New South Wales/Australian Capital Territory - November 2019
Welcome to the final edition of the NSW/ACT regional eBulletin for 2019. I would like to begin by thanking the committee members for their ongoing support and work throughout the year. I appreciate everyone’s involvement and passion for meeting our members’ needs.
There have been a number of successful events this year, of particular note is the success of our event; Physician Health and Effective Leadership. Covering topics such as burn out, workplace bullying and suicide. This event was well received with great interest. There are some fantastic events planned for 2020 and we look forward to increasing the value and relevance of membership to Fellows and trainees throughout NSW and ACT.
We held workshops in Canberra, one was held in conjunction with the Australian Digital Health Agency on My Health Record, and the other was on the MyCPD updates.The ACT continues to be a focus of member engagement and intent for the NSW/ACT Regional Committee.
The committee focuses on collaborating with key stakeholder partners from 2019, including the Clinical Excellence Commission and the Agency for Clinical Innovation.
The Committee has also been active in responding to and providing input into a number of policy and positions papers such as the 2019 Review of the Dust Diseases Scheme the Reproductive Health Care Bill Reform and the RACP Submission into the Royal Commission into Aged Care.
To round up 2019, I recently attended a roundtable discussion with Mr Brad Hazzard, NSW Minister of Health, along with other colleges. The committee will continue to advocate for physician health wellbeing moving forward.
The committee is looking forward to a busy and productive 2020. We have various activities planned, including the promotion of protected research time, strengthening our relationship with the NSW Ministry of Health, and advocating for our trainees and supervisors. I encourage you to take every opportunity to be involved, whether it's responding to our eBulletin articles, attending events, or emailing the Committee with suggestions for what you'd like us to focus on next year.
Wishing you a safe and happy 2020.
Dr Adrian Lee BSc (Med), MBBS, FRACP, AM
Chair, NSW/ACT Regional Committee
The NSW/ACT Trainees’ Committee has been working to support trainees in the areas that matter to you. We continue to advocate for quality training opportunities, fair assessment processes, and transparency with regard to official College policies and how they impact trainees.
Since our last update, we successfully held a Paediatric Advanced Training Orientation, as well as the 'Exams and Wellbeing' event. The Advanced Training Orientation was particularly well received and provided trainees with the opportunity to hear from their peers, supervisors and College representatives. We recognise that a similar event for adult medicine trainees is challenging given the variable expectations between different sub-specialties, but we are keen to hear if this would be valued by trainees in the future.
Many of you recently sat the Divisional Clinical Examination. We congratulate those who were successful, and commiserate with those who were not this time. Some paediatric trainees have raised concerns about equity between sites, particularly in view of local interpretation of policies around access to mobile phones, how and where time is spent in breaks, and what examination assistants can and can't do. There have also been concerns about the timeliness of feedback, particularly for unsuccessful candidates, and the impact of examiners arriving late to cases of the day. We have written to the Clinical Examination Committee – Paediatrics & Child Health to escalate these concerns, and they have provided us with a detailed response.
They committed to clarify instructions to improve consistency between sites. They recognise the importance of feedback to all candidates and would like to know about delays in this (please feel free to contact us so that we can escalate cases if needed). They have also informed us that there are strategies in place for situations where procedural issues may impact on exam outcomes, such as examiners arriving late in the case where rooms are spread out. These strategies are not always clear to candidates on the day, but you are able to write to the College immediately after the exam if you believe a procedural issue has adversely impacted your performance. While not a hidden rule, many candidates are unaware of this avenue.
As 2019 draws to a close, we are reviewing the year and setting priorities for 2020, including improved events with a broader focus for trainees. We want to hear from you about what really matters, so please contact us.
To learn more about your Trainee Committee including who is representing you, please see our webpage.
Dr Aimee Wiseman
Paediatrics and Child Health Medicine
Co-Chair – NSW/ACT Trainees’ Committee
Dr David Martens
Co-Chair – NSW/ACT Trainees’ Committee
Many Government decisions on workforce are based on anecdotal data. As a response to this we are updating our records to assist our future decision making for physician education programs.
Did you know the hours you work, the professional activities you are engaged in and where you work impact the paediatrics and adult medicine workforce?
You’ll find My Work Profile on the payment confirmation page that will take you to your own work profile, or you can access it in MyRACP.
