Two decades of community service

Family Doctor Week
Australian Capital Territory – Dr Rashmi Sharma OAM

About 20 years ago, Dr Rashmi Sharma opened a medical practice in the southern suburbs of Canberra with her sister Divya.

Today, the Isabella Plains Medical Centre is a thriving practice and Dr Sharma is a recipient of the Order of Australia Medal.

She is a Clinical Associate Professor at the Australian National University’s Medical School, the head of education for GP Synergy, sits on numerous Government committees and, as a Practice Principal at Isabella Plains Medical Centre, regards herself as a portfolio GP.

“I think the joy of general practice is the privilege of joining with some of your patients through their lives with them,” Dr Sharma said.

“Of the all the caps I wear, general practice is the one thing I enjoy the most. Sitting in a little consultation room with a patient is very satisfying. It keeps me grounded

“I have been in this practice about two decades – I started it with my sister who is also a GP. I have seen patients grow up and start families.

“I bumped into a patient on the street the other day and I hadn’t seen them for some years, yet I remembered the condition of their child. We have patients for life.

“And we are not just looking after patients, we are looking after the community. We have been looking after the southern parts of Canberra for two decades. We have second and third generation patients.”

As the head of education at for GP Synergy, Dr Sharma has had to spend considerable periods in New South Wales, looking after about 200 registrars the provider is training.

In recent times, she relocated to Northern New South Wales where she grew up. But that has not stopped her work in Canberra.

“I couldn’t give up my practice in Canberra. I only do general practice in Canberra,” she said.

“So, I kind of fly-in fly-out, but so much of my medical work is in Canberra.

“Some days I might see 30 patients in the clinic. We have a lot of nurses too who do a great job. We started this clinic and went from four doctors to 17 doctors, and from no nurses to seven nurses. We feel very proud of what we have been able to do for this community.”

CHRIS JOHNSON

Family Doctor Week highlights effective role of GPs

AMA Family Doctor Week recognises the work and dedication of Australia’s 36,000 general practitioners who treat families and individuals with a range of health issues day in and day out.

“Australia’s health system is one of the best in the world, and it all begins with the GP-led primary care system,” AMA President Dr Tony Bartone said.

“Eight out of 10 Australians see their family doctor once a year, and more than nine in 10 always go to the same general practice, with 65 per cent of people surveyed reporting that they had been going to their family doctor for five years or more.

“People who have a regular family doctor tend to have better health outcomes, with new research from the United Kingdom suggesting that seeing the same doctor each time you need medical care might even reduce your risk of death.

“Patients who need urgent medical care can usually obtain an appointment on the day they call, with nearly two-thirds reporting that they were seen by a family doctor within four hours of making an appointment.”

Dr Bartone stressed that GPs are specialists in their field, with a minimum of 10 to 15 years training, and they manage 90 per cent of the problems they encounter.

They are the leaders in preventive health care, early diagnosis and treatment, and comprehensive care.

“Australians rely on their trusted relationship with their family doctor,” he said.

“It’s a partnership with someone who knows their medical history, who they can talk to about their health concerns, who can advise them on how to reduce their health risks, who can assist them in managing their health, who can help them to feel well, and who can listen to them and guide them when it all starts to get too much.

“This continuity of care underpins quality health care, and is fundamental to better health outcomes.”

As part of Family Doctor Week, the AMA produced a series of videos showcasing how your family doctor is there for you. They can be viewed on the Family Doctor Week Website family-doctor-week-2018 .

Here, the Australian Medicine feature pages profile dedicated family doctors from each Australian State and Territory.

CHRS JOHNSON

Press Club speech calls for better health policy decisions

AMA President Dr Tony Bartone has used an address to the National Press Club to salute Australia’s general practitioners, and to call for significant reform of primary care.

In his first major speech since being elected in May, Dr Bartone said the challenge of transforming general practice was severely underestimated by the nation’s policy makers.

