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

The Big C at Christmas

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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

Scripted Role Play on sexual harassment of doctors by patients

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

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

* Explanation

Scripted and semi-scripted role plays (where dialogue is initially read rather than improvised) can be less threatening.  They provide most of the educational advantages of traditional role plays (e.g. experiential learning, development of empathy) while eliminating or reducing many of the limitations (e.g. lack of control over subject matter, quality of information imparted, performance anxiety), making them a more accessible and palatable option.

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

Workshop structure (approx. 30mins):  

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

2)  Introduction to session

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

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

5)  Facilitator-led Q and A “in role” – which may involve some “re-winding” / additional role play by same or new volunteers.

6)  Exercise to “de-role” readers

7)  Group discussion

8)  Conclusion

Scenario:

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

Script: 

Emma:  (At doorway) Fred Jackson?

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

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

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

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

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

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

Emma:  Happy birthday, Freddie.

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

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

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

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

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

Emma:  So what can I do for you today?

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

Emma:   (interrupting) Freddie, that is inappropriate.

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

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

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

Stop:

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

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

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

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

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

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

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

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

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

Stop:

Q and A in role 

De-role readers

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

The Medicine of Laughter

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

 

General Practice is Messy

I’ve just read a great post by Dr Marlene Pearce about the art of uncertainty in general practice.

http://thedoctorsdilemma.wordpress.com/2013/11/24/the-art-of-uncertainty-in-general-practice/

As I found myself nodding in agreement to Dr Marlene’s wise and well-written sentiments, I was reminded of a conversation I had last year…

“I’m really surprised you settled for being a GP.  You used to be such an over-achiever!  Why didn’t you choose something that’s intellectually challenging?”

I hadn’t seen my old uni friend since Med School and after the first five minutes of listening to him boast about his prestige and income, I was reminded of why I hadn’t made the effort to stay in touch.  By the time he finally got around to asking what I was doing, I was seeking means of conversational escape.

I smiled sweetly and replied, “I did. Some enjoying fiddling around with bonsai, while doctors like me find challenge and reward in being swamp gardeners,” before politely excusing myself.

I was introduced to the concept of swamp gardening by GP, researcher and medical educator extraordinaire, Dr Louise Stone, during an address she gave at the 2011 GPET Convention, and I have to admit I’m quite taken with the metaphor.

It relates to the messiness of general practice: the reality that we spend much of our time dealing with undefined and sometimes undefinable illness.  In medical school we were taught to approach a presenting complaint in a stepwise fashion:  history, physical examination, investigations, diagnosis and then finally management.  In primary care, it isn’t always so clear cut.

Donald Schön, in his book ‘Educating the Reflective Practitioner’, wrote: “In the varied topography of professional practice, there is a high, hard ground overlooking a swamp. On the high ground, manageable problems lend themselves to solution through the application of research-based theory and technique.  In the swampy lowland, messy, confusing problems defy technical solution.”

The most horticulturally challenging swamp species are conditions without nice, neat diagnostic labels.  It is hard to wage war on a nameless, faceless enemy.  If they are tough for us, they are enormously more difficult for the patients they affect.   Many have been on the diagnostic treadmill for years.  Poked, prodded and imaged over and over by various GPs; bounced from specialist to specialist. They’re told everything they don’t have.  Some latch onto the labels they accumulate along the way, grateful for any name to explain their suffering.  I recall a patient for whom a somatoform disorder diagnosis brought immense comfort.  “It’s a real disease,” she’d tell her friends. “It means my body’s more sensitive than other people’s.”

Others find such diagnoses insulting, shameful and upsetting, desperate for a more “socially acceptable” explanation.  One such patient told me that the day she was diagnosed with breast cancer was the happiest day of her life.  “At least now people will believe I’m sick,” she said.  As Dr Stone said in her address, “There will never be a Fun Run raising awareness for medically unexplained symptoms.”

No one would deny that swamp gardening can be frustrating and draining.  However, if you are searching for meaningful, important and interesting work, you’ll find it in the swamp.

