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RACGP Queensland: COVID-19: How are you going?

Dr Bruce Willett

Welcome everybody. I'd like to start off by personally and on behalf of the RACGP, acknowledging the traditional custodians on the land on which we all meet, live and work, and pay my respects to the elder's past, present and future. I'd also like to acknowledge and welcome any Aboriginal or Torres Strait Islander people who are joining us here tonight. 

On behalf of the RACGP Queensland, I'm so pleased to be facilitating the session here tonight. Thank you all for attending this webinar on such an important topic, and one that I think we sometimes let slide a little bit. And so it's really great to put the focus on it, particularly at this time.

My name is Bruce Willett. I'm the chair of the RACGP and I'm also a GP and practice owner in Victoria Point, to the south of Brisbane.

We've allowed a half an hour at the end for questions and answers. So we will try and hold the questions till then, but you can certainly ask them as we’re going.

By the end of tonight, we'd like you to be able to list some of the support services available for GPs, outline some of the strategies for initiating checking-in with colleagues and describe methods to support practice staff.
Tonight's webinar will include presentations from Dr Margaret Kay and Dr Anne Ulcoq.

We're grateful to have Margaret Kay and Dr Anne Ulcoq joining us to present. Margaret is the medical director of the Queensland Doctor’s Health Program. She continues to work part time in general practice. In 2013 Margaret competed completed her PhD in physician health focusing on how doctors can access their health care. She holds an academic title as senior lecturer with the Faculty of Medicine at the University of Queensland and has over 25 peer reviewed publications, many in doctor’s health. Margaret is a member of the expert advisory council for Doctors Health Services Limited and the Australian Doctors Health Network. She also has clinical and research expertise in refugee health.

Dr Anne Ulcoq has worked in the Doctors Health Advisory Service Queensland on call panel for 17 years. She's been a committee member and has held the role of president for the last three years. Anne has been a GP in Brisbane for the last 34 years and has owned and run a general practice for much of that time. Anne has been involved in supervising GP registrar's, teaching medical students, and doing external clinical teaching visits and teaching at GPTQ. She's interested in palliative care and works as a GP for the Hummingbird House, Queensland’s only children's hospice. She is deeply committed to supporting her community and her colleagues in this difficult time and feels that supporting doctors’ wellbeing is a priority.

They don't mention in their blurb that they're both wonderful, caring human beings and it's been my pleasure to get to know them over the last couple of years. They've volunteered extraordinary countless hours to looking after GPS and doctors health all in their own time. So I'd like to thank you both for being with us tonight and hand over to you.

Dr Margaret Kay

Welcome, everyone. And it was really amazing to see how far everyone has come to attend the webinar. Basically, the Doctors Health Advisory Service Queensland has a service arm, which is the Queensland Doctors Health Programme (QDHP) and I'm the Medical Director of that program. It's an independent service that’s supported through funding from the medical board. We're a completely independent confidential helpline and we ensure that that’s the case. People can ring in anonymously. They can ring in telling us their full name if they wish. We don't need to know it. And we certainly don't tell anyone who has rung. So we maintain that confidentiality. We've got a history of doing that for the last more than 30 years. And that helpline has been available for well over 30 years; and available for colleagues talking to colleagues - and I think that's the advantage of our service. 

So we've got a question for you now. Have you actually heard of the Queensland Doctors Health Programme or the Doctors’ Health Advisory Service QLD before? Just vote yes or no. Okay, so these are the results. So it's not really a surprise to us that two thirds of people have never heard of the Doctors Health Programme and frankly, given how much work we put into the program, we're always disappointed, but as I said, not a surprise.
At the end of last year, I was talking to the medical partner of a doctor who had committed suicide and he said to me, we've just never heard of you before. And clearly, for that colleague, it was too late and I have to say, sort of broke my heart that people are still not aware. So if one thing you can do tonight is just make sure your colleagues are aware that QDHP is actually there for you. And there's a lot that we do.

As well as answering a 24 hour line. We have a lot of GPs who rotate through the roster. We're always looking for new GPs to help take the load off - everyone just takes the roster for a week. It’s about once every 40 weeks that people take the roster at the moment and we're hoping to stretch that out to once a year.

We also promote the health and wellbeing of doctors by actually talking to other people about how they can do that. We deliver education to medical students and obviously here to GPs, but also specialists about how to look after their health, and also how to care for other doctors because I think that's a challenge, and it's something that GPs are called to do all the time. We advocate strongly for doctors health with lots of organizations, including Queensland Health and we also network with organizations. We're really pleased to be working with RACGP Queensland on this. Dr Anne Ulcoq is going to take it from here.
 

Dr Anne Ulcoq

Australia has done an incredible job so far to contain COVID-19. We move to a stage of cautious optimism.  Tempered by the challenges we were probably less prepared for, telemedicine, social isolation and possibly fewer presentations of patients with other health conditions. 

Whilst the initial anxiety increased, energy phase has past, we can't be complacent and we need to prioritize our own self-care, and support of our peers and staff that we work with.

‘A COVID Disaster Journey’ Graph on Minding Health Care Workers was done in April this year by
Margie Stuchbery.  I just wonder where you think you might be on this journey. I put an arrow where I think I might be. So definitely I had the heroic and honeymoon phase, maybe disillusionment at the moment, maybe boredom, but might be interesting just to think about this graph and reflect later at the end of our presentation.
There was a survey done by the JAMA in April on anxieties that healthcare workers had and you look at the list of the eight major source of anxiety, they are probably not necessarily things we’re anxious about at the moment, certainly in Australia, at least.

Maybe the things we typically see is still protective equipment, but I think a lot of the anxieties that people have now probably are about home-schooling. Should I send my kids back to school or to day-care. What happens as social isolation is reduced and we get back out there. I suppose I'm worried about what the future looks like and if it's going to come back again.

