Monday, April 22, 2013

What does a registrar bring to a practice?

So would been quite a while since I had the opportunity to make a supertwision post.

My last post had foreshadowed a discussion about what I bring to the practice. Tharawal has been a hive of activity since I last posted and mainly in relation to three topics:

         1.While Tharawal is particularly good at looking after chronic disease patients all too often that care is fragmented and we do not access the appropriate funded models of care. One of the things that I have been working on is about making chronic disease a simpler entity to manage within our practice. This means utilising a number of the indigenous chronic disease item numbers more effectively and also returning chronic disease to being a multidisciplinary care because at the moment's much of it is done in isolation with individual practitioners; nursing, allied health and medical all taking on separate responsibilities.

While this isn't a definitively clinical action for a new registrar it certainly is something that I'm interested in my past experience with health systems and also with health policy. The work is taking a couple of days to streamline our approach accessing appropriate item numbers and educating our practice as to how to co-ordinate care.

I was lucky enough to sit down with the Menzies School of Health Research and go through their analysis of the Indigenous Chronic Disease Package over the last two years. Campbelltown was a sentinel site for the evaluation of the project and so there has been quantitative and qualitative review of the implementation and uptake. Better chronic disease management starts with evidence.

Over the last few weeks, I have been working with our nursing staff and allied health providers as well as setting up specialist pathways to ensure that team care arrangements and chronic disease management plans.

One of the highlight programs at Tharawal is Djurali, which focuses on exercise and nutrition, using both practical and behavioural change approaches. This kind of long-term intervention is exactly what GPs often do not do well. The acute needs of patients are what take the majority of our time. This model of presenting to the doctor is also how we have educated our patients and means we are always treating illness rather than promoting better health.

For much of the new work that I'm looking at I'm trying to take a step back and take the advice of the experts in chronic disease: our nurses, Aboriginal health workers and allied health staff. From that we can look at where we each member of a multi-disciplinary team can best ‘value-add’ to the process and optimize our scarcest resource: time. Over the next few months it is my plan to develop a business case for a chronic disease nurse to manage a better system of regular proactive appointments with our chronic disease patients. What we are seeking is more active engagement with patients on their terms, where we try to recognise, understand and overcome the barriers to good chronic disease management.

           2.My second project has also been in the space of chronic disease management. Our greatest weapon in fighting chronic disease is knowledge and data. Learning about our computer systems at Tharawal it is apparent, especially in discussion with Tim, that at times this system hampers us from correctly identifying patients for interventions. One of the very small projects I have taken on is to place a single clinical item descriptor that is common to everyone with any chronic disease in our system. This means that finding those patients with chronic disease is significantly simpler for secondary prevention interventions. While it is a small thing, making sure that individuals do not fall through the cracks when it comes to being recognised as someone with a chronic disease is exceptionally important.

           3.The final area I have been working in is a much smaller, time-limited projects which is to show how larger-scale interaction with our community works. As part of the influenza vaccination programme for 2013 I asked that we identify all patients in our practice over the age of 55 as a group, to proactively target those who should be receiving the flu vaccine.

My plans are for a single afternoon of vaccinations with a number of staff members supporting the activity. It is turning out to take a little bit longer than I thought it would. Both reaching and convincing patients to come into the practice for this vaccination campaign would not have been possible without one of our aboriginal health workers, who is incredibly respected within the community. The vaccination afternoon is coming up quickly and we’ll share how it goes and that which does and doesn’t work on the blog soon.

It is becoming apparent that more than anything else I bring some more energy, an extra set of hands and importantly a new set of eyes. Taking on new projects or recognising that business as usual is good but could be improved is one of the greatest reasons to have a registrar in your practice. The inputs of supervisor’s time are a small investment to create long-term gains.

I wrote recently for Medical Observer regarding the matchmaking by registrars applying to general practices. It is all about fit and determining what you bring to the practice, if there are other registrars who are reading this blog remember that what you bring is often new perspective on old problems.

In other news, we are soon to be joined by Kate Bowman @kate_bowman, a medical student from Manchester in the United Kingdom who will be working with us for four weeks as part of an overseas elective. We are delighted to have her on board and look forward to her perspective.