2020 IPEP CONFERENCE
Welcome to IPEP Conference 2020! In these extraordinary times, we have organised the conference to be held online. The theme this year is: "Communication", which covers two very relevant topics - Telehealth and First Nations Health. There are two parts to this conference:
Part 1 - Recorded videos, podcasts, and transcripts of insightful interviews conducted with experts and professors working and researching in Telehealth and/or First Nations Health which are available to you from Monday 14 Sept to Thursday 8 Oct (AEST).
Part 2 - A live Zoom session on Thursday 8 Oct, 7:30-9:30pm (AEST) to delve deeper into case studies with some of these experts.
Please head over to this link to register - https://forms.gle/djdp5gUGjzDre6wv8
If you have any questions, please email us: firstname.lastname@example.org
A.PROFESSOR ANGUS TURNER
Angus Turner is the founding Director of Lions Outback Vision, based at the Lions Eye Institute (LEI) in Perth, Western Australia. He completed medical training at the University of Western Australia, before studying at Oxford University and completing a Masters of Evidence Based Medicine. He underwent Ophthalmology training in Melbourne. Lions Outback Vision provides eye health services throughout Western Australia to rural and remote areas and Indigenous communities in urban locations. He is an Associate Professor at UWA and an ophthalmology lecturer for the Rural Clinical School WA.
Indigenous Health: Interview with A/Professor Angus Turner [Video Transcript]
Presenter: A/Professor Angus Turner from University of Western Australia, Ophthalmology lecturer for the Rural Clinical School WA, Founding Director of Lions Outback Vision based at the Lions Eye Institute (LEI) in Perth, Western Australia
Hasnat: Hello everyone! In this interview, we are fortunate enough to have with us Associate Professor, Angus Turner. Dr. Angus Turner is a Western Australia Ophthalmologist, based at the Lions Eye Institute. He completed medical training at the University of Western Australia, before studying at Oxford University and completing a Masters of Evidence Based Medicine. Ophthalmology training was undertaken in Melbourne, followed by post-graduate training at University of Sydney in refractive surgical prac- uh, procedures. As the director of Outback Vision, Dr. Turner is actively involved in the delivery of specialist outreach services to remote and Indigenous communities. Dr. Turner is an associate professor at the University of Western Australia, where he is engaged in a number of research projects incl- umm, at the Lions Eye Institute, focusing on service delivery for remote and Indigenous people. Dr. Turner is also an ophthalmology teacher for the rural clinical school.
So again, welcome Dr. Turner. Today we’ll be aiming to explore more about your experience and work in telehealth and Indigenous health as part of IPEP’s 2020 conference. So, how are you?
A/Prof Angus: Oh, great! Well thank you so much for having me on this conference, which is the new paradigm for our sort of conferences. I’m grateful to be involved. Thank you.
Hasnat: That’s alright. Thank you for being here. Um, so right of the gate, just the first question we’ve got here is – how has telehealth changed the way you practice?
A/Prof Angus: Well, telehealth has had a renaissance this year. Or at least a discovery for mainstream practice. Um, it’s on the tips of everyone’s tongue when it comes to how to manage in a pandemic. But telehealth’s actually been the primary way I have been able to assess patients living remotely across Western Australia for the last seven years. Um, actually nine years ago, the government instituted a new telehealth initiative, which was related to Medicare and paid people for their work as a GP referrer, right through to the specialist to talk to people on video. And it really was quite unsuccessful if you look at the numbers. A lot of people have found too many barriers and haven’t really used it. Um, but for my area of practice, which is ophthalmology, we discovered a perfect partner to work with, which is the optometrist actually. And through developing connections with optometry, telehealth has become the main of how we do our remote work.
Hasnat: Hm, great! Well, that is good to hear. So in your field of practice, umm you did mention optometry, who you work with often. Are there specific other disciplines that you’re—do you feel sort of limited to being able to perform telehealth with?