I’d like to talk here about my personal pandemic timeline to highlight the range of emotions, responses, and challenges that I have personally experienced as a Brisbane suburban GP. My story is not unique, you all have stories to tell. I feel that it might try to identify some emotions you might experience and hopefully normalize them. What we've been experiencing is a very abnormal situation and it’s probably nice to hear that your colleagues have felt similar versions to yourself. A collegiate discussion then on how to ask for help, peer support and how you can support your colleagues.

So I was an earlier embracer of the pandemic as I had some time off in January, a little time to reflect on the world views and so prophesized about the pandemic. I actually did do a bit of stockpiling early February for myself and my elderly relatives. The emotions I felt around that when I was talking to people around my fears about the pandemic and then being dismissed by family and colleagues and friends. I actually felt frustrated and powerless. Then I thought I was really selfish, because I felt like I added to the stockpiling of toilet paper that had gone on.

The next thing that happened in my timeline was the 13th of March, my baby brother got married. And this was a longed for event. He’d been with his partner for 10 years. I come from a large family and there's a lot of emotional investment in this wedding happening and I found myself hyper aroused, I found myself anxious or angry at family members who were coming back from overseas and not self-isolating and still going to go to this wedding. The wedding happened obviously before social isolation and we had a wonderful time. No one actually got sick, which is amazing.

The next in my timeline was I was due to fly a few days later to America to visit my three beautiful grandchildren, something I do a couple of times a year. And we decided not to go, before international travel was stopped, and I had this enormous sense of, you know, decision not to go because I was fearful of what would happen if I got sick in the US and had to be ventilated but also I was feeling really feeling quite anxious about leaving my elderly parents, my patients and work with what we were facing with this pandemic. What is has left me with is a sense of anticipatory loss and grief because I don't know when I'm going to see these kids again, even when the borders reopen. I don't know how you travel to another country with the ongoing threat of COVID-19. I don't know how to get travel insurance. 

So the next step in my timeline was setting up my elderly parents and parents-in-law, at the average age of about 90, - trying to set them up to be safe. If the pandemic hit and relatives weren't able to go visit and support them, that they wouldn't die of starvation or run out of medication. Dealing with setting up meals-on-wheels and medical packs for them I actually felt anger, frustration and a sense of powerlessness which then very quickly moved to compassionate and caring fatigue as a doctor, daughter. 

Then there’s work and a loss of control. We're working with colleagues and staff who were fearful and anxious about COVID-19 and the flow on effect of work life. Fear of exposing our patient inadvertently to this virus whilst being able to practice safe and good medicine. 

Fear that my patient’s morbidity and mortality from non-COVID related diseases would rise due to their fears and barriers around investigation and treatment. The juxtaposition of offering reassurance and support to patients, when I'm facing the same threats - physical, financial and emotional. So who cares for the carer?
The information overload - practicing medicine with daily and changing guidelines. Our scaffold of knowledge, confidence and routine had fallen away and rising issues of anxiety, exertion, uncertainty and helplessness. The added burden of working harder and feeling more exhausted but the reduction in remuneration due to increased bulk billing for tele-health and reduction of high paying item numbers like procedures, health assessments and patients physically not wanting to come to practice - our financial security was threatened. 

Then the flu saga which happens every year. The demand for the flu vaccine and the immediacy of that for our patients outstrips the government and private supplies. These patients are already anxious and being told by the media they have to get their flu shot now because you're vulnerable. The doctors and the staff at the practice are taking a bit of abuse about that. These poor patients and the staff are already worn down by the social isolation. Many of them come to me and say, I haven't been out of the house for five weeks and you’re the first person I’ve seen. So, dealing with their anxiety and the risk of that transferring onto us.  

We’ve also lost the collegiality at work because we're not supposed to be having lunch together or meeting around the copy machine. Going from the whole you know heroics to disillusionment. We also need to be leaders and we need to care for ourselves. So the pandemic is affecting everyone's life in some shape or form. For some of us it has been a time at home to reflect, and that opportunity to withdraw from the frenetic pace of life, but for a lot of us it’s been a time of worrying and change. 

I want to just discuss and normalise some of these emotions that you may have experienced over the last seven weeks or longer. Or maybe continue to experience. So first of all, I want to talk about trauma. So trauma is the response to an event that threatens our safety and integrity as a person. The COVID-19 crisis is a threat to our world and our personal safety. It's normal to have a stress response to a threat like I was initially, feeling hyper aroused and hyper vigilant. Intrusive thoughts and distressing images that presents feelings of anxiety like sleep disturbance, agitation and looking to manage this with sort of maladaptive behaviours in the short term like comfort eating, drinking alcohol, the avoiding of news. This is a normal response to trauma and it should settled in 2,4, or 6 weeks. Hopefully that trauma and those emotions are settling. If you’re experiencing any of those responses you’re not alone, that's normal. And the trauma of COVID-19 is unlike any other threats we've ever previously dealt with. So it’s a normal reaction to an abnormal situation. 

Dr Margaret Kay

We all need some strategies to manage and basically what we found, is that we're trying to do absolutely everything at once, and really, we can only control what we can control. So we need to actually ensure that we're addressing the basics and that's for our family, but for us as well, keep washing our hands. We need to actually acknowledge our thoughts and anxieties, because I think we have to be honest with ourselves - reframing our thoughts can actually help us progress and we need to constantly be energized and that means that we actually have to take some time out to stock up.

We've sort of developed this sort of care circle, which is: control, acknowledge, reframe and energize. Anyone can put whatever they normally do in the ‘energize’ (we put friends and music). But you could actually put in all sorts of things. In acknowledging we actually put in the fact that a lot of us are worried about our kids’ education, and home schooling and trying to manage all that at the same time.  Even if we're allowed to send our kids to school, do we want to - all those sorts of things. I know things are changing now, but I think it's important that we keep everything in its place really is what I'm saying. And where that place is has been a bit confusing.

