Is the medical conference dead?

Just got back from Fremantle and the #RMA2012 Rural Medicine Australia conference hosted by ACRRM and RDAA. To be honest I was disappointed. Some pearls amongst the three day academic programme. But perhaps recent exposure to high-quality asynchronous #FOAMed learning has raised my expectations.

That said attendance was high at over 450 delegates and it was great to hear fellow South Australian doctors Martin & Fiona Altman of Murray Bridge, SA get the ‘rural doctor of the year’ award.

 

Enjoying PubMed in Fremantle

 

However a conference shouldn’t be just about the venue or the quantity of attendees – for my money I want quality medical education and networking.

So in no particular order, here are some thoughts…

1/ not enough hands on skills sessions for frontline rural doctors, too much on training pathways and RTPs etc

A real bugbear of mine. As isolated rural docs we may struggle to engage in high quality education events. It makes sense to host them at the annual Rural Medicine conference.

On offer before the academic conference were the two-day REST course and one day sessions on burns, obstetrics and ultrasound (the latter hosted by Broome Docs author and blog-o-sphere #FOAMed guru Dr Casey Parker). Casey has posted his thoughts on ‘courses for horses’ this week – have a read of his thoughts and the comments.  Add your own, please…

Whether the College will pick up on this is anyone’s guess.

There was also a hands on demo in mucosal atomisation techniques from Tim Wolfe, ED doc and innovator, who was also over for the Australian Trauma Society do in Perth. A really useful technique for rural docs (as well as retrievalists and EM docs) – but old hat to those of us swimming in the soup of #FOAMed. Better than nowt though. More info at http://www.intranasal.net

2/ turgid education sessions, mostly delivered to large lecture theatres

A conference should be about dynamism and rapid turnover of ideas, preferably in small groups – which in turn engenders breakout discussion in breaks, over meals & outside the confines of the lecture hall.

Maybe I signed up to the wrong events, but a whole day session on telehealth? C’mon, it’s not that complicated – an iPad, Skype and a robust referral pathway is all that is needed. OK, perhaps that’s oversimplification, but this session would have benefitted from more hands on, not repeated talks of existing telehealth examples and pilot studies. I lasted about an hour then drifted in/out. Similar reports from other attendees.

Shame as telehealth and social media will revolutionise medicine, especially for the rural doc. Better to offer small group sessions repeatedly throughout the event to maximise coverage. Same for other sessions, which seemed more weighted to the medical educationalista than the frontline rural doctor.

There were a few more sessions on dermatology, parallel consulting with medical students, Nextplanon and Mirena insertion etc…but sadly all held on the last day when most delegates had to check out and catch flights back to East Coast fairly early, thus cutting short these potentially valuable sessions. Bah!

I was of course excited to present my data on difficult airways and rural docs – although to be honest this would be far better and more valuable as hands on workshop aimed at anyone who is an ‘occasional intubator’. Thankfully there’s a wealth of resources out there, including Minh le Cong’s excellent online airway training at www.prehospitalmed.com. I did run an impromtu airway workshop for interested docs over a PubMed session in the hotel bar…you can download more from the ‘resources’ and ‘videos’ sections on this site.

I have reflected that using FOAMed I could’ve presented this data back in March…getting the paper published in October and presenting two weeks later was just by chance. But next time I;ll get message out sooner using #FOAMed.

Unfortunately the paper presentations were run in 4 separate venues, with erratic timekeeping making it difficult to move between concurrent sessions. I was a bit gutted to miss Dave Townsend’s talk on SoMe in medicine, but true to form he’s bunged his slides up on the interweb for all to see at http://www.davidtownsend.com.au/blog/articles/rma2012-social-media-resources/

3/ Failure to embrace #FOAMed and the power of the interweb

Well, Joe Lex put’s this better than I ever will :

If you want to know how we practiced medicine 5 years ago – read a textbook
If you want to know how we practiced medicine 2 years ago – read a journal
If you want to know how we practice medicine now – go to a (good) conference
If you want to know how we will practice medicine in the future – use FOAM

FOAM of course being Free Open Access Medical education as exemplified by medical bloggers such as http://www.lifeinthefastlane.com, www.BroomeDocs.com and ww.prehospitalmed.com etc

Gerry Considine @ruralflyingdoc summed it all up in a cheeky manner, just in a single Tweet

“if you want to know how we practiced medicine last century, ask a rural doctor”

Perhaps a that was a little harsh – rural docs aren’t deliberately obtuse. But the systems we work in are slow to adapt.

