Going Places Magazine - Issue 6 by GPRA Publications

G oing P laces

In this edition:

Taking a fresh look at General Practice An initiative of GPRA Dear fellow future GPs

How time flies – here we are back again with another edition of Going Places. We’re now up to number 6, which we feel is the best issue yet, packed with interesting GPs and articles.

The Going Places Network is now well-established in hospitals up and down Australia, with 47 GP Ambassadors covering 43 hospitals … and we’re still continuing to grow. There have been quite a few great networking events recently – you can read about two that were held recently in Adelaide and Logan, Queensland.

The featured GP in this issue is Dr Sam Goodwin, the closest thing we have to a GP Action Man, with his adventures covering the Snowy Mountains, the Whitsundays and the Kimberley – he’s now residing in Alice and enjoying the outback. A few of the other GPs we feature have also travelled extensively – Dr Joshua Wan to the rugged parts of southwest China and Dr Edi Albert from the Scottish Highlands to Antarctica! Closer to home, Dr Jacquie Johnston has pursued her love of Aussie rules and can be seen at Geelong footy matches, while Dr Hannah Chapman keeps herself fully occupied with four jobs! The interview with Dr Peter Fox is also interesting – he has been a GP for almost 40 years and still loves the challenges it provides.

As usual, we give prominence to PGPPP – the great way to experience general practice in the real world! This time our intrepid correspondent is Dr Natasha Vavrek who has just completed 12 weeks in Scottsdale, about 70kms east of Launceston, in Tasmania. There’s lots more to read – TechTalk looks at more high tech medical developments, Dr Sarah McEwan has provided an intriguing What’s your diagnosis? and there are two beautifully written patient stories contributed by Dr Genevieve Yates. We also hope you’ll find two articles – the connection between Greek mythology and medical terminology, and maggot debridement therapy (MDT) – of interest! Please enjoy – and, as always, we welcome any feedback you have … or better still, any contributions to make Going Places even better! Yours in general practice

07 Dr Sam Goodwin Enjoying GP Wonderland in Alice! 14 Dr Jacquie Johnston The GP who’s kicking goals 18 Dr Peter Fox Practice makes perfect 22 Dr Joshua Wan China on his mind 26 Dr Natasha Vavrek Natasha’s PGPPP diary 30 Dr Hannah Chapman Enjoying a mix of medical work 34 Dr Edi Albert The GP with a passion for adventure 40 Dr Jo Noble Living life to the max

Dr Lana Prout Hospital Registrar – Southern GP Training Latrobe Regional Hospital, Gippsland, Victoria GP Ambassador Gippsland GPRA Board Member (Prevocational)

Going Places! If you have a t We welcome your feedback on us an email and tell us wha few spare moments, please drop you’d like to read about and t wha you think of our magazine, goingpla ces@gpra.org.au even if you can contribute! Designed, managed and produced by wam Pty Ltd. Interviews with GPs by Fran Molloy, © GPRA 2011. No material contained within this publication may be reproduced in full or in part without the express permission of the publisher.

We would like to acknowledge the help and support provided by Australian General Practice Training and Avant, which has made Going Places possible. Our sincere thanks to all the GPs who have generously given their time to be interviewed and photographed. Going Places is published by GPRA, Level 4, 517 Flinders Lane, MELBOURNE VIC 3000. Phone: 1300 131 198. www.gpra.org.au

Meet your five new GP Ambassadors Find out a little bit about our newly appointed GP Ambassadors! Remember – GP Ambassadors are the GP champions in your hospital and can help you with all your questions about careers in general practice. Contact them today – they are waiting to hear from you! Profiles and information about all our GP Ambassadors can be found at www.gpaustralia.org.au

ANITA DEY, 25 HOSPITAL

Canberra Hospital, ACT

canberragp@gpra.org.au

I’m originally from Canberra – I studied medical science for my undergraduate degree at ANU. I’ve wanted to be a doctor since I was a teenager because I always loved learning about the human body – so Medicine seemed the ideal way to keep learning and help people at the same time. I had a fantastic medical student rotation in a local general practice and loved it so much I did a rotation as an intern. My fantastic supervisors and clinical tutors throughout medical school also showed me what a terrific profession general practice can be. I think general practice is a really unique specialisation because there are so many subspecialties to choose from. I can have a couple of days working in a practice and others doing anaesthetics or minor surgery. I really like being able to spend more time talking to patients and building a relationship with them, so I can treat them more holistically. I can help other interns who haven’t quite decided what they want to do long term. I’d also advise those of you who aren’t sure about a career as a GP to perhaps do the PGPPP program.

DONNA LAU, 28 HOSPITAL

Gosford/Wyong Hospitals, NSW

gosfordgp@gpra.org.au

I was born in Sydney to Chinese/Taiwanese parents. My first language was Chinese and I didn’t learn English until I was enrolled in school. My high school was Sydney Girls High and I went to Sydney University for both my undergraduate course and medical degree.

ERIN GORDON, 28 HOSPITAL

The Northern Hospital, VIC

northerngp@gpra.org.au

I grew up in downtown industrial Ballarat (affectionately known as “The Rat”) terrorising the streets with my posse of younger brothers on our BMX bicycles. I then proceeded to terrorise the corridors of Loreto College for the years of my secondary schooling. I was actually entertaining the idea of becoming a pilot or an engineer until a family friend recommended during my final year at high school that I should work with people in a caring role of some sort. I also liked the idea that my love of talking and my communication skills could be used to the advantage of others. Deciding on general practice was a very gradual process. After ‘trying on for size’ many other specialities, I chose general practice as it offers variety, flexibility, a chance to be involved in community, the prospect of travel and a chance to provide a real continuity of care not always experienced in other fields. General practice offers a unique opportunity to be involved in your patients’ lives and to care not only for them, but their community. I decided to become a GP Ambassador as a good friend of mine was already a GP Ambassador and recommended I consider doing the same at the Northern Hospital. Also – I am a strong believer that general practice is largely under-represented in the hospital setting. There are many JMOs who would like the experience of a general setting in their training years; consequently, providing that link to the junior medical staff really appeals to me. Anybody thinking about general practice should talk to GP Ambassadors, GP registrars, attend careers expos/evenings and join the Going Places Network to learn about the variety of opportunities GP training can provide! In particular, try to get a PGPPP placement in your first few years to really experience general practice firsthand. Joining the Going Places Network enables those interested to really sink their teeth into the variety of settings in which one can practice, the range of opportunities within the program and the necessary requirements for training. Its a great way of being able to make a well informed career decision.

I knew I wanted to study medicine when I’d been stuck inside a medical research lab for many hours with no windows to the outside world – and with my most frequent companions being the lab mice. I realised I needed more human contact! I wanted to help people in a more direct way. General practice allows you do so much, as you can specialise in so many different areas – and it allows you to maintain a great balance between your lifestyle and your career. I love being both the first port of call for most of the population’s health issues as well as being able to set down roots in a community and get to know a patient and their family. I also have a dream of travelling around rural and outback Australia, which I’d really love to do as a locum GP. I’d like to incorporate more fun and creative ways of educating people about general practice. The great thing about the Going Places Network is the way it makes you a part of a supportive group with similar goals as yourself.

NATALIE SANCANDI, 25 HOSPITAL

St George Hospital, NSW

stgeorgegp@gpra.org.au

Apart from two years in Singapore as a child, I grew up and went to school in Kingsgrove in Sydney. I completed undergraduate medicine at UNSW – graduating in 2009. I decided I wanted to study medicine when I was about eight. I was always the doctor when playing doctors and nurses. However, it wasn’t until the end of high school that I was sure of my decision. Studying biology in high school, spending time in a practice for work experience and watching RPA on TV all helped with the decision-making.

SOPHIE FLETCHER, 26 HOSPITAL

Sir Charles Gairdner Hospital, WA

charlesgairdnergp@gpra.org.au

I was born and bred in Sheffield, England and then went to medical school in Leeds. I’ve always wanted to be a doctor from when I can first remember. I absolutely loved my toy doctor’s kit as a child. My Grandmother always wanted to be a doctor and encouraged me all the way. She didn’t have the opportunity to become a doctor herself and this made it a significant goal for me to aspire to. I was always undecided between paediatrics, geriatrics and general practice. After doing a GP placement in my second year, I was set on becoming a GP. It’s all of my favourite parts of medicine rolled up into one speciality. You get to know your patients really well – to treat them and their families. You get to see all the different generations from babies and children through to elderly patients. This makes the job both challenging and rewarding. I’m really excited about being a GP Ambassador because it’s a fantastic information source and way of keeping up to date with what’s happening in the world of general practice. You can socialise with people who are on the same wavelength as you, build up a support network and make new friends.

My GP was particularly influential – providing me with an insight into life as a GP. I had always liked the idea of general practice and over time began to really appreciate the variety available. The good work/life balance and the flexible hours that general practice offers also held great appeal. There’s the opportunity to teach which is something else I enjoy and I can focus on my interest in women’s and children’s health. As a GP Ambassador I’d like to promote general practice to interns and residents who are considering PGPPP terms or who have questions about general practice as a career. I can talk about my experiences and share my knowledge – then refer them to the appropriate resources, as necessary.

Want to find your local GP Ambassador?

Here’s a complete listing covering all states. Don’t be shy – make contact! Our GP Ambassadors would really like to hear from you. The Going Places Network is expanding rapidly, so please check our website – www.gpaustralia.org.au – for the most up-to-date listing of GP Ambassadors. Name QUEENSLAND Ann Arlott Brendan Thompson Casey Kalsi Danielle Arabena Estera Bratko Katya Groeneveld Luke Dwyer Michael Cross-Pitcher Ming Lin Riley Savage Sarah Fairhall Sarah Handley Scott Hahn Simon Ting VICTORIA Claire Langford Erin Gordon Heather Pascoe Joshua Crase Lana Prout Lang Yii Melanie Winter Melissa Cairns Ramanpreet Kaur Tasmania Bec Short Natasha Vavrek SOUTH AUSTRALIA Darren Ng Gerry Considine Phil Deacon Sara Le Sebastian Rees Stacey Seakins Thomas Quigley WESTERN AUSTRALIA Mary-Therese Wyatt Shelley Davies Sophie Fletcher Yvette Bruce New South Wales Amy O’Brien Anna Elder Donna Lau Elina Gourlas Jane George Natalie Sancandi Nici Wilkinson Nicole Hall Ryan Metcalfe Sumit Chadha ACT Anita Dey

Hospital

Rockhampton Hospital Ipswich Hospital Mater Hospital Redcliffe Hospital Royal Brisbane Women’s Hospital Gold Coast Hospital Toowoomba Hospital Nambour Hospital Redland Hospital Townsville Hospital Cairns Base Hosptial Mackay Base Hospital Logan Hospital Princess Alexander Hospital

rockhamptongp @ gpra.org.au ipswichgp @ gpra.org.au matergp @ gpra.org.au redcliffegp @ gpra.org.au royalbrisbanegp @ gpra.org.au goldcoastgp @ gpra.org.au toowoombagp @ gpra.org.au nambourgp @ gpra.org.au redlandgp @ gpra.org.au townsvillegp @ gpra.org.au cairnsgp @ gpra.org.au mackaygp @ gpra.org.au logangp @ gpra.org.au princessalexandragp @ gpra.org.au

Alfred Hospital Northern Hospital Geelong Hospital Ballarat Hospital Gippsland Hospital Goulburn Valley Health Eastern Health Austin Hospital Southern Health

alfredgp @ gpra.org.au northerngp @ gpra.org.au geelonggp @ gpra.org.au ballaratgp @ gpra.org.au gippslandgp @ gpra.org.au sheppartongp @ gpra.org.au boxhillgp @ gpra.org.au austinhospitalgp @ gpra.org.au southernhealthgp @ gpra.org.au

Royal Hobart Hospital Launceston Hospital

royalhobartgp @ gpra.org.au launcestongp @ gpra.org.au

Royal Adelaide Hospital Flinders Medical Centre Flinders Medical Centre Lyell McEwin Hospital Queen Elizabeth Hospital Royal Adelaide Hospital Modbury Hospital

royaladelaidegp @ gpra.org.au flindersmedicalgp @ gpra.org.au flindersmedicalgp @ gpra.org.au lyellmcewingp @ gpra.org.au queenelizabethgp @ gpra.org.au royaladelaidegp @ gpra.org.au modburygp @ gpra.org.au

Royal Perth Hospital Fremantle Hospital Sir Charles Gairdner Hospital Joondalup Hopsital

royalperthgp @ gpra.org.au fremantlegp @ gpra.org.au charlesgairdnergp @ gpra.org.au joondalupgp @ gpra.org.au

Wollongong Hospital Royal Prince Alfred Hospital Gosford Hospital Hornsby Hospital Bankstown and Campbelltown Hospital St George Hospital Westmead Hospital Bankstown and Campbelltown Hospital Gosford Hospital Royal Northshore Hospital

wollongonggp @ gpra.org.au royalprincealfredgp @ gpra.org.au gosfordgp @ gpra.org.au hornsbygp @ gpra.org.au bankstowngp @ gpra.org.au stgeorgegp @ gpra.org.au westmeadgp @ gpra.org.au bankstowngp @ gpra.org.au gosfordgp @ gpra.org.au royalnorthshoregp @ gpra.org.au

Canberra Hospital

canberragp @ gpra.org.au

The Going Places Network helps you to find out more about general practice – importantly, it also helps you to develop a network of other doctors interested in a similar vocation and share experiences with them.

