I’ve had a bit of ‘a bee in my bonnet’ this year. I heard that! Ok, arguably it extends a little further back…like my whole career! But if you’ve seen the topics I’ve been speaking on at conferences in recent months, you’ll know exactly the soapbox I’ve climbed up onto. Inter-professional communication & collaboration. My particular focus (naturally 😉 ) has been current issues regarding the sharing of, and access to, pathology results for our shared-care patients. However, in the face of several distinct threats to the practise of both naturopathy and medicine in Australia of late, especially in the form of anti-collaborative rhetoric/push affecting both professions right now (read PHI reforms, promptly followed by proposed MBA review..if you haven’t read this regressive and repressive set of recommendations you seriously must), the question of how to improve collaboration in order to ultimately serve our patients better, has never been more urgent.
Last week, at the ICCMR conference, I outlined the current barriers for naturopaths to accessing patients’ pathology results (current and historical) and the heightened risks that this results in, either because of incomplete information or because of the subsequent direct pathology referring by naturopaths. Yes, bypassing the GP and another set of trained eyes on your patients labs comes with risks. I also spoke to the opportunities that await us if we can overcome this: in terms of improved patient outcomes, reduced risk, more economically responsible public health budget spending etc. etc. need I go on?! In the Q & A following my presentation, a doctor in the audience made two very important contributions, which deserve some additional air…she said:
“Shouldn’t the patient ultimately own their own pathology results? Then it would be a case of them electing who has access to these: their GP, their naturopath, their osteopath. Rather than the other way around – after all, we are all supposed to be members of their health care team, right?”
She said it. Not me. But I applaud her. She’s right of course. Right now, under the current proposed changes, we and integrative health care delivery and patients’ right to choose and self-direct their healthcare and public health budgetary burden…are all under threat of de-evolving. Right at the time when, with the current chronic disease burden and predicted public health budget blowouts, it should be all hands to the pump! Who has ever conducted a cost-benefit analysis of what integrative health care (successful patient sharing between naturopaths and GPs /specialists) saves the government? No one is my guess and when I proposed I do exactly this for my PhD on a particular parameter some years back, I was not so subtly told, that in spite of a great application, given the primary funding of the research group was from government, and a clear conflict of interest with the head researcher who was also a government advisor, ” my proposal was not in line with the current directives”. Yep.
Last week, a dear mentee of mine mentioned that a GP one of her patients sees responded to her respectful correspondence regarding their shared patient with absolute terror, citing possible de-registration if they are seen to be collaborating or interacting with her in any way…assuming the MBA changes go through. This doctor then decided the lesser risk, was to cease communication with this other key member of the patient’s health care team, not refer the patient for any follow up investigations (including those representative of basic duty of care) and certainly not enable access to any pathology results for this patient from the past or in the future. My mentee’s exemplary response to this doctor:
“My apologies for placing you in an uncomfortable position. I do understand the restrictions and guidelines GPs must work within for Medicare and AHPRA and understand that as you are the requesting practitioner you are liable for any pathology referred for. I make this clear to all my patients and that my referrals are on a request base only and it is up to yourself or the requesting GP for the final decision. I only try and request pathology through a GP or other medical practitioner to try and minimise both risks (of only myself viewing these labs) and unnecessary costs to the patient.
…’X’ has currently been seeking medical and alternative treatment for over 2 years and yet has had no change, if not a worsening of his condition and when I saw them 2 weeks ago, it was my understanding that not even basic assessment of full blood count, liver function and other general health markers had been completed. I had advised X that not all pathology may be covered under Medicare, and to come back to me so I could send him privately for those tests not able to be completed under Medicare. My apologies this was not made clear to you at the time of his appointment.
I take pride in my evidence-based approach to nutritional health in my practice, and work frequently with other patients’ medical practitioners in supporting their health. Thank you for your time and I appreciate your thoughts on this matter”
If the patients’ best interests are no longer the primary goal, as decided by bureaucrats, both government and organisational, is it time to ask the actual health professionals to please stand up?! Is it tipi-talk time for practitioners from all disciplines? Growl over.
Want to ensure you are writing professionally to other health care practitioners? Then our recording and resource Dear Doctor, is for you!
In this 45min podcast Rachel succinctly covers the serious Do’s and Don’ts for your professional letter writing. Rachel gives step-by-step instructions and examples for key phrasing and clear medical justifications, what terms to use when in order to come across respectfully, and how to present urgent red flags without sensationalising. This podcast is will help your professional letters improve collaboration for you and your patients need.
