ISSUE 10 FREE January — April 2013
Taking a fresh look at general practice
Dr Cass Wys maximising every dimension of life
Also in this issue: Refugee health GP profiles Clinical cases
The future of general practice
Thinking of training to be a
GP?
Applications for GP training through the Australian General Practice Training program (AGPT) open on 15 April and close on 17 May 2013. Go to: www.agpt.com.au to find out more or talk to your GP 6 Ambassador in your hospital today!
Welcome
to the tenth issue of Going Places. It is a great privilege for me to take on the role of Medical Editor for this fantastic magazine, brought to you by General Practice Registrars Australia (GPRA). Since its launch three years ago, Going Places has published many stories and profiles of GPs and GP registrars from all across the country. The breadth and depth of their knowledge and experience leave no doubt in my mind that a career in general practice is both intellectually challenging and emotionally satisfying. In this issue we bring you more profiles of inspiring doctors working in general practice.
Taking a fresh look at general practice
Our cover story profiles the multifaceted Cairns-based GP registrar, Dr Cass Wys, who shows us that it is possible to successfully juggle a busy general practice career with the responsibilities of motherhood. An excellent role model for any aspiring clinician/writer/editor, Dr Kath O’Connor shows us how she combined her clinical skills with her writing prowess to land a job with Australian Family Physician. How did a United Nations Secretary General influence a GP’s career plan? 2009 RACGP GP of the Year, Egyptian trained Dr Ayman Shenouda, recounts his fascinating story of how he ended up working as a GP in regional New South Wales. General practice really is medicine without borders, as Dr Roslyn Brooks demonstrates her selflessness by volunteering for Médecins sans Frontières. There is also a feature article on how you can get involved locally in refugee health, written by yours truly. If you would like to get a taste of working in general practice as part of your hospital rotations, you should sign up for the Prevocational General Practice Placements Program (PGPPP). Dr Adam Swalling shares his truly ‘hands-on’ PGPPP experiences in regional South Australia. We also talk to GPRA Board Director Dr Clark Maul, who told us how he transitioned from being a clown to a doctor! If you are undecided about your future career pathway, I would encourage you to connect with the GP Ambassador at your local hospital network to discuss how you can start your own journey in general practice. I truly believe that general practice is the cornerstone of the Australian health care system. We need bright and capable individuals to join our profession, to ensure that we remain effective and relevant in the delivery of health care services to the people that matter the most in our line of work – our patients. Enjoy the magazine!
Dr Chia Pang Medical Editor Hospital registrar – Bogong Regional Training Network GP Ambassador – Southern Health, Melbourne, Victoria ©2013 GPRA. All rights are reserved. All materials contained in this publication are protected by Australian copyright law and may not be reproduced, distributed, transmitted, displayed, published or broadcast without the prior permission of General Practice Registrars Australia Ltd (GPRA) or in the case of third party material, the owner of that content. No part of this publication may be produced without prior permission and full acknowledgement of the source: Going Places magazine, a publication of General Practice Registrars Australia. All efforts have been made to ensure that material presented in this publication was correct at the time of printing and is published in good faith.
Taking a fresh look at general practice 3
Is general practice the specialty you have been looking for?
13 Going Pla20ce s Prevocational docto
rs
guide to GP trainin
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General Practice Registrars Australia (GPRA) Level 4, 517 Flinders Lane, Melbourne Victoria 3001 Phone: 03 9629 8878
Taking a fresh look at general practice
The future of general practice
Join the Going Places Network today and find out more about general practice. • More than 2,300 junior doctors have already joined us • Network with experienced GPs and meet other peers interested
in becoming a GP
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• Attend free networking and educational lunches and dinners • Access free tools and resources • Get key information from your local GP Ambassador in your hospital
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Taking a fresh look at general practice
In this issue… Upfront 6 Cover story: Dr Cass Wys – A chance to shine 8 Dr Adam Swalling – PGPPP and me 11 Dr Clark Maul – Doctor, lawyer, clown
Regulars 15 Is general practice for you? 18 Going Places Ambassadors across Australia 19 Going Places Network update 20 Feature: Refugee health: What can we do to make a difference? 23 GP in the news 25 It takes 2
Taking a fresh look at general practice Published by General Practice Registrars Australia Ltd Level 4, 517 Flinders Lane Melbourne VIC 3001 P 1300 131 198 F 03 9629 8896 E enquiries@gpra.org.au W gpra.org.au ABN 60 108 076 704 ISSN 2201-1773 Staff General Manager Marketing & Communications Sally Kincaid sally.kincaid@gpra.org.au Medical Editor Dr Chia Pang
GP profiles
Editor Denese Warmington
26 Dr Kath O’Connor – The write balance
Writers Laura McGeoch Jan Walker Denese Warmington
28 Dr Ayman Shenouda – Leap of faith 30 Dr Roslyn Brooks – A volunteering life
Graphic Design Peter Fitzgerald
Clinical cases
Going Places Network Manager Emily Fox emily.fox@gpra.org.au
33 Clinical corner 34 What’s your diagnosis? 36 A difficult diagnosis
Back pages
Sponsorship & Events Coordinator Natalia Cikorska natalia.cikorska@gpra.org.au Business Development Manager Kate Marie kate.marie@gpra.org.au Produced with funding support from
39 What’s new in the AGPT program? 41 Chocolate box – GP tales with a twist 42 Book review 43 Where to now?
Printed by Graphic Impressions
FSC Logo Taking a fresh look at general practice 5
G P regis t rar P R O F I L E
Every medical career gives doctors a chance to shine, but none more so than general practice. GP registrar and mother, Dr Cass Wys, says this specialty allows doctors to maximise every dimension of their lives — both at work and at home. Speaking to Going Places magazine from her Cairns home on a balmy afternoon, Dr Cass Wys has just put her 15-month old daughter, Alyssa, down for a nap. She starts to describe a general day for her. In a snapshot, it’s busy. Very busy! It starts at 6 am when her daughter wakes. She dresses and feeds Alyssa (and herself!) before dropping her off at childcare. Cass arrives at work by 8.30 am. If she’s working one of her two and a half days as a GP at the Redlynch Medical Centre, it’s a full day of patients, including a much needed one-hour lunch break. If not, it will be treating acute injuries at the Reef Orthopaedic Clinic or a half day assisting orthopaedic surgery at Cairns Private Hospital.
Throw in some study and her work as a registrar liaison officer for Tropical Medical Training, and there’s not much time to draw breath. But when she does, she usually expels it by going for a walk with her daughter, her partner Matt and their dog Nika, or during her weekly game of touch rugby. It’s clear that this PGY2 is not one to sit in the shadows. And that’s exactly why general practice is the perfect career for her. “There is no place for a lazy GP,” Cass says. “If you want to be in this field of medicine you have to work hard. It is crucial that you assess each patient within the context of their lives, as often this can help aid in successful management of their condition – whatever that may be.”
“There were many specialties I had an interest in, it just seemed the logical step to choose general practice and be exposed to such a vast range of medicine.”
A chance to 6 6
“There is just no place for an arrogant GP who glosses over the finer details. Mistakes can be made, important diagnoses can be missed, and patients can suffer. It’s our job to help people ... we should never lose sight of this.” Cass gives the example of three women, all new patients, who came in requesting new prescriptions for the contraceptive pill. They all had clear contraindications to the pill, yet two had been prescribed it several times in the past with no documentation of risk factor status.
Debunking the tired myth that general practice is the easy option, Cass says GPs must continue to develop their skills and education to best help their patients. “We are often the first people that get to assess our patients. It is important we do the very best we can to diagnose and treat them appropriately.” Cass realised this when working with two older male GPs during her rural placements. “One of the GPs I worked with hadn’t instilled much confidence in me,” Cass, who is originally from New Zealand, recalls. “But there was a senior GP and medical officer in Balclutha (on the east coast of New Zealand’s south island) who was all that I aspired to be — diligent, empathetic, and personable,” Cass says. “His passion for general practice was still quite alive, and it was contagious! I can honestly say he inspired me to be who and where I am now.” It’s through this diligence and a commitment to good medicine that Cass has been able to make positive impacts on the health of her patients. “You have to have a system as to how you assess patients and you have to be thorough. And if you’re not sure about something, don’t be afraid to ask and find out,” she says.
