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Reflections on GP the Musical’s trip to Darwin (for GP13)

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The 8th performance of GP the Musical – the show written, directed and acted by GPs – was up in Darwin this month, as part of the GP13 conference.

Cast pre-show photo Darwin 17th October 2013

Cast pre-show photo Darwin 17th October 2013

Still buzzing from our unexpectedly sold out season at the Melbourne International Comedy Festival in April, the cast members were all eager to don their costumes and dance up a storm, despite the Darwin heat.  While high on enthusiasm, we were a little rustier than anticipated and had only a very limited time to rehearse. No doubt this was quite stressful for director Dr Katrina Anderson, but she soon whipped us into some semblance of shape using her indomitable directing skills.

Receptionist song at GPTM Darwin

Receptionist song at GPTM Darwin

It is both daunting and comforting to perform in front of colleagues. We expected a very supportive and forgiving crowd (and they were!) but knowing there were some serious heavyweights in the crowd (the likes of RACGP president, Dr Liz Marles, Chair of Council, Dr Eleanor Chew and the legendary Professor John Murtagh) did produce a few butterflies. We weren’t sure whether these VIPs would appreciate us sending up everything from E-health records to naturopathy to heartsink patients, but our college memberships were not rescinded the next day, so they must have taken the show in the tongue-in-cheek manner intended.

Professor John Murtagh was particularly effusive with his praise of the show. He told us how he had tried to get tickets when GP the Musical was at the Comedy Festival, but was turned away by the box office due to the show being sold out.  I’m sure he was too humble and polite to do the whole “Do you have any idea who I am?” routine, but we kind of wish he had!

WONCA president Professor Michael Kidd gave us a personal apology for not being able to attend the Darwin performance (he was flying out to India that evening).  He had seen the show in Melbourne but said he had wanted to see it “one more time”.

Enough of the name dropping!

We had many non-India-bound audience members who had chosen to “come back again” for a second or third viewing.  Those who had last seen it at the 2012 GPET Convention, experienced not only a more practised performance but 20 minutes of extra dialogue and two new songs (E-health records and Naturopath Song).

Mr Black and Dr Karla

Mr Black and Dr Karla

There were some changes since the Melbourne International Comedy Festival season too.  There were dialogue tweaks (deliberate ones, mostly ;-)) and a cast re-shuffling:  a previous patient became the female doctor and the doctor accepted a job promotion to become the receptionist.    Dr John Buckley returned as the unstoppable Mr Goodall.

The other change was that the show jumped on the social media bandwagon and had a live twitter stream:  #GPTM.  Photos and comments were posted during the show by both audience members and the show’s multi-tasking receptionist character (while on stage).  OK, I’ll stop hiding behind the 3rd person.  The crazy receptionist was me.   I’d obviously overlooked the fact that playing a new role for the first time with very little rehearsal would probably need my full attention.  At some point, I must have subconsciously  decided that acting, singing, dancing and playing live music in front of a large audience of colleagues, invited guests and VIPs was not enough of a challenge, and so added live tweeting into the mix.  Miraculously I managed to post numerous tweets using the prop conveniently placed on the desk at which I was sitting for much of the show (aka laptop) without missing cues or lines.   More good luck than good management, in retrospect. You can check out the tweets at #GPTM if you’re curious.

All in all, it was a tremendously enjoyable night (for the cast at least).

Encore performance at Rural Faculty Function

Encore performance at Rural Faculty Function

Wanting a little more of the  Darwin limelight, we came back “one more time” and did an encore performance of our final song, The one to see is your GP, the following evening at the RACGP Rural Faculty Function.  It wasn’t scheduled and we weren’t invited as such – we snuck onto stage while the star act of the evening, the very talented and entertaining GP band, the Medical Cheekydocs, took a five minute loo break.

We have the band to thank not only for a wonderful night’s music and for graciously allowing us to monopolise the stage for a few minutes, but for the existence of the musical at all.  For it was back in 2010, while the band (then called Simon and the GPETtes) were rehearsing on a station outside Alice Springs for the 2010 GPET Convention, that the idea of GP the Musical was first dreamed up by Gerard Ingham and myself (both then band members). We started writing the show a couple of months later, and the rest, as they say, is history.

We couldn’t have done any of it without our director and fabulous cast, so thank you all!

There are no future GP the Musical  shows scheduled at present, but who knows?  We may just “come back again” next year to a theatre near you.

Post show drinks

Post show drinks

Mr Goodall getting cuddly with Mr Black

Mr Goodall getting cuddly with Mr Black

I love being mistaken for a medical student

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“Are you learning a lot today, dear? Are you going to be a GP too one day?”

My face breaks into a smile for a number of reasons. I love it when, as a medical educator, I’m mistaken for a student while conducting external clinical teacher (ECT) visits.

First, if patients mix up which one of us is the registrar and which is the teacher, it usually indicates they trust and respect the doctor they’re consulting.

Second, it can help put a nervous registrar at ease. We have a chat and a laugh about it afterwards, and I can almost see their confidence level rising.

And third, it makes me feel young.

Before you try to burst my bubble, I know med students are not all bright-eyed 20-year-olds, but I still take it as a compliment.

For the uninitiated, ECT visits are compulsory components of GP training nationwide. Each involves a medical educator visiting a registrar’s practice and sitting in for a session, after which a report is written and kept on file.

There are some registrars who relish the idea of an educator observing and commenting on their clinical performances in a career they’ve only recently started.

They’re usually the same type of people who like doing karaoke without the benefit of inebriation, think nothing of standing up in front of a crowd to deliver impromptu speeches, and apply for reality TV shows.

Most, however, are at least a fraction anxious about their first ECT visit. For starters, having the name ‘ECT’ doesn’t exactly engender comfort and reassurance. Those who chose this initialism might have thought it amusing, but I haven’t seen many registrars laugh about it.

Indeed, one even told me she’d had a nightmare in which she received an electric shock every time she asked too many closed questions or didn’t pick up on non-verbal cues.

The training provider for whom I work has changed the name to ‘FACT’ (Formative Assessment Clinical Teaching). However, the FACT of the matter, as I see it, is that an ECT visit by any other name still smells of fear.

Most registrars relax into ECT visits pretty quickly and find the experiences educationally valuable. By the end of that first nerve-wracking visit, many say things like, “That was great — I wish you could come every week.” A few actually mean it!

