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www.racgp.org.au/goodpractice
Flying doctorDr Gerry Considine’s passion for aviation plays an important role in his life as a rural GP
INSIDE
Practice safetyUpdated RACGP resource to assist GPs and practice staff
Non-adherenceWorking with patients who are reluctant to follow GPs’ advice
Cultural awarenessIncreasing understanding of Aboriginal and Torres Strait Islander patients
ISSUE 7, JULY 2015
Good Practice is printed on PEFC certifi ed paper, meaning that it originates from forests that are managed sustainably. PEFC is the Programme for the Endorsement of Forest Certifi cation schemes. PEFC is an international certifi cation programme promoting sustainable forest management which assures consumers that a forest product can be tracked from a certifi ed, managed forest through all steps of processing and production in the supply chain by a Chain of Custody process.
Editorial notes
© The Royal Australian College of General
Practitioners 2015. Unless otherwise indicated,
copyright of all images is vested in the RACGP.
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.
We recognise the traditional custodians of the land
and sea on which we work and live.
3Reprinted from Good Practice Issue 7, July 2015
Published by
The Royal Australian College
of General Practitioners
100 Wellington Parade
East Melbourne
Victoria 3002
T 03 8699 0414
W www.racgp.org.au/goodpractice
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ISSN 1837-7769
Editor: Paul Hayes
Writer: Bevan Wang
Graphic Designer: Beverly Jongue
Production Coordinator:
Beverley Gutierrez
Publications Manager: Jenni Stiffe
Advertising enquiries
Kate Marie:
T 0414 517 122
20GP Profi le
Aerial medicineDr Gerry Considine’s love of fl ying benefi ts
him and his patients in his life as a rural GP.
23National Faculty of Specifi c Interests
Antenatal/postnatal careThe RACGP’s Antenatal/Postnatal Care
network advocates for much of the care of
women and their infants to take place in
general practice.
24Vaccination
The best shotGPs are in a unique position to help
implement policies aimed at encouraging
parents to vaccinate their children.
04Your College
RACGP news and events for July.
06Patient-Initiated Violence
Practice safetyAn updated RACGP resource aims to help
GPs navigate challenges related to a safe
work environment.
10Non-Adherence
Doctor’s ordersEnsuring patients follow the advice
of healthcare practitioners can be a
diffi cult balance.
14RACGP Resource
Cultural awarenessThe RACGP’s introduction to Aboriginal and
Torres Strait Islander cultural awareness
learning module is designed to help GPs
better engage with this patient population.
17General Practice Management Toolkit
Business plansSupporting GPs in developing a business
plan for their practice.
18In My Practice
Exercise is medicine GPs at Queensland’s Lake Kawana General
Practice believe prescribing exercise can
help improve patient health and wellbeing.
ContentsIssue 7 – July 2015
06
10 18
14
20
Book give-away*
Dr Paul Carter’s
The further tales
of a country doctor features
22 more short stories about
his journey as a rural GP.
To enter the draw to win
one of three copies of this
book, please email your
name and postal address to
Entries close 15 July 2015
*Inclusion does not imply RACGP endorsement.
Winners of Tales of a country doctor
(formerly Hale and hardy: Tales and
recollections from a country practice)
S Sweeney, J Gorman, J Nichol.
4 Reprinted from Good Practice Issue 7, July 2015
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Raising GP awarenessThe RACGP recently launched its national
‘The good GP never stops learning’
campaign, which is designed to highlight
the vital work done by GPs throughout
Australia. The campaign will remind
people that it is their GP who can be
relied upon to get them better, keep them
well and prevent further illness.
‘As GPs, we never stop learning and
are experts at looking after the health
of Australians, helping our patients
with a wide range of medical conditions
throughout their entire lives,’ RACGP
President Dr Frank R Jones said.
‘The campaign is directed at patients
to improve the recognition of GPs,
general practice and of the RACGP.
It follows feedback and research from
members that they wanted the RACGP
to play a greater role in advocating for
the profession.
‘The campaign aims to increase
recognition of the important role GPs play
in the community. We want the public and
patients to understand what the RACGP
is and the vital work its members do every
day for their patients and communities.’
The widespread media campaign will
include TV and digital advertisements.
Members will receive promotional
materials, which can also be downloaded
from the RACGP website (www.racgp.org.
au/your-practice/business/tools/support/
learning), to display in their practices.
As the peak representative body for
Australian GPs, the RACGP has close to
30,000 members and represents eight
out of 10 GPs throughout the country.
‘Collectively, GPs see more than 80%
of Australians each year. We develop
life-long relationships with our patients,
often from when they are children right
through until they have their own families
and beyond,’ Jones said.
‘We have the privilege of helping people
with everything from the fl u to pregnancy,
diabetes, sleeping problems, mental
health and cancer.
‘GPs are also the key to preventive
health and we provide our patients with a
number of life-saving services.’
5Reprinted from Good Practice Issue 7, July 2015
RACGP events calendar
July 2015
QLD
Queensland faculty OSCE
preparation workshop
Saturday 11 July, 8.00 am –
12.30 pm or 1.00 pm – 5.30 pm,
RACGP House, Brisbane
Contact 07 3456 8944 or
NSW
CEMP intermediate
Saturday 25 July,
8.30 am – 5.00 pm,
Habourview Hotel, North Sydney
Contact 02 9886 4710 or
SA
GPE – cultural
awareness/multicultural
communication
Tuesday 21 July,
6.00 pm – 9.30 pm,
RACGP House, North Adelaide
Contact 08 8267 8312 or
VIC
GP and psych program
for body image and eating
disorders
Saturday 25 July,
9.00 am – 5.00 pm,
RACGP House, East Melbourne
Contact 03 8699 0488 or
WA
Practice innovation
Thursday 23 July,
6.30 pm – 9.30 pm,
College House, Perth
Contact 08 9489 9555 or
WA
New Fellows workshop –
Big eyes, little ears
Thursday 30 July,
6.30 pm – 9.30 pm,
College House, Perth
Contact 08 9489 9555 or
August 2015
TAS
Mental health ALM –
dealing with adolescent
depression
Saturday 8 August,
8:45 am – 5.00 pm, Launceston
Clinical School, Launceston
Contact 03 6234 2200 or
WA
Emotional health of
children – FPS CPD
workshop
Saturday 8 August,
9.00 am – 5.00 pm,
College House, Perth
Contact 08 9489 9555 or
VIC
Skin cancer – theory and
practice workshop
Saturday 8 August, 8.30 am –
12.30 pm, College of Surgeons
Gardens, East Melbourne
Contact 03 8699 0488 or
For further RACGP events please visit www.racgp.org.au/education/
courses/racgpevents/
GPs tackle domestic violenceThe 2015 Australian of the Year
Rosie Batty was keynote speaker
at the RACGP Victoria Faculty’s
recent Women in General
Practice Committee Conference.
The conference theme, ‘Broken
mind, body and soul: the ugly truth of family violence’, involved
exploring the hidden epidemic of family violence and looking at
how doctors can identify at-risk patients.
‘I am here so that we can understand there are many forms
of violence,’ Batty said in her keynote address. ‘You have a
responsibility to look at the safety of your [patients] and their
children. Not by being an expert, but my knowing how and
when to have that conversation and say, “Are you okay? Is there
something you would like to tell me that’s going on at home?”’
RACGP President Dr Frank R Jones agrees that GPs are in a
position to help women affected by domestic violence.
‘GPs know our patients personally and have conversations,
not just consultations,’ he said. ‘This makes us uniquely
positioned to identify victims of domestic violence, even those
who are not forthcoming about their situation.’
The conference included an overview of the RACGP’s Abuse
and violence: working with our patients in general practice (the
White book) and provided GPs with practical information.
‘It is important GPs understand the nature of violence and
abuse and how it can manifest so they can help break what is
often an intergenerational cycle,’ Jones said.
Member information on the goThe RACGP’s new member app allows GPs to easily and
securely renew their membership while on the go with access
to a number of convenient payment methods. The app also
provides members with a single location for important RACGP
information, including QI&CPD points, exam enrolment details,
exclusive offers and more.
Once members have renewed their 2015–16 membership
they will have access to
their new digital member
card via the app.
See the app on
your smart device at
app.racgp.org.au
Please note: the RACGP
member app is not available to
download through the Google
Play or App stores.
Rosie Batty stressed the
importance of GPs understanding
the different forms domestic
violence can take.
6 Reprinted from Good Practice Issue 7, July 2015
PATIENT-INITIATED VIOLENCE
General practice is a place that provides
comprehensive patient-centred healthcare
to those who take up its services. GPs and
practice staff should ideally be able to expect
a safe environment when they come to work
and few circumstances are likely to cause
more anguish than being confronted with
patient-initiated violence.
‘Violence is one of the more stressful
factors in what is already a stressful job,’
Professor Parker Magin, a GP in Newcastle
with a special interest in occupational violence
in general practice, told Good Practice.
‘Depending on where you work, there
is a range of levels of perception of risk
in different practices and it is important
to know about those and have plans to
deal with them.’
Violence directed towards GPs and practice
staff has been recognised as a signifi cant
occupational health issue for people who work
in general practice.1
‘There is the psychological impact on the
GP,’ Magin said. ‘It is important to recognise
this because, often, the response from GPs
and their staff, when faced with violence, is
to restrict the practice so they feel safe.
‘Every practice staff member has their own
level of exposure and each will experience
different kinds of violence.’
According to a study Magin and his
practice team conducted into the prevalence
and types and levels of violence experienced
by GPs and practice staff in New South
Wales, two out of three people working in
general practice had experienced violence in
the workplace.2
‘While we found that the majority of
violence GPs experience at work is
considered “low-level” violence, such as
verbal abuse and threats, it still has a big
impact on the practice staff and really
intimidated and scared GPs,’ Magin said.