Unfortunately we're all a bit prone to using poor coping behaviours. I think whilst a lot of us have been out there exercising, a lot of us have also been eating a little bit too much. Poor coping behaviours like alcohol, smoking and other drugs are still there, even for the medical profession. Most important I think we underestimate how much we are bombarded with that constant news cycle. And I think that's really quite distressing.

Dr Anne Ulcoq 

Next emotion I’m going to talk about is anger. Anger is the normal emotion and a natural experience in response to things we perceived as being unjust. We as doctors see anger is being a bad thing that we should suppress and never show, but it's not a bad emotion as it triggers us to respond and to take action. So the anger we may have experienced over the last few weeks might been in response to lack of personal protective equipment. Fears for family safety or perceived lack of support by members of the public or family not taking this seriously and that's understandable and human. We need to acknowledge and recognize our anger. It’s a human response and it's about emotion and that you might just need to express it in a healthy way, otherwise it might come out sideways and aggravate a difficult situation. 

So we’re taught to suppress anger, but in this current environment we might just need to take a little bit off in a planned safe and healthy way. Carolyn Walker, who has been doing ‘The Joyful Doctor Podcast’ (which you can find on the internet), has a whole website devoted to this in which she talks about expressing anger either physically, verbally or written, depending upon you the way you like to express anger. So one way of dealing with it is like loud angry singing in the car, punching a mattress, venting by putting in writing in a sage format that you not going to send to anybody. 

Another emotion you might have experience over the last few weeks is guilt. Guilt is an emotion that a lot of people have expressed.  Guilt about not being able to provide our patients with a standard of care they normally would have. That feeling of being happy when you see at a funny video on COVID on Facebook when countries like Italy, Spain and the UK have been suffering and grieving. Guilt around the workforce and frontline workers, fever clinics and ICU. They’re often staffed by young doctors who may be at risk of dangerous levels of exposure. Doctors who have had to step away from work because of family commitments or personal risk to their health. A lot of them express guilt about not being able to contribute, but ultimately we are people first, and we are doctors second, and our private commitment has to be to ourselves and our family. 

So it's difficult because we have a complex relationship with being a doctor. It isn't just a job to most of us, and guilt is a normal emotion that we need to accept. There's no right or wrong way to respond to this very abnormal situation, and not worry that we’ll be judged. We have to accept that this is something we haven't chosen. That we’re not alone having to make these decisions and that for many of us it's only the least worst option that we can choose. 

Grief also affects us in a broader sense and the loss of our lives as we were living them. Lots of plans, our lives, have been turned upside down - and our future lives. Holidays, weddings, family events, funerals even need to be put on hold - and our children's education. Training and career options, working from home, loss of money and a much greater grief for our world and people and their families who have lost lives, and who might die. Our colleagues who may die in the line of duty. So how do we cope this?

Be aware that the stages of grief - shock, denial, anger, bargaining, sadness, acceptance - they don’t always follow a set order. They're not a linear process, but they are normal emotions as is the human experience of grief. We are grieving for our present world and our lives as we knew them. It’s normal to take time. So it's important to show self-compassion, and Margaret will talk to us about self-compassion, and accept that we're not going to be in control, and grief needs to unfold. Everyone's in a different stage of grief at any one point time and it may come in waves, and it may not come at a time that's convenient, but you need to take time out to deal with your grief. If you keep a lid on it because it’s an inconvenient time, it will actually come back, so you need some quiet time to experience that grief.  

Now talking about anxiety and the things that healthcare workers were anxious about at the time. This is an unprecedented, extraordinary time with no previous memory in our linked history of anything similar. We’re rattled with a jungle of emotions and are working in different ways, feelings of lost control. We don't have the answers and you don't have a usual scaffold of knowledge and protocols to support us. We are firstly affected by the economic and societal changes as are our patients, and we have families who are possibly at greater risk of infection. Anxiousness is an appropriate response to the threat and how we manage receptive feelings into resilience. Be grateful and foster positive emotions and when all else fails - stop, breathe, think and give yourself a chance to catch up.

The next thing I'd like to talk about is COVID fatigue, the risk of burn out and disillusionment. I know a lot of things have changed over the last few weeks with social isolation but the future still seems endless - days run into days. We don't necessarily have any determination between our weekdays and our weekends. We would normally take lead, but people might ask, what's the point? We can’t go anywhere anyway. This is our chance to recharge. The last of social contact at work, as I said before, we're not getting those corridor chats that you normally have. Thinking about a plan with any future activities. There is this risk that when we open up the social isolation that we might have to turn around and do it all over again. 

There's all the conflicting information that you read all the time. You know, is there ever going to be a vaccine. Is there a second strain of COVID emerging? Will you have immunity once you've been vaccinated or been exposed. There’s the anti-vaxxers and conspiracy theorists out there. There’s been an initial eagerness to get in there and starting making a difference. For some people this has been replaced by an intense lonely fatigue, and even the people who have actually been preparing to step up, but just haven't had a chance to because, basically, it's been a little bit of an anti-climax in terms of number of cases predicted compared to what we actually saw, but this perpetual state of waiting is exhausting as well. I've heard this compared to America, running multiple marathons continuously which in some is creating even more potential for exhaustion and stress.

There's concerns of poor mental health in regards to the second wave of the pandemic and that we as doctors can only soak up so much of our patients’ mental health and support before it affects us and we become traumatised vicariously. So the risk that is burn out, which is formally defined as a state of physical, emotional and mental exhaustion, caused by long term involvement in dramatic situations which this COVID crisis certainly is. So it's hard to prevent burnout. We have to recognize that it's happening and try and minimize and deal with it. We need to be aware of when we're not feeling our compassion, and we've got less compassion, and if we start feeling hopeless and helpless. If our workday has lost its sparkle, we need to think about removing ourselves from the stresses and taking care of ourselves.