I used to be nervous conducting ECT visits too. Back in 2005, when first starting out as a medical educator, I worried that I was too young and inexperienced. What if a registrar asked me a question I couldn’t answer? It took me a while to realise I didn’t need to know everything to be a good teacher, and that getting the registrar to look something up was not only okay, but a valid educational strategy.

In those early days, patients often mistook me for a student, but I didn’t view it as complimentary. I was still young enough to want to look older.

It was a bit like being asked for ID at a club. At 20, many people are miffed to be asked for ID: “There’s no way I look underage!” At 25, they think it’s mildly amusing: “I look underage? That’s pretty funny!” However, by 30, they are desperately hoping that someone, anyone, would mistake them for possibly being a teenager.

I’m now very comfortable being the age I am and have no desire to be a teen again. Nonetheless, the occasional medical student misidentification is not unappreciated!

 

First published in Australian Doctor on 13th July, 2012 On being a medical educator

http://www.australiandoctor.com.au/opinions/the-last-word/the-last-word-on-being-a-medical-educator

Theatrics can be Therapeutic

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Some patients are hard to train. As are certain colleagues. Either (or both) can make our already difficult jobs all the more stressful.

The well-adjusted, Zen-like doctors will let such annoyances wash over them like a limpid mountain stream and switch them off like a tap the moment they walk out the door.

The less compartmentalised of us need other strategies to avoid finding ourselves tossing and turning in bed, fantasising about a career change.

The traditional GP stress-buster is, of course, red wine, but fewer of us imbibe regularly these days (or at least admit to it) and we instead espouse remedies such as being yelled at by sadistic personal trainers at 5am daily.

Not being a saint, drinker nor masochist, I have been known to try writing my way to a peaceful night’s sleep. Most of my frustration-driven rants are not fit for human consumption, but occasionally I’ll be able to kill two birds with one stone by using my debriefing material in a column, story or theatre piece.

This is how ‘Mrs Ryan’ ended up on stage. The character was based on one of my seemingly untrainable, frequent attendees whose ‘poor me’ attitude and long, long list of problems each consultation had driven me to the pen. ‘Mrs Ryan’ subsequently became a major character in a day-in-the-life-of-a-GP play called Walk a Mile in my Shoes that I was lucky enough to have performed in 2011.

It was most therapeutic for me to see a comically exaggerated and fictionalised version of my patient on stage, her essence perfectly captured by a talented actor.

Each time I watched her strut her stuff in rehearsal, the antipathy I felt towards my patient ebbed further and further away.

But then, on opening night, the real ‘Mrs Ryan’ unexpectedly turned up in the audience.

I panicked. For the two-hour duration of the show I waited in trepidation, inwardly cringing each time the audience laughed at the unreasonable behaviour of the play’s most irritating character.

Post-performance, my ‘Mrs Ryan’ made a beeline for me and gushed, with a completely straight face: “That was wonderful. I loved it! That Mrs Ryan character was a piece of work, though. How do you doctors ever put up with such people?”

Despite failing to recognise herself, ‘Mrs Ryan’ changed her approach to consultations. Her lists now rarely exceed three items and she’s mindful of time constraints.

When I positively reinforced her behaviour change, she replied: “Your play helped me see how stressful your job is. I’d never thought of doctors as people with their own problems before.”

She went on: “I’d love you to put me into a story or play one day. I have enough problems to fill up a whole book!”

It turns out the theatrics were as therapeutic for her as they were for me.

“Mrs Ryan” and I have since had a good laugh over the incident and she gave permission (and her blessing) for me to write this column.

The good news is that you don’t need to be a writer to effect behavioural change in those patients and colleagues who make your life hell. Sending them to the theatre could be enough. Walk a Mile in my Shoes has hung up its boots for the moment, but there are plenty of colourful characters in GP the Musical, which may well do the trick.

Coming along yourself may prove therapeutic too – giving you an opportunity to laugh off your workday stresses, with or without the assistance of red wine.

Since this column was first published, GP the Musical has enjoyed a sell-out season at the Melbourne International Comedy Festival in April 2013 and performed at the GP13 conference in Darwin for GP13.  It features an all-GP cast.

First published in Australian Doctor on 15th March, 2013: On theatrical stress-busting

http://www.australiandoctor.com.au/opinions/the-last-word/the-last-word-on-theatrical-stress-busting

Ignorance is bliss but not necessarily a good OSCE (exam) strategy

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My recollections of sitting my RACGP OSCE (Fellowship clinical exam) are rather hazy, and not just because it was over a decade ago. I do have one bit of advice though – a do-as-I-say-not-do-as-I-did tip – try to avoid traumatic brain injuries in the month leading up to your clinical exam.

Here’s the story of how I came to be doing my RACGP OSCE exams with 6 facial fractures and left temporal lobe contusions….

Saturday, 4th October, 2003.

Photos from old computer 115

I couldn’t close my mouth. That wasn’t a good sign. Many a time I’ve been admonished for having my mouth open more than it’s shut, but on this occasion it had nothing to do with being garrulous. My upper and lower jaw no longer occluded. I sat up – gingerly, to discover that I was completely alone in unfamiliar bushland, with no recollection of how I got there. I lay back down and closed my eyes, inappropriately unperturbed.

Like a slowly developing Polaroid picture, the details appeared in my mind’s eye. The colours were increasingly vibrant yet the focus remained blurry. I remembered studying for my OSCE exams that morning before deciding to take one of horses for a ride in the State forest to clear my head. The rest was a blank; my head had been cleared too well.

Living at Pomona0013It was time to play CSI. The skid marks and saddle imprint in the mud clearly showed where Rondo had shied and fallen (probably on seeing a kangaroo – he was terrified of them), and my face had left a lovely impression at its point of impact. Thankfully, Rondo appeared on cue when called – mud-splattered and jittery but unharmed. It took us several hours to find our way out through the maze of interconnected forest trails, what with my disorientation and his being one of those rare horses with no inclination to make a beeline for home. Unlike many males I’ve known, he was excellent at taking direction but hopeless at finding it.

I remember only one thing clearly about that long ride home: laughter. My laughter – laughter which bubbled up from deep inside, slipping between my maloccluded teeth and spilling out of my bruised mouth. In my concussive haze my situation somehow seemed side-splittingly humorous. The funny side was the only side I could see.

