The NSW Doctor Sept/Oct 2023 Issue _ V2

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IT COMES AS NO SURPRISE that the Australian Medical Association was just ranked among Australia’s most trusted ethical associations. This year’s Governance Institute of Australia Ethics Index found the AMA ran a very close second to Choice, with a net ethical rating of 56, up 3 from last year. The annual nationwide survey measures perceptions of ethical issues and conduct in Australia. You can read the survey here

This is a clear indication that there is enormous confidence in doctors and the way they conduct themselves. At a time when many doctors are feeling their value is being questioned this will hopefully come as a fitting reminder of how greatly you are appreciated.

In my three months at the AMA my respect for the dedication of Australian doctors has grown exponentially. I am constantly discovering the many wonderful things that doctors do, not only within the parameters of their job, but well beyond the scope of what is expected. What I have found is that this is not for recognition, far from it. They do it because they truly care for their patients and want the best possible outcome for them. They do it without highlighting their efforts, to anyone. It seems this is the doctors’ way.

For this reason, we have started the Health Hero section in both our magazine and our fortnightly newsletter. It is a chance to celebrate the often life-changing or even life-saving work of our members. We know you don’t want to sing your own praises which is why we’re asking members to tell us about their colleagues. Tell us about a small act of kindness, or a major breakthrough. Tell us about a retiring member who leaves an incredible legacy. Tell us about your mentor, or a student whose light has shone brighter than you would ever expect.

We’ve also started a Soapbox section which is where you can tell us how you feel about any aspect of the health system. It’s your chance to express your opinion or make a suggestion. Many members have expressed a desire to communicate more broadly with other members. Feel free to take up this opportunity.

Finally, in our fortnightly newsletter Feel Good Friday we’ve started Health Hacks. If you have any tips of tricks that might make help doctors or their patients, or just help us all as humans, then please send them to us.

If you would like to make a submission to the Health Heroes, Soapbox or Health Hacks sections, please email me at magazine@amansw.com.au

I look forward to telling your stories. dr.

Rahni Sadler, Editor

THE SOAPBOX

Tell us how you feel

Write to us about what’s on your mind how you feel about health policy, management, practice, shortages, ramping, hours, staffing, equipment, public health, media coverage, public disinformation. Tell us about something your practice/hospital is doing that others could learn from. Raise an issue that you think needs to be addressed. Put the focus back on a subject that has fallen off the radar. Is there something you’ve been experiencing that nobody seems to discuss? What more could the AMA be doing for you? Write

Dr Michael Bonning President, AMA

GIVING 1000%

MEDICINE IS AN ALL-CONSUMING

MISSION for so many of us. A doctor called me in tears this morning having done five nights on call with very little sleep and ongoing one in two on-call roster that would continue for the foreseeable future. It is in thinking about every colleague who puts in long hours and is ready when the phone rings at 3am that I consider the AMA’s purpose.

I draw from a defining statement of military leadership – the responsibilities of the leader are twofold: to accomplish the mission and to preserve the welfare of the unit.

My view of medicine is that there is no opportunity for “mission accomplished” but we can improve the outcomes and steer our profession and the people we care for to better results knowing that we have improved the system for future doctors and their patients.

The second component is critical to the first – that we preserve the welfare of the unit. The unit consists of us and the people we work with, who together are responsible for the success of any clinical team.

A collegiate profession is one in which members look after each other and recognise that unity and pulling in the same direction are paramount to success. Whether someone is a GP, staff specialist, VMO, doctor-in-training or locum, they have all shown up to work with the intention to provide medical services to the best of their ability. I want us to remember

that throughout periods beset with turbulence, that we are a collegiate profession that needs to act in concert to preserve the welfare of all.

This can be through small acts in the operating theatre, the tearoom, the office, through how we communicate with our colleagues and through how our actions back up the written words of our workplace or organisational policies. More than ever, we need to stand shoulder to shoulder and look after one another. We know that this not only benefits each of us as doctors but that this flows on to our patients.

In a literal sense it’s impossible to give more than 100% but if you ask any doctor, it often feels more like 1000%. In an overwhelming majority of clinical circumstances the ultimate responsibility for patient care and outcomes rests with the doctor. At the AMA we recognise that burden of responsibility and your necessity to the health system and want to assure you that we are giving our all to advocate for the welfare of doctors on the frontlines of healthcare. Be it fighting for hospital funding, support for general practice, certainty on payroll tax or just recognition of the 1000% given by so many of our dedicated members. dr.

In this tumultuous time for health in NSW I think about why we do what we do, as doctors and as the AMA.

(NSW)

In an overwhelming majority of clinical circumstances the ultimate responsibility for patient care and outcomes rests with the doctor.

Dr Arany Nerminathan Member since 2018

FROM THE CEO

COURAGE AND RESILIENCE

We would encourage all practices to consider the “what ifs” in their environments.

AS MEMBERS WILL BE AWARE, on Monday 21 August 2023, there was a significant security incident at AMA NSW. At around 9.50am, a man used the intercom to seek entry into the AMA NSW offices in St Leonards. Staff refused to allow him access, at which point he allegedly broke through the door with a hammer and made his way into the office. We are unable to elaborate on the circumstances, due to legal reasons.

Fiona Davies CEO, AMA (NSW)

I would like to acknowledge the courage and resilience of the AMA NSW staff in managing the situation until police arrived. My team worked together admirably throughout what many found a very frightening experience, and were a great support to each other in the aftermath.

While we closed the office for the day, many staff still responded to urgent member enquiries and staff returned to work promptly the next day. In doing so, they reflected on the dedication of you, our members, to your patients and community.

The incident has served as a timely reminder to be aware of the risks faced by all businesses, including medical practices. We would encourage all practices to consider the “what ifs” in their environments and to ensure that key staff members are tasked with thinking about various risks. This does not need to be alarmist or paralysing, it should be empowering and informed.

In my organisation, I particularly benefited from staff who did spend time thinking about these issues. Too often, it is easy to dismiss such issues as not the most important thing or something that you will get around to. You don’t expect them to happen to you. We did not expect this to happen to us.

While it is impossible to take steps to safeguard against every possible scenario, the fact that we had recently upgraded simple security measures was of great assistance.

I would like to thank the many members who reached out with messages of support and concern. Your consideration and support are gratefully appreciated. dr.

The incident has served as a timely reminder to be aware of the risks faced by all businesses, including medical practices.

DOCTORS WITH LONG COVID

One of the most unsettling and least understood parts of the pandemic.

BOWRAL GP DR FIONA MACKINTOSH

is one of an estimated 10% of Australians who developed what’s colloquially known as “Long Covid” after a bout of Covid-19. She contracted the virus in February 2022.

“I had fevers and some chills, you know the achy, achy feeling. I had a sore throat and a bit of a cough and some people call it chest pain, I think it’s more that feeling like your breathing is really heavy, and it’s painful to breathe. It probably lasted a week.”

After a week of symptoms, Dr Mackintosh thought she was on the road to recovery.

“But then the fatigue hit. I just needed to keep sleeping and felt that I wasn’t able to get up. I felt like I was walking through quicksand. You go ‘Hang on a minute. This is not getting any better.

“I had taken the week off work and then went ‘Oh, no, sorry. I think I might just need to have a little bit more time off work’ and then I got to two weeks and went ‘Oh, sorry, maybe I need to take the whole month.’

“It probably took four to six weeks to realise ‘You know what? I’m not really picking up here.’ And I started to wonder, how long is this going to last? That’s when I slowed down a lot.”

The medical term for Long Covid is “post-acute sequelae of

SARS-CoV-2”. The World Health Organisation defines it as “the continuation or development of new symptoms 3 months after the initial SARS-CoV-2 infections, with these symptoms lasting for at least two months with no other explanation.”1

While there is still little known about Long Covid, it appears that it could be more prevalent among frontline health workers.

In July the British Medical Association released the first major survey of doctors with Long Covid, which revealed a “debilitating impact on health life and work”.

Carried out with support group

PRE-COVID

- I would get up around 6 am

- Do 30-40 mins of resistance training or walking

- Dress and head to work for 8.30 start

- See patients from 8.30-12.30

- Lunch and questions from registrars

- See patients from 1.30-5 pm, then questions and paperwork.

- Home around 6.30 cook dinner and family time.

- Paperwork for another 1-2 hours and prep for the next day.

Long Covid Doctors for Action the survey asked 600 doctors suffering Long Covid about the impact the condition is having on their health, daily lives, employment and finances. Doctors reported a wide range of symptoms, including fatigue, headaches, muscular pain, nerve damage, joint pain, ongoing respiratory problems and many more. Among the key findings:

● Around 60% of doctors told the BMA that post-acute Covid ill health has impacted on their ability to carry out day-to-day activities on a regular basis

● Almost one in five respondents (18%) reported that they were now unable to work due to their postacute Covid ill-health

● Less than one in three (31%) doctors said they were working full-time, compared to more than half (57%) before the onset of their illness

● Nearly half (48%) said they have experienced some form of loss of earnings as a result of postacute Covid

- Wake up after a poor sleep with heavy fatigue.

