If a doctor's practice ran the way Dutton is running health..

Boy, has it been a turbulent time in health lately. And for all the wrong reasons. Yet the federal government plough on, resisting communication or negotiation while they stick to their mantra – their proposed changes for health and necessary for the good of the country.

I keep trying to define what can be good for patients in all of this, but can only see a trail of negativity, a loss of services and values in healthcare for patients and fears of a diminishing medical workforce if education and health cuts are passed.

Then I thought about another way. Try for one or two minutes, just try to see the government’s point of view. Really, really try, maybe not be so ‘pessimistic’. Maybe see if it would make sense if I try and apply Dutton’s principles to a busy medical practice and see if these policies have any merit. Or are they simply something to apply on a grand scale rather than in a practical situation?

So, here’s my take on applying these changes to a real world setting;, what doctors and I work in every day,

A new world scenario for a busy medical practice:

Imagine this for a while and see how it fits. Doctors in this busy private practice hold a meeting behind the staff’s back and announce in unison that the situation at the practice is worse than anybody imagined. They have had some external auditors in and had no idea things were this bad when they signed the lease.

The principal doctors announce that due to the crisis left by previous tenants, there will no longer be a tea room, toilet facilities or any basic staff amenities. The principal doctors agree these measures will be tough but necessary. They did not appreciate how the previous tenants had left the premise. Hence they cannot be held accountable for what would be tough but fair changes for all.

The principal doctors inform the staff that there will be a 30% reduction in staffing commencing in 2 weeks. As a gesture of goodwill, the principal doctors will take a 2% pay cut, because, after all ‘we’ve ALL inherited this MESS’. There will be limited access to services such as Medicare or the Australian Tax Office. They were just superfluous services anyway, not really required by a busy medical practice.

Beginning in a week’s time, cash registers will be installed at reception and all staff will instruct patients to pay up before they have any chance of seeing a doctor. Even if presenting with chest pain, acute shortness of breath or other life threatening symptoms. The doctors understand that there will be ‘casualties’ due to this blanket measure but nevertheless it will work for the good of most who need health care. And it’s important for practice staff to remind patients that each and every dollar raised will go to curing their health problems via a medical research fund, so they will no longer experience chest pain or shortness of breath in the future. After all, the new breed doctors know, there is nothing in this ‘acute health care’ it costs too much and there is no return on investment.

The doctors warn the practice staff that this will be a very difficult time, but to remind patients that it is difficult for all, not just those who have recently lost their job,  have a mental illness, perhaps a physical disability or find themselves homeless of late. TOUGH. FOR. ALL. In fact, the principal doctors announce they will spend $250,000 to rebrand the practice with this telling and sage message. Staff will wear this logo on their new uniforms and doctors will add it to the business cards. Everybody will assume their rightful role in where they now fit in the practice and the greater community.  At the bottom.

When doctors finally get to see their patients, suddenly stricken with low self esteem and self worth, they will turn off their listening ears and preach to their heart’s content. They will fail to miss the tidal wave of patients surging the wrong way out of the practice door (or perhaps the right way), there will be serenity in the waiting room, but no place for reflection.

At least these radical but necessary changes will only need to be in place for three years. After that the practice lease will be up for renewal, and the new team of doctors can inherit the mess, seeing fit to do with it what they want.

Imagine this in the real world? What doctor would stand for this on behalf of their patients or their own professional lives?

Thoughts?

The dominoes are starting to tumble

A few weeks out from the State budget and one week out from a Federal Budget, we are beginning to see the direct effects of winding back health care for all, but especially for those with mental illness.

Yesterday The Age in Melbourne reported the State Government would no longer fund St Mary’s house of welcome in Fitzroy, as well as many other institutions that genuinely support and care for those with severe mental illness.  

I remember St Mary’s house of welcome from my training days. Back then it was a bustling place, a care and respite space for many inner urban patients with a mental illness. It provided a community, a haven, hot meals, clothing, shelter and love. Nowadays, it is even busier, and would have been full to the brim for years to come had it not received the news it would no longer receive government funding the day after the state government budget was delivered.

Many of the patients we knew within our service would feel safe going to St Mary’s when unwell, rather than calling a crisis team or attending an emergency department. In fact, most patients experiencing a relapse of severe mental illness avoid psychiatric services. St Mary’s provided a bridge between patient and service, our service could be alerted by their staff if somebody was unwell. They would do this in discreet and compassionate way, and would discourage psychiatric services from attending at St Mary’s to keep it as a safe place. However, services could follow up after hours and ensure treatment was provided.