In order to help provide Australian GPs
and practice staff with advice about the
best ways to manage risks and occurrences
of patient-initiated violence, the RACGP
will release an updated version of its
publication, General practice – A safe
place: Tips and tools, later this year (refer to
breakout on page 9).
‘The updated publication is important
because, given there have been some serious
incidents in recent years involving GPs, the
risk is there. It is important to bring people’s
attention to it,’ Dr Annette Carruthers, a GP
in NSW’s Lake Macquarie and a member of
the RACGP’s National Standing Committee
for General Practice Advocacy and Support,
told Good Practice.
‘It’s particularly important for new doctors
to be aware of those risks and how they
might approach them.’
Bob Milstein, a lawyer and principal at
Milstein and Associates, a legal practice that
specialises in medical negligence, believes an
updated version of General practice – A safe
place: Tips and tools is essential.
‘The latest version brings up to date the
medical legal analysis to refl ect the state of
the law as it is now, rather than once was,’
he told Good Practice.
Practice safety
BEVAN WANG
The RACGP’s newly updated General practice – A safe place: Tips and tools aims to help GPs navigate challenges related to a safe work environment.
#@$%?!
7Reprinted from Good Practice Issue 7, July 2015
‘In order for GPs and their staff to work
their way through this area, they need to be
sensitive to a couple of medical legal risks
and issues that must shape and inform their
approach. The relevant laws, in some ways,
have changed quite signifi cantly in the last
eight or so years.’
The unknown and often unrecognised
liabilities that GPs can face in regards to
staff safety is another important aspect
of patient-initiated violence in general
practice. GPs need to be aware of the fact
they can potentially be held accountable in
the event a member of the practice staff
is injured, regardless of whether the GP
is a practice owner, principal or any other
type of employee.
‘Staff are employees and are owed duties
of care under both OHS [occupational
health and safety] laws and the workers’
compensation scheme that exists throughout
Australia,’ Milstein said. ‘These laws have a
no-fault element, so the injured staff member
gets compensated in either event.
‘If there was a pattern of behaviour
which the practice failed to identify and
respond to, or if the systems were
non-existent or inherently defi cient so it
was an accident waiting to happen, then
there may well be exposures towards the
GP or the practice overall.’
It is important for GPs to consider their own health and wellbeing, but also the care they provide for their staff and patients
The safety of other patients is another area
in which GPs can potentially be exposed to
legal complications.
‘The fi rst and most important thing for
the compensation case of injured patients is
to establish that the practitioner or practice
owed them a legal duty of care to prevent
this other patient harming them,’ Milstein
said. ‘This is more likely in circumstances
where it should have been obvious to the
practitioner that they have a risky or very
violent patient who could do god knows
what – not only to staff, but also to other
patients – and they end up doing it.
‘It is important for GPs to consider
their own health and wellbeing, but also
the care that they provide to their staff
and the patients.’
Practical information
All GPs can benefi t from being aware of their
obligations to staff members and patients as
Australia’s OHS legislation becomes uniform
and more stringent.
‘There are some common themes in
OHS legislation. It is those themes that
apply across the board to all people who
run a business which, of course, extends
to GPs, whether they are sole practitioners
or partners or any other corporate system,’
Milstein said. >>
The RACGP’s practice safety checklist5
• Have a crisis response plan
• All staff well trained in responding to the
crisis response plan
• Use clinical meetings and case conferences to
discuss a practice-wide approach to patients
who present a safety risk
• All staff promptly notify a GP or practice
nurse if a patient arrives under the infl uence
of alcohol or other drugs – just as they would
notify the GP of other risk factors such as
chest pain or diffi culty breathing
• At least one staff member, in addition to
the GP, be present when the practice is open
for routine consulting (this includes on-site
after-hours consulting)
• Consulting rooms close to reception used
after-hours and on weekends
• Include practice security arrangements during
induction of all new GPs, practice staff and
medical students
• Practice team acknowledge and act on safety
concerns raised by reception staff (and other
staff as relevant) before taking a patient into
the consulting room
• Encourage practice staff to avoid entering a
consulting room with someone about whom
they have concerns
• Practice staff feel confi dent to disclose
uncomfortable feelings or episodes that
concern them
• Encourage reception staff to call the police
when necessary
• Staff are escorted to car parks after hours
(could be two staff members leaving together)
$%
8 Reprinted from Good Practice Issue 7, July 2015
Images
Park
er
Magin
; A
nnette C
arr
uth
ers
PATIENT-INITIATED VIOLENCE
>> ‘GPs need to make sure there is
a safe system, safe practice, proper
education and training, all of which
are factors they have to take on board
and deal with.’
While patient-initiated violence often
occurs spontaneously, there are measures
GPs and the practice team can employ
to help minimise the likelihood of these
situations and increase the practice’s sense
of security and confi dence.
A key strategy to prevent patient-initiated
violence as it is taking place is the use
of ‘interpersonal skills and negotiation
techniques’ so the aggressive behaviour
can be defused.3
‘When dealing with any patient it is
important to interact with them respectfully,
in a way that you would like to be treated
yourself. This can reduce the potential for
anger and aggression,’ Carruthers said.
‘For example, if you have a drug-seeking
patient you then have to politely but fi rmly
say “no”. Stick to your own framework
about when and under what circumstances
you would supply Schedule 8 drugs or
benzodiazepines.’
Magin believes taking the building’s
physical layout into account is another
of the important measures practices
can consider in working to minimise
aggression and violence.
‘Having the surgery designed so
violence is not encouraged through
calmer atmospheres is really important.
All practices need to consider it, he said.
‘A great majority of practices and consulting
rooms still have the patient between the
doctor and the door. That has to change so
the doctor is not trapped between a violent
patient and the door.
‘Unfortunately, a lot of practices are
in existing buildings so it is often hard to
remodel them too much, and new practices
often don’t see this as an important thing.’
Carruthers believes a greater emphasis
on established risk management within the
practice team can also help avoid situations
with aggressive patients.
‘GPs really need to have good
collaboration with their staff so they can
alert the GP if something happens or is
likely to happen,’ she said. ‘If someone’s
behaviour is odd, if they’re a new patient
and they seem agitated, let the staff notify
you immediately so you’re aware of the
situation and you may decide that you’re not
going to see the patient in your room.
‘It is really important to note that the
doctor and staff’s safety is paramount for a
situation that’s considered high-risk.’
While one of the suggestions outlined
in General practice – A safe place: Tips
and tools recommends practices make a
note in the fi les of patients with a history
of violent behaviour, there are potential
medico-legal consequences to consider with
such an approach.
‘It is quite proper for the practice to take
steps to alert staff to possible problematic
situations, including the violent propensities
of a patient,’ Milstein said.
‘However, staff have to remember that
patients do have a right of access to a copy
of their medical records and most probably
would not be terribly happy about fl ags in
their records, especially if they believe it
not to be true.
‘Practices need to make sure they
document everything, even the reasons
[for fl agging the patient], and that the
information is absolutely accurate and
defensible, as opposed to speculative and
loosely phrased, which could get them in
trouble with defamation.’
Informing neighbouring practices
about potentially violent patients is another
medico-legal issue GPs may consider.
‘One of the most important changes
to privacy law is one that is relevant to
notifying other practices about a worrisome
or potentially dangerous patient,’ Milstein
said. ‘The law was changed in 2014 to allow
notifi cation where you believe the patient
poses a serious risk of harm.
‘The old law was different because it
stated that you can only do so when that
threat is serious and imminent. The imminent
requirement has disappeared and, therefore,
that allows more liberal information sharing.’
Access to general practice
A further study Magin conducted into the
responses of practitioners who have faced
threats of violence found GPs often limited
their clinical practice to situations where
they felt safest.3
‘We found that GPs tend to restrict
their practice because of their concerns
about violence,’ Magin said. ‘GPs are
not denying access to vulnerable groups,
but simply restricting those who cause or
initiate violence.
‘It is fairly natural that GPs would restrict
their practices and almost all the GPs [in the
study] did this because they felt they needed
assistance on how to approach the situation.’
The same study also found GPs who have
faced threats of violence are less likely to
perform clinical work outside of the practice
because they believe it is more dangerous.3
‘We found that GPs are not doing after-
hours home visits in certain suburbs which
they consider dangerous and had to even
Left to right: Dr Parker Magin recommends practices consider building layout – not placing the patient between the
doctor and the door, for example – when creating a safe work environment; Dr Annette Carruthers believes establishing
effective risk management within the practice team can help avoid moments of patient aggression.
9Reprinted from Good Practice Issue 7, July 2015
exclude certain types of people from the
practice,’ Magin said. ‘Our conclusions
were that there is a role for training of the
actual practitioners, but it requires a
systems-level approach.
‘This is so people can feel confi dent and
safer. It has a positive impact on them and,
therefore, translates to the quality of care
they provide to their patients.’
Carruthers agrees with this approach and
cites some of the innovative after-hours
care strategies in place within her nearby
Newcastle community.
‘We have a program called the GP Access
After-Hours that operates in fi ve sites during
after-hours period and 250 local GPs work
that on a roster,’ she explained.
‘Not only do we have stress alarms,
but we’ve also ensured security at all
sites because we see that as a higher-
risk environment.
‘We do this so, for example, female GPs,
nurses and receptionists can feel confi dent
and safe because there is also a security
guard present.’
In Magin’s experience, drug-seeking
patients are among those most likely to exhibit
violent behaviour in general practice.
‘The mismatch of the expectations of the
doctor and patient are a central reason that
[situation] can lead to violence,’ he said.
‘Once you feel that violence is a possible
outcome, the advice to registrars is to agree
to the patient’s demand if that is the only way
you can separate yourself from them.
‘Once they are out of the room, you need
to then alert the appropriate authorities.’
GPs’ efforts
An international study published in
Sociology of Health and Illness found that
healthcare professionals frequently view
patient-initiated violence as a failing on
their own part.4
‘GPs often feel that if they let a situation
escalate to the point where there is violence,
whatever that degree is, then they haven’t
managed that consultation very well,’ Magin
said. ‘We also found this in our studies and
were quite surprised to fi nd that there is this
self-blame on the part of the practitioners.
