GP Journey Issue 15

GP Journey ISSUE 15 FREE

September – December 2014

Inside

Indigenous health Clinical cases Profiles Network news

Dr Jon Priestley Sharing the load

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GP Journey in this issue...

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Editorial GP Journey’s medical editor and general practice registrar, Dr Chia Pang, welcomes you to this issue.

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Feature story Cultural competence in the general practice clinic can help Close the Gap. Our feature story talks about this important health issue.

First wave Q&As Stephen Pannell shares his experience of being in the hot seat of general practice while on his First Wave placement.

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Junior doctor profile Dr Jon Priestley explains how the importance of self awareness and realising you are not alone can help with the stress of life as a junior doctor.

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It takes 2 Drs Ray Silva and Harry Pope tell us about working together in the community and share a little about each other along the way.

Registrar profile 20 How to apply22 to Dr Emily Isham, a GP the AGPT program registrar and founder 22 Applying to the of a charity that funds AGPT program training for doctors and – tips for success nurses in Congo, talks from regional to us about life and training providers medicine.

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My career Volunteering in a third world country can provide a change from daily practice and help hone your medical skills.

We give you the facts.

General Practice Students Network 30 News 31 GPSN Chairs 32 First Wave news

Published by General Practice Registrars Australia Ltd Level 4, 517 Flinders Lane Melbourne VIC 3001 P 03 9629 8878 F 03 9629 8896 E enquiries@gpra.org.au W gpra.org.au ABN 60 108 076 704 ISSN 2203-2657

Staff Interim CEO Sally Kincaid sally.kincaid@gpra.org.au Medical Editor Dr Chia Pang Editor Denese Warmington denese.warmington@gpra.org.au Writers Samantha Freestone Laura McGeoch Jan Walker Denese Warmington

Going Places Network 34 News 35 GPN Ambassadors

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Medical student profile Danielle Todd tells us how she discovered her passion for general practice, and the benefits of being involved.

Clinical 15 Clinical corner 16 Myelodysplasia 18 Murtagh’s tales 19 Perthes disease

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GP profile Dr Sarah McEwan is still coming to grips with the fact that her medical dream is a reality. She shares her journey with us.

36 Aqueous humour 37 Reviews

Graphic Designer Peter Fitzgerald

Produced with funding support from

Going Places Network Manager Emily Johnson emily.johnson@gpra.org.au General Practice Students Network Manager Alex Kirby alex.kirby@gpra.org.au

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Sponsorship and Events Coordinator Natalia Cikorska natalia.cikorska@gpra.org.au

©2014 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: GP Journey, 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.

With you on your journey 3

Editorial Welcome to issue 15 of GP Journey magazine, proudly brought to you by General Practice Registrars Australia (GPRA). GP Journey aims to show you a different view of general practice, one which you may not have come across before.

Our feature story is on the important issue of Indigenous health.

We discuss how incorporating a holistic approach, cultural competence and recognition of traditional Indigenous medicine into your practice can help close the gap between Indigenous and non-Indigenous health in Australia.

If you are looking for adventure or a change from daily practice, volunteering for an aid agency may be the answer. We chat to Médecins Sans Frontières (MSF) about how you can sign up as a volunteer and help contribute to the incredible work they do all around the world. In this section we also profile Queensland GP, Dr John Parker, who has volunteered for MSF for over two decades.

He is yet another example of a GP willing to get out of his comfort zone and provide medical care in unfamiliar territory to those who need it most. Dr Parker shares his intense experiences of working in third world countries.

Other profiles in this issue include medical students, Danielle Todd and Stephen Pannell. Danielle provides some good advice for other students and Stephen answers some questions about his First Wave Scholarship experience.

Dr Jon Priestley talks openly about the stresses of work and study as a junior doctor and tells us why he signed up to be a GP Ambassador with the Going Places Network, something that has helped him understand more what general practice is all about.

Dr Sarah McEwan talks to us about her achievements as an Indigenous Australian GP working in rural Western Australia; Swahili-speaking general practice registrar, Dr Emily Isham, shares with us her interesting upbringing and her heart for serving people in need; and in our ’It takes 2’ profile, general practice registrar, Dr Ray Silva and his supervisor Dr Harry Pope, tell us how they work hand-in-hand to provide care in their community.

And finally, in his last article for GP Journey, Dr Marcus Gunn provides some lighthearted insight into what to expect for our future medical school reunions.

GPs are sometimes caricatured as doctors who only deal with ‘coughs and colds’ and ‘tears and smears’. This is simply not true.

General practice deals with a wide scope of medicine, and it is complex and challenging. It requires the practitioners of this specialty to develop a broad skill set to tackle the wide array of medical issues that arise. It can be a satisfying and rewarding career for those who accept the challenge.

If you are interested in a career in general practice, I would encourage you to speak to your Going Places Network ambassador or representative from the General Practice Students Network.

Enjoy the magazine!

Our clinical section features an array of clinical cases and presentations and quick quizzes to test your medical knowledge.

Dr Chia Pang – Medical Editor, GP Journey General practice registrar – Bogong Regional Training Network

With you on your journey

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F E AT U R E S T O RY

Blending two worlds A holistic approach, cultural competence and a recognition of traditional Indigenous medicine can help in closing the gap.

Tips for building an Indigenous-friendly clinic Make your Indigenous patients feel welcome While your non-Indigenous patients may feel comfortable in the clinic, it may feel like a hostile environment for some Indigenous patients. Make a special effort to welcome them and adopt an attitude of cultural respect.

Become culturally informed – do a course Attending cultural competence or similar courses is highly recommended to build an understanding of Indigenous culture and the impact of European colonisation on Indigenous health today. NACCHO advises a course with inperson delivery by Indigenous presenters in preference to an online offering.

Take a holistic view of Indigenous health Understand that Indigenous perspectives bring together physical health with social, emotional and cultural wellbeing.

Consider the role of traditional Indigenous medicine Traditional healers play an important role in many Aboriginal communities.

Some GPs find it useful to work hand-in-hand with traditional healers for certain Indigenous patients.

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Image: Street art by Matt Adnate

The Indigenous view of health often incorporates mental, spiritual and physical health simultaneously – a holistic perspective that can be at odds with the symptom-by-symptom approach of Western medicine.

Today there is a realisation that a two-way exchange between Western and Indigenous medical models can achieve positive health outcomes.

Defining the Indigenous view of health Arguably one of the best definitions of health from an Indigenous worldview is the one adopted in 1979 by the organisation that became the National Aboriginal Community Controlled Health Organisation (NACCHO): “Aboriginal health does not mean the physical wellbeing of an individual, but refers to the social, emotional and cultural wellbeing of the whole community. For Aboriginal people this is seen in terms of the whole-life-view.”

Cultural competence in the GP clinic Indigenous doctors have the cultural background to foster an easy rapport with their Indigenous patients. But non-Indigenous doctors must work harder to develop a trusting patient-doctor relationship.

It is well understood that distrust born of historical trauma, racism, disconnection from land and past government policies such as the removal of children from families can translate into a reluctance for Indigenous patients to engage with mainstream Western medicine.

Fortunately, there are many training courses to assist doctors in working cross-culturally with Indigenous patients.

Their titles may include terms such as cultural safety – meaning a space where Indigenous peoples feel safe and welcome; cultural respect – meaning a respect for Indigenous belief systems; and cultural competence – emphasising tangible skills and action rather than passive cultural awareness.

Most cultural competence courses cover aspects of Indigenous history, cultural belief systems and trauma caused by European colonisation, illuminating the issues of Indigenous health today.

The overarching objective is to develop trust, so that Indigenous peoples feel ‘safe’ going to the doctor. With an attitude of mutual respect between patient and doctor, Close the Gap health targets can be more readily met.

Resources Creating the NACCHO Cultural Safety Training Standards and Assessment Process: A background paper. Available at naccho.org.au NACCHO: National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people. 2nd edition. Available at naccho.org.au Hand-in-Hand: Report on Aboriginal Traditional Medicine by Dr Francesca Panzironi. Available at http://antac.org.au/?wpfb_dl=1 Working together: Aboriginal and Torres Strait Islander Mental Health and Wellbeing Principles and Practice edited by Pat Dudgeon, et al. Available at http://aboriginal.telethonkids.org.au/kulunga-research-network/workingtogether-2nd-edition-2014

The role of traditional Indigenous medicine

Picture the scene. A traditional Aboriginal healer massages a patient to pull out an object or negative spirit. Another Aboriginal man reads the Bible. An Aboriginal woman dances. At the same time, a GP works with the patient.

This scenario is one example of traditional Aboriginal medicine working hand-in-hand with Western medicine. It’s related by a GP in a recent report titled Hand-in-Hand: Report on Aboriginal Traditional Medicine by University of New South Wales legal academic and lecturer, Dr Francesca Panzironi.

The report provides an analysis of the status of Aboriginal traditional medicine in Australia from a legal, social and policy perspective.

A key precept underpins the work. The United Nations Declaration on the Rights of Indigenous Peoples recognises that “Indigenous peoples have the right to their traditional medicines and to maintain their health practices, including the conservation of their vital medicinal plants, animals and minerals”.

Indigenous traditional healers have been part of many Australian Indigenous communities for up to 60 000 years according to Dr Panzironi, whose research interests include international human rights law, policy making and Indigenous peoples’ rights. However, there is currently scant formal recognition of traditional healers in the Australian Indigenous policy space.

But Dr Panzironi’s investigations also showed that traditional health knowledge is alive and well in a contemporary setting, particularly in the Anangu Pitjantjatjara Yankunytjatjara lands of northern South Australia.

The South Australian experience

In South Australia, ngangkari healers work alongside doctors and medical staff in community clinics and hospitals. They also visit patients in mental health settings or the prison system to calm someone who is troubled or whose behaviour is out of control.

Practices often include therapies such as massage, laying on of hands and breath work.

