Weathering the anniversary storm

I had a sudden urge to slap a patient yesterday afternoon.  I didn’t act on the urge and was in no danger of doing so, but it rattled me all the same.  I’ve never before felt like I wanted to hit anyone (with the possible exception of my brother when we were kids, at times of peak annoyance).

For confidentiality reasons, I cannot reveal the content of the consultation which triggered such an out-of-character emotional response in me.  In general terms, the patient has an unhealthy dose of the “poor me” mentality, a stark lack of insight into, or compassion towards, others, and is causing her loved ones distress and harm.  We not uncommonly see patients like this and she was not an exceptional example.  I normally handle such patients perfectly calmly. She just happened to inadvertently say exactly the wrong things at exactly the wrong time…. wrong for me that is.

My response was not about a heartsink patient, it was about a heartbroken doctor.

I have become really good at separating my “stuff” from my patients’ “stuff”.  Caring about, but not self-identifying with, patients’ problems.  Not contrasting or comparing.  Being very mindful (ie present, aware and non-judgmental) during consults.  Providing genuine empathy without taking others’ emotional burdens.  It has taken time and a heap of deliberate practice to do this well but the rewards have been oh so sweet.  Career saving.  I’ve got back my clinical work mojo. I once again love seeing patients.

But not yesterday.

Yesterday,  communicating with patients and staff felt forced. Conveying empathy felt fake. Working like that is draining; utterly exhausting.

Why were things suddenly so difficult?  Why was I feeling so vulnerable?

You are probably familiar with the acronym H.A.L.T. which, in a medical practitioner’s work context, stands for Hungry, Angry, Late and Tired. Being hungry, angry, late or tired not only affects our sense of work satisfaction but increases our propensity to make cognitive biases in our clinical decision making, and for medical errors to occur.  The idea behind H.A.L.T. as a self-monitoring tool is to:

  • encourage us avoid these states as much as we can (eg by prioritising sleep and nutrition),
  • recognise when we are affected by one (or more) of them, “halt” what we are doing, ask ourselves what influence being hungry, angry, late or tired is having on our performance, and then try to minimise its impact.

In contexts such as addiction recovery, “Lonely” is substituted for “Late”.  Same principles: halt, reflect, rectify (when possible), avoid negative impacts.

I was not working while hungry, angry, late or tired yesterday, but the principles of H.A.L.T. did apply.

Yesterday was my partner’s birthday.  And today is the anniversary of his death; two years since he was mowed down on his morning jog by an impaired driver. Two years ago today, I got the phone call we all dread. The phone call that informs you there’s been an accident involving one of your immediate family. The phone call that tells you that the person you love most in this world has been killed, changing your life forever.

I always find anniversaries hard, and with two dead partners and two dead daughters, I have had plenty of experience with them.

Should I have gone to work yesterday? The practice I work for is brilliant about such things – everyone there would have been utterly supportive of my taking the day off despite us being understaffed at the moment. Why then it is so hard for me to admit that, despite how far I’ve come and how well I’m doing overall, I’m not always OK? And that is OK to not always be OK?

I’ve told at least four stressed patients this week that it is OK to take sick leave for mental health reasons. I’ve counselled. I’ve written medical certificates. I’ve told them to put themselves first etc etc.  With the greatest sincerity and not a hint of irony.

I teach about doctors’ health and wellbeing all around Australia, and beyond. I’ve written a play about it (“Physician Heal Thyself”).  I’m extremely passionate about doctors’ self care, almost one of those annoying crusader types. And yet I find it so hard to practice what I preach.

Today, I have halted. I’m having a quiet day and I’m feeling much more settled.  Tomorrow I will start marking 1400 odd GP exam papers (the FRACGP written exams are being sat today around Australia). And on Monday I will walk back into the surgery, hopefully with my ability to empathise intact and my mojo restored.

The waves of grief come far less often and with less intensity as time goes on. The short storms that hit around anniversaries are precious reminders of what I’ve lost and how far I’ve come, and as such, should be treasured.