‘At the same time, it is made worse
because they often don’t tell anyone about it
and try to cope with it by themselves.’
GPs may also not want to ‘lose face’
among their patients, who look to and trust
them to provide help with vital aspects of
their lives. Milstein believes, however, that
community perception of a local GP is
often very different to the reality and the
comparison may be somewhat skewed.
‘It is an example of a diffi cult friction
between two opposing forces because, on
the one hand, you have the conventional
medical model, which has always depicted
the doctor as a heroic and selfl ess individual
who puts the patient fi rst and will take risks
to do that,’ he explained.
‘But, on the other hand, you have a
rights-based system of law and obligations
that is quite different. It recognises that
not only should the doctor back away from
[patient confrontation], but they also have
obligations to their staff to make sure they
don’t get harmed.’
References
1. Wright NM, Dixon CA, Tompkins NE. Managing violence
in primary care: an evidence-based approach. Br J Gen
Pract 2003;53:557–62.
2. Magin PJ, Adams J, Sibbritt DW, et al. Experiences
of occupational violence in Australian urban general
practice: a cross-sectional study of GPs. Med J Aust
2005;183:352–56.
3. Magin P, Adams J, Ireland M, Joy E, Heaney S, Darb
S. The response of general practitioners to the threat
of violence in their practices: Results from a qualitative
study. Fam Pract DOI:10.1093/fampra/cmi119.
4. Elston MA, Gabe G, Denney D, Lee R, O’Beirne M.
Violence against doctors: a medical(ised) problem? The
case of National Health Service general practitioners.
Sociol Health Illn 2002;24:575–598.
5. The Royal Australian College of General Practitioners.
General practice – A safe place: Tips and tools.
Melbourne: RACGP, 2009. Available at www.racgp.
org.au/your-practice/business/tools/safetyprivacy/
gpsafeplace [Accessed 7 May 2015].
RACGP resourceThe RACGP will release an updated
version of General practice – A safe
place: Tips and tools in late 2015 to
assist GPs and practice staff with
occupational safety in general practice.
The guide is intended to help
general practices better deal with
risk management and instances of
patient-initiated violence.
Visit www.racgp.org.au/your-
practice/business/tools/safetyprivacy/
gpsafeplace or email advocacy@racgp.
org.au for more information and the
publication’s release date.
A new Category 2 activity on gplearning
Breast cancer in the young womanYoung women with breast cancer have different needs to women in their 60s and 70s yet most services are tailored to older women. Go to gplearning.racgp.org.au to learn about diagnosing and tailoring support for young women with breast cancer.
10 Reprinted from Good Practice Issue 7, July 2015
Image S
hutters
tock
The RACGP defi nes one of the fundamental
roles of a GP as to ‘care for patients in a
whole-of-person approach and in the context
of their work, family and community’.1
That whole-of-person approach, however,
can’t always extend beyond the four walls of
the consulting room. A lack of acceptance of
GP advice and non-adherence are common
in general practice.2
Ensuring patients adhere to GPs’
medical advice following a consultation
can be one of the more problematic
aspects of the profession, for patients and
practitioners alike.
John Boyle, a psychologist who works
closely with GPs in the area of adherence,
estimates that up to one third of medical
prescriptions go unfi lled and, according to a
study published in the American Journal of
Health-System Pharmacy, 57% of patients
have been found to be non-adherent to
their medication.3
‘If we could save one third of doctors’
time from being misused, it would be a huge
saving. And if we could actually get an extra
one third of people to use the medication as
prescribed the preventive effects could be
also huge,’ he told Good Practice.
‘There are so many situations where,
if people accepted the advice, treatment
and recommendations of their doctors and
other health professionals, we could actually
reduce the cost and burden of illness to the
individual, and to society, enormously.’
Boyle feels part of the reason behind
non-adherence is the fact many peoples’
approach to healthcare is often not black
and white – not as simple as feeling unwell
and seeking a cure from the doctor.
‘In my opinion it’s related to a reduction of
uncertainty,’ he said. ‘One of the things the
patient actually wants from the consultation
is simply the information. As in, “this is
the problem”.
‘They then have the option of deciding
whether they want to do something about it or
just waiting for it to cure itself after a certain
period of time.’
Collaborative approach
While there is no way for a GP to make
sure a patient actually fi lls a prescription and
fi nishes a course of medication – ‘We can’t
force people to take the medication because
we don’t have a “pill police” division,’ Boyle
said – they do have an infl uence over the
use of drugs in that patients are required
to visit when they run out of whatever they
have been taking.
Making sure patients adhere to their
recommendations related to modifi cations
to their daily life, on the other hand, is
more diffi cult for GPs and can create a
number of issues.
‘Non-adherence also includes not adhering
to lifestyle advice, such as diet and exercise,’
Dr Chee Khoo, a GP from Sydney with
a special interest in diabetes, told Good
Practice. ‘Getting people to make lifestyle
changes in this busy era is always diffi cult.’
According to Khoo, making patients a
part of their own care and setting realistic
goals can be important steps towards
ensuring they adhere to the lifestyle changes
prescribed by their GP.
‘Much of the advice [in health guidelines
for exercise] is very impractical,’ he said. ‘For
example, they want most people to do 30
minutes of moderate-intensity exercise most
days of the week. I think it’s impractical.
‘I think if you instead sit down and work
with the patient and say, what do you like?
what can you do? what’s your time like? you
will have better results.’
Doctor’s orders
PAUL HAYES, BEVAN WANG
Ensuring patients follow the advice of healthcare practitioners
can be a diffi cult balance.
NON-ADHERENCE
11Reprinted from Good Practice Issue 7, July 2015
Khoo also suggests a greater level
of specifi city, as well as enthusiasm
on the part of the GP, can help ensure
patient adherence.
‘If people can see my passion when
I talk about exercise, then it’s kind of
contagious in that regard,’ he said. ‘If you
pay lip service to exercise plans – “I want
you to do some exercise” – the more
blasé you are in regards to it the more
blasé the patient is going to be.
‘So I spend long periods of time talking
to people about exercise in full detail. I’ll
explain to them what treadmill they can
buy, what shoes, what clothes, how often
they should exercise, what time of the
day. I will give them tips about how to
overcome the failures in the morning.
‘If you’re patient about it, you won’t
convert all of them, but slowly and
eventually people will come on board.’
Giving patients a more active role
in determining their healthcare also
gives them a sense of ownership of the
situation and, in turn, a greater feeling of
responsibility for their own care.
‘That aspect of involvement at some
level implies a degree of responsibility and
self-responsibility is what we are striving
for,’ Boyle said. ‘They know they have to
exercise or take the medication today.
‘We need to recruit patients into the
process.’
Recognise effort
Khoo’s belief in a realistic approach
when it comes to setting patients’
exercise or other lifestyle modifi cation
goals also extends to the amount of
effort they put in.
‘It’s very important [if a patient says],
“I am trying, Doc”, that you acknowledge
this,’ he said. ‘You do need to
acknowledge that it’s hard, that they may
not have the time.
‘Acknowledging is one thing, but you
don’t want to nag them, to make them
feel terrible, either.
‘You can make some gentle suggestions
like, what about exercising one or two
days a week, walking at lunchtime for
half an hour, walking to the train station
one day instead of driving every day?
Give them some lighter suggestions,
but defi nitely empathise with them that
exercise is hard for most people. >>
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11–13 Sept 2015Brisbane Convention& Exhibition Centre
AUSTRALIA’S LEADINGPRIMARY CARE EVENT
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12 Reprinted from Good Practice Issue 7, July 2015
Images
John B
oyl
e; C
hee K
hoo
NON-ADHERENCE
>> ‘You need to have that little balance of
not nagging yet having a slight frown on your
face – I’m taking interest and should notice
that you’ve not exercised. I don’t want to nag
you again like last time, but I’m kind of still on
your back a little bit.
‘It’s a very fi ne balance.’
Boyle believes the close relationship
GPs are likely to have with their patients
makes striking that balance, and making
an agreement with those patients, that
much easier.
‘Knowing the person means the doctor
is able to work with that person to achieve
better health outcomes,’ he said. ‘The doctor
knows the person and has experience with
them, knows the diffi cult areas and can titrate
the intervention.
‘For example, the doctor knows a male
patient may be a bit forgetful and recruits his
wife into the process so they can all agree
and understand what the doctor is saying.
‘That’s why the therapeutic relationship
is critical and if you work incrementally you
can build it up, help them understand and
work together to overcome the problem.
You need to let patients know that they are
part of it all and once the person feels they
are an active part in the solution, then you
increase adherence.
‘With different interventions, you just slowly
gain 5% here and 5% there and it makes a
difference. It is then in their capacity as the
patient with the condition and mine as the
doctor with the knowledge who knows how
to fi x it. It is the combination of the two that
works together to make it happen.’
Make an agreement
Boyle believes practitioners making
people more active participants in their
own healthcare solutions can include the
creation of an informal contract between
the doctor and the patient. He cited a man
he recently treated who wanted to limit
his drinking as an example in which he
utilised some positive verbal and non-verbal
reinforcement techniques.
Once patients feel they are an active part of the healthcare solution, you can increase adherence
‘We had the conversation and when I asked
him what he was going to do, he said he was
going to stop drinking,’ Boyle said.
‘I used positive head-nodding, “I think
that is an excellent decision for you. Let’s
shake on it”. I put my hand out and of
course he is going to respond. He shook
my hand and you have to say, “We now
have a contract”.
‘He came back recently and he hadn’t
had a drink. He said it was because we
made it a contract.
‘It’s those kinds of techniques you can use
to positively infl uence people’s behaviour.
We help them understand the intention to
stop drinking, to lose weight, to take the
medication and that is all just the beginning.’
