Life's Journey

                                                   

I’ve recently had the pleasure of listening to the Checklist Manifesto by Atul Gawande, a truly remarkable figure in public health and surgery. His brave and candid appraisal of the state of healthcare with a particular emphasis on surgery was simultaneously refreshing and terrifying. 

His confessions about the enormous challenges associated with delivery of care, complexity of knowledge and heterogeneity of patients as well as uncooperative health professional attitudes conjures a healthcare system prone to error and adverse patient outcome. This has become evident even in my practice as a pharmacist, where potential for drug-related errors are a frequent encounter. Nevertheless, Dr Gawande courageously confronts this engrossing problem through an amazingly simple solution…The Checklist. 

His implementation of surgical checklists in diverse hospital settings and localities has demonstrated the simplicity, elegance and cost-effectiveness of this tool. His checklist has demonstrated enormous improvements in health outcomes with results published in premiere journals including the New England Journal of Medicine. More importantly the tool has saved countless lives, which is ultimately its greatest achievement. It is evidence-based practice at the apogee of medical care. 

                       

As mentioned in an earlier post I’ve recently completed reading a book titled Mountains Beyond Mountains detailing the awe inspring humanitarian work of Dr Paul Farmer. I’ve pondered about the qualities that draws me to his work as a physician, health professional and scientist:

1. Devotion, personal sacrifice and dedication to improving the health-status of patients in neglected and extremely disadvantaged healthcare systems around the world.
2. Demonstrating that outstanding clinical-care is not solely dictated by access to high-end technology and large health expenditure. rather by the essential components of care such as; compassion, trust, cooperation and utilising a team based approach.
3. Realisation that the holistic view of healthcare must encompass not only the health of the patient but their cultural belief, customs, social and family environment, education, employment and nutrition.
4. Public advocacy and voice for those who are long forgotten by iniquitous healthcare systems. Dr Farmer and Partners in Health challenged many dogmas associated with caring for patients suffering from debilitating infectious diseases such TB and HIV. Through their actions within global health policy they were able to secure affordable access to life saving treatments and divert an impending multi-drug resistant TB epidemic.
5. Commitment to evidence-based healthcare in the most impoverished settings. It was Dr Farmer’s scientific and epidemiological research that provided the weight and support for necessity of action to improve health outcomes not just for the patient but also their community.
6. Outstanding teacher and mentor: despite his enormous commitments he continued to be a teacher and a mentor for many junior doctors both within USA, Haiti and many other developing nations.

No doubt there are many more attributes that are embodied by this outstanding individual that I have not addressed but these were the remnants that I have come to closely admire.  

                                          

There are several quintessential characteristics that contribute to an outstanding health professional. I’ve thought about these qualities and have tried to embody them in my practice as a pharmacist, yet the quest for ‘perfection’ continues. Here are my thoughts on this subject matter.

1. Compassion, kindness and empathy: These are fundamental qualities that should be pursuit by all health professionals. We are often interacting with patients in their most vulnerable state, therefore our interactions must encompass this. Our ability to empathise stems from our emotional intelligence, life experience and shared/common experience with our patients.
2. Trust: Another important quality demonstrated by health professionals. We often have access to private or sensitive information about our patients. This is a privilege and vital for harmonious and fruitful relationship between health professionals and patients. All efforts should be made to maximise this relationship, therefore trust is the key.
3. Communication: I touched upon this element in my previous post. The importance of this quality cannot be overstated. Without effective communication skills information cannot be expressed adequately or accurately. Moreover our communication skills must be audience specific. Encompassed within communication is active listening.
4. Ethical and moral conduct: Given the nature of our work and the importance of our relationship with patients and society at large we must behave ethically and uphold our professional codes of conduct. We must do no harm to our patients, respect their autonomy, privacy and consent. 
5. Leadership: We must demonstrate leadership within the context of our own profession and more broadly in the healthcare system. I’m vehement believer of public advocacy to better health outcomes for patients and their communities. 
6. Knowledge and Intellect: In order to ensure appropriate decision-making and safe practice, health professional must possess the intellectual rigour and training to provide outstanding care.
7. Researchers and Teachers: Contemporary medicine relies on the utilisation of evidence-based practice and we must pay diligence to this corner stone of healthcare by actively engaging in quality research. Associated with this is to be comfortable with critical thinking and problem-solving skills.  Moreover, we must endeavour to train and guide younger health professionals in their development and intellectual growth. 