I laughed more in that next month than I’d done in the preceding three years. Although my personal predicament lost its comedic edge fairly quickly (temporal lobe contusions and six facial fractures requiring two maxillofacial surgeries and a six-week liquid diet do tend to be dampeners), the world around me tickled my funny bone in completely new and outrageous ways. I laughed at the news. I laughed when I got stuck in traffic. I laughed over spilt milk. And most surprising of all, I laughed at corny American sitcoms. You know the ones: weak, predictable story lines, groan-worthy one-liners and canned audience laughter. I found them not only funny, but hilarious. I’d laugh so hard that I’d double up on the floor in stitches with tears streaming down my cheeks. I kid you not.

Despite my looming exams, my neurologist prescribed “brain rest” and instructed me not to study. Nothing I read seemed to be retained anyway, so I put my books aside and indulged in my new-found penchant for mindless entertainment. I laughed the days away without a care in the world.

Living at Pomona0020Three weeks after my accident, less than a fortnight after two reconstructive surgeries, and against medical advice, I sat my OSCE exam. In my brain damaged state, I was not at all worried about whether I’d pass or fail, happy to turn up and just “have a go”. I don’t remember much of it, other than wondering why my fellow candidates all looked so worried, receiving stern glances from an exam supervisor as I giggled to myself in a rest station, and having to ask one of the role players about her presenting complaint at least three times (my brain simply refused to retain the information).

I miraculously passed (although it was far from an outstanding performance!). Somewhat unfortunately, over the following weeks my ability to laugh outrageously at the banal also passed, and my sense of humour crept back to the dry and satirical side of the fence. The news of the world was again depressing, traffic congestion got my goat and split milk, although not inducing tears, no longer triggered a giggle.

I’m not sure if my laughter was the illness or the medicine, but it was definitely an integral part of the healing process. Having a traumatic brain injury was for me a far from unpleasant experience. In fact, it seemed to suggest that life is not only more painless for the brainless, but it is also much funnier.

While sitting a major exam in such a state was entirely without stress at the time, I do not recommend it as a technique to reduce performance anxiety. In all seriousness, I was very lucky to have passed, and believe that the only reason I did was that I had spent the previous 18 months preparing. Not by going home and studying every night, but by engaging in deliberate practice each and every day when seeing patients. Good communication skills and examination techniques were so ingrained that they did not require the concentration and higher level thinking that the knock on my head had temporarily disabled. These semi-automated skills alone are not enough to be a safe and competent doctor in the real world of course, but, together with a big helping of luck, were enough to carry me through the OSCE exam on the day, as I smiled and laughed my way through the stations, completely unfazed.

The Last Word on GP Matchmaking

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First published in Australian Doctor on 28th September, 2012: On GP Matchmaking

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

The Last Word on GP Matchmaking

by Genevieve Yates

When a playwright friend heard I was writing a musical about general practice, his first comment was: “It must include a love story — audiences expect romance!”

At the time I pooh-poohed the idea, thinking that medicine and love don’t sit well together, even in musical theatre. I certainly wasn’t prepared to write a stage musical version of Grey’s Anatomy with a Dr McDreamy GP character making use of the examination couch after hours.

However, as GP the Musical came to life, my co-writer, Dr Gerard Ingham, and I discovered we had indeed written a love story — about doctors and patients. Not the kind of love story that will have AHPRA knocking at the door, mind you, but one about matchmaking patients and GPs.

In Act 1, Dr White, a whiz at dermatology and care plans, is happy to treat Rebecca’s rash, but not so eager to address her psychological distress.

Dr White: “I see here that you are on antidepressant tablets ¬ Wow, that’s a high dose. Look, counselling isn’t my thing. We all have things we are good at. For example, I’m good at cycling and running but rubbish at swimming. So I do better at triathlon if I team up with a good swimmer. Play as a team, win as a team. Do you know what I mean?”

Rebecca: “Not a clue.”

Dr White: “Well, you see although we’re both GPs, Dr Anderson is better at the psychological and women’s stuff — the tears and smears. So I think it’s best if you come back later this week and see Dr Anderson to talk about your sad feelings.”

Meanwhile, Dr Anderson is struggling with Mr Black, an ex-accountant who loves nothing more than creating Excel spreadsheets documenting his bodily functions, and whose thinking is as concrete as his bowel motions.

Dr Anderson: “Mr Black, what’s really going on?”

Mr Black: “Pardon?”

Dr Anderson: “What’s bothering you, deep down?”

Mr Black: “My bowels aren’t working properly, that’s what’s bothering me.”

Dr Anderson: “I’m not talking about your bowels, I’m talking about your feelings. Are you unhappy?”

Mr Black: “I’m unhappy when I can’t pass my motions, obviously.”

The exchange continues:

Dr Anderson: “Mr Black, you come and see me nearly every week with your bodily function charts. You want me to prescribe you pills but you’re terrified of side effects. I think there are other issues going on.”

Mr Black: “Of course there are other issues. Haven’t you been listening? There are my blood pressure variations, my dizziness, my low blood sugars after meals ¬”

In Act 2, the patients swap doctors. Mr Black is introduced to the Bristol Stool Chart and gets his thrice-daily home BP readings uploaded into his medical record by Dr White. He thinks this is “maaarvelous!” Rebecca finally finds her doctor match in Dr Anderson — someone who’ll explore why she’s scratching herself incessantly and who listens to what she has to say. Both love stories resolve happily.

In true musical theatre style, the storyline is simplistic and the characters are stereotypical, but it seems to have hit the mark with doctors and non-doctors alike. Judging from the standing ovation received at GP the Musical‘s premiere in Melbourne earlier this month, it seems audiences really do love a love story — albeit one involving the improved documentation of stool consistency!

(Since this column was first published, GP the Musical has enjoyed a sell-out season at the Melbourne International Comedy Festival in April 2013 and is heading to Darwin for GP13 on October 17)

Referral Letter Etiquette

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I received a letter from a thoracic surgeon that was signed off, “With love and truth”. This caught me off guard.

The letter was on a normal-looking letterhead. It started with the conventional “Thank you for referring Mrs X for an opinion regarding…”, and went on to describe the patient’s presenting problem and comorbidities. It described the investigations undertaken, the treatments recommended and the plan for follow-up.

All stock-standard stuff, until the valediction: “With love and truth, Dr Y.”