shine
“One was a 16-year-old who had a significant blood clotting condition,” Cass explains. “The second was older than 45, a heavy smoker with focal migraines who also had a significant family history of deep vein thrombosis and stroke. The third woman was overweight and had significantly elevated blood pressure. I just couldn’t believe it! It was almost like I was doing an OSCE exam. It was clear none of these women should ever have been on the pill.” Cass completed her degree in Dunedin and did her first intern year at Christchurch Public Hospital before moving to Cairns in 2008 for her partner’s work. She spent just over a year as a resident medical officer and then nine months on an extended skills hospital placement in paediatrics before starting her general practice registrar training in 2011. Diversity and flexibility were major incentives for her to choose general practice. “There were many specialties I had an interest in, it just seemed the logical step to choose general practice and be exposed to such a vast range of medicine,” Cass says. “I always wanted to be a mum as well ... and general practice is probably the most flexible specialty when it comes to needing time off training to raise a family.” And this flexibility would come in handy. Cass found out she was pregnant during her extended skills training. “My biggest worry was informing the supervisor at my new general practice placement about the news as I hadn’t even started there and I was already going to have
to take time off mid-year for maternity leave! It was quite strange, as once I told him he actually said to me that having children would make me a better doctor. I think I must have looked like a stunned mullet — what other specialty actually encourages you to have a family and a life outside work?” Her colleagues fully supported her throughout her pregnancy, which wasn’t straightforward. “I went into pre-term labour at 32 weeks,” Cass explains. “I was advised to remain off work for the remainder of the pregnancy ... but I couldn’t fathom being at home for eight weeks so I asked if I could go back just to get out of the house!” Her practice allowed her to work two days a week for the rest of her pregnancy. Once Alyssa was born, Cass took four and a half months off and then again started back at work two days a week. “It was incredibly rewarding being able to go back to work and maintain a balance with my home and family life. Obviously the extra income was nice as well!” “Every place I’ve worked has always been really understanding and amazing in terms of family and education commitments. I have also felt well supported in my role as a GP registrar.” Down the track, Cass plans to add new dimensions to her personal life and her career. “Eventually I’d like to have another child and become a partner in a clinic. I want to be involved in medical education and become a GP supervisor, and I’m also interested in working in sports medicine. The great thing about general practice is that you have the ability to pursue other interests within medicine.” For now, she’s enjoying building relationships with regular patients. “I know them as a whole person — their family, who their partners are, their work, their finances ... I know them in the context of the community and I feel very privileged to be in a position to help them.” “No specialty has the opportunity to impact on the community as much as general practice does,” she says. “This is why general practice shines.” Written by Laura McGeogh
Taking a fresh look at general practice 7
PGPPP
PGPPP
and me Dr Adam Swalling is a big advocate of the PGPPP, having done two placements in his time as a junior doctor. Adam commenced community practice as a GP registrar in January this year. Where are you doing your junior doctor internship? Southern Adelaide Local Health Network, which consists of Flinders Medical Centre, the Repatriation General Hospital and Noarlunga Health Service. What year are you in? PGY2. You have done two PGPPPs. One in Murray Bridge and one in Aldinga, quite different areas and populations in South Australia. How was the experience different in each location? Murray Bridge is a regional centre of about 14,000 people located an hour from Adelaide. It has one large GP practice: the Bridge Clinic. Working there as an intern I experienced the full spectrum of rural general practice, in particular chronic disease management. I was rostered on-call for the hospital ED on weekends and assisted visiting surgeons and GP anaethetists in theatre once or twice a week. The town’s ‘duty doctor’ is run from the Bridge Clinic during the day, so ED presentations also come to the clinic. Aldinga Medical Centre is a busy practice in the far south of Adelaide. Working there as an RMO I saw a lot of patients who made appointments on the day, in other words, a lot of acutely unwell people. Aldinga is a rapidly growing area with many young families; about 25% of the patients I saw each day were children. How was it meeting your supervisor(s) for the first time? What did you learn from them? Great! GP practices that have PGPPP doctors do so because they are passionate and motivated about teaching junior doctors. Both my supervisors were extremely approachable and found teaching
8
opportunities every day, and both practices had a number of doctors who were approachable and interested in sharing their knowledge, so I also learnt a lot from them too. In Murray Bridge, there are a number of GP obstetricians, GP anaesthetists and GP surgeons. In Aldinga, there are GPs with special interests in women’s health, dermatology and lesion removal, paediatrics and obstetrics shared care. It was great to have different GPs to learn from each day. Tell us about some of the work you have done? I had such a broad range of experiences during my time at both practices. I was fortunate to see many common paediatric presentations such as bronchiolitis, newborn health checks, asthma education and tonsillitis. Chronic disease management, Indigenous clinics, prison clinics, surgical assisting, airway management, working on-call in the busy ED and admitting patients to the local hospital were all part of my week. Between my two PGPPPs I had a taste of most aspects of community medicine. Did you get any ‘hands-on’ experience? Absolutely! That’s the best part of the PGPPP experience, getting hands-on experience that is not possible in larger centres. I found theatre in Murray Bridge to be extremely hands-on, working with consultant plastic surgeons I would be suturing graft sites, or with a general surgeon using the laparoscopic camera equipment assisting with cholecystectomies. The GP anaethetists were great at teaching and I had plenty of opportunities inserting large bore IV cannula and maintaining airways. I would regularly be suturing in ED in Murray Bridge, or putting on casts for fracture management and performing lesion removals (often requiring flaps to close) at Aldinga. There’s plenty of scope to experience obstetrics in Murray Bridge as they have a busy obstetrics ward in the hospital. My time in general practice was more hands-on than any of my previous rotations. Can you describe an average day during your PGPPP? The only thing that was consistent is that most days I would start at nine and leave at five. In between I would vary from consulting in the clinic where no two days were identical, to assisting in theatre, or going to the hospital ED to help out with an emergency presentation or retrieval team. There really was no average day!
What are some of the important lessons you learned about patient care? Patients don’t expect you to know everything. It is more important to listen, to show the patient you care, and to know how to access information that will help them.
What was the best part of the experience? The diversity in daily practice, the opportunity to put the skills you have learned into place practically, and the friendly, supportive and experienced GPs and practice staff that went out of their way to help me get the most from my experience.
What have you learned about general practice? That it is possible to have a rewarding career whilst still having a really good work-life balance.
What was the most challenging/difficult? I found it challenging stepping up and becoming more independent in my role as an RMO during my second PGPPP. As an intern, you have a GP coming in to every consultation to make sure they are happy with your assessment and management, which is incredibly supportive. But as an RMO this doesn’t happen, and you have to stand on your own two feet a lot more. There’s always someone available to pop in and help out if you need, but it’s certainly more challenging.
Did anything surprise you about the PGPPP experience? The respect you receive from your patients and colleagues. I guess when I was a junior doctor in the hospital system there were times when I didn’t feel like a doctor due to the nature of the work I was required to do. But in community practice, I really felt like a doctor due to the little things: like having your own name on your door and the senior GPs treating you like a colleague rather than a junior. Having friendly practice staff makes you feel like you fit in instantly. The patients that come to see you don’t know you’re a junior doctor and often ask to come back and see you, which is both surprising and rewarding. Did the experience make you want to pursue a general practice career? I already thought I wanted to be a GP prior to going on my PGPPPs, and these experiences helped confirm to me I was making the right decision. Having the opportunity to work with GP registrars who are already in the training program was valuable also.
Would you recommend a PGPPP to others? Definitely, it’s the most rewarding and fun rotation that you will have as a junior doctor. What are your top three tips for someone doing their PGPPP? 1. Get out there and experience it – there is exciting and rewarding medicine outside of the hospital setting. 2. Ask questions and make yourself available all hours: you will find yourself in challenging clinical situations that you won’t see anywhere else. 3. Immerse yourself in the community you are working in: get to know the nursing and administration staff, they all have experience and can teach you something new. If you don’t chat with them, you’ll never know!
Prevocational General Practice Placements Program The Prevocational General Practices Placements program (PGPPP) provides junior doctors with a general practice rotation during their hospital training. Placements are with professional, well supervised and educational general practice environments. Contact your regional training provider (RTP) for more information or go to: www.agpt.com.au
Take the plunge - give GP a go!
Image: Courtesy of Northern Territory General Practice Education
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J U N I O R D O C T O R profile
Doctor, lawyer,clown Photo courtesy of The Community Newspaper Group
Dr Clark Maul, a junior doctor and GPRA Board Director, arrived at his current vocation by way of two previous jobs — junior lawyer and, perhaps more surprisingly, part-time clown.
The first time Dr Clark Maul worked in a hospital he wore star-spangled baggy pants, a funny hat and a big red nose. It was his job to twist balloons into animal shapes and make sick kids laugh. It happened when Clark was a teenager, a few years before he enrolled in medical school. He had volunteered to be a clown at Perth’s Princess Margaret Hospital for Children, where his mother was employed as a nurse and lab technician. It could have signalled the beginning of a simple trajectory from inspired youth to idealistic medical student to junior doctor. But it didn’t. Like the balloon animals, there were some twists and turns involved. The main snag was that Clark was already at university studying not medicine, but law.
Taking a fresh look at general practice 11
“I finished my degree and started work and I actually quite liked law and being a junior commercial lawyer,” Clark explains. “But I just thought that you live quite a long life and you probably need to take the opportunity to do the thing that you suspect you’re most suited to.” The desire to make the career change had been building for some time. The more Clark worked as a junior lawyer, the more he reflected on how much he enjoyed the environment of the children’s hospital as ‘Clark the Clown’. “As a staff member there I saw an opportunity to do lot more good than working as a lawyer,” he says. “I retired from being a commercial lawyer at the ripe old age of 25 with a view to embarking on a vocation that was slightly more civic.” While the transition meant another four years of study for a postgraduate medical degree at Fremantle’s Notre Dame University, not to mention being an impoverished student surviving on twominute noodles again, Clark believes it was the right choice. “I thought I was going to be an Atticus Finch and instead I turned out to be a doctor,” Clark says. He is now in his intern year at Sir Charles Gairdner Hospital in Perth — and loving it! So far Clark has done terms in general surgery, geriatrics, intensive care and emergency medicine, and says each stint has brought its own virtues and lessons. Listening to the old people’s stories was one aspect of geriatrics he enjoyed. “Some of them had stories to spin that I think were getting taller as the patients were getting older,” he laughs. He describes his term in intensive care as “a lucky score” and “a little bit novel for interns”. But it was his term in the ED when he “felt most like a real doctor”. “In emergency you are at the frontline, you’ve got the first opportunity to take a patient’s history and examine them and start some interventions,” he says. He shrugs off the “rather unkind” description of interns as paper monkeys. “There are people with more wisdom than us who have
12 12
deemed paperwork necessary so if the forms are there we’ll fill them in,” he says. Clark has a firm belief that junior doctors should grasp every opportunity, not hang back and do the minimum. He is Director on the General Practice Registrars Australia (GPRA) Board, and a former GP Ambassador with the Going Places Network. His previous training in the law has proved useful in flagging and interpreting legal issues for the GPRA Board. He also says his time in the workforce in another profession gives him valuable people skills when dealing with patients and their families. So how does Clark see his future career playing out, Going Places magazine wanted to know. Being a “doc of all trades” in the country has appeal, he says. He was inspired by Dr Ian Spencer of Wellington, New South Wales, with whom he worked as a medical student as part of the John Flynn Placement Program. “Having a great role model like that does wonders,” Clark says. “He had an anaesthetics background, he did obstetrics, he had a lot of paediatric experience, he also worked in the local emergency department as well as running quite a busy general practice, and he’d been a pilot as a younger man.” Clark shares his mentor’s passion for flying. He has applied for a position in Geraldton at the heart of Western Australia’s mid-west region, where a group of doctor-pilots fly their planes to remote clinics. While there, he hopes to clock up some flying hours towards his fixed wing pilot’s licence. Other plans for the near future include acquiring formal qualifications in anaesthetics so he can work as a GP anaesthetist. And Clark is really looking forward to paediatrics at Princess Margaret Hospital — this time as a doctor rather than a clown. Written by Jan Walker
Taking a fresh look at general practice 13
Did you know…
You can do your GP training in Aboriginal Health Organisations
h
C
Inspirin
g
g
wardin e R
in Victoria?
ngin e l l g a
Make a difference in Aboriginal Health!
If you have ever considered working in Aboriginal Health, you don’t need to go to remote Australia to do it - there are accredited training posts available in Victoria.
Rewarding Challenging Inspiring Important
Aboriginal and Torres Strait Islander Australians have a much higher prevalence of preventable chronic diseases and die years younger than non-Aboriginal Australians. As a GP training in the Aboriginal Community Controlled Health sector, you will gain extensive clinical experience and have the opportunity to make a difference to the health outcomes of an important population! • Practice in an unique health care setting: By training in an Aboriginal Community Controlled Health Service (ACCHS) you will work in a comprehensive primary health care setting, as part of a supportive, multidisciplinary team. • Train under inspirational GP Supervisors: who are RACGP and ACRRM fellows with years of experience.
