Rhaïa October 2020

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Editor introduction

A warm welcome to Rhaïa’s October newsletter for 2020. This edition features the theme 'An Era of Pandemics and Epidemics', with our Fellows sharing their opinions and perspectives regarding critical topics – COVID-19 pandemic, opioid and mental health epidemics.

So, 2020 has been challenging and continues to be so! The COVID-19 crisis created an unprecedented challenge nationally and globally, requiring us to become rapidly familiar with the disease and essential measures implemented by federal government and healthcare systems in Australia. This situation not only brought us changes in the way we practice (not forgetting, innovatively too) but also had a great impact upon our lives personally and those around us. Physical distancing and precautionary restrictions became paramount in order to avoid an increase in COVID-19 cases and fatalities. In more recent times, restrictions have eased in some states and territories, however the devastating impact of COVID-19 is still obvious in Victoria and New South Wales, cautioning us to remain highly vigilant to its threat and being able to manage the COVID-19 pandemic state as the new normal.

What does COVID-19 mean for rehabilitation medicine? Most patients with COVID-19 appear to recover fairly quickly, with their needs more met by local rehab services whilst a small number of patients have more serious consequences and slower recovery. In these cases, we draw attention to the role of rehab medicine in addressing specific needs of these patients. Experience from here in Australia and many other countries have shown varying levels of disorders in respiratory, neuromuscular, cognitive, physical and psychological functions amongst COVID-19 patients. Early and post-acute phase rehab have so far shown positive outcomes although more evidence is needed.

The opioid epidemic is also fast becoming a public health emergency in Australia and a few of our key rehabilitation physicians timely highlight this crisis. Healthcare providers continue to prescribe opioids at higher rates, especially in those with chronic non-cancer pain. Inevitably, this creates widespread misuse of both prescription and non-prescription opioids, with significant consequences including overdose and deaths. More careful consideration of its use in carefully selected patients with defined nociceptive and neuropathic pain conditions is needed and included as a component of a multimodal pain management plan.

Another long-term underestimated concern relates to mental health and wellbeing amongst clinicians, with an estimated 30 per cent burnout rate reported internationally. This largely occurs when there is a gap between demands and resources, with risks being exhaustion and lack of personal accomplishment, leading to absenteeism, sick leave and high economic costs on our healthcare system. On behalf of our Faculty, shedding some light on this issue is vital to help improve physical and mental health, job performance and satisfaction, achievement of work goals and better social relationships amongst our rehabilitation colleagues. The range of interventions used to address this problem remains fragmented, with no doubt, plenty of room for improvement in advocacy, education and resources.

Lastly, I would like to thank all our contributors immensely for their articles and giving us valuable insight into their own experiences working in various roles, especially acknowledging their contribution to Rhaïa during the busy COVID-19 period.

Dr Krystal Song
Editor

Readers, please note that the below articles were written several months ago. Given the fast changing circumstances of the COVID-19 pandemic, some information may have changed since the articles were originally written, particularly in relation to the COVID-19 situation in Victoria.

AFRM President’s Report

This is my first Rhaïa President’s Report.

I hope you had a chance to read the eBulletin in May where I mentioned a little about my own path to rehabilitation medicine and the many areas of work the Faculty is grappling with, in which we rely on the voluntary contributions of so many of you. We are always looking to gratefully accept more interested Fellows – many hands make light work.

The theme of this edition of Rhaïa, edited once again by Dr Krystal Song, is ‘An Era of Pandemics and Epidemics’. It is indeed amazing how this virus has profoundly affected almost every part of our normal community activity. Like many Australians, I was overseas in February and March, enjoying one of those holidays which you talk about for years and finally take – visiting Norway, Finland and Sweden north of the Arctic Circle in the depth of the northern winter. Sailing through fjords, stopping at isolated coastal settlements, the northern lights, husky sledding, reindeer and Sami culture among so much more. It was just so amazingly different from our experience of winter in Sydney – that being the point of course. The pandemic was getting traction in our minds in February, but nothing prepared us for the reality by late March. It’s remarkable to reflect upon how quickly it developed from international news story, to local border closures, to lockdown, to nightly bulletins of mounting death tolls in Europe and North America. 

Like many of you, I agreed, when requested, to major changes to my rehabilitation service as a contribution to the greater cause. In a few days, our ward was converted to an isolation ward because ironically, we have more bathrooms and single rooms than any other ward in the hospital. We were then moved to a closed surgical ward and tried to carry on our usual ward activity and therapy programs as best we could. I’m sure you also noticed that there was some reduction in usual rehab referrals but strokes keep happening and plenty of our other impairment groups continued to need our services as well. We expect a downturn in our Australian Rehabilitation Outcomes Centre (AROC) performance in the upcoming reporting period as our efficiency has been affected, but it has not been all bad news.

The pandemic forced us to look at how we could keep services going regardless. We took to videoconferencing outpatient appointments and other meetings. We started discussing with our therapists how they were providing outpatient services and many had already found ways to provide services remotely yet quite effectively. I was particularly interested to discuss the place of simple technology in supporting these services – much of which exists, some which will need development – there are plenty of biomedical engineering and computing science departments within our universities bristling with academics and students very motivated to be involved. The question is how we use this experience to change our practices in the future. Of course, when more normal activity is cautiously resumed, I expect my purpose built ward back with its architecture supporting enrichment, intensity of practice, and a milieu of enablement and compassion. We should also identify the positives we have learned and incorporate them into future rehab services and operations. The rehabilitation of COVID-19 specific complications is an entirely different discussion which I’ll leave to others in this edition.

The Faculty Executive and senior Education Committee members have continued to meet with members of the Education, Learning and Assessment Directorate of the College to develop a clear plan for our examinations which have been entirely disrupted by COVID-19 in 2020. You will all have received advice regarding the new dates for adult and paediatric Fellowship Written Exam, Fellowship Clinical Exam, Module 1 Exam and Module 2 Exam in 2021. We appreciate the need to give you, our trainees and supervisors, plenty of notice to prepare for exams and that has been a clear goal along with dates which are deliverable.

The Council conducted our planning day and Council meeting in late June which began development of the workplan for the next two years. As I mentioned in the eBulletin, we have important business to see through to completion from the last plan including the Marketing Toolkit which we have developed to help you in discussions with your hospitals, funding bodies and other organisations. Our Research Working Group will continue its role promoting research to trainees and Fellows including focusing on opportunities to access the valuable data resource which AROC provides. In addition, I believe that workforce analysis and projection is a very important task for the Faculty and includes consideration of changing work patterns and scope of practice. 

We continue to work closely with our sister organisation – Rehabilitation Medicine Society of Australia and New Zealand (RMSANZ), now led by Dr Michael Chou. The Faculty and the Society have complementary roles and I urge you all to join and support both. 

The core business of training and assessment goes on overseen by the Faculty Education Committee chaired by Dr Caitlin Anderson. In addition to the unprecedented challenges to assessment and training in 2020, planned curriculum renewal work will soon begin and presents an important opportunity to revise and update our core documents. Watch for more on this issue.

The Faculty Policy and Advocacy Committee chaired by Dr Jenny Mann has a number of policy documents underway including Rehabilitation of multi-resistant organism affected patients, Stem cell therapies in children, and Bariatric rehabilitation. The Committee regularly contributes to College submissions on a range of other social policy issues.