Rather than competing with Western medicine, ngangkari generally recognise their strengths and limitations – and when a Western doctor is needed. In fact, ngangkari are often instrumental in coaxing Indigenous patients to seek mainstream medical treatment.

“They [the traditional healers] focus a lot on pain relief, pain management and spiritual disorders, so when people feel sick or weak they may say the spirit is not there or it’s not in the right place,” Dr Panzironi explains. “Through massage and using special powerful sacred tools they are able to return the spirit to its rightful place.

“I know from a Western scientific point of view there is not a category to classify this,” continues Dr Panzironi, “but this is what they see, this is what they do, and people’s reaction is very positive.”

Australian Indigenous HealthInfoNet: healthinfonet.ecu.edu.au

For doctors and health workers who believe working alongside traditional healers may benefit their Indigenous patients, there is a register of accredited South Australian-based ngangkari (see Resources). Unfortunately, no registers exist in other states, although traditional healers may work alongside Western medical teams on an ad hoc basis across Australia.

GPRA Indigenous General Practice Registrars Network: gpra.org.au/igprn

Written by Jan Walker

The RACGP: Identification of Aboriginal and Torres Strait Islander People in Australian General Practice. Available at racgp.org.au/yourracgp/faculties/ aboriginal/guides/identification/ Anangu Ngangkari Tjutaku Aboriginal Corporation: antac.org.au

With you on your journey 7

M E D I C A L S T U D E N T P RO F I L E

Discovering the passion For GPSN National Secretary, Danielle Todd, a 12-month stint working as a receptionist in a large GP clinic uncovered a passion for general practice.

“It’s about hard work and attitude.”

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Danielle Todd always knew she wanted a career in health, she just wasn’t sure in what capacity.

So after finishing year 12 she took a year off and worked in a large general practice clinic in Queensland as a receptionist. The move – something Danielle did to get a feel for what it might be like to work in general practice – worked wonders, and gave the General Practice Students Network (GPSN) National Secretary great insight into what general practice is all about.

“The biggest thing for me was just getting the opportunity to observe the GPs and how they ran their work. I just liked it and it felt right.

“Seeing all of the different things they were doing within their practice was inspiring – cosmetic medicine, women’s health, children’s health. Some GPs would do more procedures some would do less. It was very much tailored to the individual doctor.”

Of discovering her passion for general practice, Danielle says fondly, “I had many a conversation over morning tea and lunch with those GPs. And the feeling I came away with was that it was the patientdoctor relationship that I would enjoy the most – the opportunity to provide long-term care.”

Danielle, a University of Melbourne medical student who is rurally placed, says medical school is a challenging environment but “overall enjoyable”. She is doing a full year of training in the rural hospital, environment and this, she says, is the perfect setting for a medical student who intends on becoming a GP.

When GP Journey spoke to Danielle she was getting ready to start her women’s health rotation at Wangaratta Hospital, a rotation she was very much looking forward to.

“We’ll be learning a lot about gynecology and obstetrics [but] its only for three weeks … a mini block.”

Danielle explains that there is a small campus near the hospital for the ‘extended rural’ cohort. During this time, the students are placed full-time in local general practices.

“I am learning the third year curriculum through general practice placement and some hospital time.

“It has been excellent for getting general practice exposure.You don’t get a lot of it in the other years of study.

“That was always the big benefit, and also the one-on-one learning environment. There is always either a one student/one supervisor [ratio] or one student and several supervisors,” Danielle says.

“It is definitely a benefit if you are interested in a career in general practice or rural general practice.”

In closing, Danielle offers first year medical students some advice: “It’s all about hard work and attitude, looking for opportunities and taking them when you find them.”

Written by Samantha Freestone

“Last year I was in Ballarat for the whole year, this year mainly Echuca but also Wangaratta and Shepparton.

“Something that’s been really special about working up here [in Echuca] is that the GPs are heavily involved in the hospital and also practise obstetrics, anaesthetics, surgery and dermatology – it has been a really valuable experience and very inspiring,” she says.

In Danielle’s off time, of course, she also works as GPSN’s National Secretary, a role she says has been enjoyable.

“It has been really good. I have learned lots of skills outside of medicine such as taking minutes for meetings, helping to write agendas, helping GPRA’s Future of General Practice conference councils and any other councils we may be running throughout the year.

“It’s also been great meeting people from other universities and states around the country,” she says.

Danielle was introduced to GPSN via the University of Melbourne’s GPSN club, a club of which she became vice chair.

She says she initially became involved in GPSN because of her interest in the specialty of general practice and because she knew it was a great way to find out about training pathways and meeting other medical students with the same interests.

“I have learned a huge amount around training pathways and the intricacies of training and the issues that surround it.”

Above: Danielle at the GPRA #fgp14 conference welcome cocktail party in Canberra

Next year marks Danielle’s research period before having to apply to training programs in 2016.

Find out more about the General Practice Students Network at gpsn.org.au or turn to pages 30–32 for GPSN news and the contact details of the club chair at your university.

“The first six months of next year is research – I am hoping for something to do with general practice.”

With you on your journey 9

Buy your GP Companion online at a member discount price of only $19.95

“Over 200 pages of vital information�

Medical students visit gpsn.org.au

Junior doctors Registrars visit gpaustralia.org.au visit gpra.org.au

F I R S T WAV E Q & A s

Great waves First Wave Scholarship recipient, Stephen Pannell, answers our questions about being in the hot seat of general practice.

What did you learn about general practice?

You have to know about every disease being a GP, there are common things that are seen frequently but you always need to be thinking outside of the box, thinking of masquerades, and not missing any red flags.

Did anything surprise you about the experience?

In rural medicine the GP is central to the patient’s care. I’d learnt this at uni but to see it in action, to see the way that multidisciplinary care all fits together and to see the communication required between each health professional was both surprising and fascinating.

What was the best part of the experience?

The lifestyle of a rural GP living by the coast is one that I could easily handle. A good work-life balance was easily achievable.

The beach, being so close to the practice, allowed my First Wave experience to contain lots of great waves!

What was the most challenging or difficult?

At times I felt like I was in the hot seat with the patient in front of me and my mentor observing. This was the first time I’d encountered ‘real’ patients and I felt a little nervous. It is so different to a ‘patient-actor’ scenario from an OSCE – real patients are more complicated with more comorbidities.

Did your First Wave experience inspire you to pursue a general practice career?

I’m still so early in my career and so unsure what I’d like to specialise in. The First Wave placement certainly showed me a specialisation and a lifestyle that is very appealing.

What year are you in?

I was in my second year at Notre Dame Fremantle when I did my First Wave placement. I’m currently in third year doing rural clinical school in Western Australia.

What did you learn from your supervisor?

Probably the most important thing that I learnt was skills in developing rapport and effective patient communication. My mentor had such an excellent approach to his patients. There was also plenty of learning with clinical encounters and procedural skills.

Describe an average day during your First Wave week.

Would you recommend a First Wave Scholarship to others?

I have been recommending my friends in first and second years to apply and would recommend anyone else to apply.

An amazing experience!

The GPSN First Wave Scholarship program offers the opportunity for a positive and inspiring experience in general practice under the guidance of a dedicated general practice supervisor.

Visit gpsn.org.au for more information.

There is so much diversity in rural medicine, every day presented new and interesting cases. My time was mixed between taking histories and examinations, learning obstetric care and observing procedural skills.

With you on your journey 11

J U N I O R D O C TO R P RO F I L E

A fork in the road

It took a case of burnout for junior doctor and GP ambassador, Jon Priestley, to re-assess where his career was headed – it was just what the doctor ordered.

“I became more open with colleagues regarding how I was feeling and came to realise that we are all in the same boat.”

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The journey to becoming a doctor can be a hard road, something Dr Jon Priestley knows all too well.

us are experiencing the same difficulties, but some cover up better than others.

Jon recently shared his experiences with GP Journey in the hope of highlighting the stresses placed on junior doctors and perhaps along the way, help prepare medical students for the road ahead.

“A big one for me too, was that I sought feedback from senior doctors. I received good responses and realised I was being too self-critical.”

As Jon explains, the work and study load of junior doctors “is often underestimated” with the diversity of specialties covered – which in his case has been emergency, general surgery, general medicine, paediatrics, psychiatry, obstetrics and gynaecology – leaving many feeling stressed and overwhelmed.

The existing hospital culture where you must buck up and forge on regardless is known to put immense pressure on junior doctors, an experience that often makes them feel isolated and unsupported, and this, says Jon, is one of the reasons he became a GP ambassador.

“To be honest it was difficult. I did 20 weeks of night shifts last year, let alone all the evening and weekend cover, which is not unusual for junior medical staff.”

“I wanted to get more involved and become more informed about general practice, as there are not a lot of opportunities to gain that knowledge when you’re in the hospital system.”

Jon says that since becoming a GP ambassador he has noticed first-hand his experience isn’t the exception but the rule.

And this, he says, is one of its greatest benefits as it highlights that others are having the same struggles and provides the opportunity to help.

But Jon is quick to point out that it’s not just the shift work and steep learning curve but the difficulty keeping connections with other junior doctors that makes hospital rotations tough going.

“The difficult thing with three month rotations is that you are just getting comfortable understanding the new processes on the ward and building strong relationships with the doctors and nursing staff, and then you have to start the whole process again.

“Changing jobs every few months can be so isolating. Relationships [with other junior doctors] can take time to develop. And because you don’t see many peers at the hospital, there is not a lot of opportunity to talk about the experience in any real depth.”

Jon says that at first, the bulk of questions he received as an ambassador were administrative in nature.

Find out more about the Going Places Network at gpaustralia.org.au or turn to page 35 to find the GP ambassador at your hospital.

Jon has now found the balance he needed, but it took a case of burnout before he re-assessed how he was approaching this phase of his career. Self awareness and acceptance of the situation you are in, he stresses, is key.

“I got to the point last year where I was dreading going to work.