Please feel free to contribute to qualities that I may have omitted. I’m keen to hear how you prioritise the qualities of health professionals. 

I’ve been pondering the approaches to good communication by health professionals. We know that good communication is fundamental to delivery of care to our patients. But what defines this:

1. language style: I think it is imperative for our language style to be age appropriate and take into account our patients level of education, cultural background and understanding about their own health status. I’ve often had to significantly change my communication style, word usage and sentence structure to suite our indigenous patients. Whose competence in English may differ to mine and main stream Australia.
2. Active listening: An important component of communication is active listening, which takes into account our own body language, assessing the contents of the patients conversation, their body language, belief system and culture. These are important for indigenous patients where cultural difference can lead to a break down in communication. I’m still working on this point, my problem is patience. 
3. Provision of information: This relates to the first point and it should be simple, clear and direct. We must avoid our moral values and beliefs from interfering with the extent and breadth of information provided to patients. More importantly we should allow the patient to draw their own conclusions based upon life circumstances. 
4. Questions: Our patients should be given ample opportunity to ask questions, clarifications and validations of key facts presented. This ensures that both parties agree and understand the facts presented during the conversation
5. Summarise: Prior to ending the conversation we should summarise the information presented and allow opportunity for the patient to ask questions. Furthermore, we must make ourself available for further discussion if the need arises. 

       

I come from a background as a pharmacist with an interest in rural and remote health which includes caring for both indigenous and non-indigenous patients. I have worked in remote  Australia and its diverse patient population and have experienced the joys of this unique area of practice and the challenges that are associated with rural health. 

Rural health is the delivery healthcare in the context of regional and remote localities based on geographical locations and population density. Consequently, as one might expect the services provided and patient demographic may differ in comparison to metropolitan Australia. There are evident health disparities between rural patients and those residing in metropolitan Australia, including life-expectancy, chronic disease burden and mental illness. These disparities becoming glaringly obvious when considering indigenous Australian patients who have a higher prevalence of cardiovascular disease, type 2 diabetes and end stage renal disease not mention the prevalence of mental illness including substance abuse and suicide. 

Thus from my experience several factors have become evident that explain the above observations. Firstly in rural health there is a crisis of attracting and retaining professional health staff. More frequently in the arena of tertiary healthcare doctors of various skill-base are on rotation from metropolitan hospital. This has significant advantages in addressing workforce shortages but simultaneously does not harbour long-term vision for rural healthcare and patients. Thus strategies have been introduced to attract and retain health professionals. For example; medical students are often provided with incentives to graduate and work within rural health. The Australian College of Rural and Remote Medicine is training highly qualified doctors to cater to the health needs of rural patients. Additionally Qualified health professionals are provided with relocation support, spousal employment opportunity and subsidised accommodation to ensure a smooth transition from metropolitan life to rural. 

Furthermore, there is an evident infrastructural limitations and access to specialised equipments that one may come to expect within a tertiary setting. These may be due to limitations in funding, practicality of equipments and possessing the workforce capable of using such tools. This provides a unique opportunity for health professionals to utilise creative and latter thinking to overcome such barriers. Moreover, doctors I believe possess more generalised knowledge to cope and manage patients, therefore our medical practitioners are extremely talented and committed individuals who are leaders and directors of multidisciplinary teams. In addition, assistance provided by the Royal Flying Doctor Service are imperative to saving patient’s lives and transferring critically ill patients to large health centres. There amazing work has inspired me to volunteer for this organisation and help raise much needed funds.

Resource limitations and staff retention aside. Rural healthcare is complicated by geographical and social factors that must be considered. Working in Alice Springs Hospital has demonstrated the difficulty of patients accessing healthcare due to distance and availability of transport. Consequently patients admitted in when the disease had progressed significantly or at the brink of death. Concurrently, my work with St Vincet De Paul Society in central Australia has highlighted the importance of social factors such as accommodation, employment and access to food in maintaing good health. Many indigenous patients often lack access to regular food or stable accommodation and as such complete recovery from illness is difficult to achieve. 

