation is that one week a month the locum comes in and takes the pressure off the local doctors to do the on call at the hospital but what they’re not doing is saying what arrangements they’re going to put in place after March 31^st … it’s creating some major headaches on the island, I spoke briefly to the Minister about the matter yesterday … (Byner: …what did he say?) He wasn’t in a position to make too much comment but I’m sure that he’ll pick up on it. I just want to get a sensible outcome. I’m comfortable with contracts across the state but they have to have flexibility to work in localised areas and places like the island is indeed a localised area. (Byner: …so what’s the problem?) Well the Government don’t want to pay … (Byner: …pay for what?) … pay for the locums and what they’re also saying is that they want the local doctors to do the four weeks all the time … a month at a time. The doctors are saying well if someone’s on and then on Monday morning when they come off call, they could’ve been up all night, they could’ve been treating patients, then they have patients in the clinic to deal with – they’re just saying that it’s beyond them to do all that, they could make mistakes potentially, so they are saying that why bust up a good system that works well now – the community’s very anxious about it over there, they don’t want to have – Leon Byner might have an appointment for 11 o’clock on Monday and get there or get rung up and be told no the appointment’s off because the doctor simply can’t work …  it’s a common sense approach … my view is that the Weatherill Government’s got a self-inflicted budget crisis and  that should not become the Kangaroo Island community’s emergency and it just needs fixing and fixing properly. (Byner: …alright …we’ll take some interest in this because … you’re not allowed to drive a truck past certain hours of service because it’s not deemed that you’re a safe driver, well doctors are still human and surely the same laws apply to them.)

That is all for now. More updates as and when they occur.

There is a sense of “deja vu” today, as the Kangaroo Island doctors gear up for another tedious battle with the bureaucrats at Country Health SA.

You can read more in the media release below :

Media Release 4-3-13 KI Docs

The Island doctors have been told that the status quo (them providing 21 days out of 28 for the A&E on call roster … as well as complete 365 day cover for each of the anaesthetics & obstetrics rosters) is to come to an end on 1st April 2013.

The reason? Health bureaucrats demand that Island Doctors assume responsibility for the entire A&E roster, begging the question of ‘whose Hospital is it anyway‘? If they don’t, then the doctors will be removed from the A&E roster. Currently a locum does one week per month A&E on call, at a cost borne by the Health Department. To replace the local doctors will require a locum every day of the week – costing the Health Department even more. I’m no economist, but it seems an ‘interesting’ decision financially and one for which bureaucrats seem to be unaccountable.

Elsewhere in Australia, high fees paid to locums tend to drive out resident doctors, who also have to bear practice costs. There’s also a sense of deja vu – back in 2010 the Health Department replaced the Island doctors with locums – not only costing much, much more than the local doctors, but also leading to a significant drop in service (locums who could not plaster or insert an IV cannula were notable “fails”). One locum even fled after only a few hours, citing the ‘unbearable workload’.

So there you have it – local doctors no longer allowed to provide A&E services from 1st April 2013. The threat has been made by CHSA bureaucrats that anaesthetic and obstetric rosters will also be dissolved.

NOW is the time for the Kangaroo Island community to act if they want their doctors to remain able to treat them in A&E, deliver their babies or provide emergency & elective anaesthetics.

Hit the airwaves (891 Adelaide, fiveAA), write to the media (The Islander, The Advertiser), and tell the State Health Minister what you think.

Lack of accountability

Of course this is not the only problem the island doctors have had with Country Health SA. A colleague has described trying to deal with their bureaucracy as like ‘fighting candy floss’ – with meetings un-minuted, calls unanswered and a refusal to engage in meaningful or timely negotiations, it is very hard to get clear answers. There also appears to be a lack of institutional memory regarding previous decisions. We are not alone – the recently-departed Penola GP (who quit after being required to work a ludicrous 24:7 on call for over a year) has also hit out at the bungling Country Health SA bureaucracy.

Stand out gripes for recent times on KI include :

- failure to negotiate a new contract.

The previous expired in Nov 2011 and a ‘new’ contract was finally put to rural doctors in mid-2012. We are now in 2013…and rather than negotiate for a continuation of the status quo, CHSA have suggested the above

- failure to pay doctors under fee-for-service.

Of course I cannot discuss specific patient cases, but I can say that I am still chasing payment for in-patient services dating back to April last year. A common policy seems to be for the Hospital to call for a Doctor urgently to render assistance…then the urgency of that call to be disputed some months later by a pay clerk. Suffice it to say, call out fees differ if urgent vs non-urgent, the premium being to compensate urgency and impact on own clinic patients who have to wait. There is also a monthly battle over admitted vs non-admitted services – the former payable under fee-for-service, the latter charged as a private fee to the patient. Again CountryHealthSA seems to have a low threshold for calling the duty doctor – then arguing about payment later.

I am now owed thousands of dollars by CountryHealthSA over admitted patient fees. Sadly the agreed “dispute process” has lead to a series of unanswered emails and written demands for payment over months. Despite this I have kept on working at the Hospital, but it seems there is no accountability within the organisation to resolve this…

- the anaesthetic monitor fiasco.

Unbeknownst to any of the rural doctors (including the Country Health SA clinical lead for Anaesthetics), our existing monitors were replaced by new ones, reputedly costing $17,000 each. Estimates are that there has been over $500K spent across rural SA – despite the fact that these monitors were not needed (standards not mandatory) and replaced perfectly good existing equipment. This money spent even though we cannot get vital emergency equipment for our hospitals because “no money available’.