There's a couple of slides from one of our lovely doctors in the community. Just a little sketch about how to maintain a healthy, balanced lifestyle. I've certainly been working on something creative, which I'll share with you. Mindspot has got 11 great psychological tips for frontline staff, which we are, so it’s worth having a look at. I have been creative with sourdough. That’s been my COVID-19 de-stress. Nailed it. 

Dr Margaret Kay 
We've got another question for everyone. How are you feeling today? We've got a few choices: 
  1. Hopeful 
  2. Disillusioned 
  3. Confused. 
  4. All of the above.  
 So it's always hard to know how we are feeling. It seems like most people are hopeful, which I think is nice and some who didn't click hopeful, were still hopeful because they were actually in ‘all of the above’. I actually think that sort of describes general practice a bit - that it's often a mixture of feelings. I think it's actually really important for us to check into our feelings every so often and see how we are going. Dr Anne sort of articulated the roller coaster of what I think many of us have experienced over the last little while. Cancelling travel, all sorts of different experiences that we've had - caring for relatives, whether they be the kids that we’re trying to support, whether they're the older members of the family or multiple members of the family, all draining us to some extent. So one of the things we have found in our own practices, is that sometimes different colleagues are at different stages to us at different times. Sometimes they're anxious before we are - then we realize why. Sometimes they haven't resolved their anxiety when we have and I think this is all part of us as GPs being expected to be leaders in the community in all sorts of different ways.

I must admit I've actually really valued what the RACGP have actually done with the multiple messages coming from the College. I think with some of their newsletters that, in a way, you sort of get such a big dump of different newsletters happening at different times. I found that the RACGP newsletters generally linked into stuff that was important to me and I found that really reassuring - that someone knew what I needed.
So gathering information, setting up systems, getting everything ready, really meant that we were constantly identifying where we were more vulnerable, who was more vulnerable and what we were going to do to address that vulnerability. So we will be processing, reacting, engaging and we are reassessing and we are continuing to do that because we are now, I think, as primary care physicians more aware now that we are going into the next phase - which is really based in primary care.

We’re yet to see how this next bit unfolds. All of these things we're doing are associated with feelings. Every one of them are associated with feelings and that's why we feel like it's all of the above. Multiple mixed feelings. So when we are with our colleagues…what do we say? How do we actually know what to say, and when do we actually time what we say with someone. Especially when we're GPs in a busy clinic and someone's working part time and disappearing before we've even had lunch. When do we say something (and certainly it's actually really uncomfortable)? So it's much easier not to say something. 

So I just want to talk a little bit about why that might be, because we actually take on an identity as a physician. When we grow up and do medicine when it becomes what our trade is - we are the doctor who has this white coat and underneath we're kind of trained to have that sort of sense of steel underneath. We’re crafted to be a carer of others. Of other patients, but we're not crafted to look after ourselves as much, and we know that our physician friends are also the same.

So when navigating that physician identity and engaging with other physicians, we actually find that we're also reaching out to our colleagues by navigating their physician identity. We're trying not to make them feel embarrassed as we're trying to connect. The easy way to do that is not bothering to connect, because that's actually what they're expecting of us - is to just not connect. 

There are many cultural issues that we need to get over and we need to at least recognize when we're trying to engage with our peers. So what they're kind of thinking and what we're thinking when people engage with us is like, how can I actually be a good doctor (it's almost a moral word a ‘good doctor’) if I actually need help. So therefore, I don't need help, because I'm actually a good doctor. 

One of the feelings or a couple of feelings that Anne mentioned were anger and guilt. But the other feeling is shame. It's a very common experience that people have been writing in the literature about COVID-19 is so many episodes of feeling shame about how we're responding or not responding appropriately, and we just don't know what we should be doing. It's not part of our cultural understanding as to how we should be responding. We don't mean to feel anxious, but we are or whatever that might be. But shame is a very common experience at the moment.

So when we're navigating the physician identity, we're also navigating our own physician identity in the point at which we connect. We know that we visualize our compassion to be a deliverable for patients, not a deliverable for our colleagues. We tend to have a cultural failure in being compassionate to our colleagues, why can't they just dot, dot, dot, particularly when we're talking about our junior doctors expecting them to be more resilient and things like that.

So any culture has a language and we need to start learning how to craft our language so that it actually includes compassion. Compassion for our peers. We often end up saying things like, ‘you should see a doctor about that’. Instead, what we should actually be saying is ‘I always go and see my doctor about those sorts of things’. We need to actually include ourselves when we're speaking to our colleagues and that's how we can reach out more effectively, because we're not ‘othering’ them. It is really easy to other people because if they are the ones that need help, then we remain in the carer role and that's comfortable for us. It's hardly comfortable for our colleagues, if we're constantly ‘othering’ them. 

When we're reaching out to our colleagues, what do we do? We need to be prepared.  It obviously depends on the issues that are being raised as to what we need to be prepared with, but in primary care we're flexible all the time. In reaching out to our colleagues, we need to support our peers, junior colleagues and in fact the whole team. How do we do that well. Sometimes it's about asking direct questions, but sometimes asking the direct question isn't, ‘how are you feeling’. It might actually be - ‘I had a case today that was like this, and I found it really struggling. How have you been feeling with your cases?’ So just preface it. We can ask, are you okay, but be prepared for the response, I'm fine. That doesn't mean we haven't at least triggered the self-reflection that a colleague might need to do.

What about family and patients? You might actually connect with someone by saying ‘how are the kids going at home with their education?’ ‘How are you going with Mrs. Smith, I saw her come today, I imagine she's a bit lonely’. It's a safe territory for us to talk about how we feel about our patients and our family, and start seeing whether or not someone can talk to us about their feelings.  Similarly through training and supervision, we can find spots that are safe to start with and then step from that foundation into caring. We can talk about how we're planning our personal, our career, our family around what's happening, but using ‘I’ statements are actually safe statements. ‘I noticed’, ‘I was thinking’ - using inclusive statements are safe statements. ‘How do you think we could…together’?

