GP Journey Magazine Issue 16 by GPRA Publications

GP Journey ISSUE 16 FREE January â&#x20AC;&#x201C; April 2015

Inside

Professor John Murtagh Clinical cases Profiles Network news

Rajdeep Ubeja Part of the 2015 GPSN National Executive team

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GP Journey in this issue... 5

General Practice Students Network 34 News 35 Club Chairs

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

Feature story Professor John Murtagh has been an inspiration to thousands of medical students and registrars. In this issue, we take a brief look at his career.

First wave Q&As Gemma Abraham chats to us about how she gained valuable clinical experience during her First Wave Scholarship placement.

Junior doctor profile Dr Phong Ho shares with us why he wants to follow in his migrant surgeon-turned-GP father’s footsteps.

Registrar profile Dr Sarah Freeman tells us how she found the perfect work-life balance practising at a coastal community general practice. Going Places Network 36 News 37 GPN Ambassadors

GP profile 20 How to apply26 to Dr Jane De Keyser the AGPT program shares her journey from 22 Applying to the Belgium to Australian AGPT program general practice and – tips for success the hard work it took from regional to get there. training providers

Editorial team

GPRA staff

General Practice Registrars Australia Ltd Level 1, 517 Flinders Lane Melbourne VIC 3001

Medical Editor Dr Chia Pang

CEO Sally Kincaid

Editor Denese Warmington denese.warmington@gpra.org.au

General Manager – Marketing and Communications Wayne Bruton wayne.bruton@gpra.org.au

ABN 60 108 076 704 ISSN 2203-2657

GPSN team Meet the General Practice Students Network National Executive Committee for 2015.

Clinical 17 Clinical corner 18 Shingles vaccine 20 Rheumatoid arthritis 23 Murtagh’s tales My career 29 The AGPT program 31 Changes in the general practice landscape 33 Exam survival

38 Reviews

Published by

P 03 9629 8878 F 03 9629 8896 E enquiries@gpra.org.au W gpra.org.au

Writers Alex Kirby Jan Walker Denese Warmington

Advertising enquiries Natalia Cikorska natalia.cikorska@gpra.org.au

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Graphic Designer Peter Fitzgerald

© 2015 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

Welcome Welcome to Issue 16 of GP Journey, proudly brought to you by General Practice Registrars Australia (GPRA). In GP Journey – published three times a year – we showcase the rich and diverse backgrounds of doctors working at the coalface of medicine. We also aim to feed your interest in general practice as a career by providing updates and information on the general practice training program, and by providing you with challenging and interesting clinical cases and reviews. Our first feature story for 2015 is on Professor John Murtagh. This accomplished man needs no introduction, having established himself as a world-renowned medical educator. Countless doctors have read his eponymously named textbook. I, for one, have found John Murtagh’s General Practice significantly helpful in preparing for the RACGP Fellowship exams. After 14 years as GPRA Patron, Professor Murtagh is stepping down. Another eminent figure of general practice, Professor Michael Kidd, has taken up the mantle as incoming patron. We thank both professors for their dedication to general practice and for the ongoing support and encouragement they provide to the next generation of general practitioners. In this issue we profile Dr Phong Ho, a junior doctor and Going Places Network (GPN) Ambassador. Phong shares his heartwarming story about following in the footsteps of his migrant surgeon-turned-GP father. We also profile GP registrar Dr Sarah Freeman, who has found the perfect work-life balance in a Victorian coastal town, and newly-fellowed GP, Dr Jane De Keyser, who shares with us the story of how she left her home in Belgium to become a GP in Australia.

arise as a result of a growing and ageing population. General practitioners are positioned at the forefront to tackle these challenges. I would encourage you to consider general practice as a career.

We also interviewed the new 2015 General Practice Students Network (GPSN) National Executive team, and Gemma Abraham chats to us about her exposure to general practice while on a First Wave Scholarship placement.

I hope you enjoy the magazine!

There is an increased demand on primary health care services in Australia. High calibre general practitioners are needed now more than ever to manage the increasingly complex medical issues that

If you would like to find out more about a career in general practice, our GPSN Club Chairs and GPN Ambassadors will point you in the right direction. Find your local contact in this issue of GP Journey.

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

With you on your journey

F E AT U R E S T O RY

Murtagh â&#x20AC;&#x201C; doyen of general practice

Emeritus Professor John Murtagh AM has been described as both the man who condensed the study of general practice into one book and the best educator of general medicine in Australia. As he steps down from his role as GPRA Patron, we take a brief look at his glorious career. 6

Professor John Murtagh is rarely spotted alone. Usually you’ll find him surrounded by a group of star-struck medical students, desperately waving around their iPhones eager to snap a selfie with Australia’s most famous face of general practice. Despite having officially retired, Professor Murtagh, or simply, ‘the Prof ’, struggles to turn down an invitation to student-led events. It appears he loves them just as much as they love and admire him. As John once said, “I learn from the students. They’re very interesting, gifted people.” In this issue of GP Journey we pay homage to ‘the Prof ’, general practitioner, author, educator, mentor and much-admired doyen of general practice.

The medical man

MBBS, MD, BSc, BEd, FRACGP, DipObstRCOG, Professor of General Practice, Monash University, Melbourne; Professorial Fellow, University of Melbourne.

The author

• John Murtagh’s General Practice was first published in 1994 and has been translated into 13 languages including Italian, Polish, Russian, Spanish, Portuguese, Greek, Mexican and Chinese – now in its fifth edition

• John Murtagh’s Practice Tips – now in its sixth edition • John Murtagh’s Patient Education – now in its sixth edition • Cautionary Tales – now in its second edition. The educator

• In 2010, the then President of the RACGP described John Murtagh as the most influential person in general practice in Australia. The RACGP’s library is named after him.

• Almost 60% of GPs surveyed nationally for Medical Observer

nominated John Murtagh as their number one hero of Australian medicine out of a list of medical luminaries. (Medical Observer, July 2012)

The mentor “In my first year of med school, I attended the First Wave orientation workshop in Sydney. All of the students I was chatting to were buzzing with excitement to hear from the famous Prof Murtagh, and after hearing him speak I could understand why. His incredible knack of clarifying how to reason clinically, while epitomising what it is like to practise the art of medicine was, and is, absolutely astounding. His books have saved me when I found myself stuck, and have helped me to think like a doctor. His contribution to the profession is truly astounding and is part of the reason I am so passionate about general practice.” Nicola Campbell – GPSN National Chair and final year medical student

With you on your journey 7

“Prof Murtagh taught me how to think like a GP: with thought, investigation and compassion. As a patron of GPRA he has enabled other students to share in his wisdom, experience and passion. His book remains as testimony to the indelible legacy he has left on medicine generally and the specialty of general practice in particular.” Emma Thompson – GPSN National Secretary and final year medical student “My Dad used to talk about Dr Murtagh and his manual when I was young and he had started his practice. He called him the ‘father of

Professor John Murtagh AM has been GPRA’s loyal and outspoken patron for 14 years. However, it is time to pass the baton to a new patron. GPRA is proud to announce Professor Michael Kidd AM as the Patron of GPRA, following his work with the General Practice Students Network. Michael is Executive Dean of the Faculty of Health Sciences at Flinders University, President of the World Organization of Family Doctors and past president of The Royal Australian College of General Practitioners. GPRA would like to thank Professor Murtagh for his continued support to the organisation, and its members, and the significant contribution he has made to general practice.

general practice’. I’m surprised I remember this, and even more surprised that my Dad was familiar with him, having just arrived from Vietnam.” Dr Phong Ho – GP Ambassador, the Royal Prince Alfred Hospital, Sydney “Professor Murtagh is a very inspiring individual and a true pioneer to the modern GP’s work. His book has truly helped me through my medical school life and moreover, my clinical thinking in my future career as a medical practitioner.” Dr Jenny Chen – GP Ambassador, the Canberra Hospital, Canberra

Meet your GPSN National Executive team The General Practice Students Network is run by university club chairs and overseen by a National Executive Committee. The club chairs promote GPSN at their university and are a point-of-contact for other medical students with general practice career questions. GPSN provides a range of educational and professional resources to all medical students.

Rajdeep Ubeja

National Vice Chair University of Western Sydney What aspects of general practice appeal to you? The flexibility and the breadth, and the fact that this particular specialty keeps me on my toes and allows me to explore all facets of medicine. What are your plans for GPSN in 2015? Solidify our policy and procedures to ensure the organisation runs effectively now and into the future. How do you like to unwind? I enjoy listening and making music. I love going for a drive; just driving... although it’s not very cost effective! I also love going to the gym.

