Category Archives: Health Policy

AHPRA notifications: A junior doctors guide

AHPRA-Logo

In the past year, I have been subject to two notifications via AHPRA. This seems to be a trend across Australia, with numbers of complaints/notifications rising. A recent Age article demonstrated this and some of the predictive factors. For a junior doctor like myself having only practiced for three full years, it was like getting hit with a truck full of bricks. Of course I won’t to go into details, but suffice to say nothing permanent gone onto my record. However in both cases (one being from a parent in a tertiary ED and the other from another doctor), I have learnt a great deal. Yes the medical board is there to protect the public, but both times I had the feeling of having to prove my innocence, not the other way around. I’m sure that it is more the way my mind appreciated the situation rather than the intended effect of the process, but it certainly feels for want of a better word…shithouse.  The length of time taken for each issue was also appalling. It took at least 4-5 months from initial notification to final outcome. This is something that the big GP stakeholders have recognised in this article via Medical Observer. It is something that I would not wish upon anyone, but if you find yourself there…here are my tips:

Take good notes

In both cases, I was lucky to have written good contemporaneous notes that I was able to look back on. They not only helped me remember the particular case, but also to demonstrate that I am a competent clinician to the board. I could not imagine being hauled up and not have sufficient details to help explain my actions. Take good notes, its a must.

Contact your MDO

In trouble for that mo!

In trouble for that mo!

Again on both occasions, my first phone call following the notification was to my medical defence organisation. They helped set up a file, had their team look over the case and help me draft a response. Although some doctors may feel comfortable handling the response themselves, I certainly had immense support from my MDO during what is a difficult time. You will save a lot of hassle if you wish to defend yourself from any action the board may take if your MDO is on board from the get go.

Explain your situation

When it comes to writing your response, make sure that you let the reader know the situation you are working in. That might be an overcrowded or busy ED, rural location without support, walk up clinic and everything in between. Without coming across apologetic, if you at least provide some background, the board can put your situation in context.

Ask for support

Often your character or actions will be disputed by the complaint. Fight back! You know yourself the sort of doctor you are and why you joined the profession. If you have collegues that can appropriately support you in writing, do it. These are the people that know best how you work day to day. Not a single patient, family member or doctor you’ve never met.

Debrief

Talk with someone about the situation. Even though I would consider myself a moderately resilient person, when you get that first phone call or letter, your heart sinks. Here you are practicing in a profession that aims to improve the health of others and the big stick gets pointed at you. For me I felt many emotions both times, often all at once! In order to continue practicing and maintain a love of doctoring, I needed many chats with close friends and collegues. I also needed to keep working. The patients that thank you for your time and help can certainly heal a bruised ego. Unfortunately it only takes those one or two complaints (whether justified or not) to damage a whole day of grateful patients.

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Filed under AHPRA, Emergency Medicine, General Practice, Health Policy, Rural GP

12th National Rural Health Conference Podcasts

“Live from Adelaide, its the 12th NHRC in April 2013!!”

Over the four day 12th National Rural Health Conference, I was lucky enough for sit down for a couple of minutes with some interesting delegates who told me a little about their path to the country and why they are so passionate about rural health. Listen to their stories here:

Sian Draffin (@rural_speechie)

SianDraffin

Speaking with a Speechie

Talking with Sian, a newly qualified speech pathologist about growing up in the country and now working as a speechie in these areas. We also cover the future of social media connecting with patients in her profession.

Ben Crough (@BenCrough)

BenCrough

Talking with final year pharmacy student Ben Crough. He grew up in rural NSW and is aiming towards working in remote areas. Another Robbo (@bitethedust) for outback Australia perhaps?!

Dave Townsend (@futuregp)

Time out downstairs

Time out downstairs

Talking with medical student and the current GPSN chair about his time studying in rural areas. Dave is in 4th year at the University of New England in Armidale. He grew up Tasmania and has lived in country Victoria.

Andrew (Robbo) Roberts (@bitethedust)

Blending in

Blending in

Talking with Australia’s most remote and itinerant pharmacist. Some say he travels around because no one can stand him for longer than a few days, but we know it’s because he loves his job working in rural areas. We cover issues facing pharmacy in these settings.

