GP Registrar 2018/19 by GPRA Publications

GPREGISTRAR

GENERAL PRACTICE: CENTRAL VICTORIA NEGOTIATING A FAIR DEAL

THE ESSENTIAL GUIDE FOR GENERAL PRACTICE REGISTRARS

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GPREGISTRAR THE ESSENTIAL GUIDE FOR GENERAL PRACTICE REGISTRARS

P Registrar is intended to provide advice and insights for doctors who are on their pathway to become a general practitioner. This journey leads to fellowship of either or both of the Royal Australian College of General Practitioners or the Australian College of Rural and Remote Medicine, but continues beyond fellowship as consultant GPs establish their practice and build expertise across a diverse range of clinical areas. The experiences, and learning situations, encountered on the pathway to general practice vary substantially and many opportunities and challenges may be faced. To assist registrars understand the many options open to them and to appreciate the diversity of experiences and opportunities that come under the broad umbrella term â&#x20AC;&#x153;general practiceâ&#x20AC;?, this issue of GP Registrar captures the experiences of a number of registrars whose training has taken place in different parts of Australia. Several interviews are with registrars who had training experience in the Bendigo-Echuca region of Victoria. Their stories illustrate how, even early in a career, there are many choices and opportunities that should be considered. A separate cluster of stories consists of interviews with experienced GPs who have trained and worked in the Coffs Coast region, from Sawtell to Woolgoolga, in NSW. These stories give powerful insights into the wide range of rewarding opportunities open to those who have chosen to pursue a career in general practice. Other articles in this publication address issues such as resolving workplace problems, protecting your health and negotiating an employment agreement. This edition of GP Registrar is substantially different to previous editions. The starting point for selecting content has been recognition that there are many attributes that are critical for success as a GP and the articles herein reflect

and reinforce those attributes. This publication is a contribution towards your development and success as a general practitioner. It presents information and stories that show there are many others who have preceded you and who are willing to assist you tackle your concerns and seize opportunities that will enrich your career journey. Within this publication you will encounter examples of high levels of motivation and self-discipline, the compassion for others that underpins general practice, insights into coping with the physical and emotional demands of the job, and the good communications skills that put general practice way ahead of all other medical specialities.

GPRA acknowledges the ongoing support of the Australian Government Department of Health.

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GP Registrar: The Essential Guide for General Practice Registrars Published by General Practice Registrars Australia Ltd Level 1, 517 Flinders Lane Melbourne VIC 3000 P 03 9629 8878 E enquiries@gpra.org.au W gpra.org.au Editor Iona Salter GPRA Staff CEO Dr Andrew Gosbell Manager Business Development and Communications Kevin Broadribb Communications Advisor Rachel Sharp IGPRN Coordinator Rhys Howard Executive Administration & Registrar Services Officer Mandy McDonald-Susic Financial Controller Ayshika Jayatilaka Events Coordinator Vicky Triantaflaros All efforts have been made to ensure that material presented in this publication was correct at the time of printing and published in good faith. The publisher does not accept liability for the use of information within this publication. Owing to the rapidly changing nature of the industry, GPRA does not make any warranty or guarantee concerning the accuracy or reliability of this content. ÂŠ 2018 GPRA. This work is copyright. Apart from any use permitted under the Copyright Act 1968, no part may be reproduced by any process, nor may any other exclusive right be exercised, without the permission of General Practice Registrars Australia Ltd.

CONTENTS From the President

From the CEO

WHAT IS GPRA?

A message from GPRA Patron, Professor Michael Kidd

GENERAL PRACTICE CENTRAL VICTORIA A chat with Dr Kelly Champane

Sophie Ping: making a niche in forensic medicine Putting family first: Bendigo’s Dr David Gidley Dr Jeremy Wong chose the right town Your employment agreement

What to do if you run into problems

Negotiating a fair deal for registrars and their employers

17 21 25 28 32 34 36

GENERAL PRACTICE: COFFS HARBOUR REGION Learn to say: “I don’t know” — Dr John Kramer Ending the stigma — Dr Nicola Holmes

Talking sub-specialties — Dr Stephen May It takes a village — Dr Ian Arthur

More than a GP — Dr Tim Francis

40 46 51 54 58

Exam tips — Dr Shikha Chhabra

Your wellbeing — Dr Ginita Oberoi

GENERAL PRACTICE — DIFFERENT JOURNEYS

Dr David Lam: A specialist in life

Why I am a rural GP registrar — Dr Bob Vickers 73 Finding your mob — Dr Samantha Olliver

Selfie with my supervisor — Dr Jonathan Chia with Dr Lyn Wren GP Registrar 3

75 76

FROM THE PRESIDENT

s a GP registrar, life is a blur of new information, exam preparation, training – all while you’re caring for patients, looking after your own wellbeing and fitting in everything else which life brings along. I passed my Fellowship exam at the beginning of 2016; I understand what you are going through. There is help available for GP registrars, and I encourage you to utilise these supports. Your Regional Training Organisation (RTO) and medical college are there to support you. Talking to your Registrar Liaison Officer (RLO) is also a

general practice sector and with government on issues that matter to registrars – an important independent voice in a time of great change to general practice. As many of you may know, overall responsibility for GP training will transition to the general practice medical colleges (RACGP and ACRRM). GPRA is actively involved in transition arrangements, and the long-term GP training environment, as an independent entity that is able to protect checks and measures that ensure the system works for the doctors in training. We aim to assist with ensuring the success of the new arrangements. Now, more than ever, registrars need GPRA and GPRA needs you – so I encourage all members to stay in touch and get involved. If you’re not a member already, I invite you to join. It is free to become a member and takes two

GPRA is actively involved in transition arrangements, and the long-term GP training environment great starting place for any concerns you may have about your training. Additionally, there are many government-funded services which are there if you need support with your wellbeing. However, there is one organisation that is a must-join for any GP registrar – General Practice Registrars Australia (GPRA); your independent voice in the GP sector, run by registrars for registrars. GPRA advocates for registrars in both the 4 GP Registrar

minutes to join on the GPRA website. As well as advocating for GP registrars, GPRA supports registrars in many other ways. GPRA negotiates the National Terms and Conditions for the Employment of Registrars (NTCER). This important document outlines the minimum terms and conditions under which GP Registrars must be employed in a community General Practice setting. The NTCER is being renegotiated in 2018 – another reason why it is

important for all registrars to get involved with GPRA. Your support and involvement helps GPRA ensure the terms and conditions in the NTCER are fair and reasonable for registrars as well as the training practices. As always, GPRA can provide you with free, confidential advice on matters relating to your employment agreement. GPRA staff are available to talk about any difficulties you may encounter during your training. GPRA works with you to understand your issues and provide suggestions on how to approach a difficult situation or help solve larger issues. We are an organisation independent from your practice, RTO and college. Anything you discuss is confidential. Additionally, GPRA has a swathe of useful

resources to support you through your exams. When I was a GP registrar, the GPRA Exam Book and Clinical Cases were a key part of my study group’s preparation for RACGP exams. There is also a range of free resources on the GPRA website, including free webinars which discuss how to negotiate your employment agreement, how to thrive during GP training, and more. I am excited to see GPRA further support registrars in 2018 and beyond. As always, the best ways to keep in touch are through the GPRA Facebook page, Twitter, by visiting the GPRA website, or by signing up to the GPRA fortnightly newsletter – keep in touch and get involved! Dr Melanie Smith, GPRA President GP Registrar 5

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FROM THE CEO

riginally established in 1974 and existing as an autonomous association since 2001, General Practice Registrars Australia (GPRA) has a long history and is a unique entity in the vocational medical training sector. It is the only national independent organisation run by registrars to support, and advocate for, registrars. Being solely focused on GP registrars’ needs, GPRA: • provides a truly independent registrar voice in the GP training sector, • advocates to improve employment terms and conditions, education and training opportunities and the wellbeing of GP registrars, • can complement the resources offered by RTOs and the Colleges’ training programs, and • provides a forum for GP registrars to share their ideas and training experiences. This ultimately results in a better training experience for all GP registrars, and with a membership base representing over 90% of registrars undertaking GP training across Australia, GPRA is the single largest advocate for advancing the views of GP registrars. In the other medical specialties, there is no separate entity to look after the interests of registrars. The situation with general practice; however, is substantially different and the role of a separate organisation for registrars is critical. The entry into general practice is

not through the traditional ‘apprenticeship model’ of the other medical specialities. It involves both hospital posts and placements in privately owned general practices and other community-based settings. The complexity of the situation demands the existence of GPRA so that the interests of registrars can be represented and can influence the course of training to meet future health needs of the Australian population. The profession would be greatly disadvantaged without GPRA and, as the only organisation that can effectively advocate for GP registrars, we are determined to continue to be active and effective in influencing the future of general practice. There are a number of challenges facing the future of the profession. Australia is moving from a situation of under-supply of GPs to potential over-supply, notwithstanding the

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specific problems associated with achieving an adequate supply of GPs in rural and remote areas. Furthermore, we are in a time of significant change for GP training. Reforms to GP training that commenced in 2014 continue to roll out, including the transfer of responsibility for selection into GP training

may discourage medical graduates from undertaking GP training. Cost shifting may result in medicine graduates paying higher and higher fees just to be considered for general practice training and for all the steps along the way, such as the requirements for attaining fellowship of the two colleges. Protections

The complexity of the situation demands the existence of GPRA so that the interests of registrars can be represented and can influence the course of training to meet future health needs of the Australian population. from the Department of Health to the Colleges from 2018, a number of initiatives flagged in the 2017/18 Federal Budget, and the recently announced decision to transition responsibility for GP training from the Department of Health to the two GP colleges by 2022. More than ever, it is vital that GPRA exists to support GP registrars, advocate for the future of general practice, and provide the independent voice for registrars. The Commonwealth Governmentâ&#x20AC;&#x2122;s decision to move responsibility for GP training to the two GP colleges is fair and reasonable. GPRA is keen to ensure this is a successful transition that does not disadvantage registrars but, rather, strengthens the general practice training program so that it attracts high calibre prospective candidates to this career path, and ultimately achieves the aims of access to high quality primary care for all Australians. However, potential problems may arise. Uncertainty in the transition phase

8 GP Registrar

for GP Registrarsâ&#x20AC;&#x2122; training and workplace conditions will need to be maintained when the GP colleges run the training program, accreditation and the examinations. In this time of substantial change, GPRA is focused on supporting and advocating for GP registrars and securing a sustainable future so that independent representation of registrars is maintained, and strengthened. The Commonwealth Government continue to indicate that support for general practice registrars and ensuring the quality of their training and protecting their well-being will receive due consideration. GPRA is committed to influencing national deliberations regarding general practice career pathways, the role of general practice within the wider community and the well-being of those choosing a career in general practice. Andrew Gosbell, PhD

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WHAT IS GPRA? A VOICE FOR THE NEXT GENERATION OF GENERAL PRACTITIONERS

eneral Practice Registrars Australia (GPRA) is the voice and peak body for the next generation of general practitioners. It represents more than 25,000 members, including registrars and early career GPs as well as medical students and prevocational doctors with an interest in general practice. GRPA is a not-for-profit organisation funded primarily by the federal government. GPRA President Dr Melanie Smith said “GPRA is the only national organisation run for GP registrars, by GP registrars. “It’s so important that registrars are supported to have a voice on matters that affect their clinical practice, their education, their employment conditions and their personal wellbeing,” Dr Smith said. “This is especially so in times of change and uncertainty.” As each new year dawns and a new cohort of GP registrars begin their first placements, Dr Smith encourages them to become GPRA members. “Membership is free, and allows you to not only be supported in your training and through your exams, but to also contribute to the future of general practice.”

10 GP Registrar

GPRA President Dr Melanie Smith, and CEO Dr Andrew Gosbell.

GPRA SUPPORTS FAIR EMPLOYMENT Guided by input from its membership, advisory council and committees, GPRA conducts advocacy on all levels. This ranges from personal assistance with training or employment issues, to lobbying at the highest levels of government for better medical education. Every two years, GPRA negotiates with General Practice Supervisors Australia to update the National Terms and Conditions for the Employment of Registrars (NTCER). GPRA CEO, Dr Andrew Gosbell, said negotiations are driven by evidence gleaned from GPRA’s biennial terms and conditions benchmarking survey. “Supporting fair employment for GP registrars is one of our most important functions,” Dr Gosbell said.

“For many, the first GP placement is the first time they’ve been in a small medical workplace, and the first time they will have had to negotiate an individual employment agreement. “This can be quite overwhelming, but we know the NTCER inside out, and we’re here to help with advice on contract negotiation or to assist if things go wrong.”

GPRA IS RUN BY REGISTRARS, FOR REGISTRARS

The GPRA Advisory Council is made up of GP registrars, and early career GPs, who advise the GPRA Board and CEO on important matters concerning registrars. There are also national representatives from various general practice stakeholders who sit on the council. All Registrar Liaison Officers (RLOs) are automatically members of GPRA’s Advisory Council. The Advisory Council: • report, discuss and advance issues in GP registrar training • provide advice to GPRA • provide oversight to GPRA Working Groups • support RLOs in addressing local issues • influence national change.

WHY JOIN GPRA? • personalised assistance with training or employment issues • free exam preparation webinars • exam preparation resources • opportunities to shape the future of general practice through GPRA Working Groups • fortnightly member eNewsletter with the latest in GP training, events, exam resources, and more • it is free!

provides guidance and advice to GPRA and the general practice sector, fits in well with the busy lives of GP registrars. Our member eNewsletter informs registrars of upcoming opportunities to join a working group.