Nicola Campbell National Chair Griffith University

What are your plans for GPSN in 2015? The clubs have already done an amazing job so keeping up the momentum is something we’d like to see throughout 2015. We would also like to do some online training videos and make sure that the accomplishments, events and future plans of the clubs are going up on the website. What is your favourite GPSN memory or event? Probably the standout event for me was the Goondiwindi Medical Muster, which was a 4-hour drive from where I live, but made for an excellent road trip and weekend away with fellow medical students. We learnt a lot about just about everything, given the scope of rural medicine. What are your top three study tips? 1. The pomodoro technique! Basically, work for 25 minutes then rest for five. I’ve never been able to study so easily before! 2. Be kind to yourself; it’s so easy to forget. 3. Write a to-do list!

Emma Thompson National Secretary University of Notre Dame Sydney

What aspects of general practice appeal to you? I knew general practice was for me because I really took to the idea of building lifelong relationships with my patients.You follow through from their early stages as toddlers and see them through to their elderly years; it’s very rewarding. What are your plans for GPSN in 2015? My goal for 2015 is a smooth transition from an exciting 2014 into 2015 as we head towards further growth of the organisation and through that, greater promotion of general practice. How do you like to unwind? During my downtime I love going to the beach.

With you on your journey 9

What do you want to do when you graduate? I want to be a great doctor. I definitely want to look more into general practice and gain more exposure. What are your top three study tips? 1. Study early 2. Study in groups

Jarrod Bradley

Communications and Online Media Officer University of Western Sydney

3. Make mind maps.

What aspects of general practice appeal to you? Flexibility – I’d like to take time off, travel around the world and help with MSF-style work. As a generalist this is more possible.

•

• Patient continuity – Seeing the same patients over and over again in general practice would help me gain greater insights into the patient psyche.

• Encompassing nature – the nature of general practice means that

you can do basically everything. It allows you to know a broad range of medicine, while honing in on your favourite aspects. What are your plans for GPSN in 2015? Increasing cross-communication between clubs within GPSN... I do have more complex plans but they’re clouded in study at the moment! How do you like to unwind? I play Pokémon, I chill-out and listen to music, I obsessively plan my life, I hang out with my friends, and I download and watch more TV shows than any other person on the planet!

Claire Chandler

Working Group Officer Flinders Northern Territory Medical Program What aspects of general practice appeal to you? I like the diversity of patient presentations and the ability to develop strong therapeutic relationships with patients and their families. What are your plans for GPSN in 2015? I’m really excited to lead the working groups this year. The plan is to engage as many medical students from around Australia as possible in project focused teams. What has been the highlight of medical school? Going to Palumpa for my scholarship placement and finding out how different medicine and life is 300 km from my hometown of Darwin.

Esther Zhou

Promotions and Publications Officer University of New South Wales What aspects of general practice appeal to you? My scholarship placement in first year really helped solidify my attraction to general practice and I was lucky to get this opportunity so early on. I really enjoyed seeing what GPs do and this made a difference to my choices over the course of the next few years.

Jaislie Anderson

National Events Officer University of Western Sydney What aspects of general practice appeal to you? I love the prospect of having longevity of care with my patients and having the opportunity to build a lasting professional relationship. My aim is to become a rural GP and the lifestyle that general practice has to offer in a rural setting is what attracts me most to the specialty.

What is your favourite GPSN memory or event? This would have to be the UWS Close the Gap Rural Night held in 2014. We set up a lovely picnic feast for people to dig into while they learnt more about the health disparity between metropolitan and rural/remote areas.

about 24 other classical guitarists). In July last year we toured to Adelaide to play in the International Guitar Festival, which was an absolutely incredible experience.

What are your top three study tips? 1. Get organised early! I find this helps me to plan my study better to make sure I fit in everything I need to before exams. 2. Try and keep up to date! There’s nothing worse than trying to fit a semester’s work into the one-week study vacation before exam period. 3. Find some motivation – whether this is creating a zen study cave and cramming by yourself or getting a group of driven friends together who will force you to do some work – find what motivates you and harness it!

Anmol Khanna

Sponsorship Officer University of Notre Dame Fremantle What aspects of general practice appeal to you? Flexible work environment and the opportunity to shape my career around different areas of interest. What are your plans for GPSN in 2015? Help GPSN clubs obtain local sponsorship. The plan is to provide the clubs with the relevant information on approaching local sponsors and promoting an environment where the clubs share information and collaborate.

Rebecca Calder

Local Events Officer Griffith University What aspects of general practice appeal to you? The diversity, particularly the ability to see patients at many stages of their life, with many forms of disease and illness. I particularly love the problem-solving nature of general practice – the person walking through your door could have anything or everything. In these ways I like that it offers both the freedom of subspecialty, to pursue keener interests, while also maintaining that general critical primary care role. What is your favourite GPSN memory or event? The inaugural ‘Amazing Race’ event at GPSN Griffith in 2013. This was my first taste of being involved with GPSN and I absolutely loved the experience, even though it was pouring rain on the day. We ended up putting the students into disposable raincoats (which was hilarious) and the event was an incredible success.

What is the most interesting thing you’ve seen since studying medicine? Removal of a paraganglioma at the bifurcation of the common carotid. The patient’s blood pressure was fluctuating and the surgeon, surgical assistants and anaesthetist had to perform different interventions to stabilise the patient. It highlighted the team approach needed in medicine. The surgery was successful and the patient made a good recovery.

Find out more about the General Practice Students Network at gpsn.org.au or turn to pages 34–35 for GPSN news and the contact details of the club chair at your university.

How do you like to unwind? There are two things I truly love to do when I’m not studying or working: 1. Travel – last year I travelled to Denmark and Italy and the USA. I’ve also been to the UK, NZ, France, Germany, the Netherlands, Chile, Ecuador and Vanuatu 2. Play the guitar – I’ve been playing now for nine years and am part of a community guitar ensemble in Brisbane called ‘Aurora’ (with

With you on your journey 11

F I R S T WAV E Q & A S

Scholarship recipient, Gemma Abraham, chats to us about her general practice placement.

The John Murtagh First Wave Scholarship program

What year are you in? I am a third-year medical student at the University of Western Sydney.

What is it? Honouring former GPRA Patron, Professor John Murtagh, the John Murtagh First Wave Scholarship program (previously known as the First Wave Scholarship) provides positive, early and structured exposure to general practice in a range of settings including urban, outer metropolitan, rural and Aboriginal Medical Services.

Where was your placement? I was placed at Norwest General Practice in Bella Vista, 33 kms north-west of Sydneyâ&#x20AC;&#x2122;s central business district and situated in the Hills Shire.

How does it work? Candidates apply via a formal online process. Successful candidates are then matched with a GP who mentors them during their scholarship period.

Tell us about an average day during your First Wave week. I spent most of my sessions sitting in on patient consultations with my supervisor. I was able to practise my diagnostic questioning skills and perform physical examinations. I was also able to assist in procedures such as immunisation administration, cryotherapy and suturing.

What does it involve? The scholarship involves completing a series of supervised sessions in a clinical practice. Clinical sessions are generally scheduled during university summer holidays. Participants are also required to attend a fully funded two-day orientation workshop.

What was the highlight of your placement? The highlight of my placement was the exposure to paediatrics. My supervisor taught me how to assess and examine children and gave me tips on interacting with children in a clinical setting. I also spent one of my six sessions with the practice nurse and assisted her in conducting baby checks. Following these checks, I was definitely feeling a little clucky! What was your supervisor like? To put it simply, my supervisor was amazing. He had a professional yet personable demeanour and was an enthusiastic teacher. I always felt included and involved because he gave me several opportunities to participate while sitting in on patient consultations with him, from formulating differential diagnosis lists to discussing management options. He also passed on tips from his experiences of working in both the hospital and the community and gave me advice for when I start working as a doctor. The other staff at the practice were also incredibly friendly and welcoming.

Who can apply? First and second year medical students studying at an Australian medical university. When can I apply? Applications open 29 May 2015 and close 3 July 2015. How do I apply? The John Murtagh First Wave Scholarship program is advertised online and at participating university campuses through their local GPSN club. For more information, visit gpsn.org.au or email firstwave@gpra.org.au

What did you learn about general practice? I was able to see and learn about a wide variety of conditions that I had never encountered before, as well as practise my clinical skills. More importantly, I was able to develop an appreciation for general practice. I have gained a deeper understanding of the comprehensive and continuous nature of the health care that it provides, its role in promoting health in the community and the diverse range of medicine that can be practised. Would you recommend a First Wave Scholarship to others? I would definitely recommend applying for a First Wave Scholarship if you are interested in general practice, want to gain more clinical experience or you are simply curious to find out what this specialty is all about.