There is no doubt that such wonderful facilities never come to the attention of politicians except as a cost on a piece of paper, to be cut when needed. There is no human element to the decision making. Where will these people go as these services break down? What will happen to their mental health? And if they can’t afford meals how will they afford to pay their GP’s $7.00?

Little is known about taking payments from patients in public hospitals. This seems to have been pushed to the State Government’s discretion. Will an acutely mentally unwell patient lost from services be asked to pay? Even when extremely paranoid and actively avoiding services? What is the point of newer medications and modalities of care if we are actively discouraging patients from seeking help, by taking away their places of refuge and charging them for care that they have no insight they need.

What will be the next domino to fall?

Choosing to play 'win-lose' in negotiation and how it applies to #budget2014

Greetings all,

As promised, here is another key learning from my WMA caring physicians of the world conference at INSEAD this month.

During a very busy timetable we immersed ourselves in understanding negotiation skills and multi party coalitions. The same day, I watched the Commission of Audit report and discussions fill twitter feeds. I could see what was happening, the Federal Government’s strategy behind #budget2014 was clearly win-lose negotiation tactics, where the tool of choice is power not communication.

When a party or individual chooses to play win lose, they use their power to influence and win. They need to be very aware of the risk and believe the reward will be great enough to set off the risks. Win lose negotiations fall down when such parties overestimate reward and underestimate resistance.

So what does this mean in the context of the last few days? Well, choosing to deliver a budget that is harsh, hits the most vulnerable that a society should protect, doesn't contain a lot of information about how these measures could even be implemented, and then states that it will help Australia out of a perceived economic mess, may be overestimating reward.

I don't see reward when it comes to the $7.00 copayment. I have spoken to a patient who takes warfarin, who told me that if the copayment for pathology services go through, they will take their chances rather than have twice weekly blood tests. 

As a psychiatrist, I may no longer be able to prescribe lithium as often, a fantastic medication for bipolar disorders, as lithium monitoring is crucial with weekly blood tests needed to avoid kidney and thyroid disturbance. The ridiculous aside to this is that lithium is much cheaper than newer atypical agents and more cost effective for government. But, if my patient doesn't return, doesn't have regular monitoring, and develops renal dysfunction, they will then be knocking on the bulging doors of the emergency department. For the sake of making a GP or pathology centre claim $7.00 from a patient, because, after all, they have lost $5.00 per consult, costs and burden of disease will only but rise.

What will we see playing out in the next few days? Parties that choose win-lose and underestimate resistance will feel they have won for a little while until key stake holders form coalitions and lobby to block changes. Key stakeholders that have been shut out of any discussion about this most important budget, and all important patient groups will lobby via all channels available. Let's see what win-lose really looks like in a few weeks, and at the next election.

Then, a word of advice for all, using 'win-win' in negotiation requires communication. How about Government communicate with RACGP, GPRA, AMA,  and  include doctors rather than just rule them, or reduce them to workers of another branch of the ATO.

Thoughts?

Helen

Availability Bias and delivering messages that change

Greetings all,
I have just arrived home after attending the World Medical Association 'Caring Physicians of the World' Leadership Course, at INSEAD Singapore. Over the next few posts, I plan to share some of the most amazing insights I learnt in a jam packed 5 days, surrounded by doctors and leaders from all over the world.
Today, I'm posting about the first concept that hit me between the eyes and taught me how best to communicate and influence with impact. And it stems from the concept of availability bias.

In a nutshell, availability bias is how news stories are shaped and how we are touched by events that occur around the world. News events are largely made up of stories of tragedies and disasters, or one in a million good luck stories. This shapes our understanding of issues for good or not, far greater than being presented with facts and statistics. Take for example, the horror of a plane crash. An absolute tragedy for all concerned and well worthy of headline news. Availability bias results in the decision we make to take that information and decide whether or not it is safe to fly. Because, after all, there is no report of how many planes landed safely and without incident on any given day. The information available to us leads to a bias in our thinking.

In addition, good leaders tell stories, rather than just present facts. Once the human element is lost and we can't connect on an emotional level, the impact to change is reduced, and the message gets lost within the debate.

As leaders of health debates, we must remember to tell stories and share the personal element of every issue we aim to influence. And as doctors we see and hear first hand these stories every day. As I continue to try and influence issues that impact on patients with mental illness, I will remember to embrace the impact of a human story, an experience or a tragedy rather than just present facts or statistics. We were told "statistics are humans with the tears washed off''. Such an important point of view, and one you can use when delivering powerful messages.