In closing, let me return to the pandemic. One very obvious consequence has been the cancellation of all conferences including the RMSANZ Annual Scientific Meeting originally planned for September, and RACP Congress which would have occurred in May. The Burniston Oration is rehabilitation medicine’s regular showcase at Congress and this year, our Burniston orator, Associate Professor Adam Scheinfeld has delivered his address via video. You can watch it on the Online Congress Series platform.

Let me pay tribute to my fellow Executive members, Professor Tim Geraghty (past President), Dr Caitlin Anderson (Chair FEC), Dr Jenny Mann (Chair FPAC) and draw your attention to the great work of Associate Professor Andrew Cole who worked tirelessly and continuously for the Faculty for so many years. A special thanks to our new Executive Officer Jane Henderson, Manager of Faculties Jo Goldrick and EGM Member Services Lisa Penlington who provide so much support to the Faculty.

Remember, the Faculty needs you. Many hands make light work. EOIs are sent out when specific projects are planned.

Dr Greg Bowring
AFRM President

AFRM Education Committee Report

Introduction and last meeting

The AFRM Education Committee (FEC) had their last meeting on Thursday, 3 September 2020 via videoconference. The next meeting will be held on Friday, 20 November 2020.

AFRM Education Committee Membership

Name Position
 Dr Caitlin Anderson Chair 
 Dr Jon Ho Chan Deputy Chair
 Dr Kirily Adam Lead in Overseas Trained Physicians 
 Dr Toni Auchinvole Aotearoa New Zealand Representative  
 Dr Clayton King Lead in Continuing Professional Development 
 Dr Kim McLennan Lead in Paediatric Rehabilitation 
 Associate Professor Louisa Ng Lead in Teaching and Learning 
 Dr Shari Parker Lead in Assessment 
 Dr Michael Ponsford Lead in Physician Education 
 Vacant Trainee Representative 

Dr Angela Wills has stepped down as the Trainee Representative. A call for expressions of interest has closed and a new Trainee Representative will be appointed shortly.

Updates from Committees

Changes to Training Requirements for 2020 due to COVID-19

Due to the impact of the COVID-19 pandemic a range of interim measures for training and accreditation have been made by the College to try and minimise the disruptions to settings and to progression through training. All information relating to this can be found on the College’s COVID-19 webpage.

There has also been specific interim changes to the General Rehabilitation Medicine and Paediatric Rehabilitation Medicine program requirements for 2020. Trainees and Supervisors were sent direct communications regarding these changes at the time they were finalised.

Assessments

Due to the impact of the COVID-19 pandemic, the College has made the decision to postpone most 2020 exams to 2021, including all AFRM examinations.

To give trainees time to prepare, the College will give at least three months’ notice of any rescheduled exams. The dates will depend on the ongoing improvement of COVID-19 and is subject to change.

You can find more information on the College’s COVID-19 webpage.

General Rehabilitation Medicine and Paediatric Rehabilitation Medicine Training

As of September 2020, there are 247 adult trainees and 14 paediatric trainees of the AFRM. 

Applications for Term 2, 2020 were due on Monday, 31 August 2020.

Accreditation 

There are currently 124 Accredited Training Settings for Advanced Training in Rehabilitation Medicine (General and Paediatric combined).  A list of currently accredited settings is available on the College website.

Training Term Evaluation Form (TTEF)

The AFRM Accreditation Subcommittee is currently working to update the information available on the AFRM Portal to ensure the purpose and process of the tool is clear to trainees and supervisors.

Advanced Training Curricula Renewal

In 2019 the College was developing common standards for Advanced Training to allow for an efficient development program and sufficient alignment across the different specialties. 

In 2020, initial consultation for the common learning, teaching and assessments programs for Advanced Training is being conducted to ensure they are robust and appropriate. Consultation closes 9am AEDT on Monday, 12 October 2020. 

You can find more information on the College’s Curricula Renewal webpage.

Supervisor Professional Development Program Workshops – AFRM supervisors

The College Education Committee (CEC) approved a deadline extension for the completion of the Supervisor Professional Development Program (SPDP). The deadline for workshop 1 has now been increased to the end of 2021, while the deadline for completion of all three remains as the end of 2022. 

AFRM Clinical Supervisors are required to meet both the RACP-wide and the current AFRM Clinical Supervisor Accreditation requirements. Therefore, all AFRM supervisors will need to complete all three SPDP workshops by 2022 (RACP-wide standard) and one supervisor workshop (SPDP or equivalent supervisor workshop) every three years after 2025 to maintain approval as an AFRM supervisor. Please note that there will also be a terminology change: supervisors who meet the requirements will be known as 'approved supervisors' instead of 'accredited supervisors'.

In the current climate, face-to-face workshops are not recommended. Alternatively, we are offering virtual workshops via Zoom, opening the possibility for better access and more diverse learning. Virtual workshops have a limited capacity of 30 participants to keep the discussion manageable. If you are interested in organising a SPDP workshop please contact your local Member Support Officer (MSO). 

In addition, online workshops are now able to accommodate a larger number of supervisors. There is one remaining online workshop for 2020.

All upcoming workshops can be found on the SPDP registration page

Dr Caitlin Anderson
Chair, Faculty Education Committee

AFRM Trainee Committee Report

The Trainee Committee continues to advocate for trainees as they approach a challenging and unique training environment in 2020. Rehabilitation is an important component of the health response to a pandemic and its aftermath. The Trainee Committee will be working hard to ensure that the experiences gained are complemented by high standards of training, support and representation. We have a voice in the College Trainees’ Committee, AFRM regional committees and various working groups and sub-committees that have evolved as a response to the pandemic. 

2020 Annual Trainees’ Meeting

The Annual Trainees’ Meeting (ATM) for 2020 has had to be restructured owing to the disruption created by the COVID-19 pandemic. I know from personal experience that the ATM is often the first opportunity to network with other trainees, identify areas of interest, refine examination skills and establish potential study groups. While we cannot recreate this social and practical experience, the Trainee Committee is working to deliver the content originally slated for the ATM in an online format. 

Training Logbook

The Trainee Committee has been involved in the development of a Training Logbook to monitor trainee exposure to common outpatient caseloads and to be used as a tool to identify goals for ongoing training. I thank Dr Myles Kwa for his efforts in developing this with the Faculties Training Committee. 

Computer Based Testing

After a long period of review and reflection, computer-based testing (CBT) will be reintroduced for 2021, with AFRM Module 1 trainees to serve as pilots for this assessment round. This process was in train long before the COVID-19 pandemic occurred. There has been an extensive amount of work that has gone into ensuring that examination candidates are not disadvantaged. The Trainee Committee recognises that CBT is now coming on the heels of the COVID-19 response and with increased numbers participating owing to 2020 postponement. We will continue to monitor developments. 

Curriculum Renewal

A systematic effort towards the renewal of the training curriculum is underway. The purpose is to shift towards a competency-based training model that aligns with RACP curricula frameworks and models. The Trainee Committee receives regular updates on this work and provides feedback.