This brings me to indigenous health, a truly tragic and heart breaking aspect of rural health. I was shocked to witness patients as young as 24 commence on renal dialysis. It was heart breaking to witness young men and women enlisted in hospice care that were marginally older than myself and afflicted with horrendous respiratory and cardiovascular disease. To this day it has motivated me to pursue my dreams of closing the gap. However, the task is difficult and not for the faint hearted. There are cultural barriers, communication hurtles and culture differences in the notion of health that must be overcome. Already cultural awareness training is being utilised to minimise cultural shock for both the patient and health professionals entering the realms of indigenous health, but more work needs to be accomplished. I was inspired and amazed to see the difference utilising the patient’s own dialects made with the aid of aboriginal translators.

However, communication barriers still persists and as health professional we need to be engaged in continuous education of patients particularly in the area of preventive health to shatter the growing chronic disease burden. We must deliver this information in a culturally sensitive manner to respect men and women’s ‘business’. We must also address the social factors that perpetuate disadvantage. I hope over the next several months my dream of further training is realised so that I can contribute in closing the disadvantage gap. 

                             

In my previous post I had raised several key issues that will be faced by many Australians and healthcare providers in the near future. On my next update I would like to specifically address rural and indigenous health as my focus but nevertheless I will aim to provide solutions or shed light on answers being implement currently. I have purposefully omitted my discussion about rural health so that I can effectively address this immense topic and my ultimate passion. 

I highlighted the increase in ageing population and the risk of over burden and pressure to the current healthcare system. There are a number of solutions to this existing problem of; economics, health standards and resource availability. The economics relate to the ability of the working population to support the burgeoning aged population and their healthcare needs. The second is the availability of resources (workforce, facilities and infrastructure) to support the needs of this population whilst ensuring the highest standards of care.

The economic components can be addressed by encouraging greater emphasis on retirement savings, private healthcare (to minimise pressure on the public system) and perhaps increasing the retirement age. Moreover, as health professional we are obliged to heed these warnings and ensure efficient use of resource by minimising waste (e.g. unwarranted diagnostics tests), optimising current tools and therapeutic approaches. Furthermore, new technologies can contribute positively in this aspect to improve efficiency and productivity in the care of patients. For example the advent of robotic surgery may minimise post surgery complications and facilitate a more rapid recovery thereby decreasing the time patients reside in hospital. 

The Australian government has also shifted emphasis to preventative medicine to divert the tsunami of chronic and lifestyle diseases that will be unleashed upon the healthcare system. I believe the recent changes to cigarette packaging highlight this commitment. Moreover, public awareness campaigns with regards to obesity, importance of physical activity and good nutrition mark an essential shifts in paradigm. Whats more, I reject the notion of the nanny state described by certain media outlets. These public health campaigns are essential to generating awareness and education of individuals who may not possess adequate health knowledge.

Nevertheless these approaches form an aspect of the battle against lifestyle diseases. Socio-economic factors, education, access to recreational facilities and employment are other aspects which are fundamental and immensely difficult to address. My inveterate optimism provides me with hope that through collective action we can strive towards the highest quality of healthcare in the world. The future is ours for the taking….

                                       

As a young health professional, I have practiced and worked in a diverse range of practice settings and have had the opportunity to experience a variety of roles. I’ve come to ponder upon the future of healthcare in Australia and the current trajectory and circumstances. Whilst, I acknowledge that my view is not conclusive and am not attempting reprimand or critique rather to highlight the issues that are explicitly evident in the healthcare system.

My first concern relates to the state of rural and indigenous healthcare. I have worked within the hospital setting both in Central Australia and rural South Australia. Indigenous health is a passion of mine and we are all well aware of the challenges faced by practitioners intent on closing the gap. Rural healthcare, of which indigenous health is an integral component is faced with enormous obstacles. There is an evident lack of resources and facilities that creates difficulties in delivering optimal care to patients.

Furthermore, it is a challenge to recruit and retain health professionals to stay long-term and to help address these health disparities, thereby creating long waiting periods that progress and complicate health status of patients. Moreover, the vastness of this magnificent continent generates logistical challenges in delivering care. Patients often travel long distances or may not have access to transport to seek help. 

Of indigenous health so much requires attention. Most obviously the communication and cultural barriers that impede and disconnect the patients from their health professionals. In addition the social factors that create a revolving door approach to healthcare. Factors such as inadequate accommodation, nutrition, employment and education are essential to maintaining good health. What of the cultural unpreparedness of health professionals dealing with indigenous patients? How can we integrate contemporary medicine with indigenous health concepts and spirituality? Hope is not lost, mainstream Australia is awaken to the ever widening health disparities…

Another major issue is the ageing population of Australia. This dilemma is confronted by many other countries and is not unique to Australia. Advances in medicine have led to improvements in quality of life and increased life expectancy of patients. The ageing population will be placing enormous demands on resources, trained staff and healthcare accessibility. The issues are complicated by an ever-growing list of new and costly therapeutics that place further pressure on finite resources. Is the current healthcare system prepared for the future? Are patients and health professionals positioned to accept the limitations of the current model and finite resources? 