He said the AMA has a plan, but it is one which will require upfront and meaningful new investment, in anticipation of long-term savings in downstream health costs.

Delivering the nationally televised address during Family Doctor Week in July, Dr Bartone said his overarching concern as a GP himself has always been the patient journey and ensuring that people get the right care at the right time in the right place by the right practitioner.

“The priorities for me are always universal access to care, and affordability,” he said.

“GPs of Australia, I salute you. We all salute you. Your hard work and dedication is highly valued. The AMA will always support you and promote you.”

But he described there being “something really crook” about how GPs have been treated by successive Governments.

“They have paid lip service to the critical role GPs play in our health system, often borne out of ignorance and often in a misguided attempt to control costs,” Dr Bartone said.

“General practice has been the target of continual funding cuts over many years. These cuts have systematically eaten away at the capacity of general practice to deliver the highest quality care for our patients. They threaten the viability of many practices.”

The AMA President said Australia has seen too many poor decisions and mistakes in health policy.

General practice must be put front and centre in future health policy development.

“Despite the Government’s best intentions – and lots of goodwill within the profession – the Health Care Homes trial and implementation failed to win the support of GPs or patients,” Dr Bartone said.

“Instead of real investment, the trial largely shifted existing buckets of money around. It has fallen well short of its practice enrolment targets, and it looks like only a small fraction of the targeted 65,000 patients will sign up.

“But general practice still needs transformation and rejuvenation to meet growing patient demand and to keep GPs working in general practice.”

Dr Bartone outlined the AMA’s plan for general practice, which included in the short term:

significant changes to chronic disease funding, including a process that strengthens the relationship between a patient and their usual GP, and encourages continuity of care;
cutting the bureaucracy that makes it difficult for GPs to refer patients to allied health services;
formal recognition in GP funding arrangements of the significant non-face-to-face workload involved in caring for patients with complex and chronic disease;
additional funding to support enhanced care coordination for those patients with chronic disease who are at risk of unplanned hospital admission – a similar model to the Coordinated Veterans Care Program funded by the Department of Veterans Affairs;
a properly funded Quality Improvement Incentive under the Practice Incentive Program – the PIP;
changes to Medicare that improve access to after-hours GP care through a patient’s usual general practice;
support for patients with chronic wounds to access best practice wound care through their general practice;
better access to GP care for patients in residential aged care; and
annual indexation of current block funding streams that have not changed for many years – including those that provide funding to support the employment of nursing and allied health professionals in general practice.

“In the longer term, we need to look at moving to a more blended model of funding for general practice,” he said.

“While retaining our proven fee-for-service model at its core, the new funding model must have an increased emphasis on other funding streams, which are designed to support a high performing primary care system.

“This will allow for increasing the capability and improving the infrastructure supporting general practice to allow it to become the real engine room of our health system.

“It is about scaling up our GP-led patient-centred multidisciplinary practice teams to better provide the envelope of health care around the patient in their journey through the health system.”

On public hospitals, Dr Bartone said a better plan was needed.

Instead of helping the hospitals improve safety and quality, Governments decided to financially punish hospitals for poor safety events.

“There is no evidence to show that financial penalties work,” he said.

“Public hospitals are a critical part of our health system. They are highly visible. They are greatly loved institutions in the community. They are vote changers.

“The doctors, nurses, and other staff who work in our public hospitals are some of the most skilled in the world…

“Despite their importance, and despite our reliance on our hospitals to save lives and improve quality of life, they have been chronically underfunded for too long.

“Between 2010-11 and 2015-16, average annual real growth in Federal Government recurrent funding for public hospitals has been virtually stagnant – a mere 2.8 per cent.

“The AMA welcomes that, between 2014-15 and 2015-16, the Federal Government boosted its recurrent public hospital expenditure by 8.4 per cent.

“But a one-off modest boost from a very low base is not enough.”

Dr Bartone called on the major political parties to boost funding for public hospitals beyond that which is outlined in the next agreement.

