Dr Adam Brownhill: Good evening everybody and welcome to the second webinar that we're doing on rural and remote general practice. This evening’s webinar is specifically focused on real life locuming – the challenges, anecdotes and adventures that we have along the way. So thank you all for dialling in from wherever you're dialling in from all over Australia. My name is Dr Adam Brownhill. I'm Medical Director of Urapuntja Aboriginal Medical Service and I'm also a GP at Equinox, which is a gender diverse health centre down in Melbourne. Our other expert panellist facilitator that we have with us this evening is Wendy – and I'll just let you introduce yourself Wendy.
Dr Wendy Sexton: Good evening everyone. My name is Wendy. I'm a GP and Rural Generalist. I live in, well I call Perth home, but I spend most of my time working in rural and remote Australia, particularly the northern parts of the country because I love the medicine up there and I actually prefer the climate. As the picture shows, I also spend a bit of time volunteering or working overseas in low resource settings from time to time and I really enjoy the overlap between global health and working in some parts of rural and regional Australia. So we're happy to have you along tonight. And Adam, did you want to say anything more about yourself?
Dr Adam Brownhill: Oh, just quickly, I'm an international medical graduate. I've been over in Australia for about six years now. I've done predominantly very remote and remote Aboriginal Health work mainly around the central desert – so anywhere between 400 and 700 kilometres from Alice Springs. And, again, I absolutely love the opportunities that Australia and rural and remote working gives me. It's enhanced my skill set and I face an interesting and new challenge every day, and I learn something new every day as well.
Dr Wendy Sexton: I think we probably both enjoy seeing parts of Australia that not everybody gets to experience outside of the big urban centres.
The RACGP would like to acknowledge the traditional owners of the land on which this webinar is being broadcast, and we pay our respects to Elder's past, present, and emerging.
Dr Adam Brownhill: We've got a kind of rough running order and as is always the case working out rural and remote, the running order might be a little bit fluid depending on timing, but we took on-board the feedback from the huge number of questions we had sent to us after the first webinar to structure this webinar. In roughly this order, we're going to go through the prescribing of drugs of dependence, talk about getting paid, we're going to talk about the challenges and the opportunities of your education and CPD when you're out rural and remote. Wendy and I obviously both have an interest in critically unwell or emergency patients and we're going to call this a kind of ‘when you're it’ session, and then we're going to have a session talking specifically about Aboriginal and Torres Strait Islander health and the cultural side of things like that. We’re hoping to have a 20 to 30 minute Q&A session, but it all just depends on where this goes. The whole thing is being recorded and will be available to be sent out and accessed afterwards (as is the first webinar still). So I'll hand over to you Wendy now – let's get things rolling.
Dr Wendy Sexton: Okay, thanks Adam. So there were a number of questions last time about prescribing drugs of dependence. And so we thought we'd take that on and we've got a bit of a scenario to kick things off. The question that we’re going to frame this around is: How do I deal with drug dependent patients and doctor shoppers when doing locum work? For example, a 20 year old woman who presents requesting a prescription for alprazolam or dexamphetamine. To help give us some underlying principles and some wisdom on this topic, I'd like to introduce one of our guest speakers tonight, we’ve got Dr Ferghal Armstrong with us. I'll let him do a bit of an introduction of himself and then perhaps take on this topic of this young twenty-year-old and how we're going to manage this consultation.
Dr Ferghal Armstrong: Hello everybody. My name is Dr Ferghal Armstrong. I'm a graduate from Belfast in Northern Ireland and I came to Australia in 2014. I set up practice and Koo Wee Rup and I've continued my interest in pharmacotherapy and addiction medicine from the UK into Australia as a South East Melbourne Primary Health Network GP Mentor for pharmacotherapy, and I'm also one of the trainers for the RACGP MATOD program, which is medication-assisted treatment of opioid dependence. So that's me.
This question that I've been given touches on the vast expanse that is pharmacotherapy and addiction. I'll answer the first question literally and then I'll expand on that. So literally the question is what do I do if somebody wants dexamphetamine or alprazolam. The short answer is, I can't. The way legislation works at the moment is to prescribe dexamphetamine (or more commonly actually lisdexamfetamine) you need a permit and/or you need to be a psychiatrist or paediatrician. Alprazolam is no longer available to within the GP armamentarium.
So moving away from the issue of dexamphetamine and adult ADHD, let's talk about alprazolam and benzodiazepine dependence first of all and then I'll talk about opioids.
Fundamentally, alprazolam is a short-acting benzodiazepine and because it is short-acting, it gives one a great rush to the head. That's why people love it – because they had a bad day, they feel terrible, and they take alprazolam and within a matter of five or ten minutes they just feel great! They feel lovely and safe. Unfortunately, it's because it's so short acting that it’s very prone to dependency. This is a theme that we're going to discuss or talk about throughout the evening. Short-acting drugs are very prone to dependency. In the case of alprazolam, that's all the more true.
Now, if you have someone who for whatever reason has been prescribed alprazolam privately by somebody else (perhaps a psychiatrist) and they come to you and say ‘I need more alprazolam’, what you have to do is do the dose equivalent to a longer acting benzodiazepine. A commonly used long-acting benzodiazepine is diazepam. So while alprazolam might have a half-life of less than 10 hours, diazepam and its metabolites have a half-life of over 96 hours. So the whole idea about alprazolam conversion is that you convert it to the equivalent dose of diazepam once a day. That means then that the patient gradually, over weeks and months, comes down to the diazepam dose. An appropriate way of reducing diazepam would be roughly 10% a week, 10% a fortnight if you want to be kind to them. At that rate, there would be no risk of seizures – most people will tolerate that reduction. On the seizure point of view, you can also be reassured that the dose of diazapam of 30 milligrams but no more will pretty much guarantee a patient not having seizures. So if you really are worried about benzodiazepine withdrawal seizures, diazepam of up to 30 milligrams is a sufficient dose to avoid that risk.
Another question that people have asked me is what do you do with reported street consumption of benzodiazepines. It's common practice to prescribe no more than 40% of what is reported by a patient from the street. So for instance if they're saying that buying Valium a hundred milligrams a day, you might consider giving them 40 milligrams a day.
