Volume 217 Issue 2

Many technical and regulatory hurdles have been overcome, but the field has a long way to go

Gabrielle O'Sullivan · Joshua G Philips · John EJ Rasko

mRNA vaccine development will continue to accelerate, and further improvements to the technology may mitigate some of the current limitations

Isabella Overmars · George Au‐Yeung · Terence M Nolan · Andrew C Steer

A 48-year-old female health care worker of European descent, who was otherwise well and on no regular medications, developed cough symptoms the day before testing positive for coronavirus disease 2019

Nicole Seebacher · Julie Kirkham · Saxon D Smith

A previously well 4-month-old boy was admitted to a tertiary Victorian paediatric hospital in February 2022 following a febrile convulsion

Andrea Zhu · Nikki Petrakis · Mohamed Gaber · Daniel Mason · Vanessa Clifford · Julian Kelly

Kindness can help to ground us as clinicians and reconnect with what makes us human

Anneliese Willems

Evidence-based respirator selection, fit testing, fit checking, and proper use are all vital for staff and patient safety

Micah DJ Peters

There is clearly an unmet need for timely, equitable access to cataract surgery in Australia

Alexander Foss

An Indigenous-led study aims to empower and support Aboriginal and Torres Strait Islander women to be smoke-free

Michelle Kennedy · Hayley Longbottom

Fit test results and performance evaluation by health care workers should be incorporated into respirator procurement decision making

Irene Ng · Benjamin Kave · Fiona Begg · Charles R Bodas · Reny Segal · Daryl Williams

Timely and equitable access to cataract surgery can prevent fall-related injuries and support healthy ageing

Lisa Keay · Kam Chun Ho · Kris Rogers · Peter McCluskey · Andrew JR White · Nigel Morlet · Jonathon Q Ng · Ecosse Lamoureux · Konrad Pesudovs · Fiona J Stapleton · Soufiane Boufous · Jessie Huang‐Lung · Anna Palagyi

The overall cancer detection rate increased and colonoscopy detection indicators were maintained during the 2020 lockdowns

Daniel Schneider · Michael Swan · Simon Hew

Using a multidisciplinary, pragmatic, patient-centred, non-judgemental approach may allow people who inject drugs to achieve improved outcomes for invasive infections and reduce their risk of subsequent admissions

Lucy O Attwood · Megan McKechnie · Olga Vujovic · Peter Higgs · Martyn Lloyd‐Jones · Joseph S Doyle · Andrew J Stewardson

To the Editor: We read with interest the article by Agarwal and colleagues1 outlining the recommendations from the Health Services Research Association of Australia and New Zealand for implementing patient‐reported outcome measures (PROMs) to guide clinical care. The article regrettably fails to acknowledge that most of the commonly used PROMs — largely developed without direct patient participation — may merely provide a patient‐rated version of a measure that nevertheless reflects the clinician’s or researcher’s, not the patient’s, perspective.2,3 Importantly, “patient‐reported” conveys only that the measurement instrument — usually a scale or questionnaire — is completed by the patient. The emphasis is placed on the source of the information (ie, the patient) rather than on its content. It does not automatically imply that the information thus obtained is necessarily of value or relevance to the patient. As an attempt to shed light on this issue, our group elaborated a classification system for PROMs according to the degree of patient involvement in their development:2 patient‐generated PROMs — a type of PROM developed entirely from the patient perspective, as at all stages of PROM development the researchers are themselves patients; patient‐centred PROMs — a kind of PROM that explicitly incorporates, to a greater or lesser extent, patient priorities, given that patients themselves codeveloped the PROM jointly with other stakeholders (eg, clinicians); patient‐valued PROMs — a variety of PROM developed without patient input but valued by most patients because it reflects, at least in part, their priorities; and patient‐irrelevant PROMs — a type of PROM developed entirely without patient participation, whose contents are evaluated as not relevant by patients themselves. Fortunately, the epistemic injustice of disregarding the patient’s perspective in PROMs development is being progressively abandoned, and there seems to be a growing consensus that patients should be significantly involved — through truly participatory methods — in developing any new PROM.2,4,5 Without genuinely incorporating the patient’s perspective in PROMs development, PROMs collection will not contribute to a true and meaningful involvement of patients in their health care.