STOP PRESS!

ors! o more GP Ambassad We’ve just recruited tw l, VIC pita lissa Cairns Austin Hos thern Health, VIC Dr Me Dr Ramanpreet Kaur Sou

Going Places – ISSUE #6

COVER STORY

DR SAM GOODWIN

Enjoying GP Wonderland in Alice! am currently on the Australian College of Rural and Remote Medicine (ACRRM) pathway. I work in Alice Springs – two days a week at the local hospital doing anaesthetics and two days a week with Central Clinic, in an office-based GP setting. I also do one day a week as a medical education registrar, which I really enjoy. I only started this new routine a few weeks ago – previously, I worked for 12 months with the Royal Flying Doctor Service. I’m still available to work with them, whenever I’m needed.

Going Places – ISSUE #6

COVER STORY I’m really happy with the flexibility and variety of the work I do on a daily basis. I can work in primary care as well as in secondary care in an emergency environment. My general practice training allows me to work across different environments, so I never feel like I’ve been pigeonholed into any speciality or role from day to day.

I grew up in Townsville, North Queensland, in a major regional area. Then I went off to a boarding school in Charters Towers – a rural town – so I feel I have grown up experiencing both a regional and rural remote perspective. At school, I was keen to leave in Year 10 to become a carpenter, but my mother convinced me to finish school. She was persuasive and I actually enrolled in pharmacy in my first year at James Cook University, then I changed to medicine the following year. When I started studying medicine, I thought cardiothoracic surgery was the way to go and that’s what I thought I’d end up doing. But after a couple of rural terms, I realised I really wanted to do general practice – particularly on the rural pathway. When I was working at Tumut, in the Snowy Mountains, the GPs in town also staffed the hospital and I was amazed at what they could do. They all seemed to be impossibly good at everything, from a medical point of view – they were delivering babies, doing anaesthetics, admitting their own patients into hospital, dealing with car accidents, and seeing regular patients in their clinics day to day as well. It seemed as if they were all Superheroes. I was blown away by their broad skill base and the variety of work they did. It was then I realised what they were doing was far more interesting to me than any other medical work I had seen. In my second year of medicine, I successfully applied for the North Dakota Rural Bursary – founded in 2000 by a US doctor, Dr Lynn Kratcha MD – to do a rural elective and experience rural practice in another country for a month. Despite it being a small community, there were a

Life is never dull and I just never know where general practice is going to take me!

number of family medicine physicians and a reasonably-sized hospital, so I learned a great deal there. Then, in my fourth year, I did a rural placement to the Whitsundays. Oh my goodness – what a tough gig that was! Actually, the GPs in Proserpine were the front line, just as I had seen earlier in Tumut. They were the senior medical officers at the hospital and worked across accident and emergency, general medicine, obstetrics, and anaesthetics … and were all working independently, too. While there was support from large tertiary hospitals, retrieval services and so on, these doctors were still very much the front line in a rural and remote context. All of this was just reinforced that this variety and flexibility was something I really wanted to pursue. I spent my last two years of med school at Darwin, doing an elective in the Ecudorian Amazon, which was two months in a really remote, third world setting. Two Ecuadorian interns were also doing their remote service along with me. They were extremely helpful, as my Spanish wasn’t strong! In this scenario you can’t do a lot – you can treat the major stuff like malaria and skin conditions, but, to be honest, there wasn’t any high-powered practice involved. Something that cemented my decision to move to general practice was a trip out to Kalkarindji, a remote Indigenous settlement, 80km south west of Katherine on the Buntine Highway, when I was a sixth year medical student. I was with an opthamology team – we went out there to collect a patient who had long standing trachoma, and was now pretty much blind. We turned up in very poor setting and “persuaded” this old man to come to the clinic. Unfortunately, there was almost nothing we could do for him … and yet here we were, in this environment, trying to make some sort of difference from a very specialist point of view. In reality, it was very much a public health problem. After a rural term in the Kimberley where I worked for the Aboriginal Medical Service and the hospital – again, all GP based – I moved here to Alice Springs to do my internship, with the mix I am doing now – covering remote medicine and Indigenous health. I’ve been on a steep learning curve over the past five years. Now, being five years postgraduate, I can work for the Royal Flying Doctor Service as the sole doctor on the plane. Of course, I do have the support of my supervisor back in Alice Springs Hospital by phone, whenever I need some assistance. That amount of independence is not something you would get in many other specialties, and you certainly wouldn’t get it

in major centres. One thing I realise is that doing rural and remote and indigenous health doesn’t mean you have to stay out here. The skills of a general practitioner are transportable and equally valid in any metropolitan area. My work at Central Clinic in Alice, which is an office-based role in a typical urban eightdoctor practice, is really testimony to this.

My other general practice office-based experience prior to this was out on Groote Eylandt, in the Gulf of Carpentaria in northeastern Australia, where I worked across four community clinics in Indigenous health. There’s plenty of chronic disease, and also challenging health issues that are heavily dependent on socio-economic status. For example, someone might present with pneumonia. That pneumonia might well be as a result of their chronic obstructive lung disease. But that’s also as a result of their socio-economic status, or related to diabetes. I enjoy all these types of very complex case management situations. I still have to complete my fellowship, so I did an advanced skills in anaesthetics and I’m working two days a week in the hospital to really enhance and improve my own experience. Life is never dull and I just never know where general practice is going to take me!

Photography: Moving Pictures

Going Places – ISSUE #6

Considering the road towards general practice?

Going Places Events What have we been up to?

BBQ at Logan Hospital Queensland – 2 June 2011 This was a great opportunity for doctors to enjoy a lunchtime event within the dining area of the Logan Hospital, Queensland. Dr Scott Hahn, the GP Ambassador for Logan, was the host and manned the BBQ so everybody would have the opportunity to chat with him while he was cooking! Attendees were able to enjoy a snag while talking to the Regional Training Providers who were there. A clinical educator was also on hand to answer questions and talk about life as a GP. It was a really successful event – and a nice break for doctors, who could enjoy a bite to eat and some good company without having to leave the hospital.

Dr Scott Hahn, GP Ambassador

Join the Going Places Network and we’ll help you get there!

Educational and Networking Dinner Adelaide – 3 May 2011

eVenT

3 M AY 2 011

educational Dinner Meetin g

On 3rd May, the South Australian contingent of the Going Places Network ran an educational and networking event at the Lion Hotel in North Adelaide.

“ThinGS YOU neeD TO KnOW”

This event was designed to update interested doctors on the changes to the AGPT selection process, as well provide an enjoyable evening out – with the opportunity to meet like-minded colleagues and hear from long-standing successful urban and rural GPs.

The selection process for General Practice training has changed… come and learn the facts

The evening attracted more than 40 interested doctors who not only enjoyed a sensational meal and wonderful company, but also got to hear some short but inspiring and entertaining talks from Dr Tim Kelly (a rural GP in SA) and Dr Danny Byrnes (a urban SA GP). Dr Kelly actually joined the proceedings by SKYPE – testament to the assistance technology now offers remote GPs!

www.gpaustralia.org.au/goingp

laces

In addition to these talks, guests were provided with some insight into the new selection process by Dr Sarah Meertens and Dr Sarah Parker from the SA RTPs. The evening also provided an excellent opportunity to speak to the RTPs directly about applying for general practice and the GP training programme.

•

• •

Join the Going Places Network. Visit gpaustralia.org.au or call 1300 131 198

Those who attended rated it as an excellent event, which they felt was well hosted and very worthwhile. Due to the overwhelmingly positive feedback, a similar event is being planned for next year. Dr Tim Kelly

More than 1,200 junior doctors have already joined us. Meet other people with an interest in general practice Hear from experienced GPs Attend networking and educational events Speak to GP Ambassadors in your local hospital area Access tools and resources

•

When : Tuesday 3 May Where : The Lion hotel (Tower 161 Melbourne St, northroom), Adelaide TiMe: 6.15pm for a 6.30pm start rSVP: hUrrY! Places are limited. rSVP name, position, hospital and mobile number to louise.comey@gpra.org. au by Wed 27 April

Dr Sarah Meertens

gpaustralia.org.au Online support for junior doctors interested in general practice

10 GPRA280711045

Join online it’s free!

It happened this way … More great stories from the front line. This time, two poignant and emotionally touching observations contributed (and beautifully written) by Dr Genevieve Yates – one of which is from her new book, Silver Linings, reviewed in the last edition of Going Places. Please note that patients’ names have been changed.

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The phone rang at 5am on a Sunday morning.

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

I struggled to engage my sleep-addled brain. I wasn’t on call. Who was ringing me at this un-Godly hour? “This is Dr. Errol Jones. I’m an obstetrician at the Royal Women’s. We have a problem with one of your patients, Jessica Delaney.”

My MDO is responsible and reliable.

Jessica! Nineteen going on fourteen. Pregnancy was a game to her and a baby at the end would become a fashion accessory: something that would make her just like her friends. Worse, she saw a baby as a money earner – with the baby bonus, the single parent pension and Centrelink not pressing her to look for employment, she thought she’d be on Easy Street. I’d been trying so hard to get through to her, but I felt like I was banging my head against a brick wall. I thought back to her most recent consultation, about four weeks earlier. I’d been trying to motivate her to abstain from alcohol, cigarettes and marijuana while pregnant … to little avail. “But I have managed to, like, give up tea and coffee though. Well, I never did like coffee, but I always had, like, a cup of tea in the mornings.” “A cup of tea each day is perfectly fine.” “But I read in those pamphlets you gave me that excessive caffeine is, like, harmful in pregnancy. So I, like, gave up my cup of tea. I don’t want to harm my baby!” What was she doing at the Royal Women’s? She was nowhere near her due date.