It is challenging to sail the diagnostic sea without sinking under the weight of over-investigation or being capsized by a missed serious condition.  It takes intellect and bravery to negotiate the treatment maze without a map. And there’s immense reward and satisfaction to be gained by wading through the swamp with your patients, weeding and planting.  Efforts which, if you’re lucky, will occasionally bear fruit.

Even if I had spent time explaining it, I suspect my old uni friend would not have understood the fundamentals of swamp gardening.  My cryptic answer made an impression though.  I heard that he’d commented that “Genevieve‘s gone all flower-power closet hippy.  Must come from living near Byron Bay.  Shame, that.  She used to be kinda normal.”

Adapted from my piece, “Swamp Gardening” first published  RACGP’s Good Practice magazine, Jan/Feb 2013  – “Portraits of General Practice” Column

Plagarism on Media Watch

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

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

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

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

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

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

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

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

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

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

I wish him well.

………………………..

Written in October, 2012

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

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

Listen to your heart – my response to ABC TV’s Catalyst program

In the last fortnight or so, there has been a lot of talk about the two part Catalyst special on cholesterol and statin medications. The Heart of the Matter aired on the 24th and 31st October on ABC TV  and received widespread publicity in both the mainstream and medical press. Despite currently being on leave from clinical work, I’ve been approached my numerous concerned friends and non-medical colleagues asking for my opinion on the issues raised. In my role as a medical educator, I’ve had an enquiry or two from somewhat confused registrars wanting to know what to say to their worried patients.

Now this is not a bad thing in itself. Increasing public awareness of important health issues, transparency and rigorous independent scrutiny of established scientific “facts” are vitally important.  Like many others, I abhor the tendency to over-medicalise, and the increasing pressure from many sources to over-diagnose and to over-treat. Having said all that, I was disappointed in Catalyst’s treatment of the issues raised.  I thought it was sensationalised and unbalanced, and therefore irresponsible to air.  Using emotive terms such as “toxic”, “organised crime” and “conspiracy” is not helpful to anyone.

Although the Catalyst shows came with a token disclaimer, I worry that such scaremongering will result in fear-based rejection of statin medications.  I’m not saying that statin medications are  beneficial to everyone, far from it, but there are certain subsets of patients for whom statin therapy may well be lifesaving and I worry that these some of these patients may be adversely affected.

On the positive side, it has brought the topic of heart health to the public’s attention, and provided a good opportunity for doctors  to reassess their patients’ absolute cardiovascular risks, review their need for medication, and to provide education and  advice on all lifestyle risk factors. The shows also emphasised the importance of regular exercise and a diet low in refined sugars.  All good things.

And I was inspired to create my first ever YouTube mash up/ musical parody. I’m not sure if this was a good thing or not, I’ll let you be the judge…

It was created on a whim while travelling.  I had no recording equipment other than my laptop’s cheap and nasty internal microphone (I apologise about the audio quality!) and was overtired.  I know fatigue is not a legitimate medico-legal defence regarding duty of care to patients, but I wonder if it is a reasonable excuse for questionable creative content?  Perhaps, like shopping when hungry, it is merely ill advisable. All just a bit of fun really, and a chance to try out my Camtasia software for the first time.

Feel free to comment below if you so wish.

If you missed the  Catalyst shows and want to see what the fuss is about they are available on YouTube.

Episode one link

Episode two link

For an excellent summary served with lashings of evidence and a sprinkling of humour, check out Dr Robin Park’s blog post.

For some great advice to junior (and senior!) doctors, check out Broome Docs “Letter to my registrars:on statins and stuff” in which a great comparison is made between the current media storm on statins with the uproar over HRT in 2002.  Like Casey, I was a bright-eyed bushy-tailed registrar when the WHI results were first released and remember all too clearly the widespread patient (and doctor) panic over HRT.  It taught me some valuable lessons.  Firstly, I learned to not take medical information imparted to me from on high as the gospel truth, but to always question and to keep questioning “truths” over time. As I’ve become more experienced, I have discovered that nothing in medicine is absolutely right. The more I know, the less certain I’ve become. Secondly, it introduced me to the swinging pendulum: HRT was all good, then all bad, and now rests somewhere in the midline – sometimes good, sometimes bad, depending on the clinical situation. Thirdly, it got me in the habit of using sentences such as “based on current guidelines / what we know at the moment, I would suggest ‘X’ but this may change as further evidence comes to light,” rather than sentences like “Evidence shows that ‘X’ is the best treatment for you.”

