Why are you here and not somewhere else?

This is a piece of installation art by Jeppe Heine, which lives in the Booth School of Business at the University of Chicago. To me it asks the question of what is important and why does it matter. It is just the right question to bring together what I’ve been thinking about over the last week at Tharawal:

• Why am I here?
• Now that I’m here what am I trying to achieve?
• Why do patients come here?

In this post I’ll deal with the first question and then move on to the others I love going to work – wherever that work might be. Tharawal like some, but not all, of the places I have worked has a great vibe – that quality that is difficult to quantify, takes many forms but you know it when you see it. At Tharawal it stems from individual and community ownership of the work – this is the reason for Aboriginal Community Controlled Health Organisations.

And that ownership means services exist that actually benefit our patients. Trying to find useful services (outside of your own area of practice expertise) is often one of the banes of trying to deliver good healthcare. Tharawal is a magnet for great clinicians and members of the community. That, in turn, engenders a degree of drive amongst the whole team to deliver better care.  The practice escapes from the notion of individuality and that each person is trying to achieve something on their own. 

And I’m now a part of that team.

The best experiences of my training have been where this kind of team exists.  You can’t quite know this is going to be the case when you pick a practice.  But sometimes there are inklings. Now that I’m here the concept of ‘fit’ comes into play.  I’m still new to the place but the first steps have been promising. There are projects with Tim, ideas for improving current programs, outlets for my own teaching interests and a challenging clinical environment.

So I’ve lucked into a great job and now is the chance for me (and Tim) to make something of it. This week has involved the first draft of a conference abstract to both talk about the conception of supertwision and also to give us an idea of where we are going. Doing that is giving me a better understanding of what I am trying to achieve while at Tharawal – the subject of the next post.

The start of something...

When Tim Senior and I started together, it was with a degree of excitement that has continued to mark our relationship in the practice. It was a Tuesday afternoon, my first in the practice, and Tim was letting me in on his plans for #supertwision. In the intervening weeks the plans have grown and become better informed as we both come up with ideas about how to engage with social media with general practice in the context of indigenous health.

 

Across the first weeks in the practice (as I slowly put together this post) I reflected on what my perspectives are about the delivery of healthcare. The basic determinants of health have been a sideline in the previous parts of my career looking after people in a tertiary teaching hospital. The ideas of wellbeing including personal freedoms, good social relations AND physical health are the cornerstone of indigenous health. Wellbeing considers a more holistic view of health which is in keeping with the concept that:

 

“There is no word in Aboriginal languages for health.”

Prof Judy Atkinson

 

It is becoming clearer, from the first few weeks and Tim’s pearls, that a ‘traditional’ view of the general practice consults won’t reach through to encompass true wellbeing. Trying to find a consult style that works will be a big part of what I blog about over the next 6 months.

 

This is my first exposure to general practice in an Aboriginal Medical Service and also my GPT1 term (my first term as a trainee on the Australian General Practice Training Program). So even understanding general practice in the healthcare system is a little alien to me. The practice room is now starting to feel like my own and a place for expression for the people who come in.

 

My postgraduate career has been a bit of a mixed bag; working for the military, having clinical interests in maternal & child health and mental health, working my way through a Masters in Public Health and taking a stint away from clinical practice to be an advocate for the health profession. But maybe it’s the kind of mixed bag that will make for a successful and enjoyable journey in indigenous health, you can watch my progress and tell us what you think.

 

Follow our journey here at the blog, with the #supertwision hashtag and with each of our accounts (@timsenior and @michaelbonning) where we both post on things in healthcare and beyond that interest us.

 

What should new GPs read?

There are many doctors around Australia who have just started their higher professional training to become a GP, the most effective of medical specialists. The learning curve from hospital to primary care is often steep. People can present with anything, everything and nothing, the medical is intertwined with the social, cultural, economic and political, and working out what to do can be quite unclear. All of this happens in a room with a closed door and no one else around, unlike in the hospital wards, which are far from private. It's testament to the quality of doctors choosing to do GP training and the quality of GPs doing the training that so many do so well.

So, with this in mind, and now a couple of weeks in, it's worth thinking about what would be ideal introductory reading for a new GP?

I received a few very interesting suggestions on Twitter.

