ISSUE 21 FREE
September – December 2016
Claire Chandler Happy and on the right path
Also inside gpra networks | medico-legal | clinical | profiles
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In this issue...
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3 Welcome
Feature 4 GPRA and its networks Published by General Practice Registrars Australia Ltd Level 1, 517 Flinders Lane Melbourne VIC 3001 P 03 9629 8878 E enquiries@gpra.org.au W gpra.org.au ABN 60 108 076 704 ISSN 2203-2657 Editorial team Registrar Advisor Dr Mary Wyatt Editor Denese Warmington denese.warmington@gpra.org.au
Discover how GPRA supports medical students, prevocational doctors and GP registrars through its various networks.
Profiles 6 Claire Chandler Claire Chandler talks to us about being a voice for students and advocating for the things she cares about.
8 Kerry Chen Chair of the GPSN Working Groups, Kerry Chen, chats to us about advocacy, community and making a difference.
18 Dr Jodie Forlonge Dr Jodie Forlonge spent two decades flying Black Hawks before starting a career in medicine. She shares her journey.
22 Dr Dan Huynh General practice wasn’t the first specialty Dr Dan Huynh experienced, but it has given him the most satisfaction.
24 Dr George Forgan-Smith
Writers Laura McGeoch Denese Warmington
Dr George Forgan-Smith tells us how working out who you want to help and creating a following guarantees work.
Graphic Designer Jason Farrugia
10 GPSN working groups 13 Cultural immersion weekend 14 GPSN club contacts 15 First Wave Q&A
GPRA staff CEO Sally Kincaid General Manager – Marketing and Communications Wayne Bruton wayne.bruton@gpra.org.au Advertising sales Rosa Gentile rosa.gentile@gpra.org.au
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General Practice Students Network
Going Places Network 20 Q&A with Dr Yu-Na Kim 21 GP Ambassador contacts
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Medico-legal 26 Subpoena to produce
Clinical 27 GPRA clinical cases 28 Emergency medicine
Also inside 30 Reviews © 2016 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. This publication is intended for medical students, doctors and health professionals and, as such, may contain material of a medical or graphic nature. GPRA does not accept liability for the use of information within this publication.
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Welcome Welcome to Issue 21 of GP Journey, proudly brought to you by General Practice Registrars Australia (GPRA). GP Journey prides itself on showcasing the interesting and exciting aspects of general practice and the stories of general practitioners, general practice registrars and medical students in general practice placements. I hope you enjoy reading this issue, and consider your own journey into the specialty of general practice. The feature story in this issue focusses on GPRA and one of its many networks, the General Practice Students Network (GPSN). GPSN has grown from a special interest group for medical students interested in general practice nine years ago, to a network that empowers medical students to be involved in the health of their communities. GPSN has representation in all universities across Australia. In this issue, current GPSN Chair, Claire Chandler – a final year medical student with the Flinders University Northern Territory Medical Program – talks about her passion for public health and general practice; and Kerry Chen, a medical student from the University of New South Wales who heads up the GPSN Working Groups, discusses the group’s work and the many community projects they run throughout Australia. Also in this issue, Dr George Forgan-Smith, a Melbournebased GP, talks about his special interest in men’s health and how tailoring your practice to suit your interests can guarantee ongoing work that you enjoy. Dr Dan Huynh, a GP registrar and Registrar Liaison Officer with GPex in South Australia, tells us about his reasons for choosing general practice over orthopaedics; and Dr Jodie Forlonge, a prevocational doctor from Joondalup in Western Australia, shares with us her journey to general practice via two decades in the military flying Black Hawks and working in areas of conflict and war. The John Murtagh First Wave Scholarship is a wellestablished and competitive scholarship for first and second year medical students. It allows selected students to experience general practice early in their medical training. In this issue, we talk to Timothy Le, a second year student from the University of Sydney about highlights from his placement in an inner city Sydney practice.
GPRA is free to join for medical students, prevocational doctors and registrars and I would encourage you all to join this wonderful organisation and be part of the conversation to make general practice the best it can be. As part of your membership you will get access to resources to help you study for exams, regular access to clinical articles from Murtagh and Medicine Today and, importantly, peer support through its networks. General practice is both a demanding and rewarding career. The most enjoyable aspect of the job is that there is never a dull moment; there are always issues to be explored with your patients and opportunities to help them improve their health or quality of life. If you are interested in a career in general practice, I would encourage you to talk to your local GPSN Club Chair or GP Ambassador and become a member of GPRA today. This is my last editorial as Registrar Advisor on GP Journey, and I would like to take this opportunity to thank you for your support of this wonderful magazine, and wish you all the best in your future careers. Enjoy this issue of GP Journey. Dr Mary Wyatt General practitioner – Canning Vale, Western Australia Registrar Advisor, GP Journey Registrar Representative, RACGP Council
GPRA is a not-for-profit organisation whose primary goal is to advocate for the future generation of GPs, supporting doctors from medical student to recently fellowed GPs.
With you on your journey 3
F E AT U R E
A
brilliant career GPRA is with you all the way What is GPRA? General Practice Registrars Australia (GPRA) is a not-for-profit organisation representing over 25,000 medical students, prevocational doctors and general practice registrars through targeted networks and activities. One of GPRA’s key programs is GP First. GP First’s networks and activities are aimed at increasing the profile of general practice as the medical specialty of choice to medical students and prevocational doctors. The GP First program encompasses the:
Being part of GPSN is being part of a community that provides peer support and access to professional development, including the opportunity to apply to the John Murtagh First Wave Scholarship program.
Connect with us There are many ways to get involved in GPSN. At the university level, members have access to events run just for them by their university GPSN club, or become part of the club executive, where they can continue their passion for general practice through advocacy and events.
• John Murtagh First Wave Scholarship program
At a national level, members can become involved with GPSN working groups, attend the GPSN national conference or become part of the GPSN National Executive team.
• Going Places Network (GPN).
Why join?
Both GPSN and GPN are supported and funded by GPRA.
As a GPSN member, there are many benefits available to you, including access to events, discounts and professional resources as well as national representation on external committees. We are constantly working on new benefits, based on member feedback. As a GPSN member, you also become an Associate Member of GPRA. Both GPSN and the Going Places Network, which is for prevocational doctors, are represented on the GPRA Board and on various external organisations. The GPSN National Executive and Council work to ensure you have the right support to assist you on your journey through medical school, your transition into the hospital system and onto general practice.
• General Practice Students Network (GPSN)
The General Practice Students Network The General Practice Students Network is a national network of university clubs based at every medical school in Australia, supported by a national executive committee. Club chairs promote GPSN at their university and are a point-of-contact for medical students with general practice career questions. GPSN clubs host a range of educational and career-focused events across Australia. Activities include clinical skill sessions, social events, seminars and conferences and networking opportunities.
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John Murtagh First Wave Scholarship program
National council The GPSN National Council comprises the local university club chairs and the national executive. The national executive meets frequently throughout the year to discuss, debate and share ideas, and to further develop the network. Turn to page 14 for a full list of GPSN University Club contacts. To find out more about GPSN, visit gpsn.org.au
The Going Places Network The Going Places Network is for prevocational doctors interested in the most challenging and versatile medical career of all – general practice! Joining GPN gives you access to national general practice focused events, publications, professional and online resources, peer support and more.
What is a GP Ambassador? GP Ambassadors play a pivotal role in the Going Places Network. As the champions of general practice in their hospital, they have a strong dedication to developing and promoting GPN while being the primary point of contact for other prevocational doctors wanting to find out more about general practice.
