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ISSUE 5 JULY 2011 4 5 6 10 12

Health standards in Australian prisons An ordinary doctor’s extraordinary practice Designing a safe practice Maintaining aged care GP visits Social media in general practice

Telehealth helping patients disadvantaged by distance New rebates will be available for patients in eligible outer metropolitan, regional and remote areas, as well as those in eligible aged care and Aboriginal medical services who access specialist care via video consultation – a description of geographic area eligibility is available at www.mbsonline.gov.au/telehealth. RACGP President, Professor Claire Jackson, says that telehealth will enable GPs to more effectively facilitate other specialist involvement in the care of patients in outer metropolitan, regional and remote Australia. The RACGP is developing telehealth standards for general practices, paying close attention to issues of consent, privacy and

confidentiality, and has plans to develop an online education training module on video consultations. “The telehealth standards on video consultations for GPs will be developed to ensure the identification of potential risks and risk mitigation strategies, including protocols for establishing patient identification, protecting patient privacy, and determining the level of clinical appropriateness of video consulting,” says Professor Jackson. The telehealth standards taskforce, chaired by Dr Mike Civil, will meet for the first time at the end of June, and the RACGP will provide members and other stakeholders with further

information on the development of the standards during the consultation process. Dr Civil says the taskforce is gathering information at the moment, including interviewing people who are currently supplying a telehealth service. He envisages the standards going through two or three drafts, with feedback being sought on each draft, and says the taskforce plans to incorporate a field review before the standards are finalised. The government has not mandated that doctors should use a particular type of videoconferencing technology and indeed has

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Photo © istockphoto/Fritz Hiersche

From 1 July, health practitioners will be able to access increased Medicare rebates for services through the government’s telehealth initiative.

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News

Telehealth helping patients disadvantaged by distance (Continued)

mentioned Skype as a possible technology. Dr Civil points out that the onus is on doctors to ensure the quality of videoconferencing and that privacy and confidentiality requirements have been met. These are areas where the RACGP standards will be very important for GPs. He intends that the taskforce doesn’t get ‘bogged down in the technical minutiae’ of which technology is preferable. He

identifies education and training in using videoconferencing and managing information after consultations as significant areas for GPs. The telehealth standards on video consultations for general practices are planned to be made available in October 2011.

between GPs and patients in other circumstances.

A new era in medical consultations

The government has acknowledged that major obstacles to telehealth have been the costs to medical practitioners

The Federal Government’s introduction of Medicare rebates for telehealth consultations heralds a new era in medical consultations. The proposed Medicare items cover a consultation between patient and specialist, where the patient is accompanied by a GP or GP representative, but Dr Civil hopes the MBS items will extend in the future to cover consultations

“Elderly people at home needing check ups is an example. But telehealth could also extend to busy professional people for whom it is time inefficient to come into their GP’s surgery. And younger people who are already techno savvy would feel comfortable having a medical consultation via videoconference.” Dr Civil says that while

Incentive payments

2001–12

2012–13

2013–14

2014–15

$6000

$4800

$3900

$3300

‘Service incentive’ paid each time an eligible specialist provides, or aged care facility hosts, a telehealth service

$60

$48

$39

$33

‘Service incentive’ paid each time a patient-end health professional provides a service

$40

$32

$26

$22

‘Bulk billing incentive’ paid each time a practitioner bulk bills a service

$20

$16

$13

$11

One-off ‘on-board incentive’ paid to: • eligible practitioners who invest to provide at least one telehealth service • aged care facilities that register with Medicare and host their first telehealth consultation

Dr Jenny May is a GP working in a six doctor practice in Tamworth in northern New South Wales. The practice services a large geographic area and has been preparing for telehealth. What will telehealth mean to your practice? If we can get it up and running it will increase patients’ access to specialist care. Currently, waiting lists for psychiatry for instance are long, and while we have a number of dedicated Medical Specialist Outreach Assistance Program (MSOAP) specialists they cannot satisfy the need.

It will admittedly add another layer of complexity – not only the vagaries of patients turning up but the vagaries of the technology too. As well as getting our heads around new billing arrangements. But all these things are sortable. Are specialists to whom you commonly refer planning to invest in video conferencing? We would like specialists who already have relationships with the community to be used in the first instance. The combination of face-to-face and telehealth is the ideal as new patients and patients with clinical signs need face-to-face and sometimes inpatient care – the more they are linked up the better the care. We know from Barbara Starfield’s [Johns Hopkins Bloomberg School of Public Health] work that

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the initial focus is on videoconferencing, standards will also need to encompass other, newer technologies that will be starting to influence general practice, such as text messaging appointment reminders, using email to communicate with patients, and using media such as Facebook and Twitter. The government has acknowledged that major obstacles to telehealth have been the costs to medical practitioners of setting up for telehealth and a lack of adequate infrastructure to support videoconferencing and

To find out more visit www.mbsonline.gov.au

How it works • Residential aged care services need to register as a telehealth hosting facility. Health professionals don’t need to register; they are recognised as telehealth providers upon successful lodgment of their first MBS telehealth item number • A GP working in an eligible area refers a patient to a specialist, consultant physician or consultant psychiatrist for a consultation via telehealth • The patient attends the consultation in the GP surgery, Aboriginal health service or aged care facility. The patient and specialist see and hear each other via videoconferencing technology. The patient is accompanied by the GP (or practice nurse or Aboriginal health worker providing services on their behalf ), nurse practitioner or midwife • The health professionals then bill using one of the new MBS item numbers or fee item numbers. The fee item (specialist service) and MBS item (patient-end service) claimed in conjunction enable the consultation to be recognised and remunerated by Medicare as a telehealth consultation • Assuming the health practitioner continues with telehealth consultations, payments accrue and are paid every quarter.

continuity makes a difference. Regional specialists would be the best to really cement the ‘hub and spoke’ models of health service. Alas many of our regional specialists have huge workloads already. MSOAP provides another good opportunity to piggy back onto existing referral patterns and relationships. We will work hard to try and persuade some of our MSOAP specialists to try it out. Do you think patients will be happy to consult with a specialist via video conferencing? I do think that patients will respond well to the service, particularly when it might be saving them a 600 km round trip to see the specialist in person. The technology will take some getting used to but many people

use web cams or Skype at home so can handle a talking computer screen. Time and effort saving to get the same result will be very acceptable to patients. The capacity to fund the time of someone sitting in also means that their comfort and understanding can be monitored. Time will tell. Currently there is poor access to specialist opinion. If this improves it will be very acceptable to GPs and patients alike. It must complement care, not fragment it, and it must fit in with clinical workflow. My understanding is that about 30% of specialist consults will be suitable so this is not a panacea – it will work well for pysch, postsurgery, chronic disease monitoring and consults where talking is the mainstay.