I’m positive that this one, like the last, will clear soon…. revealing clear skies and calm seas.  For underneath the currently choppy surface, I am at peace.  I’m happy, I’m fulfilled and I’m loved.  Truly loved.

Most of all, I’m grateful.  I’m grateful for many things, including the silver linings of the storm clouds – the wisdom, strength, opportunities and sense of purpose which have been given to me by that which has been taken away.

Plan A didn’t work out for me. Neither did Plan B or C.  But Plan D is working pretty well, and I’m buoyed by the knowledge that there are 22 more letters in the alphabet if I need them.

(15th July, 2017)

 

After the storm… with Amalie’s tree in foreground

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“Doctor Doctor” – almost enough to bring you to tears

In a 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.”

“Here is a referral to a dermatologist.”

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 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.

The RACGP has been doing its best to enlighten the wider community as to what versatile and clever ducks we GPs are, through its “the good GP never stops learning” campaign.  However, there are certain sectors of the general public who only pay attention when information is presented in the form of a “soapie” or a reality TV show on a commercial TV station.

We haven’t been doing too well in commercial TV-land in recent years.  Where once “G.P.” and “A Country Practice” appeared on Australian screens, audiences now take their medicine from TV hospitals’ dispensaries.  The morgue is a popular place to linger – forensic pathology has been hot for years and is showing no signs of dying (sorry!).  Our Australian veterinary colleagues’ have fared better. 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”.

So when I heard there was a new Australian TV drama about rural general practice coming to Channel 9 in September 2016, I thought “Great! This might do the trick.”DocDoc_655x441

Until I heard the premise of “Doctor Doctor”.  From Wikipedia “Heart surgeon Dr Hugh Knight receives a life-changing punishment from the Medical Tribunal and is sent to work for a year as a country GP.”

From the Channel 9 website “Now the only way to salvage his brilliant career is to work as a lowly GP.”

Hmm…  I don’t think this program is going to do us any favours.

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!

Going the extra mile.

Today I’m a very good doctor.  Not that I’m ever a bad doctor.  Mostly I really care, but there are times, I confess, when I just go though the motions.  Conversely, on days like today, I take my usual care factor up a notch or two.  I take thorough social histories, address all of those important preventative health issues, explore my patient’s concerns deeply and end up running an hour or more late, to the chagrin of the receptionists.

Madison is next on my list; the usually sullen teenager whose last HbA1c was nearly the same as her age. First impressions are surprisingly favourable. Her skin’s glowing and she’s actually smiling at me! Not only has she brought in her recent blood sugar readings, but they’re actually pretty good.  She admits to having had purposely taken her insulin incorrectly in the past but proudly tells me that she’s been taking it perfectly for several weeks now, and that she’s never felt better.

insulin pen“So what made you change your mind about taking your insulin?”

“I don’t know. Just happened I ‘spose.”

“Please try to think carefully about possible factors. I’d really like to know.”

I’m very interested in finding out which of my warnings carried the most sway. I don’t ask for self congratulatory purposes; seeing her looking so well and happy fulfils this already.  It is for intellectual interest and self improvement.  I want to use the feedback from Madison to help me with future non-compliant teenage diabetics; to make me a better doctor.  It is one of my “very good doctor day” quests; on a less engaging day I would just be grateful that Madison was looking after herself at last and not feel the need to delve deeply into the reasons.

As Madison ponders, I mentally try to predict what she will say. I often play this game when seeing patients.  In Madison’s case, I reckon my emphasis on the short term results of skipping insulin last visit would have been the trigger for change.  The prospect of long term risks, such as developing kidney failure in middle age, does little to scare most teenagers.

“Come to think of it, there was something that, like, changed my mind.   Do you watch (name of badly acted Aussie soap)?”

“No, I don’t get much time to watch TV.”

“It has lots of medical stuff in it. You’d like it.”

Not likely.  I smile at Madison indulgently. I wonder where she is going with this.  A doctor character who reminds her of me?

“There was this epileptic girl on the show. She didn’t take her medication properly and she ended up having a fit when she was out surfing and she, like, died.”

“That’s sad.  And?”

“And what?”

“I’m a little confused. How does this story relate to your diabetes?”

