The House Call

This is a true story but some details have been removed or altered to de-identify the people involved and protect their privacy.

The call came as I was sitting down to dinner.  My tuna casserole was never going to win any culinary prizes and there was no ‘plating up’ involved, but the food was hot and I was hungry.  I put my fork down with a sigh.

“Can you come and see me Doctor?  My breathing’s really bad.”

It was after 8 and I’d had a long and dispiriting day.  You know the kind… filled with the worried well (“I’m still feeling dizzy at times, perhaps it’s a brain tumour?”), and the unworried unwell (“Strewth, Doc, it’s only a touch of sugar.  Stoppin’ me tablets won’t kill me.”).  I wasn’t officially on call.  Should I get someone else to deal with this?  No, this one had my name on it.

I’d first met 58 year old Peter ten weeks earlier, and had seen him a dozen or so times since.  Diagnosed with malignant mesothelioma the previous year, he had opted for the most aggressive treatment possible: surgery, chemotherapy and radiotherapy.  Stubbornly determined to beat the disease, he’d sought other options when his specialists had run out of theirs.

His quest had led him to an ‘holistic healer’ who ran an ‘exclusive private health retreat’ on a tucked away acreage property not far from the town in which I worked. Without qualifications of any kind nor recognition from any professional body, the healer peddled hope, and it came with a hefty price tag.  The ‘scientifically proven, powerful, herbal remedies’ were ‘imported directly from the USA’ and did not come cheap.  Client’s bank accounts often became emptier than their colonic-irrigated bowels.

The potion used in Peter’s residential programme was particularly pricey.  For his treatment he paid about $30,000 a month, with the expectation that it would last between two and three months and give him a 95% chance of total cure.  For this desperate man, such odds could not be ignored.  He liquidated all his assets, including his house and car, paid the $20,000 up front fee and moved into the ‘health retreat’.

Two weeks into his regimen, Peter ended up in my consulting room for the first time, brought in by the healer’s assistant.   He was dehydrated and had significant electrolyte disturbances from the brutal starvation and purging regime to which he had been subjected.  After IV rehydration, he insisted on returning to the retreat for continued holistic treatment, against my strong advice.

A week later, I saw him for the drainage of a pleural effusion which was significantly interfering with his breathing.  He flatly refused to go to hospital, and so I performed the procedure under the supervision of my supervisor (being as I was a GP registrar at the time).

The pleural tap needed repeating several times over the next few weeks, as his chest cavity continued to steadily fill with fluid.  He looked worse each time he came and was losing weight rapidly, yet he remained optimistic, fervently believing that his ill health was evidence that the treatment was working.

“You get sicker before you get better because the herbs draw out all the toxins from your cells and they go into your blood.  Once they’re in the blood, you can flush them out of your body but it takes time.  My healer says that my cellular toxin levels are now really low and that the cancer cells are almost functionally normally.  It’ll only be a few more weeks and I’ll be better,” he explained.

Unfortunately for Peter, his toxins outlasted his ability to pay for their removal.  When his monetary funds dried up, so did the healer’s hospitality.  The dying man was ‘discharged’ from the retreat and left to fend for himself.  Too sick to travel, he stayed in the local area and moved into a dilapidated caravan.

At first he was devastated and disbelieving, coming to see me three times in as many days to debrief.  “He told me that if I’d had enough money for another month’s treatment I would be cured.  I begged him to treat me and let me to pay him back later but he refused.  How can a healer, of all people, be so heartless?”

Peter’s shock soon gave way to anger, resentment and self pity, which became all-consuming and indiscriminate.  He wanted nothing to do with anyone even resembling a health care worker: hospital staff, doctors, palliative care nurses, alternative therapists and even meals-on-wheels volunteers.  When I’d tentatively knocked on his door a week earlier, he had yelled out, “Leave me the hell alone!”

I’d slipped a note under his door with my mobile phone number and a message encouraging him to call me whenever he needed help.

The phone call came that Wednesday evening and the consumption of my tuna casserole was postponed.

Peter was in a bad way.  His abdomen was grossly distended by ascites, making his matchstick limbs appear even more insubstantial.  Lying in urine, faeces and vomitus, the stench was almost overpowering.