Help!!! I’m about to share the stage at the 3rd International Acid-Base Symposium on the 25th-27th Jun, with the best acid-base researchers in the world, all of whom I actively stalk (well read and recite everything they’ve ever published but close enough!) I’m terrified and excited in equal doses…but urgently need to change my presentation approach because until now I’ve had the privileged position of simply fulfilling the town-crier role, announcing far and wide the findings of their incredible research into acid base physiology and their findings about impact of chronic mild metabolic acidosis. But I can’t quote Arnett to Arnett! I can’t tell Dawson-Hughes about the incredible insights of Dawson-Hughes’ large body of work in this area! Oh my Goodness (cue, shaking knees), I’m going to meet Thomas Remer…of Potential Renal Acid Load Formula Fame!!
Yes, my partner is a musician and through him I have brushed shoulders with all kinds of famous…but nothing that has made my heart beat quite this fast!
Must buy an autograph book for them to all sign.
Joking (kind of). (more…)
Quite the month for it, I hear. My inbox has run hot with practitioners deeply concerned about some serious finger pointing that’s been going on.
The fingers in these instances have belonged to medical practitioners and the direction they’re all pointing, is seemingly at any complementary medicine their shared patient is taking.
Here’s a couple of good examples: “Your high blood pressure is the result of the combined mineral formula you’re taking!” These were the words of a GP to a 50 something female patient when he discovered she was taking a calcium, magnesium, potassium containing formula. The patient was hypertensive at the initial appointment, at which time the naturopath encouraged her to actually seek review, assessment and prescription of an anti-hypertensive, however the patient declined. The nutritional prescription was recommended in response to high acidity (raised anion gap) and prematurely low GFR (impaired renal function). Patient’s HBP continued to be problematic so the next doctor she sees, points the finger and says, it must be this product!
Would anyone like to explain that to me? In fact, that was my advice back to this very concerned and understandably rattled practitioner…just to cordially request the GP to outline the mechanism by which this might occur. (more…)
Ever wondered where on earth (or Mars?!) I came from? As much as I can’t keep quiet on some topics, my personal journey to here has been a bit of closed book to many. Recently during an interview with Andrew Whitfield-Cook from FxMedicine, which was supposed to be strictly about postgraduate education paths and the desperate need for mentoring, internships etc for naturopaths, the sneaky devil got me to spill the beans on a whole lot more!
Having been involved in so many aspects of naturopathic and integrative health care education over the past 15 years, of course I do have a lot of ideas about how practitioners can best accelerate their learning and development, the need for more independent education and the importance of fostering critical thinking.
I think you already know that I feel passionately about this but do you know the whole story? Who I have been mentored by and how I continue to tread the path of the ‘student’? (more…)
May was the month of teenage girls presenting with severe digestive problems, especially ‘food intolerances’, leading to avoidance of specific foods and at times significantly reduced food intake overall. As integrative health practitioners, validating and creating insight for clients on the nature and source of their food reactions is our bread and butter, right? Is it wheat? Dairy? Gluten? FODMAPs? Salicylates? Oxalates? We are not surprised by how many ‘sick’ patients we see in spite of a theoretically ‘healthy diet’ – healthy for others perhaps but not for the individual in front of you, right? But what if I told you that each of these teenage girls had a BMI < 18 kg/m2, does that change your opinion about your role? Would you assess, monitor and manage these teenage girls differently? You should.
Take the example of one of my clients: 14yo female with a BMI 16.3, who had her first confirmed food reaction under 2yo with failure to thrive, which was attributed by a paediatrician & dietitian at the time to severe salicylate sensitivity. She underwent jejunal biopsy at 3yo for suspected coeliac disease, due to ongoing concerns and a primary relative with CD but it was NAD. In the 11 years since, there have been a couple of other digestive diagnoses based on solid evidence, such as mainstream stool PCR testing. So surely, the fact that she is underweight & that she skips lunch at school due to digestive discomfort is proportionate and explained by her organic digestive issues. Or is it? (more…)
Recently, I posted about my very positive experience of the AIMA NZ conference, prior to that I was gabbing on about the upcoming ACNEM Brain Health conference in Melbourne in May and now I am going for the conference hat trick! I want to revisit a really impacting lecture for me at last year’s Australasian Society of Lifestyle Medicine (ASLM) conference, delivered by the Emeritus Professor Mark L. Wahlqvist AO, BMedSc, MBBS, MD (Adelaide), MD (Uppsala), on the relationship between ecology and human health.