With you on your journey 13

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

Family medicine Dr Phong Ho, a junior doctor and GP Ambassador at Sydney’s Royal Prince Alfred Hospital, is following in the footsteps of his migrant surgeon-turned-GP father – and he admits he has big shoes to fill.

“So it’s 11 at night and your pager goes off.” 14

“Do you have any personal heroes?” When GP Journey poses the question, Dr Phong Ho shoots back the answer. “My dad,” he replies. Phong was four years old when he came to Australia from Vietnam with his father, mother and little brother in 1990. The story that followed was one of hard work for a migrant family seeking a better life. Phong is now an intern at the Royal Prince Alfred Hospital in Sydney and was recently accepted into the general practice training program. He is also a GP Ambassador, advising and inspiring junior doctors at RPA who have an interest in general practice. As for his own inspiration, Phong says he needs to look no further than his father, Dr Minh Ho, a GP with a practice in Canberra. “Dad built everything up everything from scratch. You can imagine when we came to Australia we didn’t have much money. We came over with about a thousand dollars. “Dad had been a general surgeon in Vietnam but when we came here he retrained as a GP. He had to study and do all the exams. “He was on kind of welfare payments for the first two years in Australia. Mum was working in day care, and we were renting a little house in Adelaide. “From there Dad was able to build his own GP practice in Canberra with a broad base of patients, buy the family a house, send my brother and I to private school, then send me to Sydney to do my university studies.” Phong’s first degree was in pharmacy, but about halfway through his course he had a change of heart. “I thought medicine would suit me better,” he says. Phong came to believe that medicine offered more scope for a varied and rewarding career path. But he admits that cultural conditioning may have played its part. “In Asian communities you’re expected to do one of the big three – medicine, dentistry or law,” he says with a wry smile in his voice. He finished his pharmacy degree, then worked as an intern pharmacist for a year. After successfully applying to do a postgraduate course in medicine at the University of Sydney, he continued to work part-time as a pharmacist while studying. Phong’s transition from medical student to intern has not been without its nervous moments. “I was a bit unlucky in that I began my internship on night shift. If you can imagine a hospital of 700 beds at RPA and you’re covering half of them. That’s 350 beds. “There are only the ICU and emergency doctors plus one other doctor there more senior than you, and you’re the first person who gets paged if anything goes wrong. That’s pretty daunting. “So it’s 11 at night and your pager goes off. And you receive a call to say there’s this patient and their blood pressure’s low and they have a high fever, what do you want to do.” So what did Phong do? “I asked for help. My advice to other junior doctors is that if you’re worried about a patient, or if you’re thinking

Phong Ho and his family (Phong is third right) of escalating, you probably should. I believe it’s always better to overcall it than not call at all.” Phong says his skills and confidence have surged during his intern year. “Being able to get lines in, take bloods quickly, assess a patient and know when to refer and when to do it on your own – that practical side is a lot better since my internship. I really enjoy doing things with my hands,” he says. The potential for combining hands-on procedural work and consulting work is something that drew Phong to general practice. With his affinity for procedural work, Phong has a strong interest in dermatology. Through his father’s old networks in Vietnam, Phong recently spent a week’s working holiday in a cosmetic medicine clinic there. He observed and learnt a range of skills such as Botox injections, fillers, liposuction, hair removal and the aesthetic excision of moles and skin lesions. Phong will remain at RPA during 2015 to complete his general practice hospital terms. He has applied for paediatrics – one of the mandatory hospital terms for GPs – as well as dermatology/ endocrinology. He will also continue as a GP Ambassador at RPA. “I communicate a lot by social media,” he explains. “I’ve been posting information about the general practice application process such as when to sit for the tests and how to prepare for them on the Facebook pages for RPA interns and residents.” Out of hours, Phong is something of an action man. “I like to run and cycle a lot, ride my motorbike, hit the gym, go surfing and use my GoPro – or sometimes just laze around on the beach. And I Iike all the usual things like going out with friends. “I think that whole lifestyle balance thing is really important, and general practice has that flexibility,” he says. His goal for the years ahead? “Finish training and then join a general practice as a partner or pair up with colleagues and have a practice of our own. I am interested in the business management and commerce side as well as the medical side,” he says. Phong has considered taking over his dad’s general practice when he retires, but with a network of friends in his adopted hometown of Sydney “it’s a question of how my life plays out over the next few years”. Whatever happens, Phong says “at some point I want to make my dad proud.” Written by Jan Walker

With you on your journey 15

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CLINICAL CASES

Clinical

CORNER

Clinical Corner case studies are provided courtesy of Medical Observer. The following are by Dr Ian McColl. A different sort of scale

The yeast infection pityriasis versicolor presents as white scaly patches surrounded by tanned skin, in warmer climates. In cooler climates it presents as pink or brownish patches. Sometimes this rash is mistaken for psoriasis but the scales are different. With psoriasis, scraping shows a thick, candle wax-like scale while the scale in pityriasis versicolor is finer and bran-like.

Treatment is best with 10 days of daily ketoconazole 200 mg followed by 200 mg weekly for 10 weeks. The causative organism, Malassezia furfur, is part of normal flora. consider medications as a cause. Treat with strict sun protection and hydroxychloroquine if slow to respond.

Nailing the diagnosis

Sometimes a subungual haematoma can look like a subungual melanoma. Usually a subungual haematoma slowly grows out, but in this case the nail was unchanged after six months. There was also a suggestion of Hutchinsonâ&#x20AC;&#x2122;s sign (pigmentation of the posterior nail fold), but careful inspection shows this pigmentation is confined to the cuticle.

Diagnosis aided by distribution

When the nail was removed the pigmentation left on the nail bed was confirmed as blood, not melanin. The patient was a golfer and continually injured his nail in poorly fitting shoes. Always be on the look out for subungual melanoma because it is usually discovered late when the lesion is thick.

The distribution of a rash can be a clue to its aetiology.

This rash is confined to the V of the neck and extensor exposed surfaces of the arms and upper back and hence is suggestive of a photo-induced disorder. An annular, slightly scaly rash like this is seen in subacute lupus erythematosus. To confirm the diagnosis, perform a skin punch biopsy and collect a second specimen for immunofluorescence, as well as checking ANA and ENA antibodies. In subacute lupus, expect to see a positive Ro ENA antibody; it is responsible for the photosensitivity state. Donâ&#x20AC;&#x2122;t forget to For more images, see medicalobserver.com.au/clinical-review/dermatology With you on your journey 17

Shingles vaccine Is it worth the effort? Commentary by Michael C Wehrhahn and Dominic E Dwyer

Studies in more than 150 000 people suggest the shingles (zoster) vaccine can halve the incidence of herpes zoster and reduce its complications even more in people aged 60 years and over. Case Scenario

Jessie, aged 72 years, has just returned from a holiday in the USA. During the trip she met several Americans around her age who had been given ‘shingles vaccine’ by their local doctors. They were surprised that Jessie had never heard of shingles vaccine and even more surprised that it was not promoted strongly in Australia for those aged over 65 years. Jessie comes to see you to ask about the vaccine and whether she should have it. She is in good health with treated stable hypertension and takes statins for hypercholesterolaemia. She says she had a severe bout of chickenpox when she was in primary school.

Commentary

It is true that there has been little publicity about the shingles (zoster) vaccine in Australia since it was recommended in 2009 in the Australian Immunisation Handbook for all adults aged 60 years or older.1 The main reasons are probably the relative scarcity of this vaccine in Australia until recently and the vaccine’s cost. The adult varicella zoster vaccine is 14 times more potent than the monovalent childhood varicella zoster vaccine and therefore requires significantly more live attenuated virus to manufacture. It costs around $180 to $200, excluding the cost of administration. In the USA, the zoster vaccine has been approved since 2006 for those aged 60 years and over, and since 2011 for those aged 50 years and over. Since 2008, the US Centers for Disease Control and Prevention (CDC) have recommended routine use of the vaccine in all persons aged 60 years and over unless it is contraindicated. In Australia, the Therapeutic Goods Administration has approved the zoster vaccine for prevention of herpes zoster (shingles) in people

aged 50 years and over as well as for prevention of postherpetic neuralgia (PHN) and reduction of acute and chronic zoster-associated pain in those aged 60 years and over. The vaccine is in the early stages of assessment for PBS listing. Risk of herpes zoster In Jessie’s case, her history of chickenpox as a child certainly puts her at risk of herpes zoster, along with about 90% of the population who have likewise been exposed to chickenpox. About a third of these people will experience herpes zoster during their lifetime, with the incidence greatest after the age of 60 years. Furthermore, it is now recognised that recurrent episodes of herpes zoster are more common than previously thought, with the chance of recurrence over an eight-year period being 4% for men, 7% for women and approximately 20% for people with HIV infection. General practice data in Australia suggest that the number of cases of herpes zoster doubled between 2000 and 2010.2 The reasons are thought to be a combination of the ageing of the population and the increased use of immunosuppressant medications. It is also possible that the widespread use of varicella vaccine for children and non-immune adults (introduced in Australia in 2005) may have reduced the opportunities for re-exposure to varicella zoster virus in the community; re-exposure may boost waning immunity in adults. Risk of complications Should Jessie develop herpes zoster, she is at risk of developing PHN, which is considered to be more severe in patients older than 70 years. PHN is generally defined as moderately severe pain in the distribution of the shingles attack that persists for at least three months and may be associated with a reduction in quality of life.