Following the contract, Boyle recommends
a second step that he calls goal-acquisition.
‘If we get them to say, “This is how I will
remember to take the medication”, “This is
how I will lose weight”, we are fl eshing out
the part where they will be successful with
hardcore plans,’ he said.
‘We need to look at things from an “if”
perspective and a “then” perspective.
‘What is going to stop you from going to
the gym? What could stop you from taking
your medication?
‘If you can identify the obstacles and the
pitfalls, prediction gives control. You can
formulate a plan that you can activate as
soon as you encounter the obstacle, rather
than coming to the obstacle, scratching your
head and not knowing what to do.’
Khoo agrees with the potential benefi ts
of making a contract. However, he cautions
doctors against being too heavy-handed
in the approach and says it is important to
make patients aware of the more immediate
benefi ts of following medical advice.
‘We can’t scare our patients because
that’s not going to work. An “If you don’t
do this your tail is going to fall off” type of
message is not going to work,’ he said. ‘You
need to sit down with the patient and explain
to them why you want them to exercise.
‘The benefi t of exercise for patients with
diabetes, for example, is not just that the
numbers are good – the HBa1C is good,
glucose levels are good – because the
patient doesn’t feel that. Tell them if you
exercise you are going to feel a lot better,
be less tired.
‘Bring all those important issues together
with the advice about exercise then, at the
end of the day, it’s for them to decide what
they want to do.’
References
1. The Royal Australian College of General Practitioners.
Becoming a GP in Australia: What is a GP? Available
at www.racgp.org.au/becomingagp/what-is-a-gp
[Accessed 5 June 2015].
2. The Royal Australian College of General Practitioners.
Putting prevention into practice: for the implementation
of prevention in the general practice setting (Green
book) (2nd edition). Melbourne: RACGP; 2006.
3. Bieszk N, Patel R, Heaberlin A, et al. Detection
of medication non-adherence through review of
pharmacy claims data. Am J Health Syst Pharm
2003;15(60):360–66.
Left to right: Dr Chee Khoo believes making people more active participants in determining their care helps them to
follow practitioners’ advice; psychologist John Boyle suggests making a ‘contract’ with patients about their healthcare
can make a positive difference to adherence.
O U R F U T U R E I N P R A C T I C E
Melbourne Convention and Exhibition Centre
21 – 23 September 2015www.racgpconference.com.au
GP15 program now available!The RACGP is excited to present the GP15 program which will share insights and ideas about how the past and present will form our future in general practice.
Be stimulated and fascinated at GP15 by
Learning about the breadth and depth of general practice
Unlearning previous “truths”
Conversing with experts around medico legal matters
Participating in practical demonstrations of new technologies
Contributing to discussions about evolving hot topics
Managing unexpected situations - CPR and disaster management
Meeting colleagues from across Australia and overseas.
There are many opportunities for you to connect with colleagues and build new relationships throughout GP15’s education program and social functions.
To view the preliminary program visitracgpconference.com.au/program
GP15 app available in August 2015!
14 Reprinted from Good Practice Issue 7, July 2015
Images
Just
in C
ole
man; Tim
Senio
r
RACGP RESOURCE
Cultural awarenessPAUL HAYES
This updated RACGP learning module is designed to help GPs better understand and engage with Aboriginal and Torres Strait Islander patients.
Australian GPs and medical students are
likely aware of the health issues commonly
faced by Aboriginal and Torres Strait
Islander peoples, as well as the healthcare
disparities between that population and
non-Indigenous patients.
What can be less clear for GPs of all
experience levels, however, is the details
behind those health issues and disparities,
and how to best approach them with the
patient. A greater level of GP awareness
of Aboriginal and Torres Strait Islander
peoples’ cultural and social backgrounds
can have a signifi cant impact on achieving
better health outcomes.
‘When I talk to medical students about
what they feel is important in Aboriginal
[and Torres Strait Islander] health, they
usually list particular diseases that are
more prevalent,’ Dr Justin Coleman, a GP
and medical educator who has worked in
Aboriginal health services for close to a
decade, told Good Practice.
‘But what I say to them is, in fact, the
majority of medicine you will practise in
Aboriginal [and Torres Strait Islander]
health is just good, solid medicine that
you’re taught extensively in medical school.
The trick is how to translate that into
Aboriginal and Torres Strait Islander health
so the outcomes are actually affected
for the better.
‘It isn’t in the actual medical content,
it’s the way medicine is delivered. That’s
why understanding the cultural aspects
is so important.
‘You could be the cleverest physician
in Australia and have absolutely terrible
outcomes in Aboriginal and Torres Strait
Islander health if you lack that ability to
bridge the theory with the practice.’
Better understanding
The RACGP’s newly updated ‘Introduction
to Aboriginal and Torres Strait Islander
cultural awareness’ active learning module
(ALM) is designed to provide GPs with a
greater level of knowledge about Aboriginal
and Torres Strait Islander cultures,
histories and health needs, and help
improve the delivery of appropriate care in
general practice.
First launched in 2010, the module
has been completed by more than 2000
GPs, practice managers, receptionists and
allied health staff. The updates provide
a more interactive experience for users
and completion now offers 40 Quality
Improvement and Continuing Professional
Development (QI&CPD) points.
According to Coleman, who was a
member of the ALM’s review panel, there
is a relative lack of cultural awareness in
Australian general practice and increased
understanding among GPs will ultimately
help patients and healthcare professionals.
‘You miss out on so much if you are either
unaware that your patient is Aboriginal or
Torres Strait Islander, or if you are aware
but really don’t have much idea about how
that might change things for the relationship
between you and that patient,’ he said. ‘The
beauty of a cultural awareness ALM is that
it starts to fi ll that gap in knowledge and, in
the end, doctors and patients benefi t.’
Janelle Speed, who has worked as an
Indigenous lecturer at the University of New
England’s School of Rural Medicine and
Health in New South Wales and was also
on the ALM’s review panel, believes efforts
to increase cultural awareness in healthcare
are vital in order to achieve better results for
Aboriginal and Torres Strait Islander patients.
Introduction to Aboriginal and Torres Strait Islander cultural awarenessThe active learning module introduces
participants to Aboriginal and Torres
Strait Islander cultures, histories and
health needs, and helps improve the
care they deliver by exploring issues
facing GPs, practice staff and Aboriginal
and Torres Strait Islander patients.
On completion, learners should be
able to:
• describe two ways in which current
and past experiences of Aboriginal
and Torres Strait Islander peoples may
infl uence current health circumstances
• identify at least one strategy to ensure
the correct, consistent identifi cation
and recording of Aboriginal and
Torres Strait Islander patients in
general practice
• identify at least two strategies that
their practice could use to address
some of the key barriers to access for
Aboriginal and Torres Strait Islander
peoples in mainstream primary
health services
• identify at least two ways in which
effective communication and the
doctor–patient relationship can
infl uence clinical outcomes for
Aboriginal and Torres Strait Islander
patients
• outline the rationale for participation in
cultural safety training, engagement
with local communities and continued
learning, planning and improvement to
develop a culturally safe practice
• identify at least three specifi c
actions that could be implemented
immediately in their own health service
to enhance cultural awareness.
Visit www.racgp.org.au/yourracgp/
faculties/aboriginal/education/cultural-
awareness for more information.
15Reprinted from Good Practice Issue 7, July 2015
‘That’s why we need to bridge the
understanding between the different
cultures – so they can both see how they
can best communicate and engage and
fi nd out how to get the best outcomes,’
she told Good Practice.
As an Aboriginal woman with an
extensive background in cultural awareness
education, Speed is passionate about
sharing that knowledge, particularly in the
area of medicine. She feels programs like
the RACGP’s ALM are important because
they offer participants the chance to learn
about areas of healthcare that go beyond
the physiological.
‘I think the medical world comes from a
very biomedical model, whereas health is
viewed by Aboriginal people as a very holistic
type of thing,’ she said. ‘I think [the ALM
helps to] educate people as to what the
differences are and how to develop skills to
overcome those issues.
‘It helps educate GPs as to what the real
health issues are for Aboriginal people, rather
than only hearing the one-line things like
“close the gap”.’
Dr Tim Senior, a GP at Sydney’s Tharawal
Aboriginal Corporation and medical advisor
for the RACGP’s National Faculty of
Aboriginal and Torres Strait Islander Health,
also hopes the ALM will give participants
a better idea of how Aboriginal and Torres
Strait Islander peoples defi ne health [refer to
breakout on page 16].
‘It’s a much more social defi nition. It’s about
being connected to family and community
and reaching your potential, which is possible
even in the presence of disease. Whereas,
the WHO [World Health Organization]
defi nition only has the absence of disease,’ he
told Good Practice.
‘This is intuitively understood by Aboriginal
and Torres Strait Islander peoples; that just
dealing with biology or using medication to
tackle a problem doesn’t actually get to the
root causes of that problem.
‘Once [GPs] start understanding that, we
realise that management of diabetes, for
example, is about medication, food security
and a good diet, and also about being
connected to family and community and
working for other people in the community.
‘When we are too focused on the pure
biology of the medicine we are not doing our
Aboriginal and Torres Strait Islander patients
a service. They often feel they have been
short-changed in their care.’ >>
Left to right: Dr Justin Coleman believes the ALM will help participants appreciate the importance of the delivery of medicine as well as the medicine itself; Dr Tim Senior describes the
Aboriginal defi nition of health as a more social one that doesn’t always rely on biology and medication to tackle a problem.
The GPMHSC is sponsoring the Emotional health of children ALM at GP15.
This FPS CPD activity will enhance your skills in interviewing children and
teaching them cognitive strategies for managing anxiety and depression.