There must be a plan to lift public hospitals out of their current funding crisis, which is putting doctors and patients at risk.

And Governments must stop penalising hospitals for adverse patient safety events, he said.

The wide-ranging Press Club address also went to aged care, with Dr Bartone describing it as “one of the highest profile segments of the health system – but for all the wrong reasons”.

He added that aged care was now emerging as an area in need of significant reform as the population ages and lives longer.

“An increase in funding for GP visits to aged care facilities would result in many savings, including from reduced ambulance transfers to hospital emergency departments,” he said.

“Changes to after-hours care remuneration must consider services that are currently provided under ‘urgent’ item numbers to patients in aged care facilities.

“We also need to ensure that the critical role that nurses play in caring for older Australians is recognised in those facilities.”

On private health insurance, the President said affordability meant very little without value, and that the Government knows the issue is at crisis point.

“Australians want reasonable and simple things from their insurance,” he said.

“They want coverage. They want a choice of the practitioner, and a choice of the hospital. They want treatment when they need it.

“We can’t have patients finding out they aren’t covered after the event, or when they require treatment and it’s all too late…

“Australians do not support a US-style managed care health system. Neither does the AMA. One area we are disappointed with in the recent announcements is pregnancy cover.

“It does not make sense to us, as clinicians, to have pregnancy cover in a higher level of insurance only.

“Many pregnancies are unplanned – meaning people are caught out underinsured when pregnancy is restricted to high-end policies.

“Pregnancy is a major reason that the younger population considers taking up private health insurance.

“They are less likely to be able to afford the higher-level policies. We need to make sure it is within reach.

“And having female reproductive services at a different level to pregnancy coverage is, to us, problematic, and will leave a lot of people caught out.

“There will be much more to talk about as the private health reforms are finalised and bedded down.”

Dr Bartone’s full address to the National Press Club of Australia can be found at: media/dr-tony-bartone-speech-national-press-club

Whatever it takes to clear up ambiguity over My Health Record privacy concerns

During the Q&A segment of his National Press Club address, AMA President Dr Tony Bartone said promised a face-to-face meeting with Health Minister Greg Hunt to gain assurances the Government will take further steps to ensure the privacy and security of the My Health Record.

Dr Bartone said there had been a groundswell of concern from AMA members, the broader medical profession, and the public about the 2012 legislation framing the My Health Record, particularly Section 70, which deals with the disclosure of health information for law enforcement purposes.

“The priority of the AMA at all times has been to support the My Health Record, and its precursors, for the important clinical benefits it will deliver to doctors, patients, and the health system,” Dr Bartone said.

“The AMA has always been protective and vigilant about the privacy of the doctor-patient relationship, and this should not be affected by the My Health Record.

“Given the public debate, I support calls for the Government to provide solid guarantees about the long-term security of the privacy of the My Health Record.

“I will do whatever it takes to ensure that the security concerns are raised and cleared up as a matter of urgency.

“This may involve examining the legislation.”

Mr Hunt contacted Dr Bartone directly after the Press Club to set up a meeting to discuss all aspects of the rollout of the My Health Record.

CHRIS JOHNSON

More than just writing a script

Family Doctor Week
Western Australia – Dr Simon Torvaldsen

Dr Simon Torvaldsen is Chair of the AMA WA Council of General Practice, and he is also one of the owners of Third Avenue Surgery in Mt Lawley, just a few kilometres north-east of Perth’s city centre.

In an area that overall has a somewhat middle-class flavour, his patient demographic is quite mixed.

“It’s mainly mortgage belt and professionals – I have quite a few doctor patients – but also a significant number of elderly, less wealthy patients who have lived in the area for many years, plus some tenants of cheap unit accommodation,” he said.

“We are privately billing, although we bulk bill most pensioners. Our standard appointment is 15 minutes and most doctors see four patients per hour or somewhat less, as we do not discourage longer appointments and have a focus on quality care and patient satisfaction.”

