Are you a member of Australia’s underground GP college?

In terms of moving GPs into the 21st century, GPDU's resistance movement may be just what the doctor ordered

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Australia has a virtual underground GP college or, if you like, a GP resistance movement. In terms of moving GPs into the 21st century of social digital engagement and learning, it might just be what the doctor ordered.

“Where there is power, there is resistance,” says Michel Foucault in his seminal work on power and knowledge, Defacing Power.

When we think of power in the GP realm we generally think of the RACGP, AMA, ACRRM, Department of Health, (DoH), The Australian Medical Board and so on.

When we think “resistance” these days, it’s not a big leap to Australia’s largest “unofficial” GP social collective, the Facebook group GPs Down Under (GPDU).

GPDU has quietly and without intent, built into the national powerhouse of direct digital GP engagement in Australia and New Zealand. A few years ago that title might have gone to Australian Doctor, the weekly newspaper, the website of which attracts upwards of 6,000 comments a year to its articles from about 8,000 or so registered Australian GPs.

But that’s what happens when technology meets “the people” – in this case “the people” being a group of highly energetic and well-intentioned GPs.

Today, GPDU has about 3,900 GP and GP registrar members, 1,750 of whom engage directly via posting, and has more than 190,000 direct engagements per year. Those who don’t engage are at least likely to be watching and taking things in. To give that some perspective, that’s more than 30 times the engagement levels of Australian Doctor, and GPDU has achieved those numbers in just three years.

On a per-doctor basis, this level of engagement for a peer-to-peer private doctor network is higher than any of the global private-doctor network sites, some of which are commercialised and valued in the tens of millions of dollars and have many staff working for them.  These sites include Sermo and Doximity in the US and Doc2Doc in the UK.

It’s little wonder some of the powers that be in the colleges are worried about where GPDU might be heading. There is a professional social engagement phenomenon happening here and it is, on any global measure, quite extraordinary. In the old worlds of the RACGP, ACRRM and the RDAA you will often see quite a bit of tribalism. On GPDU, doctors from every creed seem to be there – in a neutral virtual forum – solving problems for each other.

VALUABLE DATA

The data that passes across the site daily, would, in a commercial world, be very valuable – to government, to big pharma, to insurance companies and to other groups. Literally within seconds of some interesting clinical event a doctor can get a peer-validated reading from the Australian GP community. And if you’re interested – which the government and various health bodies would be – you can get a very quick read of the pulse of the GP community on political and regulatory decisions affecting the profession. But you have to be a GP, or a GP registrar, to be a member. Strictly.
How did an amateur Facebook group come to have so many members, engaging in such a deep manner, and talking so openly to each other, so quickly? How was this done without any reference to the official powers? And with no money involved?

Why are the established and powerful doctor-based organisations so far unwilling, largely, to engage meaningfully with this group? And why, behind closed doors, is the establishment in these groups quite concerned by GPDU’s rise to prominence?

The answer might lie somewhere in what Foucault talks about.

Foucault regards power as neither an agency nor a structure. “Instead, it is a kind of ‘metapower’ or ‘regime of truth’ that pervades society, and which is in constant flux and negotiation.”

POWER IN FLUX

Power, as we see it in the various colleges and regulatory bodies in medicine, through GPDU, appears to be in some state of flux and negotiation. If responses to the rise of GPDU are anything to go by, this “flux” seems to be quite uncomfortable for the incumbents of power.

The secret to GPDU’s phenomenal engagement levels likely lies in the fact the founders and moderators of the group religiously and voraciously guard the independence and “GP-only” purity of site.

Its not-for-profit mission is to help GPs in their everyday working lives via more effective peer-to-peer engagement. Particularly in solving clinical dilemmas and in clinical learning.

Another secret might lie in the expertise that the group of founding administrators have developed in professional learning, medical education and social media.

“We are trying to make this a safe place for GPs. One they can truly trust for information and learn without fear of any repercussions to what they see and contribute,” says one of the founders and often-time administrator, Dr Karen Price.

Other admins on the site include Drs Lindsay Moran-Jayaram, Tim Leeuwenburg, Nicole Higgins, Kat Maclean, and Kate Kloza.