- Stiff and sore. I may lie in bed for an hour before being able to get up.

- Finally after 18 months, I am able to get ready quickly.

- See patients for two hours maximum before I’m too tired.

- Come home for lunch.

- Nap most most afternoons.

- Push myself out of bed to possibly do very light exercise.

- Maybe ½ hour of paperwork.

- Dinner, family time, bed.

“It gets very boring having to be around home and not venturing too far. I think the times I have been most frustrated have been major events or family time that I have to miss because I’m too tired or have just done too much in the lead up and now can’t move. When I’ve overdone it, I can get quite emotional.”

Dr Fiona Mackintosh

19 MONTHS LATER

A DAY IN THE LIFE OF DR FIONA MACKINTOSH

● 54% of respondents acquired Covid-19 during the first wave of the pandemic in 2020 and 77% of these believed that they contracted Covid-19 in the workplace

● More than 65% of doctors responding said their post-acute Covid symptoms had not been investigated thoroughly and effectively by an NHS Long Covid clinic or centre. And almost half of doctors reported not even being referred to an NHS Long Covid clinic at all.

Included in the survey were first person accounts from affected doctors:

“I nearly lost my life, my home, my partner and my career. I have received little support to help keep these. The impact on my mental health nearly cost [me] my life again.”

- Locum junior doctor

“I can no longer work, finances are ruined. I didn’t have employment protection so am now unemployed and penniless.”

- Salaried GP

“Life is absolutely miserable. Every day is a struggle. I wake up exhausted, the insomnia and night terrors are horrendous as I live through my worst fears every night. Any activity such as eating meals, washing etc will mean I have to go to bed for a few hours. I am unable to look after myself or my child, exercise or maintain social relationships. I have no financial security. Long COVID has totally destroyed my life.”

- Consultant

“I am almost housebound and have had to buy a mobility scooter

for the few occasions that I am well enough to get out. For the last 6 weeks I have been relying on family members to help me look after my children.” - Consultant

Professor David Strain, BMA Board of Science Chair, said: “We know that throughout the pandemic Covid-19 had a profound and often tragic impact on healthcare workers, but now this report and the heartbreaking accounts within it lays bare the debilitating effect that the virus continues to have on those doctors living with long-term symptoms.

“Contrary to what some may associate with the term ‘Long Covid’ these doctors are not just ‘a bit tired’, nor are they ‘withdrawn due to the isolation of lockdowns’. They are living with a range of serious health conditions caused by their initial Covid-19 infections, most likely caught while they were caring for others on the front line.”

Dr Fiona Mackintosh has been incredibly fortunate in that she had taken out income insurance years before Long Covid hit. It removed the financial pressure and allowed her to focus on slowly getting better.

“I read some research that said, ‘If the symptoms persist around the 12 week, 16 week mark, then you might have it for a year and it will fade off.’ So, I had that on my mind. Once I got to that phase, I went okay, right. I’m just going to have to lean into it and wait it out.

“I think I was also just so tired and so fatigued that it was just actually a little bit overwhelming to really think about the future. It was making me more anxious. It was easier to go, ‘Yeah, right, whatever. I’ll just sit

and watch TV’.

So many things would come up that I was wanting to do, and I’d just have to go ‘At the moment you’re not well enough. You’re just going to have to go back to bed and rest”.

It’s been a very slow process for Dr Mackintosh who quite literally could not walk from the front of the supermarket to the milk on the back shelf. Her journey to recovery took a sideways turn after a Covid booster in July last year.

“The fatigue did improve a bit but then I got pain. It is a very generalised body ache that’s sometimes in odd places like the inside of my elbows and my ankles and there is a real heaviness to it because I’m tired. I get this thing similar to restless leg syndrome that people describe.

When she sought help, Dr Mackintosh was taken aback at how little was available. “My GP heard this clinic had opened at St Vincent’s and we made a referral in about March. I didn’t get in until August. By that stage my symptoms

“Tai Chi... gives me the opportunity to think about how pleased I am that I have come this far, and to look forward to hopefully returning to the life I once had.”

had changed from just fatigue to more pain because of the booster and I’m not sure that’s what they were focused on. It seemed at that stage that the clinic was screening patients for more serious illness to exclude significant breathing issues or cognitive changes and the fatigue wasn’t something they were really able to offer any management options.

“They said ‘Okay, see how it goes. We think you might be okay by the end of the year. I was given some self- management guidelines from the UK and my physio was able to discuss her treatment with the clinic physio. Recently, I had a talk to the Long Covid physiotherapist about some breathing techniques, as there has been more research on breathing techniques and rehabilitation for autonomic dysfunction.”

“At the time I was very unwell the access to assistance for Long Covid was very difficult, with hardly anything available or with very long waiting times. And the clinics are only based in the Sydney with nothing available regionally.” Dr Mackintosh said.

Recently a virtual clinic opened above Royal North Shore’s old emergency department. Dr James Zhang says Northern Sydney Long Covid Service offers virtual care “It means we can provide for patients while they’re at home. You’ll be validated, you will be heard ,and we will come up with an individualised plan for how we can look after you.”

It connects patients to the right support from allied health workers to specialists such as neurologists. A similar service is running at Nepean Hospital.

The Hills Private Hospital also advertises a fully supervised reconditioning outpatient program

for patients suffering Long Covid as does the Mojo Klinik in Neutral Bay.

Dr Ken McCroary, who appeared before the House of Representatives Standing Committee on Health, Aged Care and Sport’s Inquiry into Long Covid, says that one of the recurring themes of the ongoing Covid-19 pandemic is confusion and uncertainty. He believes the percentage of doctors affected by Covid could be smaller than those in the UK but not by much.

“I think we hope for the best but expect the worst. It’s true we were lucky to avoid some of the initial health disasters and Covid onslaught due to the benefit of distance and our island isolation. But we still had a significant number of health care workers infected early and I’d thus be expecting quite significant long-term morbidity and the other social sequelae of Long Covid in our local cohort too.

“Thankfully the bulk of our health workers had the luxury of being vaccinated prior to our first infection; despite GPs never being considered a priority group for immunisation by the Federal Government.”

Dr Mackintosh is one of the few doctors who’ve chosen to speak publicly about her condition. “I’m quite a private person but I am happy talk about it because hopefully I can encourage more research into the causes and possible treatment options.

“For me it’s been more than 18 months and I am much improved. I will wake up with a heavy fatigue after a poor sleep and a stiffness, but it does wear off after about half an hour of moving around. I can certainly manage breakfast and shower and get myself dressed, do all those things now.

In the beginning I’d have to have breakfast, then have a rest, then shower, then have a rest and so on. Now I can do about two hours work but I do end up fatigued at the end of that.

“I tried to see myself as lucky to be home because I’ve got a teenaged daughter and she’s had me at home more giving her more attention.

I used to walk 5km twice a week with a friend. Now I can just manage 5000 steps on a good day. Last year, that would have been nearimpossible, giving me significant post exertion malaise. We were on a trip, and I walked 5000 steps. I ended up having to rest in bed for 2-3 days to recover.

“I have recently been able to manage some slow exercise, Pilates and Tai Chi, which is so exciting.”

“Tai Chi has been lots of fun. It’s a different form of therapy but it gives me the opportunity to think about how pleased I am that I have come this far, and to look forward to hopefully returning to the life I once had.” dr.

THE UPSIDE OF DEMENTIA

LIVING BEYOND A DIAGNOSIS OF DEMENTIA

WHEN BRENDAN GREER was diagnosed with dementia at age 61, he and wife Jenny felt all their life plans fall away.

“We’d done all our financial planning and we had our retirement all mapped out with all these trips and things. Then we thought ‘Oh gosh. Wow. That’s our future gone.’”

Brendan quit the high-level sales job he’d loved for years and resigned himself to an ongoing decline in his cognitive abilities. He felt the light had gone from his world “I wasn’t in a black hole, but the sky was pretty gloomy.”

That was until the couple attended the inaugural Rementia Together retreat in August. Dementia is a Latin term meaning to be “without the mind”. Rementia translates to “return to the mind.”

The five-day Sydney-based residential retreat is designed to revolutionise life for those in the early stages of dementia. “Instead of looking at what they can’t do we switch the focus to what they can.”

Program Director Donna Ward told The NSW Doctor.

Each retreat caters to five couples. “We want to give them hope and a way to live into the future. For them and their support partner not to suffer with dementia but really live their best life past the diagnosis.”

Program creator Tamar Krebs said.

Tamar Krebs is the Founder and Director of Group Homes Australia, specialists in Alzheimer’s & Dementia care. Its motto is “Doing

Dementia Differently”.

“We recognised that there was a substantial gap in dementia care. Diagnosis is improving, but living with dementia in the community is not.

“Dementia is the only chronic disease in 2023 that you get a progressive degenerative terminal disease diagnosis, and then virtually no support. If you get diabetes or hypertension, you get a lot of support in terms of how to live with this new disease, whereas with dementia, there’s very little. People are told to go home and get their affairs in order – when these people have many years of life ahead that could be much better managed.