He was clearly in great discomfort and I felt out of my depth.  I urged him to allow me call an ambulance, but he vehemently refused.  Rifling through my doctor’s bag, I offered an assortment of medicinal substances including analgesics, diuretics and tranquilisers, but he turned them all down.  Even my attempts to remove his expelled body fluids and change his clothes and bedding were met with resistance.

“I can’t help you if you won’t let me,” I exclaimed, frustrated.  “Why did you call me?”

“I… don’t want… to die… alone.  Please… stay.”

Each word required tremendous effort, leaving him breathless and exhausted.  His pleural effusions had constricted his fragile lungs, reducing them to a fraction of their original volume.

“Is there someone I can call for you?”

“No… yes… my son.  Tell him… I’m… sorry.”

Peter had previously told me of the falling out he’d had with his only child, David, over his decision to seek expensive alternative therapies.  Believing David was only concerned about the spending of his inheritance, he’d cut off contact.  Too proud to “go crawling back penniless and have him tell me ‘I told you so’,” the rift had not been repaired.

This was my chance to do something meaningful and I grabbed it gratefully.  I needed it as much, if not more, than Peter did.  I found his address book easily and called his son, hoping for a heart-warming reconciliation…but this was real life, not a made-for-TV movie.  The phone rang out; no one was home.  I spent the next hour ringing around trying to locate David, to no avail.

Frustrated, I sat holding Peter’s hand as he drifted in and out of consciousness.  I knew what I had to do.

“David says he’s sorry too, and that he loves you very much.”

Peter’s face relaxed, a hint of a smile evident on his lips.  He squeezed my hand.

“Thank… you… for… caring.”

I stayed with him until he died later that evening.  No one should have to die alone and unloved.

I couldn’t give him the hope of a cure, at any price, and he’d refused my offer of help to ease his physical suffering, but what I was able to give Peter was priceless.  I was able to restore a dying man’s faith in humanity, at least a little.

 

 

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A deeply personal experience of post-traumatic growth: “Just a GP” Podcast

A few days ago, I was lucky enough to sit down, “virtually”, with three passionate and innovative doctors (Ashlea Broomfield, Charlotte Hespe and Rebekah Hoffman) as a guest on their fabulous new podcast “Just a GP”.

They asked me on the show to talk about how personal tragedy has affected me – as a doctor and in other aspects of my life.  It is a heavy topic; a topic society doesn’t much talk about.  I felt privileged to have the opportunity to address it, difficult as it was to speak about.

I spoke about post-traumatic growth – the idea that positive psychological change can occur as a result of adversity.  This is different to resilience, which is about how quickly and completely you “bounce back”. The difference between resilience and thriving is the recovery point – thriving goes above and beyond resilience, and involves benefiting from challenges. It is about finding meaning in the seemingly meaningless.

Post-traumatic growth should not be thought of as “getting over” grief.  You don’t get over grief – you absorb, adjust and accept it. You find a new normal, changed forever.

Not everyone is a fan of “post-traumatic growth” as a concept. Some believe it to be “motivated positive illusion” whose purpose is to protect us from the possibility that we may have been damaged.  If I’m happy and at peace just because I’m deluded, I honestly don’t mind – it works for me. 🙂

Whether you believe that people can become psychologically stronger after adversity or not, I do hope you enjoy the podcast, and that the tips I give about supporting others who are grieving will be of use.

You can’t go back in time and make all the bits of your life pretty, but you can move forward and make the whole picture beautiful.

Also available via the usual podcatchers.

 

 

Leaving the Swamp Behind

12 months ago today, on the 2nd anniversary of my spouse’s death, I wrote a blog post about experiencing an urge to hit a patient (“Weathering the anniversary storm”). I explained that leading up the anniversary, communicating with patients and staff felt forced, and that conveying empathy felt fake.

This year, there have been no anniversary storms… just clear, calm and reflective waters.

Admittedly, verbal communication has been a little tricky due to a viral URTI, but laryngeal inflammation aside, I’m feeling as caring as ever.  More so, if anything.

On my partner’s birthday yesterday (he was killed on the morning after his 39th birthday) I made his favourite cornbread and lit candles, reminiscing about the love and beauty he brought to my life and to the world-at-large.

Birthday cornbread

Today I’m reflecting on the blessings and opportunities he continues to bring me, albeit in absentia.

