Do we need a Romantic movement in medicine? Involving patients in medical education

Why this picture? ...Read on...

I have had a very interesting conversation with Anya de Longh on Twitter and commenting over on the AMS Doctor blog. She wanted to know how patients can be more involved in medical education. There have also been helpful contributions to this discussion from David Chessor, Meerat Kaur and Clare Morris. And then Anya asked "What are the biggest obstacles for clinicians in accepting teaching from patients?"

I don't have an easy answer to this, and would love to hear other people's thoughts. I also don't think it's something I can do justice to in 140 characters, as I think the answers to this questions are tied up in what we call the Hidden Curriculum - those unstated values which get acted out by doctors and medical students.

Why is something so obvious so difficult?

It does seem obvious to me that patients (and for that matter carers) should be involved in teaching doctors (and, for that matter, all health care professionals). I don't think there are that many people who would argue against the idea. So why is it so difficult to do? I think there are some particular ways we have of thinking about medicine that lead us to discounting the patients' views. I'll suggest what I think these are here. I don't want to suggest that these ways of thinking are wrong - they have been beneficial in many ways - but there are other ways we need to think, too.

Medicine is thought of as a technical discipline

The way we conventionally teach and talk about medicine makes it look like it's a technical and scientific discipline.The study of medicine becomes the study of scientific facts about diseases. This exhibits itself in traditional physiology and pathology, as well as the monitoring requirements of diseases, such as diabetes. Eventually, all that you need to know about a disease is the numbers assocated with its monitoirng - so you assume that you know all about someone's diabetes if you know their HbA1c, their fingersprick sugars, their cholesterol and their blood pressure. The way we teach using cases which concentrate on disembodied signs and symptoms of disease, and the way we encourage "taking a history" as the extraction of facts related to a diagnosis, with any other information deemed (by the doctor) to be irrelevant - ideed, patients who concetrate too much on these "irrelevant" facts may even be deemed to be poor historians. In our teaching, we pose clinical problems that always have an answer (and usually only one answer). We seek an objectivity that means anyone can mark the assessments. We develop and use symptom scoring systems to reliably diagnose or calculate risk for a huge number of conditions now, and we can even use the fact that people use more emotion-laden terms for their breathlessness to diagnose their chronic lung disease.

Evidence based medicine, in its success at giving us confidence about which treatments and tests work, has resulted in an inadvertent limitation in the sort of questions it is legitimate to ask in medicine. We are encouraged to ask "In a man aged 65 do the benefits of aspirin outweight the risks for primary prevention of cardiovascular disease?" It's not even assumed that we might ask the man himself of course - it is posed as purely an informational question. There are other types of legitimate questions that patients ask which the evidence has no answer for.

• "Should I see my sister with lung cancer on the Central Coast next week?"
• "Why do I feel so guilty about allowing my mother to go into a nursing home?"
• "How can I make her love me again?"
• "Who can I talk to? I feel so lonely."

In seeking out objectivity, we have crowded out the need for the voice of the patient without even realising it. If all you need to know about a disease is its pathology and biochemical markers, there's no need for a patient voice. Yes, we teach patient centred medicine, but if they know what's good for them, they'll fall into line with our objective evidence. Ultimately, when medicine is scientific, technical, "objective" then it is owned by us doctors, and patients don't really need to be involved.

Solutions

I have deliberately painted an overly bleak picture. In reality, there are many doctors (including most GPs?) who practice and teach medicine entirely inclusive of the patient's voice. Helman, a GP and anthropologist, wrote in a classic 1981 paper about the questions that patients want answered when they see a doctor:

1. What has happened?
2. Why has it happened?
3. Why to me?
4. Why now?
5. What would happen if nothing was done about it?
6. What should I do about it.or whom should I consult for further help?

It's apparent that only question 5 (and perhaps 1) is readily answerable by evidence based medicine.Medical schools are using the humanities - usually novels and film - to teach about the experience of being ill. However, it's notable that these approaches can still both be taught entirely sepearately from actual real patients - again, we have the capacity to go to research libraries to learn.

