ISSUE 9 FREE October— January 2012/13
Taking a fresh look at general practice
Our vibrant group of GPs showcase the vast range of opportunities in general practice ‘Chocolate box’ - GP tales with a twist ‘It takes two’ – meet our new dynamic duo Find out more about Electronic health (e-Health) records Plus, your favourite features ‘Dr Fairytale’ and ‘Guess the diagnosis?’ and more
Navy medical officer Lieutenant Commander Joel Hissink
An officer and a gentleman The future of general practice
A healing journey in general practice
Have you ever given thought to working as a GP registrar in an Aboriginal and Torres Strait Islander health training post? These posts can be undertaken as part of the Australian General Practice Training (AGPT) program. Talk to your local regional training provider today for more information or go to: www.agpt.com.au 6
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In this issue…
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On the cover... Lieutenant Commander Joel Hissink (Photography: Peter Leslie Photography)
Regulars 5 Going Places Network update 6 Going Places Network across Australia 9 It takes two 11 Chocolate box 21 GP in the news 23 Clinical corner 24 Feature article – E-medical records 31 What’s new in the AGPT program? 36 What’s your diagnosis? 41 Think you have the flu? Time to ask Google 42 Dr Fairytale 42 Book review
Profiles 12 Dr Erwin Wong — The PGPPP and me 14 Dr Courtney Lai — Having the best of both worlds 18 Dr Jillian Collier — On track with the Rural Generalist Pathway 26 Lieutenant Commander Joel Hissink — An officer and a gentleman 28 Dr Jacqueline Heagney — Medicine on the fly 32 Dr Raymond Seidler — King of the Cross 34 Dr Glenn Pereira —Skills for a country practice Produced with funding support from
Welcome
to the ninth edition of Going Places magazine, an in-depth view of the amazing career that is general practice! As usual, we have the mix of the unusual. Dr Sarah McEwan makes our palms hot and itchy in “What’s your diagnosis?”, Dr Gerry Considine shows us what hypnotism and “The Wizard of Oz” have in common with bladder management and Dr Ian McColl explains why we should be selective in our choice of greeting a patient, and which dark spot we sample, in “Clinical Corner”. If you are considering a career in general practice, then consider a Prevocational General Practice Placements Program (PGPPP). Dr Erwin Wong takes us on this PGPPP journey, where we see that some headaches need more than a CT. Rural general practice can be an outstanding career, incorporating a wide range of procedural and clinical skills. Dr Jillian Collier and Dr Glen Pereira tell us about the importance of being an all rounder. Dr Jacqueline Heagney wears the right uniform for compliments and as a GP with the RFDS she literally flies through her day. Speaking of uniforms, Navy medical officer Lieutenant Commander Joel Hissink shows us how military medicine fulfils his desire to perform humanitarian aid work. Ever thought that you’ve encountered the wrath of a patient? Dr Courtney Lai regularly has thousands of people shouting at him as he balances his driving passions as AFL umpire and resident doctor. Dr Raymond Seidler ignored a warning about blowtorches and his gastrointestinal mucosa when establishing his practice in King’s Cross, and has been a GP to the stars. He also issues a note of caution, highlighting how important it is to know a bit of patient background before taking their gynecological history. Dr Jane George reviews a book about an exceptional Australian, Dr Chris O’Brien and his battle with a devastating disease. Dr Joshua Crase takes us through the maze of e-health, described as the single-most important revolution in healthcare since the advent of modern medicine. Pull up a pew, grab a medicinal drink, sit back and dive in! The world of general practice awaits! Heal (and have fun), Dr Mike Cross-Pitcher Medical Editor Hospital Registrar – Central and Southern Queensland Training Consortium GP Ambassador – Nambour General Hospital, Sunshine Coast, Queensland
General Manager/Editor: Sally Kincaid. Writers: Sarika Shah, Jan Walker, Sabeha Mohamed. Graphic Design: Peter Fitzgerald. Going Places Network Manager: Emily Fox. Business Development Managers: FSC Logo Kate Marie, Natalia Cikorska. Print: Graphic Impressions.
©2012 GPRA. All rights are reserved. All materials contained in this publication are protected by Australian copyright law and may not be reproduced, distributed, transmitted, displayed, published or broadcast without the prior permission of General Practice Registrars Australia Ltd (GPRA) or in the case of third party material, the owner of that content. No part of this publication may be produced without prior permission and full acknowledgement of the source: Going Places magazine, a publication of General Practice Registrars Australia. All efforts have been made to ensure that material presented in this publication was correct at the time of printing and is published in good faith.
Taking a fresh look at general practice 3
At Healthscope, our Medical Centres are focused on the career development and education of our Practitioners. We offer young doctors the opportunity to work in modern facilities with access to high quality equipment and resources across various locations in Australia. We also provide ongoing national training and education opportunities, with a major focus on Chronic Disease Management in primary care, and encourage young doctors to pursue areas of special interest to foster their growth. With flexible hours and employment packages on offer, our centres provide a supportive administrative environment for young doctors looking to enhance their professional development.
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Going Places Network update Over 2000 junior doctors are going places Not wanting to miss out, junior doctors across the country have been signing up to the Going Places Network in droves. With over 1000 new members signing up already this year, membership is rapidly growing and currently stands at over 2300 members. Not yet a member? What are you waiting for? Join today and find out more about careers in general practice through events, publications and heaps of other free resources.
Going Places events Going Places events have been running all over the country. Highlights include several networking dinners, GP information evenings, a PGPPP information evening and an otoscope and joint injection workshop. More events are planned throughout the country for the rest of the year. Events will be promoted at your hospital, but you can also keep an eye on the Going Places Network website at gpaustralia.org.au/events
GP Australia website – top GP careers information source
With well over 2000 unique visitors a month, the Going Places Network website gpaustralia.org.au continues to be a popular one-stop shop for junior doctors seeking information on careers in general practice. The website is full of essential information and resources, including a nifty GP earnings calculator, information on the Australian General Practice Training program (AGPT), how to apply, blogs, videos and much more. Visit gpaustralia.org.au
Here is a round up of the latest Going Places news, events and resources. Handy publications Going Places prevocational doctors guide to GP training Jam-packed with all the essential information on general practice training, this is the essential go-to handbook for any junior doctor considering a career in general practice. See your GP ambassador to get your copy.
GP companion This clinical pocket reference book contains a goldmine of facts and figures on essential treatment for a range of medical conditions, preventative medicine and clinical reasoning — very handy for those on a PGPPP rotation. Get your copy at a Going Places event or download the e-book version at www.gpaustralia.org.au/content/publications
Check out our website gpaustralia.org.au for all the resources and essential information.
Make the most of your PGPPP rotation gpaustralia.org.au Taking a fresh look at general practice 5
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QLD 1
Cairns Base Hospital
Linda Maluish
cairnsgp@gpra.org.au
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Jamie-Lea Whyte
townsvillegp@gpra.org.au
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Mackay Base Hospital
Stephanie Davis
mackaygp@gpra.org.au
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Rockhampton Hospital
Rupert Jayraj
rockhamptongp@gpra.org.au
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Nambour Hospital
Michael Cross-Pitcher nambourgp@gpra.org.au
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Redcliffe Hospital
Matt Tatkovic
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Princess Alexandra Hospital Fiona Simpson
princessalexandragp@gpra.org.au
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Toowoomba Hospital
Richard Hargreaves
toowoombagp@gpra.org.au
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Ipswich Hospital
Brendan Thompson
ipswichgp@gpra.org.au
10 Logan Hospital
Scott Hahn
logangp@gpra.org.au
Nicole Hall
campbelltowngp@gpra.org.au
12 Bankstown Hospital
Jane George
bankstowngp@gpra.org.au
13 Royal North Shore Hospital Sumit Chadha
royalnorthshoregp@gpra.org.au
14 Westmead Hospital
westmeadgp@gpra.org.au
15 Royal Prince Alfred Hospital David Ford
royalprincealfredgp@gpra.org.au
16 Wollongong Hospital
Laura Harnish
wollongonggp@gpra.org.au
17 St George Hospital
Natalie Sancandi
stgeorgegp@gpra.org.au
18 John Hunter Hospital
Craig Roberts -Thomson
johnhuntergp@gpra.org.au
19 Horsnby Hospital Network
Marianne Moore
hornsbygp@gpra.or.au
20 Tamworth Hospital
Amanda Siebers
tamworthgp@gpra.org.au
ACT 21 The Canberra Hospital
Anita Dey
canberragp@gpra.org.au
VIC 22 Eastern Health
Edward Skinner
boxhillgp@gpra.org.au
23 St Vincent’s Hospital
Erwin Wong
stvincentsgp@gpra.org.au
24 Goulburn Valley Health
Edmund Siauw
sheppartongp@gpra.org.au
25 Austin Health
Melissa Cairns
austingp@gpra.org.au
26 Ballarat Hospital
Garry Matthews
ballaratgp@gpra.org.au
27 Barwon Health
Ineke Woodhill
geelonggp@gpra.org.au
28 Peninsula Health
Michael Toolis
peninsulagp@gpra.org.au
29 Southern Health
Sara Tarafi
southernhealthgp@gpra.org.au
29 Southern Health
Chia Pang
southernhealthgp@gpra.org.au
30 Western Health
Elizabeth Bond
westerngp@gpra.org.au
TAS 31 Launceston General Hospital Kaylee Barnett
launcestongp@gpra.org.au
32 Royal Hobart Hospital
Rachael Foster
royalhobartgp@gpra.org.au
SA
33 Flinders Medical Centre
Adam Swalling
flindersgp@gpra.org.au
34 Flinders Medical Centre
Sam Manger
flindersgp@gpra.org.au
35 Lyell McEwin Hospital
Sara Le
lyellmcewingp@gpra.org.au
36 Modbury Hospital
Sarah Maltby
modburygp@gpra.org.au
37 Royal Adelaide Hospital
Eliza Hannam
royaladelaidegp@gpra.org.au
38 Royal Adelaide Hospital
Adelaide Boylan
royaladelaidegp@gpra.org.au
39 Queen Elizabeth Hospital
Kerry Summerscales
queenelizabethgp@gpra.org.au
NT
40 Royal Darwin Hospital
Jasmine Banner
darwingp@gpra.org.au
Jemma Smith
royalperthgp@gpra.org.au
WA 41 Royal Perth Hospital
42 Sir Charles Gairdner Hospital Clark Maul
charlesgairdnergp@gpra.org.au
43 Fremantle Hospital
Kate Reid-Milligan
fremantlegp@gpra.org.au
44 Joondalup Health Campus
Tamla Wilke
joondalupgp@gpra.org.au
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Don’t have a GP Ambassador at your hospital? Email the closest one, or contact the Going Places team on goingplaces@gpra.org.au
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It takes
Drs Jennie Robinson and Lucy Alexander are GPs at Claremont Village Medical Centre in Hobart, Tasmania. Jennie is a registrar at the practice and Lucy is her supervisor. Jennie says that she wants to be as dedicated a GP as Lucy is.