This article originally appeared in Medicine Today 2013;14(11):67–68 and is reprinted here with permission.

In up to 50% of patients with PHN, pain is not effectively relieved despite treatment, and occasionally it persists for years.

with influenza vaccine, it should not be given within one month of pneumococcal vaccine.

Features that are predictive for the development of PHN include more severe initial pain, more extensive rash and age over 50 years. In people over the age of 80 years, PHN is estimated to occur in about 30% of people with herpes zoster.

Booster doses of zoster vaccine are not currently recommended. Zoster vaccine is contraindicated in people with significant immune impairment, such as those taking high-dose corticosteroids and those with HIV infection who have a CD4+ T-cell count less than 200 cells/µL.

Should Jessie have the added misfortune of a herpes zoster attack involving the ophthalmic branch of the trigeminal nerve (herpes zoster ophthalmicus), she has a significant chance of direct eye involvement (about 50% in the absence of antivirals; Figure). Neurological complications such as meningitis, myelopathy and cerebellitis also occur less commonly. Vaccination prevents shingles and postherpetic neuralgia Early research found that the childhood varicella vaccine was not effective in boosting cell-mediated immunity to varicella zoster virus in older people. Much higher levels of attenuated virus were required to elicit and maintain immunity, probably as a consequence of decreased responsiveness to vaccines in older people in general.3 Since 2005, several large studies have been published demonstrating efficacy of the adult zoster vaccine. The Shingles Prevention Study, involving 38 546 patients aged 60 years and over, showed a 50% overall reduction in shingles cases (64% for those from 60–69 years and 41% for those from 70–79 years).4 There was also a 67% reduction in PHN in those aged 60 years or older. The primary study endpoint, however, was burden of illness due to herpes zoster. This was measured by a severity of illness score defined by the area under the curve of herpes zoster pain (based on responses to the ‘worst pain’ question in the Zoster Brief Pain Inventory) plotted against time in the six months after rash onset. This burden of illness score was reduced by 61% in those who received the vaccine (66% in the 60 to 69 years age group and 55% in the 70 years and over age group). Furthermore, the number of severe cases of PHN (more than 80 days of the ‘worst pain imaginable’) was reduced by 82%, and 80% of these cases occurred in those aged 70 years or over.5 A further large study of 75 761 people who received the zoster vaccine found a 55% reduction in herpes zoster (across all age groups) in addition to around a 60% reduction in zoster ophthalmicus and in hospital admissions when compared with unvaccinated age-matched controls.6 Another study reviewing the vaccine in over 22 000 people aged from 50–59 years found the vaccine well tolerated, with an efficacy of 70%.7 Most recently, a much larger American cohort study involving 766 330 randomly selected people aged 65 years or over found vaccine efficacy of 48% (37% if immunocompromised) in almost 30 000 herpes zoster vaccine recipients (more than 4000 of whom were considered immunocompromised).8 A 59% reduction in PHN was also found in this study. Tolerability and administration of zoster vaccine Although injection site reactions occur in up to a third of patients who receive zoster vaccine, these are generally mild. There is no difference in serious adverse events when zoster vaccine is compared with placebo. The vaccine can be given to patients who have already had herpes zoster, although it is suggested that they wait at least a year after the attack. Although zoster vaccine can be given concurrently

Conclusion

Jessie is likely to benefit from zoster vaccine. If she is willing to be vaccinated and the vaccine cost is not an issue then we believe it should be offered. At her age, zoster vaccination reduces the risk of herpes zoster by about half and is expected to reduce the risk of complications such as PHN or zoster ophthalmicus to an even greater extent. Authors Michael C Wehrhahn MBBS, MPH, FRACP, FRCPA is a Clinical Microbiologist at Douglass Hanly Moir Pathology and an Infectious Diseases Physician at Macquarie University Private Hospital, Sydney. Dominic E Dwyer MD, FRACP, FRCPA is a Medical Virologist, Infectious Diseases Physician and Director of the Institute of Clinical Pathology and Medical Research, Westmead Hospital, Sydney, New South Wales. References 1. National Health and Medical Research Council. Australian immunisation handbook. 9th edn. Canberra: Australian Government Department of Health and Ageing; 2008 (updated online 2009). 2. Grant KA, Carville KS, Kelly HA. Evidence of increasing frequency of herpes zoster management in Australian general practice since the introduction of a -varicella vaccine. Med J Aust 2010;193:483. 3. Kimberlin DW, Whitley RJ. Varicella-zoster vaccine for the prevention of herpes zoster. N Engl J Med 2007;356:1338–1343. 4. Oxman MN, Levin MJ, Johnson GR, et al. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med 2005;352:2271–2284. 5. Oxman MN. Vaccination to prevent herpes zoster and postherpetic neuralgia. Hum Vaccin 2007;3:64–68. 6. Tseng HF, Smith N, Harpaz R, Bialek SR, Sy LS, Jacobsen SJ. Herpes zoster vaccine in older adults and the risk of subsequent herpes zoster disease. JAMA 2011;305:160–166. 7. Harpaz R, Hales CM, Bialek SR. Update on herpes zoster vaccine licensure for persons aged 50 through 59 years. MMWR Morb Mortal Wkly Rep 2011;60:1528. 8. Langan SM, Smeeth L, Margolis DJ, Thomas SL. Herpes zoster vaccine effectiveness against incident herpes zoster and post-herpetic neuralgia in an older US population: a cohort study. PLoS Med 2013;10:e1001420. 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 19

Could it be rheumatoid arthritis? by Dr Michael Tam and Dr Joel Rhee Case study James, a fit 70-year-old man, recently saw a GP registrar for a general check-up. James had symptoms of arthritis in his hands. The registrar assumed this was osteoarthritis but ordered a rheumatoid factor test along with other pathology tests. The rheumatoid factor came back elevated at 50 IU/L. On James’ follow-up visit, a clinical assessment was conducted. James had only a few moments of stiffness in the morning. His hands were not tender, swollen, ‘boggy’ or inflamed, and there was no clinical evidence of synovitis. There were, however, bilateral bony lumps around his distal interphalangeal and proximal interphalangeal joints (Heberden’s and Bouchard’s nodes) consistent with nodal

osteoarthritis. James said he was able to do most of the things he wanted to do, including playing a weekly round of golf. In view of James’ elevated rheumatoid factor, the likelihood that James has rheumatoid arthritis must be considered. What’s the evidence?  To answer the clinical question of whether James has rheumatoid arthritis, we need to know two things: • the baseline likelihood, or ‘pre-test probability’, that James has the condition • the test characteristics (ie. the sensitivity and specificity) of an elevated rheumatoid factor for rheumatoid arthritis diagnosis.

Pre-test probability  Ideally, first we want to know the prevalence of undiagnosed rheumatoid arthritis in Australian men aged 70 years. Although we couldn’t find any Australian data, in an American population, the residual lifetime risk (the risk for persons who reach a given age without yet developing a disease) of developing rheumatoid arthritis for men at age 70 was 0.73% (about 1 in 140). The lifetime risk in US adults is 1.7% for men.1 As it is improbable that the prevalence of undiagnosed rheumatoid arthritis is higher than the residual lifetime risk, 0.73% can be considered the upper boundary of undiagnosed prevalence of the condition in men this age.

Although an elevated rheumatoid factor increases the odds of rheumatoid arthritis about fivefold, in James’ circumstances, his individual post-test probability would rise from less than 0.1% to no more than an uninspiring 0.5%.

Then, we can estimate James’ pre-test probability of rheumatoid arthritis by taking his clinical presentation, along with the population prevalence, into consideration.

