“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!

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Dealing with the Known Unknowns

If patients want a GP with excellent theoretical knowledge, I recommend they seek out a GP 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.

In my RACGP Censor role, 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 far past 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 GP who have just sat their RACGP exams.

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

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.

Genevieve’s RACGP Fellowship and Awards Ceremony Speech – “You can do it all, just not all at once!”

On Saturday 21st September, 2013,  I was honoured to be the guest speaker at the 2013 RACGP Fellowship and Awards Ceremony. It was held at the Queensland Conservatorium of Music, Southbank, Brisbane, for the new Fellows of the RACGP, their family members, RACGP staff and members, and dignitaries.

My brief was to enthuse, inspire and entertain the 500 odd attendees with my personal journey – not an easy task. I thought long and hard about what to say – how to frame my narrative in a way that was truthful but interesting, different but relatable, somewhat humourous but inoffensive, and inspiring but not totally immodest.

I’m not sure that I succeeded in these aims, particularly in humbleness department, but I did my very best and had an awful lot of fun writing and delivering it.  I’m very grateful to the RACGP for the invitation.

If you have a spare 20 minutes and want to judge for yourself whether it is appropriate to talk about sanitary products while dressed in an academic gown and delivering a formal address, here it is….

RACGP Fellowship Ceremony Speech, 2013 (Powerpoint with audio)

or if you prefer Windows media player 

Fellowship ceremony speech in wmv format

or in .avi …

Fellowship ceremony speech in avi format

Genevieve with Linda Landreth (RACGP) at Fellowship Ceremony

Genevieve with Linda Landreth (RACGP) at Fellowship Ceremony