I have come to this in realising that our traditional objective approach doesn't work in Aboriginal and Torres Strait Islander Health. Where doctors (and other health professionals) need to be assessed or taught on cultural competence, Aboriginal people need to be involved in this. In asking Aboriginal people what they want from their doctors, they do want them to know the clinical science, but they also want them to have an appreciation of their lived experience. And reading about it is OK, but just doesn't come close to actually working in a community.

But this is what my patients wanted in Sheffield in the UK, too. Being a doctor is not just an example of applying evidence to a blank canvas. The way we teach and disciss medicine can make it seem as if it is, though. We need to find a way of appreciating the subjective, and combining our learning of scientific skills with hearing of the experience and priorities of those living with the conditions we discuss.

I was reminded of Richard Holmes' book The Age of Wonder, about the influence of the Romantic movement on science through the 1800s. (And also Craig Shuftan's book Hey Nietzsche Leave those Kids Alone - possibly the best book title ever!) Romanticism is about the power of the subjective experience. I wonder (in both senses!) if we need to recapture a Romantic movement in medicine - alongside our objective disembodied knowledge, we need a sense of the subjective experience of illness.

There are examples of patients being involved at all levels of medical student education. It does take individual and institutional goodwill, though. Here are my thoughts on how we could do it right now.

If you are a patient

• Take every opportunity you feel able to, to politely teach the doctors, nurses and students what you feel they should know
• Give them and the service feedback
• Ask around and find teachers enthusiastic to include you at the clinic, in the hospital and at the university 

If you are a student

• Take every opportunity you can to learn from your patients
• Ask them what they think you need to know
• Tell your teachers how much you appreciated learning from the patients

If you are a doctor (or other health professional) involved in teaching

• Take every opportunity to involve your patients in teaching your students
• Ask what they'd like your students to know
• If they want, help get them involved further with other organisations

If you are responsible for medical curricula

• Think about how you could get patients involved in development, delivery and assessment of learners
• Find out which individuals and groups are interested in getting involved
• Think about how the hidden curriculum at your institution sidelines patient voices.

You will have other, better ideas. Or you might completely disagree. I'd be interested to hear your comments below. It's my feeling that only by involving patients in medical education, do we help students really understand what is meant by patient centred, patient empowerment and partnership. And we bring a little wonder and Romance back into medicine.

GPs, Obesity and the Law – an amateur speaks

Recently the medical press, and the mainstream press have reported a case where a man won $365,000 damages from his GP for failing to do enough about his obesity. Like many GPs, my first reaction is WTF... My second reaction is to assume that there must be more to the case than just what is reported, and the case is going to appeal. So we don’t know all the details, but it does raise questions about responsibility and how well doctors influence behaviour. I think this brings us on to broader questions, too, about the role we ask doctors to perform in society and who is responsible for a healthy society.

Obesity is a risk factor for many health conditions, and as such, often ends up being managed in GP consultations. Sometimes it’s raised by the patient themselves, sometimes by the doctor. There is no miracle cure, it’s hard to lose weight. It takes a sustained change in diet and a sustained change in activity levels, both of which can be hard to do. Many people don’t want to try, many people try, and get frustrated by failure. This is only made worse by the images of success in tabloid “news stories” (read “marketing”) about celebrities and miracle diets. There is recent evidence that surgery can be helpful in weight loss, including preventing the complications of this. Even the surgery, though, doesn’t stop the requirement for long term lifestyle changes.

Read that paragraph back again, and note the language I used. Words like “risk factor,” “health conditions,” “managed in GP consultations,” “cure,” None of those words is wrong, but this is a very medical model and thinking like this will always ultimately mean the search for weight loss medications, and ultimately surgical solutions. It looks to me like the court has used a medical model like this – obesity is a medical condition, medical conditions are diagnosed and then have the (single) correct treatment given by the doctor to the patient and the patient gets better. See how passive the patient is in this scenario. And all the responsibility is on the doctor. That would seem to me to be how the court can come to a conclusion like this. However, real life is not quite this simple. As well as the medical language, see how I used moral language too: “...don’t want to try,” “failure.” To some extent the court judgement is about apportioning blame – a moral judgement – on one of the parties. Shall we choose the patient? Shall we choose the doctor? I don’t find this a particularly helpful way of thinking about this situation. This way lies arguments about compliance, and the set of discussions that assumes the people who come to see their doctors are frustrating nuisances. Reality is all just a bit more complicated than that.

