Thread by @docdanz007

Warm welcome for fellow GPs from @DrMurton. It’s so good to get together with ones people! #gp21 #RNZCGP

Now hearing from @AndrewLittleMP, the Minister of Health, acknowledging the hard work of the last 18 months. “No room for complacency” #gp21

The usual platitudes acknowledging workforce shortages, GP burnout and the important place of #primarycare in our NZ health system. What is going to be done to address this? #gp21

Here it comes: “The Labour Party is the party of public health”. @AndrewLittleMP #gp21

Lots of talk about building hospitals… 🙄
(Read the room Andrew! 😉) #gp21

Three waters gets a mention, along with housing, climate change, child poverty. #gp21

Now onto the health reforms. This is what we came here to learn about. #gp21

Now talking governance and accountability within the new health system. Explaining why Health Targets disappeared. #gp21

Health System Indicators framework is coming. The new accountability structure for the new health system. “Not fixed in stone”. #gp21

12 indicators: eg child wellbeing - Reducing admissions to hospital for preventable illness. This is regularly monitored and targeted improvements made at the local level. #gp21

Wow. 69% of under-25 able to access specialist mental health services within 3 weeks. Nice!

This one drew a laugh, I suspect because of how far we are falling short of this indicator.

#gp21 #HealthIndicators #NZhealthreforms

Call from the floor to make fruit and vege free for the poorest and to start taxing sugar. @AndrewLittleMP engaging with this question without committing to anything. Watch this space. #gp21

Now talking nurses. Good support for nursing from the floor at #gp21. Commitment to pay equity in primary care but not really answering the question about workforce.

Question from the floor regarding the “constipation” within the Department of Immigration for foreign trained GPs getting residency. “What are you (@AndrewLittleMP) doing to deliver a dose of laxative to your Immigration minister colleague?!” #gp21

The heat is on @AndrewLittleMP from the floor at #gp21. We hear the talk/promises every year and yet we don’t see the improvements/outcomes.

Now addressing funding model and how it is not “fit for purpose” in complex consultations esp when language barriers or low health literacy is involved. 15 minutes is just not enough! #gp21

Question about proportion spend of GDP in health. What does @AndrewLittleMP see as the “right” amount. A politicians reply follows. 🤷‍♂️
#gp21

Overall impression of the minister: optimistic address not making light of the challenges ahead, moving into a somewhat combative stance in question time when some of the current pitfalls and challenges raised. I guess par for the course at these conferences! #gp21

Bit starstruck TBH.🤩 #gp21 #RNZCGP @AshBloomfield

Boy he’s good. Engaging already with comments raised in earlier talks. Remembering “4 points” from @DrMurton that I had already forgotten. #GP21

Estimates 30% of his time these days is spent on #COVID19. Wonders what he did with all the free time 18 months ago! (Jokingly) #gp21

Humanity coming through. Waking up in cold sweats, acknowledging other health leaders experiencing the same 12-18 months ago. #GP21

Acknowledging his and our “sighs of relief” when we went into level 4 last year. #gp21

Up front about their approach through the pandemic (esp the 1pm standups).
Don’t pretend we have all the answers.
Be honest when we don’t have an answer.
Be ready to change.
Leading with humility.
Listening to advice.
#gp21

From bend the curve to crush the curve.
“If people understand why, they will get on and do what needs to be done.” #gp21

Talking about continuous improvement. Applicable to the whole health system but MIQ is a brilliant example. 1700 recommendations (I think) for continuous improvement over 15 months! #gp21

Acknowledging that every time he announced a case, that is an actual person. Leading with compassion is the key. Good to hear he’s a bit fan of kindness! #gp21

Talking about personal resilience. The need to take a holiday “It made national news!” The humanity of this guy is phenomenal. #gp21

Talking about the call to “go with Pfizer” earlier this year. Easier to roll out a programme with a single vaccine, regardless of prior purchase commitments. #gp21

Addressing the vaccination equity question. Very much on the ministry’s radar. Good data coming out from groups 1-3 showing equity so far. Forward bookings however looking more weighted to other groups. #gp21