James’ case demonstrates the minimal utility of rheumatoid factor testing in someone without inflammatory arthritis and highlights the importance of history and examination in diagnostic assessment.

Likelihood ratios (LRs) are the odds that a clinical feature would be expected in someone with the condition of interest compared with someone who does not have the condition. Values for LRs can range from zero to infinity:2 • LR <1; the feature reduces the likelihood of the condition • LR = 1; the feature has no effect on the likelihood of the condition • LR >1; the features increase the likelihood of the condition. James’ signs and symptoms (or lack thereof) for arthritis are associated with the following LRs: • No morning stiffness; LR = 0.5

Discussion  Positive test results must be interpreted in clinical context. For James, the probability that he had rheumatoid arthritis was no higher than 1 in 200 despite an elevated rheumatoid factor. In his case, the important determinant is his relatively tiny pre-test risk: James’ negative clinical features had a larger impact on the probability of arthritis than the rheumatoid factor result.

Although the arithmetic shown here is unlikely to be routinely used by clinicians, the underlying idea can be conceptualised in an intuitive qualitative manner: post-test probability depends on pre-test probability.4 Most test results will change the probability of diagnosis by only one qualitative category: very unlikely (<10%); unlikely (10–33%); uncertain (34–66%); likely (67–90%); and very likely (<90%).4 In this case, the pre-test probability for rheumatoid arthritis was clearly ‘very unlikely’. An elevated rheumatoid factor might at best change this probability to ‘unlikely’.

• No active swelling in three or more joint areas; LR = 0.5

Authors

• No active symptoms in wrist, metacarpophalangeal or proximal interphalangeal joints; LR = 0.4

Dr Michael Tam is a GP at Fairfield Hospital’s general practice unit, Sydney, and a conjoint senior lecturer at UNSW, Sydney. Dr Joel Rhee is a GP in Sydney and a senior lecturer in general practice at UNSW, Sydney.

• No rheumatoid nodules; LR = 0.98 • Presence of symmetrical arthritis; LR = 1.2. These LRs are multiplied (0.5 × 0.5 × 0.4 × 0.98 × 1.2) to give an overall LR of about 0.12. Thus, James’ clinical picture actually reduces his odds of rheumatoid arthritis about eightfold. Factoring in the previous value of 0.73%, his pre-test probability is less than 0.1% (<1 in 1000). Test characteristics  The sensitivity and specificity of an elevated rheumatoid factor for rheumatoid arthritis diagnosis varies between studies, but reasonable estimates are a sensitivity of 69% (ie. the percentage of affected people who are correctly identified as having the condition), a specificity of 85% (ie. the percentage of healthy people who are correctly identified as not having the condition) and a positive LR of 4.9.3

References  1. 2. 3. 4.

Arthritis and Rheumatism 2011;63:633–39.  American Family Physician 2005;72:1037–47.  Annals of Internal Medicine 2007;146:797–808.  Evidence-based Medicine 2011;16:163–67.

This article was first published in Australian Doctor, 6 May 2014 and is reprinted here with permission. australiandoctor.com.au

With you on your journey 21

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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.

A 6-year-old boy with knee pain and a limp Charlie is a healthy and active six-year-old boy. His mother brings him to the surgery because she is concerned and puzzled by his complaint of right knee pain. Charlie says that he has had a sore knee on and off for 2–3 days. He has developed a noticeable limp. His mother could not find any soreness or other signs on the knee. Charlie’s mother states that there is no history of an injury, although he has been playing football recently. About two weeks ago, he did have a mild upper respiratory infection. On examination the child looked well, 50th percentile for height and weight with normal vital signs including his temperature. Examination of the knee was normal with no localised tenderness and a normal range of active and passive movements. However, examination of his right hip revealed limitation of internal rotation, abduction and extension. Charlie complained of knee pain during these movements, especially passive movements. Diagnosis Irritable hip due to transient synovitis related to a preceding viral infection. Plain X-ray was normal but ultrasound showed fluid in the hip joint. Charlie was treated with bed rest and ibuprofen and settled to normality in seven days. A follow up X-ray was arranged in six months to exclude Perthes disease. Practice point Remember that pathology in the hip can present with ipsilateral knee pain.

A dangerous case of post-flu fatigue Melinda, a 17-year-old student, attended because she was feeling weak in her arms, especially in the right arm and wrist where she described a tingling sensation that had been present for the past 24 hours. Her recent history was that of a febrile illness ‘rather like the flu’ a few days beforehand and then she unwisely played several games of tennis in a tournament that finished the previous day. She eventually had to withdraw.  Melinda also complained of headache, nausea and an aching jaw as well as the right arm weakness. Sensation to touch was normal and her reflexes were equivocal. I attributed the problem to soreness following sporting overload after a viral infection. Notwithstanding her age I considered the possibly of carpal tunnel syndrome. Upon planned review two days later, I noticed a dramatic and disturbing change. She walked with considerable difficulty into the surgery, looking well, but was weak in all limbs with obvious motor weakness and loss of reflexes. She was also having breathing difficulty and her peak flow was markedly reduced. Diagnosis She was in fact suffering from Guillain-Barre syndrome (acute idiopathic demyelinating polyneuropathy). She was admitted to hospital where she eventually received assisted ventilation for a few days without developing complete paralysis.

With Withyou youon onyour yourjourney journey 21 23

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

The sweet life For her general practice terms, Dr Sarah Freeman embarked on a sea change from Melbourne to a laid-back coastal community. Now her lifestyle strikes an ideal balance – professionally and personally.

“It’s not the easiest job to do and I think to be a good general practitioner is very difficult.”

Aboriginal health and I find it really enjoyable,” Sarah says. “I believe everyone has the right to access quality health care.” Issues in Aboriginal health can be complex, with socio-economic and cultural factors intersecting with medical ones, she explains. The community-controlled model is a direct response to this. It’s a non-hierarchical, team-based approach at a one-stop shop clinic in which a doctor is just one member of a team.

Sarah at work at Wathourong Aboriginal Co-operative in North Geelong If GP registrar Dr Sarah Freeman ever wrote a prescription for her own wellbeing it may read something like this: “Before seeing your first patient in the morning, spend half an hour exercising on the beach while inhaling the bracing sea air, listening to the gently pounding surf and producing stress-busting endorphins”. In fact, that’s exactly what Sarah does since a sea change whisked her away from the madding crowds of Melbourne to the more laid-back lifestyle of Jan Juc, a coastal town near Torquay just south of Geelong on Victoria’s Surf Coast. Sarah is a GP registrar nearing the end of her fellowship who is also a Registrar Liaison Officer. She says her time in a smaller regional community has allowed her to find her professional and personal sweet spot. “After I finished my hospital training in Melbourne I wanted to do general practice but in a slightly more regional setting. Where I am now is the perfect compromise between city and country because it’s on the beach and has a real community feel. But it’s half an hour from Geelong which has a big hospital, and an hour and a half from Melbourne. I find it a nice balance.” There’s a balance in Sarah’s working week too. She currently divides her time between Karuna-maya Medicine Tree, a general practice clinic in Jan Juc, and Wathaurong Aboriginal Co-operative, a Community-Controlled Health Organisation in North Geelong. GP Journey was intrigued by the Karuna-maya Medicine Tree name. Sarah explains that in Sanskrit, karuna means compassion and maya means the application of that sentiment. Medicine tree alludes to the wisdom and healing of nature and links it with Western medicine and scientific practice. Sarah sums it up this way: “It’s basically about compassion in a very integrative practice. There are six GPs, some of whom have an interest in acupuncture or hypnotherapy, and we have other practitioners on site such as a naturopath, osteopaths, dieticians and psychologists. “I don’t really have any particular training in natural medicine myself but I believe there’s a role for it and the clinic is very holistic and patient-centred.” Sarah’s other job is in Aboriginal health at Wathaurong Aboriginal Co-operative and it has immersed her in a different side of general practice for an extended skills term. “This is my first exposure to

