Unsung heroes: Australian GP response to COVID-19

“There are decades where nothing happens; and there are weeks where decades happen.”

Vladimir Ilyich Lenin

HISTORY does not often allow you to write in its book, for good or bad, but the next chapter of the story of Australian general practice is being written by many unsung GP heroes whose response to coronavirus disease 2019 (COVID-19) is changing the rules.

At the beginning of the COVID-19 crisis, there were no rules to follow, only a new playbook to be written. How was this playbook written? Why has it succeeded up to this point? And how can it continue to succeed?

In essence, the story of the GP response to COVID-19 is one of communication, collaboration and teamwork.

The management and consultancy firm McKinsey list a set of principles for leadership during crisis. Responding to the coronavirus outbreak and “future challenges” these principles include:

• communicate effectively — maintain transparency and provide frequent updates;
• organise a network of teams;
• elevate leaders during a crisis; and
• make decisions amid uncertainty — pause to assess and anticipate, then act.

Communicate effectively

One of the largest groups underpinning the GP response has been the GPs Down Under (GPDU) Network established on Facebook. Consisting of over 8300 GP members, GPDU encouraged open information sharing, which I believe was fundamental in raising awareness of the significance of COVID-19 and developing strategies to protect, prevent and mitigate its spread through clear messaging, use of personal protective equipment (PPE) and the establishment of telehealth and respiratory clinics.

According to McKinsey:

“… crisis communications from leaders often hit the wrong notes. Time and again, we see leaders taking an overconfident, upbeat tone in the early stages of a crisis — and raising stakeholders’ suspicions about what leaders know and how well they are handling the crisis.”

The beginning of the crisis was heralded by downplaying of the significance of the virus, inconsistent messaging and confusion. Australians were seeing reports of people dying on the streets in China and Europe, yet the perceived message was that it was still okay to go to sports events and go to see the GP to get tested.

The most glaring example involved a Cronulla Sharks National Rugby League game. On 13 March 2020, Prime Minister Scott Morrison stated: “Well, I do still plan to go to the football on Saturday” after announcing measures to limit organised non-essential gatherings of persons of 500 people or greater from Monday 15 March 2020. The goal may have been to project calm, but in the information age, when facts and figures can be cross-checked in a millisecond and referenced to experience, these words and actions were a major source of cognitive dissonance. In the end, the Prime Minister cancelled his attendance and led by example to demonstrate that the COVID-19 crisis had to be taken seriously.

The GP family is a broad church that draws upon a wealth of knowledge and experience. While the broader community waited for new information by the day, GPs were receiving updates from other GPs by the second.

One such GP was Dr Chris Chau. On 25 January 2020 he posted this on GPDU’s Facebook page:

“I am a GP in Australia and I was also a public health physician in Hong Kong in the past. I would like to share some of my thoughts on the proactive approach to the newly emerging coronavirus (nCoV) infection. Symptoms of nCoV infection include fever and [upper respiratory tract infection] symptoms. However, there are cases presented with very mild symptoms – fatigue, diarrhoea, muscle ache and headache without fever in the early stage of the disease. This has made the contact tracing and disease prevention difficult. Since there is no imported case yet in Australia, during this time, as a GP, I rely on detailed travel history taking. For patients with above symptoms and positive travel history, we should approach them with great care. They should wear surgical masks and be separated from other people in the clinic. They must stay in an isolated room while staff should wear N95 mask and gloves in managing these patients. Since there are cases where transmission through mucosal contact e.g. via conjunctiva, is suspected, therefore wearing goggles is also recommended. From my experience, I am concerned about an uncontrollable spreading of the disease that can actually happen anytime and anywhere.”

Following the post, the network was abuzz and the seed of the future COVID-19 response was materialising before our eyes. I think many GPs caught a glimpse of the future leaders of our profession. In the same thread, Dr Kat McLean wrote:

“Agree we need to be very cautious. Our clinic plan: social media/website/phone message advising patients unwell with recent travel from China, or concerned they have possible coronavirus (or measles) to phone reception. Table with a sign and masks on it just inside the doors. Isolation room set up a trolley with P2 masks, gloves, gowns and glasses on it.”