“And so that got us thinking about ‘How can we do better in Australia?’” Tamar said. “I felt we had an obligation to teach people with this diagnosis the skills and strategies to live well.”

Group Homes Australia sought and received government funding for 33 five-day getaways. Each for a person living with dementia (PLWD) along with their primary support person. While most are romantic couples, there are retreats dedicated to other forms of supporters. In October there will be a retreat for couples made up of a parent with dementia and their daughter.

“While participants have fun, this is not respite – this is a lifeline to a world many PLWD and their loved ones thought had already gone.” Tamar said.

The program includes lectures by an occupational therapist on how to adjust the home environment, a social worker who talks about sex and intimacy, a GP who addresses food, mood, exercise and sleep, a neurologist who speaks about and answers questions surrounding diagnosis, research, medication and outlooks, a financial planner, as well as talks by Tamar on demystifying dementia, unmet needs and communications, Donna about human needs, Dementia Australia on the variety of supports in the community and the advocacy programs PLWD can get involved with, as well as a dementia advocate – a PLWD sharing his living experience, how he was diagnosed and what he’s done for the past ten years speaking to conferences, boards, governments and being an agent for change.

Jenny & Brendan Greer

“It’s a nice thing for doctors to have something besides a diagnosis to give.”

“They could really see their life differently.” Tamar said. “They could see where they could get involved, have a purpose, how they could get out and about – which both helps them and other PLWD.”

The practical side includes providing “cognitive ramps” to allow those with dementia to return to or continue the activities they loved.

“When people have a physical disability, we build wheelchair access ramps. When something is falling away in the mind and you can no longer do something, for example sequencing that affects a certain part of the brain, we provide cognitive ramps to give people that independence back.”

Donna Ward explained.

“If they loved cooking, we teach their support person to help put steps in place to facilitate their ability to cook again. If they loved golf, we provide tools to get them back on the golf course.”

Tamar and Donna made sure the program was both engaging

and entertaining “It’s not just about information. It’s about different styles of learning, through movement, peer support, psychological ventilation, emotional support through music, art, virtual reality. Through experience you can have wonderfully fun moments. You don’t need memory to have enjoyment.”

“We had an art session which was all about perspective and creating narrative. We asked their perspective and challenged their perspective. There was no right or

wrong. It was just about changing their narrative. It was really cathartic.”

It was a whole new world for Jenny and Brendan “We sort of had our own perceptions of what we saw and that was really interesting because we learnt we could see things differently and also we could go off and do that ourselves.” Jenny said. “I could take Brendan into the NSW art gallery and do that as an exercise that’s fun and good for both our mental stimulation. Also, I can get a picture from the past and discuss that with Brendan.”

Participants were also invited to join a drum circle which Tamar said was a highlight for all. “You create your own rhythm and together you find each other’s. It was connecting through music and motion. They were dancing and drumming and laughing. It was beautiful.

“We also did virtual reality travel. This facilitator brought 5 headsets and asked them where they wanted

The retreat was inspired by a 1980s respite program designed by Professor Henry Brodaty and Doctor Meredith Gresham. Researchers followed participants for eight years after they attended the ten-day program. Tamar said they found it vastly impacted participants reliance on external support.

“From the public purse perspective they reduced the use of carers, it reduced the hospitalisation rate, there was a reduction in behavioural and psychological symptoms of dementia and the biggest benefit was the reduction in admission for people going into long term residential care.”

Participants at the inaugural Rementia Together retreat.

Tamar Krebs & Donna Ward

“We recognised that there was a substantial gap in dementia care. Diagnosis is improving, but living with dementia in the community is not.”

Tamar Krebs, Founder and Executive Director of Group Homes

to travel to. They went to France, Italy, a farm. For an afternoon they were completely immersed, giving them great joy and plenty of laughter.”

Just as important was the peer support. Early on breakout sessions were introduced. One for PLWD and one for partners.

“They’re two separate groups so they can really start to bond and create that peer support moving forward. And that’s a critical component because we know dementia can be very, very lonely for both partners. The groups carry on via WhatsApp and I think that’s really important going into the future.” Tamar explained.

Jenny found the groups incredibly rewarding “Initially I was sort of holding back, I wasn’t sure I wanted to share my true feelings but it was facilitated so well by this amazing social worker. When I heard other people opening up, I realised I could learn so much. Another wife said, “You’re so protective of Brendan” and I realised that I was wrapping him up in cotton wool. I discovered I have to let Brendan be Brendan otherwise he will get frustrated. Don’t shut him down by doing things for him, facilitate his independence.”

Brendan and Donna are now planning on taking the six-week Mediterranean cruise they had had reservations about.

“With the information and the interaction and the dialogue that was shared, it revitalised me.” Brendan said. “It increased my scope of understanding and showed me the increased possibilities for life. I was no longer focused on all the impossibilities. We left there feeling we’re ready to fight our best fight. Being armed with information and understanding is a tremendous platform to work from.”

Jenny left feeling jubilant “The retreat was life changing. It’s really

FEATURE

informative and it gives you hope and you go ‘Okay, life’s not over.’ It gives you the tools to get back a lot of what you’d given up, and shows you how even though you have dementia, you can have quality of life.”

That quality of life has been further enriched for Brendan who is taking a step he thought would no longer be a part of his future. He’s returning to the golf course. “The reason he didn’t want to was because he was a bit worried about being out on the golf course by himself. And they taught us what you do is you’ve got to expand your life, not contract it. You therefore need to bring other people into your life. You let the golf pro know, he will tee you up with the same people each Wednesday and they know Brendan’s situation and they

can help him get out and play that game of golf.” Jenny said.

For Brendan, it’s a chance not only to do something he loves but to do it with his loved ones. “I’m going to play golf with my sons. I didn’t think I’d get to do that. I’m looking forward to getting my handicap down.”

Donna Ward said the retreat far exceeded expectations. “When they arrived all of the couples talked about how much smaller their world had become since they had their diagnosis. When they left, they couldn’t believe how much room there was to grow”.

“We had this one couple and the husband did not want to share his diagnosis with any of his friends. It was affecting him and his partner because they weren’t able to socialise. His partner was nervous to go out and leave her partner because she was worried about him, but couldn’t tell anybody or ask for help. On day two, after we talked about human needs and unmet needs. He said “That’s it. No more shame. We’re going home and we’re gonna tell everybody.” Having seen the pain that that was causing, the worry, it was causing his partner and then the lightness by the end of the week, they were both making jokes. It was wonderful.” dr.

For more information or to apply for the Rementia Together retreats please go to www.grouphomes. com.au or phone 1300 015 406

“It increased my scope of understanding and showed me the increased possibilities for life. I was no longer focused on all the impossibilities. We left there feeling we’re ready to fight our best fight.Being armed with information and understanding is a tremendous platform to work from.”

Brendan Greer, Rementia Together retreat participant

RACISM IN HEALTH CARE

What does racism in healthcare look like for First Nations Peoples and what can we do to help?

stereotyping, and unsafe physical spaces that further disadvantage minority groups10. Racism directly impacts the health of Aboriginal and Torres Strait Islander (ATSI) peoples. These experiences can lead to poorer-self reported health status12, lower perceived quality of care, underutilisation of services, delays in seeking care, failure to follow recommendations, distrust, interruptions in care, and avoidance.

racism and inadequate reporting has a detrimental effect14 on the growing number of ATSI health practitioners.

INSTITUTIONAL RACISM9 is embedded in governance structures and processes, as well as in the delivery of services and in workplaces. It can be seen in attitudes, behaviours or processes which amount to discrimination through prejudice, ignorance, thoughtlessness, racist

Racism experienced by First Nations health practitioners Racist remarks and behaviours burden practitioners operating within the health system. Systemic

Despite the extent to which ATSI health professionals experience racism, according to AHPRA’s 2019/2020 annual report16, 7,637 health practitioners identify as ATSI. This exceptionally low rate demonstrates the extent to which institutional racism may influence the number of ATSI people wanting to enter the health system. It also demonstrates a key issue within the health system regarding cultural competence, as a limited number of First Nations practitioners impacts

A background paper prepared by Australians For Native Title & Reconciliation (ANTAR)

“Systemic racism in the health system directly influences Indigenous Australians’ quality of and access to health care services.”

Australian Indigenous Doctor Association13

“Indigenous doctors are 5.5 times more likely to report bullying as a major source of stress, 10 times more likely to experience racism, and 27% of Indigenous health students reported being very stressed by racism.”

Australian Indigenous Doctor Association15

upon the cultural safety procedures and knowledge implemented.

What is being done to address racism in the health system?

Peak ATSI health bodies22 argue that boosting culturally safe clinical care may substantially contribute to Indigenous health improvements. Moreover, help address the gaps23 in health and wellbeing between non-Indigenous and Indigenous Australians. The 2020 National Agreement on Closing the Gap24 has recognised the importance of listening to the voices and aspirations of ATSI people and has implemented this as a foundational measure in the new approach to address inequalities between First Nations people and non-Indigenous Australians. This new approach recognises the need for community-controlled organisations in order to deliver best services and outcomes, and the urgency for government agencies and institutions to address systemic racism and promote cultural safety, and transfer power and resources to communities. Both of these critical elements have been adopted as priority reform areas two and three of the Agreement.