MyRACP supported internet browsers are Microsoft Edge, Chrome, Firefox and Safari.
How does My Work Profile benefit you?
Workforce data will be made available to you and will help:
- new Fellows decide which geographic area to work in Australia and New Zealand
- new Fellows choose between private or public practice
- you understand how your work hours compare with your peers
- the RACP and stakeholders including government policy-makers make better workforce decisions, based on current data
- Fellows understand activities they are undertaking; research, administration or clinical.
For more information, please read the My Work Profile FAQs. For details on what data will be collected and how it will be stored, please read the Privacy Statement.
Hear what others have to say about My Work Profile
Balancing medical science with humanity
We are excited to announce the keynote speaker for RACP Congress 2020, Professor Catherine Crock AM.
Professor Crock is not only a doctor at the Royal Children's Hospital; Melbourne, she is a music and theatrical producer, a humanitarian, a mother and a strong advocate for culture change in healthcare.
After identifying the direct correlation between organisational negativity and staff wellbeing and effectiveness Professor Crock founded the Hush Foundation and the Gathering of Kindness events. She is dedicated to building, nurturing and instilling a culture of kindness throughout the healthcare system.
Her two plays “Hear Me” and “Do You Know Me” have been performed in hospitals and aged care settings across Australia raising awareness of patient centred care, communication and patient safety issues and encouraging a shift in the culture and behaviour in healthcare.
Her keynote address Balancing science with humanity: how kindness restores the whole in medicine will be a not-to-be-missed highlight of RACP Congress 2020.
Join your colleagues at RACP Congress 2020, from Monday, 4 to Wednesday, 6 May 2020 at the Melbourne Convention and Exhibition Centre in Melbourne, Australia.
Visit the Congress website to find out more about the program and to register.
Dr Howard Chilton has been a neonatologist for over 40 years. We caught up with him to find out about his fascinating career since his arrival in Australia in 1978. If you’d like to find out more about Dr Chilton, visit his website.
What is the most rewarding aspect of your role?
I’m just very fond of babies. It’s a remarkable thing. I had no intention of doing paediatrics while I was studying medicine at St Mary’s in London. After graduation I worked in adult medicine and surgery, the usual post-registration resident and registrar jobs. I then thought I better do a paediatrics term, as I wanted to do my membership and become a physician.
By this time, I’d escaped the cold of London and gone to Durban, South Africa to do some surfing and get some sun, as well as work as a physician. So I got a job in Harare Hospital in Rhodesia (now Zimbabwe). By luck the job happened to be entirely neo-natal with the boss, a young Professor recently returned from Baltimore, USA.
Within three days of starting, I suddenly realised that this was what I wanted to do for the rest of my life. I loved looking after these appealing little babies who have their whole life ahead of them. The job was so worthwhile. If you’re an adult physician you tend to mostly deal with the middle and end of life, rather than the beginning.
What changes or initiatives do you want to see in the medical community, in particularly paediatrics?
In my neonatal niche I believe it is so critical to have sound, evidence-based parent education. It’s important to help parents with their new baby so they can relax enough to enjoy them and start them on their life path in the most optimal way. That often takes a fundamental change in the mind and outlook of the parents. It’s not a trivial task and they need to be given the tools. 90 per cent of mothers who take their baby home say “what do I do now? I have no idea what comes next!” This is really sad. I think we need to educate our teenagers so when they get older they understand the responsibilities of parenthood. I believe that the key to that is an understanding of the evolutionary biology and the developmental psychology of babies. This will give them insight into babies’ needs and how to meet them. So when they make the decision to have a family, they make it knowingly.
It’s for that reason that for the last 16 years, up until my retirement from my Sydney practice a month ago, I gave an hourly talk each week to parents (and anyone else who would listen) in the postnatal ward of the Royal Hospital for Women. I have also written a few books for parents over the years. At present ‘Baby on Board’ (originally Finch Press, now in its 4th Edition and recently picked up by Booktopia Publishing) and ‘Your Cherished Baby’ (Pan Macmillan) remain available.
You see so many new mums come through your doors, what is the best advice you would tell a new mum?
The human baby is deeply attractive and is designed to make us fall in love with them and awaken our nurturing instincts. So listen to and believe in yourself. Unfortunately everybody else feels the same about your baby and wants to get in on the act by trying to help and give you what is often conflicting and unhelpful advice. You need to filter this through your instincts and your common sense. Beware of Dr Google and social media advice.