For some “fat facts” from the ever-reputable Rosemary Stanton, you can find her article in the MJA here. She points out that Catalyst “relied on the opinion of a journalist and four US experts — a nutritionist, two cardiologists and a physician — but failed to note that three of the experts market a range of “alternative” products via their websites (www.jonnybowden.comwww.drsinatra.comwww.proteinpower.com), including diet “aids” (with “slimming” claims), anti-ageing, “brain power” and detox supplements, plus a variety of bars, shakes, drinks and powders. One product even claims its citrus bergamot content will lower triglycerides, blood sugar and inflammatory LDL (low-density lipoprotein) cholesterol and raise HDL (high-density lipoprotein) cholesterol.”

And finally, a must read: the ever-witty Dr Justin Coleman weighs in with his sceptometer blowing a fuse in the process.

Assessing fitness to drive – dealing with bullies.

Dr Andrew Gunn has just published a highly entertaining piece on the serious topic of assessing fitness to drive in the elderly.

http://drandrewgunn.com/2013/11/01/the-last-word-on-fitness-to-drive/

I agree with Andrew that the current system has the potential to cause real damage to the doctor-patient relationship and that routine practical testing for older drivers would be a significant improvement. What do you think?  (please comment below)

Anecdotal evidence seems to suggest that some patients will doctor shop with their fitness-to-drive paperwork and lie and/or bully doctors into signing the forms. As a junior GP registrar I felt unprepared to deal with such demanding patients, and on a couple of occasions caved in against my better judgement. One of the most memorable was with “Betsy” (name has been changed).

Betsy was an exceedingly frail 88-year-old who hobbled painfully slowly and breathlessly into my room using her wheelie walker. Her list of medical problems was long and impressive, and included uncontrolled diabetes, heart failure and Parkinson’s. The medical certificate form for her driver’s licence renewal flapped almost comically in her shaking hand. Despite its being patently obvious that she was unfit to cross a road unaccompanied let alone get behind the wheel, I’m ashamed to say that I was bullied into signing the form, for lurking underneath that frail exterior was a very aggressive and manipulative woman. I didn’t sleep well that night, terrified that my cowardice might result in great harm to some innocent road user.

Less than a fortnight later I heard that Betsy had died at the wheel. Imagining the worst and having visions of being hauled up in front of the coroner to explain my negligent action, I spent the next few hours in a state of panic. To my immense relief, I discovered that far from causing an horrific multi-vehicle accident, Betsy had in fact executed a perfect parallel park in town, but failed to alight from her car. Cause of death: massive CVA.

I’ve never gone against my clinical judgement when signing a driver licence medical certificate again, much to the chagrin of several patients.

I’m willing to bet that a fair proportion of us doctors were subject to bullying as schoolkids. Some of us disguised our intellect, played rugby, hung out with the cool kids and went on to become orthopaedic surgeons, but many of us, myself included, found ourselves in the nerdy camp. Orchestra, choir, debating, chess club, maths quizzes and science summer schools were not the kind of extracurricular activities which helped one climb the school social ladder. Add to that a goody-two-shoes attitude, the wrong wardrobe, acne, braces and a few extra kilos, and you get a bully’s pin-up girl – or rather, voodoo doll.

Time went by; we all grew up and I for one relished the idea of living and working in a mature, fair, supportive, adult world. Alas, I was to discover that not all schoolyard bullies grow out of their penchant for pushing others around.

While only a small number of patients attempt to bully us, the ones who do can cause considerable headaches.  Ignoring those who put our physical safety at risk (that’s a whole other topic), the ones who put undue pressure on us to grant their wishes can be more than just unpleasant to handle – their behaviour can result in our treating them inappropriately.

