 Good evening everybody and welcome to this webinar which is with the MHPN and the General Practice Mental Health Standards Collaboration and tonight we're looking at tips and strategies to enhance communication between medical and mental health professionals. Currently we have over 600 people logged in and we have 2,500 registrations for this so it's clearly a topic that people are really interested in. We'd like to acknowledge the traditional custodians of the land across Australia upon which our webinar presenters and participants are located. We pay respects to the elders past, present and future, for the memories, the traditions, the cultures and the hopes of Indigenous Australia. My name's Mary Emma Layas. I'm a doctor based in Far North Queensland where it's been raining heavily all day. We have panel members from Melbourne and South Australia as well who I'll introduce shortly and participants from all over the country. I've facilitated a number of MHPN webinars before and my background is in general practice and psychotherapy but now I'm working as a psychiatry registrar. So I've had, I worked at a headspace, two different headspaces for a long time and the topic of collaboration is really important to me personally as well. The general practice mental health standards collaboration have commissioned the MHPN to plan, produce and deliver this webinar which is focusing on communication between medical and mental health professionals. To learn more about this topic you're encouraged to read the GPMHSC practice guide which is about communication between medical and mental health professionals. It's available in the bottom right hand corner of your screen. There's a little folder icon. That's the resources tab. It's also available on the GPMHSC website and in a moment I might ask Morton to just tell us a tiny bit more about the GPMHSC because I've just realised many of the Allied Health participants probably won't know much about that. Now you've been introduced to the panellists before tonight through the webinar invitation but I'd like to introduce each person individually tonight. So I think first of all I might start with Samantha. Now Samantha you're in Victoria and I noticed on your bio that you have established a practice called SAM and I wondered if you could tell us a little bit about that and what SAM stands for? Yeah, about the first person that's actually asked that. I assume it stands for something. Yeah, I like that. Obviously it's an acronym for my name but my business sort of covers a wide area from general mental health to sort of performance psychology because I trained in both. So the acronym stands for F is for Seek and then A is for Arrive and M is for Maximise. So it can indicate seeking treatment, arriving, actually getting there and achieving what you want or really flying to the next level. Thanks for asking. It's great to have you on the panel and from your background we can see that you've had a lot of experience with interdisciplinary collaboration in mental health so it's going to be great. Now Heather I'd like to invite you, I'd just like to introduce you. So you are not only a peer worker but you also teach peer workers and it sounds like you've been involved with that area of mental health support for a really long time. Could you just tell us a little bit about that? Yeah, so obviously I've got to live this through myself and I was bit inspired by Sherry Mead who's a great peer worker and eventually I was the first peer worker in the South East of South Australia and then moved to Adelaide and now I'm actually lecturing in the certificate for mental health peer work and mentoring some peer workers in Cisabot. Welcome and it's probably one of the newer sort of professions that we need to learn more about how to collaborate with his mental health peer workers because not every organisation is employing peer workers yet but it does seem to be the direction that things are going and in my experience it's really, really helpful. So it's great to have you on the panel. Thank you. And Morton, so Morton you're a GP in Melbourne and you have a lot of other experiences well on the bio. You're also very involved in interdisciplinary collaboration. I just wondered if you could just tell the audience a little tiny bit about the GPMHSC of which you are the chair, I understand. Because I don't know that our allied health professionals will know what the GPMHSC is. Sure. Thanks Marion. Thanks to everybody for joining this webinar tonight. Yes, I'm the chair of the GPMHSC. The GPMHSC has been around for about 14, 15 years now. But it's in the last 10 years has been charged by the federal government with developing the standards for the general practitioners in order to undertake training for the use of the better access in mental health item numbers through Medicare. And we also provide the training standards for those GPs who are doing focus psychological support item numbers through Medicare. So we're all about education and training and the standards required for GPs to meet in order to access Medicare in this vital area. Great and I guess that historically the mental health professionals network and the GPMHSC came about roughly the same time in relation to the better access item numbers in Medicare. MHPN was maybe a little bit later. The GPMHSC has been around a bit longer and some of the people on the GPMHSC had the ideas around the MHPN to try and facilitate interdisciplinary communication, harmony and working better for our patients. Great. Well, I think the numbers for this webinar indicate how important this topic is and I guess that's why both these organisations exist really. So I just want to bring this back to just a few ground rules. So to make sure that everyone has the opportunity to gain the most from the live webinar, we ask that everybody remembers the following ground rules. Please be respectful of other participants and panellists and just behave as though you would in a face-to-face activity. There are going to be many people who watch the webinar retrospectively in the MHPN webinar library. For those who are live, the chat box is just as though you were sitting in a room with other people. Now, you may also interact with each other by using the participant chat box. Please note that if you post your technical issues in the participant chat box, you might not be responded to. So if you have any technical issues, you need to put them in the technical help box, which is just there. So there's a phone number that you can ring. There's also technical support frequently asked questions there. Now, just to bring us back now to the vignette. Just to notice that the vignette refers to psychologists and GP, but there's not vignettes that actually include specific mention of professions like social work and occupational therapy. It's not a deliberate oversight, mental health nursing as well. It's just the way that the cases were written. So we could substitute other disciplines for those, but we're both recognising that under better access, lots of disciplines provide focus psychological strategies and the mental health nurses are under the mental health nurse incentive program. So through a facilitated panel discussion about these cases, we're going to describe key principles for effective communication between medical and mental health professionals, identify challenges and obstacles to communication, improve