So, to summarise the first point – short-acting alprazolam needs to be converted to the equivalent dose of long-acting diazepam whose half-life is 96 hours or more. Once that dose of diazepam has started, it’s given on a daily administration, and then it is down titrated preferably to 0 at about the rate of 10% a week or 10% a fortnight. So that’s how you manage benzodiazepine dependency.
Now, how do you actually broach the subject? Don't ever underestimate the power of ‘no’. We, as doctors, are trained to be ‘pleasaholics’ and it takes a lot of courage to say to someone ‘I'm not able to help you in the way that you want to be helped’. I couch this statement in phrases such as ‘I’m committed to providing you with the best and safest healthcare’ because we are, you know – this is not lying, this is a truism that we have a duty to actually provide the best and the safest healthcare for our patients and anything else is now colluding with their dependency.
Now a lot of people say to me: well what happens when they are on a huge cocktail and you've got to manage multiple conflicting poly-pharmaceutical consumptions. Is it possible to say ‘no go away’? I don't think it's reasonable to say to someone: you've come for help, but I'm not going to help you because you're too hard or you're too dangerous. I encourage my colleagues to take on the patient, identify what they’re on, prescribe as a baseline what they are on so long as you are amalgamating all of the benzodiazepines into one diazepam dose (and remember the guidance – 30 milligrams is enough to stop a seizure and no more than 40 percent reported total dose), and then institute the down titration. So within that first conversation, the patient has to understand they are there with you to get down titrated – they’re not there with you to maintain the dose in any meaningful way for them. And once you have offered them that message that yes, you will help, and yes, you'll continue the prescription as a way of down titrating, it’s up to them. If they want to continue with your relationship with them whilst you try and provide them with the best and the safest care, that's great. But if they reject that offer of help, well then it’s on them, you've done your best, and I don't think that any doctor would be criticised for saying: I'm not able to help you in the way that you want that help.
Now, on another side note – people have said that, you know, we're all involved in patient centred care and I think the point has to be made we're not involved in patient-led care. There's a difference between patient centeredness and patient led and I think patient led care involves collusion on the part of the treating physician and that is a line that we should never cross.
So, let's recap a little bit again. Remember the power of ‘no’ – it's very difficult to say no to our patients, but we have to learn how to do it. Emphasise that our actions are motivated by the desire to provide the best and the safest care. And finally group all of the benzodiazepines into one long-acting valium and down titrate at a rate of about 10% per week or 10% a fortnight, weekly scripts or daily scripts if you have to.
The next issue I want to address is in terms of the practicalities. What do you do when you're not convinced that you're the only prescriber? Within the whole of Australia there is of course the doctor shoppers helpline – you need to give them a ring and find out if they've hit that radar. The problem with doctor shopping is that the data is three months old before it even becomes useful and it doesn't include data on private prescriptions and you can't really rely on it when you're making decisions there and then. Within Tasmania and within Victoria, there are services called prescription monitoring, and certainly within Victoria, they're beginning to roll out safe scripts and that will help Victorian GPs enormously. And I think the good news is that when safe scripts seem to be achievable, safe, and workable, it will be inevitable that safe script gets rolled out in various forms and formats throughout the rest of the states of Australia.
So, going back to the question – what do we do about the benzos? Well I hope I’ve addressed the benzo issue. What do we do about the dexamphetamine? Well, again, you can rely on the law – unless you’ve got a permit you cannot prescribe dexamphetamine. The other thing about this is that no one is going to die if you don't prescribe them dexamphetamine. With benzodiazepines there is a fear about seizure disorder (but, again, you can address that with 30 milligrams).
Let's widen up this discussion to the management of what I consider a more common presentation, which is the chronic pain opioid dependency issue. Now, when we talk about opioid dependency everyone's first thought is heroin. So a lot of the audience will think well, look, I'm not dealing with pharmacotherapy, I don't have a cohort of patients that are abusing heroin off the streets. But what I would urge you to consider is that you actually do have a cohort of patients who are prescription opioid dependent. So your cohort of patients that you've been giving opioids to or, for instance, your colleagues have been giving opioids, these patients are now dependent on it. And there's a very frightening statistic which I want you all to write down. If you are on more than 100 milligrams of oral morphine equivalent, you are at a risk of death that is seven times higher than those patients in chronic pain who are not on opioids. So let me repeat that, if you're on more than a hundred milligrams of OMA (oral morphine equivalents), you're at seven times higher risk of death.
Now that evidence really only come recently into the consciousness of the chronic pain world. Prior to the last couple of years, we've all been taught that, you know, opioids are good, that being pain-free is a human right, and that the management of worsening pain on opioids is basically escalating the doses of opioids. And now, all of a sudden, this data comes out that says that actually the minute you go across the threshold 100, you're putting your patients and severe risk. It's like turning an oil tanker – it takes a long time for the initial message to trickle through to universal action. But, you know, we are at the forefront of that action. We now need to be aware that the minute you start prescribing more than oral morphine one hundred, your signature is putting your patients at risk of death. And that's a very challenging thought on a Monday morning – just imagine you're wearing your dark suit at the coroner’s court and having to explain your actions to the family barrister. That's what I think of when I'm faced with my challenging patient on a Monday morning or for instance on a Friday afternoon – Who do I want to deal with more, the angry patient or the grieving family and their barrister?
So, this begs the question, what is oral morphine a hundred milligram equivalent? So oxycodone and oxycontin – 60 milligrams of oxycodone a day is equivalent to a hundred milligrams of oral morphine. So that's 30 milligrams BD of target and that's not a big dose. But once you get to it you are at seven times higher risk of death. Other equivalencies, I'll go through them. So oxycontin 60 milligrams, polexia 250 milligrams, hydromorphone 20 milligrams, buprenorphine moorestown patch 40 milligrams, and a fentanyl patch 25 milligrams. These are the doses of those opioids which are roughly equivalent to oral morphine equivalent 100 milligrams. Those are the doses of opioids beyond which, or at which, you are putting your patients at risk.