Like so many of these things, Dr Price and the other founders had no idea what they were starting when they founded the group. They were simply frustrated by how hard it was to communicate with each other around basic clinical issues using the normal lines of communication of the established organisations.

The utility of a modern social-media platform offered them a way around that frustration, efficiently and without cost.

Dr Price and her cohorts didn’t set out to undermine the power bases of groups such as the RACGP and some commercial medical-education groups. And if you ask them today, they are somewhat aghast that The Medical Republic would suggest that some might be seeing them this way.

But they weren’t, and still aren’t, entirely prepared to play by the old rules either.

“Some of us were on an RACGP committee for member engagement but there was no really effective way to engage with members,” says Dr Price. “The College was relying on Friday faxes and then email blasts, but they were very hit and miss and very controlled. When we wanted to do an email to lots of members we were told it was spamming.”

COMPLEMENTING THE COLLEGES

GPDU sees itself as a complement to what most of the established GP colleges and groups do. Something of an infill for some of the deficiencies of being big, slow, bureaucratic and overly political.

“There is a strong desire with GPDU to unite the RACGP, RNZCGP, ACRRM, RDAA and non-vocationally registered doctors. This is a unique space and one that has been expressly stated in many ways on GPDU”, Dr Price told TMR.

But, while  the groups in power will pay some homage to GPDU, and even say publicly it serves a role, there are clear signs they are displeased that some aspects of what they have tried to achieve in GP engagement in the past have been re-imagined in another place, and re-imagined in a manner that is far more functional.

RACGP President Dr Bastian Seidel is a member of GPDU and does occasionally engage.

He told TMR: “I do post and comment, unfortunately not as much as I’d like to. It’s just a time issue for me.”

But when pressed about GPDU and the College competing in some ways for learning and engagement, Dr Seidel plays a dead bat.

“I believe that GPDU has had a presence at our annual GP conference over the years, which I think was well received. I’ve been on panels with some of the GPDU administrators at GPTEC when we talked about social media. I’ve also co-presented with GPDU’s Dr Nicole Higgins on SoMe at that same conference. I have not been approached re other “events in concert” by anybody else.”

Some sense of Dr Seidel’s reluctance stance might be sourced in the RACGP’s decision last year to set up its own version of GPDU, called shareGP. The RACGP will deny that shareGP is in response to GPDU and will tell you that it serves a different function. For instance, it is supposed to be a means by which College committee members can communicate more effectively on tricky issues. But if you read the shareGP objectives, it’s all mostly all the stuff that GPDU already does, and does very well.

So far, shareGP has failed, if net engagements are anything to go by. TMR asked several GPs who had joined what they thought and none were particularly enthused.

Something is fundamentally missing from this new professional space. Something that GPDU offers. That is the ability to have fierce conversations through thoughtful and focused moderation. And the ability to do it and not get pinged by anyone for overstepping the mark, accidentally or not.

GPDU’s administrators work hard to try to provide an environment where GPs will largely be protected from any company, or organisation, repercussions. They also aren’t afraid of a bit of silliness and humour. The group is careful about not taking themselves too seriously.

But you suspect the major reason for GPs using GPDU over shareGP is much more raw. It’s not the RACGP. It’s the place where there are no overseers with agendas, be they good or bad. It’s a place that has some degree of purity. The purity of GP-only conversations, protected from private enterprise, government and the colleges alike.

We are trying to make this a safe place for GPs. One they can truly trust for information and learn without fear of any repercussions.

ANONYMITY HELPS

But it’s not entirely safe. You can get mauled from time to time. But at least that happens under the watchful eye of independent and passionate moderator GPs who have the sole intention of promoting useful peer-to-peer communication.

Part of why this can happen is GPDU sanctions a degree of user anonymity.

Many doctors on GPDU use avatars to help in protecting their identity. Anonymity on website forums is quite controversial. But the GPDU administrators have thought carefully about it.

Says Dr Price: “In some circumstances people will be emotional about an organisation or group, but if we stop that entirely by identification then you will often prevent a debate from even being had. We know that sometimes GPDU is snapshotted [which is against our policy] and used in internal organisational discussions. In some organisations this can be good, but in some it can be used against people.

