Author Archives: Genevieve Yates

Making Valentine’s Day matter, without spending a cent

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For many years, I rallied against Valentine’s Day.  I saw it as crass commercialism of love.

If I’m honest, I think that underlying my objection were memories of teenage angst.   Unlike all of the “popular” girls at school, I didn’t receive a single Valentine’s Day card or gift.    In the typical heightened emotional mindset of an adolescent, I saw Valentine’s Day as an annual reminder of how unloved and unlovable I was.

I learned the truth at seventeenJe ne regrette rien
That love was meant for beauty queens
And high school girls with clear skinned smiles
Who married young and then retired
The valentines I never knew
The Friday night charades of youth
Were spent on one more beautiful
At seventeen I learned the truth

Janis Ian “At Seventeen”

Fast forward a couple of decades and I found myself with a man who loved Valentine’s Day.  Growing up in America, for him it was a much hyped event.  According to Wikipedia, “in the United States, about 190 million Valentine’s Day cards are sent each year, not including the hundreds of millions of cards school children exchange”,  and “the average Valentine’s spending has increased every year, from $108 a person in 2010 to $131 in 2013”.

For my partner and his family however, Valentine’s Day was not about sending cards or gifts, it was about showing friends and family how much you appreciated them.

In some Latin American countries, Valentine’s Day is known as “Día del Amor y la Amistad” (Day of Love and Friendship). Part of this is about performing “acts of appreciation” for friends and colleagues: acts like a kind word, helping someone out with a chore, expressing gratitude, and telling colleagues, friends and family how much they mean to you.

You could argue that we should be doing this every day of the year, and you would be absolutely right, but it can help to have a day to remind us to focus our efforts on nurturing our various relationships, personal and professional.

Extending this further, it may be a timely reminder to check in on the most important person in our lives: ourselves.  How are you travelling? Are you nurturing your body and mind? Showing yourself a little self love? As we are all aware, we need to look after ourselves properly in order to help others.

My Valentine’s Day-loving partner is no longer with us, may he rest in peace.  However, I would love his non-commercial passion for Valentine’s Day to live on and be shared with others.  So I’m asking you all to consider reaching out to those in your life this Valentine’s Day, and bestowing upon them “acts of appreciation”. And, if you feel so inclined, put aside five minutes to take stock of your own state of happiness and well-being, hopefully showing yourself a little bit of self-compassion and kindness as you do so.

Do GPs ever regret referrals?

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Dr Justin Coleman's avatardrjustincoleman

Je ne regrette rien Je ne regrette rien

An Australian study (featured today in Medical Observer) has found prostate cancer patients are more likely to regret surgery than radiotherapy. This had me wondering; if my patient regrets surgery, should I then regret having referred them to a surgeon?

We would like to think our referrals are always based solely on the best outcomes, but can we really claim, as Edith Piaf did, Je ne regrette rien?

Or are we in fact sometimes swayed by factors other than outcomes – things like tradition, familiarity, friendships, or yesterday’s guidelines? It’s hard to identify any one referral as adamantly wrong, particularly if we self-reflect through rose-coloured lenses. But surely not every decision can be all La vie en rose.

If a GP refers to a surgeon in the private sector, the patient usually ends up getting surgery. Something about hammers seeing everything as nails?

So…

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IMReasoning – a brilliant podcast on clinical reasoning and great KFP study resource

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imreasoningI don’t often give unsolicited plugs for FOAMed resources but felt I needed to share my delight at having recently discovered the IMReasoning podcast. It is the creation of two internal medicine physicians, Dr. Art Nahill and Dr. Nic Szecket, working in Auckland and is described as “Conversations to inspire critical thinking in clinical medicine and education”.  I have binge listened my way through most of the episodes and thoroughly enjoyed them all.  They have found the sweet spot – demonstrating a near perfect balance between the informative and authoritative, and the entertaining and self-deprecating.

While relevant and helpful to us all, I think it is particularly of value to those intending to sit the FRACGP Key Feature Problems (KFP) exam for the first time, and for those who plan to re-sit.  It is also a “must” for supervisors and medical educators trying to develop clinical reasoning skills in their learners.

The KFP exam is designed specifically to test clinical reasoning.  It tends to have high failure rates and many candidates find it the hardest of the three Fellowship exams to get through.

As an RACGP State Censor, one of my jobs is to give feedback to failed candidates. While exam technique and knowledge gaps are undoubtedly factors for many, time and time again I see doctors with good clinical knowledge but poor clinical reasoning (memorisers, not thinkers).   They tend to find it difficult to assess patients in the context of the scenario given and to identify the key features/critical steps.