Jennie:
Lucy:
I decided I wanted to be a GP after completing a Prevocational General Practice Placements Program (PGPPP) term. I loved the fact I had the opportunity to really get to know my patients. I also liked the flexibility general practice offered in terms of working hours and the opportunities to extend myself in my interest areas.
I graduated in 1987 and after three years in the hospital system I started general practice and have worked as a GP ever since — which is over 20 years now! I have always worked in practices linked with training — firstly as a registrar myself, then as a training advisor and now as a supervisor.
Before starting general practice training, I completed two years of psychiatry training. However I wasn’t really enjoying it, particularly the on call work, so I decided to have a year away from psychiatry. During that year I completed the PGPPP term. I found I could still see many patients with mental health issues and found I had the opportunity to really understand each patient’s individual circumstances and provide ongoing help and support. The general practice setting just seemed to suit me better. During my PGPPP term I also enjoyed the opportunity to learn new skills and build ongoing relationships with patients and their families. After my PGPPP term I decided not to return to psychiatry and instead start GP training.
I decided to be a GP after my GP terms as a student. I really enjoy the wide spectrum of patient presentations, being the first doctor to see and hear a person’s story and the puzzle of working out the diagnosis. I find caring for people and their families over a long period of time is fascinating and essential for good general practice.
I have been working as a registrar at Claremont Village Medical Centre for 18 months. It is a six-room practice with a total of 12 GPs and is owned by three partners. The fantastic GPs, nursing staff, practice managers and reception staff all make it a very enjoyable and supportive place to work. Lucy has been my supervisor for the last 18 months. She is an amazing supervisor. Lucy has been supportive, understanding and always willing to help. She is always very patient with me, despite my numerous questions! When I had a week off studying for my exams Lucy phoned me to wish me luck — it made me feel supported and less nervous about the exams. Lucy is also the sort of person who cares about your general well being — she keeps encouraging me to wear flat shoes to work so we can go for a walk at lunchtime! As a GP, Lucy is kind, empathic and thorough. She is the sort of doctor you would like to have as your own GP. I am inspired by Lucy’s ability to be an active, interested and loving parent whilst also being dedicated to her career as a GP.
I choose to also be a supervisor because it allows our practice to have young doctors with fresh ideas and new perspectives. We have benefitted from having Jennie — she is a breath of fresh air. If I had to use five words to describe Jennie I would say she is: intelligent, caring, diligent, cheerful and committed. On a lighter note she is also very fashionable and sadly a St Kilda supporter! General practice is very different today compared to 20 years ago. There are a lot of frustrations and inefficiencies in the system that we deal with now such as hospital and specialist waiting times. It seems a lot harder to provide definitive management because of all the services that require you to fax off a referral to be considered before the service is provided. This creates a level of dissatisfaction in that as the doctor you don’t know whether you have sorted the patient out definitively at the end of the consult. You have to make contingency plans constantly and see patients more times to solve the same problem. When I first went in to general practice I could phone a services provider during a consult and make the appropriate appointment before my patient left the practice. These frustrations are what have become known as “red tape” but they are also a waste time and money. General practice can often be stressful. We have a very happy staffroom where we try to gather at lunchtime. If anyone has had a stressful session they can debrief amongst colleagues. I think that talking with other GPs is the most effective way to manage the odd challenging day.
I would like to be as dedicated to being a GP as Lucy is, with ongoing energy and interest for my patients. I would like to be a GP who patients can trust and rely on no matter what they are going through. The GPs in the practice I work in are wonderful and create a supportive and enjoyable working environment. I am very thankful that I have found a practice that seems to be right for me.
My words of advice for junior doctors wanting to be a GP is that you have to be able to deal with uncertainty and you have to like people and their stories. It is important to be kind but it is essential for you to be able to run a business so that you can stay in practice for the long haul.
In five to ten years time I see myself continuing to work in general practice and hopefully also involved in medical education. I would like to be working in the same practice, seeing many of the patients I see now. I might even be supervising a registrar or two.
Do you know a pair who could feature in future ‘It takes two’? A GP and a patient? A practice manager and a registrar? Your mentor? A GP who inspired you? Let the Going Places team know by emailing goingplaces@gpra.org.au
Taking a fresh look at general practice 9
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Taking a fresh look at general practice
Dr Gerry Considine is a rural GP registrar currently working in outback South Australia. He is especially interested in emergency medicine and paediatrics. Outside of medicine, Gerry hobbles around the football field, plays in a two-piece blues rock band and has recently gained his pilot’s licence. It is the connection with the community and human stories that keep his passion for medicine alive.
‘Somewhere over the rainbow’
When you’re a GP, you never know what you’re going to get…
“I remember my first removal of a suprapubic catheter very well. In fact, it will be something that will remain in my memory for a long time to come. During medical school there had been plenty of standard IDC insertion and removal rehearsals with those hard rubber models…the ones with the unrealistic non-malleable appendages and ‘bits’. I had even managed to practise many real life IDCs on the hospital wards as a senior medical student (and longed for those practice manikins that actually held their shape!). But I had never been able to attempt or even witness a removal of a catheter that went straight into the lower abdomen. We had learnt all about suprapubic techniques in paediatric rotations, but my first foray into this area was during a country general practice intern placement country General Practice Placements Program (PGPPP). My patient for the day was a 50-year-old lady who had been using suprapubics for the past year. However, she had found the whole process so painful and unbearable that each change was conducted at the hospital under analgesic cover. Unfortunately her low level of pain tolerance meant that these episodes were usually quite a scene. Luckily the GP in this town was open to trying alternative techniques and enrolled the help of a local hypnotist. On previous changes the patient had been instructed to imagine everyone naked and giggled her way through the whole procedure. Then it came my turn. Fortunately the naked trick was not being used this day. As I entered the room I could hear singing. My patient had been hypnotised and was already in a trance like state singing ‘Somewhere over the rainbow’! So it came to be that my first suprapubic catheter removal was performed with the patient calm and singing sweetly in my ear. Unfortunately, the Wizard of Oz has lost some of its magic for me and I will never think of the Yellow Brick Road in quite the same way again!
Dr Gerr y
Considine
Do you have a story to share – an unusual case, a miraculous recovery or an amusing anecdote? Let us know, email goingplaces@gpra.org.au
Taking a fresh look at general practice 11
PGPPP AND ME
PGPPP diary Where are you doing your junior doctor training?
St. Vincent’s Hospital Melbourne What year are you in? PGY3 Where are you doing do your PGPPP? The Clinic Footscray. It’s a cosy clinic just west of the central shopping area. What’s the local community like? Footscray is a diverse area with successive layers of immigration and home of the Western Bulldogs AFL team. A significant part of the current population originates from South East Asia and Africa, including a large population of refugees. Your practice is based within a diverse and changing community, what do you enjoy most about it and what are the major challenges?
The most enjoyable aspect is the diversity itself: being exposed to new cultures and new ways of thinking. It’s fascinating to see how people from various cultures adapt to life in Australia and how the current residents and environment adapt to them. An occasional challenge is language, but we are very lucky to have good access to phone interpreters and there is a growing amount of patient information available in different languages. Most of the patients I’ve encountered here genuinely want to get better and improve their health and that goes a long way in our ability to help them.
How was it meeting your supervisors for the first time? What have you learned from them? My two supervisors (Drs Helen Dooley and Jeff Rubin) have been wonderful! They were very welcoming from the moment we met and Dr Dooley even took the time to drive me around the local area and get me oriented. Their experience has been invaluable and they have shared some brilliant suggestions for management strategies which can’t be found in textbooks. We also have a registrar at the practice whom has been fantastic and it was nice being able to ask him about questions regarding the training program.
Dr Erwin Wong is currently on a Prevocational General Practice Placements Program (PGPPP) at the Clinic in Footscray, Victoria. It is an area renowned for its ethnic diversity with a high number of new and first generation Australians predominantly from South East Asia and Africa. 12
Tell us about some of the work you have done? There is so much diversity! Consults have varied widely from discussing and administering vaccines to looking at rashes, testing for sexually transmitted diseases to confirming pregnancy in a lady with morning sickness. The list could go on and on. Dr Dooley and I also recently went to a local company and did some basic health screening and talked about preventative medicine. Of course, the winter weather has brought on a fair amount of coughs and colds as well but I often use these chances for opportunistic health checks and discussions.
Did you get some ‘hands on’ experience?
Has anything really surprised you about this experience?
I’ve had the chance to watch an Implanon insertion and a few skin excisions. I’ve also had a play with the liquid nitrogen for some cryotherapy and syringed a few ears. Although the latter isn’t glamorous, seeing the immediate relief of patients after clearing the wax is its own reward! I’ve also learnt that giving vaccines to four year-olds usually requires three pairs of hands!
The availability of any of the doctors for a second opinion if I am stuck or unsure has been a bonus. It’s not only great for my learning and confidence but also ensures the patient is getting the best outcome. And they do this on top of their own busy lists which makes it even more amazing.
Can you describe an average day for you during your PGPPP A typical day would be arriving at the clinic in the morning, reviewing new investigation results in my inbox and making any appropriate follow-up, then seeing the patients I have booked for the day. The registrar and I also get 1-1.5 hours of dedicated teaching set aside twice a week. Is there a patient who you will remember more than others? I had a medical student in her 20s present with a new onset headache and nausea and vomiting. There were no infective symptoms or focal neurology found, but I referred her to Emergency where a CT brain was normal and she was sent home. Her symptoms persisted the next day, she decided to go to class anyway, and luckily one of her mentors decided to get her an urgent MRI which showed a venous sinus thrombosis. This young lady will always stick in my mind not only because of the uncommon final diagnosis, but also because the case illustrated the importance of encouraging patients to re-present if their symptoms persist and the referral does not resolve their issues. What have you learned about general practice? It is diverse and flexible. This applies both to the specialty itself and the larger picture of work-life balance.