Now going further into the problems with long-term opioids. Apart from the usual side effects of opioids based on the Mu receptor, I use a mnemonic SPEAR for that – so we'll go through that. S is for sedation, P for physiological dependency, E for emesis, A for analgesia, and R for respiratory depression and retention of urine and retention of faeces or constipation. So, apart from the SPEAR side effects, which are all mediated physiologically by Mu receptor agonism, we also have evidence emerging of longer term side effects with chronic opioid use which includes osteoporosis, falls, cognitive impairment, fractures, opioid-induced hyperalgesia (which I'll come to again in a second), and tolerance. Also quite worrying for our male patients, there are opioids (and in particular morphine) where high doses is associated with hypothalamic pituitary gonadal access dysfunction – so, you know, you can end up with infertility. So I tell my male patients that their balls can shrink if they take too much morphine for too long, and that tends to focus their minds somewhat.
Now, let's discuss opioid tolerance versus opioid-induced hyperalgesia. So opioid tolerance is a situation whereby the pain gets worse than the particular dose of opioid and to actually get on top of the pain you need to have a higher dose. So the presentation of opioid tolerance is worsening pain despite the dose, and the management of that (in the first instance at least) is increasing the dose. Opioid-induced hyperalgesia is sometimes quite a difficult concept to get over to patients, but basically what it means is that the dose of opioids that you think are helping your pain is actually contributing to your pain. So in the context of opioid-induced hyperalgesia more opioids actually worsens the pain, and the management of it is actually either to reduce the dose of the opioids, rotate the opioids into something else, or switch to some other painkiller with anti-NMDA receptor activity (so by that I mean either methadone or ketamine). But in terms of being a rural GP practitioner, the first thing to do with opioid-induced hyperalgesia is to actually reduce the dose of opioids.
Now another point to understand about the role of opioids and chronic pain is with the best will in the world there is no actual good evidence of benefit for opioids beyond three months. Most trials of chronic pain and the use of opioids lasted three months and certainly the ones with osteoarthritis of the knee, the hip, and the back, have demonstrated some benefit for Tramadol, and also for Tramadol in the context of neuropathic pain. But the most you can expect out of the average opioid, irrespective of dose, is a 30% reduction for three months, and then you start getting into problems and that’s when you start getting the side effects. So you have to tell your patients, even though you think that these opioids are helping your pain the most you can expect is 30% reduction in pain and the price that you're going to pay is potentially very serious. That's a very sobering point – you're not going to be able to eradicate somebody's pain with opioids in the long term. Now bear in mind I'm only talking here about chronic non-cancer pain.
Interestingly enough, until recently, there was no longer term evidence, but there was a paper published describing the SPACE randomised control trial from America (so that's the SPACE RCT if you want to google it) and what they did was they took cohort of patients with effectively osteoarthritis of the knee, osteoarthritis of the hip, and osteoarthritis of the back (so lumbago) and they gave half of these people opioids and the other half they treated with non-opioids and they monitored them over 12 months. The findings of this trial suggested that those people who were not given opioids had less pain at the end of 12 months than those treated with opioids. And, furthermore, the ones without opioids had none of the opioid side effects. So now, for the first time, we have good evidence of the harms of opioids at 12 months and we have good evidence of the lack of efficacy for opioids at 12 months. So, again, as research is happening, we're now getting an increasing body of evidence that is slowly turning the oil tanker away from thinking that opioids are good towards the position that opioids are bad (or at least they shouldn't be used first line and their use should be considered and limited).
So this then brings us onto the concept of: what is pain? So the definition of pain is an unpleasant sensory and emotional experience due to actual or potential tissue damage, or described in terms of that damage. Back when I was graduating from medical school, the further sub classification of pain according to the type of pain was very easy – you had nociceptive pain (which was tissue damage pain) and everything else was just lumped into this group of syndromes called neuropathic pain. So it was dead easy – you had nociceptive pain and neuropathic pain, and nociceptive pain was tissue damage (a broken leg, a stubbed toe, a knife in the guts, whatever) – all tissue damage was nociceptors, and everything else was put into the classification as neuropathic pain. However, more recently, pain specialists have decided that the diagnosis with neuropathic pain is now dependent on a disease, or dysfunction, or damage in a proven way of the somatosensory system. So you need to have a diagnosis like an amputation, or MS, or diabetes, or you need to have an image like a transection of the cord or a tumor or something affecting the somatosensory system – that then is enough to diagnose neuropathic pain. But then that leaves a huge cohort of diagnosis which is neither nociceptive or neuropathic, and so they have come up with a third category of pain syndromes and they have called these the nociplastic pain syndromes. The nociplastic pain syndromes are characterised by alterations and descending spinal inhibitory pathways and an increasing spreading central sensitisation. And within this nociplastics group we’re talking about the primary headache syndromes and also the syndromes associated with central sensitisation. I have a little mnemonic for that and that is FLIC. So F stands for fibromyalgia, L for lumbago, I for irritable bowel syndrome, and C for complex regional pain.
Dr Wendy Sexton: Ferghal, I'm just going to jump in right now and reflect on some of the great points that you've brought to us so far, because you're clearly very passionate about this topic, and I know that there's a lot of interest that could probably take a longer session, but we're also getting a few questions through that we might be able to get you to answer a bit later as well. But I just wanted to reflect on a few things that I've heard you say that I think have been really helpful and really good (and you might want to jump in too Adam). I think it's really important for us to remember the difference between, you know, patient-centred care and patient led care and that by saying no, sometimes that is helping patients more than saying yes – even though that's often the easier option and what is quicker for us to do. So, I think that's always important to enable us to take control and do what's in the patient's best interest. And I think the whole context that you were also alluding to, particularly with this this new classification of pain is there's always more than just what's going on physically and there is all the psychosocial stuff and, as a locum, we're often meeting the person for the first time and we don't understand all of those issues and that really adds to the challenge.
Dr Adam Brownhill: So whilst Wendy and I both love our jobs our job satisfaction doesn't necessarily pay the rent or pay the mortgage. And so we thought we’d touch briefly on getting paid. There was a question that was sent in that was: I'm still waiting to get paid after three months. How do I ensure that I get paid promptly?