Register at racgpconference.com.au/alms/emotional-health-alm/
16 Reprinted from Good Practice Issue 7, July 2015
Image R
AC
GP
RACGP RESOURCE
Unique history
Upon completion of the ALM, GPs will be
equipped with not only increased awareness
of Aboriginal and Torres Strait Islander culture,
but will also be able to describe some of the
unique past experiences that may infl uence
the current health circumstances of this patient
population. According to Speed, such insight
is important because these experiences are
such a fundamental aspect of past and present
Aboriginal and Torres Strait Islander culture.
‘Understanding the impact of colonisation
and how it affects people today [is important],’
she said.
‘Even though we fi rst had colonisation
200-odd years ago, the impact is still felt today
and there is a lot of intergenerational trauma
that has been passed on through that.’
Coleman’s time working in Aboriginal health
services opened his eyes to these experiences
and he agrees that understanding them is
extremely important for working towards better
health outcomes.
‘The intergenerational trauma that this
has caused has a huge impact – family
disruption, Stolen Generation, high mortality
rates. Tragically, in every family there’s either
been deaths in the family or in the extended
family,’ he said.
‘All those things impact heavily on the way
patients can prioritise their own health needs
and I think that’s very important to understand.’
The experiences ALM participants will work
to understand, however, are not limited to the
distant past.
‘I think a crucial one, which is not only
experienced by Aboriginal and Torres Strait
Islander peoples but is certainly acutely
experienced by them, is the social determinant
of poverty and low-socioeconomic status,’
Coleman said. ‘I think that infl uences
everything from likely education level, including
health education and world view on health,
to employment level, likelihood of smoking,
and the capacity of that person to actually
change their day-to-day life to fi t in with your
management plan.’
A greater understanding of these types of
experiences, according to Senior, will allow
patients to better trust their GPs, who will then
be able to expand their management plans and
think beyond the walls of the consulting room.
‘Knowing about those issues allows us to
be more culturally appropriate in terms of how
we’re involving people in care, how we’re
helping people make appropriate decisions
about their health,’ he said. ‘Because if
we’re not doing that we’re just assuming that
everyone shares our cultural values without
even thinking about it.
‘Nothing happens without trust. So any
discussion about stopping smoking, about
taking medication, about referrals to see other
services, none of that happens if the person
discussing that isn’t trusted.’
Practice level
The ability to better grasp why patients may not
be properly adhering to a healthcare strategy is
another of the advantages of the ALM.
‘The benefi ts for the GP is getting an insight
into why some of their management plans and
expectations don’t seem to work, which in the
past, without cultural awareness, may have just
confused the doctor,’ Coleman said.
‘I think one of the crucial aspects of the
doctor–patient relationship with an Aboriginal
or Torres Strait Islander patient is the
communication and the subtle things that are
unsaid during the consultation, and knowledge
of the social determinants of health and how
that is impacting on the consultation.
‘Once you grasp how that is infl uencing
every aspect of the consultation, I think that
you’re in a much stronger position to be able to
get better outcomes.’
According to Speed, the lessons learnt
in the ALM can also help GPs better
understand the needs for these patient-specifi c
health programs.
‘A lot of people don’t understand why
Aboriginal people have special health programs
and why we do these things, because they
think everybody should get equal care,’ she
said. ‘So what we need to educate them on is
that it’s not equality that’s needed, it’s equity,
and Aboriginal people are a long way behind
in that fi eld.’
While Coleman is a strong advocate for
registrars and medical students completing the
cultural awareness ALM, he is also keen to
see more seasoned practitioners take up the
continued development.
‘I think it is brilliant content for experienced
GPs,’ he said. ‘So much of the content that
experienced GPs learn is biochemical or
medical updates, but the ALM is more about
the chance to refl ect on our own practices,
what actually occurs during a consultation. It’s a
bit more humanity-based.
‘It’s not so much medical content as
self-refl ective content – how much we know
about the background of these things and
increasing your ability to read how your own
consultation is going. It allows you to treat the
patient as much as the illness.’
Reference1. National Aboriginal Community Controlled Health
Organisation. Defi nitions: Aboriginal health. Canberra:
NACCHO; 2008.
Defi nition of Aboriginal healthAccording to National Aboriginal Community Controlled Health
Organisation (NACCHO), Aboriginal health means not just the
physical wellbeing of an individual, but refers to the social, emotional
and cultural wellbeing of the whole community in which each
individual is able to achieve their full potential as a human being,
thereby bringing about the total wellbeing of their community. It is a
whole-of-life view and includes the cyclical concept of life-death-life.
Healthcare services should strive to achieve the state where every
individual is able to achieve their full potential as a human being and
thus bring about the total wellbeing of their community.1
Left: ALM participants will learn how current and past experiences of Aboriginal and Torres
Strait Islander peoples infl uence their current health.
17Reprinted from Good Practice Issue 7, July 2015
GENERAL PRACTICE MANAGEMENT TOOLKIT
PAUL HAYES
The fi fth module of the RACGP’s General practice management toolkit has been created to support GPs in developing a business plan for their practice.
General practice is a business like any other
and requires effective forward planning in
order to operate successfully. In an effort
to support GPs who run their own practice,
the RACGP’s General practice management
toolkit (the Toolkit) contains a module
designed to support the development of
business strategies.
The fi fth module in the recently updated
Toolkit, Business plans, offers GPs
information on how to best plan for their
practice’s future.
‘GPs are usually under time pressure,
which often leads to them maintaining
current processes rather than planning
ahead,’ Dr Neville Steer, practice owner
and primary GP and author of the Toolkit,
told Good Practice.
‘The Business Plans module provides
an approach that GPs can use to develop
a strategy to manage and develop their
practice over the medium to long term.’
The module includes information on
areas such as business strategy; marketing
plans; implementation and action planning;
monitoring, control and evaluation;
and developing a business plan. It also
includes a number of useful resources and
other references.
Think about the future
According to Steer, the busy nature of
general practice, coupled with the temptation
to maintain the status quo and not fi x
something that isn’t broken, means the
development of effective and innovative
business plans can make a signifi cant
difference to staff initiative and enthusiasm.
‘The business plan will record the future
objectives for the practice and this can be
an effective communication and motivating
tool,’ he said.
‘When the plan is used as part of practice
meetings, for example, it helps keep a
strategic focus in addition to dealing with the
regular business decisions.’
That goal-setting and motivation, Steer
said, can also allow non-clinical staff
members to work more independently in
order to help move the business forward.
‘Having a business plan in place can allow
the practice manager to implement actions
necessary to achieve the practice objectives
without continually waiting for direction from
the practice owners,’ he said.
‘In addition, developing the staff in the
practice can also have a very positive impact
on business performance.’
Quality assistance
The module helps GPs – who may not have
a background in business training – to better
understand how to develop an appropriate
strategy, recognise what is needed to
implement the plan and develop measures
and processes to assess the outcomes of
the planned initiatives.
‘Implementation is the usual stumbling
block for most businesses. Having an
implementation plan agreed upon, with
regular reporting on progress, improves
outcomes,’ Steer said.
Steer believes it is important for GPs to
remember the core role of their profession
and to use the plan to better structure the
provision of quality healthcare.
‘General practice is a professional services
business,’ he said. ‘It is under pressure from
competing health providers, so customer
service and marketing are two areas that can
yield signifi cant improvements.’
However, Steer is also quick to suggest
GPs not ‘over think’ their plan and try to
include too much.
‘It can be diffi cult to put together
a business plan if there are too many
key objectives,’ he said. ‘Maintaining
focus on the most important objectives
allows the practice manager to produce
tangible results.’
Engaging the assistance of external
experts can also be helpful for busy GPs
trying to develop a plan that will best suit
their individual practice.
‘Business specialists can often help
GPs look at their business from a different
perspective,’ Steer said. ‘They can also
bring a broader range of knowledge that can
contribute to improving the operation of the
practice as a business.’
Business plans
Imag
es L
ake
Kaw
ana
Gen
eral
Pra
ctic
e
IN MY PRACTICE
BEVAN WANG
The GPs at Lake Kawana General Practice believe prescribing exercise can help improve patient health and wellbeing.
Located on Queensland’s Sunshine Coast, Lake Kawana General Practice offers holistic healthcare and is housed with pathology services, allied health professionals and other medical specialists.
The practice is known to many in the community and aims to attract GPs from various backgrounds. Dr Dominic Radford, an RACGP member since 2013, is a UK-trained GP who joined Lake Kawana General Practice in 2014.
‘General practice was always something that I was interested in, in terms of the autonomy with which you get to function as a clinician, making diagnoses and working in the community,’ he said. ‘I met one of the [Lake Kawana General Practice] partners at a social function and got chatting to him. I realised the practice was somewhere that allows the GPs to really use the interests and skills they have for the betterment of the patients.
‘I became really interested in joining the practice because it had a much younger patient population where I could put my skills and interest in sports medicine to good use.
‘I have a particular interest in the management of tendinopathies, which I treat with extracorporeal shockwave therapy. I have also found that to be an effective treatment for plantar fasciitis, bone pain associated with post-fracture, and many soft tissue injuries.’
Lake Kawana General Practice started with two associates in 1993, gradually expanding to five in 2005, and has continued to grow. It is now home to up to 12 doctors and four nurses at any one time.
‘As the practice got bigger and more successful, the partners wanted to expand the size and the facility to accommodate the patients,’ Radford said. ‘They moved into the purpose-built building we are in now, which is specifically for general practice.
‘It’s a big practice with large consulting rooms, but we’ve also got large treatment areas where we have full-time nurses working on the more acute cases and injuries, as well as some surgical procedures in the dedicated treatment rooms.’
While the Sunshine Coast might be well known for beautiful beaches such as Noosa and Maroochydore, it is also a rapidly expanding residential area for young professionals and families.
‘At Lake Kawana General Practice we certainly have a much younger demographic because we are located within a business hub where there are a lot of offices. People of a working age come to us as their primary carers,’ Radford said.
‘Areas of new residential housing surround the business hub and there is a lot of building work going on at the moment, which is attracting a lot of young families.’