Similarly, Dr Karen Price – newly elected President of the Royal Australian College of GPs (RACGP), posted:

“Thanks Chris. The RACGP have a page which will be constantly updated. Cameron Loy, Anita Munoz and I provided feedback on a document the health department is preparing. Issues include bringing any patients into the clinic in the first place. Isolation gloves, goggles, mask as you say are imperative.”

March 2020 was a time of great uncertainty for the GP community. The fear of being identified as a COVID–19-affected clinic was palpable. No other example best illustrates the ability of general practice to place the patient first, despite the threat of loss of reputation, financial loss and scrutiny than the actions taken by Dr Higgins.

Dr Chris Higgins is a GP in Melbourne. In early March he returned from the United States with a cold, and returned to work. He said:

“I had a cold when I returned from the USA last Saturday morning, which had almost resolved itself by Monday morning, hence my decision to return to work. I hesitated to do a swab because I did not fulfil your criteria for testing, but did one anyway on Thursday evening for sake of completeness, not imagining for one moment it would turn out to be positive.”

His positive test provoked an astonishing reaction. The then Victorian Health Minister Jenny Mikkakos held a press conference on 7 March 2020 during which she admonished Dr Higgins by stating:

“I have to say that I am flabbergasted that a doctor that has flu-like symptoms has presented to work” and publicly outed his clinic.

When the world had recognised the deadliness of COVID-19, and major sports institutions such the US National Basketball Association had shut down, Victoria decided to proceed with the Melbourne Formula 1 Grand Prix.

The cruise liner Ruby Princess had disembarked into New South Wales with 2650 people on board and was ultimately linked to 900 COVID-19 cases and 28 deaths. Recognising that the Grand Prix – with attendance figures typically around 300 000 – had the potential to bring over 100 Ruby Princesses to Melbourne on the weekend of 15 March 2020, doctors helped raise awareness leading to the cancellation of the Grand Prix.

Visible among these voices were Dr April Armstrong and Dr Norman Swan, who helped raise awareness in the media about the petition to stop the Grand Prix, and state heads of the Australian Medical Association (AMA), in particular Victorian AMA President Professor Julian Rait and Western Australian AMA President Dr Andrew Miller, who appeared on various media outlets to raise the medical professions concerns.

McKinsey also notes:

“Authority figures are also prone to suspend announcements for long stretches while they wait for more facts to emerge and decisions to be made.”

Also helping fill the information void in March were GPs such as Dr Kat McLean, Dr Wendy Burton, Dr Suresh Khirwadkar, Dr Nic Tee and Dr Mark Raines among others, who helped produce many great educational articles on COVID-19 on websites such as GPs Can.

After Dr Chris Chau’s post on GPDU, things really started happening. By 27 January, the GP community was advocating for clear and consistent messaging from health authorities as the “go to GP to be tested” message was causing mass confusion.

Dr Kerryn Phelps, active in communication, noted on 27 January that NSW Health was advising unwell patients to call their GP for a conversation first, but sought opinions from other GPs in different states about their experiences.

Dr Bernard Shiu in Victoria noted:

“Have just phoned 1300 022 222 three times, and spoke to three different nurses. All three times the nurses were told to tell the patients with suspected symptoms and travel history to see their own GP.”

Dr Ira Pant also noted:

“SA Health (because we have not had any cases yet!!!) is regurgitating the Department of Health advice and we are expected to test.”

It was through these discussions about how to best identify and test for suspected cases, that GP teletriage was born. The idea of teletriage was to allow doctors to communicate (over the phone) with at-risk patients, the best management options for their respiratory symptoms before they could enter, and potentially spread COVID-19, in the clinic.

GP teletriage arose out of the GPDU leadership team acting on advice from the communication team. Past RACGP President Dr Harry Nespolon stated in the same thread:

“Another free GP service! Thx”

Bernard Shiu replied back:

“Harry can we negotiate a new item number for phone triage regarding this?”

Harry Nespolon wrote back:

“Bernard Shiu I would think so.”

It would be easy to say “the rest is history” but the truth is far more complex.

Though the impetus for telehealth was visible as early as January, the RACGP had to actively advocate and lobby for its implementation.