“It made me see that if you don’t, like, take your medication properly, it can be really dangerous. So I started back on my proper insulin doses.”

“It had nothing to do with what I told you last visit? Nothing at all?”

It is Madison’s turn to smile indulgently.  “I know you tried to help me but, to be honest, all I heard was, like, ‘blah blah blah’.”

Going the extra mile today suddenly seems overrated.  I think I’ll take the usual route to lunch.   The receptionists will be pleased.

(names and identifying details have been changed to protect patient privacy)

The other side of the fence

pregnancy testThis column was written in October 2014…

Countless consultations start with the words “I’m pregnant.”

I quickly learned not to jump in with an enthusiastic “Oh congratulations, I’m delighted for you!” Make no assumptions.  Sensitively ascertain the patient’s state of mind before celebrating or condoling.  A new pregnancy can generate a range of emotions in the mother-to-be, from despair to ecstasy, but in my experience indifference is rarely, if ever, predominant.

Likewise, I imagine that for many GPs the news of a patient’s pregnancy also triggers an emotional response in them.  The emotions felt may be simply a case of transference, they might be an inherent sense of wonderment at the creation of a new life, or they may be complex, perhaps intertwined with feelings surrounding the GP’s own reproductive history.

Barring the occasional faux pas as a result of an incorrect assumption, I think we GPs are, on the whole, very good at managing both our own and our patient’s emotions surrounding a desired pregnancy, and mostly pretty good at handling those surrounding an undesired one.  From what I’ve observed, however, many of us are far less comfortable handling those involved with a lost or non-pregnancy.

Admittedly, it is very hard to know how to respond to a desperate patient who wants nothing more than parenthood, but for whom this dream has remained elusive.  While the drive to procreate differs between individuals, for many of us, myself included, it can be an overpowering one.  The primal reproductive instinct is at the core of many people’s sense of identity and life purpose, as well as having cultural, social, spiritual, financial and familial implications.

After nine years and five miscarriages, I’m sitting here typing this as my 23 week daughter moves around in my distended abdomen, reassuringly.  On my joyful and life-changing journey through this so far remarkably straightforward pregnancy, I’ve had many new experiences.  I’ve relished discovering that my clothes are too tight.  I’ve been relieved beyond words to get the “all clear” on the 18 week morphology scan.  I’ve discovered that, despite my best efforts, I have become one of those annoying super-gushy types of pregnant women.

The most surprising aspect to me, however, has been the reactions of friends and colleagues.  Without exception their responses have been overwhelmingly positive and supportive, for which I’ve been immensely grateful.  What has intrigued me though is that many have started to treat me more inclusively, seemingly because I’m now “one of them”, a member of the “parenthood club”.  When I’ve gently explored this with a few, they’ve reflected that it has been difficult for them to juggle their desire to talk freely about their kids while being sensitive to my situation, and that at times it has been easier not to engage at all.  I know I’ve played a part in this too.

In my experience, both as a patient and as a medical educator observing doctors-in-training, many GPs face a similar struggle when interacting with patients with infertility and/or miscarriage.  Either resorting to platitudes or avoiding the heart-of-the-matter can leave vulnerable patients even more isolated and unsupported.  Unlike disorders like cancer, disclosing and discussing infertility and miscarriage publically is somewhat of a social taboo, and this, I believe, is part of the problem.

While we are told, for good reason, that it is important to leave your personal baggage at the door of your consulting room, it’s not always that easy.  We all have things in our past (and/or present) that can potentially influence how we feel about, and interact with, certain patients.  Being aware of these factors and their effects is vital, but is it always necessary to neutralise them?  Not only is complete objectivity impossible in the kind of work we do, but judicious and thoughtful use of our life experiences can make us better clinicians – and better teachers.

I hope that I can use my experience to help support both patients and other doctors in managing the complex emotions surrounding fertility issues, and also encourage more open discussion in the general community.

While immensely thankful and blessed to now be on the green side of the reproductive fence, I will never forget how painful and isolating it can be on the other side.