staff

Editorial notes

Managing Editor Denese Warmington Editor Nicole Kouros Features Writer Rosemary Moore Production Coordinator Morgan Liotta Graphic Designer Beverly Jongue

© The Royal Australian College of General Practitioners 2011 All rights reserved. Requests for permission to reprint articles must be made to the editor. The views contained herein are not necessarily the views of the RACGP, its council, its members or its staff. The content of any advertising or promotional material contained within Good Practice is not necessarily endorsed by the publisher.

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the high speed transmission of data and images. The government hopes these obstacles will be overcome ‘to a significant degree’ by planned improvements in infrastructure, especially the National Broadband Network, and the Medicare telehealth initiative. The RACGP will continue to advocate for further implementation of telehealth supporting high quality primary healthcare delivery.

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News

New standards for care of prisoners The RACGP has developed standards to guide GPs and other health professionals working in prisons to deliver safe and high quality healthcare. The Standards for health services in Australian prisons cover health services for sentenced and remand prisoners. The access that prisoners have to healthcare choices is restricted. Doctors need to balance a patient’s right to privacy and confidentiality against a need for safety and security. Prisoners often have complex clinical needs, including higher rates of some communicable diseases, use of illicit drugs and mental health needs. The RACGP Standards point to areas where extra vigilance is needed to ensure patients within prisons get high quality and safe care, including: • informed patient decisions • interpreter services • clinical autonomy for medical, clinical and allied health staff • continuity of comprehensive care • continuity of the therapeutic relationship • engaging with other services • respectful and culturally appropriate care • confidentiality and privacy of health information • transfer of health information. Dr Lynton Hudson, Chair of the RACGP National Standing

Committee – Standards for General Practices, says that while access to healthcare is a human right, the prison environment presents significant challenges for the delivery of high quality primary healthcare. “The National standard guidelines for corrections in Australia, developed by the state and territory jurisdictions, stipulate that each prisoner is to have access to evidence based health services, provided by a registered and competent health professional, providing a standard of care comparable to that which they would receive in the general community. This requirement poses a number of challenges for health professionals. “The RACGP Standards are specifically designed to support GPs who are trying to achieve better health outcomes for people incarcerated in Australian prisons or detained in custody.” Dr Cameron Loy, a member of the RACGP’s Custodial Health Network, and a GP who works in custodial settings, says that the

closed environment of prisons represents a challenge for GPs, requiring them to consider issues that are absent in other healthcare settings. “Health professionals often need to consider issues unique to custodial settings when making clinical decisions – even seeking an X-ray can be a complicated logistical task. Health professionals also have a heightened awareness of patients’ right to autonomy and confidentiality. “The patient population in prisons is generally characterised by complex clinical needs, often with an overlay of alcohol and drug use, mental health problems and personality disorders. Health professionals deliver good health outcomes with careful understanding of the pressures in delivering care in prisons, and the various drivers behind patient presentations,” Dr Loy says.

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“GPs in prison care can see clinical events rarely seen in clinical practice, such as food refusal. How to make decisions in such situations is not supported by a large body of evidence so the GP sometimes needs to work from the fundamentals of what a doctor’s role is in custody to find a decision that protects the patient as well as their own professionalism. “Doctors need to work hard to keep themselves separate from the punishment of a prisoner and their loss of liberty, and all the issues this carries with it. The challenge for the GP is to keep separate from the issues of correctional management, and work to deliver fair and consistent high quality medicine, which many prisoners have never sought to access before incarceration. “The RACGP Standards add another link in the chain to consolidate the role of a doctor in a prison. It can be a tool to support GPs working to achieve better health outcomes, addressing the complex health needs and the unique work environment of a prison.”

Reprint from Good Practice Issue 5 – July 2011

1st edition

The RACGP Standards for health services in Australian prisons are available at www.racgp.org.au/ standards/prisons

Dr Cameron Loy outlines features of the prison environment that make it a demanding and rewarding workplace. “Prisons are a unique general practice. Not the least aspect of this uniqueness are the convolutions GPs make just to get to the consulting room. Prisons pose a challenging environment in which to deliver healthcare. The doctor and the patient are subject to the constraints and rules of the institution. While many health problems encountered in prisons are similar to those found in usual general practice, what is happening in prisons is far more complex and requires careful general practice across the scope of the discipline to produce health outcomes. “Research on health activity within prisons is often focused on psychological medicine or on injecting drug use and blood borne viruses and GPs in prisons have to consider as highly important their patients’ right to confidentiality and autonomy in making decisions for their health. In particular, a GP in prisons is faced with requests for decisions on issues not found in community practice – a raft of housekeeping items within prisons, a spread of over-the-counter and supermarket products.

Standards for health services in Australian prisons

Queen’s Birthday Honours 2011 Congratulations to the following GPs whose outstanding contribution to our community has been recognised. Member of the Order of Australia

Medal of the Order of Australia

Dr Joanna Mary Flynn (RACGP Fellow) South Yarra, VIC – For service to medical administration and to the community, particularly in the areas of practice standards, regulation, professional education and as a GP. Ms Mary Elizabeth Martin (RACGP Member) South Brisbane, QLD – For service to the Indigenous community through the Queensland Aboriginal and Islander Health Council, to the review of professional standards, and to community nursing. Professor Kerryn Lyndel Phelps (RACGP Fellow) Double Bay, NSW – For service to medicine, particularly through leadership roles with the Australian Medical Association, to education and community health, and as a GP.

Dr Rodney Paul Barkman (RACGP Life Member) Corowa, NSW – For service to the community of Corowa as a GP. Dr Bruce Wallace Ingram (Nonmember) Hawthorn East, VIC – For service to medicine as a GP, and to professional associations. Dr Richard Wayne Lehmann (RACGP Associate) Temora – For service to medicine as a GP in the Temora region. Dr Peter James Robinson (Nonmember) Deniliquin, NSW – For service to medicine as a GP in the Deniliquin region. Dr Natale Anthony Romeo (Nonmember) Cecil Park, NSW – For service to the community through fundraising roles with the Italian Affair Committee.