WHAT CAN YOU FIND AT GPRA.ORG.AU? • the National Terms and Conditions for the Employment of Registrars (NTCER) • GP registrar and VR GP positions on the jobs board • GP earnings calculator • an employment agreement template • exam books, resources and webinars • video interviews with current and former registrars.

GET SOCIAL!

General Practice Registrars Australia /gpraorg @GPRALtd

MEMBERSHIP IS FREE

GET INVOLVED IN A NATIONAL WORKING GROUP

The Advisory Council form small issue-based Working Groups to address specific concerns or future needs within general practice. Topics addressed by GPRA Working Groups include the NTCER, registrar wellbeing, Close the Gap, rural and remote GP training and more. GPRA’s Working Groups are expert, agile groups that focus on one issue at a time. A Working Group remains active until their specific aim is achieved. This model, which

GPRA is independent from your practice, RTO and college. Anything you discuss is confidential. GPRA can support you with any difficulties which you may encounter with your training or employment.

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WHY YOU’VE MADE A GREAT CAREER CHOICE

A MESSAGE FROM GPRA PATRON, PROFESSOR MICHAEL KIDD Michael is currently Professor of Global Primary Care at Flinders University and Chair, Department of Family & Community Medicine, University of Toronto, Canada. From 2013-2016 Michael was President of the World Organization of Family Doctors (WONCA). He is a past president of the Royal Australian College of General Practitioners (RACGP), a Council Member of the Australian Government’s National Health and Medical Research Council (NHMRC), and a board member of several health organisations, including beyondblue.

have been invited to share some thoughts with you about contemporary general practice, and to reflect on the critical role of general practitioners in healthcare systems in Australia and elsewhere in the world. I am convinced that general practice is a great career choice. And that it will always be so. If you want a career where you can go home at the end of each day for the next 40 or 50 years, knowing that you have made a positive difference to the lives of your individual patients, and to the health of your local community, then you have made the right choice in training to become a general practitioner. General practitioners, no matter where we work, ensure that healthcare services are affordable, safe, appropriate and equitable. At a time of rapid change, with significant social unrest and distrust and conflict in many parts of our world, general practice provides stability and comfort to our patients, our communities and our nation. People know who we are and what we do. After all, general practitioners have been part of our lives for a very long time. One of the first GPs to record thoughts about medical practice was Hippocrates. We now recognise that Hippocrates was a genuine GP, sitting under a plane tree, seeing patients of all ages, treating all conditions, providing first point-of-contact as well as continuing and comprehensive care, and recognising the links between the physical, psychological, social and spiritual influences on his patients’ health and wellbeing. 12 GP Registrar

Few of us get to practice medicine nowadays sitting outside in the shade of a plane tree, but over the centuries each culture has developed its own healthcare providers who can meet the needs of its own population – as village healers, as country doctors, as gatekeepers to the rest of the healthcare system, as general practitioners. I believe we are at the beginning of a new golden age for general practice. In countries all around the world, the message is getting through about the importance of strong primary care and the role of general practitioners in ensuring universal access to healthcare for all people. You know the many healthcare challenges our world is facing. It is becoming increasingly apparent that our generalist tradition of primary care is the only way that nations will be able to

effectively tackle the diverse health challenges facing the people of the world. Strong general practice is needed to effectively address the rise of chronic health concerns in many nations, especially the rising rates of cardiovascular disease, diabetes, respiratory disease and cancers, as rates of smoking, obesity, poor nutrition and lack of physical activity continue to rise. Strong general practice is needed to effectively address the rapidly rising burden of mental health problems across the world. Strong general practice is a key to the control of communicable diseases, including dreaded diseases like HIV, tuberculosis and malaria, and new and emerging diseases like SARS and new strains of influenza. This is a remarkable time in human history, as we now have the ability to turn a pandemic like HIV into a controllable, low-level endemic disease – but this will only happen through strong primary care. Strong general practice is the only way nations will be able to effectively manage the healthcare needs of the increasing proportion of elderly people, providing sensible healthcare options, including compassionate end-of-life care. Strong general practice is the way to effectively contain rising healthcare costs in our nations, through support for better preventive care, health promotion and improvements in chronic disease management and the management of co-morbid conditions. Strong general practice enables us to address the inequities in healthcare and ensure that all people, wherever they live – and especially those who are vulnerable and marginalised – can access high quality healthcare services. If we are going to have strong general practice, then we will need enthusiastic, dedicated, welltrained and well-supported specialist general practitioners, like you. As GPs, we are specialists in primary medical care and in the generalist tradition of medical practice. We are specialists in preventive care and health promotion; in early diagnosis and management; in the management of undifferentiated illness, acute conditions, medical emergencies, and people with complex chronic diseases and multiple morbidities. We are specialists in the management of mental health challenges and the impact of social and environmental issues on health; in palliative care and supporting our patients to die with dignity. And each of us is a specialist in the unique

healthcare needs and concerns of our own unique patient population. We are specialists. Don’t let anyone tell you otherwise. Governments need to value our generalist traditions and support the generalist approach to high quality primary medical care. The evidence is clear that health systems based on strong primary care, which includes strong general practice, are the most efficient, equitable and cost-effective. Every family should have a general practitioner who they can trust for their medical care and advice. As general practitioners, we are also in the business of leading and inspiring. Each of us is a leader in our local community. Through our commitment to quality care and training and the application of research into clinical care, we ensure the health and wellbeing of our individual patients, and of our local communities.

GENERAL PRACTICE IS A GREAT CAREER CHOICE. AND THAT IT WILL ALWAYS BE SO. We have a respected voice and the opportunity to be effective advocates about key health issues. You will be aware that changes are under way in GP training in Australia. We must make sure that any changes continue to support the high quality of the training provided to our nation’s registrars, preparing you to provide medical care and advice over the years ahead to the people of Australia, and wherever else you may work in the world. It is critical that our nation’s registrars are engaged in consultations about any changes and that the voice of our registrars is loud and clear in response to proposed changes and their likely impact. I advise you to keep yourself informed about the changes, be vocal, and support your GPRA leadership to provide a strong and representative position on behalf of all registrars, and on behalf of the people who will benefit from your care and advice now and in the future. Professor Michael Kidd, GPRA Patron GP Registrar 13

hen medical graduates enter general practice, they often donâ&#x20AC;&#x2122;t have a detailed understanding of the challenges and opportunities ahead of them. Their hospital experience does not adequately prepare them for their new working environments. In addition, they often donâ&#x20AC;&#x2122;t appreciate the diversity and scope of experiences at their disposal should they choose to undertake their GP training in a rural region. The editorial team at General Practice Registrars Australia interviewed a number of general practice registrars and recent fellows from the Bendigo-Echuca region of Victoria. 14 GP Registrar

This small collection of stories illustrates the variety of experiences and the many rewards that can be part of the journey toward becoming a general practitioner. The registrars who made time available for these interviews chose to undertake their general practice training away from major cities and by telling their stories they may encourage others to take a similarly rewarding pathway into general practice. The interviews for the stories in this section of GP Registrar were made possible as a result of the generous assistance of Murray City Country Coast GP Training.

GENERAL PRACTICE CENTRAL VICTORIA

GP Registrar 15

16 GP Registrar

THE SPECIALTY FOR THE PEOPLE PERSON:

A CHAT WITH DR KELLY CHAMPANE

rowing up in Botswana, Kelly Champane’s desire to be a doctor was more than just a career choice. It was also a deeply personal and political aspiration. “When I was growing up my country was hard hit by the HIV/ AIDS epidemic,” said the GP registrar, who is now based in the regional Victorian city of Bendigo. “I went through a stage where I saw so many people die, from friends to family members to young kids. “I had a best friend who died at the age of 11 from AIDS – she was born with HIV. She was an orphan, her parents died a couple of years prior and she was raised by her grandma. “I guess that growing up in that era, I just wanted to do something that would help… I knew that I wanted to be a doctor to try and help my country.” Ten years ago there was no medical school in

Botswana, and the only pre-med course accepted just 60 students per year. “I pretty much just gave it 110% all through primary and high school and senior school,” Kelly said. Kelly was accepted to and completed pre-med at the University of Botswana, then came to Australia to pursue her medical degree in 2010. Like many medical students and pre-vocational doctors, she agonised over which specialty to choose. Her gut had always told her to do general practice, but as she went through her studies and hospital residency, doubts started to creep in. “[Medicine] is such a competitive world, so sometimes saying you want to be a GP can be looked at as though it was some sort of lack of ambition,” Kelly said. “I think that was one of the things that made me hesitate because I was thinking ‘I’m ambitious, I’m driven’.” A lack of exposure to GPs contributed to this myth. “As a med student, you feel like you have a lot of role models in other specialties, not so much in GP land.” GP Registrar 17

“[During my residency] I had a supervisor who was an emergency physician and everything seemed so exciting, I looked up to him and thought he was amazing in all his work. “So I thought ‘okay, this is what I want to be.’

“As cliché as it sounds, I always tell people I found myself on that trip,” she said with a laugh. “I had time to think and really introspect on who I really am, and I what I really want out of my life. “I know that I want a more balanced life at the

“I went through a stage where I saw so many people die…I just wanted to do something that would help.” “I think in retrospect I looked up to him as a role model, it was not so much the work itself.” A solo trip around South East Asia gave Kelly the clarity she needed, and the courage to trust her original inclination towards general practice. 18 GP Registrar

end. I want to look back when I’m 70 and know that I have lived. “I knew that I wanted to start a family and actually have time for them, and do other things outside medicine, like public health.”

Kelly realised general practice takes no less ambition than any other specialty, just a different skillset. “I thought ‘you know what, I really like the holistic approach to patient care, I know I’m a people person’, and for me it’s not just about the disease, it’s about the person. “This is in no way a lack of ambition. This is a certain specialty which is for a certain type of people, and I am one of those people.” Kelly began her GP training in 2017, and now works at Bendigo Primary Care Centre in Central Victoria. In 2018 she will be taking up an academic GP registrar position, working part time at Neal Street Medical Centre in Gisborne and part time as an associate lecturer and researcher at the University of Melbourne’s Department of General Practice. When GPRA spoke to her in late 2017, she was studying for the KFP and AKT exams in February. “It’s not easy, to be honest, because we work fulltime,” Kelly said.

“GP work is exhausting in itself in that it’s constant, you’re constantly talking to people throughout the day. By the time you get home you are just absolutely drained, so to sit down and study, it’s really not easy.” As a member of the Australian National Committee for UN Women and an ambassador for African education charity One Girl, Kelly’s outlook is global. “Both Botswana and Australia have given me so much – Botswana in terms of investing in my education, and Australia in equipping me with an excellent medical skill set and world class education,” she said. “It’s only morally right for me to contribute in both countries.” She plans for her clinical work to be a parttime occupation, and is also studying a Masters of Public Health with the view to start her own medical clinic and health organisation one day. And long-term? “Venturing into leadership in my country, the Ministry of Health… or the president!”

GP Registrar 19

20 GP Registrar

SOPHIE PING MAKING A NICHE IN FORENSIC MEDICINE GP Registrar 21

ophie Ping is currently with the Victorian Institute of Forensic Medicine and she says the pathway that led her there is not common. “As a general practitioner, I saw a lot of domestic violence. I saw a lot of women who didn’t have health literacy. Then it sort of came to me in a flash one day – the realisation that I wanted to do forensic medicine,” Sophie says. “Some of my mentors had done this previously and, in Ballarat, there are only two people qualified to do forensic examinations. In some ways I am creating a bit of a niche for myself.” Sophie’s role entails examining alleged offenders and victims of physical and sexual assault, and assessing people’s fitness for police interviews. She says most referrals are from the police. “If the police are considering going ahead with charges, they will contact the Ballarat Centre for Sexual Assault to undertake a physical examination. “We take photos and samples. We also consider such matters as whether the person is drug affected or needs increased medical attention.” Sophie is intrigued by some people’s morbid curiosity about what she does. “They have a fantasy that it is like CSI. In some

ways it is, but often it is just an extraordinary amount of paperwork. “It is tiring and draining and you need to be incredibly prescient and aware of what you are saying. You need to be careful not to use jargon or say something that might be misinterpreted. “You second guess yourself a lot. But at the worst possible moment in someone’s life you are there to help them and that is extraordinary. A full sexual assault examination of a female with other injuries could take two to four hours and during that time you might see a shift in the patient. “You actually develop a fleeting but intense relationship… they have a person who is there for them – who is entirely interested in everything they are feeling. They understand that what you are doing is to help them. “It requires a combination of skills. If you come out feeling that you have done the best you can for a patient, and you actually see a shift in how they are emotionally, over those few hours. It is quite extraordinary and you know you have done something. “The majority of the time people will come up and say thank you so much for taking care of me. It is really powerful.” Before medicine Sophie first applied to do medicine straight out of high school.

I SAW A LOT OF WOMEN WHO DIDN’T HAVE HEALTH LITERACY.

