pain - racgp · pain points gps are at the forefront of care in australia’s growing opioid...
TRANSCRIPT
www.racgp.org.au/goodpractice
Pain points
GPs are at the forefront of care in Australia’s growing
opioid problem
INSIDE
Online healthThe quality and efficacy of online prescription,
referral and medical certificate services
DisabilityGPs’ role in the continued rollout of the
National Disability Insurance Scheme
RACGP awardsSome of the best of general practice
ISSUE 11, NOVEMBER 2017
3Reprinted from Good Practice Issue 11, November 2017
Editorial notes
© The Royal Australian College of General Practitioners 2017.
Unless otherwise indicated, copyright of all images is vested in
the RACGP. Requests for permission to reprint articles must be
made to the editor. The views contained herein are not necessarily
the views of the RACGP, its council, its members or its staff.
The content of any advertising or promotional material contained
within Good Practice is not necessarily endorsed by the publisher.
Printed by PMP Limited, NSW
We acknowledge the Traditional Custodians of the land and sea
on which we work and live, and pay respect to Elders, past,
present and future.
Published by
The Royal Australian College
of General Practitioners Ltd
100 Wellington Parade
East Melbourne
Victoria 3002
03 8699 0414
www.racgp.org.au/goodpractice
ABN 34 000 223 807
ISSN 1837-7769
Editor: Paul Hayes
Journalists: Amanda Lyons;
Morgan Liotta
Graphic Designer: Beverly Jongue
Production Coordinator:
Beverley Gutierrez
Publications Manager: Joe Ennis
Cover image: iStock
Advertising enquiries
Sye Hughes, 0474 500 770
3
ContentsIssue 11, November 2017
06
06 Addiction Medicine
Agony and ecstasy GPs have a crucial role in helping to curb
Australia’s prescription opioid epidemic.
10 Online Health
Virtual doctor Debate continues as to the quality and
efficacy of online prescription, referral
and medical certificate services.
14 Disability
Design for life GPs want to know more about their role
in helping eligible patients access the
National Disability Insurance Scheme.
18 RACGP Awards
Honour roll This year’s RACGP award
winners show some of the best of
general practice in Australia.
22 GP Profile
Family ties Dr Michael Bartram’s roots lie in rural
medicine, where he continues his
parents’ legacy.
24 In My Practice
Gem of the north Preston Family Medical Practice
prides itself on a personalised and
holistic approach to community-based
healthcare.
26 Nutrition
Managing gout Diet as adjunctive therapy.
22
10
14
4 Reprinted from Good Practice Issue 11, November 2017
YOUR COLLEGE
Abuse and violence learning activityThe RACGP has developed a new gplearning
program designed to help GPs work with
patients affected by abuse and violence.
‘Professional development program
on family abuse and violence’ looks at
the prevalence of family violence in the
community, as well as the social complexities
and dynamics that contribute to violence
against women and other vulnerable groups.
It is designed to help GPs and practice
teams work together and connect with other
services in the community.
GPs who take part in the program
will learn how to better use their skills
in communication, risk-assessment
and care management in the context of
family violence.
It is hoped that improving the level of
response will help general practice contribute
to the early identification and intervention in
cases of family abuse and violence.
Healthcare professionals involved
in the program include Prof Kelsey
Hegarty (co-Chair of the RACGP Specific
Interests Abuse and Violence network),
Prof Jan Coles, Dr Ronald Schweitzer
and Dr Caroline Johnson. ‘Professional
development program on family abuse and
violence’ will be available from 9 November
and is a Category 2 QI&CPD activity.
Log into gplearning or visit
www.racgp.org.au/familyviolence to learn
more about the program.
racgp.org.au
Emergencies: are you prepared?
To stay up-to-date simply register for a Clinical Emergency Management Program (CEMP) workshop today
For further details about workshops and to register, please visit racgp.org.au/cemp or contact 1800 626 901
5135
5Reprinted from Good Practice Issue 11, November 2017
Image R
AC
GP
New RACGP recruitment hub
The RACGP has launched recruitGP, the college’s
new platform for general practice employment
opportunities across metropolitan, rural, regional and
remote Australia. The platform provides job seekers
and employers a single source that allows them to
reach the RACGP’s 35,000 members, as well as
almost countless general practice stakeholders.
recruitGP is free for RACGP members and
Aboriginal and Community Controlled Health
Services, and requires a fee of $374 for
non-members, QI&CPD participants and all
student members.
Visit www.racgp.org.au/recruitGP, or contact
1800 472 247 or [email protected] for more
information.
RACGP events calendar
November 2017
VIC
Perform CPR – A workshop
for GPs
Thursday 9 November, 6.00–8.00 pm,
RACGP House, East Melbourne
Contact 03 8699 0488 or
VIC
Medication-assisted
treatment for opioid
dependence (MATOD)
Saturday 18 November, 9.00 am – 5.00 pm
(registration from 8.45 am),
RACGP House, East Melbourne
Contact 03 8699 0411 or
QLD
CPR workshop
Tuesday 14 November, 6.30–8.30 pm,
College House, Brisbane
Contact 07 3456 8933 or nicolette.
VIC
Clinical Emergency
Management Program
advanced
Saturday–Sunday 18–19 November,
8.00 am – 5.00 pm, Melbourne Parkview Hotel
Contact 03 8699 0557 or
NSW
Twilight online: Adolescent
and antenatal vaccination
Wednesday 15 November,
7.30–8.30 pm, online webinar
Contact 02 9886 4707 or
SA
Managing chronic pain and
complex injury claims
Tuesday 21 November, 7.00–9.30 pm
(registration and light dinner from 6.30 pm),
College House, North Adelaide
Contact 08 8267 8310 or
NSW
STIs and HIV:
Everybody’s business
Wednesday 15 November,
7.00–9.30 pm
(registration from 6.00 pm), Albury
Contact 02 9886 4703 or
TAS
Accredited CPR workshop
series 2017–19
Friday–Saturday 24–25 November,
6.00–7.00 pm (Friday); 9.30–10.30 am
and 10.30–11.30 am (Saturday),
College House, Hobart
Contact 03 6234 2200 or
VIC
Clinical Emergency
Management Program
intermediate
Friday 17 November, 8.00 am – 5.00 pm,
Melbourne Parkview Hotel
Contact 03 8699 0557 or
QLD
Introduction to point-of-care
ultrasound for rural GPs
Saturday 25 November,
8.30 am – 4.30 pm,
Bond University, Robina
Contact 1800 636764 or
NSW
Skin cancer
essentials – Central Coast
Saturday 18 November,
9.00 am – 5.10 pm, Gosford Hospital
Contact 02 9886 4703 or
VIC
Walking on thin ice:
Methamphetamine in
general practice
Tuesday 28 November,
6.30–9.00 pm, Wangaratta
Contact 03 8699 0411 or
Visit www.racgp.org.au/education/courses/racgpevents for further RACGP events.
Mandatory reportingThe RACGP has made a submission to the
Australian Health Ministers’ Advisory Council
regarding the Health Practitioner Regulation
National Law mandatory reporting requirements
for healthcare professionals.
The submission recommends that mandatory
reporting provisions be removed from all
states’ legislation. This is designed to allow
healthcare practitioners to enjoy the same level
of confidentiality as other patients when they
access medical treatment, particularly in the area
of mental health.
The RACGP is concerned that doctors
experiencing issues of mental health are reluctant
to seek help due to fear of being reported.
According to the current law in most states
and territories, treating doctors must inform the
Australian Health Practitioner Regulation Agency
(AHPRA) ‘if they have formed a reasonable belief
that a registered health practitioner has behaved
in a way that constitutes notifiable conduct’.
Western Australia does not have mandatory
reporting obligations and Queensland has local
adaptions to the requirements.
Visit www.racgp.org.au/yourracgp/news/
reports to access the full submission.
AMANDA LYONS
GPs have a crucial role in helping to curb Australia’s growing opioid problem.
Kim Ledger will never forget how
opioids irrevocably changed his life.
‘It was nine years ago, coming on
10 years ago, but to me it’s like it
was yesterday,’ he told Good Practice
as he recalled the death of his son,
28-year-old actor Heath, following an
accidental overdose in January 2008.
Heath Ledger was caught in a
punishing production schedule at the
time of his death, flying between three
countries and often filming scenes
in bitter cold. A chest infection soon
developed into pneumonia, and he
experienced insomnia.
Heath visited a variety of
doctors on his travels, collecting a
veritable cornucopia of prescription
medications, including opioids and
sleeping pills.
‘He took that combination, which
he was warned about by his sister
[Kate],’ Kim explained.
‘She said, “You can’t mix
prescription medication with Ambien,
you don’t know what that’ll do”. And
he said, “Katie, Katie, it’ll be fine”.
‘But that combination just happened
to put him to sleep forever.’
In combination,
the opioids, sleeping
pills and the chest
infection had a depressing effect on
Heath’s respiratory system, causing it
to shut down. He became a high-profile
casualty of what was then emerging as
a prescription opioid epidemic, which
includes the use of legal drugs such as
fentanyl and oxycodone.
This phenomenon has claimed
thousands of lives in Australia and
around the world.
While Heath’s death was the result
of a medication mix he didn’t realise
would exact such a heavy toll, other
opioid users have a more long-term
relationship with these types of drugs.
Many become unexpectedly hooked after
using them as a treatment for chronic
non-malignant pain.