There has been significant turnover in the Committee membership in the last few months. I would like to thank Dr Tim Butson, Dr Imogen Windle, Dr Kisani Manuel, Dr Christopher Martin, Dr Myles Kwa, Dr Morgan Hee and outgoing Chair Dr Angela Wills for their hard work and dedication in representing their Faculty and for their advocacy on behalf of their fellow trainees. I would particularly like to thank Dr Ashlyn Baker for her work as Chair and for her participation and advocacy while commencing work as a New Fellow. Thank you also to Stacey Barabash (previous AFRM Executive Officer) and the continuing support of Jane Henderson (current AFRM Executive Officer) and Joanne Goldrick (Manager, Faculties).  

Dr Philip Gaughwin
Chair, AFRM Trainee Committee

COVID-19: Virtual Rehabilitation Emergency

Sorry, what? Wuhan has opened a Coronavirus rehabilitation clinic? 

It was 6 March 2020. Only the first week of Autumn, but already the summer of bushfire Armageddon felt an Armageddon away: The World Health Organization (WHO) had declared a public health emergency at the end of January, and the Diamond Princess had been front page news for most of February. 

A rehab clinic? That’s weird. Not quite as weird as naming a pandemic after a beer, but still, weird.

Stranger still, was that I wasn’t reading the news in a medical journal or even reputable online newspaper, I found out about it on YouTube. YouTube! Since when does YouTube break medical news? Sure, we’re all Scooby-Doo digital, but isn’t that like discovering a Cochrane review on well, Scooby-Doo?

I googled again. ‘COVID-19 + Rehab’. Various alternatives. Nup. Nup. YouTube was it. The Lancet, The New England Journal of Medicine (NEJM) and indeed the Journal of Rehabilitation Medicine would all be weeks away.

And then…Wow. The video. The post COVID patient: on O2, needing Ax1 to walk. And his doctors in full Apollo 13 PPE. WT?!

To put 6 March in context, Tom Hanks was diagnosed with Coronavirus on 12 March, Peter Dutton on 13 March and any rehabilitation medicine physicians returning from international conferences would still have two weeks to isolate at home before the new hotel quarantine rules kicked in on 28 March. 

But offshore, unprecedented, unprecedented WOW. In Europe, tales of overrun hospitals, the rationing of ventilators and moribund healthcare workers. In the USA, CDC epidemiology detailing average patient age, comorbidities and length of hospitalisations – all LOUD warning bells for rehab physicians. And from both sides of the Atlantic, an estimated 50 per cent ICU mortality. LOUDER bells still. Fifty per cent of patients will survive and will probably require rehab. 

So how do you begin to plan rehabilitation for a single patient with a new disease, let alone for potentially thousands, and all at the same time? 

Was this to be an actual, unironic, unprecedented ‘rehabilitation emergency’?

At the time, we certainly thought so. Across the worst hit Australian eastern seaboard, rehabilitation physicians performed a collective ‘get up and go’. It was a huge rehab Scooby-Dooby-Doooo!

In Brisbane, outgoing AFRM President Dr Tim Geraghty worked alongside incoming AFRM President Dr Greg Bowring to advocate within the RACP, whilst in Melbourne RMSANZ President Dr Michael Chou rallied the Society.

In NSW, Associate Professor Steven Faux established a Community of Practice (COP) for Rehabilitation, with Dr Elizabeth Thompson and Professor James Middleton heading up COPs for Disability and Spinal Cord Injury respectively, whilst Dr Jenny Mann worked with the Faculty as the Faculty Policy and Advocacy Committee Chair.

In Queensland, Dr Elissa Farrow advocated as Co-Chair of the Queensland Rehabilitation Clinical Network and in Victoria, Professor Fary Khan and Dr Bhasker Amatya published one of the first rehabilitation articles pertaining to COVID-19 internationally in the Journal of Rehabilitation Medicine.

French Mauritian Australian Dr Rajen Ragavan, zoomed in to a hastily formed COVID-19 Rehabilitation ‘SIG’ from the mid-north coast of NSW to detail the COVID-19 rehab response happening in the middle of France, whilst pulmonary rehabilitation physician Dr Barbara Hannon teleconferenced from Melbourne with an airtight presentation on pulmonary rehabilitation in the age of COVID-19. 

Many more have dedicated countless hours to formulating COVID-19 plans for their hospitals and clinics, alongside colleagues in Allied Health, AROC, the Faculty and Society.

But back to YouTube. And breaking news. It’s mid-May as I write this, and the first Cochrane review on COVID-19 and rehab is to be announced. Instead, we’re following an unembargoed trail of clues about COVID-19 in the mainstream media, then waiting for days for verification in a more citable source. Reports of cardiac complications in The New York Times, days later in The Lancet; Large vessel strokes on 7.30, almost a week after in the NEJM; Early case reports on Twitter! Could YouTube be the new UpToDate?

Sometimes preparing for a hypothesised pandemic of rehab patients has felt a tiny bit like Scooby-Doo does evidence-based medicine. Thankfully, unless there’s a late peak or second wave, it will have all just been a bad cartoon.

Dr Jane Malone
COVID-19 Rehab Group Convenor
St. Vincent’s Clinic, Sydney

COVID-19: A Rehabilitation Perspective 

On 11 March 2020, the World Health Organization (WHO) declared COVID-19 as a pandemic outbreak. This disaster rapidly spread worldwide, and resulted in over 340,000 fatalities, with over five million confirmed cases (as of 25 May 2020). The resilience of robust health systems in most developed countries remains challenged, with an overwhelming impact on healthcare systems and economies of most developed and developing countries.1 No effective or specific medication regime or vaccine is yet available to treat COVID-19. Global data showed that a significant number of people have recovered and many discharged or transferred to subacute care.

Depending on the severity of COVID-19 impact, various impairments resulting in disabilities are reported: respiratory, neurological and/or cerebrovascular dysfunction, functional impairments, psychological issues, and others.2,3 Many of these are amenable to rehabilitation (within hospital or in the community). The current focus of COVID-19 management is acute management, stopping virus transmission, reducing morbidity and mortality, and post-acute management and rehabilitation of survivors. There is evidence from past disasters, including pandemics [influenza (H1N1) and Ebola] demonstrating the beneficial effect of interdisciplinary rehabilitation in improving physical and mental function, reduction in hospital stay and improved reintegration of patients into community.2 This is yet to be trialed in COVID-19 cohorts. Notably, the WHO and global healthcare authorities recognise the importance of rehabilitation-inclusive disaster management plans for comprehensive care. Published guidelines/protocols recommend appropriate and timely rehabilitative care of COVID-19 survivors during their stay in hospital and after discharge.3

The role of rehabilitation professionals is important in the current pandemic, with resource needs being more complex due to increased care demands from both new COVID-19 patients and existing patients with complex disabilities. Organisational and operational challenges in rehabilitation settings need to be considered.1 There is the additional burden for maintaining strict safety of staff and patients, infection control, space allocation, etc. As knowledge on COVID-19 evolves, management plans and standards continue to be driven by rapidly accumulating scientific knowledge. Various innovative approaches for rehabilitation within the context of pandemic have been implemented, including virtual rehabilitation, telerehabilitation, smartphone apps, home rehabilitation etc. Key recommendations from rehabilitation-specific guidelines published for COVID-19 patients to date are summarised below:2,3  

Recovery 

  • inclusion of rehabilitation personnel in the acute COVID-19 response team 
  • interdisciplinary care model (led by a rehabilitation physician)
  • commence rehabilitation as early as possible with an opportunity for further triaging into post-acute pathways within health network
  • provision of timely community rehabilitation services 
  • patients with complex needs (or slower trajectory towards recovery) should receive specialist rehabilitation for longer periods.

