ISSUE 11 FREE May — August 2013
Taking a fresh look at general practice
Dr Rabia Khan Front line doctor
Also in this issue: Dr Aleeto Fejo – Wakapi Anyiku Doctor Oomparani Murtagh’s tales Clinical cases The future of general practice
Explore the Possibilities Talk to one of the 4 Victorian GP training providers about your career in general practice. They can explain how the training program works, how you apply, eligibility and hospital requirements, pathway and other training options.
Make General Practice Your Choice
Bogong GP Training www.bogong.org.au
www.southernGPtraining.com.au
Incorporating the Australian General Practice Training and Prevocational General Practice Placements programs
VMA General Practice Training www.vma.com.au
Beyond Medical Education www.beyondmedical.com.au
For more information contact: Pauline Ingham, VicNet Marketing & Research Officer RWAV Phone: 03 9349 7825
Welcome
Time has gone by really quickly, and we are now into the 11th issue of Going Places magazine, a publication brought to you by General Practice Registrars Australia (GPRA). We’ve got another fantastic issue, with profiles of GPs and GP registrars from very diverse backgrounds. This issue’s cover story profiles GP Ambassador at Shepparton Hospital, Dr Rabia Khan. She shares with us her intense experience saving lives on the battlefield while serving in the Pakistan Army as a Captain.
Taking a fresh look at general practice
Our feature story on Dr Aleeta Fejo highlights her unwavering resolve to become a doctor. She is now working as a GP, and passionately serving the Indigenous community in the Northern Territory. Dr Fejo’s inspirational work won her the inaugural GPRA ‘Aboriginal Doctor for Everybody’ Award. Practising medicine in a remote area is challenging in itself. Imagine adding into the mix, climatic extremes such as living in sub-zero temperatures! Dr Lizzie Elliott shares her experience working in Greenland and Macquarie Island. She is another clear example of an Australian GP who is truly going places. The indefatigable Dr Casey Parker is a rural procedural GP who is pioneering the digital frontier in medical education. He shares with us his exciting new blog – broomedocs.com. I’ve checked it out, and it is very impressive! Irish-trained GP, Dr Patrick O’Sullivan shows us how he manages to indulge his wanderlust and fit in some locum GP work at the same time. Dr Nay Nay Moe Swe recounts her tale of overcoming adversity in order to study medicine, and then making the courageous move from Myanmar to Australia for further postgraduate training. Dr Marcus Gunn recalls a humorous experience with a serious take-home message about communication, in the first of a new series. Did you know that you can work in a GP clinic as one of your hospital rotations as an intern or resident? It’s called the Prevocational General Practice Placements Program (PGPPP). Dr Iyngaranathan Selvaratnam shares with us his eye-opening PGPPP experience working on a remote island in the Northern Territory. General practice provides the platform for doctors to positively influence patients’ health with a personal touch. I’d like to take this opportunity to urge you to get in touch with your nearest GP Ambassador to chat about how you can begin your career in general practice. Enjoy the magazine!
Dr Chia Pang Medical Editor GP registrar – Bogong Regional Training Network
©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
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In this issue… Upfront
Cover story
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Dr Rabia Khan served in the Pakistan Army as a Captain for almost six years after graduating from the army medical college and basic military training. Now, as a junior doctor and GP Ambassador in regional Victoria, she has big dreams for her future as a GP in Australia.
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PGPPP and me Dr Iyngaranathan Selvaratnam talks about his fascinating PGPPP term on Elcho Island, off the coast of Arnhem Land.
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GP registrar profile Dr Nay Nay Moe Swe travelled here alone from her native Myanmar. She tells us about her GP training and her new life.
Regulars 19
Going Places Network update Check out the latest Going Places news, events and resources.
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It takes 2 Drs Jenny Alexander and Mark Overton chat to Going Places about working together as GP registrar and GP supervisor.
22
Feature story Dr Aleeta Fejo, recipient of GPRA’s Aboriginal Doctor for Everyone Award, shares her 20-year journey to becoming a GP.
15
My career – AGPT applications
17 18
10 great reasons to be a GP
20 21
Your GP Ambassador Network
5 minutes with ...
Conference update
GP profiles 26
Dr Lizzie Elliott talks about her exciting work, including her new role as medical officer with the Polar Medicine Unit in Antarctica.
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Dr Casey Parker of ‘Broome Docs’ talks about using the blogosphere and Twittersphere for the medical education of young doctors.
Dr Patrick O’Sullivan travelled the world as a GP. Here he shares his sense of adventure with the next generation of GPs.
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 Editor Denese Warmington Writers Laura McGeoch Jan Walker Denese Warmington Graphic Design Peter Fitzgerald Going Places Network Manager Emily Fox emily.fox@gpra.org.au 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
Clinical cases
Back pages
33
Clinical corner
FIGJAM
35 36
Murtagh’s tales
39 40 42
The AGPT program
43
Where to now?
Nipple soreness and swelling during breastfeeding
Taking a fresh look at general practice
Reviews
Printed by Graphic Impressions
FSC Logo Taking a fresh look at general practice 5
J U N I O R D O C T O R profile
On the medical GP Ambassador Dr Rabia Khan came face to face with mass human suffering as a trainee army doctor in Pakistan. Now as a junior doctor and GP Ambassador in regional Victoria, she’s making a new life. The first thing that strikes you about Dr Rabia Khan is that she looks far too young to have done what she’s done and see what she’s seen. Who would guess this fresh-faced young doctor has already witnessed a miasma of mass human suffering? In displaced persons’ camps. In war zones. In the aftermath of some of the world’s worst floods and earthquakes. Working in such settings was part of her medical training and career as an army officer in her birthplace of Pakistan. Rabia served in the Pakistan Army as a Captain for almost six years after graduating from the army medical college and basic military training. She won an award for the most outstanding cadet in her year. “During this tenure I was exposed to the unique experience of dealing with war casualties, flood and earthquake victims in Pakistan,” Rabia says. “We were not only providing them with medical care but food, clothes and shelter.” When Going Places magazine asked her how she dealt with these confronting experiences, she was matter-of-fact. “My father was an officer in the Pakistan Army. Many members of my family have been in the military and a number of them have been doctors. In Pakistan, the army is one of the most prestigious organisations and a very noble profession. “Being born into army life, these (working in war zones and humanitarian camps) were the sorts of things my father was involved with over the years so I had it in the back of my mind that I would be doing all this.” Even as a young child, Rabia knew she wanted to be a doctor. “It was always my father’s dream that all his daughters should be doctors. I’m the eldest of five sisters. But I didn’t feel pressured because it was my passion as well. Now all my younger sisters
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frontline sharing her energetic enthusiasm for general practice with her peers. “I have big dreams for my future as a GP,” she says as she goes on to list the benefits of a career on the civilian medical frontline. The variety of work, being involved with the community and the ability to balance career and family all appeal to her. She hopes to begin her GP training next year.
“I was exposed to the unique experience of dealing with war casualties, flood and earthquake victims in Pakistan.” are either working as doctors or completing their training to be doctors back in Pakistan. “In my society, sons are traditionally more highly valued than daughters but my parents were determined that their daughters should be given the same opportunities as sons.”
Rabia says everything is falling into place for her, including her personal life. With her husband still working in the Pakistan Army, too much of their contact lately has been by Skype. However, on the day Rabia spoke to Going Places, he was about to visit her on extended leave, with plans to soon join her permanently. Living alone while settling into a new job, new home and new country has been the most difficult part of being an international doctor in Australia, she says. But it has been made easier by her supportive friends and hospital staff. And she keeps busy with many outside interests. “I love to read, I love to cook and I love photography. When my husband gets here I will be complete.” So what will she remember most about her formative years in the Pakistan Army and what impact did it have on her as a doctor?
Rabia says that some people in Australia are surprised that women in Pakistan, a Muslim country, should be encouraged to pursue higher education and the professions. Rabia is quick to debunk this perception. “It’s not like that at all,” she says. “In Pakistan we have women in almost every profession.”
“There’s one incident I recall when I was working with war casualties at the Combined Military Hospital in Rawalpindi. This officer had lost both his legs just before he was about to get married. The wedding went ahead in the ward. It was an overwhelming experience I’ll never forget.”
So how did Rabia end up in Australia, Going Places wanted to know.
In the relief camps, Rabia says medical teams had to do the best they could with very limited resources. “I think it’s made me an adaptable doctor — and even more passionate about my work,” she concludes.
“I came to Australia for my honeymoon in 2010,” she says. She and her husband, also an army officer, fell in love with Australia. “ I met up with many friends who were working here, so I thought why not give it a go? ”
Written by Jan Walker
Now midway through completing her Australian general registration, Rabia is working as an admitting officer in the emergency department at Goulburn Valley Health Hospital, Shepparton, where she has been employed since April last year. Rabia is also the GP Ambassador at the hospital for the Going Places Network,
Taking a fresh look at general practice 7
PGPPP AND ME Dr Iyngaranathan Selvaratnam was looking to challenge himself both personally and professionally. A PGPPP term on remote Elcho Island off the coast of north-east Arnhem Land, gave him just that — and much more. Where did you do your junior doctor internship? I completed by internship at Alice Springs Hospital in 2009. What year are you in? PGY5 and in my second last year of GP training. You did your PGPPP on Elcho Island through Northern Territory General Practice Education. Why did you choose to go there? It was blind luck really, but in the end, I feel like it was fate that took me there. I had been in Alice Springs for 18 months and I wanted to get back up near the water. I also wanted to experience what it was like living in a remote Indigenous community and to challenge myself both personally and professionally. Elcho Island was a perfect fit. It is off the coast of north-east Arnhem Land and the main township, Galiwinku, has a population of 2500. Several smaller outstations are dotted along the Island, some of which I was fortunate enough to visit. With the PGPPP, you do have the opportunity to express preference over where you go, so I encourage prospective applicants to do their research.