Examples abound – my airway survey showed that few rural docs have access to the same up-to-date kit as their city specialist colleagues. Of course cost and caseload constraints factor in this, but to hear rural docs having to practice without a minimum standard of equipment is of concern.

Similarly access to bedside ultrasound is constrained – resources like the newly launched iBook (Introduction to Bedside Ultrasound) will help improve training. The cost of a decent USS machine may seem prohibitive, it will pay for itself if it means avoiding a costly transfer out of Dingo Creek to tertiary centre.

Finally, sitting in the medicopolitics session, one of the founding fathers of RDAA commented to me that ‘nothing has changed’ in 25 years of such debates. Sobering stuff, more so when the politicians are talking about linking pay to performance – despite the clear concerns elsewhere about such systems.

If you haven’t already read it, see Dr Clare Gerada’s address to the GPs at RACGP conference last week – key points about problems inherent in the overzealous measuring, medicalisation and marketisation which have destroyed UK medicine.  This does not bode well for us in Australia – read Dr Gerada’s thoughts at http://tinyurl.com/GeradaSpeech

SoMe has the potential to link doctors concerned with such events – we’re seeing this with the #interncrisis campaign which has snowballed in past few days to maximise media exposure.

As isolated rural doctors, using these resources could help us do two main things

(i) speak with a common voice on medico-political matters

and

(ii) vastly raise the bar in ongoing medical education and the delivery of ‘quality care, out there’ – not through the turgid medium of conferences, papers and ALS courses, but through evolving, dynamic, cutting-edge media bringing evidence-based practice to rural docs and their patients.

So, what for the future?

Despite my gripes about medical conferences, I am going to attend #SMACC2013 www.smacc.net.au next year. Although a critical care conference, there are valuable lessons applicable to my workplace in rural emergency medicine. Besides, casey Parker @BroomeDocs owes me a beer.

I’m also going to focus more on the maxim of delivering ‘quality care, out there’.

From 2013 I’ll move try and focus http://www.ki-docs.com towards more hypothetical case discussions – not so much though on ins/outs of EBM (www.broomedocs.com does that well) – but explore concepts such as situational awareness, logistics over strategy, audit and other topics to help “get things done” to aid the rural doctor improve his/her practice.

“Quality care, out there” – the future is #FOAMed

Zen & the Art of ED Management

There has been a lot of discussion this week regarding pressure on the Emergency Department at Flinders Medical Centre in South Australia.

Rack ’em and stack ’em!

I have a ‘soft spot’ for Flinders. I worked there as a junior resident and then registrar in the late 90s/early naughties and like to think that I learned a bit. The Consultant staff were excellent and engaged in training. The nursing staff were fantastic. And the work was great fun – I certainly enjoyed the immediacy of emergency/critical care but was seduced away to rural medicine by the lifestyle advantages and variety that this work offered. More importantly, the one thing that affected my decision not to complete training in ED/ICU was the lack of control over factors in my work (some might say that dealing with Country Health SA is similar, and you would be right, but more of that in another post).

The big issue for the ED is ‘access block’ – the inability to efficiently deal with emergency patients because there are insufficient beds in the ED..because there are patients waiting for beds ‘upstairs’ ie: in medical and surgical wards. And why are there no beds? Because the medical and surgical wards are either run at 100% capacity leaving no room for ‘surge capacity’…and/or that medical beds may be clogged with patients awaiting discharge to home, nursing home or country hospital.

Because there is no slack in the system, the clogging of ward beds filters back to the ED causing access block. And when the ED is full, the unhappy situation arises when ambulances cannot handover their patients because the ED is full and ambulances are ‘ramped’(literally wait on the ramp outside the ED). And tying up ambulances waiting outside EDs means there are not enough ambulances to deal with emergencies in the community.

