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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

Scripted Role Play on sexual harassment of doctors by patients

The findings of a survey of 180 doctors by Melbourne and Monash Universities hit the media in Oct 2013 after being published in MJA. The survey results showed that 55% of Australian female GPs had been sexually harassed by patients and 65% been asked for inappropriate examination. It was stated that less than 7 per cent of the GPs  surveyed said they had been trained on how to deal with sexual harassment by a patient.

Reading the report prompted me to consider how we could cover this with trainees and thought that a scripted role play (*see explanation below) may be an effective method to broach this difficult topic.  I wrote the short script below to use with GP registrars.
Please feel free to use and/or adapt it if you wish.  All I ask is that appropriate attribution is made and that you let me know how it goes if you do run it with students or junior doctors. I always appreciate receiving feedback.

* Explanation

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.

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

Workshop structure (approx. 30mins):  

1)   Prior to the session, two volunteers are sought for reading role play (and permission is obtained – no one is ever pressured to read).  I would suggest the roles are played by two females to minimise any discomfort, given the material.

2)  Introduction to session

3)  Scenario (projected via PowerPoint and/or read aloud)

4)  Reading of dialogue by volunteers with break midway (as per script) for discussion

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

Scenario:

Dr Emma consults with new patient, 72 year old Fred Jackson.

Script: 

Emma:  (At doorway) Fred Jackson?

(Emma comes in with Fred, an elderly man.)

Emma:  (holding out her hand to shake) Hello Mr Jackson, my name is Emma Roberts. Welcome to the clinic.

Fred:  Well hello Emma, aren’t you a sweet little thing?

(Fred shakes with his R hand and uses his L hand to stroke Emma’s forearm. She withdraws it quickly without any fuss or change in facial expression and motions for Fred to sit. They both sit down.  Fred edges his chair a little closer to Emma’s. She edges hers back slightly)

Emma:  How can I help you today, Mr Jackson?

Fred:  No need for the formalities, darlin’, we’re all friends here.  I’m been Freddie since the day I was born, seventy-two years ago today.

Emma:  Happy birthday, Freddie.

Fred:  It’s all the more happy now I’ve seen you, darlin’. You’re the kinda present I’d love to unwrap. Tasty! (drawn out pronunciation: Taste-ee)

Emma:  Let’s focus on health matters, shall we?

Fred:  I’m just having a bit of fun, darlin’. I don’t mean nothin’ by it. You wouldn’t begrudge an old man a bit o’ harmless fun on his birthday, now would ya love?

Emma:  I’d feel more comfortable without that kind of banter, if that’s OK.

Fred:  You’re a bit uptight, aren’t ya love?  No worries, I’ll tone it down.

Emma:  So what can I do for you today?

Fred:  I know what I’d LIKE you to do for me, with those soft white hands and rosy red….

Emma:   (interrupting) Freddie, that is inappropriate.

Fred:  Sorry, sorry.  Don’t get your cute little knickers in a twist. I’ll behave.  OK, well it’s kinda embarrassing. I’ve bin havin’ problems with me waterworks. No longer Niagara Falls, more like a pissy little dribble that won’t even put out unless you talk to it real nice and buy it dinner first. (laughs at his joke)  Me regular doc reckoned it is probably me prostate and wanted to stick a finger up me bum to check it out. I told him, no way any bloke is putting any of his bits in my hole – just doesn’t feel right, ya know love?

Emma:  It’s a routine medical examination, Freddie, there is nothing sexual about it.

Fred:  Maybe, but I’d feel a lot better if a nice young lady doctor did it. You’ll treat me gentle, I can tell.  Might even be fun, and God knows, I don’t get much of that kinda fun anymore.

Stop:

Discussion:  How do you think Emma is feeling right now?  Why is Freddie behaving this way? (dirty old man, inappropriate but harmless/ well meaning or someone  who is trying to cover up his embarrassment with “humour”) How has Emma handled things so far? What would you have done differently? What can she do now? Get volunteers to say what they think Emma’s next response should be)

Emma:  First, I’ll need to take a full history and perform a general examination. If I agree that a rectal examination is indicated, I will ask my colleague, Dr Michael Harris to come in and act as chaperone.

Fred:  We don’t need no chaperone, darl. I trust ya. I’ll put my bum in your hands anyday.

Emma:  It is for my comfort as much as yours, Freddie. It is my policy not to perform that kind of examination without someone else present.

Fred:  How about a sexy nurse then?  Always fancied a threesome.

Emma:  Again, I must warn you about your language, Freddie. I find it offensive and if you continue, I’m going to have to ask you to leave.

Fred:  Sorry love. I’m harmless. Just like joking around.

Emma:  If are not comfortable with Dr Harris being present, and you need an intimate examination, I’m afraid I’ll have to ask you to go elsewhere for the examination. I’d be happy to pass on any relevant information to the doctor of your choosing.

Fred:  Blimey!  Are you some kind of bloke-hating women’s libber? Talk about overreacting to a bit of friendly chat.

Stop:

Q and A in role 

De-role readers

Group Discussion:  Has anyone experienced inappropriate sexual behaviour from patients? How did you handle it? Stats (55% GPs 2013 study) What are your options? What systems in place in your practice?

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

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

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.

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

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!

20130927-222931.jpg

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

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”

Nomadic 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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PGPPP – Sending junior doctors out into the big bad world

Aust GovtAbout seven or eight years ago, some smart cookies came up with a grand plan, called the PGPPP. They had managed a trifecta.

First, they’d come up with a solution for the escalating problem of there being too many medical graduates for too few hospital jobs: namely, send the junior docs into general practice.