‘The accidental addict,’ Kim said. ‘In
a very short space of time, people can
become addicted to oxycodone and
products like that.’
Such was the case of 30-year-old
nurse and mother of two, Katie Howman,
found dead following a fentanyl overdose
in her Toowoomba home just before
Agony ADDICTION MEDICINE
6 Reprinted from Good Practice Issue 11, November 2017
From left: Dr Evan
Ackermann feels GPs
are obliged to continually
monitor patients who
use opioids; Kim Ledger
became a founding
patron of Scriptwise, a
non-profit organisation
dedicated to reducing
prescription medication
misuse and overdose in
Australia, following the
death of his son, Heath. Images
Thin
kst
ock
; R
AC
GP
; K
im L
edger;
Hest
er
Wils
on
Christmas in 2013. Investigations
revealed she had visited 20 different
doctors and 15 different pharmacies
over the previous 13 months in her
search for opioids.1
Opioid overdose and dependence
has become such a problem in the
US – resulting in more than 90 deaths
a day – that it has been declared a
national crisis.2 Overdose deaths have also
increased in Australia, with the Australian
Bureau of Statistics’ (ABS’s) Causes of death,
Australia 2016 recording the highest number
of drug-induced deaths in the country since
the late 1990s.3
‘There were 1808 drug-induced deaths
in 2016, with those deaths most commonly
associated with benzodiazepines and oxycodone,’
James Eynstone-Hinkins, ABS Director of Health
and Vital Statistics, said.
So what has led us to this opioid epidemic, and
what can GPs do to help to curb it?
Too good to be true
In the late 1990s, prescription opioids seemed
like an ideal answer to the often-difficult problem
of chronic non-malignant pain.2
‘There was an
increased demand to
treat chronic pain. There
were very few options and
very little research that had
been done on this problem,’
Dr Evan Ackermann, a GP with
a special interest in opioids, told
Good Practice.
‘This was mixed with a situation of
some fairly aggressive drug company
marketing of opioids and a change of
clinical attitude towards pain. Normally,
pain would be part of the healing process,
but people started to say we should be
looking at pain as the “fifth sign” and
treating it aggressively.
‘It was a cultural shift across the
healthcare sector, from pharmacy right
through to general practice, specialists
and hospitals.’
Dr Simon Holliday, GP and Chair
of the RACGP Specific Interests Pain
Management network, is not surprised that
opioids were considered so effective.
‘If you or I or anybody took opium or
opioids, all our problems would go away.
They are cure-alls.’ he told Good
Practice. ‘We all feel great when
we use these drugs and they
relieve our symptoms.
‘But the problem is, it’s all short term
and we now know that our problems will
come back worse if we take this approach.’
The most obvious factor in the rise in
opioid use is the fact their long-term use
can lead to dependence, which in turn can
lead to the development of a substance-use
disorder. This occurs in part because users
become increasingly tolerant to the drugs’
effects, which means higher doses are
required to sustain the same level of relief.
Dr Hester Wilson, GP and Chair of the
RACGP Specific Interest Addiction Medicine
network, explained that increasing dosage
unsurprisingly comes with great risk.
‘If you are on a larger dose, anything
over 80 mg depending on how well you
are, you are at risk of overdose,’ she
told Good Practice.
A further complicating factor is that
patients often don’t recognise exactly what
they are experiencing.
‘It is hard to see dependency and
addiction in yourself,’ Dr Wilson said.
‘And because of the way that opioids
act in the brain, they affect the way people
think and feel. Their ability to recognise
and think, “Actually, this medicine is not
helping me very much, it’s causing me
problems”, is impaired.’
The right indications
Despite the problems surrounding opioid
use in Australia, these medications can still
have a valuable place in patient care, but
only for specific indications.
‘There is a lot of good evidence for the
use of opioids in severe, acute pain, for
treating malignancy and malignant pain,
and for treating patients who have drug
addictions or substance use disorders,’
Dr Ackermann said.
They can also have an important role in
palliative care.
‘Opioids are fantastic at improving dying,’
Dr Holliday said. ‘They really decrease
people’s anxiety and pain.’
However, Dr Ackermann advises GPs
to carefully reflect before prescribing for
chronic non-malignant pain.
‘GPs need to consider the adverse
effects and the possibility of drug misuse if
prescribing opioids at any stage,’ he said.
‘GPs are obliged to have a long-term
relationship with the patient and to
undertake monitoring.
‘If there are any signs of abuse, misuse
or dose escalation that GPs feel may be
ongoing, then they have a responsibility to
cut back [the prescription]. And if there are
signs of a substance-use disorder, then
they have the responsibility to organise the
appropriate services for that patient.’
While opioids offer a seemingly
straightforward solution for intractable
pain problems, many non-drug therapies
can also be considered for more
sustainable relief. >>
and ecstasy
7Reprinted from Good Practice Issue 11, November 2017
From top: Dr Simon Holliday wants GPs to be
better equipped to provide effective, multimodal
pain management; Dr Hester Wilson warns
against the instinct to label people affected
by opioid use as drug addicts and/or
inappropriate users.
8 Reprinted from Good Practice Issue 11, November 2017
Image A
nth
ony
Tass
one
ADDICTION MEDICINE
>> ‘Exercise movement has shown a lot
of benefits for all types of chronic pain,’
Dr Ackermann said. ‘The talking therapies,
mindfulness and cognitive behavioural
therapies are also good in managing chronic
pain. Also using the allied health field,
physiotherapists and occupational therapists.
‘All other medications have a role before
opioids and that still includes paracetamol
and the non-steroidal anti-inflammatories.
Even some topical therapies as well.
‘Opioids have a limited role and they really
are second or third line down the track.’
Dr Wilson has found that communicating
honestly with patients about the risks of
opioid use can also help them to consider
other options.
‘By the time we’ve been through all the
issues around the side effects of opioids,
the problems they can cause and things we
need to put in place, patients generally say,
“Actually, I don’t think I want to go for that,
I’m going to continue with the psychology
and the physio”,’ she said.
Given opioids can be a hot-button
topic and difficult to discuss with patients,
Dr Ackermann believes that stigmatisation
of the issue is not helpful and
patients should be approached in a
non-judgemental way.
Patients should not simply be labelled as
drug addicts and/or inappropriate users.
‘We’ve just got to be very careful as
practitioners that we treat these people
appropriately,’ he said. ‘And that is with
respect for those people who need services
for ongoing, genuine pain, and also for those
who have an iatrogenic dependence, or may
have a substance-use disorder.’
Dr Wilson agrees, illustrating her belief
with her own clinical experience.
‘There is a sense out there sometimes
that it’s just people choosing to do this,
that there’s a dichotomy between the
genuine pain patient and the bad drug user,’
she said. ‘My experience is that they’re the
same group of people.
‘Opioids interact with us as a species
in a particular way; all of us are at risk
of side effects and one of those major
side effects is dependency and addiction.’
Supports and possible solutions
One possible solution that has been
proposed to help prevent doctor-shopping,
such as that which Katie Howman practised,
and lower the rates of opioid overdose
is the implementation of a real-time
prescription monitoring (RTPM) system
throughout Australia.
RTPM is a software that will
monitor pharmacy-dispensing
records for all Schedule 8
medicines. These records will be transmitted
in real-time to a centralised database that
doctors and pharmacists will be able to
access during consultations. Tasmania has
had such a system – the Drugs and Poisons
Information System Online Remote Access,
or DORA – since 2012, and its operation has
been deemed a success.
The Victorian Government announced a
commitment in the 2016–17 state budget
to implement RTPM in the state, to be
rolled out in stages in 2018.4 Federal Health
Minister Greg Hunt has also announced a
national RTPM system to be implemented by
the end of 2018.5
Dr Ackermann is supportive of the
system’s implementation, but cautions that it
alone is not the whole answer.
‘We also have to look at policies,
procedures and standards in general practice
to make sure they are supporting GPs to
provide appropriate care,’ he said.
Anthony Tassone, President of the
Victorian Branch of the Pharmacy Guild of
Australia, agrees that RTPM is only part of
the overall solution.
The Pharmacy Guild of Australia’s Anthony Tassone
believes greater collaboration between GPs and
pharmacists is a key to helping patients affected by
opioid misuse.
New RACGP guidelinesThe third part of the
RACGP’s Prescribing drugs
of dependence in general
practice, focusing on opioids,
is scheduled to be released in
December. These guidelines
– broken into parts C1 and
C2 – have been developed
in response to increasing
community and clinical concerns
about the use and safety of
opioids. They are designed to
help GPs prescribe judiciously,
acting in accordance with
national and state regulations,
accountable prescribing, and
understanding pain and pain
management.
Visit www.racgp.org.au/
drugsofdependence for more
information.
9Reprinted from Good Practice Issue 11, November 2017
‘It is also essential to have
appropriate drug addiction treatment
and counselling services for patients
who have unfortunately developed a
dependency to prescription medicines,’
he told Good Practice.
‘Further health professional workforce
training in helping engage with patients
who may be seeking more frequent or
higher amounts of prescription opioids,
benzodiazepines or other substances,
and having referral pathways for other
assessment such as pain management
services, are also important.’
Tassone also believes that systems like
RTPM can help build closer links between
GPs and pharmacists.
‘Working collaboratively in open
communication is in the best interests of
the patient, and is something that doctors
and pharmacists do every day,’ he said.