Joan Trujols · Santiago Duran‐Sindreu · Maria J Portella

In reply

Anupriya Agarwal · Rachael L Morton

AN abiding childhood love for The Phantom took Queensland GP Dr Jillann Farmer to the top of world as Medical Director of the United Nations, but, she says, it is general practice that continues to “feed my soul”. Dr Farmer served with the UN from 2012 until mid-2020, responsible for not only the UN’s responses to Ebola virus disease, Zika virus disease and COVID-19 but also effectively serving as the Surgeon-General for 70 000 UN military peacekeepers around the world’s hottest of hotspots. Her medical career began as a bonded rural scholarship holder for Queensland Health. “I worked in a few jobs that they couldn’t fill with volunteers,” she said in an exclusive podcast. “While I didn’t particularly like that at the time, it was really good to do and a very important part of the overall formation of my character – as in, the kind of doctor I became.” But it was the concept of the UN that prompted a 180-degree shift in her career as a GP. “I used to read Phantom comics,” she said. “Diana, the Phantom’s wife, works as a nurse at the UN. The Phantom would drop her off at the curb on First Avenue near 42nd Street [near the UN headquarters in New York]. They would even have little pictures of the Secretariat. “So that was part of it. But I also remember a book I had as a child, that had a story about UN Day at school and all the different costumes and food. I guess I’d always had a fascination with other cultures and other countries.” How she became Medical Director of the UN is a tale of fate and coincidence in itself. “I did an executive development course very generously sponsored by Queensland Health, and one of the modules was about power,” said Dr Farmer. “I realised that I had quite a lot of girly baggage about power. And I realised that I would need to process that and come to terms with it if I was going to be able to progress in my career, because I discovered that I was very reluctant to exercise power. “Then one day somehow something blipped onto my screen: a Harvard University executive development course called ‘Women and Power’. I thought this looks like it’s been made for me. “So, I used some of my professional development leave and took myself off to Harvard and did this course. While I was there, I met a woman who was working at the UN, and I was actually a little underwhelmed by her. “And I now know that she was actually working in a very junior role, but I remember sitting there thinking ‘you actually don’t seem that crash hot’. Maybe I could successfully compete for a job at the UN. “Then on the way home on the plane, when they were giving out the magazines, someone handed me a copy of The Economist, and I discovered that was where the UN advertised their jobs. I went home, I took out a subscription to The Economist. The third edition that got delivered to my letterbox had the advertisement for the Medical Director job, and I thought, why not? “I applied. I just wrote an application. People say to me all the time, how did you get that job? And the answer is, I applied. You don’t get it if you don’t ask.” Two interviews later, Dr Farmer was offered the job. “It was so funny, because my husband, bless his little cotton socks, when I put the application in he was like, ‘yes, dear, yes, you’re right’. I got an interview and he was like, ‘oh, that’s interesting’. And then I got a second interview, and he was starting to get nervous. “Then the offer came, and he was very supportive and said, ‘it’s the UN, you can’t say no’.” Her 7.5 years as Medical Director were never dull. One of the most challenging moments came in 2017 when Syrian residents were bombarded with chemical weapons by their own government. “The reality that most people are unaware of is that the majority of UN personnel in any location are locally recruited people,” said Dr Farmer. “The international staff like me, in the actual field are the minority. So when you’re considering something like Syria, even if we got all the international staff out, there were still many thousands of locally recruited staff, and that introduced some interesting complexities to it all. “I had to learn really fast about chemical weapons, about a chemical weapons chain of care, about the appropriate use of injectable antidote kits, about shelter-in-place, about hoods, about rescue chains – which working as an Australian GP had really not prepared me for. “But one of the things that I learned relatively early in my career is to just ask for help. And if the person you ask, doesn’t know how to help you, they will often know who will. “And luckily, the Office for the Prevention of Chemical Warfare was, at that time, a specialised agency, not quite part of the UN, but definitely affiliated with us. So I had access to some really good advisors.” Surrounding herself with people who know more than her has been a key part of her career, says Dr Farmer. “Absolutely critical, and one of the places where I see leaders fail is when they can’t surrender the desire to be visibly the cleverest person in the room. It’s really unfortunate because you do so much better when you surround yourself with people who know more about their stuff than you do.” Dr Farmer’s last 6 months with the UN coincided with the start, and in New York, the peak of mortality caused by the COVID-19 pandemic. “It was terrifying,” she said. “The city had an incredibly robust public health response, which was overwhelmed very fast. The city also had a commissioner who was appointed directly for liaison with the UN and she and I worked closely together. “There’s a concept in diplomacy called the host country and the host city. And as a host city, New York had particular responsibilities towards the diplomatic community. As the medical director of the UN, I had the ability to help them discharge those responsibilities, and to navigate some of the diplomatic complexities. “The UN is a big advocate for health equity, and none of us wanted