It appears, according to my reading of the Yarrabah Primary Health Care Centre Indigenous Land Use agreement it "includes" pharmacy services ... I don't know whether this is political speak that it (at the time of the agreement) provided pharmacy services or if there is any obligation to provide pharmacy services.
Whatever the actual obligation, the pharmacy service that was here is now closed.
This means unhappy and angry community members.
This means sub-standard health care, both medical and dental.
Yarrabah has not been approved for Section 100 of the National Health Act so we are reliant on the goodwill of a nearby pharmacy to provide a non-profitable dispensing service to the community.
The eligibility criteria for participation in the program are given below.
Eligibility criteria
. The Health Service must have a primary function of meeting the health care needs of Aboriginal and Torres Strait Islander peoples.
. The clinic, or other health care facility, operated by the AHS from which pharmaceuticals are supplied to patients must be in a remote zone as defined in the Rural, Remote and Metropolitan Areas Classification 1991 Census Edition.
. The AHS must not be a party to an arrangement, such as a coordinated care trial, for which funds from the Pharmaceutical Benefits Scheme have already been provided.
. The AHS must employ or be in a contractual relationship with health professionals who are suitably qualified under relevant State/Territory legislation to supply all medications covered by the Section 100 arrangements and undertake that all supply of benefit items will be under the direction of such qualified persons.
. The clinic or other health care facility operated by the AHS from which pharmaceuticals are supplied must have storage facilities that will:
- prevent access by unauthorised persons;
- maintain the quality (eg chemical and biological stability and sterility) of the pharmaceutical; and
- comply with any special conditions specified by the manufacturer of the pharmaceutical.
Yarrabah is RRMA 5 (a new classification system is in place, but the Department of Health Section 100 page still refers to RRMA classifications)
The Department of Health and Aging refers to Yarrabah as being "outer regional" incidentally exactly the same as Cairns, the major town about an hour's drive away.
Unless Yarrabah is reclassified it will never gain access to the Section 100 system.
Here's hoping there will be another pharmacy prepared to assist the community and quickly.
Meantime, our "after hours" stock of medications are dwindling fast.
Monday, October 31, 2011
Wednesday, October 19, 2011
The financial imperative for honest doctors
Honesty in the medical profession is taught in the context of the doctor-patient relationship. It possibly always has been, it possibly always will be. While the Hippocratic oath does not overtly mention honesty, Vaidya's oath and the Oath of Asaph do.
However, in the process of this "learning" we discover how to stretch the definition of truth and the justification for blurring the boundaries. We distract by a philosophical narrative of "what is truth?" !
This article at Bioetica, a very good paper on honesty and medical ethics, makes interesting reading ... overt lying is disapproved, but acknowledges the "need" to choose what is said in each circumstance.
"This paper argues for truth in the doctor/patient relationship but not for flat-footed or insensitive communication. The presumption is always for truth and against lying. But the arguments support the need to make humane clinical judgments about what is told, when, how, and how much."
If you are interested in further reading, "Teaching Medical Students to lie" addresses another area where medicos are introduced to the attraction of dishonesty.
Once presented with reasons to be given less than forthcoming with the truth then this will naturally spill over into other areas as a doctor including financial dishonesty.
Add to the mix the cultural imperative for dishonesty in certain cultures (ie. being honest creates a survival disadvantage) then we have in this country a minefield.
The taste of reward for dishonesty is provided by our Australian Medicare system. Bill an item 36 instead of an item 23 (or a 23 instead of a 3) and don't get caught. Bulkbill a removal of a deep foreign body instead of a superficial foreign body and don't get caught. Bulkbill a longer, or deeper laceration repair than reality and don't get caught. Bulkbill for a Chronic disease management plan, or Mental Health care plan when not needed and don't get caught. Do it a few times and you realise how easy it is. If everyone does it, then the HIC computer profiling won't pick it because it compares your activity with your peers.
Once you see you can get away with it, then it spreads further. Locum doctors bill for a few hours they didn't work, a few call backs that didn't happen ... yes it has happened, on at least one verifiable occasion in my recent past experience.
Question is why bother about it ? Why care ?