@timsenior diving bell and the butterfly
— madhu singh MD (@thinkalot) January 30, 2013

@timsenior The Other Side by @grangerkate so that they realise how small actions can have a big impact
— Elin Roddy (@elinlowri) January 30, 2013

@grangerkate @timsenior Yep! It's not a rant - it's a really good book! I also love Intelligent Kindness by Ballard and Campling.
— Elin Roddy (@elinlowri) January 30, 2013

@timsenior @atul_gawande 's Better. Improving health care from both patient and systems perspectives.
— Melanie Thompson (@dr_mel_thompson) January 30, 2013

@timsenior Advice on learning how to access and use social media eg mashable.com/social-media/ Why-this is the future wrt information streaming.
— Deborah Verran (@VerranDeborah) January 30, 2013

 It's interesting that when people want to recommend reading to produce good GPs, they don't go for writing about diseases, they go for writing about understanding humans in difficult circumstances, often serious illness.

(The obvious exception is Deborah Verran's suggestion. Will the use of social media be so crucial that we all need to know it? Is it comparable with, say, skills like minor surgery, breaking bad news or clinical audit - whether we like it or not we are just going to have to do it? I'd love to hear your thoughts on this - comment below or tweet on the #supertwision hashtag)

What would I suggest? Here would be my top 3 suggested readings. Of course, I might change my mind, but these are today's thoughts. And, somewhat to my suprise, this is all core general practice literature. But all three have changed my practice for the better.

3. General Practice by Prof John Murtagh
What Australian GP could go without Murtagh? Just about every GP I know has one close at hand. Though the clinical chapters are excellent, the safe diagnostic strategy outlined in the early part of the book is gold for any GP at any stage in their career.

2. The Doctor, his patient and the illness by Michael Balint
Excuse the inappropriate gender specific pronoun here. This book was published in 1957, and is arguably the best book on general practice ever written. This was the book that moved general practice away from a purely biomedical paradigm and made the profession take an interest in the dynamics of what was happening when a doctor and a patient meet in a room. There's been a lot of other work done on this since then, but Balint is still a cracking read, full of mind-expanding insight. You can get a taste of the ideas here. ("the most frequently used drug in general practice was the doctor himself”). Don't rely just on this summary - do read the book. And don't worry if you're not sure about the group methodology - the insights are still valuable.

1. The Mystery of General Practice by Iona Heath
This is the best, and most beautifully written, description of general practice I have come across. It's a must-read for anyone interested in what your family doctor does. It's short (easily the shortest of these threee recommendations) and you can download it for free at the link above. You might start reading and worry about the relevance of commentary on 18 year old health reforms in another country. But don't worry. It's highly relevant still, and the description of the role of a GP in a community and in reducing health inequalities will make you proud of your chosen profession.

Those are my top 3 picks. I'd love to hear your suggestions, either tweeted on the #supertwision hashtag, or posted as comments here. And if you don't post your suggestions, Michael Bonning will have to read what I suggest. Is that really fair?

Supertwision! Join a new experiment in social media and medical education

This week Dr Michael Bonning and I started working together in our Aboriginal Community Controlled Health Service as supervisor and GP registrar. Over the next 6 months we will work closely together to learn about working as a GP, particularly in an Aboriginal Health setting. I say we, because, though technically I am the supervisor and Michael is the learner, I will learn just as much as he will. Most GPs I know involved in teaching would say the same.

Over the next 6 months, we will cover the medical conditions often seen in general practice, we will learn safe approaches to any and all combinations of symptoms that people might have. We will learn about the crucial nature of communication and interaction the consultation and how to do this effectively. We will learn about listening and giving voice to people who often aren't heard in a complex medical system.

However, that's just my perspective. And given that both I and Michael are interested in the use of social media in medicine and medical education, this is a wonderful opportunity for an experiment. Over the next 6 months we will ask questions, link to documents and resources and invite discussion about being a better GP, particularly in the context of an Aboriginal community, and most likely other communities traditionally underserved. We would invite anyone interested in  the subjects discussed to join in and contribute. We only have 2 perspectives, and you will have others. You'll be aware of guidance and discussion we've not come across, perspectives new to us. I would imagine that GPs, patients, Aboriginal and Torres Strait Islander people, communities and organisations, educationalists, other medical specialists, other professionas allied to medicine would all have something to contribute to our discussion.

The other purpose is to lift the lid on what doctors do, especially GPs. Is it just about diagnosing? How do we think about doing the work better? Where do we go to learn new things? What disciplines are relevant? I hope that seeing GP apprenticeship happen in real time will enable people to see the complexity of what their doctors are doing, and enable them to have more productive conversations with their doctor.