Alison Fairleigh (@alisonfairleigh)

Discussing mental health in the bush

Discussing mental health in the bush

Talking with rural mental health advocate and ‘power-tweeter’ Alison Fairleigh about living in the country and what motivated her to do something about her passion of mental health in the bush.

Katherine King & Rachael Purcell

Presentation1

Talking with Katherine and Rachael who are both medical students in Victoria about their presentation at NHRC 2013. They looked at the supports and challenges for medical students on rural placements.

Donna Burns

Dance floor destructors!

Dance floor destructors!

Talking with Donna Burns about working and living in the country and what took her there. Donna currently works for Hunter Medicare Local in both rural and larger regional towns, but has some ideas if she was the NSW Health Minister!

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Filed under General Practice, Health Policy, Rural GP

Breathing New Life 2013 (Part 2)

Continued from Part 1

The Leaders’ Forum discussing GP Workforce 2025 was one of the highlights of the conference. Chaired wonderfully by Dr Emily Farrell, it comprised a veritable who’s-who of GP leadership. Prof Murry from ACRRM (covered in the early stages by Dr Davies), Dr Hambleton from the AMA, GPRA Chair Dr Vergara, GPSN Chair Mr Townsend, Dr Baker from NGPSA, Dr Marles from RACGP, Dr Kammerman from RDAA, Sharon Flynn chair of the RTP CEOs and Prof Kidd (no introduction required!).

Leaders Forum FTW

Leaders Forum FTW

Rural workforce issues were a hot topic for the forum generating plenty of debate and also activity on the Twitter feed and some novel ideas for improving recruitment were offered:

Filling in for Prof Murray, ACCRM trainee Marion Davies provided some great advice for aspiring rural doctors during their training:

Up and coming GP leaders like Dave Townsend summarised that training needs to have improved information about where it is possible, communication between providers and collaboration towards a common goal. Dave also demonstrated his Gen Y talent by not only taking part as a forum leader, but also concurrently tweeting the points made by the person sitting in the next chair:

Not so technically savvy, but more than capable of contributing important points was Dr Hambleton. Even though a GP himself and quite likely able to multitask, his AMA media person was helping to keep the Twitter-stream flowing:

Not only was the topic of learning raised, but also that of teaching and growing our pool of supervisors. Trish from NGPSA admitted that supervisors were getting older and also dealing with a more challening mix of trainees:

Twitter-iffic

Twitter-iffic

One suggestion that Dr Ashe Nicholas provided was to increase the membership and role of the General Practice Registrar Medical Educator Network (GPRMEN). This group of registrars would serve to promote the idea of teaching to form and hopefully increase the future number of medical educators and supervisors. Given that the number of AGPT applications are increasing, a much larger cohort will be needed and won’t simply fall from the sky:

For some, the seed of teaching had been planted long before even commencing GP training as described by Dr. Mel Clothier, a gorgeous GP registrar from Clare. Dr Clothier had positive experiences in teaching medical students in her higher levels of med school and tweeted from SA:

Even the wonderful students tweeted suggestions as to how best promote general practice during medical school. It really summed up the beauty of such a conference. Where else could the future of the field so easily fire off ideas to be considered by the top leaders who have the ability to effect change:

The students were a crucial part of the day, not only tweeting, but also providing help for the older generation not across social media or infographics. The infographic (below) constructed by Rebecca Wood, council member of GPSN, summarised the main points made by each forum leader on the topic of workforce issues:

On-the-fly infographic courtesy of @rfrwood

On-the-fly infographic courtesy of @rfrwood

Unfortunately not all the questions were covered, but one that will continue to generate discussion  included the future of primary health care research:

Briefly summarising the latest in GPRA news and updates, Mr Amit Vohra was also proud to launch the new look GPRA website. He told everyone of the brilliant work of GPSN and its incredible cost-effectiveness as a GP promotion tool. Amit also pointed to the Going Places network as the fastest growing of them covering 65% of Australian teaching hospitals while filling the “black hole” that some GP registrars find themselves in while working there. Some of his final remarks centred around the jump of 25% to 35% of all AGPT applicants having been involved in one of the programs. What an amazing pipeline that I’m sure will only increase in calibre and flow (no urology jokes).