22 GP Registrar

GP TRAINING “It is always worth reviewing general practice training. We should not rest on our laurels. Some general practice educators and supervisors have very set ideas about general practice training,” Sophie says. “The current training arrangements are an idealised, stylised system but we need to accept that people have

different learning styles. We should explore options for problem-based learning and group learning. We should also facilitate self-knowledge about learning styles and preferred methods of study. “There is a lot of content within the course but there are gaps in the mental health training and there should be

“I didn’t get in. That’s okay. I think things tend to happen at the right time for the right reason and, if I had gone into medicine when I was 18, by now I would be burnt out and very angry,” she says. “I did an Arts/Science degree. Then I did honours in science. Then I did a PhD in neurophysiology. I worked in research for a while. “I was a senior tutor in medicine physiotherapy at Melbourne University. I was made redundant and that turned out to be the best thing that ever happened to me.” Sophie went to Samoa for a year and worked there at the University of Medicine, which offers mostly online programs. “Scholarships were offered to Samoans and Pacific Islanders to try and improve medical education. I ran the campus and taught the introduction to medicine module.” “It is a patriarchal, religious society with a lot of non-verbal communication which is tricky… they are keen to be seen to be helpful. Hence, some people will say yes to everything but simply not do it. It can be very frustrating.” Sophie left Samoa and went to Darwin for three years, where she coordinated the nursing science degree. She then decided to make the move to medicine. “I sat the GAMSAT and was fortunate enough to get in.“I went to the School of Medicine at Deakin where I was enrolled in the Integrated Model of Medical Education in Rural Settings program and spent third year in rural general practice. Through this program I learned a lot and it did not diminish my desire to be a GP.” Maryborough magic During the first half of her final year, before moving on to forensic medicine, Sophie lived

more practice with patients. It would be good to have more content on pattern recognition and application of knowledge. “General practice is moving fast and the way we train GPs needs to be reviewed and move forward. It is not helpful to say “this is the way it has been done and this is the way we are going to keep doing it”.

and worked in Maryborough where she “saw real medicine”. “I was at one of the general practices at Maryborough. We all worked together and we took turns to run the urgent care centre. We would see our patients during the day then be on on-call overnight or run the clinic on the weekend. “Maryborough has a district health service with about 25 acute beds and two emergency beds. There is a nursing home nearby. Local GPs see all of their patients in the hospital, including people in acute beds. “They take turns to run the urgent care centre and see a lot of acute medicine such as heart attacks and strokes. They decide whether somebody needs to be evacuated to a hospital. “When you are working there, you have to trust your own judgement and have back-up plans.” Sophie’s advice for new registrars “I would always suggest that people do more than one year in a hospital. The knowledge acquired will be useful. Much of general practice is about pattern recognition and feeling comfortable. Take that extra year. It is only a year. “Additionally, general practice training is only two years, so if you are not sure which speciality you want, absolutely do general practice! There are so many transferable skills. And we get to do so many different things – it is not sitting in a little room all day seeing people with coughs and colds. “You have such an impact on people’s lives and you have an impact in different ways. It is about improving health literacy. It is about seeing families. It is about teaching people things about themselves that they didn’t know. It is an opportunity to be really intimately involved in people’s lives without an “all care but no responsibility” attitude.” GP Registrar 23

24 GP Registrar

Putting family first:

Bendigo’s Dr David Gidley

here’s lots to consider when choosing the right placement: the hours you’ll be expected to work, the variety of clinical cases you’ll be exposed to, the training and support available. For those with young children, choosing a training region or placement can also go hand in hand with choosing where to set up life. This was front of mind for Dr David Gidley, a registrar at Bendigo Primary Care Centre in central Victoria.

Originally from Canada, David was living in Adelaide with his wife and two young sons when he decided to apply for general practice training. With family in Perth, great memories of holidays in Victoria, and the schooling needs of a son with autism to consider, David and his wife studied their home town options with the zeal of an overachieving registrar studying for the OSCEs. “We looked at Ballarat, Ararat, Bendigo, Adelaide, Perth, and outside Brisbane,” David said. “My wife went travelling, she went up and interviewed the schools, we spent a good month travelling around Victoria checking out the schools.” In the end it was Bendigo that ticked the most boxes. So, after applying and being accepted into the general practice training program for Western Victoria, David set his sights on finding the ideal placement. “I came to [my regional training organisation] saying ‘this is the school my children will be attending, I’m willing to drive 60 minutes each way, where can you put me?’ “And they sort of looked at me like ‘what, you’re picking the school and then you’re going out from there?’” It may be an uncommon approach, but David’s glad they put their kids’ needs at the forefront of the decision. “He is very happy, and we’re very happy as well,” David said, referring to his older, autistic son. “Bendigo is very family-friendly, as a city goes, GP Registrar 25

there’s lots of child-based activities throughout the year; the Easter Festival here is huge.” A detour into ENT The path that lead David to general practice is unusual. Growing up in a small, one-doctor town 300 kilometres north of Toronto, he had long admired the local GP. “He treated every family in the town, and I knew him really well and I always wanted to be like him,” David said. “I always admired that relationship he had with the entire town.” As medicine is not available to undergraduates in Canada, David began by studying biology.

but it didn’t appeal to me in terms of my mental health.” An enjoyable ear, nose and throat rotation followed, leading David to think he had found his specialty, and he successfully applied for and began ENT training. While he enjoyed it in a clinical sense, workload-wise it turned out to be exactly what he had mistakenly feared of general practice. “Two years ago, I was averaging 100, 110 hours a week,” David said. “I didn’t see my children; I didn’t see my kids at all for three months when I was studying for my exams.” Moving into a rented apartment or motel room in order to study was the norm for ENT

I came to [my regional training organisation] saying ‘this is the school my children will be attending, I’m willing to drive 60 minutes each way, where can you put me?’ But upon graduation, the prospects for doctor hopefuls with only a bachelors were bleak. “Medical schools in Ontario at that time were saying ‘we won’t accept your application without a masters or a PhD’, and I really had no interest in doing a masters or a PhD.” Instead, he threw in the job at a cranberry farm that he had been doing since his teens, and went travelling instead. He met his now wife in Edinburgh and they eventually settled in Adelaide where David studied medicine at Flinders University. He spent his third year in the country with a GP whose work ethic David described as “extraordinary”. “He’d call me up at 10 o’clock at night saying ‘oh I’m going to see this patient at the clinic, come on over’. “And I didn’t realise how different he was from every other GP, so I got a little bit concerned about how many hours I’d be working as a general practitioner, how much responsibility I’d have to my patients. “It’s nice to be that wanted and that needed, 26 GP Registrar

registrars, and “one chap even moved back in with his parents for the entire final year”. Eventually, David decided ENT wasn’t worth the toll it was taking on his relationship with his family. “I came home once when I’d been staying away for three months for exams and my sons were two and four. “My father-in-law had been staying, and I came in and my son looked at my father-in-law and said ‘hi Dad’ and just looked at me with this blank expression on his face and said nothing. “That was the end of my surgical training.” Video won’t kill the GP star David started on his new path – general practice training – in 2016. He is especially glad he did so when he considers the future of medicine. “Robotics in surgery and 3D printing and genetic mapping and everything else that’s coming along is going to put more and more focus on technology and less focus on clinical skills,” David said. “I have some concerns about how the specialties

own grandparents, whose goal was to live to see him and his sister graduate. “[Patients] are often offended the first time I bring it up,” David said. “They think I’m saying they’re dying and they’re saying ‘why are you giving up on me?’ and I’m saying ‘I’m not giving up on you, I just want to know what we’re fighting for’.”

are going to manage that… their role is going to become very simplified.” General practice, he thinks, is the exception. “You’ve got to know the patient and the family and the story, because we deal with mental health as much as we do physical, and the social implications of the [medical] choices that they make as well.” Talking about death One area where people skills are as important as clinical skills is palliative care – something David defines broadly. “When the person turns 65 you don’t say ‘oh, you’re about to die’, but you say ‘what are your plans for the next 10 or 15 or 20 years? How do you want to live your life and what are we going to do if things arise?’ “That’s actually starting to slide into an end-oflife planning issue which is technically palliative care.” It’s not a conversation all GPs – nor patients for that matter – find easy. But David takes inspiration from the frank talks he had with his

Registrar camaraderie For David, one of the best parts of being a registrar is the camaraderie. “We all get along with one another,” he said. “It’s a strange thing – when you’re medical students you’re all competing for who gets the highest mark – you still get along but there’s a little bit of competition. “When you’re an intern you’re always trying to get into that training program. “Once you’re a GP registrar, we’re all there

to pass. “You’re not trying to be the most expert on anything because you can’t remember it all in a five- or ten-minute consult, but you have to know enough to know you’re treating the patient appropriately, and sharing that information amongst registrars is really good.” David has a study group in Bendigo, and also studies via Skype with a registrar in Mildura.

“You get to study the stuff you want to study and you get to teach other people the stuff you’re good at.” He may be a little older than the average GP registrar, but David has no regrets about the road he took, with its detour into ENT. “Even the long road that it’s taken me to get here – I graduated in 2007, so ten years later I’m still sitting a fellowship exam,” he told GPRA when we spoke to him in late 2017 before the OSCE. “There’s been bad bits and good bits to it all but I’ve learned at every step.” GP Registrar 27

DR JERRY WONG CHOSE THE RIGHT TOWN: “WE ARE PLANNING TO BE IN ECHUCA FOR SOME TIME”

28 GP Registrar

GP Registrar 29

lthough he grew up in Melbourne, Dr Jerry Wong is enjoying the challenges and opportunities of working in Echuca, where he splits his time between two different general practices and does regular on-call work at Echuca Hospital. “At the end of year 12, I decided to do medicine. I am not completely sure why I made that decision but I wanted something challenging and something meaningful, like helping people. That decision sent me on a good journey. “The decision to choose general practice came in the last year of med school. There was no single specialty that I loved: I liked aspects of everything. So, I thought general practice might be a good choice. I also knew that I wanted to work in the country.”

would be like to work in a rural area. It made a big difference to me.” The move to Echuca “I did the diploma and then the advanced diploma in obstetrics before starting my GP training in Echuca at the beginning of 2017. “I spend half my time at the Njernda Medical Centre, which provides medical services predominately for Indigenous people, and half my time at Echuca-Moama Family Medical Practice, a mainstream practice. Working at these two practices gives me a broad range of experience and prepares me well for the RACGP exams. I also do regular work at Echuca Hospital where I sometimes see really sick patients and do some emergency medicine. The high dependency unit at the hospital increases the range of experience and challenges. Finally, I am also on-call for obstetrics. “There are a number of GPs in Echuca and there are three supervisors for obstetrics. There are enough people doing obstetrics that you don’t have to be on-call

“… there are many great teaching practices in rural areas.” Jerry’s wife is from Cootamundra, NSW where she had a good experience growing up. “She encouraged me to think about working as a rural doctor. I was also thinking about doing obstetrics at that point and I knew that, as a GP, I could only do some obstetrics in a rural area. “After finishing med school, I went to Ballarat for a couple of years. I did my internship there. It was a step away from being in Melbourne towards what it would be like working as a rural GP.” Jerry says he went on a GO RURAL trip, organised by the Rural Workforce Agency, Victoria. “That trip helped to me to see what it 30 GP Registrar

every night. That is something to consider when choosing a practice: do you want to be the only GP obstetrician in town or do you want to be where there are lots of other people who will be on-call to share the load?” Success depends on great supervisors Jerry says that if a registrar is offered a nonmetropolitan place for GP training they should keep in mind that there are many great teaching practices in rural areas. “I would recommend that a registrar who is going to a rural area make inquiries about the different practices. Talk to other registrars and hear about their experiences. It is great to end up

erry says working at Njernda Medical Centre has been helpful in terms of the exposure to Aboriginal health issues. “There I have often come to see that there are many other issues impacting on health. It is often a very complex situation. “Mental health and social circumstances are more regularly part of considerations when looking after the health of a patient and that really requires a holistic approach. It is also important to build trust and then to work together, along with the other staff at Njernda, to find solutions to health problems that may be intertwined with social and economic issues. In the end, it is rewarding working here. “It is a privilege to work with a population that is disadvantaged and I hope my small contribution will help empower members of the Aboriginal community.”

at a practice where you want to be there and they want you to be there as well. “The role of supervisors is critical and I can acknowledge without hesitation that there are great supervisors in Echuca. They are always willing to take a call and to come in to assist if you are feeling out of your depth. “One of the reasons I chose to work in Echuca is that I knew that I would always be supported.” Choosing the right town “I never considered working in a city. I knew I would get a really good experience in a country area. I knew I would be supported, see lots of interesting cases and have a good work-life balance. “Lifestyle is important when you have a family. In Echuca there are many advantages. For example, you do not have to travel far to your practice. You can be home with the family in ten minutes. This town is really welcoming. It is a pleasant supportive community.” Jerry notes that Echuca attracts a lot of tourists. “You especially notice that around Christmas and school holidays. It’s part of what makes this town attractive to live in because it feels alive and there are always interesting events going on. “When you are choosing a practice, you must research the local culture. You want to know the town is nice to live in. That’s why we chose Echuca. We are planning to be in Echuca for some time. Our eldest son is going to the local pre-school and we are involved in many local community groups.” In the years ahead “I would like to work overseas and work with a mission organisation. That has probably influenced my decision to become a procedural GP as well. Having procedural skills is important if you want to work overseas where there may be less access to specialists. You have to know how to be creative

when you don’t have resources at your finger-tips. You have to know something about public health. So all these generalist skills that I am learning as a rural GP will be vital to that overseas environment as well. “Australia has a good model for general practice training. The training leads you toward being an independent, holistic doctor. I would like to use my training and skills in a developing country and help them develop their general practice training.” Jerry is not expecting to work overseas for some years. Echuca has many attractions and he is not in a hurry to leave. “One of the attractions of working here is the variety and I feel like you can do as much as you feel comfortable with. You can’t just write referrals and expect people to be seen quickly by a specialist. So, if you want to take something on – do more training and increase your competence – you can often manage patients yourself instead of referring them to specialists. People in rural communities love that. If they feel you are providing a good service, and giving good care, they generally prefer that to being sent to Bendigo or Melbourne.” Looking after your own health “There is always a natural inclination for registrars to keep quiet about their own health issues but it is better to open up. The RTOs and supervisors handle these things well and registrars can really get help if they need it.” Jerry notes that moving to a rural location often means losing contact with colleagues. “I often wonder what the people I went to med school with are up to these days. When you move away from Melbourne you do lose contact. Addressing that issue – perhaps by keeping contact with old friends via social media, or just by making new connections and friends and throwing yourself into your new community – is part of protecting your well-being and keeping healthy.” GP Registrar 31

YOUR EMPLOYMENT AGREEMENT READ BEFORE YOU SIGN THE DOTTED LINE

t the start of each new training term, you and your employer will need to sign an employment agreement. This agreement outlines the terms and conditions of your

employment. GP registrar employment agreements are covered by the National Terms and Conditions for the Employment of Registrars (NTCER), negotiated by GPRA. The NTCER outlines: the minimum which GP registrars can be paid, leave entitlements (such as annual leave and personal leave), hours of work (such as ordinary hours, on-call, overtime) and more. Know what you are entitled to Regardless of whether this is your first training term or your fourth, make sure you’re familiar with the NTCER, which can be found at gpra.org.au. The NTCER guarantees basic terms and conditions of employment; a training practice cannot offer you less than what the NTCER states. You can negotiate with your employer for conditions and benefits greater than the NTCER – in fact, many registrars do, and successful negotiation is more likely in GPT2 and beyond. Be prepared for a bit of give and take. Your practice is a business, and your employment should be a win-win situation. 32 GP Registrar

Know your benchmark Every two years, GPRA produces the Terms and Conditions Benchmarking Report. Review this report for information about the terms and conditions of other registrars’ employment – see what the average registrar earns in different parts of the country, and at different stages of their training. Knowing this may help you feel more confident when you negotiate your agreement with your employer, particularly if you’re looking to receive terms and conditions above the minimum. Talk to the practice Discussions about your employment may occur with your GP supervisor, practice manager or another person within the practice. Some things should be brought up during the interview. For example, if you wish to take an extended period of leave. Other matters are more appropriately brought up when you are offered the job. Don’t be afraid to ask questions. If both parties’ expectations are clearly understood from the beginning, there are less likely to be problems later on. Use a template… and understand every bit You may wish to suggest to your employer that you use the template employment agreement available at gpra.org.au.