I think this podcast might help people better understand what the KFP is about. From here on in I intend to recommend the IMReasoning podcast as a KFP study plan essential.

You can find it at http://imreasoning.com/  and it is also available to download via iTunes.

I recommend starting from the beginning as the episodes build on each other.

In Episode 31: Stump the Chumps International with Genevieve Yates, I present a case for Art and Nic, attempting to “Stump the Chumps” with a very GP-type case. I chose the case because it illustrates some of the clinical reasoning and management challenges when assessing and managing some of the more complex primary care patients. (Spoiler alert – there isn’t a glorious diagnostic prize revealed or a great “ah ha” moment”).

 

Open letter to OSCE candidates

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The below is a copy of an open letter sent to all 2016.2 OSCE candidates today. It was written by the RACGP National Assessment Advisor, Dr Guan Yeo. I’m posting it here as it is one of the best OCSE tip summaries I’ve seen, containing many a gem, and will hopefully be helpful to future OSCE candidates also, when they start to prepare for this last FRACGP exam hurdle.

You can find other OSCE related posts here, here and here. My YouTube channel http://www.youtube.com/user/DrGenevieveYates  has links to various physical examination clips and other videos which might also help in OSCE preparation.

Dear candidate,

How are you progressing in your preparation for the Objective Structured Clinical Exam (OSCE)?

By now I expect you have your regular small-group timed roleplay sessions up and running. Improving your performance in the rating areas that apply across multiple OSCE stations is a good way to maximise your chances of success.

Use this quick list to check your performance, eg.:

Rating areas Some features of good performance
Communication and rapport Patient centred? Empathic? Patient expectations? Simple language explanations?
History General and focussed questions? Orderly? Demonstrates safe diagnostic strategy? (Murtagh)?
Physical exam Hand hygiene? Explains and is considerate of patient comfort? Orderly? Gives positive findings and significant negatives?
Investigations Prioritised? Staged – initial and later Investigations? Differentiates between your differential diagnoses?
Management Prioritised? Considered patient supports? What does the patient think/understand? What are the obstacles (eg. to behaviour change)? Safety-netting?
It is time to critically review your clinical experience and familiarity with conditions represented in the ICPC2 groupings, e.g. women’s health, mental health, musculoskeletal, ENT, etc. Study up now on the common presentations in your areas of weaknesses: How do they present? What history or examination do you target? How do you prioritise investigation? How do you manage – short term and longer term, explanations, drugs and non-drugs, again prioritisation.

Finally, hopefully you have already booked in for a trial exam. This is often useful to ‘polish-up’ your preparation.

To use your time effectively during the exam consider the following:

  • In the three minute reading time, do read the instructions line by line. Some nervous candidates miss entire lines as they read. It can be helpful to put your finger against each line as you read – it is simple, may sound silly, but it works. You don’t have to memorise – there is the same set of instructions on the desk inside the station.
  • When in the station, if you are nervous, it is easy to miss visual cues. So if eye contact is not your strong point, train yourself to look regularly at the ‘patient’.
  • Use the time at rest stations wisely. Besides toilet breaks and drinks of water, regroup your thoughts, use short meditative exercises/mindfulness, focus, and regain your composure in readiness for the next station. Avoid dwelling on previous cases as that won’t improve your scores, but rather prepare yourself mentally for the remaining stations.

I hope that you have found this information useful and I wish you well in the OSCE.

Dr Guan Yeo
National Assessment Advisor OSCE

General Practice – a strong-link or a weak-link profession?

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Not long ago I ran into a recently Fellowed GP whom I’d had the pleasure of supervising as a medical student several years ago.  She was exceptional – bright, keen and an amazing communicator who just “got it”.  During her time with me she joined in with my group registrar teaching and exam prep workshops (AKT/KFP and OSCE).  In the mock OSCE she did better than most of the registrars who were about to sit their Fellowship exams.  After three weeks in general practice (as a student) and a two hour session on what the AKT and KFP were about, she passed both written practice exams (which were shorter than but of a similar standard to the real thing).  Mind you, she wasn’t perfect – there were gaps in her knowledge, and nothing can replace clinical experience, but she was safe.  She knew what she didn’t know.  She knew how to find out.  She was a fantastically self-directed learner.

Fast forward the present day.  I asked her how she found GP training, which she had done with a now-defunct RTP.  She started with some generically nice comments but on my drilling down further she admitted that although it was great socially, the education program didn’t really challenge her and she felt it was, in essence, an exercise in box-ticking.

There are certainly many bright registrars who are extended and challenged during GP registrar training,  but she got me thinking, are we going about this the right way?