This started me thinking about the evolution of the complimentary close. When I was at high school (which wasn’t that long ago), valediction etiquette was drilled into us. We were taught that correspondence other than personal letters should be signed off ‘Yours faithfully’ to those with whom one is not personally acquainted, and ‘Yours sincerely’ to whom one is. Clear, simple rules.

Then email came along and blurred the boundaries. ‘Regards’ and ‘Warm regards’ seemed to me to be a pleasant mix of the formal and the familiar. I used to think ‘Cheers’ was a little informal for use in business emails but it’s grown on me. However, a medical specialist’s letter signed off “With love and truth” is a different kettle of valedictorial fish.

To me, using the word “love” in a valediction has certain connotations. The trouble is that there are no clear rules of etiquette here. Most would agree that the word love does not belong in formal business correspondence, Dr Y being an obvious exception.

When it comes to personal emails and letters, though, it can be a case of “everyone’s playing the game but no one’s rules are the same”. I sign off “Love, Genevieve” frequently when communicating with friends and family by email. I mean ‘love’ as a term of endearment rather than ‘love’ in a romantic sense, and I write it almost subconsciously … except if I’m attracted to someone.

Now here is where it gets complicated. If I really like someone, but am not in love with him, I will think very carefully about how I sign my emails and usually will not use the word ‘love’ in case he gets the wrong impression. So, family members and platonic friends, male or female, will get “Love, Genevieve”. If I like someone romantically, he may or may not, depending on my depth of feeling.

Now how can anyone be expected to interpret that? I have male friends who sign some of their emails to me with ‘love’ and some who don’t. Does that mean anything? Almost certainly not, but if I applied my own process to them it might … which almost certainly would be wrong. An ex-boyfriend once told me that he signs his emails with ‘luv’ for close friends and family, and with ‘love’ when he’s ‘in love’ romantically.

His e-mail valedictions changed from ‘luv’ to ‘love’ at an apparently significant moment in our relationship. He was waiting for me to comment, giving him an opening to tell me that he loved me, but I didn’t even notice. If I had, I would have interpreted the change as his having learnt how to spell.

I can be fairly sure that my “With love and truth” thoracic surgeon harbours no such romantic feelings towards me. After all, I’ve never even met the man.

According to my patient, his quirkiness does not end with his letter endings, but overall, she is delighted with the care she’s received and the thoracic surgery has been a resounding success. That has to be worth a little love and truth.

First published in Australian Doctor on 19th April, 2012 On Referral Letter Etiquette

http://www.australiandoctor.com.au/opinions/the-last-word/the-last-word–on-referral-letter-etiquette

“I want you to be my friend, not my patient” – social dilemmas for rural GPs.

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I’ve just read a brilliant column by Dr Mel Clothier in this month’s Rural Doctor…

Making friends is hard to do | Rural Doctor
http://www.ruraldr.com.au/opinion/last-yarn/making-friends-is-hard-to-do

She talks about how hard it is for rural doctors to separate their professional and social lives. This is such an important, difficult and often under-appreciated problem for rural doctors, especially when they’re starting out and trying to get established in a rural area. Although such dual relationships are challenging for everyone, I get the impression that the friendship/ patient dilemma is often hardest for young single females (would be happy to hear any opinions to the contrary!).

I know that I found it really hard as a registrar. This aspect of rural practice contributed significantly to my being almost burned out by the end of my training. Overworked and socially isolated, I thought that I may have made a big mistake in becoming a rural GP.

Trying to make social connections for the purposes of friendship are problematic enough, but add the desire for an intimate relationship into the mix, and you have a whole other layer of messy. For very good reasons, the separation has to be absolute, which cuts down one’s dating options in a small country town drastically.

When I’d first moved to a rural area, two years out of med school, romance was the last thing on my mind. My boyfriend had died during my intern year – of testicular cancer – and it took me a long time to be ready to move on. When I finally was ready to consider a new relationship and hopefully, in time, a family of my own, I was working 60hrs a week in a small country town. A good breeding ground for horses and cattle, perhaps, but not ideal for a young, single female GP.

And so, I chose the obvious solution – did what any overworked, lonely, newly Fellowed country GP would have done – I took four months off work – to do a reality TV show. It was the ABC’s Outback House, not A Farmer wants a wife, although in retrospect, the latter may have been more useful.

It was a life changing and meaningful experience – one that I would never ever do again, even if paid large sums of money– and certainly not a solution I would suggest to you. 😉

There are no easy answers, I’m afraid, but putting the effort into maintaining relationships and supports outside your local community (including online ones) is really important. As hard as it can be to do, I try to decide (together with the other person involved) whether they are going to be a (close) friend or a patient. I spend a good deal of time explaining why it isn’t beneficial to either of us to be both.

It does get easier!

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More fewers and fewer lesses please: politics, education and pedantry

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There were many aspects of the recent electoral campaign that disappointed me. I suspect many aspects disappointed you too. I’m not going to talk policies or ideologies in this post, but rather vent about a small, pedantic bee which buzzed around in my bonnet: language use. Not the nauseating rhetoric and three-word slogans, although these were mighty frustrating, but the demonstrations of politicians without a firm grasp on the English language.

The examples are too numerous and depressing to list, but Kevin Rudd using “bunch” as the collective noun for practically everything and Tony Abbott confusing suppository with repository are ones that stood out for me. The latter was great for a laugh… I had fun writing tweets like “It is well established that Tony Abbott is not the suppository (sic) of all wisdom but the big question is, will he be the enema of social justice?”

On-the-fly gaffs can be forgiven, but when an ALP TV campaign advertisement, for education of all things (!!), warned that there will be “less teachers, less opportunities and less programs” under a Coalition government, I felt a rising tide of despair.

Upon awaking to a new Australian government on the 8th of September, I turned my attention away from the election-news-filled Australian media and soothed my pedant’s itch with this highly entertaining piece from the Calgary Herald.

I literally died of laughter, but I’m still here, by Gene Weingarten.
Calgary Herald Saturday, September 07, 2013

http://www2.canada.com/calgaryherald/news/theeditorialpage/story.html?id=407695ec-3b5b-4c37-809c-41

Unlike the dearly-loved family member who sent me the link, I’m not a Nazi when it comes to language and grammar. I’m relatively unfazed by the relaxing of rules in informal writing, especially when emailing, texting, tweeting and blogging.

I don’t fervently object to the addition of new words to the Oxford English Dictionary, nor the shift in word meaning over time, even if that results in antonyms becoming synonyms. And while missing apostrophes and the seemingly unstoppable Americanisation sometimes grates, I accept that language is a dynamic and evolving beast.