How was it meeting your supervisor for the first time? What did you learn from them? I had four supervisors out on Elcho because at the time the community didn’t have a permanent GP. They were all fantastic, each very individual, but all very supportive, and they definitely always had your back. Each of them were remarkably skilled in general practice, but they equally knew their limits, which is one of the most important things to be aware of as a remote practitioner. Tell us about some of the work you did in this unique part of the world. Working in a remote Indigenous health service exposed me to an incredible array of experiences, ranging from trying to find runaway suicidal patients in the surrounding bushland with local police, going to the homes of rheumatic heart disease patients to give them their monthly bicillin injections, and stitching up lacerations on people’s dogs! One day I went from managing a severe strongyloidiasis infection in a 3-year-old to driving the clinic’s troop carrier ambulance to emergency call-outs. I enjoyed my time out there so much I ended up taking annual leave and staying for an extra week for the Healthy Lifestyle Festival. It was
an incredible experience to really become part of the community and to step away from medicine, which is only part of the comprehensive primary health care puzzle. It is this that I have a real passion for, and where inevitably the biggest gains in Indigenous health outside of the obvious social determinants will be made, particularly through health education. Did you get some ‘hands-on’ experience? As the only health provider for the township of Galiwinku, I saw a mix of general practice and emergency department presentations, and as there was no one else to compete with in the clinic, you could get your hands as dirty as you wanted to. Supervision by the senior doctor was never an issue, and whenever you felt out of your depth, they were there by your side. Describe an average day during your PGPPP. It was such an incredible change from the shift work in the emergency department at Alice Springs Hospital that I had just finished. Fantastic hours of 8.00 to 4.30 with no after-hours or weekends, although I did go in plenty of times in the evenings with the on-call nurse and when the doctor was called in out of my own interest. This was when I saw some of the sickest and most difficult to manage patients. It amazes me how many acute mental health presentations, chest pains and septic patients we had to monitor for extended periods while awaiting the CareFlight plane for evacuation. I was fortunate to be able to split my time between the clinic and the chronic disease and mental health teams. All the programs are nurse, midwife and Aboriginal health practitioner led, and they make up the backbone of these remote clinics. They do such an incredible job.
Did anything surprise you about the PGPPP experience? I was amazed at how welcomed and accepted I was by the staff at the clinic and the community itself. I was ‘adopted’ by one of the local families and was assigned a place within the complex kinship system. I also didn’t expect to make so many life-long friends out of the experience with reunions, birthdays and weddings invitations following my time there. You’re now in your second six months of GP training in Darwin. Did your PGPPP experience influence this decision? Well I can’t lie. Since the last three years of med school I have wanted to do general practice. A big influence was my time at the Mulungu Aboriginal Health Service in Mareeba (Queensland) in my fourth year. This is where I developed both a keen interest in Indigenous health and general practice. As a result, I signed up for GP training with NTGPE as an intern. My time on Elcho reinforced to me that I had made the right decision. Essentially my time on Elcho was a phenomenal working holiday, but don’t tell anyone at NTGPE that! You’ve also done a Dip Trop Med. Was this influenced by your PGPPP experiences in the NT? Living in a remote Indigenous community definitely opened my eyes to the broader social determinants of health, particularly housing and education. I have always wanted to practise medicine in the developing world, and unfortunately much of the pathology and circumstances of our most disadvantaged Indigenous people are similar to their third world counterparts. So I was definitely motivated to do the diploma, particularly to start furthering my education in public health.
1.Go in with an open mind and heart.
Having worked in a remote Ethiopian village clinic earlier in the same year, one startling realisation hit home while working on Elcho. In the village in Ethiopia, despite their nomadic pastoral subsistence way of life with essentially no infrastructure, I got the sense that the villagers were happier and healthier, especially from a spiritual viewpoint. This just goes to show that in ‘closing the gap’ it is not just physical disease we need to manage, but also the loss of identity and cultural roles among our Indigenous people.
2.Embrace each and every experience that your community has to offer. Good or bad, you will have something to talk about at the end of the day.
What was the best part of the experience? Overall, I just had an amazing time, which was made possible by the incredible people I lived and worked with, the inspiring people that make up the community, and the blindingly beautiful place that Elcho Island is.
3.This is an incredible opportunity to learn about people and medicine, so offer to help out where you can, even after hours.
I loved my work there, but I also loved being able to go out camping on the beaches, getting out on the water and catching a whole heap of fish. Attending events such as the school’s 30th anniversary celebrations, also made me feel very much a part of the community.
What are your top three tips for someone doing their PGPPP?
What are some of the important lessons you have learned about patient care? Indigenous health is such a challenging field. Just when you think you’ve got it all figured out, everything you know gets turned on its head. All you can do is continue to go in with an open heart and mind, be willing to learn, and be flexible and inventive.You need to take the time to listen and be yourself. When people realise that there’s no bullshit attached to you, they will warm to you and open up. General practice is often not about definitive solutions like surgery, but rather progressively working through problems and having a plan A, B and C for each time the patient comes to see you. What have you learned about general practice? My philosophy of what medicine is really about was reinforced on Elcho. To me, it is about understanding your patients in all their facets, sharing in their hopes and dreams and helping them to make them a reality. General practice is the one specialty where I think you can truly practise medicine in this way.
What was the most challenging or difficult? Definitely stepping up and working more independently as a doctor. It’s easy as an intern/RMO to become reliant on your superiors to make all the decisions. The PGPPP experience is a rewarding way to start being really pushed to further your knowledge and skills and to build your confidence. I never felt out of my depth though, due to my supportive supervisors. The remote nurses and Aboriginal health practitioners were also a wealth of knowledge and support. Would you recommend a PGPPP to others? For anyone thinking about general practice as career, or just looking to try something different, I wholeheartedly recommend you give a PGPPP term a go. In my opinion, every new doctor should try it, whichever training pathway they choose, because it gives a better understanding of what happens out there in general practice and the challenges GPs face pre- and post-hospital admission. Living in a rural, remote or Indigenous community also provides a much better understanding of the circumstances of many of your patients that end up in tertiary centres.
Taking a fresh look at general practice 9
Ayesha Richardson, NTGPE program participant
Ayesha Richardson at Goulbourn Island Coast camp site with a turtle shell from dinner the previous night.
Embrace a new experience Immerse yourself in the Northern Territory through our Prevocational General Practice Placement Program. For further information contact education@ntgpe.org.au or call 08 8946 7015 www.ntgpe.org.au
G P registrar profile
A GP in a land of opportunity While media headlines often portray a health system in crisis, Myanmar native and GP registrar Nay Nay Moe Swe, says she is lucky to work in a country that can provide the resources she needs to do her job and care for her patients.
Originally from the Southeast Asian country of Myanmar (also known as Burma), a developing country whose progress has been hindered by political and social unrest, Nay Nay Moe Swe doesn’t take the ability to live freely, study or pursue a career for granted. She is now working in a “very busy” clinic in Colac, 200 km west of Melbourne, but her general practice journey has taken her across thousands of kilometres and a couple of international borders.
But she went on to complete the relevant medical and English exams and has “no regrets” about her big move, despite having to leave her parents and family. Three months after arriving, she received a job offer to work in the heart of Australia, Alice Springs. Her Australian experience was just about to get really interesting.
“When I arrived in Alice Springs for my resident job, I felt a major culture shock for the first time,” she says. “Alice Springs is like a small city with a very multicultural population and the Indigenous population was such a new community for me.”
“Here [in Australia], our clinical knowledge can be applied without limitation “ of Aboriginal Australians and their culture are very government funding. interesting.You do really need to have a different “I worked in a company that manufactured electronic approach to get their medical history and diagnosis,” We have all chips. The earnings were not a great deal, but that small of the she explains. “And when you have the diagnosis, you savings covered the expenses for medical school.” facilities to apply our need to modify your language and communicate only with the patient, but also with their family skills to save a life or fix not After a year, she returned to Myanmar to complete and community because the whole community her degree and the first year of her hospital internship. up a medical problem.” may look after them due to their tradition.” “After I finished high school, I couldn’t study in Myanmar because the universities were closed for a few years,” she told Going Places magazine. However, because Nay Nay’s father was also a Taiwanese citizen, she was able to work in Taiwan in a non-medical field and save money for university.
“The medical university was run by local doctors and I’m always proud to say that I studied medicine in Myanmar,” Nay Nay says. “I am always grateful to the teachers from my home country.”
However, the poverty, limited access to facilities and continuing political unrest meant that Nay Nay would once again have to pursue a medical career abroad. Leaving her home of Yangon, formerly known as Rangoon and Myanmar’s largest city of around six million people, Nay Nay headed to Australia, the ‘lucky country’. Travelling alone and on a skilled migrant visa, Nay Nay arrived in Sydney in 2008. Her first challenge was to get through immigration. “It was very, very scary – and that was just the test to get out of the airport!”
It was at the Alice Springs Hospital that Nay Nay’s medical experience flourished. “It gave me a great opportunity to learn about different types of medicine. I experienced general medicine, general surgery, psychiatric medicine, paediatrics and emergency medicine. It also gave me the opportunity to study and gain qualifications.” “So, I found I liked paediatrics, but also thought I’d like to be a psychiatrist and also wanted to be a physician ... I really loved to do everything!”
Taking a fresh look at general practice 11
She is continuing to be challenged by the diverse medicine that rural environments offer. “We have 10 GPs here [at her Colac clinic] and it’s a really busy centre. The GPs do just about everything.” “I could be seeing a newborn baby or a 100-year-old patient,” she explains. “I generally see a fracture once a week and I also see a lot of mental health problems, because I have an interest in this area.” “I think GPs play a very important role in medicine ... because once you establish a good rapport with your patients they will keep coming back and let you know what their true feelings or problems are,” she says. “Australians really do rely on their GP.”
Top left: Doing an anaesthesia rotation Above: Nay Nay still loves to keep her Burmese traditions Left: At the Alice Springs Hospital
“I have some very lovely elderly patients in Colac who bring me flowers from their garden. They are really open and I have gained their trust.” After a full day of patients, Nay Nay relaxes by cooking food from home and exploring Australia with Htun. However, Myanmar and her family remain close to her heart. To share the value of her Australian experience, she volunteers to write health education articles, with a focus on mental health, for a Myanmar weekly health journal and has further plans to help local medical students. “I have never actually told anyone this, but one day I would like to go back and practise and help students to study emergency medicine. They currently do not have the right opportunity through a lack of resources.”