Having done locums both here in Australia and back in the UK, I can completely empathise with this question. When I first started as a GP in the UK I got myself into a bit of a sticky wicket where I ended up working directly for GP practices and I came across this problem. It's incredibly stressful, especially if you're still working at the GP practice.
Just taking a step back, the main ways that we get contracted as it were to work in GP practices is either directly (your contacts are Joe Bloggs GP surgery in Alice Springs and they've been advertising for a locum and you go directly to them), you may go through a workforce agency, a PHN, and/or you may go through a locum agency. And the reason why it's important to look at the differentiations between these is because it's who you send your bill to, what your expectations are, and what your pre-agreed contract was.
So if I am working directly with a GP clinic, I have my kind of terms and conditions which I email the clinic manager and I make sure that the clinic manager signs those terms and conditions and sends it back to me. And in there is something stating I will get paid at the end of each two-week block and you will pay me X number of dollars to this bank account. If you're going via a PHN, normally what happens is the PHN will pay you, and, again, there will be a contract with the PHN. If you're going through a locum agency, again, you will have a contract with the locum agency and then the locum agency themselves will have a separate contract with the employer. The single most important thing is to make sure you've got a contract of some form or other – if you don't and it's just all done in a bit of a handshake, then, unfortunately, you can end up in this situation, which I did many years ago and learned to my cost.
So, I think the vast majority of us are employed by locum agencies or workforce agencies. I do some work now directly with some GP clinics but I've built up a relationship with them and, again, I’ve got my terms and conditions that I email to them and get sent back so I've got something in writing. I don't know how you go about doing things Wendy and whether or not you've ever had any issues in the past?
Dr Wendy Sexton: Yeah, that's a good question Adam. And I think the first few locums you do, you don't necessarily understand all of this stuff about contracts, particularly if you've just been working in the same place for a little while. So some excellent points there, but I generally try doing as much as you can at the front end with that contract to make sure everything's going to flow smoothly – it’s really important. But I also think there's a lot to be said about the follow-up as well. And as far as that goes, that means, depending on whether you're coming in as an employee or contractor, if you're having to produce an invoice yourself and send it off and your payment is contingent on that, you need to make sure that you know who to send that invoice to and that the invoice has been received, because otherwise it'll be a few weeks down the track and nobody's got the invoice so you won't get paid. So I always find that really important – make sure I've got a copy and I've sent it to the correct person. If I don't get an acknowledgement of the invoice, I chase up straight away so that I know that it's where it needs to be. Then, secondly, I usually put a reminder in my phone or my inbox or in my diary so that I know to follow up when anticipating that I'll be paid in two weeks after the invoice goes in.
But you're correct in talking about the contract, as far as it goes, because some health agencies that you work for or Departments of Health if you're doing a hospital locum or other places are used to paying on 30 day terms, which means that it can be quite a long time from the time you actually start your work, complete however many weeks of work, send in your invoice, then wait for 30 days for payment. So I do encourage people to insist on 14-day terms and then you can follow up appropriately. But you need to make sure that you've got a contact person to go to and that those terms are clear and that the invoice is in the right hands. Then, generally, there are less problems with that. But, like you, I've learned the hard way of waiting and waiting and waiting for money to come.
Dr Adam Brownhill: I know that we had an awful lot of questions last time about what we do… there's a classic example here – I'm worried about going on my first locum and being on call and a really unwell child comes in. And this is something that scares everybody. I had a reasonable amount of emergency experience and a small amount of obstetric experience, but we've all got patients and scenarios and situations that we’ll all find that push our buttons, and before we started the teleconference we were talking off-air and Ferghal was admitting that he would find situations in rural and remote locations to be possibly quite challenging, and in the same way that I'd find managing his patients possibly quite challenging. I think the first thing to remember is that, fundamentally, you are not alone. You are never alone. You might feel like you're alone but there are some amazing remote area nurses and there are some amazing consultants on the end of phones.
I teach on the ACRRM REST course and we kind of keep it simple – it's about the DRS ABC and gaining some time so you can call for the cavalry to come or somebody really clever like Wendy to come and give you some advice over the phone. But my fundamental thing I've learned is that you are never alone and you can always call for help – it doesn't matter what time of day it is.
Dr Wendy Sexton: I think that's a fantastic point and really important to think about the resources that you have right there with you (and you've often got more resources than you think you do), as well as who can you call – and picking up the phone is a really important part of helping to manage that. And I think this topic is really important because it creates a huge amount of anxiety for almost everyone I chat to about going out and locuming rural and remotely. Think about who you have with you – you may well have some very experienced nurses or Aboriginal health workers or you might be able to call in a GP anaesthetist or someone else, but always try and get the people on board. If the paramedics have brought you in a patient they're often an excellent option to assist and do really practical skills, like putting cannulas or assisting with CPR and all those sorts of things. And so that's kind of worst case scenario. If you've got a little bit more time, obviously, you just need to breathe, you need to think about whatever algorithms (ABC's as you've talked about), and then pick up the phone. So depending on where you are, as to what that might look like, pretty much wherever you are in Australia you can always call Royal Flying Doctor for assistance. Even if you're not planning to or not sure if you need to transfer the patient straight away, they are always there and available and I find them really helpful. Some places they can actually teleconference in and have a look at the patient. Some states have got their own emergency Telehealth service and they are available and dial in and can kind of run your critically unwell patient scenario – and all of that I find really helpful. So one of the questions I generally ask when I arrive is who's going to be my support and backup if things don't go as planned.
Dr Adam Brownhill: Yeah, and we're very lucky in the central desert around Alice Springs – we've got direct dial in to a retrieval control 24/7 or one of the registrars if they're busy. So depending on where you are, it can be the video conference with the TV link or it can just be on the phone and they talk you through things. But I would also really strongly reiterate to people that a lot of you already have these skills. I think it's good and natural and normal for you to be frightened of this, if you weren't it wouldn't be quite right, but you do have the skills and it's teamwork. So, like I said, I sometimes let some very experienced ED nurses lead certain parts of managing ill patients because they’ve put a plaster of paris on more times than I have. So it's about working to team strengths, knowing your limitations, and phoning a friend – because there are always friends around for you to phone – we've all been in similar situations.