You often give the same advice day-in-day-out. How do you keep energised and keep up the momentum for each new patient?
It’s so important and it never bores me. I keep reading the journals and finding new information that enhances the whole structure of my narrative. There’s so much new exciting research in this field coming in all the time. It’s not a static science by any means.
What’s the biggest change/challenges you’ve seen in the hospitals since 1978?
When I arrived as Director of Newborn Care the sister in charge of the main post-natal ward for the Royal Hospital for Women told me (without a hint of irony) that if it wasn’t for her nursing staff, then she thought one-third of the babies would die. How about that for confidence in parenthood!
Happily we have seen the pushback to a lot of the cultural baggage parents had to carry around: from ‘cry it out’ sleep training to ‘routine based’ and other harmful and disempowering methods of parenting. I feel our approach to babies is now much more sensitive to their biology and the babies and parents benefit from this more evidence-based model.
Also when I arrived back in the 70s when parents lost babies or had stillbirths, they often never had the opportunity to see and grieve their baby, the baby just disappeared. Helping parents to deal with and integrate perinatal loss into their lives has improved enormously since those days.
There have also been massive changes in neonatal intensive care since then too. In those days we had primitive ventilators and no surfactant, so rates of pathology and losses particularly from prematurity were higher than they are today. The job was hard and sometimes very stressful work.
Happily I had two excellent colleagues which whom I shared the workload: Dr Peter Campbell and Dr Paul Garvey. Together we ran a very successful and innovative NICU at the Royal Hospital for Women for more than 20 years.
How do you manage work-life-balance, if there’s such a thing?
I don’t think I did it very well. I didn’t spend enough time with my own kids when they were growing up and I spent too much time at the hospital. In the early days as a Director of Newborn Care, I seemed to be there all the time. The joke was in our house that as soon as when I came home, the kids said, “Who is that man?” then I was going to cut back!
We certainly didn’t spend enough time thinking about work-life-balance at that time anyway because we were brought up in a time when medical workaholicism was a virtue. In my resident days for instance I worked up to 120-hour weeks, alternate nights and alternate weekends for years.
It’s good to see that people now training in medicine are given time to sleep and time to learn. Just throwing them in the deep end to see if they sink or swim was not great policy. My early days were exciting but were not very good for the soul.
What’s the greatest piece of advice you’ve ever received?
It was from a wonderful Zen Buddhist teacher called Joko Beck. She said that “With the tools that life has given them, everybody is doing their best”.
So judgement of others is always something that I’ve avoided which has really helped me in medicine. So when somebody tells you that 'so and so' has brought their baby back in yet again, it is easy to feel frustrated; but you invariably find that she is perfectly justified in her feelings in her particular circumstances. Judging people is never justified.
The second thing I learnt is that you must be kind to everybody. Teaching this to students is absolutely critical. Health workers must always be compassionate and caring, even when, especially when, they’re tired and overworked.
And the third thing is everyone in healthcare needs to watch what they say to patients. Beware of off-hand remarks. They need to realise the power of their words when dealing with people. I recently had a mother and her two year old in my clinic. It was a hot day but the child had two jumpers on. When I asked why, the mum said that the doctor had told her at his birth that he had ‘weak lungs’. His notes showed he had some ‘wet lung’ that lasted less than a day. That remark really affected how she felt about him and had restricted his life. When people are talking with their doctors it is likely that they will never forget the words that are said to them.
If you could go back in time, what information would you give yourself when you were starting your career?
I’ve had a terribly satisfying life in medicine. I was really lucky, I fell into the perfect niche that absolutely suited me down to the ground.
Medicine is such a wide field. Within it there are so many tiny little niches that are available so everyone should be able to find their passion. For some it’s general practice: looking after whole families with their day-to-day issues throughout a lifetime. Other people want specialise in the hundreds of fields available. You’ve just got to find what invigorates and energises you. Then nurture the passion.
Originally from India, Dr Naru Pal migrated to New Zealand in 1995. After passing his final Fellowship exam (Australasian Faculty of Public Health Medicine) in 1998, he worked in New Zealand before moving to Western Australia in early 2001. He then worked as the Inaugural Medical Director of Sunrise Aboriginal Corporation Coordinated Care Trial (CCT) in Katherine, Northern Territory.