Third Avenue Surgery has 10 consulting rooms.

“The work is so varied. From parents worried about their small children with fevers, to depressed and anxious teenagers,” Dr Torvaldsen said.

“My oldest patient died recently aged 104. I managed the sudden and somewhat unexpected deterioration, counselled family, provided palliative care, arranged nursing support and she passed away peacefully at her low-care aged care facility. It avoided hospital admission, which would have been expensive, futile, and most likely a poor quality, undignified end to a long and worthwhile life.

“Also recently, I had to gently nag an ophthalmologist who came in with wax impacted in his ear, jammed in by his attempts to remove it using various eye surgery instruments. Fortunately, it was easily removed by me. We doctors are not good at self-care, and general practice is a specialty in its own right. He will get me to do it next time.

“It is certainly not all coughs, colds and minor illnesses. Although we see plenty of that and the real skill is in picking the more serious conditions from the minor illnesses, especially as they often present to us in the very early stages.

“So much of what we do in general practice is about ensuring good communication and good understanding. It is not enough to just write the script.

“The reward is in the long-term care and seeing people through all sorts of things, as well as seeing the results of our medical care and the difference we make to people’s lives.

“We sometimes forget the degree of trust they put in us. And for me, the sheer variety keeps the day interesting and the brain nimble.”

CHRIS JOHNSON

A positive influence in patients’ lives

Family Doctor Week
New South Wales – Dr Danielle McMullen

For Dr Danielle McMullen of the Church Street Medical Practice in Newtown, being a family doctor is an enormous privilege.

Primary care is a passion, as is the whole medical profession– she has held numerous roles in the AMA, including being on the NSW AMA Board since 2014 and Vice President of AMA New South Wales since May this year. She is also now on the Federal AMA Board.

In the big and busy city clinic where she works, Dr McMullen is known for being down-to-earth and approachable, funny and witty, calm and competent, and extremely good at her job.

She is a strategic thinker and a problem solver.

“I’ve been here at this practice almost three years and I have gradually put the family trees of people together,” she said.

“Eventually it dawns on you, or a patient tells you, that you’re also treating their whole family.

“I see about 25 patients in an average day, and they are all ages. My patients are between the ages of zero years and 96.

“The highlight of being a family doctor is that you get to know the family you are treating, and, in some respect, you become part of the family.

“That is really profound and quite a privilege. They genuinely care about us, and we care about them. We are giving them medical care, but it’s in the context of their whole lives. We really get to know them.

“You know how far to go with treating their health because you know what else is going on for them.”

Dr McMullen insists her passion for general practice came from wonderful mentors and supervisors. Because of that, she wants to give back and has ensured she remains an advocate for the profession and for excellence in training of young doctors.

When she is not treating patients, Dr McMullen likes to hike, and she has just signed up to a gym.

“I am taking my own advice, which I dish out liberally to my patients, that they need to do more exercise,” she said.

For Dr McMullen, it is the appreciative patients who make her work immensely worthwhile.

“It is pretty special when we are given real heartfelt thanks, because you know you have helped someone,” she said.

“You have been able to do something for them that has been positive in their lives – like when someone gets pregnant after having been trying for so long.”

CHRIS JOHNSON

Your patients’ health in their hands

Information for AMA Members from the Australian Digital Health Agency about My Health Record.

By Professor Meredith Makeham

Australians are being offered an important choice over the next three months about how they want to interact with their health information.

By the end of 2018, all Australians will have a My Health Record created for them, unless they choose not to have one.

The decision, importantly, is theirs to make after considering the benefits of having immediate online access to their health and care data, and being able to share it with their clinicians.

They will have access to information such as their medicines and allergies, hospital and GP summaries, investigation reports and advance care plans which could not only save their life in an emergency but also help their clinicians find vital information more quickly so that they can make safer health care decisions.