patient outcomes by implementing tips and strategies to enhance communication and reduce challenges. So really, this is about communicating better so that we can help our patients get better outcomes. Now, just to let you know, there's a couple of changes. If any of you have been on MHPN webinars before, this is a slightly new upgraded platform. So because this series has become so popular, we've made improvements to the platform. So it has a slightly different look. So just a guide for the audience. To access the chat box, there's a spot down the bottom where you can click open chat and the chat box will open in a separate tab. The resources are down in the little folder icon in the bottom corner and you know about the technical support issue. At the end, we would like you to participate in our exit survey, which does inform MHPN's future webinar plans. So please participate in that. The feedback is taken really seriously. Now, the other thing is that tonight's format is going to be a bit different because we have a series of vignettes rather than one case study. So it will be a little different to what you're used to. So you've all read the vignettes where you've been distributed prior and they're also down in the resources tab if you need a refresher. So we're going to spend most of the time with the panel unpacking the hypothetical scenarios, having a bit of fun with them, hopefully. And the aim of this is to generate tips and suggestions and ideas and strategy. So it will perhaps be a little bit more informal, but we're really confident that you're going to get lots of useful things out of the conversation. We will have an audience poll which will help us guide the conversation and then each of the presenters has made an individual presentation which is available to you in the slides, in the resources box. We may or may not formally go through those depending on how the discussion goes. So the expert contribution of each of the panellists is available in this slide, but we may not necessarily formally cover that. Now just before we go on to our first vignette, I'm going to take, coming back to that in a second, I'm just going to take an executive decision because I am the one in the facilitator's care. I wanted this slide to be in here because I think some professions are very comfortable with shared decision making and others if not necessarily traditionally how they've operated. So I just wanted to articulate that this is really a foundation of good practice in mental health and there's lots of research to show that shared decision making contributes to better outcomes. So at a minimum, both the clinician and the patient are involved in the treatment decision making process and actually often there may be other people like family and carers or more than one clinician. The clinician and the patient share information with each other so it's a two-way street. Both the clinician and the patient take steps to participate in the decision making by expressing their treatment preferences and then a decision is made together to agree on the treatment plan that's going to be implemented. So it's a decision that everybody can live with rather than one person dictating what will happen. So just to keep that in mind that that's probably what we're aiming for. Now I'm going to bring us back to the panel and we're going to start with talking about Karen. So I might just read a couple of little bits about this because what I liked about all of the vignettes that they were really quite real. So let's say you're the allied health clinician and you've got a busy clinic and you've got a better access referral for a young first-time mother Karen and she is keen to come but she's got a young baby and it's quite hard for her to come. She's frequently changed the appointment but at the same time she's saying it's really urgent and as the allied health clinician you've been winning the GP and trying to find out a little bit more and you're worried about perhaps this is urgent or it has an element of risk and you're frustrated because you can't get through to the DT. So I think I might start first of all by asking you Samantha as the psychologist whether this kind of scenario is familiar to you or other allied health clinicians that you know. Absolutely. This one actually scared me to go off first because I was thinking there's so many different ways I could look at this one and I'm not exactly sure which one would be the best way but it would be very common and likewise I'd say even at my practice my practice manager probably does the same thing at my end to protect me and I think that's... Have you found anything that works to try and get through to the DT? We're going to ask the DT in a minute but what's worked for Lauren? Well the two things I think what I try and do first is I try to butter up the practice manager first so I will make it very clear that I'm not trying to interrupt their session with a patient and that I wouldn't appreciate the same but that it's pretty urgent for me to get hold of this person because I'm trying to take this referral and I really do try and get them to give me an indication that GP's available so even if it's a lunch hour sometimes if they keep blocking it I have actually offered my mobile after hours so that I can get that GP to at least give me something so I can get back to the client I've also sent letters that at least say I've got the referral the referral's sitting here but I can't take it because I need a bit more history and I need to talk to you first not screened as much as an email or something else maybe so I've tried that if that all of that doesn't work I get my top dog practice manager who butters up people really nicely to speak to the other practice manager and what she will normally do is try and arrange between our diaries a 5-10 minute phone consult but in our diaries that we both know we're available for and the final option I go to is probably I ask my client when are you seeing the GP next if they're going to review with them soon or vice versa I might be reading with the consent of the client if I took that client into the first session and try and get the GP because normally the practice manager would be okay with that situation so it was sort of a scenario I really don't know whether I've hit the right spot okay thank you actually Heather I'm going to just bring you in so just thinking about it for a person in Karen's position some of the questions that came in from the registrants for the webinar there is some questions about sometimes that patient confidentiality can be a perceived barrier so I wonder whether as the client how you feel about the psychologist or the social worker allied health clinician contacting the GP to get a bit more information is that something that you feel clients would be comfortable with this really resonated with me because I was actually in this situation of being a young mum and knowing that I needed to go and get help and having been referred to help but not being able to get there were all sorts of reasons for the new bus I'm just wondering is there anything that would stop the psychologist actually contacting the person so the psychologist is actually contacting the client is there anything Karen do just to see whether or not there's some sort of obstacles that are preventing her from actually coming and making her feel welcome to bring the baby or