Related to the previous paragraph is the growth of chronic and lifestyle diseases that are becoming more prevalent in younger adults and children. We are faced with a growing epidemic of obesity, diabetes and Cardiovascular disease. These iIllnesses were absent in or less prevalent in previous generations of similar age group. This places further pressure on resources and management of complications associated with these conditions. Nevertheless, hope is not lost and positive steps in the right direction are being taken….More on that in my next update.

                            

Of late I have been dwelling on two magnificent books; Emperor of All Maladies & Mountains Beyond Mountains. The first provides a discourse on the history of cancer comprised of triumphant moments and periods of sheer human despair. It documents the progress of medicine and of individuals such as Dr Sydney Farber who paved the way for modern oncology. Figures whose genius and insight may be unknown to the general public and villains/curmudgeons whose unethical and extreme actions mark several tragic moments in humanities relentless fight against cancer.

The second Mountain Beyond Mountains which I’ve almost completed reading is a narrative bibliography of Dr Paul Farmer. Through this book I have felt a plethera of emotions. I am left speech less by Dr Famers intellect and innate goodness and commitment from the beginining of journey into medicine. He envisioned a future where individuals will have access to equitable healthcare, without categorisation based upon monetary capacity. Whilst his focus was treating the poor in Haiti, the organisation that he established (Partners In Health) enabled his vision to prosper in many corners of the world. Furthermore, I admire his determination, strength and public activism. He challenged scientific and mainstream medical thinking in the area of healthcare delivery and infectious disease. He saved countless lives where established thinking and current care models would have simply neglected. Dr Paul Farmer, you inspire me and I hope to follow in your esteemed footsteps. 

                                   

You attend a party where a friend informs you that her father, with whom she is very close, has been diagnosed with Alzheimer’s Disease. Your friend’s father is a widower and your friend has no siblings. Though your friend’s father is only in the early stages of his disease, he is already becoming forgetful. Your friend confides to you that she is worried that she may have to truncate her university studies to look after her father at some time in the future.What advice would you offer to your friend?

Answer:

This must be an extremely difficult circumstance to be confronted by my friend. The situation must also be heart-breaking for her father specially heading into the future. In this situation I would offer my friend as much support as possible in my capacity. I would encourage her to discuss her concerns with me freely and without fear of judgment or insensitivity. Also, I would support her with regards to her university studies and encourage her to discuss her situation with the university faculty to explore options for her to continue and successfully complete her studies. Thereby securing her long-term future. 

Furthermore, I would encourage her to discuss her feelings with other family members who may also be in a position to support herself and her father (if possible). This could be broadened to include the father’s physicians who will undoubtedly have access to support systems now and in the future.

Moreover, it may be prudent for my friend to engage in a candid discussion with her father regarding his wishes for the future whilst he retains the ability to form decisions. It would important for my friend to be aware how to cope if his health condition deteriorates and what he wishes to be provided with regards to his healthcare. 

Also worthwhile to ensure the conversation is conducted with privacy and the environment is conducive to the discussion. It may be also suitable to seek an alternative setting if the party is loud and inappropriate for a heart to heart talk. 

You board a train and are seated next to an elderly man whom you have met before but do not know well. You engage in conversation. The elderly man recollects his youth and laments the challenges of old age. He continues by revealing to you that he has recently been diagnosed with cancer. How do you respond as a person?

Answer:

In this scenario, I think we must afford this gentleman with optimal opportunity to express his concern whilst respecting his privacy. This must be a fine balance and he should not feel pressure in revealing more information than is necessary. Concurrently we must acknowledge the limitations of our own knowledge, expertise and skill-base. It my be beyond our capacity to counsel or support this individual conversely he may not be needing our support or assistance. Certainly, we should be mindful of the milieu in which this discussion takes place and the degree of privacy conferred. I would provide the opportunity for him to:

• his thoughts and feelings regarding his conditions 
• his healthcare plan and needs
• his support network
• what he wishes for the future 

This is a difficult scenario because of the superficial nature of our relationship, the environment and amount of time available during this commute.