So, next time you are presented with facts about a healthcare issue, perhaps that you disagree with or can't relate to, remember the concept of availability bias. Hear the presenter as a journalist at the airport commenting on all the places that landed safely, and influence with your own personal, authentic story (de-identified of course), for the good of your patients and to really make change.
Best wishes,
Helen

Leading from the Couch - Psychiatry and Leadership

In just under a week, I will be attending the World Medical Association (WMA) Caring Physicians of the World Leadership Program at the INSEAD business school in Singapore. I will be one of a number of delegates from around the world representing our respective local medical associations. I am attending as a psychiatrist and will be learning and engaging as much as I can to become a better leader in this most challenging and important area of medicine.

Although a terrific honour, this is also confronting, and has led me to ponder what it is to be a psychiatrist and a leader? And even more importantly, can we still call ourselves leaders in debates around mental health or mental illness?

In a world that is post de-institutionalisation, over time more and more non-government organisations, consumer lobby groups and front line services such as Lifeline do an amazing job at helping people in crisis, enhancing the awareness of mental illness and attempt to reduce stigma. Government funding is directed at large organisations so that they can fund projects and inform the metal health debate. Office bearer positions within these organisations are not reserved for psychiatrists but a range of mental health clinicians. In fact WE are largely being labelled 'mental health clinicians' when we are Psychiatrists with medical degrees and post graduate training. And although funding and awareness is all important, I should not be at the expense of evidenced based care that psychiatrists are trained to deliver.

Today on Twitter, SANE posted a comment from their CEO, Jack Heath. In a recent comment in the Age he stated that more than 2500 people died by suicide in this country in 2012. He described this as deeply concerning, not least because it is the highest number of suicide deaths in the past 10 years. He called for collaboration between clinicians, NGO’s and Government. He believes mental health clinicians need more skills in recognising and managing suicidal tendencies. But what about psychiatrists, who are trained in this and can do this work being engaged in this debate. Actually, why aren’t we leading it?  

I am concerned about the ‘dumbing down’ of a profession I am very proud of. When I have a patient in crisis and need to call crisis services, I rarely get to speak to a medical colleague. Imagine a cardiologist sending in a patient to an emergency department with chest pain only to be told he cannot speak to the admitting officer, another doctor. And psychiatrists are largely losing traction as leaders in hospital multidisciplinary teams. Policy is often informed and determined by others.

Two ways I see that psychiatrists will continue to experience challenges as becoming leaders in the mental health debate:

1.    The Monash University Medical School now offers a course titled 'Medicine of the Mind' rather than psychiatry. I can only imagine the outcry if they offered orthopaedics as ‘Medicine of the Bones’. Not only is this a watering down of our skills and abilities, it may discourage medical students becoming future psychiatrists. Medical students need to be educated that psychiatry covers more than just the mind.

2.    On 16 April 2014, Dr Murray Patton, current President of the Royal College of Australia and New Zealand Psychiatrists (RANZCP) spoke on ABC Radio National about addressing community misunderstanding about psychiatry. He reported results from a survey of 1500 members of the public in Australia and New Zealand, which will be released shortly. Perhaps the most staggering finding was that more than half of Australians (56%) are unaware that psychiatrists have undertaken medical training as a doctor, and 15% of the community incorrectly thinks a psychologist has medical training. This would be unthinkable in other specialities in medicine, and one ponders how this has happened? If patients don’t know what we do, they may not feel comfortable being referred to us. Hence the barrier to effective evidenced based treatment widens.

So, I will be heading to off to Singapore, as a medical doctor, passionate about psychiatry and willing to work out how I can become involved as a leader in this very important debate. The incidence of mental illness is a global concern, a local issue, and we need a strong empowered medical workforce for generations to come.

Should we be banning Stilnox?