bring a support person to look after the baby or wash the charts sure I guess well I might just ask Sam and then we'll go to Morton as the GP but Sam is there I guess different professions and different clinicians may have different views about it but what would be the kinds of reasons that might make you reluctant to contact the client directly till you've got more information I guess as we were going off this scenario the psychologist seems a little concerned about taking the referral before they're speaking to the GP so I guess if you engage with the client before that and the person's fairly urgent you might be inclined to see that client or almost start some of the assessment over the phone and then that makes it a lot harder to sort of put them off so in that case that would be hard but I certainly have I have in cases where it's been hard to do that I've at least tried to sort out whether it's a child minding situation and encouraged them to bring the baby because I work with children and adolescents so that's okay for my practice and my staff are okay with that so I would certainly try and do that if there wasn't the concern if it hadn't been written yet I really wanted to speak to the GP and the referral yeah I guess sometimes something might turn out to be much more complicated than is appropriate for better access or might be needing actually a tertiary referral service or something and I guess some practitioners would be a bit cautious about establishing a therapeutic alliance for someone that maybe they then couldn't continue okay Morton, I'd like to invite you in so let's imagine that you are the GP is your practice manager keeping people away who need to talk to you and how do you cope with that or how do you it's a good question and look most receptionists tend to be fairly protective of their clinicians whether that be psychologists GP anybody who has a front desk has a degree of defence I guess one of the issues is that it's about having that conversation with the front staff as to when it is appropriate to interrupt and also when is it appropriate to organise appearance or discussion time with other practitioners because of course GP's are going to be being contacted by the local cardiologist or the local police or we get calls from all sorts of people every day as well as our patients inquiring about urgent test results or things that they're particularly worried about and we all do have systems in our practices to deal with that they can often be improved but it is about having a process around that and certainly for me personally in my practice my reception staff know that if somebody says it is urgent about a particular patient they will ask the person who's ringing them do you really need to speak to Dr Rowland right now or can he ring you back and he's got time at X and that's usually during my lunch break or when I'm driving between meetings or something like that or after hours and unfortunately many GP's do work long hours and many do work shifts as many allied health professionals do too so sometimes I won't be getting back to people until 6.30 7.30 at night sometimes in that case it would be quite helpful to have the allied health clinicians mobile number and to know whether you could call back after hours and look I also say if this needs to be you can send me an email inside that good old fashioned fax machine still exist in general practice very much and we can certainly accept a fax and generally we get that waved under our nose very quickly if it's got urgent written on it so I mean there are lots of different ways of doing it and certainly my practice if somebody says it's urgent and I must talk to him straight away because a patient is in difficulty my girls interrupt me so yeah I leave it to people to work with my reception staff and they know that yeah and I guess on the note of the one page fax I've actually found a hand written fax often stand out because there's lots and lots of types things come through but if you get like three sentences on a hand written fax it captures your attention yeah exactly and sometimes the cursory referral may be because there's stuff that you actually don't want to see in terms of if you've actually given them the referral as well and if that's the case generally I would ring the practitioner that I'm referring them to but not all my colleagues probably do that it's an interesting point that Heather as the consumer what's your sort of feeling about the clinicians maybe communicating information or opinions that you don't get to see do you think that's sometimes necessary or appropriate or are there any kind of guidelines around that in all honesty I would prefer that something was discussed with me or with me present I guess if it was information concerning the safety of the baby or something like that I guess that's a different matter and certainly as a peer worker I would have conversations around both types of issues well but I would say most of the time it would be nice to know what the concerns were I can certainly kind of address them if you don't know what they are I also think it's really important that Karen some sort of communications maybe with the GP because the chances are that Karen may go back with the baby young bubs seem to get sick and need vaccinations so she's probably more likely to turn up there it's probably worth just adding to that by saying that the information that I would put through to the practitioner rather than putting it all on paper Heather I certainly would discuss with the patient it's usually things like very long stories because many GPs know their patients over many many years and know their family histories and their mothers illnesses and the factors their social circumstances and all of those sort of things and to actually sit down and write all of that out can take an hour and you don't necessarily have that time as a GP whereas a five minute conversation with the other practitioner often sorts that out now I certainly tell my patients that that's what I'm going to do rather than keep it from the patient I don't believe in not sharing that information but I let them know what I can actually tell them rather than have it unseared on the referral Excellent thank you very much all for that one so I think what I would like to do because to be honest we could talk for an hour and a half about Karen or any of the scenarios but we're going to just try and cover them more of them so that we get the opportunity to look at a number of different issues but before we do I'd like to go to the poll so you've got to pop up on your screen and you can vote what you would like us to talk about so you've got about 30 seconds have a look at those topics there and then choose your favourite I think it's the case of vote for your favourite rather than vote early and often you've got a few seconds there so I think the poll's open and we should start to see some results coming in yeah that's really good much more responsive than waiting for election results but we don't Anthony Green we don't have him commentating he's stuck with me but it's not nearly as complicated so I think that's pretty much adding up to everybody so we might close the poll thank you for that so what people are really interested in in particular is working with different opinions approaches and professional hierarchy so everyone's picked the trickiest one and then to do with