Has the experience made you want to pursue a general practice career? I was already keen on general practice and this experience has done nothing but help. What’s been the best part of the experience? Getting to know my patients. There are so many great stories to be told. What’s been the most challenging or difficult? An important part of being a good GP is knowing all the resources you can tap into for patient information and referrals. I am still learning these, but it’s something that comes with time. Would you recommend a PGPPP to others? Why? If someone is interested in general practice, then it’s a no-brainer. If someone is unsure or even not interested, it still presents a rare first-hand and well-supported experience to an underexposed side of medicine for junior doctors. What are your top three tips for someone doing their PGPPP? 1. Be curious. 2. Ask questions. 3. Have fun.
Prevocational General Practice Placements Program The Prevocational General Practice Placements program (PGPPP) provides junior doctors with a general practice rotation during their hospital training. Placements are with professional, well supervised and educational general practice environments. Contact your regional training provider (RTP) for more information or go to: www.agpt.com.au
Take the plunge -‐ give GP a go!
Taking a fresh look at general practice 13 Image: Courtesy of Northern Territory General Practice Education
J U N I O R D O C T O R profile
Best
of both worlds Combing his two passions in life – medicine and sport, Dr Courtney Lai is a second year resident at the Peter James Centre in Melbourne and a goal umpire for the Australian Football League. Going Places magazine talks to Courtney about medicine, footy and having the ‘best of both worlds’.
Main Picture: Courtney outside the Peter James Centre where he did his rotation. Inset left: Courtney at work. Inset right: Courtney’s other side as an AFL umpire.
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As a young boy Courtney was always kicking a ball, swinging a bat or shooting some hoops. “Sport has always been in my blood” says Courtney. “I actually discovered medicine through sport.” Playing footy, cricket, netball and golf, Courtney experienced his fair share of sports injuries. By the time he was 18 years old he had already had two knee operations, a shoulder reconstruction and numerous other procedures. “I became quite fascinated with the medical side to all my injuries and this is where the seed for a career in medicine was firmly planted.” “My GP was also a great mentor. I really admired the confident and competent way in which he dealt with his patients, the effective manner in which he ran a two-doctor practice and the genuine continuity of care he offered,” he reflects. As for umpiring, Courtney says that he “just kind of fell into it”. After his numerous injuries, Courtney’s orthopaedist suggested that he should stop playing football. Despite this he was adamant that he wanted to continue being involved with his school footy team. He set his sights on becoming the team runner, only to find out that the position was already filled. Thankfully, the coach had other plans for Courtney. “The coach suggested that I become the team goal umpire and that’s how it started” he explains. At medical school Courtney carried on umpiring as a means of earning extra cash. He secured a position with the Southern Football League in Victoria in 2005, from then on his career in umpiring snowballed.
“There are many parallels between medicine and umpiring – both doctors and umpires require numerous common skills to be able to do the job effectively. As a doctor I greatly benefit from being able to develop these key skills in nonmedical environment.” After a couple of years umpiring at the Southern Football League he was picked up by the Victorian Football League (VFL) and ended up umpiring two VFL grand finals in 2009 and 2010. Then came the grand slam — in 2011 Courtney was promoted to the Australian Football League (AFL), his first game being Melbourne vs Adelaide at the MCG. Since then Courtney has umpired numerous games including Gold Coast’s famous last-kick victory over Richmond in 2012 and another thriller between Essendon and North Melbourne. Courtney is currently in his second year of hospital training. He combines busy residency life with umpiring. As an umpire he has to be available every weekend between February and September and needs to work this in with his weekend shifts at the hospital. He also trains along with other umpires twice a week for two hours. Going Places magazine asks Courtney how he manages to juggle his grueling life as a resident with umpiring. “It’s not easy, but it’s not impossible. You have to believe that you can do it,” says Courtney. He credits his successful juggling act to knowing what he wants, negotiating and being surrounded by supportive people.
AFL and the hospital; luckily for me both have been very understanding.” “Negotiation is also a key factor. Anything is possible if you are willing to negotiate and also be prepared that you may have to give up something along the way. If the overall goal is that important to you, in the end you will be ok with it,” he explains Courtney also highlights the importance of a supportive network – great colleagues who are happy to swap shifts, and understanding friends and family who accept that they are not going to see you every weekend. Going Places magazine asks Courtney if there are any similarities between his careers. “There are many parallels between medicine and umpiring — both doctors and umpires require numerous common skills to be able to do the job effectively. As a doctor I greatly benefit from being able to develop these key skills in non-medical environment. The same applies to umpiring as well,” says Courtney. Courtney explains that both his roles require the ability to make frequent decisions under pressure and maintain a high level of composure and control. Working effectively as a team, learning from feedback and being able to concentrate for long periods of times are other common themes. Finally, the requirement for accuracy and the fact that there is no margin for error are further distinct parallels. When Going Places magazine interviewed Courtney for this article, an umpiring decision he had made the previous weekend was being scrutinised on every Australian TV channel. “That was nerve racking.” “Although as a doctor it is possible to find yourself at the mercy of the media, I’ve always said I am much more likely to end up in a media scandal as an umpire!” he declares. When asked about the future Courtney says he still wants to do another year as a resident and is considering joining the Australian General Practice Training program (AGPT). “I am drawn to general practice for many reasons. A big pull is the opportunity to work in the community and the diversity – I want to be able to offer continuity of care. The ability to pursue a subspecialty in general practice is also a major consideration. I am considering sub-specialising in sports medicine. I also want to continue to umpire for as long as I physically can – which I hope is still going to be a good few years yet, hence the work-life balance in general practice is also a draw card.” So what will happen when Courtney’s umpiring career eventually comes to a halt? Will it spark the end of his sports career? Not one to give up on his passions Courtney simply says; “I’ll morph like I always do. When my career in umpiring looks as if it is going to end I will probably transition into a team doctor.” Courtney’s career may take many twists and turns, but one constant is likely to remain — his philosophy of carving out a career where he can enjoy the best of both his worlds. Sarika Shah
“It is very important to be clear about what it is that you exactly want. From the onset I was able to clearly articulate my needs to both to the
Taking a fresh look at general practice 15
G P registrar P R O F I L E
On track with the Rural Generalist Pathway When Jillian Collier was awarded a Rural Bonded Scholarship in medical school it planted the seed of an exciting career in rural medicine. Fast forward several years and that seed has grown to see her follow the Rural Generalist Pathway, move to Goondiwindi and face a variety of hospital and community-based challenges that only come with being a GP registrar in a rural community.
After speaking with Dr Collier about her journey on the Rural Generalist Pathway the proverb, ‘give a man a fish and you feed him for a day; teach a man to fish and you feed him for a lifetime’ springs to mind. This principle is what underpins the Pathway — teaching young doctors how to deal with the unique challenges of rural medicine. “The Pathway is producing doctors who are more rounded and have firmer skills to practice in an isolated rural area.” Jillian explains. Jillian believes that the Pathway provides great support and access to specialised rotations that are particularly relevant to the rural setting. “In your junior years, there are set spots in various hospitals for you to access rotations such as anaesthetics and obstetrics. The pathway allows you to begin this specialised training earlier so you are better prepared when you start working in a rural area.” During her first three years of training, Jillian was required to attend a yearly two-day workshop, which was solely focused on rural professional development. “The workshop went through various skill stations including airways, obstetrics and other emergency presentations common to rural medicine. It was a really helpful learning environment.”
Jillian Collier at work.
Rural Generalist Pathway — more information
• •
The Rural Generalist Pathway was pioneered in Queensland as a Queensland Health initiative to provide a fully supported, incentive based, career pathway for junior doctors wishing to pursue a vocationally registered career in Rural Generalist Medicine. New rural generalist training programs are now being rolled out allover Australia. For more information, talk to the GP ambassador at your hospital or visit your local state government health website.
She speaks fondly of the workshop as it not only developed her professional skills but also increased her exposure to like-minded individuals. “It was a really good opportunity to network and meet other doctors who were working in rural areas and it gave you a bit of insight into different rural towns.” Over the last 5 months, Jillian has been one of a number of GP registrar’s in Goondiwindi. Although a small town community with some geographical limitations (it’s located 350 km southwest of Brisbane), it’s certainly not limited in availability of highly skilled medical professionals who are ready to lend a hand when needed. “We always have a second GP on call who knows the town and capacities of the hospital, and what medical conditions need to be flown out to Toowoomba or Brisbane.” “We also have someone who can provide anaesthetic skills and someone who is obstetrics on call. That means we’ve always got airway backup and someone we can ring for any obstetric emergency.”
It’s clear she loves both equally, “At the end of the day it’s all general practice and I’m lucky enough to experience all sides of it on a daily basis.” The Rural Generalist Pathway has exposed her to a variety of experiences outside of the traditional GP mould. “It’s a unique situation you’re in. You see the complete spectrum of a disease, you treat a patient in the emergency department one week and then you become responsible for their chronic disease management in the GP clinic the next.” “When working in a rural area, you can really witness disease progression and get the whole picture of someone’s health.” The geographical limitations of Goondiwindi have taught her how to be more aware of her situation. “The most valuable skill that I’ve learnt here is knowing my boundaries and when to ask for help. When working in a rural location you have to have a great appreciation of what you can deal with in your current location and what medical conditions need to be flown out for specialised medical treatment.”
For Jillian, moving to Goondiwindi for her rural GP training was an obvious choice. “The main advantage of working in Goondiwindi is the great support network. There is a team-based approach to the way we do things and you’re never alone. For a GP registrar, support is very important.”
about being based in Goondiwindi is a far cry from the stories of isolation and hardship that plague a lot of rural communities who are engaged in a desperate search for medical professionals. “Goondiwindi is a place that is quite lucky. They’ve had a stable senior GP presence for a number of years and that has meant they have a really good team out here which really aids the health of the community.”
Given there is so much benefit and
“In the morning I wear my hospital opportunity in a career in general Jillian’s one gripe is the hat and am faced with acute and practice perception that general practice is emergency medicine and in the easy. “Because it’s such a generalised don’t appreciate afternoon I wear my clinic hat and job,thata lotto beof people a good GP is really issues difficult, you have to have a broad deal with chronic management base and be able – it’s almost like doing two jobs.” toknowledge resource a huge range of Listening to Jillian talk with such pride
One of those senior GPs is Dr Susan Masel who is the Medical Supervisor at Goondiwindi Hospital. She and her husband, Dr Matt Masel live in Goondiwindi and have so for the last 10 years. They are two of the GP partners of the local clinic and are key figures within the community. “They’re such a good example of that rural doctor mould. Between them their skill set is amazing, yet they’re still really nice people, very down to earth and have a lovely family.” Although the Masels have built a core medical community, they are no strangers to rural workforce issues and the barriers in attracting medical professionals to the area. “Hopefully the improvements in wages, increased support and good training positions will encourage more people to consider rural practice and reduce the shortages.” At present, Jillian splits her time between the Goondiwindi Medical Centre and the local hospital. “In the morning I wear my hospital hat and am faced with acute and emergency medicine and in the afternoon I wear my clinic hat and deal with chronic management issues – it’s almost like doing two jobs.”
available services.”