‘Tools such as real-time prescription
monitoring and the further adoption of the
digital myHealth record will help facilitate
this further.’
Dr Ackermann advocates multidisciplinary
care and collaboration between GPs and
other health professionals.
‘GPs working constructively with
physiotherapists and utilising pharmacists
to assist the management of chronic
pain,’ he said.
What Dr Holliday would like to see –
and what he is working towards with a
project called TEMPO, the ‘time-efficient
management of pain in the office’ – is for
GPs to be equipped with the skills to provide
effective, multimodal pain management
in the practice.
‘Then GPs can deliver great pain care
to people very cheaply and accessibly,’ he
said. ‘There was a study which showed
that when excellent pain care is introduced,
it makes it a lot easier to facilitate
opioid tapering.6
‘So it’s a win–win; by introducing excellent
pain care in general practice, we should be
able to get people off the opioids.’
Dr Wilson believes that GPs can also have
a key part to play in treating substance-use
disorder itself.
‘In more and more states around Australia,
GPs are actually able to commence
buprenorphine as Suboxone, as a film
that goes under the tongue,’ she said.
‘In some states, GPs can continue the
prescription of methadone to people once
they’ve been started.
‘The evidence is clear that people do much
better on a structured program and that GPs
can be part of that, even if it is just continuing
to support their patient and getting them
to the nearest drug and alcohol treatment
service to get onto treatment and, once
they’re stable, continuing to support them.’
References
1. Coroner’s Court of Brisbane. Inquest into the death
of Katie Lee Howman. Brisbane: Coroner’s Court of
Brisbane, 2015.
2. National Institute on Drug Abuse. Opioid Crisis.
Maryland, USA: NIDA, 2017. Available at www.
drugabuse.gov/drugs-abuse/opioids/opioid-crisis#four
[Accessed 27 September 2017].
3. Australian Bureau of Statistics. Drug induced deaths in
Australia: A changing story. Canberra: ABS, 2017.
4. Department of Health and Human Services. Real-time
prescription monitoring. Melbourne: DHHS, 2017.
Available at www2.health.vic.gov.au/public-health/
drugs-and-poisons/real-time-prescription-monitoring
[Accessed 27 September 2017].
5. Greg Hunt. National approach to prescription drug
misuse. Canberra: Australian Federal Government,
2017. Available at www.greghunt.com.au [Accessed
27 September 2017].
6. Sullivan M, Turner J, DiLodovico C, D’Appolonio
A, Stephens K, Chan, Y. Prescription opioid taper
support for outpatients with chronic pain: A randomized
controlled trial. J Pain 2017;18(3):308–18.
hesta.com.au/no-butts
no butts about itWe’ve implemented a portfolio-wide tobacco exclusion.
Has your super fund?
Issued by H.E.S.T. Australia Ltd ABN 66 006 818 695 AFSL 235249, the Trustee of Health Employees Superannuation Trust Australia
(HESTA) ABN 64 971 749 321. Before making a decision about HESTA products you should read the relevant Product Disclosure
Statement (call 1800 813 327 or visit hesta.com.au for a copy), and consider any relevant risks (hesta.com.au/understandingrisk).
Supporter
2016
10 Reprinted from Good Practice Issue 11, November 2017
Images
Thin
kst
ock
; R
AC
GP
The young woman was in tears as she
entered her regular GP’s consulting room,
soon asking for a referral to a surgeon
for a breast augmentation. During the
subsequent discussion, it came to light
that the young woman’s partner had made
it clear her breasts were too small.
However, following a conversation about
relationships and body image, the young
woman decided she needed time to think
things over and discuss the issue with
friends, and that she would come back to
her GP if she needed further assistance.
Had she instead visited an online
medical service, inserted her concerns into
a standard questionnaire, she would not
have had the opportunity for that private
and more familiar interaction. The outcome
may have been very different.
Online services
People go online to do their banking, buy
movie tickets, order food, find someone to
do their gardening, and for nearly every other
thing in their lives.
Why, then, should they not do the same
when it comes to accessing prescriptions,
referrals and medical certificates?
‘The risk with online services performed
outside of the usual GP–patient relationship
is that they can fragment care and may not
provide continuous, comprehensive general
practice care to patients,’ Dr Edwin Kruys
told Good Practice.
‘The Australian GP model of care has
been very successful in keeping Australians
well and out of hospital. Patients who
maintain strong relationships with a usual
GP or practice team experience better
health outcomes.
‘Online services should enhance, not
dismantle, this successful model.’
These online medical services, such as
Qoctor, provide single-event services and can
be accessed by anyone, regardless of their
medical history.
Prescriptions, referrals and medical
certificates may be provided by doctors with
no previous knowledge of the patient and
minimal information by way of an online
questionnaire, and who require no subsequent
Virtual doctor
PAUL HAYES
Debate continues as to the quality and efficacy of online prescription, referral and medical certificate services.
ONLINE HEALTH
11Reprinted from Good Practice Issue 11, November 2017
Types of online servicesOnline services addressed in the RACGP’s ‘Online prescription, referral and medical
certificate services’ position statement include:
• prescription services, where a patient can access prescriptions online by choosing
medications from a website and completing a survey for assessment. Some surveys
may result in a doctor contacting the patient for more information. Medications
prescribed by these services may be delivered to the patient’s home
• referral services, where a patient can access a referral to a medical consultant
(ie other medical specialists) by completing a survey online
• medical certificate services, where a patient can be provided a medical certificate
(eg for days absent at work) by completing a survey online.
Visit www.racgp.org.au/support/policies to access the full position statement.
consultation with the patient. Patients can
access some services without speaking to a
doctor and are charged a fee (eg $20 for a
referral to a specialist).
‘These services cut out access to the
holistic elements of general practice,’
Dr Emil Djakic, GP and Deputy Chair of
RACGP Expert Committee – General Practice
Advocacy and Funding (REC–GPAF), told
Good Practice.
‘We train GPs to provide holistic care and
these services put in referral systems that
ignore the initial elements of providing this
type of care.’
The increasing prevalence of these online
services led the RACGP to release a position
statement in order to address the dangers the
college believes fragment patient care. (Refer
to breakout, above.)
‘General practice is characterised by
personalised, longitudinal care,’ RACGP
President Dr Bastian Seidel said.
‘These online services provide patients with
prescriptions, referrals or medical certificates
without sufficient understanding of their
medical history and social context, which is a
safety issue and may affect quality of care.’
The position statement outlines the
RACGP’s key issues on the subject:
• Online prescription, referral and medical
certificate services do not support
continuity of care.
• Online prescription services risk
patient safety.
• Online prescription, referral and
medical certificate services compromise
quality of care.
• Online prescription, referral and medical
certificate services increase complexity,
inefficiency and cost.
• Online prescription, referral and medical
certificate services may be used
predominantly as a profit-driven tool.
• The qualifications of doctors providing
general-practice-style online prescription,
referral and medical certificate
services are unclear.
Standard questions
There is genuine convenience in the
use of online medical services. The possible
fragmentation of care, however, can
present dangers for patients. In a
typical example of a patient using online
medical services, Sarah* travelled a risky
path to diagnosis.
Having accessed an online healthcare
provider, she received a referral for sleep
apnoea. Given no practitioner was present,
she missed out on the opportunity to have
checks on her blood pressure, body mass
index (BMI) and cardiovascular risk factors.
Had Sarah presented to her GP in person,
he or she would likely have determined
that a discussion about weight loss was
appropriate; however, this was missed when
she bypassed a physical examination for an
online consultation.
By using an online referral service with
an unknown provider, Sarah was referred
directly to a sleep study and recommended
continuous positive airway pressure therapy
(CPAP). She did not have the opportunity to
discuss reversible causes of sleep apnoea
and avoid unnecessary steps and treatment.
This type of scenario can lead to
contradictory recommendations from
unconnected doctors.
‘It becomes a patient safety issue. Without
access to the treating GP’s notes, the online
doctor has no means of otherwise confirming
the information provided,’ Dr Kruys said.
‘There is also no guarantee the patient’s
usual GP will be informed following a patient
accessing certain online services.’
A more established therapeutic relationship
also allows GPs a better understanding of
the person sitting in front of them.
According to Dr Nathan Pinskier, GP
and Chair of the RACGP Expert Committee
– eHealth and Practice Systems (REC–
eHPS), informal aspects in more familiar
consultations can be key to diagnosis.
‘In a normal consultation with the usual
care provider, the provider has access
to your medical record and there is a
relationship. There are verbal and non-verbal
cues that occur during a consultation
and those can’t occur online,’ he told
Good Practice.
Such a situation – where there is no
physical examination and the clock is often
ticking – can result in corners being cut,
Dr Pinskier argues.
‘If a patient presents [online] with, for
example, a sore throat, a headache and a
fever, the diagnosis may be an infection,’
he said.
‘It’s very difficult online to determine
whether that is viral or bacterial and, because
you haven’t conducted an examination,
whether or not antibiotics are provided. >>
From left: Dr Bastian Seidel is concerned online services may undermine the importance of the GP–patient
relationship; Dr Edwin Kruys believes fragmenting care via unconnected doctors can create a patient safety issue;
Dr Emil Djakic argues online services ignore key elements of general practice’s holistic care.