The John Murtagh First Wave Scholarship program provides early and structured exposure to general practice in a range of settings. See page 15 for our First Wave Q&A profile. Contact firstwave@gpra.org.au
GP Ambassadors also help us run our GPN events, from hospital-based coffee mornings and educational workshops to larger networking events, such as winery tours and barefoot bowls.
How can a GP Ambassador help me? GP Ambassadors are always willing to give honest and useful advice. Whether you have a question about a career in general practice and the training program, or just simply want to chat, your local GP Ambassador will make time for you and offer you the support you need.
How can I contact my GP Ambassador? Visit gpaustralia.org.au/gp-toolkit/ambassador-directory/ for a state-by-state listing of our GP Ambassadors. Or locate your hospital-based GP Ambassador from the Australiawide list on page 21. To find out more about GPN, visit gpaustralia.org.au
With you on your journey 5
g n i ak M the most
S T U D E N T profi l e
of it
Claire Chandler has headed-up the General Practice Students Network, talked public health with Canberra politicians and enjoyed a “mind-blowing” rotation in Samoa. And she’s just getting started. Growing up, Claire Chandler had her heart set on being a paramedic. “I was a St John Ambulance cadet and represented the Northern Territory in the Australian First Aid competition three years in a row,” she tells GP Journey. “I enjoyed helping people and was determined to be a paramedic,” she recalls. “But they told me I needed more life experience.” It was time for a new plan. “I thought: ‘Well, why not aim to be a doctor?’ I love helping people. I’ve got an iron stomach and can handle all the blood, guts and gore.” Now a final year postgraduate student with the Northern Territory Medical Program, Claire, 24, is making the most of her medical journey. When she spoke to GP Journey, she was partway into a six-week rotation at Melbourne’s Royal Women’s Hospital. But before hitting Melbourne’s bustling city and crisp winter, she spent the previous rotation in an almost parallel setting: tropical warmth and relaxed islander vibes in Samoa’s only city, Apia, home to around 37,000 people.
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Claire worked in the emergency department at the nation’s main hospital. “The clinical experience was just mindblowing,” she says. “It was a setting of such extremes of disease. I was seeing things every day that you usually only read or hear about.”
I feel very lucky “ Pull quote. that I’ve“ ended up in ” a
As well as tropical diseases, she saw haemorrhagic strokes, including in young people, and complications from chronic diseases, such as diabetes and heart disease stemming from poor diets.
position that I can be a voice for students and advocate for the things I really care about.
The impact of culture on health was also an education. Claire says some Samoans rely on community healers and are reluctant to seek modern medical attention. This sometimes means treatable injuries escalate to life-threatening illnesses. Claire recalls one patient who suffered a dog bite but waited seven weeks to go to hospital. By the time he arrived, he was riddled with sepsis and “on the brink of death”.
A place on the Rural Australian Medical Undergraduate Scholarship scheme complemented Claire’s rural experiences by giving her the chance to attend conferences, such as the National Indigenous Drug and Alcohol Conference, and get an insight into national rural policy.
“Samoans have a huge regard for healers who use herbal remedies and traditional rituals within their community,” she says. Being able to show respect for this work, while trying to talk about the need for certain modern medical intervention was crucial for the hospital team to successfully treat patients. Choosing to live with a Samoan family helped Claire to get a better understanding of where her patients were coming from and about the huge importance that Samoans place on family. Her hosts folded her into their daily life; they took her to church and showed her how to skin a coconut for the Sunday feast. They made sure she never went hungry, loading her up with eggs, bacon and panikeke (round deep-fried pancake balls) every morning. The doctors and nurses – usually clad in thongs – were equally welcoming and made sure their new charge got to it. “I was ‘clerking’ patients, doing complete histories and examinations and developing treatment plans,” she says. She participated in several attempted resuscitations and was even team lead in one. She says medical students can also expect this hands-on experience in rural Australia. “The work you can do when you go rural is great. The doctors have a lot of time for you.” Claire has honed her clinical skills in small communities around the Top End, including at Humpty Doo (“one of the best named towns in Australia!”) and Palumpa through the John Flynn scholarship. As well as the work, it’s the people who attract her to rural places. “I like people who are laid back and who have a good sense of community and family.”
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The opportunity to lead Australia-wide initiatives is partly why she joined the General Practice Students Network. She’s been a big support to the network, first as Rural Working Group Chair, then as Working Group Officer and now as National Chair. “I feel very lucky that I’ve ended up in a position that I can be a voice for students and advocate for the things I really care about, like rural general practice, rural health and Indigenous health, and to keep those things on the agenda.” Her involvement with GPSN led to her becoming the student representative on the RACGP’s National Rural Faculty. This role has taken her to Canberra to talk health with politicians and learn more about medico-politics at the highest level. “A medical student from the Northern Territory wouldn’t usually do that! It’s been a whirlwind of a journey.” And while she doesn’t know yet if she’ll definitely specialise in general practice, she is “certainly partial to the idea of general practice and the connections you can make with people”. For now, Claire is excited about having just accepted an offer to do her internship at Alice Springs. She’s keen to find new outdoor places – part of the appeal of staying in the Top End – to take her “half-blind rescue dog” Manny for a run, which she says helps her to de-stress during the intense phases of medicine. And there’s no regret about not becoming a paramedic. “I’m just really thankful that I got into medical school and for the opportunities with GPSN and the NT Medical Program,” she says. “I’m so happy that I’m here and feel that I’m on the right path.”
With you on your journey 7
S T U D E N T profi l e
Making an
impact
Being part of the General Practice Students Network has shown Kerry Chen that even medical students can help shape the national health care picture. In the end, it was a Facebook post that “popped-up” on her news feed that prompted Kerry Chen to join the General Practice Students Network. At the time, Kerry was a third-year medical student at the University of New South Wales. She was trying to navigate her way around the 20 or so medical clubs available to join, but none seemed quite the right fit. The GPSN Facebook post highlighted an opportunity for medical students to get involved with the community. It sparked her interest. She took on the secretary role for GPSN’s Community Working Group and hasn’t looked back. “I then realised there was so much more to GPSN to what I had seen at a local club level,” she tells GP Journey. “Being involved with GPSN has opened my eyes to health inequities within different communities and helped me to understand how to advocate to make improvements in these areas,” Kerry says. It’s also shown her that it’s not just qualified and experienced doctors that can help to even-up these inequities. Students can also play a part. “Being part of such a big national organisation, I think we have a lot of sway.” Now in her fourth year of medicine, Kerry is GPSN’s Working Group Officer. The working groups develop initiatives that tackle the important issues facing medical students. There are currently four working groups: Community, Rural, Close
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the Gap, and Research – and each has its own initiatives and between four and 10 members. The Close the Gap Working Group has developed a program, alongside Northern Territory General Practice Education, that offers up to 10 medical students the chance to go on a cultural immersion weekend in the Tiwi Islands. “The aim is to help medical students better understand what’s culturally appropriate to say when working with Indigenous Australians and how to maintain their trust,” Kerry says. “We found that a lot of medical students felt that even after cultural training in medical school, they didn’t always know how to talk to these patients.” (Turn to page 13 to read GPSN Club Chair Nik Partsanis’ review of the weekend he spent in the Tiwi Islands as part of the program.) Meanwhile, the Research Working Group is planning a Student-Supervisor Research Network that will help form a database of primary care researchers looking to work with medical students who have an interest in research. The Rural Working Group is developing a mentorship program to address the common concerns that students have about working in rural or remote areas, and ways to ensure students going to these areas have adequate support. And the Community Working Group is in the early stages of planning a homeless health initiative, which would include running “health checks on the street” later this year. This group has also been working with the Men’s Shed Association. Medical students share men’s health information and meetings, and carry out blood pressure and finger-prick diabetes tests (alongside a registered nurse).
