Consulting with wet pants… but it could have been much worse.

You know you’re in trouble when, during a routine skin excision, you start wishing you’d ordered cross-matched blood. Okay, so maybe that’s a slight exaggeration, but as the pulsing deep temporal artery spurted like a Yellowstone geyser, I started wishing that the infiltrative BCC had chosen to infiltrate somewhere else.

Bleeding in surgeryI summoned my colleague for help, calmly mentioning that I was “having a slight problem with haemostasis” in an attempt not to alarm the patient — the statement being reminiscent of Monty Python’s Black Knight saying “It’s just a flesh wound” after his arms were amputated. Several artery clips and ligatures later, we managed to tie off all three of the arterial branches that had been transected as they traversed the tumour excision margins.

The specimen was removed, the defect repaired uneventfully and the patient left the surgery happy enough. Those of us left behind (including the nurse facing the mess, the backlogged patients and my now-running-late colleague) were not as chipper, but the only real casualty was my outfit.

My new blouse and favourite trousers had been sprayed, liberally and repeatedly, with scarlet. I felt like a living piece of modern art. After rinsing out these offending items, I was suddenly faced with a teenaged-girl-like “I have nothing to wear” crisis, but fortunately was able to scrape over the respectability line by putting my dark-coloured trousers back on and borrowing a cardigan to go over my undershirt.

Having wet pants is not pleasant but, according to the Medical Board, it’s preferable to consulting with no pants at all. I wished I’d worn a gown, but it’s not standard procedure and I didn’t expect to be Jackson Pollocked.

I try to live life by the six Ps (Prior Planning Prevents Piss Poor Performance), but the truth of the matter is that surgical challenges, like everything else in medicine, can catch you unaware. Our medical training teaches us to respond coolly and logically under pressure, but the fight or flight response can result in unwise decision-making, particularly in the inexperienced.

I recall a story I was once told of a GP registrar who got into trouble excising a skin cancer, when, unable to close the defect, he panicked and decided to reattach the lesion. Yes, you read correctly. He took the specimen out of the jar and started to sew it back onto the patient’s leg.

I’m not sure how he planned to explain his actions to the patient, or whether he even realised that the hole he was digging for himself was far bigger than the one he was filling with formalin-soaked tissue.

Personally, I’d much rather get timely help to save my skin than struggle on alone in an attempt to save face. Anyway, the story goes, the practice nurse had the nous to alert another of the practice’s GPs, who swept in and saved the day.

Thanks to my colleague’s skilled assistance, my surgical “uh-oh” experience also had a happy ending. The histopathology came back with clear margins, the patient’s post-op course was smooth, his wound healed beautifully and the blood washed out of my clothes without staining.

I’ve been left with a much better appreciation of the anatomy of the deep temporal artery and some good hands-on practice at clipping and tying off its branches, although I’m going to try to steer well clear of that particular artery in future.

It could have been a lot worse: I could have been wearing white.

(The involved patient has consented to having this published)

First published in Australian Doctor on 7th September, 2012:  On getting help

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

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Painful sports talk.

When the following column was published in Australian Doctor, I received considerable backlash from readers.  I was accused of being catty, socially inept and un-Australian amongst other things.  One reader said I should be ashamed of myself and another called for Australian Doctor to “do the right thing and let this column fade into obscurity.”

While this certainly was not the first time my light-hearted tongue-in-cheek columns have been misinterpreted, I was a little surprised at the vitriol generated over what was intended as a self-deprecatory fluff piece.

As for being un-Australian, I would have thought that my “taking the piss” was very Australian!

So what was the fuss about?  Read on and make up your own mind, and I’ll get back to watching the Winter Olympics….

………………………………………..

I’m not a big fan of inane chit-chat. I’ve absolutely no objection it if fulfils a purpose such as putting a nervous patient at ease, but there are times when talking about the weather, the price of petrol, Paris Hilton’s latest furry handbag accessory or Auntie Mildred’s stamp collection drives me up the wall. Sitting around the patio on a Sunday afternoon “shooting the breeze” with my in-laws used to be a regular torture. Thank goodness for divorce. 😉

image rubgy unionThere is only one type of conversation I find more painful than small talk, and that is sports talk. Rugby in particular.  I’ve never understood the fervour of armchair sports fans.  If watching testosterone-laden men thump each other in their attempts to grab an egg-shaped piece of air-filled leather toots your horn, I’m not going to criticise. Just don’t feel offended if my eyes glaze over and I start looking for an escape route if the conversation turns to ladders that aren’t the type you use when painting a house.