My assertion is that the funds siphoned off into the pockets of dishonest medical professionals (who quite readily justify their actions in a multitude of articulate contortions) are funds not available for the provision of services needed, but cannot be provided for the lack of resource. Yes, there are other significant reasons for ballooning medical costs, such as the self-interested growth in medical middle management, but this corruption of the medical profession by the loss of personal honesty has contributed, in my opinion, to the demise of medical care.
Meanwhile, we get crap instant coffee at work to save a few cents.
Enjoy !
However, in the process of this "learning" we discover how to stretch the definition of truth and the justification for blurring the boundaries. We distract by a philosophical narrative of "what is truth?" !
This article at Bioetica, a very good paper on honesty and medical ethics, makes interesting reading ... overt lying is disapproved, but acknowledges the "need" to choose what is said in each circumstance.
"This paper argues for truth in the doctor/patient relationship but not for flat-footed or insensitive communication. The presumption is always for truth and against lying. But the arguments support the need to make humane clinical judgments about what is told, when, how, and how much."
If you are interested in further reading, "Teaching Medical Students to lie" addresses another area where medicos are introduced to the attraction of dishonesty.
Once presented with reasons to be given less than forthcoming with the truth then this will naturally spill over into other areas as a doctor including financial dishonesty.
Add to the mix the cultural imperative for dishonesty in certain cultures (ie. being honest creates a survival disadvantage) then we have in this country a minefield.
The taste of reward for dishonesty is provided by our Australian Medicare system. Bill an item 36 instead of an item 23 (or a 23 instead of a 3) and don't get caught. Bulkbill a removal of a deep foreign body instead of a superficial foreign body and don't get caught. Bulkbill a longer, or deeper laceration repair than reality and don't get caught. Bulkbill for a Chronic disease management plan, or Mental Health care plan when not needed and don't get caught. Do it a few times and you realise how easy it is. If everyone does it, then the HIC computer profiling won't pick it because it compares your activity with your peers.
Once you see you can get away with it, then it spreads further. Locum doctors bill for a few hours they didn't work, a few call backs that didn't happen ... yes it has happened, on at least one verifiable occasion in my recent past experience.
Question is why bother about it ? Why care ?
My assertion is that the funds siphoned off into the pockets of dishonest medical professionals (who quite readily justify their actions in a multitude of articulate contortions) are funds not available for the provision of services needed, but cannot be provided for the lack of resource. Yes, there are other significant reasons for ballooning medical costs, such as the self-interested growth in medical middle management, but this corruption of the medical profession by the loss of personal honesty has contributed, in my opinion, to the demise of medical care.
Meanwhile, we get crap instant coffee at work to save a few cents.
Enjoy !
Tuesday, October 18, 2011
Yarrabah 12 months on ...
...
Telephone reception is still poor (apparently there was a Telstra tower in town but it was removed, reason uncertain, but at supposedly at the request of the community) ... the Telstra signal from distance is poor, and only connectable while outside, the Optus signal is stronger but will still drop out while insidethe main buidling. Yarrabah is the only place I've been to where Optus provides a better signal then Telstra.
Telephone in the accommodation unit is blocked from making calls more than local calls (remote NT placements permitted calls home from accommodation, although some have a Telstra 3G tower in town so not needed for those with a Telstra mobile, Eidsvold and Doomadgee even provided a loan mobile phone).
Internet connection limited by QHS filters, despite statement that the accommodation units are wired for internet connection, there is no facility in the units for accessing the internet.
I complained 12 months ago .. Yarrabah despite its geographic proximity to Cairns, feels one of the more isolated places to work in if one must live there as well.
Last week I have requested permission, at my own expense, to install a second telephone line to the main doctor's unit and pay for an ADSL subscription with wireless modem. I expect with the multiple levels of management (no one locally is permitted to make this sort of decision) that it will be a while (if ever) before a response to my request.
Meantime I look forward to my fortnightly weekend off where I can stay in Cairns overnight.
I guess its just a heads-up to others looking at coming here ... this feels more isolated than it should be.