Why did I find his talk so impacting? Why should every integrative practitioner take the time to watch this? (more…)
Just back from a truly wonderful Australasian Integrative Medical Association (AIMA) conference in NZ. I don’t know what it is about the land of the long white cloud but they seem to produce some of the loveliest, most earnest health practitioners and this conference reflects this, setting itself apart each year as a result of its very organic mix of speakers (general practitioners, naturopaths, nurses, specialists) who are all equally embraced and lauded. To boot we had medical students invited to attend this year and guess what, these 20 or so med students…they stayed for the full weekend much to everyone’s surprise(!), loved it and want more. Really. At the AIMA NZ conference, on the two occasions I have spoken, I feel a sense of coming home…no I don’t mean I am about to move there (too cold!!) but I mean coming home to integrative medicine. (more…)
This year has kicked off with lots of time spent re-calibrating my own and other practitioners’ businesses models via business mentoring and it’s such a privilege. One symptom that seems to creep into almost every practitioner’s business model though, is one of over-delivery. (Curse that empathy and all those good hearts hey!) Over-delivering comes in many forms, it might sound or look like this…
“I always run over”
Rather than responding to this with further self-criticism and , pledging better allegiance to the clock – we could hear this as a reflection that our appointment structure is out-dated or unsuitable. We need to restructure to allow for the time we really do spend and need to spend with our clients and then adjust the appointment fees appropriately. Having said that be aware of the other golden oldie: (more…)
Make the most of this special offer! If you become a 12 month subscriber before the end of January (that’s tomorrow!) you receive 10% off ALL individual mentoring sessions in 2017!
And just so you know what we have in store for you as an Update in Under 30 Subscriber this month: Rachel’s kicking off the year with ‘Melatonin – Misunderstandings and Mistakes’ – an amazing clinical update about what we are getting right and wrong with Melatonin. This podcast answers in particular, one of the most common sources of fascination & frustration for clinicians, the reasons behind the Melatonin non-responder. We’ve all encountered patients who have taken Melatonin for sleep problems and reported no benefit, or initially responded and then lost efficacy quickly, or even patients who experienced insomnia after taking. What does this tell you about your patient and what should you do to resolve this and better still, prevent it? Now we know. (more…)
I became interested in working in mental health not entirely of my own free will. I guess you could say, it had made it’s way into my world via family members and friends as well as my own problems when I was younger. So when I was at uni and I came across any information about mental illness, whether it was pathology or prescription, it was when I undoubtedly resonated most strongly with what I was learning. I’ve had some great opportunities throughout my career to feed my interest, met some wonderful mentors and some other powerful teachers who were often my patients. It’s now become a running joke among my teenage children that all my friends are either psychologists or have some sort of mental health diagnosis, ‘…and what does that say about you?’ they love to add teasingly. Well it says a lot probably: that I enjoy people who are comfortable talking about the psychology of our lives and ourselves, that I deeply appreciate that to be human is to suffer and we all suffer it’s just a question of degrees and the bravest of us share that with others. Lastly, I think it tells you that I live in the real world with real people 🙂 (more…)
Fresh faced students, new graduates and seasoned practitioners alike, are forever reminding me of the challenge we experience as practitioners when it comes to instigating real change in our patients health related behaviours … the change we KNOW will make a difference to their health and wellbeing. ‘If only they actually listened to us!?!’ has been screamed by the novice and seasoned practitioner alike. With an overwhelming desire to share our wealth of knowledge, the discovery that information ≠ change can lead us to despair at times.
In a recent interview with Dr. Azita Moradi (Consultant Psychiatrist) as part of our Access the Experts webinar series, I was quite surprised (and pleased) to hear that Azita sometimes spends a whole session with a patient discussing the possibility of change, before even touching on the reality of change. Azita’s discussion surrounding the neuroscience of change and the challenges this may pose in the therapeutic relationship was fascinating, and certainly resonated with the practitioners taking part in the webinar. Azita’s interview was full of clinical gems reminding us that just as in other settings, if we give a man a fish he eats today but if we teach a man to fish we feed him for life. Hand and in hand with this, we need to have a strong understanding and appreciation of how to engage clients in making positive changes to their lives, often when it seems most difficult to do, such as in mental health patients.
Knowing how to improve behavioural change in patients generally, is integral to everyday practice, and its value cannot be underestimated. (more…)
“Access the Experts with Rachel Arthur” is a month long intensive webinar series focusing on the best of Mental Health Education. Every Thursday night for the month of July, Rachel will be interviewing a hand-picked guest speaker about a particular area of expertise in Mental Health.