Infection control

  • public health safety measures (social distancing, hygiene, visitor restrictions, etc) 
  • provision of separate rehabilitation services for both COVID-19 and other patient cohorts
  • access to PPE 
  • stringent safety and cleaning procedures. 

Assessment and prescription

  • individual rehabilitation needs and goals of care 
  • appropriate clinical pathways for patients with complex needs
  • rehabilitation programs to include: exercise, activities of daily living practice, emotional/mental support, education, information, and equipment/assistive devices 
  • careful consideration prior to rehabilitation program prescription (stable clinical presentation with stable respiratory and haemodynamic function, considering pre-existing disabilities, etc) 
  • provision of assistive devices and rehabilitation-palliative care (where required)
  • adequate education/information and training for patients (+/- carers/family).

Community reintegration 

  • access to supported discharge and community reintegration programs
  • integrated care planning for those with longer term care needs.

Professor Fary Khan, Director of Rehabilitation
Dr Bhasker Amatya
The Royal Melbourne Hospital, VIC

1. Khan F, Amatya B. Medical rehabilitation in pandemics: Towards a new perspective. J Rehabil Med 2020; 20:jrm00043.
2. Amatya B, Khan F. COVID-19 in developing countries: a rehabilitation perspective. J Int Soc Phys Med Rehabil 2020. (Accepted for publication)
3. Phillips M, Turner-Stokes L, Wade D, Walton K. Rehabilitation in the wake of COVID-19 - A phoenix from the ashes (Issue 1). London: British Society of Rehabilitation Medicine (BSRM) 27 April 2020.

COVID-19 and Rehabilitation Services: a catalyst for change?

The arrival of the COVID-19 pandemic in Australia and Aotearoa New Zealand has undoubtedly had asignificant impact on rehabilitation services.

Preparations for COVID-19 have seen rapid changes in the structure and activities of rehabilitation services including conversion of rehab wards to manage COVID-19 patients requiring rehab, transfer of inpatients to community-based services and uptake of telemedicine. There has been a dramatic reduction in the activity of many rehab services, particularly services which have a large proportion of post-elective surgery patients. This is another lead hardship for some rehabilitation physicians who have had a dramatic reduction in their workload to the extent where some of my colleagues have been ’stood down’ and are now looking for new positions.

As Director of Rehabilitation at St Vincent’s Public and Private Hospitals, it has been very much a rollercoaster dealing with many COVID-19 planning meetings in a rapidly changing scenario and counselling team members who have been concerned about the risks posed by COVID-19 on services and to themselves.

It’s early June as I write this article and a component of the plan at St Vincent’s Public was to convert one of the rehabilitation wards to a COVID-19 stepdown ward. We quickly scoured the information coming out of Wuhan and Italy to see what types of patients we would be dealing with and developed a basic respiratory rehab protocol. In retrospect, I’m pleased the plans didn’t eventuate as we were woefully unprepared with the biosecurity of the ward, availability of appropriate equipment and staff training. At St Vincent’s Private Hospital, it was planned for the rehab ward to be converted into a public palliative unit ward for six months. The Rehabilitation Nursing Unit Manager and I vehemently protested against this development as we could see that the ’curve’ had started to bend at the time and that the move would be unnecessary. Our position has been vindicated as the move didn’t eventuate.

Several positive developments have emerged from the crisis. At St Vincent’s, we will be making some changes to increase the flexibility and options of the sites and types of service delivery. This includes the ability to provide rehabilitation on acute COVID-19 dedicated wards rather than on a subacute ward to avoid the risk of infection in a highly susceptible patient group. The crisis has fostered a rapid uptake of telemedicine as a vital form of service delivery. Many of the rehab outpatient consults where physical treatment is not required are now delivered by telemedicine. We will aim to continue to use telehealth to a greater extent on the inpatient wards for liaison with patients’ families and carers, for administrative and educational purposes across our campuses and to contribute to St Vincent’s project of developing a ’hospital beyond the walls’. 

St Vincent’s is progressing towards a home/community (I have included community here as many of our patients don’t have a regular place of abode) rehabilitation program which is fully integrated with the current GEM@Home service, delivering rehab to a broad group of patients. We will also explore the use of virtual and robotic home-based therapy which is showing some promise in trials that have been conducted in Australia and overseas.

The COVID-19 crisis has demonstrated the reliance that the private sector has on referrals following elective surgery, which according to AROC data, comprises at least 40 to 50 per cent of private rehabilitation episodes. This sector faces a number of challenges including the push for private health funds to move most of rehabilitation care for joint replacements to home-based care, the increasing scrutiny of rehab programs by the funds and a likely decline in the number of people taking up private health cover during a recession. It could be that the ’golden age’ of growth of private rehab services in most states of Australia may be over. It is imperative rehabilitation physicians are united in our efforts to ensure we demonstrate the effectiveness of rehab and to develop opportunities for growth in new fields which could include prehabilitation, cancer rehab, bariatric rehab and other areas.

There is an opportunity for some of the resources, priceless for the COVID-19 response and not yet required, to be diverted to improving support health and housing services for people with social disadvantages. St Vincent’s is working with the Department of Health and Human Services Victoria (DHHS) and social services to repurpose facilities set up during the COVID response for ’social rehabilitation’, aimed at people suffering from homelessness, chronic substance abuse and complex disability. 

I wish all the best for rehabilitation physicians and their colleagues and families during what will continue be a challenging time for us all. It has certainly been the most challenging in my 30 years as a Director of Rehabilitation Medicine.

Dr David Murphy
Director of Rehabilitation
St Vincent’s Hospital & St Vincent’s Private Hospital, Melbourne

Running a Rehabilitation Outpatient Service during COVID-19 

As a diligent clinician, you would have likely taken heed of your state/territory health authority advice and stopped all face-to-face consultations in your rehab clinic. Now you feel very comfortable doing all your consults on video or phone telehealth (also thanks to the new MBS billing criteria). However, with the easing of restrictions, what will you do next? Also, you now have a list of patients who require their usual botulinum toxin injections and ring you at regular intervals to ensure you don’t forget them.

This is the issue that we are all facing now – how to consult and inject our patients in the ‘new normal’ COVID-19 world. This article is not intended to be a comprehensive review (trust me, there’s not much out there) but rather to briefly outline the clinician, patient and environmental issues that we face in restarting our ambulatory services.

1. Clinician Factors

In Victoria, guidelines were drafted to identify staff at higher risk of becoming seriously unwell if they were infected with COVID-19. This included people who were immunocompromised, aged over 70 years (over 65 with chronic medical conditions) or pregnant women. In our health service, everyone completed an individualised workplace safety plan to ensure these factors were identified and any risks minimised. This was a good start in identifying who was at higher risk. It does not, however, reflect or record the individual’s beliefs or their comfort levels with seeing patients in person. Some of your clinicians may ask for additional PPE and hygiene measures; some of which might sound reasonable but may not align with your hospital’s policies. Therefore, it is important to have early individual discussions with your fellow clinicians to ensure that your team feels supported throughout our new journey.