At the core of what GPs do is behaviour change. We can get frustrated at how difficult it is to change people’s behaviour, but we will attempt to get people to stop smoking, reduce alcohol consumption, increase physicalactivity and eat more healthily. You can even view the prescribing of medication as behaviour change – for example from not taking aspirin daily, to taking it. One of the most widely used models to guide the way we do this is called motivational interviewing, which uses a stages of change model. In this model, people have change their thoughts about whether they want to make changes, and by understanding this GPs can adapt their discussions accordingly. 

Some people are described as being in a pre-contemplative stage, where they don’t recognise any need for change. Often doing anything more than raising the issue at this point just gets people annoyed. It’s when people are ready to make changes that you can dive in and make really practical suggestions. The trick is moving people around from being pre-contemplators to contemplators. It’s also crucial to note that failing to maintain change is a normal part of the cycle, and therefore not failure! This approach takes time, more specifically many conversations over numerous consultations. It also usually involves much more than just weight. It is unusual that there would not be other pressing issues too – physical health issues, mental health problems and social problems. And all of these interact – if you manage your anxiety by eating chocolate bars (and many do) then you need to talk about anxiety, stress and alternative ways of handling it and ways of changing that. It’s why GPs put such store on the relationship they have with their patients. These conversations have no hope without it. As it is, the evidence that we are effective at this is short on the ground (though I suspect that trials take a slightly reductionist approach – it’s unlikely that a trial would randomise to “Take as much time to cover all the issues which you and the patient believe might be relevant over several years” versus “usual care.” (Because that probably compares like with like!) I find it difficult to believe that a single referral would have made the difference in this case.

But this is a bigger issue than just what I as a doctor might be able to do with a patient over a period of time.  What we have managed to do is is create societies that make people sick. We develop our towns and cities with little green space, few cycle paths and pavements, and keep widening roads for all our cars to sit on unmoving. Physical activity becomes a product to be bought, either by joining a gym or by buying a Wii. We allow people to tell us that we are too busy to cook, so we should eat highly processed foods instead. If they’re unhealthy, then it’s a treat that you deserve, but if you can be told it’s healthy based on the presence or absence of single ingredients, then that’s even better. But you’ve got to eat processed. Because you’re busy. And you deserve it.

When we point out that the reason people become unwell is because of the environment they live in, then we get to do a bit more victim blaming – it was their fault; they had a choice. (Yes, but they were so busy! And couldn’t afford the gym)

So, by some strange combination, we end up with a situation where we are trying to claim that the person is unwell because they made a series of choices, and that the doctor is responsible for them staying unwell because they didn’t persuade the patient to make a different series of choices. Eh? (Another WTF!) 

Perhaps it’s useful to change the toxin. 

Imagine, if you will, a village where someone is poisoning the water supply. People are getting sick. You would want your village doctors to treat those who are getting sick. And you might want whoever is poisoning the water supply to stop. Instead they are telling us the water is very delicious. You deserve this water. And look how shiny the bottle is! Yes, you could go to the next village and collect water that isn’t poisonous. But you are so very BUSY. And look how cheap our water is. Lovely shiny bottles, see. You might ask why the village elders don’t stop the poisoners. Well the poisoners do donate much needed funds to the elders. And the system of self regulation, whereby the poisoners commit to reducing the amount of poison in the water to slightly less poison in 10 years time (never mind that they have missed similar targets in the past). And people do have a choice about which water they drink. And it does generate quite a lot of money (see how rich those poisoners are!) that generates tax revenue to fund those doctors you need to see because for some reason your personal choices mean you are all being poisoned! 

It seems obvious to me that a society that tells its doctors they are responsible for patching up (somewhat resource intensively and a little ineffectively) problems that are caused by the society we make people live in has got its priorities a little wrong. I’m left with a strange fantasy world where in the court of appeal damages are paid to both the doctor and patient by processed food manufacturers, town planners and the leaders who allowed them to poison our metaphorical water supply.

Where can you find an excellent doctor?

Performance related pay?