Unfortunately, I did not immediately apply the lesson learned with “Betsy” to other unreasonable demands made of me.  One busy morning, as the only doctor on duty, I was rung by the practice principal’s wife and informed that a “VIP patient” (a close friend of hers) was en route with “something in his eye”. “No care is to be spared!” was her instruction.  I was mildly offended at the insinuation that I spared my care according to whim, but all such thoughts were swept away by the arrival of a distraught wife with her vomiting husband in tow.  I did not need fluorescein to find the foreign body: he had a 2cm diameter bamboo rod protruding from his orbit.  A simple case of ambulance to the nearest hospital, I know, but the patient and his wife flatly refused to be treated at a public hospital, but instead insisted on driving to a private ophthalmologist (there being no private hospital emergency facilities nearby).  After valuable minutes ticked away with my arguing the point, I acquiesced. I had a difficult phone conversation with a local ophthalmologist, hurriedly scribbled a letter and sent the patient on his way.

Later that day, I received a deservedly irate phone call from the ophthalmologist on whom I’d dumped this unstable patient.  It was a metaphorical poke in the eye with a big stick, and I still wince when recalling the dressing down. Luckily, the patient’s outcome was a relatively good one, all things considered.  He lost the eye, but did not suffer any intracerebral complications.

As children we are told, “It’s all fun and games until someone loses an eye.”   It took me a long time to learn this lesson, but learned it I have – I’m no longer a pushover when it comes to bullies.

 

(Identifying details have been changed to protect patient privacy. Blog post has been adapted from my column “Dealing with bullies” published in MIPS Review Spring Edition, September 2011)

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

Halloween, 31st October 2012

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

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

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

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

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

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

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

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

“Yes, but that’s different.”

“How?”

“It’s over the phone.”

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

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

“I don’t have $500 or ID.”

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

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

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

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

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

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

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

………………………

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

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

Reflections on GP the Musical’s trip to Darwin (for GP13)

The 8th performance of GP the Musical – the show written, directed and acted by GPs – was up in Darwin this month, as part of the GP13 conference.

Cast pre-show photo Darwin 17th October 2013

Cast pre-show photo Darwin 17th October 2013

Still buzzing from our unexpectedly sold out season at the Melbourne International Comedy Festival in April, the cast members were all eager to don their costumes and dance up a storm, despite the Darwin heat.  While high on enthusiasm, we were a little rustier than anticipated and had only a very limited time to rehearse. No doubt this was quite stressful for director Dr Katrina Anderson, but she soon whipped us into some semblance of shape using her indomitable directing skills.

Receptionist song at GPTM Darwin

Receptionist song at GPTM Darwin

It is both daunting and comforting to perform in front of colleagues. We expected a very supportive and forgiving crowd (and they were!) but knowing there were some serious heavyweights in the crowd (the likes of RACGP president, Dr Liz Marles, Chair of Council, Dr Eleanor Chew and the legendary Professor John Murtagh) did produce a few butterflies. We weren’t sure whether these VIPs would appreciate us sending up everything from E-health records to naturopathy to heartsink patients, but our college memberships were not rescinded the next day, so they must have taken the show in the tongue-in-cheek manner intended.

Professor John Murtagh was particularly effusive with his praise of the show. He told us how he had tried to get tickets when GP the Musical was at the Comedy Festival, but was turned away by the box office due to the show being sold out.  I’m sure he was too humble and polite to do the whole “Do you have any idea who I am?” routine, but we kind of wish he had!

WONCA president Professor Michael Kidd gave us a personal apology for not being able to attend the Darwin performance (he was flying out to India that evening).  He had seen the show in Melbourne but said he had wanted to see it “one more time”.

Enough of the name dropping!

We had many non-India-bound audience members who had chosen to “come back again” for a second or third viewing.  Those who had last seen it at the 2012 GPET Convention, experienced not only a more practised performance but 20 minutes of extra dialogue and two new songs (E-health records and Naturopath Song).

Mr Black and Dr Karla

Mr Black and Dr Karla

There were some changes since the Melbourne International Comedy Festival season too.  There were dialogue tweaks (deliberate ones, mostly ;-)) and a cast re-shuffling:  a previous patient became the female doctor and the doctor accepted a job promotion to become the receptionist.    Dr John Buckley returned as the unstoppable Mr Goodall.