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“Jessica’s just under 30 weeks and has developed severe preeclampsia. She was airlifted down to us overnight. We need to do an emergency C-section but she’s refusing consent unless you say it’s OK.” Dr. Jones sounded both frustrated and embarrassed. “I’ll put her on.” “Genevieve, is that you? I’m so scared. Please tell me what to do. They’re, like, confusing me. They say that I could, like, die and that the baby could, like, die too if they don’t do the surgery straight away. But they also say that the surgery is really risky for us and that we could, like, die anyway. I just don’t trust them so I made them ring you. I know you will look after me.” The caesarean was uneventful and both mother and premmie infant did well. Jessica was very grateful for my ‘help’. “Thanks for, like, sorting out those doctors for me. I knew you’d know what to do. You always give me good advice. I’m so lucky to have, like, such an awesome doctor.” Jessica is unlikely to win ‘Mother of the Year’ anytime soon, but she has grown up fast and proven to be a caring and devoted mother.

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It turns out I wasn’t banging my head against a brick wall after all.

Madison is next on my list – the usually sullen teenager whose last HbA1c was nearly the same as her age. First impressions are surprisingly favourable. Her skin’s glowing and she’s actually smiling at me! Not only has she brought in her recent blood sugar readings, but they’re actually pretty good. She admits to having purposely taken her insulin incorrectly in the past (I suspect in the interests of weight loss), but proudly tells me that she’s been taking it perfectly for several weeks now, and that she’s never felt better. “So what made you change your mind about taking your insulin?” “Dunno. Just happened I s’pose.” “Please try to think carefully about why. I’d really like to know.” I’m very interested in finding out which of my warnings carried the most sway. I don’t ask for self-congratulatory purposes; seeing her looking so well and happy fulfils this already. I want to use her feedback to help me with future non-compliant teenage diabetics: to make me a better doctor. It is one of my very-good-doctor-day quests. On a less-engaging day I would just be grateful that she was looking after herself at last and not feel the need to delve deeply into the reasons. As Madison ponders, I mentally try to predict what she will say. I often play this game when seeing patients. In this case, I reckon my emphasis on the short-term results of skipping insulin last visit would have been the trigger for change. The prospect of long-term risks, such as developing kidney failure in middle age, does little to scare most teenagers. “Come to think of it, there was something that, like, changed my mind. Do you watch Rhinestone Bay?” “No, I don’t get much time to watch TV.” “It has lots of medical stuff in it. You’d like it.” Not likely. I smile indulgently. I wonder where she is going with this. A doctor character who reminds her of me? “There was this epileptic girl on the show. She didn’t take her meds properly and she ended up having a fit when she was out surfing and she, like, died!” “That’s sad. And?” “And what?” “I’m a little confused. How does this story relate to your diabetes?” “It made me see that if you don’t, like, take your meds, it can be really dangerous. So I started back on my proper insulin doses.” “It had nothing to do with what I told you last visit? Nothing at all?” It is Madison’s turn to smile. “I know you tried to help me but, to be honest, all I heard was, like, ‘blah blah blah’.” Going the extra mile today suddenly seems overrated. I think I’ll take the usual route to lunch. The receptionists will be pleased.

Going Places – ISSUE #6

Dr Jacquie Johnston

The GP who’s kicking

I’m one of the club doctors for the Geelong Football Club and I also work full-time as a GP registrar in a medical centre at Point Lonsdale from Monday through to Thursday. I’m usually at football training on a Monday night and occasionally also on a Wednesday night and then I support the team on match day – that takes up a full day on the weekend. So my week is fairly full!

grew up in South Gippsland, in Victoria, where my father was a country GP. I always thought becoming a GP and living in the country would be the very last thing I would ever end up doing … but here I am! My father was a classic all-round doctor, who also did obstetrics, anaesthetics and procedures at the local hospital – and my mother was a nurse. Dad worked very long hours, and we could never count on him to be around for a birthday party! There was a level of unpredictability and I had to share my father with the community, which I guess is what put me off being a GP. Thankfully that lifestyle has now changed and general practice is totally different. Growing up, I was really involved in sports. I was always football mad, but as a female growing up in the country, playing footy wasn’t an option, so I played netball, basketball and tennis. Then, at about 16, I became a football boundary umpire. Leaving school, I enrolled in undergraduate medicine at Monash with the aim of working in sports medicine. During my training, I discovered I really enjoyed orthopaedic surgery. So, on graduation in 2000, I pursued a surgical pathway with the aim of getting onto the orthopaedic surgical training program and I then spent several years working in orthopaedic surgery. I did six months in the Latrobe Valley, had three months at Dandenong and then three months at Monash, before moving out to Geelong, for relationship reasons. I also worked in Melbourne for a year, commuting to and from Geelong every weekend. By this stage, I had a partner and a young child. I was an orthopaedic registrar when my partner, Michelle, had our daughter, Joanna. Then, when our baby was just three weeks old, I had a country posting … four hours away from where we lived. My job had been very transient in nature – six months here, six months there. I’d had a number of other country surgical postings in orthopaedic and I loved working in the country. I felt that I got better jobs and better experience from working there. But on this occasion, it was the timing of the move. I was transferred to Bendigo so Michelle and Joanna moved with me. But that prompted me to re-evaluate where I wanted to work, and what I really wanted to do. It was at this point I decided to give general practice a go. Michelle and I both wanted to come back to Geelong. There were opportunities through the Australian General Practice Training program, so I started on the program at the beginning of last year. It was a big change after spending about nine years in the hospital system, as a surgical registrar and an orthopaedic registrar. When we decided to move back to the Geelong region, there was a registrar position – a country job, with accommodation – at

Point Lonsdale, on the Bellarine Peninsula, about half an hour outside Geelong. We thought we would stay there for six months and then move back to Geelong. But we didn’t move – we just didn’t want to leave Point Lonsdale. Within a few weeks of starting at Point Lonsdale, I had asked to return this year. It’s a great clinic with a bit of a track record of registrars coming back to stay! My second term was at Drysdale, about 15 minutes down the road. However, by then, we had fallen for the environment of Point Lonsdale, so we sold our house in Geelong and moved down here permanently. We’re only half an hour from Geelong, so my football commitments are easy to manage. Last year, through a friend, I was asked to be the team doctor for the Geelong Falcons, an elite under-18 football team. It was a great experience and then, this year, I was approached to work for the Geelong Football Club. So after all these years, I’m fulfilling that ambition I’d had when I was sixteen – to be a sports doctor. I passed my GP exams earlier this year and will have finished my time early next year, so I’m hoping to take up some sessions within a sports medicine clinic. One of my GP supervisors here is a senior doctor for the Geelong Football Club, so this clinic has a bit of a sports medicine focus for the area, as well. I’m also undertaking a post-graduate diploma in sports medicine through the University of Auckland – just one subject per semester – with the aim of furthering my GP training. But even with the additional study and fellowship exams, I’ve still got enough predictability as a GP to actively continue my interest as a football umpire. I umpire local senior football, which is something I’ve continued to do since I was a teenager. As an orthopaedic registrar, the commitments made it a lot harder to be able to get to umpire regularly … but from last year, I could actually combine everything and still have plenty of time for my family.

Photography: Barefoot Media

Going Places – ISSUE #6

What’s your WITH DR SARAH McEWAN

It’s 5pm on Tuesday afternoon and time to go out to the waiting room and bring in the next patient. Paul was a tall, athletically built, 21 year old male, who didn’t outwardly appear to show signs of having any medical problems. I looked at his medical records and noted that he hadn’t been to the practice for over six months. Last time it was for an opinion on some suspicious looking moles, which he thought were melanomas – but these turned out to be benign. He had also mentioned feeling very queasy on a regular basis, but no action had been taken or medication prescribed. I asked him how I could assist him and he told me that over the past six months he had been suffering from intermittent nausea and abdominal pain. From how he described the discomfort, it appeared to be coming mostly from around the right upper quadrant, occurring mostly after eating. Paul explained that it comes and goes in waves – a dull ache that reoccurs every week or so, but not with any specific repetitive pattern that he could readily identify. When it happens, taking a few Panadol seems to make the discomfort disappear and he then forgets about it – until the next time. He has made this appointment for an examination as he’s curious what the problem could be (and has been nagged into it by his girlfriend!) – so he’s hoping it’s not serious. I interrogated him about his lifestyle and habits. In response to all my questions, I knew he worked as a labourer on a farm and he was in good physical shape. He assured me he didn’t drink excessive amounts of alcohol and didn’t take drugs. So that ticked a few boxes. He hadn’t travelled overseas for some time and he hadn’t been involved with a large number of partners with unprotected sex. Quite the opposite – he was in a stable relationship for over a year and even had an STI screen performed at the start of the relationship, which showed NAD. Somewhat unusual for someone of his age, he didn’t have any tattoos. By this stage I’d become really curious. I didn’t believe he had alcoholic hepatitis from binge drinking or viral hepatitis from a “naughty” overseas trip. And I felt confident that gallstones were highly unlikely – far more prevalent if he would have been female, over-weight and over 40! After taking a thorough history, and a physical examination – which showed no tenderness anywhere, it was still a mystery. Nothing seemed to fit … it wasn’t a clear-cut case of saying “aha!” and all the symptoms leading to a diagnosis of what could be the most likely culprit. This definitely fell into the “something different” category.

This was something I’d only ever seen in a text book and when I was studying – I’d never actually come across a patient who had presented with it – the possibility of hydatid disease. Could it possibly be?

Curiouser and curiouser. I decided that I would send some bloods off and see where that led me, so I arranged a referral for him to have some blood samples taken at our local pathology lab. I requested a range of samples to be scanned for FBC, E/LFTs, CRP, LIPASE etc., as a start.... It’s now 10am Friday morning and I noticed the results of Paul’s bloods were available. The results came as quite a surprise – or shock! The bloods were showing abnormalities in everything! There was lipase in the thousands and the liver function tests were really abnormal. He also had a mild anaemia noted on his full blood count with a slightly raised eosinophil count.

AT THIS POINT WHAT WOULD YOU CONSIDER? I considered the Eosinophilia, and noted down a list of what I suspected these results could possibly indicate. One by one, I crossed the possibilities off my list as being quite, very or highly unlikely. I felt the only way to find a possible explanation was to look at his liver to see if there could be a problem there. I phoned Paul and organised for him to go to the local hospital for an upper abdominal ultrasound scan. He promised he’d make an appointment early the next week. Over the weekend, I was out walking my dog, Jetta, and a thought suddenly came to me as Jetta was busy concentrating doing a No.2 … As he worked on a farm and was in contact with animals – especially all the farm working dogs – I wondered if it could possibly be something connected with tapeworm.

I phoned Paul and asked him to come in to meet with me for a chat – I certainly didn’t want to alarm him and give the poor guy a syncopal event! I thought I explained the situation really well – very cool and calm – so as not to send him into shock and I carefully explained how I thought the hydatid actually got to his liver. It’s most likely he had acquired these hydatid cysts from tapeworm, which had ultimately been picked up in dog faeces. I reassured him that this problem could be treated and modern medicine could ensure he would make a good recovery. I referred Paul to an upper gastrointestinal surgeon in a tertiary centre who ultimately decided upon the best course of treatment. A few weeks later I heard back that they had organised surgery – the surgeon would kill the worms and eggs during an operation to reduce the spread, as they can seed into the lungs, brain and other organs … and this can potentially be fatal. Unfortunately, I was unable to catch up with Paul following his operation as I was then on a locum contract, but I received confirmation of his sincere thanks for the diagnosis … it was not something he would have ever dreamed he would have had!

Hydatid Cysts – Clinical Findings The problem is asymptomatic in many cases – most cysts are only symptomatic when they are 5 cm or more. Symptoms frequently come from the pressure on affected organs. There could be:

This was where is all became interesting........

• Jaundice or abdominal pain if cysts are in the liver

It’s now Tuesday afternoon and the results of the ultrasound landed on my desk.

• Cough, dyspnea and chest pain if they are in the lungs

The ultrasound scan returned showing an echogenic focus in his liver. The imagery appeared to show what looked like a number of overlapping circles of differing sizes – each between 25mm and 35mm.