People only talk about two types of doctor. The really bad ones, and the really good ones. I like to think there are a lot more of the really good ones around. Many of us have met doctors we really admire, either colleagues or patients. It can be hard to pin down, though, just what it is that makes a really good doctor, especially one who is consistently good. Is it just a matter of personal opinion? Or if you recommend a really excellent doctor to me, can I be confident that we'll agree?


Interestingly, a team in Toronto have done just this to try and find out more about what was considered excellence in doctors. They asked doctors in their academic medical centre who they considered to be excellent physicians, and then interviewed the people who were named the most. The interviews came up with three consistent themes that described excellent clinicians: Core philosophy; deliberate activities; and everyday practice.

1. Core Philosophy
This was the personal values and beliefs held by excellent clinicians. There ere two components to this. The first was an intrinsic motivation, described as "passion" and "drive" for clinical care. This was described as putting patients first, curiosity about all aspects of patient care, including intellectual curiosity, and relationships with patients and colleagues. This drive sustained excellent practice over time, too.
The second component of the core philopsophy of excellent physicians was humility. There was an open-mindedness and desire to learn from alternative perspectives. It also exhibited as reflection on ones own abilities and limitations, though not as false modesty! Humility contributed to strong people skills ("people who are truly good clinicians never make a family or a colleague feel that they are beneath them") but it also contributed to good diagnostic skills, helping to avoid some common diagnostic mistakes. Humility also saw these clinicians downplaying their role in achieveements, attributing their success to others and circumstances.

2. Deliberate activities
These were the activities sought out by clinicians to maintain their performance over time. There were 2 components to this. The first was reflective clinical practice, where excellent clinicians described self awareness, attention to ones performance and learning from ones mistakes. The second was scholarship. This included research, teaching and knowledge synthesis, dissemination and application - essentailly applying research findings into practice - "...we need to try and advance thinking about a topic." This wasn't some academic desire for research for increasing publication, either. This was all related back to improving patient care.

3. Everyday practice
There were four components to this, and all were viewed as necessary for excellence. These were clinical skills and cognitive ability, people skills, engagement (enthusiasm and commitment) and adaptability. These are fairly self explanatory.

I think this description is useful, without containing too many surprises. Though it looks at a small number of doctors in a particular type of practice in one city in Canada, theses characteristics look familiar enough for us to imagine (hope?) they are transferrable to other settings.

So, come with me now to another setting. This paper reminded me of a paper published over a year ago asking a different question in a different setting. What are the characteristics of doctors working for over five years in challenging settings in Australia? These settings included Aboriginal health, drug and al;cohol services and in prisons. They identified three behaviours from their interviews.

1. Respect for patients
These doctors had a huge amount of respect and admiration for their patients. They described it as a privelidge to work with them, and were very interested in their patients as people, in the biography of them as a person.

2. A sense of control
These doctors  had control over  their working life. They made active choices in their career, and made the most of opportunities. Most worked in portfolio careers, and had interests in other clinical fields, research, advocacy or teaching. (Interestingly, this would be borne out by the 2009 Workforce survey, describing the smaller numbers of hours on average worked per week by those in Aboriginal health.) This sense of control is probably the reason why organisational factors or poor pay rates did not come out as negatives!

3. Intellectual interest
These doctors all found their work intellectually stimulating, and reflected deeply on it.

Though the categorisation is different, these two lists strike me as being very similar. The core philosophy of excellent physicians, may well translate out as profound respect for their patients in those working in underserved areas. The second paper describes a common thread of social justice motivation in deciding to enter this field of work. The deliberate activities of reflection and scholarship would overlap well with the intellectual interest of those working in challenging areas. The control over their careers is the mechanism for allowing this to happen, but could be described as one of the deliberate activities undertaken by excellent physicians. The everyday practice activities combine the intellectual curiosity and respect for patients. Being adaptible is what allows people to thrive in challenging circumstances - celebrating small, incremental change and not being bogged down in difficult organisational environments. It would seem obvious that enthusiasm and commitment is required to stay long term in these fields, and both these shine through the quoted section of the interviews.

This isn't definitive, of course, though I do find it suggestive. There are many unanswered questions. Would patients agree with this classification of excellent doctors? Would they even agree that those chosen were excellent? Would it be possible to have these characteristics and not be excellent, or stick around long term?