I wasn’t sleeping well, not eating well and I started losing weight.

I was not in a place I wanted to be.

“When I admitted this to myself there came the realisation that I didn’t want to feel that way so I looked at ways to fix it. Talking with colleagues and family helped enormously,” Jon explains. “Finding [a way out of it] was a process of highlighting exactly what it was that was making me stressed.”

Jon says he discovered that his main stress stemmed from a fear of forgetting something, such as following up of investigations, and of being out of his depth. So to combat this he became more judiciously organised, something he says, is key for your intern year.

“I had a daily planner rather than depending on memory alone.

I also forced myself to exercise more, which was difficult initially but that brought on more sleep, which then made me hungrier.

I became more open with colleagues about how I was feeling and came to realise that we are all in the same boat. So many of

“You get mainly training queries, in terms of how it is set up, what rotations need to be done etcetera. The majority of questions tend to be about applying to the AGPT program,” Jon explains. But, he says, being an ambassador does inevitably turn into a support role.

“Sometimes it’s about having someone to have a chat with, about the emotional support. I’d like to hope that people would find me approachable.”

Jon is now looking forward to his PGPPP term at the end of this year, which will be based at picturesque Lakes Entrance in Victoria, and the opportunity to engage in holistic care is high on his agenda.

“I am looking forward to the outpatient environment. The one-onone. You have more time to educate when people aren’t acutely unwell. I’m looking forward to building relationships with patients and of course the lifestyle in Lakes Entrance,” he says.

Reflecting on his rotation experiences, Jon says his choice to follow a career in general practice is confirmed. But while he acknowledges that a hospital career isn’t for him, the experience, he says, was essential to getting him where he is today.

“The experience and the exposure have been invaluable. Now, two and a half years in I am not too concerned about the range of presentations I see and, because of the variety of rotations, I have a good grasp and understanding of different illnesses.”

The road travelled so far has been a tough one, but Jon wouldn’t have it any other way.

Written by Samantha Freestone

With you on your journey 13

CLINICAL CASES

Clinical

CORNER

Clinical Corner cases studies are provided courtesy of Medical Observer. The following are by Dr Ian McColl.

The unprotected balding scalp

Most men who go bald do so slowly. During the early phase of hair loss they may not appreciate how much cumulative UV damage occurs to the scalp. By the time they start wearing a hat, a lot of skin mutations have occurred and skin cancer slowly evolves, made worse if subsequent hat use is sporadic.

This man had a poorly differentiated squamous

cell carcinoma (SCC) excised and grafted, but shortly afterwards a series of pink nodules arose spreading along local lymphatics. Histology confirmed poorly differentiated SCC with perineural spread. His cervical glands were not clinically enlarged.

The clinical differential for this would be a speckled lentiginous naevus, but it followed a definite sunburning episode.

A case of non-infective pustules

When you see pustules like this on a red base you usually think of an infective cause, particularly herpes simplex if the pustules are grouped, and staph folliculitis when associated with hair follicles.

Legacy of a day in the sun

This may not look like much but it is an area of freckling confined to a strip along the patient’s lower back in an area where she was sun burned one day when working in the garden – her top slipping up when she was bending; revealing her unprotected skin.

Just one episode of sunburn caused all these freckles to arise on her skin. It serves as a reminder of how little sun exposure is required to cause permanent damage to skin. These pigmented lesions are better described as lentigines because the melanocytes now continue to make melanin irrespective of ongoing sun exposure. Freckles by contrast fade in the winter months.

However, pustules can be a marker of inflammation rather than infection. The neutrophilic disorder, Sweet’s syndrome, is one inflammatory pustular disorder to consider but this is another.

It is pustular psoriasis.

Infiltration of the epidermis by leukocytes is seen in all types of psoriasis, but it is maximal in pustular psoriasis and usually seen when a patient has been improperly treated with oral steroids and the steroids are wearing off. This condition can generalise very quickly.

For more images, see medicalobserver.com.au/clinical-review/dermatology With you on your journey 15

CLINICAL CASE REVIEW

A presentation of myelodysplasia Commentary by Peter A Castaldi

Is leucocytosis in this middle-aged man in the absence of infection an inflammatory condition, a major systemic disorder due to his recently developed gout or something more serious?

CASE SCENARIO Bill, aged 59 years, is a non-smoker and has, on average, 6–8 drinks on four days of each week. He has had hypertension, hypercholesterolaemia and osteoarthritis at least since he first attended your practice two years ago, and has recently developed gout.

He takes intermittent colchicine and regular allopurinol for his gout, and is also taking indomethacin, irbesartan and hydrochlorothiazide.

There is no recent history of fever or infections, and although he has plethoric facies there are no notable physical findings.

A recent blood test showed a haemoglobin level of 141 g/L (normal range 130–170 g/L), a platelet count of 140 x 109 per L (normal, 150–400 x 109 per L) and an elevated white cell count of 15.4 x 109 per L (normal, 4.0–10.0 x 109 per L); the white blood differential count was neutrophils 11.2 x 109 per L (normal, 2.0–7.0 x 109 per L), lymphocytes 1.8 x 109 per L (normal, 1.0–3.0 x 109 per L) and monocytes 1.8 x109 per L (normal, 0.2–1.0 x 109 per L). A repeat blood test has confirmed the leucocytosis.

A haematologist’s opinion was sought because of the recent onset of gout associated with leucocytosis in the absence of infection.

A bone marrow study ordered by the specialist showed changes consistent with a myelodysplasia with a normal cytogenetic profile 46XY. No intervention was offered and he continues under observation.

COMMENTARY From time to time patients are referred to a consultant because of leucocytosis as the dominant abnormality in the blood count. In an otherwise well person it is usually easy to exclude causes such as infection, an inflammatory condition or a major systemic disorder such as malignancy on clinical grounds or with limited imaging to target areas of symptoms. In a person with leucocytosis, the development of gout may be significant because gout results from the increased turnover of purines and accumulation of uric acid that is caused by enhanced white cell production occurring in the bone marrow and

other sites. There are no other pointers in the presentation so everything depends on the investigations.

The white cell differential is informative with a dominant neutrophilia and slight monocytosis, and the platelet count has shown mild thrombocytopenia. The normal lymphocyte count effectively excludes chronic lymphocytic leukaemia, the most common of the blood malignancies in a person of this age group. Granulocytosis and thrombocytopenia, although mild in degree in this patient, when consistent are important pointers to a more serious disorder and cannot be ignored. Although an acute attack of gout may well be associated with granulocyte leucocytosis, this patient’s gout is in a stable phase with no gouty arthritis, and the leucocytosis would have another cause.

Blood film examination in a patient with myelodysplasia in the early stages may show immature granulocytes such as band-form and other immature neutrophils (Figures 1a and b). Bone marrow aspirate and trephine samples showed moderate hypercellularity and changes in red cell, granulocyte and platelet precursors consistent with a myelodysplastic syndrome or possibly an early myeloproliferative disorder (Figures 2a and b). The population of abnormal precursor cells was confirmed by surface marker studies documenting a limited population of myeloid blast cells. The absence of any chromosomal abnormality in this patient, as indicated by his cytogenetic profile 46XY being normal, was a finding of favourable prognostic significance.

Taken together, these findings confirm the original impression of a presentation at an early stage of a significant bone marrow disorder.

The patient and his GP are informed of the nature of the condition and the serious implications. Ongoing observation and monitoring of the patient’s blood count and physical state are mandatory to detect as early as possible the development of more definitive markers such as anaemia, advancing thrombocytopenia or physical changes such as splenomegaly, any or all of which would warrant repeat full assessment.

It is usual for the GP and consultant to collaborate during this monitoring period.

This article originally appeared in Medicine Today 2014;15(4):54–55 and is reprinted here with permission.

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Figures 1a and b. Blood films. a (left) Myelodysplasia, showing macrocytic anaemia and a band neutrophil (an immature neutrophil with a non-segmented nucleus). b (right). Normal, showing normal red blood cells and a polymorphonuclear neutrophil (with the typical segmented – or multilobular – nucleus)

Figures 2a and b. Bone marrow trephine biopsy. a (left). Myelodysplasia, showing increased density and immature cells and overall cellularity. b (right). Normal, showing more sparse cellularity and predominance of mature forms

On the basis of current findings, it is more likely that evolution will be towards a myelodysplasia, a relatively uncommon but serious group of haematological disorders with a poor long-term prognosis.

As the condition evolves, intervention will be with supportive blood transfusion and general care. There are some chemo-therapeutic interventions available that can have a temporary limited benefit.

Stem cell grafting has a place in the right circumstances of recipient suitability (including age usually less than 60 years), donor availability and clear evidence of evolution towards an otherwise fatal outcome.

Myelodysplasia and myeloproliferative disorders have some features in common but are two quite different disorders, the former being disorders of the myeloid stem cells that result in ineffective production of myeloid blood cells (ie. red cells, platelets and nonlymphocyte white cells) and the latter diseases in which there is excess production of myeloid blood cells. There are more effective therapeutic interventions available for myeloproliferative disorders, and the long-term outlook for these disorders is generally more favourable.

The labels should not be treated as interchangeable.

CONCLUSION Even relatively minor changes in the blood count if consistent on repeated testing should be treated with concern and further

examination and testing arranged. Gout of recent onset in an otherwise healthy person, if associated with leucocytosis and/or thrombocytopenia, is a further signal for intervention. A diagnosis of a myelodysplasia or myeloproliferative disorder, while serious, may still be a prelude to slow evolution, and short- or long-term advantage is possible with a range of treatments.

Author Peter A Castaldi AO, MD(Syd), DU Paris(Hon), FRACP is Emeritus Consultant at Westmead Hospital, and in private practice in Sydney, New South Wales.

Competing interests: None.

Medicine Today provides GP Journey with selected articles from its archive of peer reviewed clinical content.