12 Reprinted from Good Practice Issue 11, November 2017
Images
RA
CG
P; A
ifric
Boyl
an
ONLINE HEALTH
>> ‘But, under the pressure of a
consultation, given it’s online, it’s more
likely than not … that antibiotics might
be prescribed.
‘There is a risk that doctors won’t adhere to
best practice guidelines.’
Patients, however, may not appreciate such
concerns and it is not surprising many want to
go online for at least some of their healthcare.
‘I get the impression that many patients
would appreciate conducting more of their
healthcare business from home or on the go,’
Dr Kruys said. ‘Used in the right way, online
services offer benefits.
‘For example, [there may be benefits] with
regards to greater flexibility for GPs,
alternative business models, reduced waiting
times, less travel time for patients and doctors,
and improved access for patients living in rural
areas or patients with mobility issues.’
Dr Pinskier agrees that online services can
be advantageous, but stressed the ‘used
in the right way’ aspect of their integration.
In the same way the RACGP is in favour
of after-hours healthcare being provided by
qualified GPs with a relationship with the
patient, so it is with online services.
‘If it integrates into the fabric of general
practice, then it can be made to work. Where
it’s a deputising arrangement, so your regular
doctor is not available and the service has
access to the medical notes, is acting as
a locum and standing in the shoes of the
regular doctor,’ Dr Pinskier said.
‘That can be complementary because
they may have some guidance from the
practice or the doctor in relation to managing
that individual.’
Staying in front of the future
According to Dr Aifric Boylan, GP and
CEO of Qoctor, online clinics are catering
to a specific healthcare need and the
general practice profession can benefit
from embracing the technology, rather than
swimming against the tide.
‘Online healthcare is already happening.
It’s not going to be a matter of choosing
whether to engage with it,’ she told Good
Practice. ‘It’s up to clinicians to be part of the
innovation or risk becoming sidelined.
‘Other entities will look to exploit the
opportunity of online healthcare, but
may not have the same experience or
ethos that healthcare professionals can
bring to the table.
‘Broadly speaking, people are managing
many aspects of their lives online. They are
seeking solutions to their health problems
via the internet, and the quality of answers
and solutions they find depends on whether
healthcare professionals are positioned to
meet them in this virtual space.’
Dr Boylan believes online healthcare
services and the standard questions they pose
to patients provide an opportunity to cover
areas that may slip through the cracks in the
course of a run-of-the-mill consultation.
A standardised digital approach, she argues,
helps to ensure every important question is
asked in the context of each treatment type.
‘There is no question that online healthcare
offers an opportunity to build in comprehensive
screening, where all key information is
gathered. It can also give the patient time to
reflect upon an answer, or to understand why
the question is being asked in the first place.’
Dr Pinskier understands the idea that
technology can be used in such a way, but
warns against the lure of ‘disruption for
disruption’s sake’.
‘Uber is championed as a great example of a
disruptive technology. That has created access
to immediate transport all over the world,’
he said. ‘However, Uber doesn’t turn a profit
and it has had problems in London around
quality and safety.
‘So some things that may, on the surface,
appear to be very desirable and feasible,
might have underlying issues that still need
to be sorted out.
‘We do need to embrace some of the
technology, no question about it. [And]
organisations like the RACGP need to be
strong and vigilant and develop appropriate
standards and processes.’
* Not her real name.
Telehealth servicesThe RACGP is not opposed to
primary care services provided
external to a general practice, but
rather wants to ensure they maintain
continuity of care and support
existing GP–patient relationships.
Its 2017 ‘On-demand telehealth
services’ position statement outlines
a number of principles for the use of
such services, including:
• on-demand telehealth services
should ideally be provided by a
patient’s usual GP or practice,
and only provided when deemed
appropriate by the GP
• on-demand telehealth services
should only be provided by doctors
with an appropriate level of
education and clinical competency
• on-demand telehealth
services should only be
provided to unknown patients
when appropriate
• patient notes should always
be sent to the patient’s usual
GP or practice.
Visit www.racgp.org.au/download/
Documents/e-health to access the
‘On-demand telehealth services’
position statement.
From top: Dr Nathan Pinskier understands the appeal
of some online services, but warns against ‘disruption
for disruption’s sake’; Qoctor CEO Dr Aifric Boylan
argues online services help to ensure comprehensive
screening by asking all important questions.
To meet the needs of our members, The Royal Australian College of General Practitioners (RACGP) has made
improvements to the planning learning and need (PLAN) activity.
Some features of the upgrade will include an enhanced reflective learning experience thanks to a new and improved
interface coupled with user-friendly navigation. Within PLAN, you will find tips and resources on how to get the
most out of your professional development.
For assistance, please contact the RACGP QI&CPD department on 1800 4RACGP | 1800 472 247.
The PLANactivity has been improved
518
3
Visit myRACGP and log in to racgp.org.au/myracgp
PLAN is a mandatory quality improvement activity worth 40 Category 1 QI&CPD points
Images
Thin
kst
ock
; B
ee H
ong L
o; B
ob D
avi
s
14 Reprinted from Good Practice Issue 11, November 2017
DISABILITY
Design for life
AMANDA LYONS
GPs want to know more about their role in helping eligible patients access the National Disability Insurance Scheme.
Resources and information for GPs• The RACGP has made a variety of submissions to the Federal Government with
general practice feedback on the NDIS. Visit www.racgp.org.au/yourracgp/news/
reports for more information.
• Inclusion Melbourne has put together a GP Statement of Evidence form for GPs to
fill out with patients. It is designed to provide people with disability clarity regarding
their NDIS assessment needs. Visit www.inclusiondesignlab.org.au/gpform for
more information.
• The Royal Australian College of Physicians has developed a comprehensive guide to
the NDIS. Visit www.racp.edu.au/ndis-guide-for-physicians for more information.
Stephen’s* parents are very optimistic about his
future as he takes his first steps into adulthood.
An 18-year-old man with Down syndrome,
Stephen leads a relatively independent life.
He is in his last year of high school, has good
communication skills and gets on well with
his peers. His parents believe that with some
employment training and support Stephen will
be able to get a job when he finishes school.
In order to help Stephen continue towards an
independent future, they make an appointment
to see their GP, who has known their son
since he was a child. As the family’s long-time
healthcare provider, their GP is the first point
of contact in accessing the National Disability
Insurance Scheme (NDIS) so Stephen can get
the ongoing support he will need to live a more
self-sufficient life.
‘GPs are involved in supporting their patients
with disability throughout their life,’ Adj Assoc
Prof Bob Davis, GP and Chair of the RACGP
Specific Interests Disability network, told
Good Practice.
‘They are there when the diagnosis of the
person’s disability is made, they are there in
support as patients go through school and into
the workforce with an adult support service, right
into aged care.’
There are close to 460,000 people in Australia
under 65 who live with at least one permanent
and significant disability.1 The funding and delivery
of care for these people has undergone an
enormous change since July of last year, with the
nation-wide rollout of the NDIS.
The introduction of such a major scheme
has not altered GPs’ importance to the care of
patients with disability. However, despite their
central role as assessors of patient eligibility,
the majority of GPs recently polled by the RACGP
reported feeling they had not received adequate
information about the scheme, and did not feel
supported in providing the required services or
evidence for patients.2
‘The NDIS has little widespread input from
general practice and none of the packages invite
GP feedback,’ an RACGP member said at a
GP advocacy network meeting in Newcastle
in September this year. Given such concerns,
what key information should GPs know about
the NDIS?
Purpose
The provision of disability funding and care
in Australia prior to the NDIS tended to be
somewhat piecemeal.
‘For example, if you acquired your disability
through a road traffic accident, everything was
supplied. But if you have disability from birth,
then you had no coherent support, with services
provided through various government agencies,’
Adj Assoc Prof Davis said.
‘The other issue was that patients tended to
go from one process or transition point to the
next with no clear plan, so services needed to be
made on the run.’
As a national system for a very broad
population, the NDIS is designed to be ‘person-
centred’ and tailored to individual needs.
‘People with disability have the same right as
other Australians to determine their best interests
and have choice and control over their lives,’
Chris Faulkner, General Manager Operations
for the National Disability Insurance Agency
(NDIA), the body responsible for the rollout,
implementation and administration of the NDIS,
told Good Practice. >>
15Reprinted from Good Practice Issue 11, November 2017
From left: Paediatrician Dr Bee Hong Lo has found people with disability usually feel most comfortable with their GP as their main
healthcare contact; Adj Assoc Prof Bob Davis feels the NDIS represents a positive shift towards ‘person-centred’ disability funding
and care in Australia.
16 Reprinted from Good Practice Issue 11, November 2017
Image N
atio
nal D
isabili
ty Insu
rance
Agency
DISABILITY
>> ‘The NDIS recognises that everyone’s
needs and goals are different, and provides
people with disability with individualised
support and the flexibility to manage their
supports to help them achieve their goals and
enjoy an ordinary life.’
The shift towards a person-centred model
is also reflected in funding distribution.
‘Previously, individual service providers would
be funded and patients would go to them
for that service,’ Adj Assoc Prof Davis said.
‘Now, the funding comes from the individual
and the individual can purchase the service
from these providers.’
The GP’s role
While a person with disability is likely to
receive treatment from a range of specialists,
their GP remains the key practitioner in
their lives.
Dr Bee Hong Lo, a developmental
paediatrician, has found patients often
feel more comfortable with their GP as
healthcare ‘point-person’ when dealing with
issues of disability.