A/Prof Angus: Well, some of the barriers to telehealth were to do with assessments of the eye and how people are going with their vision. And although general practitioners certainly do see a lot of patients requiring eye assessment, some of it’s quite difficult. I’m not sure in your medical school, if you’ve- or any of your schools at the moment, you’ve come across much eye healthcare? But traditionally, it’s squashed into one week throughout the course and one quick exam, and that’s really it! So even assessing the visual acuity, checking the pressure of the eye and certainly having a look at the back can be quite a challenge or a bit scary for some people to actually do properly. So if there is a regional town, there’s an actual optometry store, in that shop where you can get your glasses, there’s also a visual field machine for checking for glaucoma, there’s a camera that can take pictures for diabetes and the back of the eye photographs. And there’re also, often, machines that are now taking three-dimensional pictures of the back of the eye called OCT. And that’s really been the gamechanger as to why we work so much with optometry. Because a three-dimensional map of what’s happening at the back of the eye is pretty much what I would need to have anyway if I had that patient in my room with me. So armed with that information, I can actually talk to the patient and discuss some surgical options for them. And in essence, what that does is, when I turn up in a country town and I’m only there for a couple of days, I might as well do surgery and actually do the bits that I can help with, rather than spending days just talking and trying to work out what to do. That can all be pre-organised. Turn up to surgery, and then the optometrist can follow up later.
But your question was other areas of health. Well really, the general practitioners have been the main other group. We haven’t really tried with other disciplines.
Hasnat: Okay, that sounds great. Looks like you are getting to the main sort of key you need to get to the patients, um, through optometry and just telehealth in general so- Um, now a question here is for, I guess, um new practitioners or practices wanting to start on telehealth. So what’s- how do you begin consulting via telehealth?
A/Prof Angus: Well fortunately, the Australian government in 2011 said, just try anything, see how you go. So, in Australian’s way, that’s essentially meant that we can use Skype, um, or FaceTime and there had been concerns about, um, the security of some of the more social media type apps. But when it comes to making the project work and actually being pragmatic, it’s been a good move to enable all sorts of providers to do telehealth because if you put in too many barriers to the actual infrastructure it’s yet another reason why it would fail. And I have had a few classic examples where someone’s calling me from a remote town. I remember one in Kununurra, which is north Kimberley- east Kimberley, um, essentially the optometrist wasn’t familiar with video consultations and was wondering what to do. And the patient who was much older said, oh I do FaceTime everyday with my grandkids and pulled out his own phone. So you can actually simmer out the barriers that way and have a good video chat.
Hasnat: Oh great! Now you did mention a few platforms there. Through the years, have you found one being, I guess, better than others? And what platform do you find yourself mainly using?
A/Prof Angus: It’s really trying to make the providers feel comfortable and in the end, I must admit, most of us have gravitated back to Skype. So the Skype channel that we have means we can all have it on at the same time - in terms of my colleagues. And we can share on call. So fortunately, I’m not on call today. But my phone will ring anyway, and I can pick it up if I miss- if they’re already on another call, I can pick up the telehealth.
Hasnat: That’s good. And again, going back to someone wanting to start out in telehealth, um, obviously I guess aside from a webcam and audio equipment. Is there any other things that is needed to start integrating telehealth into the practice?
A/Prof Angus: I think the only other aspect is – how to schedule. So another, I guess, problem, and why not that many people do telehealth in the past, um, although it’s changing rapidly, has been to do with fitting in, getting everyone in the same room at the same time. And by that I mean, the patient and the referrer are sitting somewhere in the remote clinic and they need to talk to the specialist but if you’re not available and say I’ll wait an hour, you know, you’re putting everyone out. And you know that optometrists- I don’t know if you’ve ever got your glasses done, they tend to be exactly on time and they have an adequate amount of time for each patient, quite good customer service and specialists sometimes- you’ll wait an hour or two before you get seen. So we seem to work on a different rhythm. And with telehealth, I’ve been very conscious that other people are waiting, I need to sort that out, and I’ve just jumped onto those calls. That’s why we’ve set up an on call roster. Because for many years, I was the only one doing it. I was dropping things left, right and centre to make telehealth work. But we did do some research based- auditing of the difference it makes to be on call. And interestingly, the group that really benefited to the instant attention were Aboriginal people. So the reason for that- there was a tenfold increased uptake for Aboriginal people in the year that we introduced on call. And that’s because small communities- the optometrist might only be visiting for a day. And so they’re there for a day, and there’s no other opportunity to book another day. Whereas, your standard shopfront regional town, you can actually say to the patient, we’re going to book you in next week for telehealth. And they come at a set appointment time. So if you try and understand that it’s really that we have to be on call and responsive to improve our access in remote communities.