Dr Wendy Sexton: Yeah, and I think just to finalise or kind of finish up on this point, sometimes it's not the arresting patient, where you know how to go into your advanced life support CPR algorithms, that are the most difficult. Often, it's that really unwell patient that you've got a bit of time to try and stabilise and hopefully improve, or they look like they might deteriorate, and in that category you can still use your algorithms and still use your training. And use the wisdom in the room – ask your colleagues – you can say to the nurses ‘this is what I'm thinking, has anyone else got any other ideas or thoughts’ and take those on board as you feel appropriate. But it's also the time to pick up the phone to your nearest emergency department and just ask for some advice. And I've always found if you are very upfront on the beginning of the phone call and say I'm calling from Timbuktu and I really need some help, i've never had anyone be difficult or obstructive then. Everybody is keen to help and wants a good outcome.
Just before we move to Aboriginal and Torres Strait Islander health, I just want to remind people that it's not only in the heat of the moment and when it's all going badly that you have help available to you. Sometimes when you're out there all on your own you do need to debrief, so have a think about who that might be and, you know, if you've got someone like Adam to contact, or you can contact people through GP Down Under (it’s a fairly safe space to do that), or you might have a colleague back at home. But please don't sit there feeling stressed that you've done the wrong thing and you've had this stressful experience (even if it has good outcome or you're not sure). Make sure that you reach out and debrief afterwards.
I think now we're going to move on to the next question, which was one about cultural awareness and preparation to go and work perhaps in a place where there's a higher percentage of Indigenous people. And the question that we had was: I've never treated an Aboriginal or Torres Strait Islander patient. What do I need to know before I go on placement in an Aboriginal community? And we're lucky enough to have Dr Tim Senior with us this evening, who has a wealth of knowledge and has a lot of experience and I'm looking forward to what you have to share with us Tim.
Dr Tim Senior: Thank you. Good evening everyone. One of the beautiful things about webinars is that we get to do them all over the country and I've just got in from playing indoor soccer so if I sound a bit out of breath then that's the reason why. I hope you can hear me well. There's lots of really important points on this and I’ll be saying some of the very similar things that you've already heard about teamwork and questions and asking for help.
The first picture I want to show you is this rather beautiful map of Australia because it reminds us that when we're talking about Aboriginal and Torres Strait Islander health, Aboriginal and Torres Strait Islander is the phrase that colonisers made. It sounds singular, but Australia is a country made up of many different countries. And so wherever you go, make sure that you know the Aboriginal country that you're going to, because Aboriginal people will say, partly, I'm Aboriginal and Torres Strait Islander, but they'll also say I'm Aranda, or I’m Awabakal, or I’m Tharawal, or I’m Larakia, and they’ll all identify with one or more nations that they’re part of. If you know the land that you're going to then people will recognise that you know a little bit already. The other important thing this map tells us is that everywhere is different. When you look at central desert areas in Australia, there's no particular reason why culture there will be the same as in southeast Australia or as in tropical north Australia, let alone the Torres Strait Islands which aren't Aboriginal at all and are much closer to South Sea Island and Melanesia. So we talk about Australia as a multicultural country – it's multicultural even before any Europeans came and visited here first off.
So the thing to remember is all communities are different. Someone said to me, when you've seen one community, you've seen one community. And so if you've been to one community and you're going to a different one, it will be different to where you're used to. If you get the opportunity to go back regularly to the same community that actually stands you in really good stead – there's nothing that many patients, including Aboriginal and Torres Strait Islander patients, like better than continuity of care where you get to know what's happening.
All of the communities that you could possibly go to will have had the experience of doctors going in and trying to tell them how they can do things better. Don't be that doctor. Go in, keep your eyes and ears open and your mouth shut unless you're spoken to, and doing lots more listening than talking will guide you really well. The community know their circumstances really well, they’ve been living in their circumstances for a long time. They know the people there, and the politics, and the families. If there's a problem there, they will know, and they will have been trying to solve it. We doctors find it very difficult to walk past the problem without trying to solve it and I think just watching and seeking advice rather than telling people what to do will actually make communities warm much more to you.
It's worthwhile doing cultural awareness or cultural safety training before you go. The RACGP does a gplearning ‘Introduction to Cultural Awareness’, which you may have done and that's worth doing. I know the Remote Area Health Corps do a series of online teaching before people go and do locum work in the Northern Territory. So take the opportunity to do some of those pieces of training before you go. But remember as well (keeping an eye on that map) that, wherever you go, there's nothing like face-to-face learning with the people who are in that community. Even the Northern Territory has a huge number of different countries that you can see and the top end is different to the central desert area so learning from the community that you're in will be really helpful as well as sort of generic knowledge about general Aboriginal and Torres Strait Islander culture.
One thing that can be really useful for that, if we move on to the next slide… You may recognise that as being the WHO definition of health. The second one is the Aboriginal definition of health – and I find this really useful. I find it really useful partly because when I show this to my non-Aboriginal friends, they read that and they go, oh, yes, of course, that's what health is. But this is the definition that Aboriginal and Torres Strait Islander people will intuitively use about their health and it's much less individualistic and it's much more about being connected to country and family and community. So, you’ll often find when you're in a community, the sorts of problems that people have that impact on their health aren't just individual, they're connected to their connections to other people and community and to country, and the solutions to those problems also encompass that broader perspective. So people will be up for discussing medications and they'll want discussions around that, and up for psychology applied to the individual if that's available where you are; but often in Aboriginal communities, they have group solutions to problems. So there might be exercise groups – where I work there's a line dancing group – there's community kitchens, community gardens, there's men's groups, there's art groups, there's music groups and those things are there, partly for fun, but partly also because they keep people well. We all understand that intuitively, but it's worth asking when you get there about what sort of resources there are for those sorts of issues.