However, if you find this at least plausible, as I do, then there are some consequences that flow.

If you are involved in medical education, then perhaps the excellent role models you need to seek out are those who have been working long term in the undesirable parts of medicine. That would often mean getting out of the teaching hospitals.

And if you're wanting to develop an excellent workforce for areas usually difficult to staff, then perhaps creating an environment where there is room for adaptability and scholarship will go some way to encouraging excellence in your recruits.

If you're a patient seeking out excellence, it may be that you'll find it in those doctors working away in the places no-one wants to go!

Perhaps I've got this horribly wrong - do let me know your thoughts!

P.S. For further reading, The BMJ had a whole issue devoted to good doctors. Start with the editorials and letters (if you can get past the paywall. Sorry.)

check out this from JAMA: A Physician = Emotion + Passion + Science - an opinion piece, but sounds familiar doesn't it.

And finally, if, as a doctor, you consider yourself a scientist, then you might want to define science in this rather wonderful way:  Science is formalised humility

References
 
Mahant S, Jovcevska V, & Wadhwa A (2012). The nature of excellent clinicians at an academic health science center: a qualitative study. Academic medicine : journal of the Association of American Medical Colleges, 87 (12), 1715-21 PMID: 23095919

Stevenson, A., Phillips, C., & Anderson, K. (2011). Resilience among doctors who work in challenging areas: a qualitative study British Journal of General Practice, 61 (588), 404-410 DOI: 10.3399/bjgp11X583182

Hurwitz, B. (2002). What's a good doctor, and how can you make one? BMJ, 325 (7366), 667-668 DOI: 10.1136/bmj.325.7366.667

Rizo, C. (2002). What's a good doctor and how do you make one? BMJ, 325 (7366), 711-711 DOI: 10.1136/bmj.325.7366.711 
(And the other letters with this one!)

Brook, R. (2010). A Physician = Emotion + Passion + Science JAMA: The Journal of the American Medical Association, 304 (22) DOI: 10.1001/jama.2010.1807

Fixing AHPRA's draft Social Media Policy

There has been a lot of comment among Australian health professionals on social media about the Australian Health Practicioner Regulation Agency's (which I'm going to call AHPRA from now on!) preliminary consultation document on social media policy. (The policy is available here.) For a flavour of the debate, have a look at the posts on Croakey and read the comments, too. The only positive comments I've seen are that AHPRA are venturing nto this area and inviting feedback. The preliminary consultation document itself reads like it was written by someone who's not used the internet for the last decade!


There seems to me to be an obvious way forward for them, though. It is a related to the Medical Board, but would be appropriate for all the other health practitioner boards, too I would imagine. Ironically, the whole policy could be written ina single tweet with room to spare!

Practitioners engaging with social media are reminded of their obligations under Good Medical Practice.

As doctors, we have already been given guidance in a document called "Good Medical Practice" (Opens PDF document). The principles in here would be good guidance for the way we engage with social media. Most of the document relates directly to patient care and would only be tangentially relevant, but the initial principles and some of the later sections are highly relevant, and would produce some very different recommendations.

To quote:

"Doctors have a responsibility to protect and promote the
health of individuals and the community."

  The way we use social media can be measured against this statement.

"Good medicine is Patient Centred"

It seems to me, it is impossible to be patient centred if we are not willing to listen to what our patients say, both as individuals and as groups. There are many people who would find it easier and more natural to comment on the services they recive through social media, rather than face to face. There are already websites dedicated to hearing patient views - Patient Opinion is probably doing this best, based on some good outcomes from the UK. I have had interesting discussions with mental health advocates from around Australia, and heard the opinions of many Aboriginal people about their experfiences, which is essential in my role as a GP working with Aboriginal people. Restricting who I might connect with or how I might engage in discussion would seem to be counter-intuiitive towards achieving patient centredness. The potential that social media has for hearing the perspective of our patients has enormous potential to improve our practice, and it would be a shame to miss out on this because of fear of making a wrong step. There are boundary issues, and the vast majority of health care providers are aware of these, and reflect all the time on how their social media activity impacts on this. I have seen very thoughtful online discussions about whether o follow patients or not, which have used both professional guidance and other people's perspectives. Patient advocates often contribute to these iscussions, which give them a richness often missing elsewhere. It's worth pointing out that the same boundary issues often come up for practitoiners working in a small rural town, and are certainly taught about in GP training.