General practice was the one specialty that combined all her medical interests. While working as a resident medical officer during 2010 and 2011, she did two placements on the Prevocational General Practice Placements Program and this helped confirm her decision. And while she may have been far from home, she wasn’t short of company from home. “There were only two other Burmese doctors in Alice Springs when I arrived in 2008. By the time I left in January 2012, there were about 30!” One of these doctors was Htun, who she had met in medical school. He came to Australia seven months after Nay Nay and during their hospital internship they realised they were each other’s “forever soul mates” and got married in 2009. Her brother and sister also came to Australia to work, and along with Htun, Nay Nay says the four of them had a wonderful two years in Alice Springs. Nay Nay and Htun then moved cross-country to Victoria. Before settling in Colac, she spent the first eight months of her GP training working with Indigenous Australians, but this time in a ‘city’ setting at the Wathaurong Aboriginal Clinic in the regional city of Geelong. In addition to clinical skills, Nay Nay, who is now an Australian citizen, has had to learn the fundamental role that GPs play in Australia. “There is no GP training in Burma. For example, a person with a physical injury might be seen by a general physician, while a person with a mental health issue might be seen by a psychiatrist.” Nay Nay has also learned how to treat non-acute injuries and illnesses. “I was used to seeing people in emergency situations where we would fix their problems on the spot. But as a GP, not all of your patients’ problems can be fixed in one visit.” “For some patients, just listening to them and to keep supporting them is the best therapy. They express what they are feeling to their GP and just feel relieved,” she adds.
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Her past experience reminds her that she is simply lucky to have the resources to do her job. “Here [in Australia], our clinical knowledge can be applied without limitation of government funding. We have all of the facilities to apply our skills to save a life or fix up a medical problem.” “Some patients still complain that the facilities are really poor, but it’s not true when you compare the facilities to some developing countries. In a poor country, it’s really hard to get the resources for simple treatments.” “People here are really fortunate.” Written by Laura McGeogh
“So, I found I liked paediatrics, but also thought I’d like to be a psychiatrist and also wanted to be a physician ... I really loved to do everything!” Nay Nay discovering snow for the first time
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 Ambassador in your hospital today!
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M y C areer
Australian General Practice Training applications Applications for the 2014 Australian General Practice Training (AGPT) program will be open from Monday 15 April to Friday 17 May 2013. Many doctors choose general practice as a career for the great advantages and challenges it brings. Being a GP requires extensive medical knowledge and offers the opportunity to undertake procedural medicine while allowing for balance between work and family life. AGPT is the leading training program for GP registrars in Australia, offering training in rural, remote and urban settings. So why not apply now to start your training in early 2014?
There are 1200 training places available in the 2014 program and entry into the program is competitive. An overview of multi-staged AGPT application and selection process is outlined in the diagram below. However, applicants are encouraged to visit the AGPT website at agpt.com.au and to download the 2014 AGPT Applicant Guide and 2014 AGPT FAQs for detailed information regarding applications, the National Assessment Centres, shortlisting and selection.
MAY
APRIL
Key dates for application and selection – AGPT 2014 Online applications Open 10.00 am AEST* 15 April 2013 Close 10.00 am AEST 17 May 2013
Stage 1 – Application and eligibility check You will submit an online application, supporting documents, referee details and up to four regional training provider (RTP) preferences. Your application and supporting documents will be checked to establish if you are eligible for the AGPT program. You will be notified by email if you are ineligible.
JULY
JUNE
IF ELIGIBLE
National Assessment Centres run 15–30 June 2013 Applicants notified of scores 10.00 am AEST 22 July 2013 Applicant preference changes 10.00 am AEST 22 July 2013 – 10.00 am AEST 29 July 2013 Applicants notified of shortlisting 31 July 2013
Stage 2 – National assessment You will be emailed and requested to attend a National Assessment Centre, where you will undertake a Situational Judgment Test (SJT) and Multiple Mini Interviews (MMIs). The standardised results of these assessments will determine your total AGPT selection score. After receiving your total AGPT selection score you will have the option to change your RTP preferences. Depending on your total AGPT selection score and your RTP preferences, it will be established whether you can be shortlisted to a RTP. You will be notified of the outcome by email.
AUGUST
IF SHORTLISTED
Regional training provider assessments 3–11 August 2013
Stage 3 – Regional training provider selection and placement offers The RTP will examine your application. They may ask for additional information, an interview, or make a decision based on your total AGPT selection score. The RTP will then decide whether or not to offer you a training place in the 2014 AGPT program, and will notify you. Your written acceptance of an RTP’s offer of an AGPT place, within seven days of the offer being made, will confirm your selection into the AGPT program.
Applicants will be notified by the end of August 2013 as to whether or not they have been successful in obtaining a training place in the 2014 AGPT program. *Australian Eastern Standard time (i.e. Sydney time)
Taking a fresh look at general practice 15
Is general practice the specialty you have been looking for?
13 Going Pla20ce s Prevocational docto
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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
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Taking a fresh look at general practice
10 great reasons to be a GP 1 Every day is different
General practice is not all coughs and colds or tears and smears. The diversity of patients and medical presentations is one of the most enjoyable aspects of general practice.
2 Intellectually stimulating One of the most challenging roles of a GP is diagnosing medical presentations. Every day you will use the knowledge you learnt at medical school. General practice is a daily brainteaser that doesn’t allow for boredom.
3 Treat the patient, not just the illness Unlike many other specialties, GPs can offer holistic continuity of care to their patients, building long-term relationships as they treat patients and their families over their lifespan. As a GP you have the power to make a real difference to many lives.
4 Subspecialise! GP registrars can undertake special skills posts in paediatrics, anaesthesia, emergency medicine, academia and many others. The GP training program offers all GP registrars an opportunity to pursue a subspecialty of their choice.
5 The choice is yours As a GP you decide where you work and what hours, tailoring your workload to suit your life stage and your career.
6 Reap the rewards GPs are well remunerated, usually without the extremely long working hours faced by other specialties. There are also lucrative financial
incentives for GPs to work in areas where there is a shortage of doctors — typically rural areas. But even if you decide to be metro-based, you will be well rewarded.
7 Fast, flexible and funded The AGPT and RVTS programs are funded by the Australian Government and provide lucrative financial incentives for rural GP trainees. Rural GP trainees can also get a HECS rebate.
8 Supportive training, supportive workplace Solo GPs are becoming a thing of the past, with many practices employing several doctors as well as practice managers and practice nurses, allowing you to do what you do best in a supportive, interactive environment.
9 Seeing the good with the bad Being a GP you get the highs with the lows, treating not just sick patients but managing patients during positive times in their lives such as pregnancy, and for preventive health programs.
10 General practice can take you there Winter as a ship’s doctor in Antarctica; treating the kids to a summer holiday on an island in the Great Barrier Reef; pursuing a research interest; flying around Australia treating medical emergencies: Wherever you want to go, whatever you want to do, a career in general practice can take you there.
Taking a fresh look at general practice 15
5
MINUTES WITH...
Lester Pepingco GP Ambassador
Which hospital are you based at? Royal Prince Alfred Hospital in Sydney, NSW
What are you looking forward to most as a GP? Seeing a wide range of patients and conditions, as well as the opportunity to provide patients with long-term continuity of care.
Why did you choose general practice? The opportunity to develop a broad range of skills and knowledge that I can apply in the care of my patients, the diversity in presenting conditions, and the opportunity for preventive medicine.
Who inspires you? My beautiful, compassionate, and loving wife Michelle.
Which three words best describe you? Organised, cheerful, hungry!
What three things would you take to a deserted island? Plenty of water, my wife, and my bible.
Which cartoon character are you most like? Mike from Monster’s Inc.
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6
Taking a fresh look at general practice 19
Going Places Network update Hobart dinner event On a windy Hobart night, students and junior doctors flocked in droves to the first Going Places dinner event for the year, at the Duke Restaurant. Two very inspirational and informative speakers, Dr Lizzie Elliott and Dr Christine Boyce touched on the variety a career in general practice can offer and spent the night networking with attendees. It was a great event, with some positive information sharing between the student and prevocational doctor networks. Stay tuned for details of the next Tasmanian dinner, which will be held in Launceston in June.
Membership of Going Places Network has reached a record 3000 members! The Going Places Network phenomenon has caught on, with a record 3000 junior doctors joining the network. With the rapid increase in membership, we hope to be able to provide every teaching hospital in Australia with a GP Ambassador. Not a member yet? What are you waiting for? Join today, simply visit gpaustralia.org.au and find out more about careers in general practice through events, publications and heaps of free resources.
Dr Nici Williams former Westmead Hospital GP Ambassador awarded the 2012 GP Ambassador ‘Above and Beyond’ Award Proud door prize winners, Dr Lauren Kelley, Dr Samantha Hack and Dr Ingrid Smethurst
This award is presented by the Going Places Network to a GP Ambassador who has actively gone above and beyond expectations in carrying out their role.
A real perception changer, Nici attended and helped at various conferences (BNL 2011 and NZ Prevocational Doctors 2011), regularly attended NSW events and was a key speaker at the Firstwave Workshop in 2012.
The go-to publication 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 Prevocational junior doctor doctor s guide to GP training considering a career in general practice.
Going Pla2c01e3s
See your GP Ambassador to get your copy.
General Pract ice Registrars Level 4, 517 Australia (GPR Flinders Lane, A) Melbo Phone: 03 9629 urne Victoria 3001 8878
Taking a fresh look general practi at ce
The future of gener al pract ice
GP Companion 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.
Have you said hello to your GP Ambassador? The Going Places Network currently has 43 GP Ambassadors in 42 hospitals around Australia. All are keen, passionate and enthusiastic about general practice and would love to have a chat with you. If you are unsure about your future career path, don’t be shy to contact your ambassador. Like you, they are junior doctors in your hospital and are available to help answer your questions and point you in the right direction. Look out for the GP Ambassador posters in your resident quarters, visit gpaustralia.org.au or turn to page 20 of this issue of Going Places to find out who your GP Ambassador is.
about the various GP pathways than she had experienced.