To view the full archive, visit Medicine Today’s website at medicinetoday.com.au or download the new Medicine Today for iPad, available from the App Store at https://itunes.apple.com/app/id666623264 Registration is free to all members of GPRA, GPSN and GPN. With you on your journey 17

CLINICAL QUIZZES

Murtagh’s tales Drawn from over 30 years experience as a GP, Professor John Murtagh’s clinical cases provide valuable insight to the problems that GPs can encounter.

Jaundice in a neonate A 2-week-old infant boy was brought in by his mother as she was concerned about his increasing jaundice. He had a normal delivery but became jaundiced on day three. Both mother and baby are blood group O positive and the baby’s blood film was normal. He was treated with phototherapy for two days, but since discharge on day seven the jaundice has persisted, despite the infant being well with satisfactory breastfeeding.

On examination the infant was active and clinically normal apart from jaundice. Urine and stools were normal in colour. Investigations were: serum bilirubin 240 µmol/L (conjugated <10 µmol/L), FBE normal, urine culture normal.

Questions 1. What is your provisional diagnosis?

2. For that diagnosis what is your management?

3. What is the most common cause of non-physiological neonatal jaundice?

4. What cause of neonatal jaundice demands urgent referral?

Answers 1. Because of unconjugated hyperbilirubinaemia the most likely diagnosis is breast milk jaundice.

2. The mother should be reassured that the condition is self-limiting and requires no treatment. The diagnosis can be confirmed by suspension of breastfeeding for 24–48 hours, which will result in a fall of serum bilirubin. In this situation, temporary expression of milk will maintain lactation.

3. The most common cause is haemolytic jaundice, especially ABO blood group incompatibility.

4. Beware of conjugated bilirubin, which is pathologic and indicates biliary atresia in the newborn. Also consider neonatal hepatitis.

Unexplained stroke in a healthy adolescent A 15-year-old schoolgirl, who had been in perfect health, was found in the early hours of the morning, collapsed on the floor of her bedroom. Her parents had been woken by a loud noise (presumably due to her falling) and found her lying on the floor unable to speak or move.

On examination during a home visit, she was lying stuporose on the floor, unable to speak or understand the spoken word. She had a dense

18

right hemiparesis involving the arm, leg and face, and swallowing was impaired. There was no neck stiffness. Cardiac examination was normal. There was no evidence of bruits in the neck and ocular fundi were normal. The patient was transferred to hospital by ambulance where she underwent investigation. There was no evidence of emboli or blood in the urine. Routine haematology and urine tests, ECG and chest X-ray were all normal.

Questions 1. What could be an explanation of this unusual presentation?

2. What further investigations are appropriate in this case?

Answers 1. This patient has had a paradoxical embolus, also called ‘cryptogenic stroke’. It can occur with a patent foramen ovale, atrial septal defect or ventricular septal defect.

2. Further investigations included CT scan of the brain, angiography and tests for thrombophilia, including lupus anticoagulation screen.

These tests revealed cerebral infarction but no haematological disturbances. However, a transoesophageal echocardiograph using a contrast demonstrated right to left shunting through a large patent foramen ovale. The defect can be closed with a percutaneous image-guided ‘umbrella’ device.

A hippy hippy ache

by Dr Michael Lovegrove

Case study A seven-year-old boy presents to your surgery with a history of an aching right hip. He is well, but is starting to limp, particularly after activity.

He doesn’t recall any significant trauma, but he confides that there has been an ache on and off for the past month.

The boy is afebrile and has a mildly reduced range of motion.You arrange an X-ray of the hip.

Q. What is the diagnosis?

A. The X-ray shows increased density in the epiphysis of the right

femoral head with slight flattening of the bone in this area. There is a slight increase in the gap between the femoral head and the acetabulum consistent with a joint effusion.

This is consistent with Perthes disease, a condition where there is avascular necrosis of the femoral epiphysis. The cause is not clear, with no clear association with trauma. If the diagnosis is unclear, a bone scan or MRI showing decreased blood flow to the femoral epiphysis can confirm the condition.

It is most common in males aged 4–12 years (mean age is seven), with a male-to-female ratio of 4 to 1. It is more common in Caucasians, but does still occur in other ethnic groups.

Q. When do you worry?

A. For any limping child, the first priority is to rule out septic arthritis. If there is fever, marked limitation of movement or muscle spasm, then urgent referral for evaluation is needed. The differential diagnosis includes transient synovitis and slipped upper femoral epiphysis.

The prognosis of Perthes disease is good if caught early and in younger children. If there is already extensive collapse of the femoral epiphysis at diagnosis, then the outcome is likely to be worse. Onset in an older child (10 years and up) is also associated with a worse outcome as there is less time for remodelling to occur.

Q. What do you do?

A. Even if mild, Perthes disease should be managed through

a paediatric orthopaedic service.

Management options include surgical osteotomy, bracing or a conservative approach with physiotherapy. The aim has been to keep the femoral head enlocated in the acetabulum to reduce pressure on the growing bone, but recent studies have not found significant differences in the outcome of the different treatments.

Studies are ongoing to determine the best management.

Monitoring with X-rays to show healing is necessary.

Remodelling can take several months, and avoidance of sport is required until healing is complete.

Author Dr Lovegrove is an emergency medicine specialist working at Princess Margaret Hospital and Joondalup Health Campus, Perth, WA.

This article was first published in Australian Doctor, 27 June 2014 and is reprinted here with permission. australiandoctor.com.au

With you on your journey 19

Award winning GP Training on the NSW north coast An outstanding training program delivered by an award winning medical education team on the beautiful north coast of NSW. Training nodes in Ballina, Coffs Harbour and Port Macquarie.

Visit our website to hear our registrars talk about their experiences with NCGPT: www.ncgpt.org.au â&#x20AC;&#x153;North Coast GP Training is a fantastic place to be a registrar. The region has amazing beaches end to end, stunning hinterland, and a perfect climate. When at work, the education and training program at NCGPT is superb - come and join us!â&#x20AC;?

Dr David Chessor 2013 RACGP Rural Registrar of the Year 2013 GPET Registrar of the Year

All you could want from General Practice Offering Rural Generalist posts in Anaesthetics, Obstetrics and Emergency Medicine. Academic posts and Aboriginal health posts available.

It takes Dr Ray Silva is a registrar at Fairfield Chase Medical and Dental Centre in Sydney.

Dr Harry Pope is a credited authority on refugee health and mental health in general practice, and Ray’s supervisor.

Ray:

After working in ED departments for 10 years

– where the stress of the work can become draining – I decided that I wanted to be a GP. I liked the idea of general practice and the opportunity to build a career that could fit in with my lifestyle.

Fairfield Chase is a large-scale centre and I have a lot of independence in how I practise. On Wednesdays I assist Harry in the occupational health clinic and on Friday nights we work an evening shift together. If anything interesting or unique presents itself during the day, Harry will call me around and take me through it.

Likewise, if I don’t feel comfortable with a consultation or I simply don’t know the answer I will give Harry a call and we will sort out the problem together.

I also have an interest in gastroenterology, and had completed about half of the requisite number of scopes to gain my accreditation before switching to general practice. I have been fortunate that through my placement at Fairfield Chase I have been able to sit in with a gastroenterologist at another primary medical centre, which will allow me to complete my qualification.

Harry is professional, knowledgeable and approachable. I admire the manner in which he interacts with his patients. Many of his patients can be quite demanding and at times, difficult, but Harry is always empathetic towards them and takes the time to engage with each of them. Harry is confident in his knowledge of medicine through his desire to continue learning. He was involved with the University of Western Sydney as a tutor and runs small group learning meetings for the GPs at Fairfield Chase. He also recognises that no one GP can know everything about medicine and the importance of having a network of GP colleagues and other health professionals to turn to for support.

I’d like to continue to expand on my skills, possibly even obtaining a further qualification in a subspecialty such as dermatology. In 5–10 years I can see myself living in Sydney and working in a multi-GP practice before moving to solo practice.

Do you know a pair who could feature in a future It takes 2?

A GP and a patient? A practice manager and a registrar?

Your mentor? A GP who inspired you? Let us know by emailing goingplaces@gpra.org.au

Harry:

I have been a GP for 33 years and have

worked that whole time in the Fairfield local district, a demographically challenged

and disadvantaged area. I wanted to be a GP because of the independence of the occupation and the range of skills that GPs can utilise.

This has been my first term as a registrar supervisor. I was involved with the University of Western Sydney as a tutor and as a clinical supervisor at our practice. Our organisation, Primary Health Care, advised that it was willing to support both the supervisors and registrars and commit to the highest standards and quality care.

I believed that by having registrars on site we would be able to deliver better medicine by encouraging a collegiate environment in the workplace that put a focus on reviewing and questioning practices.

If I had to describe Ray in five words I would say he is confident, competent, personable, obliging and questioning. He is willing to go the extra mile. On his first day I had him attend a local community stakeholders network committee meeting as a registrar representative!

One of the biggest career benefits of general practice is satisfaction.

Relationships with our patients may demand a lot from us but they are also rewarding many times over. I feel most satisfied when I have had an impact on a patient or their family. Often we can’t change the outcome, as in terminal illness, but can help those suffering by being there, being supportive and providing hope, as well as by making them feel they aren’t alone. This applies to all aspects of medicine, not just mental health or refugee health.

One of the challenges that new GPs face is that medicine is so rapidly progressing that it is difficult to be across everything. Technology makes advice on medical matters available to our patients whether the advice is valid or not. We need to be confident enough to counter the panic this advice sometimes instills in patients.

The single most important quality that GPs can offer to their patients is support and empathy, but not so much that you burn yourself out. A good GP feels for his or her patients. If you are continually distressed by your patients’ circumstances then you risk emotional collapse and lose perspective and the ability to help negotiate them through their problems.

My advice for junior doctors wanting to be a GP is to find your niche in medicine. What you enjoy will sustain you professionally throughout your career.