Hasnat: I see, that does lead into the next question as well. So with COVID19 and massive shifts in the way we live, how has the Indigenous population been affected in your experience?
A/Prof Angus: Well there was much concern as being a particularly vulnerable group of patients and people and communities that were closed off. So that’s actually made it quite difficult to provide adequate care. In particular, we have a circuit of monthly visits to many communities, um, to enable injections into the eye and that’s to treat something called diabetic maculopathy. And we’ve been kind of… in being able to access actual communities and very careful not to be the doctors who bring in a condition when we didn’t know, um, in terms of COVID19. So it has made it difficult. Optometry has been put into the, you know, nice but not necessary- non-essential category. And that’s meant that for six months, it’s been quite a delay in what we’d really thought of as preventative health. So we’ve had a lull, and I really trust that- fortunately, in Western Australia, we’re living in our little bubble. Um, so things are back to normal, essentially. But we’re very conscious that the rest of Australia and many places, and also, the future is not that certain.
Hasnat: What are some considerations for telehealth that are particularly important when working with the Indigenous populations?
A/Prof Angus: That’s a good question because I think- we’ve tried to see if there’s any particular barriers. Um, and I’d say they’re not obvious to me. In that, when we’ve discussed with patients, they’d actually quite enjoyed the telehealth. Um, patients turn up for surgery and make jokes about having seen you on TV or you’re a sort of TV doctor. And it’s actually been a- and almost better rapport. The good thing about the video chat is that even if it seems like a small interaction, the patient has some trust and understanding of where they’re going to and you can actually relieve some fears. For example, relating to needles or what’s going to my eyeball, are they going to take it out and then put it back in. And you can have little discussions where the patients’ fears can be allayed. So when you ask, you know, what are special things to do- I think the good way telehealth has worked in Australia is, this idea of the video has meant we’ve actually got someone facilitating next to them. So I have a very experienced optometrist in a clinic who knows all about the cultural safety and Aboriginal health. Um, you know, things to do and things not to do. And if we’re having a bit of trouble communicating on the telehealth, that optometrist is right at hand to make the interactions smooth.
Hasnat: Well! Um, another question that’s actually just popped up in that respect is, um, in the telehealth appointments that you have with these patients and the optometrist, is it always in a situation where the patient is with the optometrist? Are there cases where, for instance, if the patient can’t make it for whatever reason, do they sometimes video in from home with the optometrist in the same line? Is that a situation?
A/Prof Angus: Well funnily enough, that has actually happened. Another kind of innovation, if you like, or having to cope with the pandemic has meant that I’ve had a perfectly good referral with all the information I need and there’s no point that patient going to the optometrist to have their hand held for that interaction. So I’ve been able to call them at home. And again, the rules changed quickly and the government said you can actually just phone on a telephone. And this is actually something I’ve been advocating for anyway because for my patients who are vision impaired or even blind, you know, the most important thing is a clear telephone line. Um, some patients in the elderly demographic might not actually even have internet or a smartphone, so it’s actually easier to talk on their landline to communicate the essential health information. So, you know, from this respect there’s been a lot more, you know, do what works best for you as long as you keep a good medical record and you follow and abide by principles of good healthcare. I think it’s, um, reasonable to do that.
Hasnat: Oh great. Um, so are there any specific needs that have emerged more recently in your practice, or become more important for health practitioners to address now in this current year of, like, I guess covid.