No matter what specialty “ you go into, you can learn a lot from general practice, especially because our health care system requires specialists to keep in contact with GPs.
”
While Kerry always planned to do medicine (“I was one of the weird kids who thought that everything gory and gross was amazing”) she is yet to decide what specialty to choose. She does know, however, that she wants the opportunity to provide “holistic care” and to pursue other medical interests, such as obstetrics and gynaecology. Kerry believes all medical students can benefit from being involved with GPSN and experiencing general practice. “No matter what specialty you go into, you can learn a lot from general practice, especially because our health care system requires specialists to keep in contact with GPs.”
“It’s a great chance to give back and to help the men learn a bit more about their health and encourage them to see their GP at least once a year,” she says. As well as health advocacy, GPSN has given Kerry a “really good introduction” to general practice. She did the First Wave Scholarship in Winmalee, a small town near the Blue Mountains. The “hands-on” experience saw her take patient histories and blood pressure, and she also did an abdominal examination. “It was amazing! Like with most rotations, I think the doctor that you are attached to makes a big difference to how you will feel at the end of the rotation. The GP registrar I worked with was so lovely. I was thinking: “I want to be that kind of doctor!”
She says that having access to GPSN’s medical resources is an extra bonus. In particular, she says the “amazing” GP Companion pocket guide has “saved my life so many times in clinics!” But it’s the opportunity to advocate and create personal friendships and professional connections that have made the biggest impact on Kerry during her time with GPSN. “It’s helped me to create a support network that I know I’ll be able to contact later on down the track. And on a community level or national scale, it’s helped me start to understand what’s required of our health care system to provide the best community health.” “It’s just a fantastic organisation to be involved with.”
The experience showed her the personal reach that GPs can have. “The patients would kind of treat the GP as more of a friend and be more trusting and tell them more.”
With you on your journey 9
W or k ing groups
GPSN National The aim of the GPSN Working Groups is to develop national initiatives that tackle important issues facing medical students. They provide experience and a pathway for students wanting to pursue further roles in policy making, research and public health, as well as increasing the productivity of GPSN at a national level. Meet two of your working group chairs.
What inspired you to get involved? As a medical student with a keen interest in general practice, I was looking for more ways that I could be involved. I have always seen community health as an important aspect of primary care, so when I heard about the projects the Community Working Group are involved in, such as the mental health seminars and men’s health checks, I knew it would be a fantastic opportunity to get involved.
What is the main project your group is currently working on? Currently the Community Working Group is developing an exciting project looking at improving health for the homeless. Our long-term goal, working with a wonderful organisation called Orange Sky Laundry, is to develop a counselling and health screening program for homeless people. The objective is to direct them to health services available to them in their local area as well as provide support and education services.
Has your involvement benefited you personally? During my time with the group I have had the privilege of working with a number of passionate and dedicated medical students from across Australia. We have had the opportunity to discuss our ideas regarding community health and work as a group to turn our collective vision into a reality. On a personal level, the group has also allowed me to gain invaluable leadership experience, which I hope to use as a foundation as I progress through my career.
Has your involvement with GPSN and its working groups enhanced your interest in general practice as a career choice?
Maelynn Burridge
Community Working Group Chair
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My experience with GPSN and the working groups has highlighted the scope and importance of general practice in Australia. I see it as the ‘first line of defence’ in health care and my involvement has spurred my interest in general practice for my future career. I’m looking forward to maintaining my involvement in the Community Working Group as a student and hope to continue to work on community health projects throughout my career.
Working Groups Being part of GPSN has also allowed me to promote rural practice in a broader sense. The requirements for rural practice differ greatly from that of metropolitan practice, necessitating a broader skillset and more lateral thinking, often due to a lack of resources. The challenging aspects of practice and quality of life achievable for those living in a rural area should be highlighted to medical students alongside the benefits for the communities affected.
What is the main project your group is currently working on? The Rural Working Group is trying to develop a rural doctor mentorship program for medical students. We hope the program will attract the attention of all students, so we require input from both students who are intending to pursue a career in rural medicine, as well as those that are not, to best determine how change can be effectively implemented. We plan to work with national council to implement this program later in the year.
Has your involvement benefited you personally?
Madeleine Kelly
Rural Working Group Chair
What inspired you to get involved? Being from a rural area, I have always had the intention of returning to the country to practise. Living in a small town gave me insight into the difficulties of reduced access to medical care, particularly with chronic diseases requiring regular management. My studies at university also highlighted the multifactorial nature of issues occurring in rural and remote areas. These experiences encouraged me to get involved and do my part in reducing the burden of disease and increasing the health and wellbeing of those living rurally and remotely.
It has expanded my understanding of the challenges facing rural practice and is a fantastic reminder of why I applied to medicine in the first place, which was to promote rural health. I am really passionate about endorsing rural medicine and general practice to my colleagues, and the Rural Working Group has been a good platform for me to do so. It is important for students to know that GPSN is not just a club for those who want to become GPs, but promotes the fundamentals of primary health care, such as patient education and disease awareness.
Has your involvement with GPSN and its working groups enhanced your interest in general practice as a career choice? Being involved with GPSN and networking with other likeminded people has definitely encouraged me to pursue a career in general practice. It has kept my enthusiasm for rural medicine going through my studies and I am grateful that I have had the opportunity to be in a position to influence the future of rural practice in my own small way.
With you on your journey 11
GPRA
with you on your journey GPRA is run by members for members. From GPSN university clubs, to hospital-based GP Ambassadors and a national general practice registrar support team, GPRA is with you on your journey from medical student to general practitioner.
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First 20 16 The essentia l guide for
As a prevocational doctor or medical student you automatically become an Associate Member of GPRA when you sign up for membership. As a member you receive regular communications about local events and updates about general practice training. You also receive the following member benefits:
General Practice Registrars Australia RRP $34.95
The essential general practice pocket reference
C u ltura l I mmersion W ee k E N D
Connecting at a deeper level By Nik Partsanis, GPSN Club Chair, Deakin University, Vic The cultural immersion weekend to the Tiwi Islands organised by the GPSN Close the Gap Working Group was amazing. The most important thing that I learnt from the weekend came from something Richie Fejo, the senior cultural educator, explained to us. He told us that Indigenous culture could be thought of like a volume dial: with 0 being muted, and 10 being extremely loud. We were fortunate enough to see that volume dial turned right up to 10 during the weekend, and this enabled me to see the richness of Indigenous culture.
Lessons learned At the end of cultural immersion weekend I was left with more of an understanding of how Indigenous peoples value family and the deep relationship they share with the land. A good example of this was when we were driving through the bush with a few of the locals – they kept spotting small birds and animals in the bush. At the time, I thought to myself that I could barely see anything other than trees! From a medical perspective, everything I witnessed and learnt during cultural immersion weekend will help me to connect with my Indigenous patients, at a deeper level through better understanding.