As with many general practices throughout Australia, Lake Kawana General Practice has seen the treatment of chronic disease increase in recent years.
‘We do a lot of family medicine. We see a lot of children because of the young population and we end up doing a lot of routine health checks and vaccinations for kids,’ Radford said. ‘But, as myself and a lot of the other doctors at the practice have noticed, we also have to deal with a lot more chronic diseases. A lot of diabetes, heart disease, hypertension.
‘There is also a large number of patients with respiratory issues, asthma and COPD [chronic obstructive pulmonary disorder] and they make up a large proportion of our workload.’
18 Reprinted from Good Practice Issue 7, July 2015
Exercise is medicine
Staff members at Lake Kawana General Practice are encouraged to use their special interests to help patients and achieve better outcomes.
19Reprinted from Good Practice Issue 7, July 2015
Prescribing exercise Radford was introduced to sports medicine after he started working in general practice in the UK
‘I was really enjoying general practice, but wanted something else in addition to that,’ he said. ‘I just got really interested in working in sports medicine at various football clubs and decided to do my specialist training in the UK.
‘You would be amazed how many people come in to see me for a general practice consultation which then turns into a sports medicine injury, and vice versa.’
Radford set up Sunny Coast Sports Medicine when he joined Lake Kawana General Practice in 2014, with the two services located at the same premises.
‘I moved over to Australia and wanted to continue to do [sports medicine] along with my general practice,’ he said. ‘So I continued to promote myself as a GP and was also able to provide sports injury care and musculoskeletal medicine.
‘The sports injury clinic was something I went to the partners with because I already had considerable experience. The partners were very keen because they already had a couple of patients who needed that type of care that would be suitable for extracorporeal shockwave therapy.’
Radford believes the patient relationships and skills GPs possess make them best equipped to deal with the bulk of sports medicine, especially anything related to musculoskeletal medicine.
‘The vast majority of people with musculoskeletal issues initially present to
their GPs,’ he explained. ‘A lot of the time people would be referred directly onto physiotherapists, which may or may not always be the correct course of action.
‘As a doctor, we have access to imaging for diagnostic purposes that allows you to make a more accurate diagnosis. Once you have that, you can tailor the treatment more effectively to get better outcomes.’
While most people may commonly perceive sports medicine as consisting largely of exercise-induced problems, Radford describes it as much more wide-ranging and inclusive of people’s everyday life.
‘Not doing any exercise can cause huge musculoskeletal injury, like lower-back pain, for instance, and people can get tennis elbow from just using a computer mouse at work,’ he said. ‘Inactivity is definitely something that will lead to an increase in musculoskeletal injuries.
‘Inactivity is going to be a big issue in the future for all health practitioners, especially in general practice.’
For Radford, taking the time to talk with a patient and discuss exercise as a prescription can help to encourage them to be more active.
‘The key term we use is “exercise is medicine”, meaning that doing appropriate exercise can be as good for you as taking cholesterol-lowering or blood pressure medication,’ he said. ‘Appropriate ways to exercise are certainly something that I spend a lot of time talking to patients about.
‘I also spend a lot of my time talking about alternative forms of exercise, non-impact exercise such as cycling or cross-training, stepping machines, all of which have very low risks of injury, but offer a good cardiovascular workout and are good for people’s health in general.’
Radford finds patient resistance a significant barriers to prescribing exercise.
‘It is not easy to get people to go out and do some exercise, but the important thing is to try and explain the benefits,’ he said.
‘Trying to get people enthused about exercise can also help with adherence and show them that they can enjoy it and it is not just a chore.
‘It is important that today’s GPs think about other options that their patients can do, rather than just prescribe medication, and exercise is a great first step.’
Lake Kawana General Practice’s purpose-built location is home to a number of other healthcare services, including pathology, allied health professionals and other specialists.
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GP PROFILE
Aerial medicinePeople often say it is important to have
hobbies and interests outside your
chosen profession and general practice
is no different. While some may think
of hobbies as pastimes like collecting
stamps or writing poetry, Dr Gerry
Considine’s interest takes him tens of
thousands of kilometres into the air.
‘You really need to do things outside
of medicine and fl ying my plane is there
for me. It’s what I do when I have had
a stressful day,’ he told Good Practice.
‘I know a GP who is into knitting, another
who breeds donkeys and there are others
who have veggie patches and animals.
‘It is very important for those in
high-stress jobs, like GPs, to have
something outside of their profession
because if you just stick to that, as much as
you love it, it is simply too much.’
Considine, who has been an RACGP
member since 2011, is a GP in the
mid-north South Australian community of
Clare, but grew up in the outer-suburbs
of Melbourne. He completed a science
degree at Monash University before
making the move to Adelaide to complete
medical school.
‘I did my undergraduate degree in
biomedical science fi rst and did a year of
honours in cellular immunology,’ Considine
said. ‘I found that to be a bit boring because
I didn’t really want to be working with a
pipette and cells all day long.
‘I got a medical school position at Flinders
University in Adelaide. That was good for
me because I was able to move out of home
and start fresh.’
Like many in general practice, Considine
was interested in several different aspects
of medicine. He originally considered
becoming a paediatrician, but always knew
he wanted to practise a number of areas
of medicine.
‘During my third year I went out to
a town called Quorn [in SA’s Flinders
Ranges] and spent some time with Dr
Tony Lian-Lloyd, who is a real renegade
rural GP,’ Considine said. ‘[Lian-Lloyd]
and other GPs in rural towns showed me
that I was not just able to do paediatrics,
anaesthetics and surgery in the city, but able
to do all of that as a rural GP.
‘I couldn’t see myself only working as a
paediatrician all my life, or only with people
who were asleep under anaesthetics, or
only older people.
‘I really wanted to do a bit of everything.’
Considine has worked in the Adelaide
Hills region of SA and spent time as a
general practice registrar on the state’s
Eyre Peninsula after leaving medical school.
‘I have always wanted to work in rural
communities because, for me, it was also
about being a bit more independent in your
own practice and not sending patients to the
specialists straight away,’ he said.
‘You can do a bit more of your own
work fi rst and, if you get to the end of your
investigation and knowledge, then you can
ask for help.
‘There is also the element of variety
because people [in rural towns] simply don’t
have the option of going down the road to
the local emergency department if they’re
unwell like they would in the city.’
Looking after yourself
GPs in rural and remote communities often
tend to work long clinical hours on top of the
external work usually associated with life in
general practice.
‘There is not necessarily a lot of appetite
for rural general practice [among medical
students and registrars] at the moment,
especially solo practices, because there is
a lot of on-call work and high rates of burn
out,’ Considine said.
‘One of the big things is to work in a
practice with other doctors, or in a model
where doctors work in a team because it
helps alleviate that fatigue.’
Aviation has always been a passion for
Considine. It was a push from a fellow
fl ying doctor that encouraged him to take
on the training.
EFIILE
Images
Gerr
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onsi
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BEVAN WANG
South Australia’s Dr Gerry Considine believes his passion for aviation has helped him become a better rural GP.
20 Reprinted from Good Practice Issue 7, July 2015
‘As a kid, I was always
fascinated by aircrafts
and wanted to be a
pilot, until the middle
of high school when
that went away and the
love for medicine came
in,’ he said. ‘I thought
it would be great to
be able to work in the
country and own a
plane so I can fl y out to
clinics and help more
remote communities.
‘It turned out that my
fi rst registrar placement
was with a doctor in Wudinna [on SA’s Eyre
Peninsula] who owned two planes himself.
He really encouraged me to do it.’
Today, Considine’s own aircraft, Plane
Jane, allows him to travel to rural and remote
communities much faster than if he was
stuck on the bitumen.
‘It is a really good way to get to those
clinics quicker than you would otherwise,
but also allows [my wife and fellow GP] Mel
and myself to get out of our town and have
a holiday we otherwise wouldn’t be able
to in the short time,’ he said. ‘Rather than
spending the whole time driving to Kangaroo
Island for six hours on the weekend, we
can fl y there in an hour, spend the weekend
and then fl y back.
‘It keeps us going and prevents burn out.
We can just leave it all behind for a bit and
come back recharged.’
When comparing obtaining his pilot’s
licence to his pathway to RACGP Fellowship,
Considine believes the two processes
actually complement one another.
‘They are both equally challenging, but
there are lots of similarities between them,
lots of theories to know,’ he said.
‘Then there is a practical exam where
someone is watching you do the OSCE
[Objective Structured Clinical Exam] and it’s
the same thing for your fi nal exam on the
pilot’s licence.
‘I would say they are as enjoyable as each
other and I think they are complementary
because after a long day in the clinic I
will often de-stress and go for a fl y around
the local area.’
Considine hopes to use social media
and the internet to form greater professional
relationships with other remote healthcare
professionals in Australia and beyond.
You really need to do things outside of medicine ... flying my plane is what I do when I have had a stressful day
‘There is a lot of scope for collaborative
learning. Not only among people who are
learning from their medical educators in
their state or training organisation, but from
different places all across the world,’ he said.
‘In rural general practice, the internet helps
to break down the professional isolation that
GPs often experience.
‘GPs who are active on the internet
also need to be aware of some of the
limitations of social media, as well as the
dangers. But they should remember to use
it for some of the amazing benefi ts like
collaborative learning.’
Community involvement
As GPs all around Australia would
understand, local engagement is vital
to a healthy community. For Considine,
rural general practice works best when
the GP makes an effort to connect with
the local people.
‘I am attracted to places where I can
really be a member of the community and
contribute. Not just as a doctor, but where
I can play some football or music, and get
involved,’ he said. ‘When people ask me
what it’s like living in the town as a doctor,
I tell them that I am actually a member of
the community fi rst and foremost who then
happens to be a doctor.
‘Knowing people outside of the
consulting room means you can begin to
build a support network and friendships.’
The relationship between the community
and its GP is something Considine believes
goes both ways.