First published in Medical Observer, 17th April 2015

The ending to my pregnancy story was not a happy one. You can read about what happened here

https://genevieveyates.com/2015/04/27/lived-experience/

 

Lived Experience

“The problem with young doctors,” a GP supervisor of mine used to say, “is not that they don’t know enough or even that haven’t doctored enough – it’s that they haven’t lived enough.”

By “lived”, he wasn’t referring to going bungy jumping in New Zealand – unless of course that particular experience had resulted in being in traction with multiple fractures. He preferred to employ doctors with lived experience of being ill or injured, of having children and, preferably, of caring for a beloved parent or grandparent in an aged care facility as well.   He wanted doctors who really understood what it was like to be a patient and/or the loved one of a patient. To him, a personal health record was far more important than a professional one.

The transformation of doctors by personal illness or tragedy is not an uncommon narrative. Hollywood has used variations of this plot numerous times in films like The Doctor (1991).  On the small screen, many a Grey’s Anatomy, House or Chicago Hope doc has been forever changed by a personal brush with cancer/trauma/addiction/leprosy.

Albeit without the glamour of a Dr McDreamy standing by, I too have been profoundly shaped professionally by personal illness and the loss of loved ones.  These experiences have taught me things that years of medical training did not.

Physical illness has taught me why patients need patience. Experiencing days when it feels like I’m trying to walk up the down escalator has brought home to me why people with chronic illness can get so drained doing “routine” things.

My most valuable lessons though, have come from seeing my loved ones suffer, and from being the one left behind and thus coming to the realisation that a patient’s death is not the end of the story.

As an intern, in 2000, I lost my then partner, Adam, to testicular cancer.  At such an early stage in my career, as a medical student and then a very junior doctor, watching a loved one struggle with and ultimately lose his battle against an incurable disease was particularly influential in my development as physician.

loving memory tombstoneI learned firsthand that treating cancer is so much more than trying to cure. That it’s more than trying to alleviate symptoms when cure is not possible.  I discovered that it is about how whatever life left is lived, and ultimately, how one dies.  This philosophy sat comfortably with me and helped me help countless patients over the years.

Much as I loved and respected Adam’s mother, I didn’t really understand her response at the time. She was in the “chance of cure at any cost” camp, wanting any treatment which had even the remotest possibility of success. This drive persisted even when it became painfully obvious to me and to Adam’s treating doctors that cure was impossible, and that Adam’s aggressive treatment regimens were causing terrible suffering.

But now I get it.  I understand now how maternal love can be so powerful that it overwhelms intellect, logic and fiscal responsibility.  For I too became a mother… and lost a child.

In December 2014, my only child, Amalie, died of neonatal sepsis. It had taken me 9 years and 5 miscarriages to meet her, and our time together was tragically short but will be forever treasured.

When she was in the NICU, fighting for her life, I would have given anything to see her pull through. In those frightening moments, no treatment would have been too extreme, no cost too great.

I thought I understood intellectually why the death of a child is so devastating for a parent.  Now I understand it viscerally, and realise that I had no idea what it is really like.

It is too recent and the emotions are too raw for me to incorporate this “lived experience” into my clinical practice in a meaningful way right now. But I will.  As I have done before.

Adam and Amalie have made me a better doctor.  They’ve made me a better person. I owe them so much.  I can’t pay them back but I am, and will be, paying it forwards.

I think my old GP supervisor would be proud.

First published in Medical Observer, 24th April 2015

 

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

Keeping abreast of the situation

old-lady-in-bikiniLorraine and Frank Cooper were booked in for skin checks. I had previously met Frank a few times but Lorraine only once. Like many older Australians they had managed, with the assistance of unprotected fair skin and direct sunlight, to achieve decades of perfect skin-cancer-growing conditions, and their crops of lesions were maturing nicely. Frank in particular rarely escaped without donating a skin chunk or two to our friendly local pathologist.

I quickly scanned their charts then walked into the crowded waiting room.

“Frank and Lorraine please.”

Frank sauntered over from where he’d been standing. Lorraine closed the two year old New Idea, placed it back on the rack meticulously, and headed towards me. They met in the doorway. Frank beamed at Lorraine, she returned his smile with her mouth but frowned with her eyes.