With a hint of frustration she continues, “For those who think that general practice is the easy way out, they really just need to spend one afternoon sitting in a GP clinic, to see how challenging the job really is.” This common misconception is a stark contrast to the respect and value rural GPs receive from city and visiting specialists. “I think city specialist’s have a real respect for rural doctors because you have to be a little more self sufficient. Given our geographical limitations, it’s better for our patients if we can arrange investigations and initiate treatment early prior to their specialist review.” The name Goondiwindi derives from an Aboriginal word meaning ‘the resting place of the birds’. When asked if this has any significance to her situation Jillian ponders. “Maybe. Goondiwindi is a great place to work, the community is great and the support is readily available so it ticks all the boxes in that sense.” With a genuine warmth and honesty in her tone she continues, “It’s my resting place for the next two years. After that I can’t rule out anything just yet.” Jillian wants to graduate in both the RACGP and ACCRM fellowships as she has recognisable qualifications that will allow her to sit for both. After she completes her examinations and training she wants to go travelling for a while. No doubt her advanced skills in rural medicine will be portable on any road she travels. Sabeha Mohamed
Taking a fresh look at general practice 17
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better lifest yle and plent y of wor k o pport unit ies
more diverse se pat ient ba t han t he cit y
l ovel y sense of c ommunit y
Advance your career in country NSW Career diversity and finanCial rewards • The diversity of country practice provides job satisfaction and broad ranging experience, giving you a clear career advantage over city-based practitioners. • Country practice provides financial benefits, from relocation subsidies to practice incentives and more economical living. and the living’s good! • Country NSW living offers a range of social, sporting, hobby and community activities for all ages and interests. • There’s everything from spacious sandy beaches to vineyards, great fishing rivers, excellent hiking, snow ski fields and the adventurous outback! • It’s friendly, laid-back, culturally diverse and offers a supportive community lifestyle. • Choose from a bustling regional city, a picturesque coastal location or a friendly rural town with plenty of wide open spaces.
enquiries nsw rural doctors network recruitment team
If you don’t have Fellowship of either the Royal Australian College of General Practitioners or the Australian College of Rural and Remote Medicine, that’s OK. RDN will help you through the key steps to becoming a rural GP: • We’ll discuss your circumstances and eligibility with you. • We’ll help you find a suitable GP position in an eligible location. • We can help with advice about employment conditions. • We can help you obtain a Provider Number for rural General Practice. Country NSW is an exciting place to carve out a lifestyle and a career. Go where your skills are genuinely valued: search GP Vacancies at www.nswrdn.com.au
t 02 4924 8060 e recruit2012@nswrdn.com.au find us on
MIPS - there is a choice Join MIPS to access a range of membership benefits. At MIPS we offer you a range of membership categories to choose from to match your professional practice. Membership benefits include MIPS Members’ Medical Indemnity Insurance Policy, MIPS Protections for non medical indemnity matters, medico-legal and dentolegal advice, Group Personal Accident cover, risk management education sessions, special member benefit offers, e-publications and more! Apply online at www.mips.com.au Medical Indemnity Protection Society Ltd po box 25 carlton south vic 3053 | info@mips.com.au | www.mips.com.au member services | p. 1800 061 113 | f. 1800 061 116 | abn 64 007 067 281
Medical Indemnity Protection Society Ltd (MIPS) is an Australian Financial Services Licensee (AFS Lic. 301912). MIPS Insurance Pty Ltd (MIPS Insurance) is a wholly owned subsidiary of MIPS and holds an authority issued by APRA to conduct general insurance business and is an Australian Financial Services Licensee (AFS Lic. 247301). Any financial product advice is of a general nature and not personal or specific.
GP in the news Free edition
Going Places - taking a fresh look at general practice
GPs lead the way on euthanasia in Netherlands
Eight years after euthanasia was legalised in the Netherlands, rates have stabilised at the same level as seen before legislation, a study in The Lancet reports.
A review of euthanasia rates in 2010 found that rates had increased after an initial dip, to account for 2.8% of all deaths in the Netherlands. The increase was attributed to an increase in explicit requests from patients for euthanasia, although only half of these were granted. Euthanasia was mostly undertaken in younger people, cancer patients and in general practice rather than in hospital or nursing homes, the study found. Of the 6861 cases reviewed for 2010, 475 were classed as euthanasia, 2202 as intensified alleviation of symptoms and 974 as forgoing of life-prolonging treatment.
Murtagh: a legend of general practice
ALMOST 60% of GPs surveyed nationally for Medical Observer have nominated Professor John Murtagh as their number one hero of Australian medicine out of a list of medical luminaries. POLL: Who is your medical hero? The author of John Murtagh’s
General Practice gets recognition wherever he goes, particularly from students who study the source of his legend – what Professor Murtagh refers to simply as ‘the book’. It was Professor Murtagh who fielded the most requests for
A long-awaited antenatal blood test for Down syndrome could be available in Australia as early as next year, specialists say. The PrenaTest offers a non- invasive alternative to amniocentesis for diagnosis in highrisk pregnancies. The test is usually done between the 12th and 14th week of pregnancy. Women who receive a negative blood test result are expected to benefit most, as they will be spared invasive diagnostic procedures.
Source: Australian Doctor, australiandoctor.com.au
signatures and pictures at the Australian Medical Students’ Association conference last week, despite the presence of big drawcards like former Prime Minister Kevin Rudd and AFL triple premiership-winning coach Mick Malthouse. The ‘Prof’s’ book, a 1535 page guide to primary care, struck a chord when it was first published in 1994 and has reverberated throughout the profession ever since. Source: Medical Observer, medicalobserver.com.au
Skype’s the limit for telehealth consultations
Source: 6minutes.com.au
Down Syndrome blood test due in 2013
Issue 9 - 2012
More faith in GPs to help treat mental illness
The belief that GPs can help people with mental illness has grown among Australians over the past 15 years, a study shows. A survey of more than 6,000 adults found an increase in the belief that GPs can help those suffering from depression, depression with suicidal thoughts, early schizophrenia and chronic schizophrenia, compared to 15 years ago,
*Articles have been shortened from their original form.
according to a study published in the British Journal of Psychiatry. The surveys which were carried out in 1995, 2003/4 and in 2011 found that overall the general public have moved towards seeing health professionals as the most helpful type of intervention for mental illness.
Source: 6minutes.com.au
A Melbourne GP, fed up with not being able to find a specialist to conduct telehealth consultations, has launched a free website designed to connect doctors via the Skype video-conferencing program. The website allows practitioners interested in telehealth to register their specialty, location and Skype address; search the resulting database for others to connect with; browse registered practitioners with an interactive map; and features a forum and instant messaging. The creator, Dr Jonathan Brown, said he had received dozens of registrations in the first week and he hoped the site would help other GPs struggling to make telehealth consultations. Source: Medical Observer, medicalobserver.com.au
Taking a fresh look at general practice 21
MEDICAL OBSERVER
NOW ON
SedTical FeeIkR ly m
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publication on iPad!
iPAD KEEPING YOU CONNECTED EVERY WEEK
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Download free at the App Store
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PGPPP – Prevocational General Practice Placements Program
Experience a General Practice rotation in NSW!
www.agpt.com.au The NSW Prevocational General Practice Placements Program (PGPPP) has recently undergone expansion creating more opportunities for junior doctors to experience accredited General Practice rotations as part of their training. Speak to your JMO Manager to see if a General Practice rotation is available in your network.
Clinical
CORNER
Medical Observer provides Going Places magazine with some interesting clinical case studies and tips for treating patients. This issue’s case studies are from Dr Ian McColl. Eyelid lumps and bumps
However, shake this hand at your peril. This is Norwegian or crusted scabies, and these scales are chock full of scaThese clear fluid-filled vesicles around the lateral epicanthus have been there for bies mites. This is the most contagious form of scabies you will ever see. Cases like this end up causing epidemics of some months. scabies if they are admitted into hospital or nursing homes undiagnosed. This gentleman had three hospital stays for unrelated conditions prior to his skin condition being correctly diagnosed. It is best treated with ivermectin orally followed by six days of topical permethrin cream overnight. In addition, steroid cream can treat the inevitable associated eczema from scratching. For dermatoscopic images of the mites log into www.skinconsult.com.au
A hairy finding on this scalp They are asymptomatic. These are hidrocystomas. They are usually of eccrine or sweat gland origin. Simply incising them with a needle will cause them to empty but they may recur. They can be punch excised or treated with a CO2 laser. Surprisingly they also respond to atropine drops, but this causes problems if the drops get into the eye. Apocrine hidrocystomas also occur in this area but they tend to have a bluish tinge about them. Notably, the lesion on the upper eyelid seen here was a basal cell carcinoma. For histology of these lesions, see www.skinconsult.com.au
A handshake with a catch THIS hand looks pretty innocuous, slightly red with a bit of scale. Perhaps it might be psoriasis or a hyperkeratotic eczema?
The elderly bald male scalp can be a minefield. Often there is a mixture of solar keratoses, SCC in situ and invasive SCC but in this case it was a melanoma in situ in among multiple seborrhoeic keratoses.The melanoma is the darker area indicated by the arrow. Several of the other darker and scaly areas here were examined by shave biopsy but they were all seborrhoeic keratoses. A dermatoscope is very useful in examining these patients and eliminating some areas from biopsy. Surface scale is less likely with a melanoma in situ however even with the dermatoscope it can be difficult to distinguish between a dark flat seborrhoeic keratosis and a melanoma in situ. For dermatoscopic and histology views log into www.skinconsult.com.au
MEDICAL
Taking a fresh look at general practice 23
Electronic health (e-health) Electronic Healthcare Record E-health and the Personally Controlled Electronic Healthcare Record (PCEHR) will provide integrated and distributed healthcare for all Australians, particularly benefitting rural and remote communities, elderly patients in care facilities and patients with chronic diseases. E-health will improve the delivery and continuity of medical care for the patient who requires input from multiple specialists and a general practitioner over vast distances. Ultimately, the aim of e-health is to reduce healthcare errors and make medical care Visit GP safer for all patients.