However, I’m saddened by grammatical ignorance: errors committed without deliberate intent. With a government erroneously uses “less” instead of “fewer” in an advertisement boasting about its educational credentials, I shouldn’t be surprised that increasing numbers of young Australians are blissfully unaware that there is anything incorrect with such sentence construction.

Call me old fashioned, but I support the “You need to know the rules before you can break them” dictim. I apply the same principle to my practise and teaching of medicine:  I tell my students, “Get familiar with the clinical guidelines first. This allows you to make an informed choice whether or not to disregard them under certain circumstances.”

I’m all for a solid foundation – an advocate for anatomy and physiology subjects in medical school, and a focus on the three R’s in primary school.

And in the next  federal electoral campaign I would like to see fewer three-word slogans, fewer “bunches” and fewer ads using “less” instead of “fewer”. But I don’t mind if Tony Abbott adds to his “suppository” of verbal slips – they keep things entertaining.

(In case you’re wondering, my choice to start the last two sentences with conjunctions was entirely deliberate :-))

“Get off your buttocks”: the baby steps approach to role modelling in general practice

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As GPs we really should be setting a good example to our patients regarding our health.  GPs know all too well what we should be doing – we preach it every day to our patients. We sometimes get frustrated when patients don’t follow our advice, perhaps not reflecting on whether we always take our own advice regarding our lifestyle choices.

Having said all that, I know as well as anyone that we are imperfect creatures. I’m not holding myself up as a poster child for good GP behaviour.  It would be hypocritical of me to preach to others about being hypocritical when preaching to patients about lifestyle modification.

Just like for our patients, contemplating adopting an “ideal for health” lifestyle (regarding exercise, diet, alcohol, sleep, stress etc.) may be overwhelming for some GPs and as a result, lathered with a plethora of excuses and tossed in the too hard basket.

But don’t despair… every little bit counts.  Baby steps.

If you are someone who is not following every preventative health recommendation and living a completely indulgent-free life, whether GP or non-GP, and wish to start with something relatively easy-to-do but with huge health benefits, read on…

But first, stand up.  Get off your buttocks and have a good stretch.

Done? Good.

No, don’t sit down again, stay standing while you watch this…

Of course, we’ve known that a sedentary lifestyle is bad for your health for decades but the thing that gets me going is the increasing body of evidence which suggests that the adverse health effects /risks of prolonged sitting are not ameliorated by daily exercise.

6.5 – 8 hrs a day of sitting will increase your risk of  things like heart disease, diabetes, obesity and even things like distal colon cancer (100% increased risk) even if you exercise before and after work every day.

I’m not suggesting we routinely conduct GP consultations standing up.  But I’m sure there are lots of opportunities during your day to spend more time on your feet and less time on your buttocks.   For the past six months or so I have been doing about half my computer work at home standing up and I feel so much better for it physically.  There are some great sit-stand workstations available – they adjust so that you can work at them either sitting or standing. My “standing” set up home at home is much more crude – an external screen and keyboard on top of my  3 drawer filing cabinet, raised with old phone books!  Works just fine, but is not the most professional look.

I’d love to hear from anyone who has adopted more standing / walking into their daily lives – how they’ve managed the process and whether they feel better for it. Please feel free to comment below.

And if you need some motivation…..

For people who sit most of the day, their risk of heart attack is about the same as smoking” ~ Martha Grogan, cardiologist, Mayo Clinic

Today, our bodies are breaking down from obesity, high blood pressure, diabetes, cancer, depression, and the cascade of health ills and everyday malaise that come from what scientists have named sitting disease … Every two hours spent just sitting reduces blood flow and lowers blood sugar, increasing the risk of obesity, diabetes and heart disease.”~ James A. Levine, MD, PhD

Prolonged sitting should be considered within occupational health and safety policies and practices just like other elements of posture.”~ British Journal of Sports Medicine

We’ve become so sedentary that 30 minutes a day at the gym may not counteract the detrimental effects of 8, 9 or 10 hours of sitting. ~ Genevieve Healy, PhD

OK, I’m off to get some sleep… I should have been in bed 2 hours ago. What was I saying about not always practising what I preach?  I have written this entire blog standing up, so it’s not all bad!

Genevieve’s RACGP Fellowship and Awards Ceremony Speech – “You can do it all, just not all at once!”

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On Saturday 21st September, 2013,  I was honoured to be the guest speaker at the 2013 RACGP Fellowship and Awards Ceremony. It was held at the Queensland Conservatorium of Music, Southbank, Brisbane, for the new Fellows of the RACGP, their family members, RACGP staff and members, and dignitaries.

My brief was to enthuse, inspire and entertain the 500 odd attendees with my personal journey – not an easy task. I thought long and hard about what to say – how to frame my narrative in a way that was truthful but interesting, different but relatable, somewhat humourous but inoffensive, and inspiring but not totally immodest.

I’m not sure that I succeeded in these aims, particularly in humbleness department, but I did my very best and had an awful lot of fun writing and delivering it.  I’m very grateful to the RACGP for the invitation.

If you have a spare 20 minutes and want to judge for yourself whether it is appropriate to talk about sanitary products while dressed in an academic gown and delivering a formal address, here it is….

RACGP Fellowship Ceremony Speech, 2013 (Powerpoint with audio)

or if you prefer Windows media player …

Fellowship ceremony speech in wmv format

or in .avi …

Fellowship ceremony speech in avi format

Genevieve with Linda Landreth (RACGP) at Fellowship Ceremony

Genevieve with Linda Landreth (RACGP) at Fellowship Ceremony

Mid-air consulting… Aussie GP style

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It’s an early morning flight. You’re tired, grumpy and regretting not grabbing a coffee before boarding. The seatbelt sign is turned off and the mouth of the person sitting next to you is turned on.

She starts yapping away, trying to engage you in small talk. Not wanting to appear rude, you reply, all the while wishing she would just shut up. The situation turns from grim to dire as she moves from the trivial to the personal.

I was en route to present at an international medical humanities conference in the US, and, I have to confess, I was that annoying talker. Why? I noticed a mole I didn’t like on my fellow passenger’s forearm.