Take the time to read your agreement carefully and make sure you understand each clause. Make sure both parties have signed the agreement before you start work. Do not sign anything that you have not read, do not agree with, or do not understand. Seek advice If you’re unsure about something or want advice, speak to your Registrar Liaison Officer or contact GPRA on registrarenquiries@gpra.org. au or 03 9629 8878. GPRA can give you personalised, confidential support and advice regarding your training or employment. Keep it up to date Your situation can change during the year. It’s important that any changes to your hours or

conditions are recorded in an amendment to your original employment agreement. You should sign a new agreement at the beginning of each term, even if you are staying on at the same practice. Learn more There are plenty of helpful resources on GRPA’s website. • booklet: Negotiating employment: Essential knowledge for general practice registrars • the Terms and Conditions Benchmarking Report • video: Signing your first GP contract • webinar: Negotiating your contract – navigating the NTCER.

Your essential negotiating checklist These are the key topics that should be covered in your employment agreement. Working hours ordinary hours and days of work session times and locations, and administration time training and employment load on-call, after-hours, additional ordinary hours average number of patients per hour Education and supervision protected and non-protected in-practice teaching educational release time supervision Remuneration base salary or percentage of billings or receipts plus superannuation payment for ordinary hours payment for off-site work, including hospital VMO, nursing home and home visits payment for after-hours and on-call work payment for on-call – on premises and off premises

frequency of billing and payment cycles payment for working on public holidays payment for each leave type SIP and PIP payments any other allowances and expenses

Leave annual leave personal and carer’s leave compassionate leave study leave parental leave Other matters medical indemnity insurance personal safety and occupational health and safety fatigue management restrictive covenants renegotiation date dispute resolution process termination of employment Contract paperwork written agreement completed, signed and dated by you and your employer BEFORE starting work and a copy retained for your records

GP Registrar 33

WHAT TO DO IF YOU RUN INTO PROBLEMS

ike any job, general practice training has its ups and downs, but for the vast majority of GP registrars their training placements and experiences are positive and rewarding. However, it is not unusual for registrars to have concerns and encounter problems. Most difficulties with workplaces and training stem from lack of awareness, assumptions or misinterpretations by the registrar or the training practice – or both – rather than intentional acts. Open, honest and early communication is the key to solving most of the issues faced by registrars! Don’t delay if you have questions or concerns – it’s better to raise these with your supervisor or practice manager as early as possible and in a spirit of collaboration, as this can quickly resolve many issues. Occasionally, registrars find themselves in situations where they are unhappy about some aspect of their training. This may include practice placement, relocation or educational issues; interpersonal problems; or disputes about remuneration or other employment conditions. Many registrars can find it challenging to raise these matters with a supervisor, training practice or even their regional training organisation (RTO) due to concerns about escalating conflict and power imbalance issues. Try not to get too worried by this, as there are a range of options and supports available should you be facing any of these difficulties. You are not alone! Who to talk to for support In general, most problems can be resolved locally with the training practice or Regional Training Organisation (RTO), particularly if dealt with early. Remember that avoidance or “trying to put up with it” rarely resolves a situation and more often just makes things worse. The most appropriate person to talk to depends 34 GP Registrar

on what the problem is and how you want to go about dealing with it. Your Registrar Liaison Officer (RLO) is often your best option as they provide local support and advice – no matter what the problem. RLOs are registrars too, and part of their role is to provide peer support to you. In some circumstances, the RLO can act on behalf of a registrar if the registrar feels unable to confront an issue themselves. Your RTO will also have a staff member as a point of contact for registrars, who can assist or direct you to other staff or medical educators in the organisation who can provide advice. The staff at General Practice Registrars Australia are available to talk about any problems or difficulties you may encounter with your training. Our registrar enquiries service can be contacted via registrarenquiries@gpra.org.au or on 1300 131 198. All matters are treated confidentially. We will work with you to understand your issues and provide suggestions on how to approach a difficult situation or help solve larger problems. We can speak directly with the RTO to clarify any misunderstandings, and can provide assistance with dispute resolution. Seeking a resolution Try to understand the causes of the situation. If it is an issue with your work conditions or remuneration, check your employment agreement, the National Terms and Conditions for the Employment of Registrars (NTCER) and any relevant workplace policies at your practice. Contact GPRA if you need clarification on any issues within the NTCER. If it is a training matter, review your RTO’s training handbook and policies and any relevant ACRRM/RACGP policies. Use this information to try and objectively assess the situation and the role you may have played in the issue.

In the event of a dispute, ensure you document all relevant information. Keep a record of times and dates of events, make notes of any verbal advice you are given, retain copies of any correspondence and try to stick to factual occurrences. Speaking with the other party (e.g. supervisor or practice manager or owner) is the preferred strategy when attempting to resolve the situation. Before doing so, plan and prepare. Ensure some time is set aside in a neutral location to have this discussion. Respect and active listening are critical. Focus on the problem and on finding a solution, not the people involved. Present your point of view using “I think” or “I feel” statements. Seek to understand the other party’s viewpoints. Acknowledge and record any areas of agreement. Need to take it further? If you are unable to resolve a situation by speaking with the other party, you may need to escalate the matter. Every RTO has an appeals policy and process. If you cannot find yours or need support with this process, contact your RLO. Should that not resolve the issue, there is a further appeal process that involves the medical colleges (ACRRM and RACGP) and the Department of Health. These appeals are a last resort when all else has failed. GPRA offers assistance and advice during

these processes. We have been involved in a range of registrar appeals. So contact us if you find yourself in this situation. Often, early intervention and discussion results in better outcomes for all parties, so get in touch with us as soon as you realise. Legal advice might also be required in very difficult and complex situations. While GPRA does not have the resources to provide legal support or representation, your medical defence organisation and/or the AMA (if you are a member) may be able to assist. Sometimes issues arise that suggest the possibility of a systemic problem; for example, a policy or situation that is disadvantaging a particular group of registrars. GPRA can collaborate with or lobby relevant stakeholders to review and change their policies. We have been involved in and advocated on a range of issues with general practice training in Australia. This has often resulted in positive change for all registrars. Take care of yourself Any dispute or conflict can be very stressful and, on top of the pressure and challenges of just being a GP registrar, this may lead to negative impacts on both your professional and personal life. In these circumstances it is vital that you pay attention to your own wellbeing and be proactive in seeking personal and professional support to help you deal with stress.

WHO YOU SHOULD YOU CALL? Getting to know your Registrar Liaison Officers Got a question about your training or employment? Need a sounding board for advice? Want to talk to someone who’s been there? Registrar Liaison Officers (RLOs) are registrars or new Fellows who are employed by Regional Training Organisations (RTOs) to provide confidential support and information to GP registrars. They advocate for your interests on a local or national level, and can act as a conduit between you and your RTO. Whether you have a specific issue, a general question or just want a chat, RLOs are there to

assist you with any aspect of your work, study, training and wellbeing. If your situation requires it, your RLO can help you submit enquiries or complaints (whether anonymously or identifiably) and can refer you to health professionals for your own care. Many RLOs also organise group events so that registrars can socialise and support one another. All RLOs are members of the Advisory Council of General Practice Registrars Australia (GPRA). GP Registrar 35

NEGOTIATING A FAIR DEAL FOR REGISTRARS AND THEIR EMPLOYERS

hen you’re starting out as a GP registrar, it is important not to forget about the non-clinical aspects of the new path you are on, such as the terms and conditions of your employment. For some, this will be the first time in your professional career that you have had to negotiate this. In a hospital, your wage is determined by an award and there is not much flexibility for negotiation. GP registrars and GPs have more flexibility. The terms and conditions of your employment are negotiated between you and your employer, and then laid out in an employment agreement. You and your employer will have to sign this agreement before you can start at the practice. Employment agreements outline remuneration, leave entitlements, work hours and other employment terms and conditions. Remember – don’t sign any employment agreement that you have not read or do not understand! Contact GPRA or your RLO for advice on your employment agreement. A minimum standard The minimum standards for all employment agreements are set out in the National Terms and Conditions for the Employment of Registrars (NTCER). The NTCER includes: • the minimum which GP registrars can be paid • their leave entitlements (for example: annual leave, personal leave, study leave) • hours of work (for example: ordinary hours, oncall, overtime). The NTCER guarantees basic terms and conditions of employment, and you can negotiate with your employer for conditions and benefits greater than those within it. 36 GP Registrar

The NTCER applies to all registrars, including those in GPT/PRRT. The NTCER does not apply to those in community-controlled health, Australian Defence Force Registrars, some Aboriginal Medicine Services, and registrars on remediation. The NTCER is reviewed and renegotiated every two years by General Practice Registrars Australia (GPRA) and General Practice Supervisors Australia (GPSA). How the NTCER is reviewed Dr Ashlea Broomfield has been on GPRA’s Terms and Conditions Committee for two rounds of negotiations. She helped review the document for the 2014 negotiations and was on the face-to-face negotiating team in 2016. She said while most registrars and practices had agreements that worked well for them both, the NTCER is there to protect the most vulnerable registrars. “The feedback I have received from registrars is that there is a certain number whose employment conditions are very good and who are very happy with their circumstances,” she said. “In fact the GPRA benchmarking surveys show that most registrars are paid at fortnightly and receive a percentage of billings. Most of them were paid above the minimum standards and conditions. “However, the document isn’t there to protect those registrars – the document is there to protect

Essential reading for all new registrars View the National Terms and Conditions for the Employment of Registrars (NTCER) at gpra.org.au. On the GPRA website, you can also find: • a template employment agreement • a GP earnings calculator • the Terms and Conditions Benchmarking Report – see what the average GP registrar is earning.

Working hours Full-time GP registrars work a minimum of 38 hours a week. This includes education time and administration time. Consultation hours – the hours spent seeing patients – are usually between 27 and 33 hours a week. However, this can vary, especially in rural areas. GP registrars usually receive a base wage and a percentage of income generated by the number of patients they see in the practice.