The central role of community controlled services25 (CCHS) is transferring control to community members to ensure the health and wellbeing of the local community is addressed. Parties within the Agreement have acknowledged that CCHS are better for First Nations people, achieve better results, employ First Nations people, and are often the preferred service type.

Where CCHS aren’t available, it is critical that mainstream services provide care that is culturally safe. Culturally safe health care26 involves understanding a patient’s culture, acknowledging differences

and being actively mindful and respectful of these, understanding theory of power relations, having an appreciation of historical contexts, and acknowledging racism at an individual and institutional level and its impact on First Nations peoples.

“You cannot have an aboriginal flag or piece of artwork or a totem attached to your facility and then think you’re culturally safe and responsive to the health needs of that community.”

Jamie

Newman, CEO of Orange Aboriginal Medical Service31

What more can be done?

Under the Racial Discrimination Act 197532, it is unlawful to discriminate against a person based on race, colour, descent, national or ethnic origin, or immigrant status. This protects people from racial discrimination in public life, for example getting or using services, but clearly this isn’t enough.

“Aboriginal and Torres Strait Islander peoples’ lives, health and wellbeing cannot be put at risk because of underlying racism and prejudice.”

Professor Fiona Stanley33

The Australian Government announced its support of the United Nations Declaration on the Right of Indigenous Peoples34 in 2009. This Declaration is an international instrument on the rights of Indigenous peoples and has established a universal framework of minimum standards for the survival,

dignity and well-being of Indigenous peoples. Despite Australia’s voting in support, it is obvious that several Articles within the framework have not been met, for example: Australia’s Race Discrimination Commissioner, Chin Tan, has launched a plan to establish a National Anti-Racism Framework and has called on the Federal governments support. Racism is an economic, social and national security threat to Australia and we need to treat it as such. In October 2022 the federal government allocated $7.5 million over four years for the commission to build a strategy to promote racial equality in Australia.

Healthcare Initiatives to combat racism: ST VINCENT’S & KATHERINE HOSPITAL

Sydney’s St Vincent’s Hospital37 recently went from being the worst in the state to one of the best when caring for ATSI patients in emergency, similar to the actions of Katherine Hospital38 in the Northern Territory.

“A high number of Aboriginal people were coming in through our emergency department and were leaving us, not completing their treatment.”

Pauline Deweerd, Director of Aboriginal Health at St Vincent’s39

“More than ¼ Indigenous patients left Katherine Hospital before completing treatment, often without informing staff.”

Simon Quilty, Physician40 Related Links.

“You cannot have an aboriginal flag or piece of artwork or a totem attached to your facility and then think you’re culturally safe and responsive to the health needs of that community.”

Jamie Newman, CEO of Orange Aboriginal Medical Service31

SCOTT DALEY HAS BEEN the person behind the scenes making change happen at St Vincent’s, implementing the new Indigenous Flexi-Clinic. The program ensures Aboriginal patients in emergency are quickly triaged, treated, offered support or care by an Aboriginal staff member and referred for ongoing care through the expanded Aboriginal health unit where possible. This approach allows for connections to be formed and has made a big difference for outcomes and safety levels. One of the key successes has been expanding the Aboriginal health unit’s operating hours, ensuring patients are able to complete their treatment. Since the

introduction of this program, the rate of incompleted treatment for Indigenous patients reduced from 19.5 per cent to 1.6 percent.

The NT Department of Health conducted an investigation into the staffing crisis at Katherine Hospital and found significant deficiencies in nearly all essential dimensions of safe clinical service provision, with the root cause being that the unsustainable medical service model, progressively getting worse. Following this, a group of doctors joined the hospital with the objective of turning the rate of incomplete treatment around. The rate of incomplete treatment by Indigenous patients in Katherine Hospital dropped from

11 per cent to 4 per cent with the introduction of specific measures by these new practitioners. Changes that improved the rate of incomplete treatment were, the implementation of highly trained specialist doctors invested in the community, interpreters, and consultations with families regarding complex treatment plans.

The challenges that St Vincent’s and Katherine Hospital faced around providing care for ATSI peoples aren’t unique, so these cases of community initiatives could be seen as blueprints for hospitals around the country. dr.

Changes that improved the rate of incomplete treatment were, the implementation of highly trained specialist doctors invested in the community, interpreters, and consultations with families regarding complex treatment plans.

Scott Daley, Former Aboriginal Health Manager, St Vincent’s Hospital

Read the full Antar Racism in Healthcare report here.

Anti-racism in the Emergency Department:

Navigating clinician experiences of racism

By Dr Lai Heng Foong, Senior Staff Specialist, Emergency Medicine Chair of Public Health and Disaster Committee, ACEM (Australasian College for Emergency

Trainee experiences of racism, bias and discrimination

Racism has been shown to be directly linked to poorer health outcomes for patients.1 What is less appreciated is the impact of racism on medical training, whether in medical school or during postgraduate training. Doctors and medical students from ethnically minoritised backgrounds are up to three times more likely than their white counterparts to fail examinations, including: undergraduate and postgraduate assessments, machine marked written assessments, practical clinical assessments, assessments with pass or fail outcomes and assessments with continuous outcomes.2 Ethnic minority graduates of UK medical schools have worse outcomes during recruitment for foundation, specialty training and consultant positions, and progress more slowly through training even after accounting for examination failure.2,3 These differences are unlikely to be attributable to learner deficits; a systematic review found these differences remain after controlling for pre-university academic

attainment, socioeconomic status, own and parents’ first language, motivation for being a doctor, study habits, living arrangements (home or away) and personality.3 An international review found that minority medical students ‘experienced less supportive social and less positive learning environments [and] were subject to discrimination and racial harassment’.4 This differential attainment in doctors of minority racial groups has been extensively studied in the UK, but not in Australia even though similar issues exist.

As a trainee, I did not feel empowered to raise issues of racism I encountered in the workplace. The incidents were many but the most destructive encounters were ones where I raised the issue of discrimination in training or examination process and was told by my senior that racial discrimination did not exist and I should just work harder, put aside my personal commitments, in order to pass my examination. I would also often have racist encounters with some patients, who preferred to be seen by ‘white’ doctors, or old white men who made passes at me, treating me like a prospective ‘mail-order’ bride. All these incidents reduced me to either a trainee with ‘deficits’ or an object to be desired. There were also many microaggressions, including failure to register my name and failure to

As there is a paper written on racism from an Australian First Nations perspective, this article will focus mostly on other ethnically minoritised groups.

Minority-group physicians are more likely to work in and with underserved minority communities, and they generate better engagement and health outcomes for patients of similar ethnic/racial background.6

Dr Lai Heng Foong

be heard – I always had to repeat things and I was made to feel like I could not be understood.

Cultural diversity in the medical workforce has been shown to improve the accessibility and quality of healthcare for minority groups.6 Minority-group physicians are more likely to work in and with underserved minority communities, and they generate better engagement and health outcomes for patients of similar ethnic/racial background.6 Addressing racism in medical training is an integral part of reducing racially based health disparities.

How to respond to the racist patient or colleague

According to the Challenging Racism Project of the University of Western Sydney, almost 40% of racist incidents in Australia occur in public spaces, including on public transport.7 This extends to the doctor-patient encounter in EDs. When confronted by a racist patient, a doctor is placed in an ethical dilemma, to ignore what they say, or to confront them about it. People of colour are more likely to encounter racism in the workplace.8 Personally, after many encounters with racist patients, I have developed a graded approach that is a compromise between zero tolerance to racism and my duty of care to patients. For example, when I encountered an elderly white man who demanded to see a ‘white doctor’, I calmly explained that I am the most senior doctor in ED and if they wanted to see my intern, a white male doctor, he is very welcome to, but they would be speaking to me anyway. I said I would give him some time to think about it, walked away, and when I came back he acquiesced to me being his treating doctor.

The Medical Defence Union has provided some practical advice to manage this situation.9 First, make a written note of what was said or done, with verbatim quotes if possible, so there is a contemporaneous record of the incident. Second, make a note of people who were present and witnessed the incident, so they can be asked for statements during any subsequent investigation. Third, ensure that you report the behaviour so it can be investigated by your workplace. Fourth, if the patient shows signs of agitation or anger, try to state boundaries and state that racism is not tolerated in your ED. Be prepared to end the consultation if you feel there is an imminent risk of physical aggression.

How to create an anti-racist health organisation

To create an antiracist health system, we need to first acknowledge that racism permeates every level of society. When people say they have encountered racism, our response is never to deny that they did, or ‘blame the victim’. It takes courage to come out and say that they have experienced racism. We need to create a system that is inclusive, diverse and committed to eradicating structural and entrenched racism. We need all doctors to reflect on their privilege.

