Keeping abreast of the situation

old-lady-in-bikiniLorraine and Frank Cooper were booked in for skin checks. I had previously met Frank a few times but Lorraine only once. Like many older Australians they had managed, with the assistance of unprotected fair skin and direct sunlight, to achieve decades of perfect skin-cancer-growing conditions, and their crops of lesions were maturing nicely. Frank in particular rarely escaped without donating a skin chunk or two to our friendly local pathologist.

I quickly scanned their charts then walked into the crowded waiting room.

“Frank and Lorraine please.”

Frank sauntered over from where he’d been standing. Lorraine closed the two year old New Idea, placed it back on the rack meticulously, and headed towards me. They met in the doorway. Frank beamed at Lorraine, she returned his smile with her mouth but frowned with her eyes.

“You want us to come in together?” Lorraine asked.

“Only if you’re comfortable doing so.”

“No worries, Doc!” Frank said without hesitation.

Lorraine shrugged, “I guess so.”

“So who wants to go first?” I asked after we were seated and the usual pleasantries exchanged.

“Ladies first,” Frank volunteered.

Lorraine looked mildly irritated. “It should indeed be me, but not because I’m a woman. I was booked in first.  I heard the receptionist saying that his spot was at 3:15. Mine was at 3.”

At that point, I recall wondering whether Frank had done something to really annoy her that particular morning, or whether her touchiness was simply a result of years of accumulated frustration.

Lorraine’s history-taking unfolded uneventfully, but I hit resistance when it came to her examination.  As is my habit, I asked her to undress down to her underwear behind the curtain and to cover herself with the provided sheet.

“Is he going to stay?” she inquired.

“Not if you don’t want him to,” I quickly countered, sensing her discomfort.

“It’s OK, Luv, you’re behind a curtain, and anyway, it’s not as if you’ve got anything I haven’t seen before.”

“But you haven’t seen mine!

An alarm bell rang. It didn’t seem like something a wife would say – at least not without a “for years” or “recently” tacked onto the end.

I glanced again at their charts: same surname, different phone numbers, different streets, different towns. Uh oh!

Taking a deep breath, I somewhat sheepishly inquired, “This may seem like a silly question, but you are married, aren’t you?”

“Married? I’ve never met him before in my life!”

Luckily for me, both were very understanding and forgiving, and could see the funny side.

Frank was relegated post-haste to the waiting room while Lorraine had her solar keratoses cryotherapied in private.

Later, Frank lamented, “I was hoping to get a peek at some live bosoms. It’s been a long time.”

I must have looked shocked.  He rushed to explain. “I’m no perv.  I just happen to love breasts. All of them: pancakes or melons, firm or dangly. The only complaint I’ve ever made about a pair of bosoms is that they’re too… clothed.”

When I sought their individual consent to write this column (I didn’t want to breach their privacy a second time!), Frank’s face fell when I explained that I would need to give him an alias.

“I’d quite fancy my name in print,” he lamented. “Well, at least use my ‘all breasts are beautiful’ line, OK? I want to do my bit to help all the ladies out there be proud of their assets. And hopefully, bare them more often. But not too much time in the sun, of course, Doc. There’s too much breast cancer around nowadays as it is!”

(names and identifying details have been changed)

First published in Medical Observer, 25th July 2014

Coming to terms with how little we know

computer-labAt this very moment, I’m “invigilating”  the RACGP’s KFP exam (one of the three Fellowship exams) in Brisbane.  To the uninitiated, the word “invigilate” is of British origin dating from the mid-1500s, specifically meaning “to watch examination candidates, especially to prevent cheating.”  I know this because my mother duly informed me of such in an email this morning.  I casually that mentioned to my mum, during a Skype call earlier this week,  that I was going to be invigilating on Saturday and she was curious enough about the unfamiliar (to her) word to look it up.

As I look into the sea of earnest faces as they type away (yep, the exam is computer based), all I can think of is “thank God it is them and not me.”  I may be the “teacher”  but I reckon that if I sat the exams today, I’d probably fail.

If patients want a GP with excellent theoretical knowledge, I recommend they seek out a GP registrar who is about to sit, or has just sat, the Fellowship exams.  Breadth-of-knowledge-wise at least, for most of us, it is all downhill from there.

Drs David Chessor and Suzanne Lyon - recent successful RACGP exam candidates.

Drs David Chessor and Suzanne Lyon – recent successful RACGP exam candidates.

In my medical educator and RACGP examiner roles I spend a lot of time working with GPs in the peri-exam phase of their careers.  I’m constantly impressed with how much “stuff” they know and find myself wondering where all the “stuff” I used to know has gone.  I’m not yet forty, so can’t blame age-related cognitive decline.  I did get a knock to my head which resulted in six facial fractures and temporal lobe contusions, but I passed my FRACGP OSCE exam three weeks later so it can’t have done me too much harm.

And yet here am I, constantly having to look up drug doses, item numbers, clinical guidelines and the anatomy of the facial nerve.  Sometimes I feel like I’m just an ignorant lump of carbon.  The human brain is an unfathomably complex and wondrous organ, but its data storage and retrieval capacities are beaten hands down by a $5 USB flash drive.

What I find most frustrating is that it’s not just the old facts which have slithered out of reach: it’s the newer information too.  I try to keep up.  I read.  I listen.  I discuss.  But some things just don’t stick.  I’ll read an article on the newest research findings regarding the pathophysiology of chronic kidney disease, for example, and think, “Yep, I get it.  Kidneys sometimes confuse me but this I understand.  I follow the logic from start to finish.”

It’s like a light bulb.  A light bulb which blows five minutes after I’ve closed the journal.  Nothing.  Ask me to explain a single pathological process and I would probably say something like, “Well it is to do with sodium and tubules… and umm… you know, it is a great article.  I can email you a link if you like.”

Now before you put in a concerned call to the Medical Board, let me assure you that I am a safe and competent doctor.  I’m pretty good at knowing what I don’t know, and just as importantly, knowing how to fill the gaps left by the information that sneaks out of my cranium after dark.  I can Google with the best of them and I’m adept at ‘phoning a friend’.

What’s helped me most in my quest for knowledge retention is teaching.  For me it is not a matter of “Those who can’t, teach”, but more a case of “If you don’t know it, teach it”.  I find that there is nothing as effective for memory-boosting as explaining to others, especially with the luxury of repetition.  By the third or fourth time of delivering a particular topic, the content is usually firmly cemented in my brain.

While it is all very affirming and enjoyable to teach what you know well, preparing for and then teaching things you don’t know much about is so much more valuable.  If you’re up for the challenge, combining an unfamiliar topic with a knowledgeable group is even better.  You can channel and feed off their combined wisdom, and practise your skill at deflecting or redirecting those tricky questions.

I may know less about more nowadays but I’m happier than I’ve ever been.  Perhaps ignorance is indeed bliss.

Luckily, there is a lot more to being a good GP than the instant recall of facts and figures.  For the pathophysiology of kidney disease you can always ask Dr Google, or a registrar who has just sat those dreaded exams.

I may not have been capable of passing the AKT/KFP exams if I was a candidate today, but I think I’m doing a passable job as an invigilator.  I did, at least, remember the meaning of “invigilate”.  Unlike my mother.  For the irony of her looking up and emailing me the definition of “invigilate” this morning is that 6 months ago (at the time of the last AKT/KFP exams) my mum and I had a Skype conversation about the word, during which I explained its meaning.   Perhaps “invigilate” for her is like the “pathophysiology of chronic kidney disease” for me.

This has  been adapted from a piece was first published in Portraits of General PracticeGood Practice magazine, August 2013 (Article Download)