Trusted health care providers – GPs, specialists, pharmacists and others – are likely to find their patients want to talk to them about their decision. The My Health Record system is here to support better, safer care – not to replace current clinical record keeping systems or professional communication. Neither will it replace the patient-doctor relationship and clinical judgement. It is simply a secure online repository of health data and information that wouldn’t be accessible otherwise.

The data flows into the record from securely connected clinical information systems in hospitals, general practices, pharmacies, specialists’ rooms, and pathology and radiology providers. It also provides access to Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) data, the Australian Immunisation register and the Australian Organ Donor registry.

People understandably want reassurance that the Australian Digital Health Agency (the Agency) holds the privacy and security of their health information as its first priority. The system’s security has not been breached in its six years of operation. There is no complacency however – My Health Record system security operates to the highest standards, working with the Australian Cyber Security Centre and others. It is under constant surveillance and threat testing.

The legislated privacy controls are world-leading and easily accessed on the consumer portal. They include features such as a record access control – similar to a PIN – that a person can apply to their entire record so it can’t be viewed unless shared with their clinician. In an emergency, the legislation allows a clinician to ‘break glass’ and see vital medicines and allergy information. However, all instances of this are audited and people can choose to receive a text or email informing them if this happens.

The steps required for a healthcare practitioner to view a My Health Record require a number of security authentications to take place. For a provider to access the My Health Record via their clinical information system, they must be a registered health care provider – for example, registered with the Australian Health Practitioner Regulation Agency. They must also have a valid provider identifier and work in an organisation with a valid organisational identifier.

Software must be conformant, with a secure and encrypted connection to the My Health Record system. In addition, the patient must have a record on the provider’s clinical information system as a patient of the practice.

The Agency has not and will not release documents without a court/coronial or similar order. No documents have been released in the past six years and no other Government agencies have direct access to the My Health Record system.

We know 230,000 hospital admissions occur every year as a result of medication misadventure, costing the Australian taxpayer $1.2 billion annually. Many of these could be avoided if people and their clinicians had better access to vital medicines and allergy information.

The ‘Medicines View’ is a recent addition to My Health Record. It provides a consolidated summary of the most recent medicines information from notes entered by GPs, hospitals, pharmacies and consumers.

Over the past 12 months, the system has enriched its clinical content. Public and private pathology and imaging providers are now connecting and a vast increase in connected pharmacy systems as well as hospitals has occurred. This will accelerate the realisation of benefits as clinicians find they can access a more comprehensive source of information within the My Health Record system.

This month, a national communication plan was launched to ensure Australians are well informed when making their decision. Almost 20,000 My Health Record education kits were distributed to GPs, community pharmacies, aboriginal health services, post offices and public and private hospitals.

Our role as health care providers is to be our patients’ advocate, to support them in making the decisions and choices that will lead to better health outcomes and ensure that they have access to safe and effective care. My Health Record isn’t here to solve all of our problems, but it is an important step forward in our ability to deliver a safer and better-connected healthcare system.

Clinical Professor Meredith Makeham is Chief Medical Adviser of the Australian Digital Health Agency.

How digital tools are revolutionising patient care

Imagine you’ve recently had a heart attack.

You’re a lucky survivor. You’ve received high-quality care from nurses and doctors whilst in hospital and you’re now preparing to go home with the support of your family.

The doctors have made it clear that the situation is grim. It’s a case of: change your lifestyle or die. You’ve got to stop smoking, increase your physical activity, eat a healthy balanced diet (whilst reducing your salt), and make sure you take all your medicine as prescribed.

But before you leave the hospital, the cardiology nurse wants to talk to you. There are a few apps you can download on your smartphone that will help you manage your recovery, including the transition from hospital to home and all the health-related behavioural changes necessary to reduce the risk of another heart attack.

Rapid advancements in digital technologies are revolutionising healthcare. The benefits are numerous, but the rate of development is difficult to keep up with. And that’s creating challenges for both healthcare professionals and patients.

What are digital therapeutics?

