Monthly Archives: November 2013

General Practice is Messy

Posted on by
Reply

I’ve just read a great post by Dr Marlene Pearce about the art of uncertainty in general practice.

http://thedoctorsdilemma.wordpress.com/2013/11/24/the-art-of-uncertainty-in-general-practice/

As I found myself nodding in agreement to Dr Marlene’s wise and well-written sentiments, I was reminded of a conversation I had last year…

“I’m really surprised you settled for being a GP.  You used to be such an over-achiever!  Why didn’t you choose something that’s intellectually challenging?”

I hadn’t seen my old uni friend since Med School and after the first five minutes of listening to him boast about his prestige and income, I was reminded of why I hadn’t made the effort to stay in touch.  By the time he finally got around to asking what I was doing, I was seeking means of conversational escape.

I smiled sweetly and replied, “I did. Some enjoying fiddling around with bonsai, while doctors like me find challenge and reward in being swamp gardeners,” before politely excusing myself.

I was introduced to the concept of swamp gardening by GP, researcher and medical educator extraordinaire, Dr Louise Stone, during an address she gave at the 2011 GPET Convention, and I have to admit I’m quite taken with the metaphor.

It relates to the messiness of general practice: the reality that we spend much of our time dealing with undefined and sometimes undefinable illness.  In medical school we were taught to approach a presenting complaint in a stepwise fashion:  history, physical examination, investigations, diagnosis and then finally management.  In primary care, it isn’t always so clear cut.

Donald Schön, in his book ‘Educating the Reflective Practitioner’, wrote: “In the varied topography of professional practice, there is a high, hard ground overlooking a swamp. On the high ground, manageable problems lend themselves to solution through the application of research-based theory and technique.  In the swampy lowland, messy, confusing problems defy technical solution.”

The most horticulturally challenging swamp species are conditions without nice, neat diagnostic labels.  It is hard to wage war on a nameless, faceless enemy.  If they are tough for us, they are enormously more difficult for the patients they affect.   Many have been on the diagnostic treadmill for years.  Poked, prodded and imaged over and over by various GPs; bounced from specialist to specialist. They’re told everything they don’t have.  Some latch onto the labels they accumulate along the way, grateful for any name to explain their suffering.  I recall a patient for whom a somatoform disorder diagnosis brought immense comfort.  “It’s a real disease,” she’d tell her friends. “It means my body’s more sensitive than other people’s.”

Others find such diagnoses insulting, shameful and upsetting, desperate for a more “socially acceptable” explanation.  One such patient told me that the day she was diagnosed with breast cancer was the happiest day of her life.  “At least now people will believe I’m sick,” she said.  As Dr Stone said in her address, “There will never be a Fun Run raising awareness for medically unexplained symptoms.”

No one would deny that swamp gardening can be frustrating and draining.  However, if you are searching for meaningful, important and interesting work, you’ll find it in the swamp.

It is challenging to sail the diagnostic sea without sinking under the weight of over-investigation or being capsized by a missed serious condition.  It takes intellect and bravery to negotiate the treatment maze without a map. And there’s immense reward and satisfaction to be gained by wading through the swamp with your patients, weeding and planting.  Efforts which, if you’re lucky, will occasionally bear fruit.

Even if I had spent time explaining it, I suspect my old uni friend would not have understood the fundamentals of swamp gardening.  My cryptic answer made an impression though.  I heard that he’d commented that “Genevieve‘s gone all flower-power closet hippy.  Must come from living near Byron Bay.  Shame, that.  She used to be kinda normal.”

Adapted from my piece, “Swamp Gardening” first published  RACGP’s Good Practice magazine, Jan/Feb 2013  – “Portraits of General Practice” Column

Plagarism on Media Watch

Posted on by
Reply

I like watching the ABC’s Media Watch. It’s comforting knowing there’s a watchdog out there, revealing the details of misleading broadcasts.