“You want us to come in together?” Lorraine asked.

“Only if you’re comfortable doing so.”

“No worries, Doc!” Frank said without hesitation.

Lorraine shrugged, “I guess so.”

“So who wants to go first?” I asked after we were seated and the usual pleasantries exchanged.

“Ladies first,” Frank volunteered.

Lorraine looked mildly irritated. “It should indeed be me, but not because I’m a woman. I was booked in first.  I heard the receptionist saying that his spot was at 3:15. Mine was at 3.”

At that point, I recall wondering whether Frank had done something to really annoy her that particular morning, or whether her touchiness was simply a result of years of accumulated frustration.

Lorraine’s history-taking unfolded uneventfully, but I hit resistance when it came to her examination.  As is my habit, I asked her to undress down to her underwear behind the curtain and to cover herself with the provided sheet.

“Is he going to stay?” she inquired.

“Not if you don’t want him to,” I quickly countered, sensing her discomfort.

“It’s OK, Luv, you’re behind a curtain, and anyway, it’s not as if you’ve got anything I haven’t seen before.”

“But you haven’t seen mine!

An alarm bell rang. It didn’t seem like something a wife would say – at least not without a “for years” or “recently” tacked onto the end.

I glanced again at their charts: same surname, different phone numbers, different streets, different towns. Uh oh!

Taking a deep breath, I somewhat sheepishly inquired, “This may seem like a silly question, but you are married, aren’t you?”

“Married? I’ve never met him before in my life!”

Luckily for me, both were very understanding and forgiving, and could see the funny side.

Frank was relegated post-haste to the waiting room while Lorraine had her solar keratoses cryotherapied in private.

Later, Frank lamented, “I was hoping to get a peek at some live bosoms. It’s been a long time.”

I must have looked shocked.  He rushed to explain. “I’m no perv.  I just happen to love breasts. All of them: pancakes or melons, firm or dangly. The only complaint I’ve ever made about a pair of bosoms is that they’re too… clothed.”

When I sought their individual consent to write this column (I didn’t want to breach their privacy a second time!), Frank’s face fell when I explained that I would need to give him an alias.

“I’d quite fancy my name in print,” he lamented. “Well, at least use my ‘all breasts are beautiful’ line, OK? I want to do my bit to help all the ladies out there be proud of their assets. And hopefully, bare them more often. But not too much time in the sun, of course, Doc. There’s too much breast cancer around nowadays as it is!”

(names and identifying details have been changed)

First published in Medical Observer, 25th July 2014

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)

Could I have saved my doctor?

image stethoscopeThe first thing 22-year-old Casey ever said to me was, “How is your day going, Doctor?”

While not the most unusual opening line of a first-time patient, there was something about the way she said it that rang a vague alarm bell.  Casey had complex physical and mental health needs, and over the following six months I saw her numerous times.  She had survived childhood leukaemia, but her type 1 diabetes and Crohn’s disease were making daily life difficult.

Regardless of what she was going through, Casey always spent at least a minute or two each consult enquiring about my well-being. I initially thought that her questions may just have been merely social pleasantries. I didn’t think too much about her commenting that I looked tired or asking if I was overdoing things – perhaps because my friends and family were doing likewise. I smiled sweetly when she gave me beauty tips and fashion advice. But when she started asking me particularly personal questions about my relationships, health and resilience levels, and not accepting my brush-offs, I knew things had gone too far.

Casey is certainly not the first patient who has asked me unduly personal questions. I usually find such intrusiveness quite easy to deflect, and for the boundaries between myself and an inquisitive patient to be maintained without the need for explicit definition. There was, however, something different about Casey’s approach: a desperation, a need, something raw. I did not get any sexual vibes, or even overtones of seeking friendship, just a sense that my being happy and healthy was of tremendous importance to her.  It felt like she genuinely cared about me – I just couldn’t work out why.  Something about it did not sit well, so I decided to address and gently explore this with her.

It didn’t take much probing.

“Twelve months ago our family GP killed herself.”

Casey’s face contorted with the effort of trying to hold back the floodgates of intense emotion.