He successfully led the service from its inception to becoming an independent community controlled health service over five years. After this period in the Top End, he found himself in the beautiful South West Australian coastal city of Bunbury where he undertook a consultant position in Public Health Medicine with WA Country Health Service. Some of the key opportunities in this role included strong leadership to manage the pandemic (H1N1) 2009 successfully and implement Ebola Virus Disease (EVD) Preparedness strategies in 2014. Additionally, he led WACHS – South West Public Health Unit to be nominated as a finalist in the WA Health Excellence Award twice.
He worked for a decade there before moving to Liverpool, Sydney last year.
Dr Pal is now the Director and Senior Staff Specialist of Public Health at the South West Sydney Local Health District. His main responsibility is to protect the health of the community through control of communicable diseases and some environmental health risks.
Alongside his passion in medicine, he was involved in various community activities including the Rotary Club and Bunbury Multicultural Group.
His interests in medicine expands from paediatrics to public health medicine, rural and remote medicine and health service management. His broad range of clinical experience expands from rural and remote to metro areas and from developing to developed countries.
You have had a very interesting career, what are some of your career highlights?
One career highlight would be when I led Sunrise Health Service Aboriginal Corporation Coordinated Care Trial (CCT), Katherine, NT from the start of its operation to a successful independent community controlled health service as inaugural Medical Director (May 2003 – August 2008). A less recent highlight was from 1991 to 1994, when I led a primary health care service at a rural area in India with a multidisciplinary team of 120 staff. Together, we improved the worst performing area in family planning and childhood immunisation to the top performing area within a three year period.
You are currently a member of the Aboriginal Torres Straight Islander Health Committee (ATSIHC). What has been the Committee’s greatest achievement?
In my opinion the greatest achievement is the development of the Medical Specialist Access Framework (MSAF) – a guide to equitable access to specialist care for Aboriginal and Torres Strait Islander people.
Some of the committee’s other achievements include the development and finalisation of Aboriginal and Torres Strait Islander Health Position Statement to strengthen the College’s capacity to develop a coordinated College approach to improving the health and social outcomes for Aboriginal and Torres Strait Islander peoples in Australia.
Fostering a close working relationship with the Māori Health Committee. Australian Indigenous Doctors Association (AIDA) and National Aboriginal Community Controlled Health Organisation (NACCHO) to address Indigenous health issues.
The committee has also developed the Indigenous Strategic Framework (ISF) to support the RACP in reflecting on what’s needed to shape a College, a physician workforce, and health system which values and encompasses Indigenous perspectives on health and wellbeing.
What is a practical way we can incorporate cultural awareness through our daily interactions?
It is crucial that we overcome cultural differences early in our career and have the knowledge, training and appropriate skills to work effectively with people from diverse backgrounds. Education and training on cultural safety are the most effective ways to promote cultural literacy and awareness.
Other strategies include:
- bridging the cultural gap with respectful verbal and non-verbal communication
- celebrating diversity (e.g. festivals of other culture, food)
- being curious
- paying attention to differences in other people’s culture, and
- accepting that your culture is not a better one but a different one.
What else have you learned throughout your career that you feel is important to share with our members?
As the current health system has a significant proportion of duplication in health service provision, I urge everyone to better coordinate healthcare through care coordination with incorporation of prevention into clinical practice.
As healthcare expenditure steadily rises, it is time for physicians/trainees to have an awareness of the costs and benefits of diagnostic and therapeutic interventions to make an informed decision to maintain a successful and sustainable healthcare system.
Lastly, learn to maintain your own health (physical, mental and emotional health) and wellbeing, learn to identify your own symptoms and seek appropriate professional care for its management. Remember – you are never alone.
Unique Professional Development opportunity available to RACP Advanced Trainees and new Fellows.
There is a strong focus on technical skills during training for junior doctors, so it is not often that they get the opportunity to develop skills in improving the processes of care that their patients receive.
To help our junior doctors develop these skills, a partnership was formed between the RACP and the Clinical Excellence Commission (the statutory body responsible for quality and safety in NSW) to teach RACP members the methodology to undertake quality improvement in their workplace.
This 12-month, workplace based program, starting in March 2020, will guide participants to learn and apply improvement science methodology, to undertake their own local clinical improvement project and enhance the safety and quality of the care provided by their teams.