Are you interested in making a real difference in Aboriginal Health?
Contact the GP Education and Training Officer
(03) 9411 9411 www.vaccho.org.au 14
• Enjoy work / life balance: Enjoy the flexibility of a family friendly workplace with 9-5 hours, leave for conferences, study and personal life. No more shift work! • Complex medicine: You will gain extensive exposure to a wide range of clinical presentations including chronic disease management, preventative health care, health promotion and public health.
Victorian Aboriginal Community Controlled Health Organisation
M y career
Is general practice for you?
Are you considering specialising in general practice? You are? Then you will need to know all about the Australian General Practice Training (AGPT) program. The AGPT program is managed by General Practice Education and Training (GPET) Limited, who manage the AGPT program and the Prevocational General Practice Placements Program (PGPPP) on behalf of the Australian Government. GPET has a Board made up predominantly of GPs.
Taking a fresh look at general practice 15
GPET was created to establish a regionalised approach to general practice training, which is now delivered by 17 regional training providers (RTPs) across Australia. The AGPT program involves a three-year or four-year full time or part time equivalent commitment by registrars. Training is conducted within accredited medical facilities by accredited supervisors and assessed by experienced medical educators. The training includes self-directed learning, regular face-to-face educational activities and in-practice education. During training, registrars gain valuable practical experience in accredited teaching hospitals, rural and urban practices and specialised medical centres. Training is based on the curricula prescribed in the specialty of general practice by the Australian College of Rural and Remote Medicine (ACRRM) and The Royal Australian College of General Practitioners (RACGP). These curricula are documented extensively by each organisation and details are available on their respective websites.
The most flexible and transferable specialty! If you decide to take up a career in general practice you will be joining one of the most flexible and transferable specialties in medicine. Registrars undertaking general practice training through the AGPT program do so in either the general or rural pathway. These pathways determine the area where you train, not the content of your general practice training. Most RTPs offering both rural and general pathways have little or no difference in the training given to either group. The only significant difference is that the rural pathway puts some restrictions on where its registrars can be placed during their training. The allocated pathway places are used by the Australian Government to ensure that at least 50% of general practice training places across the country are located in rural areas. That said, a registrar’s training pathway has no implications on where they can later practise as a GP.
The AGPT landscape Australian Government
General Practice Education and Training Ltd
Australian General Practice Training
Prevocational General Practice Placements Program
Australian General Practice Training program
Training providers
Hospital/practices
Vocational training
Fellowship of the Australian College of Rural and Remote Medicine
Quality general practice experience
More information? 16
Fellowship of The Royal Australian College of General Practitioners
Specialist recognition
• Australian General Practice Training: agpt.com.au • Australian College of Rural and Remote Medicine: acrrm.org.au •The Royal Australian College of General Practitioners: racgp.org.au
Taking a fresh look at general practice 17
Connect with your GP Ambassador State
Hospital
Ambassador
QLD
Cairns Hospital
Linda Maluish
cairnsgp@gpra.org.au
Gold Coast Hospital
Vacant
goldcoastgp@gpra.org.au
Logan Hospital
Vacant
logangp@gpra.org.au
Mackay Base Hospital
Stephanie Davis
mackaygp@gpra.org.au
Nambour Hospital
Michael Cross-Pitcher
nambourgp@gpra.org.au
Princess Alexandra Hospital
Vacant
princessalexandragp@gpra.org.au
Redcliffe Hospital
Vacant
redcliffegp@gpra.org.au
Rockhampton Hospital
Rupert Savariar
rockhamptongp@gpra.org.au
Royal Brisbane & Women's Hospital
Vacant
royalbrisbanegp@gpra.org.au
Toowoomba Hospital
Vacant
toowoombagp@gpra.org.au
Townsville Hospital
Helen Frazer
townsvillegp@gpra.org.au
SA & NT
Flinders Medical Centre
Jacob MacKenzie
flindersgp@gpra.org.au
Lyell McEwin Hospital
Sara Le
lyellmcewingp@gpra.org.au
Modbury Hospital
Vacant
modburygp@gpra.org.au
Royal Adelaide Hospital
Adelaide Boylan
royaladelaidegp@gpra.org.au
The Queen Elizabeth Hospital
Kerry Summerscales
queenelizabethgp@gpra.org.au
Royal Darwin Hospital
Jasmine Banner
darwingp@gpra.org.au
TAS
Royal Hobart Hospital
Abby Gleeson
royalhobartgp@gpra.org.au
Launceston Hospital
Julia Lachowicz
launcestongp@gpra.org.au
VIC
Geelong Hospital
Ineke Woodhill
geelonggp@gpra.org.au
Austin Hospital
Vacant
austingp@gpra.org.au
Western Health
Vacant
westerngp@gpra.org.au
Eastern Health
Janie Maxwell
boxhillgp@gpra.org.au
St Vincent's Hospital
Vacant
stvincentsgp@gpra.org.au
Shepparton Hospital
Vacant
sheppartongp@gpra.org.au
Ballarat Hospital
Darren McCorry
ballaratgp@gpra.org.au
Peninsula Health
Michael Toolis
peninsulagp@gpra.org.au
Southern Health
Vacant
southernhealthgp@gpra.org.au
NSW
Royal Prince Alfred Hospital
Lester Pepinco
royalprincealfredgp@gpra.org.au
Royal North Shore Hospital
Vacant
royalnorthshoregp@gpra.org.au
Westmead Hospital
Vacant
westmeadgp@gpra.org.au
Tamworth Hospital
Vacant
tamworthgp@gpra.org.au
Campbelltown Hospital
Vacant
bankstowngp@gpra.org.au
Wollongong Hospital
Pavan Phanindra
wollongonggp@gpra.org.au
Hornsby/Mona Vale/Manly
Marianne Moore
hornsbygp@gpra.org.au
John Hunter Hospital
Vacant
johnhuntergp@gpra.org.au
St George Hospital
Vacant
stgeorgegp@gpra.org.au
Canberra Hospital
Vacant
canberragp@gpra.org.au
WA
Royal Perth Hospital
Jemma Smith
royalperthgp@gpra.org.au
Sir Charles Gairdner Hospital
Vacant
charlesgairdnergp@gpra.org.au
Fremantle Hospital
Kate Reid-Milligan
fremantlegp@gpra.org.au
Joondalup Health Campus
Vacant
joondalupgp@gpra.org.au
Want to get involved? 18
Going Places Ambassadors are junior doctors who have a real passion and enthusiasm for general practice. We currently have vacant positions around Australia. To find out more about becoming a GP Ambassador, email goingplaces@gpra.org.au
Going Places Network update Over 2400 junior doctors are going places Not wanting to miss out, junior doctors across the country have been signing up to the Going Places Network in droves. With over 1300 new members signing up already this year, membership is rapidly growing and currently stands at over 2400 members. Not yet a member? What are you waiting for? Join today and find out more about careers in general practice through events, publications and heaps of other free resources.
Going Places events Going Places events have been running all over the country. Highlights include several networking dinners, GP information evenings, ‘Spring in the Hills’ winery tour and a ‘GP by the Sea’ event in Wollongong. More events are planned throughout the country for 2013. Events will be promoted at your hospital, but you can also keep an eye on the Going Places Network website at gpaustralia.org.au/events
GP Australia website – top GP careers information source With well over 2000 unique visitors a month, the Going Places Network website gpaustralia.org.au continues to be a popular one-stop shop for junior doctors seeking information on careers in general practice. The website is full of essential information and resources, including a nifty GP earnings calculator, information on the Australian General Practice Training program (AGPT), how to apply, blogs, videos and much more. Visit gpaustralia.org.au
Check out the latest Going Places news, events and resources. Handy publications Going Places Prevocational doctors guide to GP training. Jam-packed with all the essential information on general practice training, this is the essential go-to handbook for any junior doctor considering a career in general practice.
13 Going Pla20ce s Prevocational doctors
guide to GP training
See your GP Ambassador to get your copy. General Practice Registrars Australia (GPRA) Level 4, 517 Flinders Lane, Melbourne Victoria 3001 Phone: 03 9629 8878
Taking a fresh look at general practice
The future of general practice
GPCompanion This clinical pocket reference book contains a goldmine of facts and figures on essential treatment for a range of medical conditions, preventive medicine and clinical reasoning — very handy for those on a PGPPP rotation. Get your copy at a Going Places event or download the e-book version at www.gpaustralia.org.au/content/publications
Check out our website gpaustralia.org.au for all the resources and essential information.
Make the most of your PGPPP rotation gpaustralia.org.au Taking a fresh look at general practice 19
Refugee health
What can we do to make a difference?
Many of you may have watched the hugely popular SBS television series ‘Go Back To Where You Came From’. For many viewers, like myself, it gave a new perspective on the precarious journeys refugees undertake to arrive on Australian shores. The show’s portrayal of how these refugees attempted to flee (successfully or unsuccessfully) a life of violence, torture and poverty was gut-wrenching and yet, at the same time, thought provoking. What can we, as health professionals, do to look after the health and wellbeing of refugees in our community? In recent years, refugee health has gained increasing attention in Australia. The United Nations High Commissioner for Refugees (UNHCR) defines a refugee as a person who ‘owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality, and is unable to, or owing to such fear, is unwilling to avail himself of the protection of that country’.1
Refugees were first given legal status as a group when large numbers of European people were displaced during World War II.2 Since then, Australia has accepted more than 750,000 refugees and humanitarian entrants.3 In recent years, refugees have mainly arrived from Afghanistan, Iraq, Sudan, Democratic Republic of Congo, Somalia and Sri Lanka.4 These refugees have resettled in all Australian states and territories. For the past five years, New South Wales and Victoria have consistently absorbed more than half of the annual total refugee intake.4
Why is refugee health so important? Australia needs more GPs to be at the interface between the Australian health care system and the refugees who need to utilise it. One such person is Victorian GP, Dr I-Hao Cheng, who is an expert on refugee health. Dr Cheng is the Refugee Health Program Manager at the South Eastern Melbourne Medicare Local. He also works as a GP at Hill Medical Services in Noble Park, whose patients consist of a relatively large number of former and new refugees.