‘Community engagement is really crucial
because you won’t survive long as a rural
GP if you are not part of the community,’
he said. ‘I found that works well by having
a bit each way with the community.
‘If you are a doctor and you are
expecting the town to come in to see your
room, your environment, your space, and
they are opening themselves up to you as
a doctor, you need to do the same as a
community member.’ >>
Flying his own aircraft, Plane
Jane, helps Dr Gerry Considine
relax away from the consulting
room and more easily access
patients in remote areas.
21Reprinted from Good Practice Issue 7, July 2015
22 Reprinted from Good Practice Issue 7, July 2015
Images
Gerr
y C
onsi
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GP PROFILE
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>> While separating private and professional
lives is recommended for people in many
professions, this can sometimes be diffi cult to
achieve in smaller communities.
‘You need to realise that people in the
supermarket will ask you about their test
results or the rash they have,’ Considine said.
‘You need to set boundaries early and tell
them nicely that you are not at the clinic in
order to give them the best care.
‘Most of the towns I’ve worked in are pretty
good at that. They understand that if they
keep bothering the doctor at the supermarket
or at the football ground, [the GP] is going
to get sick of it and will either leave or get
really annoyed.’
Considine is also enthusiastic about
attracting registrars and medical students, and
retaining existing GPs, in rural communities.
‘I am extremely passionate about general
practice and want to push that as a career
choice because this way we can get the
best quality GPs coming through,’ he said.
‘There might be people out there who
hadn’t considered it, but who would be
fantastic GPs.’
Considine believes medicine in rural
communities is going to change signifi cantly
as the use of telemedicine increases
around Australia.
‘When I am on call, I often have
to consult emergencies via a video
link-up to the patient, with the
nurse there with the patient. It
is invaluable to be able to see
the patient, zoom in on the
observation machine and ask
the nurse what’s going,’ he said.
‘The other use of telemedicine
would be for specialist review,
especially in the country, because
telemedicine means that patients
don’t have to drive six hours to
see a specialist.
‘There is a real potential there
for people in remote communities
who struggle to drive a couple
of hours to see their doctor and
receive greater holistic care.
Telemedicine will defi nitely change
the game and allow for better
coordination of care.’
Dr Gerry Considine believes engaging with
people and activities in the local community helps
rural GPs better connect with their patients.
ith
lps
nts.
23Reprinted from Good Practice Issue 7, July 2015
NATIONAL FACULTY OF SPECIFIC INTERESTS
Antenatal/postnatal careBEVAN WANG
The RACGP’s Antenatal/Postnatal Care network believes much of the care of women and their infants, before and after birth, can take place in general practice.
The RACGP’s National Faculty of Specifi c
Interests (NFSI) Antenatal/Postnatal
Care network was established in 2012
and advocates for GPs to have greater
involvement in obstetrics.
‘GPs know that pregnancy doesn’t start
six weeks or 12 weeks after you’ve fallen
pregnant, and it doesn’t stop six weeks
after you’ve delivered,’ Dr Wendy Burton,
a Queensland GP with a special interest in
obstetrics, told Good Practice.
‘Pregnancy is an important part of the
whole-of-life continuum and it goes from
preconception advice to early pregnancy,
through the trimesters, to postpartum and
into infant care and parenting advice.
‘GPs can provide excellent care as
we are the speciality that looks after
the mother and the child, the father, the
siblings, the grandparents and so on,
which can result in one medical home for
the entire family.’
As Chair of the Antenatal/Postnatal
Care network, Burton believes the broad
capacity of general practice is what puts
GPs in such a good position to treat
pregnant women and their children.
‘General practice is the craft group that
has got that really big picture,’ she said.
‘The generalist part of my role means that
I can address Mum’s upper respiratory
infection, or I can talk about Granddad’s
prostate cancer, or check the toddler’s
ears, as well as provide antenatal and
postnatal care.
‘GPs look beyond the care of the weeks
before and after the birth. Our scope is
much wider.’
Burton acknowledges that while GPs
should have an active role in the care
of expectant mothers, every woman is
different in terms of the type of care
they require.
‘There is no single model of care that is
suitable for every woman because it does
depend on her presentation, risk profi le
and personal preferences,’ she said.
‘You might be in a position where the
GP works really closely with the midwife
and the obstetrician, or where a woman
has all of her care provided by the
midwifery or obstetrics team.’
Maintaining skills
Following her many years of experience in
antenatal and postnatal care and general
practice education, Burton has found there
are some who would prefer GPs refer
expectant mothers to other specifi cally
specialised healthcare professionals.
‘We certainly need both our midwifery
and obstetric colleagues to provide support
and intrapartum care and, additionally, some
women will be better suited to care provided
by a specialist,’ she said. ‘But the generalist
hat that GPs wear means they can talk to
women about their diabetes or whatever their
other health needs are before, during and
after their pregnancy.’
Burton feels that rural and remote GPs are
generally more likely to use their obstetrics
skills than their urban colleagues, and GPs
who work in the city can risk losing those
skills if they do not use them regularly.
‘I think there is a point where if you are
not putting your hand on the tummy often
enough, for example, you may lose the
skill,’ she said. ‘In that case, sometimes the
appropriate thing for GPs to do is to refer the
pregnant patient to a colleague who knows
more about it.
‘The move towards the big group practices
means there should always be someone
in the group who is experienced and
knowledgeable in this area.’
Burton considers antenatal and postnatal
care an area in which GPs need to be
adequately skilled in order to best help
women, especially when providing shared
care to those whose pregnancy falls into the
low-risk category.
‘I will always argue that GPs are suitable
maternity carers, but I will also argue that
there should be minimal credentialing in
this very important sector,’ she said. ‘Some
GPs have lost their skills in this area and
they should hand a woman’s care over to
somebody else, whether it is a midwife,
obstetrician or another GP, who is up to date.
‘There are some gaps in our skills and
knowledge and we need to close those.
If we don’t look at the gaps and where we
can improve, we risk being not up to the
important task of providing best practice,
evidence-based care.’
About the networkThe NFSI’s Antenatal/Postnatal
Care network was established
in 2012 and advocates for GPs’
expanded role in the care of
women and their infants.
The network is working to
obtain the views and perspectives
of members of the general
practice profession, especially
those in urban communities, in
order to better inform its position.
Visit www.racgp.org.au/
yourracgp/faculties/specifi c-
interests or contact pam.
[email protected] for more
information or to join.
24 Reprinted from Good Practice Issue 7, July 2015
Image S
hutters
tock
Parents have a number of decisions to
make when they are expecting a child, from
the colour of the bedroom or the type of
nappies they use, to trickier issues related to
vaccination and other areas of healthcare.
Australia’s current childhood immunisation
rates are relatively stable at between
85.5–93.1% across all jurisdictions for
children younger than fi ve.1
‘Immunisation is one of the cornerstones
of public health and it is the most effective
intervention we have in preventing many
serious and often deadly childhood
infections,’ Dr Vicky Sheppeard, Director
of Communicable Diseases Branch, Health
Protection NSW, told Good Practice.
‘Australia has a really good rate of
vaccination and, speaking for NSW, there
has been an increase in the coverage of
immunisation and we are also working on it
to be more timely.
‘NSW Health is achieving close to 95% of
immunisation rates by the time children are
entering school.’
A vaccine coverage of more than 90% is
required to achieve effective ‘herd immunity’,
a form of protection from infectious diseases
in which a large portion of the population
is vaccinated. It can be as high as 95%
for some vaccine-preventable diseases,
such as measles.
However, non-vaccination rates in some
Australian communities continue to rise, with
some as high as 7%.2
‘Northern NSW, the Sunshine Coast
[Queensland] and parts of metropolitan Sydney
are some of the areas where there are larger
numbers of people who are conscientious
objectors and who choose not to vaccinate,’
Sheppeard said. ‘When we get infections such
as measles being introduced, that does provide
a scenario where the more unvaccinated
people we have, the bigger the spread of the
measles outbreak will be.
‘It is important for people to realise that there
is still polio and diphtheria in the world and you
can still catch those outside of Australia.’
Dr Scott Parson, a Melbourne GP with a
special interest in childhood immunisation,
witnessed the impacts of non-vaccination fi rst
hand during two decades spent practising
on Queensland’s Sunshine Coast, which has
one of the highest levels of non-vaccination
in Australia.3
‘We certainly saw an increase in vaccine-
preventable diseases up in the Sunshine Coast,
mainly the classic ones like pertussis, tetanus,
chicken pox – a lot more chicken pox,’ he
told Good Practice. ‘The herd immunity is still
reasonably strong, but we are really worried
about measles because if that hits badly there
are going to be serious consequences.’
While there are certain geographical
communities that are less likely to vaccinate,
other populations are also on health
professionals’ radar.
‘Aboriginal [and Torres Strait Islander]
communities, for example, have been diffi cult
to get to, but they have been targeted really
well by the various state health agencies in
the last few years,’ Dr John Cunningham,
a Melbourne orthopaedic surgeon and
spokesperson for Stop the AVN, a group
that opposes those who campaign against
vaccination, told Good Practice.
‘Their vaccination rates have been
improving.’
Communication techniques
According to a 2004 study published in
Australian Family Physician (AFP), parents’
The best shot
GP COMMUNICATION
BEVAN WANG
GPs are in a unique position to help implement policies aimed at encouraging parents to vaccinate their children.
25Reprinted from Good Practice Issue 7, July 2015
concerns about vaccination are primarily the
effectiveness of the vaccine, safety, side
effects and a preference for so-called natural
approaches.4 Cunningham warns against
the proliferation of misinformation about the
perceived harms of childhood vaccination.
‘Doctors need to be educated as to
the common misinformation that these
anti-vaccination leaders promote,’ he said.
‘They should be prepared to combat these
people and put it in a way where parents
aren’t being attacked.
‘Doctors need to equip parents with
the right information so they can make an
informed decision.’