‘A lot of parents who have children with
disability or developmental delay, their first
approach is to their GPs,’ she told Good
Practice. ‘Even if they’ve been referred to the
paediatrician by their GP, many choose not to
go back to the paediatrician.’
This gives GPs a central role when
evidence is required to support a patient’s
access to the NDIS. This process may
involve completing the ‘supporting evidence’
section of the NDIS Access Request form;
documenting that the patient has, or is
likely to have, a permanent disability; and
confirming the extent to which the patient
has a significant disability-related impairment
through the provision of copies of relevant
reports or assessments.
In Stephen’s case, the Access Request
form included questions about his mobility,
motor skills, communication, social interaction,
learning, self-care and self-management.
His GP was able to use records of
Stephen’s assessments over the years,
including one from a paediatrician and copies
of an intelligence test (WISC–IV), in order to
complete the form more accurately.
Once a patient is granted access to the
NDIS, a local area coordinator or NDIA
planner will help develop a plan for use of the
funding. These plans are structured according
to outcomes and funding categories, and
explain how the funding itself is expected to
help the person with disability.
While GPs are not directly involved in
developing the plan, familiarity with it can be
helpful for ongoing care.
‘It may be useful to be aware of what
services can be purchased by the patient
with NDIS funds, as they may complement
those available through Medicare; for
example, supports over and above services
that can be accessed through a mental
health plan,’ he said.
RACGP members have reported
frustration that the NDIS does not inform
them regarding whether patient applications
have been successful, and nor do GPs
automatically receive a copy of their patients’
plans. There is also concern that patient
assessments for the NDIS will themselves be
too time-consuming and costly, but Faulkner
reassures that they are intended to fit into a
GP’s normal timetable.
‘GPs are expected to complete an Access
Request form during a consultation, paid
through Medicare,’ she said.
Adj Assoc Prof Davis provides further
detail on how GPs can seek remuneration for
extra time taken on NDIS assessments.
‘Chronic disease management [Medicare]
items facilitate GPs’ involvement in the
development of management plans, team
care arrangements and case conferencing,
which really tie into the types of support that
NDIS provides,’ he said.
‘The other thing GPs need to be aware of,
especially if their patients have an intellectual
disability, is that they will have access to
annual health assessment items 703, 705
and 707. They can use those to follow up on
their patients.’ (Refer to breakout, left, for
more information on MBS items.)
In addition to the individual patient-focused
aspect, the NDIS has a second side that
is focused on information, linkages and
capacity-building (ILC). The purpose of
ILC is to facilitate inclusion for people with
disability by funding organisations to carry
out activities at a community level.
Issues and concerns
However good the intentions, the NDIS
rollout has not been without its problems.
One of the most pressing issues is the
challenge of providing information for NDIS
access, as many eligible patients have a
complex medical history.
‘Often the patient has more than one
disability. They may have an intellectual
disability, problems with vision and hearing
and even a psychiatric disorder, all of which
might impact on their ability to participate in
the community,’ Adj Assoc Prof Davis said.
‘It’s important GPs cover all of those.’
Adj Assoc Prof Davis has worked with
Inclusion Melbourne, a service for adults with
intellectual disability, to provide a resource
that helps GPs include the correct information
in NDIS applications. However, NDIS
staff members can also have issues with
information collection.
‘For instance, a young man with Down
syndrome was interviewed over the phone
[by an NDIA planner] about his disabilities,’
Adj Assoc Prof Davis said. ‘He was quite
articulate and over the phone you would think
he knew what was going on. But his resulting
plan did not include the fact that he was blind.
Chris Faulkner of the National Disability Insurance
Agency believes her agency has had success in
building relationships with GPs.
MBS itemsItems 703, 705 and 707 are all
time-based MBS health assessment
items and can be applied for people
with intellectual disability. Chronic
disease management items 721,
723, 729, 731 and 732 enable GPs
to plan and coordinate healthcare
of patients with chronic medical
conditions, including those who
require multidisciplinary care.
Visit www.health.gov.au for
more information.
17Reprinted from Good Practice Issue 11, November 2017
‘That is an extreme example, but the
problem is, once the plan is set up, it can be
difficult and take some time to change.’
Dr Lo emphasised that early
intervention in childhood disability is
often handled differently from adult disability
under the NDIS, with more focus on its
ILC aspect, because childhood conditions
can often be subject to change and may
not end up being lifelong. This can be
another point of confusion for patients,
who are often overwhelmed by a surfeit
of information related to the NDIS – even
when it may not actually apply to them or
their family.
‘People don’t understand and they think,
“If my child has poor fine-motor skills, or is
slow in developing language, or might be
a bit deaf, I can get NDIS funding”,’ Dr Lo
said. ‘But that’s often not the case at all.’
Similarly, Adj Assoc Prof Davis has also
found that some GPs and patients can be
confused as to what does and does not
qualify for NDIS funding.
‘NDIS will fund a physiotherapist and
[occupational therapy] where the issue
would be access to the community, but
it may not fund it in that post-operative
recovery period in which one would expect
health to be involved,’ he explained.
While these distinctions may seem
confusing, they arise from the fact that
that NDIS is intended to complement the
mainstream health system rather than
replace it. Under this rationale, NDIS
funding is provided for supports that help
people to overcome disabilities in their
day-to-day lives, such as aids, equipment
and home modifications. This also extends
to allied health and other therapies,
including physiotherapy, speech therapy or
occupational therapy, for care specifically
related to the disability.
Conversely, the diagnosis, assessment
and treatment of health conditions
remains the responsibility of the health
system. This includes clinical services,
such as GPs, hospital care, surgery,
specialists, dental care and medications.
Sub-acute care such as palliative and
post-acute care, including nursing care
and wound management, also falls
under this category.
RACGP members’ most common
criticism of the NDIS remains its lack of
consultation and communication with GPs.
In response, Faulkner said the NDIA has
had success in building GP understanding
and connections through regular meetings
with Primary Health Networks.
It remains to be seen how the relationship
and information-sharing between the
NDIA and GPs will develop as the scheme
continues to take its place in Australian
healthcare. But Adj Assoc Prof Davis
believes that, despite initial problems,
the NDIS will ultimately have a positive
impact on the provision of care for patients
with disability.
‘The NDIS is quite a monumental change
in the approach to disability and, as GPs,
we can facilitate the process and use it for
benefits to patients’ health,’ he said.
* Not her real name.
References
1. National Disability Insurance Agency. A GP’s guide
to the NDIS. Canberra: NDIS. Available at www.ndis.
gov.au/people-disability/fact-sheets-and-publications
[Accessed 4 October 2017].
2. The Royal Australian College of General Practitioners.
In practice newsletter, 28 July 2017. East Melbourne,
Vic: RACGP, 2017. Available at www.racgp.org.au/
yourracgp/news/inpractice/28-07-2017 [Accessed 4
October 2017].
Can you identifythe warning signs of family violence?
Listen between the lines. Family violence is
hard to talk about.
visit racgp.org.au/familyviolence to find out more
PAUL HAYES
‘So, what are your special interests?’
A common question asked of many GPs.
For long-time Tasmanian GP Dr David
Knowles, this line of enquiry stirs some
emotions about his love for general practice
and serving his community.
‘I often get asked and I always find it hard
to answer. I thrive on the comprehensive
and continuous care that I can provide in my
practice,’ Dr Knowles, the 2017 recipient
of the RACGP’s Rose-Hunt Award, told
Good Practice. ‘I see a lot of people with
diabetes and we run a dedicated nurse-led
clinic at our practice, I see a lot of patients
with haemochromatosis and manage their
venesections, I do dedicated travel sessions.
‘My community influences my skillset.’
This attitude also influences Dr Knowles’
approach to education, especially fitting
given his is also the RACGP’s 2017 General
Practice Supervisor of the Year.
‘I want to inspire our medical students and
registrars, just as I have been inspired by my
mentors,’ he said.
As a person who describes himself as ‘not
someone who likes the limelight’, Dr Knowles
took the news of winning the Rose-Hunt,
the RACGP’s highest accolade, in his stride,
though the significance of the award was
certainly not lost on him.
‘I am honoured and humbled that my
peers and the RACGP would deem I was
worthy of this award. Many of my GP heroes
and mentors are previous winners of this
prestigious award and to be included on a
list with them is hard to fathom,’ he said. ‘I
am actually delighted that my college would
have chosen someone who works more in
the background and whose primary job is
at the coalface.
‘I think for every member who is out there
working with their communities, this year’s
award is a recognition of what they do,
because that is what I do and I know this is
valued by our college and our Council.’
While the Rose-Hunt is a major honour,
acknowledgement as a general practice
supervisor ‘sits most comfortably’.
‘To be recognised for this role is a great
honour,’ Dr Knowles said. ‘Our practice
creates an environment where everyone
aims to be the mentor, and we create
an environment where medical students,
registrars, nursing students and pharmacy
students feel comfortable to ask any question,
challenge themselves and learn.
‘Is does not take long for everyone
to realise they are teachers themselves.
I am taught something new every time
I turn up to work.’
Amanda BethellWhen she answered a middle-of-the-day call
from RACGP SA&NT Immediate Past Chair
Dr Daniel Byrnes, Dr Amanda Bethell wasn’t
really expecting any big news. She certainly
wasn’t expecting to learn she had been
named the RACGP’s 2017 GP of the Year.