With you on your journey 21

G P R E G I S T R A R P RO F I L E

On a mission Dr Emily Isham spent her early childhood in Africa as a “missionary kid”. The experience continues to light her way as she completes her general practice registrar training in Tasmania while running a sponsorship program for student doctors and nurses in Congo.

“My interest in medicine was always within the context of the developing world.”

22

“I was a missionary kid in Africa,” says GP registrar Dr Emily Isham, as she reminisces about her upbringing with Christian missionary parents in the Democratic Republic of the Congo, one of Africa’s most troubled hotspots.

“During my medical degree I went to Ethiopia to work at the fistula hospital in Addis Ababa with Dr Catherine Hamlin for six months. That sparked my interest in women’s health, especially in the developing world,” she recalls.

It’s a simple statement that helps to shed light on Emily’s deeds and dreams – not to mention her ability to speak fluent Swahili and French as well as English.

Emily assisted Dr Hamlin in the operating theatre, went to her home for dinner and attended church with her. “She is an amazing woman.

To be her age and to be practising surgery is incredible,” she reflects.

But first to where she is today. When GP Journey caught up with Emily, she was completing her second general practice term at Kingborough Medical Centre on the outskirts of Hobart while finishing a Master of International Public Health through the University of Queensland.

As if that’s not enough, she’s a boot camp exercise instructor, she plays piano and violin, she’s active in her local church and she runs a charity to sponsor Congolese student doctors and nurses. Oh yes, and she’s the mother of two young children!

“I’m doing my registrar training part-time because I have a two-yearold son and five-year-old daughter,” she says. She and her husband Seth, a teacher, both work part-time “so one of us is always home with the kids”.

“I really do like the variety of general practice work,” Emily says. That variety has included the adrenalin rush of an expedition medicine course that featured rescue medicine and rock climbing – a highlight of the General Practice Training Tasmania program for Emily, a former triathlete who describes herself as “outdoorsy”.

So when did Emily first decide she wanted to be a doctor? “My uncle was a paediatrician so from a very early age I said I wanted to be paediatrician like my uncle.”

“Later, my husband and I went to Thailand. I worked in the leprosy hospital in Chiang Mai and he worked at the local school. So it cemented our desires to work in a developing context again.”

Another experience with the John Flynn Placement Program in Tennant Creek introduced Emily to working with disadvantaged Indigenous populations closer to home.

During her prevocational hospital training, Emily initially considered becoming an obstetrician but later had a change of heart. “I did my DRANZCOG but when my daughter was about two years old I realised that the life of an obstetrician wasn’t really compatible with the family life I wanted.”

General practice rolled together all of Emily’s interests, and her family moved to Tasmania, her husband’s home state, for her vocational training.

But while Tasmania is a world away from Congo, Emily’s upbringing in Africa continued to exert its influence, as did the Christian values she and her husband share.

Having kept in touch with her Congolese school friends, she was acutely aware that many of them were unable to get the medical training Australians take for granted. Yet there was a desperate need for doctors and nurses in Congo.

Even more influential was what she witnessed as a child in Africa.

“As a missionary kid, I lived with my dad, who is a pastor, and my mum, who is an audiologist, and my brother and sister right on the border of Rwanda in a town called Bukavu. We could see Rwanda from our window and we were there during the genocide. So I saw a lot of agencies like the UNHCR and MSF working during that. That began my interest in medicine. My interest in medicine was always within the context of the developing world.”

“I really struggled with the unfairness that by virtue of my birth and skin colour I had the right to go to uni and become a doctor and I didn’t have to pay any fees upfront. Once they finished high school they may get into university but they couldn’t afford the fees. I really hated the thought of that.”

Emily did her undergraduate medical degree at the University of Melbourne. Several people and experiences had a profound effect on her.

The project has an alliance with the Panzi Hospital in Bukavu, a general hospital that assists women who have been victims of sexual violence and trauma. Congo is known as the rape capital of the world because rape is used as a weapon of war and a means of shaming women.

Left: Emily with members of The Mafunzo Project committee Far left: Kabuto (third from left), Nursing Director at Panzi Hospital and in charge of directing The Mafunzo Project in Bukavu, with some of the sponsored nursing students

Emily applied for a grant through a Christian mission organisation and established a charity called The Mafunzo Project, which funds university expenses for doctors and nurses in Congo.

“We originally started with 14 students and we now have 28 – 12 nursing students and 16 medical students. We want to keep building it up but it all takes time,” Emily says.

So what’s next? “I’m doing a rural general practice term in Huonville and I’ll do my general practice exams this year. “Next year my husband and I are planning to study theology, then we’ll probably apply to a mission organisation and head overseas to work.”

Find out more about The Mafunzo Project at themafunzoproject.org Written by Jan Walker

With you on your journey 23

G P P RO F I L E

No dream too big

As a schoolgirl, the idea of a medical degree seemed out of reach for Dr Sarah McEwan. Now this Wiradjuri woman has a world of medical opportunities and new dreams firmly in her grasp.

“General practice just seemed to speak to me as I was growing up.

That’s all I ever knew in terms of a ‘doctor’.”

24

Watching her dad volunteer with local rescue squads around their hometown of Mudgee in central New South Wales, gave Dr Sarah McEwan her first insights into the mechanics of the human body and inspired her to consider a career in health. As a good student, university placements in nutrition, dietetics or even physiotherapy were realistic options.

But a chance meeting at a high school careers expo opened up an opportunity that Sarah hadn’t dreamed about.

On one of the expo stalls, Sarah spotted two fellow Indigenous Australians, Lillian and Denise, from the University of Newcastle.

They saw potential in Sarah and told her about university entry options for Aboriginal students wanting to study medicine.

“Medicine really wasn’t on my radar until that day,” Sarah tells GP Journey. Before she knew it, the “excited and a little bit scared” 17-year-old was on her way to Newcastle. “I didn’t have enough time to over-think it and talk myself out of it!”

Fast-forward 15 years and Sarah has proved medicine was meant to be. She has fellowships with both The Royal Australian College of General Practitioners and the Australian College of Rural and Remote Medicine (ACRRM). Specialising in general practice was a natural choice. “General practice just seemed to speak to me as I was growing up. That’s all I ever knew in terms of a ‘doctor’.”

She has received many accolades, including ACRRM Rural Registrar of the Year, a WA Health Award and a University of Newcastle Indigenous Alumni Award. She is building up the “letters” after her name with a succession of postgraduate qualifications. “You can’t be overeducated,” Sarah believes.

This medical expertise is crucial to her work in Port Hedland, a mining town of 20 000 people on the Western Australian Pilbara.

Its tropical location, Indigenous population and fly-in fly-out workforce – some of whom fly-out to Southeast Asia – makes the area a “challenging” general practice landscape. “I need to keep abreast of what’s happening both nationally and internationally,” Sarah notes.

As a District Medical Officer at Port Hedland Health Campus, Sarah and the team at the 44-bed hospital see about 60 patients a day and more than 370 births each year. Although not currently working as a GP (she splits her time between emergency and obstetrics and gynaecology) the majority of emergency cases are general practice presentations, Sarah explains.

It was during a second year university elective that Sarah first visited Port Hedland and worked with an Aboriginal Medical Service and the Royal Flying Doctor Service. She and her husband Darcy, and their Staffordshire bull terrier Jetta, moved there four years ago.

In addition to the dynamic medical environment, the area’s Aboriginal and Torres Strait Islander population suits her on a personal level.

“The culture is still intact up here,” Sarah says. “The culture, history and landscape are just beautiful.”

Sarah notes that 35 percent of patients presenting to Port Hedland Health Campus are Aboriginal and Torres Strait Islander Australians.

“I feel proud to be an Aboriginal person working in the community.”

Left: Sarah in front of the Port Hedland Health Campus, WA

“I can interrelate with the community in a manner I feel comfortable with,” she says. “People often mention that I speak differently around my mob. If I was working in an inner-city area I would have to dress differently, speak differently …”

Non-Indigenous doctors, Sarah says, can still play a valuable role in improving Indigenous health. She describes a mentor who worked successfully in Port Hedland for 15 years. “If you immerse yourself in the community for long enough and you are open enough, you can open your skills and be accepted.”

Sarah’s longer-term goal is to be involved at a medical administration and government level to improve systems and process to provide “a more equitable delivery of medical service”. To this end, she is building on a Graduate Diploma of Clinical Education by doing a Master degree in medical administration. She is also a General Practice Education and Training (GPET) Board member.

Sarah’s WA Health Award recognised her work to create better long-term healthcare outcomes through a contraception clinic she designed. “I do terminations in hospitals that I work in, but I was feeling at a loss at finding out how we can prevent women getting to the point of needing one.”

“The aim was to reduce the termination rate by 10 percent in two years. We reduced it by 20 percent.” Key to the clinic’s success was a self-referral process and provision of “culturally appropriate and gender-specific” contraception advice.

Sarah is still coming to grips with how her medical dream became a reality.

“It was like it was just meant to happen. Sometimes I have to pinch myself and ask: ‘How did I even get here? How did it happen?’”

She recalls her first patient as a GP. “A young guy presented for alcoholism. I didn’t even know where to start to help him. It almost turned me off being a GP. I thought: ‘Is this what it’s going to be like every day? I’m not going to know what to do’!”

A little self-doubt, she believes, is “healthy” and drives her to build her skills. “A good GP needs to know what they don’t know.”

Grateful for those who have helped her, Sarah is giving back to the profession and inspiring future doctors. This includes being part of the Health Heroes documentary, which follows different Aboriginal health workers, and contributing to GP Journey magazine. She also gave the address for graduating medical students at the University of Newcastle this year.

“I’m always open to being a mentor and leader for others. It’s not about me, but about inspiring other people to dream for the future.”

