During May and June 2017, the Department of Planning, Transport and Infrastructure (DPTI) will be replacing tram tracks along Jetty Road, Glenelg.
These works are necessary as the existing tram tracks and associated infrastructure have reached the end of their useful life. New rail and associated infrastructure will be installed to ensure the continued safe and reliable Glenelg tram services are provided for the 9.23 million passengers using this service each year. Cyclist safety will also be improved with an upgrade to Tram Stop 16 on Jetty Road, as part of the project.
Project completion is expected at the end of June 2017.
Jetty Road closure
To minimise disruption to tram passengers, businesses, residents and visitors to the Jetty Road precinct, the works will be undertaken during the planned closure of Jetty Road from15 May – 9 June 2017 inclusive.
DPTI appreciates your patience and cooperation whilst these important works are undertaken.
During the closure of Jetty Road
Tram services to Glenelg will terminate at Stop 15 Brighton Road, with normal services to resume from mid June 2017.
Bus services that use or cross Jetty Road will be re-routed to avoid the construction site and will follow the bus routes used during major events. For information about the temporary routes, please visit www.adelaidemetro.com.au or alternatively please visit www.adelaidemetro.com.au/user/register to sign up to My Metro to receive updates when there are changes to travel conditions, straight to your inbox or mobile phone
Traffic detours will be in place throughout the closure with signage and traffic controllers advising motorists of the changed traffic conditions. Road users are requested to observe traffic signs and restrictions.
Pedestrian accessto businesses along Jetty Road will be maintained at all times during the closure period, with pedestrians able to cross Jetty Road at Brighton Road, Moseley Street and Moseley Square. An additional pedestrian crossing will be provided on the western side of the intersection of Jetty Road with Gordon and Partridge Streets.
Car parking along Jetty Road will not be available during the construction period. Signage will be in place to direct motorists to alternative public parking sites. Disabled parking will be relocated 60 metres north of current locations and clearly identified with signage.
Loading zones located in side streets and to the rear of businesses will remain in place during construction. However, loading zones on Jetty Road will be temporarily removed during construction and relocated to side streets in close proximity to Jetty Road.
During the construction period, large trucks will access the site to deliver materials including steel rails and remove construction waste such as concrete. Heavy machinery will also need to be transported to and from the work site.
Heavy vehicles will be restricted to main roads wherever possible including Anzac Highway, Colley Terrace, Jetty Road and Brighton Road. Occasionally, heavy vehicles will need to use local streets to access Jetty Road, however this will be mitigated where possible.
Construction machinery associated with the works will be stored at the southern end of Byron Street, Waterloo Street, Nile Street and Sussex Street. Pedestrian access to Jetty Road will be maintained at these locations.
A site compound will also be established on the Jetty Road end of Nile Street.
‘a well person who simply needs a letter to see a specialist should be able to get one without requiring a GP consultation’
Why does a ‘well person’ need to see a medical subspecialist rather than a specialist in Primary Care – their GP?
They don’t need a letter to ‘see a specialist’. Anyone can see a subspecialist doctor in Australia by paying their own money for it. A GP referral is only needed so that the patient may receive a Medicare rebate for the subsequent subspecialist consultation.
A referral is a formal transfer or handover of care from one doctor to another. I don’t think the Qoctor AI measures up.
There are many benefits of online health services and they can complement traditional face-to-face GP visits. But there are also examples that raise questions.
The young woman was in tears. When she came in she had initially asked for a referral to a surgeon for a breast augmentation. During the conversation it turned out that her partner had made it clear that her breasts were too small.
We ended up having a chat about relationships and body image. At the end of the consultation she decided she needed some time to think things over and talk to good friends, and that she would come back if she needed further assistance.
The problem with online referrals
At first sight, the Qoctor website seems an easy, convenient online medical service that provides sick certificates and referrals.
The site tells visitors: “(…) we understand that a well person who simply needs a letter to see a specialist should…
The good GP has a stewardship role in the Australian medical system and part of this is referring to subspecialist and hospital care. This is an important role and we don’t take it lightly. We want to do our best for our patients and help them get the care they deserve. One of the challenges is referring to public hospitals, where our referrals sometimes get ‘bounced’ back to us. In private practice, for the patient to receive a (Federal) Medicare Benefit (like when you see Your GP), the GP referral must be to a named provider (Dr Smith, Dr Jones, for example). When referring to a public hospital, there has historically been no Medicare rebate for the patient – public hospitals are funded by the State Governments and Medicare is funded by the Federal Government, and care is free at the point of service. This is changed recently, and public hospitals are now using Medicare funds to run their services. Therefore they now seek named referrals. But to who? It’s very hard to find out exactly which doctor will be seeing you, and so it’s hard to do a named referral, which may delay you being seen.
So, as a public service, we’re Here to Help! Bernie Cummins (Director of Nursing Statewide Outpatient Reform) has provided the following documents to help GPs and patients navigate this system and avoid the ‘named referral bounce’.
We are going to promote Health Equity by bulk billing where we can and discounting our fees where the current patient’s rebate from Medicare doesn’t cover our operating costs. We bulk bill children from birth to age 10, and DVA card holders of all ages. We discount our fees for Aged Pensioners and those in financial hardship.