• Pain, flushing and urticaria

At this stage what do you think the problem is?

Other symptoms arise from leakage of cyst contents or infection of cysts:

Treatment for hydatid cysts from tapeworm Surgery is the main form of treatment for hydatid disease. One of the risks of surgery is that a hydatid cyst may rupture and spread tapeworm heads throughout the patient’s body. To reduce this risk, the doctor may prescribe high doses of the drug albendazole in conjunction with surgery. This drug helps to destroy any remaining tapeworm heads. The basic steps of the procedure are eradication of the parasite by mechanical removal, sterilization of the cyst cavity by injection of a scolicidal agent (essentially formalin, hydrogen peroxide, hypertonic saline, chlorhexidine, absolute alcohol, and cetrimide), and protection of the surrounding tissues and cavities. This patient could also be treated medically with chemotherapy agents – however this is only in selected cases and for certain types of worms. The risk of disease recurrence is high. About one in three people treated for hydatid disease develop the condition again and need repeat treatment.

• Anaphylactic reaction • Fever and sepsis The liver is the most common organ involved (mostly right lobe) then – in order: lungs, muscles, bones kidneys, brain and spleen.

Going Places – ISSUE #6

Dr PETER FOX

Practice makes

Dr Peter Fox has been a GP for nearly forty years – he graduated from Melbourne University and St.Vincent’s Medical School in 1972, so he brings a wealth of experience to general practice.

perfect! “We needed more doctors and so, being an area of shortage, we These days, he heads his own award-winning practice, the were able to bring in a number of overseas-trained doctors over Geelong City Medical Clinic, with eight other doctors – and says time.” Peter’s introduction of more doctors helped to significantly that he still loves going to work each day. reduce the patient-doctor ratio in the area. When he started in medicine, Peter was intrigued by psychiatry, In 2007, the Geelong City Medical Clinic was recognised by but by the time he reached his intern year, he’d decided that he being awarded Royal Australian College of General would prefer to be a generalist rather than a specialist. “Every working day Practitioners Victorian General Practice of the Year, as well as taking out various local business awards. Getting into general practice was far less keeps me intrigued Peter says that the success of the practice has formal in the seventies, he recalls. “We would been due to a number of factors – but he nominates work at the hospital and then spend out-of-hours, and motivated.” Katie, his second daughter, to take the honours for evenings, weekends, and holidays doing locums. the awards. “She has brought a combination of skills to the practice There was no need for a provider number or any formal training – – excellent business management, meticulous preparation for locuming at different practices was the best way for junior doctors accreditation and the ability to make sure the doctors and staff to get a feel for the patient base, the locality and the GP mentors.” work in an harmonious environment.” After completing his internship and hospital residency, Peter Despite his business and professional accolades, Peter views joined a practice in Melbourne and stayed there for more than his greatest achievement in general practice as having managed twenty years. a career in medicine without missing out on spending significant With up to eight doctors, his first practice offered a variety of time with his family. “I think it’s more achievable to have a good mentors. “Having such a diversity of personalities and different life balance and manage family practicing styles around me helped me to develop my own time in general practice, than it approach.” He was later involved in mentoring medical students is in most specialist practices. and registrars himself – and time flew very quickly, he says. While most of us work on-call “What kept me in that practice for twenty years is the same and out-of-hours, you can share thing that has kept me doing general practice throughout my the load and certainly have some professional career: every working day keeps me intrigued and control over it. It’s not nearly as motivated,” says Peter. demanding and onerous as the “My next patient could bring anything from the need for a hospital on-call requirements – simple reassurance to the overwhelming, emotional discovery of and you have a great deal more an inoperable lung cancer. It could be the joy of pregnancy or the choice. The flexibility of rostering support and education of a newly diagnosed diabetic,” he says. is possible within general practice Peter explains that the evolution of primary care since the 1970s and can provide precious time to has been extraordinary; immunisation has almost eliminated spend with family.” many serious illnesses in childhood, computers make patient Peter’s family would certainly understand and appreciate the histories easily accessible and advances in the management of workings of a busy practice – his wife of 41 years, three adult chronic conditions – like diabetes and coronary artery disease – daughters and two sons, have all worked in various roles in his allow delivery of far better outcomes for patients. practice over the years. He says his patients are the best resource he has for keeping up In his spare time he has been able to take up areas of interest with the dynamic and fast-moving changes in medicine. “There’s a and relaxation – sailing on Corio Bay and around the Bellarine lot of interaction with specialists about my patients and, of course, Peninsula has become his most recent passion, and Geelong the weekly and monthly journals. offers such an amazing array of bays, beaches and surf. Peter initially commenced practicing in Geelong, just to look “A career in general practice is something that can hold the after one practice for a GP who was taking a year off to go sailing. interest of the most curious person for a lifetime. I love the variety of However, by 2001, he had set up the Geelong City Medical Clinic having a small amount of all sorts of different medical challenges. near the Geelong Hospital. For me it’s the perfect recipe for a harmonious and interesting His new practice had an open-access policy for acute patients environment, rather than the slog that I found in hospitals.” who could drop in without an appointment if there was an overflow at the nearby emergency department. Photography: Barefoot Media

Going Places – ISSUE #6

Tech Talk • Review

Coming to a screen near you! A look at how video technology is helping medical science. For anybody who ever saw the movie Fantastic Voyage with Raquel Welch back in 1966, the idea of being able to see (or actually be) inside the human body was pure science fiction. Fast forward to 2011 – 45 years later – and it’s now possible to send a miniature camera right down through the digestive tract to record about 119,000 high resolution images at three frames per second over a period of 11 hours. As you’d be only too aware, the traditional way to look inside patients is to put them through multiple procedures, looking for the source of problems – such as bleeding or ulcers – using either endoscopies or colonoscopies. These methods can be invasive and uncomfortable experiences for patients, despite being performed with anaesthesia. And even after these procedures, they might need to have exploratory surgery to further investigate the problems. In 2001, the first camera pill was approved by the US Federal Drug Administration for diagnostic applications. Over the past ten years, capsule endoscopy has come a long way and now the latest models allow doctors to see right inside the small intestines – ideal for taking a close look at suspected gastrointestinal bleeding, Crohn’s disease, cancer, coeliac disease or polyps. However – until recently – there was no way to control or steer the capsule as it made its way through the body. But that has now changed …. there’s a new pill camera, which can be steered and stopped wherever required – at any stage – from the oesophagus onwards. This is a huge advantage, as the journey through the oesophagus is only three or four seconds – at two to four frames per second, that represents very few frames to examine. It has now been demonstrated that it’s possible to hold the pill camera in the oesophagus for up to 10 minutes, even with the patient in an upright position. Even when a pill camera reaches the stomach, its weight moves it very quickly, dropping it to the lower wall. Sometimes this is even too fast to provide usable images, so this control is a huge leap forward. But, as they say – that’s not all. Philips have been working hard to develop and perfect its iPill – the next generation of the camera pill.

For many years, Philips Research has been developing its IntelliCap for electronically controlled drug delivery. In addition to the potential benefits of this new technology to improve patient therapy, the IntelliCap promises to be a valuable research tool for the development of any new drug that is delivered via the intestinal tract. The challenge for scientists at Philips Research was to find a way of navigating a drug-loaded pill capsule to the site of disease, where they could then release a metered amount of drug from its reservoir via a microprocessor controlled pump into the gut at the precise location. As the iPill moves through the body, its wireless transmitter communicates information about both pH levels and temperature, providing doctors with internal information about the patient. The iPill can be adjusted en route and when in the correct position it can dispense medication all at once, in a series of bursts, or gradually. If there’s an adverse reaction, the delivery of the medication can be stopped instantly. The combination of navigational feedback, electronically controlled drug delivery and monitoring of the intestinal tract promises to make iPill technology a valuable research tool for drug development. It could ultimately accelerate the development of new drugs, because it can open up the possibility of targeting almost any kind of drug to a specific location in the intestinal tract. The iPill is undergoing clinical trials, so you may be seeing it very soon!

Video is also making a big difference to assist doctors with tracheal intubation: on a day-to-day basis to ensure first pass success and to assist with teaching. The GlideScope – the first commercially available video laryngoscope – was designed by Canadian vascular and general surgeon John Allen Pacey, MD and introduced in 2001. This was the first scope to embed a miniature video chip into a modified Macintosh laryngoscope. The GlideScope achieved the transition from direct to video laryngoscopy and heralded the way for many more models including McGrath and Storz to be introduced. Along with GlideScope these brands dominate the video laryngoscope market. There are many other companies with video laryngoscopes, including Pentax-Airway Scope, Airtraq, Bullard and Bonfile. The GlideScope comprises a handle similar to that of a standard laryngoscope and a non-detachable blade that has a maximum width of 18 mm and a curvature of 60 degrees in the midline. A digital camera and two light-emitting diodes are embedded at the tip of the blade. The wide-angle lens, the central insertion of the blade and the camera being remote from the laryngeal structures result in a wide field, giving an improved view of the glottis. There’s also the advantage of a patent anti-fogging system which, together with a design that tends to keep the camera free of blood and secretions, makes it easier to obtain a view of airway structures. In 2005, the first major clinical study comparing the GlideScope to the conventional laryngoscope was published. In 133 patients on whom both GlideScope and conventional laryngoscopy were performed, intubation was successful in 128 (96%) of GlideScope laryngoscopy patients, compared with only 98 (74%) of patients on whom conventional laryngoscopy was used. In August 2009, the team at Verathon collaborated with Professor John Sakles from the University of Arizona Emergency Department to achieve the world’s first tracheal intubation conducted with the assistance of telemedicine technology. During this demonstration, Dr. Sakles and the University of Arizona

Telemedicine service guided physicians in a rural hospital as they performed a tracheal intubation using the GlideScope. The features of the GlideScope have been shown to contribute towards improved training outcomes. A 2010 study conducted at the American University of Beirut Medical Center using 42 medical students* demonstrated that medical students with no experience in tracheal intubation can achieve significantly higher successful intubation rates using rigid laryngoscopy in patients with normal airways if they were first trained with a video-assisted technique (GlideScope) as compared to direct laryngoscopy. With a success rate of almost 81% after the third intubation, the GlideScope might be a very powerful tool for training medical personnel in succeeding with tracheal intubation using a rigid laryngoscope that otherwise requires high number of intubations. New models, featuring advanced digital technology, are coming onto the market – GlideScope Cobalt AVL defines advanced video laryngoscopy. Airway views in DVD-clarity help users get the view they need to get a tube placed quickly. And real-time recording captures the details of difficult airway cases. The Cobalt AVL features a redesigned color monitor. There’s also a unique onboard 4-Step Technique video tutorial that describes and illustrates tips for successful GlideScope intubation. Another advanced element of the Cobalt AVL is integrated, real-time recording. High-quality digital files of intubations are downloadable and viewable on a PC. The records can be valuable for teaching and helping confirm tube placement.

*Tracheal intubation following training with the GlideScope® compared to direct laryngoscopy: C. M. Ayoub, G. E. Kanazi, A. Al Alami, C. Rameh, M. F. El-Khatib May 2010.