risk is also something that's a high on people's priority and then confidentiality and then the amount to share and then the roles and responsibilities so I think if our panels don't mind keeping that in mind that they were the issue in the order there so look at hierarchies and risk and then I'm going to go back to the slide before with everybody's pictures there we go now just so that people know Heather's camera internet is playing up a bit so we're going to have a fixed picture of Heather but she's still on audio so she's very much there and she's not going to look quite so alive on the picture so I think we might go to a different kind of patient we'll pop over and see Bill so Bill has depression and there's a lot going on so his wife has her own health issues that's Angela but she's just suddenly had to go into state to look after grandchildren after their daughter was involved in a serious car accident now you're not quite sure when Angela is coming back it's not quite clear whether she's going to continue to be able to support Bill looking after his many health issues and you would like to have a consultation with all of the health providers so in this case he has a psychologist rehabilitation counsellor a dietician and a physician now the rehabilitation counsellor isn't going to come unless Bill comes as well because that's a particular principle of theirs but you're not quite sure if he's resilient enough to actually talk about your concerns or to hear your concerns so I think I might actually first ask Heather to respond to that one thinking about being in Bill's position and the GP seems to have a genuine concern for Bill's welfare and wants to hold this meeting to care for him but Heather what do you think about that one I think Bill's probably I think he probably has an idea that his wife Angela might be in a position that she's struggling to care for him I don't think he's lying to that so I think actually including Bill in the discussion and the concerns is really important plus the fact that Angela's not coming back or we don't know when Angela's coming back he probably needs his support anyway so personally I would involve Bill and Angela in the discussion with the other self-professionals and I wonder if he'd be a little bit relieved that other people had been able to imagine the things that he may himself be worried about I think so too he's probably been seeing it for a while and he'll probably feel quite a bit of guilt around the fact that she's not managing as well and the fact that she has to look after his wife I think would be really a relief for them to sit down and have a discussion about what kind of helps out there and coming back to you Morton so how do we get all these people in the room and everybody's got kind of different professional philosophies and theoretical backgrounds let align the funding model that makes it really hard to have case consultations what are we going to do? Yeah it's a difficult one look the first thing that I would I agree with Heather in that it would be best with Bill in the room and I'd be certainly trying to work with his other councillors outside of this meeting to make sure that he actually was resilient enough to be part of this I would certainly have had a prior discussion with him as to whether he would like to be involved in that and I would be upfront with him and saying it's going to be a hard conversation and I'm just concerned that he might find it very difficult and give him that option to go to the nuts and bolts though of setting it up often I would start with one or two key supports for him and find out whether they were happy to be involved in that and then try and broaden it from there it is really really difficult to coordinate everybody together and for that number of people you're really going to end up I suspect eating into somebody's lunchtime or afternoon tea or something like that to get it all together but if we are all in agreement that it is really important for this to occur for the patient's well-being most people will give it a go and accept that it's worth doing certainly from a GP's perspective particularly if it was on telehealth but face to face there are some item numbers that could be found but it is about fitting it in with all your time and how it would function I'm going to name the elephant in the room the position would get paid for the telehealth consultation the GP doesn't get paid for the telehealth but they would get paid for the face to face consultation but Samantha as the allied health clinician has no item number to claim for case consultations case consultations Samantha do you want to comment on that and whether that's a barrier for allied health to participate I definitely think so I think what for myself as a psychologist how busy I am in the practice I really have to take at that after hours sometimes even Saturday morning or weekends it would be hard to have a case discussion like that with that many people that would do it justice over my kind of lunch hour which could go across a couple of hours in and out, in and out but I have had this situation if this was under better access or things like that then yes it wouldn't be funded yet but it's not just parties schemes that do fund for that case consultation so there is definitely opportunity for psychology to be involved in those and I can think of a couple of examples where I have tried to get everyone in the room and some people have wanted the client some people have not wanted the patient so I would agree I actually agree with everyone the resilience I wasn't sure whether that was a physical resilience so I would probably be talking to the GP and making sure that nothing was going to happen if he got stressed considering the illnesses that he has and how complex it is if I was the psychologist I would be actually preparing for that session and looking at all of these that he might be worried about or might be stressing out and I have actually had support people so I agree with Morton and asked them to bring somebody so that they don't feel like they are sort of all these professionals talking about them and no one to speak for them if they also needed that we are fighting lots of third party funders to try and get these case conferences paid for for everyone who is involved and I must say even for general practice there is payment or item numbers available so it is still much more financially viable just to see four standard consultations in that hour just your standard general practice than to spend an hour in a complicated sort of case consultation so even though there is some recompense it is still not really encouraging or promoting this kind of practice one thing I was thinking to myself when Morton said it would be attractive for all of us to get in the room with a patient but also I always say to people as private practitioners there is lots of other reasons that are good reasons to do multidisciplinary communication and it is not always about being paid that imagine getting in a room with someone with one patient and talking to all of those people and the networks that you are forming and the things that you end up discussing about some other people that you may need to refer between or actually get this shared care happening so I think there is a lot of benefits that are not just financial that we need to consider Yeah I was thinking about that but I was actually