Get your copy at a Going Places event or download the e-book version at gpaustralia.org.au/content/publications
Passionate, committed and driven are three words to describe Nici, whose belief in general practice, bubbly personality and approachable manner ensured her success in this role. Nici embraced the role of ambassador to ensure future cohorts of junior doctors at her hospital and elsewhere had a less frustrating and easier means of accessing information
Taking a fresh look at general practice 19
Your GP Ambassador Network
NSW & ACT Bob Vickers John Hunter Hospital johnhuntergp@gpra.org.au Nik Boyd Gosford Hospital gosfordgp@gpra.org.au Angela Kwong Bankstown Hospital bankstowngp@gpra.org.au Phoebe Norville Royal North Shore Hospital royalnorthshoregp@gpra.org.au Matt Allan Westmead Hospital westmeadgp@gpra.org.au Lester Pepingco Royal Prince Alfred Hospital royalprincealfredgp@gpra.org.au Georgina East St George Hospital stgeorgegp@gpra.org.au Kristin McMahon The Canberra Hospital canberragp@gpra.org.au Marianne Moore Hornsby Hospital Network hornsbygp@gpra.org.au Hannah Britten Tamworth Hospital tamworthgp@gpra.org.au Pavan Phanindra Wollongong Hospital wollongonggp@gpra.org.au QLD Linda Thomson Cairns Base Hospital cairnsgp@gpra.org.au Louise Knapp Gold Coast Hospital goldcoastgp@gpra.org.au Tom Hobman Logan Hospital logangp@gpra.org.au Stephanie Barnard Mackay Base Hospital mackaygp@gpra.org.au Michael Cross-Pitcher Nambour Hospital nambourgp@gpra.org.au Tim Chan Princess Alexandra Hospital princessalexandragp@gpra.org.au Fiona Scoffell Redcliffe Hospital redcliffegp@gpra.org.au Rupert Jayraj Savariar Rockhampton Hospital rockhamptongp@gpra.org.au Paul Adams Toowoomba Hospital toowoombagp@gpra.org.au Helen Frazer Townsville Hospital townsvillegp@gpra.org.au SA & NT Jacob Mackenzie Flinders Medical Centre flindersgp@gpra.org.au Sara Le Lyell McEwin Hospital lyellmcewingp@gpra.org.au Kiren Kodali Modbury Hospital modburygp@gpra.org.au Adelaide Boylan Royal Adelaide Hospital royaladelaidegp@gpra.org.au Kerry Summerscales Queen Elizabeth Hospital queenelizabethgp@gpra.org.au Jasmine Banner Royal Darwin Hospital darwingp@gpra.org.au VIC Janie Maxwell Eastern Health boxhillgp@gpra.org.au Rabia Khan Shepparton Hospital sheppartongp@gpra.org.au Claire Owen St Vincent’s Hospital stvincentsgp@gpra.org.au Amanda Nikolic St Vincent’s Hospital stvincentsgp@gpra.org.au Mahila Abbass Austin Hospital austingp@gpra.org.au Darren McCorry Ballarat Hospital ballaratgp@gpra.org.au Ineke Woodhill Geelong Hospital geelonggp@gpra.org.au Amran Dhillon Northern Health northernhealthgp@gpra.org.au Katherine Exon Southern Health southernhealthgp@gpra.org.au Jomini Cheong Southern Health southernhealthgp@gpra.org.au Elizabeth Bond Western Health westerngp@gpra.org.au TAS Abby Gleeson Royal Hobart Hospital royalhobartgp@gpra.org.au Rose Tilsley Launceston Hospital launcestongp@gpra.org.au WA Jemma Smith Royal Perth Hospital royalperthgp@gpra.org.au Kevin Fontana Sir Charles Gairdner Hospital charlesgairdnergp@gpra.org.au Elyne Fontana Sir Charles Gairdner Hospital charlesgairdnergp@gpra.org.au Kate Reid-Milligan Fremantle Hospital fremantlegp@gpra.org.au Becky Dodgson Joondalup Health Campus joondalupgp@gpra.org.au
Want to get involved? 20
Going Places Ambassadors are junior doctors who have a real passion for general practice. To find out more about becoming a GP Ambassador, email goingplaces@gpra.org.au
BNLupdate
At the 2013 Breathing New Life into General Practice Conference in Canberra, meetings between students, prevocational doctors and GP registrars tackled current issues, and new initiatives were planned for the future. Below is a quick look at the outcomes of these meetings. Going Places Network meeting Delegates evaluated the network’s member benefits and investigated implementing new initiatives to encourage more junior doctors to join the network. A discussion around what has worked well, and what improvements could be made to the program, also took place. The key theme which arose from the meeting was that there is a high demand for more ambassadors in all teaching hospitals in Australia. Currently the network is in 65 per cent of teaching hospitals, not high
GP Ambassadors Dr Janie Maxwell,
Dr Adelaide Dr Abby Gleeson enough for Boylan, the network’s rapidly growing
membership, which is sitting at 3000 junior doctor members. In 2014, the network hopes to have the capacity to invite every GP Ambassador to the BNL conference.
General Practice Student meeting The National Executive unveiled four new working groups to tackle a range of issues facing medical students: solutions for rural general practice; closing the gap; community; and policy and procedures. The groups will be made up of medical students and will be led by a group chair.
GPRA Chair Report – Dr Ed Vergara It was an inspiring BNL conference in Canberra this year, with GP Workforce 2025 as the theme. Inspiring speakers, keynote addresses, and stimulating discussion among the delegates kept the conference buzzing. Live Twitter feeds during the conference not only kept those unable to attend in person up-to-date on discussions, but also formed an essential component to the sessions. Pertinent and probing questions through Twitter feeds kept speakers grounded to what the delegates wanted to know.
GPSN National Chair David Towsend, said the idea was conceived from the “large interest in student members to make a real and significant difference to the important issues facing us as medical students and as potential future general practitioners.”
Advisory Council meeting The Advisory Council meeting prior to BNL brought together registrar liaison officers and national representatives to network and discuss issues relevant to registrars. Topics included the new RACGP vocational training standards, the validity of registrars working as contractors, the bi-College accreditation process, and bullying within general practice. The council’s subcommittees were reinvigorated with new chairs, secretaries and members willing to work on these issues and more to ensure a registrar voice is heard on matters that influence the training program. Aboriginal and Torres Strait Islander health was highlighted by the Close the Gap Subcommittee, which had a strong focus at the BNL conference.
Inspiring speakers and fascinated attendees at BNL
BNL delegates
Taking a fresh look at general practice 21
Aboriginal doctor for everybody Dr Aleeta Fejo experienced many struggles on her long journey to become a GP but was determined to see it through. All this makes her uniquely qualified to help a new generation of Indigenous trainee doctors.
“Aleeta’s own pathway to general practice is an inspiring one involving decades of study, false starts, new starts and dogged determination to make a difference.” Dr Aleeta Fejo is not one who seeks the spotlight. But when the cameras flashed at this year’s Breathing New Life into General Practice Conference as Aleeta took centre stage to accept a special award, she paused to reflect on just how far she had come. Aleeta received the inaugural Wakapi Anyiku Doctor Oomparani (Aboriginal Doctor for Everybody) Award in recognition of her passionate advocacy for Aboriginal health and her work in assisting Indigenous registrars. “I never expected to win an award for something I had been doing for so long anyway, but it’s nice to be recognised,” she says.
Aleeta believes it’s crucial to support the surge of Indigenous doctors coming through. Indigenous medical students now represent 2.5 per cent of medical students, roughly in proportion to Australia’s Aboriginal and Torres Strait Islander population for the first time in history. “But we must support them through to completion. We can’t afford to lose even one,” Aleeta says. Completing a fellowship is a marathon rather than a sprint for any medical student. For aspiring Indigenous doctors it can be an ultra-marathon, with several fiendishly gruelling obstacle courses thrown in. “These registrars often come from big families and poor families,” Aleeta says. “They are often older, with extended family responsibilities, other community responsibilities — so many issues that a lot of non-Aboriginal doctors don’t have.” That’s why Aleeta was instrumental in founding the Indigenous General Practice Registrars Network (funded by GPET and managed by GPRA), which provides peer group support, advocacy and professional development for Indigenous registrars. Aleeta’s own pathway to general practice is an inspiring one involving decades of study, false starts, new starts and dogged determination to make a difference. “It’s taken me more than 20 years to finish all my medical training and GP fellowship, but there are many reasons for that,” she says. As a mature-age student, mother — and, for a time, single mother — Aleeta had to fit study and work around her family. “But I never once thought of giving up,” she says. “I thought my story started when I was 28 years of age, but actually it started before I was born. I am a Larrakia traditional owner, inherited from my father, and I am a Warramunga woman from my mother.” Growing up on her father’s tribal land in Darwin, Aleeta left high school in 1979 as one of only 30 Indigenous students who had ever matriculated in the Northern Territory.
