Counting our blessings

US dollarsAustralian general practice has been pummelled over the past year. With its proposed co-payment plans, prolongation of the rebate freeze, defunding of Medicare Locals and shake up of Vocational Training among others, the Abbott government has delivered punch after punch.

Understandably, many of us have become disillusioned, angry and distrustful. Some are fantasising about a career change or considering early retirement. Meanwhile, there are unprecedented numbers of medical students and prevocational doctors asking, “Should I even consider a career in general practice?”

When under attack counting one’s blessings does not come naturally, but this is exactly what’s needed. I don’t want to sound like the kind of doctor who tells his patient “Cheer up, it could be worse”, but will briefly reflect on a medical system more broken than ours, despite multiple resuscitation attempts.

According to statistics from the World Health Organisation, in 2012 the US spent more than twice as much on health per capita than did Australia ($8,895 US cf. $4,058 US)(1). Much of this was private expenditure, but even so, government spending on health in the US is higher than in Australia (in 2012, 8.3% of GDP cf. 6.1% of GDP)(2). And what do they have to show for it? Lower life expectancies, higher rates of premature death, unhappy doctors and patients financially crippled by medical bills.

At times of life-threatening illness, having to worry about accumulating massive medical bills is a significant extra burden. I speak from personal experience.

Last December, while on vacation in the US, I developed pyelonephritis and became pretty ill, very quickly. To complicate matters, the infection brought on premature labour. My newborn daughter, Amalie, was rushed to the NICU, and I found myself in a high dependency unit with early sepsis. Three days later, my beloved daughter’s system was overpowered by the E. coli infection, while my body, with the help of modern medicine, was well on its way to recovering from it.

There are no words to describe the pain felt. While the medical and nursing staff did everything they could to comfort, those working in the finance department were not so empathetic. Within hours of losing Amalie, I was presented with hospital bills (not including physician fees or other charges) for over $70,000 US, and told “We expect payment at the time of service.” Salt was rubbed into my already almost unbearable wound.

I couldn’t get back to Australia fast enough.

Many of our current woes are because Australian general practice is so directly and largely dependent on government funding. We GPs are tremendously vulnerable to the whims of politicians whose motives are often self-serving rather than altruistic and whose promises are meaningless. On the flip side, when done well, there are big benefits for patients and doctors alike in government playing such an active role in healthcare funding and regulation. Keeping private health insurers, drug companies and other health-related corporates on a leash helps limit overall health expenditure, and therefore the downstream financial and emotional consequences for vulnerable patients.

I’m not for a moment suggesting that we lie down and take the ongoing beating that’s thumping our profession, or that the proposed changes are not ill thought out and unfair. Quite the opposite. Individually and collectively we need to take stock, remind ourselves of all that is good about Australian general practice, and then use this to further ignite our passion and do whatever we can to defend and strengthen our great profession. Let’s help make it something we can enthusiastically recommend as a rewarding career choice for our best and brightest, without crossing our fingers behind our backs as we do so.

References

 

First published in Good Practice magazine, March 2015

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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 http://foam4gp.com/ 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)

Perspective. It’s a fascinating concept, any way you look at it.

job_interviewThe story sounded familiar, uncannily familiar. It had been a long day of interviewing applicants for GP training and the answers being given were having an increasingly ‘I’ve-heard-this-all-before’ flavour, but I’d definitely heard this particular example earlier in the day.

Both applicants described a specific hospital-based incident in which a lack of teamwork almost resulted in patient harm. The details were identical, until it came to the story’s climax.

Each applicant clearly and convincingly described how he unilaterally saved the day, despite being hampered by his colleague’s incompetence. I have no idea whose version of events was accurate. Maybe one (or perhaps both) was deliberately trying to mislead, but I got the impression each genuinely believed what he was saying.

Perspective. It’s a fascinating concept, any way you look at it.

I’m sure we’ve all had the experience of hearing two somewhat conflicting sides of a patient’s story, usually from different family members. They’re generally not too difficult to reconcile and/or the differences are inconsequential, but occasionally they throw up a real challenge.

I had an elderly patient with advanced dementia, who was cared for full-time by her daughter. Everything seemed to be rolling along happily enough until the other daughter visited from interstate. There were the usual familial disagreements about what should happen to Mum, but in this case the second daughter came to me with some pretty serious allegations of elder abuse.

The son, with a third version of events, got involved, as did a neighbour, whose story conflicted with everyone else’s. The relevant authority dipped its toe in and then hastily withdrew it, claiming there was “no clear case”. It was right — the case was anything but clear.

As it happened, in the midst of the bickering, claims and counter-claims, the matriarch at the centre of the drama conveniently brought the matter to a close by getting pneumonia and slipping away quietly and quickly in hospital.

Blessedly, she was without any significant assets for her offspring to contest, and they were civilised enough to not involve any lawyers in the division of her crocheted tea-cosy collection.