Second, the program would create new and challenging jobs for administrators. Trying to get private GPs, public hospitals, Medicare and GP training organisations to communicate and work effectively together would require not only a magic wand, but would also generate more administrative hours than one could poke a stick at, and enough hot air and paperwork to significantly increase Australia’s collective carbon footprint.

Third, and most importantly, they had an alliterative name. Prevocational General Practice Placements Program — P, G, triple P. With such a rollicking, rhythmical ring, the program was surely guaranteed to be a hit.

AGPT

Yes, there is nothing that health authorities like better than a catchy initialism. The lettering was new but the concept of sending underprepared junior doctors out into the big bad world of Medicare-controlled private general practice was not. Public hospitals have been doing it for years.

I was a junior doctor at the turn of the century. Keen on rural general practice, I volunteered for two five-week rural relieving terms, and at only 14 months out of medical school, was sent to run the hospital and the general practice in a one-doctor town in country Queensland. There was no pharmacy, no radiology and no handover.

The practice medication cupboard had been locked and the key hidden, as the doctor’s dispensing rights didn’t extend to me. The trouble was that items such as aspirin, Maxolon, Ventolin and adrenaline had also been locked away. The only medication available was methadone: I found a half-full bottle in the doctor’s top desk drawer. Hmm.

A particularly nasty gastroenteritis epidemic swept through the town during my stay, depleting the hospital’s meagre supplies of IV fluid and anti-emetics. One memorable Sunday, sick as a dog myself with gastro, I’d dealt with a farmer’s compound fractured leg, a child with severe facial lacerations and an inebriated fellow with haematemesis, when a teenager presented with symptoms of meningitis. It took five hours for the retrieval team to collect her. As I sat waiting, dehydrated and nauseated, watching her Glasgow Coma Scale drop steadily, I had an epiphany: this is not particularly enjoyable.

My second term was not much better. On the upside, a particularly traumatic sequence of events gave me the impetus to take up writing to debrief. I later penned a story loosely based on the incidents, What Would the Coroner Think?, which earned me an OzDoc award in 2008. I subsequently translated it into a short film that is used in medical education throughout Australia.

Wondai pharmacy

I’ll always be grateful to Queensland Health for throwing me in the deep end before teaching me to swim. It might have turned me off rural general practice but it sure gave me great writing material.

Thank goodness the creators of PGPPP didn’t adopt that sink-or-swim approach. Bureaucracy notwithstanding, its heavily supervised and structured general practice attachments are educationally sound and proving beneficial all-round. Not so good for dinner-party horror stories, though.

Published in Australian Doctor on 15th Sept, 2011:  On Placement Programs

http://www.australiandoctor.com.au/articles/b3/0c0725b3.asp

How I became a better whore

“You’re a boring whore! Fix it.” The barked criticism came like a slap in the face. The director of Les Miserables was right, though. I was a boring whore.

Two whores and a sailor

Two whores and a sailor

Actors need to immerse themselves in their roles, shed inhibitions and squelch embarrassment. I was not managing to do this while rehearsing the Lovely Ladies prostitute scene. My performance was overly self-conscious and restrained.

Three days later I found myself at a medical education conference, attending a session discussing learning plans. A popular tool in adult education generally, and a training requirement for all GP registrars, learning plans are actively disliked by many. Done purposely and thoughtfully, they can be of great benefit; completed hastily or reluctantly because they are compulsory, they are next to useless.

I have to confess that, as a registrar, my own learning plans were dashed off with little thought, submitted and then promptly forgotten. I’d never thought this technique would work for me.

At the conference, the attending educators were instructed to each write a learning plan that addressed an aspect of their non-medical lives. We were asked to choose something that we genuinely wanted to improve. I instantly knew what I’d write about, and completed the task with seriousness and sincerity.

The facilitator randomly picked a few participants to read out their learning plans. The topics were predictable: “I want to exercise each morning”, “I want to get at least seven hours of sleep a night” and the like. Yes, you can see where this is leading …

I should have anticipated being called upon, but when the “We have time for one more, how about you?” came, along with direct eye contact and a kindly smile, I momentarily panicked. Surveying the room of mostly middle-aged, male faces, many of whom I didn’t know, I considered making something up on the spot. Instead, I stood up, took a deep breath and read out: “I want to be a more exciting whore.”

I then outlined my proposed methods for achieving this objective and how I intended to measure my progress. Without explanation, I then sat down.

Silence. Not a sound. Most eyes were glued to me, the others looking anywhere but. The atmosphere was thick with shock, amusement, confusion, suspense and fascination.

I didn’t leave them hanging for too long. After my disclosure as to why I chose the topic and the context in which I was “whoring”, there were audible sighs of relief and a sprinkling of laughter throughout the room.

It was memorable for those present. Four years later, I still get the occasional question about my “whoring” when I run into certain educators at conferences.

I am pleased to report that my learning plan well and truly achieved its aim. I enacted my plan exactly as written and practised diligently. I knew I had been successful when the director instructed me to “Tone it down a bit. This is a family show, you know!”

Not high-class hookers!

Not high-class hookers!

I now feel a lot more comfortable extolling the benefits of learning plans to unconvinced registrars. I tell them: “I used to think that I wasn’t a learning plan-type person either but I’ve discovered that if you choose a relevant and important objective and spend time and effort working out how to achieve it, the technique can really work.”

I tend to leave out: “It didn’t do much for my medicine, but it turned me into a fabulous whore.”

First Published in Australian Doctor on 21st July, 2011: On Becoming a Better Whore

http://www.australiandoctor.com.au/articles/10/0c071810.asp