Want advice on your employment agreement? Contact GPRA! Email registrarenquiries@gpra.org.au or phone 03 9629 8878 the most vulnerable registrars, and also the most vulnerable practices.” The base salary in the NTCER is benchmarked against the salaries of PGY3 around the country, but Ashlea said it is important to keep in mind the differences between states. “There’s a difference between what a PGY3 is paid in New South Wales for example, compared to Western Australia – a big difference,” she said. There are also differences between how much each clinic can pay their registrars. “The negotiation process involves trying to come to an agreement that doesn’t disadvantage practices but also doesn’t disadvantage registrars. “I believe registrars deliver a real value proposition for practices. But from the alternate perspective, registrars cost practices money [in that they are subsidising some of their training] and so we need to be able to show that there’s a benefit, not a deficit, from taking on a registrar.” The future An NTCER negotiation will take place in mid2018, and the following one in 2020, and GPRA’s negotiating team will be busy preparing and communicating with GPSA in the lead up. “It’s a whole day of negotiation,” Ashlea said, “but that’s only the face-to-face negotiation. After that process there are things that both parties take back and discuss with their respective organisations and then propose different changes thereafter.” The whole process usually takes a few months. Ashlea said one thing that could do with improvement was the way the bonus that registrars receive at the end of a placement was calculated. “The minimum terms and conditions allows practices to pay a base rate of pay for 13 weeks or roughly three months,” she said. “At the end of a three month cycle they calculate how much a registrar has billed, and then give a

bonus payment in terms of a percentage. “If the registrar has taken leave during that time, the leave has been paid at the base rate of pay, but those weeks are still included in the 13-week period. So, the extra percentage that they might earn has actually decreased. “However, if they didn’t take their leave during that time, and they were paid out their leave at the end of the term, the registrar would be better off.” Ashlea said this acts as a disincentive for registrars to look after their own health, and it was something she hoped would be addressed in the future negotiations. 2018 minimum salaries For full-time GP registrars, the 2018 minimum salaries: GP term 1 - $1,448.62 per week GP term 2 - $1,741.62 per week GP term 3 and above - $1,860.09 per week. Established GPs can earn good money. The actual amount depends on the nature of the practice and hours worked. In addition, there is the opportunity to run your own medical practice or work flexible hours. Find out how much you could earn using our calculator: gpra.org.au/gp-earnings-calculator Incentive payments GP registrars may be eligible to receive financial incentive payments in addition to their salary. Most of these extra payments are offered by the Department of Health to encourage GPs to practise in areas of need, such as rural, remote and outer metropolitan areas. Payments vary depending on experience and the location’s remoteness. For example, a first or second year GP registrar could earn an incentive payment of $25,000 a year for working in Coober Pedy, South Australia or in Bourke, New South Wales. GP Registrar 37

GENERAL PRACTICE COFFS HARBOUR REGION 38 GP Registrar

A DIVERSITY OF PRACTICE – MANY CAREER PATHWAYS

n this issue of GP Registrar there are interviews with GPs from the Coffs Harbour region of NSW. The interviews are with GPs who have pursued the profession for a number of years. The stories illustrate the breadth and scope of general practice. They cover many career pathways, activities and interests open to those who have chosen general practice as their profession. This collection of stories has been put together to assist GP registrars to consider options for their own training and planning for their future. The first story is based on an interview with Dr John Kramer. In June 2017, Dr Kramer was awarded the Medal of the Order of Australia (OAM) for “service to medicine as a general practitioner in regional areas”. This simple citation does scant justice to a man who has delivered much, including mentoring many GP registrars, and who is a long standing champion for rural general practice. John started work as a GP at Woolgoolga, on the NSW Mid North Coast and is still there. Of course, life has not been static. The population has more than trebled and his practice, now in a purpose designed centre, is a cornerstone of the community. Although his entire career as a GP has been in one NSW coastal town, he has accepted many challenges and pursued many exciting career options. Dr John Kramer is a Conjoint Lecturer at the School of Medicine and Public Health, The University of Newcastle. He is also Co-Convenor of the Primary Care Course at the University of NSW Rural Clinical School. John is a fellow of both the RACGP and ACRRM and has also been a long-term active member of both the RACGP Rural Faculty and the NSW Faculty.

oday I would like to acknowledge Dr John Kramer, a wellrespected general practitioner from Woolgoolga. Dr Kramer started working in Woolgoolga in 1981, when the town’s population was just 1,800, and he has never been tempted to leave. He was recently honoured at the 2016 New South Wales Rural Medical Service Awards for providing 35 years of service to the Woolgoolga community. In this time he recounts many great moments, a baby being delivered at 25 weeks at the surgery and many successful resuscitations. He has a genuine concern and care for his patients. His passion for delivering quality health care to those who live in Woolgoolga is matched by his dedication to teaching and supervising GPs. He is heavily involved in teaching medical students. He has also spent a lot of time working with students with learning difficulties at Woolgoolga High School. I have to mention his other great passion: trains. His office is filled with much train memorabilia. On behalf of the Woolgoolga community, I acknowledge and congratulate Dr Kramer for the significant contribution he has made to our community. I thank him for his 35 years of service. The Hon. Kevin Hogan MP Member for Page GP Registrar 39

LEARN TO SAY

“I DON’T KNOW”

AND OTHER TIPS FROM A SEASONED SUPERVISOR

40 GP Registrar

ural general practice can mean a greater diversity of patients and a greater diversity of career options Dr John Kramer says many young doctors are hesitant to go rural, often because of a perceived lack of diversity in small towns. “But it’s not always the case,” he said. John lives and works in Woolgoolga, population 5,385, on the NSW Mid North Coast. The area is known for its beaches, its blueberry farms and – surprisingly to some – its large population of Punjabi-speaking Sikhs. John says the Sikh community started arriving just after World War II and, initially, worked as agricultural labourers. Many bought their own banana plantations. More recently large areas of land have been converted from growing bananas to growing blueberries. The first Punjabi-speaking doctor moved to the area around the same time John did: 1981. Another, Dr Harjinder Singh, came to John’s practice as a registrar, and stayed on. John said interpreter services are now easily accessible when the need arises, making it more convenient to treat culturally diverse patients. He also works once a month at a refugee clinic in nearby Coffs Harbour where many patients have suffered trauma or been the victims of sexual assault. He said it is not uncommon for people coming from tropical areas to have had malaria in the past. “We’re getting refugees coming in now and that is further diversifying the ethnic mix in Woolgoolga. This is also happening in other country towns,” John said. “Additionally, rural GPs see patients from more diverse socio-economic backgrounds than their city counterparts. You deal with all sections of society, from the bottom rung to the very top. “In Australian cities, the suburbs tend to be very stratified. So, you can expect a certain type of patient in some places. Obviously, if you’re working in a deprived or disadvantaged outerurban area you’re going to have a different range of problems.” Making general practice work and being part of the community John has a clinical interest in children with learning behavioural problems – children with autism spectrum disorder, ADHD and co-

morbidities. “One way of following up their management is through case conferencing. Each term I go to one state primary school and one high school in Coffs Harbour and case conference for selected young people. The conferencing is with teachers, school counsellors, parents and, when they are older, the young people themselves. “One afternoon a week I Skype with a developmental paediatrician with the parent and sometimes the child in my office, plus any medical students who happen to be around. Having medical students present can be helpful because they can discreetly take the child away, perhaps to measure their height and weight, when a confidential conversation is needed.” “Every rural or regional area has a deficiency in services and using newer technology is one of the ways of reducing the disadvantage. “There are certainly great rewards in general practice by being part of the community that you’re working in, part of the lives of the people that you’re looking after, and dealing with multiple generations of families,” John said. “In the last little while I had the experience of meeting the fourth generation of some families – you can’t put a value on the sort of thing. “The relationship you have with those families is powerful. There’s a degree of trust that is developed and they are almost like part of your extended family.” So does John seeing himself living out the rest of his life in Woolgoolga? “I’ve been here for 36 years, I’m not in any hurry to leave,” he said. Then with a smile and a gesture to the newlyrenovated Beach Street Family Practice: “we’ve built this new building, and we have to get a return out of it!” Terms and conditions of employment for registrars Moving from a hospital into general practice also brings a change in the way a registrar is employed. Instead of having their terms and conditions dictated by an industrial award and being paid out of a state healthcare budget, registrars negotiate their contract directly with their employer, who is often also the practice owner. Contracts must comply with the National Terms and Conditions for the Employment of Registrars (as well as other minimum standards applying to all employees in Australia) but GP Registrar 41

“The hospital system steers them to thinking they can have an answer to every problem and if they don’t, they’re somehow deficient” compared to a hospital, there is still generally more at stake for both employer and employee. That’s not to say registrars shouldn’t be prepared, which is where General Practice Registrars Australia (GPRA) comes in. “Registrars need some industrial help,” John said, “because every employment contract is a negotiation, even with the national terms and conditions.” “This,” he added, “is a big improvement on what we had previously.” John said one thing registrars often don’t understand is the costs involved in running a practice. “They can’t be expected to know that until they’ve arrived, and that is one of the most important things to teach all registrars, as a supervisor – the costs of running a business. “And that in turn makes any negotiations that they and I have about running a business much more informed.” Before taking the plunge Dr Kramer says there are insufficient opportunities for young doctors and students to talk to somebody to find out what general practice is really like. “There are many questions that typically need to be asked: How hard is it? How often do you have to be on-call? What is it like when your patient dies? 42 GP Registrar

“Some registrars are good at asking for help and others aren’t. It is important, right from the beginning of a placement, that you tell your registrar it is alright to ask questions. “I tell registrars that if they need to know something straight away, while the patient is there, ring up and someone can come and have a look. “Especially for new registrars, it is important to provide opportunities to discuss issues and concerns. Sometimes I will knock on their door and ask if there is anything they would like to review or discuss. There are also scheduled teaching times and corridor consultations. Dr Kramer takes special note of registrars who may have moved away from their families and friends and are lacking in those extra supports. He says that supervisors and practice managers, in these circumstances,

“You deal with all sections of society, from the bottom rung to the very top.”

at the very least, should be aware of that situation and can make allowances such as letting them finish work at lunch time on a Friday so they have time to drive to Sydney, or wherever their family and friends are located, for the weekend. “Sometimes registrars have problems that are not work related. It may be something happening in their personal life. You try not to get caught up in their personal matters because your role as a supervisor is your key role. However, if they need some help or counselling, you try to make sure action is taken. Sometimes they can talk to another doctor in the practice who is not their supervisor. “We try to make sure every doctor has their own doctor but it is harder in rural areas. In some places people are comfortable doing it in-house. That tends to be what we do here

General practice has rewards Dr Kramer says that it is impossible to understand the scope and depth of general practice until you have been immersed in it for a while. He says there are much greater non-financial rewards in general practice compared to other medical specialties, just by being part of the community you are living in. You are part of the lives of the people you are looking after. “These things are more noticeable in a rural community. You deal with all sections of society. Within this context, he likes having registrars in his practice. “It keeps you stimulated and, when they ask questions, it enhances your own learning. “They ask you why you do things a certain way and if you can’t come up with a sufficiently robust explanation then you need to ask yourself if you should be doing it differently. They challenge you in gentle ways. “Registrars help you top up your own knowledge. “Students are also part of the equation here. We have a lot of medical students coming through, from the rural medical school in Coffs Harbour and from Newcastle and other campuses, and I like to ensure that the registrars spend time with them because the registrars have to learn how to teach. GP Registrar 43

ohn Kramer has supervised his fair share of registrars over the years. “One of the attractions for registrars at this practice is that it is in a very nice coastal setting. “You can go and swim in the ocean every day, if you want to. There is lots of bushland behind us with trails for walking, running, horse riding, and driving. “It is a growing community with many retired people but also many young people. “The age group 20-40 is less represented because people often go away to the cities for work or study and they often travel overseas. They tend to return later in life. Dr John Kramer says, by and large, he has had very good experiences with registrars. “Among them were many good doctors and some absolutely brilliant ones. “Some of the very clever doctors have been overseas trained. Where people get their primary degree often doesn’t determine how they will perform in practice. “Often, success is related to their personality type. Signs of success include being curious and willing to try new things. “Success seems to come more easily to those who can admit that they don’t know something and need to ‘find out’. One of the most important success factors for all of us is to learn to say early in a career that there are things we don’t know and, when it is important, to set about seeking understanding and answers. “ John says that the experience in hospitals steers registrars towards thinking they must have an answer to every problem and that if they don’t then they are somehow deficient. “When you move into general practice, you have to unlearn some of those hospital attitudes and ways of thinking.” When asked to reflect on registrars over several decades, he says that the high standard of registrars has continued. “The one significant difference that I have noticed with recent registrars is that they are not prepared to work the long hours that those of us from the baby boomer generation experienced.

44 GP Registrar

“However, with the benefit of hindsight, what we did was not really acceptable. We did what was required because we didn’t know any better. Recent registrars have a more realistic approach to managing life.” Dr Kramer says taking on a registrar is a two way leap of faith. “They take a leap of faith with us and we take a leap of faith with them.” He says that in general practice, in the community, you see a lot of undifferentiated illness. “People present in the earlier stages of an illness and the signs and symptoms may not be typical of any specific thing. It is often not possible to make a diagnosis straight away. “Practice in hospitals doesn’t support that model because they like to have clear cut conditions and treatment. They tick boxes and get funding. Moving from a hospital to general practice requires a different approach. “We always tell registrars early in their career that it is alright to ask questions. We tell them if they need an answer while the patient is there to ask for help. If it doesn’t need to be sorted out straight away, make a note of it and we will talk about it at the end of the session. Lunch breaks can be used for this.” Dr Kramer says he organises joint consultations and joint home visits to create opportunities to build trust and an environment in which they feel comfortable raising issues and asking questions. For those considering a career as a general practitioner, John suggests they talk to a GP, perhaps their own GP, about what is entailed.

REVIEW OF AGPT On 22 January 2018 GPRA was invited to participate in a review of AGPT Australian General Practice Training (AGPT) program policies: I represented GPRA at the negotiations and was supported by a research and analysis team consisting of GPRA staff and registrars. By working together, and

1. Registrars who are on an Extension Awaiting Fellowship and wish to work below the Collegeâ&#x20AC;&#x2122;s minimum Full-Time Equivalent (FTE) requirement are now able to do so as long as they negotiate and agree their preferred working hours with their training facility. 2. Registrars can apply to their RTO for an Extension for Assessment Purposes if further time is required to complete their skills training term. 3. There are certain instances where a registrar may undertake paid employment while on Category 1 Leave and this should be discussed and agreed with the registrarâ&#x20AC;&#x2122;s RTO.

When we work together as a team, and utilise rigorous analysis and research, including the skills of our registrars and our other members, we can make practical changes that will enhance the lives of those making a commitment to general practice and a better health system.

presenting valid arguments and evidence, we achieved some key outcomes. Many organisations may claim credit for the benefits we achieved for registrars but it was GPRA that took the lead in achieving some key positive outcomes. We campaigned for and achieved these benefits:

4. Registrars can take leave immediately following a period of a different category of leave. 5. Category 2 Leave can be taken outside of Core Vocational Training. Registrars can sit College exams/assessments while on a period of leave, with RTO approval. 6. For registrars who are placed on Category 2 Leave due to being unable to be matched to an appropriate Training Facility, this Category 2 Leave will not count towards their Category 2 Leave allowance or the training time cap.