Adding 12-15 yr olds to the programme will help to address equity too and an announcement on this may be coming in the not to distant future. #gp21

Not looking at a 3rd shot for booster at this stage despite Pfizer recent recommendations. More likely an annual booster shot to account for emerging variants. #gp21 #COVID19nz

Addressing vaccination questions, has a plan to build a more integrated vaccination programme, not just Covid. #gp21

Question from the floor:
“Can I have a selfie?” 😂🤣😂
#GP21

@AshBloomfield has noticed a positive shift in complacency levels, especially amongst the business community, probably as a result of the emerging troubles in Australia as they deal with the delta variant. We can’t afford to rest on our laurels. #GP21 #COVID19nz

Question about what happens in the future, looking to eventually opening up: Normalising regular vaccination (not just #COVID19) is on their work programme. “Health at the border” also an emerging issue that the ministry is doing a lot of work on. @GP21 #COVID19nz

“Rearranging deck chairs on the Titanic”. Theme of the panel session. Bit gloomy when moving into a new health system. Maybe reflects everyone’s baseline cynicism? #GP21

More talk about why the Titanic sank than how to rearrange the deck chairs. Probably appropriate! Also focus on systematic issues but above this, the cultural issue. “Excusing the inexcusable”. #GP21

Big call from @tiekemanu regarding the biggest chance for transformational change within our health system (especially in terms of Treaty partnership) in a generation. But well backed up with experience and examples. Lots of optimism here! #GP21

“A fundamental rewrite of some of the core features of our health and disability system.” Stephen McKenan #GP21

Health NZ to be the accountability structure for service provision, incentivising a long term view. This is very good to hear - how much independence from the Ministry, though (to avoid continuous political tampering for short term outcomes)? #GP21

Final session this morning from @DavidTipene on “Cultural Safety, Cultural Competence and Health Equity.” #GP21

A positive view of the above is put forward by Prof David Tipene-Leach. It can actually be an empowering thing for the practitioner! #GP21

“Inequity comes down the generations.” #GP21

“All we are asking you to do is acknowledge historical trauma in everything that you do in your workplace” #GP21

Advocacy around the social determinants of health is key. #GP21

Institutional racism: Expectations around prompt and timely daytime attendance, name pronunciation, number of whanau/visitors in a room, BMI limits for renal transplantation (not evidenc based!)
@DavidTipene is on fire today! #GP21

The historical evolution of cultural safety. Nicely laid out by @DavidTipene. #GP21

Such a good talk from Prof David Tipene-Leach. Clear and practical. The best overview I’ve heard on cultural safety. #GP21

At the end of the day, this is a high trust model. We should be motivated by the empowerment that comes from practicing in a culturally safe way. No policing should be required! (Would it even work?) #GP21

Why no #twitter shoutout @conferenceinnov? This is where all the cool kids hang out! 😎 😂 #GP21

Okay, my brain is full and under fuelled. Now to get lunch! #GP21

First up for my afternoon concurrent session. It’s @chloecuriosity on ePrescribing. I’ve got my coffee and am ready to go! #GP21

Now John McMenamin on digital alcohol screening in Primary Care. #GP21

Final speaker from this session is Bryan Betty, Medical Director of @RNZCGP. Surverys, advocacy and the media. #GP21

The importance of the workforce survey: it has highlighted looming issues with the workforce crisis and current issues with high levels of burnout. #GP21

High levels of burnout in 31% in GPs, up from 22% in 2018. I have lost my own GP to burnout this year. #GP21

Now to the Mental Health Insights survey. Told the college what we already knew about access to secondary mental health services. Generally poor and GPs struggling with managing moderate-severely affected patients with lack of secondary support. #GP21

For the record, 63% of GPs felt unsupported by their local secondary care teams in managing these patients! #GP21

Final (elective) session of the day is on Postnatal Distress (PND) with Liora Noy. #GP21

Very positive presentation here. Liora making a good case for treating PND intensively and well - it virtually always gets better. Getting parents through with support will get them through their Illness. #GP21