Ramping has been a common phenomenon at Flinders Medical Centre in the past few weeks. Last Friday I was at an EMST course at Flinders and heard that the Director of ED, Dr Di King had resigned after being called into the CEOs office and asked to guarantee that ramping would not occur.  Of course this is impossible – Dr King has no more control over this than anyone else – the solution lies with the CEO and Minister of Health, not the ED Director. And so Di resigned, putting more pressure on a beleaguered Health Minister.

Yesterday Dr Dave Teubner came out and said it was safer for people to remain in an ambulance than to be seen in the ED. Dave is a passionate ED doc…he is not some hopeless academic, but a chap who really gives a damn. He is of course correct – it is better for people to be at least in an ambulance with oxygen, suction and a paramedic than lost in a corridor in the ED, unobserved and awaiting assessment or treatment with access to neither.

In essence, the whole idea of a well run health service should be to ensure that care is escalated with every referral. It is frankly dangerous to have care take a step downwards from ambulance to ED, as is the case at FMC when under bed pressure.

This is a concept that is a particular hobby horse of mine – the idea of ensuring there is never a ‘therapeutic vacuum’ or ‘inertia of care’. Every single thing we do should improve patient care, not stall it or even detract from it.

Certainly people admitted to an ED should see an increase in the level of care delivered to them. And so on…every single doctor, nurse, paramedic is doing his or her utmost to make this happen.

But the system seems to conspire against us.

And of course this is not just about ramping in the ED. It also applies to rural medicine, to the operating theatre, to in-patient care and to discharge.

Like many people working in health, I get hot-under-the-collar bemoaning failures in ‘the system’ where things could (and should) be better. Particular bugbears include 

• lack of equipment to manage a difficult airway in rural EDs and theatres
• lack of ownership of equipment and emergency training for rural staff
• cost-shifting between State and Commonwealth coffers for ED patients
• lack of discharge summaries from people who have been admitted and discharged from metro hospitals

…and so on.

What can we do to improve things?

Well, political pressure is one – I would imagine that Dr Di King’s resignation has served to highlight the issue locally and perhaps prod the Health Minister into action. 

More so, we can engage and try to make things better. I’ve been revitalised in the past few months by some of the information coming through the blog-o-sphere, with concepts of relevance to my practice that one is not going to get from a textbook or clinical placement. So I’ve done a survey on difficult airway equipment for rural GP-anaesthetists. I’ve offered to run some small group scenario-based sessions for nursing staff at the end of each of my anaesthetic lists and whenever I am on call for A&E. And I’ve been developing a web-based repository of emergency training for local use…how to set up the oxylog, where to find and use the rapid rhino kit for dealing with an epistaxis, a dump mat for RSI etc.

Another new idea is borrowed from the UK – a ‘one minute wonder’ fortnightly update on topics of relevance for our multiskilled rural nursing staff – basically a single A4 poster explaining how to find/set up/use a piece of ED equipment – displayed on the wall above the iStat machine to give people something to read whilst waiting for the iStat or Troponin reader to do it’s stuff.

Small things, but they might make emergency management in the bush easier.

Of course, the astute reader would wonder why these initiatives are not flowing ‘top down’. It would seem intuitive to have a minimum standard of airway equipment in rural hospitals, to have standardised ED kit and protocols, to train staff in equipment use beyond the token annual ALS refresher.

But this doesn’t happen. Change takes time, there needs to be initiative and drive, and solutions need to be appropriate to the local situation.

Anyone else got any pointers to drive change and improve emergency management in rural areas?

Obfuscation & the ‘Blame Game’

Well, I was not expecting that the letter in my last post would be referred to in ‘The Weekend Australian‘ in follow-up to a previous report. Thanks to Dr Scott Lewis of Wudinna for telling me.

Oh dear.

There seems to be confusion about the issue of ED patients being charged fees in rural SA hospitals. It’s something that has been an issue locally every since I have been on Kangaroo Island, and my colleagues tell me has been going longer still. I refer to the fact that patients presenting with serious problems (examples might include assessment after a car crash, a suspected fracture/dislocation, a forensic medical exam after sexual assault, repair of a complex laceration) are forced to pay the attending doctor, whilst they would receive the same service for free in a metro ED or interstate.