Written by Laura McGeoch

With you on your journey 25

MY CAREER

MSF feature

Full exposure If youâ&#x20AC;&#x2122;re after adventure or a change from daily practice, or just want to hone your skills, a stint volunteering in a third world country can provide just that.

But volunteering can also provide life-changing personal benefits.

26

“I am driving to the Whitsundays on Monday, have a briefing in Sydney on Tuesday and am then off to Manus Island, Papua New Guinea on Wednesday for the International Health Service.”

This was how the interview between GP Journey and Dr John Parker began, and it made us a little envious of the adventurous life he seems to lead. Of course, as our conversation continued, we learnt he has possibly paid a heavy price for his worldly experiences.

Nonetheless, John is as enthusiastic today as he was when he began his adventure into medical volunteering 20 years ago.

John speaks with urgency, kindness and passion. A self-confessed adventure seeker, these days he works exclusively in a contract capacity for various aid agencies around the world. But until 2004 he ran his own general practice in the Whitsundays, splitting his time between the practice and extensive volunteer work for Médecins Sans Frontières (MSF), work he still does to this day. Work, he says, that made him a better doctor and a wiser human being.

“When I said I was going over for the first time, my family and friends were asking ‘what are you doing?’ and ‘why are you doing it?’ and I think my response at the time was something to the effect of ‘giving good medical care where it is appreciated’. Mostly, they were selfish reasons, seeking that sense of adventure. But over the years you do question your motivation and your motivation does change.

“Once you have volunteered as a doctor in a third world environment your perspective changes quickly, as do your reasons for volunteering. You realise what a fantastic medical system we have in Australia, despite its flaws. I think all registrars should volunteer in a third world country for a few months at the start of their careers, because you are exposed to what real poverty is. You come to truly understand health and you appreciate the role you play so much more. It brings you great joy to help, but of course, there is also sorrow, for there is still death.”

John speaks in depth about his missions and the collaboration between aid agencies and how the flow of care depends on many players that form part of a community.

When John first signed up as a volunteer doctor, it was in 1994 with the Red Cross as the Hutus fled Rwanda into the Congo.

This page: Dr John Parker participating in morning rounds with the medical team in the burns unit centre, northern Iraq

The Tutsi army had invaded Rwanda after the genocide as John was sent to Congo and within a day MSF was also setting up a clinic.

“Within 24 hours [Médecins Sans Frontières] had a great clinic up and running. It was well stocked, it had furniture, was well staffed and I remember saying to myself ‘next time I am volunteering with those guys’.”

Médecins Sans Frontières, says John, excels in primary health care and is known for its expertise with regards to logistics and being prepared for outbreaks.

“They have warehouses all over the world and pre-empt outbreaks based on cyclical outbreak events. They are prepared with relevant kits and staff on standby. When you have an ongoing project, they have fantastic systems for pre-ordering and we have a great buffer stock.”

John talks about the struggle to treat thousands of desperate people in Africa, dying from the same illnesses that are preventable and easily managed in Australia.

“In 2004, I went back to Nigeria to treat the meningitis epidemic in the ‘meningitis belt’. Every dry season it occurs and getting antibiotics to these people is a major challenge.”

In Nigeria, John worked from a large temporary clinic and was not only treating the seasonal meningitis outbreak, but was also rolling out an HIV program and a TB/pneumonia program.

“One of the strengths of MSF is to negotiate with drug companies to allow cheap drugs to be made and distributed into the third world.

MSF excel at medical activism,” he says.

It is this commitment to aid – despite politics or religion – that appeals to many who volunteer for MSF. As John says, “MSF is egalitarian. Everyone flies economy and everyone stays in the same basic accommodation, even the board and the upper-level executives. The pay isn’t excessive. As a career, you make a fraction what you would make in normal working conditions but it is extremely important work.”

The worldly doctor talks of heading up a burns unit in Iraq, of treating 300 major burns in three months but, despite his experiences, he still sounds a little confounded by what he has seen.

“My career, to a certain extent has been a little over-the-top. Not all volunteer work is so intense. I don’t want to scare off any registrars.

But working in the third world showed me what medicine really is, it honed my medical skills.You don’t have the imaging, you are on your own, you do things you don’t think you can do, because you have no choice and then realise that you can.

“You learn that you can’t always cure but you can always care.”

Written by Samantha Freestone

To learn more about becoming a volunteer with Médecins Sans Frontières turn to page 28.

With you on your journey 27

How it all started In 1970, the Groupe d’Intervention Médicale et Chirurgicale en Urgence (Emergency Medical and Surgical Intervention Group) was formed by a group of French doctors who entered into the Biafran zone in Africa to ‘provide aid and to emphasise the importance of victims rights over neutrality’.

After entering the country, the volunteers, as well as Biafran health workers and hospitals, were subjected to attacks by the Nigerian army. They witnessed civilians being murdered and starved by the blockading forces. The doctors, who would later found Médecins Sans Frontières, publicly criticised the Nigerian government and the Red Cross for what was regarded as complicit behaviour. These doctors knew that a new aid organisation was needed, one that would ignore political-religious boundaries and prioritise the welfare of victims.

In 1971, as the Biafran conflict was escalating, Médecins Sans Frontières was officially founded. In 1999, almost 30 years later, the organisation won the Nobel Peace Prize for its work in humanitarian medicine.

Interested in becoming a volunteer with MSF? Médecins Sans Frontières Head of Field Human Resources, Robin Sands, answers some common questions about the MSF application process.

Where do I start?

The best place to start is at the MSF website to review the criteria and other useful information.

What experience do I need?

You must have a minimum of two years experience postqualification, ie. have started PGY3 (applications submitted prior to completion of PGY2 are not accepted).

How long does the application process take?

The application process takes about four weeks, plus an interview.

Successful applicants must complete the four day pre-departure training, which is run three times a year (February, June, October).

Once this is done most applicants will leave, on average, within three months depending on what their availability is.

Is there a minimum time commitment?

All applicants must be available for a period of nine months.

For some specialists, such as surgeons, anaesthetists, obstetricians and gynaecologists, a minimum of six weeks applies due to the workload they undertake in the field.

Can I choose where to be deployed?

As all positions in the field are there to respond to the medical needs of patients, each volunteer makes themselves available to be deployed where they are most needed. All volunteers can refuse a placement if they are not comfortable with the role or the context proposed to them. It is worth noting that all volunteers can also choose to leave the field at any time if they are uncomfortable with the context or security situation, without consequence.

What attributes do I need?

Beyond technical skills/qualifications applicants need:

desire to dedicate part of one’s life to assisting people who • Aneed help

• A genuine interest in people from other cultures • The ability to share knowledge, experience and skills with others • An interest to challenge oneself professionally, personally and culturally •

Willingness to invest personally by being away from family and friends for an extended period.

Plus

ability to work well as a part of a multicultural • Demonstrated and multidisciplinary team

• The ability to organise, prioritise workload and use initiative • Willingness to work in potentially unstable environments • The ability to cope with stress.

Will I be paid?

In addition to a modest salary, MSF covers the costs of transport, accommodation, vaccinations, insurance and psychosocial support.

It also provides a local allowance to cover the cost of food and daily expenses in the field.

Can trainees and medical students volunteer?

The nature of the work of MSF requires that fully qualified personnel be able to arrive in the field and start work immediately.

To ensure the largest amount of the organisation’s resources goes to providing medical care, we do not provide the space or the resources for trainees and students in our teams.

For more information visit msf.org.au/join-our-team/who-we-need

28

Become a GP in Northern Territory 3 Experience rural generalist medicine NTGPE offer highly supported, flexible and challenging vocational training opportunities for those passionate about comprehensive primary care. Our placements support rural and remote training and provide excellent opportunities for training in Aboriginal health.

“General Practice Training in the Territory has helped me rediscover what ‘real’ medicine is about and given me the opportunity to better understand the world my patients live in beyond the walls of the consulting room.”

Dr Iyngaranthan Selvaratnam

3 Great exam results With national awards won by our GP Registrars in 2012 and 2013. NTGPE Registrars are supported by a network of experienced GP Supervisors providing practice based teaching, mentoring and professional development.

3 Choose from a variety of training locations Registrars have the ability to choose from a variety of locations, ranging from urban mainstream general practices to remote Aboriginal community clinics and regional hospitals.

For more information email registrar@ntgpe.org or call 08 8946 7667 /ntgpe

@ntgpe

www.ntgpe.org

General Practice Students Network News Local events GPSN clubs around the country have been busy hosting a variety of career-focused events and clinical skills workshops over the past few months. Hundreds of medical students have attended these events, which have featured inspirational speakers presenting on topics that have included Indigenous and rural health, and general practice training pathways.

Melbourne University Suturing Night, May 21

GPSN clubs have also provided medical students with the opportunity to practise their suturing, plastering and a range of other clinical skills at their events, as well as providing time for questions and networking with renowned GPs and industry stakeholders.

GP Companion The latest edition of GP Companion has hit the shelves and is available to medical students for the special price of $10 when ordered through their university club chair.

GP Companion is the ideal reference for medical students and those undertaking general practice rotations. It contains the essential facts and figures on a range of common medical conditions, preventive health and clinical reasoning. GP Companion covers everything general practice, from dermatological assessment to cardiovascular medicine to the diagnosis and management of common presentations.

Working groups

Notre Dame Sydney Careers Night, July 24

All four GPSN working groups have been progressing well. Led by National Working Group Officer, Amer Mitchelle, the groups are set to launch some exciting projects over the next six months. Projects and initiatives include the release of ethics applications, draft policy documents and presentation templates. For those wanting more information about the groups and their projects, please email Amer Mitchelle at wgo@gpsn.org.au Sophie has displayed exceptional organisational skills and has been a great asset to the network. Congratulations Sophie!

National Executive projects and activities The GPSN National Executive Committee is set to release its new rules and regulations document, which will reflect the current structure of GPSN.The document will standardise many of GPSNâ&#x20AC;&#x2122;s activities and define national executive roles. It will be presented to students at the October GPSN Council meeting.