"Professionalism embodies all the qualities described
here, and includes self-awareness and self-reflection.
Doctors are expected to reflect regularly on whether they
are practising effectively, on what is happening in their
relationships with patients and colleagues, and on their
own health and wellbeing. They have a duty to keep their
skills and knowledge up to date, refine and develop their
clinical judgment as they gain experience, and contribute
to their profession."

I would argue that our use of social media is entiely underpinned by professionalism, self awareness and self reflection, and that those practitioners who do this regularly in their professioanl life are also doing this for their social media use. Those who struggle  with this in their day to day practice are also likely to struggle in social media. However, I wouldn't be surprised of they also had practitioners and non-practitioners telling them clearly when they thought a boundary had been crossed. Our use of social medis reflects our personality after all. (And here is a good example of a medical student learning the hard way! But this is a brave exmple of reflective practice after a mistake.)

"For the doctors
who undertake roles that have little or no patient contact,
not all of this code may be relevant, but the principles
underpinning it will still apply."

And his would be the same for social media use.

"Doctors have a responsibility to contribute to the
effectiveness and efficiency of the health care system."

Social media has been a very effective platform for doing this, and disseminating messages about this. Again, social media is not the only way of doing this, but is one of the many tools. From the wording of this, it could be argued that doctors on social media should be encouraging this!

 "There are significant disparities in the health status of
different groups in the Australian community. These
disparities result from social, cultural, geographic, healthrelated
and other factors....Good medical practice involves using
your expertise and influence to protect and advance the
health and wellbeing of individual patients, communities
and populations."

This has been one of the main reasons I have been using social media. I work in Aboriginal health, and have used my social media presence to engage internationally, and advocate for improved services, as have many people all over the world. Again, the prionciples of Good Medical Practice would seem to indicate that an active social media presence to engage on issues like this would be part of our duties, rather than something to be discouraged.

 "Doctors have a responsibility to promote the health of
the community through disease prevention and control,
education and screening"

One of my most re-tweeted tweets was about the measles outbreak in South West Sydney. I encouraged people to ensure they were fully vaccinated. I would hope that many people saw this message, and that I was doing ym duty under Good Medical Practice.

"In professional life, doctors must display a standard
of behaviour that warrants the trust and respect of the
community. This includes observing and practising the
principles of ethical conduct."

This section, which includes a parts on professional boundaries and advertising, would be highly relevant for our use of social media - are we behaving in a way that warrants the trust of the community - I don't think this means having no opinions at all, but might go to how we express them. The principles behind these would be (and probably have been) useful starting points. There is an issue for clarity, though, about advertising in social media, where the interactive nature can blur the line between patient engagement and advertising - mainly because big corporations want to "engage" with their customers, and the wording and tools look the same, even if the intent is different.

"Conflicts of interest"

This hasn't been explored much, but would be relevant. It is being discussed a little in the journalism world, and in the medical world in the context of drug companies and publication in journals, but there would be room for declarations somewhere, I would imagine.

I am sure these are not the only sections of  Good Medical Practice that would be relevant, but this would seem to be the obvious place to start.

There is much discussion in the #hcsmanz community at the moment, so do please put your in your two-pennies here, at Croakey or on twitter.

Health Care and Social Media - Look in the rear view mirror occasionally

When I was learning to drive, I remember having it drilled into me to look in the rear view mirror regularly. If you were slowing down, look in the mirror, if you were changing lanes, look in the mirror, if you were reaching for your mobile phone while eating a pie, look in your mirror.

Now I'm relatively new to Twitter (and haven't quite got the hang of Facebook, don't use Linked In to its full potential, haven't even got a Pinterest account and love Citeulike...etc...etc) but some of the most interesting conversations that I've been following have been about HCSM and HCSMANZ - health care and social media.