This page from the top: Aleeta and her husband Ned Aleeta receiving the inaugural Wakapi Anyiku Doctor Oomparani award at the BNL conference, presented by the Hon Warren Snowdon, Minister for Indigenous, Rural and Regional Health Aleeta on one of the BNL conference panels (left) with Julie Tongs from Winnunga Nimmityjah Aboriginal Health Service and Liz Marles, President of the RACGP
She got a job at the Department of Social Security and stayed for seven years, but became disillusioned with a system she believed was keeping Aboriginal people in poverty. Her next job was at the Menzies School of Health Research analysing statistics on low birth weight Aboriginal babies. It was a revelation. “We found out these babies were so small because the mothers were starving. When I was able to see the statistics I understood why
I had to go to so many funerals,” Aleeta says. “My father said to me if you don’t like the way things are done, go and do it yourself. That’s when I decided I’d be a doctor and try to help my people.” At 28 Aleeta moved to Melbourne, with her young family in tow, to undertake a three-year science bridging course at Monash University. On finishing that, she started medicine at Melbourne University in 1992 and became the first Indigenous Territorian to study medicine. But she struggled as she tried to balance family and study. In 1993 she gave birth to her third child. She transferred to science, moved back to Darwin — now a divorced mother of three — and completed her first degree. She worked three jobs to save up the money to study medicine again, then packed up her kids and moved to Adelaide for a fresh start at Flinders University. “I was raising my kids as a single mum, studying medicine, working part-time and volunteering at the local Aboriginal health service. It was hard, but I got through.” Aleeta relocated to Darwin for the last two years of her medical degree and remarried. She finally graduated in 2004. “I was so happy, and then I was scared. I worked every extra shift to gain experience, knowledge and confidence,” she recalls. After joining the general practice training program she took a job in Katherine, driving 300 km home to Darwin to see her family every weekend. She completed her fellowship last year. Aleeta is acutely aware of being a community role model. “When I was the doctor for my son’s football team I had a uniform with a big ‘Doctor’ written on the back. I used to walk up and down in front of the grandstand so that people could see that I was a doctor. I thought it might plant the seed that they could be a doctor too.” Aleeta now lives in Katherine and drives or flies 300 km each week to work at the remote Ngukurr Aboriginal community near the Gulf of Carpentaria. So with a job she loves, a supportive husband, grown-up children and an empty nest, is it time to take things a little easier? Not at all. Aleeta is planning to do a PhD. “It’s going to be on the topic closest to my heart and that is helping Indigenous registrars. Aboriginal people like to have Aboriginal doctors, and Aboriginal doctors need support.” Written by Jan Walker
Taking a fresh look at general practice 23
24
It takes
Jenny:
I first thought about being a GP when I graduated from medicine, and did a few months part-time GP work straight after my intern year (in the days when it wasn’t necessary to go through a training program to work independently as a GP). But I then changed careers and worked as a journalist, mainly in newspapers as a writer and sub-editor. I enjoyed that very much, but eventually I realised that I really missed working as a doctor, making management decisions and hopefully using my own life experiences to inform my clinical judgement so that patients could benefit. I also considered a career in psychiatry, as I have always been interested in how people think and feel, however, after doing an adult inpatient psychiatry term I decided that what I would really enjoy about general practice would be the variety, with a mix of people and problems, including mental health, and a chance to really deal with the whole person and all aspects of their health. It was the right time for me to go back to medicine, so I began on the road to retraining and a year later started back in the hospital system as a full-time hospital medical officer. Mark has been my supervisor for about three months. He is friendly and supportive, and happy to be asked anything ranging from practical administrative-type questions, through to the full range of clinical problems and the more philosophical side of being a GP. Mark is interested in what I need to learn, and good at getting me to think through clinical problems for myself in a constructive, non-critical way. As a GP, Mark has a caring manner, really listens to his patients, and works to a high standard clinically. I think because his patients know he takes them seriously, Mark has a large number of loyal patients with whom he has formed a long-term relationship. What I admire about Mark is that he has a quiet, patient manner and is a good listener. He also appreciates the funny side of life – the quirkier aspects of everyday situations. I’d like to emulate his thorough, unflappable approach to patient care, his ongoing interest in clinical medicine and his good relationships with his patients. In 5–10 years time, I imagine I will probably be working in suburban general practice, but possibly in rural practice – I grew up on a farm in the Western District of Victoria and did a rural PGPPP term at Lakes Entrance, in Gippsland, which I really enjoyed – I think there are many good things about country life. Wherever I’m working, I also hope to be doing some teaching and writing as well.
Drs Jenny Alexander and Mark Overton are GPs at Narregate Medical Clinic in Narre Warren, southeast of Melbourne. Jenny is a registrar at the clinic, and Mark is her supervisor.
Mark:
I did my general practice training in New Zealand in 1989, and have worked as a GP since then. I was initially interested in general medicine and had a fantastic mentor as a first year HMO in New Zealand. However, after a bit more life experience and reflection, I decided that being a GP offered much more variety and freedom. I have been very fortunate in working in a range of settings around the world, including refugee camps in Hong Kong in the early 90s, followed by work in rural China and then in Beijing as a medical assistance and aero-medical transport doctor. Then I settled down in Melbourne, where I have worked for the past seven years in one practice. I would never have been able to have these experiences if I had been in a specialist training program and had to jostle for consultant positions. I have always being interested in medical standards and the exam process. So being a GP supervisor seemed like a natural progression from a role at the RACGP (where I was the Victoria state Censor, helping to oversee the College exam process), to being involved in helping to train the next generation of GPs. Our practice, and the company that owns it, is welcoming of registrars; we have a great clinical mix from emergencies to chronic care, and we appreciate the chance to help to educate the next generation of GPs. Jenny is careful, thorough and caring. I admire her willingness to come back to medicine after a long period of time pursuing a different career. The changing political landscape and the effect that it is having on general practice can be a challenge for new GPs. However, the variety, flexibility, and ability to work in a wide range of settings with confidence are the biggest career benefits of general practice. Having said that, what does frustrates me about general practice is the long waiting lists for public hospital appointments and operations for patients who cannot afford private health insurance.
My words of advice for junior doctors wanting to be a GP is to check it out and see all the benefits it has to offer. The single most important quality that GPs can offer to their patients is attention. By this, I mean the doctor’s relaxed, undivided, non-judgmental attention on the patient. Without getting caught up in the distractions of whatever else is going on around you or in the clinic, or in the thoughts and feelings that may be swirling around inside of you. Attention is healing in itself. If a patient feels that they have been listened to, and their concerns have been heard and responded to, this by itself is therapeutic. And patients will be more satisfied and forgiving of any mishaps that occur on the way.
Do you know a pair who could feature in future ‘It takes two’? A GP and a patient? A practice manager and a registrar? Your mentor? A GP who 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
“I knew there was a lot of variety in general practice,
A GP with snow limits On the ice, Greenland, 2008-10
The ski-equipped Hercules used for transportation on and off the Greenland ice sheet
Living on an ice sheet in Greenland and working with an international scientific expedition team is a world away from a suburban doctor’s consulting room. But it’s exactly where GP Dr Lizzie Elliott found herself – three times, in fact – when she decided to specialise in general practice. As the only medically trained person on the Greenland expedition team, which was studying climate change, Dr Lizzie Elliott says her main focus on the ice sheet was to mitigate risks and avoid any emergency evacuations. “It can be really difficult for a plane to land and take off on an ice sheet,” she told Going Places magazine. “The ideal temperature on the ice is about minus eight degrees. If it warms to just one degree above freezing, the ski-equipped Hercules isn’t able to land or take off.” The importance of keeping a safe camp, where numbers peaked at around 85 people, in such an isolated location was highlighted when Lizzie had to coordinate an evacuation for a serious, but not life-threatening injury.
problem,” Lizzie says. “When I wasn’t doing medical work, I helped with the general running and maintenance of the camp … cooking, cleaning and helping the scientists.” The work was done in summer and due to Greenland’s latitude, the camp lived in virtual 24-hour sunlight. But despite the light, the team had to keep vigilant in the freezing temperatures. “Luckily the scientists had experience working in even colder weather, so I actually learnt a lot about hypothermia from them! We had a buddy system in place and we really didn’t go off site at all,” Lizzie explains. “It was important to watch out for your buddy in case they started to become unusually tired or grumpy.”
“One of the team members suffered a de-gloving injury to one of their fingers,” she recalls. “Fortunately, we were able to get them on the next flight five days later.”
“We lived in a semi-permanent ice camp and tents were set up at the beginning of each season, which ran from early May to late August. We were in heated tents but the temperature inside still hovered around minus 10 degrees at night.”
Part of the scientists’ work was to drill 2500 metre-deep ice cores and then use the information from the cores to assess climate variation. “The scientists were used to working in an office. But because they were now doing physical labour, some of them suffered musculoskeletal injuries.”
“We had sleeping bags that were suitable to minus 30 degrees and we’d zip them up right over our heads,” Lizzie recalls. “You’d pull your arm out in the morning to unzip your bag and you could feel the ice crystals covering it! You’d then reach over and grab your water bottle to find that it had frozen.”
“Part of my job was also to help the camp around the sometimes difficult psychological element of living in an isolated camp, being away from family and having to live and work with people on a 24/7 basis.”
So, how did Lizzie make the journey from being a medical student at James Cook University in her tropical hometown of Townsville to going on three expeditions (from 2008–10) to the other side of the world?
“However, most of the medical work I did there was very much opportunistic medicine and people would approach me if they had a
Part of the answer lies with her choice to specialise in general practice.
26
but I didn’t know there was so much different training available.”
Modelling the ‘Mark V standard diving dress’, Tasmania, 2012 Top: Lizzie, second from right, at the 11th Festival of Pacific Arts, Solomon Islands, 2012. Below: Hitting the snow, Macquarie Island, 2011 Looking for a change of scenery, Lizzie moved to Hobart to complete her general practice training. “While I was there, I completed a special skills post in expedition and travel medicine offered by my training provider, General Practice Training Tasmania,” Lizzie says. “I really enjoyed it. I had a colleague who was also outdoorsy and this also helped foster my interest.” “I was able to work the course into my job at the GP clinics I worked at, and they were so flexible and supportive of training.” “The job in Greenland came about during my final year of medical school when I went to Denmark,” says Lizzie who did a comparative study on general practice in Denmark and Australia. “I met the scientist who was running the expedition and a year or so later I received an invite to join.” “I knew there was a lot of variety in general practice, but I didn’t know there was so much different training available.” “Once you start meeting like-minded people, it’s phenomenal the type of doors that then open.” She eased herself into the expedition scene, staying for 2.5 weeks in her first season and then working her way up to just over two months during her last venture. Like many GPs, Lizzie is embracing the opportunities that general practice offers. “I wear quite a few hats right now!” Lizzie received her RACGP fellowship last year. She recently secured a job as a medical officer with the Antarctic Division at the Polar Medicine Unit and works there three days a week. For the remaining two days, she works as a GP in a suburban Hobart clinic and as a consultant to the Hyperbaric and Diving Medicine Unit at the Royal Hobart Hospital. As well as Greenland, general practice has taken Lizzie to the Solomon Islands in 2012 where she worked out of a “make-shift office” as the GP for the Australian team attending the Festival of Pacific Arts. “I was looking after a team of about 70, and this included all of the artists and the support crew for the artists.”