“I really value the resources of the Aboriginal health worker to arrange appointments and follow up patients to get their investigations done and then come back for the review, with a driver available if needed. The idea is to make it as easy for the patient as possible,” Sarah says. The Aboriginal health worker may act as a culturally appropriate go-between too, she adds. “If I might be a bit worried about someone but they’re not ready to talk to me I might get the Aboriginal health worker to approach things a little differently and ‘have a yarn’ as they say.” The clinic at Wathaurong Aboriginal Co-operative has a diverse range of other health team members and services on site – from social workers to pathology services – so it has given Sarah valuable experience of being part of a multidisciplinary team. Sarah is quick to dispel the myth that being a GP is an easy option. “It’s not the easiest job to do and I think to be a good general practitioner is very difficult. It’s something that requires you to work hard to be abreast of all the knowledge.” Sarah grew up in Launceston and despite the fact there were no other doctors in the family, medicine always appealed. “I’ve always been a people person, I like helping people and I liked science so it seemed like a good option.” After completing her medical degree at the University of Tasmania, she moved to Melbourne for her internship at Austin Hospital for a change of scene and to gain some big-city experience. “During my second year I did six months in paediatrics and six months in obstetrics. I completed my obstetrics and gynaecology diploma and considered going into these specialties but ultimately I made the decision to do general practice and I love it.” When it came to her general practice terms, Sarah embarked on her sea change with her husband Bob and recently successfully completed her fellowship exams. She says living in Torquay has been a great fit for her interests outside medicine too. “I’m not a surfer but I love to boogie board. I did the City to Surf in Sydney and I’m considering trying the Great Ocean Road Half Marathon.” However, as much as they love Torquay, Sarah and Bob are planning a possible move back to Tasmania in the near future to be closer to family and maybe start a family of their own. “I’d like to find myself in a nice family-based practice and get involved in medical education as well. I think it’s really important to encourage students and junior people coming through to take an interest in general practice.” Written by Jan Walker

With you on your journey 25

G P P RO F I L E

Striking it rich

â&#x20AC;&#x153;When I was studying I wanted to do it all, and I was very passionate about medicine so I thought general practice would be the best choice for me.â&#x20AC;? 26

In between seeing patients at her Airlie Beach practice, newly-fellowed general practitioner, Dr Jane De Keyser, spends her time kayaking, sailing, camping and fossicking for gold – not typical hobbies you would expect a woman from Belgium to dabble in! “I work 36 hours a week so I have a great work-life balance up here,” Jane tells GP Journey. “Back in Belgium I’d see about 20 patients a day. Half of these were house calls, so most of my time was spent in the car – I much prefer working as a GP in Airlie Beach. “On the weekends I get out and enjoy the outdoor lifestyle. I just love it here.” With a vision of coming to Australia to make her fortune gold mining, Jane packed up her life in Belgium three years ago and relocated to the sunny Whitsunday region of Queensland. Despite having seven years of general practice experience in Belgium under her belt, Jane needed to obtain Australian registration before she could practise in Australia – a process that involved passing three exams/interviews before getting into Australia, and then a mix of 10 courses/exams to gain fellowship so she could stay more than four years. “It was a lot of work and there were a lot of hurdles I had to jump through, but it’s done now,” she says. “Looking back on it, the course was really rewarding and interesting so I’m happy I did it.” Jane chose to fellow with the Australian College of Rural and Remote Medicine (ACRRM), which she describes as a “hands-on and vibrant course”, and was awarded her Fellowship at ACRRM’s annual conference in Sydney in October 2014. Jane was one of 83 doctors awarded the FACRRM in 2014 and completed a specialist pathway program designed for international medical graduates who possess

skills and experience deemed to be ‘substantially or partially comparable to those on an Australian-trained Fellow of ACRRM’. When asked why she chose to call Australia home, Jane initially replies with a simple, “why not?” but later adds that she was attracted to the idea of a life in Australia following a journey through the outback and a four day visit to Coober Pedy to fossick for opals back in 2003. “It was either The Netherlands or Australia,” she says. “Australia’s health care system is similar to the Netherlands, but I thought why move to the Netherlands when I can move to Australia? So I packed and came over here on my own. “I’m an only child so it was a bit of a hit for my parents, but they’ve come to visit me twice and they love it here.” Jane’s journey into general practice was an accidental one, and although she loves her career it wasn’t something she had always dreamed of doing. On her last day of school she was asked by teachers what she wanted to do – she admits she didn’t have a clue. “I was staring at my arm and I was thinking, ‘what’s under the skin’?” she reflects. “I really wanted to know, so I thought I should become a doctor.” Jane’s father was a medical rep so the industry wasn’t completely foreign to her, but her grades weren’t of the highest standard so there were a few people who doubted whether or not she would ever achieve her goal. Now over a decade later (it takes nine years to become a GP in Belgium) and Jane is an accomplished GP who notes the variety and scope as the highlights of a career in general practice. “When I was studying I wanted to do it all and I was very passionate about medicine so I thought general practice would be the best choice for me,” Jane says. “General practice was also the shortest course, which was ideal for me as I felt I had studied enough. I love my job so I’m very happy with the choice I made.” Jane’s practice – The Doctors Airlie Beach – comprises a receptionist, a nurse and pathology lab – a luxurious set-up compared to clinics in Belgium. “In Australia it’s more organised and you do your job in a team environment,” she says. “But over in Belgium you do everything – I much prefer the set-up over here.”

From left to right members of The Doctors Airlie Beach: Paula Lucus (RN), Dr Eleanor Carey, Dr Thomas Koeck, Dr Jane De Keyser, Dr Gary Coulter

Although Jane is yet to strike gold, (not counting her first and only gold nugget in 2012; valued at $13!) she has found love in Australia and in a few years plans on travelling around the country working as a locum alongside her partner, who is a world sailor. “We met in 2012 at a rodeo and it was love at first sight,” she says. “My plans are to stay in Australia and travel around with my partner working and doing all the things we like outdoors.” Written by Alex Kirby

With you on your journey 27

Melbourne Convention Centre

22–24 April 2015

#fgp15

The Future of General Practice 2015 conference will bring together medical students, prevocational doctors and general practice registrars from around Australia and deliver an educational program that focuses on leadership and innovation. Outstanding industry leaders will present their views and opinions of general practice and the direction it is taking. Student education days will be held on 22–24 April, while the prevocational doctor and general practice registrar combined education days will be held on 23–24 April. This exciting new program will provide attendees with many networking opportunities. The social highlight will be an imaginatively themed cocktail party – with a twist – a not to miss event on the Thursday evening.

For more information and to register attendance

fgp.org.au

MY CAREER

Interested in becoming a GP? Get set for a start in 2016 The Australian General Practice Training program

The Australian General Practice Training (AGPT) program is a postgraduate vocational education and training program for prevocational doctors who want to become general practitioners. General practice is a rewarding specialty that provides varied clinical work, continuity of patient care, the opportunity to subspecialise, dynamic team-based medicine and flexible working hours. The AGPT program delivers the vocational training programs of The Royal Australian College of General practitioners (RACGP) and the Australian College of Rural and Remote Medicine (ACRRM). It takes 3–4 years to be ready to attempt fellowship. General practice training provides valuable practical experience in different training locations, including teaching hospitals, rural and urban practices and specialised medical centres.

Extended skills and advanced specialised training

During training a number of extended skill and advanced specialised training posts are available to develop skills relating to your special interests. For example, you can choose to undertake an Aboriginal health training post where you will be immersed in a unique cultural environment and gain experience in Aboriginal health, seeing significant common and uncommon conditions. Academic posts are also available during training where you can undertake a project in partnership with a university to develop skills in research, teaching, project work and critical evaluation of research, relevant to the discipline of general practice. Other examples of extended skills training include but are not limited to, anaesthetics, palliative care, mental health and dermatology.

Applying to the AGPT program

The application process consists of three stages: 1. Application and eligibility check To apply to the program you will need to register online at agpt.com.au and complete the online application form.Your eligibility will be assessed during this first stage. Overseas trained doctors and Australian Defence Force doctors can also apply to the AGPT program. 2. National assessment If eligible you will be invited to stage two, where you will complete both a Situational Judgement Test (SJT) and a Multiple Mini Interview (MMI) at a national assessment centre within Australia. The SJT is an online test comprising 50 multiple-choice questions, which takes 120 minutes to complete. MMIs involve rotations between interview stations. Both of these tests require applicants to draw on their own experiences and assess the applicant’s suitability to general practice.