It seems apt that the process is a public and transparent one, but I admit I’d never stopped to consider the effect on those named and shamed. That is, until I watched, transfixed, as Dr Tanveer Ahmed was exposed for serial plagiarism.

I immediately wondered how he felt, watching the show. How his family and friends would react … his colleagues … his patients. Would this be the end of his expanding career in public life or would he bounce back from scandal, with a profile even bigger than before, as do the likes of Alan Jones? Would this have implications for his clinical career? I really felt for him.

I’m not sure why it seemed so personal; I’ve only met Dr Ahmed once, briefly. Perhaps it was my getting to know him through reading his memoir, The Exotic Rissole. Maybe it was because I felt a certain kinship, being a fellow doctor-writer, although, unlike him, I am not even a speck in the public eye — thank goodness.

Kinship doesn’t guarantee loyalty, as was patently obvious in the media aftermath of Dr Ahmed’s outing. His harshest critics seemed to be fellow medicos, particularly his psychiatrist colleagues, several of whom displayed considerable schadenfreude in their Media Watch website postings. It seems not even psychiatrists are above a metaphorical “na-na-nee-na-na”.

Not that I’m defending Dr Ahmed’s actions. His is a clear-cut case of plagiarism on a grand scale, and it is right and proper that it was revealed the way it was. What astounds me is how he got away with it for so long. Even before the Google age, when I was at school plagiarism was promptly noticed and punished, although I do recall two notable exceptions.

The first was of an unremarkable Year 10 student who submitted a remarkable short story that earnt him top marks in his English assignment and first place in the school’s writing competition. Within hours of its publication in the school newsletter, the headmaster received several calls revealing the story to be a well-known Jeffrey Archer piece meticulously copied word-for-word. Unfortunately, the embarrassment didn’t end there. It had been entered into a statewide competition, and the plagiarism was discovered before the submitting teacher had facilitated its withdrawal. “At least,” it was noted, “the teacher recognised and rewarded good writing.”

Which segues into my second exception. My younger brother constantly complained about going through school in my academic shadow. He is not without brains — in fact he’s far smarter than I am — but, like many bright schoolboys, he was not overly interested in applying himself. Two years behind me, he felt unfairly compared with his ultra-nerdy goody-goody sister. He even had “proof” of reverse favouritism, in the form of an English book review assignment.

Facing the deadline and having not even read the book, my brother decided to print out my two-year-old review, which was conveniently stored on our home computer, and submit it with only the name and date changed. On the return of “his” assignment, he felt both outraged and vindicated that his received an A-, while my identical one had earned an A+. His self-righteous indignation remained private, for obvious reasons.

Dr Ahmed’s transgressions are no longer a private affair, but at least he didn’t respond with indignation. I thought his Australian Doctor-published response was frank, apologetic and most importantly, in his own words.

I wish him well.

………………………..

Written in October, 2012

First published in Australian Doctor on 24th October, 2012: On plagiarism

http://www.australiandoctor.com.au/opinions/the-last-word/the-last-word-on-plagiarism

Listen to your heart – my response to ABC TV’s Catalyst program

Posted on by
4

In the last fortnight or so, there has been a lot of talk about the two part Catalyst special on cholesterol and statin medications. The Heart of the Matter aired on the 24th and 31st October on ABC TV  and received widespread publicity in both the mainstream and medical press. Despite currently being on leave from clinical work, I’ve been approached my numerous concerned friends and non-medical colleagues asking for my opinion on the issues raised. In my role as a medical educator, I’ve had an enquiry or two from somewhat confused registrars wanting to know what to say to their worried patients.

Now this is not a bad thing in itself. Increasing public awareness of important health issues, transparency and rigorous independent scrutiny of established scientific “facts” are vitally important.  Like many others, I abhor the tendency to over-medicalise, and the increasing pressure from many sources to over-diagnose and to over-treat. Having said all that, I was disappointed in Catalyst’s treatment of the issues raised.  I thought it was sensationalised and unbalanced, and therefore irresponsible to air.  Using emotive terms such as “toxic”, “organised crime” and “conspiracy” is not helpful to anyone.