It is call to action that has been mentioned on a regular basis. There is a drug on the market that despite repeated requests from the public and medical profession continues to be available. It's called Stilnox, the chemical name being Zolpidem. It's a newer type of sleeping tablet, and has been linked to a number of adverse events, usually related to amnesia after taking it, and has been reported to have led to patients performing acts they have no recollection of the next day.
This I don't refute, and, just as an aside, other sleeping tablets can lead to the same adverse effects. The risk of these events occurring seem to be increased when patients combine Stilnox with alcohol, which is against the recommendations of the manufacturer.
The NRL have raised concerns that Stilnox use is rampant among rugby players, and they feel the medication is being used to achieve a 'high' in players that are subjected to random drug tests, because it is not seen as a performance enhancing drug, hence goes undetected during routine drug screening. Perhaps they are referring to the adverse effects as outlined above. But Stilnox does not act on the same chemicals in the brain as amphetamines, so I am not sure about this.
What really annoys me about this whole debate associating athletes and sleeping tablet use is that we are not addressing the underlying question. Why do elite athletes need to use sleeping tablets like Stilnox at all?
As a clinician who specialises in sleep disorders, I am aware of the high rates of anxiety and sleep problems in elite athletes. While there will always be a temptation for some to misuse substances, by and large elite athletes have sleeping problems because of unrealistic expectations placed on them by their clubs. Athletes become sleep deprived as they attempt to adhere to match timetables, early morning training and jet lag when travelling to and from international events.
What is more rampant within the sporting profession than Stilnox use is a lack of understanding of the impact of 'cheating sleep'. Sleep is often seen as something to trade off against late nights and early morning obligations. This is despite the growing body of evidence which demonstrates convincingly that chronic sleep deprivation leads to a range of health problems, including obesity and cardiac disease.
Take for example the way the AFL match fixture runs in 2014 compared to when I started watching about 30 years ago. Matches can run untill 11pm on a Friday or Saturday night, players travel interstate on a regular basis and must attend early morning training sessions. Or, what about Olympic athletes that travel to other countries and are in the pool or on the track well before jet lag has dissipated, expected to do their very best during hours when they would normally be asleep. Sleep is 'cheated' at the very times that they are under scrutiny to do well. And this is without the added effects of performance anxiety which may also cause temporary insomnia.
So do we ban a drug or educate the sporting profession about the need for restorative sleep? I don't advocate that we use sleeping tablets on anything more than a temporary basis, and always in conjunction with psychological and behavioural strategies. But if external pressures mean physically less time in bed, how do athletes cope? Is this really why the use of sleeping tablets is rife within the sporting profession? And why label an athlete as a drug user when they have legitimate sleep disturbance and need professional help?

Taking it for the team

It is always hard to stick your head up and fight for a cause. Or so I hear. I have always been a crusader thats is passionate and controversial. I don't always conform but often question, looking for solutions where possible. As a result, I dont always 'fit in'. That can be tough, and I know I can polarise, but it's all I know, even if it creates personal angst at times. 

The recent @AHPRAaction debate has fuelled passion and outrage within me from the get go. I have watched the argument intently, and yesterday, I added my name to a petition that will be delivered to my governing body as a doctor and psychiatrist. Many of my colleagues agree with my views on this assault on free speech but are too concerned of potential backlash, and as such resist from adding their name to the petition. It doesn't mean they don't care but they fear consequences. 

Do I fear consequences? Of course I do. Do I fear my potential vulnerabilities as we move to a society focused on social media? Resoundingly, yes. I felt comforted today as I checked the list and found doctors I admire adding their names to the petition. Today, Dr Mukesh Haikerwal threw his support behind #APHRAaction that counter proposed regulations by AHPRA regarding social media. If there is one doctor I would state cares about his peers, its Mukesh. I was priveliged to have an office bearer position within AMA when he was involved at state level, then as federal president. I am reassured that I am actively supporting a cause with no certain conclusion, and involves a body that can de-register me, but I am one of many including Mukesh. I can state vehemently that this is not fair, encourage lively debate and influence a decision that can only become more relevant as we move towards a future intertwined with social media. 

I have been reflective during this debate. Why do we fear backlash as doctors? It begins as medical students and interns.  We learn not to show weaknesses or vulnerabilities, or ask for help. We work hard but don't make it into our chosen specialty. We fail our college exams a few times and we keep fronting up for work. We struggle with the challenge of entering private practice while distracted by the intricacies of small business, while feeling we are alone. We learn somewhere in medical student training it's not OK to say we are struggling, and as such, human. But when we feel we are being treated unjustly? Why do we find it so hard to stand up for our rights?

The @AHPRA debate has been one sided largely because of lack of comment from the body that has imposed the regulations. I am proud I am on the side that has united doctors that are fearful of governing bodies, but more fearful of living in a world where all that is said about us publicly is negative. I know I am not alone when stating I am not a doctor for the notoriety. I don't need testimonials. My patients thank me behind closed doors, and on a difficult day that is all I need to keep going. But what of the next few years and social media trends? Did I sign up for a calling that is gruelling, challenging, terrifying yet rewarding only to see criticism about me? The balance might tilt and the tweets, posts and updates may shatter me on a difficult day. That's why I am fighting now. And being surrounded by the likes of Mukesh, I know I am doing the right thing by myself and my profession. And I am so proud to be one of my colleagues that has put their fears aside recently and exposed themselves as campaigners against these regulations. 

Let's hope we tip the balance in our favour.