3. Training provider selection and placement offers On completion of the SJT and MMI, applicants are notified of scores and given the opportunity to change preferences and undertake placement assessments with their training provider if successfully placed into the program. 1500 funded training places will be available for the 2016 intake. Selection into the AGPT program is a highly competitive merit-based process that ensures the best candidates are selected. If you are interested in applying to the program, you are encouraged to read the 2016 Applicant Guide. You should pay particular attention to the selection criteria you will be marked against and the example questions. Key dates for intake into the AGPT program for 2016 10.00 am AEST 13 April 2015

Applications open

10.00 am AEST 8 May 2015

Applications close

15 June – 6 July 2015

National assessment centres – computer delivered SJT

26 June – 19 July 2015

National assessment centres – MMIs

10 August 2015

Applicants are notified of scores and given the opportunity to change preferences (preference distribution matrix posted)

10.00 am AEST 17 August 2015 Applicant preference changes due 19 August – 18 September 2015 Training providers placement assessments 21 September 2015

Outcomes due

Further information

The AGPT program is managed by the Department of Health and delivered by a national network of training providers dedicated to supporting GP registrars as they embark on a career in general practice. To find out more about the AGPT program or to obtain a copy of the 2016 Applicant Guide visit agpt.com.au

With you on your journey 29

GP Journey and GP First apps now available free from iTunes GP Journey GP Journey ISSUE 14 FREE

ISSUE 13 FREE

May – August 2014

Dr Mark Wenitong Leading by example

Also in this issue: Your career

GP profiles

Clinical cases

• Direct email capacity from within the apps • Free updates as information changes

concerning the general practice landscape.

Download free today App suitable for iPad only – search in iTunes Newsstand

Prevocational doctors visit

gpaustralia.org.au

Heart and soul medicine

Your career

web from within the apps

gpsn.org.au

Dr Jenny Wray

Also in this issue:

• Extended information • Interactive clinical cases • Animated images • Link to resources and further information on the

Students visit

January – April 2014

Changes in the general practice landscape Changes to the general practice training program announced by the Federal Government in May 2014 have led to a major restructure of the administrative aspects of the program.With changes due to come into affect some time in 2015, GP Journey answers your key questions. How are the changes going to be articulated to current and future candidates? Current and future candidates who are members of the Going Places Network will be kept informed about the changes via regular e-blasts. Updates will also be posted on the GPN website at gpaustralia.org.au If you are a prevocational doctor and would like to be kept informed about the changes, visit gpaustralia.org.au and join today. Membership is free. How much notice will current registrars receive before these changes take place?

compromised during these administrative changes. If you need support or advice during your general practice training, contact the GPRA registrar services team at registrarenquiries@gpra.org.au When will new training providers and the regions they cover be announced? The new general practice training landscape should be confirmed by July 2015. When the changes are confirmed all information will be available on the GPN website at gpaustralia.org.au Members will be kept well informed and updated as information arises via regular e-blasts and our bi-monthly e-newsletter. Who will run the application and interview process? The two general practice medical colleges â&#x20AC;&#x201C; ACRRM and the RACGP â&#x20AC;&#x201C; will run the application and selection process that was previously administered by GPET. Visit gpaustralia.org.au for more information. Will the level of experience candidates gain in general practice change? The general practice training model is of a high standard and that standard will be maintained. How will centralising administration and amalgamating training organisations be better? Refining and improving the current training model will streamline and improve the training and administrative processes.

Will the rural and general pathway streams still be available? Current registrars will be given ample notice of these changes and there should be no interruption to their training. However, in the event General practice registrars can continue to elect the rural and general that their existing training provider faces difficulties, the Department of pathway streams. Health has a business continuity plan in place. Will rural and remote training be impacted by reduced numbers How will the changes affect registrars currently on the program and of training providers? starting general practice terms after December 2014? General practice training in rural and remote areas will not be affected Registrars commencing training after December 2014 will be informed by the changes. of all changes. The quality of general practice training will not be

With you on your journey 31

Exam survival Read broadly, then deeply For many students exams are a time of Have a comprehensive general overview of a topic before you increased caffeine intake, decreased sleep • start delving into detail about a particular area. and copious amounts of procrastination. • Keep content fresh in your memory by regularly quizzing yourself on topics you have previously studied, and looking back over Emily Jenkins, an intern at the Royal your old notes. Melbourne Hospital, provides some Be realistic great tips to help you get through. • Avoid guilt. It’s unproductive and demotivating. Didn’t study for a day?

Know how you learn best and use your time productively

Didn’t study for a week? Didn’t study for a month? It’s not the end of the world! Adjust your plan and hit the books again.

• Everyone learns differently, so it’s important to identify which ways • It’s absolutely essential to factor in breaks and downtime. Burnout is a you learn best to make the most of your time. If you’re a tactile

learner, listening to lectures double-speed as you fall asleep may not major issue and will hinder your exam performance much more than a few well-deserved regularly scheduled breaks. be your best approach. Similarly, drawing elaborate colour-coded diagrams probably won’t suit auditory learners. Be kind to yourself

• Knowing how you learn best also means knowing where and when • I cannot stress enough how important it is to maintain a balance you are most productive. Some people work best with other people around they can bounce ideas off, others would just find this distracting. Tailor your study time around your best times.

•

Maintain self-control. This is the hardest part. When you sit down to study, make sure you actually study. As hard as it can be sometimes, catch yourself when you’re losing focus and redirect your focus back to the task at hand.

•

Reclaim transport time and other wasted time during your day – load important lectures or podcasts onto your iPod and listen to them when driving, or use time on public transport to read over your lecture notes.

• Be honest with yourself. If you can’t motivate yourself to get to a

between uni/study and life. Way too many medical students burn out or simply fall out of love with medicine.

• No one will judge you for asking for help. Having the self-awareness of

knowing when you are out of your comfort zone and asking for help is absolutely essential for safe practice as a doctor.

• Remember that your faculty/supervisor/tutor is there to support you. Don’t suffer in silence – resolve issues early.

Make the most of ward time

• Never, ever miss a day on the wards.You will learn more here than anywhere else.

• Seize every opportunity to see patients and practise procedures. Have

lecture, are you really going to be able to motivate yourself to listen the self-discipline to report back every patient you see to one of the to eight hours of lectures at home when you’re surrounded by a doctors and constantly seek feedback on your performance. myriad of distractions? Don’t overlook other allied health professionals. Spend a day with the

• Have a pool of resources at your fingertip – load your phone

laptop with medical apps, carry GP Companion in your pocket.

• Get on twitter and join the #FOAMed revolution. Know what to study, make a plan

•

path nurses and never miss a vein again. Get the physios to help you perfect your musculoskeletal exams, or the social workers to talk you through the different support services or schemes your patients may be eligible for.

Ask for feedback

• Medicine is infinite: work out what you need to cover. Don’t forget • Seize every and any opportunity to get feedback – whether from your case study based teaching – whenever there’s a weird left-field question on an exam it’s inevitably pulled from a PBL.

• Make a study plan. Break it down into bite-sized chunks. Allocate

peers or your superiors (and be prepared to offer constructive feedback in return).

• Put yourself out there – when your tutor asks for a volunteer, stick your

one chunk of learning to each time spot so you know exactly what hand in the air! you need to do and when.

• Pharmacology can be daunting. Don’t learn drug doses, but

It’s never too late

•

understand basic mechanisms of action, indications and any specific 80/20 rule: 80% of the answers lie in 20% of the content. Accept that you are not going to cover everything and get smart with what you contraindications/side effects of common drugs and drug classes. do focus on.

With you on your journey 33

General Practice Students Network News October Council meeting In October more than 40 GPSN members from across the country gathered at The University of Sydney for the network’s second council meeting for 2014. At the meeting council members reflected on 2014 and celebrated their clubs’ achievements, heard from other student networks and learned valuable leadership skills. The meeting was the largest October council in GPSN’s history and was hailed by delegates as a huge success.

Innovation Award – Joint Case Base Amazing Race, Deakin University, Monash University and Melbourne University Best Promotional Strategy – University of Western Australia.

GPSN National Executive Committee 2015 GPSN is proud and excited to announce the GPSN National Executive Committee for 2015 led by National Chair, Nicola Campbell from Griffith University. GPSN would like to thank the outgoing National Executive Committee for all their hard work and dedication to the network in 2014. Turn to pages 9–11 in this issue of GP Journey for a full list and brief interviews with the 2015 Executive Committee, or visit gpsn.org.au to find out more.

GPSN 2014 awards

Around the clubs

The annual GPSN awards were announced and presented to winners at the October council meeting. The following awards recognise individuals and clubs that have gone above and beyond in promoting GPSN and general practice. Congratulations to all 2014 winners, and thank you for your contributions to the network.

In 2014, GPSN clubs around the country hosted 196 events to educate and inspire medical students to pursue a career in general practice.

Above and Beyond Award – Sofia Dominguez, University of Notre Dame Sydney Club of the Year – University of Western Australia Event of the Year – Indigenous Health Forum, University of Sydney

More than 2000 GPSN members attended the events, which covered topics such as Indigenous and rural health, clinical skills, networking and orientation activities.