Sydney University Careers Night, July 24

Over the past few months GPSN has been actively involved in advocacy issues involving general practice and medical students.The national executive committee has submitted opinion pieces on mental health, the MRBS/BMP schemes and the recent co-payment model.

The committee has also been working closely with the Australian Medical Studentsâ&#x20AC;&#x2122; Association on the revamped Get-A-GP campaign, as well as mental health initiatives and policies.

Visit gpsn.org.au

30

Chairs NATIONAL COMMITTEE University University of Melbourne Griffith University University of Melbourne Notre Dame Fremantle Monash University University of Notre Dame Sydney Notre Dame Fremantle University of Western Sydney University of Western Sydney Monash University

Position National Chair National Vice Chair National Secretary Working Group Officer National Events Officer Internal Communications Officer Sponsorship Officer Local Events Officer Promotions and Publications Officer Online Officer

Name Joseph Monteith Nicola Campbell Danielle Todd Amer Mitchelle Jessica Deitch Emma Thompson Anmol Khanna Likhitha Sudini Rajdeep Ubeja Emily Jenkins

Contact chair@gpsn.org.au vc@gpsn.org.au ns@gpsn.org.au wgo@gpsn.org.au neo@gpsn.org.au ico@gpsn.org.au sponsorship@gpsn.org.au leo@gpsn.org.au publications@gpsn.org.au media@gpsn.org.au

Name Shona Schadel Jarrod Bradley Emma Gordon Aaron Chu Natalie Campbell Hayley Morgan Sofia Dominguez Jenny Chen

Contact undsyd@gpsn.org.au westsyd@gpsn.org.au newengland@gpsn.org.au unsw@gpsn.org.au wollongong@gpsn.org.au newcastle@gpsn.org.au undsyd@gpsn.org.au anu@gpsn.org.au

UNIVERSITY CLUB CHAIRS NSW and ACT University of Sydney University of Western Sydney University of New England University of New South Wales University of Wollongong University of Newcastle University of Notre Dame Sydney Australian National University

SA and NT

Flinders University Shauna Madigan flinders@gpsn.org.au University of Adelaide Christopher Le adelaide@gpsn.org.au Jennifer Dang adelaide@gpsn.org.au

Northern Territory Medical Program (Flinders University) Haley Stratton ntmp@gpsn.org.au VIC Deakin University Alex Drucker deakin@gpsn.org.au Monash University Amanda Tan monash@gpsn.org.au University of Melbourne Sophie Dunn umelb@gpsn.org.au TAS University of Tasmania Saranga Jinadasa utas@gpsn.org.au

Caitlin Cannan utas@gpsn.org.au WA University of Western Australia Erin Bock uwa@gpsn.org.au University of Notre Dame Fremantle Emma Price notredame@gpsn.org.au QLD Bond University Frank Dorrian bond@gpsn.org.au

Chloe Tyson bond@gpsn.org.au James Cook University Lawrence Ling jcu@gpsn.org.au University of Queensland Johnson Huang uq@gpsn.org.au Griffith University Jenna Weetman griffith@gpsn.org.au

With you on your journey 31

First Wave News 2014–15 recipients announced The General Practice Students Network is pleased to announce the following successful recipients of the 2014–15 First Wave Scholarship Program.

Congratulations to all our scholarship recipients.

NSW and ACT University of New England Henry Law Jessica Mumford University of New South Wales Nadia Perera Hannah Uebel University of Newcastle Susan Jacob Pariza Khale University of Notre Dame Sydney Amanda Rohl Lara Sharplin University of Sydney Jessica Norman Ellie van der List University of Western Sydney Gemma Abraham Michelle Yu Australian National University Nicolas Grandjean-Thomsen Rowena Penafiel

SA and NT Flinders University Andrew Hughes Jessica Pollard Jonathon Schubert University of Adelaide Stuart Brown Dhiren Dhanji

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VIC University of Melbourne Nancy Li Janaka Lovell Julia Smith Monash University Robert Gillies Nishani Nithianandan Mihiri Weerasuria Deakin University Tara Sasse Jack Turley

QLD University of Queensland Ridhwan Shams Lu Zhang Bond University Ben Ierna Sarah Thomas Griffith University Lucy Holden Jeremy Lee James Cook University Meth Delpachitra Amraj Gill Sylvia Shrestha Tejas Singh Karan Singh

TAS University of Tasmania Isabel Di Tommaso Zara Gray

WA University of Western Australia Gareth Massy Myoorra Ratnasingham University of Notre Dame Fremantle Kim Fendel Kim-Siobhan Robitschko

The First Wave Scholarship, first awarded in 2008, is already producing some of the finest general practice registrars in Australia. The program is designed to give students much-needed, hands-on clinical experience in a real-life general practice setting.

The 2014–15 First Wave scholars will be placed in a rural general practice or Aboriginal Medical Service and receive 21 clinical placement hours in a general practice with a dedicated and inspirational mentor, a fully-funded two-day orientation workshop, as well as an (up to) $800 stipend.

Sound like this could be you?

Turn to page 11 of this issue of GP Journey to read a personal account of a First Wave experience.

For more information and to learn how you can apply, visit gpsn.org.au

Going Places Network News Joining the Going Places Network gives you access to general practice focused events, publications, online resources and loads more.

See below for what’s going on in your state.

Not a member? Join at gpaustralia.org.au

What an exciting time it has been in Victoria and Tasmania these past months! Our annual Hobart dinner event was held in April, which saw a mix of students and junior doctors attending and hearing from passionate and inspiring speakers that included Dr Emily Islam, Dr Rohan Kerr, Dr Patrick O’Sullivan and Dr Rekha Ratnagobal. The evening concluded with a dynamic Q&A session on a career in general practice.

We hope to hold one more event this year, so keep in touch with your hospital GP ambassador for details or check out our website at gpaustralia.org.au/events

VIC and TAS

Following on from the success of our Hobart event was the annual Launceston dinner.

Students and junior doctors flocked to the Northern Club Hotel to hear from our speakers Dr Rose Tilsey, Dr Natalie Burch, Dr Michael Fox and Dr Simen Sletvold.

Thanks to General Practice Training Tasmania for donating the lucky door prize. Plans are now underway to run the annual Melbourne, Geelong, Ballarat and Shepparton dinner events. Visit gpaustralia.org.au/events for details.

NSW and ACT Well done to our new GP ambassadors; they have done an amazing job settling in over the past few months. A big thanks also for their patience while we searched for a new NSW and ACT Coordinator, a role that we are pleased to announce has now been filled by Adriana Cecere. Adriana will be getting in touch and reaching out to connect with all our ambassadors.

Over the next six months we plan to host some great events across NSW and ACT. Stay tuned and look out for news of events around your hospital and at gpaustralia.org. au/events

34

QLD

Welcome to our new co-ordinator, Faye Haste. Faye will be taking over the role from Renata Schindler. Renata has done a fabulous job and we wish her all the best as she pursues other business interests.

As Renata’s former assistant, Faye comes to the role with a good understanding of the GP Network in Queensland. Consequently she is ready to hit the ground running and is already planning events in Mackay, Toowoomba, the Sunshine Coast (a winery tour) and Brisbane. Keep an eye out for details at gpaustralia.org.au/events

SA and NT Congratulations to all those offered a place in the 2015 training program. We wish you all the best and look forward to supporting you throughout your training. In July we ran the Joint Injection Workshop and Dinner event.This workshop has been hugely popular in the past and is a great way for doctors to hone their joint injection skills while enjoying the company of friends and colleagues. Feedback from the evening was overwhelmingly positive with many commenting on the value of the hands-on session. Appreciation and thanks to our fantastic presenter, Dr Grant Baker and facilitators Dr Penny Need, Dr Ian McCombe, Dr Paul Molyneaux and Dr Don Cameron.

Their experience and expertise made for a truly valuable educational opportunity.

In the meantime, if you have any questions about the program or becoming an ambassador (the Wollongong Hospital GP Ambassador position is still open), contact us at goingplaces@gpra.org.au

WA In May, over 20 doctors joined us for the ‘How to tailor your GP training’ event.

Welcomed by Dr Robert Grohs, GP Ambassador at Royal Perth Hospital, the evening began with a presentation by WAGPET medical educator, Dr Rebecca Hunt-Davies. She focused on the opportunities to sub-specialise, undertake training to become a GP proceduralist and the possibility of dual training while on the AGPT program. Rebecca provided an overview of RACGP and ACRRM program structures and highlighted how training settings outside general practice can be incorporated into the AGPT program to enhance community care delivery.

The take home message from the night was ‘you are in charge of your own path’, so research college requirements before you start (see the colleges and WAGPET websites) and discuss your intentions with your training advisor once accepted into the training program.

We plan to hold another event for junior doctors later in the year. Keep an eye out for details at gpaustralia.org.au/events

Ambassadors

Want to get involved?