How to provide culturally safe care and develop cultural competence

Many studies have demonstrated that cultural competence saves lives, improves health outcomes and strengthens the doctorpatient relationship.11 Developing cultural safety should be focussed on organisational and systemic improvement, rather than an educational journey alone for the individual; instead of being an educational exercise, it is rather a reflective self-assessment of power, privilege and biases, as demonstrated above.

To build a culture of antiracism, we should assess patterns of hiring, salary, retention, advancement and leadership appointments for all health system employees and develop a plan to rectify disparities.17 Leaders of healthcare organisations must be invested in efforts against institutionalised racism by integrating antiracism in training and education, supporting research to test these efforts, financially incentivising clinical care matrices to align with eliminating disparities and altering existing policies and practices.10, 13 dr. Read the full report here. Related Links.

Dr Lai Heng Foong working with Médecins Sans Frontières in Angola in 2002.

DOCTORS AND DENTISTS

Helping each other help patients

WHILST THE MOUTH IS often considered separate to the rest of the body, medicine and dentistry go hand-in-hand. Dentistry is a relatively small profession with a big heart but perhaps less reach, so we’re asking our doctor friends to help spread the word about the benefits of dental prevention.

A difficulty faced by dentistry and healthcare in general is that patients often present with established disease, where treatment may be substantially more extensive and expensive than prevention. There are opportunities to guide patients toward reestablishing good oral health once they attend a dental practice; the greatest challenge is getting people through the door.

Almost 29% of Australians aged 25 to 44 have untreated tooth decay. In NSW dental conditions were the

HANDY ORAL HEALTH QUESTIONS

• Have you had your teeth checked and cleaned by a dental practitioner within the past 12 months?

• Have you noticed any bleeding gums during pregnancy?

• Do you have any tooth pain?

• Have you had fillings or other dental treatment in the past?

• Do you brush your teeth twice a day with a fluoride toothpaste?

• Do you floss between your teeth?

third-leading cause of potentially preventable hospitalisations. Let’s try to mend this with an integrated approach.

Tooth decay is a very common yet preventable disease, with modifiable risk factors. Oral hygiene and diet improvement, along with fortification of enamel via topical fluoride form part of our armamentarium to prevent tooth decay.

As a first point of contact, in both sickness and health, doctors, nurses and other non-dental primary healthcare providers are perfectly poised to assist dental practitioner efforts to improve community oral health.

Early Childhood Oral Health

Babies start to cut teeth within their first year, with a full set of baby teeth by around 2-3 years old. Baby teeth serve important functions, including chewing, speech, psychosocial function and maintenance of space for adult teeth. In NSW 40% of children develop decay in their baby teeth by 5 years of age. To add to this, dental conditions were the highest cause of preventable hospitalisations in the 5-9 year age group (almost double the rate for asthma and 4 times higher than ear, nose and throat infections)

Decay can progress quickly in baby teeth due to thinner tooth structure, and by the time a cavity is visible the dental pulp may already be involved. It is therefore important to regularly assess child dental health from a very early age in order to prevent pain, infection,

and burden on a stretched public health system. We also need to develop positively charged trusting links between children and dental practitioners with continuity of care.

The Blue Book (My Personal Health Record) issued to newborns in both NSW and the ACT is a wonderful way for medical professionals to highlight oral health and direct patients toward oral health services. With an oral health screen included at each scheduled health check from 6 months of age up to 4 years of age within the Blue Book, there are worthwhile opportunities for our esteemed medical counterparts to become oral health champions.

> How can you help?

1. Complete a “lift the lip” check as part of each health check from

6 months of age. Look for white or brown spots that don’t rub off, cavities, inflamed gums or abscesses. If a problem is found, direct the patient to private or public dental services.

2. Encourage parents to take a child for their first dental check-up by one year of age.

3. Remind parents to take their child for regular dental check-ups.

4. Remind parents to brush their child’s teeth twice daily, and start using a fluoride toothpaste from 18 months of age.

5. Remind parents to check if their child is eligible for the Child Dental Benefits Schedule.

Maternal Oral Health

There is a misconception that women should avoid visiting the dentist while pregnant. Conversely, it is actually very important to maintain good oral health during pregnancy, including maintaining routine dental visits. Most dental procedures can be completed during pregnancy, including dental x-rays, with the second trimester considered the most favourable for treatment.

Maternal decay risk correlates with child decay risk, with a higher incidence of child tooth decay when a mother has poorer oral health.

Morning sickness and altered eating patterns may increase tooth decay risk, while gum problems may be intensified during pregnancy due to hormonal changes, with pregnant women often presenting with gingivitis and increased risk of periodontitis. Untreated periodontitis (gum disease) during pregnancy is associated with pre-term birth and low birth weight.

> How can you help?

1. Discuss oral health at antenatal

visits and encourage pregnant women to get their teeth and gums checked by a dental practitioner.

2. Ask specific questions about oral health.

3. Reassure pregnant women that most necessary dental treatment can be completed during pregnancy, including check-ups, cleans, x-rays, fillings, root canal therapy and extractions.

4. Discuss maternal oral health again at the 1-4 week newborn health check.

Geriatric oral health

Dental health issues are one of the biggest health concerns globally with an increased presence amongst older people. Studies within a global context have shown that 20% of adults aged over 65 have tooth loss and more than half have gum disease.

Compromised oral health may lead to reduction in chewing ability, social avoidance, restricted food choices leading to discomfort, pain and undesirable quality of life. Furthermore, gum (periodontal) disease and tooth decay may exacerbate the risk of systemic diseases such as diabetes.

Conditions such as obesity, dementia and diabetes place older adults at a high risk of dental disease. As a consequence, older individuals may experience dental trauma, broken teeth, dry mouth (xerostomia), gum disease and missing teeth compromising overall function.

Within Residential Aged Care Facilities (RACFs), it has been shown that individuals had compromised oral health and did not receive adequate dental care in time. So it becomes important to integrate oral health checks periodically within RACFS. dr.

TIPS FOR DOCTORS VISITING A RESIDENTIAL AGED CARE FACILITY

• Perform regular mouth checks having a look at the tongue, lips, gums, teeth and dentures (if present) as a starting point.

• Perform routine oral hygiene management activities such as cleaning after meals and provision and periodic replacement of dental hygiene management aids such as toothbrushes and floss.

• Create a network of local dental providers. This is especially useful when there may be a dental emergency.

• Ask the oral health screening questions from the ‘oral health care for older people in NSW’ toolkit and if answer is ‘yes’ to any of those questions, seek appropriate referral to the nearest dental professional.

• Keep a log of patient’s oral health concerns and changes and discuss with nurses, visiting medical and dental professionals.

By Dr Jodie Olivier and Dr Mohit Tolani, Australian Dental Association (NSW Branch)

Health Heroes

DR DEVIN DEO

DR

“During one of his paediatric rotations, Devin was part of a team providing care to an extremely premature baby with poor family support who had a multitude of medical conditions, resulting in the baby having to spend many months in the hospital. What he did for that tiny baby was remarkable.”

DR DEVIN DEO

Position: Senior Resident Medical Officer

Nominated by: Dr Billy Tran

28-YEAR-OLD DEVIN DEO was not destined to be a doctor, well not as far as his doctor parents were concerned “They kept telling me all the horror stories ‘You’re gonna be awake until 3am while everyone’s asleep and you’re going to be wondering why.” They told me what a hard life it is to be a doctor, what a hard road I would be paving for myself.”

“Despite everything they told me they were such an inspiration to me. I think all the warnings somehow made me more determined to do it”.

“Then I had a patella dislocation with ligament tear, twice, and had it operated on by an orthopaedic surgeon, and he took such good care of me. It was awesome. From before the surgery to after and all the follow ups and everything. He just explained everything to me so well. He reassured me, and he was

Deo

exactly the sort of doctor I wanted to be. Having gone through that experience of having somebody who not only was medically capable but who could also give that empathy and reassurance had a powerful impact on me. The way he conducted himself is still the basis of how I am trying to conduct myself.”

Devin was born in Malaysia but grew a love for Australia when visiting as a child. “There’s just something about the people that’s just so welcoming and I felt it would be a lovely place to be at.”

He was nominated by Dr Billy Tran who said “Devin is a hero because he’s so dedicated and passionate in striving to provide the utmost care to his patients. Devin consistently seeks to improve himself in terms of clinical skills and regularly goes above and beyond what is required of him in caring for his patients.

“He has an exceptional ability to communicate with patients and carers, which is especially powerful in his current rotation in oncology. Devin has cultivated such a wonderful rapport and established deep personal connections with many patients and parents

Devin described the experience. “This baby was born at like 26 weeks. He was in the hospital for more than 100 days and he pretty much spent every day on his own in this tiny little room. Because his parents weren’t there, and the nurses were so busy he was basically in bed all day, so the back of his head became flat. I would literally take him outside in a pram with the oxygen tank on and the nasal prongs on his nose. I would push him around the hospital corridors, and often around the little garden so he could get some sun. It was just so he could experience the world beyond the walls of his room. I would carry him and just walk him back and forth and talking to him, giving him little cuddles.