Politics is bad medicine when it comes to taxpayer health and Medicare ought to be ringfenced from partisan brinksmanship by an Independent Medicare Authority, Royal Australian College of General Practitioners President Dr Bastian Seidel told the National Press Club on Monday.
In an impassioned defence of primary care, Dr Seidel said the Medicare Authority would entrench the current MBS review in perpetuity and allow for contemporary pricing of items based on value to patients and clinicians.
Making the case for change, he offered some sobering observations:
less than 2% of NHMRC medical research funding goes to General Practice
the cost of two minutes of operating theatre time is more than the Federal Government spends on Medicare, per annum, for a patient seeking GP care ($30.40 per person per month – less than a Foxtel subscription)
if you increase the number of GPs by 1 per 10,000 people the death rate goes down 9%; if the number of non-GP specialists is increased the death rate rises 2%
1 in 20 patients is already delaying or avoiding seeing their GP due to cost
We’ve reproduced Dr Seidel’s remarks as a longread on primary care, below (with thanks to the RACGP). We’d love to hear your thoughts.
Dr Bastian Seidel writes:
The RACGP has come a long way since its foundation almost 60 years ago.
As an academic medical college we set the standards for the medical specialty of general practice. We write the curriculum, provide education and hold postgraduate exams, ultimately leading to the Fellowship of the College. And clearly Fellowship of the RACGP is the premier qualification of excellence & distinction within the medical specialty of general practice. Its national and international recognition is second to none, and rightly our fellows are using their post-nominals with pride and dignity.
The RACGP is now the largest medical organisation in Australia. We have over 35,000 active members in all states and territories. Over 80% of all Australian GPs call the RACGP their professional home.
Achieving recognition as medical specialists in our own right has been an uphill battle for GPs for decades. We only achieved vocational recognition as specialists in the 1990s.
However, for many, we are still seen as #JustaGP, a term that symbolises the academic and professional discrimination our members are still subjected to.
Old habits die hard.
85% of all medical research is wasted
Look at our esteemed universities. We only have a few full Professors of General Practice nationwide. The implications are significant: poor representation of general practice in the undergraduate teaching of medical students for example. Students are lucky to spend a few weeks of their five-year training in our specialty in the community. The vast majority of teaching takes place in the hospital setting.
Consider medical research: less than 2% of NHMRC research funding is awarded to research conducted in general practice. Ninety eight per cent of research funding will end up in tertiary care centers, hospitals and metropolitan institutions.
Shouldn’t we ask ourselves whether the evidence derived in those high-tech silos applies to care in the low tech general practice setting? Shouldn’t we ask whether efficacy demonstrated in controlled hospital environments translates to effectiveness in the complex real world of comorbidities, social, economic and cultural contexts of general practice?
It is self-evident that the answer to both questions has to be a firm no. That’s why 85% of all medical research is wasted. This is not what our patients expect, this is not what the taxpayer expects either.
Law of diminishing returns
Although major gains were achieved funding hospital-based treatments and hospital based research in the 20th century, the 21st century shows us a clear example of the law of diminishing returns.
As a nation, we can’t continue on those old trodden paths. They lead to nowhere. Let’s pause and reflect, because we need to consider nothing else but a shift of the norm.
The norm should be that 21st century health care is delivered in the community, not in hospitals, and subsequently the focus needs to shift from offering expensive treatments of disease in institutions, to effective strategies to maintain health in the community.
I’d argue that patients want health, not necessarily treatment. Isn’t it time that our health system was reflecting that?
Primary care a 21st-centry bargain
Australia’s health system is hospital-centric. And we should be proud of the advances we’ve made in the tertiary care sector, in particular in the last century. Hospitals in Australia are of the highest standard, whether they are public or privately run institutions.
However, hospitals are extraordinarily expensive to run.
The total recurrent health expenditure for public hospital services alone is over $45 billion per year. $19 billion are contributed by the Federal Government, the remainder is contributed by the states and privately. The cost of private hospitals is over $12 billion, that vast majority covered by private health insurance which again is subsidised with over $6.5 billion dollars per year by the taxpayer.
Compare that with the $7 billion the Federal Government spends on GP care in this country. Sounds like GP care is a 21st century bargain.
Hospitals don’t function without multiple layers of administration and bureaucracy. Despite best efforts and increased funding over the years, hospitals are now at breaking point. Waiting lists are getting longer by the week. There are now waiting lists to be on a waiting lists. Variance of care and treatment is making national headlines.
Still, hardly any politician can afford not to support public and private hospital funding. Any shortcoming in the delivery of clinical services is usually followed by a loud call for ever increasing funding.
There are multiple reasons for it. Firstly, hospitals are very good in treating patients. Those treatments are often procedure-based and are just expensive.
A minute of theatre time at the Fiona Stanley Hospital in Perth is budgeted at $160. So, the cost of two minutes of theatre time is more than the Federal Government spends on Medicare for a patient seeking GP care.
Not per minute – per year.
One solution of course would be to ask the theatre team to hurry up. Clearly time is money – but it would not do the complex issue justice. We need to have less operations, we need less treatment. We need to focus on maintaining health and we need to focus on prevention. And that has to happen in the community, not hospitals.
Triple digit millions
Emergency departments are overcrowded. Public and private hospitals struggle to meet treatment targets. It’s a nationwide issue.