The “best and the brightest” are chosen for AGPT training.  Meanwhile, there are large numbers of general practice trainees who are working essentially unsupervised and unsupported.  Some of these have gone down this route by choice; however many are doing so because they are either ineligible for AGPT (usually due to their residency/registration status) or failed to get into the AGPT program.  There are some fabulous GPs amongst them, but there are also many that struggle, both in practice and with their Fellowship exams.  The support for these doctors just isn’t there.

While pondering this inequity, I was reminded of a podcast to which I’d recently listened.  It discussed the difference between weak- and strong-link sports.

soccerIn soccer, research shows that the way to maximize wins is to improve the worst players.  Success typically comes to those teams who have better 9th, 10th, and 11th players rather than those who have the best player.  It is argued that this is due to the nature of the sport, being that one player typically cannot create opportunities alone.  Thus it makes sense to invest in making the least talented players better.  Soccer is a weak-link sport for this reason.

basketballAlternatively, basketball is a strong-link sport.  Typically, the team with the best player wins.  It’s a star-driven sport because one player can have an outsized impact on the game despite also having the worst player on the floor as a teammate.  It is nearly impossible to prevent a great player from getting the ball, and/or helping his/her team score.

The question this threw up for me is whether Australian General Practice is closer to soccer or basketball.  Should we spend more time and resources trying to create a climate that maximizes the number and the relative success of already really successful and talented doctors, or should we do more to help those who are unsuccessful?  Obviously both are important, but which approach best defines and strengthens our profession?

Personally, I think we should take the weak-link approach.

I hasten to add that I’m not advocating a drop in standards, nor a regression to the mean.  We will still have our GP stars, and these inspiring individuals will continue to do our profession proud.  They still need (and deserve) support during training.  My point is that their needs are different, and perhaps the standard AGPT program is somewhat wasted on them, or at the very least would be more useful for others.  I would like to see a more tailored approach.

I’m also not suggesting that any doctor, regardless of suitability, should be working in general practice, and supported to do so.  There should be, in my opinion, baseline competencies, knowledge and experience required – a cut-off point, so to speak, below which a GP provider number cannot be issued.  This would require everyone entering general practice, not just those applying for AGPT, to undergo a rigorous selection process perhaps including an entrance exam.

For those who have reached the required standard of entry, I would like to see the distribution and type of support based on the needs of individuals.  It would be fantastic if extra Commonwealth funding was put towards GP training, but that is unlikely to happen. However, I think we could do so much more with what we’ve got. There are limited resources available, but wouldn’t be wonderful to see quality training opportunities given to those potentially great GPs who have the most need for structured and supported training?

Pie in the sky thinking, but a girl can dream…

 (The views expressed are entirely my own and do not reflect those of my employers.)

 

Sharks and sausages – the risks are small but is it worth it?

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One of my favourite quotes from medical school was “There are consistently more people in Queensland killed by choking on sausages than by shark attacks.”  I liked the quote so much it inspired me to write a play called “Death by Sausage”, which toured around South East Queensland in 2010. DEATH_BY_SAUSAGE

It highlighted to me how ridiculous is society’s fear of shark attacks, given how unlikely they are statistically.

I live about 200 metres from Lighthouse Beach in Ballina.   It is once again in the national news following a serious shark attack this morning:  the 4th in under two years, including a fatal one.

http://www.abc.net.au/news/2016-09-26/ballina-shark-attack:-teenage-surfer-bitten-at-lighthouse-beach/7876892

At least 3 of the attacks (I’m not sure about the 4th) have been near “the wall” – where the Richmond River meets the ocean.  With the out-flowing river water there are lots of nutrients, lots of fish and lots of sharks. I’m sure it is more complex than this but the upshot is that this is a very small area where sharks particularly love to hang out.

I love “my” little beach – less than a kilometre long – and visit it daily. I no longer go out past about waist deep water though.  It seems I’ve bought into the shark attack fear I scoffed at for so many years.  My justification is as follows:

Lighthouse beach, Ballina

While acknowledging that the chance of a shark attack is still rather small, this is the very spot where these recent attacks have occurred, while there are many, many kilometres of good surfing beaches in the local area without any reported attacks. Why would anyone choose to swim/ surf near “the wall” at Lighthouse Beach?