thinking from the point of view of the consumer so I would like to just bring Heather back in I mean to me I think there may be so much kind of gold in that meeting with everybody there that it is worth lots of individual appointments has that been your experience or other consumers Heather I think there is a lot to be going by having different people looking at different perspectives and things too I mean as a consumer goes to each person they are just seeing one person's view rather than a holistic view of themselves and I think it would really help feel just to be able to look at his whole life and a holistic view of what other people think and how things are going Yeah I've certainly as a practitioner I really value the different perspectives that different people with different kinds of training bring because they often think of things in a way that I just have not been trained to think so it is really important I think we've well actually I'll ask the panel is there anything that any of you also wanted to say about Bill before we move on to another one anything that you've been thinking about while the others have been talking more than anything from you I think the other thing to say is that you can do this in small groups you don't have to have absolutely everybody there all at once and you may actually do it a little bit by self you have a conversation with the psychologist and you start the process of building Bill up it's about coordination and making sure that the right jigsaw puzzles are being put together for the patient and that's never easy and then at the end to have everybody in the room is really helpful but in our private it's actually really really hard to achieve the times where I've seen it work well has been in the community health sector where that's a lot more easy to organize but in if you've got everybody working in private practice it's actually really really difficult to get everybody in one place at one time it does happen that here in rural settings it's certainly in my rural practice many years ago it was much easier to do those sort of things because people were around and you would just get everybody together at lunchtime at the hospital board room or something like that and bring the patient in and have that sort of conversation it's much more difficult if people are one side of the city or on the other side so we do need to be aware of logistics and sometimes just being on the phone may not be as good but can be helpful as well in that sort of meeting so a teleconference thank you I really appreciate it when people point out the benefits of rural practice I think it's absolutely true and I've seen amazing multi-disciplinary practices where the practice has been set up so that allied health can come in and they don't have visiting specialists and there's meeting rooms so they can conduct groups and it can be excellent and I think for recovery as well for consumers small communities are often rich places so it's really great to point out the benefits of rural and regional settings Heather was there anything else you wanted to say about Bill's situation before we move on I was only just a little bit concerned about leaving Angela out of the picture as well because if you're making decisions about her ability to care for Bill I kind of think she should be involved in the conversation as well yep good point so we might have to dial her in on a teleconference or at least talk to her in advance and see what she'd like to contribute yep and while you're talking about richness of rural communities can I just add that that was my experience and I think that's why I've actually gained so much is having a multi-disciplinary team of people and having those cross conversations that actually helped me that's really great to hear and Sam anything else you wanted to add regarding Bill I guess the two things I was thinking about like the people looking at the different approaches and the hierarchies and I sort of looked at it from the consumer might think it's a good idea because you get lots of heads together about the one person and there's lots of good reasons why all the professionals should do it but if we look at that first slide that shared decision-making that you were talking about we're really trying to get the client to feel empowered with all of the professionals so really it's probably the dynamic of a patient sitting there and listening to all of the practitioners their different approaches which one they align with best which way do they want to go you know do they think they should look at weight loss first once they've heard the dietitian talk or do they think actually they need to work on the psychology stuff before they go in for surgery I think it gives them a much fuller picture of which feels right to me now I've heard all of you talk and I can see that you've got different approaches and you all want me to do your approach but which one would suit me at that particular time I don't think I've thought about that in that way until we've looked at that case look there's particular models that actually focus on the value of the client being able to hear the discussions between the different disciplines there's this one called open dialogue which has some a good evidence in the early psychosis field and the interprofessional conversations which are actually witnessed and heard by the patient and their family are seen of that listening in all directions is seen of particular value that's a really good point that you made and Sam I'm going to drop you in a little bit because you're still on here so we're going to go to another one I'll let you collect yourself so we're going to just talk about we're going to talk about Tina so you mentioned that you see adolescence in your practice so Tina is a gymnast and she's taken a gap year out of uni to train as a competitive gymnast in the state championships and the GP's referred her about her anxiety and in the course of her talking to you she's disclosed that she's actually abusing laxatives neither the GP or her mum know about this but she says it's the only way she can keep her mum off her back and her mum's a trainer so I'm wondering about the communication here so well this is actually like some of my clients because I actually worked with gymnast for many many years and I do this kind of work in for psychology so it was a great case I'm not sure I can answer it it's a simple answer you don't have to do it on your own remember where we're all here I think this is hard because there's quite a bit of work you probably need to do with with Tina to get her to the point to understand you know your role and duty of care and what you might consider harmful and what sort of agreement are we going to come to because I will at some stage definitely need to liaise with people in this case and definitely when it's got to do with abusing medication or pills so I think there'll be lots of conversation about that and make it very clear to her if I think there's harm that I may need to make those calls and see how she feels about that so that would be the first thing I think it's very common for the young people to say that and I've had it not just with laxatives but all sorts of medications that they're on even if it was contraception it could be anything but this case the use could actually cause harm and it would alarm me what else is going on so just to check I know