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“The health of refugees in Australia is important because of the increasing number of refugees settling in Australia. The annual national intake has recently increased from 13,750 to over 20,000 a year,” says Dr Cheng. A major study conducted by the Department of Immigration and Multicultural Affairs has shown that refugees in Australia have a higher rate of long-term medical and psychological co-morbidities than other migrants. Additionally, they also report a poorer state of wellbeing and have complex health issues.5 A different approach is needed when dealing with refugee health issues, as they often present with health problems that are considered less common among the general Australian population. Last year, Dr Cheng and his colleagues published a paper about the primary health care needs of refugees.6 The paper reported common health problems more prevalent among refugee populations, including: malnutrition and nutritional deficiencies (eg. vitamin A, vitamin D, iron and folate deficiencies), infectious diseases (eg. schisotomiasis, intestinal parasites, tuberculosis, syphilis, hepatitis A, B and C, malaria), and mental health conditions (eg. post-traumatic stress disorder, depression). Children may have growth and developmental problems and incomplete immunisation. Women may have complications related to poor pregnancy outcomes, female genital circumcision and physical abuse. Poor health among refugees can serve as a significant obstacle to settlement. If health problems are not identified early and managed well, it can lead to a significant medical and financial burden, both to the individual and to the Australian health care system.
It is very important to recognise the barriers that might prevent refugees from accessing health care. These include lack of understanding of the Australian health care system, language difficulties, cultural differences, lack of transportation and financial constraints.5,7 It is imperative that health care providers understand these potential problems in order to provide timely and adequate health care services to the refugee population. The good news is that there is an array of resources readily available to assist GPs with the delivery of health care to refugees. These include community-based migrant resource centres (located nationwide), which can help with re-settlement issues such as accessing health care services, employment and housing. Interpreting services are available throughout Australia via the Translating and Interpreting Service (TIS) National, which operates 24 hours a day, seven days a week. This service is free to all GPs. GPs can also undergo professional training in refugee health with organisations such as the New South Wales Refugee Health Service, Victorian Foundation for Survivors of Torture and The Centre for Ethnicity and Health.
Where do I start? If you are new to the area of refugee health and would like to get involved, a good place to start is by reading the excellent handbook, Promoting Refugee Health: A guide for doctors, nurses and other health care providers caring for people of refugee backgrounds.8 It contains a comprehensive list of resources that you can connect with in every Australian state and territory.
Conclusion Despite the ongoing media spotlight on the complex political issues surrounding refugees and asylum seekers in Australia, the health care needs of this underserved and vulnerable group often go unnoticed. There is a need to raise awareness among the medical profession – including junior doctors – regarding refugee health issues and to develop a response that is both caring and compassionate. As Dr Cheng puts it, “Remember their humanity. Care for their concerns, and work through and beyond the biomedical model to address them.” Written by Dr Chia Pang
Chia Pang is a hospital registrar with the Bogong Regional Training Network and a GP ambassador at Southern Health. He is also the medical editor of Going Places magazine. Chia is currently halfway through a Master of Public Health at Monash University.
The GP registrar’s experience Junior doctors can also get in on the act, as demonstrated by Dr Andriy Boyko. Andriy is a GP registrar who works at the same clinic as Dr Cheng. In November to January last year, he worked at the Christmas Island Detention Centre providing primary health care to refugees. Along with several other GPs, his role was to carry out triaging, health assessments and screening. He signed up for the job through an organisation called ‘International SOS’. “I wanted to do something unique and interesting,” says Andriy, who has previously worked as an ED registrar. “You get to see the issues first-hand and start to understand different points of view about the debate around refugee and asylum seekers. You realise how complex these issues are.” Andriy worked primarily with new arrivals and was tasked with systematically going through the medical history and physical examination as part of an initial health assessment and screening process. “Many of these patients have not experienced adequate health care in the past, so there are a lot of health issues that are unidentified. They have not heard of diseases like high cholesterol and hypertension. Let’s be honest, your cholesterol is not an issue when your house is being bombed.” On what has the experience taught him, Andriy says, “When you work in an area where you have limited resources, you learn to really rely on your clinical skills. You can’t simply send them off for a CT scan. You become much better at your clinical skills and become more confident. You become a better doctor for it.” Photos courtesy of Andriy Boyko
References 1. Refugees. Geneva: United Nations High Commissioner for Refugees, 2012. Available at www.unhcr.org/pages/49c3646c125.html [Accessed November 2012]. 2. History of UNHCR. Geneva: United Nations High Commissioner for Refugees, 2012. Available at www.unhcr.org/pages/49c3646cbc.html [Accessed November 2012]. 3. Refugee and Humanitarian Issues: Australia’s Response. Canberra: Department of Immigration and Citizenship, 2011. Available at www.immi.gov.au/media/publications/ refugee/ref-hum-issues/ref-hum-issues-june11.htm [Accessed November 2012]. 4. Statistics on Australia’s current Refugee and Humanitarian Program. Surry Hills, New South Wales: Refugee Council of Australia, 2012. Available at www.refugeecouncil.org. au/r/stat-rhp.php [Accessed November 2012]. 5. Lehn A. Recent immigrant’s health and their utilisation of medical services. Results from the Longitudinal Survey of Immigrants to Australia. Department of Immigration and Multicultural Affairs. Immigration Update 1997;32–38. 6. Cheng I-H, Russell GM, Bailes M, Block A. An evaluation of the primary healthcare needs of refugees in south east metropolitan Melbourne. A report by the Southern Academic Primary Care Research Unit to the Refugee Health Research Consortium. Melbourne: Southern Academic Primary Care Research Unit, 2011. 7. Murray SB, Skull SA. Hurdles to health: immigrant and refugee health care in Australia. Australian Health Review 2005;29:25–9. 8. Promoting Refugee Health: A guide for doctors, nurses and other health care providers caring for people from refugee backgrounds (3rd edn). Melbourne: Foundation House, 2012. Available at www.foundationhouse.org.au/LiteratureRetrieve.aspx?ID=104997 [Accessed November 2012].
Taking a fresh look at general practice 21
At Healthscope, our Medical Centres are focused on the career development and education of our Practitioners. We offer young doctors the opportunity to work in modern facilities with access to high quality equipment and resources across various locations in Australia. We also provide ongoing national training and education opportunities, with a major focus on Chronic Disease Management in primary care, and encourage young doctors to pursue areas of special interest to foster their growth. With flexible hours and employment packages on offer, our centres provide a supportive administrative environment for young doctors looking to enhance their professional development.
GP in the news Free edition
Going Places – taking a fresh look at general practice
GPs cramming more into consultations
If the working day feels busier, that’s because it probably is, with a long-running study showing GPs are cramming more and more into a 15-minute consultation. There has been no increase in the average consultation times since 2002–03. However, over that period, the number of issues patients seek help with at each appointment and the number of procedures and tests carried out during consultations have steadily crept up. The information is the latest from the BEACH program, a University of Sydney project, which has collected data on activity in general practice since 1998. Project leaderAssociate Professor Helena Britt, from Sydney Medical School, said the results also showed patients were visiting their GP more frequently. “That’s probably also a reflection that we’ve got continuing earlier diagnosis of chronic conditions.” “The growing involvement of practice nurses was one reason GPs were managing to fit more into each appointment,” she suggested. Source: Australian Doctor australiandoctor.com.au
Taking a fresh look at general practice
Issue 10 – 2013
GPs the linchpin for mental health reform GPs and primary care should be
at the centre of any government
support program for people with a mental illness, according to the nation’s first report of its kind into mental health. As part of its recommendations, the report stated, ‘priority should be given to the financing of multi-disciplinary primary care (through GPs and other primary health care organisations)’. The report has also recommended mental illness be given the status
of a chronic disease, revealing that life expectancy of the mentally ill is cut by 25 years due to the increased likelihood of heart-related conditions, diabetes and obesity. People with a psychotic illness reported diabetes rates over three times more than the general population, and one-third carried risk of a cardiovascular event within five years. The report also revealed that only 35 per cent of the 3.2 million
GPs see specialists as poor communicators
GPs think specialists are poor communicators who rarely provide timely information about patients and often alter medications without notice. In a survey of 500 Australian GPs, just 13% said specialists made information about patients available when it was needed. Less than a third agreed they were always advised of changes that specialists made to their
*Articles have been shortened from their original form
patients’ medications or care plans, and 32% said they always received a report from specialists with ‘all relevant health information’. The Australian GPs were surveyed as part of a study published in Health Affairs that compared the health systems of 10 countries. Source: Australian Doctor australiandoctor.com.au
people who reported they had a mental health difficulty in the previous 12 months used mental health services. Source: Medical Observer medicalobserver.com.au
Doctors unite in call for GP training resources
A coalition of health groups has called for a suite of government measures to help general practice accommodate the coming wave of medical students, interns and registrars.
Extended infrastructure grants to general practices, a doubling in the value of the Practice Incentive Payment for teaching, and redirecting remaining funds from the controversial GP Superclinics program into existing practices topped the list of proposals from United General Practice Australia (UGPA), said spokesman Steve Hambleton, president of the Australian Medical Association (AMA). The $117 million infrastructure grants program, which in 2010 and 2011 enabled 425 practices to extend their premises, provided exceptionally good value for money and should be renewed, said Dr Hambleton, representing the coalition of the AMA, The Royal Australian College of General Practitioners, the College of Rural and Remote Medicine and the Rural Doctors Association of Australia. Source: 6minutes.com.au
Taking Takingaafresh freshlook lookatatgeneral generalpractice practice 23 23
MIPS - there is a choice Join MIPS to access a range of membership benefits. At MIPS we offer you a range of membership categories to choose from to match your professional practice. Membership benefits include MIPS Members’ Medical Indemnity Insurance Policy, MIPS Protections for non medical indemnity matters, medico-legal and dentolegal advice, Group Personal Accident cover, risk management education sessions, special member benefit offers, e-publications and more! Apply online at www.mips.com.au Medical Indemnity Protection Society Ltd po box 25 carlton south vic 3053 | info@mips.com.au | www.mips.com.au member services | p. 1800 061 113 | f. 1800 061 116 | abn 64 007 067 281
Medical Indemnity Protection Society Ltd (MIPS) is an Australian Financial Services Licensee (AFS Lic. 301912). MIPS Insurance Pty Ltd (MIPS Insurance) is a wholly owned subsidiary of MIPS and holds an authority issued by APRA to conduct general insurance business and is an Australian Financial Services Licensee (AFS Lic. 247301). Any financial product advice is of a general nature and not personal or specific.
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It takes Dr Nichola Davis is a Cairns-based GP, medico legal advisor for Medical Indemnity Protection Society (MIPS) and a senior lecturer at James Cook University School of Medicine and Dentistry based at the Cairns Clinical School in Far North Queensland. She is also the Year 4 Cairns JCU MBBS Academic Coordinator. Alison Ryan-Hewson is the Year 4 Administrative Coordinator at the school.