The following examples outline the differences between a Personally Controlled Electronic Health Record implemented as part of Australia’s e-health infrastructure and other medical records currently in use:
– controlled by the patient and shared with • PCEHR specific providers Electronic Healthcare Record (IEHR) – controlled by the • Individual healthcare provider and held centrally; shared with other providers;
limited or no access by the patient
Medical Record (EMR) – controlled by a single hospital or • Electronic general practice and inaccessible to the patient.
Eventually the PCEHR may contain the information mentioned in the below diagram: medical practitioner consultations, laboratory and imaging test results, hospital discharge summaries, medication and allergies etc. Once the full extent of the PCEHR is realised, clinicians and the patients will have access to a full long term medical record of their treatment. Return Presently, the PCEHR contains some Return Visit GP of the information mentioned in the to GP to GP diagram – specifically, a personal health profile, current medications Check for Check for Review Dischargrye chargean advanced Reviewand allergies, Personally Disand changes a changes m m any su mmary any su to SHP Controlled care directive custodian. changesto SHP st changes since est test Request te Requlast to SHP since last Electronic to SHP The PCEHR also allows visit visit Health Records patients to restrict access to sections of their record, The personally controlled and be notified if another electronic health record Update SHP, put copy Update SHP, put copy Review SHP, put copy ofVisit Visit Hospital Review SHP, put copy of of Discharge Summary party accesses their Hospital (PCEHR) system has been of Discharge Summary in EHR Service Radiologist result in EHR Service stay in EHR Services in EHR Services Radiologist result stay record. developed as part of the
1
2
Commonwealth Government’s national e-health program (initiated in 2005) to bring consumer-focussed e-health capabilities to the Australian health system in order to drive improvements in quality, safety and access to health and medical care.
16
EHR Service
2
Update SHP Test result
Test result
3 Return to GP
6
5
5
EHR Service
The medical profession ery ry and Bthe Book surg ook surge Review Update Review PCEHR SHP SHP SHP
controversy in the medical Referral The Referral profession, in particular expressed decision decision support support by the Australian Medical
34 Return
Visit
to GP Specialist ferral Re
4 Visit
Association is around the emphasis Specialist Referral on patient control of the e-health record.
The introduction of the PCEHR system in July 2012 allows an individual who registers The current PCEHR proposes that: for a PCEHR record to include key clinical EHR Service – E-Health Record Service – E-Health information such as medical conditions, medications, EHR Service Record Service “… Every Australian is encouraged to take Summary Health SHP – Summary Health Profile personal responsibility for authorising the allergies, adverse reactions and SHP event– summaries for Profile establishment of their own e-health record and their healthcare providers to securely access. storage of the information. They are empowered to have the choice of As PCEHRs become more widely used and the PCEHR system matures, sharing it with trusted sources such as their doctor, their carer, or the consumers will be able to access their own health information online — hospital in which they are treated … Both patients and providers will anytime, anywhere — and so will their authorised healthcare providers. need to find maintaining the PCEHR desirable, valuable, and productive in order for the record to be sustainable…”. A patient is not able to alter, edit, or remove any part of a document from their PCEHR. However, they can delete a document as a whole.
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and the Personally-Controlled (PCEHR) in Australia This is why the PCEHR should not be relied upon as a complete record. Healthcare providers have an obligation to ensure that any information uploaded to a PCEHR is accurate and up-to-date as at the time of upload. This has resulted in the medical profession stating that doctors will be unlikely to trust the integrity or validity of the data in the PCEHR. Data record integrity is critical for medical practitioners as it opens up a medico-legal minefield. For example, could a healthcare practitioner be held liable for a poor patient outcome if a medical action was based on information not disclosed by a patient in their PCEHR? A parliamentary paper comments, “…the personally-controlled shared electronic health record is just one piece of the puzzle... It is doubtful that any registered health practitioner would rely solely on this record without first checking its veracity and currency with their patient…” .
E-health, or electronic health, has been described as “…the single-most important revolution in healthcare since the advent of modern medicine, vaccines, or even public health measures like sanitation and clean water…” Moreover, “…It will be imperative that consumers are made aware that with the right to control access to their health record comes a responsibility that incomplete information in their PCEHR may harm their health care….” . In other words, the medical profession and the consumer are entering unchartered territory, and a certain amount of trust between both parties is required for the PCEHR to be a helpful piece of patient history. Following discussions with the medical profession, clinicians have been granted authorised access to the entire medical record of the individual in an emergency situation. This ensures full and transparent access to vital information for a patient incapable of communicating with the clinician.
Privacy Considerable time has been devoted to patient privacy in creating the PCEHR. Some points to consider:
•
the PCEHR is an opt-in system where patients will have ultimate control over whether or not they have a PCEHR. The system will also allow consumers to control who may access information contained in their PCEHR
the default access setting for the PCEHR is that only healthcare • providers involved in the healthcare of a consumer may access
their PCEHR
organisation from accessing their PCEHR or restrict access to particular clinical documents within their PCEHR.
patients may choose to set and manage advanced access • controls which will allow them to prevent a healthcare provider
The initial PCEHR system proposed by NEHTA was in favour of a distributed database. This means that a patient’s health information is not stored on a single server or database that could be a target for hackers. The patient can control the PCEHR’s location, back up and record retrieval method. Patients can access and view their record at ehealth. gov.au on a device of their choosing as long as it has internet access, however specific applications are not being provided for mobile devices such as ipads, tablets and smart phones just yet. The risk of a distributed approach is that patients who are unfamiliar with the electronic world (such as the elderly) may not be comfortable or capable of storing their record in this way and may prefer a single repository and point of access for usability reasons. Healthcare providers can access the system via registered and approved desktop software, through the Provider Portal. Dr Joshua Crase Dr Joshua Crase is a PGY3, former GP ambassador and former computer engineer. He is currently taking a break and traveling overseas until 2013. In this issue he explores the topical subject of e-health records. This article continues at gpaustralia.org.au/content/e-health where you can find out about: • the opt in question • the roll out and conclusions. You can also go directly to the rest of article online by scanning this code on your iphone.
Taking a fresh look at general practice 25
G P profile
An officer When Navy medical officer Lieutenant Commander Joel Hissink found himself sweltering in a makeshift medical centre with Pakistani flood victims, he was moved to write down his thoughts in a journal. Humanitarian work such as this has been just one highlight of his career so far as a military doctor. “I knelt next to the father and boy with my hand rested on the boy’s back, gently patting him to sleep. The boy, named Ahmed and 18 months old, was exhausted. He was cradled in his father’s lap, folded in half, awkwardly but comfortably as infants do. His weary eyes opened from time to time to reassure himself that his father was still there. They had walked five kilometres through 40-degree heat to seek our help at the Camp Cockatoo Health Centre in Kot Addu, Punjab Province, Pakistan.” These words were penned in a journal kept by Lieutenant Commander Joel Hissink, a medical officer in the Royal Australian Navy. Joel was part of a joint AusAID and Australian Defence Force (ADF) medical task force that delivered emergency relief to thousands of displaced people after the Pakistan floods of 2010, one of the world’s worst-ever natural disasters. Humanitarian missions like this are a rewarding side of the work carried out by doctors in the ADF. Going Places spoke to Joel some two years on, but the experience was still fresh. “It was an amazing opportunity to do what many doctors dream about, which is working in a humanitarian environment. That’s one reason why many doctors are attracted to the military” Joel explains. One of the initial challenges was setting up a field health centre in the oppressively steamy heat. In the first few days, conditions were rugged, there were no showers and the medics slept under mosquito nets on the soccer oval. But within a couple of weeks, the team had created a camp equipped with showers, emails and phones, and an airconditioned recreation tent. “Phone calls to the family were limited to 10 minutes a day, so that was tough” Joel recalls. “People were coming in from a nearby displaced persons camp and were also travelling from further afield – up to 220 kilometres – to reach our centre” he says. The team treated some 215 patients a day across 53 days for malaria, cholera, tuberculosis, malnutrition, skin and eye infections and diarrhoeal illnesses.
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“It was an amazing opportunity to do what many doctors dream about, which is working in a humanitarian environment. That’s one reason why many doctors are attracted to the military.”
Main picture: Joel at Camp Cockatoo Health Centre Left inset: At the controls of a hyperbaric chamber at HMAS Penguin in Sydney Middle inset:Treating a young child at Camp Cockatoo Health Centre Right inset: Joel working with divers at the navy base Below: Joel in a hyperbaric chamber
and a gentleman Back in Australia, Joel’s life as a Navy medical officer is a world away. He is currently posted to the HMAS Penguin naval base in Mosman, New South Wales. This is the site of the Navy’s submarine and underwater medicine unit and Joel is in charge. His work centres on occupational health – keeping sailors, submariners, divers and assorted Navy crew medically shipshape. Duties range from conducting medicals on Navy divers to formulating diving policy across Navy, Army and Air Force. The unit oversees a hyperbaric chamber that treats divers – both Navy and civilian – for decompression sickness, known as ‘the bends’. However, safer diving practices today make this a rare occurrence. Joel is also involved in diving research projects in collaboration with naval and civilian diving organisations around the world. In his current posting, Joel can indulge his dual passions of keeping fit and kayaking by paddling his sea kayak to and from work. “I’m also able
“I’ve been able to inblog One day a week he practises at a civilian general practice nearby Dee Why, an activity endorsed by the Navy as part of his continuing about topics professional development. However, as a Navy medical officer, he could be deployed to an that other operation at any time. people don’t Joel was originally attracted to the ADF because of its educational and career opportunities, financial security and passportabout.” to see the world. talk He rendered assistance during the Tampa incident, he supported a team to spend plenty of time with my wife and kids every day, which is great” he says.
of Navy personnel clearing unexploded ordnance from World War II in Papua New Guinea, he served on missions in the Middle East and East Timor, and he trained in Spain with navies from all over the globe. “I had never been outside Australia before joining up” Joel reflects. Joel’s voyage into medicine took an indirect route. He joined the Navy on leaving school in 1997 and trained as an officer in the navigation branch, studying a Bachelor of Science, and focusing on oceanography and management. However, even as a boy he had an interest in medicine. “My grandfather was a doctor in the Dutch Army in Indonesia and then in Sydney, so there was a family connection.” Later, Joel became aware of a new postgraduate medical program where the Navy would sponsor his medical training and he could steer his career in a new direction without financial pressure. He was accepted into medical school, and he recently completed his fellowship. There have been many memorable experiences along the way, but one remains vivid, as the final words in his diary attest: “
“As I knelt in the medical tent gently patting little Ahmed, I thought of my 21-month-old son at home and I hoped that he would one day understand that this little boy needed me at that time. His blood test results revealed that he had malaria. We had medicines for him and under the care of his family he would recover quickly. I warmly smiled at his father and quietly reassured him by saying ‘sub theek hae’ — everything will be okay.” Jan Walker
Taking a fresh look at general practice 27
G P profile
Dr Jacqueline Heagney has a passion for aviation and aviation medicine. As a new GP, she found the perfect job to get her career off the ground. Dr Jacqueline Heagney is often stopped in the supermarket by complete strangers. But she doesn’t mind a bit. “As soon as people see my RFDS flight suit, they want to talk about their own experiences with the flying doctor – like the time they had appendicitis and were brought in from some remote outback station,” she explains.
