The topics were as diverse as could be imagined, ranging from life as a JMO on the Northern Rivers to medical cannabis and a surgical aid program in Timor Leste (East Timor) involving doctors from Australia, Cuba and China.
The second annual NORDOCS gathering received sponsorship from the Northern NSW Local Health District and the North Coast Primary Health Network, with the Lismore venue being provided by the University Centre for Rural Health. It was held under the barrier-less “unconference” format .
The 30 attendees also heard about the history of the local medical fraternity from 1866, the challenges of rural surgical training, managing obstructive sleep apnoea, the prospects (and challenges) of greater longevity, lifestyle medicine and modern stroke management.
Despite this diversity, a common theme through many of the presentations was one that all too often features in studies involving both clinicians and patients: the need to achieve better communications on many levels.
While the issue was touched on by various speakers throughout the day-long event, and was a focus of several presentations, it was not until the final session, a panel discussion on the whys and wherefores of hospital discharge summaries (less than rigorous, most agreed) and clinical handovers, that the subject was broached overtly.
Panel Discussion - "Discharge Summary or Same Day Handover?"
From left - Drs Katherine Willis-Sullivan, Tony Lembke, Sabine Ringowski and Kat McLean,
“We’ve got to get better at communicating,” said Dr Edward Wims, Clinical Director, Mental Health for the Northern NSW Local Health District. “In a system with no fat, we need to put our heads together.”
So began a lengthy discussion about poor communication between hospitals/community health and GPs, and about the urgent need for a policy, or a “line document” as one participant put it, that ensures GPs are reliably informed about when and why their patients are admitted to hospital, subsequent diagnoses and medications prescribed (and/or “purposely ceased”, as one participant added ), referrals and suggested post-discharge support.
It was agreed that this task should not be assigned to junior hospital doctors, nor should they be blamed for occasions when the system as it now stands does not work. A past calamitous pile-up of thousands of unread discharge documents was mentioned, the blame being unfairly attributed to junior doctors who had no control over a black-hole in the IT system.
The current situation in NSW was said by Dr Wims to be inadequate because of a budget restriction on accessing the Cerner system, and is inferior to the model in Queensland, which has better (and more costly) Cerner access. In America “documenters” are employed to compile succinct discharge summaries that are then signed off by registrars.
The issue of communications raised its head from the very start, being flagged in the title of the keynote address by Newcastle-based medical oncologist Dr Nick Zdenkowski, “Shared Decision Making”, or SDM. A one-time trainee at Lismore Base Hospital he spoke of the extensive research he had done for a 2018 doctoral thesis around the dialogues between clinicians and patients with a cancer diagnosis, particularly breast, his clinical specialty.
The communications challenge, to summarise simplistically, is to what extent doctors or patients should direct the discussions, and the future treatment options and lifestyle modifications that might best take place.
Dr Zdenkowski said the “pendulum of decisional control” had swung from the “medical paternalism of old” through to an “over burdening of patients”, giving them a degree of control that implied they have a complete understanding of the medical issues involved in a complex field such as cancer care.
Plenary speaker Dr Nick Zdenkowski with Drs Lynne Davies and Joe Gormaly
That said, the swings have been marked and encouraging. Before the year 2000, 50 per cent of all patients preferred SDM, and 27 per cent delegated the decision to their doctors; after 2000, 71 per cent favoured SDM, and only 16 per cent felt the doctor should have the sole say. In cancer patients, the view was even stronger , with 85 per cent preferring SDM , although with chronic health conditions it was lower, only 59 per cent of patients preferring a close involvement with their care planning.
“Offering some control can help maintain patients’ sense of agency,” Dr Zdenkowski said, adding that the benefits of SDM have been found to include improved disease-related and quality of life outcomes, with the conversations between doctors and patients needing only slight differences in consultation times, around 2.6 minutes extra on average, according to research.
The benefits of improved communications between doctor and patient also surfaced in Dr Andrew Binns’ discussion of the social determinants of health, almost as an afterthought, but a valuable one.
“Most people have something in their lives that they have a passion for,” said the local GP well known for his passion for the arts, especially the works of the Bundjalung community.
Recounting how he strives to connect with all patients, especially Aboriginal people, through finding a subject of interest, he added, “We need to try to find that connection, it may be art, or sport… as we know, footy is big in this area… now, admittedly that’s hard in a 15-minute consultation, and there may be a need to build up confidence, to encourage follow-up appointments… but it can be most worthwhile.”
He also addressed the topic of the inter-generational trauma experienced by many, perhaps all, Aboriginal patients who are impacted by the racism experienced by their families, including policies such as the ‘stolen generation’ history. This can have serious repercussions for their mental and physical health.
Touching on the Logotherapy concept developed by neurologist and psychiatrist Viktor Frankl, wherein the primary motivational force of an individual is to find a meaning in life, Dr Binns said that when appropriate he will inquire about a patient’s familial and cultural background. Again, this communications bond may take some time to develop, but the benefits can be great.
Dr Marion Tait, Karen Day and Cheree Freeburn
The subject was reinforced by Dr Marion Tait from Bulgarr Ngaru Medical Aboriginal Corporation in Casino who presented on “Closing the Gap in Medical Communication”, supported by staff members Karen Day and Cheree Freeburn, who had collaborated to make a learning video for clinicians featuring a less-than-ideal consultation between an Aboriginal patient and a doctor.
A video and still images also featured in the presentation “Graphic Medicine and Patient Voices” by the North Coast Primary Health Network’s Sharyn White, again aimed at helping clinicians understand patients’ perspectives on their care delivery, this time with some superb animation and scripts based on actual patient feedback. This project is pitched perfectly for the modern communications era, and Sharyn’s work, backed by the PHN, is to be highly complimented.
DrTrafford Fehlberg on Global Surgery and Timor Leste
Perhaps the ultimate communications challenge was highlighted in the talk by surgeon Trafford Fehlberg, a recent arrival in the Northern Rivers, who documented his assignment on a Royal Australasian College of Surgeons overseas program, supported by the Australian Government, in Timor Leste (East Timor).
With both a clinical and educational brief – helping to train in-country medical staff – the team he helped run treated a range of common, if advanced conditions, and performed routine surgical procedures, as well as trauma surgery resulting from circumstances such as road accidents and, much to the amazement of the audience, wounds from barbed arrows fired in pay-back disputes.
The Australians, Dr Fehlberg said, worked in tandem with surgical “brigades” from Spanish-speaking Cuba, whose major export is medical support for friendly nations, and China. In many cases, nationals from all three countries, as well as clinicians and trainees from Timor, who spoke Portuguese and local languages, would be involved.
“Were there communications problems?” an audience member asked Dr Fehlberg at the end of his fascinating talk.
“There were certainly many languages spoken,” he replied with a laugh, “but it all worked surprisingly well.”
As this innovative “unconference” heard, the same cannot always be said for communications between first-world hospitals and primary care providers within the radius of a few kilometres, and it is patients who are likely to be paying the price.
Dr Bob Lodge on Reefer Madness / Drs Bill Nardi and Richard Lucas
Dr Neil Thompson on the Northern Rivers Docs 1866-1986
Photo of the Pacific Highway Ferry at Brunswick Heads 1935