Nichola:
I qualified as a Member of the RCGP in 1990 and left the UK for Australia shortly after in 1991. Initially in the UK I pursued a career in obstetrics and gynecology, but I liked the variety of general practice as well as the flexibility. A background in general practice is a steppingstone to an enormously varied and flexible career, with the option to change paths or diversify in many different ways. For me, that has meant medico legal work, teaching and lecturing in risk management. Work-life balance can be difficult to achieve, but I am lucky that much of my work is flexible, and as my teenagers constantly nag me to keep up with technology, I have a rudimentary knowledge of the essential gadgets that help me stay in touch, even on the run. As a single parent, my children are my first priority and then I work around the work priorities that are most important at the time. Through being a GP, my patients have unwittingly educated me in many life skills. The privilege of sharing in other people’s joys and adversities brings with it a unique perspective and I hope some wisdom about life. I have watched and learnt from my patients how to handle (and how not to handle!) many things that life throws at you, such as sickness, grief and adolescent children! Through my MIPS work, I enjoy helping and guiding colleagues who are experiencing stress and worry over a complaint, adverse outcome or legal claim. At JCU I immensely enjoy interacting with the bright young doctors of tomorrow who are so enthusiastic and smart. I recall the first time I met Alison — as I invited her into the interview room — she had an amazing genuine and beautiful smile. If I had to choose five words to describe Alison, I would say she is resilient, dedicated, reliable, honest and interesting. Alison has to liaise with a cast of hundreds, which includes nurses, doctors, nursing homes and private hospitals. Most involved are very busy people and Alison is respectful and accommodating, but she still persuades them to do pretty much exactly what she wants … a true gift! Alison also has a great sense of humour. She does a very interesting impersonation of me in a panic when I thought I had mislaid the Year 4 end of year exam paper! We share the same core values but we have very different approaches. Alison is completely no nonsense on the surface but very compassionate underneath. Through her approach, Alison is an indispensible source of advice and a sounding board for ideas. I think that we have reached the stage where we can speak our mind and discuss things openly, and even agree to disagree at times!
My advice for junior doctors wanting to be a GP is … do it! But make the job your own. Pursue unashamedly any areas of interest that you have and where possible do something other than pure clinical work. The latter provides diversity and is often a little less stressful (or it is stressful in a different way!). In 5 – 10 years time I hope to be healthy and happy, and working a little less. I would love to find time to get seriously involved in research, but I wouldn’t want to give up anything else that I do at the moment!
Alison:
I have been the Cairns Clinical School JCU Year 4 MBBS Administration Coordinator for two years and have known Nichola for all this time. I coordinate everything for the Cairns-based Year 4 JCU medical students, planning their timetables, scheduling their lectures, coordinating their assessments, as well as providing administrative support to the academic staff and lecturing doctors at the Cairns Clinical School. Juggling many different timetables into an already busy schedule can be a challenge, but I’m quite methodical so when it gets really busy I’m a list person — basically its just head down and work through it. A laugh every now and then also helps! If I had to choose five words to describe Nichola, I would say she is passionate, dedicated, humorous, energetic and straightforward.
Nichola is caring and always available to listen and offer honest advice. She has a calming influence and is level headed, but most of all she has a great sense of humour, which is great for those stressful exam times at JCU! Nichola’s great efficiency and flair has contributed significantly to the successful structure of the Cairns JCU Year 4 program. She has an excellent reputation as a GP and her teaching sessions demonstrate a very broad and up-to-date knowledge of medical practice. I am constantly inspired by her enthusiasm, her knowledge and her commitment. I love seeing students progress through the years and observing how they develop into doctors of the future, although it can be frustrating sometimes when students don’t value their opportunities. In 5 – 10 years time, I think I would like to be studying. I’m inspired being around students every day! Do you know a future ‘It takes 2’ couple? A GP and their patient? A practice manager and a registrar? Your mentor? A GP that inspired you? Let the Going Places team know by emailing goingplaces@gpra.org.au
Taking a fresh look at general practice 25
G P profile
The write balance
Dr Kath O’Connor has always had a literary bent. As a rural GP and Medical Editor with Australian Family Physician (AFP), her portfolio career brings together her interests in words and healing — with time for yoga, meditation and a healthy work-life balance. At school, young Kath O’Connor was the girl who always had her nose buried in a book, who swooned over poets rather than pop stars, and who wanted to be a writer. “But when I finished school I wasn’t ready to write; I didn’t really have any life experience,” Kath reflects. “I got good marks and I thought if you become a doctor you learn all about people. Pretty naive in hindsight, but luckily the learning and practice of medicine were a good fit too.” She became Dr Kath O’Connor — GP, writer and editor. Two days a week, Kath works as a medical editor at AFP, the peer-reviewed medical journal of The Royal Australian College of General Practitioners. Two days a week, she works as a rural GP in Castlemaine, Victoria. It’s a four-day working week that gives Kath time for the other touchstones in her life — yoga and meditation, writing fiction, walking her dogs, digging in her garden, and discovering her inner countrywoman as a former city type from Melbourne. Her latest project, a chook shed hammered with her own hands, was coming along nicely when Going Places magazine spoke to her. So how did Kath find herself in the medical editor’s chair at AFP? It’s often said that the door to opportunity is labelled ‘push’.
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Back when she was a GP registrar, she approached AFP and asked if there was any writing or editing work available. There wasn’t. But, thanks to Kath’s initiative and the receptiveness of the management team, GPET funding was secured and the AFP Publications Fellow position was created. Kath became the first registrar in the role and she has continued to work as one of AFP’s three medical editors. The work at AFP involves reviewing papers submitted to the journal and deciding which ones are to be accepted. Those that pass the first round of scrutiny are sent out for peer review and sometimes back to their writers for revisions. Kath is also responsible for commissioning articles on topics to fit AFP’s monthly themes, as well as tweaking text. “Articles have to be accurate, evidence-based and important for practising GPs, but also readable,” she explains. “My favourite challenge of the medical editing job is taking complex information and shaping it so it’s really easy to read for busy GPs.” Kath has also penned some thoughtful editorial pieces for AFP. She muses on how to deal with the patient whose suffering is beyond the help of modern medicine, with quotations on mortality from the Irish poet W.B. Yeats; she contemplates what the Melbourne International Comedy Festival says about society’s alcohol ills; and she ponders the role of Eastern philosophies in Western medicine. Yoga and meditation are constants in Kath’s life. She explains that the word yoga means union — a balance of body, mind and spirit, or the different layers of self. “I do yoga classes several times a week and have a meditation practice that I try to keep. Life makes more sense when I’m meditating regularly,” she says.
Above: the delightful town of Castlemaine in central Victoria Drawn to the interface between medical and social issues, Kath began a pro bono position in an asylum seeker clinic in Footscray. It would ultimately change the course of her career — and life. “I had one patient from Sri Lanka. He had symptoms of reflux and dyspepsia that were not relieved by anti-acid medications. Tragically, it turned out to be stomach cancer and the patent died six months later. I looked after him and I guess that experience gave me the interest in the continuity of care you get in general practice,” Kath says. Some years later, having completed her general practice training, Kath experienced another turning point when she decided to visit friends in Castlemaine for the weekend. She fell in love with the place and made enquiries at a local GP clinic. “When can you start?” they said.
“My favourite challenge of the medical editing job is taking complex information and shaping it so it’s really easy to read for busy GPs.” Kath is planning a trip to Chennai in India to further explore the role of yoga in her life and how yoga as therapy might inform the way she works with patients. Kath describes her pathway to general practice as “taking the scenic route”. She began emergency physician training, but she had lingering doubts and dropped out. She took a part-time job as a hospital medical officer in a small emergency department at a hospital in Melbourne’s outer suburbs. This gave her the freedom to study courses in writing and editing on her days off.
“I never had any designs on being a rural doctor,” she says. But she has found contentment in the work and the lifestyle. It allows her to achieve the work-life balance she espouses for herself and her patients. “It’s cappuccino rural,” she says of the picturesque old gold rush town, where even coffee snobs can be assured of finding a decent brew. “I’ve been able to buy an old house with a garden and I’m loving all the physical work. “Castlemaine is a very diverse, artistic and vibrant community. It’s focused on sustainability and there are gardening groups.” There is also a local writers’ group that Kath attends and she is looking forward to putting aside a day a week to work on personal writing projects. After years of listening to her patients’ stories, she feels ready to tell some more of her own. Written by Jan Walker
There are many opportunities to blend writing and editing with a GP career. A good starting point for GP registrars is the Publications Fellow position at AFP as part of an academic term. When you begin general practice training, talk to your regional training provider or contact afp@racgp.org.au
You can read Dr Kath O’Connor’s editorial articles by going to racgp.org.au/afp and searching ‘Kath O’Connor’.
Taking a fresh look at general practice 27
G P profile profile
“The most fantastic thing that happened to me in this co Wanting to follow in his father’s footsteps and make something out of nothing, Dr Ayman Shenouda left his homeland Egypt to make a name for himself in Australia. Armed with a desire to heal and his Coptic Christian faith, Ayman found his voice and a wonderful new world through general practice.
Leap of faith
ountry was to acknowledge that I loved general practice.” As a boy growing up in the bustling city of Cairo, Dr Ayman Shenouda was aware of the impressive shadow that his famous father cast. His father, Moussa Sabry, was a novelist and journalist, best known for writing the speech of former Egyptian president Anwar El Sadat addressing the Knesset (the legislative branch of the Israeli government) during the 1979 EgyptIsrael Peace Treaty. His father had worked hard to build his success and this was something that Ayman wanted to emulate. “My dad was so popular and I felt everything I did people would relate it to my dad,” Ayman told Going Places magazine. “But he started from nothing really and I just wanted to do the same ... I wanted to start afresh.” Ayman also knew that whatever he built, ideally it would complement his Coptic faith, which is the largest Christian group in Egypt. With encouragement from his mother, who was the principal at his primary school, he decided to study medicine. “My mother always wanted me to be a doctor and this supported my Christian values of helping people,” Ayman says. He completed his medical degree at Cairo University where he met his wife, Dr Sammi Azab, who is also a GP. “In Egypt, medicine is a seven year course,” Ayman explains. “We say that if you’re not married by the end of it, you’ll never be married!” For Ayman, the best way to really start afresh was to leave Egypt. Attracted to democratic countries, he was considering the USA, but was encouraged by his father’s friend (former UN Secretary Dr Boutros Boutros-Ghali) to try Australia. “My wife at first was very hesitant and a lot of my family thought I was crazy,” Ayman says. “We were very established in Egypt and there wasn’t anything I needed.” Yet, he wanted to leave his comfort zone and find his own voice. “It’s funny because I was actually in the school choir but I wasn’t very good and I was kicked out,” Ayman laughs. “My voice was bad, but I was loud and liked to be heard.” He arrived in Australia in 1991 as a surgical registrar and started his internship at Launceston General Hospital, Tasmania. “My first day in Australia was in Sydney. I thought Sydney was so quiet compared to Cairo. Then going from
Sydney to Tasmania ... it was really quiet,” says Ayman, chuckling as he recalls the difference.
a first-class practice, he researched and visited award-winning practices all over Australia.