Interesting take on social media in PND - supportive vs toxic - quite a mixed bag. Ask parents whether they feel better or worse after logging off. Gives you a good clue whether you should encourage or discourage (and help them to find other supportive networks). #GP21

Aside on breastfeeding and PND. The former is good/preventative for the latter but when it doesn’t work, don’t persist past the point of reasonableness. For many people, breastfeeding struggles are the major trigger for their PND. Also recognise that women grieve its loss. #GP21

Slide to go with the above. #GP21

Some good general advice about helping babies settle. General vibe: routines are often counterproductive. #GP21

Love this about stimulation. Brain development *requires* stimulation. The greater risk is under-stimulation, especially in the context of “routines”. #GP21

So much good advice from Liora today. Should have mentioned that the final section of the talk was about ACT - acceptance and commitment therapy - in the context of PND. #GP21

Morena @RNZCGP! Back at the fire hydrant for another drink this morning. First up Nigel Latta, I wonder how politically incorrect he’s going to get? #gp21

Let’s just say you wouldn’t want to be an antivaxer in this crowd! #GP21

Pretty funny guy. Already mocking antivaxers, racists and toilet paper hoarders! Now having a go at his (ex)cat. He’d get on well with Gareth Morgan! #GP21

Mocking golf in a room full of doctors is pretty funny! #gp21

Three circuits: pleasure, calm and connection. It’s all in the neurotransmitters: Dopamine, seratonin and oxytocin. #gp21

Now taking aim at social media. Gulp! 😳 #GP21

Nigel Latta: “DONT WRITE THIS DOWN. You’re never going to look at this again! This is why you’re all burning out!” #GP21

Job, career or calling? More likely to burnout the more you see your work as a calling! #gp21

Acedia - the 8th deadly sin. Burnout in monks in pre-medieval times! Now taking aim at the Catholic Church. #GP21

Burnout is not adjustment disorder, depression or “general fucked up ness”. #GP21

Acknowledging the high achieving personality type that get in to medicine and now critiquing the 15 minute appointment. Alright, he gets us! #GP21

Humorous take on bureaucracy with the example of e-prescribing : only took off when we all thought we we’re going to die (ie Covid). Basically need to make Wellington feel that they are always about to die. 😂 #GP21

No one wants a “good enough” pilot, nor a doctor! #gp21

The Buddhist’s have it right here. #GP21

“John Campbell is so nice that hanging out with him makes you look like an arse”. 😂😂😂 #GP21

“There are still people writing this down! 👀” Embrace Impermanence! #GP21

“If you find something you really like, just don’t do it a lot!” #GP21

“Compassion fatigue is when your empathy is blocked”. #GP21

Habits and how to build them. Forget goal setting. It’s about setting up the system to make it happen that makes it happen. “The 2 minute rule.” Just habitually put on your walking shoes! #GP21

“Use friction” to create habits. Make it easy to do the things you do want to achieve and hard to do the things that are getting in the way. #GP21

“Habit stacking” add habits on top of already existing habits - meditate for 2 minutes after having your morning coffee! #GP21

Embrace philosophy. Sticking up for the stoics. “Focus on what you can control”. (Another humorous cat joke - he respects cats, Nigel assures us.) #GP21

Useful problem-solving vs ruminating. Need to acknowledge when it is the latter (see what I did there) and name it as such. #GP21

“We don’t get to carry people’s lives around with us and live it for them.” We need to be able to put it down when they leave. Again and again “Focus is what you can control”. #GP21

“The meaning OF life is to find meaning IN life” Viktor Frankl #GP21

Great talk from @NigelLatta. First question Is hilarious. A mum who used his book “religiously” to raise her child credits 99% of her sanity and 50% of hers child’s future success to Nigel. Nigel will happily take 50% of their earnings. 😂 #GP21

Self-compassion is important. Don’t beat yourself up over it. Be as kind to yourself as you would be to your kids, etc. #GP21

After a break for morning tea, we are now continuing in the theme of doctors mental health with a zoom conversation between @DrMurton and @ClareGerada. A reminder straight up that “Doctors make bad patients.” #GP21