And with Hobart being “the gateway to Antarctica” Lizzie had the opportunity as a GP registrar to work in the Australian Antarctic Division Polar Medicine Unit, undertaking office-based work, including policy reviews for medical and workplace practices and procedures to help support medical officers on expedition teams. This work at the Polar Medical Unit led to Lizzie being one of two doctors stationed on Macquarie Island during winter 2011. Their role was to support the expedition team and crew for the Macquarie Island Pest Eradication Project. Lizzie is already looking towards her next medical adventure by building on her diving and hyperbaric consulting work. “I’m hoping to do more expedition medicine, but this time with a diving slant,” she says. “As a GP, I can do diving assessments for both recreational and professional divers.” She has already got her open water diving certificate, which she says helps her to treat her patients. “Diving experience gives you a better knowledge base and it gives me a greater understanding of what patients are talking about.” “It’s really good having the experience with divers and the hyperbaric chamber because it also complements some of the GP work I do, such as treating people with middle ear barotrauma and those who have hypoxic wounds and radiation damage.” Lizzie is hoping that her new part-time job with the Polar Medicine Unit will give her the opportunity to go on more expeditions. Her friends joke that the spelling of her name – with the double ‘z’ and double‘t’ – reflects Lizzie’s adventurous “double or nothing” attitude to work and life. And general practice has helped prepare Lizzie for work anywhere and in any condition. “You are a Jack of all trades as a GP. And doing these types of expeditions you just go in and pitch in and help with everything. As long as you are interested and really enthusiastic with everything that is taking place, it will all work out.” Written by Laura McGeogh
Taking a fresh look at general practice 27
G P profile
What happens when hallway learning for junior doctors spills out onto the internet? Blogger Dr Casey Parker of ‘Broome Docs’ is exploring the brave new world of digital information sharing and learning for doctors. Dr Casey Parker belongs to a new breed of doctors. They are the digital docs — the bloggers and tweeters who are forming online communities where medical peers share information, case studies and the odd barb of black humour around the online water cooler. Casey, who is Director of Clinical Training at Broome Hospital in Western Australia’s north, began his blog ‘Broome Docs’ two years ago. Described as a free educational blog for rural GPs and proceduralists, its original aim was to create an online community for the registrars, junior doctors and medical students Casey trains. It has achieved all this — and much more. “I think of my blog as hallway learning that has spilled out into the digital universe,” he says. “It’s a repository for all the case studies, topics and tips I use in my training role at the Broome Hospital. Most of the content is written and posted by me. I also invite colleagues to contribute and I often ask the trainee doctors I teach to put together a blog post for homework.” The content is based on rigorous evidence-based practice, but often penned in an irreverent style that uses catchy headlines and humour. When a headline says ‘Clinical Case 082: Traumatic fluid resus or midnight at McDonald’s?’, most people are intrigued to read on. Quizzes and opinion requests are another way in which Casey engages his online audience. Crack the diagnosis and you could be the Broome Docs Brainiac of the Day! Audio podcasts are a new innovation. The content is often used as a basis for training sessions. “Recently, for example, I put up an audio session on headaches where I talk to a couple of other GPs from around Australia about how we manage headaches in our practice,” he explains. “Instead of giving a lecture to my trainees I tell them you need to listen to this before you come along to the class. Then I might give them a case and I say how would you do this? It becomes more of a Socratic discussion rather than a didactic session.” As with most successful blogs, the comment stream can make for the juiciest reading, with colleagues sharing links to information sources or engaging in lively debate. Being an open access blog, comments come from doctors in all disciplines from as far afield as Scandinavia, the USA and Canada. “Sometimes this is some of the best stuff for junior doctors because they can see doctors having an open and egalitarian debate and they can learn multiple points of view,” Casey says. Casey says he received help in setting up his blog from Dr Mike Cadogan, an emergency physician at Sir Charles Gairdner Hospital in
28
“Whenever I get a new y of medical blogs an Perth whose blog ‘Life in the Fast Lane’ receives up to 20 000 hits a day. It’s one of the biggest medical blogs in the world. “Mike has been very helpful in setting up the technical side and coding. He runs a server for a number of medical blogs including the new Global Medical Education Project (‘GMEP’), a meta-blog that amalgamates the best ‘meducation’ resources on the internet.” Using the blogosphere and Twittersphere for medical education comes under the banner of FOAMed — free open access medical education. So far, this emerging movement is most active in emergency and critical care medicine but Casey believes it has potential across all disciplines, particularly in isolated rural settings.
Casey’s online favourites Casey’s own blog: broomedocs.com Dr Mike Cadogan’s blog: lifeinthefastlane.com New GP education blog: foam4gp.com Global Medical Education Project: gmep.org Twitter: Dr Chris Nickson @precordialthump Dr Minh Le Cong @rfdsdoc Dr Tim Leeuwenburg @KangarooBeach Dr Gerry Considine @ruralflyingdoc Dr Jonathan Ramachenderan @DrJRama Dr Casey Parker @broomedocs
young doctor I give them my list nd Twitter people to follow.” Universities, hospitals and training institutions are beginning to recognise the capabilities of internet-based learning platforms, but Casey cautions that institutions and the internet can be uneasy bedfellows. The power of the internet conversation lies in free, uncensored discourse across borders and disciplines, he says. Institutions often seek to introduce red tape such as approved posts, member-only access and paywalls, which can run contrary to the FOAMed ethos. Although Casey’s blog is used for his teaching role, it is very much his own independent blog. Growing up as a country boy, the jack-of-all-trades approach of rural general practice has always appealed to Casey. A GP by training, he is a generalist hospital doctor who deals with everything from
Photos courtesy Australian Rural Doctor
emergency and critical care to anaesthetics and obstetrics, as well as his teaching role. He and his young family enjoy the cultural diversity and laid-back tropical tempo of life in Broome — “a bit like Australia’s answer to Jamaica”. His wife Dr Zivana Nedeljkovic is also a GP who works in private practice. In addition to maintaining his own blog, Casey is an enthusiastic follower of other digital doctors, and he encourages his trainees to do the same. “Whenever I get a new young doctor I give them my list of medical blogs and Twitter people to follow. I’m constantly trying to get them to join the online conversation,” he says. Written by Jan Walker
Taking a fresh look at general practice 29
G P profile
The Irish rover GP supervisor Dr Patrick O’Sullivan has travelled the world as a small-town rural doctor. Now he is enjoying the chance to “travel without being a tourist” by doing locum work around Australia, and passing on his sense of adventure to the next generation of GPs.
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When Dr Patrick O’Sullivan was a young intern in his birthplace of Ireland, he remembers thinking that he “wanted to see what was around the corner”. This adventurous spirit has defined his career. Patrick’s journey in general practice has taken him from Cork and Limerick in Ireland to England’s green and pleasant land in Wiltshire, from the snowy wilds of Manitoba in northern Canada to scenic Te Anau on the South Island of New Zealand, then across the Tasman to picturesque Ulverstone in north-west Tasmania. Now, with his youngest child settled at university in Hobart, he is working there in a city group practice on the proviso that he can keep doing what he loves most — scratching his itchy feet and working as a rural doc. “I consider myself a rural GP. I said I’d join the Hobart practice on the basis that at least three months of the year I’d be going off to do rural locum work and they very kindly said that’s fine,” Patrick says in his charming Irish brogue. When Going Places magazine spoke to Patrick he was in the middle of a two-week locum on the remote, austerely beautiful King Island, off the coast of Tasmania. “I’ve been wanting to go to King Island for about 15 years, so when the opportunity came up, I said let’s go,” he explains.
“There’s a slight frisson inside when you go to a new place.” “I got involved with the Rural Health Workforce Association which is trying to encourage doctors of my vintage to do locum work and allow our rural colleagues a bit of time off. “I do the rural locum work because I enjoy it and I get to travel without being a tourist. My wife Carole fortunately is keen to come with me as we travel around so it’s an opportunity to help some of my rural colleagues while it gives me a break from my routine.”
Patrick ’s tips Don’t • for be city P -c
junior doctor s
revoca tional G entric — Co nsider eneral lot, and doing a Pr the joy rural p s of sm actice Placem ost thr all-tow ents Pr GP me ough t n o gram.Y c a o n he mmun s GP — hair y-c ou will ity life “You d hested learn a may be on’t ha ‘superanaest a ve to b revelat doc’ to hetists eB ion. be a ru and GP need a ral GP,” iggles or som obstet GP. e Patrick ricians says. W fill spe Define hile G cific jo b y o s , u m r any tow P own w to wor ork-life k four ns just days a no doc week, d balance — A tor at a s a rur o it. Th ll. al GP, if at’s be tter for y the tow ou want n than
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The people in rural communities are another reason. While on King Island, Patrick returned from a swim to find a freshly caught crayfish on the table — a food offering from a local fisherman. Such a gesture is typical of the warmth he has found common to country communities the world over. For Patrick, the professional challenge is also important. “There’s a slight frisson inside when you go to a new place. What will it be like? What will the staff be like? What will the hospital be like? How will the first night on call go? If we didn’t have that little frisson of nerves inside, what would life be?” Prior to his King Island stint, Patrick filled in for doctors on Lord Howe Island and several country towns in New South Wales. Later this year he will do a locum in Esperance on Western Australia’s south coast. His earlier adventures in rural general practice have prepared him for most eventualities. His first job outside the British Isles was in a small town called Gillam in the icy frontierland of Manitoba, Canada. There were no roads in or out — you had to fly in or take a long train ride — and the Cree Indian population often presented with heart-sinking medical and social challenges. “When Carole and I got there we both thought — bloody hell! But then I just got on with it.” “Just getting on with it” was Patrick’s attitude when he found himself dangling from a helicopter to rescue lost, injured or ill tourists in his next job in Te Anau on the South Island of New Zealand. “We just did it, it was exciting!” he recalls. One of the most satisfying aspects of his ‘day job’ in Hobart is being supervisor to the GP registrars at General Practice Training Tasmania. He encourages the next generation of GPs not to limit their thinking to city general practice and to give rural general practice a go — and maybe even venture forth and work internationally for a while as he has. But he also advises registrars to keep their work in perspective. “The first thing for me is my family, the job does not come first,” he says. Patrick’s other interests span sailing, rugby and taking long walks wherever he may find himself across the country. “I like to impart the feeling of how lucky any registrar is that they’re going to end up with a fellowship that allows them to work anywhere in Australia and, within reason, anywhere in the world. What fantastic mobility!” Written by Jan Walker
Taking a fresh look at general practice 31
Clinical
CORNER
Clinical Corner case studies and tips for treating patients are provided courtesy of Medical Observer. The following case studies are by Dr Ian McColl. Red dot marks the spot
Acute blistering diseases are always a diagnostic challenge, This case demonstrates an important sign but much can be learnt from just looking at the blisters. in skin cancer diagnosis. This patient has both intact blisters occurring on a red The small ulcerated area on this patient’s base (seen centrally) and ruptured blisters showing a forehead illustrates the red dot sign. The superficial peeling of the skin (seen bottom left). red dot sign often signifies an underlying The diagnosis was thought to be bullous pemphigoid, basal cell carcinoma (BCC) as it represents which was supported by the intact blisters, but not by the an area of ischaemic ulceration on the superficial skin peeling. tumour surface. In bullous pemphigoid, the separation occurs at the Sometimes pin-point bleeding is noted dermo-epidermal junction and the overlying epidermis is thick and intact, hence the blisters do not rupture easily. when towelling dry after a shower. This patient had early toxic epidermal necrolysis due to a drug reaction. The diagnosis was confirmed by skin biopsy and negative immunofluorescence. For more images, see skinconsult.com.au
More than one cause for mouth lesion Always blanch the surrounding skin because, as in this case, it may show a pale zone, which indicates the clinical extent of an underlying morphoeic or infiltrating BCC. This will need excision using Mohs micrographic surgery to determine the real tumour margins, because the infiltrating component often extends another 7 mm from the apparent clinical edge. In this case, it led to a 4 cm diameter excision, and all because of a little red dot. For more images, see skinconsult.com.au
Blisters tell the story
This patient had lichen planus but presented with an acutely painful mouth. She was taking Plaquenil (hydroxychloroquine), but had also been given a topical steroid ointment to apply to the oral lichen planus on her buccal mucosa. Friable, white mucosal plaques are evident in the image. Usually lichen planus gives a white net-like mucosal reaction that cannot be wiped away. This mucosal plaque was easily wiped off. In this case, she had candida superimposed on the lichen planus. It was presumably induced by the topical steroid being applied intra-orally. She was treated with amphotericin lozenges for a week, and her oral pain resolved. Candida tends to colonise damaged mucosal surfaces and often exacerbates oral lichen planus without the help of the topical steroid, as in this case. For more images, see skinconsult.com.au Taking a fresh look at general practice 33
Murtagh’s tales A dangerous case of post-flu fatigue Melinda, a 17-year-old student, attended because she was feeling weak in her arms, especially in the right arm and wrist where she described a tingling sensation that had been present for the past 24 hours. Her recent history was that of a febrile illness ‘rather like the flu’ a few days beforehand and then she unwisely played several games of tennis in a tournament that finished the previous day. She eventually had to withdraw. Melinda also complained of headache, nausea and an aching jaw as well as the right arm weakness. Sensation to touch was normal and her reflexes were equivocal. I attributed the problem to soreness following sporting overload after a viral infection. Notwithstanding her age I considered the possibly of carpal tunnel syndrome.