2. Patient Factors

There are no specific guidelines in relation to who should attend in person to clinics, apart from many health services advocating telehealth as the preferred option. Patients should be screened using the same staff member criteria. The benefits of a face-to-face consult or procedure should outweigh the infection risk. Often, risks perceived by clinicians and patients differ. In the early stages of lockdown, many patients chose to defer their consultations. However, more recently, our experience has been that patients are now happy to attend in person when offered this option. Therefore, it is crucial that patients are reminded of their individual risks.

3. Environmental Factors

The concept of physical distancing also applies to the outpatient clinic environment. First and foremost, the issues of capacity now apply to all clinic areas. Our waiting room required reconfiguration to suit physical distancing requirements, with capacity significantly reduced. This means that your clinic (and other clinics running at the same time) will need to plan and reduce patients having to use the waiting room. No longer will having all patients attend at the same time be acceptable. Most consulting rooms now have a capacity of two people. Larger procedure rooms have capacity of between three to four people. Procedures pose the greatest challenge; pre-planning is important to ensure the room limits are met.

For our spasticity clinic, we devised a policy on recommencing procedures. All patients are booked two appointments, one being a telehealth appointment and another face-to-face appointment for the procedure itself, one to two weeks apart. The initial telehealth appointment is to ensure that patients are screened as appropriate for the procedure, goal setting and to determine approximate injection sites/dosages to minimise face-to-face interaction time. It is also to remind patients of current restrictions (e.g. entry screening to hospitals and restricting to only one person to accompany the patient).

We also restricted the number of procedures in each clinic session to ensure that patients do not have to wait and adequate time is given to room and equipment cleaning in between patients. Only larger rooms are currently being used, with only two staff members, the patient and one family member/carer being in the same room. It may be necessary to swap staff members depending on the task at hand (e.g. injector and nurse to perform ID and medication checks, and then injector and physiotherapist for the procedure itself).

These guidelines are only the beginning and likely to evolve as restrictions and case numbers change. Remember, no previous guidelines exist, so it is important that we tailor the delivery of our rehab service in this new world, to protect both staff members and patients.

Dr Edwin Luk
The Royal Melbourne Hospital, VIC

COVID-19: Have we been bypassed?

According to a study released in May by Monash University, there had been about 150 people admitted to ICU with COVID symptoms in Australia. Eighty-seven had positive swabs and all were over 60 years old. Nineteen died, 31 were discharged home and only three were transferred to another hospital (a rehab hospital?). Where did the other 128 cases go? None of them came to our rehab service in the middle of the hot spot of Sydney’s eastern suburbs and according to the NSW Community of Practice, less than five had been referred up until June.

I received my first referral from an ICU, in early June this year in a NSW country clinic, of a patient ventilated for 47 days. He had all the COVID-19 features – critical care neuropathy, inability to maintain oxygen sats on exertion, dependence in all ADLs, immobility, a DVT, and globus with PTSD from his crash intubation. He had just come off dialysis, described 'brain fog‘ and his carer was nervous and arranged early discharge and ambulatory care. There were 17 issues to address and the rehab plan involved all disciplines. So how had he bypassed the world class rehab service at a teaching hospital?

COVID-19 has drawn the spot light onto a number of challenges faced by our specialty, namely the organisation of our response to COVID-19, our research base in the rehabilitation needs of those in the post-acute care setting and our engagement with acute care physicians and policy makers. 

We have few tools to identify the rehabilitation needs of acute inpatients, apart from a formal rehab consultation. There are no large-scale Australian studies of the rehab needs of patients with complex medical and surgical conditions who are discharged from acute services. We do have studies in target groups like stroke, spinal and head injuries who are likely to have permanent disabilities, but no data on those discharged with significant deconditioning following medical illness. It is complex to represent to our acute colleagues or policy makers the need for rehabilitation services without knowing the number discharged from acute medical wards with high rehabilitation needs. 

Some would say that we should not do such a study as we don’t have the resources should we find what we expect (that a large number need ambulatory services) – but that is a chicken and egg argument. Others say we do not need to check the number with temporary disability as they will recover in time – but numbers presenting with delayed referrals to our rehab and chronic pain clinics say otherwise. AROC, Monash, Flinders etc. all have excellent credentials in epidemiology, hence it behooves us as a specialty to undertake a population based study to examine rehab needs of those discharged from hospital, their return to independence and their access to rehab services. 

The COVID-19 pandemic spotlighted an opportunity for our representative organisations to make our acute colleagues and the government aware of our existing rehabilitation infrastructure and the uses it could serve. In NSW we have models of service delivery in a variety of settings: in-reach, inpatient, outpatient and home-based services but sadly, many are unused for patients suffering the most critical health threat for over 100 years. Some may say that is because all specialties, including our respiratory colleagues, are hopeful of managing COVID-19 such that multidisciplinary rehab will be unnecessary and any deconditioning can be managed with pulmonary rehab programs based on exercise alone. Clearly this has not been the case in the US, UK, Spain, Italy or China and even if the numbers are hopefully small, why have we not been invited into the tent? 

The ability to co-exist with discipline specific exercise programs (like pulmonary rehab) is based on our acute colleagues understanding the difference between the coordinated, multidisciplinary, goal directed approach of rehabilitation medicine and a more limited exercise-only approach. The COVID-19 pandemic offered an opportunity to educate, advocate and publicise what we do and who we are. In order to achieve this, we need to be proactive rather than reactive. This requires deliberate and targeted education campaigns, simple to use tools for nurses, discharge planners, allied health and doctors to trigger early rehab consults and a new wave of rehab physicians who are passionate, well trained and hungry to work in the techniques of early rehab and rehab in the ambulatory space. 

Finally, the COVID-19 caravan cannot be allowed to move on without our organisations making our existence and offerings well known. In NSW, 100 rehabilitation doctors, therapists and nurses joined hands to advise the NSW Ministry in their COVID-19 response. Similar activities occurred in other states, but at a federal level, our utility was largely unknown. When the NSW Community of Practice (COP) was formed in April, we found out that the Respiratory COP ran a rehabilitation subgroup with no rehabilitation professional on board.  

A COVID-19 rehab response needs collaboration and cooperation and while the world turned to ambulatory care and telehealth, few in Australia knew that our Faculty had a detailed document in ambulatory care and the RMSANZ had statements on the rehabilitation response to disaster management. 

Clearly, publishing is not the same as publicising. Social media, email fatigue, and the fragmentation of governance structures in medicine, means specialties like ours need a well-resourced education and awareness committee with a firm goal of educating acute care colleagues, health policy makers and the public regarding how we might assist those with temporary or permanent disabilities, whatever their sources.

Has the COVID-19 pandemic offered our specialty the opportunity to publicise our utility, our ever-ready infrastructure and to explain the difference between exercise and multidisciplinary rehabilitation? If nothing else, it has certainly drawn attention to our gaps in understanding the rehabilitation needs of those discharged with complex medical problems. I wonder whether my new referral will feel that his day hospital treatment is just exercise, delivered too late and largely unnecessary. He may wonder why he didn’t have all this treatment earlier. 