“Surgery was appealing because patients would arrive in an acute state and they would be treated and go home happy. But I felt that they didn’t always understand their diagnosis.”
His efforts paid off. Glenrock Country Practice opened in 2005 and two years later won the RACGP Practice of the Year (ACT/NSW). In 2010, it won three of four Australian General Practice Accreditation Limited (APGAL) awards and has now expanded to 23 staff.
After struggling to pass the Australian Medical Council exam for surgery, which Ayman attributed to working too many long hours, Sammi encouraged him to move on and consider specialising in general practice. It would prove to be the best move of his life. He and Sammi took jobs as GPs in the NSW town of Wagga Wagga, which Ayman describes as a “big country town of 60,000 people”. “My first day in general practice was fantastic,” Ayman says. “It was like a dream come true, like I had discovered myself ... general practice is really exciting because you are dealing with a patient and a person.” Ayman is unequivocal about the rewards of general practice in Australia. “The relationship between doctors and patients is unbelievable. They are like part of the family and general practice is embedded into the heart of every Australian.” “Every day you get to help someone,” Ayman says. “There’s not a single day in your practice where a patient doesn’t come through your door and say ‘thank you’.” He recalls one particular patient who he will never forget. “She was about 50 and presented with a headache. I just had a feeling that she wasn’t her normal self and that there was something wrong,” he explains. “I kept trying to convince her to have a head scan. She said that although she respected me, she thought I was being a bit over-the-top.” “I finally convinced her to have a scan. Eight weeks later she came in with a shaved head and a big bunch of flowers and said: ‘Thank you for saving my life’. The scan had revealed an aneurysm and she’d been sent to Sydney straight away to be operated on.” Following encouragement from their patients, Ayman and Sammi decided to start their own practice. This was Ayman’s chance to start something from nothing. “It took about three years to start my own practice,” Ayman says. Determined to create
To top it off, Ayman, who is a Fellow of the RACGP, won the college’s GP of the Year award in 2009.This was one of the “proudest” moments of his life. He’s quick to acknowledge that the wonderful support from his wife Sammi helped him to achieve these awards. At Glenrock, the mantra is simple: patient care is the number one priority, and looking after the doctors and staff members is a close second. There is a big plasma TV for patients and consulting rooms look out onto bright courtyards with water fountains. Good printers and email systems are in place to save doctors time. “We want our patients to feel special,” Ayman says. “We don’t want to remind them of their illness, but to ease them in their journey.” As well as building a practice, Ayman has helped to build the Coptic Christian community. When he arrived in Wagga Wagga, there were just two other Coptic Christians, also doctors. Together, they received permission to establish a church. “There were two former Uniting Churches for sale, one big one and one small,” Ayman says. “We bought the big one!” He was right to be optimistic. There are now 50 families and 150 individual members of the church, including 35 doctors. By chance, the church has helped to addresses the GP shortage in the area by attracting international medical graduates, many of whom are Egyptian Coptic Christians. Looking back on his journey, Ayman has no regrets about the giant leap he took. He only wishes he had discovered general practice sooner. “The most fantastic thing that happened to me in this country was to acknowledge that I loved general practice,” Ayman says. “It’s like when you are looking for something all your life, but don’t know what it is until you find it.” Written by Laura McGeogh
Taking a fresh look at general practice 29
G P I N T E RV I E W
A volunteering life: Dr Working as a volunteer for Médecins sans Frontières for more than seven years has provided Dr Roslyn Brooks with unforgettable experiences. As a GP working in rural practice in Australia and also working for Médecins sans Frontières (MSF) in several different countries over the last seven years, how do you juggle the practical requirements of practising medicine on such a global scale? This is not really a problem for me. I work in a flexible group practice as a locum, not a regular practice member, so can take time away whenever I need to. (I also do short-term locums in Aboriginal communities.) Leaving family is a bigger concern. My husband is like me – pretty independent – but we miss each other. My family is so encouraging. They seem to get a buzz out of what I do with MSF and love hearing the stories. Your first posting for MSF was to Phetchabun in Northern Thailand for six months in 2005–06. There you cared for Hmong refugees who had fled Laos. There were reports that nearly half of those seeking medical care were children. What types of illnesses were the children suffering from and were you able to adequately care for them? To my surprise, and perhaps relief, in my first field placement most of the medical problems I had to deal with were those familiar to me in general practice – coughs and colds, diarrhoea, skin rashes – not the malnutrition, malaria, typhoid fever, tropical ulcers and TB that I was expecting. Of course, there were cases of pneumonia, diarrhoea with dehydration, very sick babies – these are always confronting. In the camp we provided only basic outpatient care and were able to refer the sicker patients, who needed hospital care, to a local Thai hospital. These refugees were settled on the outskirts of a local village. They had adequate food and shelter, and good sanitation (including wonderful open air showers!) set up by the MSF log team. Their general health was mostly pretty good. Your posting to western Nepal in 2007–08 found you in the aftermath of the Nepalese Civil War and caring for displaced people in remote Kalikot. There you provided surveillance for malnutrition and encountered endemic diseases such as cholera. How do you prepare yourself mentally and physically for such perilous environments? Kalikot is geographically remote and rugged. Physical fitness was important in this posting as my role involved some trekking to outlying villages – hours up and down steep rough paths (porters carried our heavy stuff). Even getting to the nearest village from the hospital meant a 2–3 km uphill walk, and the hospital grounds were steep and rough. I worked on my fitness at the gym before leaving, and found myself able to do the treks without difficulty. I heard other international staff had not done too well. One Filipino nurse who was quite obese had only lasted a week; another international doctor of around my age (57 years then) had developed a severe exacerbation of his hypertension and had to be evacuated. However, the violence had resolved and the setting was peaceful and safe.
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I was anxious about my lack of familiarity with epidemic diseases like cholera, and tried to read as much as I could. MSF has good basic protocols for diagnosis and management of the medical problems commonly encountered in the countries where they work, and it is reassuring to be able to refer to these. When you are assigned to a post, MSF provides a lot of information about the project and the local context. Excitement and anticipation usually balance out the anxiety! MSF is a non-aligned organisation that works with victims regardless of their creed or political affiliation. Have you ever found it challenging to maintain your independence? How do you insulate yourself from the political machinations of the zone you are working in? Caring for any patient according to their need (independent of their race, religion, politics etc.) is simply a given in medical ethics. This is the fundamental patient-doctor relationship. Of course, it is always most satisfying to help those who have the greatest need and the least hope. In general, MSF is involved with the most vulnerable, and this makes the work particularly rewarding. As a representative of MSF we do not publically ‘take sides’ in local conflicts. Although, one of our priorities is témoignage – to witness – to speak out against violations of human rights in the contexts where MSF works, and exert pressure on local authorities and others to counteract injustice. When medical care is not enough, the organisation will exercise this ability to speak out.
Roslyn Brooks Most people who work with MSF are compelled by a sense of social justice, and are angry when they see abuses of power against the weak and marginalised – whether by local authorities or international powers. In private, among the international team, and often with national staff too, there are vigorous discussions about rights and wrongs in the political context. In 2009 you worked in northern Sri Lanka just outside Manik Farm, which was a series of camps for Tamil people displaced by the 25-year civil war. Reports coming out at the time described the conditions as horrendous for the 300,000 or so people living in the camps. What keeps you going day after day when the conditions are so tough for your patients? We worked in an MSF hospital outside the camps (a referral hospital mostly for surgical and orthopaedic treatment of war injuries). I did not see conditions in the camps, but do not think they were ‘horrendous’ in general. There was certainly some crowding and problems with sanitation (eg. not enough toilets), but generally people had adequate food, water and shelter. The Sri Lankan government provided medical clinics in the camps for primary care. Stories of the violence and abuse people had suffered during the conflict, and evidence of severe mutilating war injuries were very confronting. We saw many young people and children with lifelong maiming and disability – chronic suppurating bone infections, loss
of a limb, paraplegia and hideous facial injuries. These were often compounded by the psychological trauma of having witnessed the violent death of close family members. Medicine does familiarise you with suffering as an inevitable part of the human lot (albeit so unfairly shared out around the globe), and you just get on and do what you can to alleviate it in your own small area of work. It is necessary to have realistic expectations of yourself and of the project you are working in, as you are only ever tackling a tiny fraction of the global burden of illness, poverty and injustice. I have repeatedly been astonished and touched by the courage and resilience of people under great hardship. Ironically, patients and local MSF staff have often been the ones to comfort me and sympathised that I am far from home and family, and shared my frustration at the limited help we could provide. Your last trip for MSF was to southern Malawi where nearly one in seven people is HIV positive and where health care is in short demand. In what ways can countries, such as Australia, do more to help? Obviously, financial aid is fundamental. Prevention is the key including public education about STIs in general, as well as HIV and reducing the stigma associated with being HIV positive. People must be encouraged to seek screening by having effective anti-retroviral treatment available, and programs to screen pregnant women and prevent mother-to-child transmission. Effective women’s health and family planning programs are also necessary. So is education and empowerment of women. Australia can contribute expert advice and education with its outstanding public health record in tackling the HIV epidemic. The best aid programs support the local and national authorities, government and non-government, in tackling health problems such as HIV. In terms of financial assistance, Australia can support NGOs, such as MSF, which run HIV projects. These organisations work with the Malawi government to deliver education, prevention and treatment programs with the ultimate aim of leaving the country’s Ministry of Health able to manage independently. Written by Sharon Lapkin This article first appeared in the June 2012 issue of Good Practice, the news magazine of The Royal Australian College of General Practitioners and is reprinted here with permission. Sharon Lapkin is a writer and editor with Good Practice magazine. Photos © Médecins sans Frontières and Roslyn Brooks
Taking a fresh look at general practice 31
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Clinical Corner case studies and tips for treating patients are provided courtesy of Medical Observer. The following case studies are by Dr Ian McColl.