But have a look at the data from NSW that was made public last week. Compared to the same quarter last year, almost 20,000 additional patients presented to emergency departments. The total number of presentations is a staggering 684,740. That’s for three months only and only in one single state.
The conservative cost of a single presentation to the emergency department is $250 to the taxpayer. Feel free to do the sums, we’re talking triple digit millions. Again, per quarter. One state only.
Even worse, at times patients are not waiting. They book in at reception, but leave. They are never seen by a doctor in the actual emergency department – yet – the Commonwealth is billed $70 per ‘did not wait to be seen’.
Ultimately those patients are seen by the GP the next day, and I would say, should have been directly referred to the GP when they presented to the emergency department in the first instance.
Estimated cost for the government: $15 million per annum. Again, no clinical service, but the taxpayer is charged regardless.
Not a tradeable commodity
Fragmentation and consumerism in health care also increasingly affect the patient experience. And yes, I keep saying that I still specialise in patients – not consumers, clients or users.
General practice is a vocation. Not an industrial endpoint. The patient doctor relationship is special. It’s not a business transaction between a willing seller and the highest bidder.
Health is not a tradeable commodity and we should not treat it like one.
Looking at the most recent federally funded health programs, it struck me that is has become commonplace to talk about consumer-centric mental health packages and client-based aged care services. Primary Health Networks are now commissioning bodies for some forms of health services, and I sometimes wonder whether these services will be chosen by a computer algorithm and then delivered by a remote controlled drone. There may even be an app for all of this.
How sure are we that we are improving health outcomes, walking on this uncertain path? Are we sold a promise? Of control, independence, autonomy? Maybe. But who benefits?
Never did I think that I could be perceived by either policy makers or patients as a client manager, who may be paid based on some key performance indicator and consumer feedback.
Calling patients consumer, clients or service users is also not the same as empowering them. Dr Jason Tomlinson suggests that doing so is very unlikely to change the prejudices associated with illness and disease, because these prejudices are too deeply historically and socially embedded.
The relationships between patients and their GPs have, however, evolved throughout history, as traditional hierarchies have changed. Patients have become better educated and GPs have been trained to be more patient-centred.
Treating patients as consumers can of course create significant problems as the Harvard Business Review points out.
First, patients don’t want to be there. People don’t seek out health care without reason (I’d like to add that the number of recreational colonoscopies performed is actually very low). Something is wrong and patients want it fixed.
Second, patients are not equipped to be there. Even when patients are willing to be decision makers, they may not have the tools. At a time of unusual stress, the system asks them to absorb technical information and make difficult decisions that require specialised expertise. When patients are required to be proactive decision makers, the health system is often casting a very reluctant hero into the role.
Third, patients are not in it alone. To design for patients alone is to forget that they are part of a complex system and are often not independent decision makers. Decisions are shaped by other stakeholders: friends and family who offer support, practitioners who provide care and expert advice.
Are GPs just meant to be providers selling services to health care consumers? Is it a scenario from a brave new world where consumers visit a provider for another interchangeable transaction in a commoditised society?
Ultimately this approach will lead to peak fragmentation of health care. Policy makers and program architects need to take a step back and assure us that in their eagerness to consumerise the medical experience, they don’t undermine the quality of care by demanding more of patients then they should be expected to deliver.
How come my patients are still asking me: you are my GP, what would you do, doc?
GPs find joy in small things. And as my colleague Dr Margaret McCartney wrote just last week in the BMJ, small things are indeed big things for us GPs.
I’m deliberately quoting her:
It’s when you say hello to someone who is at the practice not to see you but your practice nurse. But you know these patients, their mothers, their sisters. You know that they are at the practice to have blood tests to monitor the cancer you diagnosed last year. You both know this. The relationship that General Practice allows us to form can last decades. They weave between families and overlap across illnesses, presentations, treatment choices and even death. They make it easier to handle uncertainty, to talk about dying, to think about mortality, to grieve, to make rational choices, and to feel joy.
I’m thinking about the person you have not seen for years, but who returned to the practice to see you because you helped with his depression before.
I’m thinking about the baby born after many years of trying, when you exchange smiles with the parents, who know too well the years of tears and infertility.
I’m thinking of the bereaved husband, and the wife who came to talk to you about her fears about how he would manage after her death. His wife understood that you would still be around after she died and that you’d still be offering care to her husband.
If you rip the longitudinal care out of general practice, it’s just a set-up of interactions to be monitored by tick box targets or analysed as data on ‘activities’. Take the relationships with people out of general practice and you have an unsustainable future.
General practice is a risk sink: GPs are the depository of much uncertainty, which allows an affordable health system to exist. But it can only work when it is supported. We make judgements about who we trust, and those judgments are stronger and better when they are formed over time.
General practice is a long game, characterised by continuity of care, not fragmentation. This benefits patients, society and of course the taxpayer.
GPs are the doctors of first and last resort. We provide continuous and comprehensive care. And GPs want to be responsible for a person’s entire health care need.
That does not mean that GPs are doing absolutely everything. Of course not. But we are preventing fragmentation. Fragmentation of care and the associated poor communication leads to poor health outcomes.
People do better with General Practice
So what is the value that GPs bring to the health system?