The other change was that the show jumped on the social media bandwagon and had a live twitter stream:  #GPTM.  Photos and comments were posted during the show by both audience members and the show’s multi-tasking receptionist character (while on stage).  OK, I’ll stop hiding behind the 3rd person.  The crazy receptionist was me.   I’d obviously overlooked the fact that playing a new role for the first time with very little rehearsal would probably need my full attention.  At some point, I must have subconsciously  decided that acting, singing, dancing and playing live music in front of a large audience of colleagues, invited guests and VIPs was not enough of a challenge, and so added live tweeting into the mix.  Miraculously I managed to post numerous tweets using the prop conveniently placed on the desk at which I was sitting for much of the show (aka laptop) without missing cues or lines.   More good luck than good management, in retrospect. You can check out the tweets at #GPTM if you’re curious.

All in all, it was a tremendously enjoyable night (for the cast at least).

Encore performance at Rural Faculty Function

Encore performance at Rural Faculty Function

Wanting a little more of the  Darwin limelight, we came back “one more time” and did an encore performance of our final song, The one to see is your GP, the following evening at the RACGP Rural Faculty Function.  It wasn’t scheduled and we weren’t invited as such – we snuck onto stage while the star act of the evening, the very talented and entertaining GP band, the Medical Cheekydocs, took a five minute loo break.

We have the band to thank not only for a wonderful night’s music and for graciously allowing us to monopolise the stage for a few minutes, but for the existence of the musical at all.  For it was back in 2010, while the band (then called Simon and the GPETtes) were rehearsing on a station outside Alice Springs for the 2010 GPET Convention, that the idea of GP the Musical was first dreamed up by Gerard Ingham and myself (both then band members). We started writing the show a couple of months later, and the rest, as they say, is history.

We couldn’t have done any of it without our director and fabulous cast, so thank you all!

There are no future GP the Musical  shows scheduled at present, but who knows?  We may just “come back again” next year to a theatre near you.

Post show drinks

Post show drinks

Mr Goodall getting cuddly with Mr Black

Mr Goodall getting cuddly with Mr Black

I love being mistaken for a medical student

“Are you learning a lot today, dear? Are you going to be a GP too one day?”

My face breaks into a smile for a number of reasons. I love it when, as a medical educator, I’m mistaken for a student while conducting external clinical teacher (ECT) visits.

First, if patients mix up which one of us is the registrar and which is the teacher, it usually indicates they trust and respect the doctor they’re consulting.

Second, it can help put a nervous registrar at ease. We have a chat and a laugh about it afterwards, and I can almost see their confidence level rising.

And third, it makes me feel young.

Before you try to burst my bubble, I know med students are not all bright-eyed 20-year-olds, but I still take it as a compliment.

For the uninitiated, ECT visits are compulsory components of GP training nationwide. Each involves a medical educator visiting a registrar’s practice and sitting in for a session, after which a report is written and kept on file.

There are some registrars who relish the idea of an educator observing and commenting on their clinical performances in a career they’ve only recently started.

They’re usually the same type of people who like doing karaoke without the benefit of inebriation, think nothing of standing up in front of a crowd to deliver impromptu speeches, and apply for reality TV shows.

Most, however, are at least a fraction anxious about their first ECT visit. For starters, having the name ‘ECT’ doesn’t exactly engender comfort and reassurance. Those who chose this initialism might have thought it amusing, but I haven’t seen many registrars laugh about it.

Indeed, one even told me she’d had a nightmare in which she received an electric shock every time she asked too many closed questions or didn’t pick up on non-verbal cues.

The training provider for whom I work has changed the name to ‘FACT’ (Formative Assessment Clinical Teaching). However, the FACT of the matter, as I see it, is that an ECT visit by any other name still smells of fear.

Most registrars relax into ECT visits pretty quickly and find the experiences educationally valuable. By the end of that first nerve-wracking visit, many say things like, “That was great — I wish you could come every week.” A few actually mean it!