‘I didn’t know I’d been nominated, so it took
me a few minutes to adjust because I didn’t
know what the hell he was talking about,’ she
told Good Practice.
The news, however, was certainly
not unwelcome.
‘It’s pretty exciting.’
As an experienced rural GP, Dr Bethell’s
initial thoughts about taking up a life in
medicine were shaped (rather appropriately,
as it turned out) by what she saw in television.
18 Reprinted from Good Practice Issue 11, November 2017
This year’s RACGP award winners show some of the
best of general practice in Australia.
Honourroll
RACGP AWARDS
Image x
xxxx
XXX
‘My only knowledge of medicine was from
watching TV shows A Country Practice and
The Flying Doctors. As far as I was concerned,
that was medicine,’ she said.
Dr Bethell now practises in the rural South
Australian town of Port Augusta, about 320 km
north of Adelaide with a population of close to
14,200 people. She is very comfortable in this
type of setting and is drawn to the nature of
healthcare delivery it affords.
‘I really love the diversity. I like that in general
practice you get to meet the whole breadth
of humanity – different cultures, different
ages, a whole bunch of different health
problems,’ she said.
‘I love the intellectual challenge of seeing
undifferentiated problems; if you are a
sub-specialist you already know what a
problem is when it comes to you. I love, in
rural general practice, the ability to do both the
clinical work and the hospital work.
‘Since moving back to Port Augusta in the
last six years … I have to use so many different
skills that there wasn’t a call for in [my time in]
the city because people were going to different
places for different things.’
Dr Bethell also loves to express this love of
rural healthcare when she is teaching medical
students and general practice registrars.
‘I spend my whole time telling them that
rural general practice is the only way to go,’
she said.
‘I like the role of a mentor; I learn from the
registrars as well as they learn from me and, I
hope, the medical students.
‘A lot of the time my medical students
are at a stage where they have got all of their
[academic] knowledge, so you are seeing them
start to apply that and actually think about how
they would manage a situation, and helping
them with their practical skills.
‘So being able to, for example, take
somebody from not being able to take bloods
to being able to put a drip in really well.
‘That kind of thing is very satisfying.’
Adelaide Boylan Much like her fellow South Australian,
Dr Bethell, general practice registrar
Dr Adelaide Boylan has an immediate response
when considering what she loves about
general practice.
‘The diversity,’ she told Good Practice.
‘The opportunity to see different people at
different stages of their lives, with different
problems all day long.’
As the RACGP’s 2017 General Practice
Registrar of the Year, Dr Boylan has
embraced all that comes with entering
primary healthcare.
‘I think the diversity is so enjoyable and
makes for such interesting days, but it can
also be terrifying and a bit overwhelming at
times,’ she said. ‘It’s proven to be challenging,
but I love it.’
That diversity extends beyond the consulting
room for Dr Boylan, who divides her time
between a number of different areas of
healthcare. A typical week includes time at
a a private family general practice, in aged
care, and engaging in teaching and content
development at Adelaide University.
‘That’s the nice thing about being a
GP – having your finger in lots of different,
interesting pies. It keeps your mind open in
doing different things, while also being there
enough to contribute properly,’ she said.
Having trained and worked as a lawyer prior
to entering medicine, Dr Boylan has found
such a background can come in handy in
her new vocation.
‘I think my law training has been a good
background in communication aspects of my
job, having a little bit of an idea about risk
management and probably being less fearful of
the legal system,’ she said. ‘Sadly, in medicine
now people are terrified of the medico-legal
consequences of their decisions.
‘Hopefully that will change over my
professional lifetime.’
While she has only been in general
practice for a few years, Dr Boylan has
already experienced some of the best the
profession has to offer.
‘I’ve just come back to working at a
practice that I haven’t worked at since 2014.
It’s been particularly lovely to see a lady who
has had lots of problems with fertility, who
has had two babies in the interim,’ she said.
‘And also some adolescents and people in
their early 20s who were struggling with some
mental health problems, who have come
through the other side of that and seem to be
doing a lot better.
‘That’s really nice, to come back and
observe them after having not seen them
for a few years and feel like maybe you
were slightly involved in helping them
overcome that problem.’
Atticus Health Carrum
While some monikers are undoubtedly more
creative than others, general practices are
often furnished with names that are rather
straightforward – banal, even.
Melbourne’s Atticus Health Carrum,
however, is not one of those practices.
‘The practice was named after Atticus
Finch from the novel, To Kill a Mockingbird,’
Dr Floyd Gomes, GP and practice founder,
told Good Practice.
As Dr Gomes explained, lawyer
Atticus Finch’s efforts in defending
Tom Robinson, a black man in America’s
south in the 1930s, went a long way
in helping to determine the practice’s
overarching philosophy.
‘Atticus Finch has very little vested interest
in supporting this individual per se. He did it
as a statement of ethics,’ Dr Gomes said. ‘He
was happy enough to support an individual in
the midst of a lot of backlash.
‘The other part of that is to really empathise
or understand people from their points of
view … to try and take your lens off of the
world. I think that is the main thing that
we strive for at the practice, to try our very
best to view the world through the eyes
of our patients.
‘On the back of our business card, there is
a quote from the novel: you can’t understand
a person until you walk in his shoes.’
All of the staff members at Atticus Health
Carrum go to considerable lengths to live up
to this ideal, regularly working outside of the
practice to provide the local community with
high-quality healthcare services. This sees
them visit retirement villages, nursing homes
and even secondary schools.
‘We try to make it as efficient as possible,
but there are challenges in working in those
environments, be they IT or scheduling, that
add a layer of complexity when trying to get
out of the clinic and into the community,’
Dr Gomes said.
‘That takes people’s willingness to
be involved.’ >>
From left: Dr Amanda
Bethell was delighted to
learn she was named the
GP of the Year – even
if she didn’t know she’d
been nominated;
Rose-Hunt winner
and General Practice
Supervisor of the Year
Dr David Knowles
considers general
practice a special
interest unto itself;
General Practice
Registrar of the Year
Dr Adelaide Boylan has
embraced the challenge
– and excitement – of
primary healthcare.
19Reprinted from Good Practice Issue 11, November 2017
Images
Thin
kst
ock
; R
AC
GP
; A
manda B
eth
ell;
Adela
ide B
oyl
an
20 Reprinted from Good Practice Issue 11, November 2017
Images
Attic
us
Health
Carr
um
; C
hris
Harr
ison; G
ippsl
and P
HN
; D
enis
e P
ow
ell
RACGP AWARDS
2 nted from Good Practice Issue 11, N
CGP AWA
>> All of this effort is what makes
being named the RACGP’s 2017 General
Practice of the Year all the more validating for
Atticus Health Carrum.
‘It’s mainly at a team level because a lot
of members at Atticus Health Carrum go
outside their usual work, and it recognises
that extra effort that they put in outside the
clinic boundaries,’ Dr Gomes said. ‘The award
recognises that is something special that
they are doing.’
In addition to all of the work done externally,
the practice itself offers something of a single
point of access for locals.
‘We provide a range of different services
– GPs, specialists, a gym with an exercise
physiologist onsite, podiatry, psychology,
dietetics, massage,’ Dr Gomes said.
Atticus Health Carrum is also a teaching
practice, with general practice registrars
playing a key role in its services. This offers
the opportunity to not only educate the next
generation of doctors about the facts and
figures of healthcare, but also some of the
values behind its delivery.
‘I have a saying that I share with
registrars: remaining relentlessly solution-
focused,’ Dr Gomes said. ‘That has been the
mantra of our clinic and the way we do things
– to see things in an “as is” form, warts and all,
even though that is difficult at times, and find a
solution to that reality.’
Denise Powell
As GPs are often wont to do, Dr Denise
Powell’s first instinct was to defer praise when
discussing winning the 2017 RACGP Rural
Brian Williams Award, which acknowledges
a practitioner whose guidance and support
enables rural GPs to dedicate themselves to
their patients, families and communities.
‘It is a great acknowledgment of the work
that my colleagues have done,’ she told Good
Practice. ‘I was very surprised and honoured
that they thought enough of rural women to
nominate me when they have also done the
same amount of work towards progressing
rural medicine that I have.’
A long-time resident and GP in
Queensland’s Bundaberg region, Dr Powell
initially planned a career in psychiatry, but
came to love the frontline aspect of rural
general practice.
‘As I was progressing through medicine
as a student, I believed in my great naiveté
that it would be more useful to try to work
with people at the beginning rather that at
the significantly progressed and end stages
of mental health,’ she said. ‘I think working in
general practice suits me best.’
Dr Powell is passionate about general
practice education, and not just for medical
students and general practice registrars.
‘I think developing general practice for
people other than doctors is really important,
so I have had a number of nurses and a
physician’s assistant train in my practice,’ she
said. ‘Most of my administrative staff have
qualifications as medical assistants.’
Cassie Rickard
Gladstone Street Medical Clinic’s Dr Cassie
Rickard, the RACGP’s 2017 Rural Registrar
of the Year, has made herself a valuable
part of the workforce in Victoria’s Gippsland
region. A commitment to rural healthcare
has been evident from her time as a medical
student, seeking out remote placements in
East Gippsland and the Northern Territory.
‘I was impressed by the scope of practice
offered by rural GPs, and the satisfaction
of working in a small community,’ she told
Good Practice. ‘I feel privileged to share
patient journeys.’