“Dr Sara looked after me since the day I was born.  She found my leukaemia and my diabetes, and was there for me and my family through all of it. And then she suddenly wasn’t.”

She paused, taking the offered tissue and loudly blowing her nose.

“One day I rang the surgery and the receptionist told me she’d left the practice. I asked when was returning. The receptionist said ‘Never’. I didn’t understand. I’d only seen Dr Sara the week before and she didn’t say anything about leaving. I found out later that she’d taken an overdose.

“I had no idea she was suffering. And then I realised that I’d never asked. She cared about my health so deeply and yet I had never even considered hers.  I feel so ashamed.

“No one at the surgery ever talked about what happened. They took her name off the door and the website within days, and made out like she had never existed. My new GP said things like ‘Let’s focus on the here and now’ or ‘We are here to talk about you, not Sara’ when I tried to bring it up. Everyone knew what happened; there was no point trying to hide it. So why did they remove every trace of her?”

Casey looked to me, puzzled and angry.

“I don’t know,” I admitted. “I guess it was how they dealt with their grief.”

” I kept thinking of all the years she gave to them… and to us, her patients. All gone. I couldn’t stand it any longer. That’s why I started coming here and seeing you. .”

The depth of her grief and guilt took several consults to reveal. Over time she came to understand and accept that it was not her role or responsibility to safeguard her doctors’ health, or to worry about any emotional burden which may result from the provision of care.

Her questions of me became less personal and insistent, but she continued to ask how I was going. I thought of poor Dr Sara each time, and always answered Casey sincerely and honestly, grateful that my answers were able to provide reassurance.

(names and identifying details have been changed)

First published in Medical Observer, 25th July 2014

The Jellybean Dilemma

jelly beansAt the age of five I decided that I wanted to be a doctor when I grew up.  Having the ability to heal the sick appealed, but what clinched my decision was the jellybean jar. Our family GP had a huge bottle of brightly coloured jellybeans sitting on his desk, and I remember thinking that a job which allowed unfettered access to such delicious sugary treats was just about the best job one could ever have.  Official taster at a chocolate factory was my fallback career choice.

Fast-forward thirty odd years and I’ve achieved my childhood dream of becoming a doctor, but there is no lolly jar on my desk.  Instead of jellybeans, I offer my young patients stickers as bribes… oops, sorry… treats. For a responsible GP, this makes more sense.  While a single jellybean given at a doctor’s visit is not going to significantly increase not-so-little Johnny’s considerable girth, cause appreciable decay of Dani’s deciduous dentition or cause Tyler to throw yet another tantrum at bedtime, rewarding children with artificially coloured and flavoured confectionery sets a very bad precedent.  We should be teaching by example: promoting good health and positive parenting methods. I know this, and I practise the principle, but a small part of me wants to bring back the jellybean. After all, Mary Poppins was onto something when she sang, “A spoonful of sugar makes the medicine go down.”

Being offered a jellybean at the end of each infrequent visit to the family doctor was a childhood highlight for me.  I actually looked forward to going to the doctor. The poking, prodding and vaccinating were all tolerable, thanks to the sugar fix at the end. I would carefully carry the painstakingly chosen jellybean out to the car in my hand, lick off the coloured coating and then ever-so-slowly suck the gelatinous core, eking out the enjoyment for as long as possible.  If I’d been offered a sticker as a substitute, I would have felt cheated.  Stickers don’t taste as good as jellybeans.

I was reminded of this recently when offered some constructive feedback from a discerning young patron.

“I think you’re a very nice doctor,” she pronounced.

“Why thank you.”

“But…”

But?! I didn’t like where this was heading but I was masochistically curious.

“… I liked my old doctor better.  He had cold hands and he smelt funny and Mummy said he didn’t know what he was talking about…”

OK, now I really didn’t like where this was heading.

“… but he always gave me a frog.”

“A frog! A real frog?”

“No, Silly Billy. A lolly frog. And always a red one. They’re much better than the green ones.”

“Oh. I see. Do you like frogs better than stickers?”