Telephone reception is still poor (apparently there was a Telstra tower in town but it was removed, reason uncertain, but at supposedly at the request of the community) ... the Telstra signal from distance is poor, and only connectable while outside, the Optus signal is stronger but will still drop out while insidethe main buidling. Yarrabah is the only place I've been to where Optus provides a better signal then Telstra.
Telephone in the accommodation unit is blocked from making calls more than local calls (remote NT placements permitted calls home from accommodation, although some have a Telstra 3G tower in town so not needed for those with a Telstra mobile, Eidsvold and Doomadgee even provided a loan mobile phone).
Internet connection limited by QHS filters, despite statement that the accommodation units are wired for internet connection, there is no facility in the units for accessing the internet.
I complained 12 months ago .. Yarrabah despite its geographic proximity to Cairns, feels one of the more isolated places to work in if one must live there as well.
Last week I have requested permission, at my own expense, to install a second telephone line to the main doctor's unit and pay for an ADSL subscription with wireless modem. I expect with the multiple levels of management (no one locally is permitted to make this sort of decision) that it will be a while (if ever) before a response to my request.
Meantime I look forward to my fortnightly weekend off where I can stay in Cairns overnight.
I guess its just a heads-up to others looking at coming here ... this feels more isolated than it should be.
Sunday, October 16, 2011
Would it be fair to say ...
... that if it weren't for alcohol abuse there would be a lot less for doctors to do, and less lost sleep ?
Wednesday, October 12, 2011
Chronic Kidney disease ... (CKD)
.. in the Australian indigenous population.
Gratuitous quotations from publications ...
MJA "Streptococcal skin infection may have a major role in the epidemic of chronic renal disease among Indigenous Australians."
UpToDate "Although PSGN continues to be the most common cause of acute nephritis globally, it primarily occurs in developing countries. Of the estimated 470,000 new annual cases of PSGN worldwide, 97 percent occur in developing countries, with an annual incidence that ranges from 9.5 to 28.5 per 100,000 individuals"
** (me commenting) ** The incidence in our indigenous community competes with "developing world" figures. The incidence of chronic kidney disease in our indigenous communities is also up to 20 times greater than the non-indigenous population with a ten fold increase in death rate from CKD. If a large proportion of CKD is in fact related to post streptococcal glomerulo-nephritis (PSGN) and PSGN is a mostly preventable disease then this is a critical public health issue.
** The increased rate of diabetes is also a significant contributor to the incidence of CKD.
HealthInfoNet
"High rates of ESRD (end stage renal disease) among Indigenous people reflect the operation of multiple risk factors. The full spectrum of risk factors has yet to be identified, but known risk factors include: increasing age, low birthweight and infant malnutrition, adult weight gain and the signs of Syndrome X (increasing blood pressure, insulin, blood glucose and lipid levels), skin infections, post-streptococcal glomerulonephritis, heavy drinking, repeated pregnancies and a family history of renal disease "
"Research highlights the broader socioeconomic determinants that underlie the physiological risk factors associated with current levels of Indigenous renal disease. The socioeconomic dimensions of the epidemic considered to be at the root of burgeoning rates of ESRD include:
. overcrowded and substandard housing;
. relatively poor nutrition;
. reduced activity levels;
. high levels of tobacco and alcohol consumption; and
. community and cultural disruptions.
These factors have social origins related to absolute poverty, relative deprivation, unemployment, homelessness and fractured kinships since the time of colonisation."
"The poor social and economic circumstances that underlie the generally lower health status of many Indigenous people contribute to the high rates of kidney and urinary tract disorders in many Indigenous communities. Prevention, control and management of kidney and urinary tract disorders will depend not only on effective, acceptable treatment, but also on preventive action to address the poor socioeconomic conditions that underlie these conditions"
** .. address the poor socioeconomic conditions ..
** This is the challenge. I don't have an answer, but I am fairly sure that the last two centuries have not provided a solution.
Gratuitous quotations from publications ...
MJA "Streptococcal skin infection may have a major role in the epidemic of chronic renal disease among Indigenous Australians."