And I think, in terms of thinking about culture, keeping that definition of health in the back of your mind can be really useful because, as doctors, we tend to operate on the first one where we apply solutions to the individual and actually if we're understanding people's context and their connections, and we're seeking help from our patients, we often provide better solutions. Of course, you've just been hearing about critical care and that's less the case in critical care where you actually have to get on and manage an emergency, but often you need to be quite flexible around your management so that if you can do something that gets an HbA1c down from 15 to 12, you've helped that person. If you would normally be recommending starting five medications, if you can encourage someone just to start one or two and negotiate that, then you're helping that person, and you're much more likely to be successful than if you're just telling people what to do.
GPs Down Under was mentioned a few minutes ago, and those of you who are on there may have seen that I actually posted an invitation to people to paste advice on this question and some of the advice was really helpful – around asking the community about resources and about things you should and shouldn't do. Even just asking will give the impression to people in the community, and important people, that you're a bit better than the usual doctor they get because you're willing to go in and learn from the community rather than just tell them what to do. So be guided by Aboriginal health workers and other community members including the patients. When you first get there, ask the health worker or the person who greets you off the airplane: What do I need to know here? Are there places I shouldn't go? Are there sacred places that I shouldn't find myself? Is there any sorry business or are there any funerals going on at the moment? Many communities have a tradition where if someone dies their first name is not able to be used for a period of time. So asking that, are there any names I can't use at the moment? Have you had deaths recently?
Some of those questions will stop you getting into tricky situations and also show that you are willing to be guided by the community about those things. This works as well for individual patients. And this again is core general practice stuff – being guided by your patients. So asking questions like: ‘So what do you think caused your symptoms?’ and ‘What sort of things do you think will help get you better?’ Because that will start a conversation – very often, they're very good ideas that would work in that community; sometimes they're not but there's a discussion that you can then have about that rather than just assuming that you know.
One of the other pointers for going to work in a Community Controlled Health Service or a state-funded Aboriginal medical service is they usually have to report KPIs. The software that they use, they actually do a lot of work tidying up the data and coding the data correctly, and usually it's extracted by the software and submitted to the Australian Institute of Health and Welfare and also to state and federal governments. And this is a something they need to do for their funding streams, it causes heaps of work in the services – the workload for doing this is massive and sometimes they collect data for their own quality improvement as well. And so asking is there anything I need to know about coding the data or coding diagnosis or blood pressures or weights? Because, again, they'll be really pleasantly surprised that you know that sort of thing. Doctors often understandably infuriate practices because we’re often not very good at coding in the way that they want. And so just showing an awareness of that can be useful. They won’t expect you to get everything right, they're very happy for people to make good mistakes, as long as people are open to having advice and apologising and asking about things. They won't expect you to be perfect.
If we move on to the next slide, this is just some of the resources that are available. So there's the Third Edition of the National Guide to a Preventive Health Assessment for Aboriginal and Torres Strait Islander peoples that was published earlier this year. Most services will know about that, as you may well do as well. So that's an evidence-base guide, like the Red Book for Aboriginal and Torres Strait Islander people about the interventions that are effective in preventive interventions. There's a lot of pressure on Health Services to perform and bill Medicare item 715, the Aboriginal and Torres Strait Islander Health assessment, and that guide is the evidence around the interventions to do during that sort of that sort of health assessment. So that's worth getting to know.
The little one in the bottom right corner there is the 5 Steps to Excellent Aboriginal and Torres Strait Islander Health and that's useful if you're working in an Aboriginal community and particularly if you're not used to working in an Aboriginal Community. It sets out the Medicare and PBS things that can be really useful for Aboriginal and Torres Strait Islander people, the practice incentive payments, the Closing the Gap scheme, and sort of collects all of those things together and really just sets them out as five steps to do Aboriginal and Torres Strait Islander Health well.
Where you're going there may well be disease specific guidelines. Sometimes where you're going, but typically in remote areas, there will be conditions that you won't come across elsewhere such as trachoma, rheumatic heart disease, amyloid in the top end, and there’s some rheumatic heart disease clinical guidelines, trachoma guidelines, etc. Also knowing things like there's a syphilis outbreak in Queensland and in parts of New South Wales and knowing about some of the epidemiology of some of the diseases that you might encounter will be useful. Also tracking down if there is some of the specific guidelines and then some of the guidelines that have particular pointers for use with Aboriginal and Torres Strait Islander peoples. The College’s diabetes guidelines has particular pointers relating to Aboriginal and Torres Strait Islander people. There are some guidelines around otitis media, they were published by the Department of Health several years ago now but those can be really useful as well. And so looking out for those clinical guidelines will be really useful. Central Australia often use CARPA as well, which is often really helpful and the Aboriginal health workers will often be using those and so they'll know CARPA and refer to that. So that's often really useful to know and that guides the first steps in management.
The final thing is be aware of people's context. My sense is that, as doctors, we want to be effective, which means the tablets we prescribe are no good if people don't take them; the advice we have on healthy diet is no good if people can't follow it. So understanding people's context in the community can be really important. For example, if we're suggesting dietary advice, the things that need to be in place for someone to be able to follow that advice is that there actually needs to be the food available there in the community shop or the shops that they have access to, they need to be able to afford the food if it's there (and as you know some of the food particularly in remote areas is very expensive), they need a house that works with cooking facilities and water (and that's not always the case in remote communities with cooking facilities and refrigeration facilities), and then they need time to buy and prepare, depending on what else they've got on like housing, sorry business, and Centrelink. So, in general when we’re tempted to say that people don't care about their health or are being non-compliant, that usually just means that we haven't understood their context. It's very rare that anyone says, oh, no, I don't actually care about my health (and if they do say that there's usually mental health problems going on as well).
Dr Adam Brownhill: Thank you so much Tim. I think that was a really useful summary. I think the context is the thing that I've learned the most having worked in probably a dozen or so different communities around Alice Springs. Where I am at the moment, we've got 16 units stationed in three different language groups and each language group has a slightly different relationship to the country and a slightly different relationship with language and health, so the context is absolutely key. The use of language is really, really important. But it's one of the reasons why I find this work so rewarding as I keep going back to the same communities and developing a relationship over time.