Dr Melanie Smith President GPRA

GP Registrar 45

Ending the stigma

hether treating patients or handling the stress of being a doctor, all GPs need a good understanding

of mental health. This is something that Dr Nicola Holmes of Coffs Harbour is keen to highlight. The GP and medical educator “drifted” into the sector via women’s health, and now works with young people at headspace. She thinks mental health will be the major health challenge of our time. “Between the ages of 14 and 44, suicide is not only the leading cause of death, but its double the occurrence of next cause down,” Nicola said. “That’s where I think the big challenge in medicine is going to be – getting those statistics turned around and nurturing mental health.” That’s not to say chronic diseases and lifestyle 46 GP Registrar

illnesses aren’t also a priority. In fact, she sees them as intricately linked. “The more I’ve done it, the more I’ve realised that mental health is actually applicable to all of general practice, not just the cranky adolescents, and not just the postnatally depressed mums. “All lifestyle interventions involve motivational interviewing – for example people who are overweight and they have diabetes and they’re not exercising and they’re eating rubbish – to try and get to those guys to bring about lifestyle change, it’s actually mental health skills that you need.” Turning young people’s lives around Since starting at headspace, Nicola has discovered a passion for working with young people. “I love that age group to work with, the 12s to 25s, because I see them as particularly flexible with their whole life journey,” she said. “If you see a 10-year-old in a very difficult family who’s struggling with mental health

GP Registrar 47

issues, school refusal, violence, whatever, it’s very difficult because it’s so dependent on their family environment and you can’t do much. “And if you see people at 50 and they’re completely entrenched in their habits of thinking, they can be very hard to shift as well. “The flexible adolescent age group is very exciting to work with because they often completely turn their lives around. “It’s so rewarding when you see a kid who was set up to have gone through the justice system and dysfunction and chaos, and they actually start engaging in education, employment, and respectful relationships.” Advice for registrars Nicola acknowledges that the billing structures of mainstream general practice make it difficult to delve deeply into mental health issues. Her advice to registrars interested in the area is to find a GP with an interest in mental health to mentor them. She also recommends the courses run by the Black Dog Institute and the Australian Society for Psychological Medicine, and the free information and workbooks available on the website of the Centre for Clinical Interventions. 48 GP Registrar

“Beyond that, it’s all about confidence. “It really is about jumping in and having a go. It takes time to get confident with your own knowledge and I think also developing your own scripts, as in, the way you say things to patients. “I’ve developed a whole series of analogies and language around mental health. “So, I describe the brain as a city with all these roads going everywhere and messages like cars flying around all day and night. It’s very complicated and has a lot of traffic lights in it, and that helps the cars get around smoothly. “But when you’ve got mental health issues, you’ve got a few problems happening in there. “Commonly, you haven’t got enough traffic lights, and that’s where we use our medications and lifestyle changes like exercise, sunlight and sleep hygiene. “But you can also have problems when the roads you’re using are inefficient. So you could be entrenched in lots of negative thinking patterns, and that’s where you do your psychology to rebuild roads in the brain, and this takes a long time. “Everyone has different ways of explaining things, but it’s about finding a language that works for your patients.”

It really is about jumping in and having a go.

Nicola said asking supervisors for advice on how to explain health issues – whether physical or mental – could be even more valuable for registrars than the more technical questions they ask. “This helps registrars speak confidently about mental health” , she said, which in turn reassures patients. “One in two Australians will be treated, in their lifetime, for a mental health problem. “So, confidently normalising, and trying to break down stigma is important. And if the GP is fairly confident, the patient is more likely to come on board.” Don’t forget about yourself Looking after your own mental health is also extremely important for GP registrars who are working in new environments and trying to fit in study too. As a medical educator, Nicola said new registrars were often surprised by how much their jobs affected their mental health. “Most doctors have personalities of wanting to help and rescue and serve, and there’s often not space in that for self-care,” she said. Combined with that was the fear and stigma

around mental health that continues to linger, particularly for registrars considering confiding in their supervisor or training provider. “They’re in quite a vulnerable position because those two senior positions hold the key to whether they become an independent GP,” Nicola said. However, she said most supervisors were now conscious of providing a supportive environment, and there were certain signs of this that registrars could look out for when considering placements. “When practices have teaching for the whole practice and fortnightly, or even just monthly, clinical meetings, where everyone comes together and talks about cases, that’s a sign the practice is going to be very supportive.” Study groups are also a great way to give and receive support from other registrars. It’s also important to make time for the things you enjoy outside work. “You need to prioritise time for things that are nurturing for you as a person,” Nicola said. “For me it’s riding a horse every now and then in the forest, and I ride my bike to work. Those things keep me sane and stable. “Registrars need to have the courage to prioritise themselves.” GP Registrar 49

Beyond the bread-andbutter: talking sub-specialties with Dr Stephen May

50 GP Registrar

GP Registrar 51

f there was ever proof needed that general practice is not all coughs and colds, Dr Stephen May would be case-in-point. The Coffs Harbour GP has spent his career sub-specialising in obstetrics and anaesthetics, in between regular GP practice, and also has a diploma in child health. Such broad expertise was necessary for the young GP who moved to Coffs Harbour 33 years ago, when there were only a handful of specialists in town. “I wanted to be a well-qualified and well-rounded country GP,” Stephen said. “When we came it was small, it was country, it was lovely in the sense that all the doctors knew one another. “About a year after we arrived the town just sort of took off.” While Stephen said it’s getting less and less common for GPs to do obstetrics and

52 GP Registrar

anaesthetics in larger places like Coffs Harbour, there’s still plenty of variety on offer for the next generation of GPs. “I’m the last of that sort of school here in Coffs Harbour but there are a lot of exciting and rewarding opportunities to do things on top of bread-and-butter general practice,” he said. “We have doctors here with special interests and expertise. For example, some give their time to staff the refugee clinic at the Base Hospital, others maintain their emergency skills by regular shifts in the A & E department, numerous others are interested in skin cancer surgery, and there’s a doctor who is on the roster for mental health triage at the hospital. “Two of our doctors trained up in HIV medicine, and they were the first two doctors [in Coffs Harbour] who qualified to prescribe HIV medications. “There’s another GP who now does full-time varicose vein work. He was also instrumental in starting the Australasian College of Phlebology. “There are other individuals who perform

vasectomies, circumcisions or lingual frenotomies and yet other GPs with a special interest in Indigenous health, others in women’s health and shared antenatal care and so on.” An unexpected career choice Stephen never contemplated doing medicine when he was younger. “I couldn’t stand the sight of blood,” he said. He started out studying maths, but “wasn’t as

around his network in search of someone who can do an ECG before closing time, it’s obvious this remains a community which helps one another out. “I didn’t want to work in the big cities, I wanted to work in smaller towns,” Stephen said. “Coffs has been fantastic to us, our children had a wonderful time growing up here. If we had our time again, we would be straight back.” “To me it allows a much broader scope of

“I wanted to be a well-qualified and well-rounded country GP.” good at it as I thought,” so instead he decided to give anatomy and physical anthropology a shot in the second year of his science course. “I went to the school of anatomy and I met this lovely lady who said ‘anatomy has been discontinued from the science curriculum due to lack of interest’. “And I said ‘well where do I enrol for physical anthropology?’ and she said ‘I’m terribly sorry, but the professor died last year and the department went with him’.” The doctor attempted to assuage Stephen’s disappointment by suggesting he do medicine. “I said ‘but I can’t stand the sight of blood’. She replied ‘don’t worry, you can branch out in three years and do research in medicine, and you don’t have to go to the hospitals at all’. “But after three years I realised I wasn’t cut out for a life under a microscope, my interests were in seeing people. “So the long and the short of it is that after fainting during my first operation, which was a caesarean section as a medical student, I am proof that anyone can get used to the sight of blood. “It doesn’t bother me anymore, and I have found that medicine is my true vocation.”

clinical practice than in the larger cities.” “As a country GP you have the opportunity to provide a valuable contribution to community life in a rural or semi-rural setting. One can become involved in local sporting, cultural and community events.” In fact, doing so led to Stephen being named Citizen of the Year by the Coffs Harbour City Council in 2003. “I was very humbled by this award and accepted it on behalf of all those GPs who quietly volunteer for our community,” he said. Stephen’s practice currently has two registrars, and as a supervisor, his advice is to become involved in the community, remember to look after your own health, and find the area of general practice that stimulates you. “Find what you have a passion for and you will enjoy your working life.”

A part of the community Coffs Harbour may have grown under Stephen’s watch, but as he politely pauses our chat to ring GP Registrar 53

54 GP Registrar

It takes a village: collegial learning and teaching in Toormina

hen Dr Ian Arthur began at Toormina Medical Centre on the NSW North Coast 35 years ago,

it was a two-doctor practice. Now, with 14 doctors and a range of allied health professionals on site, it has become renowned as a model teaching practice, due to the varied and collegial nature of the work. “The doctors are all very interested in teaching, virtually all of them do teaching here,” Ian said. “Most of them have got areas of special interest, so mine is diabetes, and also cardiology and kidneys – it all goes together.” “We’ve got an addiction medicine specialist, we’ve got people who are women’s health, paediatrics, acupuncture, musculoskeletal medicine, so these areas of specialty make general practice much more interesting.” Five of the practice’s GPs began at Toormina as registrars and have stayed on. Ian said while registrars are assigned a

supervisor with whom they would probably have one session a week, much of the teaching is topic-based and is shared amongst the doctors based on their area of interest. “We encourage [the registrars] to ask questions of a variety of doctors, so it’s a collegial way of teaching, it’s not just one on one, it’s a very collaborative environment.” No two days the same Ask any rural GP about the benefits of practising out of the city, and one word will inevitably come up over and over again: variety. “If I have a patient with diabetes I look after all their diabetes, I look after their cardiology, I look after their kidney disease,” Ian said. “So it’s not like the city, where often the GP is the person who refers you to the specialist if there’s anything really wrong. “Here it’s the other way round – if [patients] have to go and see the specialist they will, but they still want to know what the GP thinks, so it’s a totally different way of looking at it.” The variety of health concerns a rural GP is faced with can be daunting at first, but Ian’s advice to new registrars is to accept that there will sometimes be a lack of certainty, and take your time. GP Registrar 55

“In a lot of general practice, you’re not certain, and you may not work it out all in one go. It takes a while,” he said. “If [new registrars] have been in a hospital they may think they’ve got to see too many patients but the GP training will start on two patients per hour, and once they’ve settled down, maybe after a month or so they go up to three patients an hour. “And then later on when they become GPT2s, if they want to they can go up to four, but that’s the maximum we allow them to see.” “Living in a small community also makes it easier to coordinate care and follow up”, Ian said, “because all the GPs and other specialists know one another. Additionally, small-town life makes for good doctor-patient relationships. “I’ve had patients who’ve been coming to me for 20, 25, 56 GP Registrar

35 years. I saw them as children. Now I see them grown up. “Even though it’s a modern building, in many ways we retain a lot of the traditional general practice family continuity of care.” The end of the 70-hour work week In his 35 years as a GP, Ian has seen big changes in the general practice workforce. “The biggest change is the number of female doctors,” he said. “When I trained, 75% of medical students were male, and now 5560% are female, and if you look at the percentage of women registrars who are going into general practice, that’s more like 70%.” Ian said this change had made it more common for GPs to work part time as women sought to balance careers

with motherhood, but men were thinking more about work-life balance too. “I think men are also realising, what’s the point of working 60 or 70 hours a week? Nobody wants to do that anymore.

don’t waste time in the traffic, you’ll be well paid, the cost of living is cheaper, the lifestyle is better, and it’s easy to get to Sydney anyway.” “And when you do go to the city”, Ian said, “you appreciate it more.”

What’s the point of working 60 or 70 hours a week? Nobody wants to do that anymore. “Working four-and-a-half days a week would be pretty standard and most people want to have regular holidays and plenty of time off. Living and working in a rural location fits well with the desire for work-life balance, Ian said. “You get much more interesting medicine, you

“Doctors are lucky in that they have a lot of choice in where to live” , he said. “If you want to be a merchant banker, you probably do have to work in the city. “There are quite a lot of occupations where you do have to, but medicine isn’t one of them.”

YOUR JOURNEY TO GP FELLOWSHIP Are you interested in people and holistic care? Want a rewarding challenging specialty? Become a highly-skilled GP – train with us Learn a range of clinical skills Be part of a local community Every day is different Work with a supportive team

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GP Registrar 57

MORE THAN A GP: THE MANY HATS WORN BY THE NEW GENERATION

r Tim Francis was an active member of General Practice Registrars Australia (GPRA) during his training. Ten years ago, he was Deputy Chair of GPRA’s Advisory Council, and advocacy and governance work has remained an important part of his career since then. This balance of clinical and non-clinical roles is something Tim said more and more GPs are opting for these days. “The expectations from the community and 58 GP Registrar

from individual doctors are very different to what they were 20 or 30 years ago,” Tim said. “A lot of the older GPs, they’re doctors, that’s what they do, that’s their life, their being, and that’s how they’re thought about in the community. “I see it as: I work as a GP – that’s one of a number of things that I do. “I also work in anaesthetics, I work in corporate governance, I work in medical education… I’m also a father and I like riding bicycles and spending way too much money on them.” It’s an approach that is probably healthier for GPs, Tim said, as the new generation is increasingly able to define themselves outside of

“The expectations from the community and from individual doctors are very different to what they were 20 or 30 years ago” their clinical work. There is also plenty of clinical variety available to GPs – especially those who practice in a rural area, like Tim does. “I made sure that all of my placements were in regional or rural areas, so I got a lot of hands on experience,” he said. “My surgical term as a med student was assisting the director of surgery and doing surgical anatomy. Had I been doing that in a capital city it would have been a very different story. “If you’re in a big city hospital and you’ve got 15 doctors on your team, and you’re the medical student, guess how much real stuff you’re going to do.”