Going Places – ISSUE #6

Dr JOSHUA WAN

China on his mind

I work two days a week at Hornsby Station Medical Practice in a northern Sydney suburb, and two days a week in an inner-city clinic in Newtown, where I did my GP training. They are both really convenient as I live halfway between the two. I started working in the Hornsby clinic to help me understand Chinese culture a little better, as we have a lot of patients from mainland China and Hong Kong … it also helps me improve my Mandarin! The patient mix is quite different – the inner-city is younger with more mental health and drug and alcohol issues, while the suburban practice is more about chronic disease. I enjoy working four days a week, having a day off in the middle of the week, which gives me time to go surfing! It’s a big difference from the hospital system where you’re working around the clock. It’s really a great change of pace. I finished my exams in 2009, but I still feel like there’s so much more I need to learn in general practice. I was born in the UK and came to Australia with my family when I was three, growing up in Newcastle. I finished high school in Sydney and was accepted into the undergraduate medical degree at UNSW. I think I went into medicine not fully prepared for what it would entail and for the first few years I wasn’t really sure I wanted to continue. In my fifth year, I did my first trip overseas, spending four weeks in Nigeria and then four weeks in a leprosy clinic in Thailand, for my medical elective. Seeing diseases like malaria and tuberculosis, HIV and leprosy – things that you don’t come across here in Australia – was the defining moment when I decided medicine was definitely what I wanted to do. I did my internship at Royal North Shore and spent some time up the coast, in Port Macquarie. I really enjoy the coast as I’m a keen surfer! After my junior resident year, I was really struggling with the hospital environment, working long hours and not really making many clinical decisions. Then I found out about a volunteer role with an NGO in southwest China, working with people who couldn’t access medical services – minority groups and orphans – and doing HIV prevention work. In 2005, I spent about three and a half months in China. I took the Australian Society of HIV Medicine manual with me, but a lot of the medications we use here in Australia were not available. It was really difficult knowing what medication you might have used or tests you could have done, but just couldn’t access over there. Many of the patients were younger than myself and two passed away when I was there because they had such advanced disease. Learning about end-of-life issues – when and how to palliate somebody outside the hospital context – was a steep learning curve for me. It’s not something you see a lot as a junior doctor. I learned so much through that process. When I returned, I realised so much of what I could learn in general practice would be really helpful when applied to developing-country medicine. I spent a year at the Kid’s Hospital at Westmead, then enrolled in the Australian General Practice Training program. I started off in Burwood, which is a very multi-cultural area in

the west of Sydney, where I was able to see a lot of migrant health, as many patients are from Southeast Asia. My first GP mentor also shared an interest in HIV, so that was great. I had a term up at Laurieton, on the mid-north coast of NSW, which has a big geriatric population. Then I spent the last year at Newtown, where I’m currently based. Since then, I have gone over to China, to Yunnan Province, to work for four to six weeks each year. In general practice there’s a real advantage being able to take time off. Each time I go, I visit three or four different sites in the area. Yunnan is a really interesting place, in China’s southwest – bordering Tibet in the north, Burma in the south-west and then Vietnam in the south-east. Each of these sites have their own medical challenges. In the northern, more Tibetan area of Zhongdian, which is about 3,000 metres high, one of the big medical problems is TB. Then in the clinic at Nu Jiang, in the southwest of the province, near the Burmese border – a valley in a very mountainous area – there are high rates of infant mortality, malnutrition and hygiene issues ... and a lot of mental health issues, as well. Then in the south, I work in an area called Xishuangbanna, which has more of a warm tropical climate where there’s a lot of human and drug trafficking. The medical problems there are mainly HIV. It is really so rewarding to be able to use your skills and knowledge to help people in need. General practice gives me those skills – but also, so importantly, gives me the flexibility to take time off to make my trips overseas. I’m just getting ready for my next trip this September when I’ll be focusing on some preventative training programs. In future I’m considering doing some public health training. Each time I go to China, I’m constantly learning. It increases my thirst for learning more and using my skills to help people.

Photography: Mel Koutchavlis

Going Places – ISSUE #6

General Practice Training in Indigenous Health Victoria

Applying for GP Training Decided general practice is your career choice? This guide will tell you what you need to know about the application process for general practice. How do I become a GP?

It is important

Is it for YOU?

It is challenging It is inspiring

One pathway into general practice in Australia is through the Australian General Practice Training (AGPT) program. Successful completion of all elements of this training program is a pathway to Fellowship to one of two Australian GP Colleges – the Royal Australian College of General Practitioners or the Australian College of Rural and Remote Medicine – depending upon which curriculum is selected. Both Fellowships are vocationally recognised under Medicare.

What is the AGPT?

The Australian General Practice Training (AGPT) program is a worldclass vocational training program for medical graduates wishing to pursue a career in general practice in Australia. The AGPT program is fully funded by the Australian Government.

What is involved?

The program involves a three- or four-year full-time (or part-time equivalent) commitment, which can be reduced with recognition of prior learning (RPL).

Who delivers the training?

The training is delivered by 17 regional training providers (RTPs) throughout Australia. Eligible applicants will be allocated to RTPs based on their application and assessment ranking, training preferences and availability of training places. Training is conducted within accredited medical practices and hospitals and is supervised and assessed by experienced medical educators. The training includes self-directed learning, regular face-to-face educational activities and in-practice education. Visit www.agpt.com.au to see who the training providers are in your State or Territory.

Where do I do my training?

The AGPT program is based on an apprenticeship model. During training, registrars gain valuable practical experience in teaching hospitals, in rural and urban practices, in extended skills, procedural and academic posts. Registrars in general practices are supervised by experienced GPs.

How do I apply?

General Practice Education and Training Ltd manages the selection of applicants into the AGPT program. Opening and closing dates of application for 2013 entry will be available at www.agpt.com.au from December 2011.

Find out more at www.agpt.com.au

What are you doing about Indigenous Health? Indigenous health is a national priority, with Aboriginal and Torres Strait Islander Australians still dying years earlier than other Australians and suffering from a wide range of preventable diseases and treatable illnesses. As a GP working in Indigenous health, you are likely to make a bigger difference to health outcomes than in any other area of medicine in Australia today! • Practice a holistic approach to primary health care in a cultural context by training at an Aboriginal Community Controlled Health Service (ACCHS). • Get an appetite for Indigenous health by negotiating part-time or sessional arrangements whilst doing your GP training. • Experience complex medicine including chronic disease, preventive health care, health promotion and public health management. • Train under inspirational GP Supervisors, who are ACRRM and/or RACGP Fellows with years of experience and in depth knowledge of the clinical status and cultural aspects of the community. • Enjoy complete flexibility with 9-5 daily hours, leave for release sessions, conferences, study and personal life.

Are you interested in Indigenous Health? Contact the GP Education and Training Officer at VACCHO.

5-7 Smith St, Fitzroy VIC 3065 P: (03) 9419 3350 E: enquiries@vaccho.com.au W: www.vaccho.com.au

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Natasha’s PGPPP

diary

10:00am

Dr Natasha Vavrek spent 12 weeks at the surgery in the town of Scottsdale (population 2,000) about 70 kilometres east of Launceston, Tasmania. It’s a friendly, busy town surrounded by farmlands, where (apparently) you’ll see crops growing, contented dairy cows grazing and forest-based industries … as well as a very busy PGPPP doctor!

Typical morning – started at the Scottsdale Doctors Surgery at 10am – I’m now well into the swing of seeing three to four patients an hour. Very efficient!

These are notes from Natasha’s diary:

8:30am

Started the morning at the Scottsdale Hospital for handover and rounds at 8.30am. Was asked by one of the doctors to go to the James Scott Wing (nursing home) and check some results – then I got roped in by one of the nurses (well, I guess I volunteered, really) to replace an IDC in one of the other patients. Got to insert the brand new Implanon NXT – the new generation of the contraceptive implant – into a couple of patients, as I did the workshop a couple of weeks ago. Some of the GPs haven’t actually had the chance to do the workshop, so I showed them how to put them in, using the new applicator. Looked at my list of patients for the day – goodness – three pap smears booked in today. I’m starting to become the Pap Smear Queen. Not really convinced that’s such an accolade! Got the results back for two suspicious moles I removed in my first week here – one turns out to be a BCC and the other an SCC!!! Luckily all margins are clear. I think I did a really good job – the patients did, too – they were happy with my nifty handiwork! Went out to the Bridport branch to see patients. I was very touched when one patient handed me a letter from his wife telling me how grateful she was for my diagnosis of a new onset AF, which resulted in the replacement of a heart valve and bypass. In the letter she thanked me for giving her a second chance at life. I felt really honoured, privileged and humbled. Very touched. This is the best bit about life as a GP – making a difference to somebody’s life, and improving their quality of life.

practical!) It struck me as astonishing that I can go so easily from discussing blood pressure meds to something as intimate as someone’s sex life … it’s this incredible diversity that makes general practice so endlessly fascinating! A patient presented with severe tonsillitis and extreme over crowding, so I quickly got her over to the hospital as an outpatient to get IV fluid, steroids and IV antibiotics. Had a pregnant woman in my office with so many complications and who was quite unwell. So I decided to call up the O&G registrar at Launceston General Hospital for expert advice. Great that specialist help is just a phone call away. Had to do something I’ve only ever done in exam settings … break bad news to a patient – diagnosis of breast cancer. To be honest, I found it was very confronting. I organised a quick appointment with the surgeon. It was a very difficult and emotional situation, however, I think I handled it well and it was a learning experience.

9:30pm

Another on-call night – 9.30pm and the only call was for advice on a very constipated patient. (My 12 weeks in colorectal surgery last year made me feel very confident about this topic!). Then at 11pm I was called in to see a very SOB (short of breath) woman. I thought nothing else would happen, so I dozed off … to be woken up at 3am for advice on a palliative patient who was very uncomfortable. Recommended some options and tried to get back to sleep – unsuccessfully. Had a teaching session on relaxation techniques with one of the GPs. She demonstrated these on me … very effectively. Actually a bit too effectively, as I just about fell asleep!

Just had my very first – er,” interesting” – consult. I had to give advice on erectile dysfunction. (Note to self: will have to do a little more research on this topic! Theoretical, not

Had a very difficult and frustrating conversation with a parent who has steadfastly decided not to immunise their children. I tried all my powers of persuasion about how immunisation is the safest and most effective way of protecting children against disease … and all the benefits. Fell on deaf ears. GRRRR … but I did my best. Just had my fifth URTI in a row!!! I suppose it’s that time of the year and to be expected. Had an elderly patient with quite severe cellulitis of the leg – sent him to the hospital for IV antibiotics. A young girl and her mother came in to talk to me – they wanted advice on contraception options. After discussing what would be best, we decided to give OCP a go. Later the same day, I had a discussion about contraception with another patient and we decided on an Implanon insertion, which I booked in for the next day. Another opportunity for more experience with an Implanon NXT insertion! I was told by a patient today that she wished I would stay. I’ll be really sad to leave behind all the patients I’ve got to know so well in Scottsdale. That’s the only bad thing about PGPPP – but it would be great to return one day as a GP … A teenager came in to see me with what appeared to me as typical appendicitis symptoms – a diagnosis confirmed by my examination. I organised some pain relief and told him to go to Launceston General Hospital Emergency Department, as they’d take care of him …

Photography: Lachlan Moore Photography: Rob Burnett

Going Places – ISSUE #6

BOOK ReviewS

Want a taste of general practice while training in hospital? The Prevocational General Practice Placements Program (PGPPP) provides professional, well-supervised and educational general practice placements as part of your training. The aims of the program are to build your confidence, exposure and interest in working in urban, regional, rural and remote areas through supervised general practice placements of varying duration – approximately 10–12 weeks. You’ll continue to be paid while you’re on your PGPPP rotation. You’ll gain an increased understanding of the integration between primary and secondary health care – this practical experience will allow you to make an informed decision about considering a career in general practice.

Eligibility for the PGPPP To be eligible to participate in the PGPPP, you must work at an Australian hospital. For complete eligibility requirements, please contact the junior doctor manager at your hospital.

