Sunday 25 May 2014

If a doctor's practice ran the way Dutton is running health..

Boy, has it been a turbulent time in health lately. And for all the wrong reasons. Yet the federal government plough on, resisting communication or negotiation while they stick to their mantra – their proposed changes for health and necessary for the good of the country.
I keep trying to define what can be good for patients in all of this, but can only see a trail of negativity, a loss of services and values in healthcare for patients and fears of a diminishing medical workforce if education and health cuts are passed.
Then I thought about another way. Try for one or two minutes, just try to see the government’s point of view. Really, really try, maybe not be so ‘pessimistic’. Maybe see if it would make sense if I try and apply Dutton’s principles to a busy medical practice and see if these policies have any merit. Or are they simply something to apply on a grand scale rather than in a practical situation?
So, here’s my take on applying these changes to a real world setting;, what doctors and I work in every day,
A new world scenario for a busy medical practice:
Imagine this for a while and see how it fits. Doctors in this busy private practice hold a meeting behind the staff’s back and announce in unison that the situation at the practice is worse than anybody imagined. They have had some external auditors in and had no idea things were this bad when they signed the lease.
The principal doctors announce that due to the crisis left by previous tenants, there will no longer be a tea room, toilet facilities or any basic staff amenities. The principal doctors agree these measures will be tough but necessary. They did not appreciate how the previous tenants had left the premise. Hence they cannot be held accountable for what would be tough but fair changes for all.
The principal doctors inform the staff that there will be a 30% reduction in staffing commencing in 2 weeks. As a gesture of goodwill, the principal doctors will take a 2% pay cut, because, after all ‘we’ve ALL inherited this MESS’. There will be limited access to services such as Medicare or the Australian Tax Office. They were just superfluous services anyway, not really required by a busy medical practice.
Beginning in a week’s time, cash registers will be installed at reception and all staff will instruct patients to pay up before they have any chance of seeing a doctor. Even if presenting with chest pain, acute shortness of breath or other life threatening symptoms. The doctors understand that there will be ‘casualties’ due to this blanket measure but nevertheless it will work for the good of most who need health care. And it’s important for practice staff to remind patients that each and every dollar raised will go to curing their health problems via a medical research fund, so they will no longer experience chest pain or shortness of breath in the future. After all, the new breed doctors know, there is nothing in this ‘acute health care’ it costs too much and there is no return on investment.
The doctors warn the practice staff that this will be a very difficult time, but to remind patients that it is difficult for all, not just those who have recently lost their job,  have a mental illness, perhaps a physical disability or find themselves homeless of late. TOUGH. FOR. ALL. In fact, the principal doctors announce they will spend $250,000 to rebrand the practice with this telling and sage message. Staff will wear this logo on their new uniforms and doctors will add it to the business cards. Everybody will assume their rightful role in where they now fit in the practice and the greater community.  At the bottom.
When doctors finally get to see their patients, suddenly stricken with low self esteem and self worth, they will turn off their listening ears and preach to their heart’s content. They will fail to miss the tidal wave of patients surging the wrong way out of the practice door (or perhaps the right way), there will be serenity in the waiting room, but no place for reflection.
At least these radical but necessary changes will only need to be in place for three years. After that the practice lease will be up for renewal, and the new team of doctors can inherit the mess, seeing fit to do with it what they want.

Imagine this in the real world? What doctor would stand for this on behalf of their patients or their own professional lives?

Thoughts?


Monday 19 May 2014

The dominoes are starting to tumble


A few weeks out from the State budget and one week out from a Federal Budget, we are beginning to see the direct effects of winding back health care for all, but especially for those with mental illness.
Yesterday The Age in Melbourne reported the State Government would no longer fund St Mary’s house of welcome in Fitzroy, as well as many other institutions that genuinely support and care for those with severe mental illness.  
I remember St Mary’s house of welcome from my training days. Back then it was a bustling place, a care and respite space for many inner urban patients with a mental illness. It provided a community, a haven, hot meals, clothing, shelter and love. Nowadays, it is even busier, and would have been full to the brim for years to come had it not received the news it would no longer receive government funding the day after the state government budget was delivered.
Many of the patients we knew within our service would feel safe going to St Mary’s when unwell, rather than calling a crisis team or attending an emergency department. In fact, most patients experiencing a relapse of severe mental illness avoid psychiatric services. St Mary’s provided a bridge between patient and service, our service could be alerted by their staff if somebody was unwell. They would do this in discreet and compassionate way, and would discourage psychiatric services from attending at St Mary’s to keep it as a safe place. However, services could follow up after hours and ensure treatment was provided.
There is no doubt that such wonderful facilities never come to the attention of politicians except as a cost on a piece of paper, to be cut when needed. There is no human element to the decision making. Where will these people go as these services break down? What will happen to their mental health? And if they can’t afford meals how will they afford to pay their GP’s $7.00?
Little is known about taking payments from patients in public hospitals. This seems to have been pushed to the State Government’s discretion. Will an acutely mentally unwell patient lost from services be asked to pay? Even when extremely paranoid and actively avoiding services? What is the point of newer medications and modalities of care if we are actively discouraging patients from seeking help, by taking away their places of refuge and charging them for care that they have no insight they need.
What will be the next domino to fall?