Digital therapeutics can be defined as any intervention that is digitally delivered and has a therapeutic effect on a patient. They can be used to treat medical conditions in a similar way to drugs or surgery.

Current examples of digital therapeutics include apps for managing medications and cardiovascular health, apps to support mental health and well being, or augmented and virtual reality tools for patient education.

Paper-based letters, health records, prescription charts and education pamphlets are outdated. We can now send emails, enter information into electronic databases and access electronic medication charts.

And patient education is no longer a static, one-way communication. The digital revolution facilitates dynamic and personalised education, and a two-way interaction between patient and therapist.

How do digital therapeutics help?

Digital health care improves overall quality of care, even in cases where a patient lives hundreds of kilometres away from their doctor.

Take diabetes for example. This condition affects 1.7 million Australians. It’s a major risk factor for developing cardiovascular disease and stroke. So it’s important that people with diabetes manage their condition to reduce their risk.

A recent study evaluated a team-based online game, which was delivered by an app to provide diabetes self-management education. The participants who received the app in this trial had meaningful and sustained improvements in their diabetes, as measured by their HbA1c (blood glucose levels).

App based games of this kind hold promise to improve chronic disease outcomes at scale.

New electronic devices are also being used by people of all ages to track activity, measure sleep and record nutrition. This information provides instant and accurate feedback to individuals and their therapists, allowing for adjustments where necessary. The logged information can also be combined into large data sets to reveal patterns over time and inform future treatments.

Digital therapeutics are spawning a new language within the healthcare industry. “Connected health” reflects the increasingly digital ways clinicians and patients communicate. A few examples include text messaging, telehealth, and video consultations with health professionals.

There is increasing evidence that digitally delivered care (including apps and text message based interventions) can be good for your health and can help you manage chronic conditions, such as diabetes and cardiovascular disease.

But not all health apps are the same

Whilst the digital health revolution is exciting, results of research studies should be carefully interpreted by patients and providers.

Innovation has led to 325,000 mobile health apps available in 2017. This raises significant governance issues relating to patient safety (including data protection) when using digital therapeutics.

A recent review identified that most studies have a relatively short duration of intervention and only reflect short-term follow up with participants. The long-term effect of these new therapeutic interventions remains largely unknown.

The current speed of technological development means the usual safety mechanisms face new ethical and regulatory challenges. Who is doing the prescribing? Who is responsible for the efficacy, storage and accuracy of data? How are these technologies being integrated into existing care systems?

Digital health needs a collaborative approach

Digital health presents seismic disruption to patient care, particularly when new technologies are cheap and readily accessible to patients who might lack the insight required to recognise normality or cause for alarm. Technology can be enabling and empowering for self management, however there’s a lot more needs to be done to link these new technologies into the current health system.

Take the new Apple Watch functionality of heart rate notifications for example. Research like the Apple Heart Study suggests this exciting innovation could lead to significantly improved detection rates of heart rhythm disorders, and enhanced stroke prevention efforts.

But when a patient receives a high heart rate notification, what should they do? Ignore it? Go to a GP? Head straight to the emergency department? And, what is the flow on impact on the health system?

Many of these questions remain unanswered suggesting there is an urgent need for research that examines how technology is implemented into existing healthcare systems.

If we are to produce useful digital therapeutics for real-world problems, then it is critical that the end-users are engaged in the process. Patients and healthcare professionals will need to work with software developers to design applications that meet the complex healthcare needs of patients.

Caleb Ferguson, Senior Research Fellow, Western Sydney University
Debra Jackson, Professor, University of Technology Sydney
Louise Hickman, Associate Professor of Nursing, University of Technology Sydney

This article was originally published on The Conversation. Read the original article.

The bush GP: what it’s really like working in a remote location

Being a GP in a remote outback location is rewarding work – but it’s not necessarily for the fainthearted. You’re likely to be the only doctor there, and if things go wrong, help may be some time coming.