In my own family, differences in perspective are fodder for amusement rather than Grand Canyon-scale rifts. My 92-year-old paternal grandmother has always been a stoic, capable woman with a make-the-best-of-a-bad-situation attitude.

Over the years, the rose-coloured tint in her recollections has intensified to more resemble a bright scarlet, and her remembered role in past events has her firmly ensconced in the driver’s seat. Now in her twilight years, she happily sits with her increasingly positive memories and regales her fellow aged-care residents with her achievements (over and over again!), feeling progressively surer that she has lived the best and most heroic life possible. That some of her stories bear little relation to the facts as remembered by other family members is of no consequence.

Mind you, these ‘facts’ are all a bit wobbly anyway. My father is always right (according to him), my mother remembers the emotions attached with great clarity (but not always the event specifics), and my brother claims to have forgotten almost everything that happened to him before the age of 18.

And me? Born with the Pollyanna gene, I’m probably more like my grandmother than I care to admit. I’m certainly not at the believing-black-is-white stage yet, but I would quite like to be by the time I reach my 90s.

It strikes me as quite a pleasant way to see out my days: a legend in my own lunchbox, utterly convinced that my life has been near-perfect.

First Published in Australian Doctor on 30th August, 2013 On Perspective

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

Should GPs wear uniforms?

I like a man in uniform. I like a woman in uniform. I like getting onto a plane and being able to instantly recognise the pilot. I like knowing whom to ask when I can’t find the 14x100mm galvanised timber screws in Bunnings.  I like never having to ask, “Excuse me, do you work here?”

I also like to be in uniform myself.  After over a decade as an un-uniformed GP, I now spend most of my working week as a uniformed medical educator for North Coast GP Training.  And I love it. Not just the work but the clothing in which I do it. The uniform helps me feel part of a team and gets me in the mood (for work!).  It decreases my need to go clothes shopping, which some may see as a negative but for me is a blessing. Most appealingly of all, it simplifies the what-am-I-going-to-wear-today decision made when half-awake each morning.

Meanwhile, it seems that in the clinical setting, dress standards appear to be dropping. I recently visited a practice at which a young GP was consulting in a crumpled T-shirt, frayed jeans and scuffed thongs.  Now I’m far from a snappy dresser myself and normally take little notice of or interest in what others wear, but even for the North Coast of NSW this seemed rather inappropriate. I don’t want to rant on about professionalism, hygiene and O,H&S as microbiologist Dr Stephanie Dancer did in the BMJ (1), but I have to admit that I’m partial to doctors wearing a uniform of sorts.

Since the 1800s, the “uniform” of doctors has been the white coat.  Give any Australian child a picture of a well-groomed, white-coated adult carrying a stethoscope and the response will be “Doctor!”, even though the chances of that child having ever seen an actual doctor in such attire are next to none.

As a medical student, I was not allowed on the wards without a white coat, professional attire and covered leather shoes. Another was once turned away from a ward round because he wasn’t wearing a tie.  A year later the same consultant refused him, as an intern, permission to go home sick, and three elderly patients died after contracting his respiratory tract infection; but I digress.  At the major metropolitan hospital at which I did my early training, while white coats for doctors were definitely on the way out, there were still strict dress codes.

Nowadays, both white coats and ties have been ditched by the majority.  Both have copped flack over being “unhygienic”, and ties have been deemed a safety risk by some institutions as they apparently make excellent nooses.  While fears that white coats are common vectors for nosocomial infections have been largely dispelled (2) (3), the argument that they are arrogant and egotistical ensigns which interfere with doctor-patient relationships continues to hold sway.

Anti-white-coaters claim traditional garb is worn to signify superiority of status and intellect, making wearers less able to interact meaningfully with their patients.  While this may apply in some circumstances, it is not a universal truth.  Interestingly, a study published earlier this year in JAMA Internal Medicine suggested that families of patients in ICU saw white-coated doctors as the most knowledgeable and honest, and the best providers of overall care (4). Those dressed in scrubs also fared well.  It suggested that when it came to life and death matters, people wanted to deal with clinicians who looked like the quintessential doctors portrayed on TV.

I don’t think white coats are likely to make a fashion comeback in Australian general practice anytime soon, but I would love to see uniforms take off.  Personally, I like the idea of scrubs – the clothing, not the TV show. They are comfortable, practical, hygienic (when regularly washed!), come in an assortment of colours and styles and make us instantly recognisable. They may not be the most flattering or fashionable items, but they should cut down the number of “Excuse me, do you work here?” enquiries, which has to be a good thing for patients and doctors alike.

1. http://www.bmj.com/content/346/bmj.f3211

2.  http://www.amsj.org/archives/2490

3. http://www.medpagetoday.com/upload/2011/2/11/864_fta.pdf

4. http://archinte.jamanetwork.com/article.aspx?articleid=1653992