Jack Snelling is the Health Minister and perhaps should take note. The Health Dept needs to save $1 billion over five years. Perhaps some savings could be made within the bureaucracy?

So whilst all this hassle is going on, I am looking forward to a few weeks off and the chance to catch up with fellow #FOAMites at SMACC2013. Will be talking at 13:30 Tuesday 12/3/13 on ‘improving rural pre-hospital care in Australia’. Come along and heckle…

SMACC FINAL PROGRAM

BASICS model for Oz?

First up, a discussion on doctors.net.uk / ausdoctors.net (the members only service for UK and Australian doctors) on ‘tips for new consultants’. Covered the sort of things that don;t get taught at medical school or in postgraduate training. Also tips on setting up a private practice and avoiding burnout. A common theme was to ‘say no’ to unmanageable workload and to try to take control of the work environment, not let it control you.

Of course all of this is relevant to rural doctors, which leads to the second theme – that of managing workload in the bush. Scott Lewis (procedural GP in Wudinna and newly appointed President of RDASA) rightly points out the constant stream of negativity regarding rural medicine. Despite this, I think Scott and I agree that rural practice really does offer the ‘best bits’ of medicine – a varied and interesting mix, with opportunities to be challenged every day.

Concurrently this week the doctor in Penola, SA has left – citing an unmanageable workload & bureaucratic bungling by Country Health SA. As well as managing a day time clinic, poor chap was on call 24:7 every day of the year and reportedly chastised for having the temerity to be more than 20 mins from the hospital on one occasion (CountryHealth SA contract allows a 40 minute response time). Ironically this doctor was brought in a year or so ago, to replace the previous doctor, who lasted only 4 months.

Of course there’s the local issue on Kangaroo Island, with the sustainable model of Island docs doing 21 out of 28 days per month on call for emergencies, as well as 365 day a year cover for each of obstetric and anaesthetic rosters. This workload was sustainable and allowed respite from the onerous emergency roster, as well as to balance the demands of running a private general practice.

Common themes?

(i) Financial Incentives

Historically money has been thrown to entice doctors to the bush. Whilst this helps, it is ironic that the same incentives are offered to fly-in, fly-out locums who live in the city and cherry pick high-paying locum work. Indeed some rural communities are wising up to this and realising that paying locums $2500 per day is a disincentive to establishment of permanent resident doctors who have to bear practice costs. KI docs got into a stoush with the Health Department (and the ACCC) a few years ago, when asking for more money to provide on call services. The money doesn’t compensate for working day & night – but it does allow one to purchase much-needed locum relief.

(ii) Control of workload

There are 168 hours per week, which I think of rather like a Mars Bar – it should be divided into equal thirds of work, rest & play. An 8 hr working day is sufficient, and allows time for rest (sleep) as well as play (hobbies, other interests – but also mundane things like cooking, eating, toileting etc). Of course most of us experience ‘bracket creep’ with work intruding into time off and eventually life can become 2/3rds work, 1/3rd rest. Not a good idea. Having strict boundaries between work and home life, as well as declining extra duties means that workload is sustainable.

Much better though to share the workload – a roster of several doctors working part-time is a better model than the traditional solo small town GP. Which leads into the third theme..,

(iii) Learning to ‘say no’

Which is the unenviable position the KI docs find themselves in currently. A model hashed out with the Health Department a few years ago allows KI docs to work 21 out of 28 days per month for emergency on call, with the Health Department providing a locum for their hospital on just one week per month. Meanwhile KI docs provided 365 day cover for separate anaesthetic and obstetric rosters. Not a bad effort for six part time doctors, and allows us time off for a break as well as mandatory upskilling.

A proposal that KI docs take full responsibility for the emergency roster and fund any locum relief themselves was met with disappointment, It sets a dangerous precedent – for if the number of doctors on KI were to fall in the future (as is likely), the remaining doctors would be forced into paying for a locum to staff the hospital. A sum of $10,300+GST per week has been suggested as typical locum costs.

Taken to a logical extreme, if the Island doctors were unable to provide the service (through ill health, absence, whatever) they could be liable for a bill of $10,300+GST x 52 weeks … all for the privilege of doing EXTRA work to their usual 9-to-5 private general practice.

This really is the crux of the tension and difficulty in rural practice. Not only are their insufficient doctors and problems with throwing money at all-and-sundry, ultimately we are independent contractors. We already have a job that consumes a standard working week – that of running our own private practice. With that come attendant costs of staffing, utilities, rent etc which must be met.

To ask us to either take time out of practice to work at the State-owned public hospital (for considerably less money) and yet still pay pay own practice expenses seems unfair. And the demands of working extra hours on call takes it’s toll.

In the city, public hospitals are staffed by doctors and nurses working shifts. They are salaried and also get benefits like annual leave, long-service leave and superannuation. In the bush? Doctors work running their own private practices and traditionally have worked ‘on call’. Sadly workloads have increased (particularly in tourism destinations like Kangaroo Island) making on call a significant burden and at the expense not just of doctor’s health, but also ability to service own clinic patients. There is no Super, no annual leave. The Health Dept just wants to staff the roster, but doesn’t really care how this is fulfilled so long as the cost is shifted elsewhere.

Add to this the demands of a Medicare Locals policy that seems to be more about ‘wants’ than ‘needs’ … and the abhorrent policy in South Australia of charging public patients a fee for non-admitted A&E services (contrary to section 19(2) or National healthcare Agreement). It all seems that costs and services are being shifted from State responsibility to private practice.

Hence it is sometimes better to ‘say no’ and do only what you can do.

Any other thoughts on preventing burn out?