Professor Barbara Starfield’s work clearly demonstrates that countries with a strong GP-centred system have much better health outcomes than countries that don’t. It’s not tertiary care and hospitals with the latest and greatest technology that’s achieving that. It’s not the fancy tools. They deliver headlines for the popular press and make national news, but not the positive sustainable outcomes our society deserves.
Looking at international evidence, if you increase the number of GPs by 1 per 10,000 people, the death rate in that community goes down 9%; if you increase the number of non-GP-specialists, the number goes up 2%. If you are a GP you average at least 35% lower cost of care and a 20% lower chance of dying for your patients. General practice improves patient’s self-rated health, it reduces health disparities among populations and reduces the effects of income inequality.
Bottom line: people do better with general practice. So why is that? Why are people doing worse when non-GP-specialists are the foundation of care?
Well, one is when specialists get outside their area of expertise, they get dangerous. Ask a cardiologist to manage a patient with pneumonia, a gastroenterologist to treat acute myocardial infarction or a chest physician to treat upper gastrointestinal bleeding — they just don’t do as well as GPs do on any given day.
Continuity of care results in a significantly lower risk of death. Continuity of care also leads to fewer hospital admissions in particular in patients who suffer from multiple and complex chronic medical conditions.
GPs were traditionally described as gatekeepers of the health system. I think that’s not the appropriate description of what we do, and it almost implies that GPs are a barrier to health or treatment.
GPs have evolved to be the stewards of our health system. We enable health by guiding, counselling, advising, comforting, healing and sometimes – treating.
GPs want to spend more time with their patients. Every minute I spend with my patient allows me to obtain more information about the life, concerns, fears and expectations. As a professional I’m trained to put this information into context.
Putting information into context over time, I ultimately gain true knowledge of my patients and the more I know about them, the less likely I’m tempted to initiate tests, order procedures or write prescriptions.
Less than a newspaper subscription
Total annual health expenditure in Australia is about $145 billion. General practice accounts for just around 5% of that. This includes the funding for Medicare, practice incentive payments and Primary Health Networks.
Over 85% of all Australians are seeing their GP at least once per year. If you do the sums, the total funding for comprehensive GP care, no matter over how many visits, is a measly $30.40 per person per month. That’s how much the Federal Government spends on GP care.
It’s less than a subscription to Foxtel, or to The Australian.
Over the last decade that figure has been virtually constant, whereas funding for public hospitals has increased over 19% in the last few years. One has to wonder whether general practice has to pay for the infrastructure of hospital medicine.
If so, we will inevitably end up with assembly line-medicine in which patients are forced through six minute consultations.
I would like to reject the notion of my colleague Dr Pamela Wible who speculates whether general practice is taken hostage to a tertiary care delivery model. One would hope not, as general practice is the solution to rein in the ever increasing costs of the tertiary hospital sector.
The savings that can be gained are obvious: if we reduced hospital admissions by 6%, we would save $2.5 billion every year. One third of A&E presentations could easily be managed in general practice, the cost savings without compromising quality care would be $1.4 billion every year.
Hospital outpatient departments are also providing over 400,000 consultations that could be better provided in general practices. The savings here: $108 million. Three simple and pragmatic measures and the taxpayer would save $4 billion per year.
Snowy Mountains Scheme
So where do the savings go? Well, of course I’d say all realised savings should go towards funding general practice (after all general practice only ever gets 5% of total health funding, less than 2% of research funding, but still see over 85% of all Australians at least once per year). But I’d be very happy with half that amount.
If we want to shift the norm, direct healthcare funding from the expensive tertiary care system to the more efficient and sustainable general practice system, that’s what we need to do.
It would take the pressure off the hospital grid. It would turbocharge the community and electrify general practice. In fact, I like it so much that I’d call it the Snowy Mountain Scheme of General Practice. The benefits would flow immediately (I’m looking at the Prime Minister’s advisor in the audience here…)
But seriously. There are only three levers for funding general practice:
Funding can be allocated directly to General Practices
Funding can be directed to individual General Practitioners and
Funding can go to directly to patients via a Medicare rebate.
There is no magic. Those are the three funding levers that are available. To policy makers and politicians.
Directly funding general practices or general practice systems so far has not had much impact. Practice incentive payments for accredited GP practices, infrastructure grants and small grants for research are cumbersome, complicated, and poorly administered.
As outlined above, payments to practices should incentivise systems that support continuity of care. The benefits are obvious to patients and practitioners. Payments should also incentivise better access to care in order to support the drive for continuity. Payments should be flexible.
General practice systems should be incubators for new ideas. Those ideas should address specific issues and concerns in the respective community. A top-heavy, centralised, one-size-fits-all approach defeats the purpose.
Practice systems are also centres of learning and research. Students need to be taught in the real complex world of general practice. And we can’t teach continuity of care in blocks of 2 weeks at a time. If we want to shift the norm of healthcare delivery, we also need to shift the norm in teaching our future GPs.
General practice systems are the natural place of research and exploration. Networks of GP practices will deliver valid research that is applicable to the complex environment we work and live in.
If we want to generate the evidence for the delivery of 21st century healthcare we need to do the research in general practices. Not academic silos. Otherwise 85% of the research will be wasted yet again. We just can’t afford that.
We need to fund a progressive workforce of general practitioners. Too often I am hearing that we need more GPs. The question asked is: how do I get more GPs for my practice? Often this is not the question that should be raised. The question ought to be: why are GPs leaving?