I still have nightmares about the time I was trapped in the operating theatre listening to an orthopaedic surgeon blabber on about rugby union matches. Oblivious to my distress, he drilled and hammered away as he plated the radius (forearm bone), pushing and pulling the fractured limb with the confident and carefree brusqueness at which orthopods excel.

It was painful, terribly painful, but I couldn’t object. Paralysed and powerless, I lay there, a terrified nine-year-old, insufficiently anaesthetised.  After what seemed like an hour, but was probably only a few minutes (all football-related conversations seem to drag on interminably to me), the anaesthetist woke up to the fact that I was awake, presumably by lifting his eyes from the sports pages for a moment to notice that my pulse had skyrocketed. The last thing I recall was his saying, “Hold that thought. She’s a bit light – time for a top-up.”

It was traumatic at the time.  The first night post-op I slept only fitfully, alone in a strange hospital room. The frightening shadows and noises of the orthopaedic ward mingled with my nightmares, nausea and pain. I vividly recall the particular dream I had that night; variations of it have haunted my dream-life for years.  It involved finding myself hanging from goalposts during a massive televised football match, attached to the metal cylinders by big screws through my forearms, crucifix style. The crowd were jeering and laughing at my attire – a hospital gown with only air on my derrière.

In my lucid moments, I begged for my parents, only to be told to be quiet and go back to sleep. None of the nurses believed my story of being aware during the procedure.

The following day the orthopaedic surgeon was likewise sceptical – until I relayed snippets of his conversation.  I do not recall if his face betrayed even a hint of embarrassment or concern, but I was probably too young and traumatised to have noticed. All I remember was that he made some off-hand rugby-related jovial comment and moved onto the next patient as quickly as possible.

Perhaps that particular childhood experience could be used to justify a dislike of rugby, having bones broken, night duty nurses and orthopaedic surgeons, but the truth is that none of these are on my list of favourite things for far less significant reasons.

It could be said that for someone who claims to abhor meaningless chat, I sure do a lot of it, in both verbal and written forms – this column being a case-in-point. A fair comment, I admit.

We should have a pointless conversation about it. Maybe after next week’s game.

……………………

First published in Australian Doctor on 5th July, 2013  On Sports Talk

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

What it means to be an Australian – Part 2

Last Sunday, on our national day,  I blogged about the staggering costs of US healthcare as I reflected on what it meant to be an Australian.

Here is the story of my own personal encounter with the US health system last year….

Playing it Safe

While in Las Vegas recently, I spent more than $5000 in six hours. Now, before you Bellagio Hotel in Las Vegascastigate me for reckless spending, I rush to tell you that I forked out because I’m not a gambler — I was playing it safe. The hefty bill came from a hospital, not a casino.

En route to visiting my family in Canada, I was enjoying a quiet stopover in not-so-quiet Sin City. I first felt some pain in my right calf while running up the hotel fire-escape stairs (I know, I’m crazy), making me think muscle sprain, but within 24 hours the swelling became quite marked while the pain wasn’t particularly severe.

Given that I’d just endured a long-haul flight sitting in a cramped, cattle-class seat, I decided I couldn’t take the gamble that it wasn’t a DVT. Hoping for an ultrasound, I limped into a walk-in medical clinic, where the consulting doctor thought it highly likely to be a DVT and sent me to the nearest ER.

I grew up on US TV medical dramas, ER being my favourite. The series began in my second year of med school and I soon convinced myself it was a useful and legitimate study resource — a view reinforced when an obscure case in my fifth-year internal medicine viva was identical to the fictional one in a recent episode, allowing me to answer correctly and with confidence.

When I turned up to my first real-life American ER and discovered my treating doctor’s name was Mark Green (the name of my favourite character on the show), I have to admit I felt a frisson of excitement. It didn’t hurt that the real Mark Green MD was attractive, attentive and charming.

Disappointingly, this is where the similarities with the TV show ended. There were no patients miraculously brought back to life from asystole with CPR and a few jolts from a defibrillator, no complex surgical procedures performed by underqualified staff, no doctors and nurses embroiled in interpersonal dramas at patients’ bedsides, and not even a token lovable but disruptive patient with an entertaining form of psychosis. At least, not that I got to see.

It was, well, like an Australian ED, except that everything was bigger: the patients (the average BMI was probably over 30), the chairs, beds, artwork — and the bill.