A/Prof Angus: Specific areas, um, I think we’re all having to be more careful about spacing of patients. The idea of just herding everyone into a massive room and having long- likely to be acceptable. Um, there’s also the issues of, um, you know, PPE in the clinic and cleaning of all of our equipment. Because if you think about a lot of eye equipment, your face and you’re having a field test or you’re having a scan and everyone’s touching the same thing. Um, we’ve also got patients this close as we come on the slit lamp. So we’ve got some plastic barriers and that sort of thing. So yeah, there’s been changes to practice in general which are very carefully observed by our optometrists and ophthalmologists. And around the world, it’s interesting to know some of the first, in fact, the first story about the whistle-blower- a Chinese doctor who died was actually an ophthalmologist. Um, and conjunctivitis, although it’s rare, is a couple of percent of coronavirus cases actually exhibit conjunctivitis.
Hasnat: Alright, um, and- so looking ahead, I feel you might have already had some experience with this. So what are some important factors that should be addressed to prepare the Indigenous population for a reopening in the future. I guess this is a bit more applicable to over here in Melbourne. Um, but you might have already seen some things in regards to this aspect over in Western Australia as well.
A/Prof Angus: Yeah, I think um, the trick is going to be dealing with the backlog of preventative care. So for example, we know already that there are some barriers to accessing basic guidelines for screening. So all diabetic patients who are Aboriginal people, the guideline is to have an annual check if- just to check for, um, any diabetes in the eye and if there is retinopathy then the guidelines change to more frequent. So um, from that respect, the same principles that are worth considering anyway is to collaborate better. And I think working with our colleagues in optometry and ophthalmology, not duplicating some of the screening role, in particular for glaucoma, diabetes, macular degeneration… And the same goes for urban access for Aboriginal people. In engaging those two professions to work together in the Aboriginal clinics themselves is a great way to access patients and prevent these patients having to go to big hospitals which just puts people at more risk.
Hasnat: Hm yeah, that- that is very good points there. So um, finally last question here I’ve got, um, is- do you think there might be repercussions of one’s experience of COVID19 that could potentially lead to difficulties in the future? I mean, for one I can think of is maybe, patients might not be comfortable for a little while to actually coming in because they’re still concerned about, um, the spread of infection.
A/Prof Angus: Yeah, I think you’re probably right. But, um, it depends on the actual, you know, conditions and fear within that State. So, um, it didn’t take long for patients to really want to seek attention for their eyes again in Western Australia. We haven’t really noticed any change in the attendance rates. Um, in fact, our patients have been coming more than ever. So we’ve had quite a few operating lists cancelled in the first half of the year, and our subsequent operations have been incredibly well attended with extras turning up just in case. And so the last few trips to Derby, for example, which is just up the road from where I live here, the patients have to come a long way from Fitzroy Crossing, it’s in a quite remote area and sometimes very hard to get patients to come. Um but actually we’ve had 100% attendance just about most days. So what fears or barriers that we might imagine, I’m not sure that I’m seeing it on the ground. But I’m sure each population will have their own things to navigate there.
Hasnat: Yup, that’s great and it’s good to see that, um, a lot of the government and patients are getting onboard and feeling quite comfortable with a lot of the telehealth aspects in your field. Again, thanks for joining us for this interview here. Before we actually close off, do you have any, um, resources some students can have a look at or any organisations that specialise and work with Indigenous people and telehealth?
A/Prof Angus: Yeah, well there are a huge number of resources probably coming online for telehealth to be more general than what I’ve been talking about, which is really checking the eye. But if you happen to be interested in the eyes, I’d go to the website for Outback Vision, that’s outbackvision.com.au. And on the front page, um, bottom left, there’s a section on telehealth where people can book in their patients but there’s also information for patients and there’s a whole heap of research papers that we’ve done, videos for patients and practitioners to explain what’s going to happen. So there’s quite a few resources to play with there. And then in terms of Aboriginal health in general, I think each State has different things to think about really is um, the message. There’s not really a one size fits all approach to Indigenous health. Um and engaging with- and through your local community control clinic, which might be an Aboriginal medical service or a service locally is worth exploring what the resources are in your area. And engaging with the topic and getting involved because there’s so much to learn both ways. It’s a very rewarding area to practice in.
Hasnat: Great! Thanks so much, again. And again, thank you for joining us.
A/Prof Angus: Pleasure, thanks for having me, bye.