many counselling professions have a sort of policy of discussing confidentiality up front particularly with young people so you talk about what's private and what are the limits of that is that your practice and do you find that that means that then when these tricky things come up you've kind of got a framework already in place I mean at the start and particularly not exactly how old she is because she's a young adult I know she's not a child so she can give consent and so I don't have to talk to any of these people about this but there will be a point that if she continues to do it that I think it's important GP's aware of that and that we have that shared care so you would talk about it up front when they're at the stage of the service agreement and I definitely would do it throughout the session I'm often talking about a lot in this situation I give some examples of the sorts of things I might feel that I might need to override that if it gets harmful so I think I'd probably work with Tina to say well do you think it's an issue and if you can show me that we can work on this and that you're not going to continue to overuse then there'll be an agreement that we'll review we're reviewing maybe two sessions how it's going but at that point we have another discussion about whether I should involve someone else at that point because it would be very damaging to break that confidentiality and you may lose that person that then could be in strife so it's a bit of negotiation I think and I might just ask Morton to come in here from the GP perspective I think sometimes when you make a referral to Allied Health I know I don't always remember to ask the client what are you happy for us to talk about as healthcare professionals involved in your care but is there some way in which the referral letter implies that some communication can occur? Look I always say when I refer anybody to another practitioner that I am always happy to talk to that other practitioner and if that other practitioner wants to talk to me I will make myself available is that okay and I actually do ask the patient at that time now sometimes that doesn't necessarily go far enough and sometimes you have to be more specific if something is particularly worrying for you I mean certainly this scenario is not an uncommon scenario in my experience the usual thing that I find out from psychologists and other professionals in this sort of setting is bulimia or an anorexia which I suspected and I've asked about but the person wasn't ready or felt comfortable talking to me about that and one of the reasons why I've sent them on may well be to try and tease that out so it is important for all practitioners to say look what are you comfortable me talking about with other doctors or other professionals because to me that sort of information is really really important for the management of my patients and also really important for me to know what I can do in terms of therapy because you may be thinking about a beta blocker or something else in terms of performance anxiety or something like that that might be part of this process and if they are abusing or have been getting juramine down the road or even you know an elicit medication and an elicit drug that is a significant problem but if I don't know about and another health professional does and haven't communicated that to me and something goes wrong I know from a legal perspective we're all in stride so in general in general more communication and I I suppose I've thought about I mean I've had lots of situations arise that I just have not seen coming and you look back and you think I wish I had said something to set this up but you didn't know it was going to happen and then I think you just have to think through carefully and I've found it good practice to consult with another of my own colleagues for my own discipline to say this is a situation what should I do and then document that I've done that and then just ring up the allied health clinician or whoever but I I think Sam's approach of raising it with the client and getting their consent for communication is the most ideal Heather I would really like you to come in here as a consumer ref what have you been thinking about while we've been having this discussion I'm actually going to put my peer work hat on because one of the things that we do as peer workers is we work with people so we don't try and make decisions for them and we're very much guided by their own decisions so I guess in this instance if I was with Tina I would be really trying to educate Tina around the long-term effects of possibly using this and explaining that I may not know that without consulting with the GP I'd also really highlight to her that the GP is bound by confidentiality also and you know she can't actually share anything with her mother about her consent so therefore it's a conversation between the two of them I think the other issue too is that it's not just necessarily about her using the laxatives it's about the relationship between her mother and herself and getting to the bottom of that it's going to require more communication and understanding what's underpinning and with that actually sitting down and looking at why she's doing what she's doing I think is a real issue and not getting on top of it Thank you so I might just come back to Sam regarding Tina and then we'll move on to another one because we started with you Sam you probably had a few more thoughts while we've been talking what else would you like to add it was a thought that I had about I think the goal I think when young people come to particularly psychology it's like they think well here's this person that they can tell all their secrets and you don't have to talk to anyone but I think setting it up so that they understand really clearly like when you might have to but everything you're doing is within their best interest and I like what Heather said that's what I meant by I would take my time to talk to that client and educate her and hopefully help her make her own decision around what might be in her best interest once she knew all the information and also like you said before Mary like almost give her examples of look when I talk to the GP and when I talk to your mum this is the kind of conversation we're going to have and these are the things I learn that I don't know when I do have these conversations so that she can understand that I could help her more but for me psychologically this is the leverage point to understand probably an underlying eating disorder in the relationship with her mother and I would make that fairly obvious that we need to talk a bit more about this because we can't keep these kind of things from everyone I think the other thing to realise is that often everyone not just young people sometimes they're working on the wrong assumptions they don't know that using well they may know that using laxatives gets to a point but they may not know that it's bad but the other thing is that there may in fact be very appropriate ways to manage their weight and things like that that they haven't thought about and so it's about educating them about what might be a better way of managing the situation at a physical level and at a psychological level dealing with what their issues may be with mum and the control of their coach or their team or whatever it is and how to manage that better and it may be that you don't