“I always loved paediatrics right from the first time I was exposed to it during my medical school days. There’s something quite beautiful about advocating for patients. I guess kids need a bit more advocacy. Obviously, when you’re in hospital, it’s a very scary place and having seen kids at their worst… and some of them go through the most frightening conditions… very life threatening and debilitating conditions, yet somehow, they are so resilient in the face of all of that, they push through. And there’s that just sort of hope that you don’t really see in many other specialties or departments or very few others.”

“Both of my parents are doctors. They really discouraged me from becoming a doctor. But they inspired me and here I am.” DR DEVIN DEO

Devin with a patient in the oncology ward at The Children’s Hospital at Westmead

Devin

as a child in Malaysia

Ash moved to Australia from Bangladesh when he was 4 and then spent most of his childhood growing up in a small rural town in NSW called Leeton.

Having finished his General Paediatric training in Sydney a couple of years ago, Ash is currently well into his second fellowship in Paediatric Intensive Care.

Ash explained “I went into paediatrics because it’s such an interesting and broad area of medicine. We look after patients as young as 24-week-old premature babies to 17-year-old adolescents.

“I was drawn to paediatrics because I quickly recognised how different the culture is in a children’s hospital. Everyone in the hospital, no matter who they arespecialists, ward clerks, the kitchen staff, everyone, they’re all here for one reason - they love working

“A truly incredible inspiration for what a good clinician should be — not only is he kind but incredibly knowledgeable and always strives to facilitate a nurturing environment for his students.”

A STUDENT UNDER DR QUADIR’S MENTORSHIP

with children. It’s a very inspiring environment to be in.”

Ash is a pediatrician who works as a senior registrar in ICU where he regularly works 14 hours shifts.

“I find working in the intensive care unit the most rewarding experience by far. We have the privilege of looking after children and families through some of the most challenging times of their lives. Seeing my little patients come back and visit when they are better, and smile and laugh is the best. My job is truly a privilege.”

Dr Jess Mills says “I nominated Ash because of his overwhelming dedication to his job and his colleagues. During his years as the Chief Resident at the Children’s Hospital at Westmead in 2020, Ash helped navigate his peers through the many challenges brought about by the pandemic. He has such a caring nature; he wouldn’t go home without doing a walk around the wards ensuring that all of the day teams had handed over and were not staying back late. He really cares.

Ash is currently a clinical lecturer with the University of Sydney and is actively involved with supervision of trainees and paediatric recruitment. He has built a strong foundation

in clinical leadership during his training culminating in his selection as one of fifty international candidates for Harvard Medical School’s Paediatric Leadership Program Certificate in 2019 and as the Children’s Hospital at Westmead Chief Resident Medical Officer in 2020.

“In Ash’s current job as one of the Senior Registrars in the Paediatric Intensive Care Unit at CHW, he helps to look after some of the sickest children in the country. In this role, Ash needs to be quick and thoughtful under pressure, be able to work cohesively in a big team and be able to communicate effectively in order to help these families through what may be the worst period of their lives. The long hours and demands of working in such an intensive environment can be very stressful for all the healthcare staff, but they just take it in their stride.” Dr Jess Mills said.

Ash believes his job is an honour and says that the rewards can outweigh the extensive demands. “One experience that really warmed my heart was when I ran into one of my oncology patients years on. I had treated him when he was 4. He had leukemia. I had looked after him immediately after his diagnosis. A few years later he saw me at the hospital café and ran up to give me a hug yelling “Dr Ash!”

ASHFAQUE QUADIR

Position: Fellow Paediatric Intensive Care, Nominated by: DrJess Mills

Ash as a small child in Bangladesh

DR JACINTA TRANG

Position: Basic Physician Trainee, Nominated by: Dr Domininc Ku

DR JACINTA TRANG

Dr Jacinta Trang is a Basic Physician Trainee currently on her psychiatric rotation. She has been at The Children’s Hospital at Westmead since the beginning of 2023.

Jacinta grew up in Strathfield in Sydney She was fifteen when she first visited The Children’s Hospital at Westmead, arriving in dramatic fashion, via a plane from Canberra after a skiing accident at Thredbo.

“I ended up on the orthopaedic ward. The people who looked after me were incredible. I saw how the nurses and doctors were able to give me hope in a time which was very uncertain and walk me through that process of recovery in a really gentle and loving way. That’s what inspired me to do medicine. Since then I’ve always wanted to work at Westmead so coming here this year has been an absolute dream come true.”

From that moment in year ten she has wanted to become a paediatrician.

“Last year, on my paediatric neurosurgical and rehabilitation terms, I was able to work with many patients and their families for almost the entire duration of the 20 weeks. For example, a few of the patients would come in with severe brain injuries, and at the time of presentation their prognosis would be uncertain. It was really rewarding to follow their journeys and see some of these patients exceed expectations and physically walk out of the department on discharge. I loved being able to get to know patients and their families well and celebrate the small and big wins with them during their recovery. For me, this was so fulfilling.

“More recently, we had a patient on the ward who had had behavioural challenges for three years. It was very difficult for her school and family to manage and it seemed like there was nothing left for them to do. It was amazing to see how the medical and allied health teams came together to support this patient during her admission and ensure that she had adequate support on discharge. I followed up with her parents after she left hospital, and I was thrilled

to hear that she’s doing really well at home. To us, for the team, that was a massive win.”

Dr Dominic Ku said of Jacinta “Dr Trang has a heart of gold and it shows every day on the ward.

She really goes out of her way to give her patients the very best experience. She dedicates time to get to know patients and their families, actively listening, speaking words of encouragement.

“She understands that being in hospital can be challenging for children and tries to brighten the day of all those that she comes across. On her current psychiatry term, she has had dance parties with the children and joined in with ward activities to make them feel more comfortable and build better rapport.

For Jacinta, there’s no better place to be than The Children’s Hospital at Westmead. “I love working here at Westmead. I love that they just have such a holistic view of health. It’s not just about getting the patient in and out and making sure their physical ailments are repaired but it’s about ensuring that they are loved in this process. You can just see it in all the staff here and the amount of joy they have in doing what they do.” dr.

“I was a patient at this hospital in year ten after a skiing accident and have wanted to come back and work here as a doctor since then. I’m so grateful that this dream has come to fruition. I love working here.”

DR JACINTA TRANG

Dr Jacinta Trang as a toddler

Medical Records:

FREQUENTLY ASKED MEMBER QUERIES

Medical practitioners and practices will often need to respond to requests for medical records of their patients, and these requests may come in a variety of forms.

As part of AMA(NSW)’s Workplace

Wednesday Webinar series, Melanie Fayad recently presented a webinar on the legal and privacy obligations for medical practices when responding to requests for access to or disclosure of patient medical records by patients or third parties. In this article, we answer some of the questions received by our members in relation to patient privacy and medical records.

Q: If we are asked to provide a copy of a patient’s full medical record, what does this include? Just the doctor’s notes and reports? Or does it extend to reports or letters from other doctors kept in the record?

If you have received a request to provide a copy of a patient’s complete medical file, and that request is accompanied by the patient’s signed and valid consent (or the disclosure is otherwise authorised under law), the documents that make up the patient’s medical record and which should be disclosed include:

• Consultation notes (handwritten and/or electronic)

• Letters to and from other doctors, healthcare providers and other correspondence

• Test results

• X-rays and scans

• Photographs

• Digital recordings

• Specialist letters marked “private and confidential” or “not to be released to a third party” form part of the record and should be produced to the third party regardless of whether the specialist has provided specific consent. As a courtesy you may wish to let the specialist know you have released the letter.

Q: What should a patient’s signed consent contain?

The patient must give written authority to the disclosure of the medical records requested by the third party. This written authority should:

• Be addressed to the practice or practitioner being asked to supply the medical records.

• Specify which documents the patient gives authority to disclose;

• Be signed and dated by the patient.

You should ensure that documents requested by the third party are within the scope the documents the patient has given authority or consent to disclose.

If you are concerned about the validity of the signed consent, including its currency, you should raise these concerns with the party making the request before proceeding further.

WORKPLACE RELATIONS

Q: Is it still acceptable to transfer a copy of a patient’s medical records by e-mail?

It is still acceptable to communicate via e-mail. Encryption is safest but not essential.

If you are sending patient information by e-mail, further security measures should be considered to protect the information against the risk of unauthorised access. These measures should be explored in consultation with your IT provider and may include:

• Password protection or encryption of e-mail attachments which contain patient information;

• Sending a secure link to the file which is stored in encrypted cloud storage.

Q: How should I respond to a phone call or a visit from the Police requesting health information about a patient?

You should not disclose patient health information to the Police based on a verbal request. The Police do not have an automatic right to access patient health information. You should ask the Police officer to put their request in writing to you along with the authority on which they rely to access the information. This authority may come from the patient themselves, or there may be a legal order or process which authorises the disclosure at law. There may be exceptional circumstances where disclosure of patient health information may be permitted based on a verbal request – for example, in an emergency or where there is a

threat to the life, health or safety of an individual or individuals. In each case, you should seek advice about responding to requests for information from the Police.

Q: Do I need to obtain a child’s consent if their parent seeks access to their health information?