“Der! Stickers are boring. Frogs are yummy.  I reckon that if you gave out frogs you’d be the best doctor ever!”

“Thanks for the feedback. I’ll take it under advisement.”

My inner child can’t help but agree with her.  A lolly-giving doctor would have definitely trumped a sticker-giving one when I was her age. Some kids love stickers and would choose the visual pleasure over the gustatory if given the choice, but many are like I was: orally fixated when it comes to treats.  I’m not about to change my paediatric protocols and I stand by my health promotion convictions, but the idea of using a spoonful of sugar or two to boost my popularity is rather tempting – almost as tempting as was the jar of brightly coloured jellybeans on my childhood GP’s desk.

(Identifying details have been changed to protect patient privacy)

First published in Portraits of General Practice, Good Practice magazine, April 2014, page 15

Mobile Phone Etiquette

mobile phone“So what’s the verdict, Doc?  Give it to me straight.”

“It’s not good news I’m afraid.  The tests revealed…”

A particularly grating ringtone emanating from my patient’s groin cut me off.  Taking the offending phone out of his pocket, he motioned for me to pause while he took the call.

Despite a ‘Please turn off your mobile phone’ sign in reception, I’ve had patients answer phones while undergoing PAP smears, skin excisions (once as I was injecting lignocaine!), ear syringes and ECGs, but this one took the cake.

“Hi mate…  Yeah, now’s fine.  Fire away…  Sorry mate, no can do.  I’m over in Perth at the mo’…  Yeah, for work…”

Five minutes and ten seconds later he hung up and casually said, “Sorry.  Good mate.  So, where were we?”

“Before we discuss your results, I need to ask: Do you know where you are?”

He looked at me as if I’d asked whether or not he believed in Santa Claus.

“ ’Course!”

“When patients show signs of being disorientated, especially when combined with inappropriate  behaviour, I need to rule out serious causes.”

“Huh?”

“You just conducted a five-minute social phone call during a medical consultation…”

“I said I was sorry,” he interjected.

“…just as I was breaking bad news.”

“Are the results, like, really that bad?”  His brow suddenly creased.  “C’mon, you can’t keep me in suspense.”

I did.

“And during this phone call, you indicated that you were in Perth, whereas in fact, you’re on the other side of the country.”

“I was just getting out of helping Johnno move house.  Anyhow you shouldn’t listen in on private phone calls,” he replied indignantly.

“Should I have stepped out of my consulting room to give you privacy?”

“Well no, just not listen.  Look, just cut the bullshit.  I said I’m sorry.  I won’t do it again.  Now can you please tell me my results already?”

I was ready to ask for suggestions as to how I could turn my ears off on demand, but didn’t want to waste any more of my time.

“The tests have revealed that you have two sexually transmitted infections,” I said, matter-of-factly.

“What?!  She said she’d just been tested and given the all-clear.  I can’t believe she lied to me!”

I refrained from mentioning kettles and name-calling pots and proceeded to discuss the specifics.  Afterwards he said, “There is no way I’m going to let the missus find out where I’ve been.”

….

It struck me recently that, as phones become increasingly hi-tech, it’s probably going to become increasingly difficult for this bloke to get away with geographical inconsistencies.  A friend was demonstrating his new latest-and-greatest Smartphone at the time…

“… and it’s got Google Latitude so you can log on and see where I am at any moment.  This phone is absolutely wonderful,” he gushed.  “The only downside is the microphone.  If I hold the phone close to my ear, the other person can’t hear me speak, but if I move it down to my mouth, then I can’t hear.  The speaker-phone function is pretty useless too – muffles the sound terribly and neither of us can hear.  I just love the phone though.  Perfect for my needs.”

“A phone that can do anything except allow you to converse with others, eh?  In other words, it’s a perfect phone for all your non-phone needs.”

“Making calls are not what phones are about anymore,” he bounced back, without even a hint of irony.