With no further ado, I would like to hand over to Cheryl, and Cheryl Shepley is going to give us a talk on what the Rural Procedural Grants Program can do for people.
Cheryl Shepley: Hello, can you hear me?
Dr Adam Brownhill: Perfectly. Thank you.
Cheryl Shepley: Excellent. So I administer the Rural Procedural Grants Program, which is a program that provides funding for eligible rural GPs to help with any costs associated when attending upskilling or skills maintenance activities. You need to be registered in the program and to qualify for participation you can be a city GP who does locum work and is providing unsupervised anaesthetic, obstetrics, surgery and/or emergency medicine services in a rural or remote area (and that is defined as being in RA2 to RA5). So you may be eligible to join – there are some exceptions, but I won't go into that now. As a rural locum, you need to do a minimum of 28 days locum work per financial year or eight distinct separate placements. And one of the criteria is you need to have commenced your placement prior to registering in the program as the grant is purely for skills maintenance and upskilling based on what you're employed at, not a way of getting skills in order to become a rural locum. So generally it's a flat $2,000 a day of financial support and if you're registered in the procedural component, you're entitled to claim up to 10 days of training per financial year, and if you're registered in the emergency component, it's up to three days per financial year, which equates to $6,000 per financial year.
There is quite a range of options of training that you can do, but it must be a minimum of six hours face-to-face learning and it must be relevant to the discipline that you're registered in (such as anaesthetics or obstetrics or surgery or emergency). The training can include a wide variety of options – so it can be a workshop, a course, a conference, a clinical attachment, an ALM, a small group learning session – there's a number of things that fit as long as it's relevant to your discipline and a minimum of six hours in total.
So, that's the program in a nutshell. It's quite a simple process to register – we just need to know where you're working, your credentials, and things like that, and payments are usually fairly straightforward and you receive them within a month of applying for a grant. If you have any further inquiries, you're quite welcome to contact us either by phone on 1800 636 764 or via email through firstname.lastname@example.org.
Dr Adam Brownhill: Excellent. Thank you so much Cheryl. I personally access the emergency part of the RPGP and use it to fund emergency courses like REST and various things like that. I find it really, really useful and it allows me to keep up my CPD. I always get paid pretty quickly as long as I've sent in the paperwork right. It’s a fantastic system. Do you know roughly how many people are accessing this service?
Cheryl Shepley: Well, through the through the RACGP, we currently have nearly 3,000 GPs registered and we're always getting more. It's a steady flow as word gets out there and it's very popular because, as you mentioned before, it helps with the costs associated with training, particularly, you know, travel and accommodation and things like that – so it's certainly very popular.
Kirsty: We've actually got some brilliant questions and the first one will follow on from Cheryl's talk – Could a GP not specialising in emergency or anaesthetics join the RPGP program?
Cheryl Shepley: Not at the moment. But if you are working in, say for example, you go to a remote Aboriginal community and you're the only GP, so effectively you're on call 24/7, you may eligible. But at the moment the way the program stands is that you need to be credentialed in one of those – anaesthetics, obstetrics, surgery, or emergency, to gain access to the program.
Kirsty: Thanks Cheryl. This question is for Wendy – I’m interested in information on locuming as part of a plan to travel with my young family around Australia for a period of 12 months. Have you heard of other locums doing a similar thing and where could I obtain information from people who have similar experiences?
Dr Wendy Sexton: Okay, that's a really great question. There's certainly lots of styles and reasons for locuming, and the circumnavigation, or partial thereof, around the country is not uncommon actually. The good news is that there's actually plenty of work available. So yes, I think it's a fantastic idea. It can be done and it just requires a little bit of planning and organisation and open-mindedness about where you want to go. So if you were to pack your family up and head off with a camper van and head north, before you do that I would recommend a couple of things. I'd probably contact the PHN for that region or that state and find out what's available. The other way to do that would be to go straight to the rural workforce agencies (and there's one based in each state and territory) and they do all have recruitment as well – so they have a list of some of the places that are available as well. The third option is to go through a commercial agency and you could tell them where you want to go and plan it out that way.
Kirsty: The next question is to both of you – Any suggestions or recommendations for offshore FIFO work such as oil rigs.
Dr Wendy Sexton: Well, I can't say I've personally done this but I have looked into it a few times and I have worked in a lot of mining towns, so there is some overlap as far as the issues that go with that. Certainly there is quite a bit of FIFO work in the mining industry as well as the oil and gas, and the general requirements are that you're (1) willing to go to these places obviously, and (2) that you've got a reasonably strong background in, or willingness to do, occupational medicine, because a lot of it is around that – you've got a younger, generally well cohort (but that doesn't mean that you still can't have someone who has chest pain or other illnesses), you’ll get a lot more work-related stuff, and you will need some emergency skills, and you will also, particularly for oil rigs, need to be prepared to do the extra training required for that (if you're going to have to get out there by helicopter, you've got to do the training for that and living in quite a confined space). So there are jobs available. A lot of these do go through commercial agencies – so that's where I would probably start with that, or word of mouth.
Kirsty: Our next question is: I'm just about to finish my Fellowship of RACGP. What do you recommend training-wise in emergency medicine to practice rurally?
Dr Adam Brownhill: Wow. I guess that depends on where you’re going. Conflict of interest, I'm a REST course instructor so I'm a big believer in the ACRRM REST course. I think it depends if you're going for a long or short term placement. ATLS, ALS, REST – any other acronyms you can chuck out there Wendy?
Dr Wendy Sexton: Yeah. I think often if you're going to be doing this in an emergency department, there will be a requirement for your credentialing with that Health Service. So that often guides what you're doing. And I like to kind of think of it as about having your Advanced Life Support for the cardiac stuff, doing something paediatrics so that you're not scared about the septic three year old we discussed, and then doing something trauma-related – and that is a reasonable coverage. The college, both college, courses do cover some of these topics, so that can be a good starting point. But that's kind of how I try and balance my alphabet course requirements. And then, if you're going to be doing more emergency or if you've got an interest in that, or you feel the need to upskill, I would kind of prioritise perhaps one of the conferences that does some updates or think about some podcasts that might improve your skills there. But I think it's a starting point, I'd probably try and get one or two courses under your belt and then head on out and you'll be okay.