For example, a few days ago I was doing bereavement counselling with a very sad patient who’d lost her husband of sixty years. At the end of the 45 minute consultation, I felt lighter, rather than heavier as I would have done previously.  As I was talking to my patient, indirectly using my lived experience to meaningfully help her, I felt my own burden lightening.

Being helped by helping others is not a new experience for me. What has changed is that the positive feelings are not always accompanied by a twinge of pain.

I’ve made it through the swamp and  to the other side.  It is not “getting over” my losses.  It is about moving forwards, with my grief, to a new place.

I hasten to add that there are, and always will be, painful moments. Grief will never completely leave me.  But the tsunami waves are less frequent, less overwhelming and, for the first time, not as predictably triggered by anniversaries and emotional interactions.

My life now is very different to that of my pre-swamp days. I am very different.  Becoming a childless mother and a widow changes you irrevocably. But I have not been changed for the worse.

For a start, I am a better doctor and educator.   I feel that I’m making a positive awareness-raising difference, as I wrote about here: “I’m more like herpes than Ebola” – spreading the message about driving fitness

I am a stronger, more appreciative and more grounded person for having loved and lost.

My life is as sweet as it has ever been.  Not sickly, fairy floss sweet, but rich and deeply layered, with the occasional hint of bitter to balance the sweet.  It is full of meaning, purpose, humour, interest and joy.  I’m lucky indeed.

I’ve gone from languishing to flourishing.

As has the tree which houses the ashes of my family.

Amalie’s tree 2015

Amalie’s tree 2018

 

Proposed changes to mandatory reporting laws for impaired practitioners

One of the perceived barriers to health care by impaired health practitioners (outside Western Australia) is the fear of being reported to AHPRA.  This particularly affects practitioners with a mental health condition. Mandatory reporting of AHPRA registered practitioners by AHPRA registered practitioners was introduced into National Law in 2010 and there is still widespread confusion as to what the requirements are.

The threshold for reporting to AHPRA is high and its purpose is to keep the public safe, not to punish or discriminate against doctors who are struggling. If a practitioner has an impairment (e.g. a psychiatric illness) but works appropriately, safely, and is managing the condition appropriately, they do not need to be reported under current legislation. The trouble is that this is not well understood by practitioners who are patients or by practitioners who are treating other practitioners.

I facilitate workshops for doctors and other health professionals on mental health and wellbeing on a regular basis. The topic of mandatory reporting comes up nearly every time, even in groups of highly experienced practitioners.  It is seen by many as a barrier to seeking help and to providing health (to other practitioners).

In WA, practitioners are not required to make a mandatory notification when their reasonable belief about misconduct or impairment is formed in the course of providing health services to a health practitioner or student. However, there is still an ethical obligation to protect the public and voluntary notifications can be made. This would generally only happen if the risk to patients is high and the health professional is unwilling to self-report.

The mandatory reporting requirements of treating health practitioners is currently under review and the Australian Health Ministers’ Advisory Council has recommended a nationally consistent approach to mandatory reporting, in line with West Australian legislation.

Ministers at the COAG Health Council meeting on 13 April 2018 unanimously agreed to take steps to remove barriers for health practitioners to seek treatment for an impairment, including mental health conditions. Ministers agreed to the drafting of a nationally consistent approach to mandatory reporting.

Watch this space!

In the meantime, PLEASE never make a report to AHPRA without discussing it with your medical indemnity organisation first. They are exempt from mandatory reporting requirements and you can discuss your situation in complete confidence.  They will advise you whether your situation meets the threshold and if so, how best to report it.

 

References:

COAG Health Council Communique 13 April 2018

https://www.coaghealthcouncil.gov.au/Portals/0/CHC%20Communique%20130418.pdf

Australian Health Practitioner Regulation Agency (accessed 31 Dec 2017) Guidelines for mandatory notifications. Available at: http://www.medicalboard.gov.au/Codes-Guidelines-Policies/Guidelines-for-mandatory-notifications.aspx

Bird, S. (2016) Mandatory Reporting of Health Practitioners, MDA National Defence Update, Winter 2016. Available at: https://www.mdanational.com.au/~/media/Files/MDAN-Corp/Publications/Defence-Update-Winter-2016.pdf?la=en

Why I may sign your fitness to drive form

A great blog post on Assessing Fitness to Drive by Dr Mark Raines

Mark Raines

“Well, Mr Terry I have some bad news. The results of your tests shows me that it is no longer safe for you to drive.”