An incisive critique of the drive for perfectionism inherent in the medical education system and beyond. Competitiveness needs to be removed. #GP21

“Every one of you will experience burnout at some point in your careers.” @ClareGerada 😳
We need to expect it and look for it. For her it was in her 40s losing her curiosity about her patients and their presentations. #GP21

Also, burnout can sometimes be an “acceptable” way of talking about depression and anxiety for practitioners, so look for these behind the “burnout” diagnosis. #GP21

I, We, They. Different levels of managing burnout. Do what makes you happy, even in snatched moments, work in teams to support the reach other and put pressure on those that create the system to do better (or if you are in positions of power, change the system). #GP21

Promoting her book which covers this ground in much more depth. #GP21

Great Q&A with @ClareGerada. Compassionate and insightful. Good questions from the floor. “We need to love our doctors.” #GP21

“How to have that conversation with a colleague?” regarding obvious burnout and mental distress, especially when in impacts on patient care. “Do what you would do with a friend.” #GP21

Allow your doctor patients to cross over from the doctor to patient side of the relationship. Don’t assume knowledge. Avoid shared decision making at the outset. That may come later once things are improving. #GP21

Good comment from @LucyOhagan about the difference between depression and burnout. “Cognitive collapse” marks the difference for her. #GP21

“Move towards your colleagues in love”. Sometimes it is about asking the next 1 or 2 questions beyond “How are you?” Thanks @LucyOhagan for these excellent insights. #GP21

“GPs, stop having this messiah syndrome where you think you can do it all!” Hard truths here from @ClareGerada! #GP21

I’m going to practice self-care and not livetweet the next session. I’m trusting any amazing insights will be so unforgettable that they will stick in my brain regardless! #GP21

Great talk on ME/CFS from Dr Cathy Stephenson - so many take home points so I did take some photos as memory aids. I knew graduated exercise was out but now pacing is the key framework (basically the opposite of graduated exercise). #GP21

Also I need to look up the NASA lean test (the poor man’s tilt). Useful particularly in places when formal tilt table testing is unavailable or difficult to access. (I’m looking at you DPH). #GP21

Late to the after lunch sessions due to meeting my family who have just flown in from Queenstown. After all THEY are very much a part of my self-care. Here’s my 7-yr-old on his first day of snowboarding just yesterday. #ProudDad #GP21

I’m at the panel discussion on Telehealth with @virtualruth, Darren Douglass, Curtis Walker and @RezaJarral. Equity is front and centre so far in the discussion. This doesn’t just mean devices in hands! #GP21

“It is here to stay” “Work with it rather than against it” “It’s not for everyone.” Comments so far from Dr Curtis Walker, chair of @MedCouncilNZ. #GP21

Now data governance with Darren Douglass. Important reminders of privacy, interoperability and sharing of data for the patient’s and indeed everyone’s benefit. #GP21

“Is the patient Telehealth ready?” We all have to do work on this by way of preparation for the changes that are coming. @virtualruth #GP21

Loaded question to Dr Walker on Telehealth in Covid lockdown - did it keep our patients safe? (Given known examples of missed diagnoses for example). Not a clear answer on this. The jury remains out. #GP21

Final question to Dr Walker regarding social media and the @MedCouncilNZ’s role in enforcing/controlling misinformation from members. Diplomatic reply but basically the council will stand by and enforce its statements but will also take into account individual circumstances.#GP21

Last session of the day. Primary care management of #COVID19 with @DeeMangin. Not a question of if but when. We as GPS are ideally placed to manage what, for most sufferers, will still be a mild-moderate illness.