I think it's really important that we have time. It's really easy to be rattling our car keys and standing up from the lunch room table, as we say, how are you going and then obviously, we're not expecting an answer. It's important that we maintain confidentiality so asking someone in the tea room how they're going is hardly going to get an answer other than I'm fine. So just be really sensitive to how you're doing it because if you're trying to stifle the conversation, you’re not actually checking in with your colleagues at all. 

We do want to support our colleagues and our peers. If we're going to do that, we also need to know why we're asking. Are we actually asking because we need to know that our peers are ready, we need to know that they are okay, so we can be okay. Are we actually seeking reassurance that what we're doing in our preparation is actually the right way of doing things? Are we actually seeking reassurance about the fact that we want to wear a mask or scrubs, or we wonder if they're coping better than us? Why are we actually asking? So I think it's really important for us to actually understand ourselves as we reach out to others as well.  There is no actual right answer to any of this. It's a complex problem, but it's really important to understand that complexity as we step into that space when we're talking with our colleagues. If they say that they're actually uncomfortable about things that we think are easy, it doesn't mean they're wrong. It doesn't mean we're wrong. It just means it's a complex space. 

Dr Anne Ulcoq 

So in support your colleagues, I just want to illustrate some things we've done at work to support our colleagues. We had a COVID Curry night – pre-social isolation in early March.  We had a meal and a chat afterwards about how we were feeling and coping with the changes. Since that time, we've tried to make a point of checking in on each other. It's been a lot of home bake sharing and a lot of half price Nandos shouted for people for lunches. We had to think quite creatively, and had a significant decade birthday - so we all got together and did a couch choir video of us all singing a song. We tried to really recognise any losses or joys as humans. We have two WhatsApp Groups. One is where we share medical information and the other one is where we share like happy things pictures of our children, our grandchildren, or a sunset. So that's the things we've done just to keep staff up - and we've done this not just with the doctors, but our receptionist and practice managers as well. 

We had lots of volunteers from QDHP doctors to share their story from COVID-19 and this is a video from a medical student who’s a beautiful videographer. We made that video because we wanted to try and normalize what everybody was experiencing and to emphasize the need of connectedness and we are stronger together. I think that message comes through clearly. The other thing is, we really want to promote our service because we don't want people who are experiencing distress to feel alone – QDHP services are always available. You might recognize some of the doctors but they all represent a good cross section of QLD doctors. There's a younger person in training, a couple of doctors in training, a retired anaesthetist. We did enjoy making the video, which is all done by people recording on their iPhones - so practicing social distancing. 

Dr Margaret Kay 

Basically, that video was almost a gift because it was given to us by a medical student who has amazing skills and I think it just shows that the caring can happen in all sorts of different ways. So we talked about our peers and what we need to do is actually to be prepared. Ultimately, that means being compassionate because being compassionate is okay, connecting is okay, validating is important and listening is okay. Encouraging self-care is okay. All of these things we can do with our colleagues. If they seem to have an issue that needs to be further explored – then do they have a GP? Encourage people – ‘I go to my GP with that sort of problem’. If they don't have a GP, then that's what the QDHP is there for - to help people connect to the health services. Treating our colleagues is obviously not okay. That needs to be independent, not by the boss or by someone in the next room.

It's okay to ask for help. As GPs struggling with our professional identity constantly, and that ultimately leads us with that cultural failure of self-compassion. We need to be able to self-reflect and check in. Are we actually pacing ourselves well? Are we actually starting to use the most dramatic language because it's one way that we're actually expressing our anxieties? Are we actually completely information overloaded and not processing things properly because our bandwidth is completely overdone?

Self-care is a really important thing and it's something we need to be experts at and something that a lot of us, when we do check in, realize we haven't actually been doing properly. Just because we go for a run occasionally doesn't necessarily mean we're experts at self-care. It's actually a really wide number of dimensions that need to be addressed. So how do you fill up your tank? We need to understand that. Our physical health and mental health and understanding the bandwidth there is important.

One way of checking in, is to use this check-in scale and the self-compassion scale. This is the short self-compassion scale from Kristin Neff, with 12 items. Basically these are really quite interesting questions because they ask us how we feel about things and quite challengingly suggest that maybe we're not being compassionate enough to ourselves. I think it's always worthwhile doing an external type check-in on ourselves because we tend not to think through the issues very well without having something external.
So now we have a question for you as the participants. Who do you think you would actually go to if you wanted to go to someone for some help? 
  1. Trusted colleague 
  2. Personal GP
  3. Mentor or supervisor
  4. Psychologist or counsellor
  5. A wise person in your life
  6. Don’t know 
Have you ever thought about who you'd go to? And obviously I'm not talking about your Mum - someone beyond family. So it looks like a lot of us actually have a GP and that's a really good thing. I think sharing with a trusted colleague, someone who understands medicine and someone who we know is not going to go out and tell the world about our concerns and worries is useful. Having people who can mentor us and our supervisors are also good people to provide advice. Many of these people, like the mentors and the wise person in our life, are not necessarily people who should be treating us, but can provide us with really sensible advice. Obviously our GP can provide us with sensible advice as well as treat us, because that's what we often do all day - to provide some advice to our patients. So I think all of that just gives us a little bit of an idea. So 44% said personal GP. I'm fairly impressed with that, frankly.

So clearly I'm suggesting that we all should have our own GP - and I do understand it's hard to find a GP that's right for us. I had many people asking me, who should I have as my GP? Just as we were going into social isolation. While all our practices were really, really struggling to identify how we're going to manage our practices, there were people who did not have a GP, who are now starting to look for someone. So hopefully, we're not going to be in that situation in the future because doctors will actually find a GP, who's the right person for them. It's got to be someone who can manage our preventive health as well as our illness and who we actually have rapport with.