“But why, young whipper snipper, you don’t understand, I’ve been driving since before you were born……”

One of the harder things I have do as a GP is to tells someone that they should no longer drive and they need to hand in their license. I have lost a few patients along the way because we have disagreed on their ability or competency.  Generally during a consultation, I consider the patient before me, and sometimes their family. But in this situation, I have a responsibility to consider the wide community. In fact, you also have this responsibility as the F3172 form you gave me to sign for your drive medical stipulates.

“If you hold a Queensland driver licence, or are applying for a Queensland driver licence, you…

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“I’m more like herpes than Ebola” – spreading the message about driving fitness

Assessing to Drive teaching Sydney June 2017

Since my partner was hit and killed in 2015 by an unfit elderly driver, I’ve been on a mission to increase awareness of the importance of fitness to drive assessments by health professionals.

My YouTube video on assessing fitness to drive has not exactly gone viral but it does have over 6800 views, steadily building over time, being passed from one person to another.  Actually, it has gone “viral” in that respect , but more like herpes than Ebola! And like herpes, I hope the message sticks with those who watch it, quietly sitting in the background and then making its presence known now and then, such as when they have to do a driving assessment on an elderly driver.   I’m not sure that the phrase “I’d rather be herpes than Ebola” will ever take off, but it works for me.

I’m very grateful for the opportunities afforded to me to speak in person at educational sessions, especially sessions run by GP regional training organisations including GP Synergy, EV GP Training, Murray City Country Coast GP Training and Generalist Medical Training.

I was particularly delighted to be a recent guest on the wonderful GP Show podcast with Sam Manger, on which I shared practical tips for GPs on how to approach driving fitness. I hope you will check it out….

http://thegpshow.libsyn.com/assessing-fitness-to-drive-with-dr-genevieve-yates-gp

Nothing can bring the love of my life back. But if sharing our story indirectly results in one fewer person being injured by an unfit driver, at least some good has come out of this senseless tragedy.

Dr Viktor  Frankl an Austrian neurologist and psychiatrist who survived the Holocaust, expoused the importance of finding meaning in terrible circumstances. He said “In some way, suffering ceases to be suffering at the moment it finds a meaning.”

Much as putting our story out there has been hard, knowing that it could possibly save someone else’s loved one has made it worthwhile.  And I’m so grateful to the many doctors who have told me that it has changed the way they approach fitness to drive assessments.

Remember, driving is a privilege, not a right.

Drug seeker basted me like a turkey

A brilliantly witty piece from Justin Coleman about being duped. I can certainly relate. I once had a regular patient with whom I spent 45 minutes talking about how she would tell her 10 year old daughter that she was dying of metastatic ovarian cancer. She was in tears, I was in tears. Understandably, she was on high doses of opioids for her cancer pain. It was only later I discovered her impressive medical documentation was fake and that she had neither cancer nor a daughter. It was all an elaborate hoax to get prescriptions.

drjustincoleman

Turkey, by Ben Sanders Illustration: Ben Sandars

This month I got done over by a drug seeker. Tattoo Man basted me like a Christmas turkey, peppered me with garnished praise and slow baked his way through my seasoned outer crust. Bugger.

Usually, when it comes to slamming the script pad shut, I’m all Fort Knox.

Reception deliberately sends all hopeful newcomers down dead-end street to my brick wall. Five minutes later they exit, loudly proclaiming to the waiting room that, in effect, my clinical decisions are being influenced by the rather unlikely combination of both my genitalia and distal GI tract.

Funnily enough, those occasions are relatively easy. My patients in the waiting room know me well enough to guess what might have happened. And everyone knows their role: the receptionists blame me, as instructed, and I blame our Practice Policy—the only thing I’ve ever written which remains unsigned.

“Sorry madam, I’d love to…

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48-second GP consultations

If I could change one thing about working clinically as a GP, it would be time pressure. I find seeing patients every 15 minutes a struggle, especially when instead of “catch up” slots there are “fit in” slots. I cannot imagine being able to feel good about my job if I only had a couple of minutes, or less, with patients. I know the environments and expectations are very different, but I’m not the high throughput type. I like taking my time… https://www.youtube.com/watch?v=zF5gcEQVxL4

drjustincoleman

Less is less

A recent BMJ study highlighted the remarkable degree of international variation in how much time GPs spend with their patients.