Although the Catalyst shows came with a token disclaimer, I worry that such scaremongering will result in fear-based rejection of statin medications.  I’m not saying that statin medications are  beneficial to everyone, far from it, but there are certain subsets of patients for whom statin therapy may well be lifesaving and I worry that these some of these patients may be adversely affected.

On the positive side, it has brought the topic of heart health to the public’s attention, and provided a good opportunity for doctors  to reassess their patients’ absolute cardiovascular risks, review their need for medication, and to provide education and  advice on all lifestyle risk factors. The shows also emphasised the importance of regular exercise and a diet low in refined sugars.  All good things.

And I was inspired to create my first ever YouTube mash up/ musical parody. I’m not sure if this was a good thing or not, I’ll let you be the judge…

It was created on a whim while travelling.  I had no recording equipment other than my laptop’s cheap and nasty internal microphone (I apologise about the audio quality!) and was overtired.  I know fatigue is not a legitimate medico-legal defence regarding duty of care to patients, but I wonder if it is a reasonable excuse for questionable creative content?  Perhaps, like shopping when hungry, it is merely ill advisable. All just a bit of fun really, and a chance to try out my Camtasia software for the first time.

Feel free to comment below if you so wish.

If you missed the  Catalyst shows and want to see what the fuss is about they are available on YouTube.

Episode one link

Episode two link

For an excellent summary served with lashings of evidence and a sprinkling of humour, check out Dr Robin Park’s blog post.

For some great advice to junior (and senior!) doctors, check out Broome Docs “Letter to my registrars:on statins and stuff” in which a great comparison is made between the current media storm on statins with the uproar over HRT in 2002.  Like Casey, I was a bright-eyed bushy-tailed registrar when the WHI results were first released and remember all too clearly the widespread patient (and doctor) panic over HRT.  It taught me some valuable lessons.  Firstly, I learned to not take medical information imparted to me from on high as the gospel truth, but to always question and to keep questioning “truths” over time. As I’ve become more experienced, I have discovered that nothing in medicine is absolutely right. The more I know, the less certain I’ve become. Secondly, it introduced me to the swinging pendulum: HRT was all good, then all bad, and now rests somewhere in the midline – sometimes good, sometimes bad, depending on the clinical situation. Thirdly, it got me in the habit of using sentences such as “based on current guidelines / what we know at the moment, I would suggest ‘X’ but this may change as further evidence comes to light,” rather than sentences like “Evidence shows that ‘X’ is the best treatment for you.”

For some “fat facts” from the ever-reputable Rosemary Stanton, you can find her article in the MJA here. She points out that Catalyst “relied on the opinion of a journalist and four US experts — a nutritionist, two cardiologists and a physician — but failed to note that three of the experts market a range of “alternative” products via their websites (www.jonnybowden.com, www.drsinatra.com, www.proteinpower.com), including diet “aids” (with “slimming” claims), anti-ageing, “brain power” and detox supplements, plus a variety of bars, shakes, drinks and powders. One product even claims its citrus bergamot content will lower triglycerides, blood sugar and inflammatory LDL (low-density lipoprotein) cholesterol and raise HDL (high-density lipoprotein) cholesterol.”

And finally, a must read: the ever-witty Dr Justin Coleman weighs in with his sceptometer blowing a fuse in the process.

Assessing fitness to drive – dealing with bullies.

Posted on by
Reply

Dr Andrew Gunn has just published a highly entertaining piece on the serious topic of assessing fitness to drive in the elderly.

http://drandrewgunn.com/2013/11/01/the-last-word-on-fitness-to-drive/

I agree with Andrew that the current system has the potential to cause real damage to the doctor-patient relationship and that routine practical testing for older drivers would be a significant improvement. What do you think?  (please comment below)

Anecdotal evidence seems to suggest that some patients will doctor shop with their fitness-to-drive paperwork and lie and/or bully doctors into signing the forms. As a junior GP registrar I felt unprepared to deal with such demanding patients, and on a couple of occasions caved in against my better judgement. One of the most memorable was with “Betsy” (name has been changed).