Finger injury fails to heal
Always check behind the ears when performing a skin cancer check, especially in males. This lesion was biopsied Beware of bleeding scaly areas on fingers. This area had been growing for a couple by the patient’s GP but it only showed scarring, however, nothing had been done to it in the past. of years. It was thought to have been due to an injury sustained in the garden that The central area does look scarred, but there is a raised had failed to heal. area around the periphery of the lesion and this is where the punch biopsy should have been taken from. This is an infiltrating and sclerosing BCC. There are only strands of BCC between a thick collagen stroma and these strands can be missed with a small punch biopsy. It is best to take several punch biopsies in cases where this diagnosis is suspected or an elliptical incisional biopsy across the edge. It will need wide excision and skin grafting to close the defect. For histology images, see www.skinconsult.com.au
A side effect of stronger steroids It was in fact a squamous cell carcinoma (SCC) in situ (ie. confined to the epidermis). Excision of this lesion would require a skin graft to close the defect. Other options include curette and cautery destruction, which is what was done in this case, photodynamic therapy, 5-fluorouracil cream twice daily for six weeks or imiquimod cream for six weeks.
Peri-oral rosacea commonly presents as red papules and pustules around the mouth with a thin area of sparing around the vermilion border. This same process can occur around the eyelid margins if a patient has been using a fluorinated steroid cream for a month or so.
The latter is an off-label use at present in Australia, but it works well. Solar keratoses on the dorsa of the hands are common but look out for SCC in situ in the web spaces. For surgical images, see www.skinconsult.com.au
What’s hiding behind this ear?
The patient may start with seborrhoeic dermatitis or blepharitis, but using any steroid other than 1% hydrocortisone can cause this condition to occur. There is overgrowth of the demodex mite in the pustules. Treatment involves stopping the stronger steroid, using oral doxycycline for one month and applying 2% sulfur in sorbolene cream carefully to the area. MEDICAL
For dermatology images see, www.skinconsult.com.au
Taking a fresh look at general practice 33
What’s your diagnosis? Kathy had not long returned from Bali when first seen in the ED. Kathy stated that she had been both ocean and pool swimming while in Bali and was concerned that she had contracted some sort of bacterial infection that had ‘led to her troubles’ with her vulva. Initially Kathy was seen by a colleague of mine in the ED. She was investigated for the possibility of a sexually transmissible infection (STI) and commenced on oral antibiotics (with the impression that marine-borne bacterium were the cause of the ulcers). Kathy went on her way with 500 mg of ciprofloxacin to be taken twice daily. She was asked to return to the ED in five days to assess any improvement. However, Kathy returned to the ED two days later, accompanied by her rather intimidating, expressive husband who had by this time viewed Kathy’s vulval ulcers himself! This viewing, coupled with the
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Dr Sarah McEwan explores the case of a 50-year-old woman, a type 2 diabetic, who presented with a seven-day history of painful vulval ulcers.
fact that Kathy had advised him that a full STI screen had been arranged to ensure this was not the cause of her problem, led to the couple having many unanswered questions and being quite suspicious of each other. Both parties were adamant that neither had been involved in extramarital affairs and, as could be imagined, were more than keen to find out the results of the tests taken so far. To everyone’s relief the STI screen returned negative. This screen included chlamydia, gonorrhoea, syphilis, HIV, and hepatitis B and C. Baseline blood tests (including FBC, UEC, LFT and CRP) micro and viral culture swabs were also taken during the first review and they too, returned normal. Kathy however, had not shown any sign of improvement with the ciprofloxacin and her vulval ulcers appeared to be worsening. At this stage it was important to see if it was possible to get a tissue diagnosis of the cause of the ulcers, so punch biopsies were taken for histology and direct immunofluorescence.
Unfortunately Kathy again returned home without a firm diagnosis and was advised to continue with the oral antibiotics and prednisone, which was added to her treatment regimen at 50 mg/day for the next five days. A follow up appointment was arranged for five days time to review her progress and to provide investigation results.
The medical student, through thorough history taking, was able to uncover that Kathy had suffered from mouth ulcers and soft palate ulcers during her holiday in Bali, before presenting with the vulval ulcers, which could possibly be a key in diagnosing this case. * Names have been changed
At follow up, the results of the punch biopsies were reviewed. The tissue biopsy demonstrated a neutrophilic infiltrate with epidermal necrosis and no malignancy and direct immunofluorescence excluded autoimmune bullous disease. I was lucky enough to be accompanied by a very astute and super-keen medical student, who had taken a very thorough history from Kathy, had examined the photographs taken of Kathy’s vulva from previous presentations, and who had spent some time researching the diagnostic possibilities of the case.
Do you know the diagnosis? Go online and see if you are right! Visit gpaustralia.org.au/content/whats-yourdiagnosis-going-places-magazine-issue-10
You can also find out the diagnosis by scanning this code.
Taking a fresh look at general practice 35
A difficult diagnosis of severe loin abdominal pain Another imitation of other pathology Classic presentations may turn out to be something very different and totally unexpected. Working in the emergency department you see a different, and generally more severe, spectrum of presentations than you do in general practice. One of the positives is that by having access to diagnostic techniques and specialist opinions, a reasonable working diagnosis can often be made. However, this does not always happen, and at times classic presentations turn out to be something very different and totally unexpected. One Saturday day shift you attend to a 57-year-old man who had sudden severe (10/10) sharp pain in his right flank, with no urinary symptoms. His observations, examination and full blood count work up was normal. Urinalysis showed a small amount of blood. A CT KUB (CT scan of the kidneys, ureters and bladder) was also normal, with no calculi and no hydronephrosis seen. The patient’s pancreas and bowel (appendix) appeared normal. Mild calcification was demonstrated in the distal aorta. There was no fracture of the spine, and chest X-ray was also reported as normal, with no air under the diaphragm. The patient was reviewed by an emergency medicine staff specialist and a physiotherapist. No cause of his pain could be found and he went home with analgesia (he lived locally). You find out later that the patient had returned in the late afternoon of the next day, with severe bilateral flank colicky abdominal pain (10/10) that could not be relieved by analgesics. He had nausea and vomited twice. The distressed patient was given morphine IV and an indomethacin suppository to relieve the pain and was then fully assessed again. A surgical registrar and consultant reviewed the patient, and the history of night sweats, mild fever and past cholecystectomy suggested cholangitis as a possible diagnosis. Medicine Today provides Going Places with selected articles from its archive of peer-reviewed clinical content. To view the full archive, visit Medicine Today’s website at medicinetoday.com.au Registration is free to all members of GPRA, GPSN and GPN.
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Admission and investigation
The patient was admitted under the surgeon, intravenous antibiotics and fluids and nil by mouth were commenced and an upper abdominal ultrasound organised for the next morning. His pain was only decreased to 5/10 with the narcotic analgesia, and because of his significant pain at the time of the scan an incomplete study was performed. Note was made, however, of an abdominal aortic dissection. The patient was immediately moved into a resuscitation bay. Fortunately, immediately and over the next six weeks, all the resources of a major teaching hospital were available to the patient. You followed his progress as outlined below. An urgent CT aortic angiogram revealed a Stanford type B aortic dissection, as indicated in the report (see report below). The box on the opposite page shows the classification of aortic dissection. With type B aortic dissection, unless complications occur such as impending rupture or ischaemia (visceral, limb or spinal) due to arterial occlusion by the dissection, there is debate whether surgical intervention by stenting improves outcomes over conservative management, especially blood and pulse pressure control by β-blockers (eg. metoprolol).
CT aortic angiogram report There is a type B aortic dissection originating just distal to the subclavian artery with both the coeliac and superior mesenteric arteries supplied by the true lumen with intimal flap extending into the origin of both vessels. The distal extent of the dissection is within the proximal right external iliac artery and the proximal left common iliac artery. The right renal, internal and external iliac arteries branch off the true lumen. The inferior mesenteric, lumbars, left renal and left common iliac artery originate from the false lumen. No carotid or vertebral arterial involvement.
This article originally appeared in Medicine Today 2012;13(8):74-75 and is reprinted here with permission.
Intensive care
The patient was cared for in intensive care. Blood pressure control was difficult, requiring β-blockers, glyceryl trinitrate and sodium nitroprusside infusions. Increasing pleural effusions necessitated a drain, and free fluid in his pelvis was also removed. His liver function tests were elevated. Ten days after admission, his severe pain was ongoing and blood pressure still difficult to control. Because of this, the patient was stented – the vascular surgeon/interventional radiologist inserted by catheter two self-expanding overlapping vascular stents into his thoracic aorta through a femoral puncture (see Figure). Blood pressure control was still difficult, and some renal ischaemia was shown on a CT scan of the stented aorta. No other ischaemia or cardiac damage was found.
Recovery
The patient remained mentally alert throughout the six weeks after the surgery, and was then discharged from hospital with support and follow up. He was looking forward to starting work again; fortunately, his work was heavily computer-based, and he was able to work from home initially. All involved in the case were grateful and pleased of the good outcome, especially after the initial diagnostic difficulty.
Authors Gordian Fulde MBBS, FRACS, FRCS(Ed), FRACS/RCP(A&E), FACEM Tiffany Fulde MBBS(Hons) Professor G. Fulde is Director of Emergency Medicine at St Vincent’s Hospital, Sydney; Professor in Emergency Medicine at the University of Notre Dame, Sydney; and Associate Professor in Emergency Medicine at the University of New South Wales, Sydney. Dr T. Fulde is Resident Medical Officer at St Vincent’s Hospital, Sydney, New South Wales. Competing interests: None. Acknowledgements The authors thank Associate Professor Anthony Grabs, Vascular Surgery, St Vincent’s Hospital, Sydney, for the CT image, and also the patient, who was known to Professor Fulde, for his permission and extra history not evident from the clinical notes. Dr Tiffany Fulde was part of the ICU team caring for the patient. References 1. DeBakey ME, Henly WS, Cooley DA, Morris GC Jr, Crawford ES, Beall AC Jr. Surgical
management of dissecting aneurysms of the aorta. J Thorac Cardiovasc Surg 1965;49:130–49.
2. Daily PO, Trueblood HW, Stinson EB, Wuerflein RD, Shumway NE. Management of acute aortic
dissections. Ann Thorac Surg 1970;10:237–47.