Now, I’m certainly not in the habit of giving strangers unsolicited medical advice, but I was sitting there confronted by this highly suspicious naevus, my fingers itching for a dermatoscope, and just couldn’t stay silent. The young American told me that it had been looked at “a couple of years ago” but admitted that he’d noticed recent change. He hadn’t been concerned about it before boarding, but I made darn sure he was before disembarking. I gave him my business card (to demonstrate that I did indeed have a medical degree), and two weeks later received a very grateful email. The lesion turned out to be an invasive melanoma with a Breslow thickness of 1.3mm

On the very next leg of my journey, I again had cause to advertise my profession. Regular readers may recall that the last time I heard “Is there a doctor on board?”, I slid down in my seat and waited for someone else to respond. This time I attempted to redeem myself by volunteering immediately when the call came over the PA system. Two minutes later, faced with an unconscious young woman, my good-deed buzz was replaced by alarm bells chiming “panic”.

According to the nearby passengers, she had been acting “weirdly” before “passing out”. I wondered if this inappropriate behaviour included asking strangers about their moles. She became responsive after some oxygen, but was confused. Later, she started complaining of severe chest, abdominal and back pain. To cut a long story short, the combination of hypoxia, methamphetamine and dehydration had precipitated a sickle cell crisis. The next three hours were not much fun for either of us.

Half an hour in, the drinks trolley came around. Unlike on many of our Australian carriers, a free beverage is offered by this American airline, although the tiny pretzel packets have been banished along with the term “air hostess”. With my patient stable at the time, I requested a tomato juice. The attendant opened a can and half-filled a tiny cup. When I politely requested the remainder of the can as well, he looked at me as if I’d asked for pretzels and called him an air hostess.

“Passengers are only eligible for one free drink,” he pronounced.tomato juice on a plane

“I only want one — a can of tomato juice.”

“But that’s two serves.”

“Hey, I’m saving a life here. Surely that’s worth the extra half can.”

“We are not allowed to give any kind of gratuity to doctors who volunteer their time to assist in an emergency.”

While I appreciate that this situation presents a legal quagmire, the fact is that in the US, this crazy country, I’m expected to tip a waiter in a bar for pouring me a glass of tomato juice, but I can’t even get an extra half-can of unpoured stuff for delivering three hours of after-hours emergency care. I know I’m from Down Under, but it all seems a bit upside down to me.

First published in Australian Doctor on 17th May, 2012 On Unsolicited Advice

 

The Last Word on being GAY

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First published in Australian Doctor, 22nd March, 2012 On being GAY

http://www.australiandoctor.com.au/opinions/the-last-word/the-last-word–on-being-gay

The Last Word on being GAY

by Genevieve Yates

I’m GAY, and have been since birth. I’m not referring to sexual orientation or to my propensity for being optimistic and cheerful in the face of adversity. I was named G.A.Y — Genevieve Anne Yates.

At primary school, I got the occasional taunt: “You’re gay! (snigger, snigger)”, to which I’d hotly reply, “Yes, I am — happy and bright. That’s its real meaning, you know.” All very sophisticated of me, it was. Since those playground exchanges, however, my initials have not given me any particular grief.

Until now.

And why would a mid-career professional woman suddenly have hassles with the trivial matter of her initials? The answer is PracSoft. As you are no doubt aware, medical software typically uses doctors’ initials as identifiers. In my previous practice I was ‘GY’ in PracSoft, but my new one uses three initials for each of its practitioners, making me ‘GAY’.

No big deal in itself. I can be whatever I want in my private life. Who cares if I’m GAY at work?
As it turns out, no one seems concerned that I’m GAY, but think I’m trying to label them GAY. Confused? Let me explain.

The billing procedure at my new practice involves the treating doctor handing each patient a printed billing slip at the end of a consultation. On this slip, the doctor writes the patient’s name, and circles both the appropriate item number and his/her initials, so that the receptionist knows what to bill and under whom to bill it. Somewhat surprisingly, this system has proven a little problematic for me.

It has become apparent that a not insignificant proportion of my male patients don’t appreciate having their names written beside a circled ‘GAY’. Oversensitive and ridiculous as this may seem to some, the fact is that I’ve been receiving an indignant comment from at least one patient a day.

I’m baffled as to why patients would think that I had the need to announce their sexuality to the reception staff via a billing slip in the first place. Do they perhaps think gay people receive a discount? Are they charged an extra fee? Have their details put in a little black book? I mean, really guys, think about it.

The complaints have not been generated just by homophobic males insecure about their sexuality. One flamboyant, larger-than-life patient, who happens to be HIV positive, gave me a little lecture about making assumptions based on HIV status.

“Worldwide, more heterosexuals than homosexuals have HIV!” he stated with authority.

I was tempted to reply that the assumptions I made about his sexuality were based not on his HIV status but on other politically incorrect reasons. We had a good chuckle when I explained that in fact I was the GAY one, and his pique was quickly diffused.

Brief explanations have been all that have been required to alleviate the concerns of most of these disgruntled patients, but in this time-poor business of ours, every extra second counts. The new print run of billing slips have the A taken out of GAY, which should give me an extra few precious minutes in my working week, and provide relief to the super-sensitive males who find themselves in my consulting room.

It has been an interesting lesson in human psychology.

Perhaps it is one you’d like to keep in mind, just in case you ever have a Dr Gary Andrew Young or a Dr Gwendolyn Amelia Yarwood come to work in your practice.

Coming Out of the Personality Closet

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It is a year today since I saw a TED talk which changed my life. OK, “changed my life” may be a bit strong but it certainly changed my sense of self-identity and self-worth.

Having spent my life thinking that I fell squarely into the extrovert camp, twelve months ago I discovered, that I am in fact, an introvert. 

It started with Susan Cain’s TED talk…

which I followed up with her excellent book, “Quiet: The Power of Introverts”  http://www.thepowerofintroverts.com/

I have since read more widely on the topic, realising that I was embarrassingly ignorant. The more I read and reflected, the more I realised that I had forced myself to “act out of preference” for most of my life, and beat myself up quite unfairly when my square peg didn’t fit into society’s round hole.

At the risk of sounding melodramatic, it was a perhaps a little like someone with same-sex attraction discovering that there are many others just like them in the big, wide world, and that their feelings are not shameful or wrong.

In case you are not au fait with what an introvert actually is, let’s start with a definition / description:

(From http://giftedkids.about.com/od/glossary/g/introvert.htm )

Contrary to what most people think, an introvert is not simply a person who is shy. In fact, being shy has little to do with being an introvert! Shyness has an element of apprehension, nervousness and anxiety, and while an introvert may also be shy, introversion itself is not shyness. Basically, an introvert is a person who is energized by being alone and whose energy is drained by being around other people.