What will you gain on the PGPPP? You’ll have a unique insight into general practice through this opportunity to work in general practice. Your placements will be well supported, providing you with these great benefits:

3 A real life experience in general practice over and above that of undergraduate training

3 Exposure to a variety of health services from migrant to aged care health services

3 Ongoing and personal mentoring by respected and dedicated GPs in the field

3 Direct patient contact in a range of primary care settings such as general practice, Aboriginal medical services, drug and alcohol services and community-based facilities

3 Enhanced understanding of the Australian health care system 3 Great networking opportunities 3 Increased confidence and independence to take into future training and work environments

The PGPPP is managed by General Practice Education and Training (GPET) on behalf of the Australian Government. It is facilitated through providers and delivered by accredited practices and medical services throughout Australia.

These are two books from Dr Ken B Moody, a general practitioner in the beautiful Scottish Borders who writes of his experiences. His books feature an hilarious but poignant series of articles – anecdotes and medical cases – covering the many colourful characters he comes across.

‘Like us’ on Facebook and spread the Going Places Network love. Visit our Facebook page to connect with other junior doctors, find exclusive offers, latest events, videos and more! facebook.com/goingplacesnetwork

GPRA220711040

General Practitioner to the Stars

View from the Surgery

Medical Report James Bond 007

Reviewed by GP Ambassador Dr Thomas Quigley View from the Surgery is a highly readable collection of short, weekly articles written by a Scottish GP, Dr Ken Moody, for a local newspaper column. In true tabloid format, most of the articles are no more than 1,000 words – meaning the book could be a great companion to GPs between patients, or as a diversion from admin! It is easy to lose sight of the fact that the book is a sample of weekly articles by Dr Moody – testament to how fortunate general practitioners are to see such a breadth of not only medicine but also life, week in and week out of their practicing life. And furthermore, that much of the most emotionally-weighted, important and interesting moments in family practice involve putting the stethoscope down and listening to the patient’s life from outside the office.

Reality GP

Spread the GP love.

Dr Fairytale

Reviewed by GP Ambassador Dr Michael Cross-Pitcher I never knew my Grandfather. He was a surgeon during the time when the world was at war and died before I was born. A photo and the stories my mother would tell about him were part of my inspiration to study and practice medicine. I would have given anything to be able to sit by the fireplace, a glass of fine wine in hand and listen to him recount the stories of his life’s work. In Dr Moody’s second offering, Reality GP, we have the opportunity to live this experience. As a rural doctor with a long history of general practice in the more remote Scottish country-side, from a time when house calls were the norm, we are taken on a rambling journey through Dr Moody’s more colourful patients, each one imbued with the author’s dry and laconic wit. We delve into the lives of such phonetic patients as Yuri Kassid (suffering from gout), Mandy Bull (with the prominent jaw) and April Schaurez (hopelessly delayed by the rain) as they fill Dr Moody’s days with unexpected diagnostic challenges. Reality GP is not an educational text (unless you are seeking a pro forma letter for that particular patient who repeatedly brings tomes of internet-sourced medical “literature” to further your medical knowledge, or wondering how you can improve a patient’s health through gambling). It is a unique opportunity to take time out and languish in the lifetime experiences of a GP-as-theyused-to-be. Light the fire ... wine be damned. This is Scotland, make it whisky!

For reasons of National Security, ”Mr Smith” would not give me his real name. However, he informed me that he was “On Her Majesty’s Secret Service”. He was of slim build, blue-grey eyes, a “cruel” mouth and short, black hair. There was a faint scar of the Cyrillic letter “?” on his hand – which he informed me came from Russia “with love”. On the surface, he appears to be a healthy, attractive man. However, ‘Mr Smith’ has a number of dangerous vices that may seriously affect his life – namely smoking, drinking and sexual intercourse. He is a life-long smoker, at one point reaching 70 cigarettes a day. In the past he has attempted to cut back himself, as this was affecting his job and cigarettes were clearly a “Licence to Kill”. In the past, he was sent to a health farm because of his boss’s concerns about his habit. ‘Mr Smith’ smokes a blend of Balkan and Turkish tobacco with a higher than average tar content called “Morland Specials”. I attempted to advise ‘Mr Smith’ about his habit but he only replied, “Doctor, No. You only live twice”. ‘Mr Smith’ drinks alcohol to excess. His intake, since I have known him, has been of 317 drinks of which 101 are whisky, 35 sakes, 30 glasses of champagne and a mere 19 vodka martinis (which he claims are his favourite). ‘Mr Smith’ feels that drinking was an important part of his job (working at Casinos, Royal engagements, etc) and that alcohol gave him inner peace – eloquently described as a “Quantum of Solace”. It was not only the amount of alcohol that is a concern, but also his food consumption. I have advised cutting back on both but he refused saying only that he would “diet another day”. As well as smoking and drinking, ‘Mr Smith’ claims to have had “pussy, galore”. He clearly indulges in meaningless affairs, mostly one night stands, with virtually every woman he encounters. He doesn’t seem concerned about STDs – sleeping with one woman despite her “Octopussy”. This may explain why he reports some genital itching and “Thunderballs”. A major concern I had for ‘Mr Smith’ was of heavy metal poisoning. At various points he referred to his Goldfinger, his Goldeneye and to “The man with the Golden Gun” – which I presume to be a euphemism. Gold poisoning, like all very metals, causes headaches, irritability, insomnia and depression. In fact, ‘Mr Smith’ did feel that “The World Is Not Enough” which would suggest a low mood was present. This type of poisoning can affect vision so I would suggest a referral to an ophthalmologist “for his eyes only”. In conclusion, I have informed ‘Mr Smith’ that if he continues to behave in this manner he will be “living daylight” hours in a medical ward and, while “diamonds are forever”, his health is not and that I would be prepared for him to “live and let die” without an intervention. By Dr Gil Myers. This article first appeared in JuniorDr.

Going Places – ISSUE #6

What’s your current role – and how did you get there? My primary role is as a GP at the Lauderdale Doctors Surgery, outside Hobart. I’ve been there about six years and work with some wonderful people. I do one to two sessions at a Family Planning Clinic in Glenorchy, north of Hobart. I also really enjoy working in the area of women’s health. I’ve recently started doing some medical education with GP Training Tasmania, the same organisation where I completed my own training … and, finally, I’m just starting a new role, doing a few sessions of after-hours telemedicine triage, from home. All in all, I think it’s a great mix. I grew up in Hobart as one of seven children from a large Catholic family. I went into medicine and completed most of my training – my university degree and my internship – here in Hobart. I did most of my hospital terms at the Royal Hobart Hospital, apart from a psychiatry term in a north-west regional hospital, and I did the fifth year of my degree at the Launceston General Hospital.

What influenced your decision to become a GP? I’d always had a leaning towards general practice, though at times in my training I entertained other ideas. But a nine-week prevocational GP placement really confirmed my choice. I worked at the Tarrant Community Health Centre. In the PGPPP, you are supervised quite closely to start with and there’s an expectation that you will discuss cases with your supervising doctors. But you do get the opportunity to see patients independently – making your own assessments and decisions. That’s something I didn’t get to do as a junior doctor in the hospital, where you would work as part of a team and mostly do the administrative roles – organising investigations, chasing up results, sometimes writing the notes and discharge summaries, rather than doing much clinical work. I found it a real contrast to be a general practice registrar, making all of the decisions and working independently. It is quite challenging at first, but I felt it made my work a lot more meaningful. Along with that independence and responsibility came a greater sense of reward and satisfaction. In contrast to the hospital environment, as a GP registrar, you do actually have the opportunity to build up the rapport and relationship with patients over time and you get to see the results of what you do. You get to follow up over the longer term, which is so different from working in the hospital system, where you see patients for a snapshot in time and don’t often find out the long-term outcome, as you may not be the person who sees that patient again for follow-up.

As a doctor you find yourself in an incredibly privileged position.

Dr Hannah Chapman

Enjoying a mix of medical work What skills have you needed to learn or develop to become a better GP? As a doctor you find yourself in an incredibly privileged position. You’re involved in people’s lives at their most critical moments. People are endlessly fascinating to me. To enjoy general practice I think you do need to like people and like talking to people – communication is a really key skill you need as a GP. I’ve also enjoyed – and really benefited from – taking on a role in medical education. It has been a great opportunity for interaction with other health professionals and my personal career development. In my medical educator position at GPTT, I do some accreditation administration for training posts and also some external clinical teaching visits to observe the GP registrars in their clinical consulting rooms. I also deliver a women’s health workshop. Separate to this, through my role at Family Planning Tasmania, I’ve run Implanon training sessions for other GPs.

What are your plans for the future? I’m just starting my new role in after-hours telemedicine, which I see as a very interesting future direction for medicine. After Hours GP Helpline is a new nationwide service, federally funded through Health Direct, operating alongside the current nurse-operated advice line. I’ll do a couple of evening sessions from 6pm to midnight and then a few hours on a weekend. I expect it will be similar to work I’ve done recently, based in an after-hours clinic. This is quite a refreshing contrast to regular general practice work, because you are dealing with just the immediate, and what needs to happen right now. In a general practice clinic you often tend to be dealing with many issues, over a period of time. While those ongoing relationships and continuity of care are incredibly rewarding, they are also demanding, so it’s good to mix it up a bit. I will continue to have a mix in my medical work. The flexibility of a general practice career is a huge attraction. Traditional general practice – both the workforce and the structure of general practice work – focused on working in one surgery for four or five days a week, has really changed. This means you can really carve your own career path, explore your own interests and develop your own niche. That variety and mix is really important to me.

Photography: Fluid Photography

Going Places – ISSUE #6

Need a little retail therapy?

Medical Terminology: A hiding place for Greek mythology Through the history of Greece and the writings undertaken by poets such as Homer, there has been a direct relationship between Greek vocabulary and mythology. This has meant that ancient practitioners essentially named medical conditions by using words that were sometimes inextricably linked to mythology. Medical researchers more recently have repeatedly turned to the extensive vocabulary within the treatises of these founding fathers of medicine and have used them to describe observations. Even today, some medical terminology can still be understood from its mythological root alone. This relationship applies to the entirety of medicine from anatomy to clinical signs.

Oedipus Complex: The clinical sign oedema, which is derived from the

Greek word ‘oidein’ (to become swollen), has mythological origins in the story of Oedipus. His father, King Laius of Thebes, was informed by an oracle that if his wife Jocasta bore him a son, he would die by his hands. When a son was born to the couple, Laius pierced and tied the infant’s feet and asked his subject to expose him on a mountainside. However, the infant was given to the King of Corinth who named him Oidipous (Latin spelling Oedipus), meaning swollen foot; because of the trauma to his feet. Years later, Oedipus grew up to kill his father and marry his mother without knowing either of their identities. This gave rise to the Freudian expression, Oedipus complex. Oedipus gouged his eyes out on finding out the truth and Jocasta succumbed to hysteria, leading to her suicide.

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Hysteria: Incidentally, the word ‘hysteria’ comes from the Greek word ‘hyster’

meaning uterus. Ancient Greeks believed that women were especially susceptible to emotional disorders, which originated from the uterus. This also explains the use of the word ‘hyster’ in medical terminology such as hysterectomy.

Ascites:

The origin of the clinical sign ascites is from the Greek noun ‘askos’, which means bag. In Homer’s mythological poem ‘The Odyssey’, Odysseus visits the Island of Aeolia where Aeolus, keeper of the winds gave him a bag containing the west winds. The ancient Greeks knew of the condition we now know to be ascites calling it ascites (the baggy disease) according to the ‘baggy’ feature of the abdomen formed from increased fluid in the peritoneum.

to these questions: • What does the average GP earn? • What is rule #2 from our junior doctor blogger? • How long does the AGPT program take to complete?

Atlas:

The Greek etymology of words extends to names of anatomical structures such as the Atlas, which is not only the name of the first vertebrae, but also the name of a Titan who took part in a war against Zeus, king of the gods. As a punishment, Atlas was condemned to bear the weight of the heavens, separating it from the earth, a comparison to the function of the atlas vertebrae, which has to bear the weight of the skull.