 In the practice team, our colleagues, maybe our doctors, our nurses, also our practice staff (as in admin staff), maybe allied health staff – there are many people who might need to have some support. And when should we actually get involved with supporting our staff? So first of all, we need to understand how we can reduce the stressors of our staff. Ensuring they're having adequate breaks - and noticing when they're not.  Ensure that there's adequate training - for example with PPE - or just actually managing those calls when people are ringing about issues of COVID-19. How are they going to handle those questions, because maybe they haven't actually ever managed a pandemic?  Remembering to provide training for your staff is important. Positive feedback to staff, making sure that they have faith in the infection control - that we're actually ensuring protection for them. Very clear communication is really important at this time and enabling communication, of course, both ways.  Sometimes, someone will be really anxious a particular day, and sometimes time will just settle that, but be observant if there seems to be something not quite right.  Ensure you always have good practice policies and obviously the number one is that staff need to have their own GP outside of the practice.  Be aware of any workplace legislation - confidentiality and people don't have to tell you their health issues. Or those sorts of things that are uncomfortable moments when staff having to disclose, I've got an immune suppressing problem that you don't know about, but I feel I need to tell you. So there was a lot of self-disclosure happening where people were feeling really vulnerable during that. Be supportive. Being supportive is not treating someone, so that's actually important to still be supportive and not run away.

There's employee assistance programs that some workplaces have, particularly the bigger GP networks, but also most of the Primary Health Networks have established employee assistance programs that we can tap into now as general practitioners.  

Before we get to question time, I just want to highlight that this is a sort of zigzag pathway. We don't know where we're heading. Clearly we're heading into the next stage, whatever that might look like. Ultimately, there'll be another stage. Eventually, potentially, we might call it reconstruction, but heading to the new normal seems to be the word we're using.  We need to be agile, I think, in primary care where we are well place to be agile. We need to be able to adapt to change in a very complex world and to continue to do that.

There are lots of really good places to get resources, but I'd like to say that the Doctors Health Advisory Service, has a really good resource page with resources for COVID-19. It links to lots of useful things that we've curated and we're continuing to build that at the moment. We're working on the website over the next week and hoping to have a lot more on there, but it's already certainly grown over the last couple of weeks.  

The TEN: The Essential Network is what has been launched recently by the Federal Government with the Black Dog Institute and they're about to put a whole lot of resources on that as well, which is designed for healthcare professionals.

So one of the other things that we're planning to do is to actually have some peer support programs for RACGP doctors, and we're just working out the structural arrangement for that, but hopefully in the next few weeks will actually launch an educational session about how to be a person who does peer support and how you facilitate peer support. We're hoping to have some sessions where people can drop in to actually experience what it's like to have a drop-in session with peer support through zoom - obviously in this social distancing world we're going to keep it in that mode for now.

Dr Bruce Willett 

That was a wonderful session. We do have some time for some questions and we'll take as many as we can. I might just ask one or two. 

You talked a little bit about getting to know your colleagues and getting in touch with their feelings, but of course it's not a good idea to be treating colleagues. How do you manage that boundary? When you’re at risk of crossing over from one to the other.

Dr Margaret Kay

So Bruce it is complex. When a patient comes in - they're coming in as a patient and there's no wondering about the boundary. They’re actually there in the room with us saying, ‘you're my doctor’ and it's kind of easy. I actually think that we don't learn much about that process as to how that patient got to see us. Therefore, when we're actually trying to work out how to see a doctor, we don't seem to get the fact that it's about actually making that arrangement with a person to be their treating doctor. So therefore, when we're in the tea room by ourselves with one other doctor, it’s very easy to lapse into asking questions and the person to lapse into answering as if they're the doctor. Clearly, if we find that we're doing that, both people - in fact, I would say the person responding especially needs to recognize that they're starting to offer treatment because treatment can actually be counselling type stuff. So it's not necessarily getting out the flu jab. I think we just need to be self-reflecting when we're having those conversations but if we're so busy at recoiling from someone who is asking sensitive questions, then I actually think we leave our colleagues in the lurch. So I see more people who are devastated by the fact that no one asked, and no one cared than I see people who felt they were over treated inappropriately. Most times if we feel someone is crossing the boundaries to over treating us when we didn't actually want treatment, we usually just end the conversation and walk away.  I think we're more inclined to not show compassion to someone, rather than treat a colleague, but recognizing the boundaries is really important.

 Dr Bruce Willett

There's a question about who staffs the Doctors Advisory Service and what it takes to get on staff at the Doctors Advisory Service. Maybe I'm asking if some of the participants would like to think about volunteering.

Dr Anne Ulcoq

So first of all, I just want to clarify that Doctors Health Advisory Services Queensland has existed for a really long time, over 30 years, and we have been taking calls 24 hours a day, every day of the year for that period of time. When I first started out, it was just a small group of doctors who got together to support doctors in need because they didn't actively seek help for a variety of reasons. As time has gone on, that on-call panel has expanded and we actively worked at increasing our doctors on that on-call panel. Obviously there's some doctors on the on-call panel who've been doing it for many, many years, and they're looking to retire and many of them have retired. As they are stepping down, we’ve been actively (through processes like this) recruiting GPs who are interested in doctors health. That's how people are recruited – if they’ve attended an education session we’ve had or they've seen a promotion that we've done and they’ve contacted us. 

What we do then is we get them to do some training to be a doctor, for a doctor. That might just be a small session with Margaret and myself one afternoon. We've got some resources now online you can do. It's good to actually think about what it's like to be a doctor for a doctor. A lot of the stuff you do is actually just being a GP but when you're actually taking the calls, you’re not actually setting up a therapeutic relationship, you’re listening to a colleague. You’re being empathetic and kind and compassionate to a colleague. Helping them see how they can find a way through a difficult situation. Often the person who rings, knows the answer themselves. They just want to run it passed someone. 