Of course there may be personal factors beyond the community’s control or influence, but there are factors the system could address. If we want to strengthen the continuity of care aspect, direct retention payments to GPs who are committed to their communities are cost effective and efficient.
Let’s be frank. The average income of a GP is now less than the average income of a hospital doctor. There are consequences. Although medial graduates who are entering a career in general practice are not preoccupied by what they can earn, the limited income potential starts to bite shortly after. We need to shift the norm here too if we want to attract the best and brightest for our profession.
Of course we need to enable patients to see their GP. GPs are the most trusted health professionals in the country with satisfaction rates over 90%. That’s an approval rating most politicians here in the room could only dream of.
I guess we must be doing something right.
But 1 out of 20 patients are already delaying or avoiding to see their GP due to cost, the main reason being the unfair and nonsensical Medicare rebate freeze. I’m saying nonsensical for a reason.
As I mentioned before, patients don’t chose to get sick. And if you are unwell, and can’t afford to see your GP, you will attend the emergency department. The cost there for the taxpayer is multiple times higher than the cost of a standard Medicare rebate to see a GP.
Prior to the last federal election, the Victorian state government calculated a cost of an extra $220 million due to additional A&E presentations and ambulance callouts as patients would avoid seeing their GP. Bear in mind, lifting the Medicare freeze for GP item numbers would cost only $160 million. That’s nationally.
We can’t afford to be penny wise but pound foolish. It does not make sense.
All political parties have now openly stated that they are committed to Medicare and that Medicare deserves to be protected. What it should mean is that funding Medicare should be protected. Specifically, what should be protected is the funding available to patients via the Medicare rebate and the services covered.
Medicare rebates should reflect the true value of a service to the patient and the community at large and the actual service should be meaningful, evidence-based and clinically indicated. We need to take the politics right out of the debate.
Medicare does not need political gatekeepers, but Medicare needs genuine stewardship. Stewardship that ensures that Medicare is not fragmented but genuinely of value to taxpayers and patients.
We therefore propose to establish an independent Medicare Authority which would incorporate the MBS review, making that review continuous and permanent. The independent Medicare Authority would also be tasked with contemporary pricing of individual MBS items based on the value to patients and clinicians.
The independent Medicare authority should review Medicare Safety Net thresholds. If we do have a safety net it should be significantly lower for patients who need to see their GP. It would be the right thing to do. The independent Medicare authority should also include the Professional Services Review as well as the Medical Services Advisory Committee.
We’ve got to bring those branches together, not drive them further apart. Fragmentation here has the same effect as fragmentation has to the delivery in health care.
Advance Australia Fair
In my editorial in The Australian a few weeks ago I quoted Professor Brian Able-Smith from the London School of Economics. Decades ago he was asked whether there were any new and significant health care policies. He answered: “The only way to organise and pay for health services well is to change the system every second year so nobody feels comfortable in it.”
In a rather bipartisan approach GPs and our patients have indeed been shaken, stirred, turned inside out and put in the freezer. The reason? Nothing in particular, other than politics.
A coherent and comprehensive health policy is a bit like making a cake. One needs quality, evidence based ingredients. Of course one needs to add some political flavours – that’s almost inevitable — but if it is all about flavours and not about substance everybody gets sick.
The RACGP is politically agnostic. As an academic medical college we are calling for a commitment to evidence-based health policies. It should not be that difficult.
If ever possible, we should keep politics right out of health care.
Because there is no Labor, Liberal, National, Green approach of looking after patients, there should only ever be the methodological, scientifically sound, logical and evidence-based approach to 21st century health care. That’s what the community expects. That’s what voters expect and that’s what will improve the health of our nation – and that can only ever be in all our interest.
The role of the RACGP is not that of a lobby group. We advocate for the public interest, not personal profits. The basis of our advocacy will always be science. The logical, common sense argument needs to prevail. Not the cheque book.
When we point out a problem, we will also offer a solution. This does not need to happen publicly. It’s possible to be an activist for a cause without being an exhibitionist. But it is our role to raise the level of health literacy amongst our patients, the public but also amongst political decision makers and the press.
Health is essential to advance Australia fair.
Dr Bastian Seidel is President of the Royal Australian College of General Practitioners
Whichever way you look at it, there is a great little health precinct on Partridge Street! Let us work together to Help You. Care Plans, Team Care Arrangements, Health Assessments, and Mental Health Care Plans may allow You to receive Medicare Rebates for Great Care from Our Team.
Many years ago, coming to general practice from an emergency medicine background, I sat down with a group of trainee GPs. We started to talk about what we would see in general practice. I’d been working as a locum in general practice for a year and I thought I knew everything. ‘Coughs and colds are the bulk of the work’, I confidently declared. Those older and wiser than me set me straight, and told me that general practice is all about depression and anxiety and that it’ll be a rare consult where these won’t play a role. They were wise words then and now, so let’s talk about major depression in general practice.
The books would describe major depression as a subjective diagnosis which depends on reported symptoms rather than objective signs. There are cardinal symptoms of depression, rather than signs. Five or more of the symptoms below, present most of the time nearly every day for at least two consecutive weeks. Depressed mood or loss of interest or pleasure must be present. The symptoms cause substantial distress or impair function, and they are not better explained by substance abuse or a general medical problem. They are over and above what the GP thinks would be normal given the patient’s situation.