Associate Professor Steven Faux
St Vincent’s Hospital, Sydney

The Opioid ‘Epidemic’ in Australia

Opioids remain one of the most useful group of drugs in acute pain and palliative care. Since the introduction of sustained-release oral formulations of opioid drugs in the 1990s and its increasing widespread use in chronic non-malignant pain (CNMP), it would be reasonable to summarise this phenomenon as well-intentioned but poorly evidenced. Compared to other drugs used on a similar scale such as statins, A2RAs and even celecoxib, there is considerably less documented patient experience in large RCTs with sustained-release opioids. It is therefore barely surprising that widespread use of these pharmacologically complex drugs has produced physiological and societal effects that were unexpected at the start of this century.

In the US, a prescription opioid epidemic, fueled in part by unscrupulous pharmaceutical companies (but facilitated by lax regulatory oversight) and the linking of funding by insurers to pain-related outcomes in acute hospitals has now become in its third wave – an illicit opioid crisis on a scale that has only been surpassed by the current pandemic in terms of public health disasters in living memory. In Australia, the illicit opioid problem has receded somewhat from the public consciousness after a peak of deaths in the late 1990s. Much more problematic has been the rise in widespread therapeutic opioid use.

The data on overdose deaths in the decade prior to 2017 clearly shows a rapid increase due to prescribing practices. The once common practice of relatively rapid titration of SR opioids to the upper part of the approved dose range is now recognised as poor practice as the benefits are smaller and less durable than previously thought, and the risks more numerous and diverse. Pain specialists are now facing up to the fact that, with the best of intentions, we oversaw a generation of pain patients whose outcomes may well have been worsened by our intervention, when we intended the opposite. 

The response by clinicians to this emerging research has been to seek a middle ground of responsible prescribing. The Faculty of Pain Medicine (FPM) has recently reviewed its guidance on opioid prescribing in CNMP, which sets out the principles under which it may be appropriate to use small or moderate doses for defined periods of time as part of a wider pain rehabilitation effort. A particular problem is the so-called ‘legacy’ patient. Just as patients with a long exposure to prednisolone may be unable to be weaned due to lack of endogenous cortisol production, there are undoubtedly a group of chronic pain sufferers who, despite their complications of opioid therapy, cannot be safely withdrawn completely. In this group, safe containment of the dose combined with compassionate management of the person who has the pain is required.

The Therapeutic Goods Administration (TGA), as part of a regulatory response to our opioid issues in Australia, has altered the indication of sustained-release opioid preparations to remove the indication for CNMP ‘except in exceptional circumstances'. Appropriate use in this setting clearly hinges on the definition of ‘exceptional’. A severe risk will be posed to long-term opioid medication users if this change in indication leads their primary practitioners to consider forced tapering. 

The introduction of SafeScript in Victoria and similar real-time monitoring software in other states is aimed at facilitating safe and appropriate use whilst at the same time, discouraging prescription shopping or diversion. Doctors who work with long-term pain patients, including rehabilitation physicians, need to remind themselves from time-to-time of best practice in this area. SafeScript comes with a range of educational modules that are available, and TGA has provided funding for Australian doctors to undertake six hours of online education in the form of the FPM Better Pain Management program. Discount codes to access this free education are available upon request. NPS MedicineWise has recently generated excellent resources to help with the decision to either start or taper long-term opioid therapy.

The long tail of the Australian opioid crisis will last for many years. We owe it to our patients not to repeat the mistakes of the past and to help those who remain on legacy doses manage as well as they can. Evidence-based and ethical use of opioids is part of the fundamental pain management toolkit of every doctor. 

Associate Professor Michael Vagg
Clinical Director Rehabilitation & Pain Services, Epworth Geelong, VIC
Dean, Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists

Resources

Opioid epidemic: what we need to change

Opioid use in Australia has increased almost four-fold between 1990 and 2014. This increase appears to have been driven by the subsidy of opioids and newer long acting formulations for the treatment of non-cancer pain.1 Since 2000, hospitalisations concerning opioid poisonings and opioid-related deaths have been related to a shift from heroin to pharmaceutical opioids. In 2015, an estimated 15 million opioid prescriptions were dispensed in Australia.2 
 

Factors leading to the growth in opioid prescribing and use include:

  • an increase in demand for treatment of chronic pain related to musculoskeletal disorders in an aging population, obesity, increased survival after injury and cancer, increasing frequency and complexity of surgery
  • initially, a more favourable attitude to treatment of chronic pain with opioids by peak bodies (now not the case)
  • aggressive marketing by pharmaceutical companies with education programs, favourable research and lobbying.

Other contributing factors are:

  • greater availability of different varieties of opioids
  • hospital discharge practices with patients continuing on opioids longer than necessary
  • limited access to viable alternatives to pharmaceutical opioids e.g. pain management programs, non-opioid medications
  • logistical difficulties and stigma around accessing Opioid Substitution Therapy programs
  • pressure on prescribers by demanding and intimidating patients, leading to inappropriate prescribing.

Interestingly, although the harms associated with pharmaceutical opioids has increased, as has non-medical use of pharmaceutical opioids, it is still at a lower rate compared to USA and Canada, but greater than the UK. Of recent times, prescription practices have changed to lower doses and smaller quantities. 

Dr Gabrielle Campbell (2019) notes that there have been a number of strategies implemented in Australia in an attempt to minimise harms from pharmaceutical opioids. These include:

Regulatory responses aimed at reducing aberrant opioid prescribing and restricting opioid supply

  • Codeine Rescheduling (2018) – now a Schedule 4 drug and no longer available over the counter.
  • Prescription drug monitoring programs (PDMPs) – designed to track prescribing and dispensing of prescription drugs of potential extra-medical use e.g. SafeScript HP portal in Victoria.
  • State requirements for applying for an opioid permit if prescribing long term, with specialist review after 12 months.

Responses to minimise harmful patterns of use and harm

  • Abuse-deterrent formulations – intention is to minimise extra-medical use by targeting use involving unintended routes of administration e.g. tamper resistant tablets, inclusion of naloxone in formulation.

Other responses to reduce pharmaceutical opioid related harms

  • Access to multidisciplinary services – the role of a multidisciplinary approach to chronic pain that integrates psychological approaches, physical therapies and appropriate medication prescription is well established. Although supported by federal government and locally, access continues to be challenging.
  • Access to Opioid Substitution Therapy (OST) – both methadone and buprenorphine are effective in the treatment of pharmaceutical opioid use disorders. However, utilisation is low in the community.
  • Naloxone availability – limited uptake of ‘take home naloxone’ is noted. An intra-nasal formulation is now available which may improve its acceptability and attractiveness for use.

Education and advocacy for consumers and healthcare providers

  • In the community, education strategies and promotion of the potential for opioid-related problems and quality use of opioids is available. There is now an emphasis on de-prescribing opioids and adopting multidisciplinary non-medication based approaches to managing pain.

It is clear that rehabilitation physicians have a significant part to play in the coordination and oversight of chronic pain management within our multidisciplinary teams. We have the skills to change the prescribing culture that exists and raise the level of awareness and present other treatment and management options for patients. We can work closely with our pain physician and addiction medicine specialist colleagues, along with primary care providers, to enhance the management of our patients who have become entangled in the opioid epidemic by improving education, communication and availability of appropriate services. 

