DISCLAIMER: I do not intend for these blogs to be seen as giving clinical advice nor as judging public health policy but rather to recount the lived experiences of family medicine physicians from across the world. I recommend you still follow your local guidance but this goes without saying.
Date of interview: 23rd March 2020
Number of confirmed cases at time of interview: 1081
Number of confirmed deaths at time of interview: 7
Population: 25 million
Today, I am interviewing Dr Phoebe Holdenson Kimura, who is a GP in Sydney Australia with a special interest in medical education and mental health. We actually have a Japanese connection because Phoebe is half-Japanese and grew up in Japan before moving to Australia and we met at the WONCA conference in Kyoto last year. I like Phoebe for her unadulterated passion for general practice and I knew we were going to be firm friends when I got to experience her enthusiasm first-hand. I was interested in speaking to Phoebe because we get a lot of information from Australia and vice versa because of the bi-directional migration between the two countries and therefore the easy transfer of information. The news of two Australian women fighting over toilet roll went viral in the UK, as did the prime minister’s speech asking people to “just stop it” and be “good Australians”, as well as the infamous story of Dr Chris Higgins (see later). So much to talk about.
Australia is a federal government, much like Germany and Spain, which means that there are huge variations between the regions. Phoebe says that three states have already taken their own lead and closed their borders (Tasmania, Western Australia and the Northern Territory) in part because they have a high Aboriginal and Torres Strait Islander population, a demographic with a high number of co-morbidities. She says that some Indigenous groups are also quarantining their own communities and stopping people from coming in or out. This reminds me of an anthropological paper written by Melissa Parker about a village in Sierra Leone who closed the community off during the Ebola epidemic in 2013-16 and actually had better mortality rates than the humanitarian response camps which shows that sometimes community action can be more powerful than state action. It will be very interesting to see how this pans out for Australia. Like the rest of the world, social distancing is encouraged but there are challenges getting everyone on board, as the scenes at Bondi Beach showed this weekend gone. Pubs, bars and restaurants have been closed today and most people are working from home. Phoebe says that some of her GP colleagues in the Central Business District (CBD) have had to close their doors, due to a lack of patients as everyone is working from home, which is hardly surprising.
Apparently, up to about a week ago, positive cases had been due to travel history but there has been a sharp rise in number of local transmission and thus the need for telephone triage is becoming more crucial. Over the last ten days, Australia has really pushed to use tele-health which was previously almost unknown. She describes it as Level 1 where vulnerable patients are consulted via telephone to avoid coming in and Level 2 where vulnerable doctors do telephone triage to avoid face-to-face communication. Phoebe describes that there has been some resistance to switching to tele-health in the past mainly from an administrative and funding perspective and perhaps this crisis can be an opportunity to modernise the Australian primary care system.
Another thing that may or may not be brought in during this crisis is how practices are paid. At the moment, Australian GPs are paid for performance, i.e. they are paid for seeing a patient, and the government has been keen to push through into a more NHS-like model where GPs are paid per registered patient – the capitation model. At the moment, Australian GPs are able to bill the government and also charge a co-payment from the patient but co-payments are not allowed when using tele-health. Phoebe wonders if there will be changes in the way healthcare is funded although there is no proof of that as yet.
I am desperate to ask her about THAT toilet roll fight incident that was caught on camera (click here for video) which had most of us in the UK shocked (but probably also encouraging more of us to go to the shops to buy more toilet roll). Phoebe says that now they have policemen manning the toilet paper aisles and supermarkets are open at particular times for vulnerable people. Here, in the UK, we also have shopping hours for the vulnerable and also NHS staff although I hear that this is still incredibly busy. Phoebe finds this all rather ridiculous as 40% of toilet roll is manufactured in Australia so they shouldn’t be getting a supply chain issue. I ask her what “being a good Australian” means especially as, from the UK, we see the Australians as relaxed and super-friendly. She agrees that Australians like to help each other out but wonders if the unparalleled economic growth in Australia for the last 27 years has meant that many Australians has lost touch of doing the right thing. She tells me that there is a shortage of salbutamol inhalers at the moment because non-asthmatics are purchasing them over-the-counter (I didn’t realise you could buy salbutamol without a prescription in Australia!) which has meant that true asthmatics are having to go without. Also hydroxychloroquine is flying off the shelves even though there is only developing evidence that it is helpful. It’s this individualistic attitude that has been mainly disappointing in this pandemic response across the globe.