In Pakistan, a patient with a laceration would barely have time to explain how it occurred, let alone have it sewn up.

Whereas in Scandinavia, by the time the consultation ends, the wound has already healed by secondary intention.

Of the 67 countries studied, Australia ranks pretty much where you would want it – our 15 minute slots put us in the top quarter. Generous enough for a country that can afford it, without being inefficient.

Half of the world’s population—predictably, the poorer half—spend less than five minutes with their primary care doctor.

A couple of minutes is all you get in Nepal or China, regardless of how long it took you to travel to the surgery in the first place. I suspect there’s not much chit chat about the…

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GP Sceptics podcast 12: Doctors’ resilience

It was a thrill and an honour to be interviewed on my favourite podcast, by two of my favourite people, on one of my favourite topics. I hope you enjoy it at least a tiny bit as much as I did.

Terry (aka Mr Perfect) wrote a lovely blog post on the episode with his take home messages here:  https://www.linkedin.com/pulse/doctors-resilience-gp-sceptics-podcast-terry-cornick/

drjustincoleman

Kat_Ritchie_pod12_small By Kat Ritchie

soundcloud

What keeps a doctor resilient, when dealing with a high-pressure job helping patients who are distressed and traumatised?

How can doctors balance empathy with self-care? Does easing a patient’s burden imply carrying it for them?

Dr Genevieve Yates teaches the art of resilience to doctors around the nation, and here we distil one podcast-worth of her wisdom.

Listen to it after a long day at work, or when you’re feeling vulnerable.

Even better, listen in bed, where Justin’s soporific opinions will guide you towards a replenishing sleep. Look after yourself, folks.

In Liz’s Special Source, Liz takes a look at the funding and influences behind ‘Therapeutic Guidelines’ — hint: it comes out clean.

Liz reveals her pin-up nerdy-researcher boy (Justin’s is Ben Goldacre), and we invite Dr Google into the GP surgery.

All this and more, in our final podcast for this ‘RACGP Year’ (October to October).

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Weathering the anniversary storm

I had a sudden urge to slap a patient yesterday afternoon.  I didn’t act on the urge and was in no danger of doing so, but it rattled me all the same.  I’ve never before felt like I wanted to hit anyone (with the possible exception of my brother when we were kids, at times of peak annoyance).

For confidentiality reasons, I cannot reveal the content of the consultation which triggered such an out-of-character emotional response in me.  In general terms, the patient has an unhealthy dose of the “poor me” mentality, a stark lack of insight into, or compassion towards, others, and is causing her loved ones distress and harm.  We not uncommonly see patients like this and she was not an exceptional example.  I normally handle such patients perfectly calmly. She just happened to inadvertently say exactly the wrong things at exactly the wrong time…. wrong for me that is.

My response was not about a heartsink patient, it was about a heartbroken doctor.

I have become really good at separating my “stuff” from my patients’ “stuff”.  Caring about, but not self-identifying with, patients’ problems.  Not contrasting or comparing.  Being very mindful (ie present, aware and non-judgmental) during consults.  Providing genuine empathy without taking others’ emotional burdens.  It has taken time and a heap of deliberate practice to do this well but the rewards have been oh so sweet.  Career saving.  I’ve got back my clinical work mojo. I once again love seeing patients.

But not yesterday.

Yesterday,  communicating with patients and staff felt forced. Conveying empathy felt fake. Working like that is draining; utterly exhausting.

Why were things suddenly so difficult?  Why was I feeling so vulnerable?

You are probably familiar with the acronym H.A.L.T. which, in a medical practitioner’s work context, stands for Hungry, Angry, Late and Tired. Being hungry, angry, late or tired not only affects our sense of work satisfaction but increases our propensity to make cognitive biases in our clinical decision making, and for medical errors to occur.  The idea behind H.A.L.T. as a self-monitoring tool is to:

  • encourage us avoid these states as much as we can (eg by prioritising sleep and nutrition),
  • recognise when we are affected by one (or more) of them, “halt” what we are doing, ask ourselves what influence being hungry, angry, late or tired is having on our performance, and then try to minimise its impact.