Jacqueline says it’s a tangible reminder of the ‘mantle of safety’ the Royal Flying Doctor Service (RFDS) brings to Australia’s remote communities. “That’s why the Reverend John Flynn set it up in the 1920s and that’s exactly what we are now,” she adds. Jacqueline joined the RFDS at the Broken Hill base in March this year. She has a passion for flying and aviation medicine – her father was a commercial pilot with Ansett and Singapore Airlines – so the position fits her like an old leather aviator’s glove. “It brings together my interests in aviation, obstetrics and general practice, and combines them all very nicely in this one job,” she says. “I’d just finished my fellowship in Queensland and it came up at the right time. It’s the sort of work that will stand me in good stead for the rest of my career.” She believes it’s an ideal job for building confidence in her skills. Jacqueline’s work can be divided into two main categories – general practice and emergency retrieval. It sounds straightforward enough, until you realise the catchment area is 640,000 square kilometres traversing some of Australia’s most isolated country in far west New South Wales, south-west Queensland and eastern and northern South Australia. Main picture: Broken Hill Base Inset top: Jacqueline Heagney consulting over the phone
“With the general practice side of things we fly out and visit different clinics depending on the day of the week and time of the month,” Jacqueline says. The names evoke classic Australiana – Tibooburra, Wilcannia, Innamincka. And the clinics themselves show the outback spirit of ‘can-do’. “There’s one place in South Australia where the people have built their own little clinic building for the whole district on their property and another one where the local community has converted an old train station into a clinic,” Jacqueline says. The medicine covers everything from antenatal checks and paediatrics to mental health and complex diagnosis. “The patients tend to be sicker than in the city because the clinic may only come to town every couple of weeks and they may have been saving up their ailments,” Jacqueline observes. She says the other side of her general practice work is telephone consulting, with a doctor rostered on call 24 hours a day, seven days a week. “I might get a call from one of the remote stations and they might have a child who’s unwell with tonsillitis. Most outlying stations have a little mini-pharmacy and I can authorise them to access that. Over the phone I have to try and assess how serious it is and whether we need to send a plane with a flight nurse or a doctor and flight nurse.”
Inset below: Landing after a hard days work
“As soon as people see my RFDS flight suit, they want to talk about their own experiences with the flying doctor.”
Medicine on
Making such judgment calls is not always clear-cut. “It can be tricky but if you do it often enough you just develop that skill of remote telephone consults – it’s like any other skill in medicine,” Jacqueline says. Mention flying doctors to most people and they’ll think of high drama in lonely landscapes – car accidents, farm and mine-site accidents, snakebites and women in the throes of labour, with the frightening prospect of medical help being hundreds of kilometres away. This emergency retrieval work is the other side of the job, says Jacqueline. The retrieval aircraft is set up as a flying intensive care ward. Jacqueline says that the logistics and decisionmaking part of the job is as important as the medical part. “There are decisions about which patients can wait and who you need to send out a plane to urgently. Then there are decisions about how we are going to get the plane there. The weather might be bad or there’s nowhere to land. In the meantime there are other calls coming in from patients who might need to be picked up sooner. You’re constantly adjusting your priorities.” Good decision-making is achieved through close teamwork between doctors, pilots, flight nurses and support staff, Jacqueline says. Jacqueline is enjoying life in Broken Hill, sometimes called ‘the capital of the outback’. She plays tennis, cycles and goes to the gym. She says there are lots of young ex-city types in town like teachers, police, government workers and miners. “There’s an active social life – sometimes too much going on,” she says with a laugh.
Jacqueline qualified as a nurse before doing a postgraduate medical degree at the University of Queensland, followed by GP vocational training in Brisbane and Cairns. She has diplomas in obstetrics and paediatrics and a certificate in aviation medicine to add to her FRACGP parchment. “Aviation medicine dewals with the physiology of flying and the effect it has on the body. It means I can do occupational work like medicals for people in the aviation industry,” she says. She soon plans to do a formal course in retrieval medicine to complement her on-the-job experience. “We keep learning all the time because of the unique nature of this job,” Jacqueline says. “I feel very proud to be working for this organisation.” Jan Walker
the fly
Taking a fresh look at general practice 29
Because you can’t keep it all in your head
Millions of drug decisions made easier with MIMS visit mims.com.au Find the best MIMS for you 38
What’s new in the AGPT program?
In the AGPT program you have the opportunity as an AGPT Registrar to undertake a variety of different posts, including academic and Aboriginal and Torres Strait Islander health training. Undertake a salaried research project The everyday practice of GPs is centred around evidence-based medicine. The AGPT program encourages registrars to undertake research and improve critical thinking. As an AGPT registrar you can undertake an academic post – a paid, part time research placement, which allows you to undertake a research project, attend research workshops, present your work at national conferences and contribute to primary care research and teaching communities.
“…Having a strong evidence base for the care we provide in general practice is vital. By doing an academic post you actually get to contribute to this body of knowledge. That’s really exciting.” Dr Emily Farrell, AGPT Academic Registrar
Make a difference whilst developing clinical and professional skills Did you know that as an AGPT program registrar you can undertake an Aboriginal and Torres Strait Islander health training post at any time throughout your training? Undertaking an Aboriginal and Torres Strait Islander health training post offers a unique opportunity to develop a range of clinical and professional skills in a challenging environment, including; • Treatment of diseases not often seen in mainstream primary health care settings • Working as part of a multidisciplinary health care team to manage complicated clinical, social and emotional issues • Complex chronic disease management • Understanding cultural protocols and communicating complex health issues • Focusing on population and public heath • Health promotion within a cultural context.
www.agpt.com.au or talk to your regional training provider (RTP)
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Taking a fresh look at general practice 7
G P profile
King of the Sydney’s iconic urban village of Kings Cross is an eclectic community that lives its life on the streets. Dr Raymond Seidler has been both a GP and a chronicler of its colourful denizens for decades. Going Places talks to Raymond about his tales from the city’s wild side. Like the spruikers outside its famous strip joints, Kings Cross knows how to pull a crowd. It’s a community of disparate and desperate characters: backpackers and burlesque dancers, residents and the homeless, artists and actors seeking fame, junkies looking for a fix. Dr Raymond Seidler established a GP practice here more than three decades ago. In this sometimes tawdry, transient place, he came and stayed. Now he’s known as a Kings Cross ‘institution’. “Be prepared to have the blow torch applied to your gastric mucosa,” warned an older colleague when a 20-something Raymond first decided to hang up his shingle in the Cross.
“I see a lot of transsexuals. To see one of my registrars ask a transsexual when she had her last menstrual period was a humorous moment. The patient replied: ‘Honey, I don’t have periods’.” Homeless people are a sizeable portion of the demographic, and the Salvation Army, Mission Australia and the Wayside Chapel send patients to him from their shelters. “Two years ago I got a small super clinic grant — I describe myself as the smallest super clinic in Australia. I’ve now got a clinical psychologist and a mental health nurse working with me,” Raymond explains. His practice, which was previously shoehorned into a tiny old twobedroom apartment, has doubled in size and is now spread over two apartments to accommodate this multidisciplinary service. “We offer a comprehensive service for homeless people who’ve never had a care plan. We get their teeth fixed at the local dentist, have them seen by the mental health nurse, arrange a referral to a psychologist. We’ve had a number who’ve actually gone back to work, found housing and reconnected with their families.” Raymond says he enjoys getting away from the confines of his office, and can often be seen walking, cycling or sipping coffee on the streets
“After 34 years, I’m still loving every minute of it,” he says. “I enjoy the ambience of the place and the people who live here. I like interesting people.” There’s been no shortage of those. They are often people at the extreme edges of society — from the underclass to the uber-successful. Doctor to the stars is one role Raymond relishes. Tom Cruise, Michael Caine and Kiefer Sutherland have all been his patients while in Sydney shooting blockbusters at nearby Fox Studios. “A lot of actors and musicians come and see me. The Cross has always attracted artists, musicians, authors and poets,” he says. Starry-eyed travellers about to fly off on gap year adventures are another mainstay of his Kings Cross Clinic, which specialises in travel vaccinations. Of course, the bohemian allure of Kings Cross has its darker side – a population of people on the brink, on the drink or on drugs. You’ll find them sitting in Raymond’s Springfield Avenue waiting room on any given day. “In 1985 I became an opiate treatment provider with a doyen in the field, Dr Alex Wodak. He said if we don’t do something about these drug users they’re all going to get HIV. With another GP I became the first GP prescriber of opiate treatment in New South Wales and we’ve been doing it now for 27 years,” Raymond explains. Going Places wanted to know if seeing desperate patients could be dangerous. “We’ve had bank robbers and murderers and all sorts of people who’ve done terrible things but for the most part they behave in an exemplary fashion when they’re around us,” Raymond says. “We treat them with civility. We don’t judge people. I tell patients if you play up in this oasis, you don’t come back.” Raymond says his unusual case mix sometimes makes for black humour – usually at his registrar’s expense.
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Raymond his bike outside Bruce bringingonlocals up to speedthe withclinic. evacuations to Moura and expected times and plans for returning to Theodore.
Cross of the Cross. “I know a lot of GPs who are uncomfortable with bumping into their patients in the street but I find that’s a real pleasure if they recognise me and feel they can ask me anything, up to a point. We have a sort of convivial relationship that occurs on the street.”
“The only piece of Australia that’s really got ‘passeggiata’ (‘street life’ in Italian)!” his father used to declare.
Raymond is a natural raconteur and communicator – blogging is just one outlet for his musings. He tweets, he writes a column in Medical Observer, his letters to the editor are regularly published in The Sydney Morning Herald and the broadcast media often call on him as an expert talking head.