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Profile

An ordinary doctor in extraordinary practice When Willie Sutton was asked why he kept robbing banks, he replied, “Because that’s where the money is!” Sutton’s law was the logic behind me giving Indigenous health a go in my fourth year as a doctor. I’d been taught how to fix diseases, so I looked for the biggest bank of health problems. Figuring that my own country was a good place to start, I threw a dart at a map of the Simpson desert and hit Tennant Creek – I was pretty much right on the money. I loved Tennant Creek, although in the 15 years since I first went there, I have met few others who share my enthusiasm. The town’s modest tourist motto is ‘Stay the night!’ because most don’t. But, as a general practice registrar working at the Aboriginal controlled health service for 2 years, the work was extraordinarily exciting, endlessly challenging, and gave me great medical freedom. There were health problems in abundance, but also a resilient and generous local Aboriginal community. I couldn’t have asked for a better entry into general practice. Having never been the type to impress my hospital superiors with my knowledge of medical minutiae, I soon discovered that working in a remote Aboriginal community suited my temperament. My natural tolerance for uncertainty, and keen ability to embrace chaos (not how my wife would phrase it) had occasionally been considered a hindrance by supervising consultant physicians. Yet, suddenly, I was among people who saw these traits as a boon. The locals didn’t want referrals to the best plastic surgeon in town; they wanted me to lance their carbuncle with whatever was handy, while they supported a peritoneal dialysis bag over their head and told me stories about their ancestors. If Sutton’s law led me into Aboriginal and Torres Strait Islander health, it was the Warumungu and Walpiri mob who made me want to stay. To the profession’s credit, no doctor I’ve ever met has questioned why anyone would want to work in the area of indigenous health, although quite a few wouldn’t be seen there for quids. And to be fair, I wouldn’t recommend it for them. If you’re a perfectionist whose

job satisfaction depends on excellent outcomes, and you expect patients to follow your 10-point postoperative manifesto, then frankly, apply elsewhere. Although a brief exposure to Aboriginal and Torres Strait Islander health won’t do your perspective any harm, anything more than a dabble is likely to lead to frustration, depression and, ultimately, sweeping statements at cocktail parties to the effect that ‘despite everything you’ve done, the whole situation is hopeless’. The truth in fact is that indigenous health in Australia is an exciting place to be. Once you accept that many poverty related social risk factors are beyond your control, it allows you to concentrate on the things you can change, and there are plenty of those. Take, for example, the steep curve at the top of the cardiovascular risk graph. Because most risks are multiplicative rather than additive, altering one factor has a huge effect. If your brief interventions reduce smoking rates by 10% from a baseline of 60%, or increase compliance with cardiovascular medication by one-quarter, the gains in healthy life years will be legion. While others are bemoaning the futility of trying to tackle the complexities of the ‘Aboriginal problem’, you will literally be saving lives.

If Sutton’s law led me into Aboriginal and Torres Strait Islander health, it was the Warumungu and Walpiri mob who made me want to stay General practice and primary healthcare are undoubtedly ‘where the money is’ in Aboriginal and Torres Strait Islander health. The hospital sector does what it can, but no ‘cutting edge’ intervention can hope to match basic primary care when it comes to putting a dent in morbidity statistics. I now like to describe myself as being at the blunt edge of

Dr Coleman sees his patient Rhonda, a woman he describes as the ‘very impressive lynchpin of a large family of traditional owners’

medicine, which is possibly why I don’t get asked to cocktail parties. All of this leads me to a confession... a lot of the medical knowledge required in Aboriginal and Torres Strait Islander healthcare can be considered as pretty simple – just don’t tell my employer. It’s not brain surgery, and doesn’t often require any gadget invented since the glucometer. Simple folk like me can learn it on the job and keep up-to-date without ever seeing a drug rep to hear about the latest nanotechnology delivery systems. My favourite, most sexy drug is still metformin, which is older than most of my patients. So mastering the medical knowledge is easy – its delivery is the complex part. The doctors I know who have mastered the art of Aboriginal and Torres Strait Islander health have combined excellent communication skills with a drive to engage their patients. Doctor-patient trust is the key, and nowhere else in medicine does it open more doors. I believe Aboriginal and Torres Strait Islanders have a particularly keen sense when it comes to detecting lack

of respect, perhaps honed by two centuries of frequent practice. But, if you are prepared to listen and learn, and to make genuine efforts at communication, the work becomes immensely satisfying. For the past 5 years I have worked in Brisbane at the Inala Indigenous Health Service, soon to become the South East Queensland Aboriginal and Torres Strait Islander Centre of Excellence. The Centre of Excellence will have twice the space of our current cramped clinic, and generous resources for research and teaching. But even when I am sitting in my excellent room doing excellent consultations, I’ll spare a thought for my colleagues plugging away in remote communities and under-resourced city clinics. Because everyone who steps into the adventurous world of indigenous health becomes a part of something meaningful, something big. They have chosen a marginal place where ordinary doctors at the blunt edge of medicine can do extraordinary things. Written by Justin Coleman Inala Indigenous Health Service

Men’s health good... but could be better A report released in June by the Australian Institute of Health and Welfare found Australian men could be doing more to protect and improve their health. The report, The health of Australia’s males, examines attitudes to health issues, rates of injury, illness and mortality, and use of health services among Australian men. It found that

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Australian men’s life expectancy is 79 years, fourth among Organization for Economic Co-operation and Development (OECD) countries. The OECD average is 76.3 years.