Morphine:

Drugs within medicine have not escaped the influence of Greek mythology. The drug morphine is named after the god of sleep Morpheus. When delivering this drug, one may use a syringe, which has mythological roots in Synrinx, a nymph who was desired by the faun called Pan. Syrinx prayed to the gods to aid her situation and they answered by turning her into a hollow tuft of reeds. In this new form, Syrinx lends her name to the syringe. The nymph also lends her name to disorders such as syringomyelia. The examples above are a few of a myriad of terms within medicine that show a direct relationship between age-old Greek mythology, and the components that define medicine. This association, which brings medicine to life, may be a method by which we can easily recall and add interest to everyday terminology of the medical field. By Tofunmi Oni & Clare Cartlidge This article first appeared in JuniorDr

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Dr Edi Albert doesn’t stay in one place – or stay still – for very long. In fact, he has arranged for Going Places to interview him by phone on his day off, while he’s out skiing on Perisher … equipped with a bluetooth receiver in his helmet. This is the first skiing GP interview we’ve undertaken.

Dr EDI ALBERT

The GP with a passion for

Edi is in the middle of a three month term working as a GP in the Perisher Valley Medical Centre in the NSW Snowy Mountains. It’s his fourth winter there – at one of Australia’s busiest remote clinics, servicing the country’s largest ski resort. And while Perisher is a challenging location, it’s far closer to civilisation than some of his previous roles have been. These have included medical work in Antarctica, as Ship’s Doctor in the Southern Ocean and various posts in the Scottish highlands. He’s even provided health screening and clinical care for asylum seekers at Christmas Island’s Immigration Detention Centre, as a locum GP. Edi also runs a small business with his wife, providing training in expedition and wilderness medicine and rescue skills. His ‘Wilderness Education Group’ is a first for Australia, although similar outfits exist in the US and Europe. He has already trained more than 100 doctors, nurses, paramedics and experienced outdoor professionals in expedition medicine – many through an eight-day Expedition Medicine course he helped set up and teach through General Practice Training Tasmania (GPTT) and TAFE when working as a medical educator. Edi grew up in England, but did his medical degree in Edinburgh, Scotland, and most of his medical training – including GP training – in the north of Scotland. It took a rural practice rotation in a little Scottish town with a small hospital for Edi to realise that, despite his enjoyment of emergency medicine, he just wasn’t suited to a large hospital environment in a big city. After completing his training as a GP in the very rural Drumnadrochit Medical Practice in the Highlands of Scotland (famous for being just next to Loch Ness), Edi was awarded a two-year fellowship in GP management and education, obtaining a Masters degree in Primary Care at the University of Dundee. The following year, he flew to Hobart for a working holiday, intending to stay a year. He started work in an after-hours GP clinic. “The work wasn’t great but it gave me a lot of time off and allowed me to travel around to see Tasmania. I decided to stay a little bit longer and then a little bit longer, then I ended up doing some teaching at the university … eventually I bought a house and 12 years later, I’m still in Australia.”

At the end of 2004, Edi left the university with a lust for more adventure. He set off with his wife and two young children in a converted bus to travel around Australia for 18 months. “We had an extended family trip, travelling up the east coast of Australia, staying in places like Alice and Kangaroo Island.” After returning to Tasmania, Edi again took up a variety of GP clinical roles, as well as working as a medical educator for GPTT. He was also engaged by the Australian Antarctic Division, for head-office health planning and administration, as well as clinical work. This role included several extended Southern Ocean voyages on the marine science research vessel Aurora Australis as ship’s doctor, and as summer station doctor for Casey Station in Antarctica. It may not surprise you to hear that there’s no such thing as a typical working week for Edi. Recently, he’s been building a house in Tasmania while working in emergency medicine in a Hobart hospital. As Edi explains about his work schedule: “It all depends on where I am and what time of year it is. My typical week at the moment is five days in the Perisher Valley Medical Centre, and then I’ll have two days off, so I hope to spend that skiing if the weather is good.” He’s also often involved in wilderness education training. “Earlier this year, I was in Nepal running a course in the Annapurna area. The course is a mixture of travelling the actual track and also teaching wilderness emergency response, search and rescue, technical rescue, high-altitude medicine, hypothermia – all those types of unusual topics that just don’t get covered in normal medical education.” Edi says he loves the wide variety of work he does as a GP. Despite the seemingly transient nature of his many roles, over the years his work has developed its own pattern, rhythms and continuity. “Here at Perisher, the same team is back here year after year – we treat others working in the valley, maybe on the slopes or in the hotels, who come back year after year. I’ve developed some continuity of care in something that you might think at first sight seems very temporary and impermanent.” According to Edi, the beauty of general practice is the way it transverses such a huge variety of roles. However, he strongly believes there’s a need to more clearly distinguish between the rural or remote generalist, which is a far more procedural role, and the ambulatory primary care setting of a GP surgery. Edi summarises general practice in his own inimitable way: “There are hundreds of really different roles that a GP can do. General practice medicine is as vast and diverse as you could ever want to make it. But if you’re a cardiologist, you can pretty much predict with a fair amount of certainty what you’re going to be doing, day in day out ...”. That’s obviously not the type of work that Edi would enjoy!

By 2001, Edi had been appointed Senior Lecturer in the University of Tasmania’s School of Medicine, where he spent the next four years re-developing both the Discipline of General Practice and helping design a new five-year undergraduate medical program. He was also a Director of both General Practice Training Tasmania (GPTT) and the Tasmanian General Practice Divisions.

Photography: Good Times Photography Alpine

Going Places – ISSUE #6

DERMATOLOGY Dr Ian McColl Read between the lines

call someone who cares The Medical Indemnity Protection Society is committed to providing its members with the security and support they need to practice with confidence. MIPS members enjoy automatic entitlement to a range of flexible and portable membership benefits including the unique MIPS Protections medical indemnity insurance, practice entity insurance, personal accident/loss of registration and gratuitous overseas practice travel insurance. Members can also access medicolegal advice, risk management and education to help them meet the challenges of practice throughout their career. They can also access the Club MIPS benefits relevant to their level of membership (such as our current VW/Skoda and IT equipment benefits). MIPS is a ‘not for profit’ organisation, whose assets are ultimately owned by its members. MIPS members are assured of equity and fairness. For example, MIPS believes that a member’s annual membership fee should reflect the need to fund the risk exposure that members bring with them to the membership and as such is based on the risk of each member reporting claims from the past as well as their anticipated/current practice.

support 24 hours a day, 7 days a week from experienced clinicians.

at MIPS we believe prevention is better than cure!

Our medico-legal advisers can assist with:

• risk management workshops and advice available throughout the year

• ethical issues • potential or actual complaints by patients • complaints by employer(s) • the preparation of coroner’s reports (and similar medico-legal reports) • Health Services and Health Care Complaints Commission matters

When papules occur in lines like this, the process is known as the Koebner phenomenon.This condition is also commonly seen in patients with psoriasis, where any injury to the skin such as a scratch or surgical wound will cause the psoriasis to show up in the site of the injury. Linear lesions may also arise when wart virus is inoculated into a scratch or when plant resin streaking on the skin causes the linear blisters of a plant contact dermatitis. The papules in the Koebner reaction shown here are those of lichen planus. They are often purplish in colour, polygonal in shape and quite itchy. Further scratching will accentuate the problem. For further images of this case go to www.skinconsult.com.au

A sole kind of feeling At first glance, this florid pustular eruption on the sole of the foot could be a severe bacterial or fungal infection. However, a bacterial swab and skin scrapings for fungal microscopy and culture from this lesion will be negative. This is localised pustular psoriasis. There are neutrophils in the pustules but they are a result of inflammation rather than infection. This condition is treated with a strong steroid cream applied twice a day and under plastic wrap occlusion at night, rather than with a topical antibiotic or oral antifungal. Patients can have localised pustular psoriasis without any evidence of typical psoriatic red scaly plaques elsewhere. For further information go to www.skinconsult.com.au

GP TIPS

• medico-legal seminars and training exploring relevant current trends and major issues

Peeling the Easy Way

• online risk management modules a convenient method of risk education able to be downloaded.

This is a tip which takes two seconds – and might save 10 seconds. But if you’ve never seen it, you’ll never do it. When gloved, peeling the plastic away from the paper backing of a suture pack can be a slippery business, as the two layers are almost stuck together.

• webinars MIPS hosts a series of webinars throughout the year. Developed initially to cater for our members in remote communities, all MIPS members have access to these interesting and interactive professional education opportunities.

Dr Andrew Montanari from Newcastle, NSW, momentarily folds towards the paper side. When he lets go, the paper stays creased and the plastic springs back, separating the two layers for easy peeling.

call us to see where your membership will take you!

GP Companion co-sponsored by MIPS

Medical Indemnity Protection Society p. 1800 061 113 | info@mips.com.au | www.mips.com.au Medical Indemnity Protection Society Ltd (MIPS) is an Australian Financial Services Licensee (AFS Lic. 301912). MIPS Insurance Pty Ltd (MIPS Insurance) is a wholly owned subsidiary of MIPS and holds an authority issued by APRA to conduct general insurance business and is an Australian Financial Services Licensee (AFS Lic. 247301). Any financial product advice is of a general nature and not personal or specific.

Paying lip service on examination Cleaning dermatoscope glass with alcohol wipes after each use is probably adequate when the instrument is only making contact with a lesion in an armpit, but if the next patient requires examination of their lip, something stronger may be in order. Dr Andrew Montanari from Newcastle, NSW, uses any handy, clear plastic, such as a syringe wrapper, as a barrier – sterile side touching the lip. Apply the usual oil to the glass and ask the patient to wet their lip.

Content kindly provided by Medical Observer. www.medicalobserver.com.au

Going Places – ISSUE #6

Maggots Most people, with the exception of fishermen and extreme animal lovers, will be disgusted by the thought of maggots crawling onto their skin. You can instantaneously conjure up an image of a rotting body plagued with flesh-sucking creepy crawlies. In fact, myiasis is the very term given to the ‘infestation of live humans and animals with dipterous larvae which feed on the host’s dead or living tissue, liquid body substances or ingested food’. But as Amilia Youkhana explains, despite its ickiness, maggot debridement therapy (MDT) could be a significant part of the management of chronic inflammatory processes such as wounds, ulcers, burns and even necrotic tumours. Chronic wounds and skin ulcers have always been difficult to treat. One important example is that of diabetic foot ulcers that frequently result in amputation. Numerous observations of soldiers at war in past centuries have shown that wounds accidentally infested with maggots not only healed quicker but also appeared to protect the host from acquiring septicaemia. Since the late eighteenth century, studies of controlled, sterile management of infected wounds, abscesses and osteomyelitis with MDT had been successful and popular until the introduction of antibiotics and aseptic techniques in the 1940s, where it was used only as a last resort. Interest in the little creatures has grown recently because of the emergence of antibiotic resistant microorganisms – MDT can reduce the risk of acquiring an MRSA-related illness.

Taking the bite out of wounds Candidates should be chosen with care. Those with a purulent, sloughy, skin lesion that is resistant or not completely responsive to treatment will benefit from MDT. It can be used alone (important when costs need to be kept minimal) or supplementary to medical or surgical treatment. Although studies are difficult to accurately evaluate and compare, it has been observed that in 80-95 per cent of cases most or all debridement is removed via MDT. There is substantial evidence to advocate the use of larval therapy in chronic leg/pressure/venous stasis ulcers, diabetic foot wounds, traumatic and post-surgical wounds and even burns or necrotic tumours. MDT is simple, cost-efficient, effective and rapid, without any known side effects aside from itching/tickling sensations felt by some patients. It is becoming more and more popular in hospitals across the globe, and as our knowledge increases, will probably open the doorway to more unconventional forms of medical treatment.