Dr Rickard balances part-time practice
with teaching through Eastern Victoria (EV)
GP Training and the Monash School of Rural
Health. While acknowledging the difficulties of
medicine, Dr Rickard found being named the
Rural Registrar of the Year helped validate her
efforts and sacrifices, as well her husband’s.
‘I also feel it recognises the efforts of
mentors and colleagues, who inspired and
supported me and helped make me the doctor
I am today,’ she said.
Honorary MembershipOriginally a psychologist, Dr Chris
Harrison has contributed much
to general practice. Receiving
the RACGP’s 2017 Honorary
Membership Award has helped
him feel even more a part of the
profession.
‘As a non-clinician researcher, it
really is an honour,’ he told Good
Practice. ‘This award makes me feel
like I am part of the club.’
Dr Harrison has been heavily
involved in general practice research
for 15 years, having worked as
a senior analyst on the Bettering
the Evaluation and Care of
Health (BEACH).
Dr Harrison has published almost
100 journal articles, contributed to
23 books and delivered close to 60
conference presentations, including
GP17, on the results of his research.
From left: Practice of the Year Atticus Health Carrum tries to see problems through patients’ eyes; Dr Chris Harrison said the Honorary Membership Award makes him feel ‘part of the
club’; Rural Registrar of the Year Dr Cassie Rickard also works to educate medical students; Brian Williams winner Dr Denise Powell believes her award is a reflection of her colleagues.
shareGP Australia’s fi rst GP professional collaboration space
Use your RACGP credentials to log in
sharegp.racgp.org.au
sharegp.racgp.org.au
more than
28,000total log-ins
over
2,000General practice discussions
6m 15saverage view time
more than
13,000total members
“ ”
4824
GP PROFILE
The apple, as they say, doesn’t fall far
from the tree.
Rural GP Dr Michael Bartram’s mother
and father were doctors, which was one
of the catalysts for him to follow in the
footsteps of his role models and pursue a
life in medicine.
‘I was impressed by what they were
doing and the way they were doing it. They
were very passionate about their work,’ he
told Good Practice.
With this guidance to help lay the foundations
for Dr Bartram to study medicine, he recalls his
parents’ haste to also teach him that life is ‘not
all beer and skittles’.
By witnessing them trying to maintain that
balance between their family and professional
lives, Dr Bartram felt he was at least somewhat
prepared for the demands of life as a healthcare
practitioner.
‘I didn’t suffer any illusions that [being a
doctor] was going to be an easy job, but it
made me aware of not over-committing myself
along the way,’ he said.
Upon deciding on his career path, Dr Bartram
moved away from his hometown of Albury, in
southern New South Wales, to study medicine
at the University of Newcastle, graduating in
1988. With an initial interest in paediatrics, he
spent the next six years working in children’s
wards and emergency departments in various
hospitals around Sydney.
Soon after, Dr Bartram realised that primary
healthcare was his calling. He re-admitted
himself into general practice training and
spent six months based in the local hospital in
Coonabarabran, in north-west NSW.
This was a period Dr Bartram enjoyed,
particularly as he was still able to use some of
his paediatric skills.
‘On one occasion, my boss’ three-week-old
daughter had bronchiolitis so they called me in.
I ended up ventilating her because they realised
I was up to the challenge,’ he said. ‘I think my
paediatric skills were a good start to general
practice – they gave me a confidence in other
areas that I wouldn’t have otherwise had.
Images
Mic
hael a
nd A
nn B
art
ram
22 Reprinted from Good Practice Issue 11, November 2017
Family MORGAN LIOTTA
Dr Michael Bartram’s roots lie in rural medicine, where he continues his parents’ legacy.
‘For as long as I can
remember, I’ve been
fascinated with all things to
do with the human body and
human conditions, so general
practice was really something
I wanted to get in to.’
Dr Bartram continued
to work in general practice
around NSW, gaining valuable
experience along the way.
He finished his training and
started a private practice in his
hometown of Albury, where he has now been
for close to 20 years.
‘The lifestyle in a country area is great for
a young family,’ he said. ‘Our kids had plenty
of opportunities and have benefitted from
that over the years.
‘With my general practice training I
would have been happy moving anywhere
in the area, but my wife and I decided
that being close to family in Albury and
having opportunities for our family was an
important facet.
‘And I always really enjoyed the cradle-
to-grave care in general practice, having
ongoing relationships with the patient over a
number of years.
‘You see people grow up through good
times and hard times, and share that with
them. That’s the thing that stimulates me
and keeps me wanting to do it.’
Community support
Once established as a rural GP in
Albury, Dr Bartram became aware of
a workforce shortage and issues of
burnout occurring among some of his
colleagues in the area.
He soon saw an opportunity to start
an after-hours clinic, giving patients more
healthcare choices and allowing GPs the
chance to keep more regular hours.
‘I did my homework, talked to people
in the neighbouring regional towns who
started up a successful model,’ he said.
‘We got the GPs in town together and
managed to get a grant and an after-hours
clinic off the ground. We’re here 10 years
later, still going strong with nearly 50
doctors on the roster.
‘I think that’s been a helpful experience
for all the GPs in town and it makes family
life a bit easier.’
Initiatives such as these have helped to
bring Dr Bartram satisfaction in knowing
that he is contributing positively to the
local community.
‘[Opening the after-hours clinic is]
an example of how you can see things
happening in a place this size and make
a difference,’ he said. ‘Being in a place
this small, you can get involved, have an
influence and see it all happen.’
Dr Bartram also derives great
satisfaction from his involvement with
general practice training, an area about
which he is passionate.
‘I enjoy seeing other people get a kick
out of what they are doing, hearing their
enthusiasm,’ he said.
Dr Bartram regards his role as a trainer
as a reciprocal one, learning skills himself
while teaching the students and general
practice registrars.
‘Having people who are learning and
asking questions, and then seeing them
grow brings me the challenge of having to
keep using my knowledge and having to
push myself a bit.’
He also attributes some of this experience
to his fellow trainers and general practice
supervisors.
‘You get advice and respect for what you
do, so it’s a great team feeling,’ he said.
‘If you enthuse enough people, others step
in and take over as well. Together we are
teaching the art of general practice.’
Now well and truly established as a rural
GP, Dr Bartram is content knowing that he is
an integral part of the community of which
he and his family form a key part.
‘Seeing my patients, it’s a great pleasure
and a privilege, but it’s only part of what gets
me up in the morning,’ he said. ‘I like to try
and make sure that everyone who needs a
bit of extra help has that available as well.
That keeps me going.
‘It’s lovely to get some recognition of the
work that you do.
‘The teaching and the time that you put
into these things – it’s a life job.’
23Reprinted from Good Practice Issue 11, November 2017
tiesI’m a member because …
Being a GP, as one of my
registrars has recently pointed out, is
hard. It is certainly a challenge to keep
on top of the variety of presentations
and then solve problems or address
issues with the resources at hand and
the networks we build over time.
My affiliation with the RACGP has
been one avenue of support and a
conduit to finding enthusiastic and well-
informed colleagues. The opportunity
provided through its training program
to teach and mentor young doctors,
and share my passion for my craft,
has been enriching over many years,
enabling me to continue to grow and
feel part of a broader community.
– Dr Michael Bartram, RACGP
member since 1989
IN MY PRACTICE
Gem of the northMORGAN LIOTTA
Preston Family Medical Practice prides itself on a personalised and holistic approach to community-based healthcare.
The biscuits and spanakopita supplied by the
Greek community of Preston, a suburb in
Melbourne’s inner north, may just be the best
homemade goods in town. At least they are
according to local GPs Dr Michelle Leadston
and Dr Catherine Keaney.
These treats, often brought in by patients,
represent just one of many perks of practising
at Preston Family Medical Practice, which is
part of the Independent Medical Practitioners
(IPN) group. Dr Leadston and Dr Keaney
view the personal relationships they have
formed with their patients over the course of
people’s lives as even more rewarding than
delicious biscuits.
‘I enjoy getting to know all of our patients
and their families,’ Dr Leadston told Good
Practice. ‘I find it interesting now that
I’m looking after grandchildren and great
grandchildren of some of the previous patients.
‘I like having a chat and enjoy the intellectual
challenge of trying to figure out what’s going
on [with each patient].’
The suburb of Preston has seen significant
changes in recent years. The wave of
gentrification has surged to Melbourne’s
north, with older generations moving out and
younger professionals and families moving in.
Many of the homes that were built to
accommodate the influx of predominately
European post-war immigrants are
being either taken over by the next
generation or knocked down to build more
modern townhouses.
Although this type of shift is inevitable
and the evolution of the local demographic
means the practice is increasingly catering
to younger families, Preston Family Medical
Practice remains home to many older patients.
Almost nine out of every 10 patients hold
either a Health Care Card or Pensioner
Concession Card.
‘We see a lot of older patients from
that post-war era. It’s very multicultural,’
Dr Leadston said. ‘We’re now looking after
four generations in one family, who have been
coming to our practice for about 40 years.’
Holistic care
Preston Family Medical Practice currently has
up to six full-time GPs, as well as two general
practice registrars, two practice nurses, a
practice manager and a handful of reception
staff members. The clinic is able to offer
services such as intrauterine device (IUD)
insertions and vasectomies, acupuncture and
shared pregnancy care.
‘There’s some procedural stuff that might
be outside of the usual city-based general
practices, where there are specialists readily
available who might do that,’ Dr Keaney told
Good Practice.