While international guidelines previously
focused primarily on GPs providing parents
with that information, there is now a signifi cant
emphasis placed on broader strategies of
communication that look beyond the black-
and-white facts and consider the individual
person in the consulting room.
A 2014 study published in the US journal,
Pediatrics, found endeavours to persuade
people opposed to vaccinations often fail
or backfi re when GPs try to use images
and narratives.5
‘My approach has changed over the years
as I realised that when you are a junior doctor
you can be more argumentative towards
people, and it is just not effective,’ Parson
said. ‘One of the main techniques that I tend
to use is not to use facts and fi gures and
science, because people with emotions won’t
be able to take those in.
‘You have to pick your person and pick your
arguments because if someone is a builder,
you might frame it like, “Being a builder,
you obviously know a lot about building.
Would you take advice from me, a doctor,
about building?”’
Parson believes the fi rst step in any
consultation about vaccination should be
engaging the parents and trying to understand
the reasons for their hesitation.
‘The fi rst thing I do is let the parents know
that they obviously care very much about
their kids, that they are obviously very wise
to have considered this topic very carefully,’
he said. ‘Basically, I want to open up a line of
communication and know how they feel so I
can modify what I say to them.
‘You have to work out whether the parents
are hesitant about vaccination but open to
discussion, non-vaccinated but sitting on
the fence, or they are non-vaccinated and
are just not going to change their minds
no matter what you say or what evidence
you provide them.’
GPs are often required to tailor their
consulting styles depending on the patient,
and the area of attitudes towards vaccination
is no different.
‘You normally only have a short consult
so, basically, if you can touch on it a little
bit and see if they are interested in talking
about it, then you can schedule for a
longer appointment,’ Parson said. ‘It is
then that you can tailor your vaccination
discussion depending on their education and
socioeconomic status, and tailor how you are
going to sell vaccination to that person who is
hesitant or a non-believer.’
Parson feels it is also important to continue
treating children who are not vaccinated
and allow for further vaccination-related
conversations when the parents are ready.
‘The last thing that parents who are hardline
anti-vaccinationists want is to come in and get
a lecture,’ he said. ‘They are simply not going
to come in if they know that every time they
do their GP is going to be hammering them
about vaccination.
‘You have to keep the lines of
communication open, keep the relationship
trusting. But if they say they don’t want to talk
or discuss it at all then you have to respect
that and just treat and manage the child.’
Convincing the hesitant
A lack of, or delay in, vaccination has been
linked to outbreaks of a number of vaccine-
preventable diseases.6 This is seen particularly
in the spread of measles in communities with
low levels of necessary herd-immunity.
‘Measles is a real sentinel vaccine-
preventable disease to monitor and it
certainly highlights to us where we have
gaps in our immunisation coverage,’
Sheppeard said.
‘It doesn’t circulate anymore in Australia,
but it is frequently introduced by people who
have travelled overseas and aren’t immune.
‘There may be circumstances where they
return to a community with a large number of
unvaccinated children. Then we can get quite
large outbreaks.’
Cunningham agrees and believes vaccine-
preventable diseases can affect those who
are not vaccinated more severely than
vaccinated people who are at a low risk of
contracting the diseases.
‘We are seeing the huge impact of
non-vaccinationists in areas of Australia where
there are low vaccination rates,’ he said. >>
Suggested approaches for vaccine-hesitant and refusing parents8
Vaccine-hesitant parents Refusing parents
• Prepare to spend time with the parent and child
• Explore and address concerns
• Do not dismiss concerns
• Discuss the risks of the disease and vaccine
• Have resources to support your discussion
• Avoid overwhelming people with too many
statistics and facts
• Offer further opportunities to discuss
vaccination or whether to vaccinate
• Keep the discussion brief but let them know they
can come back to you
• Acknowledge their concerns
• Do not overstate the safety of vaccines
• Do not be forceful around fi rmly held beliefs
• Do not confront people with scientifi c facts and fi gures
• Provide available resources
• Offer opportunities to discuss vaccination when they
are ready
Doctors need to equip parents with the right
vaccine information so they can make an
informed decision
26 Reprinted from Good Practice Issue 7, July 2015
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GP COMMUNICATION
>> ‘Whooping cough is prevalent in the
Northern Rivers region [NSW], for example,
and measles is making a comeback as well.
‘The unvaccinated populations are always
the ones who come down with the disease
more commonly and when they do get it, it
is more severe.’
It has been estimated that up to one in
three parents in developed countries such as
the US, UK and Australia has concerns about
the vaccination schedules and is reluctant to
vaccinate their children.7
‘You fi nd that when human emotions are
involved, the science tends to disappear
because people believe anecdotes and they
believe people they know, rather than their
GPs,’ Parson said. ‘GPs need to have the
information to give to parents when they have
these concerns.’
Sheppeard believes primary care is the
best place to monitor children who are
not vaccinated, or who are late in their
vaccination schedule.
‘General practice can be really effective
in picking up those people who have missed
their vaccination,’ she said. ‘Having it as a
routine thing, to check that a child is up to date
with their vaccination whenever they come in,
can really help.
‘The GP is the most infl uential person in
people choosing to vaccinate and getting
vaccinated on time.’
Changing policy
The recent announcement of the Federal
Government’s proposed ‘no jab, no pay’
policy has signalled a signifi cant change to
Australia’s vaccination landscape. Under the
new policy, parents who do not have their
children vaccinated according to the National
Immunisation Program Schedule will lose
childcare and family tax benefi ts of up to
$15,000 a year.
According to Cunningham, the new policy
would ideally make a positive difference among
parents who may have delayed vaccination for
one reason or another, as well as those who
have deliberately avoided it.
‘One of the interesting things to
note about the new policy is that the
conscientious objectors, who are a
sub-population of the refusers, are only a
third of the people who are unvaccinated,’
he said. ‘I am anticipating that, with the
new government changes, we will see the
unvaccinated population halve.
‘All the people who have forgotten or haven’t
gotten around to vaccinating their children
will have a good reason to go out and get
them vaccinated.’
Sheppeard agrees, but believes a key
challenge will lie in the primary healthcare
sector’s ability to access and update
the Australian Childhood Immunisation
Register to ensure family payments are not
unknowingly terminated.
‘[The Federal Government’s policy] will
assist parents who may prioritise immunisation
above other things if the fi nancial benefi ts
then play off against other things like life
pressures,’ she said. ‘It may infl uence some
parents to prioritise immunisation to secure
those benefi ts.
‘The real challenge for all of general
practice will be the Australian Childhood
Immunisation Register.’
References1. Department of Human Services. Australian Childhood
Immunisation Register (ACIR) statistics, 31 March
2015. Canberra: DHS; 2015. Available at www.
medicareaustralia.gov.au/provider/patients/acir/
statistics.jsp [Accessed 15 May 2015].
2. Plotkin SA OW, Offi t PA, editors. Vaccines. 6th edn.
Philadelphia: Saunders Elsevier; 2013.
3. National Health Performance Authority. Healthy
Communities: Immunisation rates for children in
2011–12. Sydney: NHPA; 2013.
4. Lawrence GL, Hull BP, MacIntyre CR, McIntyre PB.
Reasons for incomplete immunisation among Australian
children. A national survey of parents. Aust Fam
Physician 2004;33:568–71.
5. Nyhan B, Reifl er J, Richey S, Freed GL. Effective
messages in vaccine promotion: a randomized trial.
Pediatrics 2014;133:e835–42.
6. Omer SB, Salmon DA, Orenstein WA, deHart MP,
Halsey N. Vaccine refusal, mandatory immunization, and
the risks of vaccine-preventable diseases. New Engl J
Med 2009;360:1981–88.
7. Leask J. Target the fence-sitters. Nature
2011;473:443–45.
8. Danchin M, Nolan T. A positive approach to parents with
concerns about vaccination for the family physician. Aust
Fam Physician 2014;43(10):690–94. Available at www.
racgp.org.au/afp/2014/october/a-positive-approach-to-
parents-with-concerns-about-vaccination-for-the-family-
physician [Accessed 3 May 2015].
Left to right: Dr Scott Parson largely avoids facts and fi gures and appeals to each person individually when discussing vaccination with hesitant patients; Dr Vicky Sheppeard describes
GPs as the most infl uential people in helping to make decisions about vaccinations; Dr John Cunningham warns against the proliferation of incorrect information related to childhood
vaccination and believes healthcare professionals should be equipped with appropriate evidence-based material.
Parental classifi cationsA 2014 Australian Family Physician
article found parents can broadly be
placed into three categories based
on their stance on vaccination.8
The study found that a majority
of parents are ‘acceptors’, which
can include unquestioning and
cautious acceptors; parents who are
‘hesitant’ are divided into those who
have signifi cant concerns and those
who actively delay vaccinations or
only choose certain vaccines; and
‘refusers’ are those who reject
all vaccines.
O U R F U T U R E I N P R A C T I C E
Melbourne Convention and Exhibition Centre 21 – 23 September 2015
www.racgpconference.com.au
Registration NOW open!Registration is now open for GP15 and due to popular demand there are more ALM topics available than ever before:
Savewith early bird
registration rates*
An integrative approach to mental health
A patient centred approach to cancer in general practice: communications and survivorship strategies
Business tools for rural general practice
Can we do better than “I treat everyone the same”? A practical workshop to improve outcomes for Aboriginal and Torres Strait Islander people
Caring for patients who are socially disadvantaged
Dermatology for GPs: clinical management of common skin cancer presentations
Emotional health of children
Future of general practice: future proofing your practice
Introduction to research: turning your research idea into a reality
Rural hospital forum and simulation
The Latest in Chronic Obstructive Pulmonary Disease (COPD) diagnosis and management
*Discount applies to full registration for RACGP members and non-members only.
Excludes student, New Fellow and QI&CPD accredited activity provider registration.
Secure your place, register at www.racgpconference.com.au
The good GP never stops learning.
Royal Australian College of General Practitionersracgp.org.au