Betsy was an exceedingly frail 88-year-old who hobbled painfully slowly and breathlessly into my room using her wheelie walker. Her list of medical problems was long and impressive, and included uncontrolled diabetes, heart failure and Parkinson’s. The medical certificate form for her driver’s licence renewal flapped almost comically in her shaking hand. Despite its being patently obvious that she was unfit to cross a road unaccompanied let alone get behind the wheel, I’m ashamed to say that I was bullied into signing the form, for lurking underneath that frail exterior was a very aggressive and manipulative woman. I didn’t sleep well that night, terrified that my cowardice might result in great harm to some innocent road user.

Less than a fortnight later I heard that Betsy had died at the wheel. Imagining the worst and having visions of being hauled up in front of the coroner to explain my negligent action, I spent the next few hours in a state of panic. To my immense relief, I discovered that far from causing an horrific multi-vehicle accident, Betsy had in fact executed a perfect parallel park in town, but failed to alight from her car. Cause of death: massive CVA.

I’ve never gone against my clinical judgement when signing a driver licence medical certificate again, much to the chagrin of several patients.

I’m willing to bet that a fair proportion of us doctors were subject to bullying as schoolkids. Some of us disguised our intellect, played rugby, hung out with the cool kids and went on to become orthopaedic surgeons, but many of us, myself included, found ourselves in the nerdy camp. Orchestra, choir, debating, chess club, maths quizzes and science summer schools were not the kind of extracurricular activities which helped one climb the school social ladder. Add to that a goody-two-shoes attitude, the wrong wardrobe, acne, braces and a few extra kilos, and you get a bully’s pin-up girl – or rather, voodoo doll.

Time went by; we all grew up and I for one relished the idea of living and working in a mature, fair, supportive, adult world. Alas, I was to discover that not all schoolyard bullies grow out of their penchant for pushing others around.

While only a small number of patients attempt to bully us, the ones who do can cause considerable headaches.  Ignoring those who put our physical safety at risk (that’s a whole other topic), the ones who put undue pressure on us to grant their wishes can be more than just unpleasant to handle – their behaviour can result in our treating them inappropriately.

Unfortunately, I did not immediately apply the lesson learned with “Betsy” to other unreasonable demands made of me.  One busy morning, as the only doctor on duty, I was rung by the practice principal’s wife and informed that a “VIP patient” (a close friend of hers) was en route with “something in his eye”. “No care is to be spared!” was her instruction.  I was mildly offended at the insinuation that I spared my care according to whim, but all such thoughts were swept away by the arrival of a distraught wife with her vomiting husband in tow.  I did not need fluorescein to find the foreign body: he had a 2cm diameter bamboo rod protruding from his orbit.  A simple case of ambulance to the nearest hospital, I know, but the patient and his wife flatly refused to be treated at a public hospital, but instead insisted on driving to a private ophthalmologist (there being no private hospital emergency facilities nearby).  After valuable minutes ticked away with my arguing the point, I acquiesced. I had a difficult phone conversation with a local ophthalmologist, hurriedly scribbled a letter and sent the patient on his way.

Later that day, I received a deservedly irate phone call from the ophthalmologist on whom I’d dumped this unstable patient.  It was a metaphorical poke in the eye with a big stick, and I still wince when recalling the dressing down. Luckily, the patient’s outcome was a relatively good one, all things considered.  He lost the eye, but did not suffer any intracerebral complications.

As children we are told, “It’s all fun and games until someone loses an eye.”   It took me a long time to learn this lesson, but learned it I have – I’m no longer a pushover when it comes to bullies.

 

(Identifying details have been changed to protect patient privacy. Blog post has been adapted from my column “Dealing with bullies” published in MIPS Review Spring Edition, September 2011)