Each speaker is a clinician with years of experience (from a psychologist, to a GP, to psychiatrists) who Rachel has worked with and/or been mentored by and she is thrilled that these interviews create an avenue to share their incredible & very practical knowledge with a wider audience.
Rachel’s role as the interviewer will be a feature of the webinar series – ensuring you get the best of each speaker; translating the complex into easy-to-understand concepts and clinically relevant content that you can start applying immediately. (more…)
I really enjoy mentoring practitioners in business – it’s a real privilege to be able to hear about each practitioners’ aspirations and challenges. A few weeks back I had the good fortune to speak with a fresh one! A practitioner who has only been in business for a short period of time. As always before our session, I looked over all aspects of her online presence from her website, to her practice newsletters, Facebook presence etc. Goodness how things have changed from when I graduated and you literally just hung out your shingle!! As much as the online world has created incredible opportunities for people working in integrative health and the public who use our services, I think it has also of course brought the ‘competition closer’.
It’s taken a little while for me to collect my thoughts on this one. Initially there was a little flash of anger, frustration and a good deal of huffing and puffing when I heard about the RACGP guidelines recommending GPs say no to any requests from naturopaths for further investigation of their shared patients… but I’m over that now. In an interview on 702 ABC Sydney radio last week, Stephen Eddy, the vice president of ATMS, responded to these guidelines by suggesting that a blanket directive for GPs to ignore all requests from all naturopaths about all testing didn’t really sound sensible or appropriate. Here here! Surely, in the pursuit of evidence based medicine and discerning practice decisions, each case should be considered on an individual basis. I think Stephen Eddy gives GPs more credit for being able to make these judgements than their own association! (more…)
Recently a practitioner lamented that because of her clinic location she didn’t see company reps very often & felt this was a barrier to her staying current with her clinical knowledge. Of course, I had to beg to differ.
We’re quick to judge the medical profession for their reliance on commercial sources of CPD, overwhelmingly provided of course by the ‘drug reps’ but it seems we’re less fazed or concerned about ourselves being equally reliant, unduly influenced and misguided (might I add) by the people employed by the CAM manufacturers expressly to encourage us to sell more of their products! How does that make sense?
I go back to my very repetitive mantra: always be mindful of who delivers you the message/information etc. and what their agenda is.
By promoting their company’s products to us, focusing on the products’ strengths, ignoring or simply not making it a priority to know the limitations or weaknesses of the products or the evidence, ignoring or again simply not making it their business to know when superior products are being produced by competitors or when new evidence comes to light that puts into question their products, reps are only doing what they’re employed to do. But is it helpful and is it ok? (more…)
I was chatting with a colleague today about a complicated & interesting case of hers, severe hypothyroidism coupled with overt hypercortisolemia (salivary cortisol up to 230!). This is a distance patient & she’s sharing care with a couple of other health professionals with conflicting ideas…tricky!!
So when my friend received an email last week to the tune of… “things are bad, everything is terrible if not worse”, then naturally she starts worrying: What has she missed? What’s gone wrong? What more could/should she have done? Is this some sort of aggravation to the treatment she’s recommended?
This is the place our minds naturally go when faced with these scenarios however one of the things I have really learned over years in clinic is that patients, like me, like everyone else I know, are labile, in the moment kind of creatures & we’re all vulnerable to having BPDs. (more…)
So often in mentoring I hear about patients practitioners have struggled to treat primarily because of irregular points of contact….you know the type, the client who is an Irregular Regular or Random Regular, booking in to see you just once or twice a year or just in acute situations & never doing the follow-up you so want them to do, in order to address the real underpinning causes. A case I heard the other day would sound familiar to many of us, about a patient who saw the practitioner only when she experienced cramping. Each time she’d have an appointment, buy some magnesium which relieved the issue and then disappear again, only to re-emerge with the same issue at a later time. During one of these subsequent visits, the patient mentioned that she was ‘exhausted’. Following the practitioner’s insistence that the patient bring in any pathology she had had done, the practitioner realises much to her horror, the patient has been suffering from macrocytic anaemia for some years but no one had bothered to tell the patient and accordingly, the practitioner has been none the wiser as well. The practitioner of course felt terrible because she’s thorough and conscientious but is she to blame? Where does the patient’s autonomy end and the practitioner’s duty of care begin?