Teletriage and subsequently expanded telehealth, was not borne out of one meeting. Key members of the RACGP committee, such as Harry Nespolon, Karen Price, Cameron Loy, Bernard Shiu and RACGP committee members from throughout Australia had to lobby for telehealth through a series of meetings in February with the federal Health Department and Health Minister.

The initial item number for GP teletriage came into effect on 13 March 2020 and expanded telehealth item numbers on 30 March 2020.

As Dr Nespolon noted at the time:

“The RACGP has said from the start, we need telephone and videoconferencing item numbers for all patients. We need them to continue providing quality care so we can protect patients, GPs, and their teams. We have been working closely with Minister Hunt and the Department of Health to achieve this. We thank the Minister and the department for listening to our concerns, and addressing them.”

McKinsey also notes:

“Because a crisis involves many unknowns and surprises, leaders can better cope with uncertainty and the feeling of jamais vu (déjà vu’s opposite) by continually collecting information as the crisis unfolds and observing how well their responses work. In practice, this means frequently pausing from crisis management, assessing the situation from multiple vantage points, anticipating what may happen next, and then acting.”

The GP response to inadequate PPE supply highlights the assess–anticipate–act cycle. In another influential GPDU post by Dr Kerryn Phelps, on 27 January she posted a picture of healthcare workers in China in full hazmat suits and highlighted the need for Australian GPs to be given adequate masks and PPE.

Assessment was sought about whether GPs believed they were receiving adequate support and advice from the health department and government. The replies were damning, one such reply was from Dr Amy Ella:

“I’ve just read the Victorian guidelines. They recommend a standard surgical mask for GPs and state that a P2/N95 respirator could be used if ‘available’. They only recommend P2/N95 for emergency department staff. Nice to know where we sit in terms of expendability.”

In a subsequent post, Dr Rebecca Kerr noted:

“Public health document re: coronavirus updated to say just wear a surgical mask and stand to the side when collecting specimens if they have mild symptoms.”

Dr Richard White wrote:

“This is just bull. Even if a patient has mild symptoms, this virus can cause severe symptoms in the testing doctor or the next patient going to that room. This is irresponsible advice!”

GP communication and leadership teams took action to inform the media and prompt the government to address the mask and PPE issue.

The assess–anticipate–act cycle was also evident in the pivot to telehealth for most GP cases. GP clinic owner Dr Todd Cameron was influential in the pivot. He assessed the need for expanded telehealth, anticipated the sacrifices that many GP small business owners were about to make, but still took action. As the founder of M3 Health clinics in Victoria, Dr Cameron led by example through creating online presentations for other GPs about how they could set up their own clinics for telehealth by using his own clinics as a model.

His post on GPDU on 13 March is thought provoking:

“Hi all lots of commentary on the obligation to bulk bill new telehealth item numbers. Let me be crystal clear. Most of our community will be bankrupted by this. What is left at the end, whenever that may be, will be a husk of what was there before. We are lucky to have jobs that are useful and in demand just as others benefitted from the mining boom. We will bulk bill all tele consults out of compassion. I know it is rare for you to hear me say this but think about the future cost of NOT doing this. Be the clinic you want to be at the END of this crisis now.”

Future GP practice will return to face-to-face consults with private billing, but many GP practices have sacrificed and suffered.

Supporting and continuing to support general practice is key

If anything, 2020 has shown that communication, teamwork and collaboration are paramount in generation-defining moments. The coordinated response of all team members including GPs, media and social media and the state and federal governments produced a significant and effective response to COVID-19 that has saved many lives and livelihoods.

Don’t degrade and break down our broad church

Australian state and federal governments have worked with GPs during this crisis and should have seen how effective collaboration with a good system with good people in it can be. The system and the people in this system work.

As Australia continues to rebuild from COVID-19, governments must continue to support Australian general practice. We have very good people in this broad church – talented and hardworking people; people who would work through cancer and put their reputation and livelihoods at risk to look after their fellow Australians.

Jason Chua is a former dentist, now working as a GP at the SIA Medical Centre Essendon and has been involved with the RACGP on the SA New Fellows Committee.

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.