“This can at least in part be attributed to the positive lifestyle choices made by many Australian men: about two-thirds of men participate in sport or physical activity, and rates of smoking continue to decline,” AIHW Director, David Kalisch says. “Survival rates for some kinds of cancer – such as testicular and prostate – are also improving, which may be thanks to better

screening, earlier detection and improved treatment.” But trends in men’s diets and weight are worrying. Very few men eat enough fruit and vegetables and about two-thirds of men are overweight or obese. Almost half the men in Australia have had a mental health condition, about one-quarter have a disability, and close to one-third have a chronic health condition. Half have been a victim of violence

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at least once in their lives. While men go to their GP less frequently than women, they are more likely than women to present at an emergency department. Australian Institute of Health and Welfare. The health of Australia’s males. Canberra: AIHW, 2011. Available at www.aihw.gov.au/ WorkArea/DownloadAsset. spx?id=10737419201

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Workplace

Designing for Department of Veterans’ Affairs

More choice for GPs when referring veterans for mental health services GPs can now refer DVA clients to mental health professionals registered with Medicare Australia. These include clinical psychologists, psychologists, mental health social workers and mental health occupational therapists. Mental health professionals no longer need to contract separately with DVA. For more information visit: www.dva.gov.au/service_providers For information about veteran mental health issues go to www.at-ease.dva.gov.au and click on the Resources for Health Professionals tab.

Patient initiated violence or aggression affects many general practices and it can be important for general practices to consider aspects of design to help protect against patient initiated violence. Peter Locke, practice manager at Melbourne’s Northside Clinic, is an imposing 6 feet 4 inches tall. From his office he can monitor the practice reception area. If there is a disturbance at reception, sometimes all it takes to restore the peace is for Peter to walk down the passageway to the reception desk and make a gentle enquiry. All practices, however tall or diminutive their practice managers, benefit from implementing some basic design and layout features. Some of the most fundamental of these are ensuring that reception staff can see all patients and the public areas of the practice, that there is an adequate barrier between reception staff and patients, that closed circuit television (CCTV) is considered, and that consulting rooms are set up in ways that limit opportunities for aggression or violence.

Clear line of sight When Northside Clinic was being established, Peter Locke obtained a copy of the RACGP’s General practice: a safe place – tips and tools. In its previous location, the clinic’s waiting room could not be seen from the reception area. Staff definitely wanted to avoid such a setup at their new premises: as Peter says, “Someone could have died in the waiting room and not have been found until 7 pm when the receptionist went to tidy up.” The Northside Clinic reception area is at one side of the waiting room, a couple of metres from the main entrance, and receptionists

have full view of the entrance, waiting room and main corridor leading to the consulting rooms. Brendan Jones is the Director at Antarctica, an architecture practice with a special interest in general practice. Ian Watts is a former National Manager of GP advocacy and support with the RACGP, and works in the team at Antarctica. Both contributed to Rebirth of a clinic: a design workbook for architecture in general practice and primary care and Ian was one of the writers of General practice: a safe place. Features that they agree contribute to attractiveness as well as safety principles include a differentiated waiting space, clear line of sight, clear paths of movement and no clutter. “Clutter provides too much visual information. Having an uncluttered waiting area sends a signal about the professionalism of the practice. Also, clutter can provide projectiles,” Ian Watts says. “For safety, it’s important for people visiting the clinic to be in the receptionists’ line of sight.”

Protecting receptionists Northside Clinic’s reception desk is about chest height, and the staff

are on slightly raised chairs. There is a kitchen behind the reception area that can be secured; reception staff can retreat there if they feel threatened. The kitchen has a phone and all consulting rooms can be contacted from this safe place if needed. Receptionists are reminded not to leave sharp implements such as scissors on their desk, since they could be used as weapons.

CCTV and security cameras Northside Clinic has security cameras monitoring the doctors’ car park and laneway at the back of the practice. This can be viewed from any computer and the practice manager’s office, and doctors are asked to view the areas remotely before leaving at night. There is no CCTV in the waiting room. The clinic cares for a number of patients with HIV and it was felt that CCTV would be seen as a privacy/confidentiality issue. In some practices, CCTV may be valuable, and Brendan Jones and Ian Watts cite this as an example of ‘the diversity of circumstances’ and the ‘importance of tailoring design to the practice’.

Design tips Reception area/waiting room

Consulting rooms

• Ideally, the receptionist is able to see the entire waiting room, entrance and main passageway • The reception desk should be high and wide enough that a person cannot easily reach across • Receptionists should be able to get away from the reception desk without needing to go through the waiting area • If appropriate for your practice, install CCTV in the waiting room and put up notices telling people CCTV is operating. Include monitors in each consulting room • Where appropriate, include signage to say that no drugs of addiction are stored on the premises • Include signage warning that aggression will not be tolerated.

• If possible, there should be two doors for each consulting room • Furniture should be set up so that the patient does not sit between the doctor and the door • Each doctor should have a duress alarm or have an agreed way of communicating concern about a patient with other staff (eg. a telephone call using a code word) • Consider a speaker phone and a single dial to reception (allowing you to press one button and have the activity in the consultation room heard in reception) • Doors should not be able to be locked from inside since the doctor can be trapped with an aggressive patient.

AG41660

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Reprint from Good Practice Issue 5 – July 2011

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Workplace

practice safety A key suggestion of design safety guidelines is that consulting rooms have two exit points

Patient initiated aggression or violence • Patient initiated aggression or violence in general practice may include intimidating body language, verbal abuse or threats in person or by phone or email, property damage or destruction, imprisonment or a hostage situation, stalking, physical assault, indecent acts, sexual harassment or assault, and armed assault • Sexual violence in the workplace particularly affects younger, female GPs • Doctors and practice staff are vulnerable. Attacks may occur at the reception desk, in the waiting area, in consulting rooms, in passages and stairways, and outside the practice, in entranceways and car parks • Aggressors are likely to be affected by alcohol, other drugs or poorly managed mental illness and have a past history of violence. Drug seekers are more likely to be aggressive. Aggressors are more likely to be men and have a frequent consultation rate • Patients with anxiety, distress, grief or pain may behave aggressively if these factors combine with a stressful situation such as perceiving they have to wait a long time for their appointment • Effects of violent behaviour on practice staff include anxiety, effects on concentration, depression, stress related illness, social and professional withdrawal, absenteeism, loss of staff and reduced productivity.