Commencing with a face-to-face workshop, the advanced trainees bring along a problem that concerns them in the workplace. The workshop helps them refine their proposals into manageable projects and teaches them how to use the tools needed for a quality improvement study. They then return to their workplace, gather an interdisciplinary team, undertake a thorough diagnostic of the problem, generate and test possible solutions, implementing the ones that work. They then measure what the effect is and put strategies in place for the process to be sustained in an ongoing manner.
Benefits of the program include:
- applying a proven methodology to improve local care processes
- learning a contemporary approach to improvement using driver diagrams
- a deeper understanding of Quality and Safety, in areas of increasing importance in clinical care and medical management
- develop valuable clinical leadership skills
- opportunities to publish and/ or present project at national and international forums
The participants report a high level of satisfaction with the program and some, who are now consultants, have gone on to undertake further projects to enhance the quality of care and experience of their patients.
Testimonial from a past participant: “This project was a significant milestone in my career as I had interest in allergy and Immunology and my CPI project was on anaphylaxis. I was able to get into allergy training due to this project and have completed my training. Now I am working as consultant paediatric Allergist and Immunologist in private rooms.”
For further information or to register your interest in being a part of the 2020 cohort, please get in touch today.
The NSW/ACT Region’s Trainee Research Awards were held on 26 October 2019. The event was held in conjunction with an extremely successful talk on Research Project and PhDs. This year was an extremely successful year for the Trainee Research Awards with the highest number of submissions ever.
The finalists who presented their abstracts were:
- Dr Anthony Jeffrey, (Adult Medicine) – 'Metronomic administration of cytarabine and thioguanine in elderly patients with Acute Myeloid Leukaemia (AML) achieves high complete remission rates and prolonged survival'
- Dr Samantha Ennis, (Adult Medicine) – 'Assessment of DQ risk epitope mismatch after lung transplantation as a predictor of chronic lung allograft dysfunction'
Dr David Prince, (Adult Medicine) – 'Routine screening of Emergency Admissions at Risk of Chronic Hepatitis (SEARCH) helps diagnose and 're-diagnose' hepatitis B and C infections'
Dr Melanie Wyld, (Adult Medicine) – 'Costs in contemporary transplant'
Dr Prianka Puri (Adult Medicine) – 'The impact of reclassification of C3 predominant glomerulopathies on diagnostic accuracy, outcome and prognosis in patients with C3GN'
Dr Alison Freeth (Paediatric Child Health Medicine) – 'Rates and trends of prescribing acid suppression medication in children: analysis of Pharmaceutical Benefits Scheme data 2003-2017'
Dr Fernando Telles (Paediatric Child Health Medicine) – 'Characterisation of the Preterm Heart: A Meta-Analysis of Cardiac Structure and Function from Birth to Adulthood'
Dr Amber Seigel (Paediatric Child Health Medicine) – 'The use of clinician performed ultrasound in the assessment of safe umbilical venous catheter tip placement'
Congratulations to the NSW/ACT Regional winners
Dr Prianka Puri in Adult Medicine for 'The impact of reclassification of C3 predominant glomerulopathies on diagnostic accuracy, outcome and prognosis in patients with C3GN'
Dr Alison Freeth in Paediatric Child Health Medicine for 'Rates and trends of prescribing acid suppression medication in children: analysis of Pharmaceutical Benefits Scheme data 2003-2017'
Dr Prianka Puri and Dr Alison Freeth receive the opportunity to present at the RACP Congress 2020 alongside other recognised researchers and research grant recipients.
Their prize includes:
- return airfares from their nominated location to RACP Congress 2020
- accommodation for three nights, including breakfast
- complimentary registration, including Trainees’ Day
- an official acknowledgement and certificate presented at the RACP Congress Gala Dinner
Award recipients will also be invited to publish their abstracts in the Internal Medicine Journal or Journal of Paediatrics and Child Health RACP Congress supplement.
Physicians shaping Evolve
As part of a global movement, Evolve is a flagship initiative led by physicians the RACP to drive high-value, high-quality care in Australia and New Zealand. Evolve aims to support physicians to:
- safely and responsibly phase out low-value tests, treatments and procedures where appropriate
- provide high-value care to patients based on evidence and expertise
- influence the best use of health resources, reducing wasted expenditure.