‘It’s about accessibility for our population
base – those [procedural] things are really
important to access.
‘We aim to provide that one-stop shop.’
This ‘one-stop shop’ helps to support the
local community, particularly those who use
concession cards. These patients can
get procedures done with their trusted family
GP, and be bulk billed for it, rather than
potentially paying more to see a specialist.
24 Reprinted from Good Practice Issue 11, November 2017
Images
Pre
ston F
am
ily M
edic
al P
ract
ice
Above: Preston Family
Medical Practice aims
to provide local patients
with a one-stop-shop for
healthcare. Right: Dr Cath
Keaney (L) and Dr Michelle
Leadston (R) value the
diversity – and homemade
snacks – patients bring to
the practice.
25Reprinted from Good Practice Issue 11, November 2017
The clinic is also hoping to
expand its allied health services
to better provide for the varied
patient demographic
of older residents and
younger families, and to
embrace a growing focus on
team-based healthcare.
‘It will be great to have us all
in the one building to be able
to facilitate the communication
and holistic approach to any of
our patients, so we’ve got the
capacity to address issues as
they come up,’ Dr Keaney said.
Fresh eyes
Preston Family Medical Practice
takes great pride in its history
of teaching general practice
registrars, who help add to the
practice’s range of services.
‘We are an accredited practice and teaching
is a significant part of that,’ Dr Leadston said.
‘One of our doctors who recently retired has
seen 150 registrars in his time, including
myself,’ Dr Keaney added.
‘We certainly see the medical students and
registrars as an asset to our practice, as well
as us providing a service of giving back to
general practice.’
Patients have provided positive feedback
on the educational component at the practice,
something that motivates both the junior and
senior doctors.
‘It’s something that our patient population is
fine with,’ Dr Keaney said.
‘They expect to be seen by junior doctors
and have commended our teaching. They
realise that it’s an investment and an advantage
for them, because they can get a fresh
and enthusiastic view on an issue that may
have had for a while, and it’s great to get a
new set of eyes.’
Dr Leadston is putting her own fresh
views to good use as she continues the
general practice legacy of her father,
Dr William Leadston, following his retirement
earlier this year.
Father and daughter had worked closely for
more than a decade.
‘It was fun, we have a good relationship,’
Dr Leadston said. ‘Over the last few years
we didn’t work on the same day, but a lot of
patients, particularly the older ones, kind of
saw us as one entity.
‘If Dad was not there then they would say,
“Gosh, you look and sound so much like your
father”. So I think they were quite at ease
straight away and it provided a bit of continuity
for the patients, a sort of legacy.’
Dr Leadston and Dr Keaney feel this type
of family connection has helped to foster
Preston Family Medical Practice’s loyal
following of patients, many of whom often
come to see the GPs for an informal chat
about their health over longer consultations.
‘The medical service that we offer is
different to your quick “10-minute medicine”,’
Dr Keaney said.
‘We have longer appointments and we take
time to consider things.
‘So what tends to happen is that patients
return and report back that we care and
listen to them.
‘It is about being acceptable and providing
personalised, sensitive healthcare.’
Perhaps the homemade biscuits are
another way patients express their gratitude.
Either way, as Dr Leadston simply puts it,
‘We’re very lucky’.
Free for RACGP members
The RACGP’s trusted, single source
for general practice employment
opportunities across metropolitan,
rural and remote Australia.
With recruitGP you can reach the RACGP’s 35,000 members and countless stakeholders to find your next general practice challenge, or advertise for the right person to join your practice team.
5040
racgp.org.au/recruitGP
26 Reprinted from Good Practice Issue 11, November 2017
NUTRITION
Managing goutMELANIE REID
Diet as adjunctive therapy.
Gout is a form of inflammatory arthritis,
typically characterised by recurrent incidence
of joints that are red, tender, hot and swollen.
It is generally managed by drugs that either
control inflammation during acute episodes
or reduce serum uric acid levels in the longer
term; however, dietary measures can also help
reduce serum uric acid levels and risk of gout.
The European League Against Rheumatism
(EULAR) and the American College of
Rheumatology (ACR) recommend diet and
lifestyle strategies as adjunctive measures for
the management of gout.1,2
Gout is often associated with common
and serious comorbidities, such as
obesity, cardiovascular disease (CVD),
dyslipidemia, hypertension, hyperglycaemia
and renal impairment. Dietary advice
for specific patients therefore needs to
include recommendations related to any
comorbidities.1,2
There is a general lack of specific evidence
from prospective, blinded, randomised clinical
intervention trials regarding dietary strategies
for gout. The replication of hazardous lifestyle
risk factors in a conventional clinical trial would
potentially pose design and ethical difficulties.
The majority of evidence comes from
epidemiological/observational studies,
including the Health Professionals Follow-up
Study, NHANES III, the Nurses Health Study,
and the Shanghai Men’s Health Study.3
GPs can offer patients several pieces of
dietary advice for helping to manage gout.
Keep weight in check
While gout is far more common in people
who are overweight, those patients should
be advised to lose weight gradually. Rapid
weight loss (more than 1 kg per week) can
increase uric acid levels and actually trigger an
attack of gout.3
An accredited practising dietitian
(APD) can help patients design a healthy
weight loss plan.
Limit alcohol
Observational studies have found that alcohol
intake is positively associated with serum
uric acid, risk of gout and recurrent gout
attacks.1,3,4 Experimental studies show that
beer, in particular, significantly raises serum
uric acid levels.3
It is best to avoid alcohol completely during
an acute attack of gout.
Eat regularly
Skipping meals or fasting will increase uric acid
levels.3 Advise patients to eat moderate-sized
meals regularly throughout the day.
Limit sugar-sweetened drinks
Large observational studies generally find
a positive association between intake of
sugar-sweetened drinks and fruit juice, serum
uric acid levels and risk of gout.3,4
Meta-analysis of controlled feeding studies
shows that adding fructose to the diet raises
serum uric acid.
Limit added sugars to a maximum
amount of five teaspoons per day and avoid
fructose-based sweeteners.
Limit purine-rich animal foods
Purines break down into uric acid. Most large
observational studies show that intake of
purine-rich meat and fish is correlated with
risk of developing gout, as well as risk of
recurrent attacks.1,3,4
Advise patients to limit intake of meat,
poultry and seafood to one moderate serve
(eg palm-sized) per day, and avoid offal. It is
prudent to avoid meat extracts (eg Bonox and
Bovril), brewer’s yeast and yeast extracts
(eg Vegemite), as these are very rich in purines.
Note: there is no association between
plant-based purines and gout risk.
At least 2–3 cups of low-fat dairy daily
Observational studies have found that higher
intake of low-fat dairy products is associated
with lower uric acid levels and reduced
risk of gout.1,3,4
Coffee in moderation
Observation studies find that higher coffee
intake3,4 is associated with lower serum uric
acid levels and risk of gout. However, a large
sudden increase may trigger an acute attack in
a manner similar to xanthine oxidase inhibitor
drugs. Coffee should be consumed regularly
and in moderation.
Vitamin C supplement
Vitamin C supplements of 500 mg/day have
been used experimentally to reduce serum uric
acid.3 Observational studies have found that
vitamin C intake over 500 mg/day is associated
with lower risk of gout.
A serve of cherries
Limited evidence from small trials and
observational studies suggest a lower uric acid
level and risk of acute gout attacks with daily
intake of 1–2 serves of cherries (one serve is
10–12 cherries).3
Keep active
People who exercise regularly are less likely to
experience gout. Ensure that running shoes are
supportive and fit well.
Drink plenty of water
High uric acid levels can also increase the
risk of kidney stones. Adequate fluid intake is
important to reduce risk of stone formation.
Related problems
People with high blood uric acid levels are
also at greater risk of heart disease, insulin
resistance and diabetes. Weight loss,
healthy eating and being physically active
all reduce the risks linked with these related
health problems.
References
1. Richette P, Doherty M, Pascual E, et al. 2016 updated
EULAR evidence-based recommendations for the
management of gout. Ann Rheum Dis 2017;76(1):29–42.
2. Khanna D, FitzGerald JD, Khanna PP, et al. 2012 American
College of Rheumatology guidelines for management
of gout part 1: Systematic non-pharmacologic and
pharmacologic therapeutic approaches to hyperuricemia.
Arthritis Care Res 2012;64(10):1431–46.
3. British Dietetic Association, Dietitians Association of
Australia, Dietitians of Canada. Gout evidence summary.
PEN: Practice-based evidence in nutrition. Available at
www.pennutrition.com/KnowledgePathway.aspx?kpid=195
6&trcatid=42&trid=3247 [Accessed 9 October 2017].
4. Singh JA, Reddy SG, Kundukulam J, et al. Risk factors for
gout and prevention: A systematic review of the literature.
Curr Opin Rheumatol 2011 Mar;23(2):192–202.
AD
GP 18
11–13 OCTOBER 2018
General Practice:
The centre of health
in Australia
THE GOLD COAST CONVENTION AND EXHIBITION CENTRE
gp18.com.au
#GP18gc
SAVETHE DATE
Hear from your GP colleagues, learn about the latest in clinical innovations and add
to your already extensive knowledge base at GP18. This is the must-attend event for
all general practitioners.
An education program designed and delivered by GPs
Register your interest at gp18.com.au
5199