I used to be nervous conducting ECT visits too. Back in 2005, when first starting out as a medical educator, I worried that I was too young and inexperienced. What if a registrar asked me a question I couldn’t answer? It took me a while to realise I didn’t need to know everything to be a good teacher, and that getting the registrar to look something up was not only okay, but a valid educational strategy.

In those early days, patients often mistook me for a student, but I didn’t view it as complimentary. I was still young enough to want to look older.

It was a bit like being asked for ID at a club. At 20, many people are miffed to be asked for ID: “There’s no way I look underage!” At 25, they think it’s mildly amusing: “I look underage? That’s pretty funny!” However, by 30, they are desperately hoping that someone, anyone, would mistake them for possibly being a teenager.

I’m now very comfortable being the age I am and have no desire to be a teen again. Nonetheless, the occasional medical student misidentification is not unappreciated!

 

First published in Australian Doctor on 13th July, 2012 On being a medical educator

http://www.australiandoctor.com.au/opinions/the-last-word/the-last-word-on-being-a-medical-educator

Theatrics can be Therapeutic

Some patients are hard to train. As are certain colleagues. Either (or both) can make our already difficult jobs all the more stressful.

The well-adjusted, Zen-like doctors will let such annoyances wash over them like a limpid mountain stream and switch them off like a tap the moment they walk out the door.

The less compartmentalised of us need other strategies to avoid finding ourselves tossing and turning in bed, fantasising about a career change.

The traditional GP stress-buster is, of course, red wine, but fewer of us imbibe regularly these days (or at least admit to it) and we instead espouse remedies such as being yelled at by sadistic personal trainers at 5am daily.

Not being a saint, drinker nor masochist, I have been known to try writing my way to a peaceful night’s sleep. Most of my frustration-driven rants are not fit for human consumption, but occasionally I’ll be able to kill two birds with one stone by using my debriefing material in a column, story or theatre piece.

This is how ‘Mrs Ryan’ ended up on stage. The character was based on one of my seemingly untrainable, frequent attendees whose ‘poor me’ attitude and long, long list of problems each consultation had driven me to the pen. ‘Mrs Ryan’ subsequently became a major character in a day-in-the-life-of-a-GP play called Walk a Mile in my Shoes that I was lucky enough to have performed in 2011.

It was most therapeutic for me to see a comically exaggerated and fictionalised version of my patient on stage, her essence perfectly captured by a talented actor.

Each time I watched her strut her stuff in rehearsal, the antipathy I felt towards my patient ebbed further and further away.

But then, on opening night, the real ‘Mrs Ryan’ unexpectedly turned up in the audience.

I panicked. For the two-hour duration of the show I waited in trepidation, inwardly cringing each time the audience laughed at the unreasonable behaviour of the play’s most irritating character.

Post-performance, my ‘Mrs Ryan’ made a beeline for me and gushed, with a completely straight face: “That was wonderful. I loved it! That Mrs Ryan character was a piece of work, though. How do you doctors ever put up with such people?”

Despite failing to recognise herself, ‘Mrs Ryan’ changed her approach to consultations. Her lists now rarely exceed three items and she’s mindful of time constraints.

When I positively reinforced her behaviour change, she replied: “Your play helped me see how stressful your job is. I’d never thought of doctors as people with their own problems before.”

She went on: “I’d love you to put me into a story or play one day. I have enough problems to fill up a whole book!”

It turns out the theatrics were as therapeutic for her as they were for me.

“Mrs Ryan” and I have since had a good laugh over the incident and she gave permission (and her blessing) for me to write this column.

The good news is that you don’t need to be a writer to effect behavioural change in those patients and colleagues who make your life hell. Sending them to the theatre could be enough. Walk a Mile in my Shoes has hung up its boots for the moment, but there are plenty of colourful characters in GP the Musical, which may well do the trick.

Coming along yourself may prove therapeutic too – giving you an opportunity to laugh off your workday stresses, with or without the assistance of red wine.