There's a real sense that something new is about to happen, that social media has the potential to revolutionise communication and engagement in health care, across services, between different professionals and, most importantly for patient engagement in their health care and health services. Increasing effective engagement and enablement of patients could really improve health outcomes. That, I think, is really worth working towards, and social media could really help this to happen.

And now comes my but. But.

I'm writing this watching multiple tweets fly across my timeline. Twitter is such an active medium, there is so much going on, that it can seem like that's all the activity there is. But I'm thinking of some recent people I've met and onversation I's had.

A elderly neighbour is writing a history of doctors in our local area and has asked me to look at the manuscript. It's printed out on paper from an old word processor, with a hand-written cover note.

A tech-savvy senior health care manager isn't sure how o operate twitter.

Many of my patients have no computer at home, don't have a smart phone, and struggle to operate the phone they do have. Difficulty paying bills means phones often change numbers, or are cut off or not used for a time.

My local library has a sign up saying their computers are not to be used for Facebook or Twitter.

These experiences are summed up in two really important bits of research looking at the digital divide, or who doesn't have good access to computers and smart phones. In essence, it's not surprising that those on lowest incomes have least access. But the important thing about this is that those on lowest incomes also have the highest health care needs.

So, think of the elderly, with a range of co-morbidities, really needing to be engaged in high quality health care, who might, like I heard someone say this week, just say "Facebook is stupid".

Think of many Aboriginal and Torres Strait Islander people, who through reasons of geography, money, literacy or health problems may find engaging online very difficult.

Think of those with health problems or disabilities - who, by definition need health services - who may have difficulty using the technology simply becuase of their health (my elderly neighbour mentioned above has quite severe rheumatoid arthritis).

My plea, then, is to make sure, when moving forward into the bright, engaging future of using social media in health care, that we check the rear view mirror every so often to see who we might be leaving behind. We won't find them on twitter. We might not even find them in our clinics. But they are definitely out there, and need to be enaged just as much to get good health care.

P.S. Thanks to these tweeps for a conversation on this topic, too: @LeonoraOT  @lygidakis @Dr_J_Lowinger @yusunbin and @PracticalWisdom 

Low pay for health staff in poorer areas?

So, Andrew Lansley, the UK Health Secretary, is supporting proposals to pay health care workers in poorer areas of the country less. It's as if, after pushing through an NHS Bill that almost no-one in the NHS supported, which allows, some-one stood up and asked "No, I'm still not sure these changes will make care worse for those on low incomes," and so Lansley says, "OK then, how about cutting pay for hose working in the areas that are hardest to staff and hardest to work in. Will that convince you?"

Some background: In 1971 - that's 1971, whern Andrew Lansley was aboout 15 - Julian Tudor Hart published a paper which has become rightly famous. The title has passed into the health lexicon - The Inverse Care Law. It is worth quoting the abstract in full.

"The availability of good medical care tends to vary inversely with the need for it in the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced. The market distribution of medical care is a primitive and historically outdated social form, and any return to it would further exaggerate the maldistribution of medical resources."

Let me paraphrase that for the hard of understanding: Places that need health care the most, get the least.

I think there is a good argument that any public health system worth its salt should be thinking about how to tackle the inverse care law. It hasn't been solved yet, either in the UK or in Australia (or, indeed, on a global scale). Andrew Lansley's plan just walks straight in the opposite direction.

I was struck by this quote from the proposal quoted in the Guardian:

The introduction of more sensitive market-facing pay would therefore enable more efficient and effective use of NHS funds." (my emphasis)

I would have thought that effective use of NHS funds would be to improve the health of those with the worst health. And that more efficient use of funds would be to direct funding to these areas preferentially. Clearly, I am wrong. The most effective and efficient use of NHS funds must be to continually reduce pay for those who work in the areas where it is most needed, until no-one works there at all.

There are 2 reasons I care about this, and in a nese, this is my declaration on interest.

I am from the north of England and my work in the UK was in communities who had been devastated by the closure of coal mines and steel works - I was working there about 20 years after this happened, and the recovery was only just happening. So, friends who work in these places still certainly stand to lose out. And, worse, the communities will lose out as they find it harder to attract and retrain staff - especially as the staff will be graduating from universities  with bigger and bigger debts, and will need to work in higher paid areas to pay this off.