Peter Locke at Northside Clinic’s reception with Andrew Hawkins and Marion Densley

Signs Brendan Jones points to the attention paid by banks to the design of their premises: “Everything has been thought out in terms of corporate image.” General practices too may want to think about what image they are conveying, whether it’s warm and homely, and whether the practice is conveying ‘critical symbolic messages’ to important groups of patients, such as meaningful Aboriginal symbols or symbols welcoming gay and lesbian patients. All agree there should be signs clearly explaining how a practice will deal with patient initiated aggression. Rather than having a ‘zero tolerance’ policy, Northside Clinic promotes a ‘respectful practice framework’. “We make it clear that we expect patients to respect each other and respect the staff and we will respect them,” says Peter Locke. If a patient is aggressive, they are followed up and it is each doctor’s right to decide whether they will see the patient again.

Sound Noise is a common problem in general practices, but may be difficult to control in an existing building. As Ian Watts says, general practices ‘want auditory privacy’ but you ‘also want raised voices to be heard’. At Northside Clinic, raised

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voices can be heard throughout the building.

Consulting rooms At Northside Clinic, doctors can set up their consulting rooms as they wish. Some have referred to the RACGP guidelines and some haven’t. Peter Locke points out that in a small space, the setup of a desk may be dictated by something as elementary as whether the doctor is right or left handed. Ian Watts agrees that the size of a consulting room can greatly hinder setting up a room for optimum safety. One clear recommendation is that consulting rooms have two doors if possible, which may only be achieved in practices that are designed from scratch. “Some consulting rooms are just too small. It’s difficult to put in an extra door if all the wall space has been taken up by the desk, examination table and shelves.” At Northside Clinic, all doctors have a hidden safety button that alerts reception. A receptionist calls the room if a buzzer goes off, and if the doctor doesn’t respond, or responds and indicates that something is wrong, the receptionist buzzes 000. (Peter Locke says if the GPs’ buzzers directed through to 000, “We’d have the police here all the time because the doctors are always accidentally hitting the buzzers under the desk.”)

Staff training and support On induction, receptionists at Northside Clinic receive training in dealing with aggressive patients. The practice occasionally has patients who are obnoxious and rude and the practice has policies for dealing with aggressive patients and debriefing. Recently the practice had a psychologist come in to help staff with stress management techniques. Peter Locke says he is most concerned about the reception staff, who tend to bear the brunt of patient aggression – “Often they’ll be obnoxious at reception and then be nice as pie when they get into the doctor’s room” – and doctors when they go on home visits. The practice is vigilant about recording when a doctor leaves, where they’re going, and when they expect to be back. Most home visits are for palliative care and long term geriatric care.

Providing distractions Brendan Jones says a television in the waiting room won’t necessarily calm or distract patients. “Studies suggest it’s the lack of control, the inability to escape, that’s the problem with TVs in waiting rooms. It’s frustrating if you’re not interested in what’s on the TV. On the other hand, if you’re anxious, it may be good to be distracted... Having some choice for patients is the key,” he says. Northside Clinic decided not to install televisions. The clinic also decided not to install a clock in

the waiting area, since anxious or belligerent patients might become more stressed by watching time pass. Peter encourages reception staff to reassure patients that they haven’t been forgotten by letting them know where they are in the queue.

General design factors Ian Watts says that commercial imperatives can mean that general practices are not well designed from the perspectives of aesthetics and safety. Brendan Jones adds, “It tends to be the norm for a lot of practices to be squeezed into old houses. Getting those clear paths, clear line of sight, clear pathways and a contemporary look may be out of the question for some. Few GPs can point to a clinic whose design they want to emulate. “There’s no perfect model for general practices. Often there are compromises that have to be made

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but there are always opportunities. People need to be willing to invest in time with the architect. Rather than going to an architect with a problem and hoping for a fix within 4 weeks, have a real conversation with the architect.” Ian Watts says, “The architectclient relationship is like the doctor-patient relationship. We know our business and they know theirs. If you spend time at the start, it pays back.” For further information see RACGP’s, General practice – a safe place; RMIT University and RACGP’s Rebirth of a clinic; RACGP’s, Abuse and violence: working with our patients in general practice (active learning module) (www.racgp.org.au/guidelines/ abuseandviolence); Dandenong Casey General Practice Association’s, Safety and security kit for general practice

Good Practice Issue 5 – July 2011

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Issues

GPs struggling to maintain aged care visits Submissions to the Productivity Commission’s inquiry into the care of older Australians have repeatedly highlighted serious difficulties in accessing and providing general practice care in residential aged care facilities. The situation is frustrating for patients, carers, aged care services and GPs. Patients and carers report difficulties retaining their usual GP to visit once the patient has moved into an aged care facility, and difficulties accessing a new GP. Aged care facilities report a struggle accessing GPs, with one consequence of this being the avoidable transfer of elderly residents into emergency departments. The situation is also difficult for doctors. Visiting patients in aged care facilities may be frustrating and unnecessarily complicated by aged care setups, as well as by being inadequately remunerated. Submissions by the Australian Medical Association (AMA), RACGP and Australian General Practice Network (AGPN) to the Productivity Commission’s inquiry point to factors such as: • lack of nurses in aged care facilities to coordinate care with • poor ratios of carers to residents, which can mean that GP recommendations are not implemented or maintained • reliance by aged care facilities on agency staff who are not familiar with residents • poor examination facilities • the need to respond to unremunerated, unnecessary and time consuming calls from residential aged care facilities • being called out for unnecessary visits by underskilled staff • poor discharge and handover arrangements from acute to residential facilities • inaccessibility of effective electronic patient records • inadequate remuneration for doctors who visit aged care facilities • the distance of residential facilities from general practices. Various factors are contributing to the likelihood that the shortage of GPs prepared to work in aged care facilities will worsen. In its submission to the Productivity Commission, the AGPN points out: ‘Older GPs provide the majority of residential aged care facility attendances and recent graduates are less likely to work

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in these environments, suggesting that as older GPs retire we will have a further shortage of GPs willing to attend these settings.’ Dr Cameron Martin is a GP and Deputy Chair of the RACGP’s Advocacy and Support Unit. Dr Martin recalls that before Medicare, doctors visited patients in nursing homes and either billed or didn’t bill, depending on a patient’s ability to pay. With Medicare, doctors rely on payments that don’t take into account how different a visit to an elderly patient in a nursing home can be, compared with a usual GP surgery visit. “There are logistical factors in visiting patients in aged care facilities that mean you see fewer patients and get less activity done per hour than you normally would. Some of this is due to the characteristics of the elderly: they generally speak more slowly, walk more slowly and comprehend more slowly. There are the physical logistics of getting to an aged care facility, and then needing to walk to locate patients. And there are liaison requirements, including the need to liaise with family members and staff,” Dr Martin says. While the government has attempted a remedy by introducing Aged Care Access Initiative incentive payments, according to the AGPN these tend not to reward doctors who provide a great number of services or who do not work in accredited practices (perhaps 1 in 10 GPs