With you on your journey 13
G enera l practice students networ k
Your student community 2016 GPSN National Executive
GPSN University Club contacts University
National Chair
ACT
Claire Chandler Flinders Northern Territory Medical Program chair@gpsn.org.au
Australian National University
Contact anu@gpsn.org.au
NSW University of Newcastle
newcastle@gpsn.org.au
University of New England
newengland@gpsn.org.au
University of New South Wales
unsw@gpsn.org.au
National Vice Chair
University of Notre Dame Sydney
undsyd@gpsn.org.au
Jayden Murphy University of Wollongong vc@gpsn.org.au
University of Sydney
usyd@gpsn.org.au
University of Western Sydney
uws@gpsn.org.au
University of Wollongong
wollongong@gpsn.org.au
NT
National Secretary Rebecca Calder Griffith University ns@gpsn.org.au
National Working Group Officer Kerry Chen University of New South Wales wgo@gpsn.org.au
Northern Territory Medical Program (NTMP Flinders University)
flindersntmp@gpsn.org.au
QLD Bond University
bond@gpsn.org.au
James Cook University
jcu@gpsn.org.au
University of Queensland
uq@gpsn.org.au
Griffith University
griffith@gpsn.org.au
SA Flinders University
flinders@gpsn.org.au
University of Adelaide
adelaide@gpsn.org.au
TAS University of Tasmania
utas@gpsn.org.au
VIC Deakin University
deakin@gpsn.org.au
National Events and Projects Officer
Monash University
monash@gpsn.org.au
University of Melbourne
umelb@gpsn.org.au
Larry Lam University of Western Sydney neo@gpsn.org.au
WA University of Notre Dame Fremantle
notredame@gpsn.org.au
University of Western Australia
uwa@gpsn.org.au
Local Events Officer Lawrence Ling James Cook University leo@gpsn.org.au
Promotions and Publications Officer Renata Pajtak Australian National University publications@gpsn.org.au
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Get in touch If you have any questions about a career in general practice or would like to attend a local GPSN educational event, please contact your local university club chair. To find out about projects the national executive team is working on, please contact one of the team members.
first wave Q & A
The John Murtagh First Wave Scholarship provides early positive exposure to general practice in a range of settings. University of Sydney second-year medical student and scholarship recipient, Timothy Le, answers our questions about his recent placement.
Where was your placement? I did my placement at IPNs George St Medical Centre, which is in the Sydney CBD.
What did you observe while on your placement? The placement provided me a first-hand insight into general practice from an early stage in my medical studies. I observed a wide range of presentations from common colds and injuries to cancer screening and mental illness. I also observed immunisations, child health checks and occupational consultations as well as the interactions between the doctors, nurses and pathologists from an attached pathology collection centre. It was a great opportunity to see the diversity of cases that GPs deal with and to observe the busy workings of a modern medical practice.
What was your supervisor like? I had several supervisors during my placement and they were all wonderful at helping me learn something new each day. Despite their busy schedules, they made time after consultations to give me pointers and explanations about a case, which helped me to understand how doctors analyse problems. Beyond just the clinical content, the placement was a great opportunity for me to talk to my supervisors about their experiences in general practice and what they have enjoyed, and still enjoy, about their careers. It was enlightening to hear their views on how general practice has changed in the past 20 to 30 years and how influences such as government funding and corporate players could affect where the field is heading in the future.
What was the highlight of your placement? I think the highlight of my placement was having the opportunity to really see and experience first-hand what GPs do in their everyday work. While I often hear it as a medical student, it still surprised me how diverse general practice really is! No two days were the same and the work remains continually variable and interesting. It was especially a highlight to see how experienced GPs were able to effortlessly switch between cases and how often their mindset and thinking has to quickly change for their patients; for example, from managing someone with a mental illness one minute to performing a child health check the next.
What did you learn about general practice? I learnt that general practice is a lot more than knowing a bit about everything. It’s about integrating different opinions, reports and data together to form a holistic picture of a patient’s health and knowing a patient well enough to make personalised decisions for each patient. By the end of my placement, I sensed that the most fulfilled GPs were the ones that really appreciated the diversity of their work and the privilege of being a positive part of people’s lives.
The John Murtagh program allows medical students to embark on an experience of general practice that is positive and inspiring. The benefits of the general practice experience are supplemented by structured exposure to affiliated allied health services, reinforcing the growing importance of the multidisciplinary approach in patient care. The program is open to all first and second year students who are Australian citizens or permanent residents and are enrolled in an undergraduate course within a recognised medical school in Australia. For full details, including scholarship guidelines and details of the student stipend, visit gpsn.org.au or email firstwave@gpra.org.au
gpsn.org.au
With you on your journey 15
“Filled with practical advice, the GP Companion will add to the richness of your experiences during your clinical rotations in general practice.” Professor Michael Kidd – GPRA Patron
Are you a GPRA member? Get your copy of GP Companion for the special member price of
$19.95 RRP $34.95
Students visit
gpsn.org.au Prevocational doctors visit
gpaustralia.org.au
GP TRAINING
What’s your practice? General practice gives you the freedom to follow your passion, subspecialise and design the career that’s right for you. You can even train part-time. Check it out! Aboriginal health Training posts in Aboriginal primary health care offer unique and challenging opportunities and allow prevocational doctors to play a hands-on role in improving access and preventing and managing chronic disease in Aboriginal communities.
Academic/research Teaching and research can expand your career path in general practice. Research enables you to develop valuable skills to take into your clinical work and could act as a stepping-stone towards an academic career.
Military medicine Training as a registrar in the Australian Defence Force offers opportunities and challenges. There is a focus on emergency medicine and similar skills to rural general practice, including self-sufficiency in remote locations.
Rural general practice Doctors undertaking general practice training usually spend some time working in a rural area. As a registrar working in a rural practice you will see a diverse range of presentations that will not only challenge you but provide opportunities to broaden your clinical skills.
Sports medicine If you have a particular interest in musculoskeletal injuries and exercise medicine, sports medicine could be for you. You could be providing care to elite athletes through to weekend warriors or the non-exercising person just wanting to improve their exercise level or deal with an injury.
Other extended skills posts Other exciting extended skills posts you can experience as part of your general practice training include: • Custodial medicine • Drug and alcohol medicine • Emergency medicine • Forensic medicine • Mental health • Obstetrics and gynaecology • Paediatrics • Palliative care • Sexual health and HIV medicine.
What are you waiting for? To find out more about an exciting and rewarding career in general practice visit
agpt.com.au With you on your journey 17
P R E V O C AT I O N A L D O C T O R profi l e
Dr Jodie Forlonge spent two decades in the military – flying Black Hawks and working in areas of conflict and war – before starting medicine. But it’s been just the right build up. Dr Jodie Forlonge knows that it can take a while to reach a goal. And that’s okay, she says. As long as you keep moving. Two decades ago when she signed-up for the Australian Defence Force Academy straight from high school, Jodie’s long-term ambition was to become a doctor. But there were other things she wanted to do first. Like learn to fly a Black Hawk helicopter! “I chose to fly because I knew that if I did medicine I wouldn’t want to do anything else again and I’d never get to fly,” she tells GP Journey. So she embarked on a “pretty hectic” 18-month pilot course – which only 40 percent of participants pass — that involved flying nearly every day. Although she initially did a Bachelor of Arts through the academy and joined the Singals Corps, once Jodie got flying
18
she stayed in aviation. She worked her way up to Brigade Major for HQ 16 Brigade and managed the operations and deployment of around 3000 military personnel. She loves the structure and challenge of military life, and also the opportunity to serve people in need. Deployments to East Timor, Afghanistan and New Guinea have brought her much satisfaction. “I always feel like I’m helping someone when I go on deployment.” And it’s this same sentiment that made her first think about medicine while at high school in Kingscliff in northern New South Wales. “It sounds very clichéd, but it was all about helping people back then. It was about making them healthier so they can live the lifestyle they want to live.” Once Jodie felt she had notched-up enough life experience she was ready to focus on medicine and becoming a GP. She admits some of her friends “thought I was crazy” but she always knew it would happen. “I just didn’t think it would take me 20 years!” But to move forward, she had to go back — to school. Jodie was posted to Notre Dame University in Fremantle. The move
Medical moves in the military
Military medicine “ is about always trying to improve the way you look after your people.