It's worth pointing out what Supertwision won't be doing. We won't be idientifying any patients we see, or discussing the service we work in in any more than generalities. We won't be providing any medical advice on Twitter or on this blog. And do not think for one moment that what you see on Twitter or on the blog is all the teaching that is occurring. We are meeting regularly in practice and talking by phone and e-mail and you won't be party to any of that conversation. We will be involving our practice nurses, Aboriginal Health Workers other professionals and, yes, patients. To mobilise an old metaphor, what you see will be the tip of the iceberg.

So. Here we go. I hope this is a go at seeing a real innovative use of social media in health care, particularly in medical education. It may all go horribly wrong, but at the moment I'm optimistic and think we have something that many will find very interesting. You can join the conversation by following myself (@timsenior) and Michael (@michaelbonning) on Twitter and following the #supertwision hashtag. We'll be posting more long-form thinking on this blog, and would love to hear your comments and suggestions.

Cultural Educators and Medical Educators at the GPET Convention

Here I am at the GPET Convention in Melbourne, and day one was of of many satellite meetings taking place, though this was the most important one as it is backed by 60,000 years of indigenous wisdom. The Cultural Educators and Medical Educators are a group of Aboriginal and Torres Strait Islander people and GPs involved in GP training at the junior doctor and registrar level. They work for Regional Training Providers (the organisations contracted to provide GP vocational training) and Aboriginal Community Controlled Health Services, with a smattering (like me - though I used to work for an RTP) from other organisations. The cultural educators and mentors met yesterday, too.

So, some thoughts on the day? It's always a pretty inspirational group of people, who are very committed to teaching high quality primary care led by Aboriginal communities. This group really gets this now - the message has to get out wider. Those who are not really interested in this message are those who need to hear it the most!

There was a lot of very good conversation, and some new ways of presenting some familiar information.

We heard about the launch of the brochure Registrars - Journey of healing to encourage registrars to consider a training post in Aboriginal health.

We heard about the tender AGPT put out for a project to look at developing the capacity of RTPs to be able to offer cultural education and mentoring, which will be carried out by a team led by Prof Jenny Reath at University of Western Sydney, with experienced cultural educators from WEstern Sydney, Queensland and the NT.

We heard about cultural safety from Richard Frankland (yes, that Richard Frankland!) with a good demonstration of the "cultural load" often carried by Aboriginal people, as someone was given more and more stuff to carry without dropping. He presented some familiar cultural concepts in a new way, which is always useful.

And we had some reflections on teaching in Aboriginal Health from Dr Mary Belfrage, Medical Director at Victorian Aboriginal Health Service. She gave a thoughtful talk, articulating some of the important concepts that we need to get across to do Aboriginal health well. I use the word articulate deliberately, as we often know these things without being able to find the right words to describe it. And when we use the wrong words, we smuggle in assumptions and attitudes that may be unhelpful.

Let's pick out some of the examples I found most striking. In thinking about the concept of families in Aboriginal communities, she described a conversation she'd had with someone who had asked people to name everyone they considered family. Aboriginal people named 800 to 1000. An alternative conception was to ask how many people would kiss your baby each day - 30 to 50. The high numbers were striking, which tell us about the extended range of caring and responsibility in Aboriginal communities. Also striking was her nuanced conception of cultural safety - both of the variety within Aboriginal cultures and in individuals expressions of that, and in the subtle exploration of difference, for example in the area of privacy and confidentiality, where listening and negotiation makes for a more effective alternative to either an individualistic secrecy or an everything goes openess, neither of which is appropriate.

There was also an appreciation of good GP skills - some of what we think of as good practice in Aboriginal health, is actually just what GPs everywhere should be doing. We should know how to develop trust. We should be kind - not soppy, not promoting dependency, but having regard to people's experience, their discomfort. We should understand how services are received by the user.

Most pertinently for me, because this is also the way my thoughts have been moving too, is the idea that "there are no Aboriginal diseases." She gave a great example of the idea of Aboriginality as a non-modifiable risk factor in renal disease. This sounds reasonable in doctor speak - we speak like this about all sorts of risk factors. But what we are saying is that being Aboriginal is the problem. But being Aboriginal is a wrap-up of all sorts of other risk factors - socioeconomic, colonisation, disposession - which have an impact. Fortunately, the risk factor was changed. I think this is a reallt important idea, and I'll blog more about this in the future. I'm glad that this sort of discussion is beinf heard more and more.

If you want to read some more of Dr Belfrage, this MJA article is a good read.

So, lots of food for thought from today, and the conference hasn't evedn started properly yet!

You can find the program, abstracts and speaker bios here, and follow all the action on twitter #GPET12 - it looks like being quite active!