Since this column was first published, GP the Musical has enjoyed a sell-out season at the Melbourne International Comedy Festival in April 2013 and performed at the GP13 conference in Darwin for GP13.  It features an all-GP cast.

First published in Australian Doctor on 15th March, 2013: On theatrical stress-busting

http://www.australiandoctor.com.au/opinions/the-last-word/the-last-word-on-theatrical-stress-busting

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

My recollections of sitting my RACGP OSCE (Fellowship clinical exam) are rather hazy, and not just because it was over a decade ago. I do have one bit of advice though – a do-as-I-say-not-do-as-I-did tip – try to avoid traumatic brain injuries in the month leading up to your clinical exam.

Here’s the story of how I came to be doing my RACGP OSCE exams with 6 facial fractures and left temporal lobe contusions….

Saturday, 4th October, 2003.

Photos from old computer 115

I couldn’t close my mouth. That wasn’t a good sign. Many a time I’ve been admonished for having my mouth open more than it’s shut, but on this occasion it had nothing to do with being garrulous. My upper and lower jaw no longer occluded. I sat up – gingerly, to discover that I was completely alone in unfamiliar bushland, with no recollection of how I got there. I lay back down and closed my eyes, inappropriately unperturbed.

Like a slowly developing Polaroid picture, the details appeared in my mind’s eye. The colours were increasingly vibrant yet the focus remained blurry. I remembered studying for my OSCE exams that morning before deciding to take one of horses for a ride in the State forest to clear my head. The rest was a blank; my head had been cleared too well.

Living at Pomona0013It was time to play CSI. The skid marks and saddle imprint in the mud clearly showed where Rondo had shied and fallen (probably on seeing a kangaroo – he was terrified of them), and my face had left a lovely impression at its point of impact. Thankfully, Rondo appeared on cue when called – mud-splattered and jittery but unharmed. It took us several hours to find our way out through the maze of interconnected forest trails, what with my disorientation and his being one of those rare horses with no inclination to make a beeline for home. Unlike many males I’ve known, he was excellent at taking direction but hopeless at finding it.

I remember only one thing clearly about that long ride home: laughter. My laughter – laughter which bubbled up from deep inside, slipping between my maloccluded teeth and spilling out of my bruised mouth. In my concussive haze my situation somehow seemed side-splittingly humorous. The funny side was the only side I could see.

I laughed more in that next month than I’d done in the preceding three years. Although my personal predicament lost its comedic edge fairly quickly (temporal lobe contusions and six facial fractures requiring two maxillofacial surgeries and a six-week liquid diet do tend to be dampeners), the world around me tickled my funny bone in completely new and outrageous ways. I laughed at the news. I laughed when I got stuck in traffic. I laughed over spilt milk. And most surprising of all, I laughed at corny American sitcoms. You know the ones: weak, predictable story lines, groan-worthy one-liners and canned audience laughter. I found them not only funny, but hilarious. I’d laugh so hard that I’d double up on the floor in stitches with tears streaming down my cheeks. I kid you not.

Despite my looming exams, my neurologist prescribed “brain rest” and instructed me not to study. Nothing I read seemed to be retained anyway, so I put my books aside and indulged in my new-found penchant for mindless entertainment. I laughed the days away without a care in the world.

Living at Pomona0020Three weeks after my accident, less than a fortnight after two reconstructive surgeries, and against medical advice, I sat my OSCE exam. In my brain damaged state, I was not at all worried about whether I’d pass or fail, happy to turn up and just “have a go”. I don’t remember much of it, other than wondering why my fellow candidates all looked so worried, receiving stern glances from an exam supervisor as I giggled to myself in a rest station, and having to ask one of the role players about her presenting complaint at least three times (my brain simply refused to retain the information).

I miraculously passed (although it was far from an outstanding performance!). Somewhat unfortunately, over the following weeks my ability to laugh outrageously at the banal also passed, and my sense of humour crept back to the dry and satirical side of the fence. The news of the world was again depressing, traffic congestion got my goat and split milk, although not inducing tears, no longer triggered a giggle.

I’m not sure if my laughter was the illness or the medicine, but it was definitely an integral part of the healing process. Having a traumatic brain injury was for me a far from unpleasant experience. In fact, it seemed to suggest that life is not only more painless for the brainless, but it is also much funnier.

