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TIMES of great crisis have historically seen advances in health care systems and technology. “Necessity is the mother of invention”, as they say.
Wars have led to improvements as diverse as triage (sorting casualties by urgency) and surgical techniques. Previous respiratory virus pandemics have led to advances in testing, improvements in hand sanitation, greater use of personal protective equipment and reduction in activities that spread droplets, such as nebulisation of drugs.
We are now in the midst of another such opportunity in the guise of a crisis. The way we act now, and the way we organise and deliver our services, may not only influence current events but may also shape the future. If necessity inspires us to streamline and target services to where they are most beneficial, why would we want to go backwards after the crisis is over?
One such change we are now seeing is the expansion of telemedicine – where a provider offers a service at a distance. This can be done by telephone or using one of a range of audiovisual tools. The practice has been developing for some time for the delivery of critical care and psychological services to isolated areas. More recently, it has expanded to the provision of accessible acute care.
Although telemedicine was initially developed for accessibility and convenience, the service is shining in these times of infection risk. We can easily see, then, that sitting in a crowded waiting room with other sick people or having to leave home to be assessed and treated, for example, are best avoided at any time. This is especially so during any winter viral season – not just while a novel coronavirus is circulating.
Many of us already live in a digital world, and our children even more so. This winter, grandparents are connecting with grandchildren online, children are meeting classmates on their devices and adolescents are chatting and exchanging images the way they already did – electronically. It makes sense, then, to use the same familiar interfaces for health care provision.
The most important opportunity for change, however, is not limited to the technology.
We have been handed an opportunity to rethink the way symptoms are assessed and treated and the way we assess and handle risk. We can return to good clinical practice – empathetic listening, rational assessment, good explanation and shared decision making. We can dispense with the reflex “just in case” test or referral and replace it with an agreed plan to assess progress. We can wait, watchfully, for symptoms to develop or resolve, and adapt our plans as symptoms evolve.
We know we can do this – we are doing it now.
Rethinking the way we use acute care services – such as hospital emergency departments – can reap benefits all round. For the elderly, exposure to the currently circulating severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can be life-threatening, but so can exposure to influenza. The ability to be managed at home – including in residential aged care – can avoid the confusion and distress that comes from unfamiliar surroundings and being poked and prodded by strangers. The missed meals, the cold air-conditioning, the noise – all of these can be disruptive to the frail elderly. When emergency care is needed, however, providers can be reassured that other alternatives have been exhausted.
The same benefits can flow for families with young children, who can be assessed in their own home rather than dragged into a scary, unfamiliar environment. No need to separate the parents or find care for other children, unless transfer to hospital is absolutely necessary.
We have the chance to enter a new phase. We can combine the best of human understanding with the best of communication technology.
To do this, we need to move from a risk-averse, “need it solved now” mind frame to an understanding that symptoms and diagnoses evolve, and that agreed plans need to evolve too. Keeping in touch is easier than ever. Let’s not lose this skill when COVID-19 is no longer front-of-mind.
Dr Sue Ieraci is a specialist emergency physician who has worked for 35 years in public hospitals and now works in telemedicine.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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Thanks for coming back on this Sue. I think your last sentence is absolutely crucial, where you say….”In workplaces where staff are not valued or trusted, the workplace experience degrades.” This is why in my view, there has to be a re-invention of the wheel to some extent. Because in my mind to create the environment where staff are valued and trusted would require a bit of an about face, by bringing back ‘medical people’, ie Drs and nurses, into administration, as being the kind of administrators best placed to do the ‘valuing’. In my view, much of the degradation of the morale in the medical workplaces followed the trend to non-medical people holding most of the admin strings, especially the financial ones. Cheers, Pete B
Hi, Peter. I would wish that such a model were more readily available in general practice, for those who would wish to choose it. Whether the model created a satisfying workplace would depend on a range of factors – not the least of which would be who is supplying the salary.
Wherever staff are paid as employees or contractors, and where employers are responsible for both finances and risk, the current flexibility of most private practice tends to degrade. I am fortunate to work for a telemedicine group that generally values and trusts its employees and contractors, but we still need to meet targets and undergo clinical audits. In workplaces where staff are not valued or trusted, the workplace experience degrades.
Thanks for replying Sue, and I hear what you are saying, especially as relates to the inevitably more structured and restricted environment in the hospital setting. However, would you agree that out in GP land, in amongst the gum trees and ordinary folk, the element of control over how one did ones job (if salaried) would be quite limited on the part of the powers that be, so there would probably remain about the same level of autonomy there exists in GP now – possibly even more..?
Especially in the way one could have the freedom, under a system where one was paid to just do the job, without having to meet the criteria of a myriad of item numbers, and if set up properly, one could devote time on the basis of skills and need, and also use allied health professionals far more effectively, especially where their skills were more suited to the task at hand than one’s own.