Wednesday 14 May 2014

Choosing to play 'win-lose' in negotiation and how it applies to #budget2014

Greetings all,
As promised, here is another key learning from my WMA caring physicians of the world conference at INSEAD this month.

During a very busy timetable we immersed ourselves in understanding negotiation skills and multi party coalitions. The same day, I watched the Commission of Audit report and discussions fill twitter feeds. I could see what was happening, the Federal Government’s strategy behind #budget2014 was clearly win-lose negotiation tactics, where the tool of choice is power not communication.

When a party or individual chooses to play win lose, they use their power to influence and win. They need to be very aware of the risk and believe the reward will be great enough to set off the risks. Win lose negotiations fall down when such parties overestimate reward and underestimate resistance.

So what does this mean in the context of the last few days? Well, choosing to deliver a budget that is harsh, hits the most vulnerable that a society should protect, doesn't contain a lot of information about how these measures could even be implemented, and then states that it will help Australia out of a perceived economic mess, may be overestimating reward.

I don't see reward when it comes to the $7.00 copayment. I have spoken to a patient who takes warfarin, who told me that if the copayment for pathology services go through, they will take their chances rather than have twice weekly blood tests. 

As a psychiatrist, I may no longer be able to prescribe lithium as often, a fantastic medication for bipolar disorders, as lithium monitoring is crucial with weekly blood tests needed to avoid kidney and thyroid disturbance. The ridiculous aside to this is that lithium is much cheaper than newer atypical agents and more cost effective for government. But, if my patient doesn't return, doesn't have regular monitoring, and develops renal dysfunction, they will then be knocking on the bulging doors of the emergency department. For the sake of making a GP or pathology centre claim $7.00 from a patient, because, after all, they have lost $5.00 per consult, costs and burden of disease will only but rise.

What will we see playing out in the next few days? Parties that choose win-lose and underestimate resistance will feel they have won for a little while until key stake holders form coalitions and lobby to block changes. Key stakeholders that have been shut out of any discussion about this most important budget, and all important patient groups will lobby via all channels available. Let's see what win-lose really looks like in a few weeks, and at the next election.
Then, a word of advice for all, using 'win-win' in negotiation requires communication. How about Government communicate with RACGP, GPRA, AMA,  and  include doctors rather than just rule them, or reduce them to workers of another branch of the ATO.
Thoughts?
Helen


Sunday 4 May 2014

Availability Bias and delivering messages that change

Greetings all,
I have just arrived home after attending the World Medical Association 'Caring Physicians of the World' Leadership Course, at INSEAD Singapore. Over the next few posts, I plan to share some of the most amazing insights I learnt in a jam packed 5 days, surrounded by doctors and leaders from all over the world.
Today, I'm posting about the first concept that hit me between the eyes and taught me how best to communicate and influence with impact. And it stems from the concept of availability bias.

In a nutshell, availability bias is how news stories are shaped and how we are touched by events that occur around the world. News events are largely made up of stories of tragedies and disasters, or one in a million good luck stories. This shapes our understanding of issues for good or not, far greater than being presented with facts and statistics. Take for example, the horror of a plane crash. An absolute tragedy for all concerned and well worthy of headline news. Availability bias results in the decision we make to take that information and decide whether or not it is safe to fly. Because, after all, there is no report of how many planes landed safely and without incident on any given day. The information available to us leads to a bias in our thinking.

In addition, good leaders tell stories, rather than just present facts. Once the human element is lost and we can't connect on an emotional level, the impact to change is reduced, and the message gets lost within the debate.

As leaders of health debates, we must remember to tell stories and share the personal element of every issue we aim to influence. And as doctors we see and hear first hand these stories every day. As I continue to try and influence issues that impact on patients with mental illness, I will remember to embrace the impact of a human story, an experience or a tragedy rather than just present facts or statistics. We were told "statistics are humans with the tears washed off''. Such an important point of view, and one you can use when delivering powerful messages.

So, next time you are presented with facts about a healthcare issue, perhaps that you disagree with or can't relate to, remember the concept of availability bias. Hear the presenter as a journalist at the airport commenting on all the places that landed safely, and influence with your own personal, authentic story (de-identified of course), for the good of your patients and to really make change.
Best wishes,
Helen