Going Places Network GP Ambassadors are junior doctors who have a real passion for general practice. Ambassadors are able to help answer all your questions on becoming a GP, and they can provide information on how to apply to the general practice training program. To find out more about becoming a GP ambassador, email goingplaces@gpra.org.au

NSW Bankstown Hospital Gosford Hospital Hornsby Hospital Network John Hunter Hospital Maitland Hospital Royal North Shore Hospital Royal Prince Alfred Hospital St George Hospital Tamworth Hospital The Canberra Hospital Westmead Hospital Wollongong Hospital

Contact bankstowngp@gpra.org.au gosfordgp@gpra.org.au hornsbygp@gpra.org.au johnhuntergp@gpra.org.au maitlandgp@gpra.org.au royalnorthshoregp@gpra.org.au royalprincealfredgp@gpra.org.au stgeorgegp@gpra.org.au tamworthgp@gpra.org.au canberragp@gpra.org.au westmeadgp@gpra.org.au wollongonggp@gpra.org.au

QLD Cairns Base Hospital Gold Coast Hospital Logan Hospital Mackay Base Hospital Nambour Hospital Princess Alexandra Hospital Redcliffe Hospital Rockhampton Hospital Toowoomba Hospital Townsville Hospital

cairnsgp@gpra.org.au goldcoastgp@gpra.org.au logangp@gpra.org.au mackaygp@gpra.org.au nambourgp@gpra.org.au princessalexandragp@gpra.org.au redcliffegp@gpra.org.au rockhamptongp@gpra.org.au toowoombagp@gpra.org.au townsvillegp@gpra.org.au

SA and NT Flinders Medical Centre Lyell McEwin Hospital Modbury Hospital Royal Adelaide Hospital Royal Darwin Hospital The Queen Elizabeth Hospital

flindersgp@gpra.org.au lyellmcewingp@gpra.org.au modburygp@gpra.org.au royaladelaidegp@gpra.org.au darwingp@gpra.org.au queenelizabethgp@gpra.org.au

VIC Albury Wodonga Health Austin Hospital Ballarat Hospital Eastern Health Geelong Hospital Northern Health Shepparton Hospital Southern Health St Vincentâ&#x20AC;&#x2122;s Hospital Western Health

wodongagp@gpra.org.au austingp@gpra.org.au ballaratgp@gpra.org.au boxhillgp@gpra.org.au geelonggp@gpra.org.au northernhealth@gpra.org.au sheppartongp@gpra.org.au southernhealthgp@gpra.org.au stvincentsgp@gpra.org.au westerngp@gpra.org.au

TAS Launceston Hospital Royal Hobart Hospital

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

WA Fremantle Hospital Joondalup Health Campus Royal Perth Hospital Sir Charles Gairdner Hospital

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

With you on your journey 35

AQUEOUS HUMOUR

Another 10 years

By Dr Marcus Gunn

It might come as something as a shock to readers of this publication, but there’s quite a long career in medicine lying ahead.

As the population ages and lives longer with chronic diseases, the date of retirement is steadily being pushed back in order to sustain pensions. This applies to doctors, too. Add in the occasional global financial crisis that deep sixes your superannuation and you can look forward to working into your late 60s.

Medical reunions tend to follow a predictable path. They’re different to high school reunions, where most of the time is spent remembering why you didn’t like certain people back then and why it’s reasonable that you still don’t. After all, it was mainly just the coincidence of sharing a postcode or parental income bracket that brought you together. Except for academically selective secondary schools, which are a bit like a rehearsal for medical or law school.

Personally, I wouldn’t have it any other way. I enjoy my work and one of the many beauties of general practice is that you can pick up or set aside sessions as you wish, depending on what’s going on in your life at the time.

At least at medical reunions you have something in common with everybody there, even if you still can’t stand a fair proportion of them. You’re all doctors. At medical reunions there’s a ritualistic greeting process. Make eye contact, shake hands or air-kiss, check hairline, waistline, and ring finger. Only then are you ready to hazard a guess at their name and to enquire after partner, children and job (most of these you will get wrong).

But the best thing about making it through to the further reaches of the career is going along to medical school reunions. Not because they represent an evening of scintillating entertainment – they don’t – but because it’s nice every 10 years to see what your colleagues have been up to.

Preparations usually begin about six months out. This is close enough for people to maintain some vague interest in attending, yet far enough away to lose the 20 percent extra body weight that has mysteriously accreted over the decade. Those lost kilos will find you again. Inevitably.

Now that my cohort is up to its 30th reunion, it’s remarkable the difference that social media has made to its organisation. The 10th was pretty much achieved through letters and phone calls, the 20th had some emailing going on, but this one has a Facebook page, SurveyMonkey data collection and online ticketing. Mind you, our children have had to set it all up for us. Our attempts to do it ourselves were a little like that scene from 2001: a Space Odyssey (a classic movie; well worth seeing) where the Neanderthals poke at a mysterious object from space with a stick.

This is the final article in this series by Dr Marcus Gunn. We hope you have enjoyed his serious yet light-hearted approach to general practice.

36

After some rubbery chicken and too much alcohol, the evening usually dissolves into scattered tables of former Final Year group-mates – people who catch up throughout the year anyway – reminiscing about their glory days. As the night wears on the stories get taller and more preposterous, and you begin to realise that these are really good friends with whom you share some proper history. Maybe you were only brought together by some academic ability and an interest in the health sciences, but the outcome is firm friendships and a shared commitment to the profession.

I’m intending to keep going to my reunions every 10 years for as long as I keep working. After that, I really can’t see the point.

But with a general practice career that is endlessly stimulating and significantly worthwhile, I can’t see any reason to stop working either.

Reviews Pocket clinical examination

The Oxford handbook of paediatrics In an age when there are hundreds of apps appearing on the market, it’s often hard to find a reliable source. The progression of the handheld Oxford handbook to the electronic form has shown great insight by the Oxford writers and provides a great reference for clinical practice.

Talley and O’Connor’s Pocket Clinical Examination is a staple book for every Australian medical student. This app provides an easy way to carry the pocket version around and follows the familiar format of the book.

The app is arranged by the different systems (including how to assess an acutely ill patient and a geriatric patient) and has all the information found in the pocket version. It is an excellent reference on the go and allows for bookmarking and writing your own notes.

The practise OSCE section has numerous scenarios for both history taking and physical examinations and can be used with a friend. My favourite part of the app is the ‘Test yourself ’ section, which allows you to revise relevant clinical anatomy, such as the cranial nerves and anatomy of the hand and wrist.

Overall, this app is a solid choice if you are looking for a medical app for clinical examination skills.

Pros: • Useful for both revision (individually or with a friend) and as a reference tool

• Contains all the information found in the book version, including tables for diagnoses and pictures for the physical examination

• Easy to navigate, can be used in both landscape and portrait format.

Cons: • Quite pricey and can only be used on Apple devices

• Lacks the detail of the full clinical examination book • No notification when the timer on the practise OSCEs runs

out so you have to keep an eye on it.

This app is a great quick reference site, however, the information is limited to the bare essentials for a large number of medical problems faced when approaching a child with an illness.

Overall, the Oxford Handbook of Paediatrics can be a useful resource for when you want a quick overview of a practical medical disorder. However, it is lacking in terms of specific detail pertaining to physiology and pictorial guidance for doctors using it as a reference.

Pros: • Great summary of most of the common disorders from the neonatal period to the teenage child

• Covers a wide range of medical disorders • Easily accessible on a smart phone.

Cons: • Lack of pictorial guidance for practical procedure component

• Provides only an overview of common problems • Treatments suggested for infection are not appropriate as they

are dependent on resistance patterns in Australia

• Less specific on epidemiology of certain diseases that may be relevant in your region of the world.

Price: $64.99 Compatibility: Requires iOS 4.3 or later. Compatible with iPhone, iPad and iPod touch.

Rating: ★★★★ out of 5 Reviewed by Dr Helen Fraser Junior doctor and GP ambassador, Qld

Price: $69.99 Compatibility: Requires iOS 4.3 or later. Compatible with iPad. Rating: ★★★★ out of 5 Reviewed by Esther Zhou Fourth-year medical student, University of New South Wales

With you on your journey 37

Obstetrics and gynaecology: An evidence based guide, 2nd edition

John Murtagh’s practice tips, 6th edition

Jason Abbott, Lucy Bowyer and Martha Finn

A foreword to the first edition of this book in 1991 stated that when recent medical graduates were asked in a survey: ‘What does the medical course least prepare you for?’ half of the respondents selected ‘practical procedures’. Over the past 13 years I don’t feel that this response would have changed dramatically. It is what the majority of junior doctors get anxious about: doing procedural skills that they haven’t practised.

Obstetrics and Gynaecology: An Evidence-Based Guide is an excellent introductory text for GPs and doctors in training who are looking to expand their knowledge of women’s health.

The chapters are short as this is just an introductory text, but even so they provide a good summary on each topic and this enables the reader to explore new subjects easily for the first time or revise the main concepts of previous study.

While theory is dealt with in suitable depth, clinical detail is not neglected. Each section is packed full of relevant photographs as well as details on symptomology and signs, making the text practical as well as insightful.

Particularly helpful for students and trainees is the provision at the end of each chapter of MCQs and a practise OSCE station, which enables the reader to check the internalisation of concepts learnt throughout the previous pages. I reviewed this textbook as I was completing a term on sexual health and pregnancy and found it indispensible as an aid to my learning. It enabled me to easily grasp concepts that had eluded me in class due to its clear presentation and language.

I would thoroughly recommend this book to all.

Obstetrics and Gynaecology: An Evidence Based Guide is published

by Elsevier, 2013.

John Murtagh

This book, expertly written by Professor John Murtagh, is a succinct practical guide to assist both junior and senior doctors prepare for and carry out practical procedures. It is written in a compact style that gives the reader the most important information in a precise manner without complicating it with too much information. This book provides a fantastic reference point before commencing a procedural skill for the first time, or after a period of time having not utilised this skill.

Broken up into categories, Practice Tips is very easy to navigate and covers the majority of practical skills used in day-to-day practice by GPs and junior medical staff alike. With accurate ‘no fuss’ diagrams that help aid practical descriptions and step-by-step guides, this book would be invaluable to general practice registrars.

Practical Tips covers everything from common emergency procedures, injection techniques, basic plastic surgery, common trauma, ENT and musculoskeletal medicine. A must have.

Price: $120.00

John Murtagh’s Practice Tips is published by McGraw-Hill, 2012.

Rating: ★★★★ out of 5

Price: $90.00

Reviewed by Hugh Pearson

Rating: ★★★★★ out of 5

Second-year medical student, University of Sydney, NSW

38

Reviewed by Dr Jon Priestley Junior doctor and GP ambassador, Vic

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With you on your journey As a GPSN or GPN member we support you on your journey toward general practice.

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