When considering requests from parents or legal guardians for health information concerning a child (under the age of 18), you will need to consider whether the child has the capacity to make the access request on his or her own behalf. There is no defined age at which a child gains capacity. However, if a child has the capacity to consent to medical treatment on their own behalf, it is generally understood they will be entitled to confidentiality at that point.

If the child does not have capacity, then you may be able to give access to the parent or legal guardian. However, you will also need to consider whether giving access to the parent or legal guardian is appropriate, having regard to:

• Who has the care and responsibility for the child.

• Whether there are court orders or parenting orders in place in relation to the care of the child (which may extend to involvement in health matters).

• Whether the personal information of other individuals is contained within the records.

Q: Can I disclose health information to the immediate family member or spouse of a deceased patient?

Privacy and confidentiality obligations to patients extend beyond their passing. After a patient has passed away, the only person who can give authority to the disclosure of the deceased patient’s health information is the executor or administrator of the deceased’s estate.

An immediate family member or spouse or next-of-kin does not have authority to access a deceased patient’s health information unless they are the executor or administrator. There may be circumstances where the disclosure of limited information is permitted for bereavement purposes, but advice should be sought about responding to such requests.

If the disclosure is requested by the immediate family member or spouse in the context of a dispute regarding the deceased’s estate, you should not release any information without seeking advice. dr.

In each circumstance, we recommend you seek advice if you are asked to supply or give access to a patient’s medical records. The AMA(NSW) Workplace Relations Team can provide advice and assistance in relation to these matters. Please contact us workplace@amansw. com.au or (02) 9439 8822.

2023 HOSPITAL HEALTH CHECK

Thank you to everyone who took part in AMA (NSW)’s seventh Hospital Health Check (HHC). The HHC is an opportunity for the state’s doctors-in-training to express how they’re feeling about their current working conditions.

This year’s Hospital Health check was launched on May 19th and closed on June 30th. There were around 1400 participants, 30% of whom were interns, and 57% of whom were female. The hospital with the greatest number of responses was Westmead Hospital, closely followed by Royal North Shore Hospital and Wollongong Hospital.

On the whole results were encouraging, showing increased levels of overall satisfaction, decreased levels of fatigue concerns over personal health and safety, a jump in the number of respondents claiming and being

paid for all unrostered overtime and an increase in allocated days off taken on request. However, there is still much to be done. The number of respondents who reported that excessive work hours had led them to make a fatigue induced clinical error remains high, at 46%. The reporting of intimidation increased from 17% to 30%. Sick days are something doctors-in-training remain reluctant or unable to take when necessary.

While technical difficulties have prevented us from yielding as much data as has been gained in previous years there is plenty of useful information from this year’s survey.

THERE WERE AROUND 1400 PARTICIPANTS, 30% OF WHOM WERE INTERNS, AND 57% OF WHOM WERE FEMALE

We have your results!

OVERALL SATISFACTION

Last year 46% of participants agreed or strongly agreed that they felt valued by their hospital, this year that number jumped to 55%. The jump was even higher for respondents who agreed or strongly agreed that they would recommend their hospital, up 11% from 54% in 2022 to 65% in 2023.

LEAVE SATISFACTION

Overall, 8% more respondents were either satisfied or very satisfied that their leave preferences were taken into account, increasing from 61% to 69% in 2023. Among those who had difficulty taking leave, the main problems encountered were that respondents’ preferred periods were unavailable or approvals were delayed. Of all the issues experienced, all were reportedly experienced at lower rates than 2022.

FATIGUE

ROSTERING & OVERTIME

Respondents not working any overtime increased from 23.2% to 25.5% and those working 1-5hrs and 6-10hrs decreased. However, respondents working 11-15hrs of rostered overtime increased by 3.1%.

The hours of unrostered overtime worked per fortnight largely stayed the same from 2022 to 2023. However, respondents working 1-5hrs of unrostered overtime per fortnight increased 3.9% from 2022 to 27.1% in 2023.

UROT CLAIMED & PAID

The 2023 survey found an encouraging 12% increase in respondents claiming all of their unrostered overtime and being paid for unrostered overtime.

In 2023, about 45% of respondents claimed all of their unrostered overtime compared to only 33% in 2022. Of the respondents who claimed any amount of unrostered overtime, 78.9% were paid for the complete amount that was claimed which is 6% more than 2022.

The main reasons for not claiming overtime persisted from last year with the preponderance of respondents identifying ‘against the culture’, ‘not pre-approved’ or ‘negatively reflect on me’ as the cause. However, overall, the number of respondents experiencing these issues decreased by around 29%.

ALLOCATED DAYS OFF TAKEN

In 2023, the negative impacts of excessive hours decreased significantly from 2022. 48% of respondents in 2023 recorded that excessive working hours had made them feel concerned about their personal health and safety. This is an 8% decrease from the 2022 data of 56%.

There was a slight drop in the number of respondents who reported that excessive work hours had led them to make a fatigue induced clinical error from 46% in 2022 to 45% in 2023. This number is still concerning as it is considerably higher than the figure for 2021 which was 38%

The number of respondents whose roster sometimes matches expectations was very similar in 2022 and 2023. The respondents whose roster always matches expectations increased by 3% from 23% to 26% and those whose roster never matches expectations decreased from 35% to 31%. dr.

Allocated days off (ADO) that were taken on request in negotiation increased from 37.5% to 45.3% in 2023. The survey reported that respondents who had not taken any ADOs decreased from 13.8% in 2022 to 8.6%.

DIAGNOSING YOUR FINANCES: Common Tax Ailments and Cures

As you learn and progress through your medical training, are you doing the same for your evolving tax reporting requirements?

WE KNOW THAT DOCTORS can have numerous income tax benefits available to them, but the path to receiving them can be full of timing and terminology pitfalls. Below are the most common topics our clients have questions about when they first start out:

Going On a “Tax Holiday”?

A great way for Doctors in Training to gain experience in different hospitals and career options is by locuming (or consulting) outside of direct employment. It’s also a good way to earn additional income as a Sole Trader. However, this changes the way you are paid, and ultimately, how you are taxed. Considerations as you get started:

• ABN – You’ll need to apply for and acquire an Australian Business Number

• GST Registration (required if you’re expected to earn over $75,000 in 12 months) – While locuming, medical services are not always GST-free and you may be required to bill for it on top of your consulting work

• Business Activity Statements (BAS) – Lodged either quarterly or annually depending on your income to report your GST

• Tax Planning – It’s important to keep accurate records of your

Sole Trader income and carefully plan how much tax you’ll need to pay (including increased HECSHELP repayments)

• Superannuation – Sole Traders don’t generally receive Super contributions, so if appropriate, you can make your own • Insurances – You’ll likely be responsible for your own indemnity and should review your coverage.

Should I Salary Sacrifice?

Salary Sacrificing (or Salary Packaging) can be an effective tool for Doctors in Training as incomes start to increase, pushing you into higher tax brackets. It

can allow you to pay for certain expenses or make additional Superannuation contributions pre-tax, resulting in a lower taxable income and potentially saving you money. However, the conditions surrounding Salary Packaging can be complex for those who have a HECS-HELP debt.

A common assumption is that by reducing your taxable income to below the HECS-HELP debt threshold, no repayments are required. However, the ATO calculates your repayments based on your ‘adjusted taxable income’, also known as your HECS-HELP Repayment Income (RI). With Salary Packaging, your ‘adjusted taxable income’ can end up higher than your taxable income as shown below.

This can result in your employer not withholding enough tax to cover your increased HECS-HELP repayment amount. It’s important to understand how this ‘adjusted taxable income’ affects your total tax payable, which can be different from the tax withheld by your employer, so you don’t end up with a debt when you lodge your return.

While the additional HECS-HELP repayment debt above can be mitigated by requesting additional tax be withheld by your employer, Doctors in Training are also well

positioned to optimise their Salary Packaging for their HECS-HELP debt. Hospitals are exempt from paying FBT, meaning employees can salary sacrifice directly to their HECS-HELP debt without having a fee passed onto them, unlike many other professionals. If you don’t have a mortgage or other debt, paying off your HECS-HELP loan sooner through packaging allows you to not only reduce your taxable income (on something you wouldn’t ordinarily receive a tax deduction for) but also lower your repayments faster by lowering your debt faster.

Our medical specialist accountants have the knowledge and experience to guide you around potential tax blunders as you advance along your career pathway. As your tax requirements become more complicated, it’s best to seek advice.

AMA MEMBERSHIP PORTAL

We would like to thank our members for their patience during the migration to our new member portal.

The portal offers a fresh and easy to navigate design, with a host of new features all through a single sign on password to access both Federal and State resources. If you haven’t checked it out yet, login and have a look around. Over the coming weeks and months, we will refine details and add new features to continuously improve the member

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EVENTS

NETWORK IN STYLE

We are rounding out the year with a wonderful program of events. Grab your tickets now before it’s too late.

There’s really no better place to network than the AMA (NSW) gala dinner known as “Night for the Profession.” It’s for you – our doctors, bring some pals or come on your own, you won’t regret it. Keep an eye on communications for the last few events of the year including our popular Starting in Private Practice event.