My ultrasound was equivocal and the D-dimer negative, so an MRI was ordered. It seemed like a bit of overkill but, from what I could gather, MRIs are ordered for practically everything in the US: tension headaches, osteoarthritis, acute back pain, toothache, a broken fingernail.

Okay, perhaps not all of these, all of the time. It did the trick for me though, producing a lovely image of a second-degree soleus muscle tear without a thrombus in sight.

It looked a lot worse than it felt. I kept declining the analgesics the nurse tried to give me, unwittingly reinforcing her perception of the Australian stereotype. “I always thought you Aussie sheilas would be tough. All those snakes you have to kill and jellyfish that bite you. And the sharks.”

She paused, looking proud of herself. “Sheila is Australian for ‘woman’, isn’t it? I learned that on HBO. I just love learning different languages.”

I know the US health system has deep-seated problems, but my brief stint as a patient was a memorable and positive one. The staff were friendly, efficient and professional, and the facilities top notch. The only hurt was the bill. I’m not the first person to lose a fortune in Las Vegas but at least I was insured against the loss!

…………………..

First published in Australian Doctor on 12th April, 2013 about my trip to the US/ Canada in Feb/March 2013.

http://www.australiandoctor.com.au/opinions/the-last-word/the-last-word-on-playing-it-safe

An ECT visit with a twist

The GP registrar, Dr S, took a big breath before bringing in her first patient from the waiting room. It was her first ECT (External Clinical Teacher) visit and she was probably wishing she’d been booked in for the other kind of ECT instead.

“I’ve got another doctor sitting in with me today as part of my training. Is that okay, Jacquie?”

“Sure, no problem. I’m just here for my results and a quick script,” replied the 50-something Jacquie as she walked with Dr S down the corridor.

In contrast to Dr S’ obvious discomfort, Jacquie seemed perfectly at ease — until she saw me sitting in the corner. Her eyes widened and then carefully avoided any further contact with mine. She twisted and untwisted the strap of her handbag.

“Are you okay?” Dr S asked. “You seem kind of jumpy.”

The response came through gritted teeth: “I’m fine.”

“Good news about your results. They are all normal. I’ll go through each one with you now. The arsenic level was undetectable”

“No need to go through them. Can I just get a printout please? I’m in a bit of a hurry.”

“Well, okay. You wanted a copy for your naturopath, didn’t you?”

“Umm, no. Just for me.”

Dr S looked confused.

“But didn’t your naturopath give you the list of the blood tests she wanted you to have done?”

“Umm, oh, that’s right. I forgot.”

Dr S shook her head almost imperceptibly as she printed out the results. She turned back to Jacquie.

“And your script?”

“What script?”

“You mentioned you wanted a script. Was that for temazepam?”

“No, I don’t need a script. I have a spare one at home. I forgot.”

Dr S was struck with the possibility of an interesting diagnosis. Her face lit up momentarily before settling into a caring but concerned expression.

“You seem to be having some memory problems, Jacquie. I’d like to ask you a few more questions if that’s okay?”

“Not today, I’ve got to go. Thanks.”

Jacquie flew out of the room, clutching her pathology results.

Dr S turned to me, her brow creased with concern.

“Well, I stuffed that up. Should I have handled the memory issue differently? She seemed really scatty today — she’s never been like that before. Do you think early onset dementia is a possibility?”

“Just take a deep breath. You didn’t do anything wrong. Sometimes there are other things going on.”

I smiled and explained that Jacquie was a regular patient of my practice, 50km away. She’d been in to see me only a week earlier when she’d asked for a range of unusual blood tests as requested by her naturopath. I had not ordered them. I had, however, given her a script for temazepam, which she insisted she used only occasionally.

As is the case with most registrars, Dr S soon relaxed into the ECT visit and found the experience valuable educationally.

It was valuable for me too. And for Jacquie. Somewhat to my surprise, she came back to see me, contrite, and we had a frank and open discussion about what had happened.

Her memory is just fine, although she wishes she could forget that embarrassing day.

(Names have been changed and permission has been obtained from the involved parties for this account to be published).

First published in Australian Doctor on 9th August, 2012 On an ECT visit about an encounter I had a few years back, but memorable even now…

http://www.australiandoctor.com.au/opinions/the-last-word/the-last-word-on-an-ect-visit

Recapping memorable moments of 2013 – the “Prostate and Fingers” gaff

I love this time of year.  The water is warm, the days are long and the whole world seems to slow down.

