Is general practice being called the toilet bowl of medicine such a bad thing?

A couple of days ago, I heard someone describe general practice as “the toilet bowl of medicine”.

It was not meant to be complimentary.  However, on reflection, perhaps using such a statement to denigrate general practice is instead betraying an underappreciation of toilet bowls.

Like in a general practice consultation, what happens behind a closed toilet door is generally private, personal, and absolutely essential to health and wellbeing. Subtle and not-so-subtle signs of disease can be revealed.  Toilet visits can be quick and routine, or they can be long and troubled.  Those with good health and busy lives often don’t give toilets much thought, but expect them to be conveniently located and available when the need arises.  For others, toilet access is always front of mind, sometimes dictating how they live their lives.

Importantly, having an adequate number and distribution of well-functioning toilet bowls is vital to keep communities healthy including preventing and/or managing disease outbreaks.

Like ‘I’m more like herpes than Ebola’, I don’t think “General practice – the toilet bowl of medicine” is a rallying cry which will (or should!) catch on.

However, I believe we need to remind politicians, bureaucrats and our esteemed health practitioner colleagues, that although general practice may not be the sexiest of the medical professions, like sanitation, it is absolutely vital that all Australians have ready and affordable access to properly funded, maintained and supported services.  Without prioritising both general practice and toilet bowls, Australian society is going end up in the poo.

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

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

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

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

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

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

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

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

Also available via the usual podcatchers.



Medical Collegiality

HippocratesAs a medical educator, I not uncommonly have doctors, who, eager to share their wisdom and experience, approach me with tricks of the trade they think might be useful to those I teach.  I really appreciate such gestures and have picked up some wonderful insights over the years in this way. Doctors’ willingness to share knowledge and experience with others is in stark contrast to those in professions such as law and in the world of corporate business. I’m proud to belong to a profession that values collegiality over the relentless pursuit of the competitive edge.

The preparedness to teach and share medical wisdom has long been a valued part of the medical culture, stretching right back to Hippocrates. Included in his 3rd Century BC oath is “to teach them this art … without fee and covenant.”  Mind you, I’ve been told that ol’ Hippocrates was not so keen on teaching the art of medicine to women, slaves or surgeons, but as with any ancient philosopher, it is useful to quote the pieces of wisdom that suit one’s purpose and ignore those that don’t.

The FOAM movement is a shining example of medical collegiality. For the uninitiated, FOAM stands for Free Open Access Meducation – medical education for anyone, anywhere, anytime. Medicine is a rapidly expanding and ever-changing field, and ongoing learning is a constant and career-long responsibility for physicians. Proponents of FOAM want to “make the world a better place” by making access to up-to-date medical information and educational resources readily available, easily accessible, and free to all.

FOAM is independent of any country, specialty, organization, platform or media. In addition to distributing information via traditional websites, podcasts and online videos, FOAM uses social media platforms such as Twitter and Facebook to enable physicians all over the world to collaborate, discuss and share their ideas and experiences. This effective professional use of social media has demonstrated conclusively that Twitter is not just for twits, and that there is more interesting information to be found on Facebook than what some “friend” whom you haven’t seen since primary school had for dinner last night.

Emergency and Critical Care physicians have led the way in this, but many Australian GPs have also embraced FOAM. You may like to check out and make Hippocrates proud.

Of course, old school face-to-face, peer-to-peer learning is still alive, well and wonderful. Corridor and tearoom chats, small group tutorials and conferences are all fabulous opportunities to hunt and gather clinical gems.

I was facilitating a multi-specialty workshop recently at which an orthopaedic surgeon, Dr X, asked to share his revolutionary tips for communicating with patients.  With genuine pride, he recommended “his” techniques:

“It makes the patients feel more comfortable if you sit on the same side of the desk as they do.”

“It is better to start a consult with “How can I help you today?” rather than “What’s your problem?”

“Patients like it if you let them dress and undress in private by getting a curtain or screen for your room, or by leaving the room while they change.”

Ground-breaking insights!

Mind you, he had a few less conventional ones such as recommending examining patients from a one metre distance when possible, but again, as with Hippocrates’ views, if helps to focus on the agreeable components.  Despite Dr X being a surgeon, I think Hippocrates would have applauded his willingness to share his wisdom with others.

As did I.


First published in Good Practice magazine, November 2014

What do GPs actually do?

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

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

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

“My son has a strange rash on his forehead. I’d like a referral to a dermatologist please.”

“Sure, no problem. I’ll write you one now.”

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

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

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

Perhaps we can also do more to enlighten the wider community as to what versatile and clever ducks we GPs are. A hip new TV show might do the trick. We haven’t been doing too well in TV-land recently.  Where once “G.P.” and “A Country Practice” appeared on Australian screens, audiences now take their medicine from TV hospitals’ dispensaries.  The morgue is the most popular place to linger – forensic pathology has been hot for years and is showing no signs of dying (sorry!).  Other than the UK’s “Doc Martin” (and that image Doc-Martin1cranky old bugger doesn’t do us any favours), there is nary a GP in sight in recent years.  I propose that we follow our Australian veterinary colleagues’ lead. They weren’t doing too badly with Dr. Harry but have gone to a whole new level of sexy with Dr. Chris on “Bondi Vet”.