to full-time study and a virtual civilian life required some adjustment, but she was pleasantly surprised by the camaraderie within her student cohort. “It’s similar to the military in that you have a group of people who are shoved together and become friends almost immediately because they are going through the same hardships.” She admits that, as a 30-something first-year medical student, she was at times struck by the age difference between her and other students. “I do remember looking at one of my classmates and realising that he hadn’t even turned 21!” Yet as she progressed through medical school and through her internship, she found her military and life experience had given her solid leadership and organisational skills to draw on. Around the hospital wards she’s often presumed to be a registrar rather than an RMO. So what are her tips for dealing with intense medical or military situations? “I’m a two-breath person,” she says. “Two breaths can cure anything!” Jodie is now at Joondalup Hospital in northern Perth, where she is also a GP Ambassador. Following that she will spend part of her general practice training in a civilian clinic so she sees a range of presentations. For the military-specific medical training components, she’ll be setting up field hospitals and going overseas. “That’s what I’m looking forward to most,” she says. “I don’t know where my first posting will be, but I hope it’s somewhere like Iraq.”
”
Once qualified Jodie will be posted to a military unit to work as a GP. While she is looking forward to trying a “completely different lifestyle”, she knows there will be challenges. “At the moment working in emergency, I’ve got a team of people and I’ve got someone to help,” she says. “When you’re working in a general practice, it may not be that you’ve got so much help. You’ve got to look at someone, take a history, do an examination and make a decision based on that 15 minutes that you’ve seen them.” And like any GP, Jodie knows she will see her share of mental health presentations. “You’ve got guys coming back from deployment and some don’t recover for a very long time,” she says. Jodie hopes that having experienced similar deployments might be an advantage when trying to help these patients. “I can’t say that I understand or know what everyone is going through because I don’t, she says. “But I might understand how or why they are feeling the way they are feeling.” But despite the challenges, medicine in the military is “very exciting”, she says. “You get to go on deployments but still link in with the civilian world. And military medicine is about always trying to improve the way you look after your people.” It’s certainly a career and lifestyle that suits someone who admits they don’t sit still for long. “I’m always on the go. And always moving forward!” And her advice for someone considering general practice after having already tried their hand at another career? “As long as you can keep up with where you need to be, you’ve never left your run too late.”
With you on your journey 19
GOING PLACES NETWORK
Your prevocational
Q&A
What are you looking forward to as a GP? Forming good relationships and seeing the diversity of patients.
Dr Yu-Na Kim GP Ambassador Mackay Base Hospital, Qld
Why did you choose general practice? Meeting many happy general practitioners with good work-life balances and attending general practice conferences and events through involvement in GPSN.
Who or what inspires you? Different people at different stages of my life, but mostly other doctor friends, non-doctor friends and seeing people who are compassionate, kind and caring to patients.
What three words describe you? Friendly, bubbly, thoughtful.
What three things would you take to a deserted island? Friend, fresh water and sunscreen.
Looking to do something rewarding? GPRA will soon be looking for new candidates to be the GP Ambassadors for general practice in teaching hospitals throughout 2017. Join the Going Places Network at
gpaustralia.org.au 20
Our GP Ambassadors provide a vital link – a ‘go to’ person – for those interested in a career in general practice; keeping the conversation vibrant and lively through your time as a prevocational doctor, ahead of applying into the Australian General Practice Training program. If you are currently working in a teaching hospital, and are keen to help us promote general practice as a career specialty to your peers and those who will soon be entering the hospital system after graduation, please email Faye Simpson at faye.simspon@gpra.org.au
What are you waiting for? Explore the specialty of general practice while you complete your hospital training and embark on the journey of a lifetime.
community General practice plays an important role in “ preventive health. I believe that by delivering effective health education in the community we can prevent a majority of presentations to tertiary hospitals.
”
Dr Shiran Xiao GP Ambassador, Fiona Stanley Hospital, WA
Find your GP Ambassador Check out the list below for contact details of your local GP Ambassador. NSW and ACT
SA and NT
Hospital
Contact
Hospital
Contact
Bankstown Hospital
bankstowngp@gpra.org.au
Flinders Medical Centre
flindersgp@gpra.org.au
Gosford Hospital
gosfordgp@gpra.org.au
Lyell McEwin Hospital
lyellmcewingp@gpra.org.au
Hornsby Hospital Network
hornsbygp@gpra.org.au
Modbury Hospital
modburygp@gpra.org.au
John Hunter Hospital
johnhuntergp@gpra.org.au
Royal Adelaide Hospital
royaladelaidegp@gpra.org.au
maitlandgp@gpra.org.au
Royal Darwin Hospital
darwingp@gpra.org.au
Royal North Shore Hospital
royalnorthshoregp@gpra.org.au
The Queen Elizabeth Hospital
queenelizabethgp@gpra.org.au
Royal Prince Alfred Hospital
royalprincealfredgp@gpra.org.au
St George Hospital
stgeorgegp@gpra.org.au
Tamworth Hospital
tamworthgp@gpra.org.au
The Canberra Hospital
canberragp@gpra.org.au
Westmead Hospital
westmeadgp@gpra.org.au
Wollongong Hospital
wollongonggp@gpra.org.au
Maitland Hospital
VIC
QLD Cairns Base Hospital
cairnsgp@gpra.org.au
Gold Coast Hospital
goldcoastgp@gpra.org.au
Logan Hospital
logangp@gpra.org.au
Mackay Base Hospital
mackaygp@gpra.org.au
Nambour Hospital
nambourgp@gpra.org.au
Princess Alexandra Hospital
princessalexandragp@gpra.org.au
Redcliffe Hospital
redcliffegp@gpra.org.au
Rockhampton Hospital
rockhamptongp@gpra.org.au
Toowoomba Hospital
toowoombagp@gpra.org.au
Albury Wodonga Health
wodongagp@gpra.org.au
Austin Hospital
austingp@gpra.org.au
Ballarat Hospital
ballaratgp@gpra.org.au
Eastern Health
boxhillgp@gpra.org.au
Launceston Hospital
launcestongp@gpra.org.au
Geelong Hospital
geelonggp@gpra.org.au
Royal Hobart Hospital
royalhobartgp@gpra.org.au
Northern Health
northernhealth@gpra.org.au
Shepparton Hospital
sheppartongp@gpra.org.au
Fremantle Hospital
fremantlegp@gpra.org.au
Southern Health
southernhealthgp@gpra.org.au
Joondalup Health Campus
joondalupgp@gpra.org.au
St Vincent’s Hospital
stvincentsgp@gpra.org.au
Royal Perth Hospital
royalperthgp@gpra.org.au
Western Health
westerngp@gpra.org.au
Sir Charles Gairdner Hospital
charlesgairdnergp@gpra.org.au
TAS
WA
With you on your journey 21
R E G I S T R A R profi l e
Second coming It comes back “ to wanting to graduate a group of doctors that we would feel comfortable treating our parents and our children. The foundation of that is adequate and quality training.