That said, Tim cautions new registrars in rural areas against succumbing to the pressure to try and do and know everything. “You hear the stuff from ACRRM and RACGP Rural of ‘yes, you can do everything’, and then you realise, ‘actually, I can’t’. “If you’re trying to use too many skillsets, it’s hard to maintain all of them. You’ve got to make that quality call at some point.” Tim decided rural life was for him while working in North Queensland in his third year of medical school. Now, along with his young family, Tim lives in Nambucca Heads on NSW’s Mid-North Coast, and practices in nearby Urunga. GP Registrar 59

“The lifestyle, being out of the big smoke, having real things to worry about instead of what the Jones’ are doing and keeping up with them” are some of the benefits he cites. With the rise in social media and other digital tools making it easier to keep in touch, both socially and professionally, the former Brisbanite said he doesn’t feel like he’s missing out on city life. Free open access medical education – or FOAMed, as its often referred to – has boomed in recent years. The term encompasses the myriad podcasts, blog posts, videos, webinars, forums, social media

60 GP Registrar

groups and conversations which anyone can access to learn from and teach one another about practising medicine. Tim cited the GP2U Facebook group as a good place to ask peers questions about both clinical and workplace matters, but he has a measured outlook on some other platforms. “I dip in and out of [social media], I find Twitter is a bit of an echo chamber. Sometimes, you’re hearing the same things from the same people,” he said. “By the same token, if I want to go in and get an answer, I can do that. “Having those tools and knowing that I can go to them is very useful, because, otherwise, I’ll just get a narrow view if I just pick up the phone and go to the guy in the next room.” Tim said formal medical education and professional development providers were also increasingly teaching via the internet. “We’re seeing more of the RTOs [regional training organisations] use a remote supervising model as an answer to reduce the cost of providing education,” he said. “I think we’ll see FOAMed continue to grow, but my hope is that we don’t see a reduction in face-to-face.”

EXAM TIPS… FROM SOMEONE WHO PASSED AND STAYED SANE By Dr Shikha Chhabra, Registrar Liaison Officer, EV GP Training

or most of us, RACGP or ACRRM exams are the culmination of a decade or more of hard work. So when the time comes to start preparing, first off, take a moment to congratulate yourself on getting this far. Fellowship is a major milestone and it’s finally within sight. As someone who has recently gained fellowship, I’d like to share some of the tips and tricks that helped me navigate the realm of exams and emerge out the other end successfully and, more importantly, with my sanity still intact. Tip 1: Develop a study plan A lot of exam stress stems from being faced with learning the entirety of the general practice curriculum. This can feel overwhelming, to say the least. Sitting down and making a rough plan of how to tackle your study, and breaking it down into achievable blocks, will help get your thoughts in order. Tip 2: Prioritise topics wisely No GP ever has or ever will know everything. Focus on your bread and butter clinical cases and know these inside out. Next, focus on the serious, not-to-be-missed disorders and know these to a level of safe competence. Murtagh’s General Practice and the BEACH data are good sources to consult when formulating a list of topics you need to cover. Focus on your weaknesses in your study time. Make a list of the presentations you would dread seeing on a Friday afternoon and start with them. Don’t get too bogged down in sub-specialitylevel details in any one area. Instead, make sure your understanding is broad. At the end of the day, you are trying to make sure you are a competent GP with a broad base of knowledge who is safe to practice independently. Tip 3: Make the most of your everyday practice Your everyday practice will provide the best

opportunities to prepare for your exams, so be an active learner during your work day. Look up guidelines for the conditions you are seeing, know them well and apply them to your patients. This will maximise your retention of the information you are learning. Tip 4: Plan out your training with exams in mind Some people find it easier to work closer to home in the terms they will be sitting exams so less time is wasted on commuting. If you do end up needing to commute around exams, there are plenty of educational podcasts out there which can make travel time more productive. Tip 5: Keep your supervisor in the loop It is always worthwhile discussing your study plans with your supervisor, as they can be a big help to you in the exam preparation process. This could mean adjusting the number of patients you see per hour so there is sufficient time to review relevant resources after each consult. Many supervisors are also very happy to run through practice exam questions – particularly OSCE-style or StAMPS-style stations – during dedicated teaching time. Tip 6: Make your study time count with active learning Make sure your study sessions include practice questions and other forms of active learning. Sitting and reading may be an easy option after a hard day of work, but retention is always much higher if you are forced to actively recall and process material you have learnt. Tip 7: Minimise distractions Even as adult learners, many of us (myself included) often fall into the trap of trying to study while watching TV or talking to family. While this may make sitting down to study more enticing, retention and productivity will be significantly lower. GP Registrar 61

Instead, do some dedicated study and then allow yourself some well-deserved time to relax. And don’t forget the importance of a good study space. Many of us no longer have this once we’re out of university, but a comfortable and distraction-free environment can make all the difference – whether it’s a whole room, a corner of the kitchen table or even a desk in a library. Tip 8: Make use of all resources available to you If you actively start looking for helpful resources, you’ll find there are masses out there! To name a few: • • • • • • •

•

podcasts online question banks your Medical College’s resources official health guidelines books (see GPRA’s Clinical Cases Volumes 1 and 2) exam preparation workshops other registrars – ask them for old exam papers and resources – there is many a USB of useful information floating around (just keep in mind that question styles and guidelines may have changed over the years, so use these as a general guide only) your training provider – remember they are there to prepare you for exams as well as for your daily practice. Attend workshops, do prereading and use the online learning platforms offered as review resources. comprehensive courses – often quite expensive and time consuming, so may be more suitable for those not affiliated with a training provider or wanting more direction with independent study.

Tip 9: Join (or start) a study group Your peers are a great source of support because they all have the same goal in mind! Figure out what type of studying works for you and your group. I started a regular study group from early in GPT1 which focussed on practice questions and exams, though some groups would teach each other full topics didactically. I would highly recommend a study group for 62 GP Registrar

the OSCE or StAMPS exams, even if you’re usually dead-set on individual study. Once you’re through the written exams most of you will have the knowledge down pat, and that is the time to practise smooth OSCE or StAMPS “performance” techniques. The more cases you practise under exam conditions, the more you will realise how long eight minutes actually is! Getting a feel for timing becomes crucial, I know that in the OSCE there are no clocks or watches in the room! Tip 10: Take care of yourself – now more than ever We are all great at telling our patients about how important it is to get enough sleep, drink plenty of water, eat well, exercise regularly and have some sort of relaxation practice to help us unwind; but how many of us actually practise this effectively in our daily lives? While these things may seem the easiest to drop to make time for studying while working, they are more important than ever in helping you to perform at your best. At the end of the day, exams are not the be-alland-end-all. Keep some perspective and remember that there are always more important things in life. If it’s starting to feel a bit overwhelming, don’t ever hesitate to get some help. See your own GP, chat to your supervisors and training provider mentors. Your medical college may also offer free counselling – browse their website to see what is available. Good luck!

Preparing for your clinical or written exams?

Exam resources produced by GPRA are designed in consultation with GP registrars and edited by medical editors and Fellows. Resources include: • clinical case studies • written exam questions • webinars.

“

The GPRA books were a key part of my study group’s preparation... the clinical cases book provided the bulk of our OSCE practice material and we all did really well!

” Visit gpra.org.au/shop GP Registrar 63

YOUR WELLBEING: ADVICE FOR NEW GP REGISTRARS By Dr Ginita Oberoi, Registrar Liaison Officer with General Practice Training Tasmania

wide array of experiences may lead to a doctor choosing general practice training. Some doctors, knowing that they want to do general practice even in medical school, might join the program as an intern. Others might take a winding route through other training programs, working overseas or starting a family. One thing that’s certain is that when considering the wellbeing of a GP registrar, there is never a one-size-fits-all approach. Bearing that in mind, Registrar Liaison Officers (RLOs) like myself will often encounter registrars with the same barriers to wellbeing, especially during the first few months of training. Most doctors, when starting out as GP 64 GP Registrar

registrars, would have had the majority of their medical experience in a hospital. The structured days and hierarchical teams of the hospital wards can provide a stark contrast to the relative flexibility of general practice, and can come as a shock to the system for new GP registrars. Each of us eventually will find our flow and structure, but those first few weeks are hard. There are some important questions to ask in the first few days at your new practice: ‘when should I check my results?’ ‘what should I be asking my supervisor to review?’ ‘what jobs can I give the reception staff and nurses?’ and ‘how do I manage abnormal results?’ are a few of these. A lot of general practice is about managing time and information, and discussing practice

management at an early stage can save a new registrar a lot of stress. Another side effect of the transition from inpatient to community-based medicine is something I call ‘medical-admission-workup syndrome’, also known as ‘I need to do everything today’ disease. Doctors in the habit of doing detailed inpatient admissions can find the paradigm change to general practice difficult. The lesson is to remember that the patient can come back tomorrow. Remember to safety-net today and then review tomorrow. Staggering your work over several consultations can help you keep to time today. The difficulty with this approach, however, is something that is part and parcel of general practice – dealing with uncertainty. Many registrars struggle with the ‘what if ’s’ of general practice, worrying that they could have missed something. Doctors are a breed that usually like control and concrete solutions, but in general practice there isn’t always a concrete solution to be found! There are two approaches to dealing with uncertainty that I have found useful, and they can be summed up in the mantra ‘minimise stress in and maximise stress out’. What does this mean? Well, for the first part, ‘minimise stress in’ is having structures and habits in place that give you as much control and closure on your day as possible. This could mean taking 30 minutes to review your notes at the end of the day. If there is something that you notice on that review that you didn’t think of during the consultation, make a note and come back to it tomorrow. You can also utilise the to-do lists and action lists of your practice software. If a clinical question is bothering you, add it to your to-do list or make an action in the patient file to review the patient in the future. Set aside a regular and specific time to review these lists and tasks so that they aren’t looming over your mind or constantly playing in your short term memory. ‘Maximising stress out’ is all about that elusive thing we like to call ‘relaxation’. It’s a different thing for different people. For me the word relaxation conjures up pictures of clay face masks and cucumber eye patches. Unfortunately, most people don’t have a day spa at their daily disposal, so be practical about relaxation – indulge in the things that give you joy on a daily basis. It really is as simple as that!

You can also try some of these psychological doctor’s bag remedies to manage stress and anxiety. Set aside ‘worry time’. This is a designated and specific part of the day when you can worry all you want. Take it one step further by writing down your worries and then recording the outcomes – did your worries come true? Exercises like this can help you identify patterns like catastrophisation and can help focus that nervous energy and stop it from affecting you all the time. If you find yourself worrying - save it for your worry time! There’s even an app for it called ReachOut WorryTime. You can combine worry time with another helpful approach called Structured Problem Solving (SPS). Here you write down what’s is your mind and all approaches and actions you could take, from the silliest to the most sincere options. Once you’ve written down all of the actions you pick one, commit to it and plan how you will carry it out. A good model for SPS can be found at thiswayup.org.au. Be kind to yourself Often in our job we can be kind to others and so harsh on ourselves. When we have a patient who quits smoking or loses weight, we are full of praise and admiration. Yet when we get praise or encouragement from our coworkers or patient it’s in one ear and out the other. We focus on all of our failings and ignore the small victories. Whenever a patient would thank me for anything, I used to feel like a fraud. Negative thoughts would chase each other around in my mind: ‘they don’t know about all the things I’ve done badly, or how inexperienced I am, and if they did no one would thank me’. The best term I’ve come across for this is imposter syndrome. But a GP registrar isn’t an imposter. Be kind to yourselves and treat yourself as what you are – a valuable, skilled doctor. But more than that, we are not just doctors – GPs are people too and we have health needs. Have your own GP; preferably someone you don’t work with, and who you can trust. If stress, anxiety, depression or any other mental health problem is causing you distress, reach out and seek help. There is a team of people out there dedicated to helping those of us who need it. Yes, even us GPs! GP Registrar 65

â&#x20AC;&#x2030;hen a medical graduate begins the journey toward becoming a general practitioner, the demands of providing a quality service for patients and preparing for the challenging journey towards fellowship can often result in personal neglect. It is not uncommon for GP registrars to lose track of friends, let hobbies and interests slide and not pay enough attention to personal health. These things are not inevitable and, with planning and commitment, personal well-being can be protected while meeting all the challenges of general practice. 66 GP Registrar

In the story that follows, David Lam explains some of his journey into rural general practice and talks about his fascinating range of hobbies and interests. David also shares some tips for protecting yourself, staying healthy and enjoying life as a GP registrar. In the two subsequent stories, Dr Bob Vickers explains some of the advantages of working in a rural location and Dr Samantha Oliver talks about the valuable support she received from the Indigenous General Practice Registrar Network.