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

First published in Good Practice magazine, June 2013

Coming to terms with how little we know

computer-labAt this very moment, I’m “invigilating”  the RACGP’s KFP exam (one of the three Fellowship exams) in Brisbane.  To the uninitiated, the word “invigilate” is of British origin dating from the mid-1500s, specifically meaning “to watch examination candidates, especially to prevent cheating.”  I know this because my mother duly informed me of such in an email this morning.  I casually that mentioned to my mum, during a Skype call earlier this week,  that I was going to be invigilating on Saturday and she was curious enough about the unfamiliar (to her) word to look it up.

As I look into the sea of earnest faces as they type away (yep, the exam is computer based), all I can think of is “thank God it is them and not me.”  I may be the “teacher”  but I reckon that if I sat the exams today, I’d probably fail.

If patients want a GP with excellent theoretical knowledge, I recommend they seek out a GP registrar who is about to sit, or has just sat, the Fellowship exams.  Breadth-of-knowledge-wise at least, for most of us, it is all downhill from there.

Drs David Chessor and Suzanne Lyon - recent successful RACGP exam candidates.

Drs David Chessor and Suzanne Lyon – recent successful RACGP exam candidates.

In my medical educator and RACGP examiner roles I spend a lot of time working with GPs in the peri-exam phase of their careers.  I’m constantly impressed with how much “stuff” they know and find myself wondering where all the “stuff” I used to know has gone.  I’m not yet forty, so can’t blame age-related cognitive decline.  I did get a knock to my head which resulted in six facial fractures and temporal lobe contusions, but I passed my FRACGP OSCE exam three weeks later so it can’t have done me too much harm.

And yet here am I, constantly having to look up drug doses, item numbers, clinical guidelines and the anatomy of the facial nerve.  Sometimes I feel like I’m just an ignorant lump of carbon.  The human brain is an unfathomably complex and wondrous organ, but its data storage and retrieval capacities are beaten hands down by a $5 USB flash drive.

What I find most frustrating is that it’s not just the old facts which have slithered out of reach: it’s the newer information too.  I try to keep up.  I read.  I listen.  I discuss.  But some things just don’t stick.  I’ll read an article on the newest research findings regarding the pathophysiology of chronic kidney disease, for example, and think, “Yep, I get it.  Kidneys sometimes confuse me but this I understand.  I follow the logic from start to finish.”

It’s like a light bulb.  A light bulb which blows five minutes after I’ve closed the journal.  Nothing.  Ask me to explain a single pathological process and I would probably say something like, “Well it is to do with sodium and tubules… and umm… you know, it is a great article.  I can email you a link if you like.”

Now before you put in a concerned call to the Medical Board, let me assure you that I am a safe and competent doctor.  I’m pretty good at knowing what I don’t know, and just as importantly, knowing how to fill the gaps left by the information that sneaks out of my cranium after dark.  I can Google with the best of them and I’m adept at ‘phoning a friend’.

What’s helped me most in my quest for knowledge retention is teaching.  For me it is not a matter of “Those who can’t, teach”, but more a case of “If you don’t know it, teach it”.  I find that there is nothing as effective for memory-boosting as explaining to others, especially with the luxury of repetition.  By the third or fourth time of delivering a particular topic, the content is usually firmly cemented in my brain.

While it is all very affirming and enjoyable to teach what you know well, preparing for and then teaching things you don’t know much about is so much more valuable.  If you’re up for the challenge, combining an unfamiliar topic with a knowledgeable group is even better.  You can channel and feed off their combined wisdom, and practise your skill at deflecting or redirecting those tricky questions.

I may know less about more nowadays but I’m happier than I’ve ever been.  Perhaps ignorance is indeed bliss.

Luckily, there is a lot more to being a good GP than the instant recall of facts and figures.  For the pathophysiology of kidney disease you can always ask Dr Google, or a registrar who has just sat those dreaded exams.

I may not have been capable of passing the AKT/KFP exams if I was a candidate today, but I think I’m doing a passable job as an invigilator.  I did, at least, remember the meaning of “invigilate”.  Unlike my mother.  For the irony of her looking up and emailing me the definition of “invigilate” this morning is that 6 months ago (at the time of the last AKT/KFP exams) my mum and I had a Skype conversation about the word, during which I explained its meaning.   Perhaps “invigilate” for her is like the “pathophysiology of chronic kidney disease” for me.

This has  been adapted from a piece was first published in Portraits of General PracticeGood Practice magazine, August 2013 (Article Download)