The second reason is that it also allows me to reflect on the Australian context. The Inverse Care Law is alive and well here - rural and remote areas really struggle to attract doctors (and to be fair, financial reasons are probably not the whole reason for this) as do the poorer outer suburbs of the cities. In my sector of Aboriginal health, pay rates are less than other areas of General Practice, but the need is greatest. There is evidence that seeing a large number of Aboriginal patients reduces billing rates (and so GP income) by 25% - it remains to be seen whether Practice Incentive Payments will make up this gap.

Note also that practices that have a higher number of Aboriginal patients, patients from non-English speaking backgrounds and older patients are those that are more likely to be teaching students and registrars. Anecdotally, most teaching practices feel that they lose income doing this.

I suspect things would not be that different in the UK, though fee for service in Oz certainly has the capacity to exacerbate these discrepancies. The knock on effects on inequalities and on teaching are obvious.

So, Health Secretaries of the World, if you're in the market for differential pay rates, try out this method: make health workers pay inversely proportional to the median income of the area where they work. The higher the population income, the lower the health worker's income.

Naive? Idealistic? Perhaps. But I'd rather be that than actively choosing to worsen inequalities in health.

Power to exclude people from the health service?

The title of this post is taken from this BMJ article by Allyson Pollock, David Price and Peter Roderick. These are not sellers of the socialist worker on street corners. Allyson Pollock is a respected health services academic. These words are some of the scariest I've read - and there is no shortage of very frightening predictions about the likely consequences of the NHS reforms in the UK.

There is no question in my mind - the NHS bill should be stopped. And it's not just me who says this. My College, the RCGP, has been at the forefront of health service workers who are against these plans, and that's because its members are against the reforms. The government somehow claims that doctors support the bill, but they've mistaken carrying on doing their best or their patients as support. I have never known such unified support against a health reform.

Why should I care? I work in Australia. There are a few reasons why I care.

1. All my family live in England. They range in age from well into their 90s down to very early childhood. They'll probably be OK because they are all bright eloquent people. They are not on the poverty line, but don't have enough cash around to visit us in Australia. So I want them to have a good health service.

2. I trained in the NHS. The values I have as a GP I got from working in an area of Sheffield which had been devastated or decades by the closure of mining and steel works in the area. The doctors, practice staff and hospital staff who trained me worked hard to provide the best possible care to people who were not sought out by commercial firms. There's a lot of thought put into improving this sort of service - for example see the GPs at the Deep End project.

3. I now see the effects in Australia of people being excluded from the health service - not deliberately, usually just thoughtlessly - and I am astonished that a service that is the envy of the world would seek to deliberately make themselves more like the worst services.

What does that mean in practice?

Just this week, I spent half an hour on the phone trying to find an ENT surgeon who would see someone without charging extra money. This was not for something minor, either, but a condition that needs surgery to be treated if it is not to eat away the bones in your head. Seriously. Clinical need wasn't the deciding factor, income was.

Someone once came to me in tears because the specialist had said to her "You must have $2000 tucked away somewhere" about her operation. She was upset and incredibly embarrassed.

Anecdotes, yes, but most GPs practicing in underserved parts of Australia will recognise these stories as being very common. (And the difficulty of getting GPs to work in underserved parts of Australia is another part of this story, of course). Just about none of my patients have private health insurance because they can't afford it - we regularly run out of food vouchers for people where I work. Paying for medical appointments and medications comes a long way behind paying for food and rent.

Australia has a "Universal" health care system, called Medicare. Medicare statistics show (p6) that Medicare expenditure for Aboriginal and Torres Strait Islander people is just over half that for other Australians. As you may know, Aboriginal and Torres Strait Islander people have the worse helath outcomes in Australia. There is a lot of work currently to "Close the Gap," and a lot of this is around improving access. It is incredible that a service like the NHS that get's this so much more right is moving in the exact opposit direction. An NHS bill that even allows the possibility of excluding people from the health service needs stopping. Having a service in the world that prides itself on excellent access for all is an inspriation to those of us elsewhere in the world. Yes, it's not perfect. But it does a lot better than anywhere else. Until the bill gets passed of course.