GENERAL PRACTICE DIFFERENT JOURNEYS GP Registrar 67

68 GP Registrar

A SPECIALIST IN LIFE...

nd a teacher, boxer, guitarist and DJ. For South Australian registrar David Lam, general practice provides the flexibility to have a life outside of work, and his job in rural Port Lincoln has no shortage of variety. Did I always want to be a GP? Hell no! I didn’t even want to be a doctor. I wanted to study jazz. I felt no greater joy in life than playing guitar – anything and everything from John Coltrane to Red Hot Chili Peppers. But it’s no secret that most musicians require a stable job in addition to the sporadic work that comes from playing gigs, so when an offer came up for medical school, I decided to give it a go. I continued because medicine is fascinating. Bad things happen to the human body all the time, yet it seems to just want to fix itself if you know how to help it along. But the music never left me. For a decade, medicine and music battled in me like Jekyll and Hyde. When I was an intern I’d play a gig with my band, Spanish Harlem, or DJ a party with my crew, Lam Bros Disc Jockeying, and then have to jump straight in the car for an overnight shift at the hospital. I kept trying to convince myself that music was silly and I would “give up for real” in the next year. But I kept writing songs and people kept

wanting to see us play, so I pushed on. As an intern I was initially interested in surgical training, before realising that there just weren’t enough hours in the day to be in theatre and be on stage. General practice was just right. The clinic hours meant a certain amount of predictability and flexibility, and more and more I found it to be the perfect specialisation for me. Rather than leading a juxtaposed double life, I discovered that the skills that made me a good DJ and guitarist were exactly the same skills that made me a good GP. Both engage my desire to learn new skills – to watch what someone else is doing and think “that’s clever, let’s find out how they do that and give it a go next time.” Being able to read people well is essential to both too. As a GP, one of the best ways to help people is to sit back, shut up and listen to the patient. Likewise, as a musician, I am constantly reading the crowd. I am observing to see whether they are singing along, whether they are dancing, and constantly checking for that look of rapture in their eyes in order to figure out what to play next and how to play it. In both jobs, reading people works far better than pushing my own clinical agenda or musical taste down their throats. As a professional musician, I travel to and from Adelaide to play anything from weddings to AFL matches at Adelaide Oval. GP Registrar 69

David (second from left) with fellow Spanish Harlem band members on the set of their music video.

Back in Port Lincoln, I am also the club doctor for the Port Lincoln Boxing Club and a primary carer for the Marble Range Netball Club. Because sport is awesome. I also teach final year medical students on rural rotations and first year students at the University of Adelaide. Are there busy days? Plenty. But I wouldn’t have it any other way. Each of my roles defines a different part of me

If someone gets horribly unwell in the clinic, I’ll call an ambulance. However, contrary to metropolitan general practice, I will then follow the ambulance in my own car and continue to treat the patient in hospital. Rural GPs sort out so many different types of problems – stitching up wounds, catching babies, fixing broken arms and cutting out skin cancers. Outside of rural general practice, there are few other jobs where you have the privilege of

FOR A DECADE, MEDICINE AND MUSIC BATTLED IN ME LIKE JEKYLL AND HYDE. and is a unique way to do good in the world. And most importantly, all of the above experiences make life fun. Variety is the spice of rural GP life In Port Lincoln, we don’t have resident hospital doctors, which means I work in the local hospital and emergency department as well as in my clinic. This makes my job both challenging and exciting. 70 GP Registrar

serving several generations of the same family simultaneously. One day I was an obstetrician, delivering a patient’s baby. The next day I was a paediatrician, treating her sick toddler. The next I was a general physician, looking after her elderly mother in hospital. I initially worked in Port Lincoln as a student, and when I came back as a registrar I was reunited with one of the babies I delivered five years earlier. He was all grown up and I had the

OVERCOMING THE CHALLENGES David with boxing coach Pete Williams. Sport has helped David to feel at home in Port Lincoln.

Look after yourself first and foremost! I was no good to anyone on the days I was too tired and angry to make good decisions. Get your own GP. In South Australia, Doctors Health SA provides after hours and weekend services to doctors and medical students. If you don’t have a regular doctor yet, get in contact with them or the equivalent organisation in your state. It made all the difference for me. Sometimes I was just too unwell – physically or emotionally – to work, and I needed someone objective to help me get better. Get your own psychologist too Plenty of doctors with or without mental health conditions seek help from psychologists when in crisis. It took me a couple of tries with different clinicians before I found someone I gelled with, but it made all the difference. Tell your friends, your partner, or your parents what is going on with you – the good and the bad. Looking back, I was at my worst when I felt alone, and at my best when I shared with others and rationalised the struggles I faced. Take your time with your career There is no shame in this. I was burnt out immediately after medical school and took six months off before starting a hospital internship. During this time I continued to teach and play guitar, which was exactly what I needed at that time.

Know when to say “no” As doctors, we are good at prioritising a lot of tasks. But sometimes there is just too much to do, no matter how skilled you are at prioritising. In my case, I had to be strict and tell myself “no flying to Adelaide to DJ” in the three months before the fellowship exams. Exercise It sounds obvious, but physical activity is good for both the body and the soul. There were days when I was exhausted but just thirty minutes of exercise and social interaction at the boxing club would revitalise me physically and emotionally. Take overseas holidays Heed that old doctor saying: “if you are going to p*#$ off, then really just p*#$ off so that people can’t contact you!” Communicate As much as possible, explain everything that you are thinking and doing to allied health staff, nurses, patients and their families. This is crucial to good general practice. Don’t let go of the other aspects of your life Embrace the overlap in skills – it may just be that those skills you have in areas like sport, art, music or parenting are the same skills that make you a uniquely good GP. GP Registrar 71

privilege of continuing to look after him. Building partnerships with Indigenous patients to improve their health is also hugely rewarding. I worked with one Elder for 18 months before he finally agreed to take insulin for his diabetes. Ultimately, it took the both of us injecting ourselves at the same time (me with a placebo) in order to convince him that the needle didn’t hurt. He brought in his sugar-monitoring diary last week and had written next to the improved numbers “feeling better, thanks Dr Lam!” Natural beauty and a sense of community It’s also been great to support the local community as club doctor to the Port Lincoln Boxing Club, where I also train. My coach, Pete Williams, is like a father to me. He proudly travelled 700km from Port Lincoln to Adelaide to watch me graduate some years ago. Many of the boys and girls at the club are from broken homes and don’t have the money for club

to provide someone in the country with the same services and standard of preventative care that someone in the city would receive. The lack of resources can also take a personal toll. There are plenty of sleepless nights when I am on-call at the hospital, and the sheer amount of hours I put in as a country doctor means that I often have less time to spend with my incredibly supportive and patient girlfriend. Then there’s the pressure of having to juggle work with after-hours study for the RACGP fellowship exams. This combined with flying in and out of Adelaide to perform with the band or DJ crew has led to many stressful moments. What’s next? I will always do clinical work as a GP. I want to continue working in the country (at least fly-in fly-out) as there is still such a great need

I DREAM OF SETTING UP MORE MENTAL HEALTH PROGRAMS FOR TEENAGERS AND YOUNG ADULTS IN RURAL AREAS. fees, but he takes them all in and treats them like his own kids. Another benefit of working in this area is the abundant natural beauty of South Australia’s Eyre Peninsula. There are very few other places where I could clock off, drive ten minutes down the road, and be lying on a deserted beach, hiking amongst breathtaking mountains or playing in sand dunes as far as the eye can see. The challenges of working as a rural GP registrar Of course, working rurally isn’t without its challenges. In Port Lincoln, we are but twenty doctors divided amongst a population of 15,000, not including people from surrounding towns who travel in for medical care. Waitlists to see a specialist are several months long, and our small mental health and drug and alcohol services are crucial but overwhelmed. As a result I am often frustrated by being unable 72 GP Registrar

for healthcare out here. I dream of setting up more mental health programs for teenagers and young adults in rural areas. In addition, I am going to keep teaching with the university. I am keen to coordinate programs for students in rural areas and in the near future I will undertake a Masters in Medical Education. And, of course, I aim to keep boxing and to continue playing guitar and DJing. My band recently made our first music video, which was released on Triple J Unearthed, and I want to be playing big-name festivals next. I want to write a song that makes it on the mainstream Australian charts. I also want to travel the world, experiencing the music of different cultures in order to inspire my own song writing. If you would like to contact David Lam about anything in this article, you can do so via GPRA by calling 9629 8878 or emailing enquiries@gpra. org.au. You can also find out more about his music at lambrosmusic.com.

Why I am a rural GP registrar. Dr Bob Vickers is an RACGP/ACRRM registrar working in Singleton, NSW. He is a member of GPRAâ&#x20AC;&#x2122;s Advisory Council.

tâ&#x20AC;&#x2122;s late on Thursday afternoon and I am sitting in my clinic. A pleasant but profoundly deaf gentleman comes in to see me and, for the third time this week, proceeds to recount how he and my grandfather used to walk barefoot to school together, loud enough for the entire waiting room to hear the story. Many of my other patients were either in his primary school class or are siblings or children of those classmates. My patients and I discuss local issues such as the impact of mining on the town, the upcoming town musical or where my parents used to work and what they are doing now, and many other non-medical but interesting discussion topics. This connection to the community and holistic continuity of care is one (amongst many) of

my favourite things about working in a rural town. Rural towns are incredibly supportive and inclusive of rural GPs, and you can make many long term friendships. My patients say hello when I pass them at the weekend markets. Rural medicine brings about unique challenges. These include making a diagnosis and forming a management plan without easy access to pathology, imaging and timely non-GP specialist review is a challenge, but one that makes you better. Training in a rural location encourages you to build on clinical reasoning skill based heavily on history and examination findings. Rural general practice forces you to really use what tests you have available as much as possible in diagnosis. The amount of valuable information you can glean from a urine dipstick GP Registrar 73

or joint aspiration analysis is incredible, even before the samples are sent to pathology. Knowing it can takes weeks to get access to some imaging modalities encourages you to focus on being proficient and trusting your physical examination skills. Rural medicine also brings about unique benefits. I have the opportunity to contribute to the primary, secondary and tertiary care of my patients. Urban GP registrars are unlikely to be able to care for their own patients in hospital. As a rural GP registrar, I can do pre-pregnancy counselling, diagnose and manage the pregnancy, deliver the baby, give the child the immunisations and manage the immediate and long term health of mother and baby. We know not just our patients’ medical history, but often their social. Many rural patients that miss appointments in tertiary centres are put down as “forgetting” an appointment. Being involved closely in patient’s social determinants of health allows us to identify more than just “forgetfulness” as a cause for non-attendance, and gives us an opportunity to effect real positive change. 74 GP Registrar

Rural registrars also have the bonus of getting to live in the country, with all the great things that entails. I have a big house, with a great view, close to work, and there’s never any traffic. I can afford all this on my registrar salary (which is usually higher for rural doctors). I have chickens, a large veggie garden, and a great big shed. I can spend my summer evenings relaxing in my garden or riding around on my ride-on-mower while listening to music. We’ve had metropolitan doctors invited around for bonfire nights, and I can cook for them with our outdoor pizza oven without fear of smoking out my neighbours. My hope is that by showing them the rural lifestyle, I can convince them to move and work rural. The evidence suggests that a positive rural medical term can work wonders in building a sustainable rural workforce, but we don’t spend all our waking hours at work. The beauty of a rural lifestyle needs to be shown off just as much as the benefits of being a rural doctor. Rural general practice is a great profession, and an experience I think every GP registrar should have.

Finding your mob: the Indigenous General Practice Registrar Network

hen Dr Samantha Olliver was accepted into James Cook University to study medicine in 2003, she quickly realised the unique challenges she faced as an Indigenous Australian and the first person in her family to attend university. “I didn’t have anyone to show me the way,” Sam recalled. “I went blind into the profession, even networking was a big step for me.” Sam went on to work as a registrar in the Australian Defence Force. When she realised that life wasn’t for her, she completed her final years of GP training in Darwin. She felt isolated and unsupported at first, but then, everything changed. Through a friend, Sam was introduced to the Indigenous General Practice Registrar Network (IGPRN), a network auspiced by General Practice Registrars Australia (GPRA) for Aboriginal and Torres Strait Islander registrars. “IGPRN understood me and what I was going through, I felt well supported and guided for the first time,” she said. “IGPRN helped me get across the line for my

fellowship exams. They provided me with mentors, there were study groups, and of course, the twiceyearly workshops.” For Sam, the support IGPRN provided was revolutionary, as Aboriginal and Torres Strait Islander registrars face unique challenges on their pathways to becoming general practitioners. “Inside the study groups, we all understand where we’re each coming from… we’re not afraid to speak out, to ask questions or seek clarification. “In previous study groups, I’d sit silent and not say a word, not ask any questions. I didn’t feel comfortable, and I didn’t want to slow the group down.” According to Sam, getting more Indigenous Australians into general practice is an important step in closing the health and life expectancy gap between Aboriginal and Torres Strait Islanders and non-Indigenous Australians. She said community-led solutions also need to be a focus. “What we’re doing right now isn’t on the right path. There are intergenerational issues that are a difficult void to cross. “When the community is involved in a decision around healthcare delivery, it has a great effect.” GP Registrar 75

DR JONATHAN CHIA WAS THE WINNER OF THE INAUGURAL GPRA SELFIE WITH MY SUPERVISOR COMPETITION

“

Dr Jonathan Chia with supervisor Dr Lyn Wren at Quinns Mindarie Super Clinic, WA

Lyn has been a great support for me during my formative months as a GP registrar. She has provided invaluable advice and reasonable and logical clinical reasoning for difficult and complicated cases. She continues to be a source of consolation for difficult consults and has a wealth of knowledge that she is more than willing to share. She takes extra time off her busy schedule to be available to me, which I am so grateful for. She is always welcoming and happy to see patients with me even when she is running behind with her own patients. Her contribution to my training has made all the difference to how I practice and how I communicate. I am truly blessed to have Lyn as my supervisor and wouldn’t wish for any changes in my 1st year as a GP.

”

- Dr Jonathan Chia Dr Jonathan Chia’s prize was a Welch Allyn premium diagnostic set (RRP $1475.78).

76 GP Registrar

Education

Advocacy

Support

Collegiality

My profession. My community. My membership.

Join or renew your membership with the RACGP

My membership supports you in your general practice journey As an RACGP member you gain access to resources to support your exam preparation, general practice career planning, and to connect you with peers and mentors. Join or renew today racgp.org.au/membership

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GPRA President Dr Melanie Smith speaks at a GPRA exam preparation event.

Become a GPRA member today. It is FREE! GPRA is run by GP registrars, for GP registrars. We provide registrars with advocacy, support and resources. gpra.org.au

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