This is counter to the Australian Healthcare Agreement and the letter which is referred to in the Weekend Australian support this. The practice has been longstanding in South Australia, and I reckon arises over confusion over what is an emergency and what is a GP-type service.

The Australian college of Emergency Medicine have recently issued a media release that dispels the myth of triage 4/5 patients being ‘GP-type’ attendances, and highlights concern for such cost-shifting between State and Federal coffers.

Me? I am just fed up having to charge people for conditions that are more serious than your usual GP attendance, more so when they have been referred to the ED by another GP or a GP after hours service like HealthDirect. Don;t get me wrong, I am happy to charge privately for my services when it is appropriate – but charging a mental health patient, a rape victim or a car crash victim several hundred dollars just seems wrong. Much better to be paid by the Health Department, after all the doctor is attending in his/her role on the on call A&E roster, not as a private arrangement.

Today I received an email from the Rural Doctors Association of South Australia, which appears to cling to paragraph G21 of the Australian Healthcare Agreement, which allows for medicare billing in the specific circumstance of “eligible patients may obtain non-admitted patient services as private patients where they request treatment by their own GP, either as part of continuing care or by prior arrangement with the doctor” (my emphasis underlined).

The RDASA email states:

There has been a lot of email traffic and concern from you about the article appearing in the Australian over the weekend inferring that charging patients for after-hours services in publicly funded hospitals was contravening the National Health Care reform document. 

Please be assured that the RDASA Executive have taken immediate action on this issue, writing to Minister John Hill referring him to section G.19 of that Agreement and the assurances from CHSA that the current arrangements are acceptable to the Federal government. We have sought written confirmation that:

·         Doctors can bill Medicare for triage level 4 and 5 after-hours consultations that occur at public country hospital facilities

·         Doctors will not have to pay back any money to Medicare for money already collected

Maybe I am being thick, but it seems unfair to use clause G21 to then slug rural patients for services that would receive for free in a metropolitan ED or interstate.

RDASA seem curiously quiet on this issue of equity and I fear that this approach may be regarded as more about preserving doctor’s incomes than in equity for their patients. Given that many of these patients are genuinely in crisis or not-medicare compensable (particularly in a tourist location like Kangaroo Island), I would much prefer to be paid by the Hospital for my services rather than bulk bill or chase bad debts. After all, the Hospital called me as the A&E doctor for the hospital, not the patient as part of a prior arrangement or agreed private service.

Anyway, here’s my letter to the RDAA on this issue. It will be interesting to see what eventuates.

Comments, as always, welcome.

Paul Mara

President

Rural Doctors Association of Australia

10 May 2012

Dear RDAA

You may be aware of the recent ‘Weekend Australian’ article regarding billing of public patients attending public emergency departments in South Australia (http://www.theaustralian.com.au/national-affairs/state-politics/warning-for-states-on-hospital-charges/story-e6frgczx-1226347278031). Last month I received a letter from Minister Plibersek’s office (attached) which supported my concerns regarding the practice of charging public patients in public EDs for non-admitted services. This letter was posted on my blog site and subsequently referred to by The Weekend Australian without my knowledge. 

I have been seeking clarification on this matter since 2007 from the South Australian Health Department, as there exists significant potential for cost-shifting from State to Federal Health budgets. Specifically, patients who attend the Emergency Department are annoyed at having to pay fees for non-admitted attendances in rural areas.

I should clarify that these fees are being charged not just for GP-type attendances, but for ED attendances that require the resources of a hospital and can chew up considerable time for assessment and treatment. Many of these patients have been referred to a rural ED by GP-after hours services such as HealthDirect, and are not typical of GP attendances in metropolitan areas. Examples might include the assessment of car crash victims after a rollover, forensic medical examination after sexual assault; urgent mental health assessment of patient brought in by Police; the assessment, X-ray, manipulation under anaesthetic and plastering of fracture/dislocation; repair of complex laceration etc. These are services that Country Health SA has in the past deemed ineligible for admission and hence cost-shifted to Medicare by refusing to remunerate doctors on the A&E roster.