�
22
General practice wasn’t the first specialty GP registrar Dr Dan Huynh experienced, but it’s the one that has given him the most satisfaction. Dr Dan Huynh was five years into a career in orthopaedics and was working at Adelaide’s Modbury Hospital. By all accounts, he was doing a good job. He’d really enjoyed his internship and thought he’d also relish day-to-day life as a surgeon. “But as I got further into training and more into the independent operating, I realised I just wasn’t enjoying it,” Dan tells GP Journey. “I was thinking: ‘I’m going to work every day but not wanting to be here. Something isn’t right.’ “I asked myself: ‘Is this what I want to do for the rest of my life?’ Once I knew the honest answer to that, it made everything easier.” Dan made the “really tough decision” to leave his training, colleagues and mentors. He took a year off to travel and did some general practice locum work, including working in the South Australian prison system and a stint at Tamworth Hospital’s emergency department. The experiences exposed him to the non-surgical side of medicine that GPs practise. He loved what he saw and started the general practice training program. Now a GPT3 registrar at Hyde & Partners Medical Centre, a “big family practice” in Gawler half an hour north of Adelaide, Dan is experiencing a personal fulfilment that he couldn’t get by mending ankle and wrist fractures. “For me, the satisfaction from fixing someone so they can walk the next day is nowhere near the type of satisfaction I get from sitting down with someone for half an hour and working out what’s wrong with them,” he says. And he enjoys the challenge of undifferentiated presentations and making the first steps towards a diagnosis. “Unlike other specialists who see patients by referral, we don’t always know what we’re looking at. It’s like putting together a jigsaw puzzle without the final image.” But limited time and resources, which can be different for every general practice setting, can be a challenge, Dan says. This first became apparent while working in the prison system. “You’re often dealing with a subset of the population who are exposed to a lot more chronic disease,” he says. “Or they come in with a sore ear but there are also mental health issues and you’ve only got a 15-minute consultation.” Because of these restrictions, Dan says that sometimes a ‘win’ for a GP doesn’t necessarily mean being able to make
a diagnosis or solve a problem in one session. He talks about a toddler patient who has a “monumental fear” of doctors. “The first two, three or four consults, she’d cry as soon as I called her name in the waiting room,” Dan recalls. “But I’m now getting a ‘hello’ and a wave from her. We’re building a rapport. “If starting to build that rapport means that one day in years to come she’ll feel more comfortable to tell me she’s suffering from depression or is in an abusive relationship, then I think I’ve done her a justice as a doctor.” But while general practice isn’t typically about responding to emergency life or death situations, Dan says GPs can make live-saving decisions and experience “defining moments”. On Dan’s first day of work this year, he diagnosed a brain bleed in a patient who presented with a headache. “She had a history of migraines so it could have been easy to dismiss it as just another migraine, but through the course of examination there was just something not right. I decided to scan her. I will never forget that moment when the radiologist told me she’d had a massive bleed, and later on her husband calling me in tears and thanking me.” Making the switch to general practice has also allowed Dan to follow his interest in “medical politics” by becoming a Registrar Liaison Officer with the South Australian training organisation GPEx. He likes that the role helps him to advocate for registrars and patients on a bigger scale through policy development, and that it connects him to registrars around Australia. Dan is passionate about trying to ensure that registrars get the right training and support needed to produce the best GPs. “It comes back to wanting to graduate a group of doctors that we would feel comfortable treating our parents and our children. The foundation of that is adequate and quality training.” The good thing about the current registrar training system, Dan says, is that it usually gives registrars an accurate insight into the profession. “Your life as a registrar is a true reflection of your life as a GP. My life now is going to be very similar in terms of the patients I see and the work I do.” General practice wasn’t Dan’s first choice, but it’s definitely been the right choice. “I wanted a career that I could be satisfied with,” Dan says. “I wanted to be able to walk out at the end of the day and feel really satisfied, happy and proud of my work.” “Work should never be a chore. I’m really lucky.”
With you on your journey 23
G P profi l e
Creating a following Dr George Forgan-Smith says finding a medical niche and committing to a group of patients can help GPs to “future-proof” their careers. Although he’s been told that he’s quite good at them, Dr George Forgan-Smith declares that he’s “not the guy” to see for a Pap smear. But if you’re a male, and in particular a gay male, who has a question about sexual health, then George is your man. Since completing his training in Byron Bay and moving to Melbourne seven years ago, George has focused on the “hyper-niche” area of gay men’s sexual health, and has amassed a robust patient list. He still works from a citybased group practice and enjoys the interaction with other GPs, but he likes that he doesn’t have to rely on the practice for patients. “One of the absolute safest ways that you can guarantee work as a doctor now is to create a following,” he tells GP Journey. “You need to work out who you want to help, and when you know that, you can throw yourself in and serve that community.”
Despite advances in HIV treatment and research, George says there is still a lack of education – within both the gay and heterosexual community – about how the virus is transmitted and what it means to live with it. He’s passionate about finding ways to stop the spread of HIV, to improve information about it and to eliminate the stigma towards those who have it. As such, George is participating in a public health research study, sponsored by the Victorian Government, called PrEPX. The study aims to prevent the spread of HIV by giving up to 2600 people access to PrEP (pre-exposure prophylaxis) medication. A quest to provide useful and accurate information has underpinned George’s career. It first manifested with the blog, The Healthy Bear (thehealthybear.com), which targeted a subgroup within the gay community. At last count it had around 9000 followers. He then developed the Gay Men’s Health Australia website (gaymenshealth.com.au) to provide sexual health information to everyone from the young gay man who is just starting to explore his sexuality, to the transgender male now mixing in gay circles.
As an example, George has recently started to offer Rapid HIV Tests, a pinprick-screening test that can deliver an initial result within 20 minutes. (Reactive results require further blood work for a diagnosis.) He set up a website (melbournerapidhivtests.com.au) to help promote the service, and it’s worked. Each day he gets “five to six” new enquiries (most are actually from heterosexual men) about the test.
George isn’t afraid to break the mould when it comes to spreading good information. On a recent trip to the US, he talked gay men’s heath while sharing a bubble bath with a San Francisco-based blogger, who recorded the conversation for his YouTube channel. He also took to the stage at Cleveland’s Leather Appreciation Week (CLAW) to share sexual health information. More locally, and in an effort to “meet the market where they are at”, George spoke at a Bunnings hardware store during Men’s Health Week to talk about the general health issues that men face.
By offering the tests George can almost immediately relieve a patient’s concern about their HIV status. But his special interest in HIV medicine also means part of his job is informing patients about positive results. “Preparing myself for those first few times was similar to the first few times I had to tell patients they have cancer,” George recalls. But he says while testing HIV positive is “devastating and unexpected” for some patients, others, like some of his cancer patients, handle it extremely well.
Back in the online space, George has recently trained in search engine optimisation (SEO) to help ensure those people looking for the medical information he provides can find it. He now works two days a week using these skills to help other doctors and practices to develop their own websites and get good search rankings. He enjoys this new slant on his medical career, but still relishes the three days a week he spends with patients using his clinical skills and a satisfying a medical curiosity that he developed during childhood.