Drawn from over 30 years experience as a GP, Professor John Murtagh’s clinical cases provide valuable insight to the problems – and mistakes – that GPs can encounter.
Upon planned review two days later, I noticed a dramatic and disturbing change. She walked with considerable difficulty into the surgery, looking well, but was weak in all limbs with obvious motor weakness and loss of reflexes. She was also having breathing difficulty and her peak flow was markedly reduced. Diagnosis: She was in fact suffering from Guillain-Barre syndrome (acute idiopathic demyelinating polyneuropathy). She was admitted to hospital where she eventually received assisted ventilation for a few days without developing complete paralysis.
Torsion of the testis — a potential disaster Greg N, aged 15 years, presented with one hour of sudden onset of severe suprapubic and right groin pain with associated vomiting. On examination the right testicle was tender, red and swollen. Its elevation increased the pain. His GP referred him to the nearest surgeon and asked him to attend to it urgently. However, he was placed at the end of the operating list and when operated on 8 hours from the onset of the pain an orchidectomy was performed because the testicle was infarcted and necrotic. The surgeon has mismanaged the case of Greg. One of the classic challenges facing the GP is the early diagnosis and quick referral of a testicular torsion. The loss of a testicle, an avoidable problem, is a real ‘time bomb’. Apart from the distress for the patient and his family, the legal consequences are terrible for the practitioner. It is an all too common cause of litigation. The time factor: The optimal time to operate for torsion of the testis is within 4–6 hours from the onset of the pain. About 85% of torsive testes are salvageable within six hours but by 10 hours the salvage rate has dropped to 20%. 1,2 At surgery the testicle is untwisted and an orchidopexy (anchoring the testicle) is performed. A gangrenous cd testicle is removed. Cautionary tale: Many testicles are lost because of inappropriate delays with referring for an ultrasound. The patient should be referred immediately to a surgeon or surgical centre. Teenage boys presenting with acute right iliac fossa pain, nausea and vomiting are sometimes misdiagnosed as acute appendicitis.
References 1.Bird S. Medicolegal handbook for general practice. South Melbourne: The RACGP, 2006. 2.Wijesinha SS. Torsion of the testis. Update 19 February 1997; 218.
Taking a fresh look at general practice 35
Nipple soreness and swelling during breastfeeding How should a breastfeeding woman with nipple soreness and inflammation be treated? Is it eczema of the nipple, a response to an allergen or something more serious? CASE SCENARIO Anna, a 30-year-old mother, was breastfeeding her 6-week-old son. Soon after she started breastfeeding, she developed swelling and irritation of the skin at the periphery of her nipple areolae. The area was constantly swollen, weeping and sticky and very uncomfortable, especially when her baby started sucking. She had breastfed her two other children with no problems. Anna was in the habit of giving her baby ranitidine just prior to each feed but the problem persisted even when she changed the timing of the ranitidine. What has happened and what can be done to help Anna?
COMMENTARY Diagnosis Many women experience discomfort, irritation and fissuring of the nipples when they are establishing breastfeeding; however, true eczema of the nipple can also occur (see Figure). The inflammation of eczema results in raw areas, itch and fissuring, which is painful. This leads to compromise of the epidermal barrier, which in turn may result in infection. Eczema of the nipple
Anna’s symptoms are typical of infected eczema with swelling, weeping and soreness. During lactation, this is usually secondary to the physical action of suckling; however, a reaction to allergens in the baby’s mouth is a possibility. If her baby is prone to reflux, traces of medication in the baby’s stomach could still come into contact with the nipple well after ingestion.
Ranitidine, an H2-antagonist, is a very uncommon cause of allergy and is unlikely to have played a role here; however, to rule out this possible source, it would be necessary to cease it completely rather than change the timing of giving it. As it is such an unlikely cause, this would only be necessary if other measures have failed. Other causes should be addressed first. Anna may not have mentioned potential irritants and allergens that she could be applying herself. Creams, topical medications and nipple shields could all be playing a role and are much more likely than ranitidine to cause these symptoms. Topical medications may contain lanolin, tea tree oil and local anaesthetics, which are all potential allergens. Many women who develop eczema of the nipple are atopic. Another relevant question is whether the patient is asthmatic or has had eczema on other parts of her skin in the past. Psoriasis may also involve the nipple. This condition tends to occur in areas of skin that are exposed to chronic friction and trauma – this is known as the Koebner phenomenon. GPs should look for any signs of psoriasis on the rest of the patient’s skin. Candida albicans, found in the baby’s mouth, can be cultured from inflamed nipples. This may not represent true infection. Candida as a cause of breast symptoms is controversial; however, it is not unreasonable to give a trial of topical antifungal cream if there is a positive culture. True mastitis during breastfeeding is seen in about 2% of lactating women. It seems to be more common in women aged 30 years and over and where there has been obstruction of a duct. The infective organism is usually either Staphylococcus aureus or Group A Streptococcus, which gain entry via cracks in the nipple. Mastitis is acutely painful and patients may be unwell and febrile. Differential diagnoses The most feared condition in the differential diagnosis of any sort of inflammation of the nipple is Paget’s disease. This presents with a unilateral, well-demarcated, erythematous scaly plaque involving the nipple and areola. It frequently erodes and weeps. The clue to this patient’s condition being something much less sinister, apart from her age, is that both nipples are involved. A rapid response
This article originally appeared in Medicine Today 2011;12(8):63–64 and is reprinted here with permission.
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to appropriate treatment is all that is required to rule out Paget’s disease of the nipple. Papillary adenoma of the nipple is a benign condition; however, it can mimic Paget’s disease with an erosive, crusted rash and bloodstained nipple discharge. Raynaud’s phenomenon can cause pain during breastfeeding. The clue to this diagnosis is that the nipple blanches during breastfeeding, with the typical triphasic colour change seen in Raynaud’s of the fingers precipitated by exposure to cold. Treatment GPs should ensure that patients with this condition are not using any potential irritants or allergens, including soap, and take a skin swab to rule out bacterial and fungal infection. A finding of S. aureus or Group A Streptococcus should be treated with oral antibiotics. If there is true cellulitis of the breast with spreading erythema and fever, oral antibiotics should be commenced immediately. Group A Streptococcus cannot always be isolated from skin cultures. A finding of C. albicans can be treated with topical antifungal cream. The eczema will settle with regular use of a simple greasy emollient such as white soft paraffin or emulsifying ointment applied after every feed, and a topical corticosteroid ointment. A potent non-fluorinated preparation, preferably in an ointment base, such as methlyprednisolone aceponate 0.1% or mometasone furoate 0.1%, will produce rapid results in a few days, after which the weaker hydrocortisone 1% can be used immediately for any recurrences. The patient may be anxious about her baby being exposed to the ointment; however, the more potent ones only have to be applied once per day and hydrocortisone twice a day. This should be done directly after a feed. Anna should continue to breastfeed, providing it is not too uncomfortable for her. Pain relief is important and paracetamol can be given while breastfeeding. She can be reassured strongly that this is a common and harmless condition. The patient may feel more confident if she speaks with a lactation consultant at an early childhood health centre.
SUMMARY Irritation of the nipple during breastfeeding is usually due to mechanical trauma; however, if inflammation and weeping occurs then eczema and bacterial superinfection may be present. This is benign and usually responds rapidly to use of topical corticosteroids, bland moisturisers and antibiotics. Further reading •Barankin B, Gross MS. Nipple and areolar eczema in the breastfeeding woman. J Cutan Med Surg 2004;8:126–130. •Tait P. Nipple pain in breastfeeding women: causes, treatment and prevention strategies. (Review). J Midwifery Womens Health 2000;45:212–215. Author Gayle Fischer MBBS, MD, FACD, is Associate Professor of Dermatology at Sydney Medical School – Northern, The University of Sydney, Royal North Shore Hospital, Sydney, New South Wales. Competing interests: None.