Sometimes patients themselves can be a big barrier to their own wellness for all sorts of reasons and we can’t always resolve this but perhaps we need to consider introducing clinic protocols to try and better manage the Irregular Regulars. (more…)
As we head rapidly towards the change over of our calendars we would like to offer you a special on the very best educational recordings from 2014 – buy 2 CDs before Jan 31st and receive one complimentary Premium Audio Recording of your choice OR purchase 4 CDs and receive a 3 month Premium Audio subscription for free.
It’s been a busy year during which Rachel has delivered 7 very successful new seminars in the area of mental health and beyond, most notably fortifying her role as a leader in the field of diagnostics and pathology interpretation. This has included collaborations with ACNEM, Biomedica, Health Masters Live, MINDD and Nutrition Care, however, each recording is classic Rachel – full of fresh perspectives on diagnosis & treatment, colourful analogies & humour. In case you missed some of these this year or want a copy for keeps – here’s a quick summary of the 2014 recordings included in this end of year offer: (more…)
“Two great speakers – inspirational in the first half and bang on in the second – I now know how much I don’t know”
Just out now in time for Christmas…no seriously though… this year I had the good fortune to team up with Biomedica and in particular Rachel McDonald and we delivered a 3 hour seminar called Mental Health in Holistic Practice. The intention behind this collaboration was to shift the education focus for practitioners from a prescription based approach, to one really about the clinical reality of managing mental health clients. Probably most of you will agree that the ‘treatment’ counts for only a portion of the positive outcomes in your patients and this is particularly true in clients challenged with mental health issues. After more than 20 years in practice working in this area, I’m keen to share what I’ve learned so other practitioners can get there much much faster! (more…)
As most of you know, I’m a big fan of establishing good communication with the other practitioners (GPs, psychologists, osteopaths, specialists etc.) also caring for my patients and what began as occasional letters that I found exasperatingly difficult & time consuming to write has become second nature. That’s not to say every letter I write now hits the spot & evokes the desired response but I think I’ve got a pretty good run rate. So I put together some tips that I thought might help you either get started or get SMARRRTer at it!
- S – Service
- M – Medical language & conventions
- A – Accuracy
- R – Reasonable
- R – Rationale
- R – Respectful
- T – Time-conscious
- A summary of the most important medical aspects of the case is a great time saver for other health professionals & assists them in making better informed clinical decisions
- Summarise key points of reference
- e.g. Betty Smith (BMI 36kg/m2, Waist 92cm)
- e.g. Depression (diagnosed 2010, Zoloft 100mg/d)
- Pick out the salient features of the case
- What are the absolute must-knows in the case?
Medical language & conventions
- Only use medically accepted terms & diagnoses
- e.g. avoid naturopathic speak such as dysbiosis, adrenal fatigue etc.
- Quantify EVERYTHING relevant
- e.g. weight loss/gain (7kg in 3mo), DASS scores, stool Bristol type & frequency
- Include all units of measurement
- e.g. 4.6 mmol/L, 129/84 mmHg
- Summarise medical hx in table form for easy reference
- Clarify which details you have first-hand Vs second hand – be careful not to be part of Chinese whispers
- e.g. patient reports being diagnosed with lactose intolerance
- When including patients’ own words – use quotation marks
- e.g. patient reports feeling “dizzy & vague with brain fog most days”
- Clarify if some things have been self-prescribed – otherwise the assumption will be that you gave/recommended it to them
- Don’t use a scatter gun approach when suggesting investigations
- Try not to ask for subsidised testing that the GP is simply unable to do under subsidy
- e.g. Full thyroid function test can’t be subsidised without a prior diagnosis of thyroid disease or TSH outside of reference range…WEIRD BUT TRUE
- Present a brief, clear justification for any requests
- e.g. Iron studies (vegetarian diet)
- Include appropriate references when the justification is likely to be beyond expected knowledge
- e.g. as a deficiency of this vitamin has Vitamin D – both 25 (OH)D & 1,25(OH)2 D, been implicated in a large number of autoimmune conditions assessment of both forms is recommended (Smieth et al. Vitamin D in Autoimmunity. Am J Clin Nutr. 2013)
- Ask for their assistance/insight/review/guidance
- Don’t forget – you want & need it!
- Keep in mind also how the relationship your patient shares with this practitioner may be positively or negatively impacted by the respect & tone of your letter
- How far in advance should the GP receive your letter in order to give him/her adequate time to read & digest the content?
- e.g. too close to consult – GP might understandably feel ambushed/rushed/unprepared
- How much time does a GP or other professional have to spend with each patient?
- In summary the less words the better – look for ways to reduce your word count, cut to the chase and ideally get most letters down to 1 page