24
You need to work out who you want to help, “ and when you know that, you can throw yourself in and serve that community.” “I’ve always had a medical flavour about me,” says George, who grew up in Brisbane and studied at Queensland University. “In Scouts, I was always the first to get my First Aid badges.” This interest was likely buoyed by his parents’ medical careers; his father was a pathologist and his mother a nurse. But it was through his mother’s battle with lupus, which she passed away from before he started medical school, that he first experienced the personal impact of illness and the complexity of certain diseases. “It’s (lupus) one of those horrible ‘masquerading’ diseases that Professor Murtagh talks about,” George says. “Growing up, mum was always sick so I think that’s where my medical interest started.” Although George’s medical career has evolved in line with patients’ needs, technology and research, he still gets satisfaction from the more traditional facets of general practice. This includes being able to form “amazing” relationships with patients and supporting them through the health system. “I’m a big patient advocate,” he says. “And when you know someone for a really long time, you know when something’s changed or it’s not quite right, and it’s easy to advocate for them.” George says aspiring GPs should consider that it’s not just patients who benefit from genuine advocacy and support. “You can future proof your life as a doctor,” he says. “The more you can give to a group of people, the more loyal they will be and you won’t ever have to worry for patients.”
Photo courtesy Chester Beltowski
With you on your journey 25
s hard to make a se against M E D I C O - Lthe E G A L M AT T E R S pertise of Avant Subpoena to produce: a quick guide Do you understand your legal obligations with regards to releasing patient medical records? The following quick guide to subpoenas clarifies how to comply with this often-misunderstood order.
What is a subpoena to produce? A subpoena is a legal document that compels you to produce evidence. They are usually issued by courts or tribunals.
Who issues subpoenas and where do my documents go? Subpoenas are issued by the Court, usually at the request of a party to the legal proceedings. Documents should be produced to the Court. Only documents set out in the ‘schedule’ of the subpoena should be produced. It is important that you do not send subpoenaed documents to the person who asked for the subpoena. No person may access documents produced to the Court unless the Court grants permission.
Can I object to the subpoena? What if I feel it is not relevant or it will harm the therapeutic relationship with my patient?
aside or how else you should respond to the subpoena. Importantly, a subpoena to produce should not be ignored and if you have any concerns about the production of documents legal advice should be sought.
What if I don’t have the documents sought – can I just ignore it? No. If you do not have the documents described in the subpoena, you should write a letter to the Court and the issuing party informing them of this.
Can I produce copies and will the documents be returned to me? The subpoena should state whether copies or originals should be produced. Even if the subpoena does not state that copies Dr Amanda Brownlow may produced you may, in some cases with the consent Avant GPbe member of the party issuing the subpoena, provide copies. The subpoenaed documents will be returned to you, but only after the case is concluded. If you provide copies you may wish to inform the court that the documents may be destroyed by the Court instead of having them returned to you.
When served with a subpoena, you must comply with it. to comply without (discussed below) includingDo lawyers, medical advisors, claims managers year, manyFailure doctors like you willlawful face excuse a medico-legal I need my patient’s consent and,and could result in a warrant for your arrest and order for you if not, amit’sI breaching local state experts, hard to makeprivacy? a case against the . Without toa pay strong tomay defend you, action costs.team A court also find youany guilty of contempt No. You may disclose health information without the of court. impact on your career. expertise of Avant. d have a massive consent of your patient, where you are lawfully authorised There may be circumstances where you may wish to object or required to do so. The privacy legislation does not to the subpoena to produce documents. In such a case, you your legal to comply with a subpoena. ustralia’s should leading MDO, Avant has the A claimoverride against youobligation can happen at any time. seek legal advice as to whether theredepth, are reasonable prospects ofand success in applying totohave the subpoena gth of resources experience advise and setDon’t wait until it’s too late, call us today.
ct you. With 70 in-house medico-legal specialists, This publication is not comprehensive and does not constitute legal or medical advice. You should seek legal or other professional advice before relying on any content, and practice proper clinical decision making with regard to the individual circumstances. Persons implementing any recommendations contained in this publication must exercise their own independent skill or judgment or seek appropriate professional advice relevant to their own particular practice. Compliance with any recommendations will not in any way guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional or practice. Avant is not responsible to you or anyone else for any loss suffered in connection with the use of this information. Information is only current at the date initially published. © Avant Mutual Group Limited 2015. 3539 09/15 (0389)
Avant. Your Advantage
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ANT: Professional indemnity insurance products are issued by Avant Insurance Limited, ABN 82 003 707 471, AFSL 238 765. The information provided here is general advice only. You should r the appropriateness of the advice having regard to your own objectives, financial situation and needs before deciding to purchase or continuing to hold a policy with us. For full details
Test your knowledge with our general practice cases, taken from the GPRA publication, The general practice exam book. ISBN
Visit gpra.org.au
978-
9 78 0992
0-99
2453
The g e n e ra l prac tice e xam b ook
G enera l practice cases
genTehre a examl practice b
ook
6-1-
9
Kath O ’Conno r Robin Park Fabia n Sch warz Tamm ra War by Yashar Aliabad i Zadeh
4536
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Case 1
Case 2
Lloyd, a 3-year-old Aboriginal male, presents with three days of irritability. His mother reports decreased hearing. At home, he has had temperatures of up to 39°C and poor oral intake. However, he is afebrile in your clinic and appears well hydrated, comfortable and alert.
Levi is a 27-year-old male with a long history of depression. He was recently involved in a serious car accident which resulted in the death of his close friend.
Examination of the tympanic membranes confirms suppurative otitis media bilaterally. He does not have any drug allergies.
A. All patients should be screened by their general practitioner for increased risk of suicide
The MOST correct treatment is: A. Oral antibiotics B. Reassurance and observation C. Antihistamines D. Admission to hospital for intravenous antibiotics E. Chest X-ray.
When considering suicide risk assessment in primary care, which of the following statements is CORRECT?
B. The most common risk factor for suicide is substance abuse C. Females are at higher risk of completed suicide than males D. Suicide accounts for approximately 50% of deaths in males aged 20–39 years E. An individual’s suicide risk assessment should also involve an assessment of risk to others.
Answer to Case 1
Answer to Case 2
This question requires a consideration of the implications of Aboriginal and Torres Strait Islander status to particular presentations.
This question requires knowledge about the risk factors for suicide and the recommendations when performing a suicide risk assessment in primary care.
Current Australian guidelines would not suggest antibiotics for simple uncomplicated otitis media in the general population. However, in the Indigenous population, because of an increased risk of complications including perforation, mastoiditis and chronic suppurative otitis media, guidelines recommend treating with oral antibiotics.
It is not currently recommended that ALL patients be screened for suicide risk by their general practitioner.
The remainder of the options are not indicated in this child.
Suicide accounts for approximately 20% of deaths in males aged 20–39 years (50% sounds far too high). Finally, an individual’s suicide risk assessment should always involve assessment of the risk to others.
The most common risk factor for suicide is mental illness. Females make more suicide attempts than males, but males complete suicide more often than females. This is thought to be due to the methods males choose (ie. males tend to choose more lethal means).
With you on your journey 27
EMERGENCY MEDICINE
Bladder stones A missed diagnosis By Gordian Fulde and Sascha Fulde
Bladder stones are a possible, although uncommon diagnosis, in a patient with recurrent bladder infection, urgency and severe pain. As a GP working both in your own practice and in the emergency department of the local hospital you are familiar with accessing and treating renal colic. You see the patients with this presentation all year round, not just in the hotter summer months when people are more likely to become dehydrated, or perhaps it is all that very strong coffee?