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. Taking aa fresh fresh look look at at general general practice practice 37 37 Taking
Did you know…
You can do your GP training in Aboriginal Health Organisations
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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 Australian GP Training Liaison Officer
03 9411 9411 www.vaccho.org.au
• 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
Fig Jam By Dr Marcus Gunn
Maybe it’s no longer true that ‘the camera never lies’. Photoshop has put paid to that. But back in the early days of general practice training, the video camera was the pitiless judge of a registrar’s performance. Every few months, two enormous aluminium road-cases would arrive in the clinic from the RACGP. In one was a video camera the size of a small hatchback, and in the other a bulky monitor that gave a monochrome image reminiscent of the moon landing. But the image was clear enough to allow a visiting medical educator to peer into the murky depths and comment on the registrar’s recorded performance. So when I first found myself confronted by the unblinking eye balanced atop its tripod in my consulting room, fear fomented fast.
As the first few patients squeezed around the apparatus and tried to have a normal consultation despite its glowering gaze, I was surprised to find that I wasn’t as bothered by it as I’d thought. This was back in the days when being videoed was something of a novelty, of course, and for a cocky young registrar such as myself, it seemed like the ideal chance to show off. After all, I was well on the way to being a good GP. No, hang on, I was already an excellent GP and here was the chance to show it. So every consultation became a command performance for the camera, with more ham on display than at Christmas. The consultation that I was planning on submitting for a possible Oscar nomination – given that my Fellowship was clearly in the bag – involved a young mother and her three-month-old child with otitis media. I handled the matter briskly yet competently,
and as I signed the unnecessary antibiotic prescription, I remembered the video camera hulking in the corner. Here’s a chance to show off my holistic approach, I thought, and murmured solicitously as I concentrated on the script pad: “So, how’s everything going, then?” “Oh … fine …” came the response, so I ripped the Amoxil script off the pad and presented it with a flourish. I may even have winked at the camera; I hope not. I do remember the rest of the video, though. When the medical educator came by a few days later to review the tape with me, she made a point of showing the recording several times, even freezing the frame to capture the young mother’s distraught face as she raised her eyes to the ceiling and uttered the words: “Oh … fine …”. Fortunately the camera angle missed my gurning features while capturing the full agony of this woman’s undiagnosed postnatal depression. I sat in while my supervisor saw her urgently later that day and gave me a masterclass in patient-centredness. So what else did I learn from what remains the single most powerful lesson of my 30 year career? That pride comes before a fall; that you never ask an important question without eye contact; and that facilitated reflection on observed practice is a vital part of GP training. And, it’s true, the camera never lies.
Taking a fresh look at general practice 39
Reviews App OXFORD HANDBOOK OF
CLINICAL MEDICINE Murray Longmore Ian B. Wilkinson Edward H. Davidson Alexander Foulkes/ Ahmad R Mafi.
Oxford handbook of clinical medicine, eighth edition by Murray Longmore, Ian Wilkinson, Edward Davidson, Alexander Foulkes and Ahmad Mafi Tired of carrying around your Oxford Handbook, as well as your patient list/spare progress notes/path slips/radiology requests and everything else you are expected to produce at an instant during bedside rounds? Then try this App. Trusted to provide accurate information, and a must for all medical
students, junior doctors and trainees, the Oxford Handbook is now available as an App for iPhone, iPad and Android devices. It has contributions by 15 authors, and was last updated on 18 March 2013 (Version 2.3.8 of the eighth edition) – where any amendments of text, tables or figures are updated immediately in the App version (compared to waiting for all updates to be collated into a new edition in printed versions). It maintains the same familiar format where chapters continue to be mainly systems based, along with separate chapters on emergencies, practical procedures, and reference intervals – making these easy to find quickly. The eighth edition also contains a new ‘history and examination’ chapter; expanded radiology, cancer and nosocomial infection topics, and has more images. The cosmological background to the eighth edition, describing the position of the various members of the medical team involved with ‘the patient’, including the role of the GP – ‘the infinity from whence the patient came, and to whom he will return’, is a must read. The index continues to be a bit difficult to use. In the printed version, several pages were often listed per topic, only occasionally listed in bold to indicate the main section for the topic.
BOOK S A guide to evidence-based integrative and complementary medicine by Vicki Kotsirilos, Louis Vitetta and Avni Sali Doctors and medical students are renowned for the catch phrase, ‘Show me the evidence’ (as opposed to the Tom Cruise line, ‘Show me the money’!) … Well, finally it is here. A Guide to Evidence-based Integrative and Complementary Medicine addresses many serious health issues such as asthma, cancer, diabetes, hypertension, osteoarthritis and rheumatoid arthritis – just to name a few. Initially, the basis of complementary and integrative medicine is explained, as well as the fact that when treating a person we are treating them in their entirety as opposed to treating a disease state.
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It can take some time to scroll down the App version to find your topic with the index listed alphabetically under initial letter, especially when the second letter is much further down the alphabet. Instead of several pages listed, it has ‘see section’ to tap for that topic. Up to five ‘see sections’ are displayed per topic, again none in bold to indicate the main segment. Some topics are better arranged where subsections are displayed before the ‘see section’ tab. It would be beneficial if this was done for all topics with multiple see sections listed. The App is available through an iTunes account, enabling access on both iPad and iPhone. Access via both can be useful, as depending on the situation, iPhone access is useful in the hospital ward environment (you will have your phone with you anyway), whereas the iPad version is great on your desk in the GP setting – being larger, easier to see, and useful to show pictures/photos/diagrams to patients for education purposes. Overall rating: Highly recommended. Published by Oxford University Press, 2012. Available through iTunes for $51.99 Review by Dr Liz Bond, Melbourne,VIC
Each chapter provides a medical overview of the issue at hand, and then reviews the more ‘traditional treatment’ modalities. It then explores lifestyle modifications including mind-body medicine, environment and exercise, and progresses to nutritional supplementation, herbal medicines and physical therapies. The information provided is easy to read and is almost presented as a meta-analysis review. The relevant studies are discussed and the statistical significance is also adressed.
Each chapter then concludes with a table, which has the modalities and the level of evidence in accordance with NHMRC guidelines. There are also clinical tip handouts, which are easy to read and provide a patient-friendly review; which as this book is available online and fully searchable, gives patients take-away information to keep.
desk. While initially she has to grapple with the terminal nature of this condition, her mother refuses to accept the bleak prognosis. Celeste then finds herself faced with her mother’s decision as a devout Catholic, to postpone conventional supportive therapy in search of a miracle cure in the town of Nicula in Romania.
A Guide to Evidence-based Integrative and Complementary Medicine is written by highly knowledgeable people (within both the traditional medicine and integrative medicine arenas), for medical practitioners who are always being asked by their patients about complementary and integrative medicines. Who hasn’t been asked if glucosamine or krill oil are effective? At no point do the authors suggest ‘traditional’ medicines should be discarded, in fact the opposite is the case. The authors have provided an evidence-based platform from which we can all hang our hat and provide a complete treatment package, thus treating our patients as a whole person and not as a compilation of disorders.
Despite her rejection of religion and her professional discomfort about encouraging false hope, Celeste finds herself accompanying her mother and younger half-sister Nathalie, on this pilgrimage. It starts off as a journey undertaken out of duty and love, but for Celeste, it develops into a journey of self-discovery as she confronts her own inner demons: her grief about her childlessness, her ambivalence about her marriage and her unresolved anger about her stepfather. At the same time, the strains of the physical journey to Nicula unravel her frustrations towards her flighty sister, who remains childless by choice, and her mother for her blind faith.
A Guide to Evidence-based Integrative and Complementary Medicine is published by Churchill Livingstone, 2011. RRP $84.99
Overall, Pilgrimage is a well-written and easy to read novel, which will resonate with GPs who may have found themselves maligned with the treatment decisions made by their patients or loved ones. It is an insightful and thought-provoking journey into one’s identity and is sure to have readers finding parallels in their own lives. Perfect to share with friends or in a book club.
Review by Dr Kerry Summerscales, Adelaide, SA
Pilgrimage is published by Scribe Publications, 2012. RRP $29.95 Review by Dr Natalie Caristo, NSW
Pilgrimage by Jacinta Halloran Pilgrimage is a story about a collision of faith, relationships and reality. It is the story of a 49-year-old paediatrician, Celeste, and her struggles with her work, her faith, her past and her relationships. Celeste’s father died at a young age and later, her stepfather walked out on the family. In adult life, she and her husband have been unable to have children. When her mother Patricia is diagnosed with motor neurone disease, Celeste finds herself on the other side of the doctor’s
Taking a fresh look at general practice 41
Great opportunities within the AGPT program The Australian General Practice Training (AGPT) program offers registrars the opportunity to undertake a variety of interesting and challenging training posts, which exemplify general practice, including Aboriginal and Torres Strait Islander health training posts.
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-based public health Health promotion within a cultural context.
“Working at WMHSAC has been a fantastic learning experience. I have learnt so much about the culture, health barriers and day-to-day issues of the local Aboriginal people. I have done this by working with them, under their direction and by treating them as patients. I feel I am an appreciated member of the team. I look forward to seeing my regular patients as we have a good laugh together. The case mix is really interesting – as I see a great range of ages and wide scope of illnesses. A locum commented to me the other day that this was the first time she’d seen symptomatic gonococcal urethritis in a male patient – she’s been in general practice for 30 years. I’ve been in general practice for six months and have seen it at least a handful of times!” Working at an AMS is an experience I would recommend to all general practitioners. The divide in health between ‘Indigenous Australia’ and ‘Australia’ is appalling. As a profession we are in a prime position to improve the divide through the provision of culturally appropriate health care and advocacy when required. I expect my professional development in this area gained through the AMS will hold me in good stead for my future practice as an Australian GP.” Dr Kate Peters, registrar – Wirraka Maya Health Service, Port Hedland Western Australia * The term ‘Indigenous’ within the context of this document is in reference to and respect of both Aboriginal and Torres Strait Islander peoples.
Visit www.agpt.com.au or talk to your regional training provider
Applications for the 2014 AGPT program are open from Monday 15 April to Friday 17 May 2013.
Where to now?
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So, you’ve read through Going Places magazine and you’re 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.
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.
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.
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, and acute and chronic disease management.
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Visit gpet.com.au to find out more about the PGPPP.
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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. 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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Visit gpaustralia.org.au To find out how general practice training works, visit gpaustralia.org.au 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.
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