While sitting a major exam in such a state was entirely without stress at the time, I do not recommend it as a technique to reduce performance anxiety. In all seriousness, I was very lucky to have passed, and believe that the only reason I did was that I had spent the previous 18 months preparing. Not by going home and studying every night, but by engaging in deliberate practice each and every day when seeing patients. Good communication skills and examination techniques were so ingrained that they did not require the concentration and higher level thinking that the knock on my head had temporarily disabled. These semi-automated skills alone are not enough to be a safe and competent doctor in the real world of course, but, together with a big helping of luck, were enough to carry me through the OSCE exam on the day, as I smiled and laughed my way through the stations, completely unfazed.

The Last Word on GP Matchmaking

First published in Australian Doctor on 28th September, 2012: On GP Matchmaking

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

The Last Word on GP Matchmaking

by Genevieve Yates

When a playwright friend heard I was writing a musical about general practice, his first comment was: “It must include a love story — audiences expect romance!”

At the time I pooh-poohed the idea, thinking that medicine and love don’t sit well together, even in musical theatre. I certainly wasn’t prepared to write a stage musical version of Grey’s Anatomy with a Dr McDreamy GP character making use of the examination couch after hours.

However, as GP the Musical came to life, my co-writer, Dr Gerard Ingham, and I discovered we had indeed written a love story — about doctors and patients. Not the kind of love story that will have AHPRA knocking at the door, mind you, but one about matchmaking patients and GPs.

In Act 1, Dr White, a whiz at dermatology and care plans, is happy to treat Rebecca’s rash, but not so eager to address her psychological distress.

Dr White: “I see here that you are on antidepressant tablets ¬ Wow, that’s a high dose. Look, counselling isn’t my thing. We all have things we are good at. For example, I’m good at cycling and running but rubbish at swimming. So I do better at triathlon if I team up with a good swimmer. Play as a team, win as a team. Do you know what I mean?”

Rebecca: “Not a clue.”

Dr White: “Well, you see although we’re both GPs, Dr Anderson is better at the psychological and women’s stuff — the tears and smears. So I think it’s best if you come back later this week and see Dr Anderson to talk about your sad feelings.”

Meanwhile, Dr Anderson is struggling with Mr Black, an ex-accountant who loves nothing more than creating Excel spreadsheets documenting his bodily functions, and whose thinking is as concrete as his bowel motions.

Dr Anderson: “Mr Black, what’s really going on?”

Mr Black: “Pardon?”

Dr Anderson: “What’s bothering you, deep down?”

Mr Black: “My bowels aren’t working properly, that’s what’s bothering me.”

Dr Anderson: “I’m not talking about your bowels, I’m talking about your feelings. Are you unhappy?”

Mr Black: “I’m unhappy when I can’t pass my motions, obviously.”

The exchange continues:

Dr Anderson: “Mr Black, you come and see me nearly every week with your bodily function charts. You want me to prescribe you pills but you’re terrified of side effects. I think there are other issues going on.”

Mr Black: “Of course there are other issues. Haven’t you been listening? There are my blood pressure variations, my dizziness, my low blood sugars after meals ¬”

In Act 2, the patients swap doctors. Mr Black is introduced to the Bristol Stool Chart and gets his thrice-daily home BP readings uploaded into his medical record by Dr White. He thinks this is “maaarvelous!” Rebecca finally finds her doctor match in Dr Anderson — someone who’ll explore why she’s scratching herself incessantly and who listens to what she has to say. Both love stories resolve happily.

In true musical theatre style, the storyline is simplistic and the characters are stereotypical, but it seems to have hit the mark with doctors and non-doctors alike. Judging from the standing ovation received at GP the Musical‘s premiere in Melbourne earlier this month, it seems audiences really do love a love story — albeit one involving the improved documentation of stool consistency!

(Since this column was first published, GP the Musical has enjoyed a sell-out season at the Melbourne International Comedy Festival in April 2013 and is heading to Darwin for GP13 on October 17)