I also ask her about Dr Chris Higgins who is a GP in Australia who hit the headlines when he tested positive for COVID-19. He had returned from the U.S and had worked through a snuffly nose before finding out that he was positive (for the record, he didn’t qualify for the criteria for testing but had insisted on having one). She tells me that there were several points of fault in that story. One of them was that Victoria’s Health Minister had been very vocal about how flabbergasted she was that a doctor would work through illness and risk their patients. I have to chuckle at this because I think working through mild illness is pretty standard amongst doctors everywhere and it’s the self-isolating during a mild upper respiratory tract infection (URTI) that my medical friends are finding challenging. Phoebe says that another error was that the health minister had given sufficient details in her speech to allow identification of the GP (who was fairly well-known anyway as he is the father of a famous Australian singer) without mentioning his name. This breach in confidentiality, as well as the threat to take him to AHPRA (the Australian regulatory board and the equivalent to the UK General Medical Council) to have his license revoked, caused the GP community to be up in arms out of fear that the government wouldn’t have their back in a potential pandemic. Phoebe likened it to the Dr Bawa-Garba case in the UK where there was an outburst on social media and there were many requests to sign petitions. She assures me that the narrative has moved on but it wasn’t the best start to pandemic-planning since it weakened the relationship between the government and the primary care doctors.
We talk a lot about the required resilience of the workforce especially Phoebe is part of the WONCA working party for mental health. We both know that we need strategies for all the doctors out there to manage this stressful situation because this is going to be a marathon not a sprint. She says something interesting which is that, during pre-traumatic stress, there is an anticipatory stage where there is collective anxiety and uncertainty. Think about the walk from the car park to the ward before a night shift where you can be filled with dread but, once you start, you just get on with it. We are in that pre-anticipatory stage in the UK and in Australia and it’s really antagonising. I found this really helpful to place my anxiety somewhere and I know that once the storm hits and I am busy, I won’t have time to be worrying. We really hope that the whole medical community is able to pull together during this time rather than fall apart. I think we both strongly feel that the role of the family doctor in this setting is to support our colleagues in secondary care by keeping the healthcare system going whilst they tackle the sickest from COVID-19 and to keep as many patients out of the hospital as possible. We need to make sure that the paediatric immunisations continue to avoid mass breakouts of childhood infectious diseases; we need to ensure that non-communicable diseases are managed appropriately to prevent acute emergencies; and we need to ensure that our population’s mental health is addressed to avoid crises. These are challenging times for everyone and I’m already seeing different practices sink or swim.
We talk at length about physician well-being. This is a particular interest of mine (not that I am qualified in any way) and I find the way that even experienced family physicians are reacting fascinating. I’ve heard of some expressing particularly paranoid thoughts and others who are in a constant state of anxiety whilst others just soldier on but probably shutting down. We both agree that social media is helpful in terms of sharing information but can also be particularly unhelpful in the spread of mass panic. I have recently deleted Facebook from my phone and I’ve noticed a real positive change in myself. I’ve also picked out the most toxic people in my Whatsapp groups and scroll through their messages rather than reading them. We all have different ways of coping but I am definitely better when I am not picking up negative vibes off others. The family medicine young doctors movement in Europe (WONCA VdGM) will also be setting up wellbeing sessions every week for young family doctors in Europe (everyone welcome but times will be evening in Europe) and we hope that this will give everyone an opportunity to share their worries and build on each other’s resilience. You will need to join the VdGM Facebook group to see regular updates.
Burnout is a real possibility for all healthcare professionals in this pandemic. There is so much out of our control at the moment and when we have as much stress as we do in our jobs we need to have autonomy and control to thrive. The more I talk to family doctors across the world, the more I notice the need for safety. Many are hard-working and understand their call to duty but they often feel unsupported in these grueling working conditions. A lack of Personal Protection Equipment (PPE) or a lack of government support for the difficult decisions that they have to make seems to be a common theme across the globe. My worry with everyone is the possibility of physician burnout and how many will experience PTSD in these coming months. Both WONCA Europe and VdGM have called out for the need for PPE for primary care physicians to minimise risk (see the links for the letters). Although I appreciate there is a worldwide shortage, we need to protect our frontline staff.
Thanks to Phoebe for giving me the time to interview her. It sounds like she’s feeling pretty strong at the moment but I send all my heartfelt wishes to all our Australian colleagues who are just behind us on the curve and have had a pretty challenging recent past with all the bush fires.