“It’s not good for the profession to have people vilified or gagged for having an opinion, so in some circumstances, so long as it is properly moderated, anonymity is useful for debate and progressing issues.”

And in the end, the administrators on GPDU, who will only allow a GP or registrar to join after a rigorous checking process, including a peer reference and recommendation, can identify someone if something really goes wrong.

Those who run GPDU are adamant they are there to support institutions such as the RACGP and the AMA. But they aren’t going to sit back and let them get away with things that the “GP community” doesn’t agree with. Nor are they OK to let faster, more efficient peer-to-peer education and communication languish in old-style methodologies and power bases that are largely being funded by paid-for education and other fees.

“A lot of GP learning makes money for organisations and it makes careers,” Dr Price says. “But if you look at the critical care community and organisations like SMACC (Social Media and Critical Care)  and FOAMeD (Free Open Access Medical Education), they have managed to achieve an effective learning environment that is almost all free of charge to their doctor communities.

“It’s leading edge, it’s nearly all free and it’s altruistic. I can’t see why we can’t aim for that.

“Increasingly GPs and other doctors are seeing paid-for education as frustrating and unfair. People are producing content for free, for the altruistic benefit of the community, which is then taken over by a brand [the RACGP included] and they lose control of that content.

“To some extent there is an element [in GPDU] of protecting the intellectual property of the  body of knowledge of general practice from those who seek to monetise it.”

But while her ambition is to eventually see almost all education done free by the community, Dr Price agrees that disassembling the behemoth of paid-for medical education too quickly could cause more harm than good, especially to people’s livelihoods.

Whether Dr Price and her founder partners think so or not, GPDU is “the resistance”. They don’t agree with all that these powerful groups do and how they do it, so they have simply gone around them as they can.

It’s not a deliberate attempt to disrupt. But it is disruptive.

DOCTORS ARE NOT DIGITAL LAGGARDS

Healthcare is one of the last sectors to embrace so-called digital disruption. It has natural and very high market barriers that have slowed down the march of digital technology. Such barriers include things like market information asymmetry (i.e., the doctor vs patient information gap), supply and demand (doctors again) and regulatory risk (life and death in medicine).

Contrary to popular belief, doctors, however, are not digital laggards. All evidence is that your typical doctor is as digitally literate as any other professional.  Medicine is just a naturally resistant digital sector and the ecosystem isn’t there yet for them to go as fast as many would like.

Which may go some way to explaining the surprisingly rapid rise of GPDU.

All of the founders and admins on GPDU were highly engaged in social media before GPDU. And they aren’t all millennials.

In other sectors, such as finance, transport, travel and accommodation, we are seeing light-speed change being caused by disruptors. In each of these industries, entrepreneurs are  deliberately setting out to disrupt, using technology to make fortunes along the way. You’ve got less of them in medicine because it’s a complex market and hard to crack.

In a manner, the GPDU administrators may have stumbled into significant disruption. And it’s feasible they don’t know the extent to which they’ve done that yet.

Take GPDU’s key stated goal: “Accessing medical education and case commentary in a peer-supported environment”.

This seems a suitably harmless statement.

But if you look under the hood and think about GPDU’s ambitions for online social learning, you see some stuff that might end up revolutionising how the profession practices.

This goes some way to explain why groups such as the RACGP are nervous about this emerging “hive” of “do-gooders”.

MEDICAL EDUCATION RAPIDLY CHANGING

GPDU is pushing some very forward-thinking principles in modern professional learning. Principles that the bigger groups, at best, pay lip-service to, and, at worst, do not even grasp. GPDU, and the like-minded groups such as FOAMeD and SMACC, are already practicing what they preach, providing highly effective, low-cost (free) life-long, social digital learning for doctors.

If the RACGP, the AMA, ACRRM  and other medical groups think that they can keep their members competitive with the current formal-learning regimes then they likely have some serious surprises in store.

Today’s system relies heavily on intensive schooling as the key starting point and then topping up with odds and sods of didactic learning modules on the way (many of which GPs pay for). This is on its way out.