actually need to use the laxatives or the other drugs there are other ways to do it that you just haven't heard about Thank you for that I'm going to move on to the case of Anthony which is a very short vignette there I'm actually going to change it a little bit because the audience is interested in the hierarchy and I think we've touched on it already but I'm actually going to instead of the clinician being a psychologist I'm going to make them a psychiatrist so you're a GP and you're making referrals to a new psychiatrist and you know psychiatrists are often thin on the ground and so you may be using telepsychiatry and then Anthony comes back and he says he doesn't want to see the psychiatrist again and when you ask why he says it's because that he made inappropriate sexual remarks during the consultation so I will start with Morton on this but we'll be going to Heather and Dan as well so here's a tricky one Absolutely and look I have seen it in real life to one degree I guess the main thing is really to talk with the patient about what it was that they felt about the consultation was inappropriate or didn't work for them whether it was a phraseology of the practitioner whether it was an overt action that occurred that was potentially problematic and at the worst end of that spectrum would be should you as a practitioner report the other practitioner to APRA and that does sometimes happen or do you encourage Just thinking about hierarchies let's say that it was an allied health clinician and a GP and that the patients come back and said to their social worker my GP is making inappropriate sexual comments to me I'm not asking you to answer it how do we know what actually happened and is it added up to find out Look I think for the individual patient you need to work through what the issues were for that individual patient now if it is a a personal personal personal patient now if it is relatively clear that something of great of concern did really happen then you do have the option of asking the patient whether they want to take this further and certainly and now I'm probably going to become medical legal from a medical legal perspective the report to APRA actually is taken more seriously from a patient than it is from a practitioner of the same standing making the accusation So I'm just going to interrupt because I'm really interested to know what Heather is thinking here So from the consumer and the peer worker perspective how would you like us to handle this Heather? Oh well Yeah I mean if I would answer me I would just be quite clear that I don't want to go back and I may not want to engage into any conversation as to why and I may not want to make a complaint I'm not sure that I'd want to be challenged on exactly what happens because whatever it was I've interpreted it to be inappropriate I think all I would want is to be offered to make a complaint if I would like to and if I choose not to make a complaint leave it at that that would be my perspective And Sam as an allied health clinician any comments from you? I love that response Heather because I was sitting there actually trying to emphasise with a client and thinking what would they think and I think that they once they have sort of got the wrong impression about somebody and they've cut them off they want the other practitioners to support them in just finding somebody else because I don't want to negotiate that and I actually think that it would be very hard to make a report to opera if the client didn't want to talk about it anymore to substantiate where that impression came from I would offer probably I would offer to call I would say would you like me to call the psychiatrist to try and clear that up or to mend it somehow or to find out what they really meant that would also help me understand how that person might react if they think it's okay but I think if they didn't want to like Heather said they just want another referral for somebody else and they don't want to talk about it then I think that makes it very hard to make a report based on that information unless you're going to check it out with the psychiatrist or a little bit more with the patient and look I've been deliberately a bit provocative with this there's so much we don't know about the scenario and there's so many possibilities and it may have been it might be a psychoanalyst where it's completely or someone who considers it sexual relationships a really important part of functioning and so they normally ask about sexual life and the other thing is I think I have seen situations where a health practitioner has made the opera complaint based on information that their patient told them about a past incident with another health practitioner and the patient didn't want to make the complaint Morton I know you're trying to say something do you want to? I was just going to say that particularly as a GP if you've got a longitudinal relationship with your patient you may actually acknowledge and say that I certainly hear where you're coming from and let's work through this and organise another referral as appropriate but you may actually need to come back to this scenario later on in the therapeutic relationship to try and work out what it was that they felt was the problem in that relationship and that may also help the person to understand where they were at that time perhaps and some of their beliefs and things like that so it can also be used as part of the therapy but perhaps not right then that you may need to look at it later That's really good advice actually to kind of keep that in mind over time so I really appreciate stepping into that tricky territory and I think that the audience have also had a pretty lively discussion in the chat box it's not a simple scenario at all not at all in fact none of them are really like life Belinda is a patient here and I'm going to ask Heather to start helping us think about this one Belinda's been to see a psychologist or an allied health clinician that the DPs referred to and she did go for time but she's just not found it helpful so she just texted back no on the 5th appointment and didn't keep going then a few months later she mentions to a friend at work about her anxiety and she tries one of her valium and it really helps her so she goes to the GP I shouldn't say valium she just said a medication and she goes to the doctor and says I'd like some of that that was really helpful I thought you were seeing that allied health clinician so Heather what are your thoughts about this one yeah I'm naughty friend I think yeah I think to me it would be really important that you know it was highlighted to me that using these kinds of medications isn't going to be helpful in the long run and obviously there was something that I didn't get off with the psychologist if I stopped going whether I thought the progress was too slow or I wasn't actually putting in the hard work I don't know so I really probably wouldn't want the GP to continue to prescribe the medication and I can understand why they'd be looking at sending you to another psychologist but then maybe it's about having a conversation with the psychologist what we were aiming at and what we were trying to achieve and what didn't work and I suppose if we go back to the shared decision making idea it's a two way exchange of information so the GP might say well these are the reasons I want to talk about this and the patient