I was on Lighthouse beach this morning, about 90 minutes before the attack happened.   I know (by sight only) the local 17-year-old who was attacked and have talked to him and his mates once or twice.  I’m told he was one of the surfers who, earlier this year, protested against the installation of a shark barrier at the very spot he was attacked today, considering it unnecessary.  I believe he is expected to make a full recovery, thank goodness. I wish him all the best.

http://www.abc.net.au/news/2016-03-18/surfer-protest-against-shark-barrier-at-ballina/7259692

I don’t doubt that there are many more serious injuries from sausages than sharks in Queensland, but I’m betting this statistic doesn’t hold true for those who swim/surf near “the wall” at Lighthouse Beach, Ballina.

I’m not taking my chances… with sausages, or with sharks.  😉

 

Deprescribing: a fancy word for ceasing?

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DeprescribingWhat’s old is new again. Hipster beards are so in, they’re out, and where we used to simply cease medications—we now deprescribe them.

The art of commencing medicinal herbs dates back to Neolithic times. The art of stopping them began about a week later.

Probably why Hippocrates had to remind us to do no harm.

With this history, we gen-dinosaur GPs have recently been scratching our beardy chins wondering how we missed the memo that deprescribing is now a ‘thing’.

Mind you; old or new, learning how to stop medication is critical for patient care. And hopefully, now we have a word for it, tomorrow’s deprescribers will do it smarter and harder than we ever did.

Our generation received no explicit teaching, gleaning what we could from our mentors and, no doubt, from our mistakes.

A recent article in The Conversation highlights the dubious practice of using one…

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“Doctor Doctor” – almost enough to bring you to tears

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In a discussion about the frequent shedding of tears in my consulting room (most of them not mine) and my resultant high rate of tissue box turnover, my mother said, “Having never cried nor even thought of doing same when at the doctor’s, I find that rather strange.”

It got me a-thinking. Her personal experience of what “going to the doctor” entails has shaped her view about what us docs do.  And it’s not just my Mum (who actually has a pretty good idea about the life of a GP thanks to many years of my stories) – we all make judgements in life based on limited personal experiences. I’m reminded of the cartoon showing several blind men each touching a different part of an elephant and arguing over what the animal looks like.  I’m stating the obvious, I know, but bear with me.

When I first started medical school, I had absolutely no intention of being “just a GP”.  As children, my brother and I were taken to our family doctor for immunisations and referrals but not much else. My recollections are of consults that went something like this:

“My son has a strange rash on his forehead.”

“Here is a referral to a dermatologist.”

It surprised the hell out of me to learn that GPs diagnosed and treated all kinds of illnesses, and that many actually did complex procedures.  Thanks to an inspirational talk by a GP in my first year of med school and a great GP term in fifth year, I was sold on what general practice had to offer.

The message didn’t get through to everyone though.  I’ve lost count of the number of times my specialist colleagues have underestimated GPs’ capabilities. A urologist once expressed surprise that I was comfortable administering Eligard (leuprolide acetate) injections to a patient with metastatic prostate cancer. He seemed astonished that I was not only capable of mixing two pre-packaged components and giving an IM injection, but willing to do so.

I’m delighted to see the increase in positive promotion of general practice to med students and pre-vocational doctors.  Organisations like GPRA are doing wonders to attract the best and brightest to “the speciality which doesn’t limit”, and hopefully those who choose to pursue other paths will at least have a realistic idea of what we’re all about.

The RACGP has been doing its best to enlighten the wider community as to what versatile and clever ducks we GPs are, through its “the good GP never stops learning” campaign.  However, there are certain sectors of the general public who only pay attention when information is presented in the form of a “soapie” or a reality TV show on a commercial TV station.

We haven’t been doing too well in commercial TV-land in recent years.  Where once “G.P.” and “A Country Practice” appeared on Australian screens, audiences now take their medicine from TV hospitals’ dispensaries.  The morgue is a popular place to linger – forensic pathology has been hot for years and is showing no signs of dying (sorry!).  Our Australian veterinary colleagues’ have fared better. They weren’t doing too badly with Dr. Harry but have gone to a whole new level of sexy with Dr. Chris on “Bondi Vet”.

So when I heard there was a new Australian TV drama about rural general practice coming to Channel 9 in September 2016, I thought “Great! This might do the trick.”DocDoc_655x441

Until I heard the premise of “Doctor Doctor”.  From Wikipedia “Heart surgeon Dr Hugh Knight receives a life-changing punishment from the Medical Tribunal and is sent to work for a year as a country GP.”

From the Channel 9 website “Now the only way to salvage his brilliant career is to work as a lowly GP.”

Hmm…  I don’t think this program is going to do us any favours.

On the other hand, it might be wise not to let everyone know exactly what we do. If it became universally known that crying at the doctor’s is “the done thing”, it could send my tissue bill through the roof!

The Life Cycle of an OSCE Case

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Where did I come from imageI was asked recently, “So where do OSCE cases come from?  Who writes them and how do they get chosen for use in an exam?”