Visit Raymond’s blog at – kingscrossclinic.com.au/blog
He is also a popular and witty speaker for medical conferences and corporate gigs, whether on his interests of addiction and mental health, or sharing wry observations about his extraordinary tapestry of patients. And through Sydney Regional Training Provider, GP Synergy, he enjoys paying it forward to the next generation of junior doctors as a supervisor and teacher. There’s a certain symmetry about working in Kings Cross for Raymond. His parents were post-war immigrants from Europe and they spent their early married life in a flat in Kings Cross.
Raymond with some of the colourful characters of Kings Cross at the famous Piccolo Bar Cafe. Image © Roslyn Sharp
One day, Raymond hopes to write a book about the street life encountered by a Kings Cross GP. It’s sure to be a page turner. Jan Walker
. y it il iv c h it w m e h “We treat t . le p o e p e g d u j t ’ We don p u y la p u o y if s t n ie t I tell pa in this oasis, .” k c a b e m o c t ’ n o d you
G P profile
Skills for a country practice
The capacity of those living in the bush to turn their hand to anything has long been part of Australian folklore. Dr Glenn Pereira practises in the historic sheep and wheat-farming town of Forbes in the central west of New South Wales. His versatile swag of special skills — from obstetrics and anaesthetics to palliative care — is keeping the legend alive. Australians living in the bush are renowned for their ability to turn their hand to anything. Fix a ute with a length of fencing wire? Not a problem. Bake a CWA prize-winning sponge cake with eggs from your own chooks? Of course. When you’re hundreds of clicks from the big smoke, you become very competent at DIY.
It was a profound experience that shaped Glenn’s future career. “In Africa, people were dying from a lack of the basics. Just in the small village where I was there were a dozen or so deaths from a lack of water and food on a daily basis. “In Kenya, life-saving anti-malarial drugs were not being given because there were no cannulae to administer them in the government-run hospital. And I’m always surprised to be reminded that measles in the developing world is still a big killer of children — something like 150,000 deaths per year globally, for a completely preventable illness.” Here Glenn realised the power of basic primary and public health care. Although he says the medical landscape is different in Australia, he formed the view that it was by becoming a generalist he could make the biggest difference to the largest number of people. “A cardiologist I once worked for gave me some advice I never forgot. He said whatever field you specialise in, don’t have a minimalist approach. So I thought I’m going to get myself trained to the fullest as a generalist.” Glenn finished off a Masters in Public Health and completed fellowships with both general practice colleges. Along the way, he added qualifications in anaesthesia, obstetrics and palliative medicine. His final general practice post was at Forbes and he was invited to stay on as part of a five-GP private practice.
“I’ve delivered a young mum’s baby and looked after her grandma as she died, all in the same week. It’s such a privilege.” Glenn’s GP clinic is across
The same goes for rural generalists. These are the versatile GPs who have mastered both the procedural and general practice skills that communities need when they are hours from a tertiary hospital or specialist.
Dr Glenn Pereira is a rural generalist based in Forbes, a country town of almost 10,000 people in the central west of New South Wales, 380 kilometres or a six-hour road trip from Sydney.
“I deliver babies, I give anaesthetics, I deal with accidents and emergencies, I organise evacuations, I do palliative care and traditional general practice, of course,” Glenn explains.
“It really is cradle to grave medicine. I’ve delivered a young mum’s baby and looked after her grandma as she died, all in the same week. It’s such a privilege.”
While country GPs have always straddled both general practice and hospital-based medicine, there is a new policy focus to bolster rural doctors through advanced training, support and recognition. Wider use of the title ‘rural generalist’ is part of this movement.
Glenn grew up in Sydney and had completed his medical degree and three years of postgraduate hospital training when he realised he was stuck in a rut.
“There is a tendency to get on the treadmill of doctor training — you’re a medical student, you’re a resident and a registrar and you come out with some sort of specialty and then you work in that field,” Glenn reflects.
“I thought that’s rather limiting and maybe an uninteresting way to work. I took some time out and did aid work overseas for a couple of years with Médicins sans Frontières (MSF) and other agencies in places like Kosovo, Nepal, Liberia, Kenya and South Sudan.”
the road from the procedural hospital of about 40 beds. “We deliver about 160 babies per year and I do my share of those including Caesarean sections. I also give the anaesthetics for visiting surgeons, do ward rounds, help cover the emergency department and teach our three registrars, as well as a lot of complex general practice,” he says. “Of course, I do refer patients but I can efficiently manage a lot of them here.” The workload is full-on but flexible. Glenn often starts seeing patients at 10 o’clock so he can spend time with his four young children before work. He also shuffles around his schedule so he can attend parent days. “When you work in Sydney, you can spend three hours a day in a car commuting. Here I often duck home during the day and then go back to work,” he says. He has no complaints about the pay either. “I’m very well remunerated, and we can afford to get out of town and travel when we want, although we enjoy life here in Forbes.” Glenn has some final words to say on the problem of attracting doctors to the bush. His simple message? Come and try it! “I would encourage all junior doctors to do at least one rural post and get a taste of life as a country GP. It’s the best job I’ve ever had.”
What is a rural generalist? • A rural generalist is a GP with advanced rural skills. • Typical advanced rural skills are obstetrics, anaesthetics, surgery, palliative care, emergency and retrieval medicine, and Aboriginal and Torres Strait Islander health. • GPs with rural qualifications can practise anywhere in Australia — city or country. • New rural generalist training programs are being rolled out all over Australia. For more information read Dr Gillian Collier’s account of the Rural Generalist Pathway on page 16 and 17.
Taking a fresh look at general practice 35
What’s your diagnosis? Dr Sarah McEwan explores the case of a young woman experiencing hot and itchy palms that she described as being ‘on fire’.
My next patient to be reviewed on this busy Friday morning was Estelle*. Estelle had called the surgery early that morning desperate to see a doctor. She was not a patient of the practice so I was not privy to any previous medical history, which I would usually like to review prior to seeing patients not known to me. Estelle stated that she had started having hot, itchy palms over the last 24 hours and that when she awoke that morning they felt as if they were on fire. Indeed on brief inspection Estelle did look as though she was in great discomfort as she was scratching her hands intensely and uncontrollably. Estelle was a particularly difficult historian as she was acutely distressed by her current situation and seemed to be after a quick fix miracle cure. It was quite difficult to maintain her focus to gain a detailed history from her. I also had my suspicion in regards to her mental capacity as she did come across as though she may have a slight intellectual impairment. Despite this, we battled on together. I arranged for the practice nurse to send in an ice pack for her hands to see if I could perhaps assist to change the sensation of her itch long enough to gather a history from her. The ice pack seemed to help somewhat and Estelle did manage to calm down slightly. She stated that she was 18 years old, currently unemployed, of Caucasian heritage and that she lived with her parents at the nearby caravan park.
Estelle initially stated that she was of otherwise good health, she had no medical problems but had recently started on a medication prescribed by a specialist but she could not remember his name. Estelle denied any allergies to medications, she did not smoke or drink alcohol but stated that both of her parents suffered from type two diabetes and were both insulin dependent. In my mind, I was thinking that there would need to be a fair amount of investigative work to be done with this patient... Estelle could at least advise me of her usual GP, so with Estelle’s permission, I instructed the receptionists to call the practice and gain access to her medical records and the name of which specialist that she was referred to most recently and for the letter of that review to be chased up. Whilst this was all happening it gave me time to undertake a thorough physical examination. Estelle was a tall girl, she stated she was 175cm tall, however she weighed in at 95kg which put her BMI at 31. I then reviewed her other vital signs which were all within normal limits. (BP, PR, RR and temp.) Next was a review of her other areas of concern being her hands and her knees. Her hands appeared swollen and red. Perhaps this was as a result of excessive scratching but there also may have been a very mild suggestion of a fine macular rash to the palms. Her knees too were reddened (see photo below), but they demonstrated areas of raised wheals which pointed me to consider an allergic reaction as a possible cause to her discomfort.
36
At this point Estelle and I went through a series of questions to try and find out if there had been any changes to her diet, changes to washing powders, soaps, had there been any recent gardening or exposure to plants or uncommon substances. There was really nothing more uncovered from the history. Just as I thought that I had exhausted all the contact allergen possibilities, my receptionist kindly brought in the information that she had chased up in regards to Estelle’s latest review. It turns out that Estelle had recently been seen by a dermatologist for another skin complaint that she had forgotten to mention to me. The dermatologist was not entirely sure as to the nature of the skin condition on his initial review but took a biopsy of the site and sent this off for histology and started Estelle on minocycline 100mg daily and salicylic acid 2% topically daily. Estelle stated that she had been taking the treatment for about 14 days.
I then turned to Estelle and asked her if the rash she was concerned about was still present. She said “Of course I have had it for about 2 years”. Estelle then lifted her shirt, see the photo below and think about your potential list of differentials.... The potential differentials that came to my mind for this rash included: Darirer’s disease, acanthosis nigricans, confluent and reticulated papillomatosis or psoriasis. I now had another job for our tireless practice nurse: since it had been fourteen days since Estelle’s review, I hoped she would be able to chase up the results from the specialist for me. *Names have been changed
Do you know the diagnosis?
Go online and see if you are right! Visit gpaustralia.org.au/content/whats-your-diagnosisgoing-places-magazine-issue-8
You can also find out the diagnosis by scanning this code.
Dr Sarah McEwan
Taking a fresh look at general practice 37
Did you know…
You can do your GP training in Aboriginal Health Organisations
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in Victoria?
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Make a difference in Aboriginal Health!
If you have ever considered working in Aboriginal Health, you don’t need to go to remote Australia to do it - there are accredited training posts available in Victoria.
Rewarding Challenging Inspiring Important
Aboriginal and Torres Strait Islander Australians have a much higher prevalence of preventable chronic diseases and die years younger than non-Aboriginal Australians. As a GP training in the Aboriginal Community Controlled Health sector, you will gain extensive clinical experience and have the opportunity to make a difference to the health outcomes of an important population! • Practice in an unique health care setting: By training in an Aboriginal Community Controlled Health Service (ACCHS) you will work in a comprehensive primary health care setting, as part of a supportive, multidisciplinary team. • Train under inspirational GP Supervisors: who are RACGP and ACRRM fellows with years of experience.
Are you interested in making a real difference in Aboriginal Health?
Contact the GP Education and Training Officer
(03) 9411 9411 www.vaccho.org.au
• Enjoy work / life balance: Enjoy the flexibility of a family friendly workplace with 9-5 hours, leave for conferences, study and personal life. No more shift work! • Complex medicine: You will gain extensive exposure to a wide range of clinical presentations including chronic disease management, preventative health care, health promotion and public health.