Kirsty: The next question is with regard to Wendy – When you were talking about invoicing, how do you generate those invoices? Do you use a particular software package?
Dr Wendy Sexton: Good question. I've tried a different number of different things over the years and I've gone back to using a simple Excel spreadsheet. You can do everything from that (Excel or a Word document as long as you've added up your numbers correctly), but there are also a lot of apps available in both the App Store and Google Play that are specifically for generating invoices and PDFs. They can be quite useful to use and if you happen to be doing a lot of locuming, or you've got a lot going on, or you choose to have your ABN and set up as a business and you're using an accounting package such as MYOB or Xero, you can generate invoices from there as well. So whichever way, from low-tech to a bit more sophisticated, you do need to think about a couple of things when you’re invoicing – obviously that you've got the correct rate, it might include different amounts for on-call etc., GST added to that, and then if you've had to pay for any travel out of out of pocket, you need to obviously invoice for those things as well. But yes, I'm a fan of Excel to be honest.
Dr Adam Brownhill: Yeah, I use Excel and Word templates to just generate my invoices and I actually use the ATO app to keep a record of my business expenses.
Kirsty: Thanks for that. We've got a question: Could you tell us about one of your most favourite locum placements?
Dr Wendy Sexton: So many to choose from! I've had a broad range of interesting experiences and I think one of the most interesting places I've been to in the last couple of years has been out to the Indian Ocean territories. Most people have heard of Christmas Island, but not Cocos Islands. Cocos Islands is 900 kilometres further west from Christmas Island and it is the most remote Australian medical post bar Antarctica. I was lucky enough to head out there for a month last year and had an absolutely fantastic time on this very, very remote coral atoll that’s stunningly beautiful with an amazing population and a fantastic group of very experienced nurse practitioners. And that was just a generally great experience. One of the things that kind of put me off though when I got there and was having orientation was when we're going through the checklist and the nurse said to me ‘So did you hear from the previous doctor about if we have to do retrievals off shipping vessels?’ I'm like ‘no’ and then she proceeded to tell me that we'd have to go out with you Australian federal police on a choppy boat and collect people as required – thankfully that didn't happen but it certainly makes for a good tale. So that was one place that was very remote, very solo, but I've also found probably my most useful learning has been in Aboriginal communities in both Cape York and Western Australia.
Dr Adam Brownhill: Yeah – the beautiful thing about rural and remote locuming is it’s so different. I've done rural locums in Tasmania and been able to go into Hobart at the weekend and indulge my love of food and wine. I've done very, very remote longer-term locums in central Australia where I've been involved in health carnivals and school health promotions and eventually being taken out hunting with the men. They're all special in their own special way and some of them have been magical and that's why I still keep going back.
Kirsty: Okay, our next questions for Ferghal: What do you do if diazapam is used for social phobia or anxiety? What do you choose?
Dr Ferghal Armstrong: So the use of benzodiazepines for anxiety is fraught with danger and quite frankly there is no role in the long-term management of chronic anxiety syndromes for benzodiazepines. There is great evidence for CBT – the effect size of the intervention of CBT on Cohen's D statistical analysis is 0.8, which denotes a large effect size. The role of SSRIs in the management of chronic anxiety is associated with an effect size of 0.4 or 0.5. So, talking therapies are actually proving to be more efficacious in the management of chronic long-term anxiety disorders than the benzodiazepines. The problem that we've got as general practitioners is that the availability of talking therapy is somewhat limited. I mean, you know, you've had your 10 sessions, off you go, see you next year. Or there just is no psychologist around. And then, of course, when you're in a remote place, who do you turn to for help? What can you use? You resort back to your prescription pad. At that point, I would urge you to stay away from the benzos and augment the SSRIs. So, to answer your question, I don't encourage their use at all in the in the context of chronic anxiety syndromes.
Kirsty: Thanks Ferghal. I've just got another one, I'm not sure if it's on the same line, so please excuse my ignorance: Please comment on lyrica abuse.
Dr Ferghal Armstrong: Well, first of all, whoever asked this question is one step ahead of the game because not a lot of people know this but lyrica is being abused extensively by people. I used to work in prisons and I spoke to a patient in prison and he told me in great detail just how beautiful and mellow the hit with lyrica was compared to heroin, and he described it as better than heroin and as lasting longer than heroin. So the starting point is to realise that lyrica is abused. Having realised that, the next step is to ask yourself: What is the indication that I am using lyrica for, because lyrica is licensed for neuropathic pain, it's not licensed for ‘life ache’ – it is licensed in the UK for generalised anxiety disorder, but not in Australia. And it’s also licensed for a complex partial seizure syndromes. So if you're using lyrica to treat something that is not neuropathic pain, you’re probably using lyrica outside of license. You therefore really should consider weaning them off now. The reasons why you should wean someone off lyrica is an overdose is associated with psychosis and seizures and delirium. However, you have to do it slowly – a 10% to 20% per week as a reduction or you can aim for 75mg decrements every fortnight. You cannot wean people quickly off lyrica – it is fraught with danger if you do that, it is also fraught with clinical risk. So, to summarise, congratulations for recognising that it's abused, consider the indications you're using it for, if there are no indications as licensed or if there's no benefit even for a neuropathic pain condition, then you need to wean them off. You cannot do it quickly – 75 milligram decrements per fortnight would be a reasonable way to go forward.
Dr Wendy Sexton: I'd just like to say thanks everybody for being here this evening. There's been some great wisdom shared and some good messages to take home, and it's been really interesting to have a deeper discussion about these and talk about the resources. I think it's been a fantastic experience and discussion and we've covered quite a lot of ground. So, Adam, last words from you before we finish up?
Dr Adam Brownhill: Don't be frightened, you have the skills. It's an amazing opportunity. It's a wonderful experience. At times, it can be a little bit frightening, but you are never alone – there are there are lots of resources out there.