to set up a system where the diplomats and UN staff would have preferential access to testing or treatment. “So, we were in there with the rest of New York, unsure if we would get access to a ventilator if we needed it, and for quite some time, we were even unable to access testing. We were diagnosing people based on clinical symptoms alone. “It was very scary because the paramedics were turning up and triaging on site and basically black-tagging people in their homes, and then just leaving to go to the next person who might be salvageable.” Dr Farmer was on the last flight out of New York before Australia closed its borders to international travel. For the last 3.5 months of her tenure she worked remotely from her home in Brisbane, working through the night to be in sync with the rest of her staff. “I was relieved when it finally was over, even though I was very sad,” she said. “And I felt terrible. I really did have terrible survivor guilt for a while – that I was out and all of my friends were there and at risk. It was very, very hard to leave.” She returned to take a post with Queensland Health as the head of Clinical Excellence Queensland, but left in June 2021, to return to general practice. “I came back to general practice to feed my soul,” Dr Farmer said. “For a while [before returning to general practice] I felt really disconnected. I was starting to think that I would have to relinquish my registration if I didn’t return to clinical work for a while. “When I was working at the UN, every day, my medical expertise was part of the job. But when I came to Queensland Health, the job that I was in was never actually designed as a clinical job. There were always other medical people around who had more expertise. I didn’t really feel like I was making great use of my medical brain. “I’ve stepped in and out of clinical work several times throughout my career. And each time I leave, I miss it. “Each time I return, I have these moments where I stop and think ‘this is amazing’. People walk in, and I’m a complete stranger, and they just trust by virtue of the fact that I’m the doctor. “The profession still carries on with all of its challenges. There’s just that amazing trust that people let you into their life and share their stuff with you. And I’m always blown away by that.” Has working with the UN and other agencies made her a better doctor? “One of the bits of feedback that I get from my patients, and obviously, it’s not necessarily a statistically valid sample, but it’s different to what I used to get – they tell me that I really listened to them,” she said. “That’s a skill that I probably acquired and really refined and had to rely on in the UN because I was travelling in uncharted territory, knowing nothing. “That art of setting aside your preconceptions, and really listening to what the person is saying, I think has made me a better clinician.” Dr Farmer said she many concerns about general practice in its current form. “Financial sustainability remains a big issue,” she said. “The pay gap between general practice specialists and other specialists is just indefensible, when one considers the complexity and pace of general practice work. “The biggest concern I have is the split between federal and state funding of the health mechanisms, and the space that allows for finger pointing and blame, with GPs trying to bridge the gap. “State governments have been advocating for revisions to the health funding model. There’s a lot of work to be done, to try and unify that, to find a way that disincentivises the states from transferring unpaid work into general practice, because that does happen,” she said. “The disrespect for general practice is pretty aggravating. There’s been that progressive erosion of a sense that GPs are a valuable part of the health care team. “But every now and then on, I’m delightfully surprised. I got a beautiful phone call from a surgical registrar in the Northern Territory a couple of weeks ago, who was transferring a patient back to my care in Queensland, and she bothered to pick the phone up and have a real conversation with me. It was wonderful, but that shouldn’t be remarkable. “General practice remains very dependent on international medical graduates. Without them, our system would completely buckle. “But I’m not sure that we yet treat them as valued members of the profession. Our Australian society continues to hold some very racist stereotypes about our international colleagues. And that’s something I struggle with when my patients are just overtly racist about colleagues. I really struggle with that. “I know that I’ve been incredibly privileged. “I returned to general practice and within days, my books were full – not because I’m the ‘bestest’, shiniest GP around, but because I happen to be a white Australian-trained female doctor. That gives me a certain image with patients that may well not be backed up if you were to examine standards of clinical practice.” That privilege was the topic of Dr Farmer’s address to the Rural Doctors’ Association of Queensland conference a couple of weekends ago. She urged doctors to positively use the privilege they acquired the day they graduated with a medical degree. “You can’t change your past, you cannot change the colour of your skin, so you don’t have to feel bad about coming from a background of privilege,” Dr Farmer said, as reported by AusDoc. “You have to apply it selectively, but it is important that those of us who have privilege, who hold that superpower in our hands, that we speak up, that we advocate for people. “Your privilege can be used to help, or it can be used to harm. "When patients are stereotyping our colleagues because of their race, when they refuse to see somebody because of their race, that’s another opportunity for us to exercise privilege. “But … it has to be done from a place of respect and understanding of where that person is coming from.” This article was first published by InSight+. Read the original here.

Cate Swannell

Med J Aust 2022; 217 (2 Suppl).