GPs Down Under: who are we and what do we do?

This is the first of a monthly series of articles by authors from the Facebook group GPs Down Under. Karen Price and her nine fellow moderators explain the group’s raison d’être.

Who are we?

GPs Down Under (GPDU) is a GP community-led, not-for-profit group based on GP-led learning, GP peer support and GP advocacy.

GPDU is a thriving volunteer-led professional community that centres around an online discussion forum. There are now over 5000 members who engage in lively hot topics in general practice and debate. For instance, in the first week of 2018, we had 4416 comments and 3537 separate “likes” on our Facebook page.

GPDU began in 2014 and consists of both Australian and New Zealand GPs and is not affiliated with any particular college or organisation. The criteria for inclusion in the group are that you are a GP or registrar and are working in general practice with registration to practice in Australia and New Zealand. For community safety, there is a three-step verification procedure.

GPDU follows the principles of FOAMed: free, open access medical education. We use the metaphor of a national park, to bring ownership to the grassroots GP. A blog about GPDU beginnings can be found here.

What do we do?

GPDU is based on a flat hierarchy of adult learning principles and consists of asynchronous or real-time discussion of evidence, consented case studies, diagnostic dilemmas, or particular applications of theory to practice. There are group guidelines around respectful professional dialogue, and GPs are directed to be aware of social media Medical Board requirements for medical practitioners in their respective country of practice. No commercially based advertising is allowed. There are 10 GP moderators who assist with facilitation of discussions and verifying requests. Nevertheless, all 5000 members are encouraged to moderate, and there is little in the way of censorship. We do, however, keep to the themes of GP learning, peer support and advocacy.

GP learning

On the GPDU Facebook page, there is an intersection of physician content and patient preference paradigms in evidence-based medicine (here; here; and, here). We have GPs located in the outback and remote areas of Australia to urban landscapes. Variations in practice are a perennial and interesting feature of applying evidence. Three examples of discussions in GPDU follow:

1. Stress echocardiograms in general practice

This discussion centred on indications for stress echocardiograms and highlighted how differing urban versus remote access to testing affected management. Access to the echocardiogram facility varied from 500 km away to 1 km down the road. Some group members stated that these investigations were best determined by a cardiologist. Notably, rural and remote practitioners may also be managing the cardiology decisions within local GP-run hospitals.

2. Antimicrobial stewardship and prevention of rheumatic fever

Another debate consisted of criticism of the use of amoxycillin for tonsillitis and prevention of rheumatic fever complications in children. It was pointed out that this indication for amoxycillin is in the New Zealand National Heart Foundation guidelines, due to increased oral acceptance in children. There was robust discussion on antimicrobial stewardship, including clinical decision making and individual practitioner risk should there be any retrospective complications of a delay to prescribe.

3. Treating diabetes to target – impossible with mental health comorbidity

A consented case study was presented showing the delay of treating-to-target a patient with significant comorbidities who was also struggling with mental health. Most GPs are familiar with this paradigm of longitudinal relational care of patients. The complexity of decisions and competing probabilities of treatment decisions indicate a range of outcomes depending on physician context and of patient context.

Not only does GPDU show the breadth of clinical decision making in management, GPs are also the diagnosticians of the medical profession. Frequently, GPs deal with the complex painful uncertainty of who to send home with reassurance, who to investigate and who to refer to secondary care. General practice, due to its depth and breadth, requires GP advocacy and peer support for the uncertainty and complexities of clinical decision making.

GP advocacy

1. Named referrals to public outpatients

Recent issues include the current practice of outpatient requests for named referrals for federal Medicare funding of public hospital state-based outpatient care. Frequently, the National Health Reform Agreement sections of the legislation are referred to in letters back to the hospital administrators quoting, for instance, item G17b: “… referral pathways must not be controlled so as to deny access to free public hospital services”. This debate is likely to increase as GP Medicare rebates continue to lag behind parity with consumer price index or hospital-based practice. There is considerable grassroots GP advocacy questioning the legality of double dipping into health care funds normally set aside for federal use, and of patient rebate parity compared with consumer price index and hospital-based specialties.

2. Clinical handover from secondary care to primary care

There are frequent cases discussed about adverse outcomes for patients or “near misses” regarding delayed or poor quality hospital communication. These cases have allowed members to discuss systems approaches in different locations. Behind the scenes, there is an ongoing campaign to restate discharge summaries as a timely “clinical handover” from secondary care back to GP care. The implications for patient safety of a timely and appropriately received clinical handover are obvious.

Finally, peer support is an underlying and continuing theme of the GPDU community.

GP peer support

Peer support is another theme of GPDU discussions, with many GPs describing grief, fatigue, isolation and patient difficulties. There is a very raw honesty in the posts and it is not uncommon for members to comment that they derive benefit and solace from communicating with other GPs who understand the unique and complex setting of general practice. “One GP, one patient and one consulting room” perhaps is not as lonely and as uncertain as it once was. Although GPDU is not a counselling service, and this is explicitly stated in the site guidelines, there is much scope for a normalisation and reframing of events that provides support while operating in a high-performance workplace. Humour is used effectively and well within discussions. A humorous GIF or a meme becomes an effective, small, modern, satirical take on a complex world. Fun is good with learning, advocacy and support.

In summary, GPDU is a robust GP-led community that meets in an online learning space where evidence is dissected and is refashioned into a general practice setting.

We look forward to bringing you a monthly sample of the hot topics in general practice in the MJA InSight GPDU article.

We are also stepping beyond the discussion forum confines and preparing for our inaugural conference that will be held in the Gold Coast from 31 May to 1 June 2018. Much like these articles, the topics have come from within the group. See here for the conference program and booking details.

Come and be curious. We would very much like to open the doors and welcome all with an interest in learning, peer support and advocacy in the GP context.

Karen Price, Kat McLean, Tim Leeuwenburg, Alvin Chua, Nicole Higgins, Lindsay Jayarm-Moran, Kate Kloza, Jay Mien Phang, Nick Tellis and James Ware are GPs and moderators of the GPs Down Under Facebook group.

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