The change of year provides a perfect excuse to reflect and plan, with or without making accompanying resolutions. I’m one of those people who likes to take a good hard look at the used year before tossing it out and opening a brand new one.

While sentimentality occasionally creeps in, I refuse to let it linger. I certainly don’t subscribe to the “a year is like your virginity” school of thought (you only miss it when it’s gone).

My very favourite things in the media (online, TV and newspaper) at this of year are the “year in review” compilations. All the big events in an acoustically and/or aesthetically pleasing five minute clip or five page spread.

Several of the Australian 2013 recaps included Tim Mathieson’s remark about Asian women doing prostate examinations at a reception at the lodge for the members of the West Indian cricket team in late January.  http://www.abc.net.au/lateline/content/2013/s3678150.htm

I wrote this column in the wake of the uproar and thought now would be a good time to share it, in the “reflecting on the year that’s been” tradition…

The Last Words on Prostate and Fingers

So our First Bloke got his fingers burned recently. For those who missed it, during a reception at The Lodge he told the West Indian cricket team: “We can get a blood test for it but the digital examination is the only true way to get a correct reading on your prostate so make sure you go and do that, and perhaps look for a small Asian female doctor is probably the best way.”

The story spread faster than the then-still-burning southern bushfires and flooding northern rivers. It dislodged natural disaster stories from their month-long prime spots and displaced the displaced-person interviews.

Cries such as “discriminatory”, “poor taste” and “potentially prosecutable if Gillard’s anti-discrimination bill were already law” were broadcast far and wide.

It shouldn’t have come as a shock to Tim that his light-hearted comment was given the finger. Surely he could have worked out that a sentence incorporating suggestions of sexism, racism and penetration of that particular orifice, delivered at an official function with the PM at his side, would have been better left unsaid.

Then again, I doubt it was scripted or intentional. Ill-conceived attempts at black humour are par for the course when people find themselves in uncomfortable situations, and for most blokes, talking about rectal examinations would definitely qualify as uncomfortable.

Add public speaking, TV cameras and famous international sport stars to the mix, and it’s no surprise that our First Bloke was all fingers and thumbs.

I don’t want to enter into a debate on DRE/PSA testing of asymptomatic men and I’m not going to criticise his ungrammatical sentence construction.

However, I do have a bone to pick with him: his premise. I think Tim has got his facts wrong regarding finger length and rectal examination.

Many female doctors have told me that small hands make digital rectal examinations very difficult. They complain of having insufficient length to reach the superior pole of the prostate.

Many will gallantly try to push as far in as they can, but I expect this process is not a particularly comfortable one for the patient.

I believe long, slender fingers are best suited to prostate examinations. Narrow width for comfort. Long length for maximum reach.

As I have been heard to say on more than one occasion (but never near a cameraman or a prime minister): “Long, thin fingers — good for piano; good for prostates.”

I imagine The Lodge was a rather tense place on the evening of 28 January. If Julia is anything like any other woman whose partner has embarrassed her at a dinner party, Tim would have had to weather quite a storm once the guests left.

In a way, the timing was almost as unfortunate as the comment. Unlike Julia’s, Mother Nature’s fury was finally dissipating. If Tim had made his faux pas a week earlier, the Queensland floods would have washed the story away in minutes. As it was, PM Gillard was forced to go into damage control.

No doubt inspired by the recent sandbagging, back-burning and other efforts by emergency services to save the endangered, Julia knew she would need to reach deeply into her bag of tricks to combat this unnatural disaster.

She did, and in just over 24 hours, pulled out an election. Or at least, an election date.

While she may deny that the two events are linked, I have a sneaking suspicion that Australia’s launch into the longest ever election campaign may have had more than a little to do with an inaccurate espousing of the shortest digits.

First published in Australian Doctor on 15th February, 2013: On prostates and fingers

The Big C at Christmas

Cancer. The Big C. No one wants it as a Christmas gift.

Maybe it’s just coincidence, but in the lead-up to Christmas I seem to be delivering this bad news more frequently than usual.

Intriguingly, as with children’s toys, each year there seems to be a particular type that is all the rage. Three years ago, I diagnosed two leukaemias in the week before Christmas. Two years ago it was three breast cancers and, in 2012, it was two invasive melanomas.

Unlike my breast cancer and leukaemia patients, my melanoma patients took the news calmly. Too calmly. They were both unusually blasé, even for middle-aged country blokes.