We are hearing already of large numbers of practice nurses being ‘let go’, because of the financial squeeze the Covid situation is imposing on practises. If GP practises were structured more like the Indigenous health services, with everyone on a salary, this situation would never arise, and all parties could be used far more flexibly and effectively. Unlike the frustrating restrictions you (and I have also seen) in the hospital setting. Surely these benefits amount to something worthwhile..?
Thanks for your comments, Peter. You are correct that, over a career in public hospitals, I have “enjoyed the comparative security, and other benefits no doubt, and for quite a long time, of being salaried”. Like most aspects of life, it’s been “swings and roundabouts”. Security is good, lack of flexibility and control is frustrating.
One of the main reasons I left hospital medicine was due to the difficulty in changing culture in the ways I described in the article. Every day I was seeing the inefficiencies and frank harm associated with a risk-averse culture where the fear of “missing something” dominated the processes, rather than what was best for the patient. This was also fuelled by a societal need for certainty and intolerance of doubt.
Now that I am free of my “comparative security, and other benefits”, I have a lot more job satisfaction!
I am very pleased that the government has supported the use of telehealth, which has certainly helped to provide care during the pandemic but as anonymous above has stated most of the reluctance has been externally and geographically imposed. I hope telehealth for all will continue to be an option in the future. having said that – there are also some very good reasons for face to face consultations and we need to ensure both options continue to be available – and which is used will depend on the situation and needs of the patient.
the other issue that has come into sharp focus is our dependence on overseas manufacturers for almost all medical equipment and PPE–I have been unable to identify almost anything in the operating theatre, for example, that is made in Australia–to the point where suddenly we didn’t have enough PPE and ventilators, in particular. My view is that the AMA must pressure State and Federal Governments to set up suitable manufacturing in Australia as a matter of urgency, or at the very least to ensure that sufficient supplies are stockpiled and ready at all times to cope with medical crises such as the one we are going through. This also leads in to the broader arguments relating to Australia’s progressive outsourcing of manufacturing to cheap overseas labour., and the problems that occur when the overseas ‘pipeline’ stops.
Dear Sue, I have often read you comments and articles with appreciation, so it is nice to get a bit more of a backgrounder on you here. I note your service in the hospital setting for over 35 years, particularly. I must say, I find it a bit ironic as to how, having been always regarded with suspicion by most of us, as a way of caring for patients, with telehealth being limited very largely to the Bush, and other remote areas, and usually only then when involving a specialist, now suddenly, of (Covid) necessity, it has become de rigeur, so to speak. To now we have tended to castigate those who saw this as an opportunity to cream off our work by providing phone consults for a fee, but only dealing with the easy stuff, and completely buggering up all concepts of the continuity of care provided by the ‘usual GP’.
Then came Covid-19, and with it magically – all of a sudden, reservations re diagnosing and prescribing patients virtually unseen, is OK. The catch being, just so long as you provide for a face to face, hands on, physical review if considered necessary. The latter has already apparently been got around by those same top-creamers I mentioned.
So, yes, this pandemic does indeed provide an opportunity for a complete re-vamp of the structure and funding of many parts of the health system, found wanting, with GP, or primary care being top of the list in my view. I would regard telehealth as but one aspect of the changes needed. The funding model for GP is now fatally fractured in my view. Being someone who has enjoyed the comparative security, and other benefits no doubt, and for quite a long time, of being salaried, I invite you to comment re the desirability of the GP workforce having that option at least.
To save time I suggest you, and others interested, first take a quick look at my post and that of a few others, on this thread on a previous Insight, here… https://insightplus.mja.com.au/2020/15/covid-19-consequence-telehealth-will-go-mainstream/
I’m retired now, but nothing has happened over the last 45 years of GP practice in two countries, Aus & NZ, to change my personal view on this issue. This pandemic, with the drop off in attendances and woefully inadequate rebates, has just brought this festering sore to the surface more than ever. In many, if not most areas, practice finances must be getting critical. Frankly I’m quite glad to be out of it, and at least have the pension, believe it or not.
Thoughts..? Anyone..?
Thank you for this timely article which covers a number of areas in which we have been given the opportunity to rethink how we practice medicine and care for our patients. The underlying advice to not let this opportunity go by is sound and should be heeded.
All of us in the health system, from Minister to front-line doctor and everyone in between, can now see things “in a different light” because our world has been significantly disrupted. Anonymous is correct that there have been many limitations imposed by regulators and funders on the use of Telehealth. Equally, we as doctors have often not been particularly vocal or active about modernising our models of care using new technologies and systems of care.
Hopefully we can all pull together in a spirit of innovation and patient-centred care to have a better health system in 2021 than we had in 2019.
The restriction on previous telehealth use has ALWAYS been externally, and geographically imposed.
No, I am not prepared to consult by telehealth for free anymore than my patients are prepared to forgo a rebate – unless they reside outside an arbitrarily imposed perimeter.
The lifting of these restrictions, not our “sudden” discovery of the advantages of technology, is what has enabled a way forward, and we can only hope that the restrictions remain lifted, post pandemic.