Dr Stephen de Graaff
Director of Pain Services, Epworth HealthCare, VIC


1. Karanges E, Blanch B, Buckley N & Pearson S. Twenty-five years of prescription opioid use in Australia: a whole-of-population analysis using pharmaceutical claims. Br J Pharmacol 2016 Jul: 82(1): 255-267
2. Campbell G, Lintzeris N, Gisev N, Larance B, Pearson S & Degenhardt L 2019. Regulatory and other responses to the pharmaceutical opioid problem. MJA 210(1): 6-8

Managing a Chronic Pain Service during the pandemic – opioids and service disruption

As a rehabilitation physician, my approach to chronic pain has been multidisciplinary and adaptive coping. Over-reliance on poorly effective analgesics has been a challenge to manage. In 2020, our service delivery has now been severely disrupted. How will this evolve I wonder?

In March 2020, the Prime Minister announced the pandemic shutdown, and our ambulatory pain rehabilitation program at Caulfield Hospital was directed to cease face-to-face consultations and group and allied health programs. The Pain Centre was closing. 

Whilst my rehabilitation and geriatric colleagues on the same campus were decanting beds, we were assessing our staff resources for re-deployment and quickly planning. With 653 current outpatients accessing a variety of medical, psychological and physical therapies, we determined who was ’at risk‘ of a health emergency or ED presentation. We contacted patients to reschedule, postpone or re-prioritise a clinical contact and triage referrals.

In chronic pain management recently in Victoria, we have been addressing the ’opioid epidemic’, and the concerning overuse of opioids for chronic pain. SafeScript – a real time prescription monitoring of opioids as well as benzodiazepines, was set to launch on 1 April 2020. SafeScript automatically provides recent medication prescribing and dispensing information to a prescriber. This ensures identification of a patient’s opioid use, so it can be tackled. Our Pain Centre has received increased referrals for opioid management over the last 12 months. Some patients are only interested in getting opioid medication approvals for their GP, to facilitate prescribing and permits, and are reluctant to look at broader approaches to manage chronic pain. After 1 April, this reason for referrals has increased, but our service is greatly reduced as we redefine what we can offer. 

Patients’ doctors, mainly GP’s, are also under great pressure during the pandemic, and have started calling us for help, with many hoping that we would take over management. Some of these opioid dependent patients are difficult, and some more routine, but we cannot abandon them. On several afternoons, I found myself patiently listening to distressed GPs and other colleagues as they navigated uncertainty and rapid changes to deliver healthcare. I realised I was fortunate to be part of a wonderful team, so we could tackle these challenges together in our practice.

We rapidly set up our clinic onto digital platforms for telehealth and online meetings, but we lacked equipment, and as a result 80 per cent of clinical contacts in the first weeks were by telephone.

And now two months later, I am writing for Rhaïa. So, can I see some changes in future practice?

The majority of our patients are extremely grateful for our contacts despite our limited ability to deliver our service. Telehealth has been useful in our practice. Many patients do not need to travel to access the service now. But telehealth has limitations. It has greater disadvantage to vulnerable patients – the elderly, the severely financially disadvantaged, those with severe psychosocial problems, the non-English speakers and the non-technically capable patients. 

In the future, we now realise and hope that we will have an on-site service mixed with online programs. My trainee keeps telling me that “more than ever”, he sees the value of thorough physical assessment in order to plan best treatment and check diagnoses (this is music to my ears).

Conducting telehealth for patients with mental health problems (>65 per cent in our practice) has required training and practice. When telehealth was initiated in a great rush, we were given loads of technical advice which challenged us and our devices. But we received nothing about clinical and psychological management online.

Opioid management has been particularly challenging. Our efforts aim to motivate patients to develop non-pharmacological strategies and at the same time, adopting slow wean or occasionally transferring to opioid replacement therapy. We are focusing on Analgesic Stewardship, to wean opioids early after surgery or acute pain onset. We are assisted now by addiction medicine colleagues. New TGA guidance and PBS changes from 1 June 2020 regarding opioid prescribing in chronic pain will create more referrals. We are inadequately resourced to meet the expanding demand. We have been liaising much more with GPs, which is great, but it takes additional time. 

Initial pandemic planning for the public hospitals was focused on managing high acuity presentations. Our work, like my rehabilitation colleagues, is about chronic disability management, which we cannot neglect. We are grateful that to date, the pandemic in Australia has been contained. We have been stretched and stressed to deliver services, and we are practising adaptive coping. The next few months will bring further changes and challenges, and we will do what we can and also advocate for our patients’ needs.

Associate Professor Carolyn Arnold
Alfred Health, VIC

A pandemic of kindness – burnout prevention in rehabilitation medicine 

Self‐care, doctor wellbeing …. It is often an afterthought in the business of caring for our patients, our own families, in the business of life. And in the context of the challenges of COVID‐19 for vulnerable patients, over loaded colleagues (in particular in a global context) it can take even more of a back seat.

The declaration of Geneva – our modern day Hippocratic Oath, was amended in 2017 to include:
I WILL ATTEND TO my own health, wellbeing, and abilities in order to provide care of the highest standard. This emphasises that physician self‐care is not just a luxury, it is a critical factor in the work we do as healthcare professionals and to enable that work.

A positive of the COVID‐19 situation is that physician wellbeing is on the agenda in a very public forum. There is so much good will and support for healthcare workers and a recognition of the importance of a robust and healthy healthcare system. However, a 'healthy' system needs to include healthy doctors who have positive engagement in their work and who are not burnt out. There is now much more open discussion about the stressors healthcare workers face and the subsequent mental health impacts.

What of rehabilitation physicians as a group? We work in subacute and ambulatory settings; most of us are not in a front‐line situation. Are we at risk of burnout? Burnout is defined as a state of emotional and physical exhaustion, a sense of decreased accomplishment and depersonalisation (often expressed as cynicism) due to prolonged work‐related stress.1 A literature review published in 2019 by Bateman and colleagues looked at that very question of burnout in rehabilitation physicians and trainees in the United States and found that as a group they experienced the third highest rate of burnout amongst specialists.1

What do we know of burnout in our Australian context? We do not have figures specific to rehabilitation medicine, but we do have broader data. The Beyond Blue national mental health survey of doctors and medical students conducted in 2013 found high levels of burnout in all groups. Two key components of burnout, exhaustion and cynicism, were found in a third of respondents.2

The nature of the cases we deal with as rehabilitation physicians and trainees can expose us to vicarious trauma and compassion fatigue. Finite resources and high patient load can further contribute to work‐related stress and burnout. However, these concepts are not all or nothing phenomena. There is a continuum from vicarious trauma to vicarious resilience, compassion fatigue to compassion satisfaction and from burnout to positive work engagement. Are we teaching our trainees about these concepts and how to manage them? Should this be part of our curriculum?