Victorian Aboriginal Community Controlled Health Organisation
gpaustralia.org.au Your one-stop shop packed with essential information and resources for junior doctors considering a career in general practice. Want to calculate how much you could • earn as a GP? Like to get first-hand information from • experienced GPs through videos, case
studies and blogs? Need help understanding GP training? Want to get in touch with your Going Places GP Ambassador? Like to use our forum to get your burning general practice questions answered?
• • •
Go online to keep up to date with what’s happening with the Going Places Network!
Download the Going Places magazine
The Going Places magazine is published three times a year. It’s full of real-life stories about GPs from across Australia. It also includes helpful clinical information and case studies. Download it at gpaustralia.org.au/content/publications or look out for it in your JMO lounges.
Taking a fresh look at general practice 37
200 million searches are made on Google every single day. With all this data analysts have been using it to predict everything from the outcome of the US election to the winner of the X-Factor. Now they plan to use your searches to work out where flu will strike next – and outpace current disease surveillance.
200 million searches are made on Google every single day. With all this data analysts have been using it to predict everything from the outcome of the US election to the winner of the X-Factor. Now they plan to use your searches to work out where flu will strike next – and outpace current disease surveillance.
Think you have the flu? Time to ask Google ‘Google Flu Trends’ is the latest project from Google’s philanthropic arm Google.org. By combining influenza-like search symptoms such as ‘cough’ ‘flu’ and ‘fever’ with a computer’s IP address they are able to locate and plot searches on a city-by-city basis. Over the last five years Google Flu Trends has been closely correlated to the flu incidence recorded by the US Centers for Disease Control and Prevention. Traditional flu surveillance has a lag time of 1-2 weeks – the hope is that Google Flu Trends may provide an almost instantaneous early-warning system.
‘Google Flu Trends’ is the latest project from Google’s philanthropic arm Google.org. By combining influenza-like search symptoms such The Australian Influenza Report is compiled from a number of as ‘cough’ ‘flu’ and ‘fever’ with a computer’s IP address they are able to data sources, including laboratory-confirmed notifications to locate and plot searches on a city-by-city basis. NNDSS, sentinel influenza-like illness reporting from general Over the last five Google departments, Flu Trends hasworkplace been closely correlated practitioners andyears emergency absenteeism, toand the laboratory flu incidence recorded by the US Centers for Disease Control testing. A more in-depth end of season report is and Prevention. flu surveillance a lag timeFor of more 1-2 weeks also publishedTraditional in Communicable Diseaseshas Intelligence. – the hope is that Google information please go to:Flu Trends may provide an almost instantaneous early-warning system. health.gov.au/internet/main/publishing.nsf/content/cda-surveil-
“For epidemiologists, this is an exciting development, because early detection of a disease outbreak can reduce the number of people affected,” said Google.org developers Jeremy Ginsberg and Matt Mohebb.
ozflu-flucurr.htm “For epidemiologists, this is an exciting development, because early immunise.health.gov.au/internet/immunise/publishing.nsf/Content/ detection of a disease outbreak can reduce the number of people afimmunise-influenza fected, ” said Google.org developers Jeremy Ginsberg and Matt Mohebb.
“Our up-to-date influenza estimates may enable public health officials and health professionals to better respond to seasonal epidemics and – though we hope never to find out – pandemics.”
flupandemic.gov.au “Our up-to-date influenza estimates may enable public health officials and health professionals better(ISG) respond to seasonal epidemics The Influenza SpecialisttoGroup consists of medical and and – though we hope never to find out – pandemics. ” specialists from around Australia and New Zealand with an interest
Currently Google Flu Trends provides data only for the United States but the programme is expected to roll-out across other countries shortly. They also hope to extend the prediction software to track other diseases.
in influenza. The ISG works in conjunction with key Australian Currently Google Flu Trends provides data only for the United States professional and consumer groups and also with the Australian but the programme is expected to roll-out across other countries Federal, State and Territory departments of Health in their shortly. They also hope to extend the prediction software to track educational activities regarding influenza and its prevention. other diseases. influenzaspecialistgroup.org.au/ This article first appeared in JuniorDr
This article first appeared in JuniorDr
Taking a fresh look at general practice 41 43
BOOK REVIEW Doctor Fairytale Batman It is a dark winter’s night at my surgery and the last appointment of the evening.The clinic is deserted and cost-saving measures have meant that only a single, flickering light remains on. Suddenly, creeping from the shadows of the waiting room, a dark figure emerges. Dressed almost totally in a form-fitting reinforced suit, with his head covered in a frightening mask, I can make out the outline of a man - or possibly something more supernatural. At first he says nothing, then quietly, somewhere between a whisper and a threat, his voice rasps “Doctor, I have an itch...”
Laryngitis No-one should have to live with a voice that hoarse without seeking medical help. Although there are many causes for this dysphonia, inflammation of the larynx would be the most obvious - most likely due to a simple viral infection or overuse of the vocal cords. I would recommend a combination of gargling, menthol inhalation, air humidifiers and simple rest. If the problem persists I will make a referral to our local voice therapist Dr Joe Kerr.
Erythropoietic porphyria Perhaps the main reason for “Batman” only appearing at dusk is photosensitivity to sunlight. In all cutaneous porphyrias, photosensitivity presents as bullous eruptions occurring on sunexposed areas. The recommended treatment is actually prevention by avoidance of sunlight and use of sun-protective clothing. A firm diagnosis could be made by testing for porphyrins in plasma, urine, and stool, which would be elevated to levels higher than those in other porphyrias. This would however necessitate Batman removing his uniform which in itself would be a difficult task.
Histoplasmosis Quite why this “Batman” chooses to spend the majority of his time in a cave teeming with bats is beyond the limits of this consultation. However, it is common knowledge that bats carry various diseases including rabies, the Hendra virus and Ebola. What is less well known is that their excrement, called guano, has the fungus histoplasmosis capsulation present in a high enough quantity to cause histoplasmosis - an infectious disease caught by inhaling the spores. Around 10 days after exposure many sufferers complain of flu-like symptoms including dry cough, headache, impaired vision and muscle pains. Some cases, however, are more serious often resembling tuberculosis and can be fatal without treatment. My recommendation would be to have the whole cave fumigated and install better ventilation.
Attachment Disorder While obtaining a family history I uncovered that during his early childhood both Mr and Mrs “Batman” were murdered. It is well known that failure to form normal attachments to primary care giving figures in early childhood can lead to problematic social expectations and behaviours –particularly emotional dysregulation, self-endangering behaviour and hyper-vigilance. Although treatment is difficult in these cases, a narrative-therapeutic approach may allow “Batman” to open and explore other aspects to his personality rather than sticking to this Dark Knight persona. This article first appeared in JuniorDr.
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Never Say Die: by Dr Chris O’Brien Reviewed by Reviewed by Dr Jane George, GP Ambassador at Bankstown hospital
An inspiring story about grace, dignity and the fight for survival. I had the pleasure of reviewing “Never Say Die” by Dr Chris O’Brien. For those of you familiar with Dr O’Brien he needs no introduction. Yet for those of you unfamiliar with this man let me provide some background. Dr Chris O’Brien was one of the leading head and neck oncology surgeons at Royal Prince Alfred Hospital in Sydney until 2006, described by Kevin Rudd as a ‘truly exceptional Australian’. He was passionate about his work and endeavored to provide the best care for his patients. Sadly, in November 2006, Dr O’Brien was himself diagnosed with glioblastoma (an aggressive brain tumor). This updated memoir provides a first hand look at how a young boy from Sydney’s western suburbs became a leader in his field. The book explores everything from the author’s upbringing to his two and a half year battle with cancer. It describes his own experiences with chemotherapy, repeated operations and management of the challenges associated with his disease. I was inspired by the utmost grace and dignity in which Dr O’Brien faced his own fate. This book encapsulates the following themes: optimism, fighting for survival and a “never say die” attitude (all of which were embraced by Dr O’Brien). For all of us working with patients who may be facing impending death, I encourage you to read this book as it will have a lasting impact.
WHERE TO FROM NOW? So, you’ve read through Going Places magazine and now you are curious about general practice as a career. Or maybe you’ve already decided that being a ‘general specialist’ is your vocation! What’s next? Here are five ways to start going places in your career as a GP:
1 Join the Going Places Network Become part of the Going Places Network at your hospital. It’s a fun way to network with others who have an interest in general practice, while developing your professional knowledge and credentials. Looking for the Going Places Network at your hospital? Visit gpaustralia.org.au to find out more and join online.
2 Talk to your GP ambassador Our GP ambassadors are junior doctors who have a real passion and enthusiasm for general practice. They’ll be able to answer all your questions about general practice. If there are any questions they can’t answer, they’ll find the answers for you. Visit gpaustralia.org.au to meet the GP Ambassador in your hospital or area — or look out for posters on notice boards in your JMO lounge.
3 Test-drive general practice with the PGPPP The Prevocational General Practice Placements Program (PGPPP) is a great opportunity to experience life as a GP during your hospital training years. When you participate in the program you rotate into a general practice training post for a minimum of one, and a maximum of two hospital terms. Throughout your placement you are well supervised by experienced GP supervisors. You have management of your own patients and are involved in varied areas of health care, such as sexual health, drug and alcohol, aged care, paediatrics, home visits, acute and chronic disease management. Visit gpet.com.au to find out more about the PGPPP.
4 Get the A–Z on GP training Ask your GP ambassador for a copy of the Going Places Prevocational Doctors Guide to General Practice Training — your comprehensive guide to becoming a GP. They’ll also be able to provide you with a copy of the AGPT (Australian General Practice Training) 2013 Handbook, which has full details about the AGPT program.
5 Visit gpaustralia.org.au To find out how general practice training works, visit the website. It will guide you through the pathways available, the organisations involved, the nuts and bolts of applying and more, helping you to plan your path into general practice.
Taking a fresh look at general practice 43
You’re training on the job every day and it isn’t easy. Let our national medico-legal team advise you. Your medical indemnity partner, Avant 1800 128 268
IMPORTANT: Professional indemnity insurance products available from Avant Mutual Group Limited ABN 58 123 154 898 are issued by Avant Insurance Limited, ABN 82 003 707 471, AFSL 238 765. The information provided here is general advice only. You should consider the appropriateness of the advice having regard to your own objectives, financial situation and needs before deciding to purchase or continuing to hold a policy with us. For full details including the terms and conditions (and exclusions) that apply, please read and consider the policy wording and PDS, which is available at www.avant.org.au or by contacting us on 1800 128 268.
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