The case One evening shift in the local emergency department you see a patient who has presented with severe pain from recurrent bladder infection. When you enter the cubicle, you recognise each other. You know him from school days and have met him since at several sailing races. He is 60 years old and is basically in good health: his cholesterol level is controlled by diet, he has mild psoriasis, he is a smoker (an average of 10 cigarettes a day) and he drinks moderately (alcohol intake, one to three drinks a day).
had been taken during the day-only admission, and no cancer was found. An ultrasound of the kidneys and urinary tract performed as part of the work up for the recurrent infections revealed that many bladder stones were evident. These stones are seen much better in the ultrasound than in the kidney, ureter and bladder X-ray that was also performed (Figures 1 and 2). The urologist had booked him for surgery – transurethral resection of the prostate and open cystotomy – to remove his bladder stones but this had been cancelled twice due to lack of hospital bed availability, and he had been told if he had severe symptoms to present to the emergency department. Having obtained this history, the case now makes sense: the bladder stones forming from stagnant residual urine resulting from outflow obstruction, the recurrent infection in the residual urine and the bladder pain syndrome.1 The patient tells you, consistent with the bladder pain syndrome, that certain foods (steak, crumbed foods, condiments), drinks
His symptoms were impressive. The lower abdominal and pelvic pain associated with the recurrent bladder infection was so severe that he had difficulty working, sleeping or taking part in any leisure activities. The urgency also made his life miserable, as he could not be far away from a toilet. As you know from your older patients with prostatic hypertrophy, public toilets are becoming few and far between. Over the past 14 months, the patient’s recurrent and increasingly symptomatic urinary tract infections had been treated based on the results of urine cultures. During this time, the patient had had to change jobs due to the difficulties. Only recently had he seen an urologist, who diagnosed a moderately large prostate. Multiple prostate needle biopsies
This article originally appeared in Medicine Today 2014;15(4):56–57 as is reprinted here with permission. © MedicineToday 2014.
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Figure 1. Ultrasound of the patient’s bladder showing multiple bladder stones
Figure 3. The stones removed from the patient’s bladder, showing the range of size and shape (coins are for comparison)
Authors
Figure 2. X-ray of the patient’s abdomen. The bladder stones are hardly visible
(strong coffee), prolonged sitting and sexual intercourse exacerbated his abdominal pain, and he had relief from eating asparagus, boiled eggs and green vegetables. His life was miserable.
Treatment The patient was treated with increased analgesia and discharged. Ten days later, he underwent transurethral resection of the prostate and open cystotomy. Many stones, large and small, were removed (Figure 3). Postoperative recovery, which took several weeks, was – from the medical perspective – uneventful.
Conclusion You now consider bladder stones as a possible although uncommon diagnosis when confronted by the symptom of bladder pain in a patient with recurrent bladder infection and urgency. Urinary infections in men are commonly associated with outflow obstruction, and early assessment, including imaging, is important in patients with these conditions.
Professor Gordian Fulde MBBS, FRACS, FRCS(Ed), FRCS/ FRCP(A&E)Ed, FACEM is Director of Emergency Medicine at St Vincent’s Hospital, Sydney; Professor in Emergency Medicine at the University of Notre Dame, Sydney; and Associate Professor in Emergency Medicine at The University of New South Wales. Dr Sascha Fulde is a registrar in emergency medicine at St Vincent’s Hospital, Sydney, New South Wales. Competing interests: None.
Reference 1. Clemens JQ. Pathogenesis, clinical features and diagnosis of interstitial cystitis/ bladder pain syndrome. Update. Available online at uptodate.com/ contents/pathogenesis-clinical-features-and-diagnosis-of-interstitial-cystitisbladder-pain-syndrome?source=search_result&search=interstitial+cystitis+bla dder+pain&selectedTitle=2~150 (Accessed April 2014).
Medicine Today provides GP Journey with selected articles from its archive of peer reviewed clinical content. To view the full archive, first register to use the website at http:// medicinetoday.com.au/user/register and then browse the content online or download Medicine Today for iPad, available from the App Store at https://itunes.apple.com/app/ id666623264. Registration and online access to Medicine Today’s rich knowledge bank of clinical content is free to all members of GPRA, GPSN and GPN.
With you on your journey 29
Review
#fgp16 GPRA’s 2016 national conference was held over three days at the Brisbane Hilton.
The Federal Health Minister, the Hon Sussan Ley MP, opened the conference and answered some difficult questions from the delegation about future funding, and our Patron and Immediate Past President of WONCA, Professor Michael Kidd, took time from his incredibly busy schedule to address delegates and further inspire them toward a career in general practice. Dr Frank Jones, RACGP President, was available to chat during lunch and many of the delegates took up this opportunity to speak with RACGP representatives about their future careers as GPs and RACGP members. For medical students, prevocational doctors and general practice registrars, the conference was also an excellent forum to meet senior members of the profession.
Program highlights A highlight of the conference was the presence of the Young Australians of the Year – the highly successful duo from Orange Sky Laundry – who set up a volunteer-based mobile laundry facility for the homeless.
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A strong program of almost 50 sessions, incorporating learning sessions on Indigenous health and asylum health, infant and child health, women’s health, asthma, palliative care and sexual health provided abundant opportunities to learn and network with colleagues and senior members of the profession. A practical workshop on back pain assessment was also well received, with delegates having the opportunity to hone their skills. Business and academic topics were covered in financial and practice planning, becoming a GP supervisor, communication and exam tips and research programs. The high level panel discussions, where senior members of the profession spoke candidly about general practice subspecialties and the general practice landscape, and the ethical questions that many delegates may face in the future years, was also a highlight for delegates.
Membership 2016-17
I’m a member because... ‘The RACGP has been a great resource to me in my career to date, supporting me with high quality education throughout my registrar training and in starting my own practice.’ Dr Columbine Mullins, RACGP member since 2009
As an RACGP member, you join a vibrant community dedicated to supporting you on your general practice journey. You also gain access to: gplearning, an online education platform
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Reviews Apps
Medicify I can’t help but feel this app has huge potential but misses the mark slightly. It could be more concise and user friendly. Having separate profiles for different people would make it easier to use so they can see and manage their medications separately and avoid menopausal/postmenopausal women having a menstruation calendar option. Some of the sections have too many options, eg. having an every day option for vaccinations whereas a monthly/ yearly frequency option would be far more logical, and other sections could be further tweaked, eg. the investigations section should ideally have a fasting or not fasting option as this is often a cause of confusion. Also, there are a few spelling mistakes (eg. peices instead of pieces) which lowers the professional feeling of the app. Compatibility: Requires iOS 7.1 or later. Compatible with iPhone, iPad and iPod touch. Cost: Free! Rating: 2/15 Reviewed by Dr Alice Hawes Prevocational doctor, Gold Coast Health, Qld
Smiling Mind http://smilingmind.com.au Smiling Mind is an Australian developed meditation app. The app offers a series of guided meditations ranging from 1 to 45 minutes. Users have the ability to keep track of their meditation practice, set reminders, and to share their achievements through social media. It’s an easy to use app and is a great way to incorporate some mindfulness meditation into your daily life. Compatibility: Requires iOS 7.1 or later. Compatible with iPhone, iPad and iPod touch. Cost: Free Rating: 5/5 Reviewed by Madeleine Gryta Medical student, University of Notre Dame Fremantle, WA
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