RACP Fellows and trainees have recently shaped the next Evolve Strategy for 2019-21. From 1-31 July 2019 the draft strategy was circulated through Divisions, Faculties, Chapters, Specialty Societies and through the Presidents Message eBulletinl. We received 27 responses to the survey, one email response and also undertook a face-to-face consultation with the Paediatrics & Child Health Division.
We received a lot of positive feedback and a lot of constructive criticisms. We value all feedback and have made changes to the strategy accordingly. We are also looking at how we can incorporate it in the implementation of the strategy to ensure Evolve is better meeting the needs of our members. We are pleased to share the updated Evolve Strategy 2019-21 and a summary of the consultation feedback.
Get involved in shaping and implementing Evolve by emailing us.
The NSW/ACT Regional Committee are in the process of planning events for 2020. What would you like to see? What would you like to know more about? What is missing from your training? Ideas include financial, health and wellbeing, medico-legal, gender in medicine, leadership, bullying, telehealth, end-of-life law.
Get in touch with your ideas and suggestions so we can turn them into a reality.
Learn how to work more sensitively and effectively with migrant, refugee and asylum seeker patients in this new online course.
The course provides relevant facts and practical strategies for objectives such as good cross-cultural communication and facilitating easier navigation of the healthcare system. The course includes the perspectives and stories of a diverse range of individuals to help show the full picture.
Accessible anywhere and optimised for mobile on-the-go learning, RACP Online Learning Resources are free for members and counts towards Continuing Professional Development (CPD) requirements.
Fellows can claim CPD credits by listening to Pomegranate Health Podcasts
Ep53: Marrabinya — a hand outstretched
Marrabinya is a Wiradjuri word meaning 'hand outstretched'. It’s the name of a service in the Western New South Wales Primary Health Network which financially supports Indigenous Australians to attend specialist consultations. Aboriginal and Torres Strait Islander Peoples receive specialist medical care 40 per cent less often than non-Indigenous Australians. It’s easy to imagine communities out in the red desert and blame culture clash or the tyranny of distance, but most Indigenous Australians live in cities or regional communities. The Marrabinya staff explain how socioeconomic factors and institutional biases can accumulate to prevent Aboriginal patients from receiving the care they need.
Marrabinya is an exemplary model of principles that RACP has formalised in the Medical Specialist Access Framework. Indigenous leadership, cultural safety, person and family-centred approach and a context-specific approach can all contribute to great gains in the health of Aboriginal and Torres Strait Islander people.
Guests: Marrabinya Executive Manger Donna Jeffries and chronic care link staff Desley Mason, Kym Lees, Possum Swinton, Sandra Ritchie, Donna Jeffries, Melissa Flannery, Joanne Bugg, Jacob Bloomfield and Gaby Bugg.
Fellows of theRACP can claim CPD credits via MyCPD for listening to this episode and reading the resources below. Subscribe to Pomegranate Health in Apple iTunes, Spotify or any Android podcasting app
SA Annual Scientific Meeting
When: Saturday, 30 November 2019
Time: 8.30am - 3.30pm
Where: Adelaide Convention Centre
Things to do in SA: Check out the things to do while you're in SA
Following on from the success of last year’s event, the 2019 ASM promises to be as engaging and stimulating as last year. Held under the theme 'Specialists. Together' at the Adelaide Convention Centre, the program has three parts, with something for everyone.
Session one is titled ‘Pain, addiction and death’ with three speakers who will discuss the opioid crisis, brain immune systems contributing to pain, addiction and death, and palliative care.
Session two is the judging of the Trainee Research Awards by our panel:
- Professor Paul Komesaroff FRACP, President of the RACP Adult Medicine Division
- Professor Paul Colditz FRACP, President of the RACP Paediatrics and Child Health Division
- Professor Steve Wesselingh FRACP, Executive Director of the South Australian Health and Medical Research Institute (SAHMRI).
Session three is titled ‘Diseases and therapies: old and new’. The four speakers will discuss the history and modern developments of the silicosis epidemic, and latest developments with rheumatoid arthritis, stroke and lymphoma.
Full-day registration is $75 for trainees and $95 for Fellows, with medical students and non-members also welcome. Due to popular demand, half-day registrations are also being offered for the first time this year.