The GP who relies on books alone will be well read… and alone. Listen to the patient! It’s a mood disorder. How do they feel? How do they make you feel? Clinical gestalt is the theory that healthcare practitioners actively organise clinical perceptions into coherent construct wholes, or simply put, how experienced GPs can spot depression a mile off. Listen to your gut. Countertransference can be a powerful tool to show you where you need to go. We’ll come back to the Art of General Practice later. Experienced GPs can’t be everywhere, and so we need some other ways to screen for depression.
Enter the rating scales for depression. They read like the alphabet – PHQ-9, BDI, HDRS. They can be used for screening and measurement of progress. Perhaps only 50 percent of patients with major depression are identified without screening . Patients may not volunteer depressive symptoms without direct questioning for many reasons including fear of stigma, a belief that depression is not a matter for primary care, or a belief that depression isn’t a “real” illness but rather a personal flaw, as well as concerns about confidentiality and antidepressant medication .
In Australian general practice, we use the K10 and the DASS21 or 42. These are validated, easy to administer, reproducible, and recognised as part of the Mental Health Care Planning process. This enables patients with diagnosed depression to obtain a Medicare rebate for psychological therapy with a psychologist. American studies show patients are scared of psychiatric referral. Australian GPs are also scared of psychiatric referral, as it can be hard work to access private psychiatry. MBS item number 291 comes to the rescue and many psychiatrists will use this. They also know that depression masquerades as a variety of somatic symptoms. Untreated depression is associated with decreased quality of life and increased mortality. Depression can be successfully treated and treatment is effective. The earlier the better!
I recommend non-pharmacological treatment regularly. Exercise, diet, psychotherapy, GP counselling, reducing drug and alcohol use, getting more and better sleep are all options. These take time and effort, both from the patient and the GP. Remember, your time and presence are important to your patients. Ten minutes of education on diet and exercise can be worth months of medication and the effect can be long-lasting. Red flags include significant physical signs (weight loss is the big one in my opinion) or symptoms such as suicidality or psychosis on mental state examination.
Depression is not just a chemical imbalance. No pill can defeat the entirety of the patient’s life and circumstances pushing them in the wrong direction. The good GP will consider the patient in their environment and have an awareness of the social determinants of depression. Personality disorders, illicit drug use, and past abuse can lead to poor life choices and situations. Think about these before printing out a script.
When selecting an antidepressant, ask the patient what they’ve been on before. Ask about expectations and experiences and how they define success or failure. I tend to use medications that I’m familiar with and can then counsel patients accordingly. I find SSRIs to be an appropriate first line treatment. The side effects that concern my patients are anticholinergic (dry mouth), sexual (decreased libido and prolonged time to orgasm/ejaculation – so common that medications are now marketed for this purpose alone), and changes in sleep (too wakeful and agitated or too sleepy and hungover). I combat these with the advice to drink plenty of water and to time your medication according to how it makes you feel.
Traditionally, antidepressants are taken in the morning, but for those with a significant anxiety component, evening dosing is best. Trial and error will determine the optimal time for a good night’s sleep with no morning hangover. Sexual issues often require a change in medication. The newer medications promise fewer sexual issues, but often an older alternative can achieve the same goals at much lower cost.
The literature tells us the most resistant symptoms to treatment are insomnia, followed by sad mood, and decreased concentration. Depression is more likely to reoccur if these symptoms are persistent. I find that fatigue, anhedonia, guilt, worthlessness, and poor concentration are the hardest symptoms to treat successfully. It can be a long road for the patient (and the GP) back to wellness, and it can be hard to stick with treatment over time.
GPs have used many strategies to improve treatment adherence and all of us will remember pre-contemplators from our studies. We all get frustrated when patients don’t take our advice but providing information and warning of future consequences doesn’t always work. However, a solution is in clear sight. GPs have a fantastic and privileged therapeutic relationship with their patients, and can use this to capitalise on the essential window of time before you deliver your medical advice. This “privileged moment for change” prepares people to be receptive to a message before they experience it. Robert Cialdini has coined the term ‘pre-suasion’ to describe this. The therapeutic relationship allows pre-suasion, and therapeutic change can then be addressed, with consideration of the patient’s motivation, opportunity, and ability.
You can see the themes above of time and a relationship as potent therapy for the management of major depressive disorder in general practice. The initial clinical gestalt and the ongoing therapeutic relationship can be powerful tools for change. Depression is subjective and has been part of the human condition throughout history. This gives us all we need to move forward. Focus on the whole person sitting in front of you. Give them your time and expertise, be thorough, be kind, and be present. It therefore seems fitting to end with the words of a doctor from another time:
“The three grand essentials of happiness are: Something to do, someone to love, and something to hope for.”
Alexander Chalmers (29 March 1759 – 29 December 1834)
If you are worried about depression, anxiety, or have any other mental health concerns, reach out:
ACIS 131465 (South Australia – Acute Crisis Intervention Service)
Mitchell AJ, Vaze A, Rao S. Clinical diagnosis of depression in primary care: a meta-analysis. Lancet. 2009 Aug;374(9690):609-19
Bell RA, Franks P, Duberstein PR, Epstein RM, Feldman MD, Fernandez y Garcia E, Kravitz RL. Suffering in silence: reasons for not disclosing depression in primary care. Ann Fam Med. 2011 Sep;9(5):439-46.