AMA (NSW) NIGHT FOR THE PROFESSION: MUSIC & MEDICINE – OCTOBER 6TH, 2023

We are so thrilled to be hosting the 2023 AMA (NSW) Night for the Profession on the 6th of October. This black-tie gala will be a chance for our members to celebrate all their hard work and commitment as doctors, while raising money for Dementia Australia. There will be fine food, entertainment and of course, a little bit of dancing. We can’t wait to see everyone there!

PRACTICE MANAGERS MASTERCLASS WAGGA WAGGA - NOVEMBER 17TH, 2023

Our final Practice Managers Masterclass of the year will be in Wagga Wagga on the 17th of November. We are excited to invite Practice Managers from Wagga Wagga and surrounds to join us as we cover topics such as recruiting staff, billing in private practice, difficult conversations with staff, medico-legal risk management, and much more.

WORKPLACE WEDNESDAY: A WEBINAR SERIES

Our Workplace Relations Team have a wealth of knowledge, which they share in their monthly Workplace Wednesdays webinar series. Previous topics have covered difficult conversations, understanding private practice contracts, Industrial arrangements for VMOs and Staff Specialists, and more. Keep your eye out for the next Workplace Wednesdays!

CORPORATE PARTNERS

AMA (NSW) EXCLUSIVE MEMBER BENEFITS

You can find a more comprehensive list of benefits and more information visit www.amansw.com.au or www.ama.com.au.

AUTOMOTIVE FINANCE & INSURANCE

Alfa Romeo

Alfa Romeo® Program allows members to take advantage of incredible discounts across the Alfa Romeo® range. Go to www.alfaromeo.com.au/fleet or and use your Preferred Partner Login.

BMW

Members can enjoy the benefits of this Programme which includes complimentary scheduled servicing for 5 years/80,000 km, preferential pricing on selected new vehicles and reduced dealer delivery charges.

Jeep

Jeep’s® Preferred Partner Program allows members to take advantage of incredible discounts across the Jeep® range. Go to www.jeep.com.au/fleet and use your Preferred Partner Login.

Porsche Centre Willoughby

Members have access to office vehicle consultation, extended, overnight Porsche EV test drives and access to Porsche Willoughby’s Expression of Interest (EOI) program. Members also receive complimentary first year service (12 months or 15,000kms) and a complimentary voucher to attend a PCW lifestyle

Audi

Sutherland

Explore The Range Of New Audi Models. Offering luxury, performance & safety. Members can enjoy the benefits of the Audi Corporate Program, on new Non EV

Accountants/Tax Advisers

Cutcher & Neale’s expertise is built on an intimate understanding of the unique circumstances of the medical profession. Our team of medical accounting specialists are dedicated to helping you put the right structure in place now to ensure a lifetime of wealth

Chubb

Doctor-in-training members of AMA (NSW) are covered by our accident journey insurance policy if they are injured travelling to or from work.

Health Insurance

Doctors’ Health Fund aligns to the values of the medical profession and supports quality health care. The Fund was created by and is ultimately owned by doctors. Contact the Fund on 1800 226 126 for a quote or visit the website: www.doctorshealthfund.com.au

MYOB

MYOB has all the features you need to make business life easier. MYOB offers a range of products ideal for a variety of businesses, large and small. As a member of AMA (NSW), you can receive a 50% discount for 12 months.

Westpac Corporate Partners Program

Members of AMA (NSW) have access to Westpac’s Corporate Partners Program. This program provides specially-negotiated partner offers and discounts, tailored webinars and support.

CORPORATE PARTNERS

Compare Club

Compare Club helps households cut through complex financial decisions and save on some of their biggest expenses such as health insurance. Their experts have saved people on average $300 on their cover. Plus, they even take care of the

Endota Spa

Endota Spa is Australia’s largest spa network and leading wellness brand. Members can purchase discounted gift cards, products and experience a professional treatment in a haven

Blue Light Card

Blue Light Card Australia is a discount service exclusively for frontline workers and emergency volunteers, to give you a FREE 2-year membership if you sign up through their website or app. Blue Light Card helps members save money on everything from fuel and food to holidays,

TECHNOLOGY

Emirates

TRAVEL LIFESTYLE

Emirates offers AMA members great discounts on airfares around the world: Economy Class: Saver $50, Flex $70,Flex Plus $90 off. Business Class: Saver $90 Flex and Flex Plus $200 off. The partnership agreement between Emirates and

Qantas Club

Whether you’re flying interstate or overseas, the comfort and atmosphere of a Qantas lounge makes travelling for business so much easier. Be welcomed in some of the best lounges in Australia and around the world with complimentary food, beverages, Wi-Fi and dedicated check-in.

Hello Fresh

As a member of AMA (NSW), you can now save up to $200. Hello Fresh provides you with everything you need for delicious dinners every night, with extra twists that elevate your dinner. With a wide selection of easy-to-follow recipes, you can tailor the menu to suit your needs when you purchase 6 boxes. This

The Royal Exchange Sydney

The Royal Exchange of Sydney is one of the oldest and most historic business clubs in Sydney. Members of AMA (NSW) can purchase membership at half price for the year.

Solahart

Bijoux Collection

Bijoux Collection is an Australian-owned online store that provides you access to the best jewellery and accessory brands from around the world. They range from watches, to earrings, to wallets, to pendants, to

Solahart do Solar Panels, not just Solar Hot Water. We continue to build here locally in Sydney 68 years on. AMA members receive 10% off retail price of any of our Solar Power or Solar Hot Water Systems. Please mention your AMA membership. Not in conjunction with any other discount offer.

CORPORATE PARTNERS

TECHNOLOGY (CONT) EDUCATION

Dell Technologies

AMA (NSW) members can now save on Dell’s outstanding business class technology products! Through the partnership of AMA and Dell Technologies, members have access to an array of valuable benefits.

Samsung Partnership Program

We’ve teamed up with our partners Samsung to give you access to incredible savings across the Samsung mobile and wearable range. Members of the Australian Medical Association are entitled to amazing offers, limited time deals and great perks through an exclusive AMA / Samsung online portal.

Tyro

At Tyro, we are the champions for better business banking. We’ve grown to become the largest EFTPOS provider outside of the majors. AMA (NSW) members receive special merchant service fee rates with Tyro’s fast, integrated and

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THE OFFICIAL PUBLICATION OF THE AUSTRALIAN MEDICAL ASSOCIATION (NSW)

The Australian Medical Association (NSW) Limited

ACN 000 001 614

STREET ADDRESS

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ST LEONARDS NSW 2065

MAILING ADDRESS

PO Box 121, ST LEONARDS NSW 1590

Telephone (02) 9439 8822

Outside Sydney Telephone 1800 813 423

Email magazine@amansw.com.au

enquiries@amansw.com.au

www.amansw.com.au

The NSW Doctor is the bi-monthly publication of the Australian Medical Association (NSW) Limited.

AMA Training Services

AMA Training Services offers HLT57715 Diploma of Practice Management for current and aspiring practice managers. Receive the member discount for yourself or nominated staff off the first ASP term, valued at $500. Three scholarships valued at up to $2,000 each are available for current and future

AMA Victoria Career & Training Services

AMA (NSW) members have access to a careers call or resume check which is run by AMA Victoria. Additionally, members can register to be a part of the

Booktopia

Australia’s largest independently- owned online bookstore. We stock over 650,000 items and have over 5 million titles for purchase online. Booktopia carries a wide range of medical books in stock, including textbooks that are prescribed across all medical faculties in NSW and essential texts used by

Views expressed by contributors to The NSW Doctor and advertisements appearing in The NSW Doctor are not necessarily endorsed by the Australian Medical Association (NSW) Limited. No responsibility is accepted by the Australian Medical Association (NSW) Limited, the editors or the printers for the accuracy of the information contained in the text and advertisements in The NSW Doctor. The acceptance of advertising in AMA (NSW) publications, digital, or social channels or sponsorship of AMA (NSW) events does not in any way indicate or imply endorsement by the AMA.

EXECUTIVE OFFICERS 2021-2023

President, Dr Michael Bonning

Vice President, Dr Kathryn Austin Chair of Council, Dr Brian Fernandes Chair, Hospital Practice Committee

Dr Andrew Zuschmann

Chair, Professional Issues Committee and Director, Dr Costa Boyages Director, Dr Kean-Seng Lim Director, Dr Fred Betros Director, Dr Amandeep Hansa

Director, Dr Theresa Ly

Doctor-In-Training Director, Dr Sanjay Hettige

SECRETARIAT

Chief Executive Officer, Fiona Davies

Director, Services Kerry Evripidou

Director, Workplace Relations

Dominique Egan

Director, Membership Engagement and Commercial Partnerships

Gary White

Editor

Rahni Sadler

rahni.sadler@amansw.com.au

Staff Writer

Isabella Angeli

Isabella.angeli@amansw.com.au

Design

Rebecca Strahan

Advertising enquiries

Kirsty Smith

Kirsty.smith@amansw.com.au