I only hope my friend is right, and that one day soon the mobile-phone-induced consultus interruptus is also rendered obsolete.
(Identifying details have been changed to protect patient privacy)

First published in Portraits of General Practice, Good Practice magazine, June 2014, page 15

Physician Don’t Heal Thyself

One reason why I chose to do medicine was that I didn’t always trust doctors – another image stethoscopebeing access to an endless supply of jelly beans.  My mistrust stemmed from my family’s unfortunate collection of medical misadventures: Grandpa’s misdiagnosed and ultimately fatal cryptococcal meningitis, my brother’s missed L4/L5 fracture,  Dad’s iatrogenic brachial plexus injury and the stuffing-up of my radius and ulna fractures, to name a few.

I had this naïve idea that my becoming a doctor would allow me to be more in charge of the health of myself and my family. When I discovered that doctors were actively discouraged from treating themselves, their loved ones and their mothers-in-law, and that a medical degree did not come with a lifetime supply of free jelly beans, I felt cheated.   I got over the jelly bean disappointment quickly – after all, the allure of artificially coloured and flavoured gelatinous sugar lumps was far less strong at age 25 than it was at age 5 – but the Medical Board’s position regarding self-treatment took a lot longer to swallow.

Over the years I’ve come to understand why guidelines exist regarding treating oneself and one’s family, as well as close colleagues, staff and friends.  Lack of objectivity is not the only problem. Often these types of consults occur in informal settings and do not involve adequate history taking, examination or note-making.  They can start innocently enough but have the potential to run into serious ethical and legal minefields.  I’ve come to realise that, like having an affair with your boss or lending your unreliable friend thousands of dollars to buy a car, treating family, friends and staff is a pitfall best avoided.

Although we’ve all heard that “A physician who treats himself has an idiot for a doctor and a fool for a patient”, large numbers of us still self-treat.  I recently conducted a self-care session with about thirty very experienced GP supervisors whose average age was around fifty. When asked for a show of hands as to how many had his/her own doctor, about half the group confidently raised their hands. I then asked these to lower their hands if their nominated doctor was a spouse, parent, practice partner or themselves. At least half the hands went down. When asked if they’d seek medical attention if they were significantly unwell, several of the remainder said, “I don’t get sick,” and one said, “Of course I’d see a doctor – I’d look in the mirror.”

Us girls are a bit more likely to seek medical assistance than the blokes (after all, it is pretty difficult to do your own PAP smear – believe me, I’ve tried), but neither gender group can be held up as a shining example of responsible, compliant patients. It seems very much a case of “Do as I say, not do as I do”.   I wonder how much of this is due to the rigorous “breed ’em tough” campaigns we’ve been endured from the earliest days of our medical careers.  I recall when one of my fellow interns asked to finish her DEM shift twenty minutes early so that she could go to the doctor. Her supervising senior registrar refused her request and told her, “Routine appointments need to be made outside shift hours.  If you are sick enough to be off work, you should be here as a patient.”  My friend explained that this was neither routine, nor a life-threatening emergency, but that she thought she had a urinary tract infection.  She was instructed to cancel her appointment, dipstick her own urine, take some antibiotics out of the DEM supply cupboard and get back to work.  “You’re a doctor now; get your priorities right and start acting like one” was the parting message.

Through my medico-legal and medical educator work, I’ve had the opportunity to talk to several groups of junior doctors about self-care issues and the reasons for imposing boundaries on whom they treat, hopefully encouraging to them to establish good habits while they are young and impressionable.  I try to practise what I preach: I see my doctor semi-regularly and have a I’d-like-to-help-you-but-I’m-not-in-a-position-to-do-so mantra down pat.  I’ve used this speech many times to my advantage, such as when I’ve been asked to look at great-aunt Betty’s ulcerated toe at the family Christmas get-together, and to write a medical certificate and antibiotic script for a whingey boyfriend with a man-cold.

The message is usually understood but the reasons behind it aren’t always so.  My niece once announced knowledgably, “Doctors don’t treat family because it’s too hard to make them pay the proper fee.”  This young lady wants to be a doctor when she grows up, but must have different reasons than I did at her age. She doesn’t even like jelly beans! 

Adapted from an article first published in MIPS Review Autumn Edition, 2012 

Published on Meducation.net  December 2013 “Physician don’t heal thyself“,

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

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