Artificial intelligence will be on top of the basics of diagnosis in no time, as it already is for professions such as the law. Some would argue it already is getting there in medicine. If we stood still, patients with a reasonable IQ and a decent self-learning , bot-basedAI system will be able to compete with your average GP on many diagnoses in the not too distant future.

Doctors and GPs will need to change how they learn and eventually how they practice. GPDU seems to be at the leading edge of this change.

But these changes, per se, aren’t the issue. The issue is how much more efficient, effective  and interesting the medical profession might be if it embraces some of these changes a little more seamlessly.

The future of being a GP is exciting. But not if the way GPs currently learn, and continue to learn, doesn’t change.

Arguably, GPDU and FOAMeD, thought by some as disruptive outliers in the learning sector, have their act together far more than any of the colleges or regulatory bodies.  They are the natural progression of GP engagement through new technology.

WORK WITH THE DISRUPTORS

GPDU, at its heart, was set up to help GPs, rapidly and effectively, with immediate clinical questions. And talking to many GPs and registrars it is hugely helpful in this respect. Even a simple rash, quickly photographed and posted for a couple of second opinions, usually gets a rapid turnaround.

The key is that GPs feel safe to be helping each other in this environment. The other key is very sharp and timely moderation, all of which is done by volunteers.

According to Dr Price, there have been instances where a GP has entered a question during a consult and got answers within minutes. Apparently the patients in each case were delighted.

But while the founding principle of the group is around sharing clinical insights, GPDU figures quite prominently in political and policy discussions.

RDAA President Dr Ewen McPhee says: “GPDU is an excellent forum to take the temperature of GPs on the ground about key political issues. Digital disruption brought to you by GPDU is a critical circuit breaker between primary-care clinicians and health-policy leaders.”

Digital disruption brought to you by GPDU is a critical circuit breaker between primary-care clinicians and health-policy leaders.

HOW BIG CAN GPDU BE?

As it keeps growing, as it seems it inevitably will, some question whether GPDU can stay true to its vision and retain its integrity?

When confronted with the “resistance group”  and “underground” analogy, Dr Price said she far more prefers to think of GPDU as a “national park”.

“Technology is changing culture, of course, and that part is the digital disruption to traditional structures and work flows.

“We are pitched [sometimes] as revolutionary or competitive but within this community, radicalisation is just altruism and love for our profession, our patients and our colleagues. Free (as much as possible!) from graft. That’s the part I think many find hard to understand.

“A national park means that everyone is welcome. Unity. Peaceful co-existence and respect for the environment.”

To date, the group has relied on the hard work and passion of a few. And while the ideals are great, it’s hard to see how this sort of dynamic can be carried into a larger organisation over a longer period of time.

With size comes rules, and with rules comes bureaucracy, and so on.

What if the group were to be twice or three times its current size within a couple of years? It might do that, and if it did administration wouldn’t be feasible at the level it is today.

“I don’t know how big GPDU can get,” Dr Price says. “I think it’s like a community of practice though, so you will always have a core of people who will be contributing who will jump in and out, and maybe for a few months it will be a certain group that will contribute with the larger group observing.”

Recently the group has done work on putting together a constitution, complete with policies and aims for the organisation that are designed to provide continuity and guidance over the longer term.

But eventually, there will come a need for money to help with administration.

One source might be a GPDU event. This is how SMACC helps to fund its organisation.

Dr Price says the GPDU is considering events, but not to make money. She says that events are a natural and important extension to a community such as GPDU.

“Events can deepen and enrich a community. They create the opportunity for valuable face-to-face connections that enhance collegiality, decrease the isolation of practice and engender trust.”

In the face of GPDU, it feels as if the large doctor-focused organisations are going to need to have a hard look at themselves and work out where their strengths might be synergistic.

At the CROSSROADS

The founders of GPDU are probably are going to arrive at some difficult crossroads in the not-too-distant future.

The trick seems to be how you get the lumbering and powerful incumbents to embrace the innovative, disruptive and agile-thinking that is coming from GPDU and other suchlike groups.

Maybe this is what Foucault was talking about all along. Power will find a balance. That will make for an interesting few years ahead.

Especially now that GPDU has been outed as the upstart disruptor that the big guys might need to embrace, not simply push away as a threat.