We can incrementally shift the balance towards the positive end of the spectrum. Preventive strategies can target executive, organisational systems, training and individual levels. Key strategies include work force planning and rostering to enable flexibility and 'slack' in the system, facilitating shared decision making and peer support; enabling debriefing and acknowledging the contribution of each individual; supporting a culture of civility and kindness within our teams, a culture which enables psychological safety – that it is okay to ask for help and sometimes say no for psychological safety. An excellent review of burnout prevention by West et al can help those interested to explore this further.3

As individuals, what habits and practices can support us? There is research supporting the processes of fostering gratitude, giving positive feedback, finding meaning in what we do and self‐compassion. Three simple practices discussed by Dr Lynne McKinlay4 in a recent podcast that support these processes are to ask ourselves each day in our work: 

1) What can we congratulate ourselves for? 
2) What can we forgive ourselves for? 
3) What are we grateful for at work? 
4) What are we going to do for ourselves to recharge before tomorrow? 

Self‐care routines should be embedded in our daily lives, so when a crisis hits, they are already there to support us. It is never too late to start self‐care.

There are resources to assist us. Smiling Minds, a free Australian app to promote mindfulness now has a healthcare worker specific program. A fantastic resource has been developed by a national group of doctors with an interest in supporting healthcare workers during COVID‐19. It is the 'Pandemic Kindness Movement'.5 Clinicians have developed a website in which evidence‐based resources to support wellbeing have been curated. If we are distressed, we need to ask for help. Resources for this include DRS4DRS6, a web resource and 24/7 phone helpline specifically for doctors; and our RACP Support Program also with an independent 24/7 help line.

Let’s continue to advocate for the factors that evidence has shown can decrease burnout at an educational, organisational and individual level. It is all our responsibility. In this global pandemic, let’s contribute to the pandemic of kindness – not just for our patients, families, friends – but also for ourselves. It is always okay to ask for help.

Dr Sabine Hennel 
Victorian Paediatric Rehabilitation Service
Monash Children’s Hospital, VIC

References
1. E.A. Bateman, R. Viana, Burnout among specialists and trainees in physical medicine and rehabilitation: a systematic review. J Rehabil Med 2019; 51: 869–874
2. The National Mental Health Survey of Doctors and Medical Students ‐ Beyond Blue 2013
3. C. P. West, L. N. Dyrbye, T. D. Shanafelt Physician burnout: contributors, consequences and Solutions. Journal of Internal Medicine, 2018, 283; 516–529
4. Clinician wellbeing in the time of COVID – 19, with Dr Lynne McKinlay. Queensland Clinical Senate Podcast 2020 available at URL https://player.whooshkaa.com/queensland-clinical-senate-podcast 
5. “Pandemic Kindness Movement” at URL https://aci.health.nsw.gov.au/covid-19/kindness 
Health worker holding the world street art

Physician wellbeing: Let’s look after ourselves and one another

The word ‘unprecedented’ has become the defining adjective for 2020. 

First off, catastrophic bushfires across the country, then the COVID-19 crisis. With this, our already traumatised communities came to experience the uncertainties of the ‘new norm’, the isolation, difficulties of home-schooling, the fight for elusive toilet paper, wipes, hand sanitisers, the list goes on…

Serving the best interests of our patients has always been the basis of medicine. However, this is only possible when physicians are well themselves and able to care for vulnerable patients. It is, however, well known that physicians have higher burnout and suicide rates compared to the average population and many experience higher rates of depression, dissatisfaction and suicide risk through medical training and professional careers.1

Research has shown that causes of physician burnout are multifactorial and solutions to a longer lasting change are multitiered. Various stressors such as time constraints, workload, high-pressured disciplines, lack of resources and pressures of litigation all contribute to fatigue, anxiety, depression, substance abuse, suicide and cardiovascular disease. For many, burnout manifests as deterioration of values, dignity, spirit and will, and reduced job satisfaction, often resulting in medical errors and a breakdown in the doctor-patient relationship.

As rehabilitation medicine specialists, we are privileged in being able to look after some of the most vulnerable in our population, with some having significant complex needs. Compared to most specialties, the psychosocial aspect of care is prioritised as much, if not more, than the biological side, thus the widespread effects of a global pandemic on how we need to care for our patients is magnified.

Last year, the American Board of Physical Medicine and Rehabilitation alarmingly found that out of 1,536 of our American colleagues, half met the definition of ‘burnout’ with two thirds becoming more callous towards patients, thus making rehabilitation medicine one of the most ‘burned out’ of specialties.2 Whilst there are still no studies yet specific to rehabilitation in the context of the COVID-19 pandemic, the British Medical Association (BMA) recently found a staggering 45 per cent of doctors suffering from mental health problems or burnout relating to, or made worse by the COVID-19 crisis.3 Interventions for physicians incorporating elements of mindfulness, reflection, shared experience and small group learning have shown beneficial effect in improving engagement in work and reduced depersonalisation, with sustained effect at 12 months.4

We face unique stressors:

  • we worry about our patients
  • we worry about protecting our vulnerable loved ones, knowing we have a higher chance of contracting and transmitting this virus
  • we watch in horror as colleagues around the world battle unprecedented death rates like we have never seen before
  • we feel helpless as we lose our colleagues to the virus and see many needing to take on roles outside of the specialty they have trained for
  • we scramble to keep up with the daily onslaught of news and studies and ever-changing protocols
  • we fight to get adequate PPE
  • most in private practice have to figure out how to keep practices afloat due to decreased revenue as people avoid doctors’ surgeries.

So far, we have thankfully been spared the difficult decisions our international colleagues have had to make on who lives and who dies. For many, their positive coping mechanisms have been impacted upon by the pandemic. The adoption of telehealth, whilst being a boom for healthcare, has meant there is reduced day to day contact with our peers. Gyms, sport facilities are off-limits. There are no weekend getaways, dining out or having a coffee to debrief with friends outside of medicine. Some are afraid of bringing work home – hence are physically distancing themselves from their loved ones, their protective blanket from work stressors. With all the stockpiling, the hobbyist-bakers can’t buy goods to bake with.

Most doctors, being perfectionists, are often their own worst enemies. There is a pervading stigma that seeking help is weak. We have been painted as superheroes in this pandemic, yet we are undeniably human too. We have been ingrained to silo our emotions, to keep pushing on. We are experts at recognising burnout, depression and anxiety in our patients, but are blind to ourselves. And it tends to creep up on you, when it’s too late.

Hence, it is even more important in these challenging times that we look out for one another. Burnout is not a personal failure, nor merely an institutional responsibility, as booming resilience programs seem to imply. Never underestimate the power of you, as an individual, in reaching out to your colleagues and friends to ask “R U OK?”, having a socially distanced coffee and showing them the same care and compassion we shower on our patients.

Here’s a picture of our very enthusiastic team at Flinders Medical Centre in Adelaide, donning our loudest and brightest socks for #CRAZY SOCKS DAY!   

CRAZY SOCKS_COMBINED












Dr Swatee Jena
Dr Su Min Wong
Flinders Medical Centre, SA


1. Thomas LR, Ripp JA, West CP. Charter on Physician Well-being. JAMA 2018; 319:15. 
2. Sliwa JA, Clark GS, Chiodo A et.al. Burnout in diplomats of the American Board of Physical Medicine and Rehabilitation – prevalence and potential drivers: a prospective cross-sectional survey. PM&R. 2019; 11(1):83-89
3. The mental health and wellbeing of the medical workforce – now and beyond Covid-19. British Medical Association. 
4. Colin PW et al. Intervention to Promote Physician Well-being, Job Satisfaction, and Professionalism. A Randomized Clinical Trial. JAMA Intern Med. 2014; 174(4):527-533.

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