The Royal Australian College of General Practitioners

Photo © istockphoto/Maica

providing aged care services). “GPs should expect to be adequately remunerated for their work in aged care facilities, but they are not at the moment. Doctors are working in aged care for reasons of altruism, goodwill and loyalty. But they will be choosing to do it less and less often. If the government wants doctors to continue to work with the elderly in aged care facilities, they need to fund them,” Dr Martin says. The RACGP estimates that Medicare funds only about 50% of the time GPs spend on aged care in a residential aged care facility. Its submission to the Productivity Commission proposes that the requirement for ‘face-to-face’ time be removed from MBS descriptors, since so much time is needed for communications separate from the face-to-face consultation with a patient. Doctors currently receive increasingly lower fees the more patients they see, and the RACGP believes this should also be remedied. “Generally, it is impractical to bill patients in aged care facilities for consultations, so the vast majority of patients in aged care facilities are bulk billed. “What is needed is a loading on the item number. In the RACGP’s submission to the Productivity Commission, we have called for a 100% loading; the AMA has called for a 50% loading,” Dr Martin says. The Productivity Commission is due to report to the government mid year.

www.racgp.org.au/goodpractice


Issues

Up-to-date with communication? Using social media in general practice Is it relevant and appropriate for medical professionals to ‘Tweet’? How should they conduct themselves online in a dynamically changing environment? Social media is a juggernaut gathering at great speed. Is your general practice ready? Social media has been a force since 2006: first with blogging, then entered Facebook and the microblog Twitter, with a swag of other platforms. While many of us may enjoy these online communication platforms to keep up with friends and family, we have seen how businesses have also used these platforms to their advantage, using them to engage with consumers. Now the medical profession is asking: should we be using social media more actively? Late last year a joint initiative of the AMA Council of Doctors-in-Training, the New Zealand Medical Association Doctors-inTraining Council, the New Zealand Medical Students’ Association and the Australian Medical Students’ Association produced ‘Social media and the medical profession – a guide to online professionalism for medical practitioners and medical students’ (published in MJA), and there are good reasons to have policies relating to the use of social media. A recent study, ‘Physicians on Twitter’ (published in JAMA) examined an assortment of 260 Twitter users who self-identified as physicians and had at least 500 followers. It found that while half their Tweets were related to medicine or health, about 12% of the rest were devoted to self-promotion. Another 3% were described as ‘unprofessional’, meaning they used discriminatory or profane language or violated a patient’s privacy, as reported in an article in the Huffington Post. Only a few months ago a Rhode Island

physician, Alexandra Thran, posted information about a trauma patient – not the name, but enough about the condition to be considered a violation of privacy laws. She was fired by her hospital last year and disciplined by her state medical board a few weeks ago. The St Petersburg Times reported that when the University of Florida began studying the Facebook habits of its medical students and residents in 2007, it found a dozen instances in which students and residents had posted photographs on their Facebook pages of themselves caring for patients and showing findings that prompted discussion. This eventually led to a medical school policy on the use of social media.

Finding solutions Education is an obvious solution for both medical students and medical professionals. As mentioned, the AMA are taking an active role locally with their online training and the recent article, ‘Social media and the medical profession’, which discusses the relevant risk management issues. On a more informal level, the group, Health Care Social Media Australia and New Zealand, communicate via the Twitter hash tag ‘#hcsmanz’. This is a relaxed environment so users can simply follow the conversation (‘lurk and learn’) or participate. LinkedIn also has a group dedicated to this area of interest, called ‘Applying Social Media in Health’.

Internationally, education is already starting in medical courses at universities. In 2008, Hungary’s University of Debrecen Medical School and Health Science Center launched social media subjects. The founder, Dr Bertalan Meskó, is the founder of Webicina.com (www.webicina.com), the first medical web 2.0 guidance service. It will be interesting to see if such courses become embedded locally in our university courses as compulsory subjects. In Edingburgh, the Association for the Study of Medical Education in their

Helping patients with gambling problems GPs who have patients with gambling problems can contact a new online help service that provides counselling, information and support. Gambling Help Online is operated by Turning Point Alcohol and Drug Centre. It offers health professionals information, research and treatment options for working with people with gambling concerns. It includes a risk assessment tool, which may be helpful for doctors needing to reliably assess whether a patient has a gambling problem. People with gambling problems report feelings of shame and guilt. This website

The service provides live counselling and confidential email support may provide a less confronting entry point into thinking about change.  The service provides live counselling and anonymous and confidential email support from qualified, experienced

12 Reprint from Good Practice Issue 5 – July 2011

Photo © istockphoto/Retroatelier

gambling counsellors. It is useful for anyone who may be geographically isolated, unable to access face-to-face counselling services, or for those who may feel embarrassed to seek help. Gambling Help Online also assists family and friends of gamblers. People may also call the Gambler’s Helpline on 1800 858 858. To find out more, visit www. gamblinghelponline.org.au

upcoming 11 July Annual Scientific Meeting are including sessions entitled ‘Social Media and Networks in Medical Education’ bringing the topic to the fore. ‘Social media and the medical profession’ is available at http://ama.com.au/node/6231 and www.mja.com.au. ‘Physicians on Twitter’ available at http://jama.ama-assn.org/ content/305/6/566.2.extract Written by Jenni Beattie, Director of Digital Democracy. You can connect with her on LinkedIn and follow her on Twitter@jennibeattie

Accreditation against fourth edition standards begins From July, there is a transition phase for accreditation against the fourth edition of the Standards for general practices. From 1 July 2011 to 31 October 2011 practices may elect to be assessed against either the 3rd or 4th edition standards, subject to negotiation with Australian General Practice Accreditation Limited or GPA ACCREDITATION plus. From 1 November 2011 any practice that registers for accreditation or begins the reaccreditation process must be

The Royal Australian College of General Practitioners

assessed against the 4th edition standards. The opportunity to be assessed against the 3rd edition standards ceases on 31 October. For information on the new standards, you can join a teleconference with RACGP staff.