Club chairs NATIONAL COMMITTEE University Griffith University University of Western Sydney University of Notre Dame Sydney Flinders Northern Territory Medical Progam University of Western Sydney Notre Dame Fremantle Griffith University University of New South Wales University of Western Sydney

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

Name Nicola Campbell Rajdeep Ubeja Emma Thompson Claire Chandler Jaislie Anderson Anmol Khanna Rebecca Calder Ester Zhou Jarrod Bradley

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

Name Sureka Vyravipillai Larry Lam Audrey Guo Deborah Song Aishwarya Modur Jayden Murphy Pariza Khale Melissa Godwin Lucy Holden Cindy Guo

Contact undsyd@gpsn.org.au westsyd@gpsn.org.au newengland@gpsn.org.au unsw@gpsn.org.au unsw@gpsn.org.au wollongong@gpsn.org.au newcastle@gpsn.org.au undsyd@gpsn.org.au griffith@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 Griffith University Australian National University

SA and NT Flinders University Madeline Cox flinders@gpsn.org.au University of Adelaide Matthew Chu adelaide@gpsn.org.au Northern Territory Medical Program (Flinders University) Lauren Thomas ntmp@gpsn.org.au VIC Deakin University Ellie Oâ&#x20AC;&#x2122;Connor deakin@gpsn.org.au Monash University Natalie Ngu monash@gpsn.org.au University of Melbourne Laura Machan umelb@gpsn.org.au TAS University of Tasmania Zoe Hernstadt utas@gpsn.org.au WA University of Western Australia Michelle Tan uwa@gpsn.org.au University of Notre Dame Fremantle To be advised notredame@gpsn.org.au QLD Bond University Georgia Cox bond@gpsn.org.au James Cook University Radhika Patwardhan jcu@gpsn.org.au University of Queensland Lulu Zhang uq@gpsn.org.au

With you on your journey 35

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

health service for homeless men and women in Melbourne’s CBD. The annual Melbourne dinner was another great turn out. A range of speakers spoke about their careers in general practice, including Dr George Forgan-Smith, who touched on his work in mental health, male health and his volunteer work with Camp Quality.

SA and NT The SA Network wound up our events for the year with a final workshop in October. With a focus on paediatric assessment and management, the workshop provided an opportunity for doctors to prepare themselves for their paediatric terms or simply refresh their knowledge. Speakers included Dr Nyoli Valentine and the FMC GP Ambassador, Dr Brock Edwards. Brock highlighted the importance of knowing your Disney characters if you want to ‘succeed in paeds’! Sadly, most of us could not tell a ‘Tinkerbell’ from an ‘Elsa’! Apparently this is not good… if you want respect and cooperation from your little patients, spend some quality time with Disney this weekend. It was an enjoyable and informative evening and we look forward to more of the same in 2015.

VIC and TAS It’s been an action packed few months in Victoria, with two of our major events being held in Geelong and Melbourne. Students and prevocational doctors flocked to the annual Geelong dinner to hear from three inspirational speakers: registrar, Dr Sarah Freeman and GPs, Dr Ern Chang and Dr Edmund Poliness. Edmund shared his experience working at Wathaurong Aboriginal Co-op in Geelong and also his work as a GP at the ‘Living Room’, a primary

Dr George Forgan-Smith at the Melbourne dinner

Stay tuned for an exciting calendar of events for 2015.

NSW and ACT The NSW and ACT Network was busy coordinating events hosted by our brilliant GP Ambassadors. We held networking dinners in Newtown, Crows Nest and Canberra where informative guest speakers addressed upcoming changes in general practice as well as a day in the life of a GP and the variety general practice offers. Their talks left guests truly inspired. We also held lunch-time sessions at the Wollongong and Nepean Hospitals, where students and interns could ask questions on upcoming changes to the general practice training space, the course, interview process and about becoming a GP. The network attended the Careers Expo at Homebush and the Pre Internship (PRINT) Conference in Sydney in November. Around 300 students and interns attended this conference, which gave us a great opportunity to connect with new and existing members.

QLD The Queensland Network coordinated an Advanced Skills Training Networking Dinner in Toowoomba and a Variety & Life in General Practice Networking Dinner in Brisbane. We were lucky enough to hear from some very experienced and knowledgeable speakers during both events, including medical educators and GPs who have worked in Indigenous health and the Australian Defence Force. Thank you to all the Ambassadors who hosted the events, speakers and attendees – they were a great success. As well as networking events, we sponsored RMO education sessions at Princess Alexandra, Redcliffe and Mater hospitals. We look forward to hosting more great events in 2015.

WA As we look forward to 2015, we reflect on another year in WA, and what a year it has been… We have hosted two great events and the specialty of general practice in WA has seen an unprecedented surge in popularity with a record number of prevocational doctors being accepted to WAGPET’s training program. WA’s coup in ensuring the continuity of the highly successful prevocational Community Residency Program (formerly PGPPP) when federal funding ceased, was a particular highlight. A special thank you to WAGPET and the many organisations that have made the program possible, including Western Australian Department of Health, WA Country Health Services and Rural Health West. With the state-of-the-art, newly opened Fiona Stanley hospital servicing the community, 2015 looks promising and we look forward to continuing to promote the diversity of a career in general practice career to doctors-in-training across WA.

Ambassadors

Want to get involved? Going Places Network GP Ambassadors are prevocational doctors who have a real passion for general practice. Ambassadors can help answer all your questions on becoming a GP. To find out more about becoming a GP Ambassador, email goingplaces@gpra.org.au

NSW and ACT 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 37

Reviews MedicineList+

Epocrates

MedicineList+ has tremendous potential for tech-savvy patients in general practice looking for a way to keep track of their medications. This app allows patients to log details about medications such as name, dose/number of tablets, how to take (ie. on an empty stomach or more complex instructions) and at what time of the day. Reminders can be set which pop up on the phone’s home screen (like an alarm) to prompt patients when to take their medications.

As a fourth year med student, Epocrates has been a godsend in keeping me out of the registrar’s firing line! However, the breadth of pharmacological detail will no doubt be useful to both students and consultants.

It also serves as a useful tool to store information about medical conditions, specialists (and their details), and other important information such as allergies, emergency contact details and medical test results. Once set up, medications can be linked to these conditions to give patients and medical practitioners an indication for each medication. This would be a particularly useful tool for patients to be able to reference if, for example, they had an appointment with a new doctor or presented to ED, especially as most people carry their phones but do not always have ‘that little piece of paper that I leave on the fridge’.

The primary feature, the drug reference, is brilliant – with complete profiling of the drug from dosing (in both adults and children) to adverse reactions and interactions in great brevity. Big thumbs up for clueless medical students and interns!

There is also a function where you can link the app with your local pharmacy and this will update prescription information such as when you need a new script. Not every pharmacy participates in this program, but no worries, medications can be manually entered in. Pros: • Reminders when you need to take medications

• Able to carry a list of medications, specialists, medical issues

Major features of this app include: Drug reference, Drug Intx, Tables and Medical calculators, and Pill ID. All content is subcategorised, which makes it incredibly easy and quick to access the information.

The powerful interaction check is useful for polypharmacy situations, allowing you to contrast the various interactions of different drugs and highlighting important parameters to monitor; increasing the overall success of your management. Another thumbs up! Another indispensable feature are the medical calculators and tables, which range from equations (eg. cockroft gault) to guidelines on medication and management. Patients who tell you they take a ‘round pink tablet twice a day’? Fear not, the Pill ID has an amazingly complex search criteria for pills based on their shape, colour, coating and clarity. Pros: • Detailed, organised

and allergies with you for unexpected situations.

• Constantly updated database.

Cons: • App may be a bit tricky for elderly patients to set up

Cons: • Lengthy download and set up time

• No way to ‘snooze’ a reminder if you are doing something else • Premium features need to be purchased. and want a reminder later. Price: Free Compatibility: iPhone, iPad and iPad touch Rating: ★★★★ out of 5 Reviewed by Dr Amanda Nikolic GP Ambassador, St Vincent’s Hospital, Vic

Price: Free Compatibility: Android, iPhone, iPad and iPad touch Rating: ★★★★ out of 5 Reviewed by Lawrence Ling Fourth year medical student, James Cook University, Townsville, Qld

â&#x20AC;&#x153;GP Companion was an invaluable tool as a student and has proven to be vital as a prevocational doctor.â&#x20AC;? Dr Joseph Monteith (past GPSN National Chair)

Buy your GP Companion online at the member discount price of

$19.95 RRP $34.95

Students visit

gpsn.org.au

Prevocational doctors visit

gpaustralia.org.au

Your network needs you

Make your voice count on shaping the future of general practice. Simply log in and update your details so your network can keep you informed. Students visit

gpsn.org.au

Prevocational doctors visit

gpaustralia.org.au