Thanks to Klarem for the beautiful picture above, Marcia Vernon for the Beyond Blue link, and the guys at ThinkGP for their editing and help.
The Australian Privacy Principles, and the recently passed (by the Australian Parliament) Mandatory Breach Notification bills provide various guidelines, which should be adhered to by anyone who handles any electronic medical data. Basically, the principles stipulate that all medical practices must ensure that all necessary measures are in place while saving, accessing and sharing any electronic medical data to keep patient data secure. Lack of compliance to the security standards could lead to large fines for both companies and individuals. Several steps can be followed by medical practices to ensure compliance to privacy standards. These steps include:
Run a complete risk assessment of the practice
Many medical practices adopted electronic health recording systems before there were clear guidelines on what these systems should contain. This means that a practice could be using electronic systems which are not compliant with current standards. To ensure compliance, a risk assessment should be done on the current systems to highlight areas in which compliance is not enforced, and to expose areas in which changes are needed. Ensure the latest version is being used, including any security patches from the vendor.
Prepare for disaster before it occurs
All data handled by a medical practice should be safe both from loss and corruption. One of the main ways of ensuring that data is not lost in case of any mishaps is backing up of medical data daily. Data should be backed up in an offsite location to ensure that in case of incidents such as natural, or man-made, disasters the data backup is not destroyed, as well. Antivirus programs should also be installed on all computers to ensure that data is not corrupted or destroyed by computer viruses, or held to ransom by cyber criminals.
Implement an ongoing employee training programme
Any system is only as strong as its weakest link, and in some cases poorly trained employees, or temporary staff, are the entry point for hackers into medical practices. It is also these staff who are more likely to have an “oops” moment and accidentally release confidential information. A medical practice could have excellent processes and systems, but if the employees don’t use their passwords to securely access records and files the system security is rendered useless, and anyone can gain access to these records. Medical practices should continually train their staff on how to follow the right security protocols, to ensure data integrity and security.
Purchase medical products with security compliance, and compatibility in mind
New equipment bought for a medical practice should be compatible with existing systems and should offer enough security features. With the advent of connected devices, the Internet of Things, it is critical that devices are secure, and kept up to date. Before making any major purchases enough review of the product should be done to ensure both security and compatibility.
Collaborate with affected parties
Changes which need to be made to bring about cyber security and privacy compliance affect many people in the practice. Affected groups should be offered training and management must ensure that staff understand the importance of compliance to everyone involved in the practice. Also, ensure that key staff are trained on what to do in the event of a breach. A comprehensive disaster plan is essential, and must be practiced regularly.
During the course of a day, I’ll often find myself find myself glued to my phone, staring off into space, or just flat-out falling asleep in the middle of something I probably shouldn’t be falling asleep during.
I like to associate this with a lack of sleep and being on-the-go a whole lot, which in all honesty, probably has a lot to do with it. I average around 5 1/2-6 hours of sleep a night, which isn’t very good at all. But lately I’ve been thinking more and more about this for some reason, and I realize I can’t just place all of the blame on not getting enough sleep.
That’s where the word “apathy” comes into play. A lot of people may not know what that word means. I didn’t, at least not until I heard a song by OneRepublic (one of my favorite bands for those who didn’t…
The humble Pap Smear is over ninety years old so just to jog your memory, the Papanicolaou test (abbreviated as Pap test, known earlier as Pap smear, cervical smear, or smear test) is a method of cervical screening used to detect potentially pre-cancerous and cancerous processes in the cervix (opening of the uterus or womb).
The 1st of May 2017 brings about a change in Australia’s approach to screening for cervical cancer. Here’s what you need to know about an exciting revolution in health for people with cervixes!!
Pap smears involve sampling cells from a specific part of the female anatomy: your cervix. This is the gateway between the vagina and the uterus, and its function is to hold a baby inside your uterus for 9 months: then stretch to let it out!
In order to sample cervical cells, the medical practitioner uses a speculum to view your cervix; but many people consider this examination physically invasive and unpleasant. A pathologist then examines these cells under a microscope for signs of pre-cancerous and cancerous change – what we refer to as cervical cancer. Identifying these changes means you can treat early, preventing more serious disease.
Australia introduced the National Cervical Screening Program in 1991. Since then most cervix-bearing people are prompted by their GP to undergo a pap smear every two years after becoming sexually active. Since its introduction, this program has halved the incidence of cervical cancer in the general population.
The thing is: science is rapidly progressing. Our knowledge of cervical cancer has grown substantially, which has prompted a review of how we screen for abnormal changes. We now know:
You need to have contracted a high-risk Human Papilloma Virus (HPV) to get Cervical Cancer.
HPV is a viral sexually transmitted infection, like the flu, but downstairs.
Infection with HPV is really common! Most people are infected during their lifetime but clear it (like the flu!), with 12% of cervix-owners infected at any given time.
Most cervixes infected with high-risk HPV will not develop cervical cancer. The chance of a HPV infection developing into cancer is low.
There are 40 recognised types of HPV, but only 15 are currently considered high-risk.
Luckily, most HPV infections will cause no symptoms and often are cleared by your immune system.