In contexts such as addiction recovery, “Lonely” is substituted for “Late”.  Same principles: halt, reflect, rectify (when possible), avoid negative impacts.

I was not working while hungry, angry, late or tired yesterday, but the principles of H.A.L.T. did apply.

Yesterday was my partner’s birthday.  And today is the anniversary of his death; two years since he was mowed down on his morning jog by an impaired driver. Two years ago today, I got the phone call we all dread. The phone call that informs you there’s been an accident involving one of your immediate family. The phone call that tells you that the person you love most in this world has been killed, changing your life forever.

I always find anniversaries hard, and with two dead partners and two dead daughters, I have had plenty of experience with them.

Should I have gone to work yesterday? The practice I work for is brilliant about such things – everyone there would have been utterly supportive of my taking the day off despite us being understaffed at the moment. Why then it is so hard for me to admit that, despite how far I’ve come and how well I’m doing overall, I’m not always OK? And that is OK to not always be OK?

I’ve told at least four stressed patients this week that it is OK to take sick leave for mental health reasons. I’ve counselled. I’ve written medical certificates. I’ve told them to put themselves first etc etc.  With the greatest sincerity and not a hint of irony.

I teach about doctors’ health and wellbeing all around Australia, and beyond. I’ve written a play about it (“Physician Heal Thyself”).  I’m extremely passionate about doctors’ self care, almost one of those annoying crusader types. And yet I find it so hard to practice what I preach.

Today, I have halted. I’m having a quiet day and I’m feeling much more settled.  Tomorrow I will start marking 1400 odd GP exam papers (the FRACGP written exams are being sat today around Australia). And on Monday I will walk back into the surgery, hopefully with my ability to empathise intact and my mojo restored.

The waves of grief come far less often and with less intensity as time goes on. The short storms that hit around anniversaries are precious reminders of what I’ve lost and how far I’ve come, and as such, should be treasured.

I’m positive that this one, like the last, will clear soon…. revealing clear skies and calm seas.  For underneath the currently choppy surface, I am at peace.  I’m happy, I’m fulfilled and I’m loved.  Truly loved.

Most of all, I’m grateful.  I’m grateful for many things, including the silver linings of the storm clouds – the wisdom, strength, opportunities and sense of purpose which have been given to me by that which has been taken away.

Plan A didn’t work out for me. Neither did Plan B or C.  But Plan D is working pretty well, and I’m buoyed by the knowledge that there are 22 more letters in the alphabet if I need them.

(15th July, 2017)

 

After the storm… with Amalie’s tree in foreground

All that “GP stuff” in the Emergency Department

Nomadic GP

“We are just FULL of GP stuff today. We’re pretty much just running a GP clinic” you say, with a big sigh and roll of the eyes.

You’re an emergency nurse or maybe a doctor. You’re frustrated because you are working your butt off, haven’t had a lunch break or time for a wee and still people are waiting for hours and hours to be seen. The ambulances keep arriving and you’re irritated by the patients who are adding to your workload that don’t need to be here at all.

I know the stuff you’re talking about. It’s all those simple problems, the non-urgent problems, the tedious and uninteresting problems. You’re talking about the triage category 4s and 5s that don’t have a life threatening illness and can wait while you and I attend to all the exciting, high acuity, real emergency stuff. You’re talking about the sniffles and rashes, the UTIs and…

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Making Valentine’s Day matter, without spending a cent

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.

what I do for thirty seven dollars and five cents

that lady doctor

The building contractor chatted pleasantly while I checked his blood pressure, waist circumference, recent cholesterol levels, fasting glucose and urine protein. We discussed screening for bowel cancer with “the poo test” versus colonoscopy, with reference to his family history. We talked in detail about prostate cancer testing and I offered to provide him with written information as we were out of time. As I signed his script for the blood pressure medication he winked at me.

“That was easy money for you, wasn’t it?” he said as he walked out.

Thirty-seven dollars and five cents is the value this government places on up to twenty minutes of my time. This figure, the amount a practice receives from Medicare for a standard consultation, has not changed in four years, and under the current arrangement, will not change for another three. I myself receive sixty five percent of that. But are the pennies…

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Do GPs ever regret referrals?

drjustincoleman

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

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”).