The 6th GPRA Breathing New Life conference also offered an insight into GP life as part of the Australian Defence Force (ADF). To begin, Dr Kerry Summerscales described her journey swapping rifle for tuning fork. Although her time in the Australia Army was spent wielding syringes rather than guns, working in the medical corps as a pathology technician. Her stories of deployment and training then flowed into her time at Flinders Uni working with the fledgling GPSN. It prompted some to wonder in jest about the model of employment offered by the armed forces:

The rank and file then heard from Brigadier Rudzki AM, who described the different work that was available to GPs in the military. He told of his operational postings overseas and showed many pictures of the exciting jobs that he held. Having said “I’m not here to sign anyone up” the Brigadier told some amazing storied that had some wondering whether working rurally was challenging enough:

Throughout the day, the food was exemplary as always at Parliament House. They were certainly not scraps from the Cabient table that day:

Given the deliciousness of the food described, hands being used to eat therefore restricted tweeting during the meal breaks and as such was observed from afar:

The Great Debate provided a light-hearted look at some of the serious topics facing general practice. The first motion was “Mandatory return of service for all doctors is the only way to guarantee a rural workforce.”

The affirmative took a military approach led by Captain Summerscales, Brigadier Maxell and Corporal Considine who contended that we are at war against maldistribution and that we must form a Coalition of the (Medicare) Billing.

The negative team wanted to be more peaceful about the situation and offer more incentives or “carrots”to attract more doctors to the country:

By a vote of louder claps to lesser claps, the affirmative team took the honours:

The next motion was that “Generalists will rule the world in 2025” with some great debate highlighted in the resultant twitter stream:

Dr David Chessor once again demonstrated his flair for simultaneous debate and tweeting much to the chagrin of the opposition team:

and on occasion, from the audience:

At the conclusion of the day, everyone present offered a large round of applause and the ‘Twepreciation’ came flooding in:

Although all the days online action may have seen some reaching for the Voltaren gel:

For the students it was an inspiring day to hear about the benefits of a career that they may consider. For GP registrars it was sobering to understand the challenges facing them into the future. For current GPs it must have been heartening to see a motivated group of young students/doctors ready to answer the call for Australia’s health workforce into 2025. For the associated GPRA staff and organisers it was once again another truly magic day and I for one thank them one thousand times over. Until next year, ruralflyingdoc at Parliament House, signing off.

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DISCLAIMER: If any of Part 1 or 2 of this BNL summary ends up in Mr Amit Vohra’s GPRA report, then I am not pressing charges. He will however be buying me drinks for the entirety of GPET 2013….

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Filed under BNL, General Practice, GPRA, Health Policy, Rural GP

Breathing New Life 2013 (Part 1)

It is quite fitting that I sit down to write this summary of the Breathing New Life (BNL) conference held in Canberra recently. At the conference last year, I was so inspired by the stories of other GPs and the use of blogs and twitter, I decided to start my own blog. It is the one you are reading now. Since then I have kept updating my flying training progress, commented on social media policy in healthcare and attempted a humorous post (or two). Unfortunately, I never got around to summarising my experience at BNL 2012 and you can still see the lonely post here. But luckily, I was inspired once again…and hopefully a little more motivated and better at writing!

The BNL conference is the annual showpiece event for General Practice Registrars Australia (GPRA). They are the peak representation body for GP registrars in this country. In the past, GPRA has successfully advocated for National Minimum Terms and Conditions, timely GPRIPs funding, teaching guidelines and many other registrar issues. As a Registrar Liaison Officer with my GP training provider, I am lucky enough to sit on the advisory council of GPRA. We meet bianually before BNL and GPET conference in September to discuss such issues and workshop solutions.

But BNL itself is a day long conference held in the Great Hall of Parliament House that aims to bring GP training, recruitment and support into the spotlight. 2013 was no exception. From the outset, use of Twitter was encourage to pose questions, comment on speeches and connect using the hashtag #bnl2013. As the day progressed, we even started to see comment and opinion from our collegues in New Zealand. It is with this real-time connection, that the role of Twitter in health care is immediately obvious:

Highlighting the importance of the venue for the day were keynote speeches by the Health Minister, The Hon Tanya Plibersek MP and The Hon Peter Dutton MP which were both warmly received. Even though the Minister needed to hurry off to an ALP caucus meeting and the Shadow Minister was a touch late in arriving before a feisty Question Time in the house of Reps and didn’t get to answer one last question from Dr. Jonathon Ramachenderan:

Health Minister talking up GP

Health Minister talking up GP

The Minister reiterated the importance of general practice stating that “GPs are at the heart of our universal medical system.” She also affirmed the position and continuation of the e-Health record and Medicare Locals. I was heartening for all present to note that the Governments thinking in relation to the future challenges of health care revolve around improving GP access. The Shadow Minister retorted in his address that he thought that the Government could do a lot better in primary health care and echoed the Minister saying that “GP care would be central” to any future health system. My question from the floor The Shadow Minister was “given there is a lot of uncertainty about the future of government initiatives such as the e-Health record and Medicare Locals in this election year, what advice can you give to the future of GP assembled in front of you.” The response didn’t cover e-Health, but he hinted strongly that Medicare Locals were not the most efficient or efficacious way forward. Once again, Twitter provided the means to pose a few rhetorical follow-ups:

The Hon Jim McGinty discussed the work of Health Workforce Australia 2025 and the issues surrounding retention and planning with our current state of workforce maldistribution. The recent controversial paper entitled “Too Many GPs” was also given attention. And promptly panned:

With The Hon McGinty describing the report as “full of inaccuracies ,” he was quick to remind all present that given the current state of GP distribution, more are needed at the coal face. However, a number of references to nurses evidently ruffled a few Twitter feathers:

https://twitter.com/notjustagp/status/313782950024056832

Following this brief look at the future, we were allowed a moment to reflect on the amazing work done by the General Practice Student Network (GPSN) which celebrates its fifth anniversary in 2013. We heard of humble beginnings and a huge base of support that now includes over 9,500 student members. This we were told, had been largely driven by the tireless work of council chairs, their councils and the representatives on the medical school grounds holding numerous events.

It was heartening to see that indeed future GPs are out there and will be ready to meet our nations challenges in health demonstrated by Jim McGinty. The Twittersphere also erupted in e-birthday wishes for GPSN:

Indigenous health was a highly anticipated topic of the day and was supported by the GPRA Closing the Gap campaign launch. We heard from The Hon Warren Snowdon who stated that “GPs have an important central role in improving Indigenous health.” MP and Dr Andrew Laming MP noted in his speech that the “100,000 Indigenous people living in remote communities will be the real test of the Close the Gap efforts.” It was refreshing to hear bipartisan support and understanding for once.

Also On each table were a number of wristbands that will serve to draw attention to and remind wearers to effect their own small change in this area. To discuss some of the change possible, the Indigenous health panel debated, discussed and took questions from the floor and twitter:

Make a difference

Make a difference

The response to this were themes relating to difference in cultural and educational experiences felt by Indigenous students and registrars. Also that the Indigenous population are a heterogeneous mob all over the country and as such may require personalised consideration. Some suggestions from Indigenous doctors in the audience included needing to recognise cultural differences and reducing threats like ‘you might be kicked out.’ Dr Aleeta Fejo was a standout member on the panel who commented that at the GP registrar level “they are already brilliant people, as they have overcome so much just to get there.” She is a testament to this herself having recently passed her RACGP written exams and winning the inaugural indigenous General Practice Registrars Network award:

Aleeta also shared some gems about encouraging young Aboriginal children to join the GP workforce. She showed that it was as easy as asking “Are you going to be a doctor like me? ‘Coz I need your help!” Planting the seed early with children and especially their parents was the message. Getting across to the family that this prospect is actually possible. The facilitator Dr Mark Wenitong tempered that he would always check a kids ears for pus before putting the stethoscope in their ears!

There were some great opinions on how to encourage non-Indigenous registrars to consider working in an Aboriginal Medical Service. Dr David Chessor pointed out that he has got much more out of AMS work than he put in. David Townsend, current chair of GPSN commented on the need to spread this sort of message:

He went on to say that AMS cases are much more interesting and complicated. Perhaps then this side of registrar training needs to be better advertised? With Rural Health Workforce Agency doing so much good with their #gorural campaign, maybe it’s time for #goAMS? Drs Tim Senior and Michael Bonning are already doing some amazing and innovated work with the #supertwision project and should be followed with interest:

RACGP president Dr Liz Marles weighed into the benefits of AMS work given her long experience in the area with comments like “learning from patients every single day”,”…rewarding place to be” and “patients are non-demanding, generous and trusting” leading to many registrars thinking that these traits in patients have been lacking in their own non-AMS practices.