Cervical Cancer develops very slowly and over a number of years.
If you have recently left school, you would recall receiving the HPV vaccination, also known as Gardasil or Cervarix. The National HPV Vaccination Program was introduced in 2007 giving three doses of a vaccination that can protect against two high-risk HPV strains, namely 16 and 18. 71.2% of women in Australia have been vaccinated by the age of 15. Of course, this only works if you haven’t already been exposed to HPV.
Given all this new knowledge, pap smears actually aren’t the most accurate way to measure abnormalities in your cervix! A single test will accurately detect abnormalities in only 40-60% of samples, as it depends on which cells are picked up. This can be improved on with repeated testing (for example, every two years!), but HPV DNA testing is more accurate.
HPV DNA testing involves taking a swab of your cervix, and using genetic assays to look for known DNA that is HPV. It specifically tests for high-risk HPV infections, looking for evidence of the virus from their DNA. This test is better at detecting HPV infection which is the cause of cervical cancer. Using this we can have high confidence that you will not have a HPV infection causing cervical cancer.
Thus, the National Cervical Screening Program is changing to high-risk HPV DNA testing as an alternative to pap smears from the 1st of May 2017. This change benefits us because:
High-risk HPV DNA testing is more accurate.
Less of the people screened will have to undergo further diagnostic or treatment procedures. These are often invasive and potentially damaging to the cervix.
You won’t need to be screened as often! Only every five years, and only from 25 years old, until 70 to 74 years old. Of course, if your test is positive you will be required to undergo further investigation, and potentially more regular testing.
There is the potential for people to self-collect the specimen, allow those who are uncomfortable with formal collection by a doctor to still participate in the screening program.
That all sounds good, hey? However you may have some other concerns. I’ve tried to address them in the questions below…
If the pap smear is gone, does that mean the procedure is much nicer and less intimate?
No, unfortunately the procedure is almost identical from your perspective, and you will likely notice no difference. All that has changed is its frequency: every five years instead of two. This is one way of reducing how often you have to have a test! The only change to the procedure is exactly how the doctor or nurse collects a sample and its examination by the pathologists.
Wait, if I’m not getting screened before 25 could I have cervical cancer that no one knows about?
As I mentioned, cervical cancer is incredibly rare before the age of 25 and takes a long time to develop. Most women with cervical cancer experience symptoms.
The main symptom is vaginal bleeding in between periods, and/or during or after sex.
Other symptoms include unusual vaginal discharge, discomfort or pain during sex and lower back pain.
If you or someone you know is experiencing these symptoms you should make an appointment with your GP for investigation. Just because we don’t screen everyone below the age of 25, does not mean we will not test you if you have symptoms.
Why do I know women under the age of 25 who have had cancerous or pre-cancerous cells requiring further treatment?
By screening from the age of 25 a number of women will no longer undergo procedures that are unneeded because some abnormal pap smear results may return to normal over time. In fact, 90% of people with HPV clear the infection in two years, and the abnormalities return to normal! Also, evidence shows that screening below the age of 25 don’t reduce the cancer outcomes, as it is so slow to develop.
If they do have persistent infection linked with abnormal changes, they will be detected when screened at the age of 25, which is soon enough – as cervical cancer is incredibly slow in developing. Screening less often will also reduce stress, time, cost and discomfort and risk of complications from treatment of harmless abnormalities.
In addition, given the success of the HPV Vaccination Program, it is anticipated that infection with two major high-risk groups of HPV will decrease, therefore reducing the number of women who would have had abnormal cells in a pap smear.
There a few cases where screening might be considered earlier, in the case of immunocompromised patients or instances of genital contact childhood sexual abuse, which need to be managed on an individual basis.
How do I know if I was vaccinated for HPV?
All teenagers are currently vaccinated from the age of 13. Males began to be vaccinated in 2013, so if you’re past year seven you will not have been vaccinated. For females, if you finished or left school in 2006 you will not have received a HPV vaccination, but beyond that, unless you or your parents declined you’ll have received it. There was a catch up program run, but it ceased a few years ago. If you have not been vaccinated you can pay to have this done as an adult at your local GP.
You can also contact the National HPV Vaccination Program Register if you are unsure. But remember, being vaccinated only prevents against the most common high-risk strains, not all HPV, so cervical screening is still really important!
I’m in a relationship where there are no male sexual organs involved! Does that mean I won’t get HPV?
No! You are at the same risk of HPV in a relationship where sexual contact involves two people with cervixes, as one with a male sexual organ and one with a female. Don’t neglect getting screened!
Isn’t the government just trying to save money reducing how often we are screened?
There are definitely financial benefits for our government in reducing the frequency of screening tests. However, that’s not the main reason for this change. Cervical screening for HPV DNA will be put in place because evidence shows that your cancer will be detected at five-year intervals, and reduce the cost to you in time, money and discomfort of undergoing the examination.
Do you have some published scientific data to back up what you’ve said?
Of course I do! If you’re interested in the government’s process that researched and recommended these changes, head to this website. The documents on this page cite numerous resources made in reviewing our screening program, as well as published research from across the globe. This was developed by the Medical Services Advisory Committee, which is an independent non-statutory committee under the Department of Health. You can learn more about it here.
If you would like further access to specific evidence, please feel free to get in touch!