“You’re by yourself, you’re thrown in the deep end and you’ve got to manage that,” says Dr Chris Clohesy (pictured), who has spent the last five years working as a GP in remote communities in Northern Territory, after a 20-year career in the city. “There’s the constant threat that something will come up that takes you to the limit and there’s no one holding your hand. You’re asking yourself: am I up to it?”

Dr Clohesy recounts a time when he had to manage a child who had drunk petrol and was fitting.

“I was in a remote community and there was only me and a couple of nurses. We didn’t have much equipment and we were talking to Darwin by phone, with a plane a good couple of hours away. This one had a good outcome, but you remember these things. They’re frightening and challenging situations.”

And then there are the more quirky episodes that a doctor is never going to experience in a suburban Sydney clinic – such as the occasional veterinary intervention, for example.

“Late one day a chap brought in his dog, which had been run over and had a massive abdominal wound, extending from the groin to the belly. Can you do anything, the owner asked. So we sewed the dog up and gave it some antibiotics and incredibly, the dog survived. I couldn’t believe it! So you do have to think out of the square and handle some weird cases.”

The key to working remote, Dr Clohesy says, is to keep your skills and knowledge up to scratch.

“It’s a difficult process finding the educational resources to be able to upskill. I spend a lot of time hunting down courses and clinical attachments to keep me up to date. And it’s a lot of time and money. Rural and remote doctors have the same educational requirements as everyone else, but it’s a lot harder to get them. And for junior registrars studying for exams it’s really hard, particularly if you have a dodgy internet connection!”

Online learning definitely has a big role to play for rural and remote doctors, Dr Clohesy says.

“But it’s got to be good. You can’t just put something up on the internet and say, there you go. There’s still got to be some sort of human contact with that online course where you can actually talk to someone, and an expert you can contact really enhances the course.”

Dr Clohesy recently flew to Melbourne to do an Advanced Life Support course. He says he paid his own airfare, plus the $700 for the course, with the whole trip taking three days.

“That’s so I’m up to speed on the cardiac stuff I need to deal with out here. It’s not about sitting about under a palm tree on the beach; it’s a serious challenge.”

And it’s also important to keep your outside interests and lifestyle ticking over, Dr Clohesy says, whether it’s sport, exercise, fishing or reading.

“At the moment I’m getting my bikes and gym equipment shipped to me by barge from Darwin. Luckily, where I am has a swimming pool, so I can do my laps which is important to me.”

Keeping in the medical loop and maintaining your networks is also important when you’re working in remote locations.

“I belong to the AMA, I join as many committees as possible, and all that improves my interactions with other doctors.”

The job definitely has its own rewards, Dr Clohesy says.

“Most doctors are out here because they want to help, and they want to look after these impoverished people, and that gives them a huge amount of satisfaction.”

Junior doctors may think if they go rural they’ll miss out on positions in metropolitan hospitals, but that’s not at all the case, Dr Clohesy says.

“These days, as a junior doctor, it’s really positive to have a CV with some rural work on it. It shows you can work independently.”

And there are various incentives, such as the General Practice Rural Incentives Program, which pays doctors an annual amount for working in rural and remote areas, with the amount rising with each extra year of service.

“We have a public health role. I think it would be great if all doctors did a six-month stint in a rural or remote community. We’d overcome a lot of deficiencies if that happened.”

Are you working in a remote or rural community? Doctorportal Learning has a number of online learning modules that may suit your certification needs.
Our Cranaplus Advanced Life Support Certification can be completed entirely remotely, with an online theory component and a clinical assessment using Skype. This module is the only accredited ALS in Australia that enables you to undertake the clinical assessment via a virtual platform.

Which anticoagulant is the safest?

Apixaban was the clear winner in a large observational study looking at the risk of major bleeding and death with the use of the most commonly prescribed anticoagulants.