So if you are interested in helping by being on our on call panel - let us know. You can just go to our website and ring admin, or send your details in an email and we'll help you develop the skills. Obviously, we vet people and we make sure that they're doing it for the right reasons, and we make sure that their registration is up to date, etc. There’s been a lot of new people coming on to our oncall panel over the last few years, a lot of people are interested in being involved in doctors’ health and they want to help their colleagues. 

Dr Margaret Kay

I agree with that. We never really had training back in the day, and we actually have an enormous amount of training available now. We also provide more support for the doctors, so when there's a person who's come through the helpline, if they want more support we actually have a counsellor that works with us as well. So it's more than just the GP available. Sometimes people need to talk things through a few times until they can work out the pathway ahead. We have more resources available and we have more time to listen. We’re better at understanding the needs of doctors now than what we used to. We have more resources, in that we actually have pathways to get medicallegal help. We have pathways to get psychiatric or in fact psychological help. We have lots of different pathways that we just didn't have accessible in the past. So I think it's a more flexible service clearly dependent on volunteer help. At the end of the day, there are always some limitations to every service, but I would like to think that we can help much more now than what we used to.

The Doctors Health Advisory Service actually started in 1989 when it became an Incorporated
Association but before that, it still had a help line. I actually think it was such an innovative idea back then as no one was talking about doctor’s health and the people who volunteered then were volunteering for something that no one else in the community was doing.

Dr Bruce Willett

Once again thanks for all the hard work and the many hours of volunteering put into it for both of you. 
Question: Are there any more ways to increase the bottom line? 

It's probably not in the remit of this webinar. The RACGP has conducted some Practice Ownership and Business of Practice webinars. We had one last week and we'll be doing one in the next couple of weeks where we've discussed this question and the percentage of consultations that should be done by Telehealth. The President of the RACGP has said that he feels that probably no more than 40% of consultations are appropriate for telehealth, and I think that's probably about right.

It’s going to depend a little bit on the circumstances of where we are in the COVID curve. As we are relaxing things, 40% is probably going to be the top percentage that we should be doing.

Dr Margaret Kay

I'm happy to comment on one thing there. I actually think it's really important that we actually get our patients to re-trust us. So I think they get really frightened and we have to be really proactive with ensuring that patients can trust our system and a system that works for them. So we have some patients who will wait in the car until we call them and they'll come straight into our room and then straight out. We've certainly made sure that they're comfortable with doing that if that's what they want to do. Clearly we've made it look like the place is social distanced when they walk in and they can see that we're making a really big attempt at doing that. We have a space where they can wait outside the door that's actually comfortable as well. So people can choose how they want to be waiting and we really encourage them to come in. When they come in we show them how they are safe, and they get that right from the beginning with our administrative team and our nurses, not just the doctors. So it's not just us lecturing, it's actually demonstrated in everything we do to ensure that they feel safe. I think if we can cultivate that feeling of safety, that message goes back out into the community as well and people know that we're handling things okay. So I'd say that's a really important way of getting people back face-to-face.

Dr Bruce Willett

There's a question about safe work practices during the COVID crisis.
There is material about that on the College website, both on the Queensland Faculty website, there's some workflows there and on the College website. If you google RACGP COVID there's some information about that.
To be honest, it's not particularly prescriptive because it will depend a little bit on the working environment that you're in, but I just like to highlight, Margaret's comments that she's already made. I think you need to make the patients feel safe and the staff feel safe in the way that the practice is set up. If neither of them are safe, the patient's won’t come and that will harm their health because we know that there is almost certainly going to be a major fall out in patient health from not getting proper medical attention in a timely way. So it's really incumbent on us all to make patients feel safe. And of course if we're not making the staff feel safe, then we're increasing the stress on everybody and that's not helpful. So sometimes it's actually more about the feeling of safety, then than what's absolutely necessary. So for instance, in our practice at the height of the concerns - I had staff members going around and disinfecting all surfaces hourly, which was probably overkill, but I think it made everyone feel a lot safer and more happier working there. We've backed off from that now with everyone’s full consent and we’re still doing it four times a day, which everyone's happy about that, given the level of risk. It's as much about people feeling safe then what's actually happening as well.

Dr Margaret Kay 

That's that two way communication, so you start up protocol that seems to be working and then you revisit that protocol. I think that's what we do really well in primary care is we can change flexibly much easier than trying to get a protocol written from up on high in the middle of a hospital and health service that then everyone is struggling with and then they eventually revisit that in a month. We just have that capacity to be flexible and I think we need to maximize our capacity.

I'll just mention the vulnerable doctor. We've actually had a number of people who have actually been extremely vulnerable who have been really distressed, and that's the shame component. Really distressed and guilty as well because they haven't been able to go and be with their patients. So I've actually talked through with a number of, particularly GPs, who have worked out really innovative ways that they've been able to do the work that makes them feel like they're contributing. So, some of them have actually contributed to other services where they've actually provided support for other doctors.

There's a group down in Canberra, who have actually set up their own Doctors for Doctors Service all online. So that's a really interesting outcome for them and they actually found a lot of support with each other because they talked to each other about their struggle. And then they also felt that they were responding really effectively and we’d actually refer some of our patients who need treatment through Telehealth to that particular group. So that's been really an exciting thing for us to have that as a resource, but also they're giving a lot to our community.

Another thing that we found is that some people are actually okay if they don't see any sick patients. So they can just do chronic disease management plans that are actually pre-checked to make sure that everyone's healthy so they're quite happy to do that component of the work. They've actually worked with their colleagues to work out a way that makes that fair for them and for the practice. So again, that takes negotiation and other people have been increasing their strength in being able to deliver psychological support to patients in a way that they haven't perhaps had the time to. They’ve now got the qualifications like level one mental health care. So now they can actually build a different item number for their mental health care that they're giving their patients. It's actually really important for people to work out how you can capitalize on this moment and there are ways to do that. It's really important for us as colleagues who might be working in the practice face-toface to actually allow people to have a conversation two way, to try and work out what's going to work for them. A lot of them have actually been really affected by the reaction of ‘you’re letting us down’ from their colleagues.