The first wanted to postpone the treatment of his aggressive desmoplastic melanoma until February, as he wanted to have a knee arthroscopy first.

The second didn’t even want an excisional biopsy until the new year. I had diagnosed his melanoma, with its textbook dermoscopic appearance, clinically.

Understandably, I was keen to remove the little blighter before it got up to more mischief, but the patient had plans to swim at the beach and didn’t want an open wound.

I usually employ a softly-softly approach when breaking bad news, trying to not unduly scare my patients. Wrapped in comforting padding, the “this is serious” message was obviously not being absorbed through either of their thickened, sun-damaged skins.

I was pretty sure neither was in a state of terrified denial; they both seemed genuinely unconcerned.

With the first patient, I worked my way up the scary-statements ladder until he “got it”. It was quite a climb; I even needed to use the word “death”.

With the second, I took an easier route, bringing in his wife from the waiting room and re-explaining the situation. He didn’t stand a chance! The melanoma was excised the following day.

When I saw him after Christmas to do his wider excision, he told me: “You’re too touchy-feely, Doc. You should’ve just said first-up, ‘This mole is deadly. I don’t care what plans you have — it’s coming off right away’. I wouldn’t have argued if you’d put it like that.”

Minutes later, as I sat wondering whether I should be more like Dr House at times, I received a phone call from a very worried daughter of another patient.

“Mum has been beside herself all Christmas. She’s convinced she won’t live to see another one. Getting the cancer diagnosis has completely knocked her for six.”

Puzzled, I reviewed my notes. I’d seen her mother as a new patient a week before Christmas and found a small solid pigmented BCC on the skin overlying L2/3.

I told her that a biopsy would be a waste of time and recommended excision, briefly going through the risks of skin surgery. She didn’t have any questions and the procedure was booked for early January.

I like to think I’m particularly good at reading people but in this case I failed miserably. I had no inkling that what she’d heard was: “CANCER!! On the SPINE! Too urgent to biopsy! Risky surgery!”

I apologised profusely, feeling terrible that I’d wrecked their family Christmas with my careless tossing around of the C word.

The daughter replied, “Oh it wasn’t all bad. Mum finally made amends with her sister after 20 years of fighting, and decided to work through her bucket list, starting with learning how to surf. She loves it!”

So while I’d kept a patient out of the water over Christmas, it seems that I’d inadvertently encouraged another one in. I just hope she slip, slop, slapped.

 

First published in Australian Doctor on 17th January, 2013: On the Big C

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

The Medicine of Laughter

I was at a doctors’ meeting recently, at which the Tropfest 2012 finalist short film How Many More Doctors Does It Take To Change A Lightbulb was screened.

This somewhat edgier sequel to the 2006 film How Many Doctors Does It Take To Change A Lightbulb shows seven minutes of unprofessional GP conduct, spiced by per rectum jokes.

Looking around at my 30 or so colleagues, I was interested to observe that one of the most gentle, empathic and sensitive doctors I know was among those laughing the hardest. She later explained: “Laughing at misfortune is the only way I can keep caring. I’d fill up with misery otherwise … and be no good to anyone.”

A propensity for black humour has long been associated with medical students and doctors alike, and it is not hard to understand why.

Dealing with human vulnerability, illness, grief and pain on a daily basis can be stressful. Add in time pressure, bureaucratic frustrations and the expectation to remain caring, empathic and professional at all times, and something’s got to give.

We all know that having supportive family and friends, regular time off and interests outside medicine are important for our well-being and sustainability, but are these enough?

Do we also need additional ways of processing and then letting go of the absorbed grief we accumulate?

Some choose to debrief by yelling, ranting, moralising or whingeing. Others use humour in one of its many forms: dark, absurd, slapstick, satirical or otherwise. This may sometimes involve poking fun at our more intense colleagues who may, in turn, complain about those they believe treat serious issues insensitively and frivolously. Horses for courses.

It is true though, that using humour is inherently risky, particularly for doctors. Even if the intent is innocent, an attempt to lighten the mood at the wrong time or place can seriously backfire. What is funny to one person might be deeply offensive to another.

My advice: go ahead and laugh your cares away, spreading the sunshine of your humour if you will — but always treat patients with respect, tread carefully around those ever-so-serious colleagues and refrain from sharing any potentially inflammatory jokes via social media.