UpToDate "Although PSGN continues to be the most common cause of acute nephritis globally, it primarily occurs in developing countries. Of the estimated 470,000 new annual cases of PSGN worldwide, 97 percent occur in developing countries, with an annual incidence that ranges from 9.5 to 28.5 per 100,000 individuals"
** (me commenting) ** The incidence in our indigenous community competes with "developing world" figures. The incidence of chronic kidney disease in our indigenous communities is also up to 20 times greater than the non-indigenous population with a ten fold increase in death rate from CKD. If a large proportion of CKD is in fact related to post streptococcal glomerulo-nephritis (PSGN) and PSGN is a mostly preventable disease then this is a critical public health issue.
** The increased rate of diabetes is also a significant contributor to the incidence of CKD.
HealthInfoNet
"High rates of ESRD (end stage renal disease) among Indigenous people reflect the operation of multiple risk factors. The full spectrum of risk factors has yet to be identified, but known risk factors include: increasing age, low birthweight and infant malnutrition, adult weight gain and the signs of Syndrome X (increasing blood pressure, insulin, blood glucose and lipid levels), skin infections, post-streptococcal glomerulonephritis, heavy drinking, repeated pregnancies and a family history of renal disease "
"Research highlights the broader socioeconomic determinants that underlie the physiological risk factors associated with current levels of Indigenous renal disease. The socioeconomic dimensions of the epidemic considered to be at the root of burgeoning rates of ESRD include:
. overcrowded and substandard housing;
. relatively poor nutrition;
. reduced activity levels;
. high levels of tobacco and alcohol consumption; and
. community and cultural disruptions.
These factors have social origins related to absolute poverty, relative deprivation, unemployment, homelessness and fractured kinships since the time of colonisation."
"The poor social and economic circumstances that underlie the generally lower health status of many Indigenous people contribute to the high rates of kidney and urinary tract disorders in many Indigenous communities. Prevention, control and management of kidney and urinary tract disorders will depend not only on effective, acceptable treatment, but also on preventive action to address the poor socioeconomic conditions that underlie these conditions"
** .. address the poor socioeconomic conditions ..
** This is the challenge. I don't have an answer, but I am fairly sure that the last two centuries have not provided a solution.
Tuesday, October 11, 2011
Edited the blog template ...
.. hope you like it. (no the background photo is not mine, its a blog generic background)
CARH - the Red Centre ...
Three weeks in central Australia working from Alice Springs out to remote community. Week 1 Elliott, north of Alice Springs.
Flew in and provided the necessary administrative support for the three nurses. Administrative you ask ? Yep, the clinical skills of the nurses are not lacking, however due to medicare and other legal requirements, a doctor must sign off on certain processes, such as writing new "rural scripts" (free medications for 12 months), reviewing pathology results, signing patient transport requests, listening to hearts for child health checks and completing chronic disease management care plans and reviews. The electronic records system is cumbersome and process driven, hampering normal clinical work flow but at least allows region wide access to a medical record for a mobile population. If used properly (and in my opinion is often not) then it also provides a potentially effective recall system.
Second week was spilt between Watarrka (Kings Canyon) and Imanpa. Flew into Kings Creek airstrip and stopped off at Kings Creek station to provide medical services to those who needed it, stayed for lunch (this station is set up on the main road to Kings Canyon and provides a good selection of tourist and visitor activities) then headed off to Watarkka via a small community of three families off the main road, again for the necessary health checks and medical services. A day and a half at the Kings Canyon Clinic, then left on the Wednesday to stop off at another small community off the main road and then on to Imanpa for 2 days.
The third week was spent at Ali Curung, about 360km north of Alice Springs. Travelled with a young doctor who was attached to CARH (Central Australia Rural Health) for 10 weeks as part of an advanced training program.
Out of respect for the privacy of the communities I worked with I can't say much (certainly not about who and what unusual medical conditions I saw), however two things must be said.
1) I am most grateful for the communities for allowing me to onto their land and sharing with me a little of central Australian indigenous life.
2) I am again shamed that we have third world health conditions in our own back yard.
In closing, very significant bush fires were around the whole region for many weeks, including very close to the Kings Creek station after I had left. This picture was taken just off the main road heading back to Alice Springs from Ali Curung.
I may well be back for another visit to NT in the future.