Pros

Certain species of larvae, particularly the green bottle blowfly (lucilla sericata), feed on necrotic tissue only and don’t invade internal organs or break away from each other. They provide a useful method of removing necrotic tissue that would normally impede new tissue formation. They also release exudates containing certain proteolytic enzymes and chemicals such as allantoin, ammonia and calcium carbonate that act as antimicrobial agents and possibly as growth factors to encourage wound healing. Some believe that the physical effects of the crawling maggots and sucking of debris and bacteria also assist in these processes.

• Simple and fast

It is recommended that between five and 10 maggots are used per centimetre squared of wound and up to 1,000 maggots can be introduced into the wound at any one time. They are kept in place via hydrocolloid dressings (double layered and designed to allow oxygen in and exudates and debris out) and are usually left for three days. A number of applications may be needed depending on the severity of the wound and the amount of necrotic tissue removal desired. MDT is mostly used on chronic, external, non life-threatening wounds, where other interventions have failed, and has even been successfully used for necrotising fasciitis and other situations where surgery would have been risky.

CONS

• Cost-effective, especially in third world countries • Decreases chronic wound healing time and efficiency • Eliminates odour of necrotic tissue • Reduces morbidity and mortality by preventing infection of the wound • An alternative to medical/surgical methods that have failed or are unsuitable for the patient • No side effects reported apart from slight physical discomfort

• Disgust/revulsion/other psychological distress • Pain/tickling/itchiness • Fear of maggots escaping/burrowing into skin/maturing into flies (in fact, this is not true as mature larvae need to leave the wound to turn into pupae and then adult flies) • Potential allergic risk (although none has been reported thus far)

A complaint is made

Prior to drafting your response

The dreaded moment – being told that a hospital complaint has been made regarding a patient you treated.

It is important to identify the issues in the complaint that relate to your care prior to drafting your response. To do this you will need to have a copy of the complaint and a copy of the relevant hospital records.

What is a hospital complaint? This is a complaint made regarding the care and treatment of a patient while in hospital. The complaint may be made by any person, however usually by the patient or a close relative or friend of the patient. The complaint may focus on certain aspects of the patient’s care, or it may be of a general nature.

Drafting your response Generally, your response should include the following: •

The complaint can be informal (which is dealt with at hospital level) or a formal complaint which has been made to an external complaints body such as the Medical Board.

a factual outline of your involvement in the care of the patient, with emphasis on the aspects of your care that relate to the subject matter of the complaint

•

a response to each of the issues of the complaint which relate to your involvement

What does this mean for me?

•

acknowledgement of the concerns of the complainant and when advised by us, an expression of regret or apology.

It is the hospital that takes responsibility for responding to the complaint rather than individual members of the treatment team. However each relevant member of the patient’s treatment team may be asked to provide a response to the complaint. Each response received by the hospital will be used to draft a global response to the complaint. What should I do? Do not panic!

Avoid: •

providing information regarding treatment and advice that does not directly relate to you

•

providing an opinion on the care provided by other members of the treatment team.

Next steps?

In today’s environment it is not unusual to receive a complaint or claim of some type involving the care of one of your patients. If you manage to avoid a complaint or claim during your medical career, you will be one of the lucky few. This is a well trodden path however, there are many guideposts to help you through. Seek independent support It is important that you contact Avant in the first instance and prior to providing your response to the hospital. We will guide you through their complaints process and help review your draft response. Avant will act in your best interests and provide you with any necessary advice regarding possible current and future risks. We are there to support you.

If it is your treatment of the patient which is the subject matter of the complaint, your response may be provided to the complainant directly. If you do not want this to happen, it is important that you specify this when you provide it to the hospital. Care must always be taken with any written response provided, as it could be used in future proceedings. Future pathways Depending on the nature of the complaint, it’s possible that the complaint will be resolved at an early stage. This is the aim of any complaints process. Some complaints however may proceed to a more formal process, and you may have been personally identified as a respondent to the complaint. At Avant we have the necessary experience to guide you through any complaints process. Whenever you need experienced medico-legal advice, call 1800 128 268.

• Require an experienced clinician to select and sterilise the right species of maggots

(1) “Myiasis: The Rise and Fall of Maggot Therapy”, D. Morgan, Journal of Tissue Viability, 1995, 43-51, 5(2) By Amilia Youkhana This article first appeared in JuniorDr

How to: respond to patient and hospital complaints

 Ring 1800 128 268 today to find out more Important: Professional indemnity insurance products available from Avant Mutual Group Limited ABN 58 123 154 898 (Avant) are issued by Avant Insurance Limited, ABN 82 003 707 471, AFSL 238 765 (Avant Insurance). The information provided here is general advice only. You should consider the appropriateness of the advice having regard to your objectives, financial situation and needs before deciding to purchase or continuing to hold a policy with us. Please read and consider the PDS at www.avant.org.au or by contacting us on 1800 128 268.

Australia’s Leading MDO

Dr JO NOBLE

Living life

Newcastle GP Dr Jo Noble lives life to the max, cramming five different roles into a typical week – and she still manages to keep up a busy social life on weekends.

I’m never, ever bored – I enjoy it all so much!

to the max

Jo works three days in a Charlestown medical practice, one day a week at Hunter headspace (an adolescent drop-in centre), spends a few hours each week tutoring first-year medical students at the University of Newcastle and runs a fortnightly two-hour bulk bill clinic at a local women’s refuge. But that’s not all – she’s also a parttime medical educator for local GP registrars. Because of all this frenetic weekday activity, she maintains a minimal on-call roster – just one Saturday every five weeks. That leaves her free most weekends to see live bands, visit galleries and cook gourmet meals with friends. So, what’s her secret? Yoga, she says. “I’m up at 6am every morning during the week and I practice 75 minutes of Hot Power Yoga, which gives me a big energy boost before I tackle the day.” Raised (for the most part) in Sydney, Jo moved to Newcastle to enrol in undergraduate medicine and, apart from a few stints travelling overseas, hasn’t left since. “I’ve had an interest in medicine from a young age, possibly because I grew up with an aunt who was quite sick throughout my childhood. I actually did a semester of physiotherapy when I first left school, but I didn’t like it. I worked in it for a while then got into medicine at the University of Newcastle on my second attempt.” Jo says that she really loved the problem-based learning approach to medicine taken by the university. In fact, so much, that she is back there now as a part-time tutor for first-year students! “It’s such a great way to learn, because right from day one, students are given clinical situations and a patient story as the basis for their learning.” General practice appealed to Jo right from the beginning of her medical education because she was attracted by the longevity of care general practice allows. She fell in love with every rotation she tried and eventually realised that general practice meant she didn’t have to choose between them. She could cover them all! She did some of the terms in her internship and residency at John Hunter, Newcastle’s big teaching hospital, but also worked at a hospice and had placements at Tamworth and Maitland. She took a term off to travel around Europe with friends and recalls this with a big smile. “I actually did my interview for general practice training from the Australian Embassy in Paris, then had chocolate croissants and champagne under the Eiffel Tower to celebrate.” One of her GP training terms was at the urban practice in Charlestown where she now works two days each week. “I really enjoy this place, because we have an interesting patient mix – from lower income people to young professionals. It’s a reasonably big practice with a couple of nurses and it’s really well supported.”

Jo took 10 months out of her training and backpacked through Japan, Europe, and South America. “I believe that having those diverse experiences is something that adds to what I bring to my practice,” she says. She also did a rural term in a small practice in Taree where there was outpatient on-call, after-hours home visits and nursing home visits. She then returned to Newcastle to take on the role of registrar medical educator. “In Newcastle there was only ever one other person in the role for six months before I arrived, so I could develop my own projects, such as developing exam resources for registrars and getting a simulation dummy for training in GP emergencies. It was such an exciting opportunity to be involved in a team environment with a big focus on education – I’m confident it not only improved my own teaching but also my clinical skills.” Each fortnight Jo runs a bulk-billing clinic at a local women’s refuge, setting up in a room with her own medical kit. “It’s a safe place for the women to see a doctor and they really appreciate what I can provide.” She admits that one of her favourite roles is the one day each week she works at Hunter headspace in Maitland. “It’s a great set-up, with youth workers who triage all the patients and then refer them through to me and an in-house psychologist, and so on.” She explains that this is also a safe zone for young people in crisis, generally with mental health issues, who may come into the headspace drop-in centre to do a course or play pool. “It’s a place where teenagers hang out, so they have no qualms about wandering in to see a doctor and it’s great to hear they feel comfortable with me.” Jo says she enjoys the team environment, and is often involved in case conferences with the psychologist and youth worker at the centre. “Even though I really enjoy it, I find one day a week at headspace is enough, because it really takes an emotional toll on me.” The small gaps left in her working week are filled with more work as an educator, running a couple of tutorials at the University of Newcastle and continuing to work for a few hours each week with her former GP training provider as a registrar medical educator. “I run an online study group for registrars to help them prepare for each of the exams.” While Jo’s original reason for becoming a GP was so she could help people, she says she never imagined it would be so much fun. “I’m never, ever bored – I enjoy it all so much!”

Photography: Ric Woods

Going Places – ISSUE #6

Where to from here? So, you’ve read through Going Places and now you are curious about general practice as a career. Or maybe you’ve already decided that being a ‘General Specialist’ is your vocation! What’s next? Here are four ways to start Going Places in your career as a GP:

Attention Young Doctors

LOOKING TO TAKE THAT NEXT VITAL STEP IN YOUR CAREER? At Healthscope, our Medical Centres are focused on the career development and education of our Practitioners. We offer young doctors the opportunity to work in modern facilities with access to high quality equipment and resources across various locations in Australia.

OPTIONS: 1 Join the Going Places Network

We also provide ongoing national training and education opportunities, with a major focus on Chronic Disease Management in primary care, and encourage young doctors to pursue areas of special interest to foster their growth.

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, whilst developing your professional knowledge and credentials! See below for more information. Looking for the Going Places Network at your hospital? Visit: www.gpaustralia.org.au to find out more and join on line.

With flexible hours and employment packages on offer, our centres provide a supportive administrative environment for young doctors looking to enhance their professional development.

Email: goingplaces@gpra.org.au with ‘Going Places Network’ in the subject line. Tell us what hospital you are based at – then we’ll hook you up with your local network!

2 Talk to your GP Ambassador Our GP Ambassadors are junior doctors who have a real passion and enthusiasm for general practice. They’ll be able to answer all your questions about general practice. If there are any questions they can’t answer, they’ll find the answers for you!

Visit www.gpaustralia.org.au to find out who’s the GP Ambassador in your hospital or area – also look out for posters on notice boards in your hospital. 2 011

3 Find out about how you can become a GP Ask your GP Ambassador for a copy of the Going Places Prevocational Doctors Guide to GP Training – your comprehensive guide to becoming a GP. They’ll also be able to provide the AGPT (Australian general practice Training) 2012 Handbook, which has full details of the AGPT program. Alternatively, you can email goingplaces@gpra.org.au with ‘Information Pack’ in the subject line and all your details in the email. Take a look at page 25 of this issue of Going Places for our guide to Applying for GP Training.

General Practice

PREVOCATIONAL dOCTORs GUIdE TO GP TRAINING

Test-drive general practice

E LOV YOUR WORK GP training facts

GP $alary guide

An initiative of

www.gpra.org.au / RRP $10.00

AUSTRALIAN GENERAL PRACTICE TRAINING HANDBOOK 2012

4 Visit www.gpaustralia.org.au To find out how general practice training works, visit the website! It will guide you through who is involved in providing you with the information and contact details to help you plan your path into general practice.

More Information To learn more about the benefits of joining a Healthscope Medical Centre please contact Lachlan McBride on 0417 574 401 or lachlan.mcbride@healthscope.com.au Going Places – ISSUE #6