These are not uncommon questions. For many, the life cycle of an OSCE case seems to be a mysterious process, shrouded in secrecy.

It’s time we had the “Where did I come from?” talk…

It starts with a twinkle in an OSCE case writer’s eye, often during a patient consultation.  “This could be a good OSCE case,” the case writer muses, and from there, a case is conceived. It’s a long and complicated gestation, however, with no guaranteed delivery at the end.

OSCE case writers are neither a special breed nor an elitist group. They are a diverse mix of practising College Fellows from around the country, who are all experienced RACGP OSCE examiners specially trained in how to write OSCE cases, RACGP style.

Cases are based on real patients seen in the case writer’s own practice.  They are not derived from the rare and obscure conditions we all find so interesting, but from common and/or important presentations that competent Australian GPs are expected to be able to manage.

Taking care to de-identify the patient and to ensure that the issues involved are widely applicable to Australian GPs, the case writer creates a first draft using a standard RACGP case writing template.   With support and feedback from OSCE case reviewers, this initial draft may require considerable to-ing and fro-ing.

Once the first draft is complete, it gets formally reviewed by an OCSE medical educator (ME) and then road tested.  Yep, road tested.  Tried out by volunteer GPs who have not previously seen the case to see how it performs – which is not as much fun as taking a new car for a spin, in my opinion.  Essentially, these are people willing to do OSCE cases under exam-like conditions.  Some may call them dedicated, others may say masochistic, but everyone agrees that they are fulfilling an important role and helping make the OSCE better.

After the road test, the case goes through another round of review before moving to Standardisation. This is when a group of experienced OSCE examiners put its eyes on the case and marking scheme, suggests modifications if necessary, and decides on which aspects of the case (“Key Features”) are the most important.  These Key Features are then bolded to assist the OSCE examiners marking the case.

After all that, the case goes into the OSCE pool, vying for selection.  Unlike selection for the Australian Olympic Swimming Team which is, I’m guessing, based largely on swimming very fast in the right races, the selection of cases for the OSCE team is nuanced and complicated.  It is governed by the Exam Blueprint which takes into consideration many factors such as the General Practice curriculum, the frequency a condition is seen in general practice, and the importance of being able to diagnose and manage said condition.  This is why emergency presentations such as myocardial infarction occur more frequently in FRACGP exams than they are seen in a typical general practice.  They are uncommon, but you really need to get the diagnosis and management right when you see them.

The “team” of cases chosen for a particular exam needs to be balanced, so that a sufficiently broad spectrum of knowledge and skills is assessed. It may seem from the outside looking in that in some exams there are very similar cases, but even when the condition is the same, the different cases test different aspects, that is, the assessment tasks are different.

An OSCE case cannot rest on its laurels after selection for a particular exam. There is more scrutiny to come: firstly by an OSCE ME (a “fresh eyes” review) followed by the Assessment Panel Chairs (APCs), then the Quality Assurance (QA) examiners and finally the assigned examiners.  You would think by this stage there would be nothing left to review, but regardless of how many times a case is reviewed there can still be little typos or omissions which have slipped through the net.  Cases requiring last minute adjustments get “green sheets”, on which the changes are outlined for the case’s examiners.  Better to be green sheeted then yellow carded, but still, something to be avoided if possible, and with increased pre-exam reviews green sheet changes are getting fewer in number.

Finally the big day arrives and the OSCE case is role played in upwards of 45 rotations in approximately 15 exam centres around the country.

But it is still not over for an OSCE case.  Post exam, the examiners and QA examiners provide feedback on the case, and the statisticians work their numerical magic to see how it stacked up. If the case fell outside certain statistical parameters (e.g. discrimination index), it goes through a further review process.

After all that, we thank the case for its service by sticking it into quarantine for several exam cycles.

After being brought out of exile, it is updated, reviewed and road tested again before it is considered for use in another OSCE.

OSCE cases, like doctors, diet fads and mobile phones, don’t last forever. At some point, each case will need to come to terms with being pulled out of the pool.  After a bit of rehabilitation, the lucky ones will have a working retirement by being used for examiner training, mock OSCES and the like.  Others disappear, remaining only in the memory of those who tackled them on a long ago OSCE game day….

Such is the life journey of an OSCE case.

 

(First published in RACGP Queensland’s Examiners’ Newsletter, August 2016)

Dealing with the Known Unknowns

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If patients want a GP with excellent theoretical knowledge, I recommend they seek out a GP 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.

In my RACGP Censor role, 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 far past 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 GP who have just sat their RACGP exams.