Monday, October 10, 2011
Mossman, FNQ, Feb - July 2011
This was my longest locum in the one place, and reached the Queensland Health (QHS) policy maximum of not having a locum in a position for more than six months. MY role was Acting Medical Superintendent while the current Med super was on extended leave, with the view to possible job share after July 2011. In March 2011, the Med Super on leave handed in her resignation and my task then became finding a replacement. This was achieved in June 2011 with a 4 week transition.
Lesley spent approximately 4.5 of the 6 months with me, at a rental acccommodation walking distance from Four Mile beach, Port Douglas. The Mossman job was planned in August 2010, so I knew in advance that I wanted accommodation within walking distance of the beach and away from my place of work to feel like when I finished work for the day, it was finished - but close enough to return to work (15 minutes drive away) in case of emergency call-back.
This is pretty stunning for an early morning walk hey !?
I must say at this point, that Laura at VISTA realty in Port Douglas was a delight to deal with arranging the rental in advance of my arrival mid-February. A far cry from the very poor service my daughters received when looking for and arranging their rental to stay near university.
So what were my lasting impressions from this time in Mossman?
Reinforcement that this is a beautiful place. Fresh air, warmth, forest, beaches and an abundance of life.
Mossman Hospital is a delight to work at ... a sense of family and teamwork in the place, and a real sense of purpose in the workplace. Many familiar, warm faces to re-aquaint with and a few new faces to meet and get to know.
The work itself was challenging in a number of ways, but imensely satisfying. We saved a few lives, made a difference to many, and helped some die with dignity and peace. I faced my own professional limitations and provided a mentoring role for the younger doctors facing the emotional challenges of the profession.
It was also a joy to work with some medical students and a couple of new graduate doctors, in particular Katherine who's love of life and work energised the place and gave me hope that there may well be a few good doctors for the Australian community. Over the last decade or so, I have seen the degeneration of the care and commitment that doctors have for their vocation and fear greatly for the suffering of our community who will inevitably have to deal with a disinterested, disaffected and dysfunction medical profession. The selection process that permits extreme academic talent, does not properly value genuine humanity, respect and honesty, and turns a blind eye to the pollution of professional ethics inevitably produces a type of doctor that is not good for the community.
All in all, an experience that was valuable in many ways.
** A few more photos here **
.
Lesley spent approximately 4.5 of the 6 months with me, at a rental acccommodation walking distance from Four Mile beach, Port Douglas. The Mossman job was planned in August 2010, so I knew in advance that I wanted accommodation within walking distance of the beach and away from my place of work to feel like when I finished work for the day, it was finished - but close enough to return to work (15 minutes drive away) in case of emergency call-back.
This is pretty stunning for an early morning walk hey !?
I must say at this point, that Laura at VISTA realty in Port Douglas was a delight to deal with arranging the rental in advance of my arrival mid-February. A far cry from the very poor service my daughters received when looking for and arranging their rental to stay near university.
So what were my lasting impressions from this time in Mossman?
Reinforcement that this is a beautiful place. Fresh air, warmth, forest, beaches and an abundance of life.
Mossman Hospital is a delight to work at ... a sense of family and teamwork in the place, and a real sense of purpose in the workplace. Many familiar, warm faces to re-aquaint with and a few new faces to meet and get to know.
The work itself was challenging in a number of ways, but imensely satisfying. We saved a few lives, made a difference to many, and helped some die with dignity and peace. I faced my own professional limitations and provided a mentoring role for the younger doctors facing the emotional challenges of the profession.
It was also a joy to work with some medical students and a couple of new graduate doctors, in particular Katherine who's love of life and work energised the place and gave me hope that there may well be a few good doctors for the Australian community. Over the last decade or so, I have seen the degeneration of the care and commitment that doctors have for their vocation and fear greatly for the suffering of our community who will inevitably have to deal with a disinterested, disaffected and dysfunction medical profession. The selection process that permits extreme academic talent, does not properly value genuine humanity, respect and honesty, and turns a blind eye to the pollution of professional ethics inevitably produces a type of doctor that is not good for the community.
All in all, an experience that was valuable in many ways.
** A few more photos here **
.
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