might say well this is what I want to talk about and then somehow you come to some kind of agreement but it's interesting to hear from the peer work perspective that you also would be supporting what sounds like the safe practice of individualized treatment and not just taking medication recommended by friends and neighbours and I know that the peer work training does have a really big focus on safety and it sounds as though that was the first thing you said nor his friends absolutely we'd obviously be looking at what was in their best interest and trying to get them to accept that and we're approaching the end of our time so I'm going to go I think next to Sam so how was it for you I mean this does happen sometimes where patients have stopped coming and you don't know why I mean if the patient's been referred to you by a GP do you let the GP know or is that something that you think should happen yeah I was thinking about you know probably the site doesn't really realise yet that this person isn't coming back to see them and you might need to wait for a period of time of trying a couple of times you know either sometimes when people cancel then the practice manager or the office staff will just ring them back and make sure that they've offered them a rescheduling but that's okay if they would pick up then that's something wrong then they'd alert me and then I would probably call that person and even if they wanted to close have that conversation and then that would help me actually then know what I'm going to say to the GP if something happens and they don't return calls which is that what's happened 3 or 4 go past no very turns that would be the letter that I would just send I haven't seen the person they haven't called back I don't know if they're representing but we know so I guess it's up to the GP when they see the client to discuss that I mean I'd go as far as to say I'd love some feedback so if they go back to the GP and they say why they stopped going you would actually appreciate hearing that okay Morten I just if you could just start responding to that one I'm just going to whip through the slides a little bit so don't get dizzy but if you can just respond to that one look I think I would hope that my colleagues didn't get thingy about accusing the patient of not going to the therapist because it is the patient's choice at the end of the day sometimes you do need to have a break to get your own mind in order to progress in therapy so I I think that from the GP's perspective it's about trying to tease out whether they're still involved in the therapy or whether it was something that they just didn't want to do at that stage or didn't like the approach that was being taken or didn't like the hours that they could see the practitioner or there are an innumerable number of reasons why patients don't or their brother had come to live with them so they couldn't get out or they'd lost their car all of those sort of aspects so you've got to be very non-judgmental as the GP in that setting having said that I think the other thing is then exploring with the patient why they wanted or they tried the medication in the first place and trying to work out what it was that whether it was that quick fix if you like that they were wanting and then trying to talk to them about maybe there isn't a quick fix we've actually this is why we were trying to achieve this is how we're going to achieve it if you didn't like that particular practitioner let's try someone else but medication isn't always the answer even though your friend says it is so you'd be using that sort of shared decision-making approach on both those issues absolutely yeah and more than I just we're just actually approaching me in now so I wonder if there was just perhaps one final tip that you'd like to give everyone before we leave look I think the big tip I would say is that we are all busy but we all have our patients' best interests at heart I would hope and as such it is it is over to us to communicate effectively so that the patient doesn't get lost in the cracks and we give the best patient care that we can it does take time and it can sometimes be annoying but we do need to otherwise the patients lose out thanks Morton that's really great and now you will have noticed I went through this slide now those are available to everybody in the resources so we've been sitting on the end of Samantha's slide there Samantha I'd like to just bring you in is there any final tips that you'd like to leave the audience with tonight I think for me we're basically role-modelling that kind of multidisciplinary care we want to see here in this webinar and listening to Heather as a consumer I think has been very valuable for me and to really try to look from both sides so that's something that I think we can do better and the other thing coming from what Morton just said I think a lot of psychologists particularly they think their job is taking care of the person and looking people back to back and back to back but what I've discovered later in my career is leaving that time leaving a bit of time for these phone calls and this kind of communication has actually helped me look after me better too because I think that some of these cases in our lifestyle is very hectic and I think when you can talk even today doing this I've found that very validating for me to listen to other professionals and what they struggle with and I think you'll feel like you're more part of a team in private practice which is really hard sometimes Thanks so much for that Samantha and just to remind everyone that the MHSC guidelines around collaborative practice are in the resource folder and they are really useful they've got very practical things that need to be thought about so it's a really good framework to think about this collaborative practice and I'd like to last but definitely not least I think it's been such a rich contribution from you as a consumer rep tonight Heather what would you like to leave us with? I'd just like to say that I think it's really important to have conversations with the person and involve them in the decision making even if it's to sit down and look at a pros and cons so that if we don't discuss something with the GP this is the outcome we might have and if we do this is the outcome so that the person can actually make a really good decision so people don't always have all the facts and I think providing the facts and helping you to problem solve breaks down their confidentiality issues Fantastic. Thank you all so much it's been a really, I've really enjoyed it. Now I'd just like to thank also all of our participants in the audience tonight so please make sure that you do complete the feedback survey tonight before you log out there's a feedback survey tab at the top of the screen to open the survey you will be issued with the certificates of attendance for the webinar within four weeks and you'll also be sent a link to the online sources and that will include the recording of the live webinar. Remember that there are MHPN networks in your local area you can join one so that you can have actual in person interdisciplinary conversations and we'd love you to join one and remember that there's lots of online activities as well that's all there on the MHPN.org.au website and thanks so much to everyone for your participation and hopefully you've enjoyed it as much as we have Good evening. Bye