Dr Anne Ulcoq

The question is quite interesting. I read a reflection that it's very hard to support doctor’s emotional wellbeing, when their physical wellbeing and obviously financial wellbeing, is also being threatened and that's some of the questions that are coming up tonight. So I’d just encourage everybody listening, to look up the Primary Health Network which has an amazing amount of resources, as does the College website. So many emails come across your desk every day, but you probably have to read your RACGP one and the Primary Health Network one, to get all the information you need, and particularly around the questions that you're asking - how do you keep your practice viable, how do you protect yourself, how do you protect your patients. 

I've personally found that my patients are just coming back in droves. I've done more pap smears and skip checks in the last week or two than I've done in a really long time. Only because my elderly patients are not coming in, so all my younger patients can suddenly get an appointment with me. I just weigh up the risk. Basically our practice are having what we call a ‘green zone’ which is every patient is vetted with a phone call before they come and then vetted again at the front door. If they have a temperature 37.5 or over, a sore throat, a cough they’re not allowed in and have to go back to the car. 

So the idea is that we aren't seeing sick patients, we are seeing patients who have health issues and they can safely come to us and we can meet those health issues. The patients who are unwell with respiratory or fevers are managed by telehealth or they’re triaged to a fever or respiratory clinic. All of our patients had to come in for a flu needle and that was a really good way of them putting their toe in the water and seeing, as Margaret said, that we are a safe place to come. 

An interesting reflection – I was talking to an elderly neighbour who has a really bad shoulder and hasn’t seen the physio in two weeks. She said she didn't see the physio using any hand gel or wiping over any services so I don't know if I should go back. I told her to just ask because she’s probably doing those things as you leave the door but I think this goes to demonstrate this narrative - that it's not enough just to do these things - you have to be seen doing these things. Your patients trust you, they trust us infinitely and as long as we continue to do the right thing, they will return to the practices to see you. This aberration where we've seen a big drop off numbers – they won’t be sustained. People ultimately have health issues they want to deal with. A lot of them are at home at the moment, thinking about those things they haven’t got checked. I think it’s going to get better.

Dr Margaret Kay

Regarding the anonymous question - there's actually a link on our website with some training on how to be a doctor for a doctor which goes through four bits. It goes through how to look after your own self as far as self-care goes. How to actually access care and understanding how doctors access care or don't. Understanding what it's like to be a doctor patient and understand how to be a treating doctor. 

It's a four part module which takes two hours (you can stop start the module at any time) and you get a little certificate at the end that you can actually write up to submit if you want points. That's something that a lot of doctors are starting to do and we're hoping that more doctors in all sorts of areas - up and down the coast and even out west - so that people are better trained at being a doctor for a doctor because frankly the medical board tells us we all need to have a GP. So obviously, all of us GPs will be seeing doctor patients. We need to be able to do this as part of our skill set. So we need to focus on this. It's really important that we do this, and we all need to find the right doctor for ourselves because the doctor that I go to is not necessarily the same doctor that you'll go to. We all need to find the right person.

Dr Anne Ulcoq

If you can't find somebody via our website, you should find a GP like you would find your hairdresser. Ask your friend, husband, neighbour who they go to. Our website has a listed of doctors there, but it's really for people who have exhausted, those normal avenues. So we encourage you to go on recommendations.

Dr Margaret Kay

The website is the Doctor’s Health Advisory Service Queensland: www.DHASQ.org.au. We're just setting up the education page so there will be a link directly to the webinar education that you can do self-paced it your own time. It's a really high quality one that's been done with the Australasian Doctors Health Network.

Dr Bruce Willett

To address something that was perhaps unsaid in that question, there's an implication that unless you're declaring that you're willing to see other doctors as patients, that you're not. Whereas my expectation is that the overwhelming majority of GPs are willing to see other doctors as patients and I think it's reasonable to assume that you need to find a GP that seems right for you.

I guess I must confess that before I went and saw my GP, I did put in a phone call and warn them that I was a GP and checked that was okay and to ring me back if it wasn't - as a precaution. I think really just choose a GP like everyone else.

Dr Margaret Kay

That's a really good thing to do is to just let people know you’re a GP. There's a lot of doctors who are so concerned they're not going to get treated normally, that they say that they’re admin. Eventually, you can’t actually have a conversation in the way you want to have a conversation if you’re not declaring yourself as a medical person so just be upfront about it. Have a conversation as to whether or not that person's comfortable about it and ultimately we will find the right person for ourselves - and it is an individual thing.

Dr Anne Ulcoq

You really want to find a GP you’re comfortable with, not when you need your GP. So it’s good to go to a GP for your annual bloods and check-up as a way to actually be comfortable in a nonthreatening way and establish some sort of relationship. So the time to find a GP is during preventative health.  

Dr Bruce Willett

I might wrap up questions there. I’d like to thank Dr Margaret and Dr Anne and I'm also really grateful for the collaboration with RACGP and the Doctors Health Advisory Service and, thank you for all the great work that you do and have done for a long time.

Thank you so much everybody for joining us tonight.
 

Other RACGP online events

Originally recorded:

12 May 2020

Facilitated by Dr Bruce Willett, Chair RACGP Queensland, and presented by Queensland Doctors’ Health Programme (QDHP), this session focused on doctors’ wellbeing during the COVID-19 pandemic and beyond. 

The QDHP is an organisation developed by doctors, led by doctors, that was established as the service arm of the Doctors’ Health Advisory Service Qld (DHASQ). QDHP is dedicated to improving the health and wellbeing of doctors and medical students in Queensland.

Facilitator

Dr Bruce Willett
Chair RACGP Queensland

Presenters

Dr Margaret Kay

Dr Anne Ulcoq

© 2021 The Royal Australian College of General Practitioners (RACGP) ABN 34 000 223 807