On questioning this in the past, South Australian doctors have been directed to clause G21 of the Healthcare Agreement which states:

“in those hospitals that rely on GPs for the provision of medical services…eligible patients may obtain non-admitted patient services as private patients where they request treatment by their own GP, either as part of continuing care or by prior arrangement with the doctor”

The most recent (indeed, only) contract between rural doctors in SA with Country Health SA goes further, to state :

“after hours GP services and non-admitted emergency services are provided under the Medicare system (ie the patient is charged by the medical practitioner and seeks reimbursement from medicare). For the avoidance of doubt, Country Health SA shall not be liable to pay any fee for such services”

This statement in our contract neatly ties both emergency attendances and after hours GP services under the same umbrella, ie: to be charged to Medicare. This is at odds with legislation.

I understand the RDASA has recently written to the RDAA on this matter. From the email to SA members, the issue has been obfuscated by confusing triage 4/5 patients with GP-type attendances, an assertion that is not reflected in either the National Healthcare Agreements or current contracts in SA. Indeed, the Australian College of Emergency Medicine gave recently issued a media release on this very issue, dispelling the myth that “ED triage 4 or 5 patients = GP attendance” and highlighting the concern for State to Federal cost-shifting by such ploys (see http://www.acem.org.au/media/media_releases/GP_Patients_ED_attendances.pdf).

I am concerned that this issue disadvantages rural Australians In SA who may defer ED attendance for potentially serious conditions due to fear of fees. I am concerned that the SA Health Department is promulgating an interpretation of the Australian Healthcare Agreement which is at variance with other States and which both Medicare and the Federal Health Minister’s office have told me is not allowable. I am concerned that genuine GP after hours or private arrangements (where I am more than happy to charge a private fee) are being used as a cover to defray State health costs.  For the record, can I ask for your assistance to clarify with the Health Minister and RDASA:

1. that the Australian Healthcare Agreement states that eligible public patients are entitled to free emergency care in a public ED,

1. that the South Australian Department of Health is responsible for provision of emergency medical services in both metropolitan and country areas,

1. that the contract between rural doctors and Country Health SA is to participate in on-call services for Emergency Medicine (A&E), not GP-after hours services,

1. that whilst clause G21 does allow for rural doctors to charge privately (with Medicare rebate) this is only in the situation where patients “request treatment by their own GP, either as part of continuing care or by prior arrangement with the doctor”. Many patients who present to the ED have either been referred there by a GP or an after hours service (HealthDirect) or else have needs that require ED attendance. They have not requested treatment by their own GP nor is their a pre-existing prior arrangement with the doctor on call for the A&E roster for the State Health Department.

1. that in situations where a patient elects to be treated privately by their own GP then clause G21 applies and Medicare fees are allowed,

1. that the assertion that triage 4/5 patients are to be billed under Medicare is not supported in the Australian Healthcare Agreement and indeed is counter to advice from the Australian College of Emergency Medicine who dispel this myth in a recent media release and state “It is in the political interest of state governments to ensure that any definition of general practice patients seen in EDs yields high numbers. This helps perpetuate the myth that EDs have too many GP patients.”

1. that the situation as it stands in South Australia is at odds with arrangements interstate.

I would be grateful for your clarification on the above points. To my mind it is vital that rural Australians are not disadvantaged when attending the ED with a genuine need. Similarly there may be concerns from rural doctors that such Medicare-billing is not supported and there needs to be clarification that such practices are allowable in certain circumstances (eg: as part of a GP after hours service utilising the local hospital premises, ie: private arrangement, ongoing care). I am happy to charge privately for my services when it is appropriate – but charging a mental health patient, a rape victim or a car crash victim several hundred dollars just seems wrong. Much better to be paid by the Health Department, after all the doctor is attending in his/her role on the on call A&E roster, not as a private arrangement.

I am sure you would agree that it is important for rural doctors to be seen to uphold the same standards in each State and to ensure that neither patients nor doctors are disadvantaged.

Sincerely

Dr Tim Leeuwenburg

Kangaroo Island, South Australia www.ki-docs.blogspot.com