Taking a fresh look at general practice 37
“Test, Check, Save and Go” Test yourself Check the answer, explanation and link Save the references to read later “I’m happy with All while on the GO the app. It’s easy to Available on Android & Apple
Practise, practise, practise is the best way to prepare for the fellowship written examination. Dr. MCQ is a medical multiple choice questions (MCQ) app developed by Sturt Fleurieu.
navigate and it’s a great way to make good use of short snippets of study time. The questions are challenging, which motivates me to study certain topics further.” Dr. M
With 60 MCQs written and extensively reviewed by a group of Australian general “Dr. MCQ is an practitioners and medical educators, it is a reliable resource excellent study tool for for examination preparation. Its mobile format enables you both GP trainees but also for to make the most of your precious time wherever you may any medical based person be. At any stage, Dr. MCQ is a great study motivator. It wanting to extend their knowledge. may be used for self-review or in a study group. Dr.MCQ I believe the app is an invaluable is useful whether you are just starting your studies or study tool and would recommend even when the examination date is looming. it to anyone, but especially those wanting to pass the GP written examinations...buy it now to see what all the fuss is about!” Dr. C
During the very early part of your preparation, Dr.MCQ gives an indication of question structure “I like the convenience of being and allows you to develop an able to quiz myself whenever effective approach to MCQs. I am bored or in the mood to test Whilst in the midst of preparations, my medical knowledge whether Dr.MCQ can supplement your studies with its explanations I am in a cafe or at home. The and live links to a range of general practice references. The readings can even be saved, emailed or printed for review later. Closer to the examination date, Dr.MCQ can be used to gauge your level of learning. The categorised results helps you make sure you have covered all of the important topics.
questions are relevant to current practice and the links to some of the answers provide a very good source of reference.” Dr. Q
www.sfgpet.com.au/drmcq
Great opportunities within the AGPT program In the AGPT program you have the opportunity as an AGPT registrar to undertake a variety of different posts, including academic and Aboriginal and Torres Strait Islander health training. Undertake a salaried research project The everyday practice of GPs is centered around evidence-based medicine. The AGPT program encourages registrars to undertake research and improve critical thinking. As an AGPT registrar you can undertake an academic post – a paid, part-time research placement, which allows you to undertake a research project, attend research workshops, present your work at national conferences and contribute to primary care research and teaching communities.
“Without researchers in general practice we cannot be cutting edge clinicians.” Dr Ben Mitchell, academic registrar – CSQTC, University of Queensland
Make a difference whilst developing clinical and professional skills Did you know that as an AGPT program registrar you can undertake an Aboriginal and Torres Strait Islander health training post at any time throughout your training? Undertaking an Aboriginal and Torres Strait Islander health training post offers a unique opportunity to develop a range of clinical and professional skills in a challenging environment, including:
• treatment of diseases not often seen in mainstream primary health care settings
• working as part of a multidisciplinary health care team to manage complicated clinical, social and emotional issues
• complex chronic disease management • understanding cultural protocols and communicating complex health issues
• focusing on population and public health • health promotion within a cultural context.
“I enjoyed making a difference, and being known by the community (a rare feeling in an urban setting). I really enjoyed the work. You have the best of many worlds. You manage serious, interesting and overlapping conditions like a general physician, but still deal with vital young patients with families and children.” Dr Warren Jennings, registrar – urban post, Inala and Logan, Brisbane. Queensland
Visit www.agpt.com.au or talk to your regional training provider Taking a fresh look at general practice 39
Where will you go? Ochre Recruitment have expanded our borders! As one of Australia and New Zealand’s leading medical recruitment agencies, Ochre now have the ability not just to take you through our own great countries, but overseas as well!
This could be you!
You’ve probably always known that your medical degree can take you to places other people can only dream about - the opportunities available in Australia and New Zealand alone are as various as you want them to be. But what about globally? It’s one thing to work across Australia, and even making our way across the Tasman, it isn’t too difficult to combine work with the experiences available in the rugged New Zealand beauty. Once you get out of ‘our little corner’ of the world, though, that’s when things start to get a little more difficult, right?
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‘My patient conducted his own rehabilitation’ A 69-year-old patient of mine presented with recent swelling of the ankles and legs. He had undergone a coronary bypass five years previously but had continued to drink heavily, despite my efforts in advising him of the dangers. He was admitted to hospital and the gastroenterologist gave him six weeks to live if he did not stop drinking, an extra six months or more if he ceased drinking immediately. He chose to stop drinking. Over the next three weeks he did not slip into delirium as was expected, but instead gained over 40 kg. The use of up to 240 mg of frusemide had no effect. Right heart failure owing to alcoholic cardiomyopathy was partly the cause of the swelling, he had considerable delirium and Korsakoff’s psychosis began to set in. His condition became so unmanageable he was sent to the psychiatric unit. A month later he slipped into a coma and was transferred back to the hospital.
CHOCOLATE BOX
Dr Peter Schindler has been a GP for over 35 years. He has worked both overseas and in rural Australia.
When you’re a GP, you never know what you’re going to get…
I gathered the family together and indicated to them that he had only days to weeks to live. But this was not to be! In two days, he was lying in bed, fully conscious and able to recognise his family. His weight dropped and he continued to lose fluid. Owing to his abstinence, he must have gone through a huge metabolic rearrangement. His heart and brain function improved spontaneously, clearing his consciousness and allowing the continuing physical improvement. After four weeks he could sit-up, but remained too weak to walk, so a bed was made available at the local nursing home. However, he continued to surprise us: his health improved and in four weeks he was downgraded to hostel care. But he didn’t stop there … improvement in strength of body and mind continued and over the next six weeks he became a valuable carer in the hostel by assisting the nursing staff with in-resident activities, pushing the chairbound in their wheelchairs and assisting at meals with feeding. Being a retired bricklayer, he then took it upon himself to build the hostel a barbeque! He was eventually discharged home and continued to improve. He visited me regularly to monitor his enlarged heart, cholesterol, weight and fluids. He remained relatively physically strong (weighing 85 kg) and managing all his activities of daily living independently. Although initially having been given only a few weeks to months to live, he had managed to live well for almost a year before being admitted again to hospital, where he died suddenly after a short bout of pulmonary oedema. Dr Peter S
chindler
Do you have a story to share – an unusual case, a miraculous recovery or an amusing anecdote? Let us know, email goingplaces@gpra.org.au
Taking a fresh look at general practice 41
BOOK REVIEW Cautionary Tales: Authentic Case Histories from Medical Practice by Professor John Murtagh
Reviewed by Dr Liz Bond Melbourne,VIC
For those with an interest in general practice, John Murtagh needs no introduction. However, as not everyone may know the origins of ‘Cautionary Tales’, I will give you some background. John Murtagh was born into a farming family in Coleraine, in the Western District of Victoria. He developed polio when he was 8 years old. During the several months of convalescence which followed, he developed an interest in medicine. During high school, which he completed in Hamilton, he became fascinated with mathematics. He trained at university to become a maths and physics teacher. He commenced teaching at a small school of 120 students at Rainbow, but became frustrated as he was only able to teach junior arithmetic and science.* John then returned to his initial interest – medicine. He applied and was admitted to the first intake of medical students at Monash University, from which he graduated in 1966. He and his wife, a University of Melbourne medical graduate, practised together in Neerim South, at the foothills of the Great Dividing Range in Victoria. After 10 years, they returned to Melbourne, where John commenced work as a senior lecturer at Monash University,
eventually becoming professor of general practice. He also started writing books, including General Practice and Practice Tips. In addition, he became an editor of Australian Family Physician. The journal’s popularity increased when he introduced a series of features including Practice Tips, Patient Education, Lumps and Bumps and Cautionary Tales. The tales were so popular they have been compiled into a book.* Cautionary Tales is a collection of about 200 case histories from GPs, predominantly John Murtagh. The ‘tales,’ ranging from ‘Better out than Ricky Ponting’, ‘A pain in the butt’, ‘Don’t work in the dark’, ‘A doctor’s heartburn’ to ‘The country dunny syndrome or rural flu’, have been collated into chapters, which include Embarrassing moments; Masquerades and pitfalls; Sinister, deadly and not to be missed; and Lessons in communication. John, always the professor, hopes both colleagues and students can learn from these real-life cases. His emphasis is good patient-doctor communication by encouraging doctors to truly listen, connect, read and understand their patients. The teaching point and thought, which may be missed, is highlighted in the ‘discussions and lessons learned’ segment which follows each case. This book is an interesting, informative and often humerous read, which teaches many lessons and pitfalls to avoid using cases from real-life experience as a GP. Cautionary Tales: Authentic Case Histories from Medical Practice is published by McGraw-Hill, 2011. RRP $59.95 * Source: Good Practice. Issue 3: May 2012; Issue 8: October 2012
WHERE TO NOW? So, you’ve read through Going Places magazine and now you are curious about general practice as a career. Or maybe you’ve already decided that being a ‘general specialist’ is your vocation! What’s next? Here are five ways to start going places in your career as a GP:
1 Join the Going Places Network Become part of the Going Places Network at your hospital. It’s a fun way to network with others who have an interest in general practice, while developing your professional knowledge and credentials. Looking for the Going Places Network at your hospital? Visit gpaustralia.org.au to find out more and join online.
2 Talk to your GP ambassador Our GP ambassadors are junior doctors who have a real passion and enthusiasm for general practice. They’ll be able to answer all your questions about general practice. If there are any questions they can’t answer, they’ll find the answers for you. Visit gpaustralia.org.au to meet the GP Ambassador in your hospital or area — or look out for posters on notice boards in your JMO lounge.
3 Test-drive general practice with the PGPPP
The Prevocational General Practice Placements Program (PGPPP) is a great opportunity to experience life as a GP during your hospital training years. When you participate in the program you rotate into a general practice training post for a minimum of one, and a maximum of two hospital terms. Throughout your placement you are well supervised by experienced GP supervisors. You have management of your own patients and are involved in varied areas of health care, such as sexual health, drug and alcohol, aged care, paediatrics, home visits, acute and chronic disease management. Visit gpet.com.au to find out more about the PGPPP.
4 Get the A–Z on GP training Ask your GP ambassador for a copy of the Going Places Prevocational Doctors Guide to General Practice Training — your comprehensive guide to becoming a GP. They’ll also be able to provide you with a copy of the AGPT (Australian General Practice Training) 2013 Handbook, which has full details about the AGPT program.
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5 Visit gpaustralia.org.au To find out how general practice training works, visit the website. It will guide you through the pathways available, the organisations involved, the nuts and bolts of applying and more, helping you to plan your path into general practice.
Gen Leve eral Prac l 4, 51 tic 7 Flind e Regis trars er s Phon Lane, Melb Australia e: 03 (GPR 9629 ourne Vi ctoria A) 8878 3001
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Avant’s 2013 Doctor in Training Research Scholarship program will offer $300,000 in scholarships – applications open February 2013. “Avant’s investment in DiT’s is significant, just look at the Doctor in Training Research Scholarship Program as an example.”
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