Dates and details for joining the teleconference available at racgp.org.au/ standards

www.racgp.org.au/goodpractice


e-health

Protecting data Dr Nathan Pinskier is a GP, National E-Health Transition Authority Clinical Lead and member of the National Standing Committee on e-Health. Good Practice asked him some key questions about ensuring data security. The Brisbane floods exposed some problems with offsite storage of practice back up information. Do you think that cloud technology is useful for storing patient records? Is cloud technology secure? In general, yes and yes. Cloud or web based systems are increasingly coming into favour both for real time access or data back up. The advantage of a real time cloud based repository is that all data is securely managed and stored offsite. The disadvantage is that in the event of an internet connection failure that data becomes inaccessible. The solution is to provide local caching of data to ensure redundancy. How do you know if your external IT provider is expert in medical software and the needs of general practices? Undertake a due diligence. Ask for references from other practices and check them! • How long have they been in business? • How many staff do they have? • What are their backgrounds? • What software do they support? • What are the support level agreements? • How is support provided: onsite, offsite or both? • If the server fails, what is the recovery process? How long will it take? If the answer is more than 4 hours then you should be looking elsewhere. Are general practices more or less vulnerable than other businesses to cyber attack? It depends. If they implement the RACGP Computer security guidelines then they are less vulnerable; if not, then they are the same or possibly more vulnerable. What about doctors in small practices who carry their laptops around with patient information stored on the laptop – what risks are they running? The specific risk relates to other people being able to access clinical data. Password protection is essential, associated with secure storage of the laptop when not in use. Best practice is to access the clinical data via a virtual private network log in to the practice so that there is no need to have clinical data stored on the personal computer.

Securing information for e-health The importance of securing information in your practice cannot be overstated. A practice where personal information is not secured is open to data theft and corruption of records. This can result in loss of valuable time while records are restored, not to mention the difficulty of having to disclose loss of information to patients and others. There are several features of secure information: • it is accessible and available when needed • it cannot be changed or destroyed without authorisation • it is confidential. The national e-health system is designed to enhance many of these features. The fourth edition of the Standards for general practices presents a number of guidelines for securing electronic information. Here are some tips to help you prepare for e-health while making sure your practice complies with the general practice standards.

Appoint a computer security coordinator This may be one of the doctors, the practice manager, or a senior administrative worker. The person needs to have enthusiasm for computer technology and a good grasp of possible security threats. They don’t have to know how to fix computers or be technologically advanced (this is likely to be the domain of your external IT provider). They do need to understand risk averting procedures and be dedicated to making sure procedures are carried out. The computer security coordinator: • is the point of contact between the practice and external IT experts • knows when to call the IT expert but can assist staff with everyday computer matters • educates staff on security procedures • ensures procedures are followed.

How? Identify a staff position to which the role is most suited. It should be a position which already has a reasonable level of responsibility and may expand an existing responsibility. Discuss the role. Negotiate incentives to take on the new tasks – training support may be acceptable if the person is not already overburdened with responsibilities. Ensure that all practice staff are aware that the role is critical for the success of the practice. Lead by example – when the computer security coordinator requests help with procedure development or offers security training, encourage all staff to attend, and join in yourself.

Document policy and procedures Make sure you have written policies and procedures and that all staff have access to

14 Reprint from Good Practice Issue 5 – July 2011

them – and receive appropriate training. They include, but are not limited to, a back up plan, an internet and email policy, a disaster recovery plan, dealing with viruses and malware, managing remote connections, and firewalls.

How? Download the Computer security guidelines (www.racgp.org.au/ehealth/csg ) template. Save it to your hard drive. The computer security coordinator should be given a decent, uninterrupted amount of time to complete the template, liaising with other staff and external IT people as needed, and follow up any issues. Make sure all staff are trained in the procedures – don’t just provide a hard copy, but run group or individual training sessions or send staff to appropriate external training providers.

Ensure access levels for all data This means placing restrictions on levels of information, so that it is only seen by those who need to access it. It’s important to immediately remove access for staff who leave the practice.

How? The computer security coordinator should develop an access policy and assign appropriate access levels to staff. Automate the IT system group security policy to force users to create a new password after a specified period, for instance twice per year.

Make sure personal data is not on display Visitors to the practice should not be able to view anyone else’s information.

How? Set up the system so that it logs out users after a period of inactivity. Password protected screensavers should activate after a specified period of inactivity, such as 15 minutes.

Perform a risk analysis You need have a system in place to detect if your system has any security flaws. You could be at risk of security breaches because you: • don’t have or haven’t tested a business continuity or disaster recovery plan (in the event of power failure, system crash, vandalism or theft, or fire, flood or anything else the Australian climate may throw at you) • don’t back up data regularly and store it safely offsite

The Royal Australian College of General Practitioners

• don’t properly clear data from an electronic item being disposed of • aren’t well protected against malware and computer viruses • use portable devices offsite without checking that they are configured securely • don’t regularly maintain the computer network • don’t encrypt sensitive information that is transferred electronically • don’t have an internet, email and website policy.

How? See the RACGP Computer security guidelines. Read the 10-item security guide and then complete the checklist on page 5. This will tell you what steps you need to take to secure your practice information, such as: • preparing a business continuity and disaster recovery plan • having a reliable and tested back up procedure (daily back up is a minimum best practice requirement; daily, weekly, monthly and yearly copies should be retained on and offsite) • destroying hard drives that are no longer needed using a secure destruction service • rigorously evaluating your protection against malware and viruses • assessing your protection against unauthorised access (firewalls and intrusion detection systems) • having a clear and effective policy regarding confidential data on theft prone devices such as laptops • ensuring that your IT support provider has configured portable devices so that they can only be accessed by authorised users • ensuring encryption of data accessed remotely (eg. by Wi-Fi or from external sources such as a virtual private network protecting onscreen information) • establish a routine maintenance contract with your IT provider • developing an email and internet policy that takes into account the risks of using email and messaging to communicate with patients • using secure messaging when electronically communicating patient health information to another provider. For more information consult the RACGP 2010 Computer security guidelines: a self assessment guide and checklist for general practice 3rd edn, and A template to develop a policy and procedure manual 3rd edn. See also RACGP 2010 Standards for general practices 4th edn

www.racgp.org.au/goodpractice


Listings

Check out events in your state at www.racgp.org.au

July

Facilitation skills training

Emergency update for nurses Tuesday, 5 July College House, North Adelaide, SA

Tuesday, 26 July West Leederville, WA

Contact Jackie Munro tel 08 8267 8310 email jackie.munro@racgp.org.au

To help facilitators optimise learning, the RACGP QI&CPD Program has devised a new ALM which is underpinned by the principles of adult learning. The course is designed to promote high quality facilitation of medical education activities.