Personally, I like to think that I owe a good deal of my resilience to spending as much time as I can on the funny side of the fence. Writing a Last Word column each month has helped me to do just that.

I now find myself on the lookout for encounters that I can subsequently write about in a light-hearted fashion. The more I look, the more I find. Medicine may be a serious business but it is also seriously funny.

I have pages of ideas, most of which will never be submitted for publication. It doesn’t matter though. I’ve discovered that the simple act of recording such stories in a humorous style, even without sharing them with others, has been great for my mental health.

It is not insensitivity. It is not schadenfreude. It is a way of reducing the emotional burden of my job and allowing me to go to work smiling — ready to give the support and empathy my patients and colleagues deserve.

I enjoyed watching the Tropfest film. While I far prefer witty satire to predictable scatological humour, there is something about stories of inserted foreign objects that elicits a chuckle along with the cringe.

 

First published in Australian Doctor on the 15th June, 2012 On the Medicine of Laughter

http://www.australiandoctor.com.au/opinions/the-last-word/the-last-word-on-the-medicine-of-laughter

 

Plagarism on Media Watch

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

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

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

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

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

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

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

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

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

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

I wish him well.

………………………..

Written in October, 2012

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

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

Why Halloween and I aren’t so keen on each other

Halloween, 31st October 2012

I’m not opposed to giant pumpkins. I don’t have a problem with people dressing up in costume, as long as I’m not expected to don a witch’s costume to go with my chin (I was once told by a six-year-old patient that my chin is “long and pointy like a witch”, and I’ve had a chin complex ever since).

I just object to being dragged into yet other Americanised opportunity to promote childhood obesity and tooth decay.

Mind you, Halloween doesn’t seem keen on me either. This 31 October, I was travelling to Melbourne, via Sydney, heading for the RACGP to workshop the new vocational training standards. The meeting was a treat but I was tricked en route. I arrived at Sydney airport. My wallet didn’t.

I’d had it at Ballina airport when I paid for parking, but somehow I found myself in Sydney with no ID, cash or credit cards. Thanks to a kind friend who made a mercy dash to the airport with some cash, I made it to Melbourne with at least the means of getting to my accommodation.

Alas, the hotel clerk was not accommodating. Having missed my connecting flight in Sydney, I ended up arriving after midnight, and was in no mood to be told that they couldn’t give me my prepaid room without a credit card imprint and ID.

“I know my credit card details; can’t I just give you the numbers?”

“No. I have no way of verifying who you are.”

“But you take credit card bookings over the phone.”

“Yes, but that’s different.”

“How?”

“It’s over the phone.”

“Well, how about I go outside and call you on my mobile?”

“We will accept a $500 cash bond in lieu of a card, but we still need ID to give you the room.”

“I don’t have $500 or ID.”

“Then I’m sorry, I can’t help you. My hands are tied.”

I was ready to tie him up myself and steal a room key but sanity prevailed. The duty manager was called, and I eventually got a bed on which to rest my weary head.

I have a new appreciation of some of the many challenges faced by the homeless, dispossessed and utterly disorganised. For me, thankfully, it was just a blip — Halloween deja vu.

This wasn’t the first time I’d spent Halloween trying to prove my identity. In 2010, I landed at Los Angeles airport with a stolen passport, according to US Customs. I was ignominiously thrust into detention with an assortment of would-be immigrants while they “processed my case”, and released seven hours later with a curt “You can go now. Administrative error”.

Again, a missed connecting flight, which meant arriving late in Las Vegas, and an after-midnight hotel fight. They’d given away my prepaid room and claimed the hotel was full. Being Halloween in Vegas, I almost believed them, but wandering the streets at 2am with inebriated, costumed revellers didn’t seem like a good option, so I stood my ground.

They eventually found me a “special” room, which came with a full-mirrored ceiling, an enormous “love tub” set into the carpeted floor, and a bed with various attachments. I tried to convince myself it was a Vegas-style birthing suite that had been properly cleaned after last use, but the stains and lingering odours suggested otherwise. I mightn’t have minded so much if it’d come with a pool table and naked prince.

Next year I’ll try to get back into Halloween’s good books by staying at home and treating any callers to tooth-rotting ‘candy’, with my wallet and passport safely tucked away.

………………………

First published in Australian Doctor on 21st November, 2012: On Halloween

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

I love being mistaken for a medical student

“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

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

The Last Word on GP Matchmaking

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

 

 

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

Mid-air consulting… Aussie GP style

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

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.