The study, which breaks new ground in terms of its scope and design, looked at around 200,000 new users of warfarin, dabigatran, rivaroxaban and apixaban in the UK primary care setting, tracking them over a five-year period. Overall, apixaban was found to be the safest direct oral anticoagulant (DOAC) compared with warfarin for patients with and without atrial fibrillation. Patients on a standard dose of apixaban had a 34% reduced risk of major bleeding and a 60% lower risk of intracranial bleeding over the study period, compared with warfarin. Apixaban users also had reduced rates of gastrointestinal bleeding.

The safety benefits of other DOACs compared with warfarin was less clear cut. There was a reduced risk of intracranial bleeds with rivaroxaban, but only in patients without atrial fibrillation. And in patients with atrial fibrillation, dabigatran lowered the risk of intracranial bleed, compared with warfarin.

Rivaroxaban was associated with higher all-cause mortality across the board, in patients both with and without atrial fibrillation, as was apixaban in low doses, compared with warfarin. But the authors say the higher mortality with these DOAC regimens could be due to closer monitoring of patients on warfarin, or due to prescribing choices related to underlying comorbidities.

The stronger safety profile of apixaban in this study is in line with a recent meta-analysis, which also showed apixaban to be the safest of the DOACs and a better performer than warfarin. But the authors of the present study say that meta-analysis mostly involved indirect rather than head-to-head comparisons. Direct comparison studies are few and far between, because regulatory authorities generally only require studies showing non-inferiority to placebo or standard treatment.

They add that their study is the first to look at a large subset of patients taking anticoagulants for reasons other than atrial fibrillation, such as after deep vein thrombosis, knee or hip replacement or stroke. This accounts for about half of users of anticoagulants.

Overall, they say their study paints a reassuring picture for patients taking DOACs as an alternative to warfarin, particularly for those who have been prescribed apixaban.

You can access the full study here.

What the next RACGP president wants to change

Yesterday, the results were announced of the membership vote for the next president of the Royal Australian College of General Practitioners. NSW GP Dr Harry Nespolon defeated two rival candidates, Queensland’s Dr Bruce Willett and Dr Jagadish Krishnan from Western Australia.

Dr Nespolon, who practises on Sydney’s Lower North Shore, was widely seen as a change candidate. He says he wants to see a cultural shift within the college: “It needs to move away from being an autocratic organisation to an organisation that does really care for its members”.

In interviews with the medical media and in an email mailout to RACGP members, he has outlined five key focuses for his term of office, which will start this October:

GP funding

Dr Nespolon says this is the number one issue, and neither the AMA nor the RACGP has done enough to fix the rebate issue. He says the timetable on rebate increases is too slow and is unacceptable. He plans to lobby the government to allow GPs to charge a gap and directly bill the government for the rest.

“The simple reality is that if the government is not willing to support rebates to a level that allows for quality general practice, then patients will be required to make relatively small contributions towards the most important aspect of their lives, their health,” he told Australian Doctor.

GP mental health

Dr Nespolon supports developing programs specifically targeting the mental health and well-being of GPs, addressing areas such as stress, burnout, depression and substance abuse.

AHPRA’s complaints process

AHPRA needs to improve the way that it treats doctors when complaints are made against them if it is to maintain their trust, Dr Nespolon says. He says he will use his position to lobby for a less onerous and stressful complaints process.

He also says he is not in favour of the Medical Board of Australia’s plan for mandatory checks on doctors aged 70 and over. A more targeted approach is necessary, he says.

Changes to PLAN

Dr Nespolon is opposed to the PLAN (Planning, Learning And Need) activity being a compulsory component of members’ CPD, although he concedes that this will require a vote of the RACGP Board and is not a change he can make himself.

Getting GP training right

The RACGP is being handed back control of GP training. Dr Nespolon says it is crucial that the college gets this right and that it is “an embarrassment” that the college has not been in charge for such a long time.

He says he is in favour of a separate administrative structure for GP training that is at arm’s length from the day-to-day administration of the college. One solution, he says, might be to manage training through a wholly-owned subsidiary.