Home pulse oximetry is key to monitoring/managing known Covid patients at home. Along with a 5min daily “Covid ward round” Telehealth consult. Approx 2 oximeters per 1000 registered patients. #GP21

In red-yellow groups (non low risk) all patients get a pulse oximeter. Importantly, any deterioration put you straight into the red group regardless of age, health status. #COVID19 #GP21

“No investigations required” no bloods or CXRs. Keeps them out of hospital! Only reason to do investigations it to manage their comorbidities eg diabetes. #GP21

Managing patient expectations is important. Their starting point is what they read in the media. As a viral pneumonia, the normal course of the illness is more protracted than people expect, completely apart from #LongCovid. #GP21

Prone breathing anecdotally seems to help in the community too. Sats improve.
Good hydration is important for preventing acute kidney injury.
Diabetics monitor blood sugars (+/- ketones) more frequently.
#GP21

THERE IS NO EVIDENCE BASED DRUG TREATMENT FOR COVID IN THE COMMUNITY. The push for drugs (hydroxychloroquine, azithromycin, ivermectin, etc) all reflect clinician and patient desperation. The best evidence have shown neutral to harmful effects. #GP21

Avoid anti-inflammatories if possible. Small but meaningful risk of harm, primarily cardiovascular (even short course) but also renal. Paracetamol preferable and safe. #GP21

Oxygen saturation targets - 92-96%. Higher do worse as do lower!
Hospital transfer for sats<92%, HR>110, RR>24, other clinical signs. #GP21

Some very clear reasons why #PrimaryCare should be leading the management of mild-moderate #COVID19. Quite an affirming and confidence boosting session from @DeeMangin. #GP21

Final day and we’re talking climate and sustainability at #GP21. And can I just as an aside comment on how excellent the MCing has been at this conference from @julianwilcox. It’s like he’s been an honorary GP for the weekend!

Brief reflections from @TFaddy and Greg Justin’s on sustainability. Final comment from Greg - “A sustainable marriage is good for the environment!” #GP21

Sally Gaw is up with a keynote address on pharmaceuticals as environmental pollutants. A rising level of concern with building evidence behind these concern. #GP21

Interesting to understand that the sewerage treatment process is not designed to remove pharmaceuticals from waste water and so there is little to no effect on most drugs. #GP21

New Zealand is not immune to this. Lack of data primarily reflects lack of testing. #GP21

Fascinating to see some of the biological effects of environmental pharmaceuticals on the fauna of an environment. #GP21

Many ways that these environmental pharmaceuticals can affect humans too, directly (eg allergy to drugs) and indirectly (eg antibiotics resistant organisms). #GP21

Lots to think about from this talk from Sally Gaw. We already talk about antimicrobial stewardship, maybe we should be thinking more broadly about pharmaceutical stewardship with regards to environmental impacts? #GP21

Next up we have @CubaRaglanGuy talking on climate change and public health. #GP21

The big carbon dioxide experiment. From 280ppm to 410ppm in a few hundred years, half of this increase in the last 30 years. #GP21

And the result - rapidly heading towards the 1.5° of warming mark. Current rate of increase of around 2° per century. I think we’re beyond an inconvenient truth now! An unavoidable truth perhaps? #GP21

Fascinating comments on uneven heating distribution around the globe. The southern ocean is protecting Antarctica from rapid heating but at the expense of relative deep sea heating. #GP21

While I was aware of the uneven heat distribution, I didn’t realise how extreme the effects on water availability distribution are, particularly increased precipitation in Asia and some parts of Africa/South America. #GP21

This is what we’re up for folks! Also, forget viewing the glaciers. And goodbye to coastal roads. #GP21

And then there are the health effects…
#GP21

The mental health effects may be as significant (and not mitigated by ignoring the problem!) #GP21

WHAT we need to do is clear. HOW we achieve it is more tricky. #GP21

Some practical action points to take away, both at the personal level and at the advocacy level. Normalise talking about climate change it ALL THE TIME, not just when an extreme whether event is in the headlines. #GP21

And finally we WILL need to adapt, even with 1.5° warming. #GP21

We have 100% of the power to change the trajectory of climate change. Global heating can be stopped very quickly with reducing net emissions to zero. Sea level rise will take a lot longer to reverse. #GP21

Now the Peter Anyon Address from GPEP2 registrar Dr Melissa-Jane Austen. #GP21

Heartfelt address and a good reminder that being a good GP is not about study and knowledge but seeing the whole person. Thanks, Melissa-Jane! #GP21