Introverts are more concerned with the inner world of the mind. They enjoy thinking, exploring their thoughts and feelings. They often avoid social situations because being around people drains their energy. This is true even if they have good social skills. After being with people for any length of time, such as at a party, they need time alone to “recharge” When introverts want to be alone, it is not, by itself, a sign of depression. It means that they either need to regain their energy from being around people or that they simply want the time to be with their own thoughts. Being with people, even people they like and are comfortable with, can prevent them from their desire to be quietly introspective. Being introspective, though, does not mean that an introvert never has conversations. However, those conversations are generally about ideas and concepts, not about what they consider the trivial matters of social small talk.

…………………..

Like so many people, I associated introversion with less developed social/ communication skills and an element of shyness / discomfort / not fitting in certain social situations (large groups, new people etc.).  People with Asperger’s tendencies for example. So when I kept coming up as an introvert on any psychological test I took, I totally dismissed it.

A particularly memorably instance springs to mind. The owner of a medical practice I worked for as a registrar paid for a psychologist to come and test everyone’s personality as part of a staff development program. The psychologist then made suggestions as to how the workplace could be improved based on the results. The rationale was that we would be able to better work together if we understood how each of us ticked. Not unreasonable, but I came out as strongly introverted and had a big argument with the psychologist about it. I then totally bagged the whole process. I’m embarrassed about it now, in retrospect. Mind you, the psychologist obviously didn’t understand what introversion really meant, as he just doggedly stuck to the line about how valid the tests were without trying to explore or explain I got the result I did.

I’m not in the least bit shy, but the truth is, the deep truth that I’ve been hiding for as long as I can remember, is that I find being around people for long periods draining, and if I don’t regularly recharge by having time alone, I get very edgy.  I never feel lonely. Ever. In fact, I’m at my happiest when I’m by myself.  If I think of my 10 most satisfying and enjoyable days of the past 5 years, they’d all be ones I spent alone.  

I learned social skills and got very good at wearing a mask – fitting in, being a good communicator, friendly and generally well liked.  I spent my life trying to convince myself that I wanted to do “normal” social things, like going out for drinks or to a party with friends. I’ve tried to tell myself that engaging in evenings of social chit chat should be relaxing and enjoyable, rather than frustrating and draining. I’d feel relieved when I had a legitimate excuse to avoid social functions, but then feel guilty about my relief.

There have always been social things I enjoy, don’t get me wrong, like rehearsing for a theatre show/ orchestra/ choir, and interactions when the conversation is deep/ meaningful and engaging. I get a real buzz from performing in front of a crowd, whether that be through teaching/ presenting, acting or performing musically. I adore working with small groups as a medical educator.  However, I need to have my down time beforehand and afterwards to be able to do these things successfully and pleasurably.  I also prefer to do most of my day to day activities alone, if I’m given the option. I always thought there was something wrong with me because of this.  But not anymore. Not for the past year. I have been given the entitlement, in my own mind, to be who I am.

Since my lightbulb moment, I have become far more accepting of myself. I no longer pressure myself into socialising when I’m not feeling so inclined, and don’t feel guilty when choosing my own company over others.  I’m honest with my friends and family about needing “me” time, no longer feeling the need to give rationalisations or excuses.  They have all been tremendously supportive, and not taken my “rejections” at all personally, understanding that the “It’s not you, it’s me” cliché actually rings true in these instances.

Interestingly, I’m enjoying socialising more and feeling less drained by it in general. While the overall numbers of hours I spend socialising has decreased a little, the number of hours I’ve spent enjoying social interactions has increased significantly. Understanding and self-acceptance has banished the pressure and guilt, making for a much happier camper all round. I’m not at risk of becoming a crazy hermit cat lady anytime soon.  Not that there is anything wrong with being a crazy hermit cat lady if one is being true to oneself.

I’ll finish with two quotes. Firstly, from Susan Cain, to whom I owe a great deal,

“When psychologists look at the lives of the most creative people, what they find are people who are very good at exchanging ideas and advancing ideas but who also have a serious streak of introversion in them. This is because solitude is often an essential ingredient in creativity/”

And lastly from Ralph Waldo Emerson,

“To be yourself in a world that is constantly trying to make you something else is the greatest accomplishment”

Ralph Emerson

Scripted Role Play on Infertility

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Scripted Role Play Material is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License.

I use this scripted role play in registrar sessions I facilitate on infertility to illustrate how emotionally charged and difficult consultations relating to infertility can be, and how easy it is to “put your foot in it”.

Why scripted role plays? It is well established that the use of role plays in communication skills training can be of great value, however unscripted role plays in group settings can be terrifying for participants. Some will disengage and/or use avoidance strategies, impeding their access to learning opportunities.

Scripted and semi-scripted role plays (where dialogue is initially read rather than improvised) can be less threatening.  They provide most of the educational advantages of traditional role plays (e.g. experiential learning, development of empathy) while eliminating or reducing many of the limitations (e.g. lack of control over subject matter, quality of information imparted, performance anxiety), making them a more accessible and palatable option.

Workshop structure

1)   Prior to the session, two volunteers are sought for reading role play (and permission is obtained – no one is ever pressured to read)

2)  Introduction to session which starts with this clip…

…and includes a discussion on while a lot of us spend a good deal of our reproductive aged lives trying NOT to get pregnant, there often there comes a time when the tables turn and pregnancy becomes the goal, not the mistake, and that unfortunately, for many, their plans don’t go to plan.

3)  Definitions, statistics and the role of the GP in diagnosing/ managing the infertile patient.

4) Discussion on the psychological aspects of infertility.

4)  Reading of dialogue by volunteers

5)  Facilitator-led Q and A “in role” – which may involve some “re-winding” / additional role play by same or new volunteers.

6)  Exercise to “de-role” readers

7)  Group discussion

8)  Conclusion

Scripted role play on the psychological aspects of Infertility.

Characters:

Patient: Robyn, 40 year old female

GP registrar: Jeff Larson, aged 25 – 40

Script:

Jeff: Hi Robyn, I’m Jeff Larson, what can I do for you today?

Robyn: I was hoping to see Dr Kate again but the receptionist said that she’s left and you’ve taken her place.