To come in part 2: The Great Debate, general practice and the defence force, GP Leader’s forum, the GPRA update from CEO Mr Amit Vohra and plenty more tweets!

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#interncrisis

Scrubs Protest – Sat Oct 20th

Over the last few days you may have become tiresome of my tweets and re-tweets that contain a certain hashtag. ‘#interncrisis’ refers to the current shortage of jobs for newly qualified, first year doctors (i.e. that have just graduated). In Australia, these ‘interns’ shoulder a large responsibility in our public hospitals. They take bloods, write in notes, explain decisions with patients and compile discharge summaries (sometimes within a week of discharge!). Without them, our system fails. So why are we so interested in these P-plater doctors?

During intern allocations this year, it became apparent that close to 182 interns would have no hospital employment in 2013. This is not an unexpected or new issue. Since the mid-2000s, the number of medical student places has increased dramatically to address the shortage of doctors in the workforce. However, the downstream effect of this move wasn’t and still hasn’t been addressed. Even going back in 2009, NSW found that their hospitals were ‘buckling in tsunami of interns’.

Is there an #internsolution? 

So what then is the #internsolution you may ask? As many people already realise, there is a large imbalance in the doctor workforce. Rural communities and hospitals are often short staffed and rely on locums to fill vacant positions. For many years, governments have relied on this expensive option to plug these gaps. Often, this has meant an abuse of many international medical graduates (IMGs). But with the current oversupply of interns in our metropolitan hospitals and a need for medical services in the country, it should be a case of simple diffusion.

Already the Prevocational GP Placement Program (PGPPP) exists to enable interns and junior doctors gain experience in a general practice setting. Even for those not interested in a career in GP, it can provide all junior doctors a better understanding of how primary health care works. All of our patients have contact with GPs, so too should our junior doctors. A call for mandatory intern GP terms was made back in 2010, but has yet to be implemented.

PGPPP – GP Synergy banner

To many, it seems that PGPPP may be the answer to our intern crisis. It is therefore unfortunate that in a knee-jerk, myopic decision, the federal Health Minister has decided to pay for an extra 100 intern places by taking funding away from the PGPPP initiative. A single year stop gap measure that degrades for what many junior docs, a valuable entry point into general practice. A faceless spokesperson for Mrs Plibersek responded to Medical Observer, stating that the PGPPP has previously been undersubscribed. I find this hard to believe and will have to check with AGPT. In any case, a move to make intern GP placements mandatory would solve any under subscription issues! I would also be very wary of falling back on using private hospitals and corporations to accommodate interns. Yes they would be employed, but would the level of supervision and ongoing education meet the national curriculum framework?

For the states part, extra intern spots can be created in some of our larger regional centres. These communities have sufficiently sized hospitals so that interns cover the required ED, medical and surgical terms. In fact Broken Hill will host three interns in 2013 to help solve the crisis. Already in South Australia, the town of Mt Gambier currently hosts 6 interns and has done so for the past few years. SA has the ability to fund additional intern positions in towns like Whyalla, Port Augusta and Port Lincoln. There are plenty of other such towns in rural and remote Australia. Of course with any scheme such as this, adequate supervision and training is paramount.

So, what now?

Simple maths…

In the meantime we may well have to sit and watch the political hot potato been thrown between state and federal governments. In my view both need to come to the table. On one hand, the federal government is able to fund more PGPPP placements and help free up further hospital placements by also offering additional GP spots. Of course this will cost money, but manageable with a generous surplus handed down by Mr Swan. On the other, state governments can provide additional intern positions in some of our larger regional centres as seen in Broken Hill and Mt Gambier.

These changes need to happen now, before larger numbers of interns are without places. We are talking about 182 missing out in 2013, in 2014 it may be hundreds more. The next step will then be to increase training positions for the different specialities. As it stands, general practice is already oversubscribed with many taking multiple years to enter. If this second step is not addressed, we will be left with a generation of continuing medical officers without career progression staffing our already bursting hospital system. Our very own registrar crisis could be just around the corner.