Grand round education series

Contact Beth McEwan email beth. mcewan@racgp.org.au

The aim of this course is to refresh existing emergency and CPR skills and acquire new skills such as defibrillation.

Wednesday, 6 July West Leederville, WA

Cultural awareness workshop

August Exam prep and communication skills Starts Wednesday, 3 August – goes for 10 weeks College House, North Adelaide, SA Run over 10 weeks this course is comprehensive and integrated, with the aim to familiarise participants with the exam process and strengthen communication and interpersonal skills. Contact Raminta Kymantas tel 08 8267 8331 email raminta.kymantas@ racgp.org.au

This workshop involves case based small group discussions and will cover how to provide the most effective treatment to children with wheeze, how to support patients with COPD by correct staging of disease and tailoring medications in response to treatment, and how to manage exacerbations of childhood asthma and COPD.

Wednesday, 27 July College House, North Adelaide, SA

Contact Amy Cuthbert tel 08 9489 9555 email amy.cuthbert@racgp. org.au

Contact Jackie Munro tel 08 8267 8310 email jackie.munro@racgp. org.au

This workshop involves case based small group discussions and will cover initiate effective antiplatelet and anticoagulant medication in the prevention and management of heart disease, TIA and stroke plus competence in optimising medications in MI and CHF.

New Fellows education: allergies and IBS

Contact Amy Cuthbert tel 08 9489 9555 email amy.cuthbert@racgp. org.au

Thursday, 28 July West Leederville, WA

Prostate cancer workshop

CPR certification course Wednesday, 13 July The ACT Division of General Practice, ACT The ACT Division of General Practice will be hosting a CPR course to meet RACGP triennium requirements at their rooms in Weston on Wednesday 13 July. Tel 02 6287 8099 email events@actdgp.asn.au. Register online at www. actdgp.asn.au via the events calendar

Presented by Dr Jill Benson, Director of Health in Human Diversity Unit. This presentation allows GPs to fulfil their cultural awareness/safety training requirements for the PIP Indigenous Health Incentive.

This workshop is open to anyone who has gained Fellowship of the RACGP within the past 8 years and covers paediatric food and infant milk allergy and irritable bowl syndrome and food intolerances.

Grand round education series Wednesday, 3 August West Leederville, WA

Friday, 5 August Melbourne Convention and Exhibition Centre, VIC

International prostate cancer experts will join with leading figures from general practice within Australia to update GPs on the best Contact Amy Cuthbert tel 08 9489 advice to give patients who are 9555 email amy.cuthbert@racgp. MJA_GoodPractice_Banner_FINAL.pdf 1 17/05/2011 12:24:17 PM concerned about prostate cancer. org.au

Contact ICMS tel 03 9682 0244 email prostate2011@icms.com.au visit www. prostate2011.org

September

HR management workshop

Thursday to Friday, 1–2 September North Sydney, NSW

Tuesday, 9 August College House, North Adelaide, SA This informative session will provide an insight into how other practices are managing the challenging demands of general practice.

Medical receptionist course

This course covers a range of topics relevant for nonmedical practice staff to increase and confidence. Contact Lesley Jones tel 02 9886 4700 email nswact.events@racgp.org.au

Contact Jackie Munro tel 08 8267 8310 email jackie.munro@racgp.org.au

CBT and counselling skills for GPs

Mental health upskilling for IMGs sitting FRACGP Sunday, 25 September North Sydney, NSW

Friday to Sunday, 19–21 August Albany, WA This workshop has been designed for GPs who wish to develop their skills beyond the basics. Many GPs have been exposed to brief introductions of counselling skills, this course aims to take them to the next level. Contact Beth McEwan tel 08 9489 9555 email beth.mcewan@racgp. org.au

North Queensland conference Saturday to Sunday, 27–28 August Mackay Entertainment and Convention Centre, QLD This conference will showcase the best in clinical education and professional development to regional Queensland. This event will cover the latest developments that affect you, your patients and your practice. Contact Georgina Scriha tel 07 3456 8941 email qld.events@racgp.org.au

To assist IMGs sitting the FRACGP October clinical exam in 2011, the NSW&ACT faculty of the RACGP in partnership with the Blackdog institute will be facilitating this highly interactive workshop. Contact Susan Jones on 02 9886 4748 or email susan.jones@racgp.org.au

November The John Murtagh annual update course for GPs Wednesday to Friday, 2–4 November Novotel, St Kilda, Melbourne The course will cover updated management by speakers from 14 clinical departments. Contact Faye Alphonso tel 03 9902 4444 email faye.alphonso@monash. edu. Registration tel 03 9902 4498 email caroline.menara@monash.edu

FRACGP consultation skills Tuesday, 12 July to 6 September North Sydney, NSW Held over 9 weeks every Tuesday the objective of the course is to improve participants’ knowledge of the clinical FRACGP exam process, and improve their consultation and cross cultural skills across a rangeC of domains. M

Contact Susan Jones tel 02 9886 4748 Y email susan.jones@racgp.org.au CM

Facilitation skills

MY

Thursday, 14 July CY College House, North Adelaide, SA This workshop is designed to CMY provide those who deliver education K activities to GPs and others with the knowledge of how to design, develop and deliver successful sessions that engage the learner. Allocated 40 Category 1 points in the 2011–2013 triennium.

Explore new locations

Increase your earnings

Greater flexibility

www.health247.com.au Free Call: 1800 005 915 Email: info@health247.com.au

Contact Sue Whitfield tel 08 8267 8334 email sue.whitfield@racgp.org.au

www.racgp.org.au/goodpractice

The Royal Australian College of General Practitioners

Reprint from Good Practice Issue 5 – July 2011 15


Good Practice - July 2011