Jeff: Yes, Kate has moved to another practice but I have access to her very thorough notes and will help you as best I can.

Robyn: That’s always happening here. I just get used to someone and they up and leave. Is it that bad a place to work?

Jeff: Not at all. It’s great. The reason that doctors come and go here is because it’s a training practice. Kate and I are registrars – GPs in training. We’re required to work at different places to improve our breadth of experience and get moved around periodically.

Robyn: I think you’re wrong about Kate – she’s no student doctor. She’s the most knowledgeable and caring doctor I’ve ever had.

Jeff: (under his breath) So her patients keep telling me. (to Robyn) GP registrars are not student doctors – we’re fully qualified doctors doing extra training in general practice. But let’s get back to why you’ve come along today…

Stop for Q and A in role, and discussion.

How are you feeling right now Jeff / Robyn? Who has had patients complain that doctors don’t stay? Who has had patients try to make you feel guilty for leaving? How do you think Jeff handled it? What would you have done differently? Do you tell patients you’re in training? How do you explain the concept of GP registrar?

Jeff: So how can I help you today?

Robyn: I need another referral to Dr Orford.

Jeff: The gynaecologist?

Robyn: Yes. I have an appointment next week and my last referral has run out.

Jeff: Sure, I can write you one. I see from your chart that you’ve been seeing him for fertility issues. Is this what the referral is for?

Robyn: Yes. I can’t get pregnant.

Jeff: I’m sorry to hear that. It’s really common in women your age. Fertility rates drop off a lot after 35.

Robyn: I’ve been trying to get pregnant since I was 29… 11 years ago. Isn’t that in my chart?

Jeff: Probably. I’m sorry, I didn’t have a chance to read it fully before you came in. Sounds like you’ve had a really difficult time of it. (pause… then trying to make a joke to lighten the mood). Well, at least you have a good excuse to get in lots of practice.

Robyn: Pardon?

Jeff: (embarrassed) I just mean that you have an excellent reason to have regular sex which will umm… help strengthen your marriage.

Robyn: (incredulous) You think not being able to have kids helps relationships?

Jeff: No, no I didn’t mean that.

Robyn: And that business-like sex on an ovulation-centred schedule is fun?

Jeff: Well maybe not always but…

Robyn: Not that our attempts to get pregnant involve sex anymore… which is one small mercy.

Jeff: Been having IVF?

Robyn: IVF, AI, DI, IUI, ICSI, donor eggs… you name it, we’ve tried it.

Jeff: So what exactly is the nature of your problem, if you don’t mind me asking?

Robyn: I have endometriosis which Dr Orford said has also affected the quality of my eggs, and my husband has a low sperm count. Triple whammy – bad pipes, bad eggs and bad sperm. We’ve just had our 14th IVF attempt.

Jeff: 14! You must be very… umm… dedicated.

Robyn: Obsessed you mean.

(Jeff tries to protest)

Robyn: No, it’s alright, I am obsessed. I have wanted nothing in life except to be a mother. Dr Orford encouraged me to stop after 8 IVF cycles, my husband drew the line at 10, but each time I said ‘just one more try” and they caved in. It’s not going to work again though. It’s the end. That’s why Dr Orford has asked me to see him next week, I need to get a referral for him to tell me he can’t see me anymore. Talk about ironic.

Jeff:  So about that referral…

Robyn: I’m not ready to give up on my dream of having a family though. What can I do?

Jeff: What about surrogacy?

Robyn: There’s no one close that I can ask to do it for me and paying someone is illegal, even if you do it overseas. Besides, bad eggs, bad sperm, remember? Surrogacy is unlikely to work for us.

Jeff: Have you considered adoption?

Robyn: We’re too old- they won’t accept us. George, my husband, is 48.

Jeff: Fostering?

Robyn: They turned us down for that too. Long story.

Jeff: How about coaching a kids’ sporting team or doing some babysitting?

Robyn: Do you really think that’s anything like being a parent?

Jeff: In many ways, it’s better. You can give then back at the end and have a free and independent life.

Robyn: Do you have kids?

Jeff: Yes. 3 under 5.

Robyn: And how would feel if you had to ‘give them back at the end’?

Jeff: Sometimes I wish I could, believe me.

Robyn: You regret having them?

Jeff: Of course not!  They’re the best things that have ever happened to me. It’s just that…you know… kids can be a bit…annoying sometimes.

Robyn: No I don’t know, that’s the problem.  Sure, parents often complain that their kids are frustrating and restrict their lives but also say that having children is the most rewarding and fulfilling accomplishment in life.   Can you honestly tell me that this is just a myth designed to help tired and stressed parents cope?

Jeff: No… maybe… I don’t know.

Robyn:  I can’t help but think that I’m missing out on the best thing a person can do in life.

Jeff: (awkward pause) I’m really sorry you can’t have kids. I just don’t know what to say.

Robyn: Dr Kate would’ve.

Jeff: Shall I do that referral for you?

Q and A in role then group discussion

Where did Jeff run into trouble?

What could have he have done differently?

What do you do when patients ask you personal questions?

 

“Are you going to be a specialist? Or just a GP?”

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The “Are you just a GP?” question and its variants are so frustrating. You can read my rather unusual response to that question in this column:
https://genevieveyates.com/slice-of-life/miscellaneous/swamp-gardening/
(First published RACGP’s Good Practice magazine, Jan/Feb 2013)

or to quote from the song  “The One to See is Your GP” from GP the Musical:

“Specialists aren’t that special after all

Narrow, limited, not general

The one to see is your GP

Chorus:

With a little science and a lot of care

In times of trouble your GP will be there

Nobody can fix you faster

With a few words, pills or plaster

The one to see is your GP”

Penny Wilson's avatarNomadic GP

“Are you going to be a specialist? Or just a GP?”

As a medical student and junior doctor in my hospital training years, I was often asked this question by friends, senior doctors and well meaning patients.  It really grated on me, that one little word: “just”.

I always thought I’d become a GP. As a teenager, I was inspired to study medicine by my own GP who had always looked after my family with such care and compassion.  As I went through my training I dabbled with the idea of other specialties; I was fascinating by the life stories of my geriatric patients, I loved the cute-factor of paediatrics, I was hooked on the emotional highs and lows of obstetrics, I enjoyed the team atmosphere of the emergency department. But I think, deep down, that I always knew I liked ALL of medicine too much and that above all I…

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