The key to lowering health spending is in primary health care and it seems that creating more GP placements for junior docs and then increasing GP training spots will solve not one, but two problems.

What can you do to help?

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Over regulation of social media in medicine: stifiling progress?

Dr. Google will tweet you now. Like?

Over the past three days, over 600 people involved in general practice education and training converged on Melbourne for the annual GPET conference. Peppered throughout the gathering were sessions relating to the current and more excitingly, possible future use of social media in the medical field. Some areas that have already started down this track and will in the future include:

  • National e-Health Record (PCEHR)
  • Registrar and medical student training
  • Connection of doctors, nurses and allied health
  • Patient education and FAQ videos or sites
  • Medical Practice information, booking and contact details
  • Videoconferencing between rural patients, GPs and specialists

At the afore mentioned GPET2012 conference, one notable session was run by noted internet savvy practitioner Dr. George Forgan-Smith (The Healthy Bear). He highlighted to the standing room only session the different uses of internet based systems. It was inspiring to hear about the use of exciting and ever-changing web-based tools. For example:

  • YouTube: for the production of medical themed videos
  • Facebook: for your own advice site and medical practice information
  • Yahoo Answers: providing common sense answers to those too scared to ask
  • Google: Patients being able to find you and your practice

It was especially heartening to listen to this doctor who has seen lots of misinformation on the internet trying to provide his own considered (and safer) information. As a GP registrar, I am both excited and wary of the prospect of this brave new world. Already after the conference and session run by Dr. Forgan-Smith, I am newly motivated to explore the role of producing amongst others: online teaching videos, patient consent videos and education snippets.

“why don’t they just get another cup?”

Recently, the national board AHPRA has released a consultation paper to help “to clarify…the expected standards relating to social media use.” Some blogs have already highlighted the lack of clarity offered by this statement. They have punctuated the areas (below) with related examples. I won’t delve into these myself, but please visit Impacted NurseCroakey and Phillip Darbyshire as all have summarised this very nicely.

  • Professional boundaries
  • Professional behaviour
  • Confidentiality and privacy

Interestingly, Impacted Nurse has observed that already their social media activity (along with mine and many others!) would already be in breach of the proposed policy. The whole tone of the AHPRA statement is restrictive and casts a dim view of social media in medicine. In fact it highlights a lack of knowledge and experience in the very area that they look to place boundaries around.

But AHPRA is not the first group to try to address professionalism relating to social media.  The Royal College of Nurses have already released useful and supportive guidelines. Medical peak representation bodies have also been proactive and drafted guidelines addressing these issues. The AMA DiT, NZMA DiT, NZMSA and AMSA released a joint initiative way back in 2010. They identified that there was the potential for legal and professional risks. As such, many medical defence organisations have drafted and published case studies, guidelines and recommendations for their members. In the age of an increasingly connected society and the further blurring of professional and social boundaries, an increase in medico legal cases with a social media focus is inevitable. Although I agree that there is a need for nationally regulated guidelines or policy regarding online conduct and behaviour, they need to be permissive enough to allow innovation and progress while maintaining professional standards. We must not let a nanny-state approach stifle this form of interaction that has to potential to do so much for a great number of patients in an increasingly fast paced online world.

Given that AHPRA is calling for feedback on the issue of social media in medicine, the lack of Twitter/Facebook*/YouTube presence is notable. Therefore, AHPRA is asking for feedback by regular old email (socialmediaconsult@ahpra.gov.au) by COB on 14 September 2012.

*The only AHPRA site to be found on Facebook is “Asociación Hondureña Protectora de los Animales y su Ambiente”

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A copy of the letter that I help GPRA co-author as a submission to AHPRA, sent on Friday 14th September 2012:

AHPRA SM Policy Response

 

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The story is picked up by Medical Observer on the 17th September 2012:

 

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Response from AHPRA on Wednesday 19th September 2012:

“Thank you for your submission to the preliminary consultation process on the National Boards’ draft Social Media Policy.

Your feedback will be considered by National Boards but as this was a preliminary consultation process, your feedback will not be published.

There will also be a public consultation process in which you are also welcome to participate, and information will be available on the Board’s website about this soon.

Thank you again for your interest in this issue.”

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